The First Meeting with an Eating Disorder

Dr. Michael Strober, the director of the UCLA eating disorder program and a mentor of mine, wrote a seminal article (* link below). about how to approach the initial consultation with a patient with Anorexia Nervosa. I first read the article, written in carefully chosen, beautiful language, many years ago. As much as Dr. Strober was able to clearly explain the intricacies and demands of such a complex first meeting, the meaning of his words has only deepened with time.

It's a monumental challenge to alert a patient's eating disorder that the jig is up, a fencing match with the most subtle but effective of parries can set the patient on a path towards recovery, even someone seemingly unreachable. The practical effects of recovery may not be apparent for some time, but the first meeting can lay the groundwork for real change. 

I have since spent many hours wondering about the ramifications of Dr. Strober's discoveries. Although people with eating disorders are unique individuals, their illnesses are remarkably similar, and the message they need to see a path towards wellness practically identical. 

The eating disorder is so much more than the sum of its parts. It's a companion, a best friend, a lover and an all-knowing philosopher. It's a captor, abuser and torturer. It's a source of pride, an accomplishment in a sea of failure and an endless series of distorted mirrors. It's the primary basis of identity but also eclipses any true identity at all. 

It's everything one could dream of, yet it's also an illness, a common one at that, just like everyone else's eating disorder.

It's a vast emptiness. It's nothing. 

Dr. Strober states very clearly that a personal connection, one that obviates the need for the eating disorder, suddenly and completely calls into question the nothingness of this disease. The strongest eating disorders become personified, much like the personification of animals or inanimate objects in fiction.

Questioning that fallacy with an immediate and powerful personal connection can so disarm the patient that she can do little but listen in the open-minded way the illness had previously made impossible. 

What has struck me even more in the intervening years are the implications of that initial connection, the first moment of meeting an eating disorder.

It insists on the creation of a true and real relationship. It opens the door, if the treatment is to be truly helpful, to a very real and powerful connection, something both therapeutic and affirmingly existential at its core.

That powerful moment needs to be much more than a chance encounter. It insists on the need to see the special, moving and cherished characteristics of both the person and the relationship. It lays bare a vulnerability of a most profound nature. It creates a truly special bond risen from the ashes of a devastating disease, something lasting, a way to envision closeness in a world without the disorder. 

And in the wake of that intensity, pain and persistence against a wily and stubborn illness lies the foundation of a life in recovery, one that allows for the joy, pain, accomplishment and failure of an ordinary life.

That life no longer has the artificial drama and specialness of the eating disorder. It eludes the appeal of the supposed creation of a superhuman but false persona. After that devastating nightmare of an eating disorder wanes, what's left is a life that is very, very real.

The moment of meeting an eating disorder is now precious to me but fraught. Weighed down with the possibility of showing a very ill person a path towards relief, I see the import of Dr. Strober's words more clearly each day.

Eating disorders take away years of people's lives and cause endless suffering for so many patients and families. In that first meeting there is a chance to avoid years of pain.

If at all possible, I just can't pass up the opportunity to help someone escape that much suffering. 

* http://books.google.com/books?hl=en&lr=&id=3gmogQshI_MC&oi=fnd&pg=PA229&dq=Consultation+and+therapeutic+engagement+in+Severe+Anorexia+Nervosa&ots=WImTG6btD-&sig=qMblJkkRDMO69BLjiqjyoCOrM_s#v=onepage&q=Consultation%20and%20therapeutic%20engagement%20in%20Severe%20Anorexia%20Nervosa&f=false


Adolescence: a Risk Factor for Eating Disorders

Adolescence is a time of physical, mental and emotional growth. The rate of internal change is so fast that mistakes of poor judgment are inevitable. In fact, one of the last parts of the brain to mature involves planning and judgment, qualities clearly lacking for most teenagers. Combine this decision-making difficulty with the penchant for exploration and much of the risk for teenagers is perfectly clear. 

In every generation, there appears to be a new, tantalizing frontier that transforms into a universal rite of passage for adolescents. Alcohol, drugs and sex are the three most common concerns, but others have crept in like prescription pills and self-harm such as cutting. 

One of the newest adolescents crazes is the drive for thinness. With the expectation for both boys and girls to have unnaturally thin bodies, especially unnatural during the hormonal shifts of puberty, the appeal of weight loss has grown into a standard experience for teenagers. Peer pressure to restrict food, purge meals or take pills such as Adderall, laxatives or diuretics have grown almost unavoidable. Kids can find any number of weight loss guides on line as well to steer them towards these dangerous behaviors.

The thrill of seeing an effect on one's body can be exhilarating to a teenager who feels like life is an out-of-control roller coaster. The sense of pride and accomplishment, albeit one that is small and in the long run meaningless, quiets the constant feeling of confusion and replaces struggling self-worth with an immediate burst of confidence.

It's scary to reflect on just how powerful the drive for weight loss can be in adolescence and how success feels downright magical. 

As with all of the destructive behaviors for teenagers, the long-terms risks always escape their notice. Engaging in eating disordered behaviors, especially restricting food, sets off a cascade of biological and psychological responses to starvation.

No one can predict how each child will respond. No one knows if that child will just give up after a day or two, get caught in a cycle of restricting and overeating or be genetically susceptible to develop anorexia. But the increasingly common exposure to starvation for teenagers means those kids are more and more likely to find out. 

Until recently, no one would even consider these risks for a child. Eating meals through the day was a matter of course and the drive for thinness nonexistent. Accordingly, the incidence of eating disorders was very small, a rare and mysterious disease people fell into without any idea what was happening. That's not how eating disorders develop anymore. 

Adolescence has become a breeding ground for eating disorders, replete with friendships encouraging the behaviors, online groups dedicated to provide support and the social normalization of irrational food restriction. Just as drinking or using drugs at a young age can set that child up for much larger problems, food restriction increases the risk of developing an eating disorder. 

However, parents and adults are much less likely to worry about a teenager dieting than about using drugs. Those adults may themselves be restricting food or even encouraging the child to eat less. The social norms actually span generations, leaving teenagers without any idea their behavior is dangerous. The general obsession with thinness leaves children at sea to find a sane way to understand food and weight. 

With teenagers dieting and engaging in eating disordered behaviors, there needs to be a public health campaign to counter the false advertising of the food and diet industries. More specifically, children need to understand the risks of their behaviors and the expected norms that will keep them safe.

Adolescents won't necessarily follow the rules because that's the nature of the stage of life. However, exposure to the risks and norms will at least offer them some guidelines to either heed or ignore. It will allow them to know when their decisions are leading them into trouble. It will also give parents, even those struggling with food and weight, a means to teach their children a saner attitude about their bodies. 

But who understands these risks enough to spearhead the campaign? And who has enough influence to create awareness of these risks? The next post will address these larger questions. 


The Politics of Eating Disorder Treatment

Institutional health care--hospitals, rehabilitative centers, nursing homes and outpatient clinics--has undergone a transformation in the last decade from independent entities to large business. In order to have bargaining power in the marketplace with health insurance companies, institutions had to merge and garner a significant market share in their local community.

The most concerning issue with large health care business is consistent quality of care. Executives have increasingly relied on evidence-based medicine as the standard of care to show how even large institutions can provide excellent clinical treatment at all of their medical sites. 

This sea change in medical practice--large business and evidence-based medicine--has skipped mental health care which continues to exist in a world of solo practitioners and treatment centers. In fact, mental health treatment has often remained independent of the health insurance industry as well, except for the poor, the disabled and people with eating disorders.

As the spread of eating disorders breaches socioeconomic boundaries, too many patients don't get adequate care due to insurance limitations. And independent entities--clinicians or residential programs--have no purchase to bargain with health insurance companies. 

The new business model for the health care industry finally appears to be coming to the eating disorder treatment world. The Affordable Care Act provides one boon to the transformation: federal parity for mental health treatment. Any plan under the ACA must offer equal coverage for medical and psychiatric care, including treatment for eating disorders. Thus, one major bargaining chip for the insurance industry to limit care is no longer viable. 

The current trend is for well-known eating disorder programs to franchise residential and outpatient treatment centers in parts of the country with fewer resources. But eating disorder treatment remains complex and doesn't have evidence-based guidelines that are widely accepted. Finding any effective treatment is hard enough.

Instead, franchises attempt to replicate treatment through modeling and mentoring. Programs design step-by-step guidebooks to establish a new program while the program director or experienced clinicians train the employees at the new center. Sometimes, the director of the new center may actually move from the original center to start the new franchise. 

Eating disorder treatment remains long and hard without new scientific breakthroughs on the horizon. Expensive care for the chronically ill weighs heavily on the bottom line for health insurance companies so limiting care remains a cornerstone for minimizing financial outlay. This current system creates an underclass of people with chronic eating disorders and no way to find a path to recovery. A passionate group of directors of nationwide treatment centers can lobby government and insurance companies to offer adequate care for this languishing population. 

I see how noble this mission truly is. The rise in the incidence of eating disorders in recent decades, as I have chronicled extensively in this blog, is due to a combination of pressure for thinness, sedentary lifestyle, the rise of processed food and sanctioned starvation as a weight loss technique. But society has struggled to take responsibility for our self-inflicted epidemic.

Those unfortunate enough to have become ill labor for recovery in secret while everyone else marvels at what appears to be an incomprehensible illness. Making the suffering of these people public will hopefully force government and the health insurance industry to create fair and adequate treatment available to patients with eating disorders.

The parity for mental health care in the ACA and the increased potency of a centralized eating disorder treatment industry might just pack enough punch to make an impact.