Motivational Feeding for Eating

Disorders :Skills-based Learning

for Clinicians

Gill Todd – Independent Trainer

Prof. Janet Treasure

https://www.facebook.com/Kesselhausstudi

o/photos/a.358338690866599.89817.2446

16025572200/1155964107770716/?type=3

&theater

Expectations

• What we say about ourselves and our patients and our working environment stays in this room.

• For the sake of clarity one person speaks at a time.

• We will not cover specific diets.

• We will respect each other and sometimes agree to disagree.

Aims for the 2 days • Outlining the theories relating to Eating Disorder behaviour

and the psychology of health behaviour change

• Developing a therapeutic alliance with the patient and their all their Carers

• Developing Emotional Intelligence and Self-Confidence in patients, staff and family carers

• Using Motivational Interviewing techniques in the dining room or not.

• Being calm, clear ,compassionate and flexible

• We will use Scenarios relating to conversations about food weight and shape

The Days will be like this

Why Don’t People Change?

‘There is something in human nature that resists being

coerced and told what to do. Ironically, it is acknowledging the other’s rights and freedom not to

change that sometimes makes change possible.’ Rollnick, Miller, and Butler

Spirit of this workshop

• "Life is not about waiting for the storms to pass... it's about learning how to dance in the rain!“

Rabindranath Tagore

How do you ‘dance in the rain’ in your work setting?

The spirit of motivational interviewing The sun and the wind were having a

dispute as to, who was the most

powerful. They saw a man walking

along and they challenged each other

about which of them would be most

successful at getting the man to remove

his coat. The wind started first and blew

up a huge gale, the coat flapped but the

man only closed all his buttons and

tightened up his belt. The sun tried next

and shone brightly making the man

sweat. He proceeded to take off his

coat.

Family & Peer Factors

Food & weight salience

Parental weight

Teasing, criticism,‘shapism’

Personal Attributes

Negative Affect, Inhibition.

Stress sensitivity

Rigidity, weak central coherence

Coping strategies: avoidance, impulsivity,

compulsivity, addictions

Either over controlled or undercontrolled

emotionally – chaos or rigidity

High weight concerns

Internalisation of thin ideal

Environment

Maturational

Development

Perinatal

Adversity

Stress

Nutrition

Anoxia

Life events

Loss

Puberty

All Transitions

Culture: Easy access to palatable food, loss of social eating,

idealisation thinness.

Infancy Puberty Childhood

Genes

The Bio-psychosocial Matrix

S1

Co-production: Interpersonal maintaining Factors: lay and professional

Food-related fears: Treatment implications

RECOVERY= BREAKING UNHELPFUL

HABITS AND CREATE NEW

LEARNING

Food-related anxiety and avoidance are

key treatment targets

Valentina Cardi

Crap Day Exercise – How would you feel?

How can you help?

Develop Successful Strategies

Be realistic about how much you can help:

Who is the one person in this room you can

change?

Learn when to take a step back

Give more attention to the behaviours you like

and less attention to behaviours you don’t like

12

Starvation and the brain

The effect of Nutritional Problems on the brain

Brain needs 500kcal/day.

Brain needs 7 X caloric

intake of muscle

Brain function can be

damaged by irregular

pattern eating as well as

eating too little.

Sufferers lose the ability to

know when they are ‘full’

and when they are hungry.

Decreases

• Social cognition

• Emotional regulation

• Decision Making

• Flexibility

• Planning

Increases

• Compulsive behaviours

• Avoidance

• Threat reactivity

• Punishment sensitivity

Effects of starvation on the brain

Area responsible for

rational thought and

self-regulation are

most sensitive to

starvation and stress

Minnesota Starvation Study

Minnesota Starvation Study

• Social isolation, anxiety, neglecting personal hygiene, apathy

• Irritable, impatient, angry

• Depression and fluctuating mood

• Obsession over food and rituals around food

• Loss of sex drive

• Emotional anger at people with enough food

• Strong discipline ( driving them to keep with programme)

Minesotta Starvation Study

• The Surprises…….

• It took much more food than expected to regain weight ( metabolism effect)

• It took longer than expected for weight to stabilise (weight goes on in odd places)

• The emotional recovery was tougher than expected (as weight increases so emotions come flooding back)

Luckily the Brain is Plastic and can rejuvenate itself!

Preparing for Compassion

The brain can generate different types of self/mind (angry self, excited self, thoughtful self, asleep self) which attend, think, and behave differently.

Create your compassionate self (method acting) – imagine yourself as you would ideally like to be – you at your best – you at your wisest at your most compassionate. Close your eyes if that feels comfortable.

Create an image of yourself as mature, wise, kind, strong. This is image is private to you and a gift you give yourself.

Once in this state of mind –engage with communication and behaviour change skills .

Thinking style Detail vs global Rigid vsflexible

Emotional & social style Anxious Avoidant Emotional inhibition

Interpersonal Relationships Expressed emotion Accommodating & enabling

Pro Anorexia

Striving & mastery

A cognitive-interpersonal maintenance model

Schmidt & Treasure (2006) Updated Treasure & Schmidt (2013)

Eating disorder traits of anxiety, avoidance & rigidity allow ED symptoms to flourish

Thinking style Detail vs global Rigid vs flexible

Emotional & social style Anxious Avoidant Emotional inhibition

Interpersonal Relationships Expressed emotion Accommodating & enabling

Pro Anorexia

Striving & mastery

A cognitive-interpersonal maintenance model

Schmidt & Treasure (2006) Updated Treasure & Schmidt (2013)

Secondary Starvation Effects

•Accentuate eating disorder traits anxiety, avoidance & rigidity. •Valued benefits- eg emotional avoidance •Reduce social cognition (emotional expression)- contributes to poor interpersonal relationships

Maintenance Model of AN Intrapersonal

Phase 1. All Eating Disorders

Anxious, avoidant

Rigid, obsessional

STRESS

Response of

close others:

admiring

Dietary Restraint

Improved

mood

Develop &

adhere to rigid,

arbitrary, but clear rules

Sense of

mastery &

control

Weight loss

Pro-AN Beliefs

Neuroprogression & Disconnection

The Plastic Brain: Learning Learning is like tobogganing.

As we learn we develop a

pathway through the snow.

The more we repeat a task

the more the snow becomes

compacted and the deeper

and more slippery the path

becomes. Habits become

automatic.

New learning takes time &

persistence. It can take up to

5000 hours to learn a new

habit S2

Eating disorder behaviours elicit mixed emotions

Edi elicits a range of intense emotional reactions in the carer. Mirroring negative emotions keeps the cycle going. Maintain your emotional regulation by caring for yourself.

Attention to Dominance

Cardi et al 2011

Attention to Rejection

Attentional responses to rejection

-40

-30

-20

-10

0

10

20

30

40

500 ms 1250 ms

RT

sco

res ED

REC

HC

Attention to Acceptance

Attentional responses to acceptance

-40

-30

-20

-10

0

10

20

30

40

500 ms 1250 ms

reactio

n t

ime s

co

res

ED

REC

HC

Social Ranking

• Attention to judgment of others.

• High competition and striving.

• Low self esteem.

• Ignore compassion from others.

• Low self compassion.

The social world of people with eating disorders.

• Vigilance to negative.

• Inattention to positive.

• Cardi et al (2012 a &b)

Traits in eating disorders

Super

Organiser

Detail

Threat sensitivity

Super sensor

Flexibility

Soothe by

reward

Theory of Mind Understanding how

others think not just what they say

“Just back up little dear,

so you won’t cut my head

off”

About 20% of people

with anorexia nervosa

have some difficulty

with this.

Tchanturia et al 2004,

2009.

Maintaining Factors in Eating

Disorders

• High expressed emotion

• Interactions inadvertently provoke or

reward ED & extinguish non ED

behaviours

• Emotional (seeing threat)and

Thinking styles (attention to detail)

can hamper new learning (state or

trait).

Stages of change model- Prochaska and DiClemente ‘94

precontemplation

contemplation

preparation Action

Experiments

maintenance

relapse

permanent exit

MOTIVATIONAL INTERVIEWING PRINCIPLES

• MI is a process of looking at the positives for the person of staying the same ie maintaining the status quo. The person is treated not as ‘ill’ when making this decision, more that they have good sound reasons for staying the same.

• Hopefully they will see a benefit in being ‘curious’ about how they have come to make this decision and take the opportunity to explore and resolve their ambivalence about change.

• Interpretations about the persons’ behaviour are always spoken of in a ‘positive’ tone – turning negatives into positives is a great skill.

• The theory is routed in ‘normal’ health behaviour change theory • Based around raising people's self esteem.

• Ambivalence is normal, being in ‘two minds’ is normal, feeling ‘stuck’ there is very

uncomfortable and all attempts to change can feel frightening and hopeless.

• Clinicians and Carers need to learn that every interaction is an opportunity to ‘plant seeds’.

Facilitating change: Inhibit righting reflex increasing compassion

• Beware the righting reflex – built in desire to put things right.

• If you press for one side in someone who is ambivalent they will automatically argue for other side.

• Resist taking up “good” side of ambivalence rather take the side of the devils advocate.

• Foster unconditional acceptance of other persons autonomy. Set aside the desire to meddle.

• Believe in the other person.

Decisional Balance

Costs of staying the same

Benefits of change

Costs of change

Benefits of staying the same

Communication

• Teaching professionals/carers how to understand the other persons perspective by Listening out for the Emotions which are masked or substituted by the eating disorder behaviour.

• Helping professionals to work together with patients and carers to positively handle the different messages they give.

• Developing a Robust and Resilient Patient and Carer.

Communication Skills Motivational interviewing

If you argue for change

Other will argue against

change

The more you speak out loud about something the more you are likely to do it (Bem)

i.e. the person is more stuck in not changing

Emotions are important

• An eating disorder enables the sufferer to manage their emotions.

• The emotions could be anger, fear, a sense of being unlovable, a sense of not being ‘good enough’ or that success and happiness are too unreliable

• Strong emotions make life seem overwhelming, therefore feeling numb is safe, predictable.

Communication problems

What the speaker says (2) What the listener hears

(1)

(4)What the speaker means (3) What the listener

thinks the speaker means

(5) What the speaker believed they said

Use OARS to clarify all communication

Four Essential Micro-skills: OARS

• Ask OPEN questions – to get full answers, not yes/no answers, or rhetorical questions

• AFFIRM the person - comment positively on strengths, effort,intention, ‘hold the person in Mind’ Identity and Compassion

• REFLECT what the person says - "active listening"

• SUMMARIZE - draw together the persons own perspectives on change

Reflective Listening

• A reflection seeks to summarize a segment of what the person means; it makes a guess

• A good reflection is a statement, not a question

Levels of reflection

• Repeat - Direct restatement of what the person said

• Rephrase - Saying the same thing in slightly different words

• Paraphrase - Making a guess about meaning; continuing the paragraph; usually adds something that was not said directly, and can be an attempt to describe the unspoken emotions.

• Be prepared to be told you are wrong about your interpretations. This is good and should lead to more conversation.

Other types of reflection • Double-sided reflection - Captures both sides of the

ambivalence (... AND ...)

So on one hand you are saying you want to leave and on the other hand you know you will not have the energy to do anything with anybody.

• Amplified reflection - Overstates what the person says

So you think that making new friends will be impossible or

So you think that it will take time and effort to make new friends and you are worried about this

DO

• Be Reflective about yourself

• Be reflective about the person with ED

• Take a low power position

• Be kind, gentle and persistent

The MI Method level:

• Engaging

• Focusing

• Evoking

• Planning

Technical Definition: Motivational Interviewing is a collaborative, goal-

oriented style of communication with particular attention to the language of

change.

It is designed to strengthen personal motivation for and commitment to a

specific goal by eliciting and exploring the person’s own reasons for

change within an atmosphere of acceptance and compassion.

Third Edition Motivational Interviewing:Helping People Change. William R Miller

and Stephen Rollnick. Pub. Guilford Press 2013

Make all experiments SMART

• Specific

• Measurable

• Achievable

• Realistic

• Timely

• Making experiments simple increases confidence.

• Making goals a challenge decreases confidence if they fail or if they work

OARS developments/recap: affirmations

•To affirm is to accentuate the positive, to recognize and acknowledge the individual’s inherent worth, to support and encourage.

•Not the same as praise – praise subtly implies an uneven playing ground – ‘the praiser is in the one-up position’

•Avoid use of “I”: this focuses more on the clinician or carer than the patient.

•Like good reflecting, good affirming usually centres on the word ‘’you’’

Affirm

• Do not just affirm outcome –appears judgemental, conditional.

• Affirm process especially if goes against ED traits eg.if they

• Express emotion vs avoid emotions

• Connect others & world vs isolate self

• Flexible thinking vs rigid thinking

• Going for bigger picture vs detail

AFFIRM Look for the positive

• I am impressed that you have been able to have the courage to tell me what you think about that ………

• It can’t have been easy to be open about your jealous feelings

• I appreciate you explaining your gut reaction to ……

• It takes courage to speak from the heart……..

• It is an indication of your effort to think through that you have been flexible/adaptable/versatile / supple enough to……….

• You have been thoughtful and reflective and ………..

• You have been courageous/brave/ fear less to shift from your safe rituals….

Change talk: any self-expressed language that is a wish for change.

Preparatory change talk Mobilizing change talk

Desire I want to, I wish

Ability I can, I’m able to

Reasons I would probably be calmer

Need I need to, I have to, I must

Commitment I want to, I could

Activation I’m willing to, I’m ready to

Taking steps, I refused to go to 2 supermarkets

Change Talk DARN-CAT

Sustain talk: any self-expressed language that is an argument not to change and to stay the same.

DARN CAT

Desire I’d like to just carry on as I am. I’m not the one who should be thinking about change.

Ability I’ve tried to be a dolphin and it’s not me.

Reasons This helps me to have some boundaries and feel in control. Need I understand that this is the only way to manage my anxieties.

Sustain talk

Commitment I’ve tried many times – no more!

Activation Guess I’m not willing to do what it takes.

Taking steps I haven’t read any more of the book or watched the DVDs. Just been too busy…

Preparatory change talk Mobilizing change talk

(Pre-) contemplation Preparation Action

The DARN-CAT hill

Reflection: Patients/carers/staff who start intervention ready for change themselves might not be expected to benefit personally from MI (or at least from the evoking process) particularly when any ambivalence in changing their own behaviour appears to have been resolved. They may benefit more from guidance/discussion as to how to work with or use MI. Patients/Carers can be in Action sometimes and at other times be in Precontemplation. The Clinician needs to adopt a flexible approach or the patient will retreat and fight to remain the same the same.

LOL – Process of therapeutic interaction

• This started as EPE – Elicit – Provide- Elicit

• Then

• LISTEN – PROVIDE – LISTEN

• Now

• LISTEN – OFFER - LISTEN

• What do you think ‘PROVIDE’ means and what is the difference with saying ‘OFFER’ in this context? Work in small groups make a list of the differences

• Engage first – establish good working alliance

• Use sparingly – pay attention to how client responds (glazed over look, defensiveness or sustain talk) all likely signs that advice hasn’t been taken on board

• Ask permission

• Emphasize personal control

• Offer the idea of a menu of options

Offering advice...

Emotional Intelligence is Important

• An eating disorder enables the sufferer to manage their emotions.

• The emotions could be anger, fear, a sense of being unlovable, a sense of not being ‘good enough’ or that success and happiness are too unreliable

• All Strong emotions make life seem overwhelming, therefore feeling numb is safe, predictable.

• Talking about feelings needs practice.

Emotional Intelligence

• SELF TO SELF

• SELF TO OTHERS

• OTHERS TO OTHERS

• Learning this is a multi-layered back and forth process

• Come up with your own definition of ‘Emotional Intelligence’ in small groups

Menu of Options What is a Menu of Options? A selection of choices prevents the person from feeling trapped. It also allows the person to ‘save face’ It provides a sense of HOPE because there is more than one way to manage anything. It is ‘Bigger Picture’ thinking

Generate a Menu of Options for all Experiments

Never accept one way of trying an experiment in Change Behaviour

Never accept 2 ways of trying an experiment because.....?

Always generate 3 or more options even if some seem impossible or strange

You ‘Hold the Hope’ so be ready to come up with ideas so the patient

does not feel you are giving up or the future is hopeless

Asymmetries

• Clinicians/Carers have to step back from joining in the emotional dance.

• Clinicians/Carers step back from judgement and control.

• Skills of motivational interviewing are very helpful- compassion& skilful listening and the ability to side step arguing against resistance and accentuate the positive.

Knowledge and Skills

• Developing a balanced perspective ie some behaviours are normal eg. Wanting to control your life.

• Some behaviours are counter-productive eg. Arguing about food, weight and shape allows the sufferer to rehearse their reasons for not changing.

• Knowing that in order to change we all need – desire, ability, reasons, need, and commitment. If any one area is in short supply then that is where help to explore this is needed.

Carers feedback –unhelpful professional behaviours

• Many parents are thrown off balance by treatment professionals who tell parents that they played a substantial role in causation, disseminating feelings of guilt and shame, and need to find root causes.

• That emotional enmeshment is a cause of the illness and therefore parents need to take a ‘back seat’.

• That the child needs to want to get better before treatment can begin.

• By not sharing treatment plans or goals, so that whilst the patient is at home (for example weekend leave from hospital) the carer does not know what they are supposed to do.

• Telling a family their child is ‘‘not sick enough’’ to warrant treatment’

Patient feedback : Unhelpful Professional behaviours (Treasure et al • Overprotection . Over zealous uses of inpatient/high intensity care. • Excluding or disempowering the family from treatment. • Criticism or confrontation-coercive treatments Coercive treatment

under the Mental Health Act • Use of loss-of-privilege systems to motivate change. • Providing therapy with no or insufficient nutritional direction. • Accommodation. Engaging in bargaining of treatment goals with

the persuasive patient • Enabling Services. palliating loneliness and isolation • Providing the opportunity for further striving competing and • calibrating against others.

Patient view of helpful therapist/carer behaviours

• Helpful if therapist are "brave" in talking about emotions or other things that feel difficult in the therapy room.

• A patient described it as "even when I push against you, I want you to fight for me.”

• Want therapist to hold hope for change

Distressing ED Symptoms

Caregivers concerned

and anxious; don’t

understand

Caregivers respond:

high expressed emotion

Zabala et al, 2009

Kyriacou et al 2008

Sepulveda et al 2009

Interpersonal Perpetuating Cycle

The “opportunities for annoyance are many” (Venables 1931)

Guiding Principles...Emotion Focused Family Therapy

1. We believe in the extraordinary healing power of caregivers and families.

2. Caregivers and families can learn the skills they need to become their loved one’s recovery coach.

3. Parents and caregivers can overcome the fears that may keep them paralysed, or stuck in unhelpful patterns of relating to their loved one

4. Parents and caregivers need to be coached/informed. They also need for us to believe in them until they do change.

© 2013 Lafrance Robinson & Dolhanty

How to do it We ask parents/caregivers to:

1. Become their loved ones’ recovery coach (via the motivational support of refeeding / interruption of symptoms)

2. Become their loved ones’ emotion coach (via the support of processing of their own emotions)

3. Support their loved one to heal old wounds (via relationship repair, making amends)

4. Work through their own fears or emotional “blocks” (that may interfere with 1,2 and 3)

© 2013 Lafrance Robinson & Dolhanty

Animal Metaphors to understand High Expressed Emotion reactions

Kangaroo

Overprotective; desire to protect loved one from the

challenges of life and emotions by putting them in the pouch.

Types of Caregiving – which can be unhelpful as well as helpful

A kangaroo may

protect the AN bully

Jellyfish

Struggles to keep emotions in check. Can become very

anxious at times or even angry at times.

Types of Emotional Responses which can be helpful and unhelpful

Rhinoceros Controlling, constantly giving advice and arguments for change (can lead to a cycle where the loved one becomes defiant in response)

Types of Caregiving – sometimes unhelpful sometimes helpful

A rhino may elicit AN bully

talk

Balance of warmth & direction

Too much sympathy & management

Too much Control & direction

Just enough direction

Gentle guidance- keeps her safe and secure

Divide and Rule

Individual family members are set against each other (e.g. Dad is perceived by Mum as too soft and vice versa). So much energy is lost squabbling between family members that the eating disorder wins the day. This happens in Staff teams as well.

Therapeutic Processes

• Motivation to increase autonomy and APT (awareness, planning, try it) skills, to increase self-competence.

• Recovery approach to increase relatedness and skill sharing.

APT behaviour change skills

Awareness : Reflect and review when, how, why, what, with whom these occur

Planning- precision and detail to script out and vocalise the goal , and the steps to reach goal. Plan how to overcome obstacles. If -then procedures-driven by context cues.

Try it. Have courage make a change. It might get worse before it gets better. You need to practice many times to get it occurring automatically.

Processes of Recovery Approach(Leamy et al. 2011)

• Connectedness through peer support

• Hope/optimism about the future.

• Confidence to change.

• Development of identity,

• Sense of meaning in life and experiencing empowerment

Potential Mediators and Moderators of Change

Better outcomes • Patient factors (stage of illness). • Early engagement (motivation ) and treatment

responsivity (Brauhardt et al 2014). Worse outcomes • Poor interpersonal functioning, social inhibition,

shame, attachment anxiety/avoidance (Carter and Kelly 2014), Schlegl, et al. 2014).

Targeting treatment on the predictors of change (motivation, alliance) may be of benefit for enhancing retention and treatment outcomes.

I was known as the ice queen at Uni

Tutors would get annoyed as they thought I did not care. They did not know what was going on inside

Uncanny Valley : effect

I was known as the ice queen at Uni

Tutors would get annoyed as they thought I did not care. They did not know what was going on inside

Suppression

emotion reaction

↑ physiological

arousal

↓ emotional

regulation

(Oschner)

Monitoring of

own facial

expression make

that person less

responsive

I was known as the ice queen at Uni

Tutors would get annoyed as they thought I did not care. They did not know what was going on inside

Partners of suppressors have greater increases in blood pressure Negative judgment (Gross 2013)

The Isolation trap • Eating disorder in one word-

“isolation” McKnight R BMJ (2009) Personal view.

• Edi becomes a “friend”

Connection Needed for Recovery Cockell et al., 2004; D’Abundo and Chally, 2004; Hsu et al., 1992; Redenbach and Lawler,2003; Tozzi et al., 2003, Hay and Cho, 2013).

Rosemary’s scenario

• Consider this scenario. • The struggling patient is on the unsupervised table. The dining room is full

and one of the nurses has to sit on the unsupervised table as there is no room for her on the supervised table. The patient is quiet and keeping her head down so that she can do things mechanically.

• The staff member is sitting next to her and she comments that the patient is in difficulty and when there is no response, she continues by saying: How old are you ?

• • When the reply is that the patient is 38 years old, the staff member says:

How is it that you have nothing which a woman of your age would be expected to have?

• No home, no job, no husband, no car, no family ?

Rosemary

• The patient doesn't respond but is clearly affected by this . • What was this nurse aiming to achieve ? This happened just after

this nurse had been involved with the patient's family therapy session .The patient walked out of the session and the nurse had spent time alone with her mother and it seemed that mum had come out tops. Mum had had a hard time in life and now felt she was getting the attention she deserved.

• In the patient's eyes, this was at her expense. • All the missing information then impacted on treatment.The

negative core beliefs kicked back in .

Rosemary

• A quite different scenario was again on the unsupervised table with a different staff member joining. The same patient is struggling and the HCA spotted it and sat next to her. Several mealtimes had been difficult since the scenario earlier.

• The patient was self-catering and the HCA commented on how appetising it looked. Patient said there was still some left and could she serve a portion for her.

Rosemary

• She was delighted and said yes and said how much she enjoyed it.

• Outcome for patient was that she enjoyed the staff member's pleasure with her cooking and felt valued and appreciated. This was a staff member clearly enjoying another's company and in the presence of food !

Pleasing scenario at the table

• Patient says she will take the crackers instead of the toast because the bread has run out. At the next meal the same patient wants to negotiate a change of chocolate snack.

• Patient cries over her meal but eats it when the senior nurse sits next to her. When the HCA sits next to her at the next meal she refuses to eat.

STRATEGIC THINKING - Rosemary

• SOME STRATEGIES FOR STAFF • NO NUMBERS or CALORIES or WEIGHT discussion in

the dining room. • Keep talk about FOOD to a minimum • RECRUIT SUPPORT FROM OTHER PATIENTS. Patients

who appear to be veterans sometimes feel neglected and if a staff member remarks that they have experience of struggling and asks them to share their coping strategies, this can be very positive peer support for everyone.

Working Through our own Emotional Blocks

If only it were easy to simply turn off our dominant caregiving style. Much can be done with sheer effort but if you are feeling stuck – another effective strategy is to examine the underlying unsetting emotion.

Fear, anxiety, resentment and shame – our usual suspects!

These emotions can be triggered by the ED but they are also influenced by our own emotional history

© 2013 Lafrance Robinson & Dolhanty

Examples of OARS

• Open Questions, Affirmations, Reflections and Summaries should all be expressed in a neutral, caring tone.

• They are designed to be used to develop effective, clear communication which allows both parties to express themselves by exploring and refining their thoughts.

• The end goal is that emotions are able to be talked about without blame and guilt.

Using OARS • Sometimes particularly when using Simple

Reflections a direct, neutral in tone, restatement of what the other person has said without any effort to elaborate, or any attempt to move away from the sentiment, or ‘fix it’, allows the person who originally spoke to think through and develop their ideas.

• Facilitating thinking space is vital in developing a nonjudgemental stance and promotes effective listening.

• Your loved one is being pushed by her therapist to “get angry” with you. She explodes in session and yells through tears: I am not getting angry with you – you can’t handle it!

• ROLE-PLAY! Remember OARS

© 2013 Lafrance Robinson & Dolhanty

Let’s Practice – the 3 steps Attend, Label, Validate

Examples of OARS responses

• An open question: ‘I really want to know more from you about your feelings?’

• Affirmation: ‘You care so much about me you want to shield me from your anger.’

• Simple reflection: ‘I can’t handle your anger’

• Complex reflection: ‘ You would like to tell me how you feel on the one hand and you think I can’t handle the guilt on the other hand.’

• Summary: ‘Your therapist wants you to show me how angry you feel towards me and you are concerned that I can’t handle your being upset.’

You tell your loved one that you want her to confide in you when she gets an urge to purge. She laughs and tells you to forget about it – “you’ll just freak out again”.

ROLE-PLAY!

© 2013 Lafrance Robinson & Dolhanty

Let’s Practice – the 3 steps Attend, Label, Validate

Examples of OARS responses • An open question: ‘Have you any ideas about how I can help

you when you tell me you have the urge to purge?’

• An affirmation: ‘You care so much about me you would rather purge without support than talk to me about it.’

• A Simple Reflection: ‘You think I will just freak out again.’

• A Complex Reflection: ‘On the one hand I want to stop you purging by talking about it in advance and on the other this leads you to feel that I will get too emotional.’

• A Summary: ‘I want to preempt your urge to purge by talking about it in advance, this makes you laugh, as you find when we talk I become too emotional to handle the thought of you purging.’

• Your loved one is so angry with you and she bursts out that: it’s your fault I got the eating disorder! You and X are always fighting!

• As a group, let’s work this one through...

© 2013 Lafrance Robinson & Dolhanty

Let’s Practice – the 3 steps Attend, Label, Validate

Examples of OARS • An open question: ‘Tell me how you experienced this

happening?’

• An affirmation: ‘It takes courage to face me with these awful feelings.’

• A simple reflection: ‘Its my fault you have the eating disorder’

• A complex reflection: ‘The stress of X and I fighting has caused the ED’.

• A summary: ‘You are really angry and upset, and blame the ED on the fact that X and I are always fighting’

More practice

• ‘I am a puffer fish or a hefferlump’

• Attend to the Emotion

• Label the Emotion

• Validate the Emotion

More practice attend, label, validate

• ‘You are leaving me alone in this terrible place, even though they say I might die.’ How will you cope when you know its your fault.

• You don’t listen, you don’t trust me, even though I have to look after myself day after day when you are not here. You keep asking me the same stupid questions about my weight and what I am eating.’

More practice

• You know I can’t eat potatoes, they just tip me over the edge. You know I have to stick to the hospital’s menu plan yet you keep trying to give me more. I just can’t trust you.’

• ‘When I come home I won’t be eating all this.’

What if I screw up? Breaks and repairs lead to a stronger bond (like muscle fibre

and bones!) actually the repair is as healing or more healing than the EC

If you make a mistake – go back! It’s the opposite of avoidance

And let’s face it – holding ourselves accountable shows that we are human and that we care enough to make it right… We are affected when it comes to apologies!

When emotion coaching - it’s not what happens, it’s what happens NEXT!

© 2013 Lafrance Robinson & Dolhanty

Major bonus...

Not only will these emotion coaching skills bring you and your loved one closer together, these skills will increase her ability to manage emotional challenges – making the ED unnecessary to cope;

They will make your efforts to support refeeding / symptom interruption more effective!

Meal Support + Emotion Coaching = Increased success

© 2013 Lafrance Robinson & Dolhanty

Teach caregivers to become their loved one’s emotion coach

The caregivers’ attempts to refeed and interrupt symptoms will be met with less resistance and the emotional climate of the home is supportive of recovery (change).

Their loved one feels like their caregivers “get it” – they are not alone to face life’s challenges. They will feel safe going back to them for support next time.

Their loved one learns that emotional challenges are part of life and that they can be dealt with (much like dealing with thirst or fatigue)

Their loved one will eventually internalize the ability to regulate and problem-solve instead of using symptoms to cope

Summary - Emotion Coaching

© 2013 Lafrance Robinson & Dolhanty

What Friends Can Do

You can’t take the eating disorder away, but your continued friendship will almost certainly help your friend move towards recovery

©Jenny Langley Janet Treasure 107

Tips for Caring for Someone with an Eating Disorder

– Encourage them to speak to someone they trust

– Let them know you are there for them

– Encourage them to join in with normal activities

– Try to avoid focusing on food issues

– Try to boost their self esteem

– Try not to give advice/ criticism

– Try to listen carefully

– Set yourself realistic boundaries – you cannot get rid of your patients eating disorder, but you can help them on their road to recovery

© Jenny Langley

Change

• The idea of Change can be construed in many different ways.

• A Journey

• A Hero’s Journey

• A Narrative

• An Experiment

• A Series of Fortunate Events

• A set of Stages

• Snakes and Ladders

• A Chance

• Something new and exciting

• Pain and Pleasure

• A Contribution to the wider world

• A Gift

Change • Change takes time –

patience, calmness both help confidence to increase

• Flexible, Bigger Picture thinking helps Confidence to increase

• Working through Emotional Intelligence learning helps Confidence to increase

• Role Modelling Self-Compassion helps Confidence to increase

• Focusing on changing negatives into positive helps Confidence to Increase

• Accepting ‘Good Enough’ Helps Confidence to Increase

Evaluation of Learning • Small goals

• How to build better relationships

• Using their words is good communication

• Dealing with challenges, building self-esteem and confidence in patients and staff

• Having realistic expectations, working with what you have got

• Be flexible

• Working with patients anxiety

• Dance don’t wrestle

• Don’t argue!

• Not waiting for change

• Delay increases anxiety

• Perfection unnecessary

• Acknowledge that ‘shit happens’

Some Monty Roberts Quotes

“If all learning is zero to ten, then the most important part of learning

is zero to one.”

“If you can use your skills as a trainer to open a door that a horse

wants to go through, then you have a horse as a willing partner

instead of your unwilling subject.”

[describing his response to a horse’s sudden outbreak of violent

“resistance”]: “there should be a complete lack of urgency in any

situation like this. Horses need patient handling. Act like you’ve only

got fifteen minutes, it’ll take all day; act like you’ve got all day, it

might take fifteen minutes”

Further Resources Janet Treasure - www.kcl.ac.uk - Search Eating

Disorders

www.thenewmaudsleyapproach.co.uk

www.succeedfoundation.org

www.cnwl.nhs.uk/recovery-college

Beat - www.b-eat.co.uk

Anorexia & Bulimia Care - Christian Charity www.anorexiabulimiacare.co.uk

Further Resources

F.E.A.S.T www.feast-ed.org

www.progressfocused.com/2011/07/21-solution-focused-techniques.html

www.fixers.org.uk