Download Addressing self-injury and therapy-interfering behaviors in eating

Addressing self-injury and therapy-interfering behaviors in eating disorder treatment across the
developmental spectrum: A DBT approach
Approximately 25-55% of ED patients engage in non-suicidal self-injury (NSSI) (Svirko & Hawton, 2007) and between 3-35% attempt to take their
own lives (i.e. suicidal behavior or SB) (Franko & Keel, 2006). Despite these alarming statistics, most evidence-based ED treatment models do not
include a framework for directly addressing these behaviors. A therapist treating a patient who exhibits both an ED and SB/NSSI may be confused
about which behavior to prioritize (e.g., Is cutting more important to target than purging?) and whether or when to refer out (e.g. Should I refer for
depression treatment before treating the ED?). This confusion can be intensified when the patient’s ED behaviors result in medical instability and
thus may be imminently life-threatening.
Additionally, behaviors that interfere with a patients’ ability to benefit from or remain in treatment (aka therapy-interfering behaviors or TIBs) can
also complicate a clinical picture. Patient TIB’s can range from weight manipulation and hiding food to aggressive outbursts. In the context of
treatment with adolescents, parents/caregivers can behave in ways that also interfere with treatment such as not scheduling or attending
appointments or not “being on the same page” with respect to limit-setting. Finally, ED therapists may also directly or indirectly engage in
behaviors that interfere with treatment as well (e.g., coming late to session, creating an imbalance between change and acceptance). If left
unaddressed, any of these behaviors can result in lack of treatment progress, therapist burnout or patient/family dropout.
Dialectical Behavior Therapy (DBT), a therapy originally designed for chronically suicidal, difficult-to-treat patients, provides a clear and systematic
approach for dealing with life-threatening and therapy-interfering behaviors. Several studies have demonstrated that DBT with those diagnosed
with an eating disorder is both efficacious (Safer, Telch, & Agras, 2001) and effective (Ben-Porath, Wisniewski, & Warren, 2009; Federici, Wisniewsk
, & Ben Porath, 2013, Federici, & Wisniewski, 2013).
The workshop will teach participants how to address the full range of these behaviors, both in and out-side of sessions and across the
developmental spectrum.
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Learning Objectives
Following this workshop, attendees should be able to:
1. Identify patient behaviors that interfere with treatment.
2. Identify caregiver behaviors that interfere with treatment.
3. Identify therapist behaviors that interfere with treatment.
4. Formulate strategies to address suicidality, non-suicidal selfinjury and TIBs in and out of session and across the
developmental spectrum.
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Addressing self-injury and therapy-interfering
behaviors in eating disorder treatment across the
developmental spectrum: A DBT approach
Lucene Wisniewski, PhD, FAED
The Emily Program
Case Western Reserve University
Workshop Overview
I. Discussion about Difficult-to-Treat Patients
II. Brief Introduction to DBT
a. Goals
b. Structure
III. DBT Targets
a. Suicidal Behavior & Non-Suicidal Self-Injury (NSSI)
b. Therapy Interfering Behaviors
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Adult Case Example: Nadia
• 23 yr old female (9 yr history of OSFED)
• Repeated hospitalizations/residential treatment – minimal
change
– Fired by her physician for TIBs in hospital
• In outpatient therapy for 5 yrs – minimal change
• Presenting ED symptoms:
–
–
–
–
–
BMI = 18
Food rigidity
vomiting, laxative and diuretic use
Significant fear of weight gain
Suicidality?
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Adult Case Example: Nadia
• Co-morbid diagnoses
– Borderline Personality Disorder (self-injury, fears of abandonment,
anger outbursts, chaotic interpersonal communications)
– PTSD
• Significant Therapy Interfering Behaviors
– Previous therapists report feeling “burned out” and “at a loss” for an
effective treatment plan
– Financial/Insurance Barriers
– Parents have medical guardianship
– Parents interact in a hostile manner with staff
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Adolescent Case Example: Emily
• 16 year old female (2 year history of AN)
• Sophomore student at alternative high school
• Household:
– Bio mom (FT health aide at local hospital)
– Mom’s boyfriend (FT factory worker)
– 12 year old brother with autism
• Presenting ED Symptoms:
–
–
–
–
–
–
Dropped from 75%tile to 25%tile after dramatic weight loss
Highly restrictive eating, <1000 kcal/day
Runs every evening to compensate for food consumed
Extreme body dissatisfaction
Not participating in family meals or activities with food
Arguing & negotiating, hiding food
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Adolescent Case Example: Emily
• Co-morbid Diagnoses / Areas of Concern
– Mild Dyslexia
• Affects reading fluency and comprehension, writing and spelling
– Major Depressive Disorder
• Diagnosed age 12
– NSSI, suicidality (1 psychiatric hospitalization)
– Restored some weight in FBT; difficult to maintain focus due to concerns
about SI and NSSI
• Significant Therapy Interfering Behaviors
–
–
–
–
–
–
Minimal engagement / participation
“Sassy Teen” behaviors
Lying / withholding to parents and past providers
Family transportation and time barriers
Minimal adult supervision (affects support for therapeutic goals)
Mother highly critical of client (esp. surrounding restriction)
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Why is it difficult to treat individuals
who self harm?
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Summary:
Limitations of Standard ED Txs
• Lack of explicit attention to emotional processes & affect regulation
• No specific protocol for managing high-risk or comorbid Axis II issues (e.g.,
recurrent suicide/self-injury, BPD)
• Designed for pts who are more ready/willing to change
• Tx providers commonly report feeling burned out and ineffective in their ability
to effectively treat multidiagnostic ED pts.
• Most tx studies of CBT & IPT exclude pts with suicidal/self-injurious behavior
and/or prominent personality disorders.
(Lundgren, Danoff-Burg, & Anderson, 2004; Kachele, Kordy, & Richard, 2001; Kahn & Pike, 2001;
Mehran, Leonard, & Samuel-Lajeunesse, 1999; Solenberger, 2001).
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DBT…
Acceptance
+
Change
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What are the GOALS of DBT?
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Standard DBT Goals
1. To assist patients to move themselves to a
“Life Worth Living”
2. Decrease behaviors that interfere with:
– Living (e.g. suicide and self-harm, ED)
– Therapy
– Quality-of-Life
3.
Increase behavioral skills
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What is the STRUCTURE of DBT?
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Standard DBT Structure
• Individual Therapy
• Weekly Skills Group
• Telephone Skills Coaching
• Consultation team
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Adaptations for Adolescents
• Involvement of support system is important in
adult DBT and crucial in adolescent DBT
– Parent Modeling
– Treatment Compliance
• Adolescent Model
–
–
–
–
–
Family Skills Training
Inclusion in IT sessions / Family Therapy PRN
Telephone skills coaching for parents and child
Additional Skills Module “Walking the Middle Path”
Contact with ancillary providers (e.g. school counsellor)
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Including Parents in DBT IT Session
• Safety Planning
• Addressing invalidating behaviors between family members
contributing to invalidating environment
• Crisis erupts within a family
• Treatment would be enhanced with psychoeducation
surrounding DBT
• Contingencies at home are too powerful and continue to
reinforce dysfunctional or ineffective behavior
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New Adult Skills Manual
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Adolescent Treatment & Skills Manual
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Not all DBT is the same DBT!
It is important to match the patient to the DBT
that has data for their specific issues.
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How can DBT HELP us with SI/SH and TIBs?
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The problem in treatment…
The moving target!!
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depression
purging
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When there is so much to work on
(like with like Nadia & Emily)…
Where does one start???
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Targeting in DBT
Targeting in DBT is a process that transforms the
clients’ goals into specific behaviors to increase and to
decrease in order to reach those goals.
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Targeting in DBT
• When the client has a single problem that if
solved will meet his/her goals:
– that problem is the target
– and you are a lucky therapist!
• When there are multiple behaviors to
increase or decrease,
– there has to be a mechanism to determine
what is treated as a part of the overall case
conceptualization
• And in each session
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Why Target?
• Gives you a way to sort behavior when there
are multiple behaviors
– during the week
– in session
• Behaviors that are not targeted do not change
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NB
You would have already discussed this as a part
of the treatment contract!
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How does DBT target behaviors?
In sessions and conceptually:
TARGET I
TARGET II
TARGET III
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Target I
Life-Threatening Behaviors
“You can’t get better if you are dead.”
–Suicidal behaviors
–Non-suicidal self injury (NSSI)
–ED behaviors when medically unstable
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Target II
Therapy Interfering behaviors
– Behaviors that interfere with receiving
therapy
– Behaviors that burn out therapists
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Target III
Quality of Life Interfering Behaviors
- Non life-threatening or therapy-interfering ED
behaviors
- Any other quality of life interfering behaviors
that are not imminently life threatening
– e.g., unemployment, promiscuity,
prostitution, relationship issues, substance
abuse etc.
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Definition is important!
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TERMINOLOGY 101
SelfMutilation
Suicide
Attempts
Suicide
Completion
Self-Injurious
Behavior
NSSI
Parasuicidal
behavior
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Definitions: Suicide Behaviors
• Suicide Attempts
– direct efforts to intentionally end one's own life.
• Suicide Completion
– Intentionally ending one’s own life
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Suicidal Behavior in EDs
• Suicide attempts
– High in BN (25-35%) less so in AN (3-20%)
• Completed suicide
– High rates in AN (Standardized Mortality Ratio : 1.0-5.3)
• Second leading cause of death in AN
• Rate is 200x greater than in the general population (Sullivan, 1995)
– Not elevated in BN
• Clinical correlates: purging behaviors, depression,
substance abuse, and a history of childhood physical
and/or sexual abuse.
(Franko & Keel, 2006)
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“Patients with eating disorders,
particularly those with co-morbid
disorders, should be assessed
routinely for suicidal ideation,
regardless of the severity of eating
disorder or depressive symptoms”.
Franko & Keel, 2006
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Definitions
• Self-injurious behavior (SIB)
– A broad class of behaviors in which an individual
directly and deliberately causes harm to herself or
himself.
Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006
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Terms?
• Self-mutilation; “cutting”; para-suicide; selfinjury
• Confusion about how to define and classify!
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Definitions
• Non-suicidal self-injury (NSSI)
– The direct, deliberate destruction of one's own body
tissue in the absence of suicidal intent.
• Direct in that the ultimate outcome of the self-injury occurs
without intervening steps
• Deliberate in that self-injury is intended by the individual, rather
than accidental
– Destruction of one's own body tissue is required in this
definition, although it is acknowledged that the actual
physical harm caused by NSSI can vary significantly
Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006
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How often does it occur?
Rates of NSSI in ED:
25.4 – 55.25%
Rates of ED in NSSI:
54 – 61%
(Svirko & Hawton, 2007)
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NSSI in Adolescents
• Estimated that 7% - 14% of adolescents have deliberately injured
themselves at least once (Wilkinson, 2013)
• Studies suggest NSSI is on the rise, perhaps up to a 24% 1 year prevalence
rate (Miller & Smith, 2008)
• Onset typically occurs in early adolescence between 11-15 years (Rodav,
Levy & Hamdan, 2014)
• Associated with a wide range of severe clinical psychiatric diagnoses and
behavioural problems (Vaughn, et al., 2015)
• Adolescents who experience adverse childhood experiences are at
increased risk for more frequent and severe NSSI behaviors (Vaugh et al.,
2015)
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But SI/SH are not the only deadly
problems an ED patient has…
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Imminently Life Threatening Conditions for ED Clients
• Bradycardia
• Arrhythmia
• Electrolyte Abnormalities
• Chronic Ipecac Abuse
• Mallory Weiss Tear
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American Academy of Pediatrics,
available online
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Addressing Target I Behaviors in Session
•
•
•
•
•
Bedrock of DBT
Review of diary card
Setting agenda
Prioritizing target I behaviors
BCA / SA
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Special Considerations for Doing DBT with younger kids and /
or kids with special learning needs…
• May need to teach skills at a slower pace.
• Simplify terms used to teach.
• Simplify the format of the diary card & behaviour chain
• May need to repeat skills training curriculum
• Use lots of examples!
(Miller, Rathus & Linehan, 2006)
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Targeting TIBs
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Target II
• Therapy Interfering behaviors
–Behaviors that interfere with
receiving therapy
–Behaviors that burn out therapists
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Therapy-Interfering Behaviors for Specific to those with ED
•
•
•
•
•
•
•
•
•
Exercising against medical advice
Restricting intake before treatment
“Involuntary” vomiting
Manipulating weight
Refusing to be weighed
Weight loss when underweight
Hiding food
Omitting/lying about symptoms
Arguing / negotiating about food intake
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Bxs that Interfere with Receiving Therapy
• Non-attentive behaviors
– Cancel appointment/drop out
– Getting admitted to hospital
– Inadequate intake resulting in inattention during session
• Non-collaborative behaviors
–
–
–
–
Inability/refusal to work in therapy
Lying
Manipulating weight
Refusal to work on eating “in vivo”
• Noncompliant behaviors
– Not completing diary cards or homework
– Not bringing in food for therapeutic meal
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Behaviors that Burn Out Therapists
• Pushing the therapist’s personal limits
– Phoning too much
– Continuing to lose weight and refusing to
collaborate on weight maintenance or gain
• Behaviors that push the organizational limits
– Not waiting for therapist in the waiting room
– Vomiting in the lobby restroom
• Behaviors that decrease the therapist’s
motivation
– Slow progress
– Lying about intake
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TIBs of Caregivers/Parents
• Arriving late / missing sessions
• FBT – not bringing a family meal
• High expressed criticism towards client in
session
• Not following through with medical recs
• Reinforcing ineffective behaviors
• Inadequate supervision of meals/activity
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TIBs of Therapists
• Not doing DBT
• Not staying current in EDs
• Not addressing eating issues as a part of
treatment
• Having your own ED issues interfere with
objectivity
• Having emotional responses interfere with the
delivery of the treatment
• Not brining family into DBT sessions when
needed
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The function and context of an ED behavior
will determine in which target it falls
(e.g. restriction prior to a therapy session)
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TIB Examples:
Yours, Your Patient, or Caregiver
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Where does this leave us?
For patients with BOTH an ED and Suicidality and/or NSSI:
Get trained OR refer!
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