Comprehensive Treatment of Eating Disorders Preferred Provider Conference

Comprehensive Treatment of Eating Disorders Preferred Provider Conference Sunday, January 31 st Theresa Chesnut, LCSW Castlewood Treatment Center for Eating Disorders 800 Holland Road 636 -386 -6611 www. castlewoodtc. com theresa. chesnut@castlewoodtc. com

Comprehensive Treatment of Eating Disorders In less than 2 hours…

“The ‘secret’ of life that we are all looking for is just this: To develop through sitting and daily life practice the power and courage to return to that which we have spent a lifetime hiding from, to rest in the bodily experience of the present moment – even if it is a feeling of being humiliated, of failing, of abandonment, of unfairness. ” -Charlotte Joko Beck 3

Back to Basics… 4

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Compassion In other traditions, demons are expelled externally. But in my tradition demons are accepted with compassion. -Machik Labdron, The Places That Scare You 6

Eating Disorder Takes Away… • • • Ability to be human (stay out of your body!) Voice Ability to be in your body Breathe Pleasure Joy Spontaneity Allowance to have needs, wants, desires Passion and vibrancy Balance Intimacy with self and others… – Resulting in the loss of self, • Loss of soul and spirit 7

How is Recovery Measured? Recovery is not just the absence of symptoms…it is the presence of a full life as evidenced by the ability to be human. A truly recovered life will reflect spontaneity, freedom, the ability to breathe, to have wants, needs and desires, knowing that the quest for perfection is an unattainable illusion. Having the ability to embrace the feminine, having close intimate relationships, and it is being aware of the tears in your eyes (whether out of intense or subtle sadness – or out of joy – or from a flicker of utter gratefulness) and then to allow your tears to flow freely. It is a life in which decisions and choices are made more from self and less from a shame and fear based prison. It is a life where you fully experience pleasure, joy, and passion and believe and know it is good to desire and enjoy sex… 8

s a f e t y v u l n e r a b i l i t y c h i l d h o o d e a t i n g d i s o r d e r r e c o v e r i n g s a f e t y 9 v u l n e r a b i l i t y

Recovery and Treatment Process • Eventually, the eating disorder takes up residency in the head…so work to separate it by working with cognitive distortions • Offer your client education • Be aware of intense fear and body distortions • All the while taking care of nourishing the body • The goal – realigning the head, body, heart and soul 10

The client hired you to fight their Eating disorder. To be “warrior” for their recovery 11

In Reference to Eating Disorders These disorders which are so pervasive in our current world, illustrate that beneath the veneer of self reliance lies the core of powerlessness, alienation, detachment, self-hate and shame. (K. B. Walant, 1995) 12

“Each are good…but not sufficient to treat eating disorders” Dr. Mark Schwartz 13

Create Safety, Then… • Get them out of their heads! Working with cognitive distortions. • Give anticipated guidance…there is no quick fix. • Recovery work has to take place outside of the 50 minute hour. • Realities about the illness, relapse and mortality 14

Contain Symptoms 15

Imperative to know and understand the eating disorder… Inside, outside, the good, the bad, the ugly 16

Writing/Journaling • Your worst eating disorder day • Using a journal entry or intense situation, follow the thoughts and map out the feelings and triggering event 17

Writing Assignments • • Dialogue with “fat” Have family members write why they believe client has an eating disorder Letters: to ED, to the body, from the body How does the way you relate to food resemble how you relate to people • Have the eating disorder write and introduce itself: likes, dislikes, values, fears, hopes, and goals • What will your life look like in 5 years… • What did you learn in your family about food, body size, femininity, feelings 18

Free Association… always be listening for cognitive distortions/errors and be curious • • In this body… If I recover… Eating means… Thin, normal, healthy, fat…each mean… My eating disorder is active by… Without my eating disorder, I’m… From ED: – I need – I want – I hope 19

Relapse Prevention 20

“Faith is taking the first step even when you don’t see the whole staircase” Martin Luther King, Jr. 21

“Are you willing to be uncomfortable? ” 22

It Is About the Food! • Deconstructing the meaning of food • Write in detail a description of your addictive behaviors • Have a meal with your client • Explore fears of allowing self to taste, enjoy, desire food. 23

Expressive Therapies 24

Interventions • The art as a container allows the person to view and own the authentic experience thereby enhancing the observing functions, boundaries and self-esteem. • Art work allows a visual representation of dichotomous beliefs, relationships, etc… - thereby allowing the individual to a space to reconsider and revise what has been. 25

Goals of Expressive Therapies in the Treatment of Eating Disorders 1. Embodiment. 2. Development and enhance affect regulation. 3. Enhance other self functions such as boundaries and self esteem. 4. Re-associate what has been disassociated; exiled parts or ego states. 5. Access emotion/sensory motor experience (traumatic/implicit memory). 6. Dissolve dichotomous boundaries and ways of perceiving. 7. Vivify internal resources. 26

Hilde Bruch (1985) considered anorexia to be characterized by an underlying disturbance in the development of self, identity, and autonomy…Art therapy with the anorexic individual can provide a means of addressing underlying deficits in the organization of the self. 27

“The fucking MUFFIN” 28

Control of Symptom vs… Recovery 29

We have to ask our clients to be willing to “stay. ” You must be willing to “stay” with your client. 30

Relapse…relapse…lapse 31

The Balancing Act 32

Restrictive Part Exercise: Rules – yoga, pilates, work hard, push through it, don’t listen to your body, isolate, minimize, deny, don’t let anyone know, lie, rigidity, feel the pain, feel the burn, suck it up, be the best at what your doing, be better than everyone else, always compete, you don’t have a choice (belief), you have to even if you don’t want to, you always have to be in shape, control weight, weigh yourself, weight training, elliptical for 1+ hours, 2 miles in 12 minutes, count calories burned on machines at gym, you must always time yourself when exercising, miss hanging out with friend or family obligations to exercise, 3, 000 sit-ups and 100 pushups everyday, stretching everyday, out of shape, I’ll be fat, I’ll gain weight, I have to work harder than everyone else just to level out, there’s nothing wrong to exercise and take care of body if I’m going to be/am a competitive, collegiate athlete, exercise will make me happy, taking care of your body is what you’ve done your whole life – you can’t stop now, I’m slow, I’m weak, I’m proud of myself in showing off my talents to make me feel better about myself, I define (my) self-worth (is only defined) through my athletic performance and exercise accomplishments, a serious athlete can never work too hard or too long at their sport, if I don’t work hard enough my performance will suffer, even the smallest breaks from training will cause me to gain weight and be unable to compete at the same level, I have to force myself to exercise even if I don’t feel well, Exercising gives me a sense of power and control over my life. Goals: start exercising, sculpt body, lean, muscular, fit, in shape, be a yoga instructor, a personal trainer, train to play soccer competitively again, have a regime, yoga retreats, live at Kripalu, join a gym, do yoga 4 -5 times a week, do sit-ups, exercises, yoga in the morning before breakfast. Eating: Rules – pure, healthy, organic, clean, perfect, nurturing, holistic, alternative, nothing toxic, nothing processed, raw and living, simplistic, controlled, pretty, natural, fruits and vegetables, sprouting, juicing, dehydrating, food, no carbohydrates, wheat grass, highest nutrient value, health food stores, Farmer’s Markets, whole foods, Kambucha, Yerba Mate, no breakfast, a salad for lunch, edemame, rice cakes, kefir, legumes, steamed vegetables, big salads, veggie juice, no soda, no coffee, lots of water, antioxidants, café Gratitude, salad bars, raw, vegan, vegetarian restaurants, fasting, cleansing. Beliefs: in control motivated, allow self to do things that critical part would tell you’re not capable of doing, hardworker, do whatever you can to succeed, finds misleading happiness, confidence, self-assurance, determination, eating this way and carrying out this lifestyle will lead me to connect to types of people that will lead me to eating healthfully will make me happy and will bring me joy in life, I have to eat this way and weigh a certain amount in order to stay motivated, determinated, worthy, confident, capable, accepting, to be loved, and succeed (make all the things that I envision in my life to be) as true in my life, anything is possible, I can be loved and love myself when I take care of my body in this way, this is the way I grew up, this is how I am, the way I view food is different and I must keep true to myself, I’m different – I care what I put in my body, I’m helping improve mother earth’s state by eating this way, I contribute to the locals not corporations, it says to eat this way in the magazines, in books, etc. to keep healthy, there’s nothing wrong with the way I view food, other people don’t understand, they didn’t grow up in Berkeley, CA, they didn’t grow up learning about how and why to eat healthfully and organically is good for our agriculture. 33

Binge Eating Part Food: Rules: don’t tell anyone, don’t let anyone know, be secretive, be alone, eat past fullness, lie, sneak around, eat foods that are most enjoyable to the palate, do it again after the pain is gone, if no other alternative use soda or coffee, don’t be in touch with hunger and fullness, buy everything from health food stores, whole foods, don’t purge, feel the pain and uncomfort, detach from body, keep people away, do it alone, don’t go out into public afterwards, isolate, sleep the whole day, don’t live life, feel hopeless, helpless for oneself, gain weight, feel like shit, carry out on fantasies with food, gorge with food you like, eat when your sad, lonely, bored, unloved, plan the perfect binge, disociate, go to the store and buy food so no one will notice any food gone at the house, cheese with honey, almonds/peanut butter/almond butter, cereal with soymilk, indian food, pannini’s, carbs, organic Amy’s frozen food, chocolate/yogurt covered anything, baked goods, scones, muffins, breads, cookies, ice cream, chocolate, buy things that are the best quality, when desperate just eat whatever you can find to fill the void with. Beliefs: it will fill my void, I can’t cope with daily stresses and problems in life so I might as well binge, lack of control, if I can never stop eating or control what or how much I eat, what’s the point of living? Nemesis, greatest enemy, greatest fear, steals serenity, hate yourself, it makes me feel comfortable for the time being, food will love you, will lead to obesity, will lead to self-soothing, it alleviates loneliness, it comforts me, initially it’s so satisfying, it’s my only friend, a planned binge gets me something to look forward to, in the beginning it brings happiness and excitement, I deserve to enjoy food and not starve myself, doesn’t care, this will make me feel better in the moment, I deserve to self-soothe through food, nothing else will make me feel better other than the food I’m craving, if I started why stop? Why deprive myself? I’ve let myself fall a little - might as well fall the whole way, I can’t just have 1 cookie, I deserve to splurge, there’s no such thing of having a normal sized portion of what I’m craving, countering urges is impossible, if urges become present they’ll never go away until I act out, binge all you want because you know your not going to live for long, binging=death. Feelings: anxiety, overwhelming, distressed, loathing, hatred, rage, depression, numbness, suicidality, unsatisfied, shame, guilt, no selfesteem, embarrased. 34

Recovery Part Capable Creative Compassionate Self love! Connected Clear Courage Curiosity Tolerant Acceptance Strength Confidence Trust 35

Critical Part Comparing myself to unrealistic/impossible standards. I criticize for criticizing myself You can’t recover! I’m dead Failure You’re worthless You’ll always be rejected Be thin again My dreams will never come true Disgusting Stupid No success Disappointment Be perfect Therapy is not working You’ll never be happy You’re a failure I hate myself! Insecure Why did you give in? Comparing Bottled up I want to kill myself! I always quit Unworthy Don’t exist No help! No support! I can’t recover Suffer! Self is never accessible and never will be! You’re pathetic FAT! YOU WILL NEVER RECOVER! Hurt Nobody cares Unappreciative I hate myself! Depression Pesticides • • • • • • • • • • Errors You’ll never go to college Why? Too judgmental Intoxicated You will never recover! You should of… Will I… Too hard for you to handle! Toxic I’m hopeless You’re not capable Why did you trust? You’re a piece of shit Mistakes Don’t let anybody in Never accept yourself Be miserable. INSANE You’ll never travel the world. You’ll always have ED TOO HARD! Helpless Fuck me and everyone else! UGLY Exposed No progression Empty How dare you let go of your restrictive side! Incapable Don’t motivate Nothing pays off I have to live up to certain standards Mentally ill Get it right! Pointless Additives Pessimistic I don’t care • • • • • • • • • • Uncontrollable Kill yourself! Inadequate Nothing’s working End your life You’re going to become obese SHAME Criticism Don’t upset people Humiliation Vulnerable I have no capacity of succeeding in the future! I can never change Pollution! Too difficult Fake and unreal Ostracized No risks Poison! You’ll always be lonely Liar! Prison Lazy You’ll never have sex Graduate? No! Why bother? Suffer! PAIN Preservatives! Feel worse Push away Artificial Everything and everyone will reject you Artificial Nothing pays off Sink! There’s no way out Isolate Anger 36

She called upon the different Parts of herself for Help. If she was going to make it, she needed to Accept them all, Unite them all. And Believe in them all. It was time for a huddle of tremendous proportions. It was the making of her Giant. anonymous 37

What are you willing to do to recover? Risk not feeling safe? Risk being vulnerable? 38

Still willing to be uncomfortable? 39

It’s okay, – no – it is essential to ask for, and allow others to help. 40

How is Recovery Measured • Recovery is not just the absence of symptoms…it is the presence of a full life as evidenced by the ability to be human. A truly recovered life will reflect spontaneity, freedom, the ability to breathe, to have wants, needs and desires, knowing that the quest for perfection is an unattainable illusion. Having the ability to embrace the feminine, having close intimate relationships, and it is being aware of the tears in your eyes (whether out of intense or subtle sadness – or out of the joy – or from a flicker of utter gratefulness) and then to allow your tears to flow freely. It is a life in which decisions and choices are made more from self and less from a shame and fear based prison. It is a life where you fully experience pleasure, joy and passion and believe and know it is good to desire and enjoy sex…. 41

Music “That I Would Be Good” That I would be good even if I did nothing That I would be good even if I got the thumbs down That I would be good if I got and stayed sick That I would be good even if I gained ten pounds That I would be fine even if I went bankrupt That I would be good if I lost my hair and my youth That I would be great if I was no longer queen That I would be grand if I was not all knowing That I would be loved even when I numb myself That I would be good even when I am overwhelmed That I would be loved even when I was fuming That I would be good even if I was clingy That I would be good even if I lost sanity That I would be good Whether with or without you Alanis Morissette 42

Music “Precious Illusions” by Alanis Morrisette You’ll rescue me right? In the exact same way they never did… I’ll be happy right? When your healing powers kick in You’ll complete me right? Then my life can finally begin I’ll be worthy right? Only when you realize the gem I am? But this won’t work now the way it once did And I won’t keep it up even though I would love to Once I know who I’m not then I’ll know who I am But I know I won’t keep on playing the victim These precious illusions in my head did not let me down When I was defenseless And parting with them is like parting with invisible friends This ring will help me yet as will you knight in shining armor This pill will help me yet as will these boys gone through like water But this won’t work as well as the way it once did Cuz I want to decide between survival and bliss And though I know who I’m not I still don’t know who I am But I know I won’t keep on playing the victim These precious illusions in my head did not let me down when I was a kid And parting with them is like parting with a childhood best friend I’ve spent so long firmly looking outside me I’ve spent so much time living in survival mode This won’t work now the way it once did Cuz I want to decide between survival and bliss Now I know who I’m not I don’t I still don’t know who I am But I know I wont’ keep on playing the victim These precious illusions in my head did not let me down When I was defenseless And parting with them is like parting with invisible best friends These precious illusions in my head did not let me down When I was a kid And parting with them is like parting with childhood best friends 43

Music “Perfect” by Alanis Morrisette Sometimes is never quite enough If you’re flawless, then you’ll win my love Don’t forget to win first place Don’t forget to keep that smile on your face Be a good boy Try a little harder You’ve got to measure up And make me prouder How long before you screw it up How many times do I have to tell you to hurry up With everything I do for you The least you can do is keep quiet Be a good girl You’ve got to try a little harder That simply wasn’t good enough To make us proud I’ll live through you I’ll make you what I never was If you’re the best, then maybe so am I Compared to him compared to her I’m doing this for your own damn good You’ll make up for what I blew What’s the problem…why are you crying Be a good boy Push a little farther now That wasn’t fast enough To make us happy We’ll love you just the way you are If you’re perfect 44

Music “Calling All Angels” I need a sign to let me know you’re here All of these lines are being crossed over the atmosphere I need to know that things are going to look up – ‘Cause I feel us drowning in a sea spilled from a coffee cup When there is no place safe and no safe place to put my head When you feel the world shake from the words that I said And I’m calling all angels And I’m calling all you angels And I won’t give up if you don’t give up I need a sign to let me know you’re here – ‘Cause my t. v. set just keeps it all from being closer I want a reason for the way things have to be I need a hand to help build up some kind of hope inside of me And I’m calling all angels And I’m calling all you angels Train 45

Music “Super Chick” I told another lie today And I got through this day No one saw through my games I know the right words to say Like “I don’t feel well” “I ate before I came” Then someone tells me how good I look And for a moment For a moment I am happy But when I’m alone No one hears me cry I need you to know I’m not though the night Some days I’m still fighting to walk towards the light I need you to know That we’ll be okay Together we can make it through another day I don’t know the first time I felt unbeautiful The day I chose not to eat What I do know is how I changed my life forever I know I should know better There are days when I’m okay And for a moment For a moment I find hope But there are days when I’m not okay And I need your help So I’m letting go I need you to know I’m not through the night Some days I’m still fighting to walk towards the light I need you to know That we’ll be okay Together we can make it through the another day You should know you’re not on your own These secrets are walls that keep us alone I don’t know when but I know Together we’ll make it through somehow I need you to know I’m not through the night Some days I’m still fighting to walk towards the light I need you to know That we’ll be okay Together we can make it through another day 46

Protect your recovery at all costs!!! 47

When there is understanding and appreciation the protective nature of symptoms, then lasting shifts in recovery can take place 48

Staying in recovery means learning how to trust that the waves of emotions will not pull you under – the process is like an ocean tide 49