CBT as an Intervention for Co Occurring SUD and ED Treatment

Introduction

Research suggests that prevalence between eating disorders and substance use disorder is alarmingly high, however they are rarely treated co-occurring and often one is overlooked while the other remains at the forefront of treatment. For the past eight months, I have personally been studying the prevalence of eating disorders during substance use treatment and post substance use treatment. For people with anorexia nervosa, research has found that the 

For people suffering from binge eating disorder or bulimia nervosa it is suggested that these behaviours are similar to those observed in patients that experience drug addiction. (Ziauddeen H et al. 2012) It was found that energy-dense foods and fluids, think of carbs and sodas, as drugs, which when consumed, activate reward pathways that reinforce the bingeing behaviors. This phenomenon is similar to substance abuse and is relevant to people struggling with binge-eating disorder and bulimia nervosa. 

The hypothalamus is involved in different daily activities, such as eating or drinking, it controls the body’s temperature and energy maintenance, and it processes and memorizes stress control. During substance use, the addicts hypothalamus is under attack. The hypothalamus regulates our appetite, so when under attack by continued substance use, it may cause the appetite to decrease, then when the substance user takes away the drugs, the lateral hypothalamus increases appetite. (Subramaniapillai & McIntyre. 2017)

Food can also activate the mesolimbic reward system, which is the part of the brain that experiences pleasure. This activates food-seeking behaviours due to the activation of cognitive processes involved in motivation, similarly to substance use and continued cravings, drug seeking behavior, and high relapse rates.

Patients with eating disorders with substance use disorder often demonstrate worse eating disorder symptoms and worse outcomes, including increased medical complications, longer recovery times, worse functional outcomes and much higher relapse rates. Many ED programs admit patients with over-the-counter diet pill or laxative abuse, however will not admit patients abusing other drugs, such as benzodiazepine, alcohol, cocaine or opioids . The lack of available integrated treatment programs, at all levels of care, leaves clients with both ED and SUD flip-flopping between disorders and treatment providers. This in turn prolongs time in treatment, increases costs associated with treatment, and can compromise continuity of care. (Dennis, Pryor & Brewerton, 2014). In addition, studies suggest that patients who receive nonintegrated services have poorer treatment outcomes (Drake et al., 2001).

Evidence and years of research suggest that integrated treatment programs are necessary when treating clients with substance use disorder and eating disorder behaviors. 

CBT for ED and SUD

Substance use disorder and eating disorders are two very misunderstood, under studied, and complex disorders of the brain. Both eating disorders and substance use disorders have high mortality rates and high relapse rates, along with a general resistance to treatment protocols. An intervention I believe would work best to treat these disorders simultaneously would be cognitive behavioral therapy (CBT). I would use CBT groups of eight to ten, these clients would be picked after an assessment is done. The assessment would be on self esteem (Rosenberg Self Esteem Scale), substance use (DAST), and ED (SCOFF). The scoring on these three assessments would determine eligibility for the CBT Intervention Group. 

I would choose a group dynamic because it gives people the opportunity to use tools they are learning in the real world while simultaneously learning different skills, as well as makes up a group of people looking for positive change, and it gives people who may be resistant to treatment a chance to take place in some type of recovery oriented environment.

 At its core, CBT focuses on challenging and changing unhelpful thoughts and behaviors, improving emotional regulation, and the development of personal coping skills. People struggling with substance use disorder and eating disorders often have trouble with regulating emotions and stress, distressful thoughts, behaviors that are negatively affecting them, and a lack of coping skills. CBT would give those struggling a chance to examine and challenge negative thoughts, that may be bogging them down and hindering their recovery. 

Creating a dual diagnosis CBT focused group for those struggling with SUD and ED would be beneficial in creating a safe place for those struggling with co occurring disorders to share about their experiences and overcome obstacles, while also working towards a decrease in symptoms of eating disorder or substance use symptoms. 

The CBT model focuses on 1) situations: anything that happens in an individuals environment that may be influenced by behaviors. An example of a situation may be stress, which is not in their immediate control but can be caused by continued use or symptom use. 2) thoughts and beliefs: what an individual thinks or believes about a situation, how the individual interprets this. For ED and SUD this portion may be focused on negative thoughts of self, negative beliefs about recovery, belief that someone will not be able to recover. 3) Behavior: the individuals outside response or actions in response to this. For example, people with ED and SUD may feel if they overeat, they will stop thinking about drinking or drugs (sugar, think detoxing clients eating chocolate), or a client with anorexia worrying if they do not use stimulants they will “gain 100lbs.” This can cause continued use. 3) Emotions: how a person feels about a situation, emotions are not based in logic by influencing thoughts and beliefs. This can be similar to thoughts and beliefs, however the difference is that thoughts and beliefs are how they interpret the situation and emotions are how they feel about the situation. Often, emotions can come from core beliefs about oneself.

Two topics that would be highlighted and discussed in depth would be core beliefs and challenging negative thoughts. Eating disorders and substance use disorders can both stem from low self esteem, negative thoughts/beliefs of oneself, and underlying interpersonal relationship problems. Both EDs and SUD can also be trauma responses to both perceived and real traumatic experiences. 

Discussing core beliefs as a part of CBT can help clients in dividing themselves from their disorder. Creating a list of different values, such as growth, freedom, security, thankfulness, mindfulness and fun, can be a great way for these clients to see what their core values are and how they can create a space for these values in their daily lives. 

Core beliefs are a good way for clients to examine situations and change their personal perspective. For example: situation, a client continues to relapse- core belief, I am not worthy- core belief  with a changed perspective, I don’t feel worthy but I can do this- consequence 1) why would I be able to recover this time- behavior- don’t try versus consequence 1) if I try I could get it this time- behavior- I try again. This framework can help clients search for evidence against their core beliefs.

Outside of this group intervention, one would have to consider other interventions that would be necessary before a group would be a viable option. The most important piece of information needed would be that all clients are safe, meaning, medically stable and behavior free for a minimum 1) ten days for ED with BZO or ETOH co occurring 2) seven days for ED with OPI, MET or COC co occurring and 3) five days for THC co occurring. Outside of these parameters, we would need labs drawn on all ED patients, as well as medical stabilization depending on weight and ED diagnosis. These interventions would need to come before any type of therapeutic intervention could take place. 

Adult Population of ED and SUD

For the purpose of this paper, I would choose to use this intervention with the adult population.  The adult population has the ability to choose whether they want to be in a group versus the adolescent population that is often forced into treatment by family. The outliers however, would be adults court mandated to treatment. EDs and SUD can affect people of all different demographics, whether upper or lower class, black or white, educated or not, male or female, does not matter. This group intervention would open to anyone willing to show up to all ten groups over a three month period, this would be discussed upon first meeting and assessment. 

 3. ethical issues and culturally responsive practice skills

Ethical issues within treating both substance use disorder and eating disorders are making sure clients are safe and medically stable. By safe, I mean a decrease in symptoms and substance free. If a client were using substances or behaviors, medical clearance would be necessary to ensure the client is not in danger. 

For culturally responsive practice, it would be important to dissect person bias and judgment regarding people with EDs and SUD. Many people have an assumption that people with EDs are white women, while many also believe SUD is filled with lower class people. Making sure the group is bias free would be imperative in making sure clients got the care and compassion necessary for recovery. An important thing to look at would also be, who is in the group and who is leading the group, and what are the cultural differences in these people and how does that play into their healing, as well as their own personal background and upbringing. From personal experience many black clients do not feel they get fair medical treatment and do not receive culturally responsive therapy, this has been brought to my attention recently while working in a substance abuse detox center. A female black client reported that she was “surprised” I was easy to talk to, as many times she felt younger white women did not understand her or care to understand her, and she often felt outcast as a “crazy black woman.”

For EDs and SUD, many people assume that spending time in a 28 day treatment facility is a necessity. While this would be beneficial for many, it is important to note that this is not financially feasible for many people, whether it is lack of insurance benefits or the inability to take that amount of time off from work. Another part of recovery that is discussed in both ED and SUD recovery is proper nutrition. While this is not just an ED group, a culturally responsive practice that would need to be noted is that not all people can afford what a dietician or nutritionist may deem as proper nutrition.

Provide research that addresses this intervention: CBT for SUD and ED

In article one that was examined in relation to CBT as an intervention of SUD and ED, it was stated that “There is evidence for the efficacy of various forms of CBT, including self-help CBT programmes, in the treatment of EDs (particularly BN), however the efficacy of CBT in the presence of co-morbid SUD has not been examined. Sinha and O’Mally (2000) and Grilo et al. (2002) nevertheless suggest that for the treatment of EDs and alcohol abuse, a CBT approach which targets both pathogenic eating behaviours as well as alcohol use is likely to be effective. They identify particularly useful strategies such as self-monitoring, identification of high risk situations and coping skills to manage emotions or situations which may trigger loss of control. Often a “stepped-care” approach is recommended where patients begin with self-help CBT and if necessary proceed to guided self-help interventions or to group or individual therapy.” (Gregorowski, Jordaan and Seedat, 2013)

The second piece of literature I reviewed was in regards to relapse prevention and CBT framework. This was chosen to due both EDs and SUD having such a high relapse rate, and would justify using this framework as an intervention. Relapses have both affective and cognitive components: the feelings of guilt, shame, and hopelessness associated with relapse constitute the affective component, while attribution of the lapse to internal and uncontrollable factors constitutes the cognitive component (Marlatt & Donovan, 2005). The latter contributes to the “abstinence violation effect” whereby such cognitive processes can lead to giving up on abstinence goals, and strongly contributes to heavy and uncontrolled substance use in the context of a relapse. (Concord, Harris, Martin. 2017)

In a study on CBT for addiction they found that many view CBT as a relapse prevention tool. This reigns true for both SUD and ED treatment, as many are based in relapse prevention instead of a recovery oriented setting. When discussing recovery-oriented ideals, it is better to think of how CBT can be helpful in creating new ways of thinking and dealing with stress, which in turns also helps prevent relapse. “CBT can help patients develop coping strategies to prevent relapse, which is why some providers think of it as a relapse-prevention as opposed to a recovery tool. But relapse prevention, while essential to recovery, is just one part of recovery, said Laudet. “Research has shown that recovery requires improvements in all the functioning areas that have been impaired by active addiction,” she said. This includes education, employment, finances, family and social functioning, legal status, and physical and mental health. In specialty addiction treatment, CBT can be helpful to teach patients how to deal with stressful triggers. Lack of experiences with such daily tasks can be highly frustrating, causing stress and potentially leading to relapse.” (How CBT can help addiction treatment be more recovery-oriented. 2012.) 

Another important piece of research is on assessing readiness to change. For a client to partake in CBT, they would need to have a positive attitude along with the desire to change. Whether it is an ED or SUD, both clients would need to possess the readiness to change for CBT to work. “Readiness to change has been identified as an important predictor of treatment engagement in individuals with eating disorders. Participants who report low levels of readiness to change their behavior may benefit from motivational interviewing before engagement in traditional treatments for eating disorders to maximize the effectiveness (Geller & Dunn, 2011). (Hudson and Neil 2020) Clients who score lower on the scale, are less likely to engage in treatment and more likely to drop out. 

As research suggests, the use of group CBT for individuals that are in an action state of change, would be beneficial in addressing both co occurring disorders.

Treatment Resistance.

For this specific paper, I have discussed patients that score at a specific setpoint that have a readiness to change existing thoughts and behaviors. This is necessary when utilizing CBT, however it is not always necessary for clients to receive care. Many people enter treatment unwillingly, whether court ordered or persuaded by parents and loved ones. Using CBT for clients that are unwilling to change would not work, as they would not be willing to look at behaviors or thoughts as irrational or needing to change. Treatment resistance for individuals with EDs and SUD are particularly higher with men, however women can also be resistant to treatment. Some of the key reasons for resistance are the idea that it is not “that big” of a problem, they have not suffered enough consequences, they are not emotionally or mentally ready to change behaviors that feel safe, and even possibly underlying mental illnesses such as borderline personality disorder or complex trauma. All of these different outliers can create treatment resistance in an addicted individual, whether it is to alcohol or food. 

Conclusion.

In conclusion, utilizing group CBT for intervention and outpatient therapy when clients are A) willing to change B) medically stable C) dually diagnosed with ED and SUD, can create positive outcomes for treatment. Clients with co occurring ED and SUD deserve continuity in care, when researching this topic it was glaringly obvious that there is a lack of research on both co occurring disorders and different types of positive treatment. 

Treatment centers for both eating disorders and substance use disorders should create and set in place policies for treating both disorders simultaneously. Eating disorders and substance use disorder should also continue to be researched, as both have high mortality rates and often happen co occurring, or can be seen as “flip flopping” disorders. The research and treatment of both disorders simultaneously should be the standard of care in dual diagnosis treatment programs.

Works Cited

Brewerton, T. D., & Dennis, A. B. (2016). Perpetuating factors in severe and enduring anorexia nervosa: A clinician’s guide. In S. Touyz, D. Le Grange, P. Hay, & H. Lacey (Eds.), Managing severe and enduring anorexia nervosa. New York: Taylor & Francis/Routledge.

Drake, R., Essock, S., Shaner, A., Carey, K., Minkoff, K., Kola, L., et al. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52, 469-476.

Gregorowski, C., Seedat, S., & Jordaan, G. P. (2013). A clinical approach to the assessment and management of co-morbid eating disorders and substance use disorders. BMC psychiatry, 13, 289. https://doi.org/10.1186/1471-244X-13-289

How CBT can help addiction treatment be more recovery-oriented. (2012). Alcoholism & Drug Abuse Weekly, 31, 1.

Hudson, C. C., & Mac Neil, B. A. (2020). Ready or Not: Examining Self-Reported Readiness for Behavior Change at Intake Assessment for Adults With an Eating Disorder. Behavior Modification, 44(2), 214–227.

Marlatt, G. A., & Gordon, J. R. (Eds.). (1985). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press.

Morin, J., Harris, M., & Conrod, P. (2017). A Review of CBT Treatments for Substance Use Disorders. Oxford Handbooks Online. doi: 10.1093/oxfordhb/9780199935291.013.57

Subramaniapillai, M., & McIntyre, R. S. (2017). A review of the neurobiology of obesity and the available pharmacotherapies. CNS spectrums, 22(S1), 29–38. https://doi.org/10.1017/S1092852917000839

Ziauddeen, H., Farooqi, I. S., & Fletcher, P. C. (2012). Obesity and the brain: how convincing is the addiction model?. Nature reviews. Neuroscience, 13(4), 279–286. https://doi.org/10.1038/nrn3212

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