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Sunday 5 May 2013

Whacking moles the Irish way

It was inevitable that I was going to quote my great friend, Irish, after a thread on the forum.  A parent had become distressed about a clinician's advice to not push for more weight gain at the moment, as the patient's anxiety levels were going off the scale and there was an immediate likelihood of self-harm.

There were two points raised: the first was about BMI in adolescents.  I am not going to have another BMI rant and have was gently reminded by the Fairy Blogmother that, until someone comes up with an alternative, BMI is the best tool we have got.  (I still stand by my King of the Castle position that any clinician who uses JUST BMI to define recovery or as a measure of mental/physical health is an Idiot!).

The second point was the anxiety that was threatening not only the patient's sanity, but also her physical wellbeing.  How do you tackle the whole thorny problem of a patient having more than one dangerous problem at the same time and one is interfering with the other?  Especially when both problems could be life threatening and cause physical harm that could be long lasting?

(Forum thread for those who want to read it)

DBT seems to have many answers to this particularly thorny problem and Irish explains it so well.

One of the problems with the Symptom Whack-A-Mole Syndrome (hereafter SWAMS) is EXACTLY that "what do we do first?! o_0 thing. I think a common thread here is how INEFFECTIVE whacking at which ever random symptom happens to be (percieved to be) worst right now, turns out to be in the long run.

Marsha Linehan (developer of DBT) started with a clientele of patients who were suicidal, chronic and almost all had multiple diagnoses. These were women who'd endured years of SWAMS, so she developed a formal hierarchy, allowing the clinical team to focus on a few things, then move to the next issue, & etc. Instead of endless random whacking at moles as they pop-up repeatedly, you systematically target the WORST offending mole (or two). Once that problem is manageable, you target the NEXT mole.

The standard hierarchy is:
  1. Decreasing suicidal behaviors.
  2. Decreasing therapy interfering behaviors.
  3. Decreasing behaviors that interfere with the quality of life.
  4. Increasing behavioral skills.
  5. Decreasing behaviors related to post-traumatic stress.
  6. Improving self esteem.
  7. Individual targets negotiated with the patient.
Suicidality is ALWAYS ALWAYS ALWAYS FIRST, and encompasses ED that has become life threatening. It does not only refer to "has a plan" but includes "behaviors that can kill you that you keep doing even without a plan/intention". ED behaviors are also NECESSARILY "Therapy Interfering Behaviors"! Food is medicine, and if you're not eating / purging / binging, that means that your therapy is being severely interfered with.

So you see, in either case, under the DBT model, ED behaviors merit full treatment attention and highest priority. The only exception being, as in Foodsupport's situation, when even MORE threatening behaviors are in play, THOSE get priority. Anxiety (as a common for instance) is typically more like a #3. If your ED is fairly well in the recovery process, and anxiety spikes up, and starts interfering with eating (I bet a lot of us know this cycle) ... well, then the anxiety becomes #2, and you target therapy at it, to keep the progress you've made on the other more serious stuff.

The unifying theme here, is keeping your focus on the worst mole or two, so you don't wind up with SWAMS and moles running everywhere. That is just exhausting and counter-productive. Being Alive is #1, engaging in and complying with treatment is #2. Keeping #2 going is how you keep #1 happening, and how you eventually get to address everything ELSE. If you need to manage your 1b mole This Way to keep your 1a mole from popping up Over There, well, that is your situation, and that's what you need to do. 


  1. lOVE it and so true with my d they are dealing with the self harm before the AN using DBT - yes shes alive but now is 4 kg less than when she started DBT. Really wish we could whack 2 moles at a time!!!!

  2. It's so difficult isn't it Kirsten - we're whacking the self-harm mole here too, with some success and without tooooooooooo deleterious an affect on the eating mole, but the social anxiety, don't have a life mole is having a field day - oh for a one size fits all mole trap.