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Getting Better Bite by Bite interview

Authors Ulrike Schmidt, Janet Treasure and June Alexander joined us to discuss their book, Getting Better Bite by Bite: A survival kit for sufferers of bulimia nervosa and binge eating disorders. What follows are our questions in italics, and their thoughtful responses. Ulrike, June, Janet_NY AED ICED 2014--planning 2nd edition GBbBB

Early in your book you encourage an exercise in which an individual develops a detailed Bulimia/Binge Eating Disorder balance sheet. Why did you choose this as a starting point?

Very often people with bulimia, desperately want to stop binge eating, as this is a very distressing symptom. However, they may be much less keen to give up other behaviours such as self-starvation or vomiting that they use to counteract bingeing. The balance sheet helps people to consider the whole ‘package’ of their symptoms with all its pros and cons for both the person and those around them. In that way it also helps people to realize that their bulimic symptoms may to some extent fulfill some positive function in their life, i.e. bulimic symptoms may provide comfort, excitement, or relief from difficult thoughts and feelings. So this tries to get people to think about how else they can get these needs met once the bulimia is no longer in their life.   

What are some of the ways a diary can help individuals with recovery?

A diary can help in many ways. It keeps a record of what has happened over time and thus can provide people with objective evidence that they can use to monitor their progress. Especially if change is slow it can be hard to remember where you started and a diary can help assess whether a person is moving in the right direction. Diary keeping as used here also allows people to become experts on their own illness and learn to identify what circumstances trigger their bulimic behaviors and what helps them resist these behaviors. A key helpful aspect of diary keeping is that it allows the person to reflect on what has happened and to use this information to identify what they can do differently next time and to develop smart goals.  Finally, the act of writing thoughts and feelings down often reduces their intensity and ‘power’ over the individual.

When recovering from bulimia, you mention that delaying vomiting can increase anxiety. What suggestions do you offer to manage this type of anxiety?

We suggest to people that it is helpful to treat this as an experiment and that before they start delaying vomiting they consider the thoughts and feelings that will arise in response to this and how they might cope with these. We indicate in the book that people will need to use all their creativity and problem solving skills to think of how to manage the anxiety that can arise. Different distraction and diversion techniques work for different people. For many people, being with/talking to (supportive) others is a very powerful way of reducing anxiety, however this is an option that is not available to all. Activities that are mentally absorbing, e.g. knitting a complicated pattern, can be helpful too or talking to yourself in a soothing, supportive manner. It is also important to try and stick to one or two strategies at a time and use them for a week and then review how well this worked.    

What are some of the pitfalls of “selective attention?”

Selective attention often focuses only on negative, unwanted, or disliked aspects of our life or our person. It is like wearing blinders, or filtering everything through dark-tinted lenses. It keeps us unhelpfully focused on and stuck with one particular view of a situation or life in general. It stops us from seeing the bigger picture, impedes new learning and developing alternative and more balanced views. As such it contributes to making life very miserable and tough.

In your chapter entitled, “Relapse: Walking in Circles – or not,” you suggest one way to cope with the anxiety of a relapse is to plan a relapse. Can you please tell us more?

Many people with bulimic disorders believe that recovery is the total avoidance of any symptoms, in particular the total avoidance of any binges. They also believe that having one binge means that they are entirely back to square one, i.e. that all their hard work and progress has been undone. This is a classical piece of unhelpful black and white thinking. The tendency to think in these extreme ways is rooted in the fact that many people with bulimia nervosa have the perfectionist trait and unattainably high standards of recovery. So getting a person to plan a binge and bring on what they fear most, helps people feel in charge of their symptoms and dispels the myth that one occasion of overeating ‘ruins everything and that it is downhill from here forever after’.

“Finding your voice” is a skill that we know helps with recovery, assertiveness, self-esteem. Can you please list and explain your “Ground rules for assertive behavior?” 

Our ground rules for assertive behavior include the person’s right to hold and express their own opinions; the right to make mistakes; the right to refuse requests without guilt; the right to change their mind; the right to set their own priorities and goals; and the right to judge their own behaviour, thoughts, and emotions and to take responsibility for the consequences. These ground rules are simple and straightforward and concern things that most of us would not even give a second thought. However, many people with bulimia may have had or currently are in relationships where these ground rules are seriously violated. As a result the person may not know what their rights are and may feel that they always need to please others, be submissive and not have/express and act on their own views. Thus we wanted to spell out these simple rules to create a benchmark from which making changes becomes possible. 

You note, “Recovery and getting better is not about being free of problems.” What is a good concept of recovery?

We really do think that recovery is a journey through often rough, steep, and poorly charted territory where anything can happen. Recovery is a process that involves (a) developing a mindset that is open to, anticipates, and embraces challenges and (b) developing the skills necessary to deal with and circumnavigate setbacks and difficult stressful periods.

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About the authors:

Ulrike Schmidt is Professor of Eating Disorders at the Institute of Psychiatry, Psychology and Neurosciences at King’s College London. She is also a consultant psychiatrist in the Eating Disorders Unit at the Maudsley Hospital. She was a member of the NICE Eating Disorders Guidelines Development Group, Chair of the Section of Eating Disorders at the Royal College of Psychiatrists and a board member of the Academy for Eating Disorders (AED).  She is a Council member of Beat, the UK’s main eating disorders charity. She is the recipient of a 2005 NHS Award for Innovative Service Delivery, the 2009 AED Leadership Award for Clinical, Educational and Administrative Services, the 2013 KCL Supervisory Excellence Award and the 2014 Hilde Bruch Award for Outstanding Achievements in Eating Disorders Research and Treatment. Prof Schmidt has published some 300 peer-reviewed papers and 90 other publications on eating disorders, including text books, chapters, patient manuals, and web-based treatment or training packages.  A key focus of her research has been on development of brief scalable psychological treatments for eating disorders.

Janet Treasure OBE is a psychiatrist who has worked professionally with people with eating disorders for over 33 years at the Eating Disorder Unit at the South London and Maudsley Hospital NHS Trust, which is a leading centre in clinical management and training of eating disorders. She was chairman of the physical treatment section of the UK NICE guideline committee. She is the Chief Medical Advisor for Beat (the main UK eating disorder charity). She was awarded with a leadership for research with the Academy of Eating Disorders in 2007 and was also awarded a lifetime achievement award from the Academy of Eating Disorders and from Beat in 2014. She is trustee of the charities Student minds, Charlottes helix, Diabetics with Eating Disorders and the Psychiatry Research Trust and is on the scientific board of the charities SUCCEED, MAED – Mothers Against Eating Disorders and FEAST.

June Alexander is a writer and PhD candidate. At age 11, June developed anorexia nervosa and this challenge, together with a love of writing, shaped her life. Upon recovering from her illness at age 55 in 2006, June departed a journalism career to write books about earing disorders – combining life experience and professionals skills to disseminate evidence-based research for health practitioners and mainstream readers. June serves on national and international mental health and advocacy organisations, including Academy of Eating Disorders, F.E.A.S.T. and the National Eating Disorders Collaboration (Australia). Her website and blog supports this advocacy work. A mother of four and grandmother of five, June is a PhD candidate in Creative Writing at CQUniversity, Australia, exploring how diary writing can be therapeutically applied in the treatment of eating disorders, and is a life story and diary-writing mentor.


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