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.


The Functional Eating Disorder Mindset

One difference between someone with a functional and non-functional eating disorder is glaring. A person who is functioning can regularly use the relatively well parts of their life to deny the severity and even existence of the eating disorder. People who are not functional with their illness may also be in denial about how sick they are, but the medical severity means this denial is more akin to delusion and thus represents a different aspect of eating disorders. 

To understand the importance of this difference, one must have more clarity about the role of denial in eating disorders. The persistence of thoughts about restricting food, weight loss and the inherent focus on body all dominate the internal world of someone with an eating disorder. However, the reality of an eating disorder is that this mental state is the norm: it's often hard to believe others live any differently and almost impossible to imagine what that alternative feels like. It is much harder to normalize one's life experience when someone has been in and out of hospitals. 

A functional eating disorder makes it easy to think that there isn't much difference between this way of eating and normal eating. These people still struggle with many of the same professional and personal issues as people without eating disorders. They think about food and weight, like many people. It's just that their thought processes are very different and all encompassing. 

Over time these thoughts begin to blend into reality and become an overall philosophy of daily life. Moments of increased struggle may break through the denial temporarily and highlight how real the eating disorder is, but the desire to fit into a more normal framework, despite ample evidence to the contrary, trumps any urge to seek help. 

The mindset of someone with a functional eating disorder demands a very different approach to begin to change. The first and most important step is to break through the hardened wall of denial, not to counter the power of the eating disorder thoughts. More on this next post.