Category:

training in eating disorders.

5/8/2014

This is not good.

This article from The International Journal of Eating Disorders highlights the lack of systematic training in medical schools in the US to treat the psychiatric illness with the highest mortality rate.

From the abstract:

"Of the 637 responding pro- grams, 514 did not offer any scheduled or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation".

So, if your clinician is not being trained as in Eating Disorders why would you expect them to be able to provide adequate treatment? I'm not sure the situation in Australia is much better.

I would love to hear from The Australian and New Zealand Academy of Eating Disorders and the National Eating Disorder Collaboration about what they are doing to change this situation.

Chris Basten & Chris Thornton will be running some more training and Supervision programs for later this year and throughout next year. Details to follow.

CT

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Facebook doesn't cause anorexia

29/7/2014

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Many parents wonder about the impact of social media, such as Facebook, on their children. One concern is the impact on their self esteem and body image. I have been asked “Does Facebook cause Eating Disorders?” Short answer: No. Longer answer, like a relationship status: It’s complicated.

Researchers from Miami have just published an article in the International Journal of Eating Disorders that begins to highlight the complexities of the interaction between social media, body dissatisfaction, self esteem, and disordered eating.

Some previous studies have found a correlation (not causation) between greater Facebook use and disordered eating and higher levels of weight and shape concerns when compared to users of other internet activities. Posting photos and viewing photo’s is correlated to body image disturbance and an increase rate of body comparision. Importatly, these studies are correlational (those who are high in body comparison and body dissatisfaction may be more likely to look at photos) and do not tell us what might lead to what.

One longitudinal study looked at college women’s tendency to seek out negative feedback and engage in social comparisons predicted bulimic and overeating symptoms at a later date. It was postulated that Facebook use led to body dissatisfaction which led to disordered symptoms.

The Miami study took 185 College students with an average age of 18. Individuals in this study who reported a greater “negative feedback seeking style” were more likely to report an increase in their dietary restraint in their eating a month later if they received a larger number of Facebook comments. However, the "negative feedback seeking style" was measured by only one question “(I sometimes write negative things about myself in my status updates to see if others respond with negative comments about me)". Also the increase in restraint was correlated with the number of comments, some of which would have been positive and reassuring.

Individuals were more likely to report higher shape, weight and eating concerns when they received negative comments in response to personally revealing Facebook comments.

So, posting negative comments about yourself on Facebook, and receiving comments about your post (either negative or positive) did tend to increase restraint in this study, as it has in some other studies. I am not sure in would increase restraint or eating disordered attitudes more than magazines and other media images do. There is a strong body of literature indicating that these sorts of images do increase body dissatisfaction, which increases dieting which is, in turn, a risk factor for eating disorders (particularly bulimia nervosa).

As always comments and thoughts are welcome either on our Facebook page or on the Website below.

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The model or the CLINICIAN: Who comes first?

18/11/2013

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Last week I was asked by the Australian and New Zealand Academy of eating Disorders and by the National Eating Disorders Collaboration lead a discussion on what are the core competencies for someone working in the field of eating disoders. As part of that I gave a presentation entitiled "The Model or The Clinician - Who comes first?" I have attached a link to a PDF of the slides here.

I thought I might just provide some context for some of the slides so it makes some sense.

We start with a brief review of the evidence base in the eating disorders (along with one of my favourite quotes from Christopher Hitchens "What can be asserted without evidence can also be dismissed without evidence".

Slide 3 reminds us we do have Clinical Practice Guidelines to direct us, as well as a more recent Cochrane review and also (slide 4) great review by Bulik (up to 2005) and then Hay (2005-20013). Both published in International Journal of Eating Disorders.

Slide 5 suggests there is the strongest evidence for FBT in the treatment of adolescents with anorexia nervosa, but Slide 6 reminds us that that data (for full recovery - which is the standard to which I hold myself) indicates full remission for 50% of patients. (i.e. it's good but 50% ain't great).

Slide 7 & 8 makes similar point for CBT for BN. Good data suggesting good outcome for most, but again about 50% of patients remain symptomatic at end of treatment. There are also other treatments that are helpful for BN and BED, such as Interpersonal Therapy or DBT. The weight of evidence suggests however a first line treatment for BN should be CBT.

Slide 9 covers adult AN, where our results are poor. Most treatments get about 20% of patients to full remission, and get a substantially higher number to partial remission. 10,11, 12 summarise the latest study from Germany - the ANTOP study. This study again found that the type of treatment (a manualised psychotherapy or CBTE) didn't really matter in terms of outcome. Our treatment manuals aren't guiding us to what we should specifically do with adult patients in AN. I would point out however that the majority of the manuals focus on improving nutrition.

So we have some data to guide us on what may be helpful in the treatment of eating disorders. However, the question is how many practitioners are using the evidence base which suggests some empirically supported treatments exist.

Slide 15 was chosen not because the Tobin study is the best one indicating the Research Practice Gap, but because it has the coolest name (I know what you did last summer ... and it wasn't CBT) and it allowed me to put up a poster of SMG. There is a concerning "What Manual" with 21% of clinicians asked do they use a manual in the treatment of BN. I am more interested in the "flexible" user group, as this is where manual and clinician come together (maybe).

16 is on who uses manuals. Well when I here CBT, research focused and young I tend to think of my Doctor of Clinical Psychology and Master of Clinical Psychology students (some of who are pictured in the slide). When the first graduate the don't have the clinical experience, so should be sticking close to the manualised treatment where ever possible.

17 is some of the reasons people don't use manuals. I am most worried about those who don't know the manual. Slide 18 is an interesting study that indicated that even of those for whom CBT was their treatment of choice, few had formally being trained in the manual. ANZAED and the various state based training organisations must roll out training in evidence based treatment. I know Victoria have done this with FBT, as has NZ, but NSW is far behind.

RCT's dont exclude most patients - its an excuse we use when our results aren't as good as RCT. I have never met an eating disordered clinician who doesn't think they have the toughest patients that have all been excluded from RCT. The evidence generally suggests that treatments do disseminate if you use them.

Maybe our treatment models are "ignorant". I am thinking here of adult anorexia nervosa. Maybe drive for thinness or drive for control just doesn't cut it. I look forward to looking at the data coming out of neuropsychiatry labs like Walter Kaye's and the emerging research on Cognitive Remediation Training that may increase the outcomes for CBT.

The most common reason proffered for not using the Empirically Supported Treatment is that therapy is an art that should not be restrained by a cookbook. Surprisingly I agree with this to some extent. Mainly in the restraints that an RCT puts on the length of treatment. Maybe 40 sessions is not enough for adult anorexia (see the ANTOP studies weight graph that shows people keep getting better after treatment). Sometimes patients may need 30 sessions of FBT rather than stopping at 20 as the manual and RCT protocols suggest.

However, there are ideas in the manuals that help our patients. Our therapies need to reflect this.

As clinicians we need to remember that Evidence Based Practice is a three legged stool. Yes, one leg is Empirically Supported Treatments (our manuals). The other legs are clinical experience and also patients values and preferences.
Each of our camps tend to grab onto on leg of the stool and pull. The stool then looks a bit like a "hitting stick" (Slide 20) to beat people over the head with. Or as Phillipa Hay once wrote in response to our article "tyrannise" people with THE EVIDENCE.

However, as clinicians we need to however be aware of our own humanity and vulnerability to thinking errors - most importantly the confirmation bias (slide 21). This is when we do what we think works and collect evidence that it works and discount evidence it doesn't. This bias can lead us to do things that don't work continually, because we assume they do. It is this that, in my opinion, using manuals grounded in science helps us with.

You know I'm using a boring quote when I use a picture of a cute baby to keep the audience interested. I prefer the quote (from the book "Mistakes were made .... but not by me - which btw is going on my tombstone) about science being 'arrogance control'. Clinicians, and unfortunately I can't exclude myself here, can be some of the most arrogant people I now. We think we know that what we do is right and, if unchecked, our confirmation bias keeps it going.

Im not just bashing clinicians who wont use the evidence base. We need to be aware that as science evolves the evidence base will keep changing and we need to be ready to integrate new evidence into our formulations. For example the evidence for the cognitive behavioural model of BN is not as strong as I thought. I had selectively neglected a body of literature that indicates that dietary restraint may not lead to binge eating - although my clinical experience tells me it does. We all need to keep changing and adapting.

So, Im not bashing flexible manual users (which surprised some in the audience). Indeed I think I am one. The manual keeps me "anchored" to principles that are helpful. I try to integrate the concepts in the manual using my clinical experience - sometimes this is not the order the manual tells me. As clinicians we need to be aware of our tendency to drift into the latest clinical 'fad' or basing out therapy on the latest book we have read or workshop we have attended unless they have data to support them (ACT show me your data please).

Slides 24 & 25 are about the idea that maybe what we do is better than the manualised treatment. I feel all practitioners need to be accountable and to measure (and publish) their outcomes - this is the cornerstone of the generation of Practice Based Evidence. Be able to show what you do works. If it does - teach me what you do (make it disseminate-able).

We finish with the photo's of me cooking a BBQ, Jamie Oliver and Heston Blumenthal. I suggest manuals are a bit like cookbooks (which some take as a criticism). I can't cook. For me to cook chicken pizza - you need to give me a McCain's frozen Pizza that has all the ingredients included with strict instructions on what to do (including remove the plastic, turn on the oven to 180 degrees, place on a tray in the oven, leave in for 25 mins etc. Detailed step by step instructions. Heston may prepare a chicken pizza for you. It wont have chicken, pizza base and may be served as a gas - it is art, but it is not chicken pizza. Jamie however, has some instructions for chicken pizza, He includes a chicken and a pizza base. He can add to that base whatever he likes that might make it better. He doesn't need to be told when to remove the pizza from the oven - he just knows (he could tell you when to though). He uses the key ingredients in an understandable manner. He adds to the recipe in a way as guided by his experience, but his chicken pizza can be replicated by those who want to. When it comes to the treatment of our patients, I think Jamie serves as a model that integrates clinician and model.

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A Mindful Stop (Stolen from Russ Harris)

29/10/2013

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I have stolen this (stolen, not adapted, just plain stolen) from wonderful ACT therapist Russ Harris.
It is a really nice way of incorporating mindfulness into daily life.
The Mindful STOP
We all know that mindfulness is ‘good for us’, just as we all know that exercise is ‘good for us’. However that doesn’t mean we need to do intensive mindfulness meditation for 40 minutes every day! In my workshops for coaches and therapists, I like to say, ‘If we want to motivate people to exercise more, we wouldn’t tell them, “You have to go to the gym for 40 minutes a day!” Rather, we’d say, “Every tiny little bit of exercise makes a difference. If you walk for five minutes at lunchtime, that’s better than not walking at all. If you walk up one flight of stairs instead of taking the lift, that’s better than not walking up any stairs. If you park your car in the parking space that’s furthest away from the supermarket, that’s better than parking in the closest one; even walking those few extra metres across the parking lot will make a difference.” ’

Sure, if you do exercise for 40 minutes a day, you’ll be healthier than if you do it for only 10 minutes a day – but even 5 minutes a day is a whole lot better than none at all! And so it is with mindfulness skills. Just like any skill we learn, the more we practice mindfulness, the better we get. So if you’re willing and able to do 30 or 40 minutes of daily mindfulness meditation (or similar formal mindfulness practices like yoga, or Tai Chi), that’s fantastic! Those are truly excellent practices for effectively developing your mindfulness skills. However, let’s be realistic here; many of us are unable or unwilling to make the time for this type of formal mindfulness practice on a daily basis. That’s just life!

However, that doesn’t mean we need to give up on the idea of regular mindfulness practice. It just means we need to find alternative ways of practicing our mindfulness skills throughout the day. That’s why in all my books you’ll find plenty of suggestions for quick, simple, easy ways to do this – e.g. having a mindful shower, mindfully brushing your teeth, mindfully patting the dog, mindfully hugging your loved ones, mindfully drinking your tea or coffee, mindfully ironing your shirts, mindfully tying your shoe laces, taking ten slow mindful breaths, etc. After all, one of the beautiful things about mindfulness is you can practice it anytime, anywhere, any activity. (To download a one-page handout/worksheet/tip-sheet on informal mindfulness practice, click here.)

Now here’s one especially useful, ultra-brief, and very simple mindfulness practice, that you can easily incorporate into your busy daily routine, no matter how pressed for time you are. I call it the mindful S.T.O.P. Here’s how it goes:

S – Slow down (slow down your breathing; or slowly press your feet into the floor; or slowly stretch your arms; or slowly press your fingertips together)
T - Take note (with a sense of curiosity, notice your thoughts & feelings; notice what you can see and hear and touch and taste and smell; notice where you are and what you are doing)
O - Open up (open up and make room for your thoughts & feelings, and allow them to freely flow through you; use any defusion or expansion skill you like)
P - Pursue values (reconnect with your values, and let them guide whatever you do next)

The lovely thing about a mindful STOP is you can make it as short or as long as you like. You can zip through this in under thirty seconds – e.g. while you’re waiting at a red traffic light, or stuck in a supermarket queue, or waiting for your kids to come sit at to the dinner table – or you can stretch it out into a thirty minute formal meditation practice. I encourage you to try it out for yourself – not just once, but over and over and over again:Slow down; Take note; Open up; and Pursue your values. A regular mindful STOP works wonders.

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2. Once more with feeling

13/8/2013

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For those who have been to my office in Wahroonga they may recognise my slight obsession with Buffy and this is one of my favourite episodes. It also is a tentative link to my previous post.

This post is about what to do with the feelings that come along in the journey of recovery. To return to the picture that I have put up before..

In this post we are going to focus on this part of the picture. It is a small but crucial part of the picture.

At any giving time we are "stuck with" the thoughts our mind gives us. When our mind gives us thoughts that bad things will happen ("I can't cope"; "If I eat that I'll get fat") then this is going to come with feelings. You don't really get to choose the feelings that arise. If you mind predicts that bad things will happen then you will experience fear and anxiety; if it tells you how bad the world is or things you have lost, you will experience sadness; if it tells you how bad you are you will experience shame. Often the more stuck on your thoughts the stronger the feelings are, but even when you are taking a helicopter stance to your thinking the feelings may be really strong.
If you have an eating disorder you may not be very good at having emotions, they are hard to recognise and name which can make them seem even more overwhelming.
If you are human (and I am going to make that assumption about you) then you probably don't like having really strong uncomfortable emotions. You might have lots of ways to "get rid of" these emotions - this might be one of the reasons that the eating disorder keeps going. It may be a way of trying to avoid these feelings. This comes at a cost - which is usually a "smaller life".
I think a really important part of recovery is accepting that these thoughts and feelings are coming along with you for the journey of having a more meaningful life.
I have never met a patient who wanted to feel terror and panic, sadness and shame. I have however had the privilege to work with countless people who have been "willing" to have these emotions on the journey.
Willingness is about accepting that these difficult emotions are coming along for the ride. It is not about wanting to have them, but deciding to not try to get rid of them by engaging back in old behaviours.
These feelings need to be acknowledged, named (which can be hard at first- but a hint might be don't call them fat), and a space found for them. I often say to patients that it is not about "sitting with" your feelings as this always conjours up images of being in a straight jacket and rocking under a table while you sit with these feelings being dominated by them. Just know they are there and make a conscious and deliberate choice to move in a direction that moves you in the direction of a bigger life no matter what the intensity of the emotion or what your head is telling you to do.
We can talk about some ideas I have about ways to do this in a later post.
Take care of yourselves.

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1. Are you Stuck on thoughts or stuck with thoughts.

2/8/2013

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Sometimes when I work I think, I should write that idea down, maybe it would be helpful for another patient, or maybe I could use that in supervision or teaching. Given that it is not thinking about something that moves you anywhere I thought I would take action and write some of the things I do here. These ideas are just ideas and are in no way a substitute for seeing a real live person to get the help you need.

I was working with a patient of mine who we can call Mary because it isn't her name.We were looking at what was making it hard to move forward in building a "bigger life" including working, compassion and giving to others rather than a "smaller life" of weight control and counting calories.

We ended up with this picture (it goes without saying that I once got kicked out of a high school art class for being an abomination to the art world - harsh but fair btw).

There are actually a lot of different concepts in this picture. I thought that maybe I would break it down over a couple of posts.

This one is about getting stuck on thoughts rather than stuck with thoughts.

Mary had a mind full of thoughts. Her thoughts would both maintain the eating disorder (I cant cope, you dont need it) and more change oriented thoughts (your body is collapsing, it dosen't matter). She could see that these thoughts would just swirl around in her head creating chaos and confusion. She tried to challenge these thoughts but these seemed to get her more paralysed by thoughts. Eventually she would get "stuck on" thoughts - she would act as if they were commands that had to be followed. In the previous week she had been stuck on her eating disordered thoughts and followed them automatically. She had followed them thoughtlessly (without thinking about them) or "mindlessly" (without being that aware that she was following thoughts).

We then drew another picture to indicate another way of 'relating' to thinking.

This represents developing a "helicopter stance" to our thoughts (sometimes called an observing mind). We can learn to look at our thoughts, almost as if they were external to us, and see them as thoughts. We discussed how (at least for the present moments) we are "stuck with" these thoughts. We don't get to choose our thoughts we have in our heads, our minds just produce them. We can't not think, we can't choose to not have certain thoughts. These thoughts are coming with us wherever we go. They are our constant companions, at least for the time being.

The good news is that from this helicopter stance we can have a choice in where we go, rather than just following thoughts we are "stuck on".

I have found that helping people develop a helicopter stance to their thoughts be a really helpful step in moving towards creating a more meaningful life irrespective of what their head is telling them.

We can talk about the "how" to do this later.

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Mind and its potential presentation.

16/2/2013

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In 2012 I was privileged to present at the Mind and its Potential Conference. Below is the video of my presentation. It has been on our Facebook page for a while and got shared around the viral world with really good feedback for which I am grateful. I thought I should put it up on our webpage.

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"Denial" in Anorexia: Wilful or Choiceless (or in between)

25/5/2012

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The “denial” (note those “”) of the illness in anorexia is well described. It is one of the most frustrating aspects of the illness for carers and clinicians alike. It contributes greatly to the expressed emotion (frustration, anger, criticism and patient blaming) that comes from clinicians and acts as a therapist driven therapy interfering behaviour. Therapist will describe their feelings that somehow the patient is willfully lying to them, because the patient “must” be aware of their illness. They are being that naughty anorexic patient who seems to seek out to disrupt therapy.

What if clinicians ask that question that we ask patients so often “Is there a different, more workable, way of thinking about this?” As always, the answer is yes.

Until I began reading the blogs of Laura Collins, I had never heard of anosognisia. This is apparently a common problem in several brain diseases which where the sufferer no insight or is unaware of the illness. It occurs in neurological diseases such as Alzheimer’s disease, Huntington’s disease and after strokes. It can also be a feature of schizophrenia and bipolar disorder.

Some FMRI pictures and more information can be found here.

Im not sure if it has ever been studied in anorexia nervosa. Im not sure if it would be preexisting and exacerbated by starvation, or caused by starvation.

It important though for us to hold information in a way that may help us see that anorexia nervosa is not a willful choice. Holding this stance is incredibly helpful for therapist (and hence their patients).

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First Post!

6/5/2011

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What just happened. I went to bed before the budget knowing that I could do my best to treat patients with eating disorders in line with the guidelines that we know to be scientifically valid. Under the original "Better Access" Scheme, patients could typically receive 18 sessions of treatment subsidised by Medicare. When I woke up after the budget this rebate had been cut to 10 sessions. Now the government had based this figure in part on data produced by my professional body the Australian Psychological Society. This data indicated that most patients were receiving about 6 - 8 sessions of therapy before the completion of their treatment. Only about one percent of therapists were using upto 18 sessions with their patients. I think that 1% may have been me. The other 99% must have not been seeing patients with eating disorders.

Lets look a little at the treatment of people suffering from eating disorders and why we have a problem.

The eating disorders are amongst the most serious psychiatric disorders. Eating Disorders effect up to 10% of Australian women. Anorexia Nervosa is the third most common chronic illness effecting adolescent women. It has the highest mortality rate of ANY psychiatric illness, with 20% of patients dying from the illness after a prolonged history. Matched for age, patients with anorexia nervosa have a death rate five times higher than the general population. Death from suicide is relatively common, being 32 times higher than expected than in the general population (for comparison, patients diagnosed with major depression are 20 times more likely to die from suicide).

The Eating Disorders are often chronic and debilitating illness. On average, patients with Anorexia Nervosa have a similar level of disability to those suffering from Schizophrenia and Borderline Personality Disorder. In a systematic review of the literature eating disorders are shown to have one of the highest impacts on health related quality of life of all psychiatric disorders. Cost of treatment per year for Anorexia Nervosa is as expensive as that required for schizophrenia. Data from the private hospital system indicates patients with eating disorders are the most expensive patients to treat in a hospital setting. This is due to the complex psychiatric and physical comorbidity, the protracted length of treatment, and the requirement of specialist care.

We know that patients who have access to the empirically supported evidence based approaches provided by specialist services have a significantly improved outcome. This is particularly so for those who are able to access these treatments early in the course of their illness.

There are two well validated outpatient treatments for patients with the eating disorders, Family Based Therapy for Anorexia Nervosa, and Cognitive Behaviour Therapy for Bulimia Nervosa.

The treatment of the eating disorders is complex and often protracted. The treatment manuals for both FBT and CBT indicate that the number of sessions recommended for treatment 20 treatment session over a 6 - 12 month period. This is of course the problem. We had 18 sessions, which almost fitted in with what works. Now we have 10 session. This is half the recommended course of treatment. (Actually, I'm not sure 18 was ever really enough but that is an argument for another time {I suspect now in the distant past}. I'm not going to mention the problems of FBT under the current legislation).

The government’s recent reduction of this figure to 10 sessions is woefully inadequate for my patients needs. The reduction will result in fewer patients accessing appropriate treatment within an adequate time frame. Outcomes from the eating disorders will deteriorate and the personal, social and economic burden from the eating disorders will increase.

So, what to do ......
I am a great advocate of accept what you can't change AND trying to change something that you can do something about. There was a move to remove Social Workers from the Medicare Scheme which was reversed die to public pressure. I am hopeful that the same can happen here.

Lift what you want from what I have written above and send an email to the Minister for Health and Ageing Nicola Roxon and Minister for Mental Health Mark Butler

Lets not forget the Greens (whom I've heard are supportive of my position)
bob.brown@aph.gov.au
and the independants
senator.xenophon@aph.gov.au

senator.fielding@aph.gov.au

Peter.Dutton.MP@aph.gov.au

Mark.Butler.MP@aph.gov.au

Tony.Windsor.MP@aph.gov.au

robert.oakeshott.mp@aph.gov.au

Lets get active to support the effective and affordable treatment of eating disorders. I know I have.

Chris Thornton
Clinical Director
The Redleaf Practice.

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training in eating disorders.

Facebook doesn't cause anorexia

The model or the CLINICIAN: Who comes first?

A Mindful Stop (Stolen from Russ Harris)

2. Once more with feeling

1. Are you Stuck on thoughts or stuck with thoughts.

Mind and its potential presentation.

"Denial" in Anorexia: Wilful or Choiceless (or in between)

First Post!

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