New residential treatment for severe and enduring eating disorders

Transcription

1 New residential treatment for severe and enduring eating disorders Pia Charpentier Psychologist Psychotherapist CEO Center for Eating Disorders

2 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

3 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

4 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

5 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)

6 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.

7 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

8 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.

9 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

10 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

11 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

12 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)

13 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

14 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

15 AN binge/purge beginning of treatment

16 AN binge/purge end of treatment

17 Bulimia fork & knife symbolizes bingeing & purging

18 Anorexiarestricting type

19 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

20 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

21 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

22 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

23 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

24 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.

25 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

26 Some results Patients who have been in treatment between and who agreed to participate in the study and who we were able to contact N=37 Ages 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 ( ) Ended as planned 23 (62%) Ended prematurely by pt 10 (27%) Moved to another facility 1 (3%) Discontinued for financial reasons 3 (8%)

27 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)

28 Follow-up Treatment ended as planned (whole group) Bingeing No 86% (56%) Yes, daily or weekly 14% (9%) Purging No 95% (64%) Yes, daily of weekly 5% (3%) Pt feels healed Yes 81% (59%) Partly 19% (14%) Treatment after CED Therapy 90% (59%) Hospital 10% (6%) Treatment discontinued prematurely (whole group) Bingeing No 83% (29%) Yes, daily or weekly 17% (6%) Purging No 73% (24%) Yes, daily of weekly 27% (9%) Pt feels healed Yes 50% (14%) Partly 50% (14%) Treatment after CED Therapy 27% (9%) Hospital 73% (25%)

29 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