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Temperament-Based Therapy with Support for Anorexia: A Novel Treatment Interview

Laura L. Hill, Stephanie Knatz Peck, and Christina E. Wierenga joined us for an interview on their book Temperament-Based Therapy with Support for Anorexia Nervosa: A Novel Treatment. What follows are our questions in italics, and their thoughtful responses.

Who can benefit from engaging with Temperament-Based Therapy with Support (TBT-S)?

Temperament Based Therapy with Support (TBT-S) was developed to augment existing treatments for adults with anorexia nervosa and their parents and/or identified support person (aka, Supports). There are two versions of this emerging neurobiologically-informed treatment approach. Young Adult TBT-S (YA TBT-S) is specifically designed for young adults ages 18-27 and their parents; it takes a developmental approach in its model of support specific to the young adult developmental stage. SE-AN TBT-S is designed for adults across the age range and was originally tested in adults with more chronic severe and enduring anorexia nervosa (SE-AN).

Clinicians, students, and patient advocates can also benefit from engaging with TBT-S because it provides a neurobiological conceptual framework for symptom expression and maintenance in anorexia nervosa, supported by contemporary science to inform understanding of this illness. It also includes corresponding targeted interventions that can be implemented across settings to augment other treatment modalities.

Please tell us a bit about the core principles of TBT-S.

TBT-S has 5 core principles. They are:

  1. Eating disorders are biologically based. TBT-S fills the gap between research and clinical practice by acknowledging and treating underlying brain-based factors contributing to disordered thoughts and behaviors. TBT-S recognizes that there is a biological basis to psychological illnesses that involves temperament and altered brain function. This affects the regulation of eating and emotion for those with anorexia nervosa. TBT-S applies neurobiological research findings to inform treatment targets, and thus addresses eating behavior from a framework of temperament and neurobiology.
  2. Supports are a necessary part of treatment for all ages. TBT-S adopts a model of parent or support person involvement that is tailored to developmental stage and views parents/support persons as playing a critical role in recovery in adults with anorexia nervosa by providing accountability, leverage, and assistance, and a format for modifying relational patterns amongst clients and supports to reinforce recovery. Thus, clients are required to attend TBT-S with at least one parent or support person.
  3. Treat to the Traits. Traits can be expressed destructively or productively and clients can be taught to utilize their own traits as strengths throughout life. TBT-S takes a strength-based approach by recognizing that the same biologically-based and genetically-inherited traits that increase vulnerability to developing and maintaining anorexia nervosa can be shifted from destructive expressions that exacerbate eating disorder symptoms to productive expressions that become strengths in overcoming illness and help to maintain a healthier and more successful lifestyle. TBT-S teaches skills that are aligned with one’s productive traits to overcome maladaptive thoughts and behaviors.
  4. Food is Medicine. Drawing from a biological perspective, food is the natural and fundamental substance that “medicates” our bodies to be strong, healthy, and balanced. Like other eating disorder treatments, TBT-S recognizes that appropriate nutrition and body composition stabilization are necessary and fundamental to recovery. To facilitate this, TBT-S includes comprehensive dietetic recommendations and meal plans “prescribed” by an ED dietitian. The dietetic philosophy in TBT-S is that dosing energy for adults with AN is similar to dosing medicine. Clients and Supports attend dietary sessions and groups where they are “prescribed” foods and learn a meal plan tailored to the clients’ needs alongside other basic dietary information.
  5. Movement and/or Actions Are Fundamental to Change. TBT-S is a treatment of “doing.” Behavioral change requires behavioral action. Learning occurs when “neurons that fire together, wire together.” Thus, our brains are fluidly flexible to change throughout life. The brain rewires through extensive practice of new ways of expression and behaviors, and TBT-S capitalizes on this through guiding in vivo practice of new skills during treatment. In vivo activities allow clients to refine their verbal and behavioral responses through corrective feedback via their own experience or from that of others. This iterative method of corrective feedback serves to enhance building new skills. Movement can be used to interrupt destructive thoughts and behaviors to shift and move on to more productive thoughts and behaviors. TBT-S utilizes movement as a core part of the change process.

What is the difference between a symptom and a trait?

Symptoms are thoughts, feelings, and behaviors that have become problematic, dysfunctional, or harmful for persons and/or those around them. They are often influenced by traits. For example, a person with a strong impulsive trait is more likely to develop a substance use disorder or engage in binge eating than a person with an inhibited trait, who is more likely to engage in avoidant behavior. Eating disorder symptoms, such as food restriction, binge eating, purging, or excessive exercise, are behaviors that can and should be eliminated. Temperament and traits, however, cannot be eliminated, and may offer the keys to recovery.

TBT-S offers a variety of modules. What are their categories and how may they be integrated into treatment?

TBT-S is a modular treatment approach consisting of five distinct modules that include specific interventions designed to reduce eating disorder symptoms by addresses eating behavior from a framework of temperament and neurobiology (aka, “treating to the trait”) and increasing parent/support person engagement and client motivation for recovery. These include: 1) neurobiological psychoeducation supporting the biological basis of AN and rationale for the TBT-S treatment approach, 2) experiential learning via group activities addressing AN neurobiology and traits, problem solving and the role of support persons, and multi-family therapy (MFT) activities, 3) skills training for effective management of AN symptoms, 4) nutritional rehabilitation and meal support, and 5) developing a behavioral agreement that establishes a mutually agreed upon framework for necessary action and contingencies to achieve recovery.

Each type of intervention can be integrated into ongoing treatment according to clinician discretion. For example, including parents/Supports can happen throughout treatment or at specified times throughout treatment. It is recommended that the TBT-S interventions be delivered to both clients and parents/Supports. Psychoeducation about the biological basis of anorexia, including temperament and personality trait vulnerabilities and altered brain circuitry implicated in eating disorder, can set the stage to facilitate self-awareness to help parents/Supports and clients acknowledge traits that they identify with and discuss their implications for treatment and recovery. It is also intended to reduce criticism and blame while enhancing motivation and engagement with treatment by establishing the rationale for the specific TBT-S interventions. Experiential learning activities, skills training, dietary interventions and developing a behavioral agreement can occur throughout treatment.

What can you tell us about the TBT-S Toolbox?

The TBT-S Toolbox is one of the interventions that is part of the “skills training for effective management of AN symptoms” module. It was developed by Dr. Laura Hill to help clients with SE-AN and their Supports map skills to their traits to be most effective in working with their strengths to reduce eating disorder symptoms. Specifically, the TBT-S Toolbox includes all the symptom management skills taught in TBT-S. Clients are encouraged to identify their top 4 “productive” traits, and then select the 3 skills that are most aligned with these traits. In this way, TBT-S treats to the trait by identifying and committing to using skills that are congruent with one’s innate strengths to overcome maladaptive thoughts and behaviors. Clients are encouraged to identify 3 tools, recognizing that in some cases, it may take multiple skills to combat destructive symptoms.

How much neurobiology does a clinician need to know to include TBT-S into their interventions?

Developing neurobiological literacy about anorexia nervosa may be daunting for many clinicians, and it is not necessary for clinicians to be experts in neurobiology in order to administer TBT-S. The TBT-S manual includes relevant neuroscience information in bullet points to help the clinician gain mastery of the material and feel comfortable sharing the information with clients and families. TBT-S advocates for scientific humility, recognizing the value in admitting what we do not know, and giving permission to clinicians to acknowledge when they need to seek answers to questions.

Can you please connect the dots that led you to conclude, “Treat to the traits to manage symptoms with Supports for clients of all ages.”? (p. 167)

This statement summarizes the core guiding principles of TBT-S, namely that biologically determined traits contribute to the vulnerability to develop anorexia nervosa and at the same time can be expressed as strengths to overcome maladaptive thoughts and behaviors to achieve symptom abstinence and recovery. Symptom management is most effective with the help from parents and or support persons for clients of all ages, including adults for whom families/support persons are often left out of treatment.

About the authors:

Laura L. Hill, Ph.D., is an Adjunct Associate Professor of Psychiatry and Behavioral Health, The Ohio State University, and Voluntary Assistant Clinical Professor in the Department of Psychiatry at the University of California San Diego (UCSD). Dr. Hill is one of the original founders of the Academy for Eating Disorders and as Director of the National Eating Disorder Organization, now known as the National Eating Disorder Association (NEDA), from 1990 to 1994. She was also Founder, President, and Chief Executive Officer of The Center for Balanced Living from 2000 to 2017. Dr. Hill is the recipient of the Muskingum University Distinguished Service Award and the NEDA 2011 Lori Irving Award for Excellence in Eating Disorders Prevention and Awareness. She is a 2012 TEDx presenter, titled “Eating Disorders from the Inside Out,” and has spoken internationally and conducted eating disorder research for more than forty years.

Stephanie Knatz Peck, Ph.D., is an Associate Clinical Professor at the University of California San Diego (UCSD). She is Director of Intensive Family Treatment (IFT) Programs at the UCSD Eating Disorders Treatment and Research Program, an internationally known eating disorders treatment program emphasizing family involvement, peer support, and brain-based treatment. In addition to her clinical work, Dr. Peck co-developed Temperament Based Therapy with Support (TBT-S) and is responsible for the development and evaluation of the Young Adult version of TBT-S. In addition to program development and oversight, she continues to pursue her passion for helping others by providing direct clinical care for clients and family members affected by eating disorders. Dr. Peck has directly treated hundreds of clients and families over her career. Dr. Peck has presented nationally and internationally on her work related to brain-based treatments and the Intensive Family Treatment Programs with world-renowned experts. She frequently conducts continuing education seminars for professionals and has presented clinical workshops and intensive trainings for lead organizations in the field, including the Academy of Eating Disorders/International Conference of Eating Disorders (ICED), the National Eating Disorder Association (NEDA), and the International Association of Eating Disorder Professionals (IAEDP). Additionally, she co- runs biannual two-day intensive trainings at the UCSD Eating Disorders Center for invited professionals. Dr. Peck has coauthored nine book chapters and various original scientific articles on topics related to eating disorders, including brain-based treatment.

Christina Wierenga, Ph.D., is a Professor of Psychiatry at the University of California San Diego (UCSD) School of Medicine. She is a Fellow of the Division of Clinical Neuropsychology (Division 40) of the American Psychological Association (APA). She is also the Co-Director of the Psychology Internship Training Program at UCSD/VASDHS. In addition, as Co-Director of Research and Senior Supervising Clinical Psychologist at the UCSD Eating Disorder Center for Treatment and Research, she has been working with adolescents and adults with eating disorders for over a decade. She is an expert in the neurobiology of eating disorders and utilizes neurocognitive and neuroimaging approaches to study brain mechanisms underlying maladaptive behavior in eating disorders, with a focus on corticostriatal and limbic circuitry and associated functions. She has spent the last decade studying reward processing, inhibitory control, interoception, and learning to better characterize their role in altered motivation to eat and symptom expression in anorexia nervosa and bulimia nervosa. She is also heavily involved in treatment development efforts for anorexia nervosa, focused on applying a neurobiological understanding of temperament-based behavior to clinical practice. Through close collaboration with Drs. Hill and Knatz Peck, she has developed and continues to test the Temperament Based Therapy with Support (TBT-S) approach for individuals with eating disorders. She has published over 100 peer-reviewed papers, has mentored over 50 clinical and research trainees, has been continuously funded by the National Institutes of Health (NIMH, NIDDK), National Eating Disorders Association, and the Department of Veterans Affairs, and serves in leadership roles across multiple organizations, including the Academy of Eating Disorders.


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