Treatment Description and Overview

The treatment and interventions described in this chapter are based on the empirical literature reviewed in the preceding section as well as more than 10 years of our program development and clinical practice. We initially applied the standard outpatient DBT model (e.g., once-weekly individual DBT plus skills training and telephone coaching) with this population; however, our experiences indicate that once-weekly therapy is not sufficient to achieve symptom interruption and more sustainable behavior change for these particular clients. It is very difficult for even the most skilled clinician to effectively treat a client with a chronic and multidiagnostic ED presentation alone in outpatient practice. Additionally, we have observed that applying the standard DBT model, which does not include empirically supported ED interventions (e.g., weight monitoring, food exposures, meal planning), often results in little or no change to core ED symptoms. Our experience to date has suggested that treatment for this unique population requires the following components: (a) a more concentrated treatment dose (i.e., more than once-weekly individual therapy to start) that includes a treatment team, consisting of individual therapy, skills group training, nutrition, psychiatry, and medicine; (b) attention to motivational issues; (c) daily goal setting and accountability; (d) targeting of behaviors that interfere with treatment delivery; (e) meal planning, food exposure, and weight and medical monitoring; and (f) comprehensive skills training, particularly in the area of emotion regulation.

With these goals in mind, we have developed an innovative and intensive outpatient treatment model that blends the standard DBT model with empirically supported ED interventions (e.g., psychoeducation, meal planning and preparation, in vivo food exposures, monitoring of weight and medical stability, and cognitive modification of maladaptive ED-related thoughts). For a full description of the program, please see Federici, Wisniewski, and Ben- Porath (2012). In brief, most of the program is delivered in a group format and includes two DBT skills training groups per week. Consistent with the DBT model, skills groups begin with a mindfulness exercise, followed by homework review, teaching of new skills, and establishing new homework assignments with attention to potential obstacles to skill practice. Clients are also required to attend weekly individual DBT therapy, as well as to attend weekly appointments with the staff dietician and team psychiatrist. All clients have access to, and are expected to use, telephone skills coaching. All therapists attend a weekly consultation team meeting. The core intensive outpatient program runs Monday through Friday from 8:00 a.m. to 11:00 a.m. Clients who require a higher level of care because of symptom severity may attend our extended day treatment hours from 11:00 a.m. to 2:00 p.m. to have access to greater meal support and skills training. Clients are expected to limit the amount of time in day treatment to decrease dependency on treatment and encourage the development of activities beyond the treatment setting.

Our program is designed for clients who have not responded adequately to standard ED treatments such as cognitive-behavioral therapy-based day treatment, inpatient treatment, or residential programming. Given the empirical support for standard ED programming and given the experimental nature of our current treatment, clients who have never tried traditional, empirically supported ED treatments are referred to such programs first. In addition, clients must meet one or more of the following criteria: (a) presenting with a comorbid Axis I or Axis II disorder, (b) struggling with pervasive emotion dysregulation, or (c) demonstrating significant therapy-interfering behaviors that typically disrupt standard ED interventions. In many cases, clients who present with severe medical instability or dangerously low body weight may be referred to inpatient treatment or hospitalization for refeeding or medical stabilization before entry into our program. Such cases are based on a clinical team decision, given that many of our patients have had countless inpatient treatments only to lose the weight that was gained during hospitalization soon after discharge.

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