Living With Food: The Science Supporting Eating Disorder Treatment

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 

Take a look at this article by Pauline Anderson from Medscape Medical News about a research study that investigated the mortality rates associated with eating disorders. 

Mortality From "Mild" Eating Disorders Greater Than Rates for Anorexia and Bulimia 

One of the thorniest issues in eating disorder treatment is the notion of goal weight. Almost everyone in treatment wants to know what weight they’re supposed to be. The problem with this question is that it presumes the brain can and will tell the body what an appropriate weight is. This, however, is essentially untrue. When a person is healthy, the body finds the weight it needs to be.

For a person with Anorexia, the way the brain tries to control weight is through behaviors. Good treatment therefore means stopping the brain from trying to make the body do what the brain wants to. In eating disorder treatment, a client must learn to trust their body.

Goal weight is determined by your body, and is what your weight will be when you eat a healthy diet, stimulated by hunger, ending with fullness, over a period of time while engaged in an activity level that is healthy for you. The eating disorder has a very hard time believing this. This is one of the reasons a behavioral method of treatment is effective when other methods of treatment have failed. With all of this in mind, doctors and therapists use the term “goal weight” to mean many different things.

Primary care physicians are likely to use the term goal weight to define a weight where medical function (i.e.: heart, kidneys, endocrine system, bones) are functioning normally. This means that a person’s blood pressure and pulse will improve, their kidneys will function, they will experience a return of menses, and they will be on their way to reversing bone loss.

Eating disorder therapists and specialists versed in the current literature on Anorexia will determine goal weight based on research which demonstrates that the more weight a client gains during treatment and is able to maintain post-treatment, the less likely they are to relapse (Kaplan, Walsh, Olmsted, Attia, Carter, Devlin, Pike, Woodside, Rockert, Roberto, & Parides, 2009).

Any one of the treatment members discussed above may use criteria described for another. Centers using a multi-disciplinary treatment approach will form a team that consults from all of those mentioned above to best determine what a client’s goal weight might be.

The bottom line is this: no one knows what you’re “supposed to” weigh and no one can predict what you will weigh. Many doctors and therapists will be able to provide numerical guide posts along your way to healing, but no one will be able to tell you what your body truly needs to weigh. There are too many variables and every person is different. Ultimately, the goal is health and happiness.

Kaplan, A. S., Walsh, B. T., Olmsted, M., Attia, E.,Carter, J. C., Devlin, M. J., Pike, K. M., Woodside, B., Rockert, W., Roberto, C. A., & Parides, M. (2009). The slippery slope: Prediction of successful weight maintenance in anorexia nervosa. Psychological Medicine, 39, 1037-1045.

Next week: Therapy fails patients, patients don't fail therapy

Contributions by Sarah Emerman

Please take a look at this timely news article on the dilemma of current medical coverage for the treatment of eating disorders. The article features commentary from Stephanie Sizemore of the Eating Disorder Advocates of Ohio and our very own Dr. Mark Warren.  

Ohio Eating Disorder Advocacy Groups Working for Better Insurance 

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