(Editor’s note: The post below has been edited in response to the feedback received. It is now in alignment with F.E.A.S.T.’s principles and we are fully comfortable with the content. Thank you to Dr. Laura Hill for her extreme graciousness and her willingness to hear what our community had to say.)
By Laura Hill PhD
Assistant Clinical Professor, Department of Psychiatry, The Ohio State University
Voluntary Assistant Clinical Professor, Department of Psychiatry, University of California, San Diego
Temperament-Based Therapy with Supports (TBT-S)
In the field of realty, the phrase “location, location, location” is used, referring to the primary factor that impacts the cost or value of property. In mental health, it is temperament. Temperament needs to be addressed when offering support on a daily basis, during core developmental stages in one’s life, and during treatment intervention at any level of care. Temperament impacts the cost of one’s daily emotional expense, the value of prevention and the method of intervention.
What is temperament? Temperament is the biological basis of our personality. It is created by one’s genes which set the framework for brain circuit development that evolves and functions over one’s life span. Temperament consists of one’s personality traits. Every person has traits. It’s the combination of those traits that creates our character over time. We don’t get to choose our traits. We inherit them. Combinations of traits can make a person more prone toward successes and illnesses. No one is without traits. No person has a “perfect” set of traits. It is how each person trains and expresses their traits that makes their life more productive and fulfilling. Temperament is an underlying contributor to how we think, feel, and respond. Temperament is fundamental to who a person is. It influences when change can occur with less resistance.
Character is the external shaping of one’s temperament. In other words, temperament is to nature as character is to nurture, (see Figure 1.1). A person’s temperament needs to be acknowledged in order to make the best of one’s character, or to intervene if one’s behaviors become problematic. For example, a person may have an extroverted, kind, and impulsive temperament that is characterized by impulsively wanting to go out with friends, and impulsively binge eating and purging, while also being a great friend to others. Encouraging your loved one’s impulsivity when it befriends others and intervening when it triggers purging are equally important.
Temperament-Based Therapy with Supports (TBT-S) is an emerging treatment approach that acknowledges and works with a person’s temperament. Currently, ED treatments focus on clients’ characteristics, their behavioral symptoms such as binge eating, purging, food restriction, excessive exercise, or weight change. The biological underpinnings that trigger and influence ED symptoms have been ignored. TBT-S advocates that clinicians and Supports work with one’s traits to manage one’s ED symptoms.
TBT-S also stresses the fundamental importance of including Supports. Supports, the “S” in TBT-S. It is the client-chosen word for those who offer the wide range of assistance outside of treatment. Supports include clients’ parents, spouses, partners, friends, pastors, colleagues, sibling, etc. Older adolescents, young adults and older adults shared that they did not want to be “cared for” by carers or caregivers. They stated they wanted “support.” It appears that older clients draw from a wider range of support persons than do young adults.
While “Support” refers to the “who,” it also refers to the “what” and “how,” that is offered to clients. This means that the word “Support(s),” in TBT-S has a triple role, the who, the what and the how of intervention or assistance given outside of formal treatment. The word Support(s) is used by TBT-S and throughout this blog to refer to this triple role. The “S” is capitalized to distinguish the term with its unique, wide-ranging roles for persons and actions taken to assist those with ED, complementing those who provide formal therapy.
TBT-S treatment brings Supports formally and intentionally into the treatment process. It recognizes that interventions occur outside of formal therapy sessions, just as they occur inside clinical settings. Supports are the persons who offer assistance to clients’ daily meals, food intake, work, school, and social interactions. Supports are the persons who influence and offer assistance to clients most of the time. Figure 1.2 depicts the massive range of roles that Supports hold in the lives of those with ED and how their roles play out when responding to both their loved one’s temperament and to their ED symptoms. TBT-S intervenes to provide consistent information and tools inside and outside of treatment, instead of keeping Supports in the dark, not knowing what tools may be helpful.
Why is temperament important? Temperament is important for Supports and clinicians to acknowledge and utilize because it defines the nature and capacities of each person. Parents who have more than one child typically observe how temperament plays out in their children on a daily basis. Siblings of the same gender are typically quite different in many ways (unless they are identical twins). Temperament is a core element that establishes personality differences. One child may be rowdy, the other quiet and withdrawn. One may not challenge parental rules and the other may be defiant. One may have great grades, and the other child cares little about studying and test scores. One is confident, and one is uncertain. One is physically active, and one likes to sit and tinker with toys. These tendencies, called traits, are apparent at birth and throughout childhood and adolescence. They are genetically programed at conception, and cultivated during fetal development and childhood., Traits are the structural framework that set in motion the amazing differences in expressions of children. Temperamental tendencies become even more established as one ages.
Does temperament mean a child or adult cannot change? Is your loved one doomed to have eating disorder symptoms forever? Oh contraire. TBT-S explains research findings that traits are on continuums ranging from productive, strong responses that make up one’s character to unhealthy, destructive responses that also make up one’s character. Traits can shift from positive to negative responses and back again. A trait that may motivate a loved one to compulsively overexercise (destructive expression) is the same trait tendency that motivates a professional to compulsively get tasks completed (productive expression). Compulsion can be both beneficial and harmful on any given day or in any developmental life stage. Personally, I would look for obsessive and compulsive traits in the professionals I hired because I knew that they were more likely to devote extra attention to details when completing work tasks.
The field of psychology has trained clinicians for decades in childhood temperament with little focus on adult temperament. The psychological field has primarily focused on the pathology of traits when training clinicians, the destructive side, and has provided relatively little training on the productive side of trait expressions, until positive psychology was developed. The treatment tendency has been to focus on what is wrong and not what is working well. Both need attention clinically and personally.
TBT-S advocates treating to clients’ full range of trait expressions. The philosophy of TBT-S is to utilize traits as strengths. Work with clients’ productively-expressed traits, their natural strengths to use their own resources to manage their ED symptoms. It is also important to identify current destructively expressed traits and work to shift those tendencies toward more productive expressions. If traits shift toward destructive (harm to self or others) expressions, then clinicians and Supports can unite to help clients reshape and shift their trait expressions back toward healthier and productive expressions.
When are effective times to shape traits to prevent or manage ED symptoms?
I will speak to two different times that Supports could step in and “reroute” trait expressions. 1. During childhood development, and 2. During specified levels of anxiety.
1. Interventions during childhood may help prevent ED symptoms from developing during adolescence.
Childhood is a time of brain and body growth. It is a primary stage in life when trait expressions are shaped by environmental influences. For example, a child may demonstrate productive compulsive tendencies prior to puberty by always checking to make sure homework is submitted on time, or to have a clean bedroom, or to be physically active. It is a pleasure as a parent to observe such positive self-motiving trait tendencies. Then puberty hits. It may seem to parents that their child is transforming before their eyes. In some children, trait tendencies shift from being neat and tidy and physically playful to compulsivity on steroids. Physical play may become a requirement to run a specific amount of time and distance. Lessons become fastidiously monitored. Worry about good grades transforms into grades are never good enough. An impulsive desire to have friends over during childhood becomes an impulsive need to purge food. The temperament is the same, but some trait tendencies transformed from what was once productive toward destructive expressions.
As we describe in our new book, it is genes that modulate hormonal changes during puberty. Hormonal levels increase and impact some genes to shift, increasing trait expressions. “For some this translates into ED symptoms, and unhealthy behaviors. The same temperament traits that are strengths during childhood become vulnerable to triggering the illness. Genetic influences ‘tip the scale’ toward ED during and after puberty for those who have a temperament profile that increases this vulnerability. This biological tendency is magnified by pressures to diet and other environmental stressors. Increased genetic influences during puberty also appears to be true for binge eating.”
I want to make sure parents understand these important researched facts about ED. ED are not a choice. They are biologically-based illnesses, just as Type 1 diabetes is biologically based. Both illnesses are influenced by environmental stresses, but the primary causes are biological.
Dr. Kelly Klump and colleagues found that genetic influences are modest during childhood but increase during early adolescence through mid-adulthood., This fact impacts the timing for ED prevention. Parents have more influence to work with their child’s traits before puberty, than during adolescence. Childhood becomes a key time-frame for parents to help refine trait expressions that are vulnerable to developing ED. Figure 1.3 lists traits that increase one’s vulnerability to develop ED when combined in various ways.
What does “shaping” or refining traits look like? Shaping is what parents do daily. It may be a compliment to your child because they handed in their assignments on time. It may be a corrective statement about a disrespectful action and requiring your child to apologize to the friend. It may be setting limits on how much they play on the computer each night. Shaping occurs in nearly all interactions. A parent can sit back and say, “I have no influence,” or step up and acknowledge that it is those daily encouragements, corrective actions or limits placed on a child’s behavior that shape and establish healthy habits. Parental response is typically somewhere in between those two extremes.
2. When to intervene if your loved one is anxious. Anxiety is a common trait among those with ED. It tends to intensify at adolescence and may vacillate in intensity throughout life based on stressors experienced. It is expressed through excessive worry, uncertainty, or rehearsing the future while trying to live in the present. Thoughts reverberate in the minds of those with ED. For example, an adolescent may anxiously ruminate if they will binge eat when they get home from school. Others may have continuous thoughts about every calorie eaten, and establish rules to dictate what can be eaten, in order to lower anxiety. Research has found that for those with anorexia nervosa, not eating is a natural, dominant response to lower anxiety. For some, it is a natural tendency to inhibit, restrict and avoid foods. These traits tendencies can become harmful if restrictive responses become habitual during adolescence and adulthood, through ED symptoms.
Our new book, Temperament-Based Therapy with Supports for Anorexia Nervosa: A Novel Treatment, has an anxiety exercise for clients and Supports, called the Anxiety Wave. I offer two handouts from our book (to be released by Cambridge Press in November of 2021). Anxiety Wave Client Expressions, and Anxiety Wave Support Responses (see Figures 1.4 and 1.5 below).
Supports can set the context by sharing that as a parent (or other Support) you want to understand your loved one’s anxiety better; to identify what you could do more effectively. As a reminder, genes have increased influence during adolescence. Parents have less influence shaping trait tendencies during adolescence but still hold a lot of influence. Working with your adolescent’s temperament, not against it, empowers them and you to circumvent resistance. Ask them for 15 minutes to help you learn how to respond in ways that are helpful in relation to their anxiety.
Use Figure 1.4 to ask your adolescent to list actions they do when their anxiety is high and when it is low. There are options they can choose from on the right, that other clients have listed that describe their actions. They can use any of those options or write in their own.
Then use Figure 1.5 to ask your child to list responses they would like you to do when their anxiety is high and when it is low. Again, they can draw from the list on the right or write in their own ideas.
Note: the higher anxiety is, the less verbal a person is able to be and the less they can hear what others are saying to them. As one father said, “When anxiety is up, shut up.” In general when anxiety is high, take action, and use fewer words. For example, instead of saying, “I don’t know why you are worried about your body shape, you look fine.” Or, “Why are you doubting yourself, you are an intelligent amazing person!”. That doesn’t help when anxiety is high. Action does. For example, your loved one is talking about how many calories there are in the meal, you could simply say, “Stop, please get me the silverware and set the table. Now please.” That shapes the anxiety to move into action instead of stay stagnantly in thoughts. It gives a release. After eating, one could say, “Please help me put the dishes in the dishwasher,” or “I’ll wash and you dry the dishes,” or “Let’s walk.” Take a 15 minute walk after dinner. Little may be said, but you are walking with your loved one, together, and the loved one is unwinding. If there is resistance, then say, “I need to walk. I want you to walk with me. It is only 15 minutes.” You are rerouting anxiety from cognitive thinking to a physical release, lowering it from a high to a lower anxious state.
When anxiety is lower, your loved one may become more talkative. That is when you know you are helping your loved one to be in a calmer place. Bottom line try on and practice the responses your loved one listed in the Anxiety Wave Handout, to help your adolescent reshape their anxious, destructive, or self-harmful responses toward healthier tendencies. Note, when anxiety is high, and you are doing what your loved one listed, that does not mean you will be met with calm and appreciative emotional responses. You will instead experience anxious intensity. Don’t let that stop you. Move through it to help your loved one move through it with you. Move through it repeatedly to eventually help your loved one to move through it on their own.
Temperament-Based Therapy with Supports is an emerging therapy that augments other ED treatments by addressing the underlying traits that partially cause and shape thoughts, feelings, and behaviors. Supports (parents, friends, spouses, colleagues etc.) have increased influence to shape trait expressions in healthy ways during childhood and when anxiety is low. Supports can contribute toward preventing ED symptoms or managing them by working with your loved one’s temperament.
Thank you to FEAST for inviting me to write this blog. It is my first time to write a blog. It is a bit long, and I hope it is helpful. Each time I write a future blog, it will become more concise, just as each time you practice reshaping responses, it becomes more efficient and effective.
[i] Hill, L., Peck, S., Wierenga, C. (2021). Temperament-Based Therapy with Supports for Anorexia Nervosa: A Novel Treatment, Cambridge Press, Cambridge, UK. (in press).
[ii] Bulik CM, Breen G. Solving the Eating Disorders Puzzle Piece by Piece. Biol Psychiatry. 2017 May 1;81(9):730-731. doi: 10.1016/j.biopsych.2017.03.009. PMID: 28391802; PMCID: PMC6994242.
[iii] Duncan L, Yilmaz Z, Gaspar H, Walters R, Goldstein J, Anttila V, Bulik-Sullivan B, Ripke S; Eating Disorders Working Group of the Psychiatric Genomics Consortium, Thornton L, Hinney A, Daly M, Sullivan PF, Zeggini E, Breen G, Bulik CM. Significant Locus and Metabolic Genetic Correlations Revealed in Genome-Wide Association Study of Anorexia Nervosa. Am J Psychiatry. 2017 Sep 1;174(9):850-858. doi: 10.1176/appi.ajp.2017.16121402. Epub 2017 May 12. PMID: 28494655; PMCID: PMC5581217.
[iv] Cross-Disorder Group of the Psychiatric Genomics Consortium. Electronic address: [email protected]; Cross-Disorder Group of the Psychiatric Genomics Consortium. Genomic Relationships, Novel Loci, and Pleiotropic Mechanisms across Eight Psychiatric Disorders. Cell. 2019 Dec 12;179(7):1469-1482.e11. doi: 10.1016/j.cell.2019.11.020. PMID: 31835028; PMCID: PMC7077032.
[v] Mitchell, K. Innate.(2018). Princeton University Press. NY, USA.
[vi] Kaye W, Fudge J, Paulus M. New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci. 2009;10(8):573-84.
[vii] Bulik C, Blake L, Austin J. Genetics of eating disorders: What the clinician needs to know. Psychiatr Clin North Am. 2019;42(1):59-73.
[viii] Ma R, Mikhail M, Fowler N, et al. The role of puberty and ovarian hormones in the genetic diathesis of eeating disorders in females. Child Adolesc Psychiatr Clin N Am. 2019;28(4):617-28.
[ix] Bulik C, Blake L, Austin J. Genetics of eating disorders: What the clinician needs to know. Psychiatr Clin North Am. 2019;42(1):59-73.
[x] Lilenfeld L, Wonderlich S, Riso LP, et al. Eating disorders and personality: a methodological and empirical review. Clinical Psychology Review. 2006;26(3):299-320.
[xi] Wadden T, Sternberg J, Letizia K, et al. Treatment of obesity by very low calorie diet, behavior therapy, and their combination: a five-year perspective. Int J Obes. 1989;30(Suppl 2):39-46.
[xii] Bulik C, Flatt R, Abbaspour A, et al. Reconceptualizing anorexia nervosa. Psychiatry Clin Neurosci. 2019;73(9):518-25.
[xiii] Klump K, Burt S, Spanos A, et al. Age differences in genetic and environmental influences on weight and shape concerns. Int J Eat Disord. 2010;43(8):679-88.
[xiv] Klump K, Culbert K, O’Connor S, et al. The significant effects of puberty on the genetic diathesis of binge eating in girls. Int J Eat Disord. 2017;50(8):984-9.
[xv] Hill, L., Peck, S., and Wierenga, C. Temperament-Based Therapy with Supports for Anorexia Nervosa: A Novel Treatment. Cambridge University Press, Cambridge, UK. (In press).
[xvi] Klump, K. L., Culbert, K. M., O’Connor, S., Fowler, N., Burt, S. A. (2017). The significant effects of puberty on the genetic diathesis of binge eating in girls. International Journal of Eating Disorders, 50, 984-989. doi: 10.1002/eat.22727
[xvii] Klump KL, Keel PK, Racine SE, Burt SA, Neale M, Sisk CL, Boker S, Hu JY. The interactive effects of estrogen and progesterone on changes in emotional eating across the menstrual cycle. J Abnorm Psychol. 2013 Feb;122(1):131-7. doi: 10.1037/a0029524. Epub 2012 Aug 13. Erratum in: J Abnorm Psychol. 2013 Feb;122(1):137. Burt, Alexandra S [corrected to Burt, S Alexandra]. PMID: 22889242; PMCID: PMC3570621.
[xviii] Kaye W, Fudge J, Paulus M. New insights into symptoms and neurocircuit function of anorexia nervosa. Nat Rev Neurosci. 2009;10(8):573-84.