Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

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July, 2012

Sunday, July 29th, 2012

Navigating Phase III

Last week, I blogged about navigating Phase II of Maudsley Family-Based Treatment (FBT). Today I present a roadmap for Phase III, which is equal to Phase II in its importance as well as its ambiguity.

A common but ill-informed criticism of FBT is that it only addresses eating and weight. This is a misconception. Phase I focuses on establishing normal eating habits and restoring normal weight and Phase II focuses on helping the patient eat on her own in an age-appropriate way, but Phase III has nothing to do with food or weight at all. A wonderful thing about FBT is that the life-threatening eating disordered behaviors are treated first, which frees up the therapist, the patient, and the family to focus on any remaining issues in Phase III.

The goal of Phase III is establishing a healthy adolescent identity. An eating disorder engulfs an adolescent’s identity, creates extreme stress for the entire family, and strains the relationships between family members. Phase III is about restoring healthy, age-appropriate family relationships and returning the adolescent to normal life. Anything that stands in the way of these goals must be dealt with in order for the patient to recover fully.

Phase III begins when the patient is able to eat normally, with age-appropriate independence, while maintaining a healthy weight and not engaging in any eating disorder behaviors. Essentially, once all food issues have been resolved, the patient is ready for Phase III.

The authors of the FBT manual (Locke & Le Grange, 2001) advise that Phase III entails a handful of sessions scheduled several weeks apart. In my clinical experience, many patients do quite well with just a few sessions in Phase III, but others continue to struggle with anxiety, depression, body image, perfectionism, or other problems. Therefore, I offer to provide patients and families with an extended version of Phase III when I believe it is warranted. Length of illness, severity of illness, and co-morbid conditions all influence whether a patient may benefit from more treatment than the FBT manual prescribes.

In my practice, Phase III typically addresses the following issues:

1.) Returning the patient to normal development.

An eating disorder can interrupt normal adolescent development. Often, when a patient enters Phase III, she is at the same developmental level as when the illness first began. Phase III entails helping the patient develop the maturity and social-emotional skills that were lost as a casualty of ED. Depending on the age of the patient, this may entail returning to sports or other activities, getting a driver’s license, going out with friends, dating, returning to college, or developing new hobbies and interests.

2.) Re-establishing healthy relationships amongst family members.

An eating disorder can wreak havoc on family life. It is not uncommon for spouses to have major marital conflict emerge as a result of ED. Siblings may feel neglected by their parents or jealous of the patient. The patient and her parents may develop a codependent relationship over the course of treatment, which can be advantageous in the first two phases, but must be corrected in Phase III so that the patient and parent can each return to their own lives. Healthy boundaries amongst family members can be damaged by ED, and it is crucial for these boundaries to be re-established at the end of treatment.

3.) Addressing any remaining psychological symptoms of the eating disorder.

There are numerous psychological symptoms related to an eating disorder. For example, body dysmorphia, perfectionism, poor self-esteem, anxiety, and cognitive rigidity may predispose people to AN and perpetuate the illness once it has begun. For many patients, these symptoms abate or resolve on their own during the first two phases. For many others, however, targeted treatment is needed at this phase. Cognitive-behavioral therapy (CBT) can be helpful in this regard.

4.) Working through the trauma of experiencing an eating disorder.

While many treatment programs address traumatic experiences that precipitated an eating disorder, few acknowledge that the experience of having eating disorder is itself very traumatic. Caring for a child with an eating disorder can be almost as traumatic as experiencing one. In many cases, the patient or her parents (or both) experience post-traumatic stress reactions at this point, such as disturbing nightmares, intrusive memories, and avoidance of stimuli associated with the eating disorder.

It is not uncommon for parents, drained and burnt out from the exhausting work of Phase I and Phase II, to have their own breakdowns at this point. Their child is well enough that they are no longer operating in crisis mode and they have some room to breathe. Once the survival instinct is no longer employed on a constant basis, parents have permission to experience their own reactions. Some parents fall into a depression; others feel disillusioned and cynical; still others suffer from extreme anxiety or lash out in anger. These are all normal, expected reactions to the trauma of almost losing a child. It is important for parents to get their own therapeutic support at this juncture if needed.

5.) Addressing grief.

Another often neglected aspect of eating disorder treatment is grieving what the eating disorder has taken. Not all patients and families experience this grief, but some do. I believe that when there is grief associated with the eating disorder, it should be discussed openly and addressed as part of the healing process. Patients often lose friends to their illness. They may have to take a hiatus from their favorite sport, or give it up altogether. Some patients miss a semester of school. Most are isolated from society for some time. At this stage, patients can feel the pain and injustice of losing a piece of their youth irretrievably.

Some parents may mourn the loss of their child’s innocence. They mourn the loss of life as they knew it. Many parents take time off from work and become isolated from their social circle as they help their child recover. Some parents mourn the loss of dreams they once had for their child which have been thwarted by ED.

No one emerges from the hell of an eating disorder unscathed. That said, some people are able to close that chapter in their lives and move forward, whereas others remain trapped by anger, sadness, or bitterness. It is important for patients and parents to work through their grief so that they can move forward in a life unencumbered by ED.

6.) Relapse prevention.

It is important for the patient and her parents to be aware of possible signs of impending relapse and to know what to do if these signs emerge. I find it very useful to discharge patients with a written relapse prevention plan which I have developed in collaboration with the patient and family.

7.) Evaluating the patient for co-morbid conditions.

Many patients with eating disorders experience co-morbid psychiatric conditions. Patients who continue to struggle with emotional or behavioral problems after the eating disorder has been resolved should be evaluated to determine whether they suffer from a comorbid disorder. The most common comorbid disorders are the anxiety disorders (including OCD, generalized anxiety disorder, panic disorder, PTSD, and social anxiety disorder), followed closely by mood disorders (depression and bipolar disorder). Other comorbid conditions may include autism spectrum disorders (such as Asperger’s), ADHD, substance abuse, and personality disorders.

8.) Getting the patient appropriate treatment for co-morbid conditions.

If the patient does indeed suffer from a co-morbid condition, it is important for her to get treatment for it. Treatment for a co-morbid disorder may include individual therapy, psychotropic medication, or a combination thereof. Cognitive behavioral therapy (CBT) in particular has been found to help many people recover from anxiety disorders, mood disorders, and numerous other conditions.

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Wednesday, July 25th, 2012

Navigating Phase II

There is a common misconception that Maudsley Family-Based Treatment (FBT) is all about parental control of feeding. While Phase I of FBT does require parents to take control of their ill child’s food intake to help her restore her weight, FBT also encompasses two other very important phases. In Phase II, parents return control over eating to their child as she demonstrates readiness to eat on her own. Phase III involves helping the adolescent return to normal development and establish a healthy identity.

Weight restoration is an essential first step in overcoming AN, but it is only the first step. Equally important is the ability to feed oneself properly and maintain a healthy weight independently. Without the ability to eat independently, opportunities are limited and quality of life is greatly diminished. Recovery from an eating disorder is about more than just restoring a healthy body – it is also about restoring a healthy mind and a fulfilling life.

Phase I tends to be the most tumultuous and draining for the family and the most agonizing for the patient, but the task at hand is very straight-forward: eat more and gain weight.

Phase II, however, is much more ambiguous. Parents and clinicians struggle to determine when a patient is ready to begin Phase II. The patient herself may send mixed signals – she may beg for the freedom to eat lunch in the school cafeteria and go out to dinner with her friends, but yet she is clearly unable to take a single bite of food that isn’t “required” and “supervised.” To outsiders, the patient seems normal – she looks healthy, she acts more or less like a typical teenager (in between mealtimes, at least), but appearances belie the still-raging battle in her head. Still tormented by the anorexic thoughts and compulsions, she feels torn between a wish to return to the safety of emaciation and a desire to dive headlong into the normal life she has been missing.

I use the following benchmarks to help families determine when their child is ready to enter Phase II:

• The patient has been fully weight restored to his/her historic growth curve (per pediatric growth chart percentiles) for at least a few weeks. While the FBT manual (Locke & Le Grange, 2001) recommends beginning Phase II when the patient is at 90% of her ideal body weight, I have found that the vast majority of patients are not ready for any control over their food intake until they achieve 100% of their ideal body weight. In my experience, many patients need to maintain their ideal body weight for a number of months before they are ready to enter Phase II.

• The patient’s metabolism has normalized to the point that she no longer requires a very high-calorie diet. It is hard enough for the patient to feed herself a normal meal – don’t make it even harder by expecting her to serve herself very high calorie meals.

• The patient is no longer engaging in eating disorder behaviors such as restricting, bingeing, purging, or excessive exercise.

• The patient is eating all of the food her parents provide her, in a reasonable amount of time, without much fear or resistance. [NOTE: the patient will still have some anxiety around eating at this point – that is to be expected. The point is that the patient needs to be able to push through that anxiety and eat what she needs without a struggle.]

• The family is no longer operating in “crisis mode.” The parents feel confident that they can help their child defeat the eating disorder, and the child has accepted that her parents have taken charge.

• The patient expresses readiness to assume some control over her eating and confidence that she can feed herself appropriately. [NOTE: Many patients express a desire to regain control over their eating long before they are actually ready. This premature push for independence may be partially motivated by a normal adolescent drive for freedom, but it may also be motivated by ED’s desire to restrict and lose weight. Therefore, it is a mistake to use the child’s expressed readiness as the sole criteria for entering Phase II. Rather, you want to look for the child’s expressed readiness in addition to the previous criteria.]

Here are some general principles I discuss with families to help them navigate the uneasy waters of Phase II:

• Have a vision.

I like to begin Phase II with a vision of how the patient’s life will look at the end of Phase II. By the end of Phase II, the patient needs to be able eat on her own while maintaining her weight, in an age appropriate way, in the context of her family and her normal life. All patients, regardless of age, will enter Phase II eating in the same way – with parents in control of what, when, and how much they are eating. However, the end goal of Phase II is different for a 10-year-old than for a 16-year-old or a 22-year-old. A good frame of reference in creating your vision for Phase II is to look at the amount of autonomy the patient’s friends have with regards to their eating.

For example, by the end of Phase II, a pre-teen patient should be able to eat lunch with her friends in the cafeteria at school, order from a restaurant menu, select her own after-school snack and eat it without supervision. She should be able to have a few meals and snacks at a friend’s house during a sleep-over, or spend the day away from her parents on a field trip. She should still share meals with her family each day and eat what the family is eating.

By the end of Phase II, a high-school age patient should be able to prepare a simple breakfast and lunch for herself when needed, serve herself appropriate portions at dinner, eat a meal on occasion without her parents present (for example, dinner on her own if her parents are out for the evening), and go out to eat with friends. Regular family meals are still important for teenagers so that parents can keep an eye on their child’s eating behavior, even when the teen is eating many of her meals and snacks on her own. A young adult patient who is preparing for independent living should be able to plan her menu, shop for groceries, cook for herself, and eat without parental supervision.

• Take baby steps, go very slowly, and accept that this Phase will take a long time.

In my experience, Phase II usually takes somewhere between 3-12 months, depending on the severity of illness and other individual differences.

• Accept and embrace the fact that Phase II poses an inherent risk.

Like many things in life, giving a recovering anorexic more control over her food intake involves some degree of risk. It is likely that the patient will experience struggles and setbacks during Phase II. Try to learn and grow from these slips, and help her do the same. Keep in mind that you can, to some degree, manage the amount of risk involved by ensuring that the patient is genuinely ready before starting Phase II, monitoring her closely over the course of this phase, and stepping in to help her when needed. I liken this process to helping a baby learn to walk. You wait until she is confident in her crawling. Of course she will stumble and fall, but she will grow stronger each time she pulls herself back up. And you can provide her with a soft, carpeted surface on which to practice her steps.

• Have the patient practice choosing and preparing her food under supervision before she is permitted to eat unsupervised.

I typically start Phase II by having the patient choose and prepare one snack each day under parental supervision. The parents observe the child’s food selection and gently guide her in the right direction if needed. For example, let’s say the child chooses crackers with peanut butter and puts 4 crackers with a thin coating of peanut butter on each one. The parent may say: “That’s an excellent, balanced choice, but it’s not quite enough nutrition. Let’s put three more crackers on the plate and add more peanut butter.”

I usually require a patient to have at least a week of consistent success preparing a meal/snack under supervision before moving on to the next meal/snack.

• Be systematic.

I typically coach patients to proceed through Phase II by giving back control of one meal or snack at a time and allowing the child to gain mastery of each meal/snack before moving on to the next one. For example, the child may begin Phase II by assuming control of her own after-school snack, while parents maintain control of all other meals and snacks.

• Assess progress regularly.

The patient should be weighed weekly during this phase, and family members should keep tabs on her mental state and behavior daily. If she is maintaining her weight within her healthy range, and her mood and behavior around food are good, then it is time to move forward to more independence. If her weight drops, or if she demonstrates an increase in eating disorder behaviors (even in the absence of weight loss), then it is time for parents to take back more control of her food intake.

• Take back control when necessary.

Nearly every patient has a few setbacks during this Phase. It is the parents’ responsibility, with the guidance of their clinician, to take back more control over the patient’s food when she has not been able to manage eating on her own. The step backwards is a temporary measure to help her get back on track, and she will regain control when she demonstrates readiness.

• Some patients need a gentle nudge to move forward.

While many patients are all too eager to take back control over their food intake, some become overly dependent on their parents to feed them and have great difficulty moving forward. This makes sense in light of the nature of AN – being fed by your parents is a passive process which does not involve taking personal responsibility. The “ED voice” quiets down after several months of full nutrition, and the patient is able to eat well without too much guilt when she is being “forced.” The acts of preparing one’s own food, deciding what to order from a restaurant menu, or choosing whether to have a snack when no one is watching – these are all acts of defiance against the “ED voice.” Patients are flooded with anxiety, indecisiveness, and guilt when the time comes to make these choices. It is a scary step for parents and patients alike. Some patients require lots of encouragement to become more independent with their eating. I find that it is often helpful to remind the patient of the benefits of being able to eat independently, such as spending more time with friends and doing other activities away from home. Some younger patients respond well to concrete, short-term rewards for eating independently. For example, a 6th grader who successfully manages her afternoon snack every day for a week without weight loss may be rewarded with a trip to the movies.

• Be realistic.

Many parents lament that their recovering child no longer goes out for ice cream on a whim or breezes into the kitchen to grab a few cookies or gives herself generous second helpings of her favorite meals. I advise parents that it is unrealistic to expect a recovering anorexic to eat freely or spontaneously. Some people who have recovered from AN are eventually able to eat intuitively, but not until they have been well for at least a year or two.

• Don’t force Phase II into an external timeline.

Don’t rush through this phase just so that the patient can eat lunch with her friends when the school year starts go away to college at the same time as all of her friends. The only timeline that matters is the patient’s recovery timeline, which may or may not be convenient for her (or you). Each person’s recovery moves forward at a different pace.

• Remember that whatever happens is simply feedback, not failure.

Keep in mind that the patient will probably struggle quite a bit at first. Re-learning how to feed oneself properly after a bout of AN is a very difficult task. If a patient is not able to take charge of a meal or snack, that says nothing about her character or her effort or her prognosis for recovery. It simply means that she is not ready for that step yet. Expect the patient to make mistakes, and be there to help her correct them without blame or judgment. Remember that she is doing the best she can.

• Keep things in perspective.

As challenging as Phase II can be, don’t lose sight of how far the patient has come. She is eating well, she is at a healthy weight, she is medically stable, and she is in effective treatment. In the long run, it doesn’t matter whether someone breezes through Phase II or whether it takes over a year – she’s safe, she’s physically healthy, and she will recover eventually.

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