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Dieting and Overweight Patients

5/10/2015

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I was always trained that when somebody with a bingeing disorder, bulimia nervous or binge eating disorder, restricted their intake they were at a high risk of binge eating. This is called the dietary restraint hypothesis. The dietary restraint hypothesis is central to the cognitive behavioural model of bulimia nervosa and is a core focus of treatment. It is why a therapist will work on increasing the regularity of intake in an effort to decrease restriction and binge eating. In the patients I see with bulimia nervosa decreasing dietary restraint and closing the gaps between meals is almost always reported as taking the “oomph” out of urges to binge. It typically results in a decrease in the episodes of binge eating.
 
But what about patients that are overweight or obese? Often behavioural weight loss is a part of treatment and this may involve a proscribed period of caloric restriction. Dietary restraint theory would predict that binge eating would increase following this intervention. This is certainly a belief held by a number of eating disorder therapists that I talk to.
 
What does the data say? A recent review was published in Obesity Reviews by da Luz et al (2015) and also reported at the ANZAED 2015 conference.  The paper reviewed the impact on Very Low Energy Diets (VLED) or Low Energy Diets (LED) on binge eating. A LED or VLED diet is where you consume between 450 – 1250 calories, which is typically achieved by the use of meal replacement drinks. Importantly, these studies were all done under clinical supervision of the dieting, and this may be different to the dieting of patients with eating disorders. Once weight loss is achieved with the LED, food is gradually brought in to replace the meal drinks (but only up to about 1500 calories). The advantages of these treatment for obesity seems to be reduced appetite, rapid and motivating weight loss leading to health benefits, improvements in fertility and respiratory disorders. Weight loss has been maintained for up to 3 years.
 
The da Luz paper found 10 papers (out of the original 4150 that came from their initial literature review) that were scientifically robust enough to allow conclusions to be drawn.
 
So in patients with pre-existing binge eating behaviour or diagnosis of binge eating disorder did a LED or VLED lead to an increase in binge eating. There were 4 studies that addressed this question. In all of these studies significant reductions in binge eating were observed during and after the dietary intervention. In one study the reduction was 56% and abstinence was reached in 33% of participants. In another, at 12 month follow up, 57% of participants no longer made criteria for BED. There was also an indication that remaining binges were smaller in quantity at end of treatment.  Overall this seems pretty good data to challenge the thinking that we should not be prescribing diets to overweight or obese binge eating patients. The authors point out that prescribed and monitored diets may be different to the way patients typically diet and this may be important. The structure provided by having your eating and weight monitored by a health professional may be important.
 
There may be other reasons as to why the decrease in binge eating occurred. Weight loss is associated with increases in mood. If mood is better there is less need for the emotional regulation function of binge eating. LED and VLED plans also appear to reduce appetite that may lead to a decrease in drive to binge.
 
Before we get too excited and begin prescribing VLED to all patients that are overweight or obese that binge, there is a word of caution. In patients that presented with binge eating, but at a sub clinical level, results were mixed. In this group the majority of studies indicated an improvement in binge eating, at least during the dietary restriction phase of treatment, but in three studies relapse to bingeing occurred when food was being reintroduced.
 
What if you are overweight or obese but don't have binge eating but want to lose some weight and think a VLED may be helpful. Apparently not. In three studies, participants with no previous binge eating showed an increase in binge eating at the end of treatment. In one study around 10% of patients made criteria for Binge Eating Disorder after the intervention. In another study, 30% of participants reported increased binging at the end of treatment and this increased to 63% a year later (although they did not make criteria for BED). So VLED may lead to an increase in binge eating in individuals who are not binge eating.
 
Papers like this are always controversial in eating disorder conference. This is I think because when we think eating disorder the field still tends to focus on anorexia primarily, and then bulimia. We shouldn't neglect to include binge eating disorder in our thinking of eating disorders. It is the most common eating disorder and the 'newest'. It is important that, based on data like that presented in the da Luz paper, we can not simply adapt our treatments for BN to BED, we need to prepare for our traditional thinking to be challenged and extended by research specific to BED and obesity.
 
As always, thoughts are welcome.

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To Weigh or not to Weigh? That is NOT the question. The question is WHY do you weigh your patient.

2/9/2015

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At the recent ANZAED conference on the Gold Coast there was a plenary session that focused on whether we should weigh patients. The gist of the discussion was that weight (and by extension BMI) is not a good measure for health and so we shouldn't use it as one. More accurate ways to assess health were discussed, which may be great if you work in a large hospital and have access to the appropriate equipment. The lack of data as to whether actually weighing patients adds to positive outcomes was pointed out and is concerning.  However, weighing a patient is a key component in the therapies that have the most promising outcomes, which may tell us something.  My understanding is that there is also pretty strong data in obesity treatment that weighing a patient leads to better outcome.


When weighing patients is being discussed there are many black and white statements expressed - we must weigh all patients, we should not weigh any patients, we should tell every patient their weight or we should never tell patients their weight as they would become distressed. 

People seem to miss the point of why it seems really helpful to weigh patients.


I agree that weight may (or may not) be a good measure of health. I get that health is more complicated than any single measure. That is why when a patient is first seen at The Redleaf Practice we typically take a weight and ask a medical practitioner to perform a range of medical investigations, including blood test, ECG and temperature. 

The point that seems to get lost is that I don't weigh patients to see if they are healthy. I weigh my patients because they are suffering and are plagued by thoughts about their weight and the importance of it.  Their weight makes them anxious and they engage in destructive behaviours to reduce this anxiety. I can't help people with their thoughts and emotions about weight unless the number on the scale is in the room.  This is like trying to help someone with anxiety around heights but not getting them to climb a ladder. It's just not how you treat anxiety.  I weigh patients so that they can experience the anxiety and learn how to cope with it. At one level it is a chance for a patient to experience anxiety and distress and then practice the skills that we have discussed to manage their distress. This is particularly the case early in treatment.

Another way I might help a patient manage anxiety around weight is to have a patient stand on the scales and look at “the number on the scales” (i.e. let’s move away from the meaning ascribed to a weight and observe and describe the number on the scales).  We might describe what the number on the scales looks like (it’s a digital scale so pretty much like lines in different directions) and describe the scale. I’ll ask the patient what their level of distress is.  Then we keep doing this - sometimes for the whole session.  Anxiety about that number and standing on the scale will always decrease. That is what exposure is.  When asked what they learnt, patients will almost always say anxiety came and went and that they got bored (and a little frustrated with their therapist).  They learn that anxiety, as distressing as it can be, does not kill you and it, like a wave, goes away.
 


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We also might look at how inaccurate scales are as a way of measuring your worth as a human being.  We might take multiple weights in different spots and see if being weighed in a certain corner of the room makes us more worthwhile than if we are weighed in the middle of the room.  We can then have a conversation as to how this makes sense and if there is maybe a different way we might evaluate ourselves.


We might also stand on the scales and just practice our defusion skills.  When you do anything anxiety provoking the little voice inside your head will tell you to stop it. When we learn defusion we can practice recognising what our mind (or the eating disordered mind) says to us and to practice holding this lightly under the really ‘thought provoking’ conditions of being weighed.  We might do this walking to the scales, on the scales and after being weighed. It’s hard but you can learn to defuse from what the eating disordered mindset tells you about the meaning of the weight.


Not surprisingly, patients have many beliefs about weight and weight change.  “If I eat an extra fruit my weight will go up by a kilo… etc. etc. or, “if I eat regularly I will gain weight”. You gain information about these beliefs from being weighed.  A mistake that we make however, is to look at each individual weight. This is a problem because weight varies from moment to moment and making conclusions week to week is not very useful.  It feels much better to wait and draw conclusions after a series of about 4 weeks to make a decision if weight is changing (which doesn’t really fit into a twenty session therapy if you are evaluating the impact of a piece of fruit). I have found dietitians know more about what should happen to weight when you eat a certain amount and this is where I often have a dietitian involved in treatment.

It can also be helpful to have patients make predictions of what will happen to their weight each week.  When we have a graph of actual weight, cumulative predicted weight and weekly weight prediction (sometimes what you think the weight will do and what you feel your weight will do) you have a pretty messy graph that will lead to an eventual conclusion that my predictions about weight are not that accurate and maybe I shouldn’t follow them.

I’m often asked who should weigh the patient.  My answer is whomever has a rationale that you can explain whilst you look the patient in the eye.  If weight change (or weight stabilisation) is the point of treatment, weight can be used to see if that goal is being met.  That makes sense.  If the goals are not being met you may need to make a decision about the direction of treatment.  Weighing to see if a patient is healthy makes less sense, as it may not be a particularly good measure of health. Although, if you also take into account blood results, ECG results, etc. you are on safer ground.  Weighing a patient because “I’m a … insert profession..” or “It is in the manual” are pretty lame reasons if you ask me.  

One of the reasons I will weigh a patient is to elicit the thoughts about the number on the scale when they are "hot" and come with all the attached emotion. This is why the clinician helping the patient with their distress needs to be weighing the patient and not just receiving the weight from a dietitian or practice nurse (which was how weight was gathered in the original incarnations of CBT).  A story - I once weighed a patient and they lost a few hundred grams. Anorexia was initially very happy and my patient smiled. As we walked back to my office my patient’s mood changed and she began to beat her hand against the wall as we walked down the corridor. Anorexia had begun to tell her how hopeless she was because she should have eaten less and lost even more weight.  This led to a really productive discussion of how the pleasure of anorexia can be so short lived. I wouldn’t have had that conversation if I hadn’t weighed the patient. I wouldn’t have experienced how distressing a weight loss was for this patient.

There is no one reason to weigh a patient. I think it is also useful to think through the idea that weighing a patient may have different rationales at different points in therapy. Initially, weighing a patient may be an important part of the assessment process and can be useful in setting goals.  During treatment, weight is usually used to review the outcome of a behavioural experiment (does eating more lead to as much weight gain as I predict), and later in treatment can be used to help a patient decrease distress around the number on the scale and shift the attachment between the number on the scales and the sense of our worth as a person.

I can think of lots of reasons to weigh a patient with an eating disorder.  There may be some reasons not to.  I am happy to hear about them.

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Common Elements in Therapy

24/8/2015

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An interesting article was published recently by Josie Geller and Suja Srikameswaran (Advances in Eating Disorders: Theory, Research & Practice, 3(2) 191-197.  In these days of packaged, manualised and promoted evidence based therapies, they ask the question “What effective therapies have in common?” A good question indeed.  I do note that the article gives us a list of “effective therapies”, which seems to go beyond the data somewhat and includes therapies with varying degrees of evidence.  They are however a list of common therapies used in the treatment of eating disorders. (Although we also know that what people say they do and what they actually do may be somewhat different things – but I digress).

 The therapies listed as effective are Cognitive Behavioural Therapy – Enhanced (CBTE), Maudsley Anorexia Nervosa Treatment for Adults (MANTRA), Specialist Supportive Clinical Management (SSCM), Integrative Cognitive Affective Therapy (ICAT), Dialectical Behavior Therapy (DBT) and Family Based Therapy (FBT).

 The article looks at three questions related to engagement and motivation, skill acquisition and boundaries and expectations in therapy.


Engagement and Motivation

Common to each therapy was a description of a collaborative stance to treatment.  This shouldn’t be too surprising. However, within this general category there are nuanced differences.  Geller and Srikameswaran describe this as a difference between therapies that are more firm (CBT-E; FBT; DBT) in pushing for behaviour change moving to therapies that are more flexible (MANTRA, SSCM) within a collaborative stance.   In my experience of CBT-E, FBT and DBT, there is also significant differences in the “how” of collaboration.  For example, FBT is clearly more collaborative with parents than patients, whose motivation is assumed to be precontemplative of change. DBT requires a commitment to change before engagement in the “treatment” phase (although in practice these lines are a bit more blurred).  As outlined in the CBT-E manual - engagement and motivation is approached in a somewhat technique driven way – use of a decision balance sheets and an encouragement to “take the plunge” into behavior change. A problem with manual treatments is that the how to engage is reduced to techniques rather than the fluid process it is in the clinic room.

 I was really glad to see that the question of early behaviour change is touched on.  This seems at the heart of the somewhat theoretical “debate” between Josie Geller and Professor Glenn (does motivation matter) Waller.  Waller’s thesis, at least partly, is focused on the idea that early behaviour change leads to later behaviour change (and presumably motivation to continue with more behaviour change), such that pushing hard for early behaviour change is considered more important than focusing on motivation.  I would agree with both Geller and Waller. When you can achieve behaviour change you don’t need to focus on motivation and to do so may get in the way of behaviour change.  When you don’t see early behavioural change you need to step back and understand why and then work on increasing motivation.  In this article Geller and Srikameswaran raise the point that patients who can achieve early behaviour change may be a different population from those that can not.  A proportion of patients will turn up to session one having made the decision to change.

 A frustration with this discussion was that once again motivation is reflected as a binary and permanent construct, which once turned on remains on forever. Any one who has tried to change anything will know that this is not how motivation works. It is fluid and changing and the level of motivation to make the changes required in therapy needs to be a constant focus of treatment.  I also have a slight issue with the notion that when you change your behavior this increases motivation to change because change makes you feel better and want to change more.  This is especially not the case in weight regain in anorexia nervosa.  The behavioural change required leads to an increase in anxiety levels that low weight has been masking. This often leads to feeling worse until weight has been regained and held for some time.

 Do not get me wrong – I’m big on behaviour change – it is just harder than it is made out to be.

What Skills do you need to teach in therapy?


Geller and Srikameswaran note there are more similarities than differences between therapies when considering content.  The four areas that emerged were psychoeducation around the development and maintenance of the eating problem (all therapies), emotional regulation (not SSCM or FBT), focus on relationships (all therapies) and using higher values/helping patients see the bigger picture (MANTRA {core focus}; I-CAT, DBT).

Interesting is that helping patients with the eating disordered thinking (remember the C in CBT) seems to have gone out of fashion.  I would argue that CBT-E (by looking at defusing from the Eating Disorder Mindset) and DBT (through the use of mindfulness) do have a set of skills for helping the patient with the eating disordered thoughts.

The Non-Negotiables of Treatments

Non- negotiable parts of treatment have always been a strong part of Josie Geller’s stance in therapy. I may have mentioned them once or twice as well (see Freeman, Thornton & Geller 2014 for example).  Non negotiables are seen as being crucial in setting the boundaries around therapy. 

 The main common non-negotiable is the prescription of a regular pattern of eating.    This shouldn’t surprise anyone. Again, the issue of firm vs. flexible is important.  In some therapies regular eating is held firmly. FBT is the clearest example where eating is prescribed by parents and is the central focus of the therapy sessions.  Similarly in CBT-E, regular eating is central and food monitoring and reviewing food logs is central to the therapy.  In SSCM, regular eating is prescribed and encouraged, but may not be the central element of treatment sessions.

 The problem is we don’t know what is more effective.  Should I be firm or flexible? Or more realistically, in what combination should I use these ingredients and with which patients?  If my patient is not making behaviour change should I become firmer or more flexible?

 So many questions to think about?

 

 

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Etherapy and Eating Disorders

6/1/2015

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An article coauthored by the influential Christopher Fairburn  has stated that there is little evidence that etherapy is helpful in the treatment of eating disorders. Etherapy was defined as online self help programs with either little or no clinician intervention or app based interventions.  Interestingly there was no data on app-based interventions.  Etherapy, as reviewed in this study, did not include therapy sessions delivered by video conferencing (such as Skype) or guided self-help interventions where there is an active clinician component.

 

The results of the Loucas study found only 20 studies that met strict inclusion criteria, which was based on criteria used in medical research.  The use of inclusion criteria is important as it reduces the impact of results of weaker studies. 

 

Only six of the studies involved therapy treatments and one relapse prevention study (etherapy post hospital).  These studies were primarily based around a CBT intervention.  When compared to a waitlist control group etherapy did show some modest benefit in binge eating (especially in Binge Eating Disorder) and  purging behaviour.  However confidence in the effect size was low. 

 

This study has different results from two other previous reviews which were more positive regarding the role of etherapy.  This is largely due to the stricter inclusion criteria applied in the Loucas study. 

 

It is also a different results to other disorders, where internet delivered therapies appears to be more helpful.

 

Investigation of the efficacy of etherapy is important.  One of the dilemmas facing the field of eating disorders is the difficulty of people to access evidence based treatments.  The Internet is one way of addressing this.  Otherwise we have fairly good treatments available only to those that can attend face-to-face therapy during office hours.  The cost of treatment is also an impediment that etherapy will address.  Taking an evidence-based approach to etherapy is also important as some websites will claim that etherapy (ie the package that they provide) is an effective treatment.  This is a claim that needs to be proven to protect those suffering from an eating disorder.  If the etherapy provided is not as helpful as face-to-face therapy, engaging in etherapy may be stopping engagement in a more helpful treatment modality.

 

One of the problems with the way current etherapy is delivered is that it is in a self help format.  There seems to be little difference between the content of self help books and most etherapy programs apart from the mode of delivery.  Evidence based therapies are often accused (usually by people who don’t practice them) as mechanistic and minimizing the role of the clinician.  I don’t think that this is the case when they are delivered well.  Indeed, therapist should be trained to use the manuals in a flexible way focusing on the individual needs of the patient.  Etherapy needs to involve to become more interactive and delivered in a flexible manner with the specific needs of the patient in mind.

 

Of course, as a living and breathing therapist I am glad there is still a role for the therapist and a therapeutic relationship, which is a nice way of saying I am biased here. I have found that a way to disseminate evidence-based therapy to regional areas is via Skype video. One study (Mitchell et al 2008) compared face-to-face therapy with Skype delivered therapy and there was no significant difference in outcome or drop out rate.  Given the difficulties in disseminating therapist training, Skype (or similar solutions) is a possible solution to disseminating evidence-based treatments.

 

As always, comments or questions are welcome.

 

 

 

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Update on Family Therapy and Eating Disorders.

21/10/2014

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Hot off the press is an excellent review article by The Redleaf Practice Director of Family Therapy (currently a Post Doctoral Fellow at University of California San Diego) and our own Research Fellow, Scott Griffiths and Daniel le Grange.
You can read it below or as a link here
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training in eating disorders.

5/8/2014

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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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Values in Recovery

10/12/2013

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To get better you need a reason.  I think you need to know what life do you want to have, and how do you want to live that life.

To wade through the mud of recovery you need to be able to set a course towards a destination where life without the eating disorder will be more rewarding than with the eating disorder.
One way that I try to help patients find a reason to get better is to help them tap into their "values", to what is important to them.  This can be hard to do, especially if you are wired to focus on the details in life rather than the big picture.  Looking at values is a very big picture question.  That is why some people have trouble holding their values in mind.


To help people explore their values I find a number of things helpful.  You may like to consider some of these questions.  When considering them however, don't feel a need to jump to a conclusion.  Feel free to "sit inside the question" for a while - ponder it for a bit.

A simple question may be "What kind of person do you want to be?"  When these questions are asked the ED mind will probably try to jump in with 'thin' or maybe 'but I don't deserve to be that kind of person".  Practice defusing from these thoughts, see them for the words they are. Let them pass and come back to the question.

"What kind of person do I want to be?".  Maybe, "if the eating disorder went away, as if by magic, what person would I like to be?"

What sort of son? What sort of daughter? What sort of mother or father? What sort of team member, student, employer ….? Think about all the roles you play in life.

I try to get people to think about seeing their values in action.  



How would you like to behave as a son/daughter etc.  How would you like to treat people?  This includes how would you like to treat yourself?  If the eating disorder was not strong how would you treat your body?


Often people may say, "I want to be a good mother".  Ask yourself, What are the qualities of "a good mother" that you would like to embody.  Try to see your values in a behavioural light. 


Clarifying our values can give recovery purpose and meaning.  They are a crucial part of the choice point to eat regularly to a meal plan.  


See if you can sit inside these questions to help you make the decisions that will move you towards recovery.


Best
Chris.
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United we stand, divided we drop out.

4/12/2013

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In my recent talk for ANZAED, I spoke about the need for clinicians to study what they do.  To measure our clinical outcomes to see if what we do, whatever that is, is helpful.

A recent paper published in IJED did a little bit of that and more.  The paper by The Redleaf Practice's Director of Family Therapy, Dr Stuart Murray, and The Redleaf Practice's Research Fellow, Scott Griffiths (and some other guy named le Grange) looked at the importance of collegial alliance when working in FBT.  This is something that we have written about before in a somewhat provocative way.
In looking at the article a few things jump out at me.  One of the most important things to me is that 
1) patients gained weight significantly in the 15 sessions the study covered
2) patients achieved significant thinking change in 15 sessions.
As Director of The Redleaf Practice, I am really pleased of these results (that were not really the point of the study).
3) Most change was achieved early. Those early sessions need to focus on behaviour change.
4) Neither Body Weight or EDE-Q score (which measures the thinking component of the eating disorder) predicted drop out.  To me this indicates that "severity" of the eating disorder should not be a factor in offering FBT or not.
5) The alliance between clinicians was pretty stable.  Either the team members were collaborating at the beginning or they never did.  FBT still polarises.
6)Collegial alliance was correlated with drop out.  If you want families to stay in a treatment program you need a unified team from the get go.
7)Collegial alliance was correlated with cognitive change (but not weight change). That is an interesting finding. The paper hypothesises that having a united therapy team, as well as united parenting team may help the patient feel more secure and this is helpful in changing cognitions. The teams, parenting and clinical need to be seen to be bigger than the eating disorder.  

Why is alliance not correlated to weight change.  Maybe because parents are not distracted by ideology that can divides teams (my way is the right way etc) because they simply focus on getting their child well.  Maybe clinicians should just focus on that.
CT
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The Choice point

25/11/2013

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There are lots of things I wish I'd developed and written down. This is but one of them. It is not that new, it is not that revolutionary.  It is a useful clinical tool which I have used a few times this week and patients have found it powerful.  It comes from the wonderful Dr Russ Harris and his colleagues Jo Ciarrchi and Anne Bailey.  They describe the choice point exercise.


When you are living in contact with the present moment you become aware that life is full of choice points.  These are the points where we have to decide on what our behaviours are going to be.  For this meal am I going to eat anything, will I stick to the meal plan or cut back, will I binge or exercise are just a few examples.  The choice point can be used to understand the elements that go into making that choice.


First, what are the difficult thoughts, feelings and bodily sensations that show up when faced with a difficult situation.  Lets say it is lunchtime.  What thoughts might show up "I'm so fat, do I really need this (NO!), people will think I am disgusting for eating in front of them, what is a safer option .... this is all too hard" and the thousands of other thoughts that fly by in a difficult time.  These thoughts come with feelings - fear anxiety, panic, anger, sadness.  Physical sensations may also show up - hunger, sweating, thoughts racing, heart pounding.  Do any of these feel familiar to you? 


On the other side is a space to write down the values you want to live by and the skills and strengths you can use.  Values are the way you want to live your life. What is really important to you.  It might be health, it might be relationships or being more independent.  Think of the life you want if you did not have an eating problem.  It is also important to remember all the skills you may have learned in your therapy.  How might you deal with the uncomfortable thoughts, feelings and sensations that are arising around a meal.  You might know of defusion or cognitive challenging or wise mind to deal with thoughts.  You might have learned some distress tolerance skills (slow your breathing down) and emotion regulation skills (name your feelings, find them in your body, make space for them, notice them change and come and go).  You may have learnt radical acceptance and willingness.


That gets you in to the choice point.  In order to decide what behaviours to use the exercise reminds you to look at not what your mind is throwing at you but what behaviours would move you towards the life you want.  What helps you move towards the direction you want to go.  Is it bingeing. Is it restricting, is it using the skills to move you forward.


I like the exercise because it helps us keep what we want in life at the forefront of our decisions. It helps us remember  that it is not what our heads tells us that is important (our minds rarely help us move forward) but the behaviour that we choose does move us forward.  It also is a god chance to remind ourselves of the skills we can use to help us manage the moments that lead into the choice point.


Thanks to the developers of the choice points for their work, and their decision to share it with the wider therapy community.  I hope you might find it useful.  
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    Chris Thornton is a Clinical Psychologist and the Clinical Director of The Redleaf Practice, a specialist outpatient clinic for the treatment of eating disorders.  He is interested in bringing elements of positive psychology, Cognitive Behavioural Therapy and Acceptance and Mindfulness approaches to the treatment of eating disorders.   

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