How we treat
Evidence-Based Treatment at Anxiety Experts
We use two primary evidence-based theoretical orientations at Anxiety Experts: Exposure with Response Prevention (ERP) and Acceptance & Commitment Therapy (ACT). When applicable, we also treat patients using Family Based Treatment (FBT). Below are explanations of each for introductory purposes.
What is ERP?
Exposure with Response Prevention (ERP) is a type of Cognitive Behavioral Therapy (CBT) and the number one treatment for all anxiety-spectrum disorders (including phobias, generalized anxiety, social phobia, panic disorder, obsessive-compulsive disorder, body dysmorphic disorder and disordered eating). Everyone has anxiety, but some people drive anxiety up by repeatedly engaging in the three behaviors that anxiety lives on: avoidance, reassurance-seeking and compulsions (or rituals). These three Safety Behaviors are so named because they create an illusion of safety or certainty regarding feared outcomes.
The focus of ERP is to interrupt the Safety Behaviors that grow anxiety and help clients learn to accept the uncertainty and discomfort that people with lower levels of anxiety are better able to accept. This is done in two steps:
EXPOSURE: This slowly exposes people to the things that make them anxious in hierarchical fashion. Sometimes this involves thinking thoughts on purpose that the person has been trying not to think. Other times this involves going into situations that a person has been avoiding.
RESPONSE PREVENTION: This involves having the person invite anxiety while refraining from engaging in the usual Safety Behaviors of avoidance, reassurance-seeking or compulsions.
Every time a person resists Safety Behaviors and accepts the discomfort this creates, it becomes easier to resist doing them in the future, and baseline anxiety drops over time.
What is ACT?
Acceptance and Commitment Therapy (ACT) teaches people to make their own happiness in life (rather than waiting for it to come along accidentally), by going after things they value. Values are the things people care about most, things worth living for. ACT focuses on ACCEPTING thoughts and emotions (which can be very unpleasant a lot of the time), while COMMITTING to living by values anyway (ergo the ACT acronym). This means that a person can still be doing something meaningful (things that bring them closer to the life they want), while they are having very distressing thoughts and emotions. With ACT, we learn to pursue a rich, full, meaningful life while tolerating the pain that inevitably comes with it.
What is Family Based Treatment?
Family Based Treatment (FBT), also called the “Maudsley Approach,” is considered the gold standard treatment for eating disorders among children and young adults. FBT is based on the understanding that eating disorders take over an individual’s thoughts and behaviors, preventing them from making rational and healthy decisions about food, exercise and the body. Given the power that an eating disorder can have over the brain, FBT requires that caregivers play an active role in helping the young person restore weight, interrupt self-destructive behaviors (such as restricting or purging), and normalize eating habits. FBT is divided into three phases in order to gradually return control over eating to the client based on demonstrated recovery.
What are the Phases of FBT?
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Weight Restoration/Interruption of Behaviors: Since malnutrition has many negative medical, emotional, and cognitive consequences, restoring weight is the first priority. Research studies have found that the sooner clients with eating disorders are able to restore weight and interrupt any binge or purge behaviors, the greater their likelihood of fully recovering from their eating disorder. FBT requires that caregivers prepare and serve meals and snacks that are consistent with family preferences, including the foods the client enjoyed before the onset of their eating disorder. A dietitian who specializes in eating disorders meets with caregivers regularly to discuss the client's energy needs, including the amount and rate of weight gain recommended.
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Returning Eating Choices to the Client: Once weight is restored and other eating disorder behaviors are interrupted, the client is ready for phase two. In this phase, caregivers slowly transition control over eating and exercise back to the client. For example, caregivers may start with allowing the young person to portion their own veggies at dinner or allow them to choose whether they would like cookies or chips for a snack. Caregivers continue to provide support and supervision during this time.
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Establishing Healthy Adolescent Identity: This phase begins when weight stabilizes within a normal, healthy range based on the client's development and when eating and exercise are normalized. The young person gradually gains more autonomy and develops a healthy relationship with caregivers, without their disordered eating being central to their interactions. For example, the client is able to enjoy eating and engage in conversation with friends and family without thoughts about food or weight impacting them in this final phase.
Is FBT the Right Fit?
FBT is considered the first-line treatment for children and young adults with anorexia, bulimia, BED, ARFID or other disordered eating who are living at home (or with a support person). However, there are situations when FBT may not be a good fit. For example, caregivers who are unable to be involved during meal times, and caregivers with a history of eating disorders or who are on restrictive diets can make FBT challenging. Your loved one’s treatment team can discuss with you whether FBT may be a good fit for your family.
How could a dietitian help with FBT?
A Registered Dietitian is completely different from a nutritionist (a nutritionist is not credentialed- anyone can use this label). Here are 10 reasons why a Registered Dietitian who specializes in eating disorders can be a consultant to parents during different stages of their teen or young adult’s eating disorder recovery:
An Eating Disorder-Specialized Dietitian...
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Understands that 80% of people with eating disorders also have anxiety, OCD, depression, or substance abuse; balances nutrition guidance with knowledge about how other mental health problems impact food choices.
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Is trained to discern even the smallest of disordered eating behaviors from “normal” eating behaviors and attitudes, which may otherwise grow into a full-blown eating disorder if not monitored and challenged.
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Will meet a client where they are while treating the eating disorder, and help a client and/or their family feel empowered to take on food challenges and develop a more freeing relationship with food.
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Is well versed in interpreting and understanding genetic growth patterns and recognizes how weight and body composition are highly individualized.
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Is able to discern readiness for change, collaborating with the client to support an individualized treatment process.
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Will create and provide a structured meal plan that focuses on variety and steps away from rigidity or “feeling like another diet.”
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Is trained in screening protocols for the many types of eating disorders.
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Utilizes neutral food and body language, such as “all foods fit,” “weight neutral approach,” “all food has value,” “joyful movement,” or “weight rehabilitation.” Words matter and help to reduce client harm.
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Is degreed and licensed to practice Medical Nutrition Therapy. Has extensive training in the eating disorder field, including experience with Family Based treatment (FBT) and Health At Every Size (HAES) concepts. This unique skillset allows the specialized dietitian to work closely with families and caregivers to optimize treatment outcomes. This specialty training is gained during years of treating disordered eating at all levels of care, while receiving supervision and training from experts.
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Understands the importance of collaboration within a team. The gold standard of care for eating disorder treatment is multidisciplinary, including therapist, registered dietitian and primary care physician or psychiatrist.
Parent Resources- To Learn More:Families Empowered and Supporting Treatment of Eating Disorders: www.feast-ed.org/
Support for Maudsely Parents: www.maudsleyparents.org/whatismaudsley.html
Lock J, Le Grange D. Helping Your Teenager Beat an Eating Disorder (2015).Brown, H. Brave Girl Eating (2011)
“One Spoonful at a Time” article: www.nytimes.com/2006/11/26/magazine/26anorexia.html
Understanding Eating Disorders- Guide for Parents: youngwomenshealth.org/wp-content/uploads/2014/10/Understanding-Eating-Disorders-Parents.pdf
References:
1. Madden, Sloane, et al. "Early weight gain in family-‐based treatment predicts greater weight gain and remission at the end of treatment and remission at 12-‐month follow-‐up in adolescent anorexia nervosa."International Journal of Eating Disorders48.7 (2015): 919-922.
2. Le Grange, Daniel, et al. "Early weight gain predicts outcome in two treatments for adolescent anorexia nervosa."International Journal of Eating Disorders47.2 (2014): 124-129.