Podcast
Mental Note

58 - How Temperament Influences Eating Disorder Recovery with Dr. Laura Hill

By Ellie Pike, MA, LPC & Laura Hill, PhD, FAED

Mental Note is available on Apple Podcasts, Spotify, Stitcher, or wherever you get your podcasts. Search for Mental Note, and subscribe so you never miss an episode!

Discover how your personality can be both your biggest asset and greatest stumbling block on today’s fascinating episode.

When Dr. Laura Hill first encountered research showing that a person’s temperament - the baked-in personality traits dictated by their genes - dramatically influences the type and expression of their eating disorder, she was thrilled. For decades, she had felt that eating disorder treatment only focused on external behaviors, while ignoring root causes. But through brain-based research, she was finally able to see how and why disorders begin growing in the first place.

Her excitement compelled Dr. Hill to devote the next ten years of her career to work alongside colleagues and patients in developing the first ever eating disorder treatment focused on genetic traits. The result? Temperament Based Treatment with Supports - TBT-S for short. Influenced by Dr. Hill’s playful and inquisitive spirit, this approach promises thrilling possibilities for long term recovery.

Transcript

Ellie Pike:
Academic articles may sound boring to you, but when Dr. Laura Hill first got her hands on her colleague's groundbreaking neurobiological research on eating disorder treatment, she couldn't contain her excitement.

Dr. Laura Hill:
I read it and thought, this is like nothing I've ever seen before. And oh my goodness, could this be filling in gaps that I've been questioning for 30 years in treatment?

Ellie Pike:
What felt so revolutionary to her seasoned mind?

Dr. Laura Hill:
Always before, the treatment was from the outside in and suddenly we were looking at the inside out.

Ellie Pike:
AKA she felt like she was finally seeing inside the brain of someone with an eating disorder for the first time in her career.

Dr. Laura Hill:
I'm someone who has traits that are pretty disciplined, determined. I can get very stubborn and I tend to mow my lawn with a little hand mower to think things through. So, I would read the article and then stop and take notes and then I would think and read some more while I'm mowing and then take more notes. And then I'm thinking, "What does he mean by this circuit and this circuit?" So, I started moving the lawn furniture around to be able to understand what he was saying. And finally, by the end of the summer and all those mowings later, I had the lawn furniture literally organized the way the pathways that he was describing the brain and I thought, "I think I've got it."

Ellie Pike:
Today we're talking with professional lawn furniture organizer and clinical faculty member at both the Ohio State University and UC San Diego, Dr. Laura Hill. She'll introduce us to temperament based therapy with support, TBTS for short, and how it's revolutionary approach is shifting the way clinicians think about disordered eating behaviors. And if you're thinking that's a lot of clinical gobbledygook you just spouted out, don't worry. I've admired Dr. Hill and have referred hundreds of folks to her TED Talk throughout the years. She has a way of teaching that is compassionate. She has a natural enthusiasm and creative approach to explaining the biological roots of disordered behavior. She really helps us understand what people can expect through these new modalities, but more importantly, she reframes the biological cards we were dealt. Maybe character traits we've labeled as negative aren't so bad after all. Instead, they might be our greatest asset in building resilience. Ready to peer inside some brains together? Let's do it. You are listening to Mental Note Podcast. I'm Ellie Pike.

Dr. Laura Hill:
From the time eating disorders were diagnosed in 1980, we've looked at them from the outside in. We've seen them from their symptoms, not from the traits, the internal aspects. And so for 20 years we developed lots of theories. Oh, this is fear of maturity, this is inability or high resistance. This is an overly controlled adolescent who's trying to compete. I mean we can put all kinds of theories to actions and we, as professionals, have sometimes perpetuated that. And the community's first impression that's become ingrained for 20 years is that external and often misinterpreted reality of what's going on. And then when we began to look at those circuits and we began to see what's happening, what appeared on the outside, which is she's overly controlling, is in fact on the inside an inability to know and sense what's going on. I can't maybe sense hunger and therefore if I can't sense hunger, how am I to decide if I'm to eat? And if I experience very little pleasure from that hunger, then I neither can know if I should eat and I don't enjoy it when I do. And so the ability to trust decisions, not only about food but many things in life, becomes almost blinded. Anorexia has been most studied, but bulimia and binge eating research on this is very much coming to light. And as a reality, we just need to help the clients know what is under firing, what is over firing, and what they can do to potentially try to compensate for that.

Ellie Pike:
Once Dr. Hill wrapped her head around the neurobiological model of eating disordered behavior, she began to work it out with colleagues and test groups.

Dr. Laura Hill:
So, then I went back into the clinic, took one of the partial groups and said, "I need to experiment with you. Could we work together and you try on what I think this article is saying?" And I developed at that point what I called the brainwave. And the brainwave being how those circuits fire if you don't have an eating disorder, how they fire when you have anorexia, or how they fire when you have bulimia or binge eating. And the clients just went over the top, almost shocked me. I'd never seen such excitement and motivation. And they said, "This is it. This is what I'm experiencing." And then they said something that they've never asked me, I want my husband, I want my partner, I want my daughter, they started saying, "I want my support people to come in and I want them to experience this." And I said, "Well, let's bring them in next week and we'll try it out and get their feedback." And so we did. And I remember a husband turned to his wife and he goes, "It isn't this bad." And she looked at him and said, "This is exactly what I experience." And he broke into tears, went over and hugged her and said, "I had no idea." So, that was the beginning of temperament based therapy being formed. And from that time forward in 2010, we worked between the two sites in Ohio and California. I would develop another interactive tool, meet with the research team in California to make sure that it was research based, go back, and then the clients would say, "Now that I know why I'm experiencing such pain or anxiety, now I can cope with it and I can push myself forward." And once we got to the place where clients were consistently saying, "You're describing me," we knew we had arrived with that clinical tool.

Ellie Pike:
You are far smarter than I ever could be, because you were putting all of this incredible research into an experience for folks to better understand how their brain works. And I'm so glad that you're on this show and we're going to have to break it down for our listeners, right?

Dr. Laura Hill:
All right.

Ellie Pike:
I would love to dive into understanding traits and temperaments and character, and then also what are the practical pieces of that that our listeners can take away along with some advice and some lessons that you've learned to coach their support people. So, first, in your book you changed the language from caregiver to supports, and I know that this was really intentional. Can you explain why you chose this language and why supports are so important in the treatment process?

Dr. Laura Hill:
Yes. We chose the language because the adult clients asked us to change the language. Everything about this treatment approach has been client centered and client driven and research driven, those two aspects. In many ways I felt I was the person that was literally following their instructions. I would take the instructions of the research, I'd take the feedback from the clients and then create the instrument or the activity to do that. And when I would say, "Do you want me to call your husband a caregiver? Or how do you want me to refer to all of you?" And there would be a group of adult clients and their supports and they would say, "Well, what are the options?" And I'll say, "Well, the research often refers to you as caregivers. Other time it's family." And then somebody would pipe up and say, "Well, I'm not a family member, I'm a friend." And then somebody said, "Well, what you're doing is offering support, so let's refer to you as support, because we don't want to be cared for, we want to be supported." So I said, "Okay, from now on we'll call you supports." And then we decided, by golly, that's what we're putting in the name of the treatment, because that is what they are.

Ellie Pike:
Not only does TBTS redefine caregivers as supports, they also pinpoint them as crucial players in the therapeutic process.

Dr. Laura Hill:
What we've been taught in graduate school and in becoming clinicians is that as we develop, we need to individuate and develop a sense of independence. And hence upon 18, one is legally an adult and therefore should start functioning independently. But the ultimate of our own psychological and individual development is realizing who we are in relation to others. And therefore interdependence becomes the ultimate of our development and drawing upon what others can offer us to compensate where we are weak and utilizing our strengths to help others where they are weak. And so it's an interdependent experience. What we began to realize is this treatment approach is filling in the gaps where the other treatments have not addressed. And one of those is to include support people in identified sessions during therapy and clarifying what those sessions will focus on. So that, one, they from the clinician's perspective have the same concepts, understanding of what's going on around this illness from the inside of the brain, that they begin to experience and try on with their loved one, some of the tools that they could be using, and have their loved one tell them when it helps to use that tool and when it helps not to use that tool. So, suddenly you're decreasing anxiety from the support person, because they didn't know what to do, when to do it or how often to do it. And then we also found that the ability for the clients to be able to coach their own supports with those tools became ultimately critical. And so we established what is traditionally thought of as developing your goals or a treatment plan, but this is a therapeutic process that we called a behavioral agreement. The clients literally work with their support person every step of the way. So, they are working out with the structure of the tool, what the support can do, what the client can do without the support, who does what, when, and how.

Ellie Pike:
One thing I really appreciate about your book is that you bring in that genetic component and you talk about it as temperament. Correct?

Dr. Laura Hill:
Yes, correct.

Ellie Pike:
Can you tell me more about temperament and what we know about it in relation to eating disorders?

Dr. Laura Hill:
Yes. Temperament is nature, to character, which is nurture. So, if you're looking at something simple like a tree, you would say genetically it's inherited it's gene from the seed that it is, that it's going to grow into a maple tree. That maple tree will never be an evergreen tree, ever. Now, when we have our temperament, something that I think is so miraculous is that from the moment of conception, the genome starts to express and the brain starts to form. And when it structures itself, it's actually structuring and including those traits, those personality traits, it's wiring for those traits. An example being my mother had twins when I was in middle school, and when they came home, one was as anxious as can be. It was hard for her to keep her food down. She was always a little fussy baby. And the other one was as calm as could be, and she would be glad to eat her sister's food if she didn't want it. And so they had different natures, different personalities from the get go. Now how that gets encouraged, or discouraged, or shaped is based on the environmental influences from the family, from friends, from the community, from what we read, from our social media. And so the shaping is the character side, and the nature and what you fundamentally have to work with is the temperament side. Now our temperament is subdivided into lots of traits such as you may be extroverted or introverted, you may be more inhibited or more impulsive. Our traits are expressed in a continuum. You may say, "Oh, I impulsively said something that I wish I hadn't." And that may have been a little more destructively expressed in that interaction. And then the next time you go home an hour later and you made yourself impulsively just take action and go ahead and get the kitchen cleaned up. And that was a productive situation. So, our traits are going back and forth, but when they get to the point that it's only expressed destructively, then it may become a symptom, a behavioral expression that is creating problems. And for 20 years, the first 20 years of eating disorders, we only address the symptoms. Now we're saying with TBTS that you should look at the traits, because they're triggering those symptoms. And if we treat to the traits to help them shift, not eliminate a trait. You can't get rid of your traits because they are with you for life, but you can shift how they are expressed so they can become expressed more and more productively. So, temperament based therapy with support puts temperament onto the continuum of our philosophy is every trait can be both productive and destructive. And it is helping the client understand what their trait profile is so that they can intentionally work to be able to express themselves through their traits in the most productive and fulfilling way for themselves and for others.

Ellie Pike:
So, to put this into more practical terms, because I know as you're talking, I'm thinking through what are my traits and can anxiety be a trait that's kind of a genetic groundwork, but then operates on a spectrum where maybe it expresses itself over time in different ways and more productive ways? Sometimes if I need to present or say I was in school, study for an exam, my anxiety can serve me in really productive ways. But then there's other ways where it can become more maladaptive.

Dr. Laura Hill:
I could not have put it better, Ellie. That's exactly right. People can inherit an anxiety trait just like you can inherit a tendency towards extroversion, but that anxiety can work for you or against you. And what we developed in TBTS is what we call a trait profile checklist. And so it is a checklist that we developed from probably eight major personality models, drawing on their traits. And we took 54 traits. So, we're not talking just about eating disorders. Clinicians could give this to their clients for any reason. And you check what traits appears to be true for you, and then you rate yourself how you are currently using those traits from a constructive to a destructive way. And then we provide worksheets to help them shape how they could be intentionally bringing the destructive ones towards more productive. And this is the important part, Ellie, to use and identify your productive traits to actually help you reshape your destructive ones. So, I can draw upon my own traits to help me reshape the parts of me that I need to improve. And an example is one client just was a binge eater, impulsively tending to binge eat, was having trouble. We went and we were looking at when she was a child, how that impulsivity was expressed, how it is as an adult, and drawing from others. And she started saying, "I'm in graduate school and I love when I get new assignments, I just jump in and start doing all this different research." And then she realized this is my impulsivity at its best. I am binging out on research right now and going from one topic into another and getting these papers done beyond what my friends are, I'm realizing how I can use my impulsivity for me instead of against me.

Ellie Pike:
Well, one thing I really enjoy about this model is that it reframes traits not necessarily as negative, but what they are, and that there is a positive lean that we can all put on each trait. So, if our trait is perfectionism, really reframing that as what can it do for us in a positive way? And instead of moving towards a really controlling symptom perhaps of an eating disorder, reframing it as a positive asset to ourselves. Correct?

Dr. Laura Hill:
Very correct, and well said.

Ellie Pike:
So, what do we know about the traits for each eating disorder? And can you share what those are for anorexia, bulimia, and then binge eating disorder?

Dr. Laura Hill:
So, some of the traits that are common to anorexia are perfectionism, are a trait being if you were to reinterpret, how do I define or address a trait? You could say, "What's your tendency to do, or think, or respond in this way?" So, some have a tendency to avoid or pull back and inhibit themselves when something may seem overwhelming. Other may show inhibition and avoidance perfectionism, but also that results into a neurobiologically based trait of inability to trust my decisions. And that is a very common trait among anorexia and binge eating disorder. And it's because of the neurobiological aberrations that are not giving clarity for the person to know what to do. And so with binge eating disorder, I'll go to the other extreme, a common trait is impulsivity. In some cases it would be many have an obsessive tendency and others have compulsive tendencies. And so they may obsess about the food and then compulsively have to binge. So, some binge because of a compulsion trait and others binge because of an impulsive trait. One would be more planned and one would be more erratic or random. And with bulimia nervosa, a very common overlap is impulsivity. But then we have another comment trait is more extroverted with bulimia and a tendency towards introverted with anorexia, and binge eating it goes both ways. So, the amazing thing is as we look at the spread, there are a few that are common across all three disorders, which is not unlike why a person may move from one illness to another, because your traits and your brain networks could care less where one diagnosis starts and another ends, it just circuits and expresses. And a person who may be inhibited and also impulsive may end up having a anorexia tendency with a binge purge symptom, because of that impulsive trait.

Ellie Pike:
Dr. Hill, one thing I really appreciate when you talk about these traits by eating disorder, is that you don't put people in a box by a diagnosis, you really talk about them as common tendencies. And there's a lot of leeway there for self-discovery and clinical input. And I think one key piece I very much appreciate is the insight that comes with understanding temperament and traits still shows that there's some flexibility and malleability in our brain, right? It's not like all hope is lost, I'm always going to be so impulsive and I will always have the tendency to binge eat. There's really a lot of hope that I can retrain my brain. So, can you talk about that in a way that would simplify this for folks? So, where does the hope lie and what could that even look like?

Dr. Laura Hill:
In some ways, I think it's more hopeful, because I have had so many clients over the years tell me what failures they feel they are because they tried on it a treatment approach, or they were approaching it in this way and they were trying to give up their perfectionism, trying to eliminate it as if it was a symptom. They were trying to give up their impulsivity as if it was a symptom, and they failed. They were maybe able to succeed for three months when they were constantly overseeing it. But then as soon as they let up a little, their default went right back to it and what a failure they felt. And in addition, the amount of resistance that eating disorder treatment has faced over and over through the years and the decades and how shocked I was when I started bringing out the neurobiology information and the trait approach, the clients not only embraced it, but became so motivated overnight that I just kept thinking that the group, that particular pilot group, or that particular study group, was an aberration. The next group will show me that the resistance is going to increase. And resistance decreased every time, 98% of the time. And new data is just coming out from the Norwegian treatment group in Oslo. It shows that motivation significantly increased with TBTS, change in symptoms increased as clients understood how to use who they are and draw upon supports to compensate for where they're weak. We also got data from Greece in a study that was just released, and it showed the same. The increase in adolescent motivation, decrease in parental anxiety was huge as they began to learn how to utilize some tools that their own loved one needed from them, and draw upon their own child's trait profile, not who they thought they should be. One of the clinical tools that is in the book and that the clients literally told me they wanted to be included is called wire rewire. And what I would have clients to do is sit with a support person across from them, put their hands in a way that when you're unwinding a skein of yarn, you kind of wrap it around one hand to the other hand. And so I would say I want the support person to start wrapping the yarn around the client's two hands. And the two hands are about a foot apart. So, the winding begins and every client and their support person is now winding the yarn around the client's hand. And my response is, "Now I want you to describe one of the eating disorder symptoms that you have and that you would like to get rid of." And they may say, "I want to get rid of my desire to vomit, or my tendency to vomit." Okay, so we're going to get rid of that behavior of vomiting, but right now don't stop winding. Keep winding. Because what the winding is, is the firing, and you are literally circling around those two hands just like a network circuit is going around in the brain and it can never stop or the brain stops. So you have to be wiring somewhere. So, where are you wiring? And so then I ask clients what a symptom is. I ask them what a habit is, and a habit being something that becomes repetitious. And by that time, by the time they've answered those questions, there's a bundle of yarn around their two hands. And I'm going, "Look at this bundle while your support person continues to wire you, that bundle is continuing to grow. And let's say it is the action of making yourself vomit. Look how thick it is just after five minutes. Think of how thick that tendency is wired to take action after five days, after five months after five years of vomiting, you are so wired to vomit. You can't imagine not vomiting. So now you can't stop wiring, keep the wiring going, but I want you to instruct your support person and tell that person what you're going to do tonight if you were not vomiting.""Is there something you, within your tendencies, within your traits, would want yourself to do, even though it won't be easy because you're so wired to do this?" And they may say, "I want to take a walk after dinner. I don't want to go vomit." "Okay, do you need anyone to help you with that?" "Yes, I'd like my husband to take a 10 minute walk with me after." "All right, so now you're going to wire in your husband, so have that person wire in his hand so you're including him and then back to your hand. And now every time he moves around, you're saying, 'I'm asking him to go on a walk with me. Ask him to go on a walk with me. Will you go on a walk with me?" And they refine it to the point of, "We're going on a walk. Now we're walking, we're walking, and I'm saying it out loud while I'm wiring from him to me." So I'm saying, "Okay, now that you're doing that same thing after every evening meal, you've now started to rewire yourself. Now, which is thicker, your vomit bundle of wiring, or your newly forming habit of walking with your husband after dinner?" Well, clearly the vomit. Now I say, "Well, how long do you think it's going to take for you to walk with your spouse to compete with the bundle?""Oh, it's going to take months." "All right, are you hearing yourself? Because you are now prescribing to yourself what you need to do. And anytime you do something different after work, you're going to rewire a different action. So, you'll have one wire to one action, one wire to another action. But you have all wires around vomiting. So, you either do a couple similar actions repeatedly to start competing with the vomiting, or it's going to take a very long time to have a wide range of actions to finally compete. Or when you stop thinking about it, you're just going to go back to vomiting, because that would be the natural thing to do." And when the client began to realize that, they began to realize how they could rewire, why they need to repeat new actions that may be needed to repeat repeatedly in order to compete with the old, and how long it might take.

Ellie Pike:
So, in summary, rewiring the brain is possible. It takes time and it takes a lot of conscious effort. It can't just be done effortlessly, right? And when you talk about that, that conscious decision to make a new behavior happen, I actually picture walking on the grass for the first time where you see your footsteps, but you have to walk in that grass over and over again before it actually makes a trail, where it turns into dirt.

Dr. Laura Hill:
Perfect.

Ellie Pike:
But it's possible. You just do it over and over and over again. And it's hard work sometimes, because you might be tired and you want to go that old route that's already paved. And what I'm hearing from you is that once that is established over time, it can become more concrete. It can be much more of a new habit that's created.

Dr. Laura Hill:
Well said. And the beauty is somebody may say, "It's been a couple years, Dr. Hill, and I don't even think about vomiting now." And I'm saying, "You're not thinking about it because you intentionally paved new roads, and your brain is now defending those new roads and they match your traits. You're not working against yourself, you're doing things that enhance you, not work against you."

Ellie Pike:
It's a great lesson for all of us, and thank you so much Dr. Hill. I know many of us are wondering, I will listen to a podcast and then I'll be curious and I'll want that next step. So, how do I find out my traits? Is there any kind of self test I could do? Is there anything that our listeners could look into to better understand their temperament and traits?

Dr. Laura Hill:
We are finding many support people are also buying the book, even though we wrote it for the therapists. And the day that the book was released, you can get the book Temperament Based Therapy with Support from Amazon and you could go to the website tbtstraining.com. So, you're just using the acronym tbtstraining.com. And on that it provides, in fact, we'll be providing the link to this very podcast, we also have many other podcasts, but most importantly, we have three levels of training. Supports can be engaged in level one training, because it's learning more about the illness and it has all kinds of forms, handouts for them to download and utilize. For the clinicians, level one training is you become certified or you get a level of completion for learning more of the temperament bases of the illness. And that's a day's worth of training and videos, and that's all virtual. They can just sign up for the videos and literally watch them and take the quiz anytime day or night. Level two is for clinicians only and it's three days of face to face applying and practicing the clinical tools and sorting out when you would use it in your practice with your other treatments. And level three is virtually calling in over a four month period, once a month, to discuss how you're integrating it into your treatment. So, there is advanced and introductory and intermediate trainings.

Ellie Pike:
Well, I appreciate that there is information for supports along with clinicians, and we will certainly link to those websites in our show notes along with your book.

Dr. Laura Hill:
Thank you.

Ellie Pike:
And this has been such a pleasure to speak with you. This really makes a big difference and offers hope to many. So, thank you again for your time.

Dr. Laura Hill:
You're very welcome, Ellie.

Speaker 3:
(singing).

Ellie Pike:
Talking through a theory like TBTS without visuals can be a challenge, but I really hope Dr. Hill's work fascinates you as much as it does me. To summarize the basics of what we covered, first, there's a biological basis for eating disorders known as temperaments and traits. Second, we can use traits to our advantage to move towards recovery. Third, recovery is not a solitary journey. Supports our foundational persons in the process. And lastly, change is not only possible, but can be exhilarating. Once we accept who we are, rather than fight against it, we unlock new horizons of progress. Our show notes will link to the training resources Dr. Hill mentioned, as well as her book and a few videos that can help visualize the ideas we discussed. Thank you for listening to another episode of Mental Note Podcast. Our show is brought to you by Eating Recovery Center and Pathlight Mood & Anxiety Center. If you'd like to talk to a trained therapist to see if in person or virtual treatment is right for you, please call them at (877) 850-7199. ERC and Pathlight also offer a wide variety of free support groups. Check them out at eating recovery.com/support-groups or pathlightbh.com/support-groups. If you like our show, sign up for our e-newsletter and learn more about the people we interview at mentalnotepodcast.com. We'd also love it if you left us a review on iTunes. It helps others find our podcast. Mental Note is produced and hosted by me, Ellie Pike, and directed and edited by Sam Pike. Till next time.

Speaker 3:
(singing).

Presented by

Ellie Pike, MA, LPC

Ellie Pike is the Sr. Manager of Alumni/Family/Community Outreach at ERC & Pathlight Behavioral Health Centers. Over the years, she creatively combined her passions for clinical work with…
Presented by

Laura Hill, PhD, FAED

Dr. Laura Hill is an Adjunct Associate Professor of Psychiatry and Behavioral Health at The Ohio State University, and Assistant Clinical Professor in the Department of Psychiatry, at The University…