Helping patients recover from eating disorders through PLISSIT
By Andrew Walen, LCSW-C, LICSW, CEDS
Eating disorder treatment centers will tell you they follow the best evidence for care in an effort to convince you to choose their program. But when you ask the staff for details, it’s not clear they really know what best evidence means. I’ve spent a long time treating eating disorders, substance abuse, anxiety, depression, and all the related concerns. What I continually believe works best for me and my clients, and what I have trained my staff in, is to follow a simple acronym – PLISSIT.
This acronym dates back to the founders of cognitive therapy techniques like Albert Ellis and Tim Beck. My mother, Dr. Susan Walen, was the founder of The Baltimore Center for Cognitive Therapy, and was a renown psychologist, author, educator, and protégé of the aforementioned thought leaders. She in turn taught me early in my career the important of using PLISSIT. So, with all this buildup – what in the world is it you ask? Let’s get to it.
P – permission. The first and most important part of the work is giving clients permission to feel the way they feel and let them know they are not some weird alien creature for having an eating disorder. By helping clients normalize their experience given their history, underlying psychiatric concerns, and the society and culture they come from, we are taking some of the anxiety away and developing a therapeutic relationship. Give them the grace of empathy and create that bond. That’s job one!
LI – limited information. The next task is educating our clients about eating disorders, what they are, how they develop and fester, and how they are treated. By taking the mystery out of the disease and what’s needed to recover, we take still more of the anxiety away. If you are going into battle, you are less scared of the adversary if you know more about them. You can predict what is likely to happen and make plans about how to manage those obstacles. But a commonality in eating disorders is obsessive thinking and perfectionism. So, we keep it “limited” to avoid unnecessary overthinking and “what if”-ing. I find it crucial to make sure clients know their specific diagnosis, so they can put a name to the thing they are fighting. It makes it real and tangible. It’s hard to punch a cloud.
SS – specific solutions. The goal here is to give clients the tools they need to recover. We talk about eating disorders being a disease of anxiety (sensing a pattern here yet?). To get past anxiety, you must be exposed to it over and over again. That’s why our clients eat meals with us in the program every day. We teach them how to identify and then cope with their physical, emotional, and behavior response to eating, a treatment modality called exposure and response prevention (ERP). The more this is done, the more clients learn to tolerate their anxiety using the tools they are taught in groups and individual therapy. Those tools are part of a treatment called Dialectical Behavioral Therapy (DBT). The work may include distraction techniques, deep breathing, muscle relaxation techniques, and other skills. From there we work on Cognitive Behavioral Therapy (CBT) skills. Clients learn to identify if their thoughts are rational or irrational and how to dispute those irrational ones. There’s a lot more to it, but this is a snapshot of the work.
And finally …
IT – intensive therapy. This is, in essence, digging in the dirt. Some clients may never get to this stage if they can’t figure out how to tolerate their emotions and challenge their unhelpful thought patterns. For clients who are ready for this, the goal is to unpack the root causes of their disorder, the role of society, family, trauma, neglect, and other issues that may have impacted their physical and emotional wellbeing. It’s hard work and takes the longest amount of time. But for those who can get here, it’s a journey worth the trip.
So, there it is – the whole model. Elegant in its simplicity, and powerful in its efficacy. While most programs do some version of this, it may not be well thought out and planned. For us it is. If we can help you reach the goal of full and sustained recovery from your eating disorder, please reach out.