Emotion Regulation for Young People with Eating Disorders

A Guide for Professionals

Sophie Nesbitt, Lucia Giombini

• Publisher: Routledge
• Year: 2021
• eBook ISBN: 9781000408447
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Emotion Regulation for Young People with Eating Disorders is a supportive guide for professionals to help them build effective therapeutic relationships with young people struggling with eating disorders.

The book focuses on the role of emotion regulation in the development and maintenance of eating disorders. The psychological concepts discussed are an integration of ideas and theories that have been proposed by many psychologists over the last half-century. The tasks presented in the book use aspects of these theories and concepts in an applied way which can be helpful to enable young people to understand more about their emotional experience and how it has contributed to their difficulties. The approach proposed can be used across the spectrum of eating disorders as the dysfunctional emotional regulation difficulty is shared by all eating disorders.

The workbook will be helpful for Children and Adolescent Mental Health Services (CAMHS) professionals such as psychiatrists, psychologists, counsellors, nurses, occupational therapists, dieticians and therapeutic care workers.

Chapter 1

Understanding emotional experience as a window towards recovery from eating disorders

Introduction

The purpose of the workbook

When and how should the book be used?

Issue of confidentiality

Eating disorders

Overview

Treatment approaches

Workbook approach

Personal motivations

Introduction

The purpose of the workbook

Research suggests that working with adolescents therapeutically can be difficult, which combined with the treatment-resistant nature of eating disorders makes working within this field both challenging and rewarding. We also know that eating disorders can have a devastating impact on the sufferer and family members. Throughout the duration of the illness young people and their families are often offered a range of treatments. This can lead to therapy fatigue and thus engaging young people in meaningful therapeutic work can be daunting for many therapists. It has been well-recognised that young people struggle to engage in meaningful relationships and find it hard to express their emotions, independently from the treatment approach. Understanding more about how to build effective relationships with young people with eating disorders becomes very important in terms of engaging them in therapeutic work.¹

This workbook focuses on the exploration and understanding of the emotional experience in the treatment of eating disorders. In terms of structure, there are four chapters in the book. Chapter one offers a broad introduction to eating disorders and chapter two presents a theoretical basis exploring the role of the emotional experience in eating disorders. Chapter three presents a discussion of the importance of therapeutic engagement and communication within this group of young people. Within chapter three we have used clinical material in the form of vignettes; by adding these case studies into the workbook we hope to support the reader to understand how some of the concepts can be applied in the therapeutic work. Finally, chapter four provides a package of practical tools to help therapists engage young people with eating disorders in thinking about their own emotional experience and the role it plays in their difficulties.

All chapters of the book are important for the reader, as it is the concepts shared in both chapter two and chapter three that provide the guidance that will enable the effective delivery of the practical tools described in chapter four. Throughout chapter four, there are sections entitled “Notes for therapists”, however, this applies broadly to all practitioners working with young people regardless of therapeutic background or training. The language used is accessible to all disciplines.

When and how should the book be used?

The workbook has been written for practitioners working with young people with eating disorders. The psychological concepts discussed in the book are an integration of ideas and theories that have been proposed by many psychologists over the last half-century. They are well established and may be familiar to many professions working in the field of mental health regardless of training background. In line with National Institute for Health and Care Excellence (NICE) Guidance recommendations for the treatment of eating disorders,² the approach outlined in the book should be delivered in the context of multidisciplinary teamwork, with different practitioners managing different aspects of the care and risk assessment. For example, it would not be helpful for the practitioner delivering the therapy to be focusing on weight management as we don’t emphasise addressing weight and shape concerns as the main part of the work. Instead, the approach focuses on the physical and psychological experience of the emotions as a window for the young person to explore their individual and social needs as an essential part of their journey towards recovery and self-development.

In the context of the book, we have used the term “psychological distress” to refer to the collection of symptoms that combine to form a diagnosis of an eating disorder. This includes physical symptoms such as weight loss/gain or disruption of hunger drive, cognitive symptoms such as preoccupations with weight and shape or self-critical/self-disgust attitudes and behavioural symptoms such as restriction or bingeing/purging. The approach that we are proposing in the workbook can be used across the spectrum of eating disorders including anorexia nervosa, bulimia nervosa and binge eating disorder or subclinical eating disorders as the dysfunctional emotional regulation difficulties are shared by all eating disorder presentations/diagnoses.

In terms of context, the approach described in the workbook could be useful in both inpatient and outpatient settings, within key work or therapy sessions. As with all clinical work, clinical supervision is important for effective delivery and sufficient reflection and learning on the part of the therapist/practitioner. In terms of a time frame to cover all aspects of chapter four, ideally, we propose between twenty and thirty sessions, however, this may need to be carefully considered in relation to the resources available. With this in mind, it may be necessary to consider which tasks are most relevant. This will be dependent on a clinical judgement based on knowledge of the young person. Some tasks may be helpful for building therapeutic engagement initially, whilst other activities may be used further into the therapeutic process.

Issue of confidentiality

Any therapeutic work undertaken with the workbook should be considered in the context of the therapeutic relationship and all normal conditions of confidentiality should apply. As with all therapeutic work issues around confidentiality, the limits of this should be explained prior to the beginning of the work. This should be clearly documented in the clinical notes in line with best practice. In relation to feedback to the wider team, this should be discussed and considered within the context of the work taking into account the young person’s views. It is also useful for therapists to consider how feedback might be shared with parents and carers. This too needs to be discussed with the young person taking into account their views and their age. In terms of any written work produced the young person and the therapist should agree on how the work is going to be kept safe.

Eating disorders

Overview

Research suggests that the prevalence of eating disorders is increasing, affecting more and more young people. The overall lifetime prevalence of eating disorders among adolescent girls ranges from 3% to 13% and from 1.2% to 1.5% among boys. In girls, the lifetime prevalence of anorexia nervosa ranges from 0.3% to 2.6%, bulimia nervosa from 0% to 2.6%, and binge eating disorder from 1.0% to 3.0%.³

The age at which difficulties start tends to be lower, impacting on long term prognosis and increasing the need for differential treatments. There has also been some movement within the male/female ratio, with the number of young men diagnosed with eating disorders increasing. Whilst “binge-eating” behaviours and compensatory behaviours (e.g. purging, fasting, excessive exercise) have a low prevalence in young patients, a “continuum” between bulimia nervosa and anorexia nervosa exists, with a frequent transition from one disorder to another. Over recent years there has been an increased prevalence of eating disorders in young people alongside other psychiatric conditions such as depression, anxiety or obsessive-compulsive disorder. In addition, the diagnostic criteria as set out in DSM-V⁴ do not include aspects of the illness that are well known to exist, such as neuropsychological disturbances (e.g. ruminations and obsessions about weight, shape and eating and personality traits such as perfectionism and impulsivity)⁵.

Most eating disorders emerge during adolescence, a critical time for brain development, and malnutrition can negatively impact treatment outcomes and recovery. The biological impact of malnutrition is due not only to weight and shape concerns but is also maintained through issues of perfectionism and low self-esteem and self-confidence. Fairburn and colleagues⁵ have proposed a model suggesting there are common factors that are present across all eating disorders’ diagnostic categories. Understanding eating disorders in this way is referred to as the transdiagnostic approach. It is important to note that transdiagnostic approaches and disorder-focused approaches need not be mutually exclusive and that a “spectrum” model based on an impulse-control paradigm of eating disorders can be informative. We think this is particularly helpful in relation to the approach taken in this book, which thinks of eating disorders as a broader range of difficulties. In this book, we focus on thinking and emotional styles that are common in eating disorders more broadly⁵.

Treatment approaches

There are various treatments proposed for eating disorders. The NICE² guidance summarises these treatments together and evaluates the evidence base for each. With regard to this, NICE2 recommends the following psychological interventions be considered for young people with eating disorders: focused family therapy for children and young people with anorexia nervosa or bulimia nervosa (FT-AN/FT-BN). This approach aims to engage the family in helping the person to recover and is a step-by-step treatment. The first step aims to build a good therapeutic alliance with the individual, their parents or carers and other family members. Step two is to support the young person to establish a level of independence appropriate for their level of development with help from their parents or carers. Finally, the third step focuses on plans for when treatment ends and on relapse prevention.

Currently, this type of approach is most commonly offered in a community outpatient setting. For many it is helpful, but some families will struggle to engage effectively in this type of treatment. In these instances, NICE² recommends two other forms of treatment: individual cognitive behaviour therapy, which is eating disorder focused (CBT-ED) or adolescent-focused psychotherapy for anorexia nervosa (AFP-ED). These approaches aim to reduce the risk to physical health and any other symptoms of the eating disorder.

CBT-ED focuses on encouraging the young person to reach a healthy body weight through the process of healthy eating. Therapy work undertaken covers psychoeducation relating to nutrition, cognitive restructuring, emotional regulation, social skills, body image concern, self-esteem and relapse prevention. The therapy needs to be mindful of the young person’s specific development needs, whilst enhancing self-efficacy, and promoting self-monitoring of dietary intake and associated thoughts and feelings.

AFP-ED is different from the CBT-ED, as it focuses more on emotions and interpersonal processes, and how these affect the eating disorder. The therapy aims to develop a shared understanding of the young person’s psychological issues and how they use anorexic behaviour as a coping strategy and supporting the young person to find alternative strategies for them to manage stress. In later stages of treatment, issues relating to identity and independence can also be explored.

Psychological treatment for binge eating disorder in young people involves the use of cognitive behavioural self-help materials. The aim is to promote engagement in a binge-eating-disorder-focused guided self-help programme. If this approach is not helpful, group CBT-ED, focusing on psychoeducation and self-monitoring of the eating behaviour, is recommended. This approach encourages the young person to think actively about their problems and identify goals. This includes engaging in behavioural techniqu...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• About the authors
• Foreword
• Acknowledgements
• Chapter 1 Understanding emotional experience as a window towards recovery from eating disorders
• Chapter 2 Psychological distress and emotional experience in eating disorders
• Chapter 3 Therapy, clinical challenges and the world as a patient
• Chapter 4 Exploring the emotional experience in eating disorders: guiding principles and notes for therapists to work with young people
• Index