Clinical Training Day

Clinical Teaching Day | Session 1

Wednesday, March 13, 8:00 AM - 12:00 PM ET

Ethical and Legal Issues in the Treatment of Eating Disorders 

Wayne Bowers, PhD, Professor Emeritus
Jennifer Goetz, Department of Psychiatry, University of Iowa; Child/Adolescent & General Psychiatrist, McLean Hospital/Harvard Medical School
Jennifer Campbell, Center for Evidence Based Treatment Ohio
Jillian Lampert PhD, MPH, RD, Accanto Health | The Emily Program and Veritas Collaborative

Abstract: Treatment of an eating disorder often involves life-disrupting and life-saving interventions. These interventions, from admission itself to specific treatments (ie insertion of naso-gastric tube for feeding) may be seen as coercive, even when consented to by patients or parents. There are also situations in which admission and/or treatments are not consented to and are utilized in a compulsory, or involuntary, capacity. Situations in which compulsory or involuntary treatment are utilized are typically limited to patients who are in life-threatening danger from their eating disorder. Their ability to fully understand the risks and benefits of treatment may be compromised, affecting their very capacity to make treatment decisions. Alternatively, they may be deemed to be at such high risk of harm to themselves or frankly unable to provide for their basic needs, such that involuntary care (or “civil commitment”) is pursued. Inherent in the use of coercive and compulsory treatment interventions or providing care that may be less than a client clinically needs but is all they will accept for a potentially life-threatening illness are ethical dilemmas. At the very heart of these dilemmas are the balance of patient autonomy and the treatment team’s requirement to provide care in the best interest of the patient (“beneficence”) and to do it without harming the patient (“non-maleficence”). When individual patient’s ability to accurately weigh the risks of treatment owing to the very nature of the illness itself is compromised (ie anorexia nervosa), the treatment team or family may step in (with the help of the legal system) to compel life-saving care. This workshop will explore the ethical and legal issues involved in the care of individuals with eating disorders. We will highlight the literature regarding compulsory/involuntary treatment as viewed through the lens of patients and families, focusing on those aspects of treatment that were viewed as supportive vs. those that were perceived otherwise. Four experts will engage in a panel discussion around their clinical approach to managing the intersection of ethical, legal and clinical considerations in the care and treatment of individuals with severe and life threatening eating disorders. Break out groups will be organized to discuss specific cases.

Learning Objectives:
  1. Following this presentation participants will be able to outline the ethical dilemmas and principles in conflict in the care of individuals with eating disorders.
  2. Participants will be able to describe how the concepts of capacity and civil commitment can be utilized in the care of individuals with eating disorders.
  3. Participants will be able to understand the ethical implications of providing care on an involuntary (or compulsory) basis as well as the ethical implications of not providing care on an involuntary basis for patients with eating disorders.

When Clinicians are Not Cared For: Who is Really Wearing the Oxygen Mask?

Anita Federici, PhD, FAED
Jennifer Couturier, York University; The Centre for Psychology and Emotion Regulation, McMaster University 
Cheryl Webb, McMaster University

Abstract: While people are certainly familiar with burn out, staff turnover, and team polarization, little is systematically done in traditional eating disorder settings to target these prevalent issues. Across levels of care, those working in eating disorders often describe feeling overwhelmed, anxious, and frustrated. Repeated exposure to chronic and complex illnesses, the pressure to manage long waiting lists, and the high risk nature of our population commonly leads to exhaustion, empathy depletion, and contributes to less adherent treatments (see review by Couturier et al, 2021). Hage et al. (2021) found that emotional dissonance, depersonalization (removing oneself from the patient), and a waning sense of accomplishment predicted burnout among ED treatment professionals. Other studies have highlighted that burnout is elevated when clinicians are unable to address their own emotions about clients or treatment (Warren et al., 2012). Additionally, the impact and aftermath of Covid saw record numbers of clinicians leaving ED programming, many opting to work in the private sector citing flexibility and a stronger team community where burnout and quality of life is regularly discussed and collaboratively managed. 

Taking care of the team is essential for the health of our programs and the adherent delivery of the treatment models we provide. Yet, most programs (i.e., program schedules, group content) are designed to take care of the client and family, not the team. Efforts to integrate interventions that target enhancing emotion regulation for the team, increasing treatment fidelity, tolerating uncertainty, and cultivating a sense of value and belonging are often entirely lacking.  To foster resiliency and a greater sense of meaning and belonging for our colleagues, this workshop focuses on innovative and evidence-based strategies to manage burnout and increase motivation to do this very hard work across levels of care (e.g., day treatment, inpatient settings). This workshop will be highly experiential. Participants will explore current feelings of burnout and empathic fatigue, discuss obstacles to clinician care in our field, challenge assumptions and beliefs that increase burnout, and explore strategies to maximize connection and decrease isolation with our colleagues. The presenters will provide examples from their experience mentoring and leading clinical teams across levels of care. 

Learning Objectives:
  1. Explore differences between burnout, compassion fatigue, and empathic depletion. 
  2. Learn ways to track and discuss burnout on an ongoing basis across on your ED teams.
  3. Describe how a consult team can maximize team cohesion and decrease isolation across levels of care.

The Unified Treatment Model for Eating Disorders and Comorbidity

Melanie Smith, Ph.D., LMHC, CEDS-S
Gayle Brooks, The Renfrew Center

Abstract: The Unified Treatment Model for Eating Disorders and Comorbidity (UTM) is a transdiagnostic approach that addresses eating disorder symptoms as well as co-occurring emotional issues that contribute to the development and maintenance of eating disorders using a unified set of evidence-based interventions. The UTM was developed through an extensive process of adapting the Unified Protocol for Transdiagnostic Treatment of Emotional to meet the needs of patients with severe and diverse eating disorders. The interventions in the UTM and the UP have extensive research support for their use across diagnostic categories and are thoroughly integrated and informed by the focus on demonstrated mechanisms of psychopathology shared across emotional disorders--emotion avoidance, emotion intolerance, emotion dysregulation, negative beliefs about emotion, and maladaptive emotion-driven behavior. The UTM progresses through modules of treatment focused on motivation, emotion awareness and acceptance, cognitive flexibility, behavioral flexibility, and exposure therapy. The treatment is designed to be applicable to heterogeneous eating disorder psychopathology, and has been implemented across all levels of care, including virtual treatment, with demonstrated fidelity and effectiveness. The modules of the UTM, though they may appear familiar and eclectic at first glance, are in fact distinct from other approaches due to their cohesive focus on how each module addresses these shared maintaining mechanisms. This workshop will explore the key theoretical principles of the UTM and demonstrate how a transdiagnostic treatment that targets emotional avoidance can increase psychological and behavioral flexibility of individuals with eating disorders and comorbid conditions. Clinical examples, video demonstrations and experiential exercises will provide opportunities for participants to practice UTM interventions, specifically interoceptive, food, and body image exposures.  These interactive components will augment the workshop’s didactic content to illustrate case conceptualization and pragmatic applications of therapeutic techniques in a variety of treatment settings.  

Learning Objectives:
  1. Following the training, participants will be able to describe the theoretical underpinnings of the Unified Treatment Model for Eating Disorders and Comorbidity (UTM). 
  2. Following the training, participants will be able to apply UTM interventions to target emotional avoidance and emotion-driven behaviors to a clinical case example.
  3. Following the training, participants will be able to explain how emotional tolerance building exercises contribute to remission of eating disorder behaviors.

I am afraid to feed my child when they're suicidal:  A comprehensive clinical training for providers

Kristen Andersen, LCSW, CEDS-S
Gina Dimitropoulos, Chicago Center for Evidence Based Treatment; University of Calgary
Lucene Wisniewski, Center for Evidence Based Treatment-Ohio 

Abstract: Suicide is the second leading cause of death among individuals with anorexia nervosa (AN), and suicidal behavior is often associated with premature withdrawal from outpatient treatment and the escalation to higher level of care. Parents and therapists alike face the dilemma of choosing between prioritizing their child’s eating disorder and suicidality and suicide behaviours. Even if SI is not apparent at the start of treatment, it can arise during ED treatment itself contributing to parental distress and disempowerment . This is further complicated by the fact that few EBTs for EDs include strategies for coping with suicidality.  Navigating the assessment of risk in the treatment of young people with eating disorders often leaves family and treatment providers feeling unclear about how to proceed with care. This workshop is aimed at supporting clinicians to understand ways to comprehensively assess risk throughout the treatment process including the initial assessment, identify possible risk and protective factors for families presenting for outpatient treatment,  and develop interventions based on skills from Dialectical Behavior Therapy and other treatment modalities. This teaching day will also include an opportunity for clinicians to role play assessment and clinical interventions, to share and learn with each other through multiple case presentations developed by the presenters, and discuss challenging cases/scenarios of their own.

Learning Objectives:
  1. Understand the application of assessment tools that can be utilized during assessment and throughout treatment to understand suicidal/safety risk . 
  2. Describe and practice possible interventions informed by Dialectical Behavior Therapy (DBT) to support families in the process of refeeding and managing safety risk. 
  3. Process and discuss ways to manage therapist and familial burden including use of consultation teams and other measures to manage burnout  and distress.

Clinical Teaching Day | Session 2

Wednesday, March 13, 1:30 PM - 5:30 PM ET

Building a full system of care for eating disorders

Sarah Trobe, PhD Clin Psych
Emma Spiel, National Eating Disorders Collaboration
Beth Shelton, National Eating Disorders Collaboration
Louise Dougherty, National Eating Disorders Collaboration
Hilary Smith, National Eating Disorders Collaboration
Evangeline Gardiner, National Eating Disorders Collaboration
Bella Burns, National Eating Disorders Collaboration

Abstract: Eating disorders are on the rise, with evidence suggesting an increase in prevalence at a global scale (1, 2). The COVID-19 pandemic has only exacerbated this troubling trend, with no signs of improvement in sight (3).  Several effective evidence-based interventions for the prevention and treatment of eating disorders exist to address this global issue, but policy, service and workforce limitations hinder timely access to eating disorder prevention and care when and where it is needed most (4).  Thus, initiatives are required that address these systemic issues to ensure that efforts aimed at improved eating disorder prevention and care impact at scale the scale required 

In Australia, the National Eating Disorders Collaboration (NEDC) was tasked by the Australian eating disorders sector and funded by the Australian Government Department of Health and Aged care to develop a 10-year National Eating Disorder Strategy 2023-33 (the Strategy) to guide sector development and policy decision-making for the next decade. Implementation of the Strategy will help to ensure that people are able to access an effective, equitable and coordinated system of care for eating disorders. 

The Strategy draws together lived experience, clinical, and research expertise. NEDC engaged in extensive national consultations with stakeholders to identify what is required to build and embed a system of care that meets the needs of people experiencing or at risk of eating disorders, and their families, supports and communities. The Strategy provides comprehensive standards and actions based on these consultations across six core components of NEDC’s stepped system of care for eating disorders: prevention, early identification, initial response, treatment, psychosocial and recovery support, and workforce. To our knowledge, this is the first Strategy of its kind that targets eating disorder systems at the national, regional and service-level, and across the breadth of actions required across prevention, care, and recovery. 

Learning Objectives:
  1. Develop/deepen understanding about approaches to systems-level service change to improve care for people experiencing or at risk of an eating disorders, their families, supports and communities. 
  2. Learn about frameworks and approaches to enhance the effectiveness and sustainability of systems-level change, underpinned by best practice evidence in implementation science. 
  3. Develop strategies to translate an Australian approach to service reform within their relevant context(s). 

Gender Affirming Eating Disorder Care: Adaptations from Assessment to Treatment 

Scout Silverstein, MPH, Clinical Curriculum Development Specialist, Project HEAL
Teddy Goetz, University of Pennsylvania
Emil Smith, University of Pittsburgh | School of Social Work

Abstract: Transgender and gender expansive (TGE) individuals experience eating disorders (EDs) at 4-8 times the rate of cisgender counterparts. While research focusing on ED prevalence, support for gender-affirming care, and minority stress has increased in recent years, less information is known about how minority stress impacts ED symptomatology, how to work through internalized transphobia and complex grief, and how to cultivate resilience strategies in the face of increased attacks on TGD communities. This clinical teaching day will speak to social determinants of health, minority stress theory, screening and assessment tools, and treatment strategies to target common barriers TGE individuals face while in the pursuit of ED recovery. The first portion of the clinical training day will focus on social determinants of health relative to TGE populations. The second portion will introduce understanding minority stress through distal versus proximal stressors and corresponding behavior change. The third portion will teach participants how and when to modify language in assessments to better capture ED symptomatology among TGE individuals. The fourth portion will provide participants with clinical tools for addressing internalized transphobia, complex grief, and hopelessness, with a focus on building resilience strengths. This clinical teaching day offering will identify opportunities for ED prevention and promote effective treatment and care of an underserved demographic of patients with EDs. Aligned with AED’s strategic goals and conference theme of “cultivating belonging and building connections,” this workshop focuses on generating knowledge through collective expertise, building capacity in both the current and next generation of eating disorder professionals, and fostering innovative approaches to care.

Learning Objectives:
  1. Identify distal versus proximal stressors that transgender and gender expansive populations commonly experience as a result of minority stress, and their impact on eating disorder etiology.
  2. Understand how to modify language in screening and assessment tools to better capture eating disorder symptomatology in transgender and gender expansive populations. 
  3. Adopt at least five therapeutic approaches to working with clients who struggle with internalized transphobia, complex grief, and hopelessness. 

Therapist "drift" versus navigating the shifting tides

Sue Byrne, DPhil MPsych/PhD
Anthea Fursland, The University of Western Australia Swan Centre

Abstract: The eating disorder treatments with the strongest evidence base are Enhanced Cognitive Behaviour Therapy (CBT-E) for adults and Family Based Treatment (FBT) for children and adolescents. Both treatments were originally developed over 20 years ago.  In our long careers as scientist-practitioners in the eating disorder field, we have been witness to many important major developments in our field since the development of these evidence-based treatments.  There has been an explosion of research, afforded by rapid technological advances, changes in our socio-cultural climate and transformations in attitudes toward mental health that are not reflected in the treatment manuals that continue to be used in the delivery of these evidence-based treatments. While we continue to stand by our support of CBT-E and FBT, in this workshop we will we share our clinical experience and discuss these treatments in terms of their relevance today and how they might be expanded to encompass the developments in the field.  We will highlight the changes that have occurred over the past 20 years including the cutting-edge research regarding the genetic and neurobiological underpinnings of eating disorders; a greater appreciation of the effects of starvation on the brain; our developing knowledge of neurodiversity, gender diversity and body diversity; the importance of listening to the voice of lived-experience; the changing face of the eating disorder treatment team; greater awareness of the role of trauma in eating disorders; treatment advances in other mental health conditions and increasing options for treatment delivery.  We will facilitate small group discussion, reflection and feedback to explore the important differences between therapist “drift” and intentional, thoughtful divergence from treatment manuals.  We will aim to generate suggestions about how we can build on evidence-based treatments that are now almost two decades old to navigate the shifting tides of knowledge in our field.  

Learning Objectives:
  1. Describe the major developments in the field of eating disorders since the turn of the century.
  2. Appreciate the difference between “drifting” from treatment manuals and intentionally and thoughtfully individualising treatment according to a clear formulation.
  3. Describe the different ways that we could enhance our current evidence-based treatments by incorporating new knowledge and delivering them effectively in different settings.