This document outlines the phases and goals of treatment for eating disorders at Castlewood Treatment Center. The initial phase focuses on building rapport, symptom containment, and history gathering. The middle phases involve identifying the functions of disordered behaviors, exploring underlying beliefs and messages, and renegotiating relationships with food and emotions. Later phases emphasize reducing self-hate, developing life skills and relationships, and transferring secure attachments from treatment to oneself. The end goal is full recovery and living a spontaneous, passionate life.

1. Castlewood Treatment Center for Eating Disorders
New Innovations in Treatment:
Comprehensive Treatment of Eating Disorders,
Part I
March 9, 2012
Erin McGinty, LPC, NCC &
Laura Wood, RDT, PLPC, CCLS
www.castlewoodtc.com

2. Comprehensive Treatment of Eating
Disorders…
… in 90 minutes
… minus 20 minutes of Q&A
… minus 10 minutes of tangential stories
… minus one minute
… so, actually, in 59 minutes.

3. Eating Disorders
“These disorders which are so pervasive in our
current world, illustrate that beneath the
veneer of self reliance lies the core of
powerlessness, alienation, detachment, self-
hate and shame”
- K.B. Walant, 1995

4. Initial Phase of Treatment:
“Hooking” the Client and
Establishing Safety

5. Goals of Initial Phase:
• Building the therapeutic alliance
• Symptom containment & initial relapse
prevention
• Facilitation of honesty
• History gathering & insight building
• Instilling hope
• Self-responsibility

6. Building the Therapeutic Alliance
• Identify and validate fears
• Anticipatory guidance about what to expect
• Demonstrating respect and appreciation for the
eating disorder
• Collaborative treatment planning and goal
setting
• Exploring and processing previous treatment
experiences

7. Symptom Containment & Initial
Relapse Prevention

8. Symptom Containment & Initial
Relapse Prevention
Initial Relapse Prevention:
• Urge Cards
• Behavioral Contracts
• Diary Card*
• Behavioral Chain Analysis*
*Recommended Reading:
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy
for binge eating and bulimia. New York, NY: The Guilford Press.

9. Symptom Containment & Initial
Relapse Prevention

10. Symptom Containment & Initial
Relapse Prevention

11. Facilitation of Honesty
• Each evening, take inventory of how your eating
disorder has been deceptive, evasive, and/or
avoidant. Process in individual session and
present in group daily
• Dialectic: Acceptance and change

12. History Gathering & Insight Building
Pertinent Questions in History Taking:
• Sense of attachment with primary caregivers
• Messages received about femininity/masculinity
• Puberty
• Messages received around food, weight, and
shape
• Exhaustive history of the eating disorder

13. History Gathering & Insight Building
The Timeline Assignment: Create a timeline, in narrative
or timeline form, that outlines significant events,
relationships, and developments from birth up until
your current age. Include the following:
• Information about your family of origin
• Any incidences of trauma (e.g. physical, verbal, emotional, sexual,
developmental)
• The onset and progression of your eating disorder, including any
periods of recovery or remission
• Treatment history

14. History Gathering & Insight Building
A Typical Day in Your Eating Disorder: Write a
narrative about a typical day in your eating
disorder; be sure to include events, thoughts,
feelings, and behaviors, and be as exhaustive as
possible.

15. History Gathering & Insight Building
The Worst Day in Your Eating Disorder: Consider
the worst day that you can recall in your eating
disorder, and write a narrative about all of the
events, thoughts, feelings, and behaviors
encompassed in that day.

16. History Gathering & Insight Building
Children's Needs: Make a collage about what every
child needs on one side, and what you received on
the other.

17. Instilling Hope
• “Hope Merchant”
• Notebook of Hope
• Recovery Network
• Create and art piece that depicts your eating
disorder part, and an art piece that represents
your recovery part

18. Self-Responsibility
• Feelings and Communication packet
• Helping clients to be able to ask for help and
exploring stuck points in the process

19. Middle Phases of Treatment:
Breaking Ground (Denial) &
Building a Foundation

20. Goals of Middle Phases:
• Identify the functions of eating disorder behaviors
• Finding alternatives solutions and relapse prevention
• Exploring the impact of messages received
• Getting to know Protectors, healing Exiles
• Connecting to affect and the body
• Identification of guilt, shame, and self-hate
• Understanding polarities
• Renegotiating the relationship with the food: It’s not
about the food!

21. Identify the Function of the Eating
Disorder
• The eating disorder is a survival strategy
• Every eating disorder behavior serves a
function, and that function changes over time
• The eating disorder is…

22. Identify the Function of the Eating
Disorder

23. Identify the Function of the Eating
Disorder

24. Identify the Function of the Eating
Disorder
• The 10 functions of an eating disorder have to be
understood in order to give them up, they are
different for every person, and they will change
over the course of treatment
• Playing the Eating Disorder in Expressive therapy
• Ask the eating disorder to write the client a letter
expressing all of the ways it has protected him/her
and then Ask the client to write a letter of
gratitude to the eating disorder in response

25. Identify the Function of the Eating
Disorder
• Create an art piece depicting what your eating
disorder says that you can’t
• Write about what your eating disorder communicates
to your family, to others, and the world at large
• Write about how your eating disorder is your primary
relationship
• Write about the metaphors for your eating disorder
and how it is similar to the relationships you have
with people (e.g., where else in life do you restrict,
binge, or purge?)

26. Finding Alternative Solutions &
Relapse Prevention
• Every urge signals a need
• Adaptive coping responses geared toward meeting the
needs without using the eating disorder to do so
• Relapse prevention plan
• Write out your next eating disorder relapse
• Create a collage of what you wanted to purge when
you purged last night. Include thoughts, feelings, etc.
What other alternatives could you have used to
“purge” these thoughts and feelings? Share in
individual session and in group

27. Exploring the Impact of Messages
Received
• Mirror/Body Image/IFS Exercise
• After writing narratives, have clients identify “the
beliefs you formed about yourself, others, and the
world at large” as a result of an event, relationship,
etc.
• Write it, share it, draw it, expressive, cohesive
narrative
• Write about the messages you received from your
mother/father about femininity/masculinity, gender,
and sexuality.

28. Exploring the Impact of Messages
Received
• Placement Activity: Have clients create a collage on a clear
plastic plate about the messages they received growing up
around food. When complete, have clients share in a group
about these messages. Then, give each client a placemat in
group, and have each group member write a positive
affirmation on the placemat; peers can write about their wishes
or hopes for each other. When complete, have clients put the
placemats underneath the plates, and talk about the metaphor
that—underneath all of the messages they received around
food growing up—the core of each one of them is positive
(represented by the placemat)

29. Exploring the Impact of Messages
Received
• Write about the messages you received about
emotions such as anger, sadness, guilt, shame,
happiness, and fear growing up. How did you
observe these emotions being expressed in your
family of origin? What beliefs did you develop
about emotions as a result?

30. Getting to Know Protectors, Healing
Exiles
• Expressive therapies
• Internal Family Systems model

31. Connecting to Affect and the Body
• Debunking common myths about feelings
• Exploration of fear around expression of emotion
• Affect tolerance

32. Identification of Guilt, Shame, & Self-
Hate
• Psychoeducation
• Bibliotherapy:
– “Facing Shame: Families in Recovery” (Fossum)
– “Healing the Shame that Binds You” (Bradshaw)
– “There is Nothing Wrong With You” (Huber)
– “Compassion and Self-Hate” (Rubin)

33. Understanding Polarities
• Two polarized parts always protect an Exile
• How to avoid polarizing the client
• Write about the rules and beliefs of each part of
your eating disorder (restrict, binge, purge,
exercise, etc.), the feelings associated with each
part, and the goals of each part.

34. Renegotiating the Relationship with the
Food (It’s not about the food, but it is about the food!)
• Deconstructing the meaning of food
• Therapeutic meals
• Exploration of rituals at the table: Write about all
of your rituals at the table in exhaustive detail.
What is the function of each? What are the fears
around change?
• Exposure and response prevention therapy
• Write about your fears of allowing yourself to
taste, enjoy, and desire food

35. Middle-Late & Late Phases of
Treatment:
Self Development and Integration

36. Goals of Middle-Late & Late Phases:
• Acknowledgement of grief and loss
• Reduction of self-hate, building of self-compassion
and love
• Building autonomy & life skills
• Femininity and sexuality
• Transferring secure attachments in treatment to self
• Building relationships with others

37. Acknowledgement of Grief and Loss
• Elizabeth Kubler-Ross model
• Grieving the loss of the eating disorder
• Write a goodbye letter to your eating disorder

38. Reduction of Self-Hate, Building of
Self-Compassion and Love
“You yourself, as much as anybody in
the entire universe, deserve your love
and compassion.”
- Buddha

39. Reduction of Self-Hate, Building of
Self-Compassion and Love
• Talking about shame reduces shame= breaking
the silence
• Trump card
• Internal Family Systems and compassionate self-
witnessing/unburdening

40. Building Autonomy & Life Skills
• Make a list of 10 things that you do not know how to
do that are basic life skills (Toothbrush story)
• Write about the life skills you possess but feel
insecure about, the life skills you know you do not
have, and the fears around dealing with specific
things that create anxiety within
• Meal and snack outings
• Peer and solo outings
• Time for self (being alone with yourself)
• Life Skills Assessment

41. Femininity/Masculinity, Sexuality, &
Intimacy
• Complete the following sentences: “Love is…,” “Pleasure
is…,” “Indulgence is…,” “Intimacy is…”
• Complete the following sentences: “Relationships are…”
“Love is…,” Sex is…,” “Woman are…,” “Men are…”
• One’s relationship with oneself: “Doing the U-Turn”
Bibliotherapy Recommendations:
- Be the Person You Want to Find: Relationship and Self-Discovery
(Huber)
- You Are the One You’ve Been Waiting for, Bringing Courageous Love
to Intimate Relationships (Schwartz)
• Create a list of 10 qualities in women/men who you admire
• Looking at art: Women in art

42. Femininity/Masculinity, Sexuality, &
Intimacy

43. Femininity/Masculinity, Sexuality, &
Intimacy

44. Femininity/Masculinity, Sexuality, &
Intimacy
• Create a collage of the woman/man you would like to become
• Write about what a healthy sexual relationship looks like
• Reflect upon and write about your patterns in your adult and
romantic/sexual relationships. Consider how these connect
with childhood experiences. Share with your therapist and in
group
• Write about the overt and covert messages you received from
your mother/father growing up about femininity/masculinity.
Consider how this has shaped your ideas of what it means to
be a woman/man, and what you believe about yourself as a
woman/man as a result. Share in individual session and in
group

45. Transferring Secure Attachments in
Treatment to Self
• Working with child parts
• Role play what is normative versus dysfunctional
• Built-in practice time
• What parts of ones self are still treating the child
parts like the ones who caused the initial hurt—
why?

46. Building Relationships with Others
• Write about what aspects of yourself are positive and
beneficial in your relationships with others, and what
you see as the negative aspects of yourself in your
relationships
• Mentalizing (keeping mind-in-mind)
• Group interview
• Role rehearsal

47. Building Relationships with Others
• Develop a buddy system with ______. Challenge each
other daily to be spontaneous, pursue non-productive
and pleasurable activities, mindful, etc.
• Write about times you said “yes” even though you
wanted to say “no” (or already had said “no”). What
fears did you have about saying “no,” and what
excuses did you say to yourself in order to say “yes”
instead of “no?”

48. The End Goal…
“Recovery is not just the absence of symptoms…it is the presence of a
full life as evidenced by the ability to be human. A truly recovered
life will reflect spontaneity, freedom, the ability to breathe, to have
wants, needs and desires, knowing that the quest for perfection is an
unattainable illusion. Having the ability to embrace the feminine,
having close intimate relationships, and it is being aware of the tears
in your eyes (whether out of intense or subtle sadness – or out of joy
– or from a flicker of utter gratefulness) and then to allow your tears
to flow freely. It is a life in which decisions and choices are made
more from self and less from a shame and fear based prison. It is a
life where you fully experience pleasure, joy, and passion and
believe and know it is good to desire and enjoy sex…”
- Theresa Chesnut, Therapist