New residential treatment for severe and enduring eating disorders Pia Charpentier Psychologist Psychotherapist CEO Center for Eating Disorders [email protected]

Residential clinic • Opened in 2004 • Specialized in severe and enduring eating disorders with comorbid disorders like BPD and traumas • 7 beds • 1-5 day patients • 13 yrs and up • All eating disorders - mainly some form of AN and severe BN • Multidisciplinary staff

• Nurses, psychiatrist, psychologist, physiotherapist, occupational therapist, nutritionist, consulting pediatrician and internist, chef

We also have a Therapy center • Opened in 2002 • Both clinics operate currently at the same premises • Multidiciplinary team (nurses, psychologist, psychiatrist, physiotherapist, nutritionist) • Patients 11 yrs and up (oldest so far 76 yrs old) • All eating and weight disorders and problems

Our understanding of eating disorders 1 • At the core of the severe eating disorders there are • • • • •

Under developed emotion regulation skills Extremely negative self image Interpersonal difficulties – especially in trusting others Emotional over sensitivity Traumas – single events (deep loss, accident, victime of violence) or long lasting traumatic experiences (eg. abuse)

• We see, that the patient experiences the symptoms as uncontrollable • We understand that the pt feels safe with the symptoms at the same time as she suffers from them

Our understanding of eating disorders 2 • Developmental stages are built on top of each other • The skills learned in the early states support the learning of the later stages Adulthood Adolescence (value) Childhood (freedom authenticity) Infancy (safety, needs)

Our understanding of eating disorders 3 • If the early development has not been completed correctly, it forms a shaky base for the next developmental stages • The earlier the developmental defficiency, the more severe the eating disorder • The function of the ED becomes one of survival • The client experiences intense emotional pain without the symptoms • Thus giving up the symptoms without intensive help is often impossible.

Our understanding of eating disorders 4 • The healing process means building new survival skills • A lot of the healing elements come implicitly in the relationship with the nurses • Corrective experiences • The importance of HOW we are with the clients

• Usually this process requires longer treatment periods because it involves a psychological growth process

Our understanding of eating disorders 5 • Those, who had developmental problems later in their development usually do not develop a severe form of ED • symptoms can be severe, but psychopathology not

• They have acquired adequate basic psychological skills (basic safety, emotion regulation, acceptance of needs etc.) • These skills are temporarily out of use • The healing process involves the reacquiring of the skills by diminishing ED symptoms • Short hospitalization or outpatient treatment normally suffice.

The treatment has three simultaneous paths • Treatment of concrete (behavioural and physiological) symptoms • Eating behaviours and nutrition • Normalizing weight • OCD, compulsive exercise etc.

• Treatment of psychological symptoms

• Anxiety, depression, interpersonal difficulties

• Psychoeducation

• Nutrition, psychology

Creating trust and safety • Creating trust in the treatment relationship • Careful listening, taking into account the patient’s wishes • Going over principles of the treatment

• Providing safety • • • •

Presence (one nurse per two patients) Creating a safe environment for eating (adequate support) Locked doors (front door, toilets and showers) Minimizing opportunities to exhibit symptoms

Working actively to help the process of healing • Daily groups (psychoeducation, discussion, dance and movement therapy, physiotherapy, relaxation, grafting, leisure) • 3 weekly discussions with case managers, daily discussions with shift nurses • Weekly meetings with nutritionist, physiotherapist and masseuse • Psychotherapy begins when the patient is ready/interested in starting it

• Weekly challenges and practices with symptoms

• Planned with case managers, supported by whole staff

Normalizing eating • In the beginning all responsibility is on the nurses • The patient negotiates about foods and portion sizes with the nutritionist once a week • Execution of these agreements is taken care of by the nurses

• Measuring of the portions is done by the chef (or nurse – depending on time of day)

Normalizing eating • Eating together with the nurse in the patient’s own room • This allows for intensive support • At this stage the eating is usually filled with rituals and anxiety is overwhelming

Normalizing eating • As the healing progresses, the patient takes on more and more responsibility • Learning to apportion her own foods meal by meal • Cooking • Eating at restaurants • Finally taking full responsibility

• All stages are practiced until the patient can fully handle the responsibility of feeding herself

AN binge/purge – beginning of treatment

AN binge/purge – end of treatment

Bulimia – fork & knife symbolizes bingeing & purging

Anorexiarestricting type

Normalizing weight • In the beginning the weight is not shown to the patients • To diminish the obsession about weight • To avoid unnecessary and unhelpful anxiety

• As the healing progresses, the patient gets to know her weight • At this point the information about her weight does not cause her to exhibit more ED behaviours

• The weight is only talked about in extreme situations • Eg. Rapid/unexpected weight loss

• The weighing is done randomly 1-3 times every 1-2 weeks. • The lower the weight the more often the weighing is done • It can be done at any time of the day – looking only at general trends, not grams

Working with families Information about ED and our treatment programme Support for parents’ own anxiety regarding their child’s illness Weekly (sometimes daily) phone calls Regular meetings – usually once in every 1-2 months (sometimes every other week) • Group for parents • • • •

• Individually tailored family interventions • Eg. parent staying at the ward for a week • Therapeutic processes between the parents and the pt • Meals with parents

Helping the patients with their anxiety • A lot of support and presence – helping to deal with acute anxiety • Teaching the patients to use other means besides their symptoms to regulate anxiety • Relaxation techiniques, mindfulness • Asking for help when anxious (instead of withdrawing and exhibiting symptoms) • Psychophysical physiotherapy – using the body to regulate anxiety • Practising different techniques to reduce anxiety

Communicating with the patients in a special way to avoid unnecessary anxiety • Avoiding commenting appearance

• ”you look healthy / better / good” = ”you are fat”

• Avoiding talking about any numbers

• Calories, kilos, target weight, hospital weight etc. = Ed starts playing numbers games

• Avoiding blaming the patient of her symptoms

• Understanding that ED is nobody’s fault – pt feels lost and helpless with her symptoms • Externalization method

…Communication continues… • Repeating same things patiently over and over again • The ability to process information is impaired because of anxiety and low weight

• Most patients are emotionally over sensitive, therefore communication is soft and kind • Even when the patient is angry

Emotion tolerance work • The nurses accept and deal with calmness with everything that arises from within the patient

• The calmness of the nurse at the face of intense emotions of the patient teaches the her implicitly that emotions are not dangerous

• Learning to turn to the nurses when a difficult emotions arise

• Talking about emotions and sharing them with the nurses teaches the pt that her emotions are allowed and acceptable

• Learning to relax and direct attention to bodily experiences of emotions helps the pt to calm her self down

• Being with emotions shows that they can be tolerated and that they calm down after a short while.

Taking care of our nurses • Individual and group supervision 2-3 times per month • Possibility to change work persentage for every list • Massage during work hours • Supportive atmosphere among workers • Easy access to managers • Immediate problem and conflict management • Possibility to take part in the ongoing development of the treatment programme • Possibility to incorporate individual special skills in the treatment

Some results • Patients who have been in treatment between 2004-2012 and who agreed to participate in the study and who we were able to contact • N=37

• • • • • • •

Ages 13-35 yrs in the beginning of treatment (average 20 yrs) BMI in the beginning 10,24 – 29,62 (average 15,0) Duration of treatment 448 days (53-1217) Ended as planned 23 (62%) Ended prematurely by pt 10 (27%) Moved to another facility 1 (3%) Discontinued for financial reasons 3 (8%)

Some results 2 • Ended as planned • BMI in the beginning 15,5 (10,24-29,62) • BMI in the end 19,71 (16,61-24,31) • Change in BMI 3,30 (-6,63-8,92)

• Ended prematurely by pt • BMI in the beginning 13,94 (9,35 16,55) • BMI in the end 15,34 (10,92-18,18) • Change in BMI 1,43 (-1,97-4,69)

• Discontinued for financial reasons • BMI in the beginning 14,33 (12,93-15,72) • BMI in the end 17,35 (16,48-18,27) • Change in BMI 3,02 (1,58-5,34)

Follow-up Treatment ended as planned (whole group)

Treatment discontinued prematurely (whole group)

• Bingeing

• Bingeing

• Purging

• Purging

• Pt feels healed

• Pt feels healed

• Treatment after CED

• Treatment after CED

• No 86% (56%) • Yes, daily or weekly 14% (9%) • No 95% (64%) • Yes, daily of weekly 5% (3%) • Yes 81% (59%) • Partly 19% (14%) • Therapy 90% (59%) • Hospital 10% (6%)

• No 83% (29%) • Yes, daily or weekly 17% (6%) • No 73% (24%) • Yes, daily of weekly 27% (9%) • Yes 50% (14%) • Partly 50% (14%) • Therapy 27% (9%) • Hospital 73% (25%)

So, what exactly is new..? • Focusing strongly on psychological symptoms • Tolerance for all symptoms and behaviors • Incorporating comorbid symptoms into the treatment • Continuing treatment until the pt is able to take full responsability for the continuation of her healing • Not stopping treatment at the normalization of weight - this is usually half way of treatment