Sie sind auf Seite 1von 24


A Professional Journal of The Renfrew Center Foundation Winter 2010
The 19th Annual Renfrew Conference Update & Save the Date
For the 2010 Conference Are Included In This Issue.
See Page 18 for Details.

A Word from the Editor

C linicians in our field are challenged to integrate what is known with what is new, and we hope
these articles help on both fronts. The Winter 2010 issue of Perspectives includes both novel and
familiar topics. The articles on the phobic model, substance abuse, and intuitive eating provide new
perspectives on these familiar areas of our work. The articles on Emotion Acceptance Behavior
Therapy and Motivational Interviewing introduce us to novel efforts for addressing eating disorder
Contributors psychopathology. The final article is a unique and subjective description of how mindfulness might be
used to improve our treatment options. We hope these articles stir some thought. Please send your
Bethany L. Helfman, PsyD ideas and comments to
& Amy Baker Dennis, PhD
Page 1

Carmen Bewell-Weiss, MA
& Jacqueline Carter, PhD Doug Bunnell, PhD
Page 4 Editor ■

Julie Lesser, MD
Elke Eckert, MD
& Joel Jahraus, MD
Understanding The Complex Relationship
Page 6 between Eating Disorders and Substance
Jennifer E. Wildes, PhD Use Disorders
Page 9 Bethany L. Helfman, PsyD & Amy Baker Dennis, PhD
Evelyn Tribole, MS, RD Eating disorders (ED) co-occur with general population (Hudson, Hiripi, Pope, &
Page 11 substance use disorders (SUD) at an Kessler, 2007).
alarming rate. Prevalence data suggests that The co-occurrence of these disorders
Terry Nathanson, LCSW, LMT roughly 50% of individuals with an ED are yields a complex clinical picture with high
Page 15 also abusing drugs and/or alcohol, which is rates of mortality. In fact, a meta-analysis by
more than five times the abuse rates seen in Harris and Barraclough (1997) revealed that
the general population (The National Center patients with anorexia nervosa (AN) and
on Addiction and Substance Abuse [CASA], bulimia nervosa (BN) had higher rates of
2003). Not only are there high rates of suicide than any other psychiatric disorder, a
substance abuse (SA) among women with rate 23 times greater than what is seen in the
ED, women who use alcohol and drugs general population. In a recent study of
demonstrate high rates of disordered eating. 6,000 Swedish women with AN,
Editor: Doug Bunnell, PhD
In particular, 30-40% of women with an Papadopoulos and colleagues (2009) found
Assistant Editors: Jillian Gonzales alcohol use disorder (AUD) and 16.3% of that compared with the general population,
Maryanne Werba
women with SUD report a history of an ED AN subjects were 19 times more likely to
(Blinder, Blinder & Samantha, 1998; Taylor, have died from substance abuse (SA),
Peveler, & Hibbert, 1993) as compared to primarily alcohol. Among all ED, the binge-
the .9 to 3.5% of women found in the purge subtype of anorexia nervosa (ANBP)
A Professional Journal of The Renfrew Center Foundation Page 2
is associated with the highest risk of additional training to effectively treat their symptoms of a particular psychiatric
death (Bulik, et al., 2008). current population, let alone these illness better than other forms of
Given the complicated nature of these co-morbid conditions. treatment or no treatment at all. Once
disorders and the increased risk of Few treatment centers undertake the identified, clinical treatment manuals are
fatality, it is surprising to note that evaluation and treatment of co-morbid developed and designed to provide a clear
ED professionals have not routinely ED and SUD. In fact, research suggests road map for clinicians by outlining
integrated SA treatment into their that a mere 21.7% of private SA centers goals, decision points, strategies and
paradigms nor have SA professionals offer ED treatment (Roman & Johnson, timelines.
adequately incorporated ED treatment 2004). A study by Gordon and colleagues While there are no data on a specific
into their practices. It is all too common (2008) of 351 publicly funded addiction EBT for this co-morbid population, there
for clinicians to simplify these cases by treatment programs found that while half is an extensive body of evidence for
focusing merely on one aspect (their of the programs screened for ED, only the use of EBT for each population
specialty) of the patient’s presentation. 29% admitted complex ED cases. Of separately. Yet significant controversy
Regrettably, by narrowing one’s treatment these programs, very few attempt to treat remains in the SA field between
focus, clinicians may inadvertently the co-morbid ED. When treatment is “traditionalists,” followers of the self-
prolong suffering as these patients attempted, the medical model of addiction help and recovery movement, and the
vacillate between these two disorders. is often the protocol to treat both “revisionist culture,” academic
There are substantial costs and disorders (Gordon, et al., 2008). researchers interested in developing
consequences to the individual and the It is fair to say that few topics in EBT for SUD (Wallace, 2009). Many
health care field that are cumulative mental health carry as much heated addiction treatment programs continue to
across the lifespan when we fail to debate as those of EBT in general and treat based on a 12-step, psychosocial
adequately treat these patients (Kessler, et SA treatment in particular. EBT are, at model which is often delivered in group
al., 2003). It is therefore vital that clini- the present time, the best we have but settings. However, the past decade has
cians in both fields acquire knowledge of their superiority has also been hotly witnessed an enormous emphasis on the
the other, and that treatment approaches debated. Norcross and colleagues (2006) study and utilization of EBT for SA.
of both specialties be incorporated and encapsulate this debate by stating Examples of EBT for the treatment of
studied. “defining evidence, deciding what SA include cognitive behavioral therapy
A complicating factor in the qualifies as evidence and applying what (CBT) and motivational enhancement
understanding of this co-morbid group is is privileged as evidence are complicated therapy (MET), which have been
the fact that many randomized controlled matters with deep philosophical and huge manualized by The National Institute
treatment trials (RCT) conducted in the practical consequences” (p. 7). For on Drug Abuse (
ED field exclude subjects with SUD from example, RCT, used to identify an EBT, and BCFT. Additionally, several
their studies (Gadalla & Piran, 2007). rarely take into account other factors such pharmacological interventions have also
As a result, we know of no empirically as clinician qualities, which have been been approved by the FDA as adjunctive
supported treatments for this co-morbid implicated in determining patient treatments for SUD.
population. outcome. Additionally, certain treatments Researchers in the ED field, have also
Even when evidence-based practices lend themselves more readily to RCT identified the most efficacious treatments
are identified by researchers, considerable methodology (CBT for example) than for AN, BN and binge eating disorder
difficulties remain in disseminating those alternative approaches such as humanistic (BED). Maudsley, or family-based therapy
results to the practitioner in the field. or psychodynamic. (FBT), and ego-oriented individual therapy
The polarization between researchers and We strongly support the use of EBT (EOIT) have been found effective in the
clinicians is particularly evident in the SA in the treatment of both ED and SUD. treatment of adolescent AN. Cognitive
field where, despite large federally First, both disorders are protracted behavioral therapies (CBT, enhanced CBT
funded research initiatives, published illnesses that require a significant or CBT-E, and dialectic behavior therapy or
practice guidelines and manualized commitment of time and financial DBT), and Interpersonal Therapy have
protocols, a majority of traditional 12- resources by patients and their families. demonstrated specific clinical effectiveness
step programs fail to offer EBT, such as Consumers should expect that clinicians in the treatment of BN and BED. To date,
behavioral couples and family therapy who identify themselves as “specialists” psychological interventions are the
(BCFT), which is available in only would be highly skilled and would utilize only EBT for ED, however several
4% of the country’s SUD programs the most efficacious treatment interven- psychopharmacological agents have been
(Fals-Stewart & Birchler, 2001). tions available. Second, all patients and found effective in reducing target
Additionally, research indicates that families deserve access to the best symptoms.
addiction is a chronic, relapsing disorder available treatments. RCT have repeatedly Another important issue to consider
that can be managed, but not cured. Yet in demonstrated that EBT approaches work with the ED/SA patient is how treatment
clinical practice, addiction is often treated far better than random approaches. should be delivered. In an integrated
as if it were an acute disorder requiring These treatments are identified through approach, the same providers treat
crisis intervention, and relapse is seen as rigorous research and point to a specific comorbidities concurrently. This model
a failure of treatment. These findings psychological approach or pharmacologic requires a thorough understanding of
suggest that treatment providers require intervention that reduces or eliminates the relationship between the co-morbid
Perspectives • Winter 2010 Page 3
conditions. For example, does the ED the goal of enhanced patient outcomes. We Kessler, R., Berglund, P., Demler, O.,
trigger the SA? Do they occur look forward to a time when every major Jin, R., Koretz, D., Merikangas, K., et al.
concurrently? Or do they function in the national conference on ED or SA will (2003). The epidemiology of major
service of each other (i.e. amphetamine include workshops on the other specialty, depressive disorder: Results from the
abuse in the service of the ED)? Integrated and when graduate and medical schools National Co-morbidity Survey Replication
models have been proposed for SA will train their students on the complexities (NCS-R). Journal of the American Medical
and other psychiatric illnesses (i.e. of co-morbid conditions. It is our hope that Association, 289, 3095-3105.
schizophrenia, bipolar disorder) but not collaboration between these two fields and
for ED. well-funded research will lead to an Lamb, S., Greenlick, M., & McCarty, D.
Sequential treatment, on the other hand, increase in both outpatient and inpatient (1998). Bridging the gap between research
focuses on the most acute disorder first treatment centers that have the comprehen- and practice: Forging partnerships with
and is often conducted with multiple sive expertise to alleviate the suffering of community-based drug and alcohol
providers or in different locations. these patients. Finally, we recognize our treatment. Institute of Medicine.
Differences in theoretical orientation, staff limitations in providing the answers to Washington, DC: National Academy Press.
training, and treatment protocols can make many of the problems inherent in treating Norcross, J., Beutler, L., Levant, R. (2006).
continuity of care difficult. Data from the this population. We hope that this article Prologue. In Norcross, J., Beutler, L.,
SA literature suggest that when co-morbid stimulates thought and, ultimately, Levant, R. (Eds.), Evidence-based practices
diagnoses are treated concurrently and provokes action in the field. in mental health. Debate and dialogue on
integrated on-site, treatment retention and the fundamental questions (p. 7).
outcome improve (Saxon & Calsyn, 1995; Washington, DC: American Psychological
Weisner, Mertens, Tam, & Moore, 2001). References Association.
A considerable amount of cross-
Blinder, B., Blinder, M., & Samantha, V.
training between disciplines and specialists Papadopoulos, F., Ekbom, A., Brandy, L.,
(1998). Eating disorders and addiction.
needs to take place in order to use an inte- & Eskelius, L. (2009). Excess mortality,
Psychiatric Times,15, 30-34.
grated treatment model. We have found causes of death and prognostic factors in
that clinicians in the ED field are often not Bulik, C., Thornton, L., Pinheiro, K., anorexia nervosa. The British Journal of
well trained in the diagnosis or treatment Klump, K., Brandt, H., Crawford, S., et al. Psychiatry, 194, 10-17.
of SUD and are therefore ill-prepared to (2008). Suicide attempts in anorexia
treat this co-morbid condition concurrently. Roman, P., & Johnson, J. (2004). National
nervosa. Journal of Psychosomatic
They are not familiar with the philosophy treatment center study summary report:
Medicine, 70 (3), 378-383.
or vernacular of AA/NA and do not fully Private treatment centers. University of
comprehend to the complexities of the Fals-Stewart, W., & Birchler, G. (2001). Georgia, Institute for Behavioral Research.
12-step program. Similarly, clinicians in A national survey of the use of couples Athens, GA: University of Georgia.
the SA field are not always skilled in the therapy in substance abuse treatment.
Saxon, A., & Calsyn, D. (1995). Effects of
treatment of ED and other serious Journal of Substance Abuse Treatment, 20,
psychiatric care for dual diagnosis patients
psychopathology or familiar with 277-283.
treated in a drug dependence clinic. The
psychopharmacological interventions. American Journal of Drug and Alcohol
Gadalla, T., & Piran, N. (2007). Co-
Given the current chasm that exists Abuse, 21 (3), 303-313.
occurrence of eating disorders and alcohol
between both the ED and SUD fields,
use disorders in women: A meta analysis.
we strongly encourage the research Tavris, C. (2003). Foreword. In Lilenfeld, S.,
Archives of Women’s Mental Health,10,
community to study this co-morbid Lynn, S., & Lohr, J. (Eds.), Science and
population. To date, there are no formal pseudoscience in clinical psychology.
connections between the ED and SA Gordon, S., Johnson, J., Greenfield, S., New York: Guilford Press.
professional communities. Philosophical Cohen, L., Killeen, T., & Roman, P. (2008).
differences and disagreements on Taylor, A., Peveler, R., & Hibbert, G.
Assessment and treatment of co-occurring
treatment approaches have interfered with (1993). Eating disorders among women
eating disorders in publicly funded
our ability to effectively serve this group of receiving treatment for an alcohol problem.
addiction treatment programs. Psychiatric
patients. At the same time, clinicians in the International Journal of Eating
Services, 59, 1056-1059.
field are encouraged to adopt a perspective Disorders,14, 147-151.
of change. Clinicians, like our patients, are Harris, E., & Barraclough, B. (1997).
The National Center on Addiction and
often resistant to change, preferring to Suicide as an outcome for mental disorders:
Substance Abuse (CASA). (2003). Food for
practice whatever technique they know a meta-analysis. British Journal of
Thought: Substance Abuse and Eating
best whether or not it is efficacious for Psychiatry,170, 205-228.
Disorders. New York: The National Center
their population. It is our hope that this on Addiction and Substance Abuse at
Hudson, J., Hiripi, E., Pope, H., & Kessler,
article will energize both the ED and SA Columbia University.
R. (2007). The prevalence and correlates of
fields to strive for improved communica-
eating disorders in the National
tion, research, and willingness to learn and
Comorbidity Survey Replication. Biological
practice evidence-based techniques with
Psychiatry, 61, 348-358.
A Professional Journal of The Renfrew Center Foundation Page 4
Weisner, C., Mertens, J., Tam, T., & Moore, In addition to her clinical practice, founding board president of Eating
C. (2001). Factors affecting the initiation of Dr. Helfman supervises other professionals Disorder Awareness and Prevention
substance abuse treatment in managed care. in the field, writes, and lectures locally in (EDAP) and currently serves on the Board
Addiction,96 (5), 705-716. an effort to advocate for change related to of NEDA. As a certified cognitive thera-
the societal factors that make recovery pist, she has designed and implemented
Bethany Helfman, PsyD, from mental illness more difficult. multidimensional treatment programs for
is a licensed Clinical individuals with eating disorders and
Psychologist in Michigan Amy Baker Dennis, PhD, planned and executed numerous national
and New York. She is an has been in clinical prac- and international conferences for eating
independent practitioner tice for over 35 years, and disorder treatment providers and
at Dennis & Moye & has specialized in the researchers. Dr. Dennis has maintained a
Associates in Bloomfield treatment of eating disor- private practice in Bloomfield Hills, MI
Hills, MI where she ders since 1977. She has since 1988 and has taught at Wayne State
specializes in the treatment of adolescents, served as Executive University, University of South Florida,
adults and families affected by eating Director of the National and Rollins College in Orlando, FL.
disorders and their comorbidities. Anorexic Aid Society (NAAS), was the

Motivational Interviewing in the Treatment of Eating Disorders

Carmen Bewell-Weiss, MA & Jacqueline Carter, PhD
A famous adage suggests that every designed to resolve ambivalence and more likely to abandon these ineffective
journey begins with a single step, and this facilitate readiness to change and may behaviors and look for other ways to
sentiment is especially pertinent to therapy therefore be a particularly effective achieve these goals. MI is not a
directed towards changing maladaptive addition to the treatment of eating non-directive approach, as the therapist has
patterns of thoughts and behavior. disorders. MI (Miller & Rollnick, 2002) a clear intention about where s/he would
Clinicians who work with individuals with was originally designed from within the like the client to end up, and tries to
eating disorders (EDs) know well that not field of addictions to help enhance amplify the client’s reasons for change
only is it difficult to help patients to take motivation to recover from substance use when possible. However, the intent is for
that first step, but that the next step (and disorders. Its aim is to explore and resolve the client to become an advocate for
the one after that) is often just as hard. ambivalence about change by helping change, which allows him/her to choose
Because clients often present with marked clients acknowledge both the pros and the strategies employed to achieve the
ambivalence about change, an initial step cons of change by normalizing the change goals, and enables the client to take
towards seeking treatment may not actually experience of ambivalence, and by helping ownership of the changes that s/he has
result in recovery. The client’s waxing and the client situate his/her behavior within made. In so doing, the value of the change
waning motivation to change may not only the context of his/her values and goals. process may be increased—past research
have a negative impact on recovery, but it Importantly, the interaction between the has demonstrated that behavior change
can also lead to frustration on the part of therapist and the client is considered to attributable to internal sources (driven by
the clinician. Thus, as Geller and Drab be as important a determinant of the intrinsic motivation) occurs more often and
(1999) have suggested, the “mismatch individual’s motivation to change as is is longer-lasting than behavior change
between treatment focus and client something intrinsic within the client attributable to an external source (Geller,
readiness may cause a well-intentioned him/herself. Thus, rather than Drab-Hudson, Whisenhunt, &
therapy to deteriorate into an entrenched conceptualizing resistance as a client Srikameswaran, 2004). As Miller and
battle between therapist and client over characteristic, in MI, resistance is seen as Rollnick (2002) argue, people are “more
food and weight” (p. 260). It is crucial an indication of a mismatch between the persuaded by what they hear themselves
then to not only be aware of clients’ therapeutic intervention and the client’s say than by what other people tell them.”
intentions and motivation to recover from readiness to change. Resistance on the part Allowing the client to advocate for change
their eating disorder at all points in the of the client is viewed as a useful warning may also minimize power struggles
treatment process, but also to actively to the therapist to switch strategies— between the client and therapist, because
increase that intention whenever possible. to validate the client’s concerns about the therapist no longer needs to argue with
making changes, rather than pushing for the client or convince him/her to change.
Motivational Interviewing behavioral change, as this would likely be Thus, MI may be helpful in promoting a
met with more resistance. positive therapeutic alliance, which has
Motivational Interviewing (MI) is a non-
MI facilitates a movement towards been shown to be not only particularly
judgmental, client-focused style of therapy,
behavior change by encouraging the client difficult to maintain in ED treatment, but
where the goal is to increase the client’s
to put the pros and cons of change in the also an important predictor of treatment
intrinsic motivation to change by maxi-
context of his/her values and goals. By outcome (Constantino, Arnow, Blasey, &
mizing the client’s sense of autonomy and
doing so, the client may conclude that the Agras, 2005).
sense of responsibility for his or her
problematic behaviors are not, in fact,
health. It is a therapeutic approach
meeting his/her goals, and s/he may be
Perspectives • Winter 2010 Page 5
A Motivational Interviewing Prelude to client through actual change. Thus, one therapist or the participant, and when
Intensive Eating Disorder Treatment important technique in this phase is the participants were asked informally what they
creation of a detailed treatment plan thought of the sessions, their responses were
Our group at Toronto General Hospital
(clearly outlining the client’s reasons and very positive about the experience. Thus, it
and York University in Toronto recently
desires for change, and what s/he will do to seems that including an MI intervention may
conducted a study evaluating the clinical
bring about the change). Just as important be an especially useful and economical
efficacy of a brief MI intervention
in this phase is to increase the client’s addition to an intensive, hospital-based
delivered to a transdiagnostic sample of
belief in his/her ability to change by treatment program.
patients on the waitlist for either inpatient
exploring personality traits that the client
or day hospital treatment at the Eating
possesses that will be useful in changing. Treatment Implications and Conclusions
Disorders Program at the Toronto General
Clients with eating disorders often have a
Hospital. Participants were randomized to Eating disorders are associated with
great number of positive personality traits,
either four sessions of individual MI or significant costs and consequences. The
not the least of which is extremely strong
a waiting list control condition. A semi- individual suffering with the disorder is at
willpower, that have allowed them to
structured MI treatment manual was significant risk of health problems that
engage in behaviors that the general
developed by the first author. The manual can lead to death, s/he can lose social
population would typically avoid (i.e.
provides suggestions for how to introduce relationships, may not be able to pursue
dieting to an extremely low weight,
the MI treatment and explore the client’s occupational goals, and often suffers
engaging in purging behaviors, etc.).
history and current symptomatology using from various co-morbid psychological
It is important for the therapist to bring
MI principles. A distinction is made symptomatology associated with, and
these abilities to the client’s attention and
between two phases of MI treatment— potentially caused, by his/her eating
brainstorm the ways in which they may be
exploring ambivalence and preparing for behavior. In addition, treating EDs is
maximized so that change can be realized.
change. The first phase is appropriate for extremely expensive and patients with
Doing so may also demonstrate to the
clients with marked ambivalence, and anorexia nervosa who are discharged while
client that s/he do not have to lose the
includes techniques aimed at allowing the still underweight have been shown to have
important part of themselves that
client to identify both the pros and cons of higher rates of rehospitalization and higher
distinguishes them from others; they just
changing. In this phase, a number of MI levels of symptoms at follow-up than those
need to change the behaviors that they use
techniques are outlined: who completed treatment programs with
to display these character traits. Thus, in
• Decisional Balance to identify the the second phase, the client and therapist weights in the healthy range (Baran,
pros and cons of both changing and work together to build the client’s Weltzin, & Kaye, 1995; Lock & Litt,
staying the same. confidence in his/her ability to change 2003). With such significant costs,
• Writing a Letter to the Eating and outline exactly how that change can successful intensive treatment completion
Disorder as a Friend/Enemy to be realized. is of the utmost importance. The results of
identify the costs and benefits of The treatment manual was created in an the present study suggest that a short pre-
changing and beginning to connect effort to facilitate measurement of the treatment of MI is not only reasonably
with the emotions involved in change. effectiveness of MI in the treatment of inexpensive to offer and agreeable to both
eating disorders, and outlines not only the the clinician and the patient, but it is also
• Identifying the Client’s Values to
techniques involved in MI, but also a associated with better subsequent treatment
determine whether there are
suggested order in which the techniques outcome, which may have significant value
discrepancies between the client’s
could be implemented. However, the basic from both the perspective of the well-being
current actions and what is important
philosophy of MI (i.e. following the client) of the client and from a health economics
to him/her.
runs somewhat counter to these efforts. standpoint.
• Looking Forward ask the client to
describe potential future scenarios if Thus, throughout the treatment manual,
s/he decided to change or if s/he therapists are encouraged to follow the
techniques insofar as they suit the needs of References
continued with the disordered eating
behavior. the particular client, and, when in doubt Baran, S.A., Weltzin, T.E., & Kaye, W.H.
about the next action, let the client guide (1995). Low discharge weight and outcome
• Looking Backward ask the client to
the choice of technique, rather than simply in anorexia nervosa. American Journal of
describe life before the eating
following the next step in the manual. Psychiatry, 152, 1070-1072.
Preliminary results showed that
• Importance and Confidence Ruler participants in the MI condition were Bewell-Weiss, C., Mills, J., Westra, H., &
used throughout treatment to quantify more likely to successfully complete the Carter, J. (2009). Motivational interviewing
the client’s motivation to change and subsequent intensive treatment program than as a prelude to intensive eating disorder
belief in his/her ability to change. those in the treatment-as-usual condition treatment. Presented at the annual meeting
(Bewell-Weiss, Mills, Westra, & Carter, of the Eating Disorders Research Society,
Only after the client begins to Brooklyn, NY, September.
demonstrate clear resolution of 2009). In fact, with each additional session
ambivalence and expresses a willingness to of MI, patients had almost double the chance Constantino, M.J., Arnow, B.A., Blasey, C.,
move towards change should the second of completing the later treatment program. & Agras, W.S. (2005). The association
phase strategies be employed. This phase is The MI condition was not particularly time between patient characteristics and the
aimed at preparing for and supporting the consuming on the part of either the therapeutic alliance in cognitive-behavioral
A Professional Journal of The Renfrew Center Foundation Page 6
and interpersonal therapy for bulimia medically hospitalized for anorexia completing her pre-doctoral internship at
nervosa. Journal of Consulting and Clinical nervosa? Eating Disorders, 11, 1-7. the Centre for Addiction and Mental
Psychology, 73, 203-211. Health in Toronto, Canada.
Miller, W.R., & Rollnick, S. (2002).
Geller, J., & Drab, D.L. (1999). The Motivational interviewing: Preparing
Jacqueline Carter, PhD, CPsych, has
readiness and motivation interview: A people to change addictive behavior (2nd
been Staff Psychologist with the Eating
symptom-specific measure of readiness for ed.). New York: Guilford Press.
Disorders Program at Toronto General
change in the eating disorders. European
Hospital in Toronto, Canada since 1997.
Eating Disorders Review, 7, 259-278. Carmen Bewell-Weiss
She is also Associate Professor of
MA, is in the final year of
Geller, J., Drab-Hudson, D.L., Whisenhunt, Psychiatry at the University of Toronto.
her PhD in Clinical
B.L., & Srikameswaran, S. (2004). Dr. Carter has published extensively in the
Psychology at York
Readiness to change dietary restriction field of eating disorders, and she also runs
University in Toronto,
predicts outcomes in the eating disorders. a private practice treating individuals with
Canada. She has worked
Eating Disorders, 12, 209-224. eating disorders.
in the Eating Disorders
Lock, J., & Litt, I. (2003). What predicts Unit at Toronto General
maintenance of weight for adolescents Hospital since 2004, and she is currently

Eating Disorders –Dangers and Phobias

Julie Lesser, MD, Elke Eckert, MD & Joel Jahraus, MD

The complications of eating disorders are activation of the amygdala/limbic fear anxiety disorders are similar in all three
well-recognized, including physical and network compared with healthy controls subtypes of eating disorders, AN, BN and
behavioral changes (Devlin, Jahraus & after viewing high calorie foods compared EDNOS, with up to two thirds of patients
Dobrow, 2005; Kerem & Katzman, 2003). with low calorie foods (Ellison, Foong, reporting one or more anxiety disorders
There is evidence that anorexia nervosa Howard, et al, 1998), and in another study during the lifetime, with onset typically
patients, particularly at very low weight, there was more activation of the fear during childhood. If not actually diagnosed
have both structural and functional brain network in anorectics compared with with an anxiety disorder, ED patients often
changes. Resting brain imaging studies healthy controls after viewing heavier have other traits connected to anxiety such
have confirmed that low weight anorectics images of themselves (Seeger, Braus, Ruf, as perfectionism and harm avoidance.
have enlarged ventricles and widened sulci M., et al, 2002). Thus, the limbic system, Recent data from the Genetics of Anorexia
suggesting diffuse brain atrophy, as well particularly the amygdala, Nervosa study (Dellava, Thornton, Hamer,
as reductions in both gray and white is likely involved in the high anxiety Strober et al, 2009) show an association
matter. Neuropsychological research has and extreme fear responses to food between childhood anxiety and fearful
demonstrated that cognitive dysfunction is and weight issues in patients with behaviors with caloric restriction and low
a common feature of anorectics at low eating disorders. BMI in anorexia nervosa. Atypical presen-
weight, and these cognitive deficits may be Patients with all types of eating tations of anorexia nervosa, especially in
associated with brain abnormalities (Chui, disorders frequently report high levels young children, may be associated more
Christensen, Zipursky, et al, 2009). of arousal or sensitivity, described as directly with specific phobias for choking
One study found reduced dorsal cingulate feelings of disgust, connected to aspects or vomiting. Malnutrition itself may be
cortex volume in low weight anorectics, of body image or sensations. These associated with anxiety and activation
which correlated with deficits in experiences are usually linked with of a fear response, as identified in the
perceptual organization and conceptual compensatory escape behaviors that are Minnesota starvation study (Keys, et al,
reasoning (McCormich, Keel, Brumm, et maintained by negative reinforcement. 1950), and a low BMI in childhood is a
al, 2008). Although all these alterations Dietary restriction, common in eating risk factor for the development of an
appear to be at least partly reversible with disorders, is an example of an avoidance eating disorder later in life.
weight restoration, some data suggests that behavior which typically occurs in Eating at regular intervals and
at least some of these brain changes may response to specific rules and core beliefs, gradually reintroducing feared foods is
persist after weight recovery and may even in some ways similar to avoidance central to behavior change and recovery.
be related to severity of illness and to behaviors in other anxiety conditions Most treatment approaches, whether it is
outcome. such as obsessive compulsive disorder, emphasized or not, incorporate this key
The amygdala in the temporal lobe agoraphobia, social phobia or specific element of exposure therapy. There is
of the brain, and more broadly the whole phobia. an emphasis on self-monitoring and
limbic system, plays an important role There are such high rates of co-morbid evaluation of cognitive distortions.
in fear/phobic responses. Functional anxiety disorders in patients with eating Successful treatments involve learning
imaging studies suggest an exaggerated disorders that the anxiety disorders are new coping strategies and problem
fear response in anorectics. In one study, viewed as a vulnerability factor for the solving skills to contain anxiety and
anorectics showed more anxiety and more onset of eating disorders. The rates of prevent a return to avoidance behaviors.
Perspectives • Winter 2010 Page 7
In considering treatment interventions contingency management procedures, phobic thoughts, and homework involves
such as family-based treatment, cognitive modeling, systematic desensitization challenges such as breaking specific
behavioral treatment and dialectical and cognitive or self-control procedures rules, with an emphasis on increasing
behavioral therapy for eating disorders, (Craske, Antony & Barlow, 2006). reflective capacity to recognize the eating
it is useful to consider the principles of One self-control procedure designed to disorder mindset or the associated
exposure therapy for phobias, and it is help in childhood fears is called the perfectionist mindset, and using active
often helpful to use this framework in STOP technique, which stands for problem solving strategies to confront
discussing the approach to treatment and S: feeling Scared, T: having the Thought and change thoughts and avoidance
in setting goals with patients and families. that... O: some Other thought or behavior, behaviors.
Phobias are considered excessive and P: Praise (myself) for coping Dialectal behavior therapy has been
fears, and the different types (including (Silverman & Moreno, 2005). Teaching adapted for eating disorders with a focus
social phobia, agoraphobia and different this technique has been helpful in our on improving regulation of emotions
categories of specific phobia) vary in program when an impasse occurs over for patients with co-morbid borderline
age of onset. Maintaining factors for eating specific foods, either at home or in personality disorder, severe or complex
phobias share similarities to factors the hospital. Exposures are designed so eating disorders, and for binge eating
which maintain an eating disorder. that corrective learning occurs. disorder and bulimia nervosa
Three components maintain a phobia: Structured behavioral interventions for (Wisniewski, Safer & Chen, 2007). There
the cognitive (phobic thinking and eating disorders on an inpatient unit often is an emphasis on self-monitoring, active
beliefs), the behavioral (typically include components of exposure therapy problem solving, and skills training;
avoidance, such as more subtle forms in the milieu rules and contingencies specific targets include avoidance
of avoidance such as excessive reliance set up for the dining room, for gaining behaviors, with the provision of validating
on safety signals, including reliance on privileges, and in establishing criteria for (reinforcing) responses for behavior
staff helpers and familiar routines), and discharge. If a patient struggles to change. Binge eating and restricting are
the physiological (distress responses complete an item planned for a meal, a viewed as escape behaviors, which may
associated with the feared situation or replacement is offered, but the goal is to become negatively reinforced. Exposure
object). Causes of phobias include stop taking the replacements for regular protocols in dialectical behavior therapy
genetic factors and environmental foods. When a patient continues to take for eating disorders include: commitment
influences, with direct and indirect excessive amounts of replacements, strategies to prevent specific behaviors,
(vicarious or instructional) conditioning, explaining the nature of avoidance and regular eating and weighing interventions,
often combined. Negative life events, phobic thinking is typically the most and the use of diary cards to monitor
negative attributional styles, and avoidant helpful intervention. There is a higher behaviors and use of adaptive coping
coping strategies predict fear responses in risk of relapse following discharge from skills. Coaching calls are used to help
children, but these are moderated by the the inpatient unit if a patient returns to implement problem solving strategies,
type of information (negative or positive) avoidance behaviors such as avoiding with the timing of the calls designed to
given to children. Another model focuses high density foods. Patients who receive a reinforce changes in behavior, instead of
on non-associative fear responses, such as cognitive behavioral therapy intervention reinforcing avoidance or escape behaviors.
innate fears found in normal development, following discharge from an inpatient In family-based therapy, parents are
with phobias viewed as occurring as a unit show higher rates of recovery (Attia placed in charge of the regular eating
result of enhanced genetic fear responses & Walsh, 2009). In many programs, a intervention (Lock, LeGrange, Agras,
or deficits in modulating responses. transition from the inpatient unit to a & Dare, 2001; LeGrange & Lock, 2007).
Perhaps malnutrition itself is a moderating partial hospital or intensive outpatient The family receives education about
factor, since, clinically, the fears and program helps prevent a return to the risks of malnutrition and the nature
avoidant behaviors associated with eating avoidance behaviors. of the eating disorder. There is a
disorders tend to increase as the nutritional Cognitive behavioral treatment separation of the illness from the
state deteriorates, and to lift or improve focuses on recognizing and changing the individual (e.g. “I know this is your eating
as the malnutrition resolves. overvaluation of being thin, which is disorder talking…”) and a focus on
Exposure therapy for phobias targets connected to the fear of becoming fat or helping the parents address changes and
cognitive distortions and biases with the overweight (Agras & Apple, 1997). concerns about eating. This approach
learning of new, non-dangerous meanings The process of weight exposure helps the emphasizes active problem solving
(Craske & Barlow, 2007). Phobic thinking individual begin to tolerate anxiety while strategies to minimize behavioral problems
typically involves overestimates of danger looking at his or her weight and plotting and expressed emotion (criticism, hostility
and catastrophe thoughts such as not it on a graph. The data provides a context and emotional over-involvement) (Pereira,
being able to cope with or tolerate the for understanding trends in weight gain Lock, & Oggins, 2006). The parents are
feared situation. The main intervention over time and for establishing what are trained directly to view their role as
involves approaching the feared object or considered healthy weight ranges helpers, because negative interactions,
situation, hence the term exposure, so that (Fairburn, 2008). The patient learns that such as a critical stance, will impede
the individual learns that nothing bad will nothing dangerous will happen to his or progress. There is an emphasis on
happen and that he or she is able to her weight by following a pattern of validation strategies such as praise,
tolerate and cope with the situation. regular eating. Patients use self- positive reinforcement, and empathy,
Strategies in exposure therapy include monitoring logs to evaluate typically similar to principles of dialectical behavior.
A Professional Journal of The Renfrew Center Foundation Page 8
There is also a specific focus on Fairburn, C.G. (2008). Cognitive Behavior Julie Lesser, MD, special-
confronting behavioral avoidance, as Therapy and Eating Disorders. New York: izing in Child, Adolescent
in cognitive behavior therapy for eating Guilford Press. and Adult psychiatry, is
disorders. Lead Psychiatrist and
Given the recent findings in brain Kerem, N.C. & Katzman, D.K. (2003). Program Director at the
research confirming the activation of Brain structure and function in adolescents Park Nicollet Melrose
fear centers and responses in patients with anorexia nervosa. Adolescent Institute. Dr. Lesser has
with eating disorders, therapists may Medicine, 14, 109-118. completed intensive
find it particularly helpful to frame Keys, A., Brozek, J., Henschel, A., dialectical behavior therapy training. She
treatment more directly as an exposure Mickelsen, O., & Taylor, H.L. (1950). is a member of the clinical faculty of the
therapy intervention. The Biology of Human Starvation University of Minnesota Department of
(Two volumes). MN: University of Psychiatry, and is actively involved in
Minnesota Press. teaching medical students and staff.
LeGrange, D.L. & Lock, J. (2007). Treating Elke Eckert, MD, is Professor of
Agras, S.W. & Apple, R.F. (1997). Psychiatry at the University of Minnesota
bulimia in adolescents: A family-based
Overcoming eating disorders: A cognitive- and has been a consultant psychiatrist at
approach. New York: Guilford Press.
behavioral treatment for bulimia nervosa the Park Nicollet Melrose Institute for nine
and binge eating disorder. New York: Lock, J., Grange, D.L., Agras, S.W. & Dare, years. She started the Eating Disorder
Oxford University Press. C. (2001). Treatment manual for anorexia Program at the University of Minnesota in
nervosa: A family-based approach. New the 1970's and has numerous publications
Attia, E. & Walsh, T. (2009). Behavioral
York: Guilford Press. in the eating disorders area, particularly
management for anorexia nervosa. The New
anorexia nervosa.
England Journal of Medicine, 500-506. McCormick L.M., Keel, P.K., Brumm,
M.C., Bowers, W., Swayze, V., Andersen, Joel Jahraus, MD,
Chui H.T., Christensen, B.K., Zipursky,
A., & Andreasen, N. (2008). Implications FAED, is currently the
R.B., Richards, B.A., Hanratty, M.K.,
of starvation-induced change in right dorsal Executive Director of the
Kabani, N.J., Mikulis, D.J., & Katzman,
anterior cingulate volume in anorexia Melrose Institute at Park
D.K. (2009). Cognitive function and brain
nervosa. International Journal of Eating Nicollet Health Services
structure in females with a history of
Disorders, 41 (7), 602-610. in Minneapolis, MN
adolescent-onset anorexia nervosa.
(previously the Eating
Pediatrics, 122, 426-437. Pereira, T., Lock, J. & Oggins, J. (2006). Disorders Institute). After
Role of therapeutic alliance in family several years of private practice he became
Craske, M.G., Antony, A.M. & Barlow,
therapy for adolescent anorexia nervosa. the Pre-doctoral Director at the University
D.H. (2006). Mastering your fears and
International Journal of Eating Disorders. of Minnesota Medical School after which
phobias: Second Edition. New York:
39, 677-684. Wilmington, DE: Wiley he became the Medical Director of the
Oxford University Press.
Periodicals, Inc. Eating Disorders Institute. Dr. Jahraus has
Craske, M.G. & Barlow, D.H. (2007). co-authored a chapter on eating disorders
Seeger, G., Braus D.F., Ruf, M., et al.
Mastery of your anxiety and panic: in Psychosomatic Medicine, an American
(2002). Body image distortion reveals
Fourth Edition. New York: Oxford Psychiatric Association Publishing text-
amygdala activation in patients with
University Press. book, and has been featured in various
anorexia nervosa – a functional magnetic
resonance imaging study. Neuroscience media including two national public
Dellava, J.E., Thornton, L.M., Hamer, R.M.,
Letters, 326, 25-28. television documentaries on eating
Strober, M., et al. (2009). Childhood
disorders, and interviews in People
anxiety associated with low BMI in women
Silverman, W.K. & Moreno, J. (2005). Magazine, The New York Times and
with Anorexia Nervosa. Behavior, Research
Specific phobia. Child and Adolescent Entertainment Tonight Online. He testified
and Therapy, 47.
Psychiatric Clinics of North America. 14 on the need for health insurance coverage
Devlin, M.J., Jahraus, J.P. & Dobrow, I.J. (4), 819-843. at a United States Congressional Briefing
(2005). Eating disorders. In J.L. Levenson on eating disorders.
Wisniewski, L., Safer, D. & Chen, E.
(Ed.), The American Psychiatric Publishing
(2007). Dialectical behavior therapy and
Textbook of Psychosomatic Medicine (pp.
eating disorders. Dialectical Behavior
2-34). Arlington, VA: American Psychiatric
Therapy in Clinical Practice: Applications
Publishing, Inc.
Across Disorders and Settings, 7, 174-221.
Ellison Z., Foong, R., Howard, E., et al.
(1998). Functional anatomy of calorie fear
in anorexia nervosa (letter).
Lancet 352, 1192.
Perspectives • Winter 2010 Page 9

Emotion Acceptance Behavior Therapy:A New Treatment for

Older Adolescents and Adults with Anorexia Nervosa
Jennifer E. Wildes, PhD
The absence of evidence-based treatment work on the psychopathology and treatment The EABT model assumes that
interventions for older adolescents and of AN, clinical experience, and the general emotion avoidance poses two main
adults with anorexia nervosa (AN) is one psychotherapy research literature. Consistent problems for individuals with AN. First,
of the most serious issues in the eating with other recent clinical formulations of although AN symptoms may be effective at
disorders field. Although family therapy has AN (e.g. Schmidt & Treasure, 2006), EABT reducing emotions in the short term, over
shown promise in the treatment of younger is based on a conceptual model that empha- the long term, efforts to avoid emotion
adolescents who have been ill for a relatively sizes the role of anorexic symptoms in may have the paradoxical effect of
short time, this approach generally is not facilitating avoidance of aversive emotions increasing the frequency and intensity of
recommended for individuals age 17 years (see Figure 1). Specifically, the EABT aversive emotional reactions (Moses &
and older who comprise the majority of AN model postulates that people with AN often Barlow, 2006). Consequently, AN patients
patients (Bulik, Berkman, Brownley, et al., are characterized by individual features, such may become trapped in a cycle of
2007). For underweight individuals, nutrition as inhibited or harm avoidant personality emotional vulnerability, avoidance, and
rehabilitation aimed at normalizing eating traits and problems with anxiety and mood disordered eating. Second, because patients
behaviors and restoring a healthy body disturbance, that shape their experience of spend so much time focused on AN
weight is the cornerstone of recovery. emotion as aversive and uncontrollable. symptoms, valued goals in other areas of
However, there is expert consensus that This negative experience of emotion results their lives are neglected. Thus, the primary
nutrition rehabilitation alone is insufficient in “emotion avoidance,” that is, the desire to treatment targets in EABT are: 1) AN
to promote lasting improvements in anorexic avoid experiencing or expressing physical symptoms, 2) emotion avoidance, and 3)
psychopathology (Agras, Brandt, Bulik, sensations, thoughts, urges, and behaviors disconnection from other valued activities
et al., 2004). related to emotional states. Anorexic and relationships.
Psychotherapeutic interventions that symptoms (e.g. extreme dietary restraint,
combine nutrition rehabilitation with purging, excessive exercise, ruminative Conducting EABT
support, psycho-education, and other active thoughts about eating, shape, or weight)
The EABT approach to treatment combines
therapeutic ingredients may hold promise in are hypothesized to serve the function of
standard behavioral interventions that are
the treatment of older adolescents and adults facilitating emotion avoidance by
central to the clinical management of AN
with AN. Preliminary reports have suggested a) preventing patients from experiencing
(e.g. weight monitoring, prescription of
the utility of cognitive behavior therapy emotions and b) reducing the intensity and
regular, nutritionally-balanced eating) with
(CBT) in preventing relapse among weight- duration of emotional reactions.
restored AN patients (Carter, McFarlane,
Bewell, et al., 2009; Pike, Walsh, Vitousek,
et al., 2003). However, the results from one
study indicate that CBT may not be the
optimal approach for treating underweight
individuals with AN (McIntosh, Jordan,
Carter, et al., 2005). In the current U.S.
care environment, few AN patients are fully
weight-recovered at discharge from intensive
treatment programs. Moreover, many
individuals with AN do not have access to
structured treatment settings that provide
nutrition rehabilitation or address eating
disorder psychopathology. Thus, there is a
critical need for the development of effective
outpatient interventions for underweight
individuals with AN.

Emotion Acceptance Behavior Therapy

Emotion acceptance behavior therapy
(EABT) is an outpatient psychotherapeutic
intervention designed specifically for older
adolescents and adults with AN. The
principles of EABT derive from empirical
A Professional Journal of The Renfrew Center Foundation Page 10
psychotherapeutic techniques designed to Session Topics and Therapeutic Tools Phase 2. The focus of Phase 2 is
increase emotion awareness, decrease helping the patient meet her/his treatment
EABT is divided into 3 phases; however,
emotion avoidance, and encourage goals using psychotherapeutic techniques
content across therapy sessions is
resumption of valued activities and adapted from third generation behavior
overlapping, and the phases are not
relationships outside the eating disorder. therapies. The patient and therapist work
intended to be distinct. All sessions include
EABT is heavily influenced by what has collaboratively to determine the focus of
a weight and symptom check-in
been termed the “third generation” of sessions and to select therapeutic tools that
(conducted by the nurse), review of the
behavior therapies (Hayes, Luoma, Bond, address the patient’s needs. Three of the
past week from the patient’s perspective,
et al., 2006), examples of which include tools employed most frequently in
and validation of the patient’s concerns
Acceptance and Commitment Therapy EABT (e.g. mindfulness exercises, self-
about gaining weight and reducing eating
(ACT), Dialectical Behavior Therapy monitoring, and graded exposure) are
disorder symptoms. Although the focus of
(DBT), and Mindfulness-Based Cognitive described below. The patient’s progress in
EABT is intended to be on issues that the
Therapy (MBCT). Third generation meeting goals for weight gain/symptom
patient identifies as relevant and important
behavior therapies are distinguished from reduction also is evaluated during
(as opposed to symptom management),
traditional behavioral and cognitive- Phase 2 and additional goals are set,
therapists emphasize that this focus can
behavioral approaches by an increased as clinically indicated.
be maintained only when eating disorder
emphasis on the context and function of Mindfulness exercises are used to help
symptoms are at a level that does not
psychological phenomena. Thus, EABT the patient observe, describe, and tolerate
interfere with crucial psychological work
focuses on helping patients to identify the feelings, thoughts, and physical sensations
(e.g. stable weight, normal lab values).
functions served by AN symptoms, related to aversive emotional states.
Thus, close monitoring of eating disorder
including the connection between AN At the beginning of treatment, mindfulness
symptoms is prescribed for patients whose
symptoms and emotion avoidance, and to exercises are used to assist the patient in
symptoms are not stable with the
adopt alternative strategies (including connecting with the present moment by,
expectation that this focus will diminish
cultivating a willingness to for example, observing and describing
over the course of treatment. Some patients
experience/tolerate uncomfortable her/his surroundings or through deep
struggle with the idea of stabilizing
emotions and other avoided experiences) breathing techniques. Later on,
symptoms or have difficulty reducing
in the service of reconnecting with other mindfulness exercises focused more
eating disorder behaviors. In these cases,
valued activities and relationships. specifically on the experience of emotion
the focus of therapy sessions turns to
(and related thoughts/physical sensations)
symptom management and motivation
Structure of Treatment are incorporated both in-session and as
enhancement, with an emphasis on helping
between-session homework.
EABT is a manualized, individual, the patient identify discrepancies between
Self-monitoring involves recording
outpatient psychotherapy for patients age her/his eating disorder symptoms and other
experiences (e.g. emotions, activities, food
17 years and older with AN. Sessions are valued goals and relationships. Additional
intake) that occur between treatment
offered 1-2 times per week for a minimum therapeutic strategies employed during
sessions. The purpose of self-monitoring in
of 40 weeks. Weekly treatment is each phase of EABT are outlined below.
EABT is to help the patient identify links
contingent on weight stabilization (i.e., no Phase 1. As in other psychotherapies,
between AN symptoms and emotional
weight loss for > 2 weeks and medically the initial sessions of EABT focus on
reactions or disconnection from other
stable) and sustained improvements in orienting the patient to treatment and
valued activities and relationships. For
other eating disorder symptoms (e.g. building a therapeutic relationship. A
example, daily activity monitoring is
purging). Although individual therapy major aim of Phase 1 is for the therapist
used to evaluate the amount of time the
sessions are the primary vehicle for and patient to develop a shared
patient is spending on eating disorder
change, EABT is designed to be provided understanding of the patient’s illness with
symptoms versus other valued activities
in the context of a multidisciplinary eating a particular emphasis on the relation
and relationships, and to set goals for
disorders treatment team. In addition to between eating disorder symptoms and the
increasing participation in other valued
meeting with their therapist, patients patient’s experience of emotion. The
enrolled in EABT receive weekly medical EABT model is introduced, and the patient
In graded exposure, the patient and
monitoring from a nurse or nurse and therapist work together to develop a
therapist develop a hierarchy of feared
practitioner and meet monthly with a personalized model that reflects the
experiences related to a particular stimulus
psychiatrist. Patients and therapists also patient’s history, symptom functions, and
and develop a plan for helping the patient
consult with a registered dietitian for values. At the close of Phase 1, the patient
increase her/his contact with these experi-
assistance with meal planning. Finally, and therapist collaborate to set treatment
ences. For example, exposure may be used
patients and therapists may schedule goals for: 1) weight gain/reduction of
to help the patient increase willingness to
adjunctive psycho-educational or eating disorder symptoms, 2) acceptance
enter situations that provoke aversive
supportive sessions that include family of emotions and other avoided experiences,
emotional reactions (e.g. social settings) or
members or supportive others. However, and 3) participation in other valued
to address concerns more directly related
family therapy is not a component of the activities and relationships.
to disordered eating (e.g. fear of physical
EABT intervention.
sensations related to swallowing/choking).
Perspectives • Winter 2010 Page 11
Phase 3. The final 4-6 sessions of EABT was developed by Dr. Wildes and Moses, E.B. & Barlow, D.H. (2006). A new
EABT focus on relapse prevention and Dr. Marsha Marcus at the Center for unified treatment approach for emotional
issues related to termination. The patient’s Overcoming Problem Eating at Western disorders based on emotion science. Current
personalized model of AN is reviewed and Psychiatric Institute and Clinic, University Directions in Psychological Science, 15,
updated and plans for continuing accep- of Pittsburgh Medical Center. 146-150.
tance and value-based living are discussed.
Pike, K.M., Walsh, B.T., & Vitousek, K.,
The patient and therapist also collaborate References et al. (2003). Cognitive behavior therapy in
to develop a personalized plan for relapse
Agras, W.S., Brandt, H.A., & Bulik, C.M., the posthospitalization treatment of anorexia
prevention based on the course of therapy.
et al. (2004). Report of the National nervosa. American Journal of Psychiatry,
Institutes of Health workshop on 160, 2046-2049.
overcoming barriers to treatment research in Schmidt, U. & Treasure, J. (2006). Anorexia
In summary, EABT is a new treatment anorexia nervosa. International Journal of nervosa: Valued and visible. A cognitive-
for older adolescents and adults with Eating Disorders, 35, 509-521. interpersonal maintenance model and its
AN that is based on a conceptual model
implications for research and practice.
emphasizing the role of anorexic Bulik, C.M., Berkman, N.D., & Brownley,
British Journal of Clinical Psychology, 45,
symptoms in helping individuals avoid K.A., et al. (2007). Anorexia nervosa
aversive emotional states. EABT treatment: A systematic review of
incorporates standard behavioral randomized controlled trials. International
interventions that are central to the Journal of Eating Disorders, 40, 310-320.
Jennifer E.Wildes, PhD, is
clinical management of AN with
Carter, J.C., McFarlane, T.L., & Bewell, C., Assistant Professor of
empirically-supported third generation
et al. (2009). Maintenance treatment for Psychiatry at the University
behavior therapy techniques that have
anorexia nervosa: A comparison of cognitive of Pittsburgh School of
shown promise in the treatment of other
behavior therapy and treatment as usual. Medicine and Western
chronic, refractory psychiatric conditions
International Journal of Eating Disorders, Psychiatric Institute and
(e.g. borderline personality disorder).
42, 202-207. Clinic, University of
Our research group has been fortunate to
Pittsburgh Medical Center.
receive funding from the National Institute Hayes, S.C., Luoma, J.B., & Bond, F.W.,
Her research and clinical interests include
of Mental Health to conduct a pilot study et al. (2006). Acceptance and Commitment
anorexia nervosa in adults and the intersec-
of EABT, and data collection is underway. Therapy: Model, process and outcomes.
tion of eating disorders with other psychi-
The results of this study, which we Behaviour Research and Therapy, 44, 1-25.
atric and medical problems.
anticipate will be available in early 2011,
McIntosh, V.V.W., Jordan, J., & Carter, F.A.,
will guide our future work on the
et al. (2005). Three psychotherapies for
development of interventions for older
anorexia nervosa: A randomized, controlled
adolescents and adults with AN.
trial. American Journal of Psychiatry, 162,

Intuitive Eating in the Treatment of Eating Disorders:

The Journey of Attunement
Evelyn Tribole, MS, RD
Patients with eating disorders are virtually What is the best way to facilitate the consequence of complex interactions of
the polar opposite of Intuitive Eaters. attunement needed to become an Intuitive mind-body biology and malnutrition.
Intuitive Eaters possess three core Eater? This article describes when and Chronic malnutrition results in
characteristics, the ability to (Tylka, 2006): how to implement Intuitive Eating for compensatory slowing of digestion in
patients recovering from an eating which patients experience early and
• Eat for Physical Rather than
disorder. prolonged fullness.
Emotional Reasons.
Additionally, it is hard for binge eaters
• Rely on Internal Hunger and Nutrition Rehabilitation Phase I: to recognize “gentle fullness,” when
Satiety Cues. Intuitive Eating is Contra-Indicated painful binge cycles prevail. For the
• Unconditional Permission to Eat. bulimic patient, the sensation of fullness
“Broken Satiety Meter.” When an
Growing research indicates that individual is in the throes of an eating is often distorted by the cessation of
Intuitive Eaters eat a diversity of foods, disorder, she is not capable of accurately purging behaviors (such as vomiting or
are optimistic, have better self-esteem, hearing biological cues of hunger and laxatives), which can cause temporary
and healthier body weights without fullness. In this situation, I tell my bloating. Amplifying the problem is the
internalizing the thin ideal (Tribole, 2009). patients, their “satiety meter” is broken, a neuro-chemical cascade triggered by stress
A Professional Journal of The Renfrew Center Foundation Page 12
and anxiety about eating issues which, in • Duration of eating disorder. appropriately to these cues when they
turn, may blunt hunger and cause nausea. • Severity of malnutrition. arise. This also means developing the
Nutrition Rehabilitation. In the begin- • Intensity of anxiety and fear ability to distinguish between physical
ning of treatment, nutrition rehabilitation about eating. and emotional cues.
usually requires some sort of eating plan As a person’s hunger and fullness cues
• Motivation for Recovery.
(often under the direction of a nutrition resurface, it’s not unusual for fears and
therapist). This is similar to when a cast is • Medications (which can distort distorted beliefs to arise in-tandem. For
needed to support the healing of a broken hunger and satiety cues). example, some patients distort and
arm. The cast provides structure and mislabel the sensation of fullness as
Phase 2: Identifying, Normalizing and
support, but it is not lifelong, nor the “proof ” of overeating. Consequently, they
Responding to Satiety Cues
destination in recovery. The cast is used may fear any fullness and label it as “bad”
until the bone is strong enough on its own. It is vital that satiety cues are normalized or “wrong.” Or, some patients might
Similarly, a meal plan serves as structure before further exploring Intuitive Eating. believe that achieving fullness means
and support, until there is biological The challenge lies beyond “hearing” the eating just until the hunger goes away, but
restoration. For a low-weight patient, this range of physical hunger and fullness cues. not a single bite more.
includes weight restoration. Patients need to learn how to respond In this stage it is helpful to explore the
Nourishment as Self-Care. The body
has been through nutritional trauma and How Intuitive Eating Principles Apply to Eating Disorders
needs consistent nourishment with Core Principle Anorexia Nervosa Bulimia Nervosa/
adequate calories. In this phase, nutrition Binge Eating Disorder

rehabilitation is a form of necessary self- Reject the Diet Mentality Restricting is a core issue and can Restricting does not work and triggers primal
care, regardless of the absence of hunger be deadly. hunger, which can lead to binge eating.

or the presence of early fullness. This Honor Your Hunger Weight Restoration is essential. The Eat regularly—this means 3 meals and 2 to 3
proscriptive eating phase is somewhat mind can not function and think properly. snacks. Eating regularly will help you get in
You are likely caught in an obsessional touch with gentle hunger, rather than the
mechanical because, in this early stage, a cycle of thinking and worrying about extremes that often occur with chaotic eating.
patient’s willingness alone is usually not food, and have difficulty making a deci- Ultimately, you will trust your own hunger signals
sion. Your body and brain need calories even if they deviate slightly from this plan.
enough to assure adequate intake. to function. Your nutrition therapist will
work with you to create a way of eating
that feels safe to you.
Boundaries: The Role of the
Schedule of Eating Make Peace with Food Taking risks, add new foods, when ready. Take risks, try “fear” foods, when ready and not
Do this gradually, take baby steps. vulnerable. Vulnerable includes over-hungry,
Creating a schedule of eating (with the overstressed, or experiencing some other feeling
patient) helps contain “eating anxiety”
by establishing a predictable expectation Challenge the Food Challenge the thoughts and beliefs about Challenge the thoughts and beliefs about food.
Police food. Take the morality and judgment Take the morality and judgment out of eating.
of when to eat. Eating regularly helps out of eating.
foster body rhythms, which include
Feel Your Fullness You can’t rely on your fullness signals A transition away from experiencing the extreme
hormonal patterns that help the body during the beginning phases of recovery fullness that is experienced with binge eating.
gear up for digestion. as your body likely feels prematurely full Once regular eating is established, gentle full-
due to slower digestion. ness will begin to resonate. Note: if you are
In an outpatient setting, I like to withdrawing purging, especially from laxatives,
establish a built-in flexibility of 30 minutes you may temporarily feel bloated which will
distort the feeling of fullness.
for each agreed upon eating time. For
example, if the patient agrees to eat lunch Discover the Frequently, there are fears or resistance If satisfying foods and eating experiences are
Satisfaction Factor to experiencing the pleasure from eating included regularly, there will be less impetus to
at 12:00, then eating between 11:30 and (as well as other pleasures of life). binge.
12:30 is acceptable. But if that 30 minutes
Cope with Emotions You may often feel emotionally shut Binge eating, purging, excessive exercise are
of flex-time is up, the patient needs to without Using Food down. Food restriction, food rituals and used as coping mechanisms. You can begin to
stop-and-drop (the other tasks at hand) obsessional thinking are the coping tools take a time out from these behaviors to start
of life. With re-nourishment, you will be experiencing and dealing with feelings.
and feed her body. This is an important more prepared to deal with feelings that
concept, because it helps the patient emerge.

establish her self-care (nourishment) as a Respect Your Body Heal the body image distortion. Respect the here and now body.
non-negotiable priority. For example, she
Exercise You will likely need to stop exercising. Over-exercising can be a purging behavior.
might need to tell her friends she must eat Learn to remove the rigidity of nutrition— Moderate exercise can help manage stress and
first, before shopping (rather than visa where there is a strict adherence to anxiety.
“nutritional principles”, regardless of their
versa). This often requires learning and source.
practicing assertiveness skills.
Honor Your Health Recognize that the body needs: Learn to remove the rigidity of nutrition. There is
During this phase, gentle hunger cues Essential fat a strict belief as to what constitutes healthy
begin to emerge. Keep in mind that the Carbohydrates eating, and if this belief is violated, purging
Energy consequences can ensue (if bulimic). Recognize
occurrence of regular hunger cues varies Variety of Foods that the body needs:
and is determined by many factors Essential fat
including: Energy
Variety of Foods

*from Tribole, E. & Resch, E. Intuitive Eating, 2nd ed (2003). New York: St. Martin’s Press.
Perspectives • Winter 2010 Page 13
patient’s understanding and beliefs around which may arise from ordinary life There is no right or wrong way to proceed.
hunger and fullness. What is the expecta- stressors? The challenge is to create more eating
tion around satiety cues? What might • Recognize vulnerability—such as experiences that build self-trust. What does
“normal” cues feel like? What did these being too hungry, too tired, too the patient need in order to feel safe?
cues feel like before the eating disorder stressed and so forth? What types of foods and meals feel
developed? What fears arise for the patient satisfying and sustaining? What types
Intuitive Eating Trial. In the beginning, it
about the idea of responding appropriately of foods would provide more social
is best to explore a one or two-day
to hunger and fullness cues? It is also connectivity? For example, would the
Intuitive Eating trial to determine if the
important to emphasize that there is no ability to eat pizza without anxiety allow
patient is truly ready to eat on the basis of
single “correct” way to experience these more social interaction with her friends?
her biological cues. During this time, it is
biological cues. Exploring Unconditional Permission
helpful to explore these issues:
Dealing with “False-Labeling” of Body to Eat. The ability to eat any food is an
Cue Experiences. In general, there is a • Were you able to honor hunger/ important component of recovery and
three-step process to normalizing satiety fullness cues in a timely manner? Intuitive Eating. Eating becomes
cues: • How did you respond to hunger cues? emotionally neutral—without moral
1. Develop ability to identify • How did you respond to dilemma or shame—where the patient
physical cue. fullness cues? understands that one food, one meal, or
2. Normalize the physical cue— • Was there a part of you that was one day of eating does not make or break
confront the distortion (or fear) about thinking it was an opportunity for you health or weight. When guilt is removed
the physical cue. to eat less? And, more importantly, from eating, it is easier to be attuned to the
3. Respond appropriately to cue. did you act on that thought? needs and experiences of the body.
• If you were scared about an upcoming Furthermore, habituation studies show
Every eating experience is an opportunity to that the more a person is exposed to a
learn about the body. For example, if for event (such as eating dinner at a
restaurant), did you compensate by food, eating becomes less distressful
some reason the patient did not eat enough (Epstein, 2009).
food at a meal—did she get hungrier eating less?
A promising study from the University
sooner? (Usually, yes). Did she think about During this trial, a patient might discover of Notre Dame applied the Intuitive Eating
food more often? (Usually, yes). that she doesn’t feel ready, and she may principles to 30 women with diagnosed
Or, if she ate beyond comfortable opt to continue on her existing meal plan. binge eating disorder (Smitham, 2008).
fullness, did she feel satisfied and It’s important to emphasize that this is After eight, 90-minute, weekly sessions,
sustained for a longer period of time? not failure. Rather, it usually reflects a binge episodes decreased significantly—
(Usually, yes). Were there fewer thoughts patient’s desire to protect her recovery. 80% of the women no longer met the
about food? (Usually, yes). It is important to move at an emotionally diagnostic criteria for the disorder.
comfortable pace (assuming she is eating
Phase 3: Indicators of Readiness for adequate calories). Moreover, it is still The Model: Integrating Intuitive Eating
Intuitive Eating possible to move forward with other for Eating Disorder Recovery
While many patients would like to jump Intuitive Eating principles within this
framework—such as working on permis- Cook-Cottone (2006) developed the
into Intuitive Eating, it is best to look for Attunement Representation Model to
readiness indicators before proceeding. sion to eat any food. Patients often express
feeling safer trying new food challenges conceptualize the integration needed for
Is the patient able to: an individual’s recovery from an eating
• Recognize that the eating disorder is within the framework of an eating plan.
disorder. This integration also aligns with
about something deeper—weight and
eating are symptoms? Figure 1: The Representational Self: Attunement and Expression
• Tolerate risk? As a person begins
to heal both physically and
psychologically, she is able to take
and tolerate risks with eating.
• Tolerate being uncomfortable?
Trying new eating experiences can
be temporarily uncomfortable.
• Recognize (and manage) needs and
feelings? If an individual is not able
to identify her needs or cope with
feelings, she may continue to use
eating disorder behaviors such as
restricting food, over-exercise, or
binge eating as coping strategies.
• Value Self-Care? Is she willing to
feed herself in the absence of hunger,
A Professional Journal of The Renfrew Center Foundation Page 14
Intuitive Eating. This model defines • Enhances the mind–body connection Mathieu, J. (2009). What should you know
attunement as the dynamic integration of and coordination, and does not about mindful and intuitive eating? Journal
a person’s inner and external worlds. confuse or dysregulate it. of the American Dietetic Association, 109
A person with an eating disorder is skewed • Alleviates mental and physical stress, (12), 1982-1987.
or mis-attuned toward the expectations of not contribute to and exacerbate stress. Scime, M., & Cook-Cottone, C.P. (2008).
others (such as cultural expectations of • Provides genuine enjoyment and Primary prevention of eating disorders: A
thinness). See figure 1. pleasure, not to provide pain and be constructivist integration of mind and body
Internal System. Ultimately, Intuitive punitive. strategies. International Journal of Eating
Eating is an individual’s attunement with
The pursuit of exercise is about feeling Disorders, 41, 134-142.
food, mind and body. The Intuitive Eating
principles fall primarily within the internal good, not about calories-burned or used as Smitham, L.A. (2008). Evaluating an
system of the attunement model, which a penance for eating. intuitive eating program for binge eating
consists of a person’s thoughts, feelings, Similarly, health can be honored with disorder: A bench-marking study
and physiology (biological sensations of gentle nutrition. For example, a family [dissertation]. South Bend, IN: University
the body). may desire to eat locally-grown foods with of Notre Dame.
a low carbon footprint. If a person is truly
Thoughts Tribole, E. (2009). Intuitive Eating: Can you
inner-attuned, she can integrate this value
Principle 1. Reject the Dieting be healthy and eat anything? Eating
without resorting to an eating disorder
Mentality Disorders Today. Winter: 10-11.
behavior or mind-set.
Principle 3. Make Peace with Food
A person recovered from an eating Tribole, E. & Resch, E. Intuitive Eating,
Principle 4. Challenge the Food Police
disorder can eat within this dietary 2nd ed. (2003). New York: St. Martin’s
Principle 8. Respect Your Body
framework, while paying attention to Press.
Feelings hunger, fullness, satisfaction and so forth.
Principle 7. Honor Your Feelings If, however, a person enters this realm too Tylka T. (2006). Intuitive Eating assessment
without Food soon, there is a risk for the new mindset to scale. Journal of Counseling Psychology,
be embraced as another rigid set of rules, 53, 226-240.
Physiology (Body)
fueling old eating disorder thinking and Tylka, T. & Wilcox, J. (2006). Are Intuitive
Principle 2. Honor Your Hunger
behavior. Timing and readiness are the keys. Eating and eating disorder symptomatology
Principle 5. Respect Your Fullness
Ultimately, when a person recovers opposite poles of the same construct?
Principle 6. Discover Satisfaction
from an eating disorder, she trusts her Journal of Counseling Psychology, 53 (4),
Principle 9. Exercise—
inner body wisdom. She is at peace with 474-485.
Feel the Difference
her mind and body, and finally, enjoys the
Principle 10. Honor Your Health
pleasures of eating without guilt or moral
with Gentle Nutrition
decree. Evelyn Tribole, MS, RD,
The External System consists of family, has written seven books
communities, and culture. These external and co-authored Intuitive
influences include food traditions, cultural References Eating. Ms. Tribole
beauty standards and public health Calogero, R. & Pedrotty, K. (2007). specializes in eating
guidelines. Daily practices for mindful exercise. disorders in Newport
The last two principles of Intuitive In L. L’Abate, D. Embry, & M. Baggett Beach, CA. She also
Eating pertaining to exercise and nutrition, (Eds.), Handbook of low-cost preventive teaches Intuitive Eating
are components of both the inner and interventions for physical and mental PRO skills to health professionals.
external systems and are excellent health: Theory, research, and practice For more information, visit
examples of the dynamic integration (pp.141-160). New York: Springer-Verlag.
needed to achieve authentic health.
For example, a person can integrate Cook-Cottone, C. (2006).The attuned repre-
exercise recommendations for health while sentation model for the primary prevention
being attuned to the experience of her of eating disorders: an overview for school
body. This type of physical activity is also psychologists. Psychology in the Schools,
called “mindful exercise” (Calogero & 43 (2), 223-230.
Pedrotty, 2007) where exercise: Cook-Cottone, C.P., Beck, M., & Kane, L.
• Is used to rejuvenate the body, (2008). Manualized-group treatment of
not exhaust or deplete it. eating disorders: Attunement in mind, body,
and relationship (AMBR). Journal for
Specialists in Group Work, 33, 61-83.
Perspectives • Winter 2010 Page 15

Breathing Underwater
Terry Nathanson, LCSW, LMT
Holding a 3 oz. Dixie cup with two almonds tension between my impulse to chew and than losing myself in the object of my
and an apple wedge inside, I glance around inhibit thicken into a muscular articulation desire—food, spice and everything nice, is
the room. The meditation room is full with of choice that embodies the hinge of nerve racking.
a curious excitement. With 21 spiritually my jaw. Mind scrambles to get back online
seeking overeaters, I’m attending a workshop Funny thing—mindfulness. Time begins again. “Maybe it’s your gluttony of wanting
on how to recover from holiday bloat. to change on you. A moment seems like more Terry, or the nostalgic reverie of
“The morsels in your cup will become forever, which can be a delight or hell. almond mush sliding down your esophagus
a part of you,” the workshop leader says, “Okay, now bite and notice something new.” in a victorious swallow. “Naa… It’s just a
softly guiding us into a conscious eating My bite splits the almond into halves. The damn almond.” “Get real” mind’s second in
experience. invisible boundary defining otherness command back-up critic demands with
I’ve seen and heard the cliché “we are cracks under the shearing pressure of my harsh chastisement.
what we eat” hundreds of times before on desire. Snap… a whiff of bitter almond Being a good workshop participant, I
book jackets and lectures. In the Eating- ignites an updraft at the back of my throat guide my attention back in a Zen kind of
n’-Motion® workshops I lead, I have said it. drawing the almond’s aroma upward into way. Embedded in my frustration is a
Now, the richness of Susan’s words my nasal passages. My tongue follows the whisper of “just be with what is, feel sensa-
shimmer in my body as a perennial truth. trail in quick pursuit. tions as they arise.” I get distracted by the
Eating literally makes food a part of me. I need to swallow badly. It’s sort of like young guy’s toes across from me playing
This almond will become my skin, muscle, having to pee. “Don’t swallow just yet,” with the soft green carpet.
and bone very soon. Susan tells us, with the knife-like precision Holding off on the ‘rush’ of gratification
As I began to inhabit the subtlety of my that could separate light from darkness. that a good ole quick gulp delivers,
experience a realization struck me. We are She’s encouraging us to just sense rather illumination explodes! Inherent in the
what we eat, and it is in the ‘how of eating’ than think or act. “What the hell,” my pleasure of every mouthful lives its shadow
that we encounter who we really are and the agitation shouts back at her in silence. side of loss. To have means to lose and
essence of our being human. To eat is to “Let’s eat!” therefore, not have…which is to have it all.
enter into an intimate partnership with life. “Mastery with emotional eating is The Buddhist Heart Sutra on the nature of
In moments, this partnering will include mastery of the swallow,” Susan says. Now, impermanence is in every chew. Crap,
making a vow. A vow of intention beyond that piece of wisdom is worth the price of I just want to eat. I do not want reality
language itself. patience. I like that, but give me a break… with a capital ‘R’ linked to pleasure and
Simply said, to eat is to live and not to I want to swallow! satisfaction. I might as well binge if that’s
eat is to die. At its deepest level to be born, Sliding against the almond’s grainy going to be the case.
to incarnate, is to be hungry and full. smoothness changes into the feel of raw Reality is secretly sandwiched between
“Eat as if it were a moving meditation,” sandpaper. My cat, Zoë comes to my gluttony and deprivation. Here resides the
Susan says. “Be aware of your hand as it thoughts when she’s meticulously licking disillusionment of ‘forever more’ and my
brings the almond up to your mouth.” my thumb. How soft her tongue is in one avoidance of limitation. Enjoyment that is
Sitting on oversized floor pillows, the direction and pleasurably raspy in another. inclusive of sorrow, satisfaction that holds
atmosphere in our circle is full and plush. An interesting mixture of longing and frus- both fullness and emptiness, is hard for even
Slowing down my fast food style of tration vice my belly into an all too familiar the most advanced eater to swallow.
devouring, each miniscule movement takes knot of self-deprivation that swells up into Much of what I have mistaken as my
on a new significance. It’s as if the bend in my rib cage. rush-flush love for food and comfort has
my elbow, the reach of my finger, the This exercise is taking forever and been confused with my gastronomic
touching of the almond, were my first and I’m pissed. It’s Susan’s fault. She’s so strategy to end all suffering—stuffing
my last. controlling. So much for falling in love and myself silly. So much for the sanctity
“Remember, this is your mouth, your trying to impress the workshop leader with of hedonistic overindulgence! And to add
hand, your body,” I tell myself. Unfastening how conscious I am. Married and divorced insult to incarnational injury, all this
the parched safety latch of my lips, I seat all in three minutes. Talk about gulping! revelatory non-duality is another attempt to
the almond on my tongue. I can feel the … I did my mindful eating bit. I get it, find refuge from the erupting anxiety of
“Stop,” Susan tells everyone. Slamming on all right! So let’s eat. Get to the next step change. What eater wants to feel loss in
the brakes, my upper lip already molded to already! I want to gulp now! every bite? Not the smartest of advertising
my almond’s rutted surface, sticks in adher- My mind’s amperage is turned up so slogans. Reality is not exactly a big selling
ence. Its dryness bonds to my skin, sucking high I can’t shut off the sizzle. I’m not really ticket at McDonald’s or during my prime
out the remaining moisture like a paper having thoughts, but a formless kind of time 11:30 PM refrigerator raids.
towel dropped on top of a kitchen spill. restlessness. I’ve experienced these feelings I’m tenser than ever now! The clock by
Reflexively licking across the adhesive other times when I have brought a quieting the window reads 2:00 PM. It’s been two
seal the almond falls onto my tongue. Like presence to my every day ordinariness. minutes or more exactly, three and a half
driving with the emergency brake on, Being this intimate with my mouth, rather chews into an almond since we started
A Professional Journal of The Renfrew Center Foundation Page 16
‘eating.’ I’m in some Sartre-esque dining Susan gently suggests. “Whoa!” My terror It’s as if she needed me more than I her.
room experience sitting at a table with the dissolves immediately in the flush. It is as if As I see Carol’s eyes tear up, I know I
Buddha and the devil. “Food is food,” I woke up from a dream where I was face am the one who has been swallowing my
Buddha says, compassionately smiling. down in a tub of water. Sitting up back into excitement. I have been living in ‘once a
“Just swallow and enjoy, there’s more where my body, resuscitates myself and a long upon a time,’ as if it were reality. “It’s like
that came from,” says the devil.” Or was that needed “ahhhh” remedies my throat and learning to breath underwater,” I tell Carol,
the Buddha? chest in a bath of soothing vibration. This is joy radiating through my face. “This is me.”
Swallow man, swallow already…save a relief well beyond the sensuous ‘slide’ of She smiles and hugs me.
yourself, some part of me yells from above finely masticated almonds making nice on In my own element, I am breathing
the water line. You’re drowning. “Let me their way down to my belly, thank you very underwater. Fifty years later, I am in my
out” reverberates silently between my much. Tectonic plates of being have shifted own experience, here and now. No one,
gritting teeth and tongue. Judgments punch under the identity of who I thought I was as snack or meal can take me from myself
at my soft palate hard. I can’t even taste an eater. My embodied nature as animal, except for me.
anymore. In fact, I am not sure I ever really human and divine is unfolding quickly.
tasted. Flailing in terror, some part of me Sharing all this with Carol, one of the For over 25 years Terry
grabs onto my mind to make sense of this workshop participants sitting next to me, my Nathanson, LCSW, LMT
senselessness. I am going under for the mouth dilates with excitement. A restricted has helped clients with
third time.’’ flow of saliva has been freed up from a eating difficulties and self-
“Everyone breathe,” Susan lovingly history of having to swallow my aliveness. nurturance. As an eating
whispers, from the shore-line of here and I had not realized how easy I was. Just a coach, Terry blends
now far away in the distance. “Separate out little in-real-time connection and my mouth Gestalt, Internal Family
the mashed almond from your saliva,” she reaches high tide again. Surf’s up with an Systems, and eastern
encourages the group. “Use your tongue to urgent undertow not to feel my urgency. I contemplative traditions with established
push the pulp to the side of your mouth and want to go to my default program which has body-mind approaches— all to support
let your self taste.” been to hide from my revelations, longing clients in establishing their healthy relation-
My inner eye pivots in a quick one- and transparent vulnerability and swallow— ship with food.
eighty. Its fixation on the no-exit sign of ‘all gone’. I experiment with inhibiting my
Founder of Eatingmatters of New York,
hopelessness releases with a sigh. My tendency to gulp a bit longer.
Terry leads workshops at Renfrew’s annual
mouth full with saliva is ready to burst “Carol,” saliva seeping out of the left
conferences, the Omega Institute and
through my lips any second now. I had no corner of my mouth, “I swallow my alive-
Kripalu Yoga Center. Eating consultation,
idea I was literally foaming at the mouth. ness so as not to be flooded with feeling.
one-on-one sessions, and appetite re-
Muscular contractions have been pulsing This is why I gulp my food before really
training intensives, are available for profes-
in my throat in a struggle to neutralize my savoring. It is happening right now.” My
gag reflex. When my dentist waits too long true enjoyment and pleasure never breaks
in suctioning the basin of my throat during into the surface tension of my awareness.
drilling a filling, I feel the same thing. Carol empathically nods. A ‘pop-up’
This survival reflex has saved me from memory suddenly emerges into my
swallowing a fate worse than an almond awareness. I grew up in fear of my mother
many times before in my life. swallowing me up whenever I excitedly
“Swallow whenever you are ready,” expressed my aliveness, my individuality.
Perspectives • Winter 2010 Page 17

The Renfrew Center Foundation Presents: The Renfrew Center

FOOD, BODY IMAGE AND Foundation Presents


Offering 4 CEs • Center
The Renfrew 9:00amis–pleased
1:00pmto announce: Seminars for
Friday, April 9, 2010 Philadelphia, PA
Friday, May 7, 2010 Bethesda, MD
Wednesday, October 20, 2010 Boca Raton, FL
Featured Speaker:
Adrienne NEW
MA, LMSW, AREA 12:00 – 1:00 PM EST
National Training Director and Body Image Expert CUTTING EDGE TREATMENTS
The Renfrew Center Foundation
If you or a loved one has an eating disorder, The Renfrew Center is the FOR EATING DISORDERS
only treatment facility in the country with programming specifically geared
The Renfrew Center Foundation is pleased to present a half-day seminar PRESENTED BY: DOUG BUNNELL, PHD
toward observant Jewish women. All food is provided by a Glatt kosher caterer
for mental
religiousprofessionals, educators, clergy and families addressing
practice is respected. FRIDAY, MARCH 19, 2010
women’s body image issues and eating disorders within the Jewish community.
Renfrew’s Treatment Programs: MEDICAL COMPLICATIONS
• Intensive Outpatient Care
• Day Treatment Program
FRIDAY, APRIL 16, 2010
For more information, call
1-800-RENFREW or visit
FRIDAY, APRIL 23, 2010

For for The Renfrew
more Center Foundation’s seminar:
information: MOOD DISORDERS, AND
Debbie in the
at 1-877-367-3383. PRESENTED BY: SHAWN GERSMAN, MD
Sunday, June 7, 2009 9:00 a.m. - 5:00 p.m. MONDAY, MAY 3, 2010
Ramaz Middle School
114 East 85th Street
New York, NY 10028
FRIDAY, MAY 21, 2010
The Nation’s Leader in Eating Disorders Training
Presents the 2010 Spring Seminar Series for Professionals THE USE OF DBT IN THE
We’re Bringing Our Expertise toYou PRESENTED BY: GAYLE BROOKS, PHD
FRIDAY, JUNE 4, 2010
Jennifer Nardozzi, PsyD
March 26 – Chapel Hill, NC
April 16 – Indianapolis, IN
April 30 – Albany, NY
May 14 – Long Island, NY
May 21 – Cleveland, OH
June 4 – Boston, MA
9:00am – 4:00pm • Offering 6 CE Credits
For more information, visit or call Debbie Lucker at 1-877-367-3383.
19 th
A Professional Journal of The Renfrew Center Foundation Page 18

Annual O
n behalf of the 2009 Conference Committee, I
would like to extend thanks to all of the speakers,

Conference Update
attendees and staff for making Renfrew’s 19th
Annual Conference a great success. This year, we welcomed
hundreds of professionals from all over the U.S., Canada,
Australia, Italy, Israel and Brazil.
The Conference theme, The Art and Science of Eating
Disorders Treatment, featured presentations on a wide
variety of topics ranging from traditional and experiential
therapies to neuroscience and the link between mind, brain
and body.Workshops addressed the role of the therapist and
the integration of various therapeutic approaches and
evidence based treatments into the recovery process, as it has
become more essential than ever for clinicians to be
embedded in many theoretical worlds.
Dr. Joan Borysenko delivered a personal, inspirational
Keynote which addressed the psychospiritual development
of women during the major stages of the feminine lifecycle.
Her presentation was described by many attendees as
uplifting, empowering and thought-provoking. Dr. Daniel
Siegel, our Saturday Keynote speaker, examined well-being
through the lens of science. He clearly articulated complex
material in a fascinating, understandable manner, inter-
weaving science and spirituality while validating the rela-
tional work that takes place throughout treatment. Our
closing Keynote Panel, moderated by Dr. Bill Davis, brought
together seasoned clinicians - Dr. Kathryn Zerbe, Dr. Jim
Lock and Carolyn Costin, for a discussion of treatment issues
from their different perspectives.The interactions among the
panelists and questions from the audience were enlightening
and provided practical answers to many of the challenges
most clinicians face with eating disorder clients and families.
Throughout the weekend, there were also numerous oppor-
tunities for professionals to enjoy the camaraderie of
networking and reconnecting with colleagues, as well as
attending special breakfasts and evening events.We greatly
appreciate those of you who participated with such enthu-
Next year,The Renfrew Center Foundation will celebrate
its 20th Annual Conference for Professionals.We are greatly
looking forward to this milestone event.A preview of what
we have planned can be found on PAGE 20.
This update includes photos from the conference as well as a
form to order CDs if you were unable to attend or missed
some workshops. Many thanks again for making Conference
2009 such a great success and we hope to see you next
Perspectives • Winter 2010 Page 19

“What I love most and carry with

me from each conference is the
rejuvenation, the replenishment and
the sense of community with others
who do this work.Thank you!”

“Great conference, great food,

great colleagues.”

“This is the best conference I’ve

attended in my 10 years of practice.”

“It was a therapist’s heaven.”

A Professional Journal of The Renfrew Center Foundation Page 20



Feminist Perspectives and Beyond:

Honoring the Past, Embracing the Future
Philadelphia Airport Marriott
November 12-14, 2010
To commemorate this milestone, Renfrew has planned three days of invited presentations
by outstanding leaders in the field.The Conference 2010 program will address significant
aspects of eating disorders theory, treatment, prevention, and research.
Gloria Steinem
Craig Johnson, PhD and Michael Levine, PhD
Cynthia Bulik, PhD
• Traditional Therapeutic and • Neuroscience/Attachment
Complementary Approaches • The Therapeutic Alliance
• Body Image • Genetics
• Treatment Issues • Diagnoses and Etiology
• Co-morbid Conditions • Integrating Evidence Based
• Family & Group Work Guidelines & New Research
Findings into Treatment

A Call for Proposals and Posters will resume in 2011.

For more information, please visit
or call Debbie Lucker at 1-877-367-3383.
Perspectives • Winter 2010 Page 21


The 19th Annual Renfrew Center Foundation Conference
“Feminist Perspectives and Beyond:
The Art and Science of Eating Disorders Treatment”
November 13-16, 2008 – Philadelphia, PA

❑ I would like to purchase the Full Set of MP3 Recordings on USB Flashdrive $225
❑ I would like to purchase the Full Set of CDs at a 20% Discount $495
❑ I would like to ADD the Thursday All Day Workshops on CD at a 20% Discount $195
❑ I would like to ADD the Thursday All Day Workshops on MP3 USB Flashdrive $95
If you would like to purchase individual recordings, please circle the price of the items you would like.

Thursday All Day Workshops

# Presenter(s) Workshop CD
TH1 Bellofatto The Therapist’s Toolbox $50
TH2 Shure and Weinstock Wired for Connection… $50
TH3 Courtois Treating Complex Traumatic Stress Disorders $50
TH4 Kronberg, Love & McLeroy Beyond Talking: Using Therapeutic Eating Sessions… $50
TH5 Pedrotty-Stump, Calogero, Treatment of Exercise Issues in Eating Disorder Clients $50
Cover, O’Melia & Reel

Friday Workshops
# Presenter(s) Workshop CD
FR1 Butryn & Forman Introduction to Acceptance & Commitment Therapy… $20
FR2 Gerstein & Barber The Imperfect Therapist… $20
FR3 Hall, Levine & Mifsud About Men: As Cultural Victims, …. $20
FR4 Kellogg The Language of Change for Therapists and RDs $20
FR5 Weiner & Mehler Medical/Therapeutic Treatment of Anorexia Nervosa… $20
FR6 Zerbe The Resilient Therapist: Transference & Countertransference $20
FR7 Dagg & Little Fed Up: Get Fed! Family Eating Disorder Recipes $20
FR8 Feinson & Wyshogrod Reclaiming Inner Wisdom: Mindful Approaches… $20
FR9 Freizinger & Balz Managing the Chaos: Dialectical Behavior Therapy… $20
FR10 Nye In Treatment: An Inside Look at a Case of Anorexia Nervosa $20
FR11 Scarano-Osika EDNOS in Teens… $20
FR12 Walsh Eating w/ Your Genes Off? Epigenetics & Anorexia Nervosa $20

Keynote Presentations
# Presenter(s) Workshop CD
Friday Borysenko Psychology, Biology & Spirituality of Feminine Lifecycle $20
Sunday Davis, Costin, Lock & Zerbe What Makes A Difference?
Perspectives on the Art & Science of Eating Disorders Treatment $20
A Professional Journal of The Renfrew Center Foundation Page 22
Saturday Workshops
# Presenter(s) Workshop CD
SA1 Bloomgarden & Mennuti The Therapeutic Relationship… $20
SA2 Bunnell & Lowe Bringing Research into Practice… $20
SA3 Kearney-Cooke Real Girls, Real Pressure… $20
SA4 Lelwica Beyond the Religion of Thinness: Spiritual Needs… $20
SA5 Matz & Frankel The Diet Survivor’s Circle… $20
SA7 Feibish & Brendler A Model of Supervision… $20
SA8 Ice, Kraman & Wingate East Meets West: A Medical Approach… $20
SA9 Lock Family-Based Treatment of Adolescent Eating Disorders $20
SA10 McGilley, Maine, Ressler Yours, Mine & Ours… $20
SA11 Torres & Dauser The Use of Story as a Shamanistic Tool… $20
SA12 Seubert The Case of Mistaken Identity: Ego States and EMDR… $20

Sunday Workshops
# Presenter(s) Workshop CD
SU1 Brady-Rogers Neuroscience, Spiritual Practices & Transforming the… $20
SU2 Baratka & Hudgins The Therapeutic Spiral: A Model for Treating Trauma…Disorders $20
SU3 Levine & Ethridge Working Towards Recovery and Balance: … $20
SU4 McLain Do What I Say, Not What I Do: Self-Care and the Prevention… $20
SU5 Nathanson It’s More than Mindfulness: Integrating East & West $20
SU6 Schaefer & Berrett Beyond Recovery: How Clinicians Can Teach Clients the Art… $20

Please tally your charges (or we can help you with this) Amount
❑ I would like to purchase the Full Set of MP3 Recordings on USB Flashdrive - $225 each $
❑ I would like to purchase the Full Set of CDs - $495 each $
❑ I would like to ADD the Thursday All Day Workshops – CD’s @ $195 each or MP3’s @ $95 $

Quantity Amount

Individual workshop orders Number of workshops/CDs: x $20 $

Thursday all day workshop orders Number of workshops/CDs x $50 $

Shipping and Handling $5 for the first disc set and $1 for each Total S&H Cost $
additional disc set shipped in U.S.
(Only necessary if having order shipped.)
The differences in price for CDs reflect the number of discs used for the session. Full CD sets come in Total Due: $
handy multi-CD library cases. All full CD set orders must be shipped to you. Thank you for your business!

Please include payment & shipping information:

Name Phone

Address E-Mail


Payment Method ❑ Visa ❑ MC ❑ Cash ❑ Check #

Card #: Exp. Date:


Backcountry Productions • 724 Crestwood Drive • St. Augustine, FL 32086 • 904-460-2379 •
Perspectives • Winter 2010 Page 23

The Renfrew Center is celebrating its The Renfrew Center Opens

25th Anniversary as the country’s first New Facility in Bethesda, MD
residential eating disorder treatment facility. and an Independent Affiliate
Renfrew is the first and largest eating disorder treatment
in Guatemala.
network in the country and has treated over 50,000 women The Renfrew Center is pleased to announce the opening of a
with eating disorders.We provide a comprehensive range of new site in Bethesda, Maryland and AKASA, an independent
services in PA, FL, NY, NJ, CT, NC,TN,TX, MD and affiliate in Guatemala, Central America.
Guatemala, an independent affiliate. Programming offers a comprehensive range
of services including:
In 2010, Renfrew will be hosting a 25th Anniversary • Day Treatment Program
celebration at each of our sites! • Intensive Outpatient Program
Florida - April 2010 • Group Therapy
New Jersey - May 2010 • Individual, Family, and Couples Therapy
Philadelphia - June 2010 • Nutrition Therapy
Connecticut - September 2010 • Psychiatric Consultation
NewYork - October 2010
North Carolina - December 2010
Continued through 2011:
Texas - February 2011
Tennessee - March 2011
Maryland - April 2011
The Renfrew Center of Maryland AKASA is located in Guatemala,
We hope you will join us in celebration of this great milestone! is located at 4719 Hampden Lane, Central America.
Suite 100, Bethesda, MD 20814
For more information, please call 1-800-RENFREW
or visit our web site at For more information, please call 1-800-RENFREW
or visit our web site at

Your Donation Makes a Difference

s a professional and educator working with individuals Please designate below where you would like
affected by eating disorders, you are undoubtedly aware of the to allocate your donation:
devastation these illnesses cause to families and communities. ❑ Treatment Scholarships ❑ Training & Education
The Renfrew Center Foundation continues to fulfill our mission of ❑ Area of Greatest Need ❑ Research
advancing the education, prevention, research and treatment of eating
disorders; however, we cannot do this without your support.
Your Donation Makes A Difference…
• To many women who cannot afford adequate treatment.
• To thousands of professionals who take part in our City/State/ZIP________________________________________
nationwide seminars and trainings. Phone/Email__________________________________________
• To the multitude of people who learn about the signs and
symptoms of eating disorders, while learning healthy ways Below is my credit card information authorizing payment to
to view their bodies and food. be charged to my account.
• To the field of eating disorders through researching best
Credit Card #_________________________________________
practices to help people recover and sustain recovery.
An important source of our funding comes from professionals like Security Code________________ Exp. Date_______________
you. Please consider a contribution that makes a difference! Credit Card Type_______________________________________
Tax-deductible contributions can be sent to: Amount Charged_______________________________________
The Renfrew Center Foundation
Attn: Debbie Lucker Signature/Date_________________________________________
475 Spring Lane, Philadelphia, PA 19128

The Renfrew Center Foundation

475 Spring Lane
Philadelphia, PA 19128

The opinions published in Perspectives do not necessarily reflect those of The Renfrew Center. Each author is entitled to his or
her own opinion, and the purpose of Perspectives is to give him/her a forum in which to voice it.


NORTHEAST SITES Wilton, Connecticut Nashville, Tennessee

436 Danbury Road 1624 Westgate Circle
Philadelphia, Pennsylvania Wilton, CT 06897 Suite 100
475 Spring Lane Brentwood, TN 37027
Philadelphia, PA 19128 Bethesda, Maryland
4719 Hampden Lane Dallas, Texas
Radnor, Pennsylvania Suite 100 9400 North Central Expressway
320 King of Prussia Road Bethesda, MD 20814 Suite 150
2nd Floor Dallas, TX 75231
Coconut Creek, Florida
11 East 36th Street 7700 Renfrew Lane Guatemala, Central America
2nd Floor Coconut Creek, FL 33073 AKASA, Independent Affiliate
New York, NY 10016
Charlotte, North Carolina
Ridgewood, New Jersey 6633 Fairview Road
174 Union Street Charlotte, NC 28210
Ridgewood, NJ 07450