Eating Disorder Professional Treatment – Nutritional Rehabilitation

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

If you or anyone you know has the symptoms of an eating disorder described above, seek help from a professional trained in the assessment and treatment of such illnesses. It is especially dangerous to try to treat anorexia or bulimia without professional medical consultation! An eating disorder is a complex illness that requires the astute care of a treatment team, including a medical doctor and a licensed mental health therapist.

One of the first steps to getting well is being evaluated by mental health and medical professionals. This evaluation will generally include an interview with you (e.g., the “patient” who is displaying the eating disorder symptoms) and your family. The interviewer will ask for a detailed medical and mental health history, and will ask you verbal questions, as well as give you standardized paper and pencil (or computerized) tests to fill out. You may be assessed with one or more of a variety of screening tools that have been developed to assess behavior, symptoms, attitudes and risk factors of eating disorders. Some of these include questionnaires such as the Perceived Body Image Scale (PBIS), Beck Depression Inventory (BDI), Trauma Symptom Inventory (TSI), Bulimia Test (BULIT-R), Eating Disorder Inventory (EDI), or the Eating Attitudes Test (EAT).

It is important to be as honest as possible when answering questions, even though they may be difficult or painful to answer. Even though you may feel ashamed and embarrassed, particularly if your eating behavior has caused significant health changes, or has occurred for a long period of time, concealing information will impair the ability of your therapist and doctor to get you the best help possible for your condition.

If the medical professional diagnoses you with an eating disorder, he or she will then proceed with making recommendations for treatment, starting with a full medical examination. A dental exam should also be completed, particularly if you have been engaging in purging behavior.

During the medical exam, the physician will complete a routine physical, as well as ask you about your eating habits, diet, and physical symptoms of the disease. You will also be asked to complete laboratory and other tests to check for any medical complications that your disordered eating may have caused and to evaluate organ functioning. Test results will also serve as a baseline for future comparisons to determine whether treatment is helping. During treatment, a medical doctor will continue to monitor physical health, including consistent checks on vital signs, hydration level and electrolytes.

Nutritional Rehabilitation

Treatment should be multifaceted and individualized to your needs. The first priority of treatment, however, is to regain physical health and decrease the medical dangers of the disease. Nutritional rehabilitation is often one of the primary goals in the beginning and the ongoing stages of treatment. Because many individuals with eating disorders are savvy about nutrition, they often believe that they don’t need to work with a nutritionist. However, your nutritional knowledge may be distorted by the disordered thinking characteristic of eating disorders. The role of a licensed registered dietitian is to help you return to a normal weight in a healthy manner, stop using laxatives (if necessary), set realistic and healthy eating and exercise goals, plan meals, recognize hunger cues, and make healthy food choices. A dietitian can also help you recognize your distorted thinking about food and weight, as well as teach you about the nutritional dangers of your behaviors.

Eating Disorder Professional Treatment – Individual Psychotherapy

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

Unless you are in grave danger, the mental health clinician will recommend outpatient therapy for you and (very likely also) for your loved ones. Outpatient therapy is conducted in a counselor’s office, typically on a weekly basis. Individual outpatient therapy is designed to provide you with education, insight, and support. It will be important in therapy to address how and why the eating disorder developed and what continues to contribute to the disordered behavior. A mental health provider may also teach you to rectify faulty thinking, get in touch with strong emotions, increase poor self-esteem, and process body image. Homework (e.g., behavior contracts designed to reduce your disordered behaviors, monitoring sheets for tracking thoughts and behavior, and journaling to increase understanding, etc.) might also be required.

The role of the therapist also involves helping you develop new coping skills. Introduction and restoration of coping skills might include learning how to self-soothe and calm down without the use of food when upset, as well as communicating feelings and needs effectively. You must also learn how to develop a healthy social support system and ask for help when you need it. In addition, teaching the appropriate expression of anger, the recognition of faulty perceptions of inadequacy, and the appreciation of individual strengths and talents as safe alternatives to self-punishment are important. Furthermore, those who binge and purge benefit from adding more structure to their eating schedules, learning healthy food choices, and restructuring perfectionistic thoughts.

There are several philosophical and theoretical approaches that the clinician may use to guide individual therapy. The choice of approach is dependent on the clinician’s expertise and preference, as well as your needs. The most common type of therapy used for eating disorders is Cognitive Behavior Therapy (CBT). CBT is an empirically valid intervention, which means that the techniques have been vigorously researched and found in numerous studies to be more effective than other interventions or no intervention. Aaron Beck originally developed Cognitive Behavior Therapy in the 1970’s. The premise of his therapy is that feelings and behaviors are driven by thoughts (cognitions). When thoughts are inaccurate, the behaviors and feelings that follow tend to be distorted or disturbed as well. The role of the therapist in CBT is to help you identify your cognitive distortions that are causing your eating disordered behavior. For more information on Cognitive Behavior Therapy, visit our Cognitive Restructuring Article.

To treat destructive eating disordered behaviors, a CBT therapist is likely to teach a variety of cognitive restructuring techniques. For example, anorexics are challenged regarding their rigidly self-imposed expectations and perfectionism. They are helped to set more realistic goals for themselves and to decrease the importance they place on weight and body image. In recognizing their talents and strengths, their self-esteem benefits from a broader perspective of who they are and what they look like. In order to do this, a CBT therapist will often point out examples of their “black and white thinking,” a form of cognitive distortion in which people see the world in absolutes rather than shades of gray; for example, thinking I am either completely terrible or totally wonderful, rather than thinking I am generally an okay person even though I am not perfect. The therapist will challenge people to monitor these rigid cognitions and rethink them in a manner allowing for more flexibility and ambiguity.

For bulimics, CBT addresses their over-reliance on attributions of other people as an unhealthy means of comparison. Individuals with bulimia learn to focus on themselves, rather than on external standards. Bulimics also learn positive self-talk to start being more kind to themselves, as well as thought-distracting techniques to escape obsessions. Furthermore, they learn to dispute their justifications for binging and purging behaviors so as to view these dangerous behaviors from a more realistic, healthy perspective.

Eating Disorder Professional Treatment – Individual Psychotherapy Continued

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

Bingers are taught to find reinforcement and comfort in activities other than eating. Through journaling and charting, they are taught to identify, and replace negative, destructive thinking that precedes binging episodes. Bingers also develop skills to replace destructive behaviors with another activity that is reinforcing and healthy. Bingers must also be confronted regarding their minimization of the dangerousness of destructive behaviors.

Studies indicate that CBT has a 60% or higher success rate for treating general or overall psychological conditions, including eating disorders. It is important to note, however, that “successful treatment” means only that patients are no longer jeopardizing their lives and can return to daily functioning. It does not mean that they are symptom free. Because there is no cure for or complete recovery from anorexia, bulimia or binge eating disorder, you may have to work the rest of your life to prevent your relapse into a negative cycle of disordered eating behaviors. This sounds depressing, we know, but truly, with the help and support of friends, family and therapists (as needed), and through the exercise of your newly acquired coping skills, you can expect to enjoy a happier and safer life.

Other forms of individual therapy, which are not as effective as CBT in research trials, may still be useful for some people with eating disorders. These include more relationship-oriented therapies, such as various forms of psychodynamic theory and humanistic theory. Psychodynamic therapies use the relationship built between client and therapist to create insight and behavior change via a technique called transference. In transference, the therapy relationship is used as a laboratory in which troubling emotions found in other relationships (such as with family members) can be safely expressed (“transferred”) toward the therapist who acts as a surrogate receptacle for those emotions. For example, the patient may become angry at the therapist in place of being angry towards a parent, say, treating the therapist as a sort of surrogate parent for a time. The therapist can recognize this anger as being aimed at the patient’s parent, and reflect upon this to the patient, who can become more aware of and thus more in control of her actual feelings towards her parent. The therapist accepts feelings from the patient freely, allowing the patient to explore new coping styles, while backing out of unhealthy and destructive coping styles. This process can be very beneficial when combined with the teaching of coping techniques for future relationships, such as assertiveness training. Some of these therapies may be especially helpful in the treatment of co-morbid conditions, such as depression and perfectionism.

The premise of treating an eating disorder from a psychodynamic perspective is that the symptoms of the disorder are expressions of a struggling inner self that uses these behaviors as a way of communicating or expressing underlying issues. The underlying issues are developmental deficits and/or unresolved feelings and needs that if not addressed, will continue to be expressed as dysfunctional behaviors. These issues cannot be confronted directly, as the person will use defensive coping skills to protectively maintain behaviors that feel comfortable and safe. The essential goal, therefore, is to help people understand the connections between their behavior and their relationships, and how these interact to create and maintain their eating disorder.

Eating Disorder Professional Treatment – Inpatient And Residential

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

Inpatient and Partial Hospitalization

If you (the patient) are in grave physical danger and cannot be treated or maintained safely without immediate medical interventions, the mental health professional who is examining you may arrange for intensive treatment. Treatment in a more intense structured setting may also be required if your symptoms are out of control and danger appears immanent. Inpatient treatment involves twenty-four hour care in a medical or psychiatric facility (e.g., an inpatient hospital setting) designed to treat medical complications and restore weight, as well as provide limited therapy.

If you are uncooperative with treatment recommendations and doctors feel that your life is in jeopardy unless you receive intensive intervention immediately, you may be admitted to the hospital against your will in a process known as “involuntary commitment”. If you continue to refuse food and nutritional supplements while in the hospital, you may need tube intravenous (I.V.) feedings in order to save your life. Though hospitalization may be involuntary, it does not typically last for long periods of time. The goal of hospitalization is to physically stabilize you, and prevent serious medical complications and death. Insurance companies cover the cost of brief admissions to the hospital only when medically indicated, and justified by qualified physicians.

Sometimes, when you need more support than can be offered through outpatient therapy but less supervision than an inpatient program, you may be advised to attend a partial hospitalization or day treatment program. Although there are few partial and day treatment programs designed specifically for those with eating disorders, these programs are becoming more popular as a alternative to the very high cost of inpatient programs. When attending one of these programs, you attend treatment at a hospital or clinic several days per week for a few hours each day. You will not sleep at the hospital, however, but return to your home in the evening.

Residential Treatment

Residential facilities offer 24-hour care to patients who may not be in acute medical danger but who continue to engage in eating disordered behaviors and as a result need intensive support to continue functioning on a daily basis. For example, people who use binging, self-induced vomiting, laxative abuse, compulsive exercise, and restricted eating and who don’t have serious medical problems (yet), and who cannot stop these behaviors without intensive supervision, may be recommended for residential treatment. These programs generally offer specialized treatment, including supervision of behaviors and daily living activities, while still providing patients with opportunities for increasing responsibility for their own recovery. Such programs are often located in medical hospitals or exist on campus-like grounds, estates, or renovated houses. It is rare that insurance companies offer residential benefits to their customers. Often, you and your family must pay “out-of-pocket” (on your own, without insurance benefits) for residential care.

In some circumstances, you may live in a halfway or recovery house, which provide support and relapse prevention within a less structured setting than a typical residential program. These programs offer transitional situations (e.g., between hospital and regular environments) where residents can live with others who are also in recovery. Residents attend group therapy and recovery meetings, and participate in individual therapy either as part of the house program or with an outside therapist. Residents of recovery houses are typically generally free from the worst behavioral, physical and medical eating disorder symptoms and are working toward living in the community again.

Typically, care progresses along a pattern from immediate, life saving interventions in a hospital setting, to partial or residential programs and intensive therapy, to less frequent outpatient therapy sessions. As you gain physical and emotional health (or if your treatment started at a less severe stage), you will then transition to a recovery program or to outpatient services while living at home again. As needed, you may return to more intensive levels of care if your symptoms resurface or you feel out of control once again.

Eating Disorder Professional Treatment – Group Therapy

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

Group Psychotherapy

As a part of a treatment program, or in conjunction with outpatient individual therapy, you may attend group therapy. Group therapy is an excellent source of treatment and support for bulimic individuals and binge eaters, but has not been as successful for helping those with anorexia. This has been attributed to the highly competitive nature and distrust of anorexics. When in a group format, they tend to compare themselves to other group members and compete to be the thinnest.

There are a great deal of benefits from group therapy, including provision of education, normalizing (group members learn that they are not alone in their disease), support and acceptance (group members learn compassion and empathy for themselves and others), interpersonal skills and friendship, and confrontation of unhealthy behaviors. Groups may be homogeneous, where all members have the same eating disorder, or heterogeneous (members have any type of eating disorder). A heterogeneous group typically includes anorexics and bulimics as they are more similar to each other than to binge eaters. Furthermore, anorexics and bulimics share similar etiology, or causes, for their disordered behaviors. Also, anorexics do better in mixed groups because they feel less threatened when comparing themselves to more average-weight bulimics.

Peer Support Groups

Another group that may be ideal for binge eaters is a support group called Overeaters Anonymous (OA). OA is based on a disease or addiction model of treatment, sometimes referred to as the abstinence model, and parallels Alcoholics Anonymous. OA members learn to comply with the Twelve Steps, and food is viewed as a drug over which those with eating disorders are powerless. The use of an addiction model for treating eating disorders is controversial in the medical literature, and The American Psychiatric Association does not recommend this type of program as the sole treatment approach for anorexia nervosa or bulimia nervosa (recommending it only as a possible complement to other therapies). Critics of this approach suggest that there is little scientific proof that people can become addicted to certain foods; that an addiction model in which bulimics and anorexics can never be fully recovered exacerbates cognitive distortions and self-fulfilling prophecies; that promoting the abstinence of food can clearly backfire in the treatment of anorexics; and that there are too many variations in the quality of services from chapter to chapter. In light of such important criticisms, participation in OA should be viewed as a type of support group rather than as a treatment per se, and undertaken on an as-benefits basis. If such a program proves helpful, it should be continued, and if it seems to make things worse then participation should be discontinued.

Eating Disorder Professional Treatment – Family Therapy

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

Your eating disorder impacts your family members, and can also disrupt their daily routines, holidays, and vacations. Family members experience pain and strong emotions while watching you suffer, and often feel powerless. Furthermore, families with an eating disordered individual are often struggling with other addictions, emotional problems, disturbed behaviors, and interpersonal conflicts.

Thus, family therapy, a type of therapy where the entire immediate family participates, is highly recommended as an adjunct to treatment. Family therapy can be used to provide family and loved ones with education, support, communication skills, and conflict resolution. The family therapist can also teach loved ones how to respond to you without trying to control or protect you. Another important aspect of family therapy is teaching members how to have realistic expectations of one another, and reorganizing faulty roles and dysfunctional boundaries. For example, emotional enmeshment, physical intrusiveness, and protective over-involvement must be pointed out and resolved. The family therapist teaches how expectations are communicated and what might be reasonable and achievable. Family members must be provided permission and assistance in developing their own separate and healthy identities. Lastly, a strong, united, and supportive parenting team must be established.

Multifamily groups are an excellent way for families to get extra support during the treatment process. Multifamily groups offer an opportunity for several families to come together to have supportive discussions about what it’s like to have someone they love with an eating disorder. It also facilitates understanding as members are able to talk with individuals from other families who have eating disorders. A therapist trained in the treatment of eating disorders facilitates the discussions.

A study published in October 2010 in the General Archives of Pychiatry evaluated the relative efficacy of family-based treatment (FBT) and adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa in full remission.  The study found that there were no differences in full remission between treatments at the end of treatment. However, at both the 6- and 12-month follow-up, FBT was significantly superior to AFT on this measure. Family-based treatment was significantly superior for partial remission at the end of treatment but not at follow-up. In addition, body mass index percentile at the end of treatment was significantly superior for FBT, but this effect was not found at follow-up. Participants in FBT also had greater changes in Eating Disorder Examination score at the end of treatment than those in AFT, but there were no differences at follow-up. The study concluded that although both treatments led to considerable improvement and were similarly effective in producing full remission at the end of treatment, FBT was more effective in facilitating full remission at both follow-up points.

Other adjunctive treatments can also be helpful. For example, guided imagery, relaxation training, and hypnosis are sometimes used to decrease binge episodes in bulimics. These interventions work by decreasing anxiety, coping with negative emotions, and reducing impulsiveness. These strategies are practiced as a substitution for binge eating behaviors.

In addition, psychiatric medications are prescribed in some cases to control the symptoms of eating disorders and co-morbid conditions, although medications cannot cure or entirely eliminate any eating disorders. Certain forms of antidepressants (SSRI’s) have been shown to decrease binging in bulimics; and help to restore weight and prevent relapse in recovered anorexics. Also, appetite stimulants can help to boost treatment in some anorexics and bulimics. Anti-anxiety and antipsychotic medications (which help to stabilize mood and clear thinking) have been shown to be especially effective for anorexics who have high levels of anxiety and obsessive thinking.

Prevention Of Eating Disorders

Bridget Engel, Psy.D., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D. Feb 2, 2007

As most eating disorders start in adolescence, parents have the best shot at helping to prevent them from occurring. Fortunately, many things can be done to prevent the development of eating disorders. One prevention approach involves providing education via the Internet and/or in person training to physicians, schools, clergy and sports organizations. By teaching adults to be aware of the most vulnerable individuals and the symptoms, eating disorders can be caught early and treated.

Educating both male and female children about healthy eating and body image is also an important primary prevention task. Health classes in school should teach children about different body types, nutrition, the importance of exercise, recognizing hunger and the dangers of dieting.

Children also need to be taught about critical thinking – how to recognize when media images are unrealistically perfect and to not use those images as comparisons for themselves. Teaching kids strategies to reject peer pressure to succumb to the lure of trying to be thin and perfect might help too.

In addition, parents can be big advocates in building healthy body images, self-esteem and lifestyles for their children. In fact, one of the most important things that parents can do is be strong role models for their children – demonstrating what a balanced and healthy adult looks like. Model eating a balanced diet with fruits and vegetables, exercising in moderation, and participating in fun family activities, even if you are self-conscious of your weight, your abilities, or your appearance. Avoid criticizing your own body, especially in front of your children.

It’s important to encourage children to be involved in sports and other activities that build self-esteem and promote healthy physical activity. Actively teach children how to make healthy food choices. Plan and eat meals together. In addition, compliment kids – a lot. Praise them for their strengths, their talents, and their efforts. Provide your kids with lots of physical affection and let them know that you love them for who they are. Allow lots of opportunities for children to talk about their insecurities, their body image, and their efforts to fit in. Educate them about the unrealistic messages supplied in endless number by the media, and help them understand that thinness does not equal happiness. Limit the number of hours in front of the television or on the computer, and limit access to junk food and fast food as well. Avoid giving food for rewards. And most importantly, do not allow your teenagers to diet without your oversight or that of a physician or dietician. Diets should be justified, reasonable, and well-balanced.

Many parents struggle with how to teach children healthy eating habits when there is a bounty of junk foods available to their kids. For example, research conducted in 2003 found that children who were excessively restricted from junk food at home responded by sneaking treats or eating when they were not necessarily hungry, both precursor behaviors to eating disorders. However, parents also find that if they don’t establish restrictions, their children become unhealthy, obese, and unhappy with their body image. Striking a balance based on family lifestyle and the temperament of the children seems to be key by actively teaching children how to make healthy choices, eat junk food in moderation, recognize when they are satiated, and incorporate exercise into their life.

Try encouraging school administrators to take junk food and soda machines out of our schools. Advocate for purchasing books for the school library about healthy nutrition and exercise. Write to politicians about the importance of educating children about the dangers of eating disorders and the need to allocate some health monies for the cause. Write letters to media and modeling companies encouraging them to find ways to contribute to healthy lifestyles by presenting more realistic images. Shop at stores that have a range of clothing sizes for varying body types. Challenge people who make negative comments about weight or objectify others.