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Family Therapy and Mental Health

University of Guelph

Office of Open Learning

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Reflections on the Course So Far

Comments Questions Assignments

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Today

This is the End! Family Therapy and Eating Disorders Life in the CRPO Jeopardy Evaluations

Family Therapy &Eating Disorders

Assessment and Treatment

Spectrum of Weight-related Disorders

AnorexiaNervosa

BulimiaNervosa

Disordered Eating

Unhealthy Dieting

Binge Eating Disorder

Obesity

DSM 5 Criteria: AN

A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.

B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.

C. Disturbance in the way in which one’s body, weight or shape is experienced, undue influence of body, weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight.

DSM 5 Criteria: AN

Restricting type: during the last 3 months, the individual has not

engaged in recurrent episodes of binge eating or purging behaviour. This subtype describes presentation in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise

Binge-eating/purging type: during the last 3 months, the individual has

engaged in recurrent episodes of binge eating or purging behaviour

DSM 5 Criteria: BN

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

Eating, in a discrete period of time (any 2 hr. period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

A sense of lack of control over eating during the episode (can’t stop or control what or how much one is eating)

DSM 5 Criteria: BN

2. Recurrent inappropriate compensatory behaviours in order to prevent weight gain (e.g. vomiting; use of laxatives, diuretics, enemas, or other meds; fasting or excessive exercise)

3. The binge eating and inappropriate compensatory behaviours both occur, on average, at least 1x/wk for three months

4. Self-evaluation is unduly influenced by body shape and weight

5. The disturbance does not occur exclusively during episodes of AN

DSM 5 Criteria: BED

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

Eating, in a discrete period of time (any 2 hr. period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

A sense of lack of control over eating during the episode (can’t stop or control what or how much)

DSM 5 Criteria: BED

B. The binge-eating episodes are associated with three (or more) of the following:

Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not hungry Eating alone because of embarrassment Feeling disgusted with oneself, depressed, or very

guilty afterward

DSM 5 Criteria: BED

C. Marked distress regarding binge eating is present

D. The binge eating occurs, on average, at least 1x/wk for 3 months

E. The binge eating is not associated with the regular use of inappropriate compensatory behaviours and does not occur exclusively during the course of AN or BN

Eating Disorders:Prevalence

Total # of cases in the population Indicates the demand for care Anorexia

0.3% for young females Bulimia

1% in women; 0.1% in men Binge Eating

1% in general population

(van Hoeken, Seidell & Hoek, 2005)

Eating Disorders:Incidence

# of new cases in pop. in a specified period of time (usually one year)

Represents the moment of detection vs. onset

Anorexia 8 per 100,000

Bulimia 12 per 100,000

(van Hoeken, Seidell & Hoek, 2005)

Eating Disorders &Mortality

mortality rate associated with AN is 12 times higher than the death rate of ALL causes of death for females 15 – 24 years old

20% of people suffering from anorexia will prematurely die from complications related to their eating disorder, including suicide and heart problems

National Association of Anorexia Nervosa and Associated Disorders

Etiologyor

Etiology

Eating disorders are multi-determined “Unlike some illnesses, recognizing the

cause(s) does not necessarily suggest a solution” (Lask & Bryant-Waugh, p. 51) e.g. CBT approach (Fairburn)

Predisposing, precipitating and perpetuating factors

Individual, family, and sociocultural factors

Assessment

ScreeningThe SCOFF Questionnaire

1. Do you ever make yourself Sick because you feel uncomfortably full?

2. Do you ever worry you have lost Control over how much you eat?

3. Have you recently lost more than One stone (6.35 kg) in a three month period?

4. Do you believe yourself to be Fat when others say you are too thin?

5. Would you say that Food dominates your life? A score of more than 2 positive answers indicates a

need for a more detailed assessment(John Morgan, BMJ, 1999)

AssessmentSymptoms of AN

weight loss amenorrhea depression irritability sleep disturbance fatigue weakness headache

dizziness faintness constipation non-focal abdominal

pain feeling of “fullness” polyuria intolerance of cold

Mehler & Andersen, 1999

AssessmentSigns of AN

emaciation hyperactivity cardiac arrhythmia congestive heart

failure bradycardia hypotension dry skin brittle hair

brittle nails hair loss on scalp “yellow skin”,

especially palms lanugo hair cyanotic and cold

hands and feet edema (ankle,

periobital)Mehler & Andersen, 1999

AssessmentSymptoms of BN

weight fluctuation irregular menses esophageal

burning/heartburn nonfocal abdominal

pain abdominal bloating/gas lethargy fatigue

headache constipation/diarrhea/

hemorrhoids swelling of hands/feet frequent sore throats depression swollen cheeks,

parotid/ submandibular gland enlargement

Mehler & Andersen, 1999

AssessmentSigns of BN

calluses on the back of the hand

salivary gland hypertrophy

erosion of dental enamel

periodontal disease tooth decay brittle nails

petechiae perioral irritation mouth ulcers blood in vomit edema (ankle,

periorbital)

Mehler & Andersen, 1999

Assessment

Multi-disciplinary Individual

Interview, self-administered questionnaires Family

Genogram, ecomap, family history Boundaries, communication, conflict, emotional

expression, etc. Nutritional Medical

Medical history, physical examination, lab tests

Assessment

Individual Interview Get the “story” of the client’s problem(s) “What brought you here today?” Obtain a complete history of ED

Track when and how concerns arose and how they translated into specific behaviours

How it started, when it was at its worst, what it’s like now Detailed nutritional history

Describe a typical day of eating Vegitarianism/veganism, nutritional supplements Perceptions about family’s view on food, weight loss, and

health

Assessment

Individual Interview Weight and shape concerns Other changes: isolation, mood, school, social Other mental health issues/diagnoses Self-harm and suicidality Family stressors/changes For adolescents:

Smoking, drinking, abuse of street drugs or medications

Sexual history Abuse history

AssessmentComorbidities

50-75% depression/dysthymia 25% O.C.D. (lifetime prevalence) 30%-37% substance abuse in B.N. 12%-18% substance abuse in A.N.

(binge-purge type) 42%-75% personality disorders 20-50% sexual abuse

AssessmentBody Mass Index

AssessmentBody Image

(Figure Rating Scale, Skunkard & Sorenson, 1987)

Measure of Body Image Distortion- Select the body that best represents the way you think you look- Interviewer estimates actual size- Degree of distortion = actual – perceived

AssessmentQuestionnaires

Most popular: Eating Disorder Inventory 3 (Garner, 2004)

91 item self-report Drive for thinness, bulimia, body dissatisfaction

Eating Disorder Examination 16.0 (Fairburn, Cooper & O’Connor, 2008) Structured clinical interview, used most in research EDE-Q 6.0 – 28 item self-report; validated with EDE

Eating Attitudes Test (Garfinkel & Garner, 1979) 26 item self-report of symptoms

AssessmentFeatures of Medical Concern

Marked food or fluid restriction Frequent self-induced vomiting (>2x/day) Frequent laxative or diuretic misuse (>2x/day) Heavy exercising when underweight Rapid weight loss (>1kg/week for several weeks) BMI of 17.5 or below Episodes of feeling faint or collapsing Episodes of disorientation, confusion or memory loss Chest pain, shortness of breath Swelling of ankles, arms or face Blood-stained vomit

AssessmentFamily Sessions

Meet with both parents and client, if possible Discuss confidentiality Complete genogram

At least three generations (child, parents & grandparents)

Try to engage each member, allow client to listen while mom and dad are interviewed (re. family secrets)

Ask about: addictions, abuse, moves, work, school, bullying, separation/divorce, miscarriages, any hx. of mental health issues, closeness/distance, conflict, cutoff, how emotions are handled (re. validation)

AssessmentFamily Sessions

Ask client (if appropriate) to tell the story of ED: When did it first start? What happened? What did you

notice? What else was going on at the time? Often goes on for a while before anyone knows

How did it progress? Normalize secrets and shame When did others first notice? Who noticed? What was

said/done? How did you react? When was the term ‘eating disorder’ first used? By who?

What happened? Get history of treatment and response, what worked or

didn’t Family involvement, reactions, response (e.g. anger,

fear/worry, hopelessness)

Levels of Intervention

LEVEL 1 Non-intensive outpatient treatment (community, group based) Psycho-education, motivation, body image, self-esteem May include individual and/or family therapy Medical management component (GP, psychiatrist, dietician)

LEVEL 2 Specialized intensive day treatment CBT, DBT, EFT, etc. Usually for clients not responsive to Level 1 approach

LEVEL 3 Inpatient care for more severe cases of eating disorders May include medical hospital admission for weight restoration e.g.

nasogastric tube Medical stabilization then combination of individual, family, and group

therapy

The Stages of Change & Motivation

The Stages of Change3. Preparation

“I know I have an eating disorder and I am getting ready to change”

2. Contemplation 4. Action “I think I have an eating “I have an eating disorder disorder but I’m not sure and I am actively working if I’m ready to change” on changing it” 1. Precontemplation 5. Maintenance “I don’t have an “I am in recovery from an eating disorder” eating disorder and I am actively working to

maintain it”

Relapse “I have been in recovery

and slipped back into old behaviors/patterns”

The Stages of Change:Precontemplation

clients present as HARD (hopeless, argumentative, resistant, debate)

use MI principles: respect, empathy, non-judgment

focus on engagement, therapeutic alliance use of humour give them information, don’t argue, counter

myths, raise some doubt, ask them to describe a typical day for them, monitor/observe the problem, screening tools

share information, be objective

The Stages of Change:Contemplation

ambivalence about change write friend/foe letters use decisional balance (cost/benefit analysis) not pushing, but allow them to make decision help decrease the cost of changing help clarify their vision of themselves and their life (ACT) encourage small steps to behaviour change with high

probability of success, frame as an “experiment” look for and encourage any shifts (complimenting) functional analysis - what function does the behaviour

serve? (behaviour chain, ABC exercise)

The Stages of Change:Preparation

feel consequences of behaviour more internal emotional shift starts increased commitment to self to change has made some small changes think about what you stand to lose and how

you will cope (5 yr. letter, goodbye letter) social skills training, problem solving,

assertiveness validate small changes, goal setting contracting for changes, monitor follow through

The Stages of Change:Action

have successfully altered behaviour clients in action SOAR (substitute alternatives, open up

to others, avoid and counter high risk situations, reward themselves)

client may feel over-confident – discuss slips vs. relapse relapse prevention strategies, coping w/triggers response rehearsal – “Practice, practice, practice!” substitute alternatives for problem behaviour encourage honesty in talking about problems and

progress encourage self-reward for positive changes made help them take responsibility (to own) changes made reinforce stories of change and increase hope

Motivational interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”

(Miller & Rollnick, 2002, p. 25)

Three essential questions: Are they willing to change?

Has to do with the importance of change When they connect changing with something they value, something

important to them Difference between where you are and where you want to be Identify and amplify values that are contrary to present behaviour

Are they able to change? May feel willing but not able, high importance but low confidence (e.g.

past failures) – provide hope, encouragement, share success stories, testimonials

If they believe it’ll work and that they can do it, they usually do

Are they ready to change? “I want to, but not now” – relative priorities One can be willing and able to change, but not ready to do so

Motivational Interviewing

1) Expressing accurate empathy “accurate empathy involves skilful reflective

listening that clarifies and amplifies the person’s own experiencing and meaning, without imposing the counsellor's own material” (Miller & Rollnick, p. 7)

understand client without judging, criticizing or blaming

acceptance of people as they are seems to free them to change

helps to reveal ambivalence about change

Motivational Interviewing

2) Develop discrepancies MI is intentionally directed towards the resolution of

ambivalence in the service of change create and amplify a discrepancy between present

behaviour and broader goals and values (“cognitive dissonance” - Leon Festinger, 1957)

seek to enhance this within the person (internal motivation) “people are more often persuaded by what they hear

themselves say than by what other people tell them” (Miller & Rollnick, p. 39)

rehearse eating disordered thinking when defensive discrepancy has to do with the importance of change

Motivational Interviewing

3) Avoid argumentation “the more a person argues against change during a

session, the less likely it is that change will occur” (p. 8) the least desirable situation is for the counsellor to

advocate for change while the client argues against it avoid labelling which encourages a defensive reaction monitor resistance for feedback about your approach

(e.g. is the client getting angry or defensive?); it may be a signal to shift your approach or respond differently

Motivational Interviewing

4) Roll with the resistance recognize and accept that a low level of importance

of change is a normal stage in the process reluctance to change problematic behaviour is to be

expected convey understanding and acceptance of

resistance turn the question or problem back to the client,

actively involving them in problem solving counsel in a reflective, supportive manner, and

resistance goes down while ‘change talk’ increases

Motivational Interviewing

5) Support self-efficacy belief in oneself and hope for the future hope and faith are important elements of change (re. common

factors – 15%) enhance client’s confidence in his or her capacity to cope with

obstacles and to succeed in change (e.g. exceptions) recognize and acknowledge past success (complimenting) assign tasks geared toward their level, with high probability of

success give choices and options and let the client choose how to proceed empower client by encouraging her/him to take responsibility for

any changes made, helping them own their success

Methods of Treatment

Family-Based Therapy

Family-Based Therapy

Began with Salvador Minuchin and his team at the Philadelphia Child Guidance Clinic Structural family therapy – applied family systems principles

to treatment; the family as the unit of treatment vs. the individual

Identify and change transactions that maintained the illness (second-order vs. first-order change)

Introduced the family meal as part of therapy in 1975 Reported effectiveness of 86% in 53 cases followed up

over almost eight years Results and treatment described in: Psychosomatic

Families: AN in Context (1978)

Family-Based Therapy

Research on family therapy with eating disorders continued at the Maudsley Hospital in London through the 80’s and 90’s

Result was the Treatment Manual for AN (Lock, Le Grange, Agras & Dare, 2001) Became known as the “Maudsley model” Believed parents should be seen as the most useful resource in the

treatment of adolescents with AN Described as a “new form of family therapy” developed primarily by

Christopher Dare Main contributions were: exonerating parents of blame, raising

parent’s anxiety to fully engage them in treatment, focusing on weight restoration before any other issues are addressed

Family-Based TherapyPrinciples

1. Agnostic – no blame, don’t look for cause

2. Pragmatic – initial focus on symptoms, other issues can wait until less symptomatic

3. Empowerment – parents are responsible for weight restoration, family as a resource

4. Externalization – not pathologizing, separate child from illness, respect

Family-Based Therapy

Phase I (Sessions 1-10) Parents restore child’s weight

Phase II (Sessions 11-16) Transfer control back to adolescent

Phase III (sessions 17-20) Focus on other issues

Termination

Family-Based Therapy

Phase I Joining, family history, ED history, assess family

functioning (e.g. problem solving, communication, roles, emotional expression, conflict resolution, boundaries, etc.)

Reduce parental blame, separate illness from client Heighten concern and seriousness of illness Charge parents with task of weight restoration Family meal: “Bring in a meal that would set your child on

the path to recovery” Coach parents: “One more bite” Assess family process during eating

Family-Based Therapy

Phase I Keep it focused on ED Help parents take charge of eating Mobilize siblings to support client

Phase II transition: When weight is at minimum 90% IBW Client eats without significant struggle Parents demonstrate empowerment over the eating

disorder

Family-Based Therapy

Phase II Support parental management until client can gain

weight independently Transfer control to adolescent Explore adolescent developmental issues relative to

ED (friends, dating, sexual orientation, dependence-independence, decisions about school/career)

Highlight differences between adolescent’s own needs and those of ED

Close sessions with positive feedback

Family-Based Therapy

Phase III transition: Symptoms have dissipated but body image concerns

may remain Phase III

Revise parent-child relationship in accordance with remission

Review and problem-solve re. adolescent development

Review progress and terminate treatment

Family-Based Therapy

Strengths of model: Thought of as more holsitic treatment Attempts to redress boundary issues, putting parents “back

in control”; empowering for parents Separates the person from the problem – less shame

Weaknesses of model: Disrespectful of client’s suffering from AN Seems manipulative at times (e.g. playing on parent’s fear) Critique of ‘evidence’ on which approach is based – may

only be effective for those <19 with a <3 yrs. in ED (Fairburn, 2005)

Multi-family Groups

Between three and eight families with several therapists for a number of sessions (8 – 12)

Grew out of FBT work; discuss issues and share a meal Collective sharing of experience and expertise Discuss both eating-related problems and non-eating

disorder themes A resource-focused, non-pathologizing approach to family

involvement Uses the ‘expertise’ of those who have struggled with the

illness – experienced families help new families Research on effectiveness is currently underway

Methods of Treatment

Collaborative Care

Collaborative Care

Cognitive-interpersonal maintenance model (Schmidt & Treasure, 2006; 2013)

1. Thinking style• Detail vs. global; rigid

2. Interpersonal relationships• Expressed emotion; accommodating and enabling

3. Pro Anorexia (impact of symptoms on brain/body)• Striving & mastery

4. Emotional & social style (vulnerabilities?)• Anxious; emotional suppression

Collaborative Care

Involve carers as a bridge to improve socio-emotional functioning

Carers support emotional functioning by: Moderating isolation Modelling healthy emotion regulation

Have to be the regulator when starvation makes it difficult

Listen to and understand emotions

Collaborative Care

Malnutrition/starvation damage Inhibits brain function

The very organ you need to get you out of the problem is offline

Problems become more complex More rigidity, less flexibility ED takes up more brain space

Similarities to autism spectrum traits

Collaborative Care

“Divide & Rule” ED splits up the family Happens so easily Happens with teams of professionals “Machiavellian rule”

don’t negotiate with terrorists

Collaborative Care

Family as part of the solution Working together

Collaboration, shared understanding, shared skills

Step out of ED traps Care for self, regulate emotion, reduce accommodation,

reduce disagreement and division

Provide skills for change Compassion, positive communication, behaviour change skills

Collaborative Care

Carers emotionally driven behaviours Accommodating – fear, avoid anger Enabling – fear, shame, disgust Calibration – avoid anger, jealousy

Collaborative Care

Parental avoidance Concern for child’s anxiety Avoid conflict by not challenging food rituals, by reducing

portion sizes, etc. Accommodation

Impacts all family behaviours A form of avoidant coping

Short-term decrease in distress for both parent and child Reinforces behaviour

Accept: food & meal rituals, safety behaviours

(e.g. exercise), OCD behaviours w/reassurance,

competition with other family members

Collaborative Care

Enabling Try to protect the person and family from

consequences

of ED Clean up kitchen/bathroom Cover up for lost food or money (e.g. stealing) Give money or resources to allow behaviour (e.g.

binge foods) Make excuses for person with family, friends, and work

Collaborative Care

Calibration/competition Others have to eat with the person Person compares themselves to other family members,

especially siblings (e.g. twins) Enlists sibs in enabling behaviours Competes to eat less, exercise harder, etc. Judge their success/failure by other family members Person gets angry with others doing things he/she wants to

do Pressures others to engage in similar behaviours (e.g.

binging) Share the blame

Collaborative Care

Food exposure Similar to anxiety treatment Accept that anxiety will be present Understand rationale – make new memories w/food Extinction is context dependent – practice,

practice, practice! Learning that the sky won’t fall down Identify & challenge safety behaviours Laddering – one rung at a time Need to eat is non-negotiable

Collaborative Care

Collaborative care Try to involve all family members (e.g. colluding) Encourage families to care for themselves and

model good emotional regulation strategies Help families develop a strong alliance Teach families to reduce expressed emotion

(hostility, criticism, over-protection) and accommodating behaviours

Teach families effective communication and behaviour change strategies

Collaborative Care

Communication skills (MI) Empathy – reflective listening Explore discrepancies between values and

behaviour Support self-efficacy re. confidence to change Sidestep resistance w/empathy and understanding Not avoiding, not arguing Don’t get defeated if person lashes out

Four day skills training workshop

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Regulated Psychotherapy

Until this year, psychotherapy was unregulated

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Early Steps

1990’s or earlier Psychologists asked the Province for

exclusive right to the practice of psychotherapy

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Stakeholder Consultation

The Province undertook an early stakeholder consultation and drafted legislation in the 1990’s. It was flawed and did not proceed

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New Consultation

2000’s The Province tried again OAMFT got on the bandwagon and actively

lobbied for MFT inclusion Psychotherapy Act 2007

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Regulated Health Professions Act

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Almost, but not quite, entirely unlike tea…

The practice of psychotherapy is now restricted

The College regulates the practice of psychotherapy

The authorized act is not yet in force

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Psychotherapy Act Restricted titles 8.  (1)  No person other than a member shall use the title “psychotherapist”,

“registered psychotherapist” or “registered mental health therapist”, a variation or abbreviation or an equivalent in another language. 2009, c. 26, s. 23 (4).

Representations of qualifications, etc. (2)  No person other than a member shall hold himself or herself out as a

person who is qualified to practise in Ontario as a psychotherapist, registered psychotherapist or registered mental health therapist. 2009, c. 26, s. 23 (4).

Offence 10.  Every person who contravenes subsection 8 (1) or (2) is guilty of an

offence and on conviction is liable to a fine of not more than $25,000 for a first offence and not more than $50,000 for a second or subsequent offence. 2007, c. 10, Sched. R, s. 10.

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What this means

As of April 1st of this year You cannot call yourself a “psychotherapist”

unless you belong to the College For a limited time, you can still practice

psychotherapy without a license (as long as you don’t say that you are a psychotherapist or qualified to practice psychotherapy)

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Who can practice psychotherapy?

Doctors Nurses Social Workers Occupational Therapists Psychotherapists

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Further information

www.crpo.ca Regulated Health Professions Act, 1991, SO 1991, c 18 Psychotherapy Act, 2007, SO 2007, c 10, Sch R

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Professional Associations

E.g. OAMFT/AAMFT, OASW, OMA Support their members

Meeting places Educational events Insurance discounts

Do not regulate except to define who is and who is not a member (e.g. may have a Code of Ethics)

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Colleges

E.g. CRPO, OCSWSSW, CPSO Protect the public

Regulations Restrictions Penalties

Self-regulated Run by members of the profession

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You must belong to a College

You should belong to an Association Friends, support, fun, insurance The Association will help you practice within the

College’s guidelines!

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Questions about the final paper

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Break

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Final Evaluation and Closing

Goodbye! Remember that papers are due next year! Late penalty, 2% per day. Please email your final paper to

carl@mftsolutions.ca or williamcorrigan@rogers.com on or before January 4, 2016 by 5:00 p.m. Eastern Time

Don’t worry, be happy!

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