A Neurobiologically Based Clinical Tool for Eating Disorders
By Laura Hill, PhD, FAED
President & CEO, The Center for Balanced Living
In 2006, Thomas Insel, the then director of the National Institute of Mental Health (NIMH), announced that eating disorders (EDs) are serious, brain-based disorders. EDs joined the list of other brain-based illnesses such as depression, obsessive-compulsive disorder, and bipolar disorder. In 2013, President Barack Obama signed the BRAIN Initiative into law. It has been described as one of the most daring scientific advancements since walking on the moon and sequencing the gene. The project plans to comprehensively map the brain, the last uncharted organ in the body.
The NIMH has encouraged the field of mental health to shift from concentrating first and primarily on “behavioral health” to a more brain-based, neurobiological approach, focusing on the location where mental-health problems tend to originate. The journey to better understand the brain has most definitely begun. Nature published an article in July 2016 that reported 97 new areas of the brain have been identified using four different technologies to validate the mapping process. Until we can identify and understand more about the brain, its pathways, neurochemistry, and complexities, we will not be able to target and treat brain-based illnesses completely.
While multiple technologies (such as deep-brain stimulation, transmagnetic stimulation, functional magnetic resonance imagery feedback, and high-intensity frequency ultrasound) are advancing in brain-based illnesses, we need to continue to treat eating disorder clients from the “outside in,” focusing on the behavioral, cognitive, and emotional expressions. Traditional, evidence-based treatment approaches have been developed for this purpose, such as enhanced cognitive behavioral therapy, integrated cognitive-affective therapy, dialectical behavioral therapy, and acceptance and commitment therapy.
While providing ongoing ED behavioral therapies, ED therapists could more actively and intentionally begin to introduce and integrate ED neurobiological information into practice. Over the past eight years, The Center for Balanced Living, in Ohio, has been collaborating with our research partner, the Eating Disorders Center for Treatment and Research at the University of California, San Diego (UCSD), on how to apply neurobiological ED research findings to ongoing ED treatment. We have been developing, refining, and field-testing new neurobiological treatment tools with ED clients and their families. Their feedback has been integral in developing a neurobiological language based upon how the research best reflects and interprets their experiences in their own lives.
Walter Kaye, MD, executive director of the UCSD ED program, has stated that the brain organizes itself through movement. New ideas, decision making, emotion, memory, cognition, and perception could be explored and possibly enhanced with movement, compared with simply talking “about” a topic. Starting with brain-based research findings and integrating movement into an intervention, I began to develop a brain-based activity in 2010 that represents the wiring and rewiring capacity of the brain for ED clients. Their feedback and their family/support input has resulted in continued refining, while integrating ongoing research, to reflect what has become a treatment tool that serves as a metaphor for what is happening in the brain as it changes.
The neurobiological treatment tool is called “Wire-Rewire” and is described as follows:
A Brain-Based Treatment Activity
Key point: The brain wires neuropathways continuously throughout one’s life. It is capable of rewiring old habits and behavioral patterns into new patterns when a person thinks and then acts intentionally. Family and support people can augment and encourage the rewiring of someone with an ED by participating in new behavioral patterns that encourage a stronger and healthier body and mind-set. It takes focus and intention to direct a new course of action.
Purpose: To help clients with EDs realize how the brain wires and rewires pathways through metaphorical activity. This is done through an activity that helps the clients and their supports:
- Understand how ED brain pathways can be rewired into healthier pathways through the process of repetition
- Participate in a clinical tool that metaphorically demonstrates the wire-rewiring process while actively involving clients/supports in the change process
- Recognize that brain change occurs in the moment
- Apply a tool that integrates movement with cognition
- Explore solutions during the activity
- Demonstrate that changes in the brain transpire through active involvement and ongoing movement
- Experience that movement is fundamental to the change process, even if the movement is simply the movement of hands
- Activate changes in thoughts and feelings
Who: This activity can be applied to clients.
What therapy settings: Individual or group therapy and in client/family sessions or multifamily groups.
- A ball of string or yarn per dyad
- Scissors to cut the string at the end
Timing: This activity takes 20 minutes to an hour, depending on the number of people involved.
- Divide into dyads if in a group setting. It could be a client-therapist dyad or client and a support person.
- Give each dyad a ball of string.
- Ask the client(s) (or if the dyad consists of two clients, then identify one of the clients to be the one to hold the string) to hold up their hands, resting their elbows against their sides. Direct the client(s) to position their hands to create about a foot of space between their hands.
- Wire: Instruct the other member of the dyad who is holding the string to “Please begin to wind the string around one hand and then around the other hand of your partner, creating a large loop in a circular fashion, over and over again.”
- After about five rounds, ask the person winding, “What is it like to wind the string around your partner’s hands?” Note: The person is to continue winding the string while questions and answers are shared.
- Some winders share this activity is awkward at first.
- Others may say it is easy.
- Ask each person who is winding to share loudly enough for all to hear what he or she is experiencing during the newness of the winding process.
- While the winding is going on, ask the client (the person who has the string being wound around his or her hands) to identify an ED behavior that is currently difficult to overcome. For example, the client may say:
- Binge eating
- Purging (Note: This needs to be clarified. Have each client identify if this means vomiting, laxatives, excessive exercise, etc.)
- If anyone stops winding, the leader simply says, “Keep winding.”
- While winding continues, the leader asks each client to state the identified ED behavior out loud, and the leader repeats it to all in the room in a tone of voice that describes the behavior like any other biological symptom of any other illness.
- Keep the pace moving forward, the symptoms shared almost in a beat, so there is not too much attention given to any one symptom.
- Take note if the same ED behavior is shared multiple times. This may aid in the “rewind” part of the activity when solutions are being developed.
- While the winding continues:
- Ask the participants: “How would you define a rule?” Draw upon the answers of each of the clients. Repeat their answers so all can hear.
- Ask the participants: “How would you define a ritual?” Again, repeat the clients’ answers so all can hear.
- Ask the participants: “How do rules compare to rituals?” Let the clients answer this, connecting their answers into a compiled response that holds fragments of all the answers.
- Let the clients build upon one another’s definitions, reflecting back to the themes of the definitions they develop.
- All the while, explain that the winding continues because the brain never stops firing and wiring one’s thoughts and actions. The thoughts and actions fire a chain reaction, creating pathways in the brain.
- The definitions that the clients provide will probably evolve into the definitions similar to those in the handout below. Integrate definitions of rule and ritual from the handout into their discussion while the winding of the string continues. Key points include:
- That at first they may have had a rule that was violated, such as “I ate too much,” and then created a ritual to respond when the rule was broken, such as “make myself vomit to bring relief to the anxiety that I felt from breaking the rule.” The ritual is a simple action, easy to do, and brings reliable relief.
- That then, over time, the action to make oneself vomit becomes easier and second nature to them, just as the winding of the string around the partner’s hands became easier and easier. It has become a ritual. The more a person repeats the same actions, the more it becomes a ritual. The repeated ritual of the ED behaviors becomes habitual.
- Make the above point by asking the winders how easy it is to wind at this time, compared to when they first started to wind the string around their partners’ hands. It usually gets easier for most winders. This is parallel to the ED behavior. The longer they do it and the more times they do it, the less attention it takes for the brain to wire the ritual into place.
- The leader then shares, “Note that the winding is one simple action. This is true for your ED behavior. It takes one action to binge, one action to purge, and one action to restrict. It is easy and gets even easier each time you do it. Each time you do this action, your brain further strengthens the pathway to act on this ritual without thinking about it.”
- Share, “You have been winding for about 15 minutes now. Note the size of your bundle of string. What do you imagine your brain pathway bundle looks like over 15 weeks, instead of 15 minutes? Fifteen months? Five years?” Clients and supports tend to respond with amazement at seeing how large the string bundle is and how easily it has become a “mindless” (i.e., less prefrontal cortex) action.
- Make note that the clients are “wired” to practice their ED behavior, such as binge eating or vomiting after a meal. It requires less energy, focus, and effort over time, and it brings them the desired outcome: relief.
- Emphasize that with other illnesses, such as a broken arm, pain motivates us to heal. In EDs, the pain comes when one takes away the ED symptoms. It is an illness that is backward. It may be the backward nature that contributes to so much confusion about this illness. Relief comes from doing the ED behavior, not eliminating the ED behavior.
- Rewire: While the client is still holding the bundle of string, ask the client to identify an action that he or she could practically do tonight after treatment that would be a different, healthier action to replace the ED ritual.
- If the “rewire” activity takes one step, such as talking to another person instead of restricting the dinner, the partner is to wire from one hand of the client holding the bundle to another person, because the action includes a different person beyond the client.
- The client should be very specific and provide, for example, the name of the person, when the action is done, and how it is done. The winder then includes himself or herself in the action as the “other person” and winds the string from the client to the winder’s hand and back and forth repeatedly. Each time the string goes around, the client is to say what is happening—for example, “I am calling my friend Jill and asking her to talk with me while I get dinner out to keep me from avoiding the meal.”
- If the action includes only the client, such as, “I reduce the amount of time I run from three hours to 30 minutes,” then the wiring is strung from the client’s one hand to another limb, such as the leg, to show it is a different action being wired by the client alone.
- If the action requires two steps, such as, “I call my mom and then go for a walk,” then there needs to be two sets of rewiring. That would require wiring in the winder for one action and then the client, using his or her limb, for the second step.
- As the partner rewires over and over to the new directed body area or included identified other people, the client is to say out loud the action(s) each time the partner winds the string, forming the new rules. This represents wiring the new rules into a healthier ritual IF it is done night after night. If it is done only one night, such as tonight, how much string does the new rewired path have to compete against in the bundle of ED ritual that is already wired?
- Ask the partners to challenge the clients to reduce the “rewired actions” to something very simple and practical so the brain can rewire a new healthier behavior as simply as it does the ED behavior. If the client identified three steps to rewire a different action, compare how easy it would be to give up the multistep rewired activity and return back to the one step of ED behavior.
- In essence, if the ED ritual takes more than one step, the rewiring should reflect that number of steps.
- If the client says he or she wants to do this action tonight and then IDs a different reroute for tomorrow night, then each action is to be rewired to a different place on the client, or with the partner, depending on if the client is doing the action by themselves or with support from others.
- Make the point that each different action requires a different wiring. Many actions can be developed and identified, but note how many times each of the different actions will need to be done over time to compete with the simple, well-established, ED brain pathway. If the client does the same rewiring over and over, it will take less time to compete with the bundle.
- Explain that if the ED behavior is not acted on over time, the brain pathway begins to fade, while the rewired activities begin to gain strength as they become more ritualized.
- But note that the simplicity and the relief of the ED behavior can bring the action back easily if the client turns to it again.
- The rewire may not provide as much instant relief, yet, over time, relief can develop from a healthier body and brain—but it is not instant like the ED ritual.
- Strength develops as one rewires, in spite of the pain and inconvenience.
- KEY POINTS:
- The clients are rewiring their brains and have the control to do so in the present moment. Their instructions that direct their partners on what to rewire are the same as redirecting the brain to rewire.
- The clients are capable of rewiring their own brains. They are rewiring second by second as the string moves along. They hold that control in the present moment. They don’t have control of what has already been wired in the past and what will be wired in the future.
- Their brains will go back to the default ED ritual if they are not directing the brain to rewire in this moment and each moment forward.
- Rewiring will feel awkward and take a lot of focus at first, just as it did when the string winding began.
- The more they rewire the actions they identify, the more they are rewiring their brains.
- If both people are clients, then reverse partners and go through the same procedure, but step 9 does not need to be restated. If the dyad is made up of one client only with a family member, then it does not need to shift to the other person. Note: In the development of this tool, many clients have shared that it helps to have a clinician check in with each dyad to help ensure that their “reroute” is practical.
- Ask each person in the dyad to share his or her insights and “take-home message” from the wire-rewire tool practiced. Points made by ED clients who have given permission to share their take-home messages include:
- The brain can, over time, “hard-wire” itself to do the ED behavior without thinking about it. It is easy to turn to the activity at any time to calm or manage distress from eating or other life situations.
- ED behaviors become automatic to enact and require less effort over time, even though they may be harmful to the body.
- If one wants to change one’s brain pathways, it takes intentional, clear, and determined actions that need to be practiced in order to become a new, reliable, healthy ritual over time.
- The new, healthy ritual should match in steps and ease with what the ED ritual was, or it will be easy to let it go and return to the ED ritual.
- Drawing on support people via text, phone, or phone alarms to hold one to one’s schedule is valid and may be necessary to counter the ED ritual.
- Additional client-reported insights include:
- “It takes patience to change a routine.”
- “Stuff is going to fail, get tangled, and you have to wise-mind it.”
- “Simple patterns will more likely stick.”
- “It takes time and repetition to get it to where you will it.”
- “It takes a good while to rewire.”
- “Encouragement from others and telling others my reroute to hold myself accountable will help.”
- “A simple ritual needs a lot of planning, trial and error, and is awkward at first.”
- “I want to change pathways that I am committed to.”
- “It is easier to create a healthier pathway if I believe in it.”
- “It helped me to think through while it was fun.”
- “If the reroute has too many stops or options, I can avoid it.”
- (Bulimia nervosa) “I found that having lots of steps in my reroute allowed me to have more to do, and I had increased distraction that took me away from ED. It made it harder for me to go back to ED. Even when I got tangled up, I liked the tangle because it was distracting.”
- (Anorexia nervosa) “Creating a simple reroute allowed me to not think about it, but just do it.”
- (Optional) Record the client-shared “take-home message” on a list to help other clients learn from one another through the healthy messages.
Key point in summary: The brain is able to rewire new patterns, habits, rituals, and behaviors throughout life. The old patterns are default until new brain pathways are rewired through repeated actions, creating a stronger pathway that can eventually become a new default. Old patterns fade as new patterns are developed and maintained day after day over the next year or more. It takes intension, support, persistence, and repetition for new patterns to develop. People older than 30 can rewire just as younger people whose brains are still developing and wiring for the first time can, as the brain continues to grow new dendrites and neurons prior to 30 years old. It takes longer to rewire after age 30, but it is very possible with the support of others and the use of the technology around them to remind and reinforce their new actions.
Rules and Rituals
If the clinician wants to use a handout to summarize after the tool is completed, this is a guide.
Definition of a Rule: “a prescribed guide for conduct or action.” A rule can be self-made, socially made, family made, or all of the above.
Identify an ED rule:
Identify 2 healthy rules that you follow easily in any area of life:
Definition of a Ritual: “an established routine or a set of fixed actions performed regularly.” A rule may evolve into a ritual, which becomes a chain of practiced thoughts, feelings, and actions. Rituals are necessary so the brain does not have to use more energy every time it organizes a series of actions. For example, each client probably has a ritual for how he or she gets dressed each day or how he or she drives. When a ritual is forming, the brain needs increased focus and attention on the actions that are forming together. As the ritual is performed over and over, then the brain has the “wiring in place” and it takes less action.
This is just like the wiring you are doing now.
Identify an ED ritual that you follow to accommodate your eating disorder (for example, bingeing when alone, delaying eating until x time, or making yourself vomit if you eat until you feel full):
Identify 2 healthy actions that you want yourself to develop into rituals that you could do daily (for example, ask a friend to talk on the phone with you while you eat to hold yourself accountable to eat your balanced meal)—this action can become your “rewire” response in your brain to replace your currently wired ED behavior:
Additional information on the brain basis behind this metaphor tool:
It is recommended that when clients share their ED behavior that they are asked to be specific. For example, if clients say they identify “purging” as their behavior, then ask them which type of purging, as purging is the umbrella term for self-induced vomiting, laxative abuse, diuretic abuse, exercise abuse, etc. This may make clients uncomfortable, but by them saying the specific behavior out loud, it no longer holds the secrecy. The behavior is to be stated by the therapist descriptively, not judgmentally.
If a client’s identified ED behavior is self-induced vomiting, it may be helpful to share additional information about these actions. When the self-induced vomiting is repeated during an episode, the brain releases vasopressin, (pronounced ˌvāzōˈpre’sən, ˌor vasō pre’ sən). It is a hormone released by the pituitary gland (in the brain) that serves as an “antidiuretic” to stop excessive water loss during the vomiting process. When one vomits, while it appears that he or she is vomiting a lot of food, the person is actually vomiting a lot of water with each heave. The brain response to this fast loss of excessive water is to intervene to keep the person alive. Too much water loss from the vomiting results in electrolyte loss, which means that electrolytes such as sodium and chloride are being flushed out of the body in excess. A key electrolyte loss from vomiting is potassium, which is vital to keeping the heart beating. The vasopressin release creates a morphine-like high or calm. If the client feels overwhelmed or overly anxious, he or she may “crave” that calm sensation and self-induce a vomiting episode to feel it. Hence, self-induced vomiting can be addictive, a response to a rule broken, or a habit-forming ritual. To self-induce vomiting, it is a simple two-step action, just like the string being wound around two hands. It is easy to turn to and feels very good for a few minutes afterward. However, it is like Russian roulette. It is not if the heart eventually stops, but when.
It would be ideal if a simple two-step replacement action that is healthy could replace the “high” from the vasopressin release. However, there is no action that can naturally match it with an equal sensation, outside of perhaps a type of medication. This is explained to the clients. By recognizing that point and acknowledging it for what it is, the clients have within their control the ability to experiment with healthy different alternatives and to experience what they feel from doing them. For example, if they chose a simple one-two action to match their laxative abuse, it may not give them the relief from the extensive water loss, but the action may be purpose-filled and meaningful to them. The action may reroute them to a different, perhaps less intensive, action, but with a greater sense of good or a desired good. In these situations, they are moving forward, not backwards.
Clients may also choose to add a support person to their response, who may draw them out of their own ED thoughts. While that adds a degree of complication from the stand-alone ED action, it connects them to another person who can help reroute and compensate for support. The clinician explains these facts in the details provided above, to support the anorexia nervosa client preference for details over general statements. Also, another person can draw out thoughts and can offer support through a simple interaction.
When anxiety is high, and the emotion feels overwhelming, it is recommended that the rewire action be an action, such as walking or moving in an intense way, like hitting a punching bag. Anorexia nervosa clients who both restrict and purge report that when their anxiety is high, they cannot speak or don’t want to talk with others, they just want to do… Hence, if action or movement is needed at the time when one turns to an ED behavior, then replacing it with another action may seem most congruent. For example, the person is on the way to the bathroom to purge, stops, turns around, and the spouse says, “OK, let’s go for that walk now.” It may be a tense walk, a time when little is said, but it redirects an ED action with a healthy action, and the rewiring is moving forward with the help of a support person.
About the author:
Dr. Laura Hill is the President & CEO of The Center for Balanced Living, a free standing not-for-profit organization that specializes in the education, treatment and research of eating disorders.
Dr Hill is the recipient of Muskingum University Distinguished Service Award in 2014, the National Eating Disorders Association 2011 Lori Irving Award for Excellence in Eating Disorders Prevention and Awareness and was a TEDx Columbus speaker in 2012. She is an original founder of the Academy for Eating Disorders in 1993 and was Director of what is now known as The National Eating Disorder Association from 1990 to 1994.
She is the lead author of the Family Eating Disorder Manual, 2012; and has conducted research and spoken internationally over the last 35 years. She is a recipient of the national Feeding Hope award by NEDA, in collaboration with UCSD Eating Disorder and Research