Download Paper read at Eating Disorders Alpbach 2016, The 24nd

Paper read at Eating Disorders Alpbach 2016,
The 24nd International Conference,
October 20-22, 2016
GJB-ICAT-BN Alpbach 2016
Integrative Cognitive-Affective
Therapy (ICAT)
Workshop for Eating Disorders
Gerard J. Butcher MSc.,
Cognitive Behavioural Psychotherapist,
Cognitive Solutions Clinic,
Dublin, Ireland.
[email protected]
CORE MESSAGE
• Intense negative emotional states figure prominently in the
occurrence of individual episodes of bulimic behaviour. (Wonderlich
et al, 2015:33)
• Intentional targeting of these emotional states is central to treatment
using Integrative Cognitive Affective Therapy (ICAT)
• CRUCIALLY – it is the MOMENTARY experience of emotions that has
clinical significance in the treatment of bulimia nervosa
GJB-ICAT-BN Alpbach 2016
Outline Workshop
• What is Integrative Cognitive-Affective Therapy (ICAT-BN)?
• Role of emotion in eating disorders
• ICAT model of onset and maintenance of bulimia nervosa
• Structure of treatment, goals and strategies
• Comparison with CBT
GJB-ICAT-BN Alpbach 2016
Background
• Over recent years - substantial consolidation and development of
evidence-based psychological therapies for eating disorders.
• Specific forms of CBT (focused and broad), IPT, DBT, and family-based
treatment have consolidated and extended their positions as
treatments of choice.
• Significant need for further development of appropriate treatments
(Waller 2016)
GJB-ICAT-BN Alpbach 2016
What's Effective for Eating Disorders?
• Waller (2016:3) - There re ai s the possi ilit that the le el of
structure in a therapy is key to good outcomes, perhaps as much as
the o te t.
• Nutritional changes appear to be necessary for psychotherapies to be
effective for eating disorders.
• Co ludes … so e e ide e that other therapies for or al-weight
cases can be as effective as CBT
GJB-ICAT-BN Alpbach 2016
Integrative Cognitive-Affective Therapy (ICAT)
• Short-term structured psychological treatment for Bulimia Nervosa
(BN)
• Minimum 21 sessions; approx 45-50 minutes per session
• Based on models of conditioning and learning
• Retains key components (e.g., self-monitoring and prescribed eating
patterns) of previously established evidence-based treatments,
particularly CBT-E
• Ho e er, ICAT de eloped to spe ifi all target o e tar
precipitants of eating disorder symptoms - identified as potential
maintenance factors in previous empirical studies.
GJB-ICAT-BN Alpbach 2016
ICAT for Eating Disorders
• A randomized controlled comparison of integrative cognitive-affective
therapy (ICAT) and enhanced cognitive-behavioural therapy (CBT-E)
for bulimia nervosa. (Wonderlich et al, 2014)
• Conclusion: ICAT-BN was associated with significant improvements in
bulimic and associated symptoms that did not differ from those
obtained with CBT-E.
GJB-ICAT-BN Alpbach 2016
ICAT-BN Summary
• Evolved over 20 years as an intervention for Bulimia Nervosa
• Improve awareness and tolerance of emotional experience
• Formulate a well-structured plan to modify eating behaviour
• Develop skills to reduce likelihood of rash, impulsive behaviours
(context – negative emotion)
• Identify cues for emotional experiences
• Modify source of increased negative emotions or decreased positive
emotions
GJB-ICAT-BN Alpbach 2016
GJB-ICAT-BN Alpbach 2016
4 Phases of ICAT-BN Treatment
1. Phase 1: introduction and motivation
2. Phase 2: nutritional rehabilitation
3. Phase 3: identifies patterns (interpersonal and intrapersonal
precipitants of negative emotions that contribute to eating
disorder behaviours); self-directed styles; self-discrepancy
4. Phase 4: relapse prevention.
GJB-ICAT-BN Alpbach 2016
Cor ersto es of ICAT
 Importance of emotion and interpersonal behaviour
 Incorporates interventions to enhance motivation for treatment
 Develops specific skills and strategies for increased awareness and
a age e t of o e tar e otio al states, i terperso al
relationships and self-discrepancy
 Context of robust therapeutic alliance
GJB-ICAT-BN Alpbach 2016
Treatment Contraindications
• Medical instability, suicidal ideation or behaviours – Need to be stabilized prior to
commencing therapy
• Severe major depression (eg, psychosocial functioning is impaired and individual
cannot engage in outpatient treatment)
• Substance use disorder – Individuals recurrently intoxicated may be unable to
perform the work that is required
• Psychosis – Psychotic patients are not candidates for most psychotherapies
(concurrent bulimia nervosa and psychosis is rare)
• Major life events or crises – Distracting events can interfere therapy
• Competing commitments – The inability to attend sessions disrupts therapeutic
momentum
Normal Life Experiences
• Criticism, social comparison, rejection, loss
• Interact with temperamental predispositions
• Produce mental representations of the self and others that
are strongly associated with emotional states
• Organise and guide future interpersonal perceptions and
behaviour.
GJB-ICAT-BN Alpbach 2016
Effective Emotion Regulation
(Gratz and Roemer, 2004)
1. Emotional awareness, clarity and acceptance
2. Flexible adaptive strategies to modulate intensity of emotion
3. Resist impulsive behaviours; maintain ability to engage in goaldirected behaviours (in the context of emotional distress)
4. A willingness to experience emotional distress while pursuing
meaningful activities
GJB-ICAT-BN Alpbach 2016
Emotion Regulation in Life
• Negative emotion does not predict psychopathology
• I di idual s a ilit to respo d a d regulate u derl i g e otio s is
crucial
• With EFFECTIVE emotion regulation, negative emotions are NOT
controlled – accepted as part of normal emotional experience and
tendency to control or regulate potential maladaptive behaviours
• EXERCISE: Identify personal experiences of effective emotion
regulation
GJB-ICAT-BN Alpbach 2016
Role of Emotion in Bulimia Nervosa
• Wonderlich et al (2015) – participants reported on eating disorder
behaviours and experiences in 'real time' in their environment
• Connection between the experience of emotion and bulimic
behaviour – complicated connection; was negative emotion truly
antecedent or a 'post-hoc' explanation for the bulimic behaviours?
• Initially led to education about emotional states and how to manage
emotions effectively
GJB-ICAT-BN Alpbach 2016
What they didn't realise?
• "In the moments and hours before binge eating and purge behavior
occurred,negative affect was rising and positive affect was
decreasing." Wonderlich et al (2015:5)
• Important shift in focus from simply helping patients improve general
emotional functioning to assisting them in identifying and managing
emotions in the moments BEFORE a bulimic episode.
• Interpersonal and intrapersonal antecedents trigger emotional
changes which then precipitate BN behaviour.
GJB-ICAT-BN Alpbach 2016
What about Anorexia Nervosa?
• Both Anorexia nervosa and Bulimia Nervosa are characterized by
broad emotion regulation deficits, with difficulties in emotion
regulation across the four dimensions found to characterize both AN
and BN (Lavender et al, 2015)
• Racine et al (2013) identified multiple forms of emotion dysregulation
and difficulties with impulse control in those with anorexia nervosa
GJB-ICAT-BN Alpbach 2016
Avoidance of Emotions Related to Food,
Shape, and Weight
 In ED, emotions related specifically to eating, shape, and weight
issues are especially important. Such emotions are particularly
distressing and therefore frequently avoided by individuals with BN.
 Many BN behaviors function to facilitate such avoidance.
 Skipping meals, exercising, purging, restricting food intake, and
following rigid eating rules to help them minimize intense anxiety
about weight, food, and body shape.
GJB-ICAT-BN Alpbach 2016
Conceptualising Bulimia Nervosa
• Two models inform ICAT treatment
• Onset
• Maintenance
GJB-ICAT-BN Alpbach 2016
ICAT-BN Model of Onset
• Life experiences and temperamental predispositions (harm avoidance
- avoid change and situations perceived as threatening or harmful to
self-esteem; negative urgency) contribute to 3 broad risk factors
(interpersonal difficulties, negative self-evaluation, self-regulation
deficits) for emotional difficulties.
• E otio d sregulatio + stro g thi ess ideal + e pe tatio that
bulimic behaviour reduces distress = heightened risk for bulimia
nervosa behaviour.
GJB-ICAT-BN Alpbach 2016
Characteristic Risk Factors for onset of BN
• Interpersonal Difficulties – historical stresses – child maltreatment,
parental psychopathology (depression, substance abuse)
• Relationships within families perceived by the individual as conflicted,
disengaged, non-nurturing, poor communication.
• Negative self-evaluation (high self-discrepancy, perfectionism, doubts
about actions, over-concern about mistakes)
GJB-ICAT-BN Alpbach 2016
Self-Discrepancy Theory
• We arr ithi us arious do ai s of the self
• The actual self - a mental representation of the attributes or features
the individual believes he/she actually possesses
• The ideal or desired self - a representation of the attributes that the
individual or significant other would ideally like him/her to possess
• The ought self - a representation of the attributes that the individual
or a significant other believes it is his/her obligation or duty to
possess
• Related to negative mood, body dissatisfaction, body image
disturbance – influences information processing
GJB-ICAT-BN Alpbach 2016
Characteristic Risk Factors for onset of BN
• Interpersonal Difficulties – historical stresses – child maltreatment,
parental psychopathology (depression, substance abuse)
• Relationships within families perceived by the individual as conflicted,
disengaged, non-nurturing, poor communication.
• Negative self-evaluation (high self-discrepancy, perfectionism, doubts
about actions, over-concern about mistakes)
• Self-regulation deficits (increased self-criticism and self-control;
deficits in self-acceptance, appearance, performance)
GJB-ICAT-BN Alpbach 2016
Characteristic Risk Factors for onset of BN
• Heightened negative emotional states
• Emotion-regulation deficits
• I ter alisatio of the thi ess ideal of Wester so iet
• Eating-related e pe ta ies ( e efits of dieti g, i ge-eating,
purging behaviours)
• Belief that bulimic behaviour will reduce negative emotions
GJB-ICAT-BN Alpbach 2016
ICAT-BN Model of Maintenance
• Factors contributing to aetiology may have little to do with
maintenance of BN (eg initial significance of dieting may reduce over
time.
• Regardless of origins; targeting maintenance factors is most likely to
produce a beneficial outcome
• Emphasis on explicit triggering situations, emotional responding and
bulimic behaviours
• Brief periods of time – trigger situations elicit emotional experience
and precipitates bulimic behaviour.
GJB-ICAT-BN Alpbach 2016
Momentary (Trigger) Situations
• Relationship situations
• Momentary self-discrepancy
• Momentary self-criticism, self-control, self-neglect
• Eating-related situations
• Other stresses (work deadline, financial crisis)
• All the above trigger fast increase in negative emotion and
consequent decrease in positive emotion
GJB-ICAT-BN Alpbach 2016
Phases of ICAT Treatment
 Phase I – (sessions 1–4; over a 1-2 week period): introduces ICAT
and emphasizes motivational enhancement and the importance of
emotional responding.
 Phase II (6–8 sessions) nutritional rehabilitation with direct
emphasis on modifying eating behaviour, facilitated by structured
meal planning and coping skills.
 Phase III (11-12 sessions) focuses on: identifying and modifying
precipitants of negative emotional states; addresses interpersonal,
self-evaluation and self-regulation problems; food- and eatingrelated triggers of negative emotions
 Phase IV (final 2-3 sessions) emphasizes relapse prevention and
healthy lifestyle planning, along with termination
GJB-ICAT-BN Alpbach 2016
Treatment Goals
• Reduce use of bulimic behaviours in high-risk moments
• Enhance emotion-regulation skills to manage situations that trigger
emotion dysregulation and drive bulimic behaviours
GJB-ICAT-BN Alpbach 2016
ICAT – Core Skills phased in during therapy
• Phase I - Emotion identification - FEEL skill (focus, experience, examine, and
label)
• Phase II - Meal planning – CARE skill (calmly arrange regular eating);
• ACT skill (Adaptive Coping Technique) to manage bulimic urges;
• GOAL skill (Goals, Objectives, Affect, Lifestyle)
• Phase III – Modify responses to situational and emotional cues.
• Making SEA changes (Situations, Emotions, Actions)
• Assertiveness – SAID (sensitively assert ideas and desires)
• REAL skill (Realistic Expectations Affect Living); monitor and alter negative
self-standards
• Self-regulation - SPA skill (self-protect and accept)
• Phase IV - Impulse control - WAIT skill (watch all impulses today)
GJB-ICAT-BN Alpbach 2016
ICAT Core Skills; what they are, what they are not!
• Portable strategies for managing moments in time
• Teaching these skills by themselves does NOT constitute ICAT-BN
therapy
• Importance of creating and establishing strong therapeutic alliance.
GJB-ICAT-BN Alpbach 2016
Phase I - Motivation Enhancement and
Introducing Emotions
1. Establish a treatment relationship that clearly includes the patient
as a significant collaborator in the process.
2. Enhance motivation by noting discrepancies between the effects of
the ED symptoms and broader life goals.
3. “ide ith the disorder i ter s of a k o ledgi g possi le
benefits of the symptoms.
4. Remain sensitive to client emotional state and make efforts to
identify emotional reactions (basic strategy that is employed
throughout the therapy).
5. Introduce FEEL skill (focus, experience, examine, label)
6. Begin self-monitoring of food intake.
GJB-ICAT-BN Alpbach 2016
The FEEL Skill
 FEEL skill—focus, experience, examine, and label— helps gain a greater
understanding of underlying emotions.
 Basic education provided about emotional functioning - emotion is
assumed to be a normal process that indicates that something of
significance is occurring.
 Also, emphasis placed on the somatic experience of emotions and
attempting to use bodily cues to detect emotional experiences.
 Fi all , e phasis pla ed o a tio dispositio s, hi h are the t pes of
behavioral choices typically made in response to negative emotions.
 All elements emphasized throughout the treatment, and clients are
encouraged to practice the FEEL skill twice a day during Phases I and II.
GJB-ICAT-BN Alpbach 2016
Phase II - Meal Planning, Feelings, Adaptive
Coping and Goal Setting
1. Continue self-monitoring food intake.
2. Implement formal meal planning with an emphasis on nutritionally
adequate meals and snacks.
3. Introduce CARE skill (calmly arrange regular eating) and continue to
practice FEEL skill within and outside of session.
4. Develop adaptive coping strategies for urge control; actively teach
coping skills for purpose of assisting meal planning using ACT skill
(Adaptive Coping Technique)
5. Introduce goal setting (GOAL skill; Goals, Objectives, Affect, Life
moments)
6. Remain sensitive to client emotional states and make effort to identify
emotional reactions and context.
GJB-ICAT-BN Alpbach 2016
The CARE Skill
1. All eating should be planned.
2. Clients should spend time each day devising their CARE plan for
the next day.
3. Clients should plan to have no more than 2–3 hours elapse
between a meal or snack.
4. Bulimic episodes are likely to continue as the CARE plan is evolving
and should be recorded so that the clinician and client can identify
antecedents for these behaviors.
5. In the early stages, the variety of food is less important than the
frequency and overall amount eaten.
GJB-ICAT-BN Alpbach 2016
Phase II – Therapeutic Points
 It is important for the clinician and client to review meal plans and
food logs at the beginning of each session.
 The early Phase II session should focus almost exclusively on
reviewing the CARE plans and food records, with considerable
attention paid to the precipitants of problematic eating or episodes of
restriction.
 Deal with particular high-risk situations as they are modifying their
eating pattern and planning their meals.
GJB-ICAT-BN Alpbach 2016
Phase III: Interpersonal Patterns and Problems,
Self-Discrepancy and Self-Regulation
1. Initial formulation and collaborative decision about behavioural
target for Phase III
2. Determine if relationship problems are present and recurrent
3. Identify the connection between emotion, interpersonal patterns,
and self-directed styles and how these relate to bulimic symptoms
(use of SEA change diary – situations, emotions, actions – to
identify situations that trigger bulimic episodes)
4. Address role that self-evaluation may play in bulimic behavior.
5. Continue meal-planning, food monitoring and use of previous skills
GJB-ICAT-BN Alpbach 2016
Phase III Interventions
 Clients are given feedback about what appears to be their typical
interpersonal and self-directed style patterns. An agreement is sought to
target a particular interpersonal or self-directed style that seems relevant
to the ED behaviour.
 Clinician modeling of patterns and role plays in session may be useful in
terms of modifying interpersonal patterns.
 Changing self-dire ted st les t pi all e essitates a fo us o the lie t s
self-discrepancy between perceived actual self and desired self, including
extreme and unattainable personal standards.
 Interventions can focus on reducing perfectionist standards and
acknowledgment of disavowed, but potentially valuable, aspects of the
actual self.
 As discrepancy is clarified, ICAT promotes a greater level of selfacceptance and pursuit of more reasonable standards
GJB-ICAT-BN Alpbach 2016
Phase III Core Skills
 Clients are encouraged to monitor feeling states and consider action
alternatives.
 Additionally, as ICAT focuses on interpersonal patterns and selfdirected styles, the SAID (sensitively assert ideas and desires) and
SPA (self-protect and accept) skills are increasingly emphasized as
mnemonic strategies for encouraging assertiveness, self-acceptance,
and self-protection.
 Finally, the REAL skill (Realistic Expectations Affect Living) is utilised
to monitor and alter negative self-standards.
GJB-ICAT-BN Alpbach 2016
Phase III: Interpersonal Patterns and SelfDirected Styles – Strategies and Interventions
•
•
Strategy: Conduct interpersonal pattern and self-directed style analysis
Intervention: Identify interpersonal patterns of patient and specific
others as well as self-directed style
•
•
Strategy: Conduct historical analysis of patterns (optional)
Intervention: Attempt to identify historical factors associated with
underlying beliefs and interpersonal rules that inform and direct the
interpersonal pattern (optional)
•
Strategy: Focus on changing interpersonal patterns and self-directed
styles
Intervention: Carefully elicit and clarify affect in interpersonal situations
•
GJB-ICAT-BN Alpbach 2016
Identifying Repetitive Interpersonal Patterns
and Self-Directed Styles.
• Focus on social situations that are either closely linked in time to
ED behaviour or to significant emotional distress, as noted in food
logs; an explicit interpersonal transaction log can also be used.
• Monitor and record interpersonal transactions on a regular basis.
• Carefully assesses the transaction in terms of who was involved,
what was said or done, what was the emotional experience, and if
there was any ED behavior that may be linked in some way to the
transaction.
GJB-ICAT-BN Alpbach 2016
Structural Analysis of Social Behaviour
 Used to fa ilitate ide tifi atio of repetiti e patter s or selfdire ted st les - patterns of behavior directed toward the self, so
these patterns become a primary target in the modification of social
behavior in ED clients.
 Self-directed styles include attributes such as self-control, selfacceptance, self-protection, self-blame, and self-attack.
 Attempt to understand the transaction from client perspective,
including the perception of the other person (e.g., attacking,
blaming, controlling, protecting, affirming, ignoring) and the
perception of the client (e.g., defending, walling off, submitting,
expressing)
GJB-ICAT-BN Alpbach 2016
Phase IV - Relapse Prevention and Treatment
Termination
1. Construct healthy lifestyle plan.
2. Review progress in treatment and identify skills that have been
particularly helpful.
3. Develop written relapse-prevention plan
4. Educate about relapse – promote vigilance and coping perspective
for slip a age e t.
5. Introduce WAIT skill (Watch all impulses today)
6. Address emotions related to termination.
GJB-ICAT-BN Alpbach 2016
“o hat s differe t a out ICAT-BN?
• Greater emphasis on integration of interpersonal problems, selfevaluation, self-regulation, emotional experience.
• Momentary behavioural and emotional processes
• Relevance of contemporary emotion theories and application to
understanding eating disorder behaviour
• What s the sa e? - Intensive opening phase of CBT that encourages
self-monitoring and disrupts dieting behaviours.
GJB-ICAT-BN Alpbach 2016
Differences between CBT and ICAT?
• CBT - limited view of emotional responding
• CBT - less consideration of interpersonal factors
• CBT - creates an overemphasis on conscious controlled cognitive
processing.
GJB-ICAT-BN Alpbach 2016
Final Word
• As emerging research developments increase our understanding of
the onset and maintenance of eating disorders, newer treatments,
such as ICAT-BN, can be developed and enable therapists and
patients/clients to select the type of therapy approach most suited to
their individual presentation of a disorder.
GJB-ICAT-BN Alpbach 2016
References
• Racine SE & Wildes JE (2013) Emotion dysregulation and symptoms of
anorexia: the unique roles of lack of awareness and impulse control
difficulties when upset. International Journal of Eating Disorders Nov.
46(7):713-20
• Waller G. (2016) Recent advances in psychological therapies for eating
disorders. F1000 Research:702 (http://f1000research.com/articles/5702/v1)
• Wonderlich SA, Peterson CB, Crosby RD, Smith TL, Klein MH, Mitchell JE,
Crow SJ (2014). A randomized controlled comparison of integrative
cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral
therapy (CBT-E) for bulimia nervosa. Psychological Medicine Feb;44(3):54353.
GJB-ICAT-BN Alpbach 2016