Archives for posts with tag: Dr. Abigail McNally

Dr. Abigail McNally is a private practice psychologist in Cambridge, Massachusetts, whose specialties include the treatment of borderline personality disorder. According to McNally, one of the most effective treatment options for the most severe forms of this disorder is Dialectical-Behavior Therapy (DBT).

DBT was developed as an offshoot of Cognitive Behavior Therapy (CBT), which is based on the idea that intense negative feelings can be changed through changing one’s thoughts and/or behaviors. In the context of borderline personality disorder, McNally reflects that CBT techniques alone proved of limited use due to: a) the severity of the affect regulatory symptoms in BPD, b)the difficulty forming a treatment alliance, c) difficulties prioritizing areas of foci amidst a sense of constant crisis, and d) therapist burn-out amidst chronic extreme symptoms.

Developed by Marsha Linehan, Ph.D., DBT addresses these drawbacks of the CBT model by adding supportive/empathic/containing structure to the treatment model as a whole. First, DBT maintains CBT’s focus on change-related coping strategies, while adding acceptance-based strategies rooted in the Eastern meditative philosophy of mindfulness. Second, DBT maintains a pointedly empathic stance towards the patient’s dysregulated or otherwise seemingly self-destructive behavior, by validating the ways maladaptive responses may still serve an important emotion regulatory or interpersonal function. The model identifies maladaptive yet understandable ways of coping with alternative, healthier strategies. Third, therapist and patient commit to a 6-month treatment frame in which a hierarchy of pathological behaviors is addressed in order from severe (e.g., suicidal behaviors) to less severe (e.g., social anxiety). This helps to prioritize the breadth of fluctuating severe symptoms and take most seriously those that are at the most serious end of the continuum of harm. Finally, unlike most other behavioral treatment models, formal DBT specifically includes therapist participation in a peer consultation team for guidance and support. Full model DBT includes a weekly DBT skills group and weekly individual therapy sessions. Group sessions focus on the development of the four core skill areas (emotion regulation, interpersonal effectiveness, mindfulness, and distress tolerance), while individual sessions focus on the individualized tailoring and application of skills in external life. Formal DBT also includes therapist extra-session availability for skills coaching in moments of crisis as well as the aforementioned therapist consultation group.

Since its inception, DBT has been broadly applied to a range of affect regulatory disorders such as post-traumatic stress disorder, eating disorders, and substance abuse.

Diverse psychotherapeutic modalities exist for the treatment of eating disorders. Often of particular focus at the beginning of treatment, motivational interviewing (MI) is a client-centered conversational intervention that is designed to enhance motivation for change. Cognitive behavior therapy (CBT) and the more recently developed dialectical behavior therapy (DBT) both focus on building a patient’s repertoire of cognitive and behavioral coping strategies for dealing with urges to engage in ED behaviors. Interpersonal psychotherapy (IPT) and psychodynamic psychotherapy focus on identifying unconscious or core meaning and beliefs about the self in relation to others; symptom relief from this perspective arises indirectly through the resolution of core insecure attachment, negative self-image, and negative affect systems. Experientially-based orientations such as internal family systems (IFS) work towards rapid engagement of the core affective states of different parts of the self through role-playing, imaginal exposure, and related psychodrama-based strategies.

While some practitioners focus uniquely on one of the above approaches, many seasoned clinicians work eclectically and integratively with highly symptomatic ED patients. As eating disorders are over-determined in origin (genetics, family environment, cultural influences, abuse history, etc.), it is increasingly common for therapists to maintain multiple and shifting areas of focus over the course of a given treatment. Patients often benefit from a combined focus on these core change processes: 1) motivation for change (MI), 2) insight into the maintaining psychodynamics and meaning of the symptoms (more psychoanalytic and interpersonal approaches), 3) affective exposures (behavior therapy and experiential therapy), and 4) behavioral change strategies (CBT and DBT). Finally, individual outpatient psychotherapy for ED is often most effective when conducted a minimum of twice a week during the symptomatic phases of a patient’s illness.

Patients and families benefit from early awareness of a typical length of treatment and realistic course and prognosis for the disorder. Namely, when treatment is going well, ED recovery is often a lengthy and fluctuating process (change processes trend upwards on average, but slips, lapses, and relapses are a common part of the journey towards long-term remission).

About the author: Licensed psychologist Dr. Abigail McNally maintains a private practice in Harvard Square (Cambridge, MA) where she conducts psychoanalysis, psychodynamic therapy, DBT-informed psychotherapy, and integrative therapy. In addition to a general focus on anxiety and depression, Dr. McNally maintains particular expertise in the treatment of eating disorders, personality disorders, and trauma. She is the former Assistant Director of the Laurel Hill Inn Residential Eating Disorder Treatment Center as well as the former Director of Post-Doctoral Training at Two Brattle Center.

Early recognition and intervention are essential in enhancing the likelihood of recovery from an eating disorder (ED). It is very common for ED patients to hide and/or deny the symptoms of the disorder and to live a dissociated, secret inner eating disordered life that is filled with tremendous emotional pain and dysregulation with very little of this suffering apparent on the outside. Any suspicion of a disturbance in a loved one’s experience of her body, of weight, food, and eating, should be addressed immediately. Families themselves often must struggle with their own denial about recognizing the severity of the psychological trouble of the afflicted family member. The speed of recovery is enhanced by the family’s capacity to recognize and take seriously the illness and its root causes.

When an eating disorder is not medically threatening, multi-disciplinary outpatient treatment is the first recommended course of action. Ideally, ED outpatients will work with a core triad of providers: an individual psychotherapist, a nutritionist, and a primary care physician. It is very important that each of these practitioners have specific expertise in the treatment of eating disorders; signs and symptoms of EDs can be hidden, secretive, complex, and not always intuitive to a general practitioner of nutrition, psychology, or medicine. It is also very important that the clinicians agree to collaborate in the provision of care for an individual patient. Therapeutic modalities that may be used in addition to the above triad include a family therapist (with the patient), a parent guidance therapist (without the patient), and a psychiatrist.

Psychopharmacological treatment may be a useful adjunct to the total treatment package (in particular, the SSRI, or selective-serotonin reuptake inhibitor category of anti-depressants has documented efficacy), but it should always be used in combination with psychotherapy. Finally, when outpatient therapy results in insufficient progress, ED patients should be referred to a higher level of care (evening, day, residential, or inpatient treatment).

About the author: Licensed psychologist Dr. Abigail McNally maintains a private practice in Harvard Square (Cambridge, MA) where she conducts psychoanalysis, psychodynamic therapy, DBT-informed psychotherapy, and integrative therapy. In addition to a general focus on anxiety and depression, Dr. McNally maintains particular expertise in the treatment of eating disorders, personality disorders, and trauma. She is the former Assistant Director of the Laurel Hill Inn Residential Eating Disorder Treatment Center as well as the former Director of Post-Doctoral Training at Two Brattle Center.

Eating disorders are characterized by a serious disturbance in the self-regulation of eating, weight maintenance, and nutrition maintenance behaviors. This disturbance can manifest through a variety of symptoms, including undereating, overeating, bingeing, purging, body image disturbance, over-exercise, laxative abuse, diuretic abuse, ipecac use, body-checking, eating rituals, chewing and spitting out food, fear of specific foods, and an over-valuation of body for determining sense of self.

Though the active symptoms of many patients with eating disorders fluctuate and vary over the course of the illness, certain symptoms tend to coalesce around three main diagnostic categories. Anorexia nervosa is characterized by serious caloric restriction, weight loss, amenorrhea, and intense fear of gaining weight. Bulimia nervosa is characterized by recurrent episodes of objective food binges accompanied by a sense of loss of control over eating as well as recurrent inappropriate compensatory behavior to prevent weight gain, such as vomiting, excessive exercise, and laxative use. In contrast, binge-eating disorder is a “not otherwise specified” eating disorder that is characterized by recurrent objective food binges without compensatory behaviors.

Other mixed-symptom eating disorders that do not meet the full criteria for either anorexia nervosa or bulimia nervosa are given a diagnosis of Eating Disorder, Not Otherwise Specified (ED NOS). While behavioral indicators of an eating disorder may not be as severe in ED NOS patients, these individuals may still suffer from severe cognitive preoccupation with and emotional distress caused by food intake, weight, and shape.

Eating disorders have serious medical and psychological complications, even when patients appear to be at normal weight. Though eating disorders occur most commonly in adolescent and young adult Caucasian females, there is an increasing incidence of these illnesses in males and across all ethnicities and ages.

About the author: Licensed psychologist Dr. Abigail McNally maintains a private practice in Harvard Square in Cambridge, Massachusetts, where she conducts psychoanalysis, psychodynamic therapy, DBT-informed psychotherapy, and integrative therapy. In addition to a general focus on anxiety and depression, Dr. McNally maintains particular expertise in the treatment of eating disorders, personality disorders, and trauma. She is the former Assistant Director of the Laurel Hill Inn Residential Eating Disorder Treatment Center as well as the former Director of Post-Doctoral Training at Two Brattle Center.

Many people seek psychotherapy as a way of getting help with a wide range of psychological problems. A multitude of therapeutic modalities currently exist, including those that focus narrowly on concrete behavior change (e.g., cognitive-behavior therapy) versus those that open up a broader range of interwoven themes affecting general psychological well-being (e.g., psychodynamic therapy).

Psychoanalytically oriented approaches to treatment include psychodynamic psychotherapy (a term largely used interchangeably with “psychoanalytic psychotherapy”) and formal psychoanalysis. These approaches can be particularly effective for addressing maladaptive or constricted engagement in one’s life (e.g.: insecure attachment, depressive withdrawal, anxious avoidance, low self-esteem, problematic relationship patterns, feeling stuck in motivation and work, unresolved grief, addictive tendencies, and feelings of meaninglessness).

In general, psychodynamic/psychoanalytic approaches transform painful feelings, thoughts, and behaviors by getting “underneath” the overt symptoms themselves and trying to understand the meaning, original cause, and current relational patterning of the symptoms. Psychodynamic theories share a core assumption that our ways of being in the world are guided by unconscious motivations, feelings, beliefs, conflicts, and compromises.

As people grow, even relatively benign, “normal” developmental pathways have experiences of emotional pain (e.g., jealousy at the arrival of a younger sibling, feelings of exclusion from the parents’ relationship, feelings of loss of a parent’s intimate affection as the child grows up, fears of being disappointing to others, humiliation of unrequited love). Every person finds ways of managing both these subtle emotional hurts, as well as more egregious traumas and abandonments through psychological avenues. A person’s “character” or personality includes those ways in which he/she manages or defends against painful emotions. Sometimes, the ways people manage feelings are inflexible and maladaptive to current circumstances, even though they may have been adaptive as a child.

The psychoanalytic treatment approach seeks to identify and understand our evolved manners of emotional self-protection, and then gradually open up alternative more adaptive means of affect regulation. Thus, one of the paramount aims of an analytic process is to loosen compulsive, rigid ways of responding to one’s interpersonal world, opening up freedom of choice and free will.

About the author:

Licensed psychologist Dr. Abigail McNally maintains a private practice in Harvard Square (Cambridge, Massachusetts) where she conducts psychoanalysis, psychodynamic therapy, and integrative therapy. In addition to a general focus on anxiety and depression, Dr. McNally maintains particular expertise in the treatment of personality disorders, eating disorders, and trauma. A graduate of the doctoral program in Psychology at Boston University, she has completed a post-graduate fellowship at the Massachusetts Institute for Psychoanalysis (MIP), where she is currently a fourth-year candidate in the General Psychoanalytic Training Program.