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Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders
Nicole Siegfried, PhD, CEDS Clinical Director, The Highlands
Adjunct Associate Professor, UAB
Rethinking Family Therapy in ED Treatment: Strengthening the Self Through Building the Capacity to Relate
Jim Gerber, Ph.D. Clinical Director
Locations: St. Louis, MO//Pacific Grove, CA//Birmingham, AL
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● Defining Recovery
● Relapse and Recovery in Eating Disorders (EDs)
● Interventions to Promote Recovery
● Questions and Comments
Overview
• Definitions of Recovery
– Remission?
– In Recovery?
– Recovering?
– Recovered?
• Definitions of Relapse
– Relapse?
– Slip?
– Lapse?
Defining Recovery
Defining Recovery
• Partial recovery
– No longer meets diagnostic criteria for ED
– Weight restoration
– No bingeing, purging, fasting within past 3 months
• Full recovery
– All of the above plus…
– Psychological recovery (i.e., within 1SD on quality of life measures, psychological and psychosocial functioning)
(Bardone-Cone, 2012)
Full Recovery vs. Partial Recovery
“I just live my new life without
much thought to my recovery”
“The ED is no longer the voice in my head”
“I accept myself and my
body; I don’t use food to
resolve problems and I don’t
let food dominate my life.”
“She has an absolutely
ordinary relationship with
food.” (from a mother)
“Bulimia was in the rear view mirror- a scene getting smaller and smaller the farther we traveled along life’s road… until it was a mere dot and then was gone.” (from a spouse)
“The eating disorder feels
far away, like a distant
dream, very separate from
my current life”
Defining Recovery
IN RECOVERY FULLY RECOVERED
Fearful of relapse Confident in recovery
Vulnerable to major events Proactive to events
Accept body (still dislike) Love and accept body
Focus on ED Recovery Focus on Life
Attempting to Connect Connections
Moments of Joy and Peace Joy and Peace
Identity = ED True Identity
Defining Recovery
(Schaefer, 2012)
Relapse and Recovery in EDs
• Relapse Rates for AN & BN range from 22%-
51%
• Mortality rates as high as 20% (primarily from
cardiac arrest or suicide)
• Recovery Rates in AN range between 44%-
76%, with prolonged recovery time (57-59
months)
• Recovery Rates in BN range between 50%-70% (Berkman, 2007; Carter et al., 2004; Clausen, 2004; Couturier & Lock, 2006;
Fichter et al., 2006; Fichter & Quadflieg, 2004; Field et al., 1997; Herzog et al.,
2009; Keel & Mitchell, 1997; Keel et al., 2009; Keel et al., 2005; Olmsted et al.,
2005; Stenhausen, 2002; Strober et al., 1997; Van Holle et al., 2008)
Relapse and Recovery in EDs
• Weight Gain Early in Treatment for AN
• Reduced Family Conflict
• Shorter Duration of Illness
• Involvement in Work or School
(Accurso et al., 2014; Strober et al., 1997;
Treasure & Russell, 2011)
Recovery Boosters
Relapse and Recovery in EDs
• Presence of Purging in AN or Higher Frequency
of Vomiting in BN
• Family Conflict
• Poor Social and Occupational Functioning
• Poor Motivation for Recovery
• High Levels of Impulsivity
• Longer Duration of Illness or Delayed Treatment
• Premorbid Obesity
• Substance Abuse
• Severe Body Image Disturbance
(Berkman et al., 2007; Keel et al., 2005; Van Holle et al., 2008)
Risks for Relapse
1. Strong Negative Emotions
2. Paying Attention to Numbers (e.g., Calories, Sizes, Weight, Time/Distance/Calories Burned in Exercise)
3. Dieting/Eating Diet Foods/Skimping on Meal Plan
4. Comparing Self to Others (in terms of weight or recovery success)
5. Isolation
6. Engaging in or Listening to Weight/Diet talk
7. Being Around Others Who are Practicing Their Eating Disorder
8. Perceived “Failing” or Fear of Failure
9. Over-committing/Over-working
10. Over-exercise/Not Sticking to Exercise Plan
Relapse and Recovery in EDs Top 10 Relapse Triggers
Interventions to Promote Recovery
DBT Techniques Behavior Chain Analysis
• Identify the problem
behavior in detail
• Identify the
prompting event –
external trigger
• Identify vulnerability
factors-internal &
external factors that
make client
susceptible
• Identify links-specific
thoughts, actions,
sensations & feelings
• Identify
consequences
(positive & negative)
• Identify new skillful
solutions
• Identify ways to
reduce risk in future
Interventions to Promote Recovery
Vulnerability Prompting Event
Thoughts
Emotions Problem Behavior
Consequence
Consequence
Consequence
Body Sensations
DBT Techniques Behavior Chain Analysis
Interventions to Promote Recovery
BINGEING BEHAVIOR CHAIN
• On front:
• Write urge/behavior
• Write function of urge/behavior
• On back:
• Write affirmation
• Write coping skill(s) specific to that
urge/behavior
Interventions to Promote Recovery
DBT Techniques Urge Cards
• Urges typically pass within 15-30 minutes
• Individuals usually act on urge within that time,
and mistakenly attribute reduction in urge to
their action rather than passing of time
• Teaches clients that if they can “ride the wave”
of the urge for 30 minutes, it will pass.
(Linehan & Demeff, 1997; Marlatt & Gordon, 1985; www.aliceboyes.com/urge-surfing/)
Interventions to Promote Recovery
DBT Techniques Urge Surfing
• Encourages clients to find alternate
ways to rebel against the restrictions
and deprivations of their lives without
life-threatening behaviors, therapy-
interfering behaviors, and quality-of-life
Interfering behaviors.
Marlatt & Gordon, 1985
Interventions to Promote Recovery
DBT Techniques Alternate Rebellion
Relapse Prevention Techniques Three Circles
Interventions to Promote Recovery
Carnes, 2006
Attending aftercare groups and therapy appointments
Going to classes
Allowing my dietitian to be in charge
of my weight
Being honest with
others
Daily meditation
Following my meal plan
Following my exercise
plan
Skipping even one class
Coming up with excuse
not to go with
friends
Skipping a meal
Skimping on a meal or snack
Weighing myself
Staying up past 1:00AM
Running on a treadmill
Going to a gym
Committing to do two things at same time
Bingeing
Purging Exercising
when I have an injury
Trying to lose weight
lying about my food/eating Taking
diet pills
Losing weight
Walking as exercise
Going out to eat at least 1X/week
Volunteering at Habitat at least
1X/month
Taking a bubble bath at least
1X/week
Having playtime with my dogs on a daily basis
Abstinence Violation Effect
(Marlatt, 1985)
• Refers to the guilt and perceived loss of
control that a person feels after a slip.
• Based on reaction, client returns to
behaviors.
• Based on all-or-nothing thinking
– Lapse vs. Relapse
Relapse Prevention Techniques
Interventions to Promote Recovery
(Marlatt, 1985)
• Refers to choices made during slips that
appear benign, but really contribute to relapse.
– Making a choice to buy some cookies just to
have in the house for the kids.
– Making a decision to stop by the rec center
to see if a friend is there.
– Changing your snack choice to ice cream at
the last minute.
Relapse Prevention Techniques
Interventions to Promote Recovery
Apparently Irrelevant Decisions
(Marlatt, 1985)
• Refers to thoughts, behaviors, and emotions
utilized to cope with risk factors or avoid
lapse
• Helps to avoid problematic behaviors
• Not giving up on self when triggered or
activated
• Managing emotions and coping using skills
that are positive
Relapse Prevention Techniques
Interventions to Promote Recovery
Adaptive Coping Responses
• Clients with eating disorders often have a narrow Window of Tolerance
– They are unable to tolerate emotions outside of the window
– They utilize food-related behaviors to regulate their window
• Clients learn coping skills to widen the Window of Tolerance and to decrease emotions to a tolerable level without food
Relapse Prevention Techniques
Interventions to Promote Recovery
Window of Tolerance
(Ogden, 2006)
Interventions to Promote Recovery
Strengths-Focused Activities
Have Clients Take VIA Strengths Survey
(www.authentichappiness.sas.upenn.edu)
●
Explore Results with Client Individually or in
Group
●
-- Do results match your perception?
-- What ways can you access one of your 5
top strengths in recovery?
-- What are examples of ways you have used
one of your top 5 strengths in your life?
(Seligman, 2011)
Future-Minded Exercises
Individuals Who Can Connect More to Their
Future Selves May See Future Goals as More
Attainable
●
(Hershfield, 2011; Miller, 2005; Wilson, 2014)
Future-Minded Activities
-- Letter to Future Self
-- One Hundred Things to Do in My Lifetime
●
Interventions to Promote Recovery
Interventions to Promote Recovery
Future-Minded Exercises
Clients Are Encouraged to Imagine Their
“Best Possible Selves” for at Least 5 Minutes
Each Day
-- Personal, professional, and relational
domains
●
Linked to Improvements in Positive Emotion,
Hopefulness, and Optimism
●
(Lyubomirsky, 2008; Meevissen et al., 2011)
Future Self-Imagery
(Hershfield, 2011)
Write a Letter to Future Self and Either Keep
to Open or Use www.futureme.org Website to
Send in the Future
●
Future-Minded Exercises Letter to My Future Self
Interventions to Promote Recovery
(Miller, 2005)
Create a List or a Vision Board ●
Future-Minded Exercises
http://carolinemiller.com/files/100_things_to_do.pdf
Interventions to Promote Recovery
One Hundred Things to Do in My Lifetime
Nicole Siegfried, PhD, CEDS [email protected]
205-552-0417
Keeping Your Tools Sharp: Maintaining Recovery in Eating Disorders