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Tuesday, 22 February 2011

Denial- Friend or Foe In Eating Disorders

I’ve been asked to blog about denial so here we go.
Denial is what happens when someone insists that they do not have a problem with food, usually in response to the concern of carers or friends who may notice that weight is low or that someone isn’t eating very well.
Some writers suggest that “denial is something that exists in the counselling room”. In other words the person who has a problem may know that there is a problem but doesn’t really want to be helped right now.

Let’s take some possible scenarios;
They do not trust that therapist.
They are afraid of getting fat or losing control.
They get benefits from their eating control such as feeling special and powerful , or getting some attention from loved ones – who would want to stop feeling these things?
They feel ashamed of their eating behaviour, especially if they are binge eating or purging.
Or, the anorexic voice drowns out the voices of concern from other people. This voice tells them that they will feel a little better if they lose a bit more weight.

Denial- any of the above - is more likely to be present in a person who is thin. Bulimics for sure know they have a problem although they may not want to admit to it. At the same time, denial can be real – not knowing that you have an eating problem and not knowing that you are very ill. Some people who are in recovery say that, looking back, when they were in the grip of their eating disorder they were so compulsive and obsessive with food, exercise and eating rituals that they had convinced themselves that they were fine. It was as if they had been taken over by an alien being, and only if they collapse might they begin to accept that they are weak and ill.

Even then, a few days of rest convinces them that they were just overtired and can continue doing what they were doing before. We use things like muscle weakness tests to help convince some people that they are weak and that they might need to get some long term help.

I see denial around me in a great many forms. I see it in people who choose unbalanced eating patterns and who are convinced that they are allergic to certain foods, or that they can’t eat meat because they “really love animals”. I see denial in people whose gym or running patterns are a front for an addiction to exercise and perhaps the only way that they give themselves permission to eat. I also see denial in people who say that they are “working on their problem”, by going to therapy and talking, but they may refuse to turn talking into action; probably because they are terrified of change.

I also see horrible and selfish denial in parents who insist that their child doesn’t have an eating disorder. The child is just doing a lot of sport and is getting along very well at school thank you very much. God forbid that this family has a problem. Let’s not rock the boat. On the other hand, about half of all the calls I get are from worried carers, saying “how can I get my daughter/son, wife and even parent to accept that they need some help”.

Us therapists have a hard time with denial; we either call it “unconscious incompetence” or we say that someone is really “in denial” when what we mean is that we haven’t the sensitivity, the skills, the patience, the pacing and the ability to bring ambivalence, fear and resistance to the surface and deal with it safely.

So how do we sum up all the above; perhaps to say that we are all in denial to some extent about the motives for doing what we do. We might be in denial about our eating habits, our use of alcohol, or the effects of too many late nights. There isn’t a one-size-fits-all solution to the problem of “denial” but if anyone out there has some stories or some perspectives to add, please email me on admin@ncfed.com. Please!

Tuesday, 15 February 2011

Top Tips For Treatment : Focus On The Core ”Cognitive Problem”?

“The core.... problem here is the over-evaluation of food, shape and weight as threats. This manifests as beliefs such as ‘If I eat normally my weight will rocket out of control and I will never be able to stop it".”
The eating disorder mindset is very much more complex of course. There are many other beliefs which affect our behaviour with food, such as beliefs about good foods and bad foods, binge foods and safe foods and making a tragedy out of eating an extra piece of toast. Even a fat person who thinks “I will die if I do not get my treats” suffers from a distorted mindset.
It might be useful to create a whole library out of all the beliefs we encounter in someone with an eating disorder. Some of these beliefs are really just the reflection of the “real issue” underneath, which is feeling out of control. Poor self regard, feelings of ineffectiveness, mistrust of others and worthlessness are the real source of the “cognitive problem.”
We must be careful not to dismiss some of these ideas. People do have differences in their “normal appetites” and there is a place for primary disturbances of appetite in how we think about eating disorders. This means that many people have to live in a continual state of mild restraint in order to control their weight. Is that “normal eating?” I may eat “normally” and I hardly think about food and weight. But I am pretty convinced that if I were to eat exactly what I wanted, I would be heavier than I am and possibly mildly overweight, which carries health risks. Saying “no” to an extra piece of cake is par for the course and part of the way we must respond to the world we live in if we are to avoid gaining a great deal of weight over time.
So, all psychotherapists must reflect on what normal eating really is before leaping to change mindsets, and that is a whole new essay. We need to discuss the idea of normal eating with our clients before we help them to amend their ideas. Many people with anorexia do not value “normal eating” because of other values associated with normal eating such as “people who eat what they like are greedy and disgusting”.
Or, conversely, some people with weight problems may not wish to eat normally if they believe that “people who eat what they like are fun loving and sociable”.

Professor Waller (CBT Today Dec 2010) states that if what we are doing does not explicitly target these beliefs it is not “CBT for eating disorders”.

The eating disorder practitioner needs to know more than CBT if treatment is to work. CBT while crucial does not work on its own for all people, especially for anorexia. It seems to me that framing up a therapy as belonging to a specific treatment model is safe for therapists, so when we have a new tool such as “mindfulness” we call it “Mindfulness based CBT” or, if we add emotional tools to our treatment we can call it “Cognitive –Emotional Behaviour Therapy”.

It really scares me however, to think of how many therapists don’t know or understand the principles of mindset change or how to do it. Empathy, giving our clients unconditional positive regard and even working on self esteem or early trauma isn’t enough. We owe it to sufferers to understand every aspect of how they think, how they process information (such as through the filters of all-or-nothing thinking) and how this affects their behaviour, before we should consider working with them.

Monday, 7 February 2011

Top Tips for Working with Eating Disorders: It Helps to Know Some Physiology

Its crucial, not helpful, to know some physiology. Glenn Waller writes in CBT Today Dec 2010 that we need to be able to give people "key information" about their eating disorder, the effects of starving and laxative abuse. Do you really get rid of everything when you purge? Are all calories the same? Is all fat wicked? Are carbs as dangerous as we are led to believe? What is the connection between your emotions and your eating habits? What are the secrets of what diet drinks do to your body? What does normal eating "look like?"

And what does dietary chaos do to your ability to control your weight? Can you turn your body into a fat-making machine just by drinking a lot of coffee? What is the role of the thyroid and does it matter? What is the chemistry of appetite? Does fullness predict weight gain? How can you manage a diabetic with an eating disorder?

How complex do you need to get to be sure that you know enough to be useful?

The eating disorder practitioner who practices constant CPD about the physiology of food, weight and appetite is the only practitioner doing their patient justice. You need to know a great deal across a wide range of rapidly changing fields, where even specialists have difficiulty keeping up with latest thinking.

Knowing the information is one thing. Knowing when and how to communicate relevant facts is something else. Using the information to help transform behaviour, some experimentation, some risk taking on the part of your clients, is the final must-do. Knowledge ONLY becomes power when it is felt in the muscle.

I have put up some useful information online to help your clients, such as on how much do you really need to eat and the effects of undereating. Visit http://www.eating-disorders.org.uk/information.html

Sunday, 6 February 2011

What Do You Want Me To Write About?

Please followers let me know if you would like me to write about something YOU are interested in for a change. You can email me at deanne@ncfed.com

Friday, 4 February 2011

Top Tips for Working with Eating Disorders: Are You A Coach or Therapist?

This point was raised in CBT Today Dec 2010 by Prof Waller. I introduce all my eating disorder trainings by asking this question. Eating disorders are usually treated by people who describe themselves as therapists because, after all, therapy is about healing the sick, or making ill people well. And therapists do therapy, which is what they are trained to do.
I don't like regarding all people with eating disorders as fundamentally sick. Much of their behaviour makes sense. The person with anorexia sees most women trying to lose weight. Fat people get such a bad break in our society that it almost makes sense to purge if you have eaten too much so that you can stay in control of your weight. It is quite normal for a binge eater to have cravings because dietary chaos makes their blood sugar very unstable.
Prof. Waller suggests that we should coach people to be "her (or his) own CBT therapist" so that the client can make good use of the hours they are on their own, over and above the hour or so they have in the room with their counsellor. I agree and yet feel that this means a great deal more than being a coach.
Do we concur with the view that CBT in its many guises is the best we can do so far for working with eating disorders? Yes, since we are working to change behaviour, and to change the eating disorder mindset and the emotions which inform behaviour, whether this refers to starving or binge eating on chocolate.
Changing the eating disorder mindset requires us to be a guide, to help our clients cope with their lifestyle, and a teacher to provide useful information to deal with myths about nutrition and calories.
But information on its own is only useful when a person has the skills to use it appropriately - so we may need to teach some basic skills such as relaxation or problem solving skills and communication skills to help people become more effective and able to use the information which we have given to them.
When we work on the eating disorder mindset, we also confront some important barriers to change such as how much you feel you need to weigh in order to accept yourself. To do this, we have to help a person to know and realise their deeper aspirations in life rather than simply attend to the eating disorder aspirations of being in control of food and weight. This subtle task is more about being a mentor for change by opening out possibilities which were not there before.

So, coach or therapist? Definitely both and more, and even being a bit of a magician wouldnt come amiss, although the evidence base for conjouring is not yet there.