Impulse Control and Co-Existing Disorders
Katie Thompson, MS, LPC, NCC, has been a primary therapist at Castlewood Treatment Center for two years. Katie graduated from Marquette University with a BA in Communications, Education. She later earned a Masters of Science in Counseling Psychology from the University of Wisconsin- Milwaukee. Previously, she was a therapist at Rogers Memorial Hospital in the residential program for eating disorders and anxiety disorders. Katie facilitates various groups at Castlewood, including all of the Eating Disorder groups, is an active participant in the research team and specializes in eating disorders and anxiety disorders; specifically binge eating disorder. Katie coordinates the Binge Eating Disorder Program at Castlewood Treatment Center and facilitates the BED groups in both the residential and PHP levels of care. She is skilled in using DBT, CBT, IFS, ERP and group therapy. Katie is trained in Exposure and Response Prevention (ERP) and has earned her certification in Internal Family Systems Level 2. Katie lectures regionally and nationally on Eating Disorders, Binge Eating Disorder and treatment interventions.
How did you get involved in this field?
I became involved in treating eating disorders after leaving private practice at a treatment center for inner city foster care females in Milwaukee, Wisconsin.
I loved working in a residential setting and was hired at Rogers Memorial Hospital in the Eating Disorder Center which is a residential program for adolescents and adults with eating disorders. Eventually I worked in the Anxiety Disorders program within the Residential OCD program in addition to the EDC.
I took my current position as a primary therapist at Castlewood Treatment Center for Eating Disorders in St. Louis, Missouri after Castlewood expanded their program, adding a clinic to treat co-morbid anxiety disorders. I began running the Binge Groups at Castlewood about two years ago at the request of Mark Schwartz, ScD who realized that there was a vast deprivation in terms of properly treating Binge Eating Disorder (BED) and related disorders.
What is the difference between anxiety disorders and impulse control disorders or are the two interchangeable?
This is a good question.
They are not interchangeable, there is some relationship, but they are not interchangeable.
Some impulse control disorders are highly relatable to anxiety disorders and they may exist co-morbidly. Several disorders often listed as impulse control disorders can be found listed within the Obsessive Compulsive Disorder (OCD) spectrum, such as dermatillomania (skin picking) and trichotillomania (hair-pulling) and can be treated with therapeutic interventions that are effective for treating anxiety disorders.
Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) are effective to treat both anxiety disorders and impulse control disorders that are often tagged in the OCD spectrum.
An anxiety disorder is really a potent manifestation of perceived threat whereas an impulse control disorder is the consistent inability to resist urges, temptations or impulses that have a negative impact on the person or others.
A person struggling with an impulse control disorder often goes through stages of increasing tension which then leads into acting out and experiencing pleasure or pleasure-like responses from engaging in the maladaptive behavior, followed by relief and sometimes guilt. The two are very different, can manifest together and need to be addressed simultaneously in treatment.
Regardless of the category a behavior falls into (or does not for that matter), as a clinician, I am constantly seeking to understand the origins of all behaviors, their evolutions and the contexts the maladaptive coping responses exist within.
Maladaptive behaviors are often metaphors for what cannot be directly communicated or spoken; I am constantly working with clients to seek out and understand the functions of all of their behaviors because these functions are a window into the unmet need the behavior serves. How can I effectively treat a client by taking away an, albeit maladaptive, coping mechanism if I don’t understand what function it serves, or without teaching the client to replace the maladaptive behavior with adaptive responses that actually meet the unmet need?
Are impulse control disorders necessarily addictive behavior?
The field is somewhat divided on what is an addiction, what falls into the category of addiction and what does not. While much is known about how to effectively treat some addiction processes, there is still so much that is unknown about the nature of impulse control disorders and addictions in general.
There are divisions in the field among experts because research is ongoing and, while there may be some overlap in impulse control disorders and addictions, they are distinct disorders.
Recently, at the BEDA 2013 Conference, several experts talked openly about their attitudes toward what addiction is, what compulsion is, and where the eating disorder fits into all of this and vice versa, where does the concept of addiction fit into the eating disorder.
I know there isn’t a simple answer to this question so it was nice to be present for such an open and inclusive discussion.
Do your clients often substitute the behavior of one disorder for another when you are helping them through their therapeutic process? For example, a binge eater who responds well to therapy regarding the nutrition aspect flares up in another area of disordered thinking such as nail biting, drinking or acting out in other ways?
Yes. The goal here is to eliminate the game of “whack-a-mole.”
How common is it for a client to have comorbidity? Does this diagnosis present unique hurdles in therapy?
It is common.
If a case is not clearly conceptualized and a “one at a time” approach to an individual’s struggles is used, the client and the treatment team will be met with a lot of disruption in the recovery process. This is not to say that a treatment team needs to tackle all things at once, but rather using sound relapse prevention and recovery guidelines from the beginning to create abstinence and release from co-morbid stressors.
If a client presents with binge eating disorder, social anxiety disorder (SAD) and skin picking, it is recommended that the client work with a team that can address the nutritional aspect of the current struggles (a dietitian) while the SAD and dermatillomania would be addressed by a behavioral specialist trained in Exposure and Response Prevention Therapy (ERP) and CBT. This would happen in conjunction with managing the psychotherapy around the BED and other underlying unresolved issues, and ideally a psychiatrist and medical doctor for psychiatric/medication issues and for medical monitoring.
I have the luxury of working in a dynamic residential treatment setting in which I function as a primary therapist and I collaborate with anxiety specialists, dietitians, group therapists, a psychiatrist, nursing and medical doctors.
Is a client with comorbidity more likely to sublimate as work gets harder or farther along?
I would not say any more than another client.
I think clients will engage in therapy interfering behaviors (TIBs) or defense mechanisms as much as the treatment team allows this behavior to pervade the process.
Is there a special connection between any two binge or impulse control disorders? For example, do you see more people who binge eat and skin pick, or binge eat and binge drink than any other similar combination?
Not necessarily, this is usually specific to the individual. There is a high rate of substance abuse/dependency with eating disorders, so this is common.
Can a person who traditionally binges on food simply replace food with sex or gambling or shopping and have the same numbing satisfaction?
It is not a simple replacement, nor does one behavior provide the exact numbing effect as another behavior would.
This is where looking at the deprivation model a client engages in, and the core issues that all of the symptoms/behaviors ultimately lead back to, is crucial for long term recovery.
After a binge is there a difference in the level of shame experienced between a person whose bingeing doesn’t have physical consequences and one whose bingeing does?
For example, a binge eater will gain weight as a consequence of their binge. It’s an outward manifestation that people can see and therefore judge so in turn the binger feels shame. Is it the same experience for a person whose binge isn’t immediately visible and may not be judged, such as binge shopping or compulsive exercising?
I would not say that you can measure shame in this way.
People who binge on food or on other substances often have the distorted thinking pattern that their recent binge is immediately visible to the outside world, which is simply not true.
Conversely, a person may struggle with shame resulting from their body, but they do not struggle with binge eating behaviors.
I do not believe the shame is comparable.
One of the commonalities among people with disordered behavior is the need to get numb, to avoid feeling. How does that work? Does performing the act (drinking, shopping, eating…) provide enough distraction or is it that every possible bit of attention is spent on performing the behavior that there is no room left for feelings? In other words, is it the ritual or is it the ability to ignore that keeps the feelings at bay? Or something entirely different?
I think it is all of the above and also that when a person is undernourished, malnourished or under the influence of substances, they cannot actually authentically connect to feelings, cognitions and affect states.
Also the aforementioned distort one’s ability to connect with intrusions, memory, sensations and the cognitive and affective states related to trauma intrusions.
Is there any solid research to indicate why women are far more susceptible to these disorders? Or do women self report more than men and therefore that assumption is wrong?
I think men under-report and go unnoticed for a variety of reasons.
This is an area for further research and one I am interested in. I have yet to give a talk or lecture without receiving this question in some format. It is such a prevalent issue.
How important is a sense of community to those suffering disorders that manifest shame? How do you integrate that piece in your work?
Recovery work is best done in a group process, allowing the clients to work through the potent shame that binds them in the isolation and avoidance that propels the shame and ultimately the disorder.
We call this process, “Opening the Channel,” a term coined by Lori Galperin, LCSW Co-Founder of Castlewood and Monarch Cove, Castlewood’s affiliate in Monterey, California. The clients can effectively reduce and eradicate the shame that binds them in their maladaptive behaviors when they integrate the work they are doing in individual therapy into the group process. This is a necessary component of powerful recovery work and is one of the reasons I truly love facilitating Eating Disorder groups and the Binge Groups at Castlewood.
In individual therapy, I teach all of the clients I work with about “shame spirals”, shame based systems and how the eating disorder and other maladaptive behaviors are often manifestations of these processes. I challenge the clients to identify their own shame spirals, shame processes and to challenge these in relationships within the community and through their work in individual and group therapy.
When a client who has co-occurring disorders leaves your care, how do you set up symptom management guidelines when there are symptoms for more than one behavior?
Discharge planning and case management begin the moment a client walks in the door. This means that I am working in conjunction with their referring outpatient team and, if it is clinically indicated, I will do my best with the resources available to help the client replicate a treatment team for their post-discharge needs that is similar to that that they have been working with in residential treatment.
On a day to day basis it is about client motivation, consistency in the care and treatment plan and a sense that the client is accountable. If a client struggles with self motivation and engaging in the therapeutic process, then different DBT, CBT and motivational techniques can be implemented to help a client reign in their struggles and make recovery more manageable.
Katie, thank you so much for your time. Your work is very meaningful and you clearly have passion, what else would you like to share?
I am blessed to be in a position to participate in my clients’ recovery journeys each day, it is one of the most difficult, challenging, exhausting and rewarding endeavors any individual will ever choose to take on during their lifetime. The therapy is taxing, demanding and requires a level of honesty that few humans allow themselves to be vulnerable enough to ever procure.
I respect my clients, all clients out there and any individual who is struggling with an eating disorder, an addiction or other related struggles. I ask my clients each day to drudge through the most painful aspects of their lives and then to examine these agonizing details in effort to make sense of the daily struggles that create their entrapment. I am humbled by the intensity of the pain, the gravity of the loss and the seemingly insurmountable hurdles I witness daily.
For every person fighting for recovery, there are many more out there suffering in silence, and for every person suffering in silence, there are many dying alone with the pain of their disorders. My hope is that others witness that recovery is entirely possible and worth the effort of the daily fight for peace and balance.
To reach Katie:Katie Thompson MS, LPC, NCC firstname.lastname@example.org @KTherapist (follow on Twitter)
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800 Holland Rd.
St. Louis, MO 63021 Castlewood II Treatment Center
1260 St. Paul Rd.
St. Louis, Mo 63021