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My Journey with Eating Disorders
- 1. My Journey Working with Eating Disorders Child and Adolescent Outpatient Eating Disorder Program Kyla Balderson Masters of Social Work Candidate
- 2. The Beginning • Experience • First Impressions • Assumptions • Urgent Consult • Group Work
- 3. Importance of Early Intervention • Onset during adolescence when nutrition is essential to meet developmental needs • Reversible and irreversible medical conditions • Limitations on social growth Early Intervention = Faster Recovery • Eating disorder behaviours are dismissed as adolescent changes. • Stigma prevents parents from getting help.
- 4. Treatment Methods Severe Cases • Hospitalization • Inpatient • Day treatment Less Severe Cases • Outpatient • Private psychiatrists • Specialized clinics • Mental health centres
- 5. Treatment Examples • London Health Services Centre Inpatient, outpatient, day treatment, outreach • Sick Kids Toronto Inpatient, outpatient, day treatment, group therapy • Southlake Regional Health Centre Inpatient (2 beds), outpatient, transitioning work • Ontario Shores Centre for Mental Health Sciences Inpatient
- 6. Hotel Dieu Hospital’s Outpatient Treatment • Nurse Practitioner • Dietitian • Child Psychiatrist • Behaviour Therapist • Clinical Social Worker
- 7. Emotion-Focused Family Therapy & Eating Disorders Parents are the solution not the problem Three Main Components (Emotion-focused) 1. Recovery Coach 2. Emotion Coaches 3. Working through any emotions or obstacles that arise through the treatment. Three Phases (Family Therapy) 1. Re-feeding/Weight Restoration 2. Client takes back some control 3. Client returns to development of autonomy and control in their life
- 8. Parent Support Groups • Less power structure and dynamic Caring for the Carers •Share experiences and strategies •Challenge the stigma •Psycho-educational support •Encouraging self care and time away from the demands of the eating disorder
- 9. Group Work for Clients
- 10. Individual Therapy To make changes, clients need to understand the importance of change and have the confidence to make changes. Common Interventions (directive & non-directive): • Cognitive Behaviour Therapy • Dialectical Behaviour Therapy • Individual Supportive Psychotherapy • Interpersonal Psychotherapy • Client-centered therapy • Motivational interviewing • Psycho-education
- 12. Parent’s Role in Individual Work •Role modelling •Integrating skills learned in session into the home •Building confidence and encouraging goals •Active involvement throughout the emotional discovery •Demonstrated dependability and reliability
- 14. Combination of Individual and Family Work
- 15. Case #1
- 16. Case #3
- 17. Rolling with Resistance •Perfectionist qualities •Not ready to change •Little insight into the disorder •Emotional avoidance •Poor coping skills •Eating disorder has too much control • Co-morbidites •Medication complication •Medical instability.
- 18. Why Inpatient? • Weight is less than their ideal body weight based on their age, gender and stature. • Continued weight loss while in intensive outpatient therapy • Severe weight decline with refusal of food • Signs of hypothermia • Pre-hypertension or borderline high blood pressure • Resting Heart rate <50 beats • Orthostatic changes in blood pressure • Orthostatic changes in pulse • Electrolyte abnormalities, hypophosphatemia, hypomagnesemia • Arrhythmia • Suicidal Ideation
- 19. The Missing Piece at Hotel Dieu An inpatient transfer for symptom interruption causes a significant disturbance in therapy progress in the outpatient services.
- 20. Case Example/My Observations Case #1 discussed above: • Outpatient to Inpatient • Unique opportunity to work in Kidd 10 • Family’s lack of involvement and responsibility of follow through “stepping on others people’s toes”
- 21. Benefits of Inpatient & Outpatient Together • Therapy could continue without being interrupted by another service. •Follow through within the treatment •Extra support and guidance •More informed professional team •Demonstrate healthy relationships
- 22. What Does Change Look Like? • Specialized beds in hospital •Educating other professionals through seminars, workshops, and trainings • Productive communication between service professionals (Outpatient & Inpatient Coordination) •MORE FUNDING! •Research
- 23. Through My Lens • Best Memory • Difficult Moment • Most Helpful • Advice I’d Give • Taking With Me • With my Must Save World (MSW) degree.
- 24. References • Jasper, K., Boachie, A., & Lafrance, A. (2009). Family-Based Therapy for Children and Adolescents with Eating Disorders. National Eating Disorder Information Centre. • Lock, J., & Grange, D. L. (2005). Help Your Teenager Beat an Eating Disorder . New York: The Guilford Press. • Lock, J., & Grange, D. L. (2011). Eating Disorders in Children and Adolescents : A Clinical Handbook . THe Guilford Press: A Division of Guilford Publications, Inc. • Robinson, A. L., & Dolhanty, J. (2013). Emotion-Focused Family Therapy for Eating Disorders across the Lifespan. National Eating Disorder Information Centre. • Treasure, J., Smith, G., & Crange, A. (2007). Skills-based Learning for Caring for a Loved One with an Eating Disorder. London and New York : Routledge Taylor & Francis Goup.
Hinweis der Redaktion
- The onset of eating disorders typically occurs in adolescence, a time when developmental changes are instrumental to their physiological, social and cognitive growth. If left untreated eating disorders can become chronic with heightened comorbidities and death. Although most of the medical complications are reversible with treatment, some have potential to be irreversible if not treated early enough such as bone mass deficiency, growth retardation and loss of dental enamel. In regards to the social growth, eating disorder behaviours often foster social isolation and family conflict. The extensive treatments eating disorder patients have to endure may take them away from the normalcy of an adolescent’s life. This is why it is essential to advocate for early aggressive interventions to make every attempt at reversing the course of illness. Research states that the shorter the duration of the eating disorder before treatment, the better the outcome. With lower remission comes longer illness and more likely inpatient involvement. At the beginning stages in some of the eating disorder symptoms do not quite meet criteria. However if not treated, could develop into a more serious disorder. Often at this stage the eating disorder does not have complete control over the child, and therapy interventions of externalizing the eating disorder are more successful. A barrier to accessing treatment early on is that parents may not be aware of the disordered eating. They may dismiss them as average adolescent behaviour such as preoccupation with appearance, individuation from parental support systems, expression of strong attitudes as they are all common transitions of adolescents. Providing them with this independence intensifies the control the eating disorder has on the child. Also the stigma attached to eating disorders is that it is the parents fault, which limits the family from wanting to remain engaged in treatment.
- The treatment setting is determined by the severity of presenting problems. Environments can range from the most restrictive for severe cases requiring hospitalization, inpatient, or day treatment to the least restrictive (outpatient, private offices, special clinics or mental health centres). The setting of treatment is determined by the adolescent’s physical and psychiatric health. According to the National Eating Disorders Organization the most effective treatment with the longest lasting results is a form of psychotherapy, psychological counselling with medical and nutritional needs. While according to the National Eating Disorders Information Centre, due to the complexity of the onset and maintenance of an eating disorder it is necessary to have both physiological and psychological treatment provided. The physiological issues take president to ensure medical stability in the child and proper nutrition to effectively address the psychological issues. It is suggested as most beneficial when they are provided in conjunction with one another.
- London Health Services Centre offers inpatient, outpatient and day treatment programs. The inpatient services are provided for what they consider “actuely ill”. Day treatment assist with normalization of eating. While outpatient services provide assessment and treatment. Outreach workers are involved in providing psychoeducational groups. Sick Kids Toronto offeres a 10 bed inpatient unit, day program and outpatient program. The inpatient program is designed to help those with medical or psychiatric instability associated with the eating disorder. This involves interpersonal care with a strong focus on family work and group therapy. The day hospital program is a mon-fri program structured for medically stable individuals who require more support than outpatient clinics can provide. This day program is equipped with educational opportunities. Their outpatient clinic is also interdisciplinary and provides medical and nutritional monitoring, individual, family and group therapy. Some groups are psychoeducation, some are parent support groups, body image groups, interpersonal psyhcotherapy and cognitive behaviour therapy groups, etc. Works closely with community health care to transition them back into the community. Southlake Regional Health Centre provides outpatient services including individual therapy, family therapy, nutritional counselling, psyhcoeducation classes, parent support group, therapeutic groups for adolescents. Their day program provides more intensive support to manage their eating disorder symptoms. This includes a half day of school and a half day of therapy (Group, individual, family). Families are required to participate in the information sessions and meetings. They have 2 beds in the mental health inpatient unit but still includes the multidisciplinary team. They also uniquely provide a young adult eating disorder program because it ensures the necessary support being provided for those 18-25 years of age as they do not quite fit into either adolescent or adult programs. Ontario Shores Centre for Mental Health Sciences in the fall is opening a new 12 bed Eating Disorders Unit. This is to provide treatment closer to home instead of sending them to the U.S for treatments as has been done before. The target population is for adolescents who are medically unstable and need to return to intensive inpatient intervention. Their structure of care will include individual, family and group therapy, psychoeducation, meal support, nutrition and eating rehabilitation and psychopharmacologic treatment. The parents remain actively involved in the programming. Educational needs are met at the facility as well.
- Similar to most programs in Ontario and as recommended by the National Eating Disorders Association, Hotel Dieu Hospital has an interdiscplinary team including physicians (psychiatrists, family doctors, pediatricians), therapists (social workers, nurses, psychologists), dieticians, and family members active involvement. The outpatient program at Hotel Dieu follows best practice in regards to their interdisciplinary team structure. Being involved in the weekly intake appointments gave me the opportunity to learn, interact with and respect other professionals in a treatment milieu. I learned so much about each professional’s field but also about communicating efficiently regardless of different specialities, interests, personalities and fears. Although, the point of this slide is to recognize the structure of treatment at Hotel Dieu Hospital, I am also going to take an opportunity to discuss my experience being a part of this interdisciplinary team. I cannot speak for other programs that follow this structure of treatment but I can only hope it is as successful as this one. We have a nurse practitioner that often keeps the team grounded and realistic. Her experience helps guide us in knowing the severity of our clients. If she is scared, we need to be scared (as it is rare that she is scared). We have a dietician that openly expresses her high anxiety, worrying and cautiousness. This is an asset to the team as it helps us be aware of the possible negative consequences our decisions may have. She keeps us cautious and rational rather than jumping to the easiest solution or a more risky intervention. We have our psychiatrist that provides an extensive knowledge of mood and anxiety to the team. Although, I did not get a chance to work with her much she was a great support to the team. She supported the team’s decision and offered guidance when needed. We have a social worker that is sort of like the glue keeping everyone together. She sweeps in with her cape and saves the day with her interventions. Her long drawn out questions keep the team on their toes. She is assertive and realistic with her boundaries with clients. She takes the extra step as the coordinator to gain further funding, raise awareness, build on the program and advocate for her clients, team and program. There is also a behavioural therapist that I did not have the opportunity to meet with unfortunately but hope to in the future. The experience I have had learning from this team’s individual expertise but also their personalities has been eventful, humorous, energizing and extremely educational. Each individual was comfortable to speak up when uncomfortable with a decision, to communicate constructively when upset with another team member, to reach to eachother when in need of support or guidance. This team is strong, compatible and a great example of successful interdisciplinary work.
- Hotel Dieu Hospital follows an emotion-focused family therapy treatment for working with eating disorders. For a brief summary of these theories I will discuss the components of emotion-focused therapy and its work within family therapy. Emotion-focused therapy believes in the family’s ability and power to heal their child. This works nicely in adjacent with Maudlsey’s family therapy because of its focus on parents taking control of their child’s treatment. To practice emotion-focused therapy you need to hold a strong belief in the parent’s ability to take on the roles of recovery and emotion coach. This often involves seeing past their limitations, own mental health difficulties and functioning. The three most important components of emotion-focused therapy is assisting parents in 1) becoming their child’s recovery coach (re-feeding and symptom interruption) 2) becoming their child’s emotion coach (healing of old emotional injuries when medically stable). This means educating parents of the role of emotion avoidance in the onset and maintenance of their child’s eating disorder. Eating disorder behaviours are often used to manage these emotions, so similar work to symptom interruption is necessary. This involves empathizing with the feeling, labelling the feeling, validating the experience and meeting the specific emotional need that is being met by the eating disorder and finally supporting them in meeting their own needs. 3) working through any emotions or obstacles that arise through the parent or family during treatment. There is no doubt that eating disorders have a huge impact on families. Eating disorders have potential to control family interaction, behaviours, routines and strain on the relationships. Because it affects the entire family, it is suggested that all members living in the home attend the family therapy, to ensure all support is available and consistent. Each individual needs to be aware of what a eating disorder is, and what their role is in the treatment. Overall, it provides adolescents, their parents and their siblings a means to develop stronger and healthier family relationships. It also helps them to understand their relationships and offers them a source of emotional support. Family based therapy is focused around lifting blame off the parents and child, heightening anxiety to motivate the empowerment of parents to re-nourish their child and support them in treatment. Highlighting and stressing the existence of problem areas and the importance of addressing them aggressively and immediately is important, hence the heightening of anxiety as motivatior. Externalizing the illness helps families feels less to blame and guilt for their child’s illness. Parents require the support in redirecting and resolving their child’s eating disorder as it is unnatural to their regular parenting. Sometimes it is helpful for us to provide them with examples of what other parents have been doing to help them see resolution as realistic. We can support parents by being aware of their feelings and empathizing with their experience, acting as a resource to educate them, debriefing and strategizing ways to best support their child, and building their confidence. When the responsibility is placed back on the family, and the illness severity is explained families often find strengths and skills they never knew existed. Following Maudsley’s approach to family therapy, there are three phases of intervention. Phase 1: Parents are in charge of weight restoration to ensure it is consistent with what is expected of the individual’s weight and height. Often at this point, the eating disorder voice has control over the child. The refeeding process needs to be taken with care, firmness and empathy rather than harassing and geared around punishment. Phase 2: Parents hand control over eating back to their adolescents, which is a slow process occasionally experiencing setbacks. Gives the child the opportunity to overpower the eating disorder voice and start to take control of their life again. This is difficult for some parents as they are concerned with their child’s weight restoration and their ability to take control. When the child has more control over their treatment and medical stability it is a good time to begin exploring issues that may have been a factor to the development of the eating disorder. Phase 3: Supporting the adolescent’s development of autonomy. The child learns to be independent from their family but also their eating disorder. Helps the family anticipate potential issues that may arise in the maintenance and prepare to problem solve against the re-emergence of the eating disorder. The end goal is to gradually fade parental management of the eating disorder symptoms, transfer control over eating and related activities back to the child developmental stages. Continuation of working with the family in determining the factors that influenced the commencement of the eating disorder. With family therapy, hospitalization can be minimized and occasionally avoided altogether and health can be restored quicker because of the support system and skill building involved. This also helps with minimizing the disruption to the child’s physical, emotional, cognitive, and social development. During treatment, parents need to avoid making comments about their own weight, diet or exercises regardless of their weight situation. This focus around weight culture fumes the eating disorder witihin the child. Therefore the saying goes “practice what your preach”.
- Multifamily therapy is relatively straightforward that bringing people together to share their experiences can be therapeutically beneficial for potential change and recovery. It provides an opportunity for them to offer eachother support in a group where power structures are less evident in the therapeutic relationship between clients and therapist. Support groups are often facilitated by an individual that has struggled or is still struggling with an eating disorder. For some treatments the support groups are mandatory, while others are entirely voluntary. In some cases the support group is the only required form of theapy/intervention, while others have this opportunity or requirement in addition to their regular treatment. The aim of a support group for parents is to allow them to share experiences and use them towards helping and advising other individuals in similar circumstances. The parents are likely all involved in various stages of treatment providing an overview of the treatment and its potential difficulties. Support groups can also take the form of a psychoeducaton group similar to a seminar. This is provided by health care professionals and provides the parents with a unique opportunity to gather extra support and knowledge outside the treatment regimes. A combination of both would likely have remarkable positive changes to the treatment of eating disorders Parents of children with eating disorders face stigma, fear of stigma, and social isolation. The subjective burden that parents take on as a carer is relatively greater than most parents of children with psychiatric disorders such as psychosis. There are several myths present in society regarding eating disorders, one that has always stood out to me was the illness being a result of dysfunctional parenting. The physical and emotional requirements needed to care for someone with an eating disorder likely interferes with other important parental responsibilities. Parents are consistently battling with the voice of the eating disorder, the voice that comforts and soothes their child, the voice that turns their child into someone they are not. The eating disorder voice can become verbally abusive, demanding, angry, vicious and controlling. Battling against this voice without knowing the voice directly is exhausting to say the least. Parents of eating disorders are overwhelmed, causing them to isolate themselves to struggle to cope with their daughter’s routine and structure. The most important thing for parents to do is pleasurable activities timed into a schedule each week. If meeting up with others, lets go with others so that we know more people. With all the support and guidance consistently focusing around the child, the parents are left to attempt to understand the eating disorder and its roots while caring for their child and themselves. Often the onset of eating disorders is around stress, if the child is experiencing and managing their stress in this way it is essential to have the mental health of the parents assessed as well.
- Although we do not have group therapy at hotel dieu hospital specifically for eating disorder patients it is an area worth exploring. It provides adolescents with the opportunity to participate in therapy in an environment that will accept, understand, support and normalize their emotions. It can be offered as a formal therapy or self-help group. A concern is that it may create a “thinspiration” atmosphere or connect eachother to others with eating disorders who could relapse into the distorted eating again. To limit this it should be those who are maintaining. Relate it to suicidal teens: do you put them all together to create a “pack” (good and bad).
- Some of our clients are extremely unmotivated when it comes to changing their eating disorder behaviour or other forms of coping. Two main reasons why people are more ready to change: important for them to change, and have confidence to do so. This is built on in the individual therapy through highlighing positive change talk and discrepancies in their choice of values and actions. In comparing statistics between individual and family treatments, family treatment results in higher full remissions. However the therapy of combing both individual and therapy together results in the highest of full remissions. Individual therapy can help adolescents focus on personal issues and improve their health status. It can take several forms such as cognitive behaviour therapy, behaviour modification and behavioural contracting. Research states across most mental health diagnosis that successful treatment takes place when the individual wants to change for themselves. To help children become their own change agents is difficult but not impossible with the use of individual therapy intervention. Connecting them with other adults at home, and in treatment programs should be provided to assist the child in feeling belonging, authenticity, self empathy, empowerment and motivation to change. With these developing feelings, there is more control and leverage for the child to choose to leave the eating disorder before it is “taken away” through the use of aggressive and intensive programming. Research is expanding on the effectiveness of CBT techniques with adolescents. It states that bulimia nervosa and binge eating have higher treatment remissions when treated with cognitive behaviour therapy in the individual work. CBT can be used in two different forms either an eating disorder focused where it targets the eating disorder psychopathology or a broader form when the target is the maintenance factors to the eating disorder such as low self esteem, perfectionism and interpersonal difficulties. It is suggested that the focused CBT be used in less severe cases where the child still has some control over their eating disorder (which will be demonstrated in my case studies). Using the nondirective broader target of maintenance works easier with the more severe cases as the relationship with the eating disorder is to complex to approach directly. There is little differences in eating disordered risk factors between adults and adolescents, therefore if the treatment works on adults it should have similar success with adolescents. CBT is already commonly used in treating adolescent other mental health disorders such as mood and anxiety, therefore the skills and application can be transferable. It may prove that adolescents have a more openness and easier time with CBT work because of their development stage. When using CBT with adolescents a deeper focus on motivation and family involvement may be necessary. Although it is important to include the family we must be cautious and ensure the therapy goals are for the individual and not to please the family or therapist. It is suggested that using a shortened time frame for treatment and creative activities is helpful in engaging children and adolescents into change. Dialetical Behaviour Therapy can also be used with adolescents with eating disorders to focus on the mental health components of depression, anxiety and personality disorders. A longitudinal study was conducted by Miller and colleagues (1997, 2007) using shorter durations of treatment, adding content specific to eating disorders, using therapists and nurses, and facilitating weekly groups that focus on weight and eating. There were significant improvements in depressive symptoms and eating disordered behaviour. Because of the connection between emotional avoidance and eating disorder behaviour, emotion regulation and distress tolerance from DBT therapy is a suitable and successful intervention. Individual supportive psychotherapy is a short term therapy that puts the child in control of their recovery and allows them to explore the possible origins of their disorder. This may provide them with a sense empowerment and increased insight into their disorder. It makes use of the therapeutic alliance, focuses on affect and emotion, identifies recurring themes and patterns presently and from the past, and encourages different aspects of developing autonomy as an adolescent by being non-judgemental and nondirective. It views the eating disorder as a maladaptive solution to underlying psychological conflicts, past traumas, or relationship difficulties. When the underlying problem is exposed and openly discussed then a healthier solution can be explored. This therapy is client-directed and at no time should we direct a solution to their problem. Therapist should avoid making direct connections to the cllient such as during stressful situations, with her binge eating. Individual therapy can work to educate the child about their eating disorder and explore the difficult feelings underneath. The individual work is primarily geared towards topics of improving self esteem, developing new coping strategies, emotion regulation, and challenging cognitive distortions. The individual support also helps the child become motivated to recover from the eating disorder by building their control, confidence and capability. I did not discuss all of the interventions listed, however they are demonstrated and reflected upon throughout this journey presentation.
- First to place ourselves in our client’s shoes these may be some of their thoughts about their parents invovlement: Individuals do not want their parents involved in their individual work because of: discomfort in discussing personal issue sin front of their parents Feeling the illness was their own problem Individuals do involve their parents because of: They felt supportive, interested, and having time for them and the parents willingness to learn and help them through treatment Our work is to help the family recognize the “voice of the eating disorder”, to stand against it, while also supporting them to understand how difficult it is for their child to ignore/challenge this voice that has become so important and true to them. With the child, it is important to continue to externalize the eating disorder and recognize the difference between their voice and the eating disorder voice. The family can be a great support in this as they knew the child prior to the eating disorder and can recognize behaviours, reactions, emotions and personalities that are true to their child. The involvement of parents in their child’s individual work can take several forms such as pyschoeducation and supporting CBT work at home. Families are always role models. Parents often feel as if they are “walking on eggshells”, angry, frustrated, guilty, and complete exhaustion. Having the parents involved in supporting the progress their child is making in their individual therapy is essential in building the supportive parent-child relationship that can be maintained in the maintenance of treatment. Although the individual therapy is an opportunity for the child to work on their own goals separate from the family and eating disorder work. This demonstrates their ability to take control of other areas of their life until control over eating can be returned. Under emotion-focused family therapy, the parents are to take on the role of emotion coach. The emotions that surface during individual therapy can be brought to the family session while we are there to help the family take on the role of emotion coach through validation, empathy, and meeting their child’s emotional needs. In some cases, the eating disorder behaviour has caused the parents to have little trust in their child. Working alongside and supporting their child’s individual therapy work and integrating the skills learned into the family home can be beneficial in rebuilding that trust and relationship. This helps with the parent and child’s transition to phase 2 of the family based therapy. In individual therapy, occasionally a “break through” will occur where the child will reach a realization or be open to discussing a issue that influenced their eating disorder. Although they were able to disclose this information in the individual therapy, having a supportive communication between the parents and child’s treatment makes it easier to engage in this further without experiencing resistance from the child. In cases where the child is not responding to the parent’s refeeding attempts, involving them in the individual work can help demonstrate their reliability and consistency that their child may doubt. For example if a child sees their parents continued attempt they may see them as more dependable when their eating disorder voice becomes less strong. It is about remaining present, willing to listen and be able to see them as unique individuals with different needs. Parents who see their child as their child and not a new possessed form is important in the motivation to change.
- Throughout my work, I found it beneficial for me focus and redirect the clients to directions outside of the eating disorder. Giving them control and interest back in other areas of life, build their confidence to make changes. When I started doing individual work, I spent a majority of my time planning for the sessions. I had a pattern and was planned 2-3 sessions ahead at a time. However after the first two weeks I realized this was not realistic. The sessions never went as planned, and I always followed the clients direction. As a result, I spent less time over-planning and more time engaging, staying in tuned and listening to the clients. I feel this was a very important lesson for me to learn. With my individual work, I learned a lot about flexibility and patience. Some of the topics that were engaged in during the sessions were: self esteem, body image, hygiene, depression, anxiety, anger management ,coping skills, mindfulness, challenging cognitive distortions, managing healthy relationships, integrating feared foods into meal plans, preparing for transition to college, emotion recognition and regulation, and goal setting. Next I will discuss 4 cases very briefly to give a quick “snapshot” of what my individual sessions looked like.
- As I mentioned earlier, I am extremely lucky to have worked with such a strong interdisciplinary team. They treated me as if I was a part of the team and not “just a student”. My supervisor and I communicated very well throughout my placement, I always felt like I could walk into her office and share ideas, talk or get advice. The structure of the appointments varied for each family. However for a majority of the families, I would meet individually with the client and Ashleigh and Patricia would meet with the parents for some family and nutrition work. Occasionally, the client would meet with me individually while their parents waited in the living room, when meeting with the family alone was not necessary. I would receive the medical update of the client before entering the individual session and then return to update Patricia on the results of the individual session. Occasionally I would join Patricia with the client and their family immediately after the individual work. While others, we would meet for brief time to discuss the results of the individual session and our plan to put forward with the family. Patricia made sure that I could sit in with the family session as well when the client would rejoin, this was very helpful so I could see the dynamics of the client with and without their family members present. It also allowed me to advocate and support them in their goals and communicating their concerns to their family members. The next week, I would begin the individual work with following up on their thoughts, feelings and challenges from the family session.
- Briefly discuss the following: 1st session- hair across face, no eye contact, disengaged, quiet, barely spoke 2nd session- slightly more engaged, minimal eye contact, hair across the face I started to ask her to pull her hair away from her face, and ask her more nondirective questions, which resulted in her opening up more, talking more and engaging in the activity. She was admitted to the hospital due to medical instability, in which I attended the hospital to complete our weekly sessions with her. This was helpful as she was able to maintain a relationship while also feeling supported while being hospitalized. It also allowed us to not lose the progress that we made with her and her family. 5th session her hair was pulled out of her face, she was engaging in the topics and making changes in her own life. She cut her hair and purchased new clothing, and her hygiene improved. 6th session introduced DBT work with her on distress tolerance and mindfulness. She self identified the goal of cleaning her room and creating a safe and comfortable environment for her to feel independence and be able to relax. Working step by step over the next sessions we created lists of tasks/changes she wanted to make and supported her in communicating this with her family. Discussed a lot about how her parents referred to this list as a “wish list”. This made her feel as if it would not happen, and she was visibly upset by this disappointment. The following week she had a significant increase in purging behaviours and weight loss and was returned to the hospital. After she returned from the hospital, she was able to make the connection between her eating disorder behaviours and her emotional avoidance. Her inability to have control and cope with her emotions results in the relief that comes with purging. I asked her whether she was ready to discuss this with her parents or not and she agreed to but with support from myself. When in the family session she was open and clear with her parents stating “she was ashamed because of all the junk”. There was confirmed hoarding in this session and the family was pushed to make changes to benefit the client and her sister, emphasising the connection of the purging behaviours and her emotional avoidance with the stress of the hoarding present in the household. Unfortunately, this happened only a few weeks ago. I wish I could still be working with her as it was clear she is ready to make some changes in her life and just requires some extended support and guidance. When reviewing the work she has completed with her parents in the final session, everyone was pleased and stated they noticed a difference in her over the past few weeks.
- Briefly discuss the following: Obsessive Compulsive Disorder – severe case Say everything as positive her world and everything in it revolved around being her present weight. Stated she never gets upset or has arguments with friends or family reported all positive thinking not taking any medication Completed a lot of psychoeducational work. She was engaged and open to discuss it non-directively. She often responded to questions by asking a question back to me. For example “What are characteristics of high self esteem?”, “I don’t know. What do you think a characteristic would be”. When asked for her to complete coping skills or work on cognitive distortions at home she would state “if you really want me to I will but it will not help me”. She would complete the work as asked, but she was not reflecting on it or doing it for herself which made it unsuccessful. As soon as a conversation or intervention would be directive and asking her to reflect and relate to it she immediately would shut down and become non-responsive. One time she started to cry, almost like a paralyzing cry and the week after when asked about it she said she was okay and just went home after. Although her mother reported that she had a “meltdown” outside of the elevators before leaving the hospital. Her mother’s coping for it is to let it pass. The work I was doing with her was unbeneficial for both herself and I. Her insight into her illness was so minimum that the discussions were general and was unlikely to go in a direction of directive work anytime soon. She stated enjoying meeting with me but did not enjoy talking about her feelings. The sessions were no longer therapy work so they were discontinued temporarily.
- It is common that those with eating disorders have difficulty managing emotions. They may try to avoid feelings, thinking about and acknowledging emotions. Eating disorders live in fear of failure. Not ready to change – refer to motivation to change no insight eating disorder has to much control Complications in diagnosis – untreated mental health Medical instability If the individual is not meeting their caloric intake, their brain does not have the required energy to meet the needs of the self regulatory system. This involves the part of the brain that creates meaning, regulates our roles as social beings, our values, and complex functioning. When the self regulatory system is not stimulated properly, the individual may have difficulty with the following: social cognition, emotional regulation, emotional expression, decision making, flexibility, and planning. (Collaborative Care: Working together to Manage Eating Disorders- A Toolkit for Carers)
- Our primary goal in all settings is to help adolescents and children achieve physical and emotional health. Although weight is a primary concern, an adolescent’s mental health can play a significant influence on their engagement in the refeeding process. An inpatient transfer for symptom interruption is causes significant interruption in therapy progress in the outpatient services. Since we have no inpatient eating disorder specific services available in Kingston we use the generic child and adolescent floors (medical and psychiatric). Because there is no specific services, when our clients move to inpatient they are not receiving the care specific to eating disorders. Eating disorders is a speciality and therefore not a requirement of knowledge for nurses, social workers, doctors, etc. It is not that they are incapable of completing eating disorder specific care but rather that they are not educated in regards to this lethal illness. Due to the difference in hospitals, departments and transfer of care our outpatient team has little to no control over what therapy interventions are being discussed with the client. It is likely that our treatment and suggestions will vary and therefore cause an inconsistency and manipulative tool for the eating disorder upon return to outpatient treatment. When structure and communication are not present in a therapeutic milieu there is likely to be inconsistencies, holes in the treatment and a “to many cooks in the kitchen mentality” for the family and the professionals.
- Case #1 was in the hospital and we were completing our individual work. The session ran right until her meal time so I chose to end the session when the meal arrived. Immediately she refused the meal, and stated she wanted an “Pedisure” instead. The family was meeting with Patricia down the hall, so I consulted with them explaining that she was refusing a meal and would benefit from some refeeding efforts from the family. This is when it became clear that the family was not utilizing skills to refeed. Instead they were giving in and giving her a pedisure. This would have been a productive opportunity to work with the family in coaching them in how to coach their daughter to refeed. However, as an outpatient support from another hospital it was not our place to stage an intervention although it was necessary. So at times, although the hospital is the “safest” it can potential the family to lack follow through with their refeeding responsibilities.
- If the inpatient and outpatient services could come together, each specializing in family based therapy for eating disorders then progress could be made with the family throughout their entire treatment rather than being split up. There is follow through on behalf of the inpatient and outpatient services as they follow the clients to where their treatment is- building the interdisciplinary team. The family and clients have extra support and guidance- they do not feel like they are being passed through the systems of treatment It provides the family and the professionals an opportunity to demonstrate healthy relationships, reliability, dependability and care. Without the interruption in treatment they may be able to progress quicker and the hospital will not be seen as a “mini vacation” for some families.
- Specific Beds Educating others Communication between services Outpatient and inpatient coordination
- Best memory Difficult moment Change one things about services available Most helpful part Advice I’d give a student What has stuck with me the most