Integrative Modalities Therapy (IMT) for Eating Disorders

by Tara Deliberto, Ph.D.

Back in March of this year, the approach that Dina Hirsch, PhD, and I created for the treatment of eating disorders was renamed Integrative Modalities Therapy (IMT)!  Here I'll explain the reason for the change as well as the meaning of the new name.

When we started out, our aim was to create a comprehensive collection of evidence-based interventions for patients and families with eating disorders.  For the original plan, we knew that we needed to have an approachable patient-and-family-facing name.  We decided to call the first version of our book "BITE," or Behavioral Interventions, Tips, and Evaluations.  At the time, this name was fitting since the acronym represented the smallest behavioral step a person can take towards recovery (i.e. taking a bite of food) and the fully spelled-out name descriptively explained what was included in the book. It was a go!

Over the years, however, our singular book that brought together interventions, tips, and assessments grew into something much larger: an evidence-based practice treatment approach.  We soon needed to write a treatment manual for clinicians to use alongside the original book for patients and families. Our unpublished manuscript became a resource for clinicians in the trenches who needed a summary of all of the varied evidence-based interventions in one easy place.  Some have called our approach "evidence-based practice in a box."  Recognizing the potential of this type of resource, our goal became to provide clinicians with a comprehensive, practical, flexible, and scalable resource to help navigate the treatment of eating disorders. 

Considering these advancements, prior to both books being published by New Harbinger, it was time for a new clinician-facing name!  We chose to rename our approach Integrative Modalities Therapy (IMT) because it integrates a wide array of evidence-based interventions from gold-standard treatments into the three modalities of individual, group, and family therapy.  In short, the approach is both integrative and can be administered modularly across the three treatment modalities.  As a clinician-facing evidence-based practice approach, we now have the big, hairy, audacious goal of contributing to the efforts of our colleagues by helping to close the eating disorder treatment gap together.

Is Multiple Personality Disorder Real? - The Response

In April 2011, I wrote a post called "Is Multiple Personality Disorder Real?"   It is the third most popular post I've written here and certainly generates the most polarized comments / emails.   While I encourage you to read the original if you're interested in the following response, the gist is that Dissociative Identity Disorder (DID) - which was once called Multiple Personality Disorder (MPD) -  could potentially be Borderline Personality Disorder peppered with some delusional qualities. 

One very interesting & thought-provoking comment from 9/25/2012 inspired me to write this (belated) response.

Comment:
This blog post reads like it was written by someone who's never read a book or an article on DID, who's never worked with people with DID, who's just making wild assumptions. There are people dx'ed with both DID and BPD. There are also people dx'ed with BPD who don't have BPD at all, but have DID. You also make no mention of PTSD which all DID patients have, but not all BPD patients have. Look at somewhere that actually treats DID and PTSD specifically like the trauma Ward at Sheppard Pratt. But your theories seem a little half cocked.

This is my response:
Fair enough - I've admittedly not had much experience with DID - however; allow me a belated response (apologies for the delay).

First, I was generally very impressed when visiting Sheppard Pratt in May 2012.  My impression was that they offer top-of-the-line treatment.

As for DID though, I have read a bit about it.  For a summary, I would see Prof. Rich McNally's book "What is Mental Illness?" from 2011, copyright, President and Fellows at Harvard College.

In short, the book explains right after the book Sybil was published, "from near-nonexistence, MPD spread throughout North America, with the number of diagnosed cases soaring to 50,0000."  And then the "epidemic of MPD ended abruptly" because a study showing that asking leading questions is more likely to "create false memories than to recover them" (Ceci & Loftus, 1994).

The book also reads "MPD therapists inadvertently undermined the credibility of their own field when they began helping patients recall alleged memories of satanic ritual abuse" (McNally, Remembering Trauma). And that the FBI failed to uncover any physical evidence of these types of abuses (Lanning, 1992).

Interestingly enough, stories about abuse and trauma Sybil herself endured were also unfounded.  What seems to be the (even more disturbing) truth is that Sybil sought treatment with Dr. Cornelia Wilbur, who appears to have implanted false memories with the (unwitting) use of leading questions and social positive reinforcement.  When treatment tapes of the sessions between Wilbur and Sybil were researched, convincing evidence of this was revealed.  The book also states "indeed, Sybil admitted in writing to Wilbur that she had manufactured her MPD symptoms."

As such, while the symptoms of DID are in the DSM-IV, this does not mean that the disorder is not socially constructed, at least for the vast majority of cases.

[By the way, I'm not saying that there was never an organic (non-socially constructed) case of DID out there.  Saying that 100% of DID cases are socially constructed is a bit like meeting 50,000 Elvis impersonators in the year 2013 and then concluding Elvis Presley never existed. It stands though, that the ratio of hypothetical Elvis impersonators to Elvis Presley himself is still 50,000:1.] 

If someone presents with a case of DID, undoubtedly the situation is severe; however, I would argue that give the citations provided above, the idea  that the etiology (or cause) of the disorder is organic seems dubious at best.  Of course, understanding etiology is extremely important for treatment - especially if the treatment itself is indicated as a possible cause of the disorder, as was in the case of Dr. Cornelia Wilbur and Sybil.

For the cases that are not organic, but socially-constructed - which the evidence seems to suggest is most of them - perhaps a BPD identity disturbance / delusional quality may be present.  That's all.

Dysregulation of the Anxiety System & Bipolar

As per usual, I'm trying to focus on work now, but get completely derailed with a thought I feel the need (compulsively) to blog about.

I saw that someone somewhere on a remote part of the globe was reading a post I wrote a while ago postulating that fear was the first emotion to appear on the evolutionary scene. I decided to revisit it. Here's the link: http://taradeliberto.blogspot.com/2011/03/first-emotion-fear.html

While rereading the post, I had the thought that bipolar disorder may result from a dysregulation of the anxiety system. Long story short, in depression, we see that prolonged anxiety can lead to chronic sadness (via chronic exposure to cortisol and what I conceptualize as over-use of the hypothalamus-pituitary-adrenal axis). We can also see that exhilaration and anxiety are quite similar emotions. Combining these two thoughts, perhaps bipolar disorder could arise out of the dysregulation of a primary anxiety system - sometimes leading to chronic sadness and other times leading to chronic exhilaration.

Interestingly, bipolar is pretty hereditary, but like most psychiatric disorders, it is thought to be prompted by none other than stress, perhaps indicating that it stems directly from some a dysregulation of the anxiety system.

I realize that this is being done already, but the fact that stress / anxiety can trigger the onset of disorders might be a signal to look at how anxiety relates to the course of the illness (with the consideration that anxiety could be the ultimate primary emotion). In this case, while stress may trigger bipolar disorder, lack of ability to regulate anxiety may maintain the behavior. While research in which I am involved examines reward sensitivity in bipolar, I'm wondering if a layer beneath reward sensitivity is anxiety sensitivity, being that we're conceptualizing anxiety as the ultimate primary emotion in this post.

I also realize that to say anxiety dysregulation may prompt bipolar disorder because stress prompts the onset utilizes circular reasoning. But circular reasoning notwithstanding (lol), I still think this is interesting to consider anxiety sensitivity as it relates to two separate constructs of bipolar - both onset and course of the illness.

Ok, back to work.

Triggers - Avoid or Expose?

I was just thinking about the practice of identifying and avoiding triggers in therapy. Sure, inherently harmful triggers are best avoided... but what about triggers that are what we call "conditioned stimuli?"

[For the non-psychologists out there: some of us are triggered by certain things that are actually harmless, but during the course of our lives, we somehow came to associate them with feeling like crap. For instance, walking by a restaurant you used to frequent with an ex could trigger negative emotions. The restaurant itself is harmless, but you've been conditioned to feel sad when walking by it. As such, the restaurant is now a trigger.]

Some therapists may urge their patients to simply avoid all triggers. Sure, this sounds like a good idea, but is it truly helpful? If the patient is in acute / reactive pain, then throwing some more negative experiences their way probably isn't a good idea. But typically, I think that systematically exposing people to triggers, just like you would to anxiety provoking stimuli, would lead to habituation.

While this may be common practice for treating some disorders, it doesn't seem to be the case for all of them (i.e. eating disorders). For instance, when a particular food may trigger a binge, the general advice simply seems to be to avoid that food. Well, I'm just not so sure.

Combining Cognitive Therapy and Mindfulness

by Tara Deliberto


I was lucky enough to have the opportunity yesterday to get together with a neuroscientist friend and colleague with whom I used to work in Cambridge, MA. Eventually we got on the topic of merging ACT & CBT and he asked some thought provoking questions I thought I would share.

The first question - and the topic of this blog post - that got me really thinking was something like: "how long does it take before an alternative rational response replaces the (long-ingrained and continually environmentally reinforced) negative & irrational automatic thoughts?" In the moment I threw out some arbitrary response based on my extensive 2.5 years of clinical experience (lol), and immediately realized I had no clue what the answer was. Being as sharp as he is, he also immediately realized (but politely pointed out) that my response was b.s. Of course it will vary for every person, but we came to the conclusion that duration of irrational thought replacement it is probably a lot longer than the literature on how quickly people respond to CBT would suggest.

While CBT can reduce symptoms in a handful of sessions - maybe around 10-15 - and CBT w/ d-cycloserine for fear reconditioning can reduce symptoms in even fewer sessions, the time it takes before negative automatic thoughts are completely replaced could widely vary. In fact, they may never disappear. Members of the ACT community actually set expectations that negative automatic thoughts never decrease in frequency (for decent reasons I won't expound upon here). Furthermore, the difference between completely disappearing and having thoughts that one relates to effectively enough to show up as a statistically v.s. clinically significant decreases in symptoms are all very different things. While clinical improvement may be apparent from research, it is likely that people continue to have intrusive thoughts (that are experienced as at least unpleasant) well after their 10-15 sessions of CBT have ended.

There are also likely varying stages of having negative automatic thoughts disappear, ranging from:
- the thought pops up, it is suppressed, and reoccurs w/ a vengeance
- the thought pops up and one struggles to restructure it w/ a rational response
- the thought pops up and one is able to quickly ward it off w/ a rational response
- the thought pops up and one immediately labels it as irrational & mindfully releases it
- the thoughts generally tend to decrease in intensity/frequency over time
- the thought is completely irradiated

Now, the question my friend asked is important because it lead us to this idea: if there is some truth to these stages, mindfully dismissing something in the moment might interfere with the practicing of retraining the mind to have different and rational responses to the thoughts.

Perhaps if one truly retrains the mind away from irrational thoughts, they will decrease in frequency, which is arguably more favorable than continually having negative intrusive thoughts pop up that one learns to relate to differently with the use of mindfulness. It should be noted, however, that mindful awareness and release of thoughts may also, as a practice, decrease the frequency of thoughts over time. At this point, everything is speculative and is simply (what I would consider to be) interesting food for thought.

While the constant use of mindfulness early in treatment may hypothetically interfere in some way w/ long-term retraining, it is certainly a very useful practice in many situations like when refocus in the moment is paramount. Being mindfully aware of thoughts also has the major benefit of preventing people from slipping back into responding to certain irrational thoughts as if they were real and/or of utility.

I know a lot of people may have an issue with framing mindfully releasing a thought in this way; however, I am not suggesting it is a form of suppression. With mindfulness of thoughts, there is an active acknowledgement and awareness of the thoughts, which separates it from suppression. However, when it is feasible, encouraging the patient to extensively retrain themselves with engaging in active grappling with irrational thoughts might be favorable before moving into a mindfulness-based approach.

It should be noted. however, that thought disputation may not be a particularly useful type of practice for people with Borderline Personality Disorder. In fact, for this population, it might be favorable to start with mindfulness of thoughts and thought defusion exercises. In fact, research I presented in 2006 at a conference in Chicago suggests that appraising thoughts might actually be a mechanism of change in Dialectical Behavior Therapy - a treatment for BPD that does not (really) use cognitive disputation. So that mindfulness of thoughts may foster their reappraisal naturally.

Can Two Useful But Contradictory Treatments be Combined?

by Tara Deliberto


In no way do I think that Acceptance and Commitment Therapy (ACT) and Cognitive Therapy (CT) are incompatible. In fact, combining techniques from both treatment modalities in a preplanned sequence has great potential.

For argument's sake, let's assume that the two treatments can be merged in a meaningful way. If they can be merged, how would we go about integrating the different techniques (we'll save integrating the philosophies for a different day)? Well, some may argue that placing an emphasis on honing the ability to catch thoughts with the use of mindfulness techniques must precede the teaching of disputing irrational thoughts. At first glance this seems logical perhaps because it is assumed that one must be mindfully aware of a thought before being able to dispute it. I'm not so sure.

Through cognitive restructuring, if patients are first made aware of the fact that their thoughts are irrational, they may have a better framework in which to do ACT work. After cognitive restructuring, they have not only identified which thoughts are dysfunctional or irrational, but have been lead through a reasoning process of why these thoughts are inaccurate. Now with a deeper understanding of why their thoughts are irrational and a clinically significant lesser degree of belief in the verity of the content of these thoughts, they could be in a better position to recognize from which cognitions are best to defuse. Speaking practically from an ACT perspective, using the chessboard metaphor as an example, patients may better be able to identify the "black" pieces from which to defuse, while still being able to maintain self-as-context (i.e. understanding that they are the chessboard that houses the battling white and black pieces). After cognitive restructuring and focusing on self-as-context, it seems to me that people have a greater fighting chance of being able to accomplish the very cerebrally taxing feat of letting thoughts float by. In short, by first providing cognitive restructuring and framing the self as a container of both rational and irrational thoughts, increased understanding, use, and efficacy of mindfulness techniques may follow.

Of course I recognize that "irrational" thoughts are not the only type of cognitions associated with negative or dysregulated affect. There are a range of painful memories, facts, images, and maybe even manic tendencies with which disputation may not be particularly effective, and whereby defusion and mindfulness may be more appropriate; however, systematically disputing the cognitions associated with negative affect that are irrational before getting into ACT work may still generally be helpful.

Thoughts?