1. Addressing self-injury and therapy-interfering behaviors in eating disorder treatment across the developmental spectrum: A DBT approach
Approximately 25-55% of ED patients engage in non-suicidal self-injury (NSSI) (Svirko & Hawton, 2007) and between 3-35% attempt to take their own lives (i.e. suicidal behavior or SB) (Franko & Keel, 2006). Despite these alarming statistics, most evidence-based ED treatment models do not include a framework for directly addressing these behaviors. A therapist treating a patient who exhibits both an ED and SB/NSSI may be confused about which behavior to prioritize (e.g., Is cutting more important to target than purging?) and whether or when to refer out (e.g. Should I refer for depression treatment before treating the ED?). This confusion can be intensified when the patient’s ED behaviors result in medical instability and thus may be imminently life-threatening.
Additionally, behaviors that interfere with a patients’ ability to benefit from or remain in treatment (aka therapy-interfering behaviors or TIBs) can also complicate a clinical picture. Patient TIB’s can range from weight manipulation and hiding food to aggressive outbursts. In the context of treatment with adolescents, parents/caregivers can behave in ways that also interfere with treatment such as not scheduling or attending appointments or not “being on the same page” with respect to limit-setting. Finally, ED therapists may also directly or indirectly engage in behaviors that interfere with treatment as well (e.g., coming late to session, creating an imbalance between change and acceptance). If left unaddressed, any of these behaviors can result in lack of treatment progress, therapist burnout or patient/family dropout.
Dialectical Behavior Therapy (DBT), a therapy originally designed for chronically suicidal, difficult-to-treat patients, provides a clear and systematic approach for dealing with life-threatening and therapy-interfering behaviors. Several studies have demonstrated that DBT with those diagnosed with an eating disorder is both efficacious (Safer, Telch, & Agras, 2001) and effective (Ben-Porath, Wisniewski, & Warren, 2009; Federici, Wisniewski , & Ben Porath, 2013, Federici, & Wisniewski, 2013).
The workshop will teach participants how to address the full range of these behaviors, both in and out-side of sessions and across the developmental spectrum.

2. Learning Objectives
Following this workshop, attendees should be able to:
Identify patient behaviors that interfere with treatment.
Identify caregiver behaviors that interfere with treatment.
Identify therapist behaviors that interfere with treatment.
Formulate strategies to address suicidality, non-suicidal self-injury and TIBs in and out of session and across the developmental spectrum.
Lu to verify learning objectives match those submittedIdentify patient behaviors (eating disordered and otherwise) that interfere with treatment
Identify caregiver behaviors that interfere with treatment
Identify therapist behaviors that interfere with treatment
Formulate strategies to address suicidality, non-suicidal self-injury and TIB’s in and outside of session.

3. Lucene Wisniewski, PhD, FAED The Emily Program
Addressing self-injury and therapy-interfering behaviors in eating disorder treatment across the developmental spectrum: A DBT approach
Lucene Wisniewski, PhD, FAED
The Emily Program
Case Western Reserve University
Introductions

4. Workshop Overview Discussion about Difficult-to-Treat Patients
Brief Introduction to DBT
Goals
Structure
DBT Targets
Suicidal Behavior & Non-Suicidal Self-Injury (NSSI)
Therapy Interfering Behaviors

5. Adult Case Example: Nadia
23 yr old female (9 yr history of OSFED)
Repeated hospitalizations/residential treatment – minimal change
Fired by her physician for TIBs in hospital
In outpatient therapy for 5 yrs – minimal change
Presenting ED symptoms:
BMI = 18
Food rigidity
vomiting, laxative and diuretic use
Significant fear of weight gain
Suicidality?
LW TO CHANGE NADIA’S DIAGNOSIS & BX PRESENTATION SO NOT PRESENTING 2 AN CASES
Says she was suicidal in the hopstial but now is not

6. Adult Case Example: Nadia
Co-morbid diagnoses
Borderline Personality Disorder (self-injury, fears of abandonment, anger outbursts, chaotic interpersonal communications)
PTSD
Significant Therapy Interfering Behaviors
Previous therapists report feeling “burned out” and “at a loss” for an effective treatment plan
Financial/Insurance Barriers
Parents have medical guardianship
Parents interact in a hostile manner with staff

7. Adolescent Case Example: Emily
16 year old female (2 year history of AN)
Sophomore student at alternative high school
Household:
Bio mom (FT health aide at local hospital)
Mom’s boyfriend (FT factory worker)
12 year old brother with autism
Presenting ED Symptoms:
Dropped from 75%tile to 25%tile after dramatic weight loss
Highly restrictive eating, <1000 kcal/day
Runs every evening to compensate for food consumed
Extreme body dissatisfaction
Not participating in family meals or activities with food
Arguing & negotiating, hiding food

8. Adolescent Case Example: Emily
Co-morbid Diagnoses / Areas of Concern
Mild Dyslexia
Affects reading fluency and comprehension, writing and spelling
Major Depressive Disorder
Diagnosed age 12
NSSI, suicidality (1 psychiatric hospitalization)
Restored some weight in FBT; difficult to maintain focus due to concerns about SI and NSSI
Significant Therapy Interfering Behaviors
Minimal engagement / participation
“Sassy Teen” behaviors
Lying / withholding to parents and past providers
Family transportation and time barriers
Minimal adult supervision (affects support for therapeutic goals)
Mother highly critical of client (esp. surrounding restriction)

9. Why is it difficult to treat individuals who self harm?
Elaine looks at her folder in the doctor’s office & sees that a previous doctor recorded that she was “difficult.”
** MAKE LIST ON WHITEBOARD SO CAN REFER BACK LATER**

10. Summary: Limitations of Standard ED Txs
Lack of explicit attention to emotional processes & affect regulation
No specific protocol for managing high-risk or comorbid Axis II issues (e.g., recurrent suicide/self-injury, BPD)
Designed for pts who are more ready/willing to change
Tx providers commonly report feeling burned out and ineffective in their ability to effectively treat multidiagnostic ED pts.
Most tx studies of CBT & IPT exclude pts with suicidal/self-injurious behavior and/or prominent personality disorders.
(Lundgren, Danoff-Burg, & Anderson, 2004; Kachele, Kordy, & Richard, 2001; Kahn & Pike, 2001; Mehran, Leonard, & Samuel-Lajeunesse, 1999; Solenberger, 2001).
Premature withdrawal
Difficulty engaging in tx
Greater ambivalence for change
Higher relapse following a period of remission
Greater interpersonal problems

11. DBT… Acceptance + Change
Multi-disciplinary, cognitive behavioral treatment designed specifically for individuals with suicidal and intentional self-harm behaviors.
DBT emphasizes basic behavioral principles and eastern meditative practicesZen/ mindfulness techniques
+ tools of cbt
Dialectical behavior therapy (DBT) is a system of therapy originally developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people withborderline personality disorder (BPD) .[1][2] DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice
Acceptance Change 11

12. What are the GOALS of DBT?

13. Standard DBT Goals Increase behavioral skills
To assist patients to move themselves to a
“Life Worth Living”
Decrease behaviors that interfere with:
Living (e.g. suicide and self-harm, ED)
Therapy
Quality-of-Life
Increase behavioral skills

14. What is the STRUCTURE of DBT?

15. Standard DBT Structure
Individual Therapy
Weekly Skills Group
Telephone Skills Coaching
Consultation team

16. Adaptations for Adolescents
Involvement of support system is important in adult DBT and crucial in adolescent DBT
Parent Modeling
Treatment Compliance
Adolescent Model
Family Skills Training
Inclusion in IT sessions / Family Therapy PRN
Telephone skills coaching for parents and child
Additional Skills Module “Walking the Middle Path”
Contact with ancillary providers (e.g. school counsellor)
POC call skills-coach – not therapist
Adolescent informed when POC calls for coaching
No details about kid’s tx are shared during call
WMP - Module developed specifically for kids and teens
Focuses on learning there is more than one way to see a situation or solve a problem by balancing acceptance and change

17. Including Parents in DBT IT Session
Safety Planning
Addressing invalidating behaviors between family members contributing to invalidating environment
Crisis erupts within a family
Treatment would be enhanced with psychoeducation surrounding DBT
Contingencies at home are too powerful and continue to reinforce dysfunctional or ineffective behavior

18. New Adult Skills Manual

19. Adolescent Treatment & Skills Manual

20. Public Service Announcement!
Not all DBT is the same DBT! It is important to match the patient to the DBT that has data for their specific issues.

21. How can DBT HELP us with SI/SH and TIBs?

22. The problem in treatment…
The moving target!!

23. NSSI
depression
purging

24. When there is so much to work on
(like with like Nadia & Emily)…
Where does one start???

25. Targeting in DBT
Targeting in DBT is a process that transforms the clients’ goals into specific behaviors to increase and to decrease in order to reach those goals.
If my goal is to graduate from college
A targeted behavior to increase is going to class and studying and a behavior to decrease is dropping out each semester

26. Targeting in DBT
When the client has a single problem that if solved will meet his/her goals:
that problem is the target
and you are a lucky therapist!
When there are multiple behaviors to increase or decrease,
there has to be a mechanism to determine what is treated as a part of the overall case conceptualization
And in each session
If my goal is to graduate from college
A targeted behavior to increase is going to class and studying and a behavior to decrease is dropping out each semester

27. Why Target?
Gives you a way to sort behavior when there are multiple behaviors
during the week
in session
Behaviors that are not targeted do not change
: Suzanne Witterholt requested including the “Dutch Study” in the materials if it is available

28. NB
You would have already discussed this as a part of the treatment contract!

29. How does DBT target behaviors?
In sessions and conceptually:
TARGET I
TARGET II
TARGET III

30. Target I Life-Threatening Behaviors
“You can’t get better if you are dead.”
Suicidal behaviors
Non-suicidal self injury (NSSI)
ED behaviors when medically unstable

31. Therapy Interfering behaviors
Target II
Therapy Interfering behaviors
Behaviors that interfere with receiving therapy
Behaviors that burn out therapists

32. Quality of Life Interfering Behaviors
Target III
Quality of Life Interfering Behaviors
Non life-threatening or therapy-interfering ED behaviors
Any other quality of life interfering behaviors that are not imminently life threatening
e.g., unemployment, promiscuity, prostitution, relationship issues, substance abuse etc.

33. Definition is important!

34. TERMINOLOGY 101 NSSI Parasuicidal behavior Self-Injurious Behavior
Self-Mutilation
NSSI
Suicide Attempts
Parasuicidal behavior
Suicide Completion 34

35. Definitions: Suicide Behaviors
Suicide Attempts
direct efforts to intentionally end one's own life.
Suicide Completion
Intentionally ending one’s own life

36. Suicidal Behavior in EDs
Suicide attempts
High in BN (25-35%) less so in AN (3-20%)
Completed suicide
High rates in AN (Standardized Mortality Ratio : )
Second leading cause of death in AN
Rate is 200x greater than in the general population (Sullivan, 1995)
Not elevated in BN
Clinical correlates: purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse (Franko & Keel, 2006)
.clinical psych review Multiple studies find high rates of suicide in patients with anorexia nervosa (AN) [Standardized Mortality Ratio (SMR) for suicide range from 1.0 to 5.3], whereas suicide rates do not appear to be elevated in bulimia nervosa (BN). In contrast, suicide attempts occur in approximately 3–20% of patients with anorexia nervosa and in 25–35% of patients with bulimia nervosa. Clinical correlates of suicidality in eating disorders include purging behaviors, depression, substance abuse, and a history of childhood physical and/or sexual abuse. Patients with eating disorders, particularly those with comorbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms.

37. “Patients with eating disorders, particularly those with co-morbid disorders, should be assessed routinely for suicidal ideation, regardless of the severity of eating disorder or depressive symptoms”.
Franko & Keel, 2006

38. Definitions Self-injurious behavior (SIB)
A broad class of behaviors in which an individual directly and deliberately causes harm to herself or himself.
Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006

39. Terms? Self-mutilation; “cutting”; para-suicide; self-injury
Confusion about how to define and classify!

40. Definitions Non-suicidal self-injury (NSSI)
The direct, deliberate destruction of one's own body tissue in the absence of suicidal intent.
Direct in that the ultimate outcome of the self-injury occurs without intervening steps
Deliberate in that self-injury is intended by the individual, rather than accidental
Destruction of one's own body tissue is required in this definition, although it is acknowledged that the actual physical harm caused by NSSI can vary significantly
Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006

41. How often does it occur? Rates of NSSI in ED: 25.4 – 55.25%
Rates of ED in NSSI:
54 – 61%
(Svirko & Hawton, 2007)
E. Svirko, & K. Hawton. Self-injurious behavior and eating disorders: the extent and nature of the asThese figures indicate that there
is a strong association between these disorders. Impulsivity, obsessive-compulsive
characteristics, affect dysregulation, dissociation, self-criticizing cognitive style
and need for control were identified as potential factors involved in the association.
Early trauma such as childhood sexual abuse and possibly certain characteristics
of early family environment might contribute to the development of these
factors.sociation. Suicide and Life-Threatening Behavior, 37 (2007), pp. 409–421.

42. NSSI in Adolescents
Estimated that 7% - 14% of adolescents have deliberately injured themselves at least once (Wilkinson, 2013)
Studies suggest NSSI is on the rise, perhaps up to a 24% 1 year prevalence rate (Miller & Smith, 2008)
Onset typically occurs in early adolescence between years (Rodav, Levy & Hamdan, 2014)
Associated with a wide range of severe clinical psychiatric diagnoses and behavioural problems (Vaughn, et al., 2015)
Adolescents who experience adverse childhood experiences are at increased risk for more frequent and severe NSSI behaviors (Vaugh et al., 2015)

43. But SI/SH are not the only deadly problems an ED patient has…

44. Imminently Life Threatening Conditions for ED Clients
Bradycardia
Arrhythmia
Electrolyte Abnormalities
Chronic Ipecac Abuse
Mallory Weiss Tear
NOTE: LETS LOOK AT THIS SLIDE AND MAKE SURE WE HAVE MEDICAL CORROBORATION ON THIS
Bradychardia leads to arrythmia to sudden cardiac death

45. American Academy of Pediatrics, available online

46. Addressing Target I Behaviors in Session
Bedrock of DBT
Review of diary card
Setting agenda
Prioritizing target I behaviors
BCA / SA

47. May need to teach skills at a slower pace.
Special Considerations for Doing DBT with younger kids and / or kids with special learning needs…
May need to teach skills at a slower pace.
Simplify terms used to teach.
Simplify the format of the diary card & behaviour chain
May need to repeat skills training curriculum
Use lots of examples!
(Miller, Rathus & Linehan, 2006)

48. Targeting TIBs

49. Target II Therapy Interfering behaviors
Behaviors that interfere with receiving therapy
Behaviors that burn out therapists

50. Therapy-Interfering Behaviors for Specific to those with ED
Exercising against medical advice
Restricting intake before treatment
“Involuntary” vomiting
Manipulating weight
Refusing to be weighed
Weight loss when underweight
Hiding food
Omitting/lying about symptoms
Arguing / negotiating about food intake
Kb: Are there TIBs specific for adolescents that are not here?

51. Bxs that Interfere with Receiving Therapy
Non-attentive behaviors
Cancel appointment/drop out
Getting admitted to hospital
Inadequate intake resulting in inattention during session
Non-collaborative behaviors
Inability/refusal to work in therapy
Lying
Manipulating weight
Refusal to work on eating “in vivo”
Noncompliant behaviors
Not completing diary cards or homework
Not bringing in food for therapeutic meal
In vivo: RB and granola bar
Not drinking enough liquides to resolve orthostatic bp

52. Behaviors that Burn Out Therapists
Pushing the therapist’s personal limits
Phoning too much
Continuing to lose weight and refusing to collaborate on weight maintenance or gain
Behaviors that push the organizational limits
Not waiting for therapist in the waiting room
Vomiting in the lobby restroom
Behaviors that decrease the therapist’s motivation
Slow progress
Lying about intake
“any behavior that decreases the motivation of other group, milus or family members to continue offering help and stay interested in the patient’s welfare are TIBs

53. TIBs of Caregivers/Parents
Arriving late / missing sessions
FBT – not bringing a family meal
High expressed criticism towards client in session
Not following through with medical recs
Reinforcing ineffective behaviors
Inadequate supervision of meals/activity

54. TIBs of Therapists Not doing DBT Not staying current in EDs
Not addressing eating issues as a part of treatment
Having your own ED issues interfere with objectivity
Having emotional responses interfere with the delivery of the treatment
Not brining family into DBT sessions when needed

55. The function and context of an ED behavior will determine in which target it falls (e.g. restriction prior to a therapy session)

56. TIB Examples: Yours, Your Patient, or Caregiver
Have them practice in pairs
The important component is for the patient not to feel judged

57. Where does this leave us?
For patients with BOTH an ED and Suicidality and/or NSSI:
Get trained OR refer!
Comprehensive DBT