Archive for the 'Therapies' Category

Utilizing Transference & Countertransference to Deepen the Treatment of Eating Disorders, with Kathryn Zerbe, M.D.

Following an incredibly positive response to her April 2009 presentation on integrated treatment for eating disorders, we are thrilled to welcome Kathryn Zerbe, M.D. back to Baltimore for our 2010 annual professional symposium.  Dr. Zerbe will present, along with 5 other distinguished experts, at Eating Disorders: State of the Art Treatment on Saturday September 25th, 2010.  Her much anticipated  presentation will focus on psychodynamic approaches and the use of transference and countertransference to enhance clinical practice in the treatment of individuals with eating disorders.

Kathryn Zerbe, M.D. is a Professor of Psychiatry and Obstetrics & Gynecology at Oregon Health & Science University.  She also serves as the Director of the Oregon Psychoanalytic Institute and has authored over 60 clinical papers and four books including, Integrated Treatment for Eating Disorders: Beyond the Body Betrayed.  Dr. Zerbe is a Distinguished Fellow of the American Psychiatric Association and a Fellow of the Academy of Eating Disorders. She has been repeatedly selected as one of “America’s Top Doctors” and is a highly sought after speaker both in the united states and internationally.

Find out more about Dr. Zerbe’s work and her upcoming presentation in Baltimore by reading her insightful and thought provoking responses to our questions below.  And don’t miss your chance to attend all six expert presentations on September 25th, 2010. (This event has been approved for 7 CME/CEUs). REGISTER soon!  Space is limited. 

Q & A with Kathryn Zerbe, M.D.

The title of your upcoming talk in Baltimore is “Resiliency, Vulnerability and Growth: Utilizing Transference and Countertransference Reactions to deepen the Treatment of Eating Disorders”.  What specific role does vulnerability play in this process?

KZ: Bewilderment, boundaries, and burnout — these are just a few of the concerns that clinicians are liable to struggle with when treating patients with an eating disorder.  Recognizing that in our quest to be helpful to our patients, we also face a potential undertow because the work to preserve life is taxing in the short run and often takes a commitment of time, energy, and sacrifice in the long run.  Clinicians ‘in the trenches’ know these facts, but what do we do to help ourselves to deal with the hurt feelings that arise when tenacious negative transferences arise, or when we are in a seemingly unwinnable battle with 3rd parties, or experience powerlessness when the patient refutes our counsel?  Awareness to these vulnerabilities, and others, are the first line of defense in staying attuned, steadfast, and nimble in robust clinical practice.

What would you say is the biggest barrier clinicians may face in trying to implement improved strategies for utilizing transference and countertransference in the clinical setting?

KZ: “To know thyself’ and “To be true to thyself’ have been laudable goals since the time of Socrates and Shakespeare, respectively, but such ideals are easier to write about in the abstract than to achieve in real time.  With the daily challenge of managing a lively practice and tending to one’s busy personal life, it is easy to put one’s own needs on the back burner.  Taking a small amount of time weekly to think about the impact of clients is enormously helpful.  In this way, one works on the feelings and clinical formulation one has about each specific person in practice but is simultaneously humbled by what each person teaches us by sharing their unique history and viewpoints.

 

What are the potential consequences of ignoring or ineffectively addressing transference and countertransference issues in the therapeutic process?

KZ: Like most clinicians, I feel extraordinarily blessed to be working in this field where one has the opportunity to witness individuals grow and change over time.  However, burnout is a formidable foe to contend with because change is often difficult, slow, and painful for the patient.  Sensitive clinicians pick up on, or in technical parlance, “contain,” these feelings.  To avoid burnout and to keep the work fresh, invigorating, and growth promoting, the therapist  who ‘knows himself or herself’ best is in a better position to assist the patient, and this is a ‘work in progress’  that is never done until one retires from practice altogether.

In your upcoming presentation, you will discuss strategies for managing “cultural countertransference”. Can you briefly define this term in the context of treating individuals with eating disorders?

KZ: Therapists as well as patients are prone to having conscious and unconscious reactions to media stereotypes, idealized body images, and culture norms as a whole.  We clinicians are in a better position to help our patients by becoming more aware of these potential ‘blind spots’ to  the  prevailing cultural  in ourselves and thinking them through.  Recovery can be enhanced by a timely discussion and critique of noxious cultural norms in therapy.  Both patient and clinician can make use of reading, media, movies, self-scrutiny, and ongoing dialogues with peers or consultants to become more cognizant of our largely unconscious idealization and overvaluation of beauty.   However, as Dr. Catherine Steiner Adair of Harvard University pointed out when she defined the term ‘cultural countertransference,’ in the early 1990s, we must also be wary that too much focus on the culture can be a defense to deepening the patient’s treatment.

Overall, what do you hope symposium attendees will take away from your presentation at The Center for Eating Disorders on September 25th?

KZ: If participants emerge from my talk (which will use art history slides to demonstrate concepts and to provide encouragement for each therapist to bring his/her unique creativity and tenacity to the therapy hour) with permission to ‘take care of yourself’ as you take care of the patient, I will be very happy, indeed.  Perhaps there will be an idea or two that will be new to the ear, but more likely the listener will simply take more seriously the need for ‘time outs’ and the pragmatic and psychodynamic reasons that undergird that need and recommendation.  One of my heroines, Eleanor Roosevelt, said “Do something that is scary everyday!”  I keep that saying on my desk as a reminder that our daily work as clinicians presents us with mysteries and a summons for personal growth that we can’t predict when we get to the office in the morning.  The more tools that we have in our therapeutic hip pocket, the better!  So, I’m looking forward to gaining wisdom from the other speakers who come first and hearing the comments and questions from the audience to, very selfishly, enhance my individual practice!

Our enduring thanks to Dr. Zerbe for taking time out of a busy schedule to provide such thorough answers. Be sure to join us on September 25th for what is sure to be an engaging and enlightening presentation.  Download the Eating Disorders: State of the Art Treatment PROGRAM BROCHURE (pdf) for registration details and deadlines.

If you’d like to order or find out more about Dr. Zerbe’s publications, please click on the links below.  These titles will also be available for purchase at the upcoming symposium.

Published by Kate Clemmer
August 20th, 2010 in CED Events, Editor's Picks, Enhancing Clinical Practice, In the News, Professional Education, Q & A, Therapies, Treatment Providers
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Q & A with Harriet Brown: Part II

On Monday we began a 3-part blog series featuring Harriet Brown, author of the upcoming book, Brave Girl Eating: One Family’s Struggle With Anorexia.   If you missed it, you can go back and read Part I in which Harriet shared about her family’s initial discovery of her daughter’s anorexia and where their journey to recovery began. Today in Part II, we resume our conversation with her about that journey to help her daughter recover, how it affected their family, and what she has learned from it.

Harriet Brown will be speaking at a free community event in Towson, MD on August 25, 2010 – click here for details.

Q & A with Harriet Brown: Part II

You describe your daughter’s recovery as a “slow, painful, infinitely courageous climb back up to health and hope.”  Can you share some of the most important steps your family took along this difficult journey?

HB: The most important step in the journey came when we decided to use family-based treatment and, essentially, empowered ourselves to help her recover. Until then we’d been more or less sidelined; we felt helpless and we didn’t know what to do. We wanted the doctors to tell us what to do and how to cure our daughter. It quickly became apparent that they weren’t going to do that, that they didn’t seem to know much more than we did in certain ways.

When we took on the FBT, we took on both the responsibility and the power to intervene. That was a tremendously liberating step. The worst part of my daughter’s illness for me was standing by helplessly, watching her suffer and starve. The notion that my husband and I could help her required a huge mental paradigm shift—but once we made it, we were much more effective.

Externalizing the disease makes it easier to stay calm, not engage with the eating disorder, and not get angry at what often feels like oppositionality. It helps you understand, as a parent, that your child is essentially being held hostage by an illness, not acting out or being stubborn. It’s very, very helpful.

Another important step was learning to externalize the disease. Anorexia is insidious; it speaks with your child’s voice and looks out of her eyes. It’s natural to think that it’s your child refusing to eat, resisting, raging, or whatever the behaviors are. We made a conscious effort to think of the illness as something separate from our daughter, and that let us see the glimpses of the real her under the savage face of the disease. I characterize the disease as the demon in the book—it’s not that I thought she was literally satanically possessed. Rather it was my metaphor for the way the illness took over her thinking and behavior.

As parents, how did you and your husband manage to take care of yourselves and other aspects of the family while putting the necessary time and energy into supporting your daughter’s recovery?

HB: Well, I don’t think we managed this very well! We made our daughter’s recovery our top priority in the family for many many months. We more or less gave up having a social life, because most social events revolve around eating, and it was a long time before we could eat in public comfortably. We cared for our younger daughter, which mostly consisted of getting her out of the house sometimes so she didn’t have to deal with all the chaos and noise and angst. I went to work sometimes and worked at home sometimes, thanks to a very supportive boss; my husband is a freelancer, so he was home a lot. Other than that we did very little that wasn’t related to re-feeding and recovery. We became very single-minded. And honestly, I think that’s what we needed to do. When you’re engaged in such a full-on onslaught, such an encompassing, overwhelming effort, you have to focus on that as much as possible. In fact that’s advice I would offer families: Don’t think you have to keep up a normal social life during this time. Take care of recovery first, and if you want to fit in other things and they nurture you, great. But don’t feel like you have to. Most families find this process pretty absorbing.

What is the most important thing you learned in the process of parenting and caring for someone with an eating disorder?

HB: I learned the power of love. I know that sounds corny, but the truth is that no one loves your child the way you do. And no one, therefore, has the power you do, the utter commitment, the doggedness, the resilience, to see her through the hell of an eating disorder. And you need every ounce of those qualities as a parent, because this is the most grueling experience your family will likely go through.

We would like to express continued thanks to Harriet Brown for taking the time to address these questions and share her insight and experience with our readers.  Be sure to check back for the third and final Q & A post with Harriet next week.

Interested in hearing from Harriet in-person and getting a signed copy of her book? Download the EVENT FLYER for her August 25th presentation at The Center for Eating Disorders at Sheppard Pratt and find driving directions on our Events page.

Published by Kate Clemmer
August 12th, 2010 in CED Events, Celebrity Topical News, In the News, Recovery, Therapies
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Do I Really Have Binge Eating Disorder?

Q: A close friend of mine recently told me that she believes I may have a binge eating disorder.  Some weeks I don’t binge at all and other weeks I binge daily.  Do I really have a binge eating disorder?

A: You ask a very interesting, and common, question.  It also happens to be a complicated one!  First off, are you really binge eating?  Some people may feel like they’ve binged after eating one candy bar, a handful of peanuts or a single ice cream cone.  For these people, a binge involves eating any amount of something they consider to be a “bad” or “dangerous” food.  Technically, this is referred to as a SUBJECTIVE binge because it relies on each individual’s own, sometimes inaccurate, definition of how much food is “too much”.  On the other hand, while difficult to precisely define, a formally defined, or OBJECTIVE, binge consists of 1) eating a significantly larger amount of food than an average person might eat,  2) doing so in a relatively brief period of time (less than two hours) and 3) sensing a loss of control over eating during the episode.  Distinguishing between a subjective binge and an objective binge is an important part of helping you to answer the question about whether you have a binge eating disorder (BED). 

That being said, episodic, or occasional binge eating alone does not constitute BED.  Current diagnostic criteria indicates that an individual is bingeing at least twice a week for six months and experiences that “out of control” feeling during the binge in order to be diagnosed as having BED.* 

People with BED tend to eat quite rapidly, binge even though they’re not hungry, and often eat until they are feeling exceptionally full.  At the emotional core of BED is a sense of shame, and possibly disgust, about one’s eating behavior and, consequently, binges are apt to occur secretively.  Around 2-3% of the general population meets the criteria for BED and interestingly, women are somewhat more likely to have BED than men.  Some research suggests that upwards of 50% of people with BED are not obese, contrary to what people may assume.  

Its important to point out that even if you don’t think you meet full criteria for BED, it doesn’t mean you don’t have an eating disorder or that you shouldn’t seek help.  Any problematic disordered eating behaviors, including infrequent binges, could be symptoms of an eating disorder.  Regardless of the specific diagnosis, early assessment and intervention will significantly help to improve your chances for recovery.

Blog answer contributed by David Roth, Ph.D. 

Dr. Roth is a psychologist and therapist at The Center for Eating Disorders.  He specializes in the treatment of individuals with Binge Eating Disorder. 

* It is important to note that new diagnostic criteria for BED and its inclusion as a separate disgnosis is currently being developed and will likely be updated in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, scheduled to be released in May of 2013.

Published by Kate Clemmer
March 23rd, 2010 in Editor's Picks, Glossary Definitions, Nutrition, Therapies
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Should People With Binge Eating Disorder Try to Lose Weight?

Many people with binge eating disorder (BED) are obese and may have health problems related to their eating disorder.  Often times, people who are obese attempt to lose weight by joining a weight loss program or trying various diets; they may even be urged to do so by a medical professional who is unfamiliar with appropriate treatment for eating disorders.  While weight loss can sometimes be a by-product of recovery from BED, it should not be the primary goal.  In fact, attempts at controlling one’s weight through dieting, can exacerbate the binge eating symptoms by triggering a deprivation-binge cycle that ultimately results in weight gain and decreased metabolism. 

At The Center for Eating Disorders we recognize that the health problems which can accompany BED are a result of behaviors, not a direct effect of one’s weight.   Additionally, we find it of great importance to acknowledge and remind others that people can be healthy at every size and shape.  In fact, research shows that focusing on improving health behaviors – without regard to weight or the number on the scale –consistently leads to better physical health outcomes1.

That being said, people with BED, whether they are obese or not, can benefit physically and emotionally from seeking treatment for their eating disorder.  Treatment for BED includes working towards self-acceptance and focusing on the normalization of eating patterns.  This involves incorporating a wide variety of foods from all food groups and working through detrimental beliefs about food and eating.  People in recovery often find that once they are able to maintain a balanced pattern of eating and incorporate a healthy amount of physical activity that they enjoy, their body will naturally find and settle at its own appropriate set point.  This set point – the weight range at which one’s body is genetically programmed for optimal functioning - is different for every individual.  Focusing on balance and stability, rather than a specific weight or pant size, honors the health and well-being of the individual above all else. 

Questions about BED?  Join in the discussion on our Facebook page or visit our website for more information about BED and treatment options.

 

References:

1 Bacon, L., et al., (2005). Size Acceptance and Intuitive Eating Improve Health for Obese, Female Chronic Dieters.

Published by Kate Clemmer
March 19th, 2010 in Body Image, Editor's Picks, Nutrition, Therapies
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Dialectical Behavior Therapy: PART II

The growing popularity of Dialectical Behavior Therapy (DBT) in the treatment of eating disorders (ED) is of great interest to professionals, patients and families who have been struggling with the effects of an eating disorder.  Recently, our blog, “Dialectical Behavior Therapy: Part I” introduced the background and basic principles behind DBT in an effort to clarify its importance and relevance in the field of ED treatment.  Today, Part II of the blog goes a step further to help increase understanding of the DBT process and the specific ways in which it can help move patients toward recovery.  As mentioned in Part I, DBT is composed of four modules, each with its own goals and skill sets.  Each of these modules are introduced and described below:

Mindfulness: 

The art of “learning to be in control of your mind, instead of letting your mind be in control of you.”  Accomplishing this is not a task of controlling one’s thoughts, but rather practicing the ability to control one’s attention. The goal behind this module is not change, but rather acceptance of whatever one is experiencing in any given moment.  In this module, individuals learn how to:

  • be exposed to information from inside themselves to which they would usually be unaware
  • more effectively regulate these thoughts, feelings, and reactions
  • shift attention when attention on a certain thing is not productive

Distress Tolerance: 

Distress tolerance is the ability to endure and accept emotional suffering.  This is essential to good mental health since, as Linehan notes, “pain and distress are part of life; they cannot be completely removed or avoided.”  Mastering these skills is vital to recovery since ED symptoms are often used to provide immediate gratification in the relief of pain/distress.  If someone is not able to tolerate distressing feelings without acting on symptoms, then those impulsive actions will continually interfere with efforts at recovery.  The goal of this module is to decrease impulsive behaviors (i.e. self-harm, bingeing, purging, etc.) by providing alternate healthy ways of coping with negative emotions such as self-soothing, distracting, and thinking of pros and cons.

Emotion Regulation: 

As noted above, ED symptoms often serve to numb out painful emotions.  As a result, many individuals in the early stages of recovery have a hard time identifying what they are feeling and why.  Emotion Regulation skills focus on:

  • understanding one’s emotions, including learning how to identify a specific emotion and it’s function
  • reducing one’s vulnerability to negative emotional states and increasing positive emotions
  • mindfully letting go of painful emotions and/or modulating or changing a negative emotion when possible 

Interpersonal Effectiveness: 

Difficulties with self-esteem, perfectionism, tolerating distress, and the drive to please others, can often interfere with attempts to have healthy, fulfilling relationships. This module provides concrete strategies to help improve assertiveness and interpersonal problem-solving in order to facilitate healthy life changes and improve/maintain self-respect.  Skills learned in this module include:

  • asking for what one needs
  • saying no and setting healthy boundaries
  • coping with interpersonal conflict effectively. 

The Center for Eating Disorders is now offering DBT group therapy on an outpatient basis.  Each group will meet once a week for a six month period.  

Beginning June 4th, 2009, our 1st DBT group will be starting from 5:30 – 7:00 pm. A second DBT group will be starting on Tuesdays from 11:00 am – 12:30 pm. Start date TBD.  

For more information about these groups or any of our DBT programming, please call (410) 938-5252.

References

Linehan, M.M. (1993).  Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.

Behavioral Tech, LLC. (1996-2009). What is DBT?  Available at:  http://behavioraltech.org/resources/whatisdbt.cfm 

Written by: Kristin Grasso, Psy.D., Center for Eating Disorders at Sheppard Pratt

Published by Kate Clemmer
May 15th, 2009 in Therapies
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