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.