Transcript Building Your Clinical Toolbox: Advanced Treatment

Eating Disorders:
A CBT Approach
Beverly Swann, MFT
[email protected]
www.beverlyswann.com
925-705-7036
Jennifer Lombardi, MFT, Content Contributor
Let’s Get Started
 Logistics
 Learning Objectives
 Introductions / Expectations
 Syllabus / Flow of Class
 Disclaimer
Please Do:
 Ask questions
 Bring in material from your clients, taking
appropriate measures to protect identity
 Ask me to slow down or repeat material if
needed
 Network with each other during breaks
Please Don’t:
 Cell phones ringing
 Take calls during class
 Text during class
 Side conversations
 Arrive late
 Discuss any client information presented in
class with anyone outside of class
Learning Objectives
 Learn the DSM criteria for eating disorders (ED)
 Understand common themes in ED related to body
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image and weight beliefs.
Know the health problems that can occur from ED
Develop knowledge of the biopsychosocial theories
about ED
Apply assessment tools and a Cognitive Behavioral
Theory (CBT) case formulation to determine level of
care needed and appropriate treatment interventions
Develop skills in applying CBT strategies to treat ED
*Learn a lot of resources to learn more!
Introductions / Expectations
Your name
Experience/knowledge Eating Disorders
and/or
Cognitive Behavioral Theory
Expectations for the class
Why CBT?
 ED is complex disorder, commonly w/co-
occurring disorders
 Have to address behavior as well as emotion
 Malnourished clients have difficulty using
insight to make long-term change
 Provides structure and stability for anxious
clients
Eating Disorder – DSM IV-TR
Anorexia Nervosa
• Underweight (at or
below 85% ideal)
• Disrupted menses
• Fear of gaining
weight/being fat
• Sometimes
purging behavior
• Body/self-image is
distorted
• Restricting Type,
Binge/Purge Type,
Atypical
Bulimia
Nervosa
• Normal or
overweight
• Binge eating with
compensatory
behaviors
• Fear of gaining
weight/being fat
• Body/self-image
is distorted
• Purging Type and
Non-Purging
Type
EDNOS
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•
Anorexia criteria
met but still
having menses or
weight is still in
normal range
Atypical eating
disorders
Binge eating
disorder/compulsi
ve eating
Food aversion
Orthorexia
Diabulimia
Night eating
Compensatory Behaviors
 60%
 25%
 5%
 5%
 5%
?
Self-induced vomiting
Laxatives
Compulsive Exercise
Diet pills
Diuretics
Restricting food
DSM-V – ED Proposed Additions
(May 2013?)
 Avoidant/Restrictive Food Intake Disorder
(food aversion)
 Binge Eating Disorder
 Feeding and Eating Conditions Not
Elsewhere Classified (more defined than
NOS)
www.dsm5.org
DSM V: Binge Eating Disorder
 Binge eating - Average of 2 times per week for 6
months
 No compensatory behaviors
 Associated with at least 3 of the following:
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Eating more rapidly than normal
Eating until uncomfortable full
Eating large amounts of food when not hungry
Eating alone out of embarrassment of how much one eats
Feeling disgust, depressed, guilty after overeating
More About Binge Eating Disorder
 2-5% of the American population suffers from
binge eating disorder
 Men constitute 40% of those with BED
 Onset usually occurs during late adolescence
or in early adulthood
Medical Issues and Complications* Anorexia Nervosa
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Cardiac issues (bradycardia, tachycardia, orthostasis)
Problems w/kidney and liver function
Low glucose and/or sodium
Reduction of bone density (osteopenial/osteoporosis)
Muscle loss and weakness
Severe dehydration, which can result in kidney failure; fainting,
fatigue, and overall weakness.
Lanugo – growth of extra body hair on arms, chest, and back
Hair and Nail thinning
Amenorrhea
Edema
Sleep disruption
Dental/enamel loss
Tinitis
*www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/HlthCons.pdf
Medical Issues and Complications Bulimia Nervosa
 Cardiac issues (bradycardia, tachycardia,
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orthostasis)
Esophageal ruptures/tearing (blood in vomit, cancer)
Electrolyte imbalances
Elevated CO2
Edema
Sleep disruption
Dental/enamel loss
Low glucose
Low sodium
Swollen parotid glands
Blood in stool
Medical Issues and Complications –
EDNOS/BED
High blood pressure
High cholesterol levels
Heart disease as a result of elevated triglyceride levels
Type II diabetes mellitus
Gallbladder disease
Obesity
Joint/Muscle pain
Cancers
Gastrointestinal problems
Sleep apnea
Etiology
Genetics loads the gun,
and
environment pulls the trigger.
Craig Johnson, PhD
Five Reasons Why
An Eating Disorder Develops
 Genetics Loads The Gun:
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Biology
Personality Traits/Temperament
 And Environment Pulls The Trigger:
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Trauma/loss
Family Dynamics
Culture
Initiating Risk Factors
 The brain’s signal for hunger is turned down
 Anterior Insula
 Posterior Insula
 Taste is experienced differently for patients
with anorexia
 Patients with ED do not experience normal
“reward” for eating food – anorexia or binge
 Diminished self-awareness of internal body
states (dissociation)
 Family history of anxiety and/or depression
Neurotransmitters:
Development And Maintenance Of Eating Disorders
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Dopamine
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Correlated with harm avoidance
Insensitivity to normal rewards (Frank, et al 2005)
Serotonin
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High level associated with anorexia
Low levels associated with bulimia/ binge eating
disorder
Affect instability
Impulsivity
Self harming behavior
Interpersonal insecurities (Steiger et al, 2006)
Video – Erasing ED
Notice:
• Environmental factors
• Emotional factors
• Behaviors
• Temperament
• Medical complications
• Thoughts/beliefs
Cognitive Behavioral Therapy
“There’s nothing good or bad,
but thinking makes it so.”
- Shakespeare’s Hamlet
Cognitive Behavioral Therapy
 Core Concepts
1.
Thoughts cause our feelings and behaviors
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2.
Time-Limited
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3.
Not external factors (people, places, etc.)
Average of 16 to 20 sessions
Therapeutic alliance important… but not the
answer

Change occurs because client learns how to
think differently and, as a result, act differently
Cognitive Behavioral Therapy
 Core Concepts Continued
4. Goal-oriented
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Collaborative – therapist listens, teaches
and helps client implement learning
5. Stoicism
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Emphasis is on being calm
6. Socratic method
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Ask questions & encourage client to do
the same
Cognitive Behavioral Therapy
 Core Concepts Continued
7. Teach clients how
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Using specific techniques, structure and
foster patient’s skills
8. Education-focused
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Concept of “unlearning”
9. Inductive method
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Look at thoughts as “hypotheses” to be
explored
10. Homework!
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Reading assignments and practice,
practice, practice!
Cognitive Behavioral Therapy

Stages of CBT
1.
Identify problems
 Prioritize
2.
Recognize thoughts, beliefs, feelings about
the problem
 “Self talk”
 Interpretations
 Beliefs about self, relationships, situations, etc.
3.
Identify faulty thinking
 Record physical, emotional and behavioral
reactions/responses
4.
Challenge faulty thinking
 Validity testing… again and again
CBT: Important Factors for the Patient
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Therapeutic alliance
Honesty
Consistency/attendance
Expectations – progress varies
Won’t work without doing homework
Express frustrations
CBT: Important Factors for
the Therapist
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Don’t forget about the alliance &
empathy
Have a clear approach & communicate
Go to the core belief(s) about the
irrational thoughts
Can’t just identify irrational thoughts –
have to go the distance to help client
find new/replacement thought
Talk about the roadmap – but
encourage/empower the client to drive
Cognitive Behavioral Therapy
 History
 Behavioral therapy developed in the early 20th century
 Jones’ work in “unlearning” fears with children
 Pavlov’s work in the 1950’s
 Wolpe’s work with systematic desensitization with
animals
 B.F. Skinner’s “radical behavioralism” with psychiatric
disorders
Cognitive Behavioral Therapy
 History
 Cognitive therapy developed in the mid 20th century
 “Cognitive revolution” – a reaction to behavioralism
 Added “mentalistic” thoughts and cognitions
 Present-focused
 Albert Ellis’ Rational Therapy
 First form of cognitive behavioral therapy
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Aaron T. Beck Cognitive Therapy
 Discovered through free association
 Recognized certain thoughts preceding certain emotions
Cognitive Behavioral Therapy
 History Continued
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In 1980’s Merging of the Two Approaches
Occurred
 Clark and Barlow for panic disorder
 Arnold Lazarus’ multimodal therapy
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Included physical sensations
Visual imagery
Interpersonal relationships
Biological factors
Homework
 Using Assessment Worksheet, analyze one
or more clients you currently have or have
treated in the past.
Assessment & Diagnosis
 Initial Comprehensive History Includes:
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Eating disorder behaviors – current and past
Substance abuse – current and past
Treatment history – including medications
Medical complications
Social support
Temperament
Culture
History of trauma and loss
Family history of mental health, medical issues
History of abuse, self injury, suicidality
What patient views as causes - Often focuses on social as primary,
intrapersonal distress secondary. Rarely recognize biological.
Assessment – Collaborating With
Other Professionals
 Importance of treatment team
 Primary Care Physician (PCP)
 Psychiatrist
 Other therapists
 Treatment centers
 Dietician
 Release of Information forms!
Common Co-Occurring Disorders
Substance Abuse/Dependence
Depression
Anxiety
PTSD
Obsessive-Compulsive Disorder
Common Co-Occurring Disorders
Body Dysmorphic Disorder
Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Other Addictions
Medical Illnesses
Co-Occurring Disorders
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Anorexia
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Anxiety disorders – often pre-date the ED
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Obsessive compulsive disorder
Social phobia
GAD
Major Depression
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Axis II?
Bulimia
 Affective Disorders
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Major Depression
Bipolar Disorder
GAD
Substance Abuse
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Alcohol, marijuana
Co-Occurring Disorders
 Binge Eating Disorder
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Affective Disorders
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Major Depression
Bipolar Disorder
GAD
PTSD
Axis II
Co-Ocurring Disorders –
Personality Disorders
 ED clients with Borderline Personality Disorder
 Prognosis not great
 Treatment resistant
 Suicide and self-harm concerns
 ED clients with Obsessive-Compulsive PD
features
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Perfectionism
Food Rules
In Anorexia, difficult to differentiate
from starvation effects
Co-Occurring Disorders
 Example 1:
Janice is a 19 year old Olympic hopeful swimmer who has just
completed 6 weeks of treatment for bulimia. She reports that her
daily routine includes coffee at Starbucks and carrot sticks
during breaks at practice, and appetizers when she goes out
with her friends at night. She likes to go hot-tubbing after hitting
the bars.
 Example 2:
Mari comes to your office after being referred for domestic
violence counseling. She weighs approximately 220 pounds and
her complexion is very red, especially around the nose and
cheek area.
Trauma or Loss
 Several studies of both ED and PTSD
patients have shown:
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Estimated 30 to 45 percent have some trauma
history
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Sexual
Physical/neglect
Culture
 42% of 1st-3rd graders girls want to be thinner
 45% of boys and girls in 3rd-6th grades want to be
thinner
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37% have already dieted
 51% of 9-10 year olds feel better about themselves
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when dieting
9% of 9 year olds have vomited to lose weight
81% of 10 year olds are afraid of being fat
78% of 18 year old girls are unhappy with their
bodies
The #1 wish for girls 11-17 years old is to lose weight
Body Wars, Margo Maine
Culture
 Society Does Not Cause Eating Disorders
 BUT… creates toxic environment
“Genetics loads the gun
and environment pulls the trigger.”
Craig Johnson, PhD
Cultural Considerations
Research shows that eating disorders are not limited to
young, caucasian females. Studies have found rates
of ED to be roughly the same in several other ethnic
groups.
Factors to be aware of:
 Likelihood of seeking treatment – Asian and Hispanic
populations tend to utilize available treatment at a
lower rate than caucasians; African American and
Native American populations have a higher rate of
utilization
 Access to treatment
 Language barriers
Cultural Considerations
Acculturation
Socio-economic status – County clients
Gender considerations
Gay/lesbian populations
List of recommended readings:
www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/IncorpDi.pdf
www.nationaleatingdisorders.org/nedaDir/files/documents/handouts/WomenCol.pdf
Temperament
 Anxious
 Perfectionist
 Obsessional
 Harm or conflict avoidant
 Low Self-directedness
 Reward dependent
 Impulsivity (BN)
Temperament Associated with BED
 Perfectionistic
 People pleasing
 Rigid, inflexible thinking
 Difficulties expressing needs and emotions
 Conflict or harm avoidant
 Impulsivity
 Reward dependence
Personality Traits/Temperament
 Temperament & Character Inventory
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Harm Avoidance (AKA: “Peacemakers”)
Low Self-Directedness
Reward Dependence (AKA: Perfectionism)
Novelty Seeking (AKA: Impulsivity)
The Psychology of Eating Disorders
 How Patients Experience Eating Disorders
 Security (something is constant, stable)
 Avoidance (emotional numbing, isolating)
 Mental Strength (finally feeling good at something)
 Self-Confidence (getting praise)
 Identity (feeling of invincibility)
 Elicit Care (from others, without having to ask)
 Communication (communicating difficulties)
 Death (passive way to suicide)
Nordbo, et al, 2006
Types of Assessment
 Bio-psycho-social
 Medical evaluation
 Psychiatric evaluation
 Nursing assessment
 Nutrition assessment
Assessment – Screening Tools
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Eating Disorder Questionnaire (EDQ)
Obligatory Exercise Scale
Addiction Severity Index (ASI)
Adult ADHD Self-Report Scale (ASR-v1.1)
Alcohol Use Disorder Identification Test (AUDIT)
Michigan Alcoholism Screening Test (MAST)
Drug Abuse Screening Test (DAST)
Beck Depression Inventory (BDI)
Beck Scale for Suicide Ideation (BSS)
Beck Anxiety Inventory (BAI)
Brief Symptom Inventory (BSI)
Mood Disorder Questionnaire
URICA (readiness to change)
FRIEL Co-dependency Inventory
Multiscale Dissociation Inventory (MDI)
Assessment Tools
 EDI III – based on females aged 13-53
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History
91 items
12 Primary Scales
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3 ED specific
9 General psych (but highly relevant to ED)
6 Composites
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ED Risk
Ineffectiveness
Interpersonal Problems
Affective Problems
Overcontrol
General Psych Maladjustment
Sample evaluation
 Context of What You Know About Patient and Family/Loved Ones
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Assessment Tools
 Obligatory Exercise Questionnaire
 Comparison
 Scales
 30 – 40 mild concern
 40 – 50 moderate concern
 50 + serious concern
 Sample evaluation
 Context of What You Know About Patient and
Family/Loved Ones
Assessment Tools
 Temperament and Character Inventory
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7 “Personality Dimensions”
 4 Temperament
 Harm Avoidance, Novelty Seeking, Reward
Dependence, Persistence
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3 Character
 Self-directedness, Cooperativeness, Selftranscendence
Assessment Tools
 Common combinations:
 Anorexia
 Temperament
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High harm-avoidance
Low novelty-seeking
High reward-dependence
High persistence
Character
 Self-directedness varies
 High cooperativeness
 Low self-transcendence
Assessment Tools
 Common combinations:
 Bulimia
 Temperament
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Harm-avoidance varies
High novelty-seeking
High reward-dependence
Low persistence
Character
 Low self-directedness
 Cooperativeness varies
 High self-transcendence
Treatment - Levels of Care
 Outpatient – typically once a week therapy
 Intensive Outpatient (IOP) – 3-4 days/week,
half-day
 Partial Hospitalization (PHP) of Day
Treatment – 4-5 days/week, full-day
 Residential – 24/7 treatment,
client does not go home
 Inpatient – 24/7 medical
treatment to stabilize patient
medically – usually short-term
Treatment Focus
 Medical/Nutrition Stabilization for medically
compromised clients
 Weight restoration for underweight clients
 Neuronal plasticity – brain circuitry is modified
by experience – CBT!
 Resolve trauma
 Develop new habits
 Grieve loss of ED
 Discover “Who Am I Without ED?”
Video – Erasing ED
Notice:
• Co-occurring disorders
• Behavioral changes
• Thought changes
• Belief changes
• Possible CBT interventions
Cognitive Behavioral Therapy

Stages of CBT
1.
Identify problems
 Prioritize
2.
Recognize thoughts, beliefs, feelings about
the problem
 “Self talk”
 Interpretations
 Beliefs about self, relationships, situations, etc.
3.
Identify faulty thinking
 Record physical, emotional and behavioral
reactions/responses
4.
Challenge faulty thinking
 Validity testing… again and again
Cognitive Behavioral Therapy

Things to Consider When Identifying
the Problem(s)
 Gravity/severity of illness
 Length of symptoms/situation
 Rate of progress made during
treatment
 Level of stress-tolerance
 Support system
CBT – Cognitive Distortions
1) Filtering
2) Black & White
Thinking
3) Overgenerlization
4) Jumping to
Conclusions
5) Catastrophizing
6) Personalization
7) Control Fallacies
8) Fallacy of Fairness
9) Blaming
10)Shoulds
11)Emotional
Reasoning
12)Fallacy of Change
13)Global Labeling
14)Always Being Right
15)Heaven’s Reward
Fallacy
http://psychcentral.com/lib/2009/15-common-cognitive-distortions/
CBT Interventions
H
= Hungry – am I physically hungry?
A
= Angry (or other emotion) – am I emotionally hungry?
L
= Lonely – am I lonely?
T
= Tired – do I need sleep rather than food?
CBT Interventions
 Case Formulation – Vicious Flower
 Recording
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Food/Mood Log
How Treatment is Going
 Identifying Barriers to Change
 Identifying “Rules”
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Eating rules
Exercise rules
 Address impact of events on eating
CBT Case
Formulation
BeliefDriven
http://www.psychologytools.org/download-therapy-worksheets.html/
CBT Case
Formulation
Vicious
Flower
http://www.psychologytools.org/download-therapy-worksheets.html/
CBT - REBT
Ellis’ Rational Emotive Behavior Therapy
(REBT)
 ABC
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A = Adversity or activating event
B = Belief(s) about the event
C = Consequences (dysfunctional emotional and
behavioral)
 Focus on evaluating B
 Look for assumptions and thoughts that are
illogical, rigid, unrealistic &/or self-destructive
CBT - REBT
REBT assumes that humans have innate rational and
irrational tendencies
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Irrational tendencies:
Self-blame
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Criticism
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Anger
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Depression and anxiety
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Avoidance
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Addiction
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Procrastination
How might these show up in an eating disorder client?
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CBT - REBT
 Primary goal: You Have A Choice
To engage in helpful thoughts or selfdestructive thoughts
 Helpful emoting is good – unhelpful is
problematic
 Ingrain them over time with practice
 Major Insights
 Irrational beliefs are “root” of issues
 People tend to hold on to irrational
beliefs, so focus on identifying,
questioning and change
 Insight alone rarely uproots
emotional/psychological issues
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REBT – 3 Core/Common SelfDestructive Beliefs
“I absolutely must, under all conditions, perform well and win the
approval of others. If I fail… I am a bad, incompetent person, who will
probably always fail and deserves to suffer.”
 Contributes to anxiety, panic, feelings of despair, hopelessness,
depression and low self-worth
2. “Other people… MUST, under practically all conditions and at all
times, treat me nicely, considerately and fairly. Otherwise, it is terrible
and they are rotten, bad, unworthy people who will always treat me
badly and do not deserve a good life...”
 Contributes to anger, rage, vindictiveness
3. “The conditions under which I live absolutely MUST, at all times, be
favorable, safe, hassle-free and… enjoyable. If they are not… it’s
awful and horrible and I can’t bear it. I can’t ever enjoy myself… my
life is impossible and hardly worth living.”
 Contributes to frustration, intolerance, self-pity, procrastination,
avoidance and feeling paralyzed.
1.
REBT – Long-Term Goals
 Humans are fallible – move toward
unconditional self-acceptance
 Accepting what they can and cannot
change about the world
 Assessing skills
 Insight is not enough – move toward
challenging and changing irrational/selfdestructive beliefs
REBT Core Beliefs
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Each of the 3 core beliefs have the following in common:
 Awfulizing
 Frustration intolerance
 People depreciation or de-valuing
 Over-generalizing
 Catastrophizing
Each of the 3 core beliefs are dogmatic, rigid and over-use:
 Shoulds
 Musts
 Oughts
Often lead to the patient being self-critical - they become aware of
these beliefs on some level and become frustrated that they cannot
change this quality/dynamic within themselves
REBT Interventions
1. Acknowledging the problem
2. Accepting emotional responsibility
3. Assessing, questioning and ultimately
changing
4. Uses various methods, depending on
problem
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Cognitive
Emotive
Behavioral
REBT and Eating Disorders
 Useful with Temperament and Character
 Irrational tendencies:
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Self-blame – High Persistence (perfectionism)
Criticism – Low Cooperativeness (blaming)
Anger – High Novelty-seeking
Depression and anxiety – High Rewarddependence
Avoidance – High Harm Avoidance
Addiction – High Persistence (social
attachment)
Procrastination – High Harm Avoidance (fear)
REBT and Eating Disorders
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REBT and Eating Disorders
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Using the ABC
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A = Adversity or activating event – Body Changed
During Puberty
B = Belief(s) about the event –
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I can’t trust my body
My body will gain weight forever
I can’t trust myself with certain foods
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C = Consequences (dysfunctional emotional and
behavioral) – I must always be on a diet to control my
body weight (or eventually I need my eating disorder)
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Focus on evaluating B
 Look for assumptions and thoughts that are
illogical, rigid, unrealistic &/or self-destructive
Linehan’s Dialectical Behavioral
Therapy (DBT)
 Originally designed for treating Borderline
Personality Disorder
 Combines CBT techniques with Mindfulness
and Distress Tolerance
Uses cognitive challenges around distorted
thoughts/beliefs
 Mindfulness training as self-soothing skills
 Research indicates effectiveness with mood
disorders, self-injury, sexual abuse survivors and
substance abuse
 Therapist is an “ally”

DBT Basics
 Four Basic Modules in DBT Treatment
 Mindfulness - “What” and “How”
 Distress Tolerance
 Emotion Regulation
 Interpersonal Effectiveness
 3 Primary Techniques/Tools
 Diary Cards
 Chain Analysis
 Milieu
DBT – Basic Modules
1. Mindfulness – to challenge impulsivity
“What” – describe an event w/o taking emotions
and thoughts literally
 “How” – how patient attends and participates in
the event; focus on taking a non-judgmental
stance – event is neither “good” nor “bad”
2. Interpersonal Effectiveness
 Asking for what one needs
 Saying “no”
 Coping with interpersonal conflict

DBT Basic Modules
3. Emotion Regulation Skills
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Identifying and labeling emotions
Identifying obstacles to changing emotions
Reduce vulnerability to the “emotional mind”
Increasing positive events, mindfulness
Taking “opposite action” (doing something nice when you
are angry)
4. Distress Tolerance Skills
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Accepting one’s environment
Not placing “demands” on it to be different
Experience emotions without trying to stop or change them
Observe thoughts/actions without trying to stop/or control
them
Key component: acceptance of reality is NOT equivalent to
approval of reality
DBT Primary Techniques/Tools
 Diary Cards
Start with Myths Sheets (handout – G)
 Move to Diary of day, event, emotion’s function
 Chain Analysis
 Look at environmental and personal antecedents
to event
 Consequences of event
 At what point(s) could different choice(s) have
been made
 Milieu
 Provides rich learning opportunity to practice
skills on regular basis

DBT Interventions
1. Mindfulness – What & How = challenge
impulsivity of behaviors
2. Interpersonal Effectiveness – Saying “no”
and coping with conflict = challenges harm
avoidance, reward dependence
3. Emotion regulation – reducing vulnerability
to emotional states = challenges harm
avoidance, high novelty seeking
4. Distress tolerance – accepting/not trying to
change environment = challenges novelty
seeking, harm avoidance
CBT-E
 Created by Christopher Fairburn, associates
 An “enhanced” version of CBT
 Emphasizes processes that maintain ED
psychopathology – not initial development
 Goal is to create a “formulation” or
hypothesis of the processes that maintain
the “Eating Disorder Mindset” - These
become the features targeted in treatment
CBT-E Stages
 Time-limited: 20 sessions (40 for acute AN)
 Four Stages
 Stage One – 2x/week for 4 weeks
1. Establish trust
2. Formulate hypothesis of processes that maintain
ED
3. Establish Two Things


In-session Weighing
Regular Eating
CBT-E Stages
Stage Two – 1x/week for 2 weeks
1. Take stock in stability with behaviors, weight
2. Plan stage 3 – tackling mechanisms that maintain ED
 Stage Three (the Bulk of Treatment) – 1x/week for 8 weeks
1. Addressing Shape Checking, “Feeling Fat” and Mindsets

Use pie charts, monitoring records, life chart,
2. Addressing Dietary Rules

Food avoidance list
3. Events, Moods and Eating

Problem solving chart, slowing down/observing and
analyzing, pros and cons list for ED, reasons to change
list

CBT-E Stages
 Stage Four (Ending Well) – 1x/every 2
weeks for one month
1.
2.
3.
Empowering patient to “do the right
thing” and reinforcing competency
Distinguishing “lapse” from “relapse”
Learning the stages/warning signs for
return of the ED mindset
Video – Erasing ED
Notice:
• What improved in their lives?
• Life without ED?
• Hope
Local ED Treatment Centers
 Casa Serena – IOP, Concord
 Cielo House – IOP, PHP, Belmont and San Jose
 Herrick/Alta Bates – Inpatient/Outpatient, Berkley
 La Ventana – IOP/PHP, San Francisco, San
Jose, and Marin (some dual diagnosis treatment)
 New Dawn – PHP, San Francisco (some dual
diagnosis treatment)
 Summit – IOP/PHP/Residential
Wrapping It All Up
Question / Answer / Review
Eating Disorders:
A CBT Approach
Beverly Swann, MFT
[email protected]
www.beverlyswann.com
925-705-7036
Jennifer Lombardi, MFT, Content Contributor