In today's podcast, Rhonda and David are delighted to welcome Donna Fish, LCSW, a New York mental health professional who's 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' 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's how she described her experience at the workshop:
It blew my mind! I don't easily follow any one particular 'school 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's 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 "good" or "bad." I would restrict (fasting) during the week and then binge on all the "bad" 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, "Yes, 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?"
This simple change in how I talked to myself freed me and cured me! When I became more accepting and less rigid in my "eating rules," 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's 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's 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' Decision-Making Tool, as well as his "Addiction and Habit Log." (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 'Tempting Thoughts' to binge such as:
"I will definitely re start my diet tomorrow, and I won't eat that cake that I shouldn't have had, so I may as well eat more now since I've already blown it."
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 "I won't have that 'bad food' tomorrow' which tempts you to eat the cake, and then every other food that you 'won't eat tomorrow or again', since you've already had a piece.
In fact, learning how to eat a piece of cake, or whatever food you deem 'bad,' 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! A Method like 'Examine the Evidence' can be used to see if Thoughts like: "I won't eat tomorrow or have that food again," evolve into Tempting Thoughts that promote the 'binge' in that moment of temptation, and it becomes a circular game of 'Restrict/Binge'.
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 "stuckness." 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 "coercive treatment" 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's 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't 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's 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's mind set as well:
I don't 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's 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's 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 "fractal" concept, focusing on one specific moment when the patient wants help. The idea is that all the patient's 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's 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. 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.