Hi folks,

I have a postgraduate student who is interested in doing a research project on
mindfulness and body image in clients with eating disorders. She is just
beginning to explore the current literature and we certainly don't want to
pursue this if it is already being done elsewhere. I know this is Emily Sandoz's
area of expertise, but I don't know what Emily is specifically focusing on or
what anyone else is currently researching in this area at the moment.
Can everyone involved in research in this (or related areas) please send me a
brief summary of what you are specifically focusing on and where you are up to
(ie. have you published yet)?

Thanks very much,
Stella

---------------------------------------------------------
Stella Dyer
Clinical Psychologist
Centre for Psychotherapy
James Fletcher Hospital
Watt Street, Newcastle NSW 2300
Ph.  (02) 49246820
Fax: (02) 49246801
---------------------------------------------------------

Hi Carla,

Although I have very limited exposure with eating disordered clients, I do have
fairly extensive experience with children.  Many of whom have demonstrated
severe behaviors.  The fact is, when working with children they rarely
prioritize in quite the same way I or their parents might.  It is the prime
landscape for power struggle, which I suspect occurs in your setting as
described as well.

It is my experience that the core value children work towards is acceptance. 
The way they approach it can be problematic but underlying their behavior is a
need to feel they belong.  I would think that would also be true of an
eating-disordered client as well.

The struggle originates when a person such as yourself or other authority
figures feels (and rightfully so) that the behavior is life threatening and
rejects it outright.  What I have found with children who behave severely is
that if they cannot have acceptance, they will settle for control.  The harder a
person who they feel is critical of them struggles to make things right, the
more they are reinforced to exert control.

From my experience, I find that the most effective intervention I have been able
to implement is to teach parents to empower the child rather than struggle with
them.  To shift the focus from what they (the children) are doing wrong, to what
is possible in other areas that would facilitate acceptance.

This can be very effective in quite short order but of course I have the
advantage of working with the parent.  And quite often, this parent has been the
one most critical of the child in the past.  When they begin providing the child
with a lot of encouragement and positive feed back, change is sure to follow.  I
am sure you do not always have this luxury.

I hope this has been helpful.

George



--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "carlajoywalton"
<carlajoywalton@...> wrote:
>
> Hi all,
> I'd like input from people working across different clinical groups
> that may help shed some light on the issue of how ACT can be applied
> for persons with Eating Disorders when the client doesn't prioritise
> changing the Eating Disorder behaviours. Don't worry if you don't
> know about Eating Disorders, all I'm looking for is some open-minded
> thinking on this.  Some colleagues and I have been talking about
> using ACT when folks with Anorexia are at a low weight and are not
> willing to put on weight. Amongst us, we've had some differences of
> opinion as to `what the ACT stance would be'.  With most
> psychological issues, generally people come willingly to treatment
> and wanting to get rid of their symptoms. With Anorexia, ambivalence
> is part of the disorder, and generally, people don't want to put on
> weight.
>
> My question is really how much do we target behaviours associated
> with the disorder, even if that's against what the patient's agenda
> is? Let me contrast it with social phobia, for example. With social
> phobia, the associated behaviours are generally about avoiding
> social situations or situations where the person is exposed to
> perceived scrutiny. Mostly people with social phobia come because
> the avoidance is
> getting in the way of their values and it's clear how the avoidance
> behaviour stands in the way of recovery. Hence, they usually readily
> accept that avoidance is a target of treatment (in either CBT or
> ACT). With Anorexia and Bulimia, often patients do not see the
> Eating Disorder behaviours as interfering with valued living. So
> then it becomes our agenda and not theirs.
>
> We can work on increasing psychological flexibility in a values
> consistent way. However, often the patient will claim that this can
> be done whilst they stay underweight. For example, you might see a
> patient who values learning and wants to go to school, and a side
> agenda is about eating unsupervised at school so they can keep the
> anorexia. Or a patient values being a good and connected friend but
> maybe doesn't have the cognitive capacity to stay present and
> connected due to malnutrition.  It can feel fraudulent working with
> clients on an agenda that is handicapped unless they gain weight.
>
> I have just finished co-facilitating an ACT group for Bulimia that
> focussed on general ACT principles and did not specifically target
> reduction of Bulimic behaviour. I saw one of the participants last
> week for her post-assessment. She is delighted with the gains she
> has made through the group and has made amazing progress on every
> point on the hexaflex…. And still bingeing and purging everyday.
> This doesn't feel okay to me. I can work on my side of the hexaflex
> and accepting my disappointment etc, but is this really good enough?
> My co-facilitator and I weighed up at the beginning how much we
> needed to address bulimic specific behaviours, but decided not to
> because it was our agenda and not theirs.
>
> Then there is the more extreme, yet common situation of patients
> with Anorexia who aren't willing to work on weight gain and are at a
> dangerously low weight. Do you make talking about the weight,
> getting agreement about need for weight gain a priority? And yet,
> when we do that, we're really prioritising what we see as important,
> not what they want for their life. I heard Kelly Wilson use a great
> metaphor in Chicago about how if we're saying something is a goal to
> work on and it's not what the client wants to work on, it's really
> like a builder coming in and building a new bathroom on the house
> because that's what the builder thinks is needed, when what the
> client asked for was a new kitchen and they don't think they need a
> new bathroom. However, if we don't address weight gain, this is at
> the risk of the patient doing permanent damage to their bodies or in
> some cases, dying.
>
> Sorry for the length of this. In case you've forgotten what my
> original question was, it's really `what would be an ACT consistent
> stance in working with a patient who doesn't see their behaviours as
> a problem and yet, these behaviours are psychologically inflexible
> and interfere with valued living?'
>
> If you work with people with Eating Disorders, how do you approach
> these issues? I thought people that work in substance abuse areas
> might also have some ideas in this regard. If anyone has any ideas,
> please suggest them (even if you're mind says they're obvious or
> unhelpful).
>
> Thanks,
> Carla.
>
> P.S. I am sending this to both the general ACT listserve as well as
> the ACT & Eating Concerns listserve. So, apologies if you're getting
> it twice.
>

Hi all,
I'd like input from people working across different clinical groups
that may help shed some light on the issue of how ACT can be applied
for persons with Eating Disorders when the client doesn't prioritise
changing the Eating Disorder behaviours. Don't worry if you don't
know about Eating Disorders, all I'm looking for is some open-minded
thinking on this.  Some colleagues and I have been talking about
using ACT when folks with Anorexia are at a low weight and are not
willing to put on weight. Amongst us, we've had some differences of
opinion as to `what the ACT stance would be'.  With most
psychological issues, generally people come willingly to treatment
and wanting to get rid of their symptoms. With Anorexia, ambivalence
is part of the disorder, and generally, people don't want to put on
weight.

My question is really how much do we target behaviours associated
with the disorder, even if that's against what the patient's agenda
is? Let me contrast it with social phobia, for example. With social
phobia, the associated behaviours are generally about avoiding
social situations or situations where the person is exposed to
perceived scrutiny. Mostly people with social phobia come because
the avoidance is
getting in the way of their values and it's clear how the avoidance
behaviour stands in the way of recovery. Hence, they usually readily
accept that avoidance is a target of treatment (in either CBT or
ACT). With Anorexia and Bulimia, often patients do not see the
Eating Disorder behaviours as interfering with valued living. So
then it becomes our agenda and not theirs.

We can work on increasing psychological flexibility in a values
consistent way. However, often the patient will claim that this can
be done whilst they stay underweight. For example, you might see a
patient who values learning and wants to go to school, and a side
agenda is about eating unsupervised at school so they can keep the
anorexia. Or a patient values being a good and connected friend but
maybe doesn't have the cognitive capacity to stay present and
connected due to malnutrition.  It can feel fraudulent working with
clients on an agenda that is handicapped unless they gain weight.

I have just finished co-facilitating an ACT group for Bulimia that
focussed on general ACT principles and did not specifically target
reduction of Bulimic behaviour. I saw one of the participants last
week for her post-assessment. She is delighted with the gains she
has made through the group and has made amazing progress on every
point on the hexaflex…. And still bingeing and purging everyday.
This doesn't feel okay to me. I can work on my side of the hexaflex
and accepting my disappointment etc, but is this really good enough?
My co-facilitator and I weighed up at the beginning how much we
needed to address bulimic specific behaviours, but decided not to
because it was our agenda and not theirs.

Then there is the more extreme, yet common situation of patients
with Anorexia who aren't willing to work on weight gain and are at a
dangerously low weight. Do you make talking about the weight,
getting agreement about need for weight gain a priority? And yet,
when we do that, we're really prioritising what we see as important,
not what they want for their life. I heard Kelly Wilson use a great
metaphor in Chicago about how if we're saying something is a goal to
work on and it's not what the client wants to work on, it's really
like a builder coming in and building a new bathroom on the house
because that's what the builder thinks is needed, when what the
client asked for was a new kitchen and they don't think they need a
new bathroom. However, if we don't address weight gain, this is at
the risk of the patient doing permanent damage to their bodies or in
some cases, dying.

Sorry for the length of this. In case you've forgotten what my
original question was, it's really `what would be an ACT consistent
stance in working with a patient who doesn't see their behaviours as
a problem and yet, these behaviours are psychologically inflexible
and interfere with valued living?'

If you work with people with Eating Disorders, how do you approach
these issues? I thought people that work in substance abuse areas
might also have some ideas in this regard. If anyone has any ideas,
please suggest them (even if you're mind says they're obvious or
unhelpful).

Thanks,
Carla.

P.S. I am sending this to both the general ACT listserve as well as
the ACT & Eating Concerns listserve. So, apologies if you're getting
it twice.

Thomas,
Thanks for the wonderful example. This is a really artful way to introduce
creative hopelessness and the concept of a "function" to disordered eating
behavior. It also gives a touchstone one could refer to throughout treatment,
which are really like. You've given me some good ideas...
Best,
Matt

Matt Boone, LCSW
Counselor Therapist
Counseling and Psychological Services (CAPS)
Gannett Health Services phone: 607 255-5208
Cornell University fax: 607 254-5244
Ithaca, NY 14853-3101 e-mail: mb352@...
For more information about Gannett: 607 255-5155; www.gannett.cornell.edu
~~~~~~~~~~~~~~~~~~~~~~
Please note that confidentiality of non-encrypted e-mail communication cannot be
guaranteed.
For further details regarding e-mail use, cautions and guidelines, please refer
to the Gannett web site: http://www.gannett.cornell.edu/accesstocare/e-mail.html
. If you are NOT the intended recipient, please notify the sender immediately
with a copy to hipaa@... and destroy this message. Disclosure of any
information contained in this message to someone other than the intended
recipient is prohibited.

Hi there,

I would love to share some of my experiences. I´ll start with the
things that work...for me....or at least that´s what I think.

Yes, motivation is an issue. To move the clients a bit toward "my"
perspective I use a time-line as a starting point where we write up
all important life events that affect(s)ed them. And if they did some
thing as a reaction to that, and how it worked. Then I´ll go on
asking about the eating problem when it started, how it changed, up /
down in weight, exercising, purging, laxatives, bingeing, asking
about things as did it make you feel special (often yes with AN),
loosing weight in the beginning often gives a "high", self-esteem....
and so on. In the meantime while thesse events are reported I also
ask them to talk about the function of these behaviors (educating
them about how we often/always seem to behave in order to get
conesquences). What we often end up in is a sort of "something
happened - I felt bad - to take away the bad I did X- and it worked
in short term - looking at the whole process of doing X; it ruins my
life - but I dont know what else to do.
This I think gives a very nice collaborative look at the processes,
You did what you could do given your history and it seemed as it
worked. looking at it now gives another perspective.
Then write up, in columns, all the things they wanted to get rid of
(anxiety,depression, wothlessness etc) / what they did to get rid of
it / how it worked in short time / how it worke in long time /
creates creative hopelessness.

sorry if I´m being too obvious. And this part I am quite pleased with
as the majority of patients seem to be with me up to here, they
havent done any thing up to this point so I really dont know about
their motivation for change in this stage...and this they get.
Returning to this what I have tried list, over and over again is
essential - I always let the big time-line sketch be in the wall to
point at it whenever they fall back in same old behaviors or talk
about these behaviors as solutions to their "problem".

we start every session w a mindfulness exercise, very short in the
beginning, slowly let them learn the new behavior of looking at
internal events and gradually slip over to letting them do short
mindfulness exercises at home. I really find the physicalising
exercise helpful - for some patients its an eye-opener and a place
from where they can really choose other behaviors.

ok, all for now -its friday and I gotta go. Hopefully this thread can
grow with others joining in.

humbly / Thomas

6 feb 2009 kl. 16.00 skrev Matt Boone:

>
> Hello Thomas, Carla, & Alix,
>
> I'm thrilled to hear this research is going on. About 1/3 of the
> work I do is with eating disorders and disordered eating generally.
> I find implementing "full-ACT" particularly difficult with this
> group. What I mean is this: with anxiety clients, it's easy to jump
> right into all of the processes. It makes a lot of intuitive sense
> to the clients and gains appear almost immediately, usually in the
> areas of diminished control, hope, and a willingness to have some
> anxiety. But with eating disorder clients, I have to start very
> slow. The motivation for change is low. Any sort of mindfulness
> needs to be done very tentatively. It's very difficult to lead
> someone through any kind of mindfulness exercise. Usually I just
> start with short periods of physicalizing. Values conversations
> bring up tons of fusion and a lack of willingness.
>
> I'm curious to hear how it goes for you all. I also would love to
> see some of your materials if you're willing to offer them. More
> than anything, I like to start a conversation on this list about
> working with eating disorders and ACT.
>
> Best,
>
> Matt
>
> Matt Boone, LCSW
> Counselor Therapist
> Counseling and Psychological Services (CAPS)
> Gannett Health Services phone: 607 255-5208
> Cornell University fax: 607 254-5244
> Ithaca, NY 14853-3101 e-mail: mb352@...
> For more information about Gannett: 607 255-5155;
> www.gannett.cornell.edu
> ~~~~~~~~~~~~~~~~~~~~~~
> Please note that confidentiality of non-encrypted e-mail
> communication cannot be guaranteed.
> For further details regarding e-mail use, cautions and guidelines,
> please refer to the Gannett web site: http://
> www.gannett.cornell.edu/accesstocare/e-mail.html . If you are NOT
> the intended recipient, please notify the sender immediately with a
> copy to hipaa@... and destroy this message. Disclosure of
> any information contained in this message to someone other than the
> intended recipient is prohibited.
>
>
>

Thomas Parling, leg.Psykolog, doktorand
Institutionen för Psykologi
Box 1225, 751 42 Uppsala
Trädgårdsgatan 20
018-471 6221
070-205 8007
thomas.parling@...

Hi Carla,

I think the WC in London was 3 years ago, time flyes and life
changes. Its amazing to have a little daughter and see her starting
to walk, eventually talk and everything in between.

We will have a look at data so far in a near future to see if there´s
anything happening at all, and we´ll make a decision if we shall
proceed with the study. The trouble is a much lower rate in incoming
patients to the unit and also the motivational part for this kind of
"problem". I think we shall try to submit a paper this year on this
study and report on the data we have. Later when everyone has
attended the 2 year followup we´ll write that up as well.

20 weeks seems fine I think with those who have really started
regular eating habits and gained some weight. With those still in
starvation 20 weeks isnt enough I´d say (Fairburns transdiagnostic
treatment proposal prolongs the treatment for these patients up to 40
weeks!) but we´ll wait and see what data will tell. What we are
really interested in is to prevent relapse.

Ok, some more info there. Hope the presentation will be a success!
Dont hesitate to ask more if questions keep popping up.

best, Thomas


5 feb 2009 kl. 22.25 skrev Carla Walton:

>
> Hi Thomas,
>
> Thanks for responding. Congratulations on becoming a Dad. I can't
> remembe if World Con in London was 2 years ago or 3 years ago, but
> it's amazing how much changes in a short time and your life must be
> quite different now!
>
> Glad to hear that your trial is still underway. Have you finished
> the post-treatment assessments now and just waiting for follow-up?
> If so, have you had a look at the data to see any preliminary
> results? Are you going to wait to publish til after the 24 month
> follow-up? did 20 weeks feel like it was enough for participants?
>
> Enough questions for now. I feel like I'm bombarding you! But, I
> would love you to send me any more info I hvae. Not for the
> presentation, just for my own interest. I just wanted to be able to
> say what is happening in general for the presentation. They will be
> an audience of hard nosed CBT practitioners and I really wanted to
> be able to say that we had research happening it's just not
> published yet!
>
> Lovely to hear from you.
>
> Kind Regards,
> Carla.
>
> From: Thomas Parling <thomas.parling@...>
> To: eatingconcernsandcontextualpsychology@yahoogroups.com
> Sent: Thursday, 5 February, 2009 11:47:32 PM
> Subject: Re: [eatingconcernsandcontextualpsychology] Research in
> ACT and Eating Disorders
>
> Hi Carla,
>
> guess I am one of those who did not reply to your mail. My reason
> that you can add tp the list :-) Been on paternity leave! And now I´m
> back, so:
>
> 1. Were conducting an RCT for Anorexia and EDNOS AN type. First 9 -
> 12 weeks of daycare (collaboration w hospital) aiming to restore
> regular eating and resting behaviors. After that they are approached
> wether to join the study: ACT individual therapy for 20 weeks
> (elaboration of a substance abuse protocol) or Treatment as Ususal
> for 20 weeks. We are doing followups every 6,12,18 and 24 months. for
> each patient. Still in process.
>
> 2. Self help for anorexia and EDNOS AN type. RCT with a swedish ACT
> self-help book for anorexia (Ghaderi & Parling) and a waiting list
> that eventually get the self-help. (and sad to say right now I cant
> remeber how many weeks exactly the self help constitute.. .. have some
> major catching up to do)
>
> These are parts of my PhD-student research at Uppsala university,
> Sweden.
>
> Hope that helps a bit and I can give you more info if you are
> interested.
>
> Would be glad to see the results from your Bulimia research when its
> available.
>
> best,
>
> Thomas
>
> 5 feb 2009 kl. 13.18 skrev carlajoywalton:
>
> > Hi all,
> >
> > I posted in June asking about who's doing what in terms of
> research in
> > the area of ACT and Eating Disorders and didn't get a single
> response!
> >
> > I'm writing to reiterate my request, since some colleagues and I are
> > giving a presentation in a fortnight on the use of ACT with
> > Anorexia at
> > a statewide forum and I'd like to be able to talk very broadly about
> > what research is happening. To my knowledge, the published evidence
> > base for ACT with Anorexia to date is 1 case study.
> >
> > I don't know what to make of the fact that nobody responded to my
> > email. I know that there are at least 3 folks across the US doing
> > research in this area (although I'm not exactly sure the nature of
> > it).
> > I'm not sure if folks got too busy to respond or I offended
> people at
> > the Summer Institute or folks feel protective about what they're
> doing
> > and don't want to publicise or... (insert millions of other reasons
> > here).
> >
> > Eating Disorders is a hard area to do research in and I'd really
> like
> > to hope that we could be collegial and support each other.
> >
> > To be upfront about what I'm doing, a colleague and I have just
> > piloted
> > a 20 week ACT group for Bulimia. We haven't crunched the data yet
> (it
> > just finished), but eyeballing it, it looks pretty positive,
> > particularly in terms of people engaging in more valued activities.
> > Subjectively, they all report increased QOL and decreased
> bingeing and
> > purging (in some no longer B & P). We're about to start the group
> > again
> > in the next month or so.
> >
> > With some other colleagues, we are planning on looking at a
> series of
> > case studies using ACT for Anorexia. Sounds like it should be
> simple,
> > but when we sat down to work out the design, measures etc, well,
> we're
> > still in discussion and not sure when we'll actually get started.
> >
> > So, our research is very basic, exploratory stuff at this stage.
> >
> > What are others up to?
> >
> > Thanks,
> > Carla.
> >
> >
> >
>
> Thomas Parling, leg.Psykolog, doktorand
> Institutionen för Psykologi
> Box 1225, 751 42 Uppsala
> Trädgårdsgatan 20
> 018-471 6221
>  070-205 8007
> thomas.parling@ psyk.uu.se
>
>
>
> Make Yahoo!7 your homepage and win a trip to the Quiksilver Pro.
> Find out more.
>
>

Thomas Parling, leg.Psykolog, doktorand
Institutionen för Psykologi
Box 1225, 751 42 Uppsala
Trädgårdsgatan 20
018-471 6221
070-205 8007
thomas.parling@...

Hi Carla,

guess I am one of those who did not reply to your mail. My reason
that you can add tp the list :-) Been on paternity leave! And now I´m
back, so:

1. Were conducting an RCT for Anorexia and EDNOS AN type. First 9 -
12 weeks of daycare (collaboration w hospital) aiming to restore
regular eating and resting behaviors. After that they are approached
wether to join the study: ACT individual therapy for 20 weeks
(elaboration of a substance abuse protocol) or Treatment as Ususal
for 20 weeks. We are doing followups every 6,12,18 and 24 months. for
each patient. Still in process.

2. Self help for anorexia and EDNOS AN type. RCT with a swedish ACT
self-help book for anorexia (Ghaderi & Parling) and a waiting list
that eventually get the self-help. (and sad to say right now I cant
remeber how many weeks exactly the self help constitute.... have some
major catching up to do)

These are parts of my PhD-student research at Uppsala university,
Sweden.


Hope that helps a bit and I can give you more info if you are
interested.


Would be glad to see the results from your Bulimia research when its
available.


best,

Thomas



5 feb 2009 kl. 13.18 skrev carlajoywalton:

> Hi all,
>
> I posted in June asking about who's doing what in terms of research in
> the area of ACT and Eating Disorders and didn't get a single response!
>
> I'm writing to reiterate my request, since some colleagues and I are
> giving a presentation in a fortnight on the use of ACT with
> Anorexia at
> a statewide forum and I'd like to be able to talk very broadly about
> what research is happening. To my knowledge, the published evidence
> base for ACT with Anorexia to date is 1 case study.
>
> I don't know what to make of the fact that nobody responded to my
> email. I know that there are at least 3 folks across the US doing
> research in this area (although I'm not exactly sure the nature of
> it).
> I'm not sure if folks got too busy to respond or I offended people at
> the Summer Institute or folks feel protective about what they're doing
> and don't want to publicise or... (insert millions of other reasons
> here).
>
> Eating Disorders is a hard area to do research in and I'd really like
> to hope that we could be collegial and support each other.
>
> To be upfront about what I'm doing, a colleague and I have just
> piloted
> a 20 week ACT group for Bulimia. We haven't crunched the data yet (it
> just finished), but eyeballing it, it looks pretty positive,
> particularly in terms of people engaging in more valued activities.
> Subjectively, they all report increased QOL and decreased bingeing and
> purging (in some no longer B & P). We're about to start the group
> again
> in the next month or so.
>
> With some other colleagues, we are planning on looking at a series of
> case studies using ACT for Anorexia. Sounds like it should be simple,
> but when we sat down to work out the design, measures etc, well, we're
> still in discussion and not sure when we'll actually get started.
>
> So, our research is very basic, exploratory stuff at this stage.
>
> What are others up to?
>
> Thanks,
> Carla.
>
>
>

Thomas Parling, leg.Psykolog, doktorand
Institutionen för Psykologi
Box 1225, 751 42 Uppsala
Trädgårdsgatan 20
018-471 6221
070-205 8007
thomas.parling@...

Hi all,

I posted in June asking about who's doing what in terms of research in
the area of ACT and Eating Disorders and didn't get a single response!

I'm writing to reiterate my request, since some colleagues and I are
giving a presentation in a fortnight on the use of ACT with Anorexia at
a statewide forum and I'd like to be able to talk very broadly about
what research is happening. To my knowledge, the published evidence
base for ACT with Anorexia to date is 1 case study.

I don't know what to make of the fact that nobody responded to my
email. I know that there are at least 3 folks across the US doing
research in this area (although I'm not exactly sure the nature of it).
I'm not sure if folks got too busy to respond or I offended people at
the Summer Institute or folks feel protective about what they're doing
and don't want to publicise or... (insert millions of other reasons
here).

Eating Disorders is a hard area to do research in and I'd really like
to hope that we could be collegial and support each other.

To be upfront about what I'm doing, a colleague and I have just piloted
a 20 week ACT group for Bulimia. We haven't crunched the data yet (it
just finished), but eyeballing it, it looks pretty positive,
particularly in terms of people engaging in more valued activities.
Subjectively, they all report increased QOL and decreased bingeing and
purging (in some no longer B & P). We're about to start the group again
in the next month or so.

With some other colleagues, we are planning on looking at a series of
case studies using ACT for Anorexia. Sounds like it should be simple,
but when we sat down to work out the design, measures etc, well, we're
still in discussion and not sure when we'll actually get started.

So, our research is very basic, exploratory stuff at this stage.

What are others up to?

Thanks,
Carla.

George,

If you are able to post, this means that you have been approved as a member of
this
group...

Welcome!!

Emily Sandoz
University of Mississippi

--- In eatingconcernsandcontextualpsychology@yahoogroups.com, George McGeough
<stirple@...> wrote:
>
> Hello
>
>   I would like to initialize my membership in this group.
>
>   Thanks
>
>   George
>

Hi all,

I'm interested to hear what people are doing in other places in terms of Eating
Disorder research. If you're on this listserve and currently engaged in some
research looking at ACT in the treatment of Eating Disorders, I'd really
appreciate it you would post and advise what you're doing.

Also, if you know of others doing ACT & ED research who aren't on this list,
would you mind forwarding their names (and contact details if you have them)?

Thanks,
Carla.



Dr Carla Walton
Senior Clinical Psychologist
Centre for Psychotherapy
James Fletcher Hospital
PO Box 833
Newcastle NSW 2300

Ph:      (02) 4924 6820
Fax:    (02) 4924 6801
E-Mail: Carla.Walton@...

Hi Jan,

I'm guessing you've already had the appointment by now, since it's just morning
in Australia and I've just received your email.

I'm really intrigued by the client saying that the therapy is not helping her
enough because it's not leading to enough change. Many clients with Anorexia
would say that they don't want to change, so it seems like the fact that she's
saying that change isn't happening fast enough, means that there's something to
work with there. Do you know what change she's looking for? Even if the change
she wants is a control driven agenda, underneath that, there will probably be
some some way to link that to her values, i.e., "If X(whatever she states she
wants to change) were to be different, then what would you be able to do in your
life?"

I've always found it a tight balance with clients with Anorexia between
encouraging them to come, knowing that for some of them it's hard for them to
find a way to allow themselves to be there and so for the time being the
therapist has to do that. AND then on the other end, respecting when they decide
they don't want to come. It's easy to hold too tight to them, or too loose.

Had she talked with you in the last session about not wanting to come or was
this out of the blue. I generally ask clients that say on the phone that they
don't want to come, whether they'd be willing to come in and discuss face to
face and to have a chance to say goodbye. It just gives you a bit more space to
help them clarify what they really want to do, cause you've got longer and when
you get to the hard bits, it's not as easy to end it as it is on the phone (by
handing phone over or hanging up), so you've got a little more chance of being
able to work through the hard bits.

Also, it's probably not that relevant, but can you tell me what "iView" is? I've
never heard of it.

Carla.

>>> Jan Martz <jan_martz@...> 02-Apr-08 6:39 pm >>>
Dear Groups
I don't know whether anyone of you will be awake yet. I just had a phone call
from a client whom I have seen 5 times so far, introduced iView and life manual.
She is suffering from anorexia, BMI around 15 and sinking rapidly. Living with
her mother who is desperate. She just told me on the phone that she does not
want to come anymore, that this therapy, this "iView stuff" is not helping her
enough, not enough change. That she is a burden for her surroundings, who are
telling her that it cannot go on like this. I responded with sympathy, expressed
respect for her opinion, expressed my openness that she can come any time.
Expressed that I cannot guarantee how quickly her life will change, that I would
be willing to commit myself to attempt to be an instrument for her to develop
her life. Expressed my conviction that her life is full of potential, and that I
wish that she can develop this potential. Asked whether I could do anything for
her, maybe speak to
  her mother. She then passed the phone to her mother who expressed her
desperation, her unwillingness to let her daughter stop therapy, her need for
help as a mother. I offered to see her today with or without her daughter during
the scheduled appointment which is in 4 hours (8am eastern time). Any support /
suggestions would be very welcome.
thank you
Jan


----- Original Message ----
From: Patricia Aptaker <pmaptaker@...>
To: Patt Aptaker <pmaptaker@...>; Susan Chiddix <dr.chiddix@...>;
Joshua Jacobs <joshuaxjacobs@...>; Paula Johnson
<paulabjohnsonlmhc@...>; Jan Martz <jan_martz@...>; Jean Meier
<jlmeir@...>; Jean Meier <jlmier@...>; Kathryn Montgomery
<kathrynm@...>; Annie Murrell <aheart@...>; Kevin Polk
<polkkev@...>; Joe Wagner <joewag88@...>
Sent: Wednesday, April 2, 2008 5:04:09 AM
Subject: ACT Teleclass - Wednesday, 4/2/08, 4:00 p.m. Eastern


Hi Guys - just a reminder.

If you have a chance look over your emails since last session on challenges and
questions.  We can start the session with any followup.

Also attached is an article by Kevin on Creative Hopelessness with the iView.

For community marketing ideas, consider the following:
I attached a couple of articles I wrote for a local magazine in Baton Rouge,
Louisiana, called City Social.  I write an article every other weekend and call
the column "Coach's Corner."  ACT is really cool to write popular articles
about.

Also check out these website pages from local university for a class I do there:
http://appl003.lsu.edu/slas/leisureweb.nsf/$Content/Calendar+View?OpenDocument
Go under view by category
then Family Matters and Personal Enrichment
then Acceptance and Change in Everyday Life

Some ideas - Kevin can share on his stress program based on ACT.

Talk tomorrow,

Patt


You rock. That's why Blockbuster's offering you one month of Blockbuster Total
Access, No Cost.


You rock. That's why Blockbuster's offering you one month of Blockbuster Total
Access, No Cost.


      
________________________________________________________________________________\
____
You rock. That's why Blockbuster's offering you one month of Blockbuster Total
Access, No Cost.
http://tc.deals.yahoo.com/tc/blockbuster/text5.com

Dear Groups

I don't know whether anyone of you will be awake yet. I just had a phone call from a client whom I have seen 5 times so far, introduced iView and life manual. She is suffering from anorexia, BMI around 15 and sinking rapidly. Living with her mother who is desperate. She just told me on the phone that she does not want to come anymore, that this therapy, this "iView stuff" is not helping her enough, not enough change. That she is a burden for her surroundings, who are telling her that it cannot go on like this. I responded with sympathy, expressed respect for her opinion, expressed my openness that she can come any time. Expressed that I cannot guarantee how quickly her life will change, that I would be willing to commit myself to attempt to be an instrument for her to develop her life. Expressed my conviction that her life is full of potential, and that I wish that she can develop this potential. Asked whether I could do anything for her, maybe speak to her mother. She then passed the phone to her mother who expressed her desperation, her unwillingness to let her daughter stop therapy, her need for help as a mother. I offered to see her today with or without her daughter during the scheduled appointment which is in 4 hours (8am eastern time). Any support / suggestions would be very welcome.

thank you

Jan

----- Original Message ----
From: Patricia Aptaker <pmaptaker@yahoo.com>
To: Patt Aptaker <pmaptaker@yahoo.com>; Susan Chiddix <dr.chiddix@hotmail.com>; Joshua Jacobs <joshuaxjacobs@gmail.com>; Paula Johnson <paulabjohnsonlmhc@hotmail.com>; Jan Martz <jan_martz@yahoo.com>; Jean Meier <jlmeir@...>; Jean Meier <jlmier@...>; Kathryn Montgomery <kathrynm@jcmh.org>; Annie Murrell <aheart@...>; Kevin Polk <polkkev@gmail.com>; Joe Wagner <joewag88@gmail.com>
Sent: Wednesday, April 2, 2008 5:04:09 AM
Subject: ACT Teleclass - Wednesday, 4/2/08, 4:00 p.m. Eastern

Hi Guys - just a reminder.

 

If you have a chance look over your emails since last session on challenges and questions.  We can start the session with any followup.

 

Also attached is an article by Kevin on Creative Hopelessness with the iView.

 

For community marketing ideas, consider the following:

I attached a couple of articles I wrote for a local magazine in Baton Rouge, Louisiana, called City Social.  I write an article every other weekend and call the column "Coach's Corner."  ACT is really cool to write popular articles about. 

 

Also check out these website pages from local university for a class I do there:

http://appl003.lsu.edu/slas/leisureweb.nsf/$Content/Calendar+View?OpenDocument

Go under view by category

then Family Matters and Personal Enrichment

then Acceptance and Change in Everyday Life

 

Some ideas - Kevin can share on his stress program based on ACT.

 

Talk tomorrow,

 

Patt

---

You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost.

---

You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost.

---

You rock. That's why Blockbuster's offering you one month of Blockbuster Total Access, No Cost.

Hi Chris,

Welcome to the listserve and congrats on your first post. I look forward to more
from you!

The idea of 'sitting inside the question' is something Kelly Wilson (one of the
developers of ACT) talks about, or at least, that's where I know it from (it's
origins may go back further than that). Essentially it means allowing yourself
to be in the space of not knowing, not rushing to answer, but just staying with
the question. Since being exposed to this idea at the ACT world con last year
(or maybe the year before now), I've been working to do that more often. Asking
a question and then purposefully pulling back from answering it straight away or
from answering other people's straight away and I've found that in doing so,
there really is the capacity for lots of other things to emerge. The thing is if
you answer it straight away, then it's done and there's no more space for
anything else. With 2 + 2, the answer's pretty obviously 4 (although as I write
this I'm wondering if maybe there is any other possible answers.... anyway, to
the best of my knowledge, the only answer is 4). But when it comes to the work
that we do, the answer is never simply '4'. Oftentimes we try to make it that to
make it easier for ourselves, but if we sit and not answer it, then we get to
see the additional possibilities. I thought about this idea a lot when I was
travelling in January with a non-psychologist friend through Central America. I
kept saying "I wonder...." and then she'd answer with her opinion and I kept
trying to explain to her that I just wanted to wonder, without having to have
the wondering answered straight away. She thought it was very strange! Anyway,
does that make the concept clearer?

Hmm, the acceptance vs DBT one's a biggie and there's a fair bit in the ACT
archives where people have bounced this one back and forth (have a look at
www.contextualpsychology.org). Strictly speaking, distraction is avoidance and
to be black and white about it the idea in ACT is to reduce avoidance and move
towards acceptance, however... sometimes avoidance is functional. Here's my
understanding of the synthesis people have arrived around this and I'll talk
about it in relation to BPD clients, cause that's where it's come up before -
so, if you're completely overwhelmed and the option is to distract vs
overdosing, then the choice more consistent with valued living is to distract.
Distress tolerance strategies ala DBT are designed to be used in a crisis where
you've got to find the way to bear the pain without making the situation any
worse. So, how do we define a crisis? It's an interesting question in regards to
eating. Is eating a crisis? Most of us would say no, it's refueling our bodies
or perhaps indulging in something decadent. For someone with an Eating Disorder,
is it a crisis? I don't know. Maybe. I'm recalling my client who said that she
felt like she was on fire when she had an urge to binge and the only thing to do
was to binge. Well, feeling like you're on fire could probably be defined as a
crisis. The thing is that 'normal eating' (our dietitian will kill me for using
that phrase) involves 3 meals and 3 snacks a day, so that's a lot of time to be
in crisis. Who gets to decide if it's a crisis or not, us or the patients? In
DBT, it's the patients, but then I'm thinking in the case of an Eating Disorder
that if the patients tell us it's a crisis and we go 'oh okay, it's a crisis,
let's use distress tolerance then', we miss out on the opportunity to really
check out if it's a crisis, i.e., "I know if FEELS like one, but would it be
okay for us just to have a look at it? You've feeling some really strong
sensations in your body (check in with that) and your mind is having an awful
lot to say about this (elicit) and what else (elicit). So, if it was possible to
just let those feelings be there and let your mind say what it's got to say
whilst we focus on what's important to you and do this for just one moment,
would that be a crisis? And then if we could do the same thing in the next
moment?"

Also the idea with distress tolerance is that you find a way to tolerate it
UNTIL you can approach the problem. So, if the clients are always distracting at
meal times, when do they learn to approach it? I really don't know the answers
to these questions I would love others to weigh in around this, as I think the
concept of acceptance vs DT strategies in an acute inpatient eating disorder
setting is a really useful thing for us to think through...and sit inside the
question of ;-).

In terms of your comment that it seems like a paradigm shift, I agree, I think
it is. I think that's why whenever I teach ACT for the first time, people often
look baffled and confused (of course it could be that I'm just a really bad
teacher) but once they've had time to soak in and adjust to the paradigm shift,
they can get what this is about. I also think it's generally the case that as
clinicians we feel more comfortable with distress tolerance and distraction, it
gives us something to do so we don't have to stay with our own anxiety in the
face of the patient's intense anxiety. I feel safer and more comfortable when
I'm talking to an intensely suicidal patient about going to hospital - I get to
make my anxiety do down and on occasion it may be what's needed, but I think
very often it's done in the service of bringing our anxiety down and not having
to stay with the pain that the patient is in, when in fact us staying with our
own anxiety whilst we stay present to their intense pain is likely just what is
needed. So, yep, probably distress tolerance does feel safer for both patients
and staff and yet....

Just to clarify, it's not that I'm anti- Distress Tolerance (even though it
probably seems it). I do think it's got it's role, I just think our patients
overuse it and at times we encourage that and I know I've played a role in our
Borderline patients getting to the end of a year in DBT with some super dooper
Distress Tolerance skills and some highly under-developed acceptance skills.

To cite you Chris, "all thoughts most welcome" ;-)

Carla.

>>> "chrisethornton" <ckthornton@...> 19-Feb-08 3:35 pm >>>

Hi Carla
Thanks for all your posts.  I always learn alot from what you have to
offer.  This is my first.

Could I get you to expand on the notion of "sitting inside the
question" a bit more.

I love where you wrote about being with the patient in intense
emotional distress and helping them be with the emotion.  I was
wondering if you can say more about the balance between acceptance
strategies and DBT distress tolerance strategies.  Working in an
inpatient unit there is such a focus on distress tolerance and
distraction at meal times which seems at odds with trying to help with
acceptance of the distress that will naturally come with doing
something so difficult.  It seems like a paradigm shift for both
patients and staff - and both feel safer with distress tolerance and
distraction.

all thoughts most welcome

chris




--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
Walton" <Carla.Walton@...> wrote:
>
> Hi Tyler,
>
> Thanks so much for expanding on your email and being as transparent
as possible. As you say, working in an outpatient setting is a whole
different ball game to working with clients in residential care with a
deadline hanging over your head. No wonder you want to switch to
distress tolerance strategies, so you can feel like you're giving them
something. I have always worked in outpatient settings and never in
inpatient settings and I take my hat off to you, because you see these
clients at their most severe and most distressed.
>
> One of the things that struck me about the residential setting is
the amazing opportunity to work with people in-vivo when they are
experiencing such intense emotions. I work in a DBT program and the
phone is our equivalent for people to call when they're in the crisis
situations to work with them at that moment. As therapists, it's so
much more challenging that when people come in all regulated and we
can just talk about what to do when the crap hits the fan, but also so
much more powerful.
>
> I'm very much a fan of Kelly's idea of 'sitting inside the question'
without the pull of the need to answer it.... and yet, I don't really
know how to do that on a listserve. If others also value the idea of
sitting inside the question to give space for something fresh to
emerge maybe we can work out how to do that together?
>
> My main suggestion would be to lean in when the emotions are intense
and notice with the patient. What is this thing that they believe is
impossible to have. Where do they notice the emotion, what does it
look like, if it had a colour, what colour would it be, or a shape,
can they just breathe into it and have a look at it and be curious
about it.... even whilst it's threatening to overwhelm them. At that
time the emotions seem like they could destroy them and I've been
playing around with your metaphor of the classroom being on fire in my
head. Maybe there's so much smoke that it seems like there must be a
fire and that everyone will die, but if they could stay and look at
the smoke and see through it, they could see that there's no fire
(kind of like the passengers on the bus claim that they could really
hurt you, and yet, experience shows that they never have). The smoke
makes it seem like there is a fire and they probably can't listen to
your words and what you're teaching because the smoke is demanding
their attention, so go to where they are and look at the smoke with
them and they will have an urge to run out of the room, but they've
done that before and being in that room is where they need to be for
life to be lived. Does this fit for you? I think your metaphor is a
really useful one and it'd be good to play around a bit with it. It
also reminded me of a client with Bulimia who talked about having
urges to binge that felt like she was on fire and the only way to put
the fire out was to binge. Not sure how that fits in here, but it was
so evocative for me and helped me to see how could she possibly feel
like not bingeing was an option when that actually meant feeling like
she was burning alive. i can't even remember how we addressed that in
therapy,  but I do remember that over time she talked about the sense
of burning alive reducing.
>
> Also, I wonder if the more the emotional intensity the client
presents with, the more driven you feel to talk and help and coach
(that's what happens for me).
>
> Are you on the main listserve? Someone posted a question last week
about working with a young person with anorexia who is losing weight
fast and their were a couple of really lovely responses about the
therapist working on acceptance and being where the client is at.
>
> I also discussed this with some of my colleagues who had some
different ideas, so I will leave it to them to respond as I think
they'll do a better job of explaining what they mean than I will.
>
> I might leave it there for now. I had a few more half-baked thoughts
but I have a client downstairs waiting for me and if I wait to have
time to write a longer response it won't happen and I wanted to send
something off in response to your email.
>
> Thanks again for your honesty and willingness to be vulnerable and
to put your questions out there.
>
> Carla.
>
> >>> "jtbeach78" <jtbeach78@...> 06-Feb-08 2:30:30 pm >>>
> Hi Carla,
>
> Thanks for your response!  I find myself using the very same
> strategies you describe.  In my opinion, I think this works well in
> longer term psychotherapy situations when we can circle over and over
> until they're ready to approach.
>
> Where I'm having a hard time applying it is with my clients in
> residential care, where my they come in for 45-90 days. The situation
> is quite different in that all of a sudden these clients are faced
> with eating large food portions and tolerating changes to their BMI
> in very quick progression.
>
> In the interest of getting some focused feedback, I'm going to be as
> transparent as possible.  The first few days are sort of a honeymoon
> where the food portions are typically small and patient anxiety,
> although still high, hasn't reached phobic intensity.  At this stage,
> orienting someone to an ACT framework is relatively easy.  In fact
> they really see how avoidance has caused so much trouble.  Other
> treatments haven't been fully effective so maybe this is worth a try.
> But treatment changes quick from this point, and as we know many of
> these clients really have a hard time with change.  Food portions and
> body changes start happening and emotional intensity and suffering
> spike to high levels.  I try to prime my patients for this change as
> much as I can.  When the petal hits the metal is when I feel the most
> unskilled at guiding my client.  I validate, use metaphors, remind
> them of their values, remind them we've anticipated this reaction,
> etc.  All of this helps some but in the middle of such intensity
> doesn't seem to sink in the same as it did before.  Patients who were
> very eager several days before want to run for the hills.  Sometimes
> my clients look at me like I'm crazy or they just repeat that they
> don't want to feel this way no matter what the cost. I validate their
> reactions and invite them to look at them.  I talk about the nature
> of avoidance and how it can limit our ability to get free.
>
> I love the theory but many times with clients, this is the time that
> just feels weird to me.  Sometimes I feel like I am trying to teach a
> class and requesting that my students please pay attention when the
> classroom is on fire!  I start to worry and my brain starts producing
> worry thoughts:
>
>    "Am I being presumptuous in thinking I can open them to this
> approach and then help them to see some benefit in a reasonable time
> period?  Is there something else I could be providing them? Is this
> work appropriate for where they are?  Am I reasonably confident they
> have the skills to tolerate this sort of intervention?  Will they
> leave treatment with some concrete skills they can take with them in
> their continued recovery?  Should I go back to my old DBT approach
> and validate the distressing nature of the current intensity,
> encourage distress tolerance (distraction) techniques, thought
> stopping and distortion challenges?  Or should I focus exclusively on
> the validation strategy by empathizing as hard as I can, and put all
> of my focus on creating a corrective emotional experience?"
>
> So that is where I find myself sometimes.  I sometimes get
> discouraged because I feel unskilled at assisting in reducing intense
> suffering in the moment without using distracting skills.  Also, in
> spending more time coaching them towards their values, and analyzing
> language. I feel a bit pushy and invalidating of their current
> suffering. I remain patient and continue forward but its hard at
> times!  Part of the journey for me seems to be able to integrate this
> in a way that allows me to tolerate my uncertainty.
>
> --Tyler
>
>
> --- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
> Walton" <Carla.Walton@> wrote:
> >
> > Hi Tyler,
> >
> > I'm not sure if I've got any big ideas for that issue, I'm really
> wanting to write back to support your wonderings and keep the
> conversation alive.
> >
> > WIth eating disorders, I find myself continually returning to
> Creative Hopelessness and particularly the idea of workability, i.e.,
> in your experience, has that worked and what's the cost been. I find
> with Eating Disorders more than any other client group I work with, I
> need to keep revisiting that, cause often just as soon as someone has
> opened up to other possibilities, the Eating Disorder comes in and
> takes over again. In fact, I guess I find with Eating Disorders, that
> I'm often circling back over lots of ACT aspects. My take on it is
> that when the lack of food intake affects people's cognitive
> abilities, it makes it harder to take stuff in and that the affect
> phobicness and fusion with thoughts is really strong with EDs.
> >
> > In the situation of ambivalence, I'd be likely to move into values,
> so that it makes it more meaningful. E.g., "would it be worth having
> (describe painful feeling) if it meant that (describe value)?"
> >
> > Not knowing each other in these situations, I always wonder when I
> write things whether these are the things people are doing anyway.
> >
> > Carla.
> >
> > Dr Carla Walton
> > Clinical Psychologist
> > Centre for Psychotherapy
> > James Fletcher Hospital
> > PO Box 833
> > Newcastle NSW 2300
> >
> > Ph:      (02) 4924 6820
> > Fax:    (02) 4924 6801
> > E-Mail: Carla.Walton@
> >
> > >>> "Tyler Beach" <jtbeach78@> 01/11/08 10:02 AM >>>
> > Hi group,
> >
> >
> >
> > I work as a psychotherapist at a residential eating disorders
> facility.  I'm
> > new to ACT work.  I'd done some reading on it and recently went to a
> > training offered by an ACT psychologist at Duke.  I was originally
> trained
> > in DBT and mindfulness based psychotherapy, but after going to this
> recent
> > training, I realized I was doing a bit of ACT work (sans
> terminology or
> > framework) without even knowing it!  For about a year I have been
> slowly
> > moving away from some of the distraction and blocking strategies
> taught by
> > DBT (which IMO certainly have their place for certain populations)
> and
> > leaned more heavily into the defusion strategies and mindfulness
> > experiencing skills.  I find the work very rewarding and intense.
> It is
> > always an adventure during the intro stage, especially when I am
> engaging a
> > client in a conversation where I am actually asking them to stop
> fighting
> > their thoughts of being "fat" and corresponding feelings.  My
> experience is
> > that most clients are quite intrigued and like the theory, but tend
> to
> > become more ambivalent in the presence of actual affect or intense
> thoughts.
> > I wonder if others are coming up against that and what strategies
> they use
> > to keep a client engaged in the approach vs. avoidance.
> >
> >
> >
> > --Tyler Beach, LCSW
> >
>
>
>
>
>
> Yahoo! Groups Links
>





Yahoo! Groups Links

Hi Carla
Thanks for all your posts.  I always learn alot from what you have to
offer.  This is my first.

Could I get you to expand on the notion of "sitting inside the
question" a bit more.

I love where you wrote about being with the patient in intense
emotional distress and helping them be with the emotion.  I was
wondering if you can say more about the balance between acceptance
strategies and DBT distress tolerance strategies.  Working in an
inpatient unit there is such a focus on distress tolerance and
distraction at meal times which seems at odds with trying to help with
acceptance of the distress that will naturally come with doing
something so difficult.  It seems like a paradigm shift for both
patients and staff - and both feel safer with distress tolerance and
distraction.

all thoughts most welcome

chris




--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
Walton" <Carla.Walton@...> wrote:
>
> Hi Tyler,
>
> Thanks so much for expanding on your email and being as transparent
as possible. As you say, working in an outpatient setting is a whole
different ball game to working with clients in residential care with a
deadline hanging over your head. No wonder you want to switch to
distress tolerance strategies, so you can feel like you're giving them
something. I have always worked in outpatient settings and never in
inpatient settings and I take my hat off to you, because you see these
clients at their most severe and most distressed.
>
> One of the things that struck me about the residential setting is
the amazing opportunity to work with people in-vivo when they are
experiencing such intense emotions. I work in a DBT program and the
phone is our equivalent for people to call when they're in the crisis
situations to work with them at that moment. As therapists, it's so
much more challenging that when people come in all regulated and we
can just talk about what to do when the crap hits the fan, but also so
much more powerful.
>
> I'm very much a fan of Kelly's idea of 'sitting inside the question'
without the pull of the need to answer it.... and yet, I don't really
know how to do that on a listserve. If others also value the idea of
sitting inside the question to give space for something fresh to
emerge maybe we can work out how to do that together?
>
> My main suggestion would be to lean in when the emotions are intense
and notice with the patient. What is this thing that they believe is
impossible to have. Where do they notice the emotion, what does it
look like, if it had a colour, what colour would it be, or a shape,
can they just breathe into it and have a look at it and be curious
about it.... even whilst it's threatening to overwhelm them. At that
time the emotions seem like they could destroy them and I've been
playing around with your metaphor of the classroom being on fire in my
head. Maybe there's so much smoke that it seems like there must be a
fire and that everyone will die, but if they could stay and look at
the smoke and see through it, they could see that there's no fire
(kind of like the passengers on the bus claim that they could really
hurt you, and yet, experience shows that they never have). The smoke
makes it seem like there is a fire and they probably can't listen to
your words and what you're teaching because the smoke is demanding
their attention, so go to where they are and look at the smoke with
them and they will have an urge to run out of the room, but they've
done that before and being in that room is where they need to be for
life to be lived. Does this fit for you? I think your metaphor is a
really useful one and it'd be good to play around a bit with it. It
also reminded me of a client with Bulimia who talked about having
urges to binge that felt like she was on fire and the only way to put
the fire out was to binge. Not sure how that fits in here, but it was
so evocative for me and helped me to see how could she possibly feel
like not bingeing was an option when that actually meant feeling like
she was burning alive. i can't even remember how we addressed that in
therapy,  but I do remember that over time she talked about the sense
of burning alive reducing.
>
> Also, I wonder if the more the emotional intensity the client
presents with, the more driven you feel to talk and help and coach
(that's what happens for me).
>
> Are you on the main listserve? Someone posted a question last week
about working with a young person with anorexia who is losing weight
fast and their were a couple of really lovely responses about the
therapist working on acceptance and being where the client is at.
>
> I also discussed this with some of my colleagues who had some
different ideas, so I will leave it to them to respond as I think
they'll do a better job of explaining what they mean than I will.
>
> I might leave it there for now. I had a few more half-baked thoughts
but I have a client downstairs waiting for me and if I wait to have
time to write a longer response it won't happen and I wanted to send
something off in response to your email.
>
> Thanks again for your honesty and willingness to be vulnerable and
to put your questions out there.
>
> Carla.
>
> >>> "jtbeach78" <jtbeach78@...> 06-Feb-08 2:30:30 pm >>>
> Hi Carla,
>
> Thanks for your response!  I find myself using the very same
> strategies you describe.  In my opinion, I think this works well in
> longer term psychotherapy situations when we can circle over and over
> until they're ready to approach.
>
> Where I'm having a hard time applying it is with my clients in
> residential care, where my they come in for 45-90 days. The situation
> is quite different in that all of a sudden these clients are faced
> with eating large food portions and tolerating changes to their BMI
> in very quick progression.
>
> In the interest of getting some focused feedback, I'm going to be as
> transparent as possible.  The first few days are sort of a honeymoon
> where the food portions are typically small and patient anxiety,
> although still high, hasn't reached phobic intensity.  At this stage,
> orienting someone to an ACT framework is relatively easy.  In fact
> they really see how avoidance has caused so much trouble.  Other
> treatments haven't been fully effective so maybe this is worth a try.
> But treatment changes quick from this point, and as we know many of
> these clients really have a hard time with change.  Food portions and
> body changes start happening and emotional intensity and suffering
> spike to high levels.  I try to prime my patients for this change as
> much as I can.  When the petal hits the metal is when I feel the most
> unskilled at guiding my client.  I validate, use metaphors, remind
> them of their values, remind them we've anticipated this reaction,
> etc.  All of this helps some but in the middle of such intensity
> doesn't seem to sink in the same as it did before.  Patients who were
> very eager several days before want to run for the hills.  Sometimes
> my clients look at me like I'm crazy or they just repeat that they
> don't want to feel this way no matter what the cost. I validate their
> reactions and invite them to look at them.  I talk about the nature
> of avoidance and how it can limit our ability to get free.
>
> I love the theory but many times with clients, this is the time that
> just feels weird to me.  Sometimes I feel like I am trying to teach a
> class and requesting that my students please pay attention when the
> classroom is on fire!  I start to worry and my brain starts producing
> worry thoughts:
>
>    "Am I being presumptuous in thinking I can open them to this
> approach and then help them to see some benefit in a reasonable time
> period?  Is there something else I could be providing them? Is this
> work appropriate for where they are?  Am I reasonably confident they
> have the skills to tolerate this sort of intervention?  Will they
> leave treatment with some concrete skills they can take with them in
> their continued recovery?  Should I go back to my old DBT approach
> and validate the distressing nature of the current intensity,
> encourage distress tolerance (distraction) techniques, thought
> stopping and distortion challenges?  Or should I focus exclusively on
> the validation strategy by empathizing as hard as I can, and put all
> of my focus on creating a corrective emotional experience?"
>
> So that is where I find myself sometimes.  I sometimes get
> discouraged because I feel unskilled at assisting in reducing intense
> suffering in the moment without using distracting skills.  Also, in
> spending more time coaching them towards their values, and analyzing
> language. I feel a bit pushy and invalidating of their current
> suffering. I remain patient and continue forward but its hard at
> times!  Part of the journey for me seems to be able to integrate this
> in a way that allows me to tolerate my uncertainty.
>
> --Tyler
>
>
> --- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
> Walton" <Carla.Walton@> wrote:
> >
> > Hi Tyler,
> >
> > I'm not sure if I've got any big ideas for that issue, I'm really
> wanting to write back to support your wonderings and keep the
> conversation alive.
> >
> > WIth eating disorders, I find myself continually returning to
> Creative Hopelessness and particularly the idea of workability, i.e.,
> in your experience, has that worked and what's the cost been. I find
> with Eating Disorders more than any other client group I work with, I
> need to keep revisiting that, cause often just as soon as someone has
> opened up to other possibilities, the Eating Disorder comes in and
> takes over again. In fact, I guess I find with Eating Disorders, that
> I'm often circling back over lots of ACT aspects. My take on it is
> that when the lack of food intake affects people's cognitive
> abilities, it makes it harder to take stuff in and that the affect
> phobicness and fusion with thoughts is really strong with EDs.
> >
> > In the situation of ambivalence, I'd be likely to move into values,
> so that it makes it more meaningful. E.g., "would it be worth having
> (describe painful feeling) if it meant that (describe value)?"
> >
> > Not knowing each other in these situations, I always wonder when I
> write things whether these are the things people are doing anyway.
> >
> > Carla.
> >
> > Dr Carla Walton
> > Clinical Psychologist
> > Centre for Psychotherapy
> > James Fletcher Hospital
> > PO Box 833
> > Newcastle NSW 2300
> >
> > Ph:      (02) 4924 6820
> > Fax:    (02) 4924 6801
> > E-Mail: Carla.Walton@
> >
> > >>> "Tyler Beach" <jtbeach78@> 01/11/08 10:02 AM >>>
> > Hi group,
> >
> >
> >
> > I work as a psychotherapist at a residential eating disorders
> facility.  I'm
> > new to ACT work.  I'd done some reading on it and recently went to a
> > training offered by an ACT psychologist at Duke.  I was originally
> trained
> > in DBT and mindfulness based psychotherapy, but after going to this
> recent
> > training, I realized I was doing a bit of ACT work (sans
> terminology or
> > framework) without even knowing it!  For about a year I have been
> slowly
> > moving away from some of the distraction and blocking strategies
> taught by
> > DBT (which IMO certainly have their place for certain populations)
> and
> > leaned more heavily into the defusion strategies and mindfulness
> > experiencing skills.  I find the work very rewarding and intense.
> It is
> > always an adventure during the intro stage, especially when I am
> engaging a
> > client in a conversation where I am actually asking them to stop
> fighting
> > their thoughts of being "fat" and corresponding feelings.  My
> experience is
> > that most clients are quite intrigued and like the theory, but tend
> to
> > become more ambivalent in the presence of actual affect or intense
> thoughts.
> > I wonder if others are coming up against that and what strategies
> they use
> > to keep a client engaged in the approach vs. avoidance.
> >
> >
> >
> > --Tyler Beach, LCSW
> >
>
>
>
>
>
> Yahoo! Groups Links
>

Hi Tyler,

Thanks so much for expanding on your email and being as transparent as possible.
As you say, working in an outpatient setting is a whole different ball game to
working with clients in residential care with a deadline hanging over your head.
No wonder you want to switch to distress tolerance strategies, so you can feel
like you're giving them something. I have always worked in outpatient settings
and never in inpatient settings and I take my hat off to you, because you see
these clients at their most severe and most distressed.

One of the things that struck me about the residential setting is the amazing
opportunity to work with people in-vivo when they are experiencing such intense
emotions. I work in a DBT program and the phone is our equivalent for people to
call when they're in the crisis situations to work with them at that moment. As
therapists, it's so much more challenging that when people come in all regulated
and we can just talk about what to do when the crap hits the fan, but also so
much more powerful.

I'm very much a fan of Kelly's idea of 'sitting inside the question' without the
pull of the need to answer it.... and yet, I don't really know how to do that on
a listserve. If others also value the idea of sitting inside the question to
give space for something fresh to emerge maybe we can work out how to do that
together?

My main suggestion would be to lean in when the emotions are intense and notice
with the patient. What is this thing that they believe is impossible to have.
Where do they notice the emotion, what does it look like, if it had a colour,
what colour would it be, or a shape, can they just breathe into it and have a
look at it and be curious about it.... even whilst it's threatening to overwhelm
them. At that time the emotions seem like they could destroy them and I've been
playing around with your metaphor of the classroom being on fire in my head.
Maybe there's so much smoke that it seems like there must be a fire and that
everyone will die, but if they could stay and look at the smoke and see through
it, they could see that there's no fire (kind of like the passengers on the bus
claim that they could really hurt you, and yet, experience shows that they never
have). The smoke makes it seem like there is a fire and they probably can't
listen to your words and what you're teaching because the smoke is demanding
their attention, so go to where they are and look at the smoke with them and
they will have an urge to run out of the room, but they've done that before and
being in that room is where they need to be for life to be lived. Does this fit
for you? I think your metaphor is a really useful one and it'd be good to play
around a bit with it. It also reminded me of a client with Bulimia who talked
about having urges to binge that felt like she was on fire and the only way to
put the fire out was to binge. Not sure how that fits in here, but it was so
evocative for me and helped me to see how could she possibly feel like not
bingeing was an option when that actually meant feeling like she was burning
alive. i can't even remember how we addressed that in therapy,  but I do
remember that over time she talked about the sense of burning alive reducing.

Also, I wonder if the more the emotional intensity the client presents with, the
more driven you feel to talk and help and coach (that's what happens for me).

Are you on the main listserve? Someone posted a question last week about working
with a young person with anorexia who is losing weight fast and their were a
couple of really lovely responses about the therapist working on acceptance and
being where the client is at.

I also discussed this with some of my colleagues who had some different ideas,
so I will leave it to them to respond as I think they'll do a better job of
explaining what they mean than I will.

I might leave it there for now. I had a few more half-baked thoughts but I have
a client downstairs waiting for me and if I wait to have time to write a longer
response it won't happen and I wanted to send something off in response to your
email.

Thanks again for your honesty and willingness to be vulnerable and to put your
questions out there.

Carla.

>>> "jtbeach78" <jtbeach78@...> 06-Feb-08 2:30:30 pm >>>
Hi Carla,

Thanks for your response!  I find myself using the very same
strategies you describe.  In my opinion, I think this works well in
longer term psychotherapy situations when we can circle over and over
until they're ready to approach.

Where I'm having a hard time applying it is with my clients in
residential care, where my they come in for 45-90 days. The situation
is quite different in that all of a sudden these clients are faced
with eating large food portions and tolerating changes to their BMI
in very quick progression.

In the interest of getting some focused feedback, I'm going to be as
transparent as possible.  The first few days are sort of a honeymoon
where the food portions are typically small and patient anxiety,
although still high, hasn't reached phobic intensity.  At this stage,
orienting someone to an ACT framework is relatively easy.  In fact
they really see how avoidance has caused so much trouble.  Other
treatments haven't been fully effective so maybe this is worth a try.
But treatment changes quick from this point, and as we know many of
these clients really have a hard time with change.  Food portions and
body changes start happening and emotional intensity and suffering
spike to high levels.  I try to prime my patients for this change as
much as I can.  When the petal hits the metal is when I feel the most
unskilled at guiding my client.  I validate, use metaphors, remind
them of their values, remind them we've anticipated this reaction,
etc.  All of this helps some but in the middle of such intensity
doesn't seem to sink in the same as it did before.  Patients who were
very eager several days before want to run for the hills.  Sometimes
my clients look at me like I'm crazy or they just repeat that they
don't want to feel this way no matter what the cost. I validate their
reactions and invite them to look at them.  I talk about the nature
of avoidance and how it can limit our ability to get free.

I love the theory but many times with clients, this is the time that
just feels weird to me.  Sometimes I feel like I am trying to teach a
class and requesting that my students please pay attention when the
classroom is on fire!  I start to worry and my brain starts producing
worry thoughts:

    "Am I being presumptuous in thinking I can open them to this
approach and then help them to see some benefit in a reasonable time
period?  Is there something else I could be providing them? Is this
work appropriate for where they are?  Am I reasonably confident they
have the skills to tolerate this sort of intervention?  Will they
leave treatment with some concrete skills they can take with them in
their continued recovery?  Should I go back to my old DBT approach
and validate the distressing nature of the current intensity,
encourage distress tolerance (distraction) techniques, thought
stopping and distortion challenges?  Or should I focus exclusively on
the validation strategy by empathizing as hard as I can, and put all
of my focus on creating a corrective emotional experience?"

So that is where I find myself sometimes.  I sometimes get
discouraged because I feel unskilled at assisting in reducing intense
suffering in the moment without using distracting skills.  Also, in
spending more time coaching them towards their values, and analyzing
language. I feel a bit pushy and invalidating of their current
suffering. I remain patient and continue forward but its hard at
times!  Part of the journey for me seems to be able to integrate this
in a way that allows me to tolerate my uncertainty.

--Tyler


--- In eatingconcernsandcontextualpsychology@yahoogroups.com, "Carla
Walton" <Carla.Walton@...> wrote:
>
> Hi Tyler,
>
> I'm not sure if I've got any big ideas for that issue, I'm really
wanting to write back to support your wonderings and keep the
conversation alive.
>
> WIth eating disorders, I find myself continually returning to
Creative Hopelessness and particularly the idea of workability, i.e.,
in your experience, has that worked and what's the cost been. I find
with Eating Disorders more than any other client group I work with, I
need to keep revisiting that, cause often just as soon as someone has
opened up to other possibilities, the Eating Disorder comes in and
takes over again. In fact, I guess I find with Eating Disorders, that
I'm often circling back over lots of ACT aspects. My take on it is
that when the lack of food intake affects people's cognitive
abilities, it makes it harder to take stuff in and that the affect
phobicness and fusion with thoughts is really strong with EDs.
>
> In the situation of ambivalence, I'd be likely to move into values,
so that it makes it more meaningful. E.g., "would it be worth having
(describe painful feeling) if it meant that (describe value)?"
>
> Not knowing each other in these situations, I always wonder when I
write things whether these are the things people are doing anyway.
>
> Carla.
>
> Dr Carla Walton
> Clinical Psychologist
> Centre for Psychotherapy
> James Fletcher Hospital
> PO Box 833
> Newcastle NSW 2300
>
> Ph:      (02) 4924 6820
> Fax:    (02) 4924 6801
> E-Mail: Carla.Walton@...
>
> >>> "Tyler Beach" <jtbeach78@...> 01/11/08 10:02 AM >>>
> Hi group,
>
>
>
> I work as a psychotherapist at a residential eating disorders
facility.  I'm
> new to ACT work.  I'd done some reading on it and recently went to a
> training offered by an ACT psychologist at Duke.  I was originally
trained
> in DBT and mindfulness based psychotherapy, but after going to this
recent
> training, I realized I was doing a bit of ACT work (sans
terminology or
> framework) without even knowing it!  For about a year I have been
slowly
> moving away from some of the distraction and blocking strategies
taught by
> DBT (which IMO certainly have their place for certain populations)
and
> leaned more heavily into the defusion strategies and mindfulness
> experiencing skills.  I find the work very rewarding and intense.
It is
> always an adventure during the intro stage, especially when I am
engaging a
> client in a conversation where I am actually asking them to stop
fighting
> their thoughts of being "fat" and corresponding feelings.  My
experience is
> that most clients are quite intrigued and like the theory, but tend
to
> become more ambivalent in the presence of actual affect or intense
thoughts.
> I wonder if others are coming up against that and what strategies
they use
> to keep a client engaged in the approach vs. avoidance.
>
>
>
> --Tyler Beach, LCSW
>





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