Shake it up: Skill Building for Adolescents with Eating Disorders

Dena Cabrera, PsyD, CEDSExecutive Clinical Director

Rosewood Centers for Eating Disorders

ASAM Disclosure of Relevant Financial Relationships Content of Activity: 2015 Cape Cod Symposium on

Addictive Disorders

Name Commercial Interests

Relevant Financial

Relationships: What Was Received

Relevant Financial

Relationships: For What Role

No Relevant Financial

Relationships with Any

Commercial Interests

X

Glossary of TermsCommercial Interest - The ACCME defines a “commercial interest” as any proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies.

Financial relationships -Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership on advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.

Relevant financial relationships - ACCME focuses on financial relationships with commercial interests in the 12-month period preceding the time that the individual is being asked to assume a role controlling content of the CME activity. ACCME has not set a minimal dollar amount for relationships to be significant. Inherent in any amount is the incentive to maintain or increase the value of the relationship. The ACCME defines “’relevant’ financial relationships” as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.

Conflict of Interest - Circumstances create a conflict of interest when an individual has an opportunity to affect CME content about products or services of a commercial interest with which he/she has a financial relationship.

Group vs. Individual Therapy

Understanding resistance

Improving motivation to participate

Increase rapport building

Structuring and Teaching DBT and other

coping skills

Digital Identity

Stages of Change

Dialectical Behavior Therapy

Toolbox – BCA

Activities, Experientials and hands-on

games

Agenda

Help! by Shel Silverstein

Help! By Shel Silverstein

I walked through the wildwood, and what did I see

But a unicorn with his horn stuck in a tree,

Cryin’, “Someone please help me before it‘s too late.”

I hollered, “I’ll free you.” He hollered back, “Wait--

How much will it hurt? How long will it take?

Are you sure that my horn will not scratch, bend, or break?

How hard will you pull? How much must I pay?

Must you do it right now or is Wednesday okay?

Have you done this before? Do you have the right tools?

Have you graduated from horn-savin’ school?

Will I owe you a favor? And what will it be?

Do you promise that you will not damage the tree?

Should I close my eyes? Should I sit down or stand?

Do you have insurance? Have you washed your hands?

And after you free me--tell me what then?

Can you guarantee I won’t get stuck again?

Tell me when. Tell me how.

Tell me why. Tell me where….”

RISK FACTORS(3 P’s)*

• Predisposing Factors– Genetic, Family Environment, the effects of environmental

adversity, premorbid psychiatric conditions, cultural and societal pressures

• Precipitating Factors– Child Abuse, Adversity, Loss, developmental milestones,

dieting behavior, body image issues, emotional dysregulation, poverty

• Perpetuating Factors– Starvation effects from chronic dieting, unresolved PTSD,

and ongoing family dysfunction

*Brewerton, T, Overview of Evidence on the Underpinnings of Bulimia Nervosa, In: Evidence-Based Treatment for Eating Disorders, 2009.

Trends in the field of Adol and ED

• Genetic and Developmental Disorders

• Psychiatric co-morbidity - bipolar

• Transgender

• Parents – SMI and Addictions

• Multiple treatments

• Athletes

• Males with Addictions

Brain Development in Adolescence

• “Adolescent Behavior” is influenced by “raging hormones” and “underdeveloped cognitive controls” needed for mature behavior

• Both hormonal effects and brain development play a role in illnesses with onset in the teen years– Body composition, acne, certain malignancies

– Epilepsy (at puberty), bipolar d/o (late teens), schizophrenia (mid-20s).

Dr. Ovidio Bermudez, MD

It stated that the brain undergoes two major developmental spurts in a lifetime. One takes place in the womb and the second takes from childhood through adolescents. It is during the second spurt that the organ matures. The brain develops from the back towards the front. Beginning at the Cerebullum, then the Amygdala, the Basal Ganglia, the Corpus Callosum and then last the Prefrontal Cortex.

Group Therapy with Teens• The instillation of hope: The group contains members at different stages of the

treatment process. Seeing people who are coping or recovering gives hope to those at the beginning of the process.

•Universality: Being part of a group of people who have the same experiences helps people see that what they are going through is universal and that they are not alone.

•Imparting information: Group members are able to help each other by sharing information.

•Altruism: Group members are able to share their strengths and help others in the group, which can boost self-esteem and confidence.

•The corrective recapitulation of the primary family group: The therapy group is much like a family in some ways. Within the group, each member can explore how childhood experiences contributed to personality and behaviors. They can also learn to avoid behaviors that are destructive or unhelpful in real life.

•

• *** The Theory and Practice of Group Psychotherapy, Irvin D. Yalom

Group Therapy with TeensDevelopment of socialization techniques: The group setting is a great place to practice new behaviors. The setting is safe and supportive, allowing group members to experiment without the fear of failure.

Imitative behavior: Individuals can model the behavior of other members of the group or observe and imitate the behavior of the therapist.

Interpersonal learning: By interacting with other people and receiving feedback from the group and the therapist, each individual can gain a greater understanding of himself or herself.

Group cohesiveness: Because the group is united in a common goal, members gain a sense of belonging and acceptance.

Catharsis: Sharing feelings and experiences with a group of people can help relieve pain, guilt, or stress.

Existential factors: While working within a group offers support and guidance, group therapy helps member realize that they are responsible for their own lives, action and choices.

*** The Theory and Practice of Group Psychotherapy, Irvin D. Yalom

Setting up the Group

• The Group develops their own rules, expectations and hopes for the group

Treating Adolescents

Obstacles

• Resistance

• Motivation

• Parents – Overinvolved / Underinvolved

• Severe Psychiatric Issues

• Boundaries

Resistance

Resistance is something that occurs only within the context of a relationship or system.

Resistance

Patients who are labeled “resistant” represent a for the counselor to shift approach. Resistance is an interpersonal phenomenon, and how the counselor responds will influence whether it increases or diminishes.

Moving from a Symptom-Based Model

Agenda: Reduce Symptoms

to a

Readiness-Based Model

Agenda: Provide treatment matched to readiness

Integration

Motivational Approaches

DBT Skills and Tools

Understanding Change

Treasure, J., Smith, G., & Crane, A. (2007). Skills-based learning for caring for a loved oneWith an eating disorder: The new maudsley method. Routledge: New York.

Stages of Change(Prochaska & DiClemente, 1983)

Pre-contemplation(Patient not currently considering change)

Contemplation(Patient undertakes a serious evaluation of considerations for or against change)

Action(Patient implements specific behavioral changes)

Preparation

Introduction Psychodrama with Eating Disorders

• A Picture is worth a thousand words

• “Words are how people hide” - George Carlin

Warm up Activities

• Checking – in• Weather • Color• Be anywhere • Props • Bench pix • Integrity checks• Theme Song (ex. Kelly Clarkson’s “Stronger”)• Serenity Prayer • Change Rooms

“What if” game

• Handout

Communication with Adol

• Addressing Assumptions

• Disclosing Secrets – (anonymous papers)

• Understanding Invalidation

• Validation

• Increasing intimacy and emotional connection

• Increasing self-esteem

Feedback Loop Format

• Must have a 24 hour time-frame

• 2 people

• Designed for confrontations, scary topics, a possibility of the conversation escalating

• Designed to benefit the giver of the FBL –the giver expresses their thoughts & feelings & then lets go of the outcome

• No expectations of the receiver

Feedback Loop FormatStep 1. When I heard you (say you, felt you, discovered that you, noticed that you…)

Repeat what the person said/did, literally; be specific

Step 2. what I made up about that is…State your perception, interpretation, thought, reality as it impacts you

Step 3. And about that I feel…Share your emotions: (fear, joy, shame, pain, love, guilt)

Step 4. Thank you

Step 5. 24 hours

Step 6. Process (optional but recommended)

Clinical Lectures

• Boundaries

Boundaries

• Definition: A system of limit setting to enhance self-esteem

• Purpose: To contain and/or protect my reality, body, thoughts, feelings, and behavior

Signs of Unhealthy Boundaries• Revealing intimate thoughts & feelings to unsafe people

• Falling in love with someone across the room

• Touching a person without asking

• Giving as much as you can give for the sake of giving

• Believing others can anticipate your needs, even though you have not stated them

• Expecting others to fulfill your needs automatically, “mind reading”

• Falling apart – being needy & helpless so someone will take care of you

Boundaries

• Internal Boundary:

–Protects your inner self from carelessly expressed thoughts and feelings of others.

–Contains your careless thoughts and feelings when communicating with others.

–Internal boundaries are to be used in conversations to maintain healthy relationships.

Boundaries

• External Boundary:

–Protects your body and controls distance and touch from someone else.

–Contains your body from touching and getting too close to someone else’s body.

Exercises / Assignments

• Hand to hand

• Hula hoop

• Demonstrating boundary violations

Assignments

• 1st Step

• Life Story (own hand writing)

• 10th Step Daily Inventory

Connecting to Self

• Letters to your self / body / daughter

• What do you need?

• Welcome to Holland

• Journaling

• Comparison

Dialectical Behavior Therapy

Nutshell:

DBT: Searches for the synthesis and balance to replace the rigid and dichotomous responses

Enhances clients’ comfort with ambiguity and change

•Behavior Chain Analysis(Handout)

•Diary Cards (Handout)

•Pros / Cons

•Skills

Acceptance and Change Strategies / Tools

Guidelines for a BCA

1. Describe the specific problem

2. Precipitating event

3. Vulnerability factors

4. Chain of events – feelings, thoughts, behaviors

5. Consequence

6. Solutions

7. Repair

BCA

1.Consequences:

4.

4. 4.

4.

4.4.

4.

4.

4.

4.

4.

3.2.

Suicide Attempt

Cycle of DEP, shame

BCA

1.Consequences:

.

4. 4.

4.

4.4.

4.

4.

4.4.

4.

3.2.

Suicide attempt

Tired, AnxiousFriend – conflictAngry

Boyfriend Break-upMom’s critical;Dad’s punishment

2.

Break up boyfriendMom’s critical;Dad’s punishment

3. Tired, AnxiousFriend – conflictAngry

SOLUTION ANALYSIS

•Be Honest

•Ask for Help

•Radical Acceptance

•Self-Soothing

4.

4.

4.

4.Felt Shame

“ No one loves me”

Felt upset

Go to the bathroom

•Opposite to Emotion

•“Wise Mind”

•Distraction

SOLUTION ANALYSIS

4.

4.“No one loves me”

Go to the bathroom•Distraction

4.

4.

•Find a Friend

•Pros/Cons

1.

Cut / Attempt suicide

•Pray

SOLUTION ANALYSIS

1.

Cut / Attempt suicide

Consequences:

(+)Relief(+) shopping

(-) Shame, depression,

Loss of trust, $, time, low self esteem

SOLUTION ANALYSIS

Self-HarmingBehavior

__________Links can include:ActionsBody SensationsThoughtsFeelingsEvent

What will you do differently next time?Call therapist for CoachingRadical acceptance

I was vulnerablebecause of…

Unbalanced eatingPhysical illnessUnbalanced Sleeping Drug or Alcohol UseMisusing PrescriptionsStressful EnvironmentalEvents (good and bad)Old Behaviors or Memories

START

Finish

TIP THE SCALE

Benefits of NOT having an eating disorder.

Benefits of having an eating disorder.

Costs of having an eating disorder.

Costs of NOT having an eating disorder.

Key Components to Helping Patients

• Teach Life Management Skills– Mindfulness

– Emotional Regulation

– Distress Tolerance

– Interpersonal EffectivenessM. Linehan etc.

• Teach Communication Skills

- Feedback loops

- Life story

Cinema Therapy

• Mean Girls

• Soul Surfer

• Pay it Forward

• E.T.

• Lemonade Mouth

• The Lion King

Restoring Identity:Key Components to Helping Patients

• Acceptance

• Validate the wounds

• Understand / Educate re: Biological, Psychological, Social, Spiritual Connection (Medicine Wheel)

• Explore the Context and Development of their Body Image –Focus on overevaluation

Body ImageWork

IdentityWork

Body Image Therapy

My House

• We want you to compare your self to a house, outside and inside.

• First, draw or describe your life as if it where a house. Be specific. Note color size, style and condition of your “house.” What is around it? Does it stand alone or in a community?

• Now, think about the inside of your “house.” Describe what it looks like. Is it cozy an d inviting, or modern and cold? Are the rooms messy or organized?

• Keeping in mind the eating disorder and the effects it may have on your body, what type of repairs does your “house” need?

• How do you feel about your “house”?

• How would you change your house if you could change anything you wanted to?

• How did you feel about doing the assignment?

Restoring Identity

• Purpose, Meaning and Values (assignment)

• Asking and Identifying

– What are the steps to take that would be necessary to align with this value?

• Willingness and Commitment

Restoring Identity

• Our Goal is to help patients find their identity apart from food, weight, size or shape.

• To find meaning, value and purpose

• Be your authentic self

Contact Information

Dena Cabrera, PsyD, CEDSExecutive Clinical Director

Rosewood Centers for Eating Disorders

Handouts: www.dena.cabrera.com

The Rosewood InstituteDena.cabrera@rosewoodranch.com

www.rosewoodinstitute.org

www.rosewoodranch.com928.684.9594