Living With Food: The Science Supporting Eating Disorder Treatment

Understandably, one of the most difficult moments about beginning therapy for an eating disorder is when you first start treatment. In general, one is in a state of emotional distress during a crisis and is often given advice from multiple sources. With many different therapy options available, it can be difficult to be a truly educated consumer of psychological treatment. Add to this that so many health care providers believe that they hold the key to recovery and one can see how the ability to know if you are getting evidence-based care becomes very elusive. The mere fact that a therapist, physician, or other professional says they believe that a treatment is effective should never be a reason to chose that therapy. One needs something to support that belief.

In the real world we do not have time to review the scientific literature on everything a health care professional might tell us. What then can someone do first to research evidence-based treatment?

1. Remember that there are very few evidence-based treatments for eating disorders. If you are not receiving cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, or family based therapy, then the odds are very high that you are not getting evidence-based care.
2. Your primary care physician is likely to have experience with patients who have done different types of treatment in your community. Your primary care physician is therefore a critical resource.
3. When you are in a provider’s office and they are discussing care options with you, never hesitate to ask for all of the evidence behind what they are saying. At this point in time, all practitioners in eating disorder treatment should be able to back up what they are saying in a straightforward and understandable manner.
4. Finally, while doing research on treatment for eating disorders, the Internet, while helpful, may not provide definitive answers (and may be more confusing than anything). There are certain organizations that we feel are trustworthy. We highly recommend NEDA, AED, Maudsley Parents, ED Recovery, The Freed Foundation, Are you eating with your anorexic, The F-Word, NAMI, Life After Recovery, and FEAST as reliable organizations and blogs where you can learn about evidence-based care and communicate with other patients and families that may be struggling with an eating disorder. 

Next week:  CCED's Commitment to Eating Disorder Awareness Week

Contributions by Sarah Emerman 

By Lucene Wisniewski 

One of the difficult things about treating people with eating disorders is that they’re often motivated to work on some parts of treatment but not others. Many come to treatment thinking, “I want to feel better”, but they often want to feel better without wanting to eat more or to gain weight. And so, when someone first comes into my office, our first conversation is about what he or she wants to be different. Clients often express that they want to have more energy, they want think about food less, they want to feel less depressed, and they want think more clearly. Most of these things, however, cannot improve unless a person is eating adequately. I’ve had countless patients say that they would love to feel better without the problem of eating more!

This conversation often re-emerges mid-way through treatment. Because clients may get stuck on the issue of weight, this translates into a client being willing to eat more and try something new, as long as their weight does not go up too much. In this second phase of motivation and commitment a client has to decide how much of their eating disorder they are willing to give up in order to live the life they want to have.

Sometimes I will hear therapists calling people stuck in this phase “resistant”. In Dialectical Behavioral Therapy we discourage using the word resistant due to its judgmental undertones. Instead, I would say that people have varying degrees of willingness to change particular behaviors. What the patient is motivated and willing to do has to be an ongoing collaborative conversation between the patient and therapist. If you are a clinician and you get to a point in the therapy where what the patient is motivated to work on does not match what you’re willing to do with them then, it may be time for the patient to take a break from therapy. We don’t believe that some therapy is better than no therapy, rather that we aim for effective therapy at all times.

Coming soon: How do you know if you’re motivated enough to do treatment?

Next week: Men, Women, and Eating Disorders

Contributions by Sarah Emerman 

Check out this article by Sharon Begley in this week's Newsweek on why some mental health professionals reject using evidence-based care, and the growing divide among therapists who base their practices off of research and those who don't.

Ignoring the Evidence: Why do psychologists reject science?

Given the complexity of the brain, and the reality of everyday life, all of us are prone to some psychological issues. All psychiatric disorders may therefore have long term implications.

Anytime a person has had any psychological issue, whether it be anxiety, depression, panic, substance abuse, or an eating disorder, they’re always at greater risk for the return or relapse of this disorder. Recovery involves many things. Treatment must then be seen as having multiple phases.

For eating disorders these phases include:

·    Medical stabilization - Insuring that the cardiac, brain, bones, endocrine (i.e.: the return of menses) and other systems are intact.

·    Refeeding - Gaining an appropriate amount of weight, usually 95% of pre-morbid weight to prevent relapse.

·    Behavioral control - Stopping or reducing binging, restriction, purging, over-exercise, and pill usage.

·    Feeling better about oneself - Increasing self-esteem, better body image, general increased levels of happiness and the ability to experience multiple different emotions.

·    Changing the way a person thinks about food, body size, and shape

·    Having the life a person truly wants to have

One will see a therapist or be in a formal program for a significant amount of time, often measured in years. A person will also need caring and connection for the rest of their lives. Formal eating disorder treatment is likely to last one to five years given the complexity of the multiple stages of healing. All of the above happens in the context of building a supportive, knowledgeable, community that one will be able to experience for the rest of their lives. Each phase of treatment takes a variable amount of time, but no one who has ever suffered from an eating disorder should ever be without their community of care and support. In this way, although significant advances towards recovery may happen in as little as one year, healing should be seen as life-long.

Getting into recovery from an eating disorder is an extraordinary and rewarding experience. From the perspective of evidence-based therapies, particularly DBT, recovery is a path a person follows, not an end to be achieved. As an eating disorder gets better, a person gets to appreciate and enjoy their lives more and more. They come to fully inhabit their lives. For people with and without eating disorders, the process of achieving and continuing to be the person we most want to be is a joy we work towards forever. 

Next week: How do we determine goal weight?

Contributions by Sarah Emerman 

It’s difficult to do effective eating disorder treatment. There are multiple reasons for this including:

1. Issues surrounding training
2. Cost
3. Insurance, and
4. The newness of evidence-based treatment for eating disorders

Training for doing eating disorder treatment: 

Typically, specialized training is not part of the usual curriculum for virtually any mental health provider. In order to do evidence-based treatment, usually one must get training outside of standard professional education. Where to get training and how to find experts to train with may be complicated. If you are a mental health provider and you did your training more than 10 years ago, you probably wouldn’t be exposed to these ideas or techniques even if you aggressively sought them out.

Cost of eating disorder treatment:

Financial issues also exist. It is more expensive to treat eating disorders than many other psychiatric disorders since they involve complicated multi-specialty teams. These teams likely include dietitians, primary care physicians, specialist physicians, and the need for multiple weekly visits, lab work, and other medical treatments and evaluations. Practitioners must be prepared to develop a team and work in teams to adequately address the various aspects of treatment.

Insurance and eating disorder treatment:

Insurance coverage may also be a limitation to obtaining effective treatment. Most insurance plans limit the amount of coverage they provide for patients with eating disorders. Although this is true for psychiatric disorders in general, coverage for eating disorder treatment is even more limited than other diagnoses. This is the case in many states, including Ohio. True effective eating disorder treatment is neither fast nor easy. It takes a complicated multi-disciplinary treatment team working together over a prolonged period of time to reverse a behavioral disorder that may have been present for years. In general, insurance is looking to shorten the course of treatment to make it less expensive. To be effective, eating disorder therapists must resist the pressures placed on them by insurance companies.

Newness of eating disorder treatment:

Another significant issue is that many effective eating disorder treatments are quite new. Treatment now is vastly different than it was 10 years ago. In order to provide effective care, therapists must stay current and be able to do ongoing training. For a therapist, eating disorder treatment is challenging. Patients have life threatening illnesses, the eating disorder itself is resistant to change, medical complications are common, the social support for having eating disorders often isn’t strong, and frustration for a therapist is quite common. Without a supportive team and effective care, a therapist may burn out.

Next week: What is the length of eating disorder treatment?

Contributions by Sarah Emerman 

I was at my block party last night and fell into a conversation about being in your 40's with an eating disorder. Turns out a friend, Meagan (note- all names have been changed in this blog post), who is a dancer, has been pulling away from a friend of hers because her friend's eating disorder was just too intense. Her friend has been hospitalized a number of times, is still unable to acknowledge her ED, likely is in renal failure, and is probably going to die soon. Another neighbor, Tina, happened by and with some sense of disgust started explaining that she, Tina, couldn't understand eating disorders, had no food issues, loved to run just for the endorphin high, and wasn't eating at the party because she had already had dinner beforehand. I felt like Meagan at that point, just wanting to pull away. (It was a party, after all.) I made a few attempts to say that everyone has food issues and that it wouldn't be so strange if Tina had a couple of things to work on, and so on, which only served to end the conversation.

So why is this important? Because it is so clear that your best chance to get better is to get help early, have aggressive and effective treatment, and get on with your life.  If you are 45 it probably means there was nothing close to effective treatment when you were young. If your illness didn't get better through caring, family, eating and fortune, you are likely very ill now. But there is still help for many. If you are younger, or know someone who is, get yourself or them into treatment now. Don't expect anyone to just figure it out. The thoughts, feelings and behaviors are too deeply set. Don't wait to see what will happen. The odds are high that what will happen is getting worse, not getting better. There is effective treatment now. You can get better.  Now I have to go follow up with Tina.

Next week: Why don't all therapists use effective treatment?

Contributions by Sarah Emerman