cbt guided self help –part 3/3 - national eating …...–eat in restaurant with people prone to...

CBT Guided Self Help –Part 3/3 Dr Beth Shelton Senior Clinician Victorian Centre for Excellence in Eating Disorders

Beth Shelton - 2018 NEDC Members' Meeting 1-2 June Sydney

CB GSH:

6 step cumulative model:

Step 2: Instituting a meal plan

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Step 1: Monitoring Your Eating

Step 3: Intervening in Binge Eating

Step 4: Problem Solving

Step 5: Eliminating Dieting

Step 6: Changing Your Mind

Each step involves adding something to what has already been done in the preceding step(s Beth Shelton - 2018 NEDC Members'

Meeting 1-2 June Sydney

Step Two: Instituting a meal plan

• Learning to eat three meals and two or three snacks a day • Setting up in advance exactly when you should (and shouldn’t) eat


Importance of planning Creates a secure, regular pattern of eating

makes an explicit requirement not to eat at other

times

Develops capacity to organise own eating

Sample Meal Plan/times

– 7:00 am Breakfast

– 10:00 am Snack

– 12:30 pm Lunch

– 3:30 pm Snack

– 6:30 pm Dinner

– 8:30 pm Snack Beth Shelton - 2018 NEDC Members'


Step Two: Meal Planning

When to eat should be determined by

plan not by hunger or urges to eat

Initial focus on when you eat not what you

eat

“rule of 3”

– 3 meals, 2-3 snacks

– 3-4 hrs. apart Beth Shelton - 2018 NEDC Members'


Reflecting on the meal plan

Review what is happening to client’s

eating – firstly regular eating

When regular eating is established -

does eating need to be more substantial

to ward off binges triggered by hunger?

Encourage client to review “normal”

portion size

e.g: use someone else as a reference

point; consider (non-diet) prepared

meals for one Beth Shelton - 2018 NEDC Members'


• Step Two: Grace


Before moving on to step three • Not necessarily a week of “good days”

• Is she planning regular meals and snacks?

• Is she trying to restrict her eating to only the planned meals and snacks?

• Is she getting back on track when things go wrong?

• Is she adjusting to accommodate special circumstances?

• Is she reducing/ eliminating vomiting and diuretic/ laxative misuse?


CB GSH:



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Step 3

Learning to Intervene to Prevent Binge Eating

Developing and trialling strategies to manage the urge to binge

Develop further skills and resources to reduce binge eating episodes in addition to those already begun


What is a binge? • Not just over-eating

• 2 criteria – Excessively large quantity of food

– Subjective loss of control

• Specific quality

• Accompanying emotions & thoughts – Shame, remorse, self-disgust

• Impulsive • Compulsive • Pre-planned • Chaotic

• Methodical


Step Three: Learning to intervene to prevent binge-eating

1. Psychoeducation (direct to Cooper manual)

• What is a binge

• What maintains the binge eating cycle

• Binge eating triggers

2. Introduce skills

• Planning ahead

• Intervening in the moment

• Begin to list alternate activities

• Trial and adapt as homework


Practice Skills: Intervening in the moment

• Time must pass – urge awareness, surfing, distraction

• Client must make it more difficult to binge

• Generate a list of things to do instead of (unplanned) eating

• Plan pleasurable activities

• Helpful for client to create a provisional list, experiment with how it works and update the list

• Can modify stimulus as well as reponse

Beth Shelton - 2018 NEDC Members'


Step Three: Learning to intervene to prevent binge-eating

• Planning ahead, identifying potential problems and recognizing the urge to binge early in the process and taking evasive action can prevent binge-eating


• Step 3 Grace


Step THREE Key Messages:

• Binge eating is NOT inevitable once eating goes wrong

- it is possible to stop a binge once started

• Each successful ‘intervention’ makes future interventions easier


CB GSH:



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Step 4

Problem Solving

Learning problem solving steps and applying them to both eating and other problems

Reduce binge eating as unhelpful coping behaviour


Step FOUR: Problem Solving

1. Psychoeducation (direct to Cooper manual)

• Problem solving & the brain

• Binge eating

• Common problems

2. Introduce skills

• 6 step problem solving model


Proactive Problem Solving

1. Identify the problem as early as possible

2. Specify the problem accurately

3. Consider as many solutions as possible

4. Think through the implications of each solution

5. Choose the best solution or combination of solutions

6. Act on the solution

7. Critically reflect on the entire process


Typical problem themes

• Problems with eating • Depression

– Assess global vs. specific • Relationships

– Relationship problems may become evident through monitoring, raise awareness

• Feeding Others – E.g.: Preparation, children, and leftovers

• Feeling Fat – May be automatic misinterpreted negative feeling,

physical vs. emotional triggers


Practice Skills: Sample Problem


Before Moving on to Step Five

• Has client been identifying problems which make her upset (sad, anxious) or like binge-eating and recording them?

• Has client been using problem solving techniques to deal with these?

• Has client found that recording and structured problem solving has helped them deal with circumstances which would have led to a binge?


CB GSH:



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Step Five: Eliminating Dieting

• Learning to stop dieting - restricting food intake

• Gradually re-introducing forbidden foods


Eliminating Dieting

3 Ways of Dieting 1. Trying not to eat/fasting - should have been

addressed by ‘regular eating’/meal planning

2. Restricting (e.g. certain food groups. less than 1200 cal/day etc) - this needs to be addressed, not sustainable

3. Trying to avoid certain types of food (for fear of

effect on body weight/shape)- this needs to be addressed because it leaves vulnerable to future binges


Eliminating restriction

How much food is “normal”???

• Modelling with a non-dieting friend/family

• Follow suggested serving sizes on packets

• No food is in itself fattening, and conversely eating too much of any food can be fattening

• Address dietary rules/rituals


Eliminating avoidance of feared foods

1. Create hierarchy of feared foods list

2. Organize the list into degree of eating difficulty

3. Start by introducing foods from the easiest group and focus on them for a couple of weeks/days.

4. Then move on to the harder group and so on

5. Usually amount eaten is arbitrary, it tends to be the idea of having eaten it that is triggering

6. Stop when these foods are no longer unsettling


*Jenny’s List


Practice skills: Food Challenge

• Basic exposure therapy ie behaviour with response prevention

1. Pick a food

2. Plan to eat it

3. Eat it in planned way

4. Review afterwards

5. Plan to eat another feared food


Practice Skills: Coping with other types of avoidance

• Establish progressive goals

• E.g. eating with others

– Eat at home with friend/ relative

– Eat in restaurant with this person

– Eat in restaurant with people prone to make her anxious

– Eat in environment with people who are prone to make you anxious (e.g. parents)



Before moving on to step six

• Is client tackling the 3 forms of dieting?

• Are they eating enough food in meals/ snacks?

• Are they incorporating “dangerous” foods into their normal eating?

• Are they challenging other forms of avoidance?

• Are they able to eat in a controlled way, and in reasonable quantities, any food that they like?


CB GSH:



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Step Six Changing Your Mind

• Changing your mind about how important weight and shape are to you

• Growing a seed of doubt in the thin ideal

• Managing obsessive cognitions



Eating Disorder Mindset • A characteristic set of attitudes

and values concerning body shape and weight

• Thinness is idealised • Strenuous attempts to avoid

weight gain • Tendency to judge self worth

largely or even exclusively in terms of shape and weight

• Most other features can be understood as being secondary to concerns about weight & shape


Step Six: Changing Your Mind • Questioning the values supporting

overinvestment in weight and shape

• Thinking about the way you think

– Perfectionist - changing unrealistic goals and expectations and harsh self-evaluation

– All-or-nothing thinking

– consideration of alternative ideas

• Social media use….

• Self Compassion

• Alternative ways of thinking Beth Shelton - 2018 NEDC Members'


The Counter Cultural Therapist?

• How do we negotiate the process of getting our clients to behave counter-culturally? – (i.e. eat normally when plagued with media pressure

to diet and/or overeat)?

• Explaining dieting as a risk factor • Dieting as a problem rather than • a solution • Cognitive dissonance strategies • Body image strategies • Self Awareness


CB GSH:



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Ending well

• Maintaining change

• Preventing relapse

• Make relapse plan

• Responding to lapses & slip-ups

• Concluding sessions

• Moving on

• Following up…



cbt guided self help –part 3/3 - national eating …...–eat in restaurant with people prone to...

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