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Podcast 259

TEAM-CBT for Eating Disorders, featuring Donna Fish

In today\\u2019s podcast, Rhonda and David are delighted to welcome Donna Fish, LCSW, a New York mental health professional who\\u2019s doing pioneering work applying TEAM-CBT to eating disorders such as overeating / obesity, binging and vomiting (bulimia), and anorexia nervosa (starving oneself in combination with excessive exercising). These problems appear to be more prevalent in modern society, perhaps because of the emphasis on physical beauty as well as the availability of fattening foods and the financial resources to purchase them.

Donna is an LCSW and Level 4 TEAM-CBT therapist. She is a guest lecturer on eating disorders at Columbia University and Harvard University, and author of Take the Fight Out of Food. She has been a popular guest on many radio and television shows, writes for Psychology Today magazine, and more.

Donna began the interview on a personal note, reflecting on one of Dr. Burns\\u2019 workshops in 2014. She volunteered for a role-play with David illustrating the Externalization of Voices, a powerful cognitive therapy technique David developed during the mid-1970s. That experience pointed Donna in the direction of learning more TEAM-CBT.

Here\\u2019s how she described her experience at the workshop:

It blew my mind! I don\\u2019t easily follow any one particular \\u2018school of therapy, but I joined a TEAM-CBT training group that Dr. Taylor Chesney had just begun in NYC and then continued my online training until this day!

I am thrilled to combine my eating disorder training and experience with the TEAM approach, and have been training therapists at Elise Munoz\\u2019s Feeling Good Center in NYC, so that they can use TEAM with the common problem of Binge/Restricting.

Donna started her career as a professional dancer, and struggled with her own eating and body image issues. She saw these problems in her many peers and colleagues working as performers as well.

She said:

I was always on a diet, and saw foods as \\u201cgood\\u201d or \\u201cbad.\\u201d I would restrict (fasting) during the week and then binge on all the \\u201cbad\\u201d foods on weekends. My life was a yo-yo of binging and restricting.

Later, I taught myself how to eat in a healthy way, and how to say, \\u201cYes, I can have that food and I can have it right now if I want it (which I do). But do I really need it right now?\\u201d

This simple change in how I talked to myself freed me and cured me! When I became more accepting and less rigid in my \\u201ceating rules,\\u201d I paradoxically began to feel happier and more in control.

I saw so many actors and dancers who used up tremendous amounts of emotional energy struggling with body image issues and problems with eating. That\\u2019s why I did a 3-year training program in working with eating disorders.

When some of my patients who had recovered became pregnant, they worried about giving their own children an eating disorder. That\\u2019s why I wrote my book incorporating the methods that had been so helpful to them. This included a 4 Step Program to help them to give their kids a healthier relationship for life.

These are the four steps:

Step One: Talk To Your Kids About Nutrition

Step Two: Reboot the Connection Between the Belly and the Head

Step Three: Separate Hunger and Fullness from Other Feelings

Step Four: Teach Your Child Skills and Develop Confidence in Decision Making

I incorporated many of the ideas and techniques in TEAM-CBT, including Dr. Burns\\u2019 Decision-Making Tool, as well as his \\u201cAddiction and Habit Log.\\u201d (link to the free chapters on these tools available on the home page of my website).

Donna emphasized the role of restricting in the maintenance of eating disorders. She explained that restricting and fasting actually cause and perpetuate the problem because the cognitions become \\u2018Tempting Thoughts\\u2019 to binge such as:

\\u201cI will definitely re start my diet tomorrow, and I won\\u2019t eat that cake that I shouldn\\u2019t have had, so I may as well eat more now since I\\u2019ve already blown it.\\u201d

She explained:

If you commit to having a piece of that cake tomorrow as well, and in fact every single day, you are less vulnerable to the Tempting Thought of \\u201cI won\\u2019t have that \\u2018bad food\\u2019 tomorrow\\u2019 which tempts you to eat the cake, and then every other food that you \\u2018won\\u2019t eat tomorrow or again\\u2019, since you\\u2019ve already had a piece.

In fact, learning how to eat a piece of cake, or whatever food you deem \\u2018bad,\\u2019 is imperative to learning how to eat well and balanced in order to modulate your weight. The Tempting Thought that you will Restrict Tomorrow, seduces you to binge.

The Focus needs to be on Reducing the Tempting Thoughts to Restrict!\\xa0 A Method like \\u2018Examine the Evidence\\u2019 can be used to see if Thoughts like:\\xa0 \\u201cI won\\u2019t eat tomorrow or have that food again,\\u201d evolve into Tempting Thoughts that promote the \\u2019binge\\u2019 in that moment of temptation, and it becomes a circular game of \\u2018Restrict/Binge\\u2019.

Donna described some of the dangerous medical consequences of restricting and severe weight loss that you see in young people with anorexia, including brain shrinkage. She said that parents are sometimes ambivalent about treating their children who have anorexia for a variety of reasons, including the fact that anorexic teenagers are typically perfectionistic high achievers. But when the parents learn about the medical consequences, it sometimes changes their thinking.

David adds that two parents will frequently be in conflict about the best way to deal with any problem in a child, and this conflict is nearly always the cause of the \\u201cstuckness.\\u201d When, and if, the parents decide to work together as a team, the problem nearly always improves significantly. This, in fact, is the whole idea behind the fairly successful \\u201ccoercive treatment\\u201d for anorexia nervosa pioneered at the Maudsley in England.

This program involves both parents sitting on the two sides of the child, and forcing him or her to eat, and not giving in to the child\\u2019s attempt to manipulate and insist that she or he cannot, or will not, eat. Although the program sounds crude, and most parents initially resist, this type of forceful intervention is effective for roughly 50% of the children with anorexia nervosa, and can be life-saving. This is critical since a significant proportion of these children ultimately die from anorexia nervosa if they don\\u2019t have effective treatment.

Donna described additional medical consequences of various eating disorders, as well as the cycle of binging and vomiting, which leads to dehydration and actually causes the patient to feel bloated.

One of the key cognitions in patients with bulimia and anorexia is the fear of losing control and gaining a great deal of weight, so they engage in many ritualistic activities in an attempt to gain control. However, most of these efforts actually trigger a loss of control. One of the main goals of Donna\\u2019s treatment is to change this rigid mind set which is the actual cause of the eating disorder.

Donna emphasize the importance of the TEAM-Therapist\\u2019s mind set as well:

I don\\u2019t need any of my patients to change. . . The use of paradox in TEAM is powerful. I work with my patient to list the many GOOD reasons for overeating.

Donna described how she integrates the tools and strategies of TEAM into her brilliant work with patients with eating disorders, including David\\u2019s Triple Paradox technique.

David described the Triple Paradox, which is one of the latest tools he has developed for any habit or addiction, including the eating disorders. If you\'d like two never-published chapters on these tools, you will find a free offer for them on the very bottom of my home page at feelinggood.com! These two chapters were originally intended for my book, Feeling Great, but removed due to length. They are intended for therapists and the general public alike.

Donna also uses the Brief Mood Survey, testing patient\\u2019s moods at the start and end of every therapy session, along with the Assessment of Resistance, the Miracle Cure question, Dangling the Carrot, and more.

She also emphasized the vitally important \\u201cfractal\\u201d concept, focusing on one specific moment when the patient wants help. The idea is that all the patient\\u2019s suffering will be encapsulated in one brief moment when the patient was struggling, and the solution in that brief moment will often be the solution to all of the patient\\u2019s suffering.

If you would like to contact Donna, you can email her at Donna@DonnaFish.com, or visit her website, www:DonnaFish.com.

Thanks for listening today! And thank you, Donna, for illuminating how we can use TEAM-CBT in our work with individuals who are struggling with eating and body image problems.

I was personally impressed with Donna, not only for her obvious and impressive mastery of the treatment of eating disorders, but also for her warmth, grace, and vulnerability, which will definitely inspire trust and positive expectations in her many patients!

Rhonda and David

Dr. Rhonda Barovsky practices in Walnut Creek, California. She sees clients mostly via Zoom, and in her office.\\xa0 She can be reached at rhonda@feelinggreattherapycenter.com. She is a Level 4 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems. Check out her new website: www.feelinggreattherapycenter.com.

You can reach Dr. Burns at david@feelinggood.com.