The Hard Line in Eating Disorder Treatment

The refrain from clinicians who treat patients with chronic eating disorders is that there aren't any standard effective treatment options or any useful literature to read. Without a method to rely on, clinicians have turned to the field of addiction for guidance. The accepted approach for a therapist in that realm is rigid and punitive. The eating disorder version of the hard line is as follows. Present the patient with viable treatment options along with meal plans to follow and weight guidelines. If the patient can follow these rules then treatment can proceed. If not, then come back when you're ready. Outside of this simplistic, punitive approach, therapists are on their own.

The premise behind this kind of therapy is that engaging a patient in unsuccessful work will enable worsening of the disease. The eating disorder symptoms will persist without any immediate change in behaviors. More to the point, responsibility for any deterioration will now lie on the clinician's head.

It's no wonder there appears to be so many people with chronic eating disorders not in treatment. The unspoken agreement to hold the hard line among eating disorder professionals lets us all off the hook. No one needs to worry about the chronically ill. They have brought their desperate state upon themselves by refusing the correct course for recovery. Let them think about it and come back in time.

But people come to treatment for help. A one size fits all approach to treating eating disorders is not only reductive but cruel. These are complex, misunderstood illnesses with moderately effective treatments at best and few viable options at worst. How can we as therapists say we have the answer when there is no evidence behind the rigid approach to treatment?

The fear of enabling the illness can easily mask the fear of the therapist to take on such a challenging case. Working through a complex chronic eating disorder takes a lot of time and energy for the patient and therapist. There is certainly no guarantee of success and a high likelihood of managing serious medical problems that stem directly from the eating disorder. It would be more honest for a clinician to say he doesn't have time or expertise for a complex case than to place the blame on the patient. 

What happens when this patient does find a therapist? Things don't get easier. It's just as hard to assemble a team or find a program willing and able to confront the therapeutic challenge of treating someone with a chronic eating disorder, yet these options are clearly more effective than individual therapy alone.

If the patient agrees to more intensive care, most outpatient programs or residential programs cater best to younger patients earlier in the course of the illness. For someone not yet ready for more involved help, it's often a long, uncharted road to understand the eating disorder and institute behavioral changes with food. No manual exists to explain the baby steps in this type of recovery. No map points to paths to success. And no role models offer hope for the chronically ill. It's no wonder many of these patients stop seeking help.

Yet those are the available resources. Any work towards recovery either stays isolated to just individual therapy or expands into a team and/or program. The team offers more chance of full recovery because a patient need different providers to focus on all aspects of treatment and more time and energy to compete with the ever-present psychological and behavioral symptoms. Even the best therapy cannot accomplish all components of treatment. But assembling a team or involving a program also means accepting the misunderstanding and confusion that affects even experienced professionals in facing a complex, chronic illness. Although regular communication among team members and with the patient improves outcome, the patient will have to endure many challenges along the way. Being so resilient while dealing with an eating disorder isn't easy for anyone.

If we assume that treatment has begun and a team of seasoned clinicians assembled, the steps in treatment are still hard to determine. More than with people earlier in their illness, the treatment of chronic eating disorders has two critical components for success. First, it's essential for the team and patient to agree upon reasonable markers of progress and a reasonable timeframe for each step. Balancing the severity of the illness and barriers to progress is not uniform so each patient needs an individualized program. These markers fundamentally represent hope for change and recovery, a sentiment that can be hard believe after a patient has been sick for years. Yet without hope, the treatment is even more challenged from the start. I'll start with these two points in the next post.

Eating Disorder Therapy Decisions: the Hard Line vs. the Risk of Enabling

When faced with new, intractable illnesses without clear treatment, the medical field doesn't have the time to really help. The current climate of medicine forces doctors to rush from appointment to appointment without time to think or sometimes even care. Doctors are too harried, overworked and under-appreciated to be capable of more than the basic standard of care.

Challenging treatment for difficult diseases demands both creative thinking and compassion to open up the possibility of clinical improvement, let alone a cure. There's no room for that kind of medicine anymore.

Eating disorder treatment has come a long way in recent years. If the person's disease is relatively uncomplicated, compassionate treatment is enough. For example, the course of care for an adolescent with her first serious episode of an eating disorder is fairly routine. The patient starts in an inpatient program or intensive outpatient program, depending on severity of the symptoms, in order to normalize eating behaviors and weight. An outpatient team takes over treatment after a period of weeks or months while reintroducing the patient back into normal life. The patient is still young enough to allow the strong presence of family to guide treatment decisions, and the enforced cessation of symptoms often is enough to halt the progression of the disease.

Patients with a chronic eating disorder have had a different course of illness. They have adapted their lives around variable eating disorder symptoms and have had to recognize the dominance of the disease in their lives. They are old enough to be independent and not under the aegis of parents' decisions. They come to treatment often not ready to follow the set course of interventions but solely because they are sick of their illness and want help either to manage it or to get better.

What are the treatment options for these patients? Some clinicians follow standard practice. If the eating disorder symptoms are severe, inpatient or intensive outpatient treatment is necessary. In fact, many clinicians will stop treatment unless the patient seeks more intensive care. The reasoning is that outpatient treatment cannot be successful without normalizing eating and weight. Continuing treatment without medical stabilization sends a message of false hope, perhaps even enabling the disease to remain dominant. Many clinicians interpret this approach as tough love, similar to an approach used to treat addiction, while many patients interpret it as rejection and confirmation of the hopelessness of their cause.

Any different treatment for people with chronic eating disorders has no blueprint. The years of being ravaged physically and psychologically by these illnesses takes a toll. The first step in treatment involves a thorough medical and emotional inventory and a reasonable assessment of short and long term goals. Even then, the path to improved symptoms and quality of life won't present itself clearly.

If the initial assessment both on the part of patient and therapist leads to further treatment, it involves breaking new ground. Any progress stems from creative approaches both from patient and clinician and a willingness to try them even if they fail. All the while, the treatment has to include intensive management of the medical effects of the illness and hope that continued care isn't a means to allow the eating disorder to worsen.

There are risks to both approaches to treatment. Taking the hard line leaves the chronically ill patients alone with their disease with nowhere to go for help. Therapy with the chronically ill revolves around the constant presence of uninterrupted symptoms and the medical consequences of an eating disorder. Without clearly successful interventions for eating disorders, patient and clinicians are stuck with these hard choices.

The next few posts will address these two camps of eating disorder treatment and what it means for a patient seeking help.