Threats and Punishment in Eating Disorder Recovery

One of the reasons this blog focuses on compassion as a core value of treatment is that threats and punishment comprise such a large part of the attitude of clinicians and families towards eating disorders. 

Shame is a central part of an eating disorder, and punishment is an underlying manifestation of almost all eating disorder thoughts. These two values are truly the engine that drives most eating disorders. Using those attitudes to approach these illnesses only strengthens their hold on the person who is suffering. 

The general public struggles to understand all psychiatric illnesses, but eating disorders may be the least understood. Still glorified as a successful diet and as a source of envy, most people are hard-pressed to see the torment patients endure. 

When the symptoms finally come out in the open and the medical or social repercussions become clear, family and friend responses are very often punitive. Threats quickly rise to the surface, and the underlying message is that an eating disorder is not an illness but a willful choice of behavior meant to ask for attention or cause trouble. It's extremely rare for the first question about the eating disorder to be, "What is wrong? How can I help you?" Yet this is the only question that might really avert the severe illness that often ensues. 

The public opinion of an eating disorder as a successful diet or an adolescent rite of passage only explains part of this general attitude. The other part is that eating disordered thoughts and behaviors just make no sense to most people. As explained in a recent post, once eating behaviors are ingrained, they become very automatic. Someone with relatively normal eating patterns will find disordered behavior completely confusing and almost unthinkable. Hence the most common initial suggestion of a parent with a newly diagnosed child with anorexia: just have a milkshake! This sentiment only makes the sick person feel more alone and more scared. 

Similarly, it appears to be almost universal to think that anger and threats will somehow snap the person out of an eating disorder even though those reactions only alienate and isolate the person further. Kindness and compassion are the way most people would approach a loved one in pain and suffering. That's no different with someone who has an eating disorder.


The Role of Automatic Eating Patterns in Recovery

A common question when starting recovery is how long does treatment last. That question is hard to answer exactly, but the answer must reflect the reality: it takes quite a long time to recover.

This reality is important for patients, clinicians and loved ones to understand because one underlying tenet of treatment is patience. Slips and struggles cannot turn into a reason for the patient, her family or the therapist to blame her for the illness or the length of time needed for recovery. Everyone needs to understand that this process includes many ups and downs, struggles and successes.

Since people can fully recover from these illnesses, it's perplexing to many why recovery takes so long. Changing eating patterns from disordered eating to normal eating seems like it ought to be very straightforward, yet realistic progress could not be more complex. 

The biological underpinnings of the recovery process are useful to better understand why. 

Some human behaviors, like those of animals, are largely innate and do not require much conscious attention, such as breathing, sleeping, walking or eating. Although we often use our abilities to attend to these actions, our more primitive brain functions will take over and force us to perform these tasks if we choose not to. 

Our brains are hardwired for these specific actions because they are necessary for survival. The gift of conscious awareness and attention can only go so far before our animal instincts force us to continue these tasks. Eating falls into that category. 

Most eating disorder patients who have restricted long-term reach a point where their hunger reaches starvation level and their minds don't let them starve anymore. As upsetting as this is, our bodies are programmed to live. But, as I have written many times in this blog, eating in and of itself doesn't equal recovery. 

Similarly, our brains appear to develop powerful eating behaviors that become ingrained in our daily life. There is a large variety of these behaviors: grazing, substantial meals through the day, constant food obsessions and disordered patterns. However, once those patterns are set, they become deeply entrenched in our daily routine. Since food behaviors appear to be well-protected, primitive behaviors, these patterns become locked into very fixed circuits in the brain. 

Changing those fixed circuits takes a lot of time, practice and attention. Eating like we did when we were children is not akin to riding a bicycle after years of not doing so. Relearning how to eat is a long, arduous process in which every step is not intuitive and demands attention and focus. Over time, the mind can learn a new way of handling food thoughts and behaviors, and the new patterns gradually become unconscious and automatic. Those behaviors do change, but the transformation of any unconscious process takes quite a bit of time.


A New Treatment Option for Adults with Anorexia

A new concept in the treatment of eating disorders, most specifically anorexia, in adults is a five day intensive program tested at a few medical centers in the country. Initial data are promising, and the advent of new treatment options are very welcome to clinicians. 

The core modalities of treatment are similar to what is used in most clinical settings. The combination of education, cognitive tools, group sessions, family meetings and nutrition counseling comprise the large majority of the treatment. 

What is unusual about the program is that both patients and their closest family members attend the entire program. Almost all residential programs have family sessions and include families in support groups or even for a full day, but no program has ever included families the entire time. The Maudsley method incorporates a very strong parental role but only to treat adolescents and not as support but as the leaders of the recovery effort. 

When families are fully included in treatment, the message about recovery is very different. It's also reflective of much of what I have written in this blog. Family and friend support is critical for recovery. When people try to recover alone, they remain trapped in their own minds, in a world historically dominated by the eating disorder thoughts. Close, open, loving relationships can serve as a competing force to the eating disorder and allow the person to see how those relationships can be much stronger and more fulfilling than the eating disorder. 

Often what makes open relationships so hard is that loved ones have a lot of trouble grasping what support means for someone in recovery. A five day program intended to educate family in how to provide support can be of great benefit. 

It's unclear how successful this fledgling program will be, but the more important message is how necessary support from loved ones is for recovery. Any successful recovery needs to utilize that support, however it appears in someone's life, to open the door for a life without the eating disorder.


The Role of Evidence-Based Treatment in Eating Disorders

Currently the evidence-based treatment for eating disorders is limited to cognitive behavioral therapy (CBT) for bulimia and binge eating disorders. There have been many studies and ample evidence that CBT reduces binge eating episodes by about half for people binging at least daily in research protocols lasting usually around 2-3 months. There is robust and repeated evidence for this benefit which makes CBT the important initial intervention for a patient new to treatment with any form of binging. 

The treatment involves daily food journaling including meals, assessment of binge/purge behaviors and thoughts/feelings. During each session, the therapist and patient review the journal and assess the interplay between the internal experiences of thoughts and feelings with the food behaviors.

Increasing awareness and understanding enables patients to see much more clearly when they are at risk for a binge and to make different decisions to avoid them. This learning process enables more regular eating thereby decreasing starvation as a main trigger for binging. The journaling also starts the process of identifying the emotional triggers for binging, a longer and more involved component of therapy and treatment. 

Typically, CBT remains an important part of therapy for longer than 3-6 months. The treatment helps patients remember the need for normal eating and continue to increase the understanding of how emotions trigger binges. 

Evidence-based research does not track patients for longer than six months. Long-term studies for psychiatric illnesses are much too expensive and involve too many variables to be realistic. Only a few have ever been done for any psychiatric disorders at all. 

Moreover, there is no evidence-based treatment for anorexia despite the fact that patients with anorexia do get better and recover. 

After a few months of treatment, all patients with eating disorders would be left without options if evidence-based treatment was the only reasonable and reliable option for care. 

The reality is that the concept of evidence-based treatment sounds positive but represents a very limited understanding of eating disorder therapy. This approach offers treatment for a subsection of people with eating disorders. It offers short-term symptom relief with no guidance for long-term treatment or for maintenance of those gains once six months are completed.

Effective clinical care takes into account research evidence and uses it as a part of therapy. However, successful recovery involves a combination of all available treatments applied for each individual with the overall goal not as symptom relief but true recovery.


The Limitations of Evidence-Based Treatment in Eating Disorder Recovery

Evidence-based treatment is a catchword in psychiatry, and more broadly in medicine, in recent years. The general idea is to attempt to codify medical treatment by supporting proven approaches to illness. However, the concept is more or less meaningful in different branches of medicine. 

When treating high blood pressure or diabetes, the overall effect of a treatment is fairly easy to determine. In each case there are specific measurements to be followed which can show clear evidence of improvement. A algorithm of treatment based on these results is easy to create. 

Psychiatric diagnosis is itself a more creative endeavor. Although the DSM criteria for illness are very specific, translating a person's symptoms into a clear diagnosis is not always so simple.

For instance, questionnaires used to quantify the severity of depressive symptoms can seemingly create a quantitative measure of illness; however, these tests are nowhere near as objective as a blood pressure reading. Moreover, the results cannot make any clear correlation between medication and improvement in the way that blood pressure medications affect blood pressure readings. In addition, there is no evidence of long-term effect of treatment since mood is so variable and based on so many life factors. So doctors end up relying on clinical experience and signs of individual improvement, something more tangible but much less concrete. 

Evidence-based data for treating people with eating disorders is even more limited. There are many short-term treatments that show reduction in symptoms, almost exclusively binging and purging, for up to 3-6 months. Although that relief is meaningful, people seeking treatment are interested in recovery, not temporary gains, and there is no evidence-based treatment for recovery. 

The branch of mental health treatment focusing on evidence seems to lose sight of the goals of patients for the goals of research when it comes to eating disorder patients. 

The increased interest in research in eating disorders is crucial to generate knowledge and potential long-term benefit, but the expertise in this treatment is still much too limited for clinical work.

More personal models which create community and alternative ways to cope with life outside the eating disorder offer one way out of these all-consuming illnesses. To be sure, there are other ways too, but the promise of research as an alternative is still years away. For now, patients seeking treatment need to understand the path toward recovery not short-term gains. They need hope for their own individual future. 

The next post will explain the use of evidence-based treatment in eating disorder recovery and how it fits in with other treatment.


The Risks of the Finance World in Residential Eating Disorder Centers

A recent New York Times article pointed out changes in the eating disorder residential treatment industry that have caused significant changes to the programs. I still recommend residential treatment for many patients, but it's important to realize that these are not hospitals but have been bought by for-profit businesses with several, often contradictory, motives. Programs originally started by passionate individuals are now owned by holding corporations which have an influence on overall treatment. The educated patient needs to weigh all these factors into the decision to seek residential care. 

Originally, treatment programs were all based in hospitals. They sprung from psychiatry programs in larger academic centers through the 1980's and 1990's when the need for eating disorder treatment followed the skyrocketing incidence of these illnesses. Although these programs still exist, changes in health insurance coverage have shortened hospital stays to only a few weeks and limited the hospital-based programs to provide primarily medical stabilization. Few still include long term treatment that can lead to recovery. Most hospital programs will refer recently stabilized patients to residential centers. 

About 20 years ago, driven individuals started to create independent residential treatment facilities. Many of the founders were in recovery from an eating disorder themselves. They sought to provide a caring, kind and hopeful environment--qualities that much of the literature suggests are crucial to successful treatment. The growth of these centers stems from the extremely low success rate of outpatient treatment and hospital-based programs. 

Because there is so little treatment proven to be effective in eating disorder recovery, the residential programs focused on creating an experience that reflects the knowledge of very experienced clinicians, a novel idea at the time. The notion that programs need to focus on evidence-based treatment is not viable: if treatment were that effective, there wouldn't be a need for residential centers. Evidence-based treatment typically reduces symptoms at best, but many programs strive instead for full recovery. 

A number of programs have successfully managed and treated a large number of patients, often some of the sickest and chronic ones. Integrating people into a community of recovered individuals who can provide ongoing care and support, seemingly crossing standard boundaries in psychotherapy, has been remarkably effective for many patients. 

As for-profit businesses, the residential centers are also of interest to financial firms looking for a profit, and this problem has become a new and concerning issue in the industry. 

Over the last few years, financial firms bought some of the most well-established and successful programs and, eager to expand the company for eventual sale, have opened many new branches across the country very quickly over the last few years.  But expanding an eating disorder program is very different from opening more franchises of supermarkets or clothing stores. Replication of a successful treatment center is a more complex endeavor that involves hiring and training the right staff and incorporating a complex treatment philosophy. 

The new programs are very uneven in staffing and therapeutic approach. It has proven extremely difficult to create the support and commitment of a treatment center to other branches opened across the country. The need to increase profitability, not for patients' benefit but for the financial backers, has compromised the quality and compassion of residential care. Accordingly, patients must beware of which program they choose to enter and need to educate themselves on each branch's reputation.

On a final note, the newspaper article doesn't acknowledge the long-term benefit of residential treatment to the eating disorder community. These programs have offered hope and recovery to people otherwise condemned to chronic, debilitating illnesses. The committed clinicians and administrative staffs have created an environment of healing unparalleled in the eating disorder treatment world.

The problem lies with introducing for-profit financial companies into the mix. That combination doesn't benefit patients at all.


Confronting the Denial of a Functional Eating Disorder

People who are outwardly functional who have an eating disorder constantly question how sick they really are. Our society is littered with fad diets, the constant pressure for thinness and value judgments around weight. These realities make it hard for someone to clearly see their eating disorder. 

The glamorization of restricting, seeming universality of over-exercise or purging and the creation of diets using herbal laxatives have even normalized symptoms themselves.  It feels like the norm to obsess over every meal and over any weight change, no matter how small. 

The distinction between food and weight obsession and an eating disorder seems like a fine line to the person with a functional disorder. The significant restricting, regular binging and purging or any other symptoms can seem to fit into some version of the distorted norms of food and weight in today's culture. 

Under the surface, the constant intrusive thoughts of the eating disorder, in addition to daily symptoms, clearly define the circumstances of a functional eating disorder as opposed to someone overly focused on food and weight. 

Initial attempts at treatment need to introduce and reinforce the concept that a functional eating disorder is indeed an eating disorder and just as serious. Any words that mitigate the severity confirm the denial and pave the way for longer periods without treatment. The message that this eating disorder is real and serious needs to be consistent and clear. 

For someone who has not been in much treatment, it's also important that the message is kind and compassionate. The diagnosis needs to convey that starting treatment will feel liberating since a functional eating disorder feels very much like a prison, even if that path is arduous and long. The compassion also counters the internal, punitive thoughts that dominate someone in this situation who feels trapped in a cycle of misery. 

Balancing firmness about the diagnosis with compassion allows this person to engage for the first time with the possibility of a new way out of their dilemma. Although that feeling is precarious, it opens the door to the key of any successful eating disorder therapy: hope.