3. Terry Schiavo
Ice Tea
Bulimia
Medical Negligence
1 Million Dollars
Friday, March 13, 2009
4. Major Diagnoses
BED - Binge Eating Disorder
AN - Anorexia Nervosa
BN - Bulimia Nervosa
Friday, March 13, 2009
5. BED - Depression, anxiety, adjustment disorder,
dependency issues.
AN - Obsessive Compulsive Disorder. Family
frustrations and fears, physician’s referral due to
weight loss. Client feels nothing is wrong.
BN - Personality disorder, extreme depression.
Referral from therapist colleague, self-referral. “I
believe you are the only person who can help me!”
Friday, March 13, 2009
10. Binge Eating Disorder
ABANDONMENT
Pleasant & compliant.
Distorted Body Image
Use Eating as Source of
Comfort & Distraction
Friday, March 13, 2009
11. Binge Eating Disorder
Diagnosis - Depression, anxiety, dependency issues & weight issues bring the
client to treatment.
Referral
Nutritionist
Overeaters Anonymous (12 Step group for compulsive eating)
Group therapy addressing BED.
Medications from Primary Care Physician or Psychiatrist
Exercise Classes for Large Bodied People
Friday, March 13, 2009
12. BED Treatment through the lens of
ABANDONMENT
Weight History to identify pertinent themes.
Teach methods of postponing a binge and becoming more aware of feelings.
Encourage engaging in activities of interest that one is putting off until thinner.
Cognitive Behavioral Therapy to challenge distortions.
Trauma therapy.
Process the client’s efforts to be compliant and agreeable with the therapist.
Teach emotional awareness, acceptance, containment and communication.
Give permission to client to experience and express anger.
Friday, March 13, 2009
13. BED Treatment through the lens of
ABANDONMENT
Cognitive Behavioral Therapy to challenge distortions.
Trauma therapy for dissociative symptoms.
Solution Focused Therapy.
Process the client’s efforts to be compliant and agreeable with the therapist.
Challenge compliance gently as a wish to maintain what the client experiences as a
fragile connection.
Teach emotional awareness, acceptance, containment and communication.
Create a predictable safe therapeutic environment while encouraging client to
differentiate, express anger and declare expectations.
Friday, March 13, 2009
14. BED Treatment through the lens of
ABANDONMENT
Teach the use of mirror work to recognize and accept body as it is not as client
imagines it is.
Encourage involvement in exercise.
Encourage forms of bodywork with appropriate practitioners such as massage and
yoga.
Teach the use of the hunger scale.
Teach methods of limiting food, such as choosing small portions of three types of
food and eating them slowly then choosing more.
Doing a food history with foods a person feels is an inevitable binge food.
Friday, March 13, 2009
15. Anorexia
CONTROL
Severe Restricting or Cessation of
Eating
In Therapy Against Their Will
Terrified of Eating and of Gaining
Weight
Distortion Believing They Are Fat
Despite Emaciation
Friday, March 13, 2009
16. ANOREXIA
Diagnosis - client usually comes with suspicion of diagnosis from referring source.
Assemble treatment team.
Nutritionist, IMMEDIATELY!!!!!
Psychiatrist & Primary Care, SOON!
Evaluate for immediate hospitalization in eating disorder unit.
Eating disorder group, if one is available.
Continue evaluating need for hospitalization throughout treatment.
Friday, March 13, 2009
17. AN Treatment through a lens of
CONTROL
Establish rapport using Motivational Interviewing strategies.
Explain relationship between restricting and an effort on client’s part to establish
control over something.
Wonder about what she feels out of control of together.
Weight History to begin the detective work of understanding.
Establish and maintain an aura of acceptance of the symptoms and recognition
that others are freaking out about her eating.
Friday, March 13, 2009
18. AN Treatment - Continued
NEVER pressure her to eat.
Assist her in understanding why others are frightened for her.
Invite family members in for family therapy and extract their commitment to not
pressure her in her presence.
Conduct ongoing family therapy to assist the family in learning appropriate
communication strategies and boundaries.
Friday, March 13, 2009
19. AN Treatment - continued
Needs - help the client to realize it is acceptable to have needs.
Needs - help the client to sort out how to get some of their needs met.
Fear of Being Fat - This fear exists at delusional proportions.
Discuss meanings client has attached to body size.
Explain that angst about life has gotten displaced onto body size.
Cognitively challenge this as a distortion and teach client to do the same.
Friday, March 13, 2009
20. AN Treatment - continued
MOST IMPORTANT
DON’T PANIC!!!!
Working with anorexics is frightening.
The therapist will feel overwhelmed and experience extreme helplessness.
Reach out to knowledgeable colleagues.
Persevere. As you learn to contain your helplessness and hopelessness and
proceed your client will learn to do the same and you will be on your way to
recovery.
Friday, March 13, 2009
21. The devestation of eating disorders.
http://www.youtube.com/watch?v=I6e98OlDclU
Friday, March 13, 2009
22. Bulimia
TRUST
Bingeing & Purging
Inconsistent
Unreliable
Risk of Premature End to Therapy
Loathing of Body, Emotions and
Need for Closeness
Friday, March 13, 2009
23. BULIMIA
Diagnosis - Client will come from other therapists and have seen many therapists.
Client will present as personality disordered, borderline, histrionic or even bipolar.
Referral
Nutritionist.
Medication consult with psychiatrist.
Primary care physician.
Couples therapist.
Possible need for referral to inpatient trauma unit.
Friday, March 13, 2009
24. BN Treatment through a lens of
TRUST
Establish rapport. Remember this person has extreme issues with trust. Do an
extended and careful history of all previous treatments and predict that the client
will have a strong impulse to prematurely terminate this treatment.
Obtain client’s promise to discuss this impulse with you before acting on it.
Explain and educate that bulimia develops when certain individuals are subjected
to extremely untrustworthy people or environments.
Pay careful attention to issues of timing, phone calls, and other contact.
Development of trust is built on therapist acting in predictable ways.
Friday, March 13, 2009
25. BN Treatment continued
Prescribe not bingeing, with permission to binge.
Prescribe not purging, with permission to purge.
Refer to nutritionist and maintain regular contact with the nutritionist to discuss
client progress and compare notes.
Develop an understanding that bingeing and purging are symbolic for how
difficult it is for client to take good things in and keep them.
Friday, March 13, 2009
26. BN Treatment continued
Recognize client’s loathing of her body.
Recognize client’s suspicion about caring.
Weight History to understand weight fluctuations and changes in eating behaviors
along with stresses and betrayals in life.
Encourage physical self care: appropriate exercise, massage, use of lotions, and
safe, nonsexual touch.
Friday, March 13, 2009
27. BN Treatment continued
Teach emotions 101. Dialectical Behavior Therapy is helpful. Clients have been
traumatized by emotions of others and are often fearful of their own emotional
experience.
Trust is the belief in another person’s integrity.
Help client hope that as they integrate they will choose more trustworthy people
to relate with.
Conduct limited family sessions for the purpose of education about the eating
disorder and refer to colleague for more extensive work.
Friday, March 13, 2009