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Psychological Dimension of Eating Disorders Pt.3


Fall 2003, Volume 2, Issue 4

Following The Remuda Review’s bio-psycho-social-spiritual model of eating disorders, we continue exploring in this issue eating disorders’ psychological dimension. We discuss practical CBT skills in depth, and supplement with a description of equine therapy for eating disorders.

Editorial Staff
Cognitive-Behavioral Therapy: Applications and Skills
Marian Eberly, RN, MSW, CISW, DAPA, Division of Patient Care Services
A. David Wall, PhD & Dena Cabrera, PsyD, Department of Psychological Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

"New wine must be poured into new wineskins." (Luke 5:38)

Cognitive-Behavioral Therapy (CBT) is commonly considered the most scientifically-valid psychotherapeutic approach to eating disorders (American Psychiatric Association, 2000; Richards & Baldwin, 2000). It is also particularly consistent with and expressive of Scriptural truth (Wall, 2003). One component of CBT found to be especially helpful to eating disorder patients is the learning and practice of specific skill-sets. In learning new skills, maladaptive emotional and behavioral patterns which keep patients entrenched in the eating disorder are replaced with adaptive and effective methods for managing emotions and choosing behaviors.

A recent CBT treatment model includes cognitive and behavioral skills work specifically designed to support patients who struggle with emotional and behavioral regulation problems, such as those with borderline personality or self-injury/parasuicide (Linehan, 1993a). Like these patients, eating disorder patients struggle with an impaired ability to regulate their emotions and frequently demonstrate a lack of ability to tolerate distress. These primary skills deficits require clinical attention if patients are to find relief from the emotional chaos and destructive results of their choices and actions. In our view, after nutritional restoration, attending to these skills deficits is the single most important ingredient in the provision of clinical treatment for those with eating disorders. The teaching of Biblically-based skill sets supports patients in tangible ways long after termination of treatment.

Between 23% and 80% of eating disorder patients are diagnosed with personality disorders, most often cluster B (dramatic-erratic) disorders, particularly borderline personality disorder or traits (Wonderlich, 1995). At Remuda, we have determined that 99% of patients have one or more indicators of emotion regulation problems, including a personality disorder diagnosis and/or psychological test data suggestive of such problems. As such, eating disorder patients routinely evidence emotion dysregulation issues similar to those suffering from borderline personality. This is clearly not new information for those familiar with eating disorders. The comparison between eating disorder and borderline personality traits is striking. See Table 1.

Given this association between borderline personality and eating disorder features, it is has become evident that eating disorder patients can benefit from skills training that addresses the common behavioral and emotional dysregulations. Specifically, the acquisition of Biblically-based skills can help to decrease labile emotions, interpersonal chaos, impulsiveness, confusion about self and identity, cognitive dysregulation and distortions, and spiritual confusion; and can serve to increase interpersonal effectiveness, emotion regulation, distress tolerance, and acceptance, as well as awareness of self, environment, and God’s action in the patient’s life.

The CBT skills training model is predicated on several assumptions regarding these difficult to treat patients (Linehan, 1993b):

* Patients are generally doing the best they can
* Suicidal and borderline individuals’ lives are unbearable as they are currently being lived
* Patients may not have caused many of their problems, but have to solve them anyway
* Patients need to do better, try harder, and be more motivated to change
* Patients want to improve
* If patients could do something different, they would
* These patients need to learn new ways of dealing with their thoughts and feelings through the acquisition of skills
* Patients must learn new behaviors in all relevant contexts
* It is essential to believe in patients’ ability to get out of the misery and build a life worth living: to instill hope
* Validate whatever you can, truthfully

Table 1. Comparison of Borderline Personality and Eating Disorder Traits

BORDERLINE PERSONALITY (Area of Dysregulation)

1. Emotional Instability (Emotional)

2. Anger Problems (Emotional)

3. Unstable Relationships (Interpersonal)

4. Efforts to Avoid Loss (Interpersonal)

5. Suicide Threats, Parasuicide (Behavioral)

6. Self-Damaging, Impulsive Behaviors, including ETOH/Drugs, Promiscuity, Shoplifting (Behavioral)

7. Cognitive Disturbances, Black-and-White Thinking (Cognitive)

8. Unstable Self and Self-Image (Self)

9. Chronic Emptiness (Self)

EATING DISORDERS (Area of Dysregulation)

1. Emotional Instability, Numbness, Alexithymia (Emotional)

2. Anger, Hostility, Irritability (Emotional)

3. Conflictual Relationships (Interpersonal)

4. Weak Social Support, Isolation (Interpersonal)

5. Self-Starvation, Parasuicide, Medical Complications (Behavioral)

6. Impulsive Behaviors, including ETOH/Drugs, Bingeing, Purging, Promiscuity, Shoplifting (Behavioral)

7. Cognitive Distortions, Black-and-White Thinking, Rigidity (Cognitive)

8. Low Self-Esteem (Self)

9. Lack of Identity (Self)

The model relies on a two-fold premise: acceptance on the one hand and change on the other. These balance and counterbalance one another: we validate patients while challenging them to change the eating disorders’ cognitive distortions. This two-fold approach is clearly consistent with Scriptural wisdom. Jesus often implored us to do both-and. In the story of the woman caught in adultery ( John 8:1- 11), Jesus forgave the woman—validating her worth as a human being; and he also told her to "go and sin no more"–challenging her to change. In essence, this dual message mirrors the essential Gospel truth that we are forgiven and must also change our ways of thinking and acting to proceed in a new direction.

At Remuda, we have been strategically incorporating an adapted form of CBT skills work into our curriculum since 2000, fully integrating the skills with Scriptural truth. Our Biblical adaptation has been accomplished without compromising the integrity of the Word of God or the Biblical integrative work that is foundational to the Remuda system.

We initially utilized the CBT skills training approach with the most refractory patients to supplement standard treatment interventions. We soon found it to be exceptionally beneficial to the entire patient population. Our front line treatments continue to be nutritional and medical stabilization, family therapy, and traditional CBT. Yet the inclusion of Christian CBT skills training has enhanced our treatment program, influencing and improving our therapeutic outcomes significantly (Cumella, 2003).
CBT Skills Training

The overarching goal of CBT skills training is to modify or replace learned behavioral, emotional, and thought response patterns associated with problems in living, patterns which contribute to the personal and interpersonal misery and distress of the patient and which may impact her health.

For many eating disorder patients, modifying or stopping certain eating disorder behaviors may be incredibly difficult, creating resentment and resistance to therapeutic interventions. Therapeutic suggestions are often met with defensiveness fueled by irrational fears and a perceived threat that the treatment team is attempting to control the patient and intrude on his/her security. At the same time, patients are often aware that the choices they are making are life threatening, and they realize that they are harming themselves. As therapists take the stance of emphasizing validation and acceptance, recognizing how difficult it can be for patients to embrace change, therapists are able to support patients emotionally as they work through this ambivalence. Skills training then provides an opportunity to objectify patient ambivalence by putting the focus on the need to change maladaptive symptom behaviors and learn techniques/tools to assist with this change. All the while, patients feel validated as persons with legitimate needs that they have been attempting to address through their eating disorder.

CBT skills training squarely focuses on these core strategies of validation and problem solving in an attempt to facilitate change. Validating patients’ needs provides an empathetic understanding of their difficulties and suffering. Problem solving focuses on developing, enhancing, and building necessary adaptive skills. Thus, the course of therapy includes changing behaviors and incorporating cognitive and behavioral techniques to increase the patients’ understanding of the function(s) underlying symptom behaviors. In this process there is an identification of the antecedents that lead to problem behaviors as well as the consequences of those behaviors. Once antecedants are identified, prevention strategies are created to decrease maladaptive behaviors in the future. Because eating disorder patients’ need to pay attention to modifying their behaviors, not just insight or understanding, skills acquisition results in sustained life changes.

In fact, skills training addresses all three aspects of the human soul—the emotions, thoughts, and will (Wall & Eberly, 2002). It helps patients to regulate emotions effectively, to modify thoughts realistically, and—because of its validation of their legitimate underlying needs and dignity as persons—helps them to feel free to choose new behaviors without feeling that their identity is being compromised.

While engaged in skills training, the daily use of a self monitoring tool helps patients keep track of skills they have been using as well as other tools and skills available to them. Other cognitively-focused techniques, such as worksheets and assignments, assist patients in their behavioral progress, accountability, and skill generalization. For instance, in skills training patients are taught how to conduct their own behavior chain analysis, which helps them identify a problem behavior, what may be interfering with solving the problem, and skills that can be used to replace the behavior.

Four CBT skills training modules (Linehan, 1993b) have been reorganized, adapted, and modified for use at Remuda through thoughtful integration with Scripture. The redesigned skills training sessions emphasize two goals: 1) decreasing behaviors likely to interfere with therapy and recovery, and 2) increasing skill knowledge, strength, and generalization. The validation and problem solving strategies are used throughout. Each of the four skill sets is described below.

1. Practicing Presence. The goals of this module are to learn how to observe, describe, and therefore participate more effectively in life.

These goals are achieved by giving your attention to being in control of your own mind, instead of letting the mind be in control of you. "Take captive every thought to make it obedient to Christ" (2 Corinthians 10:5). Patients are encouraged to practice being aware of their environment, thoughts, and feelings: tuned in to potential triggers that may lead to harmful behaviors. Patients stop and consider the logical outcome of a decision to engage in a particular behavior and learn how to slow down their thoughts to keep them from racing to a preconceived judgment. They weigh this consideration against the emotions pushing them toward the behavioral decision, seeking the wisest choice they can make. In this process, Christians are encouraged to seek the mind of Christ and be prayerful and attentive to the Holy Spirit’s guidance. In essence, this skill is about learning to be a more careful observer and listener, to oneself, others, and the Holy Spirit.

Jesus modeled staying in the present and not being so future focused that we create distress for ourselves. He said, "…do not worry about tomorrow, for tomorrow will worry about itself" (Matthew 6:34). Practicing the presence of God, being quiet before God, truly attempting to be still, and letting go of distractions are skills that require time and patience but have lasting rewards. These skills can assist in experiencing peace and contentment. "Be still before the LORD and wait patiently for him; do not fret… A little while, and the wicked will be no more… But the meek will inherit the land and enjoy great peace" (Psalm 37:7,10-11).

2. Interpersonal Effectiveness. Both successful/effective and unsuccessful/ineffective people have problems. It is the attitude toward the problems that distinguishes one from the other (e.g., Seligman, 1998).

This module’s goal is to learn how to meet one’s interpersonal objectives, find and maintain positive relationships, and maintain/improve self respect in the process.

To achieve these goals, patients learn to ask themselves objective questions. E.g.: What specific results am I trying to attain in this interaction? What do I have to do to get the results I want? Clear communication techniques are learned and then applied to real life situations. For example: learn first to identify what you are feeling or needing and how to express that confidently; then learn to ask for your needs to be met in ways that do not devalue or invalidate the other person or yourself. This exercise, reinforced over time, is similar to teaching assertive communication but with a shift toward operationalizing the concept of interpersonal effectiveness. Learning to anticipate a response from others and realizing what is and is not helpful are keys to becoming a socially effective communicator and effective interpersonal problem solver.

In this module there are opportunities to talk about many emotions, especially anger. A Scriptural concept frequently cited is: It is appropriate to be angry, but do not sin (Ephesians 4:26; James 1:19). Under certain circumstances, anger can be a healthy emotion. But learning to regulate anger and be kind to those who have hurt you is a challenge. Patients are encouraged to look out for the needs of others as well as for themselves (Philippians 2:4) and are challenged to find this balance by asking the question: How do I want this person to feel about me after we end this interaction? Finding this balance is important in helping patients to formulate an other-centered interest.

Overall, Interpersonal Effectiveness Skills help patients learn how to attend to relationships by balancing priorities vs. demands, building mastery in communication, and increasing self-respect.

3. Emotion Regulation. In the Emotion Regulation module, patients develop a greater understanding of emotions, reduce emotional vulnerability, and learn techniques to decrease their emotional suffering.

Emotion regulation involves exercises in cognitive modification and restructuring. Examples of how patients strengthen their ability to regulate emotions include: building on positive experiences, such as choosing to do one thing each day that prompts positive emotions, and accumulating more positive experiences over time; listing small steps toward a goal and taking the first step to achieve that goal; attending to and repairing relationships. Reaching out to new relationships and working on current relationships serve to increase confidence in one’s ability to navigate relationships successfully, which builds positive emotions and enhances social support.

Another emotion regulation skill is to "avoid avoiding". Ambivalence and avoidance often go hand in hand. For those with alexithymia—a condition of emotional unawareness often seen in eating disorders—emotions are a befuddlement. Patients have been successful in emotionally numbing themselves for a long time through the eating disorder, and often are not comfortable with this new skill of “avoiding avoiding”. It is not unusual to encounter resistance due to the level of fear that emotions provoke in these patients. However, "avoiding avoiding" is essential to be effective in making and keeping relationships. It is important to teach patients that they are not their emotions, however blunted or out of control they may experience their emotions to be. Patients will often be confronted about faulty thinking, such as: "Since I feel fat, I am fat; since I feel inadequate, I am inadequate." Patients need to return to the basics of observing their emotions first, allowing themselves to experience the emotions, renewing the mind often by recalling that they are not their emotions, and practicing acceptance of their emotions for what they are.

An emotion regulation approach especially helpful for those with anorexia is learning "opposite action" skills. Patients are encouraged to do the opposite of or act contrary to an emotion, but not try to hide or avoid the emotion. Examples include: when feeling afraid, choosing to approach; when depressed, getting active; when angry, behaving with kindness. These opposite action skills teach patients to challenge themselves rather than reinforce familiar ineffective behavioral responses. This is similar to exposure with response prevention, another modality used with severe eating and anxiety disorders. Every time an anorexic patient approaches food and consumes it, s/he learns that despite his/her feelings of fear it is important to approach the food anyway. Over time, because of exposure to the feared object, the anxiety and fear diminish and eating normalizes. Previously, food avoidance was the only way the patient knew how to reduce anxiety. Avoidance was negatively reinforced by the anxiety reduction it afforded. With exposure, however, the avoidance behavior is not reinforced and the anxiety about the feared object diminishes. A similar change occurs when using “opposite action” skills.

To strengthen emotion regulation skills, it can be helpful for patients to study and meditate on the broad range of emotions that Jesus exhibited in Scripture—how He appropriately and freely expressed emotions and also used personal restraint and self control. Jesus became frustrated with his disciples on occasion, yet never attacked them. When hit, the human instinct is to hit back; when forced to go a mile, to express resentment; when robbed, to seek restitution or punish the robber. And yet, Jesus taught us to do the opposite: to turn the other cheek, to walk the second mile voluntarily, and to give to the one who would steal from us. The book of Proverbs also contains wisdom on how to manage emotions.

4. Distress Tolerance. Learning to tolerate distress is not easy for anyone. We are not born with this skill, but must learn it. The task is made more difficult for those who have been raised in invalidating environments. These individuals must learn the art of combating negative self-talk while purposefully remaining in the distress and coping with it.

The focus of Distress Tolerance Skills is learning how to accept life’s realities: distressing events will happen. We need tools in our toolboxes to deal with the distressing moments when they occur: crisis survival strategies. Being better equipped to deal with these realities fosters patients’ self-efficacy and confidence in their capacity for life management. Patients also learn how to develop a list of pros and cons before making major life decisions that could result in greater distress.

Among Distress Tolerance Skills are acceptance skills–a focus on learning to accept what is happening at the moment. Accepting and tolerating unavoidable suffering is not a new concept for Christians. Jesus said, "In this world you will have trouble. But take heart! I have overcome the world" ( John 16:33). In this vein, it is essential to challenge the schema that life is supposed to be easy and to help patients shift to a more mature understanding which recognizes that life includes distress. Patients are more able to make this shift when they develop a relationship with God, who promises to be with them "to the very end of the age" (Matthew 28:20). Such a secure relationship provides an opportunity to confront issues of fear and trust. Also, knowing that one is not alone with one’s suffering can alleviate the awfulness of the experience. "I will ask the Father, and He will give you another comforter and He will never leave you…" ( John 14:16; The Living Bible).

Helping patients to find meaning in suffering or distress can also be useful. Victor Frankl, a holocaust survivor and founder of existential psychotherapy, wrote of how he was able to survive the horrors of the Nazi concentration camps by using this strategy (Frankl, 1997). Helping patients search for the positive in their pain is abundantly supported by Scripture. Christian believers are able to keep troubles in perspective when aware that they have come with a purpose and blessing. Our trials help us to help others and refine our faith and character (1 Peter 1:6-7; 2 Corinthians 1:6). There is often a silver lining in the dark clouds of suffering.

The question of trauma is often brought up in relation to distress tolerance. Can you and should you teach patients to tolerate the distress of an awful trauma? Tolerating distress does not imply an approval of the act that created the pain. The trauma needs to labeled and addressed as trauma. But as awful as the trauma was, the patient now has to deal with the reality of it, including the distress it has led to. There is no way forward without doing so.

By improving distress tolerance skills, patients may ultimately find themselves at a point where they can forgive themselves for things they have done which are creating distress, and also forgive others’ failings. In the Christian community, this is an aspect of grace… we receive it unconditionally and we are called to extend it to others. This understanding assists patients to recognize that moral laws exist for our protection: they prevent distress and so it makes sense to accept them. But, there is also "no condemnation for those who are in Christ Jesus" (Romans 8:1). We are forgiven for our failings, and free to change our ways, making healthier and moral choices that will not likely produce distress but instead contentment, peace, and joy.

Of course, when patients are confronted with the need for behavior change, resistance often increases—hence, the infamous "power struggle." The skill of acceptance helps patients to understand that the need for change is not predicated on someone else’s will being forced upon them, but rather that certain behaviors result in distressing consequences. Patients are taught that they are accepted just as they are and can accept themselves as they are, but also that they will benefit from change. At Remuda, we recognize the clear parallel between this approach and Christian teaching. Change takes place best in this context of acceptance. "Let us then approach the throne of grace with confidence, so that we may receive mercy and find grace to help us in our time of need" (Hebrews 4:16).

For the thousands of eating disorder patients with whom Remuda has used CBT skills, outcomes have been positive (Cole, 2003). Patients frequently mention on discharge satisfaction questionnaires how much CBT skills training has helped them in recovery. Other eating disorder specialists are recognizing similar efficacy for CBT skills training with eating disorders (e.g., McCabe & Marcus, 2002), with more than 10 papers recently published so demonstrating. These skills therefore appear to be effective additions to more traditional CBT with eating disorder patients. As with all therapeutic models, for Christian practitioners Biblical integration is necessary. Parts of CBT skills training have been modified or deleted at Remuda to accomplish such integration and maintain our Christ-centered, Biblically-based treatment philosophy.

American Psychiatric Association (2000). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, Suppl., 157, 1-39.

Cole, L. (2003). The efficacy of skills training with eating disorder inpatients. Unpublished doctoral dissertation, Argosy University, Phoenix, AZ.

Cumella, E.J. (2003). Treatment outcome reports: Rio adult intensive center. Wickenburg, AZ: Remuda Ranch at The Meadows Center for Anorexia and Bulimia, Inc.

Frankl, V. (1997). Man’s search for meaning. New York: Pocket Books.

Linehan, M. (1993a). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.

Linehan, M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press.

McCabe, E.B. & Marcus, M.D. (2002). Is dialectical behavior therapy useful in the management of anorexia nervosa? Eating Disorders: The Journal of Treatment and Prevention, 10, 335-337.

Richards, P.S & Baldwin, B.M. (2000). What works for treating eating disorders? Conclusion of 28 outcome reviews. Eating Disorders: The Journal of Treatment and Prevention, 8, 189-206

Seligman, M. (1998). Learned optimism: How to change your mind and your life. New York: Free Press.

Wall, A.D. (2003). Cognitive-behavioral therapy with eating disorders: A Christian perspective. The Remuda Review: The Christian Journal of Eating Disorders, 2, 1-8.

Wall, A.D. & Eberly, M. (2002). Five Biblical factors in eating disorder development. The Remuda Review: The Christian Journal of Eating Disorders, 1, 6-10.

Wonderlich, S.A. (1995). Personality and eating disorders. In K.D. Brownell and C.G. Fairburn (Eds.). Eating disorders and obesity: A comprehensive handbook (pp. 171 – 176). New York: The Guilford Press.
Equine Therapy with Eating Disorders
Edward J. Cumella, PhD, Bradley Hoffman, EAPI, & Cheryl Musick, EAPI
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

“Ask the animals, and they will teach you.” (Job 12:7)

According to a recent article in Eating Disorders: The Journal of Treatment and Prevention (Cumella, 2003), equine therapy may yield a variety of psychotherapeutic benefits for patients with eating disorders. Possible benefits include:

* Self-Confidence: The learning and mastery of a new skill— horsemanship—enhances patients’ confidence in their ability to tackle new projects, such as recovery.
* Self-Efficacy: Learning to communicate and achieve harmony with a large animal promotes the experience of self-efficacy instead of helplessness and may encourage patients to take on other recovery challenges.
* Self-Concept: Riding helps patients to develop a more realistic view of themselves through awareness of their size in relation to the horse. This is especially important in treating the body image misperceptions common in eating disorders.
* Communication: Horses’ sensitivity to non-verbal communication assists patients in developing greater awareness of their emotions, non-verbal cues, and the role of non-verbal communication in relationships.
* Trust: Learning to trust an animal such as a horse also aides in the development, or restoration, of trust.
* Perspective: Through grooming and care activities for a specific horse, patients are able to put aside the absorbing focus of their mental illness and direct their attention outwardly toward safe and caring interactions.
* Anxiety Reduction: Many studies of human-animal interaction indicate that contact with animals significantly reduces physiological anxiety levels. Some patients initially fear horses, but horses’ genuineness and affection allay these fears, which may approximate exposure therapy for anxiety.

Temptation Alley: An Equine Experiential Exercise
Bradley Hoffman, EAPI
Equine Department
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

Instructions: An equine specialist sets up a maze-like alley laced with hay, grain, and escape routes that are tempting to a horse. The goal is for the patient-rider to guide the horse from a starting point through the maze to the end of the alley. Two others stand on either side of the horse and assist the patient by holding the end of lead ropes attached on each side of the halter.

Experience: We set up a temptation alley experiential to mirror the family structure of a patient who was enmeshed with her mother. The patient sat on the horse bareback, without a saddle or reins to assist her. Parents stood on either side of the horse, each holding the end of a lead rope. The family was asked to move the horse through the alley. The family completed the course. Then, however, we disconnected dad’s lead rope. We asked dad to support his daughter not by being attached but by speaking words of encouragement and responding to her needs when she asked for help. Mom and patient then attempted to complete the course with only mom connected on one side to direct the horse. With the lead rope now connected only on one side, the patient and mom ended up going in circles and getting frustrated. After about 15 minutes of struggling to move forward, they realized that being connected in this manner was unbalanced and incapable of promoting progress. Finally, the patient asked: "Mom, would you give me your rope?" The patient then created reins from the lead ropes and was able to direct the horse through the alley, while mom and dad came alongside in support. The patient’s affect changed dramatically once she realized that she was able to problem-solve effectively and complete the goal.

The family discussed the experiential. The patient was overjoyed, stating, "I feel like I have some power and control back in my life." Mom indicated that she felt as though a huge weight had been lifted from her. She realized that she had been taking on more responsibility than she needed to. She compared temptation alley to recovery, realizing that she is there as support but her daughter is the one who has to do it. The patient said that she now feels empowered for recovery and that using this experiential has shown her that she is capable of anything.

* Decreased Isolation: For many individuals with mental illness, there is a history of feeling rejected, different, and isolated from other people. Horses’ unconditional acceptance may invite patients into relationship and enable them to practice non-verbal relationship skills.
* Self-Acceptance: Many patients are concerned that they will embarrass themselves while riding. As patients learn that other participants are engaged in their own equine experiences and observe the comfort of the horses in their own skin, fears of embarrassment are often reduced and self-acceptance increased.
* Impulse Modulation: The need to communicate with a horse calmly and non-reactively promotes the skills of emotional awareness, emotion regulation, self-control, and impulse modulation. Research indicates that animal-assisted therapy reduces patient agitation and aggressiveness and increases cooperativeness and behavioral control.
* Assertiveness: Communicating effectively with horses requires riders to demonstrate assertiveness, direction, and initiative, potentially enabling patients to express their needs and rights more effectively in other relationships.
* Boundaries: Many patients have experienced prior relationships as controlling or abusive. Healing may take place as patients discover that riding occurs within the context of a respectful relationship between rider and horse, and that, although physically powerful, each horse typically operates within the boundaries of this mutually respectful relationship.
* Creative Freedom: The playful aspects of riding and team equine activities can help restore spontaneity and the ability for healthy recreation and play in those who are emotionally inhibited or over-controlled.
* Spiritual Growth: Feelings of joy and spiritual connection are often discovered or revived as patients experience the earth’s beauty during equine rides and develop an appreciation for the horse as a unique creation.

Overcoming Fear: An Equine Experiential Exercise
Cheryl Musick, EAPI
Equine Department
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

She stood on the porch in front of the tack room, tears streaming down her face. Nursing had already notified equine staff about the terrified patient who might not ever ride a horse. Her peers were concerned and gathered around her to soothe her fears. But she crossed her arms, set her stance, and said: "I am not riding."

I took her aside and gently assured her that I would stay with her. I explained that staff had deliberately selected her horse, Laramie, for his gentle nature. I gave her time to discuss her fears and to hear the calm confidence of my voice. I challenged her to take just one step at a time rather than looking at the whole picture. Her entire group cheered as she swung her leg over the saddle for the first time.

Her knuckles were white as she tightly gripped the saddlehorn. We encouraged her to stay focused and relaxed.

But her eyes widened with fear as she watched her peers trotting and cantering around the arena. She gripped her saddle, set her jaw, and firmly stated: "I will never do that."

I challenged her again to take just one step at a time.

I fondly remember her family week rodeo. She laughed and took her hand from the saddlehorn waving enthusiastically to the audience. My heart danced with warm pride during her victory lap—a moment to celebrate her successes in recovery. Her face was full of sunshine and joy as she cantered around the arena.

I will always remember the day she said goodbye to her horse. Tears streamed down her face as she wrapped her arms around his neck and choked out the words: "Thank you so much…I’m going to miss you, Laramie."

The article describes the process of equine therapy as follows:

"Patients may participate in one or more Equine Therapy sessions per week, including trail rides, arena sessions focusing on advanced skills, riding to music, team activities, rodeos, and instruction in horse care, grooming, saddlery, and equitation practices. Patients are typically paired with specific horses based on an assessment of patient riding needs and experiences. Safety is addressed in several ways. Patients wear safety equipment and begin Equine Therapy only when approved by a physician. Horses are carefully selected for characteristics that make them suitable to patient contact. Horses receive continuous schooling and training for their participation in Equine Therapy. Experienced Equine Therapists understand the safety issues associated with good horsemanship. Staff may also be trained and certified in Equine Assisted Psychotherapy by the Equine Assisted Growth and Learning Association (EAGALA), a non-profit organization that promotes, educates, and provides standards of practice, ethics, and safety in Equine Therapy. Staff may obtain continuing education through the Equine-Facilitated Mental Health Association (EFMHA), which sponsors, promotes, and organizes research on the efficacy of Equine Therapy in a mental health context. EFMHA offers publications regarding the effectiveness of Equine Therapy and hosts an annual Equine Therapy training conference."

The accompanying insets describe two equine experientals that have occurred at Remuda. Each exemplifies several benefits of equine therapy in treating eating disorder patients.

Cumella, E.J. (2003). Is equine therapy useful in the treatment of eating disorders? Eating Disorders: The Journal of Treatment and Prevention, 11, 143-147.

Permission was obtained to reproduce the material quoted above.

Next Issue: Psychological Dimension of Eating Disorders Continued

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