Part VII-B UCSD EDC2014: Review

And we’re finally back after almost three months! As you can see, a big part of the radio silence was due to a significant website migration that was underway and you’re now looking at the results of that effort.


What remains of the UCSD EDC2014 Review on the blog is the in-depth look at the ICAT; a set of revelations and insights into binge eating disorder that were the result of the roundtable discussion that followed the ICAT presentation by Drs. Stephen Wonderlich and Carol Peterson; and then wrapping it all up with Drs. Janet Treasure and Ulrike Schmidt presenting their research and development on MANTRA (Maudsley Model of Anorexia Nervosa Treatment for Adults).

So let’s get to working through the details of ICAT. We now enter the Land of the Acronym yet again…

There are eight core skills that are developed within the ICAT approach:

  1. Emotion awareness (FEEL): Focus, Experience, Examine and Label
  2. Meal planning (CARE): Calmly Arrange Regular Eating
  3. Urge management (ACT): Adaptive Coping Techniques
  4. Goal setting (GOAL): Goals and Objectives Affect Life-Moments
  5. Relationships (SAID): Sensitively Assert Ideas and Desires
  6. Self evaluation (REAL): Realistic Expectations Affect Living
  7. Self regulation (SPA): Self-Protect and Accept
  8. Impulse control (WAIT): Watch All Impulses Today

The treatment structure is as follows:

  • 21 sessions, 50-minute sessions twice/week for first month then weekly
  • Clinician manual and patient workbook
  • PDA/Smartphone/Paper Wallet coping skills
  • Four phases of treatment

The development of ICAT has been over ten years in the making and thedriver for developing this treatment modality was to address two fundamental ideas:

  1. Bulimic behaviors serve avoidance and escape functions regarding aversive states of emotion.
  2. Bulimic behaviors may also be a means of promoting positive states of emotion.

And many of you may likely recall I address this positive-negative duality of bulimic behaviors in the blog post: Techniques II: When finite energy goes up against the drive to survive.

While I might take issue with rigidity in meal planning (because it is actually reinforcing avoidance that only worsens the overall threat responses to food intake), I do believe that ICAT “keeps its eyes on the prize”, so to speak, by paying solid attention to emotion as a source point for treatment.

The ICAT principles encompass the recognition that emotion is a cue for bulimic behavior. By promoting emotional awareness; identifying and developing strategies to ease emotional intensity; all while helping a patient refuse to enact behaviors that are destructive when she is emotionally distraught; ICAT is tearing a good number of useful pages out of the dialectical behavior therapy model that helps a patient apply levels of meta-cognition that can take her beyond being a slave to the intense emotion of the moment.

Drs. Wonderlich and Peterson did an excellent job of interweaving actual (anonymous) therapy session dialogue into their slides as a way to demonstrate the challenges faced by patient and therapist. But more importantly it reflected how the emotional challenges are realized for the patient in everyday life.

The techniques taught and reinforced within ICAT are about attempting to modify episodes (moments) and not focus on broader constructs such as personality, attitudes and schema. It’s about learning those skills to manage those moments. It’s about addressing those every day emotional challenges.

The progression is Situation > Emotion > Action. The goal is to understand a bit more of the situational and emotional cues that trigger bulimic behavior and then to understand what that behavior’s function might be. From there, the therapist and patient work to identify different responses to those cues that are not bulimic behavior.

The ICAT treatment phases are as follows:

  • Phase I: Engagement and education
  • Phase II: Meal planning and adaptive coping
  • Phase II: Self-oriented and relationship problems
  • Phase IV: Relapse prevention and treatment termination.

In Phase I, motivational interviewing features prominently— noting the discrepancies that the patient experiences between the eating disorder symptoms and her broader life goals. By acknowledging there are possible benefits to the symptoms, the therapist doesn’t end up inadvertently getting a patient to defend the very behaviors she has actually come in to address in therapy.

Identifying and naming emotional states is not easy for patients and the therapist takes an active role in Phase I in identifying and naming emotional states and reactions. It introduces the FEEL skill and heightens that critical inner-state awareness that is needed for the development of meta-cognition.

Phase II is the nuts and bolts elements of ‘normalizing’ eating behaviors alongside ongoing monitoring of feelings, situations and drive for bulimic behaviors.

As I have pointed out in multiple other posts on this site, reducing the likelihood of a binge session is counterproductive to training the threat identification system to eventually stand down when it comes to food. Creating rigidity in meal plans and eating times sets a patient up for exacerbated levels of distress when an eating session occurs either in response to ongoing actual energy deficits within the body, or to emotional distress.

Now certainly if the meal plan provides enough energy and helps the patient to avoid delaying food intake (many bulimics will have eating sessions naturally enough at the end of the day when they have delayed eating most of the day and are in a state of energy, and therefore cognitive, depletion), then that could buoy them up sufficiently to stabilize mood. In other words, if the patient must eat a good breakfast, snack and lunch before 1 pm, then she is of course far less likely to be so severely energy depleted at the end of the day as to need an intense eating session at that time.

But this does mean that ICAT’s usefulness within the framework of Homeodynamic Recovery Method has to incorporate within the Phase II framework that it is not the reduction of binge eating that is an end goal of any kind, but rather that everything is building upon techniques and meta-cognition that allow a patient to tolerate the distress of “bingeing” by finding adaptive responses that replace the drive to enact restriction in response to that distress.

The Adaptive Coping Technique (ACT) is taught and practiced during phase two.

Adaptive responses include:

  • Using the FEEL skill to identify your emotional state.
  • Being flexible and open-minded.
  • Thinking about what might help with your recovery and health within that moment.

Coping responses include:

  • Is there something I can do to solve a core problem here?
  • Is there something I can do to just help a little bit?
  • Is this a feeling or situation that cannot be changed?
  • Is it time to self-soothe?
  • Is it time for distraction?
  • Would my bulimic behaviors really help at this moment?

Technique responses include:

  • Coping is a learned skill and it improves with practice.
  • What might help me cope just a bit better right now?

I won’t go into all the acronym techniques listed above, but the ACT information gives you a good example of how on-the-ground and practical much of the ICAT program is.

Phase III is getting into all the interpersonal patterns, self-regulation and self-evaluation that tend to push patients into distressful emotional states that lead to bulimic behaviors.

While building on all the skills from Phases I and II, now the patient and therapist together look at the following core questions:

“Is there a pronounced interpersonal disturbance that interferes with recovery?”

“Is there a pronounced self-evaluation problem (self-discrepancy) related to failure to meet standards that interferes with recovery?”

“Is there a pronounced pattern of self-regulatory behavior that interferes with recovery?”

“Do interpersonal, self-regulatory, and self-discrepancy behaviors interact meaningfully?”

The key strategies for social problem solving within the ICAT approach as as follows:

  1. Assert
  2. Stay the same
  3. Disengage
  4. Separate
  5. Fight

The therapist applies role playing to help the patient explore these interpersonal resolution options. It helps to consider that whatever the path, it doesn’t always work out and that tolerating outcomes can be explored prior to taking any action in the patient’s “real life”.

The focus on self-regulating behavior has to do with the go-to behavior style under stress and it will usually fall within one of these three categories:

  1. Self-critical
  2. Self-controlling
  3. Self-neglect

The antidote is SPA (self protect accept).

Within the self-evaluation behaviors, the focus is on a tendency towards actual vs. desired self-discrepancy. In this state, positive attributes are discounted; there are unrealistic and perfectionistic standards at play; and a chronic experience of shame, frustration and inadequacy is present.

And the key strategies for narrowing that gap of actual vs. desired standards are to do the following:

  1. Identify the core standards and assess the size of the discrepancy and the probability of attainment for the desired state.
  2. Assess the purpose or function of that standard and how that fits within the history of standards you have set.
  3. Are their concerns about changing that standard to pull it more in line with a realistic outcome? And might not new, more adaptive standards be worth investigating?

Phase III is delving into experiences that are particularly emotionally dysregulating and trying to develop new ways of managing those experiences all while continuing with awareness training, good eating and urge management.

Phase IV is relapse prevention and treatment termination. The basics of lapse management include the promotion of the ideas that recovery requires vigilance, flexibility and practice. Phases II-IV of ICAT work very well with the Homeodynamic Recovery Method for remission from an eating disorder. Any time I see a program that formally recognizes that remission is a practice I’m vehemently nodding my head in agreement.

The ICAT program explains the distinction and risk factors between lapses and relapses and encourages self-awareness as a key tool for reversing those states.

The remaining 16 slides in the presentation went through all the clinical data pertaining to how ICAT stacks up against other treatment protocols, specifically CBT-e (Enhanced Cognitive Behavioral Therapy). The short answer is that it is equivalently effective as a treatment approach for bulimia as is CBT-e.

More information on CBT-e can be found here. And an explanation of the development of ICAT can be found here.

Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., & Crow, S. J. (2014). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological medicine, 44(03), 543-553.

Wonderlich, S. A., Engel, S. G., Peterson, C. B., Robinson, M. D., Crosby, R. D., Mitchell, J. E., ... & Simonich, H. K. (2008). Examining the conceptual model of integrative cognitiveaffective therapy for BN: Two assessment studies. International Journal of Eating Disorders, 41(8), 748-754.