Recovery Timeline for Maudsley FBT

I recently conducted an informal survey of parents who had used the Maudsley Method of Family-Based Treatment to help their children recover from eating disorders. My intention was to gather some preliminary data on recovery milestones which I could share with patients and families who are just embarking on the recovery journey. Then I realized that other people may benefit from this information as well.

The following data were collected from parents of some of my patients (past and present) as well as from parents on FEAST’s caregiver forum, Around the Dinner Table. A total of 22 parents submitted responses. The patients (20 female, 2 male) ranged in age from 10 – 24 years when their family started Maudsley (mean age = 15.3 years).

The patients in my sample varied dramatically with regard to the length of their illness. Some parents reported that they began Maudsley within a month after their child’s first eating disorder symptoms appeared. Other parents had watched their child continue to suffer from the devastating effects of ED through many years of ineffective treatment and numerous hospitalizations before finally turning to Maudsley as a last resort.
Granted, this is not good science, but it is a start.

Length of time from onset of symptoms to beginning of refeeding
Mean = 18.8 months
Median = 6.25 months
Range = 1 – 132 months

Length of time from start of refeeding to weight restoration
Mean = 6.7 months
Median = 4.5 months
Range = 2 – 24 months

Length of time from weight restoration to acknowledgement of having ED
Mean = 1.1 months
Median = 0 (acknowledged having ED when he/she became weight restored)
Range = 0 – 16 months
(90 % of the sample acknowledged having ED at or before weight-restoration)

Length of time from weight restoration to developing motivation to recover
Mean = 4.6 months
Median = 0 months (motivation developed at the time of weight restoration)
Range = 0 – 24 months

Length of time from weight restoration to eating independently while maintaining weight
Mean = 7.8 months
Median = 6.5 months
Range = 0 – 36 months

Length of time from weight restoration to mood normalization
Mean = 3.3 months
Median = 2 months
Range = 0 – 12 months

Length of time from weight restoration to normalization in anxiety (return to pre-ED level)
Mean = 6.5 months
Median = 3 months
Range = 0 – 36 months

Length of time from weight-restoration to absence of body dysmorphia
Mean = 6.9 months
Median = 4 months
Range = 0 – 24 months

Clearly, more rigorous research is necessary in order to draw definitive conclusions. However, I’ve drawn some preliminary conclusions based on my data:

1.) The Maudsley Method can be effective for children, adolescents, and adults. It can be effective for both males and females.
2.) The Maudsley Method can be effective even for young adults who have been ill for 10 years or more.
3.) Most patients who are beginning Maudsley treatment have anosognosia – they do not recognize that they are ill and do not have motivation to recover. The patient does not have to “want to get better” in order for treatment to begin.
4.) The majority of patients develop insight and motivation to recover around the time that they reach a healthy body weight. For some patients, insight and motivation develop gradually after a number of months at ideal body weight.
5.) Patients generally require continued meal support for an average of 6 months after weight restoration.
6.) The manualized Maudsley approach (Lock, LeGrange, Agras, & Dare, 2001) recommends beginning to hand control of eating back to the patient when she reaches 90% of ideal body weight. This is probably too soon for most patients.
7.) The majority of patients must sustain a healthy body weight for 3-6 months before depression, anxiety, and body dysmorphia abate.

This is interesting food for thought (pun intended). I am interested in conducting a much larger survey on families that have used Maudsley. I’d like to gather enough participants and enough data points to be able to do some actual complex statistical analyses – maybe some ANOVA’s or multiple regressions. Through this study, I’d like to examine which variables contribute to recovery time. For example, what features differentiate patients who are able to eat independently at weight restoration vs. those who need continued meal support? What differentiates the patients whose psychological symptoms melt away with weight restoration vs. those who continue to struggle? Most importantly, I would like to use data from this future study to find ways in which the Maudsley method could be improved.

What questions would you like to see answered? I welcome any and all suggestions!

Everything I Need to Know I Learned From Adolescents

A 31-year-old woman named Monica recently died from anorexia nervosa (AN) following a 15-year battle with the disease. Her death is an eerie reminder of what we already know: eating disorders are dangerous, deadly, and difficult to treat. Traditional treatment for AN typically takes 5-7 years. Less than half of patients with AN will ever fully recover, and of those who do recover, one-third will relapse. Nearly 20% of patients with AN will die as a result of their illness.

Just a decade ago, only 30% of patients fully recovered, and now nearly 50% will fully recover. The reasons for the improved prognosis include greater awareness about eating disorders, which leads to earlier diagnosis and treatment, and the advent of more effective, evidence-based treatment for adolescent AN, such as Maudsley Family-Based Treatment. But early diagnosis, early intervention, and the Maudsley method primarily benefit adolescents. Consequently, I would presume that the 20% increase in recovery rates over the past decade is primarily due to the recovery of more adolescents, not the recovery of more chronically-ill adults.

Although AN typically begins in early adolescence, those who die from the disease are more often adults who have battled it for many years. The most effective course of action is early diagnosis and aggressive, evidence-based treatment as soon as symptoms appear. Unfortunately, there are countless adults with AN who have struggled for years or even decades. As of this time, there are no evidence-based treatments for adults with AN, nor are there any medications which have been proven to benefit adults with AN. CBT has been shown to be moderately beneficial in preventing relapse in weight-restored AN patients but shows no benefit in underweight anorexics.

A lot of the AN treatment offered today is outdated and ineffective. Fortunately, however, there are more and more clinicians and treatment centers who are adopting modern, evidence-based approaches to treating adolescent AN that have much higher success rates. For example, the Kartini Clinic, the UCSD 5-Day Intensive Family Program, and the Children’s Hospital at the University of Chicago have adopted a highly-practical family-based, evidence-based approach to treating adolescent AN based on the Maudsley Method.

We can learn a lot from the success of these adolescent programs. I believe that we can use the basic principles of Maudsley FBT and the philosophy of these adolescent treatment programs to develop effective treatments for adults. Medicine, psychology, and psychiatry do this all the time in the reverse; that is, they extend effective adult treatments to adolescents. If a particular medication or psychotherapy approach demonstrates effectiveness in adults, clinicians automatically begin using it in adolescents, often without any research data to support its use in this population. Clinical trials are then conducted on adolescents, and research data follows.

Consider the basic principles of Maudsley FBT:
1. Conceptualization of AN as a biologically-based brain disorder of unknown origin
2. Externalizing the illness
3. Viewing family members as vital resources in a patient’s recovery
4. Recognition that most of the symptoms of AN are direct result of malnutrition and thus will abate after weight restoration
5. Focus on nutritional rehabilitation and weight restoration as non-negotiable first priorities in treatment
6. Acknowledgment that patients with AN are unable, in the acute phase of illness, to make healthy decisions regarding food and weight
7. Coaching parents to provide emotional and nutritional support to their child
8. Addressing psychological symptoms and other comorbid disorders after weight restoration

Which of these principles are irrelevant in the treatment of adults?

I see no logical reason why we cannot use Maudsley FBT in the treatment of adults with AN. Based on the patient’s circumstance and living situation, spouses, roommates, friends, or significant others may be enlisted for meal support in lieu of parents. The specific details may need to be tweaked in order to be relevant to an adult patient’s situation, but the general principles would remain the same. After all, the physical and psychological symptoms of AN are the same regardless of whether the patient is an adolescent or an adult. AN stunts growth and development and prevent sufferers from becoming independent, fully-functional beings. Thus, adults with AN are regressed physically, sexually, and socially to the point that they often resemble adolescents anyway.

The differences that do exist between adolescent and adult forms of AN are not inherent to the disease itself or even to the age of the patient. Rather, they are imposed by society. We, as a society, have arbitrarily determined that teenagers are fully responsible for their own healthcare decisions once they reach their 18th birthday. This is the case regardless of whether the patient has an ego-syntonic, anosognosic condition such as AN which impairs their judgment and insight. By virtue of their illness, adults with AN are unable to make healthy decisions for themselves. And yet, the law prohibits parental involvement, even parental notification of treatment, unless the patient signs a release. The law clearly sides with AN, not with the patient.

Family support and family involvement are powerful predictors of good outcome. Unfortunately, most therapists consider parental involvement in an adult patient’s treatment unnecessary or even detrimental. These therapists believe that the etiology of AN is rooted in controlling parents, separation anxiety, and issues related to independence and autonomy. Thus, they keep patients separated from the very people who love them most and who may be best equipped to help them achieve full recovery. This is counterproductive because a patient’s physical and psychological wellbeing must always take precedence over the developmental issues of emerging adults which, incidentally, have never been proven to be causally related to AN. Adult patients’ lives are threatened as a result of ignorant adherence to an unproven theory.

I firmly believe that Maudsley Family-Based Treatment can be effective in young adults. In fact, I have used this approach with young adults in my practice with great success. I have seen patients who have been sick for a decade, hospitalized multiple times, and endured several courses of ineffective residential treatment finally achieve recovery as outpatients through FBT. I look forward to the day when FBT is widely available to adults, as well as adolescents, with AN.

In Defense of Helicopter Parenting

Last month, Time Magazine ran an article about the dangers of over-involved, over-protective parenting (otherwise known as “helicopter parenting” because these parents tend to hover over their children). The article is well-researched, well-written, and very interesting. As a therapist who frequently encounters this phenomenon in the parents of my adolescent and young adult patients, and as a product of this type of parenting myself, I have a few thoughts and observations on the issue.

I agree wholeheartedly with the author that today’s parents are far too over-involved and over-protective, and this is particularly true amongst middle- to upper-class families with well-educated parents. According to psychologist Eric Ericson, the primary developmental task of middle adulthood (ages 30-50) is seeking satisfaction through productivity in career, family, and civic interests. This is precisely the age at which adults are parenting young children and adolescents, and for helicopter parents, their striving for productivity is channeled into their children. Parents’ intentions are good, but the outcome can be problematic. You see, the middle adulthood psychosocial task of productivity stands in diametric opposition to the adolescent developmental task of identity formation. Children need to play, explore, relax, and interact with their surroundings in creative, imaginative ways. Adolescents need to loaf, “hang out,” date, experience “teen angst,” spend quality time with family and friends, develop their social skills, make their own choices (within reason), make mistakes, and learn from them.

Ideally, a healthy person will emerge from adolescence with a solid self-identity, resilience, confidence, good problem-solving skills, and the ability to tolerate discomfort and failure. Having worked in several college counseling centers, I can attest that many kids arrive at college without these skills and attributes. Their lives have been geared entirely towards achievement in academics, arts, and athletics, often not for the love of science or music or soccer, but because their parents pushed them and/or because they believed it would improve their chances of gaining admission to a prestigious college. Quite often, they don’t know how to structure their time, study properly, deal with disappointment, or make decisions independently. Sadly, many of them do not know who they are or what they enjoy.

Helicopter parenting has the potential to be quite harmful to children by increasing their stress and anxiety and preventing them from developing self-confidence, resourcefulness, problem-solving skills, distress tolerance skills, emotion regulation skills, and creativity. Children and adolescents are over-scheduled, over-worked, and pushed to succeed, often at the expense of their emotional health. There is not enough unstructured time for kids to play, explore, or create. There is little room for adolescent identity formation in between AP classes, Princeton Review SAT prep courses, college applications, three varsity sports, band practice, clubs, and mandatory community service hours.

These issues notwithstanding, one problem I have seen far too often in my profession is the tendency for therapists to blame helicopter parents for causing their child’s eating disorder. It is easy to look at over-involved parents and an adolescent’s misguided search for control and identity through self-starvation and conclude that the former caused the latter. But the belief that over-involved, controlling, or enmeshed parents cause children to develop anorexia nervosa (AN) or bulimia nervosa (BN) lacks solid scientific evidence. What’s worse, this belief has the potential to undermine treatment, disempower parents, confuse children, perpetuate deadly symptoms, erode physical and mental health, destroy families, and turn an acute illness into a chronic and disabling one.

There is a correlation between over-involved, over-protective parenting and the development of AN, but correlation does not necessarily indicate causation. If variable A (helicopter parenting) and variable B (child’s development of AN) are correlated, there are several possible explanations for the relationship between these two variables:

1.) A causes B
2.) B causes A
3.) Variable C causes both A and B
4.) Variables D, E, F, G, H, I, J, K, L, M, and N work together in complex ways to influence the development of both A and B.

Let’s examine each possible explanation.

1.) Explanation 1: Helicopter parenting causes children to develop AN. There is no reliable scientific evidence to support this explanation. Ironically, this explanation is touted far more frequently than the others, even by clinicians who specialize in treating eating disorders.
2.) Explanation 2: A child’s AN causes parents to become over-involved or over-protective. There is some evidence to support this explanation. If parents were not anxious, cautious, protective, or hovering before their child developed AN, you’d better believe they will be once their child becomes ill. This phenomenon is not unique to AN. Parents of children with any illness or medical condition naturally worry about their child and do whatever they can to protect her.
3.) Explanation 3: A third variable causes both helicopter parenting and AN in children. There is a wealth of evidence to support the genetic transmission of AN as well as related personality traits. The personality traits that predispose people to developing AN – anxiety, obsessiveness, perfectionism, and harm-avoidance – are largely genetic. In an adolescent female, these traits are likely to manifest as an eating disorder. In a middle-aged, middle-class, intelligent, well-educated parent, these traits are likely to manifest as over-involvement, over-protection, and over-investment in their child.
4.) Explanation 4: A complex interaction of other variables work together to produce both helicopter parenting and AN in children. This is the most thorough, and probably the most accurate explanation. As stated in explanation #3, genetics plays a major role in the development of AN. A wealth of environmental variables are also believed to influence the development of parenting style as well as AN (e.g., level of education, income, culture, peer group, family background, exposure to stressful life events).

I love working with adolescent children of helicopter parents. I require parents to be fully informed and actively involved in their child’s treatment, and helicopter parents slide seamlessly into this role. They are excellent candidates for Maudsley Family-Based Treatment because their anxiety level is high enough to propel them towards action, they thoroughly educate themselves on their child’s condition, they seek out the best treatment and resources, they are vigilant and persistent, they maintain a very high level of involvement and supervision, and they are tremendously invested in their child’s recovery. Misguided, ill-informed, old-school therapists argue that these characteristics caused the child’s AN, and they advise parents to “back off” and allow the child to make her own choices about food and weight and treatment. This approach rarely leads to lasting recovery.

While helicopter parenting certainly has the potential to cause harm, it can also be used to the child’s advantage in recovery if channeled properly. Helicopter parents tend to be wildly successful in Maudsley Phase I (re-feeding / weight restoration), and largely successful in Phase II (helping the adolescent eat properly on her own). Some of these parents are eager to step back in Phase III as their child deals with psychological and social issues and develops a healthy adolescent identity. Other parents struggle to let go when the time comes. With proper guidance from a good therapist, however, most helicopter parents can learn to manage their own anxiety enough to allow their children to blossom and develop as healthy, independent young adults. This does not come naturally for them, but never underestimate the power of the helicopter parent. If the therapist who helped save their beloved child from a life threatening illness coaches them to step back and let go, they’ll do it.

Eating Disorders: Prevention and Early Intervention Tips for Parents

There is a fair amount of internet advice for parents on how to prevent eating disorders in their children. The majority of this advice centers around teaching children about healthy eating habits, moderate exercise, positive body image, and media literacy. This is great advice for parents to follow, but it does not prevent eating disorders. It may help to prevent body dissatisfaction and dieting, but these things are not the same as an eating disorder.

Ironically, many children and adolescents who are in treatment for anorexia nervosa or bulimia nervosa report that their illness was triggered by a health or nutrition class at school, training for a sport, or a general desire to adopt the much-touted principles of “healthy eating and exercise.” Unfortunately, most of the information children receive on the benefits of “healthy eating and exercise” is really our fat-phobic society’s disguised attempt to shield our precious children from this horrible “obesity epidemic.” To make matters worse, this information is delivered to children by teachers, physicians, coaches, and parents – supposedly knowledgeable authority figures whose job is to educate, protect, and nurture them. Children who are predisposed to eating disorders are usually compliant, rule-bound, anxious, obsessive, perfectionistic, driven, and eager to please. They are virtual sponges who soak up this “healthy eating and exercise” information and follow it to the letter. The obesity hysteria terrifies them, and their obsessive, perfectionistic temperament makes them stellar dieters. This is the perfect storm for the development of an eating disorder.

I do not believe we should stop educating children about nutrition and exercise out of fear that they will develop eating disorders, much as I don’t believe we should stop educating adolescents about safe sex and contraception out of fear that they will become sexually active. More information is usually better than less, as long as the information is accurate, useful, and effective. The middle school and high school syllabi on sex education provide information which is accurate, useful, and effective (whether kids act on that information is another story). The information kids receive on “healthy eating and exercise” has not succeeded in improving their overall health, preventing eating disorders, or combating this alleged “obesity epidemic.”

I believe that, in terms of nutrition, kids should be taught about what to embrace rather than what to avoid. They should learn the importance of eating lots of fruit, vegetables, dairy products, protein, fat, and grains, and drinking plenty of water. They should be taught to enjoy their favorite snacks and deserts as well. They should not be taught about calories or the evils of sugar and fat; they should not be advised to avoid any foods, they should not learn to label foods as “good” or “bad,” and they should not be taught about the dangers of obesity or the virtue of thinness. Most importantly, I believe children should be taught about the dangers of dieting, much as they are taught about the dangers of drugs, alcohol, and unprotected sex. The dangers of dieting are grossly underrated.

Even if nutrition education is accurate, useful, and effective, it will not prevent eating disorders. That being said, what steps can parents take to prevent their children from developing eating disorders? In my opinion, it all boils down to three basic principles: 1.) accurate information, 2.) vigilance, and 3.) immediate, aggressive, effective intervention.

Accurate information
The pop-psychology literature will have you believe that if you have a healthy body image yourself, encourage healthy body image in your children, nurture positive self-esteem, and preach the importance of healthy eating habits and exercise, your child will not develop an eating disorder. This assumption is simply untrue. Parents need to know that seemingly healthy, well-adjusted children with positive body images and excellent parents develop eating disorders all the time. Good parenting does not make your child immune. It can, however, improve your child’s chances of full recovery.

If your child develops an eating disorder, let go of guilt, shame, and self-blame. While it is natural for parents to blame themselves, guilt is a hindrance to effective action. Of course you have made mistakes in parenting – everyone has! You may be an imperfect parent, but this does not mean you caused your child’s illness. Despite what you may have heard in the media, there is no reliable scientific evidence to suggest that parents cause eating disorders. If your child’s pediatrician, dietician, or therapist suggests that the eating disorder is your fault, this is an indication that he or she is not aware of recent research on the etiology of eating disorders and effective treatments. Get a second opinion. Anorexia nervosa and bulimia nervosa are biologically-based brain disorders, just like autism and schizophrenia. Although you are not to blame for causing your child’s eating disorder, it is your responsibility as a parent to ensure that she gets proper treatment. This responsibility includes protecting your child from outdated, ineffective treatments, which can often do more harm than good.

Parents also need to know that eating disorders are not limited to rich, white teenage girls. This stereotype is antiquated and dangerous, as it prevents individuals outside these demographic categories from being diagnosed and properly treated. Eating disorders strike children, adolescents, and adults; girls and boys, men and women; people of all ethnic, cultural, and economic backgrounds. Several years ago, during my training, I treated a severely underweight teenage boy with anorexia nervosa whose previous pediatrician had told him: “If you were a girl, I’d say you were anorexic.” As a result of this doctor’s failure to intervene, the patient’s condition rapidly deteriorated over the next two years, and by the time he presented in my office, he was in horrible shape.

Vigilance
Here are some concrete steps that parents can take to help prevent eating disorders. You may notice that, unlike other prevention tips you may have read, these tips center around proper nutrition and exercise. This is because all the feminist, feel-good, positive-body image talk in the world is not going to prevent eating disorders. Remember, anorexia nervosa has existed for centuries, long before thinness became fashionable. Eating disorders are triggered by an energy imbalance (consuming fewer calories than you expend) and perpetuated by malnutrition. If a child never becomes malnourished, she is extremely unlikely to develop an eating disorder.
• Make family meals a priority. As a parent, it is your job to prepare and serve nutritious foods. It is far better for a family to sit down to a balanced breakfast of cereal, milk, fruit, juice, and yogurt instead of grabbing a nutrigrain bar and running out the door.
• Closely monitor any changes in your child’s eating habits. Even seemingly “positive” dietary changes such as skipping desert, becoming vegetarian, or reducing fat intake can signal the onset of an eating disorder.
• Adopt a zero-tolerance policy towards any level of malnutrition. Do not allow your child to diet, skip meals, or cut out entire food groups. Children and teenagers need to eat three substantial, nutritious, well-balanced meals every day. Supervised, supported full nutrition is the best defense against an eating disorder.
• Be aware that eating disorders are sometimes triggered by unintentional malnourishment (for example, weight loss due to physical illness, depression, anxiety, stress, or surgery; fasting for religious purposes; side effects of a medication; intense physical exercise without a commensurate increase in nutrition). This type of malnourishment must be taken equally seriously. Dieting is not the only pathway to eating disorders (although it is the most common pathway in modern Western cultures).

Parents need to be on guard for early signs of eating disorders, especially during early adolescence, when most eating disorders develop. Since eating disorders are genetically transmitted, your child is much more vulnerable to developing an eating disorder if you or a relative has suffered from an eating disorder. Family histories of major depression and other mood disorders, anxiety disorders, OCD, and addictions are also risk factors for developing eating disorders. If you have a family history of eating disorders or other mental illnesses, you should know that your child is at greater risk for developing an eating disorder, and you should be extra vigilant.

Some early signs of eating disorders masquerade as “healthy” behaviors or extreme dedication, or can easily be dismissed as typical teenage behavior. However, parents know their kids well. Most parents recognize, long before formal diagnosis, that something is “not quite right” with their child, but they aren’t sure what is wrong or they don’t know what to do. Here are some early signs and symptoms:
• Change in eating habits. This can take many forms, including following a formal diet plan, skipping meals, eating only at certain times, refusing to eat with other people, or anxiety around food. Even seemingly positive dietary changes, such as becoming vegetarian, reducing fat intake, skipping snacks and deserts, and eating only organic foods, can be early signs of an eating disorder.
• Increased preoccupation with food: taking about food, reading diet books, collecting recipes, cooking, serving food to others, sudden interest in what other people are eating.
• Change in mood or behavior. Parents often notice dramatic changes in their child’s personality, such as irritability, anxiety, depression, moodiness, frequent crying, restlessness, withdrawal, changes in sleeping patterns, or loss of interest. Increased dedication to schoolwork, sports, or other extracurricular activities and obsessive behavior in other areas can also be early signs.
• Increase in exercise. The child may begin solo running, take up a new sport, or show increased dedication to her current sports. If she is an athlete, she may begin training excessively outside of team practices. If she is a dancer, she may begin practicing at home, signing up for more dance classes, and auditioning for every possible performance opportunity.
• Weight loss, failure to gain weight, or failure to make expected gains in height. ANY weight loss in a child or adolescent, even a few pounds, may be cause for alarm. ANY failure to grow or gain weight as expected warrants further examination.
• Loss of menstrual periods.
• Signs of binge eating (for example, large amounts of food disappearing overnight).
• Signs of purging (for example, discovering laxatives in your child’s purse or smells of vomit in her bathroom).

Immediate, Aggressive, Effective intervention
I have never heard a parent say: “I wish I had waited longer before getting my child into treatment.” Most parents whose children are in treatment for eating disorders regret not intervening sooner. In addition, many parents report that they wish they had sought out evidence-based treatment immediately, rather than continuing with ineffective treatment as their child’s health declines. If you notice any of the signs or symptoms listed above, take action immediately. Here’s how:
• Educate yourself about eating disorders and evidence-based treatment. FEAST (Families Empowered and Supporting Treatment for Eating Disorders) is an excellent resource for parents.
• Do not praise your child for her “healthy eating” habits or willpower around food. Instead, tell her that you have noticed a change in her eating habits and that you are concerned. For example: “I notice that you’re not enjoying ice cream with our family anymore. What has changed?”
• Be prepared for your child to insist that she is just trying to eat healthily, exercise more, or improve her performance in sports or dance. Many eating disorders begin this way but quickly spiral into deadly obsessions.
• Be prepared for your child to be in denial or to resist your efforts to intervene. Teenagers never say: “Mom, I think I’m developing anorexia nervosa, and I’m worried about my recent weight loss.” Denial, resistance, and lack of insight are symptoms of this disease, NOT indications that everything is OK. Don’t back down.
• Don’t waste time on “why.” When your child is developing an eating disorder, it is tempting to try to understand the reasons for it. Resist this temptation and tackle the symptoms immediately. The very foundation of ineffective eating disorder treatment begins with endless search for the “root cause” while the child continues to starve, binge, purge, and over-exercise as her physical and mental health deteriorate. A patient with an active eating disorder is generally unable to make effective use of psychotherapy because her brain is not functioning properly. Eating disorders are life-threatening illnesses with serious mental and physical risks. Think of your child’s eating disorder as a tumor. It must be removed immediately, or it will grow and metastasize. The surgeon does not need to know the reason for the tumor in order to operate and remove it. The sooner you intervene, the better your child’s chances for complete recovery. There will be plenty of time for psychological work, including an exploration of potential triggers, later on in recovery, once your child is well-nourished and physically healthy.
• As soon as you suspect a problem, take your child to the pediatrician for a complete physical exam. Unfortunately, most physicians do not have specialized training in eating disorders and are unlikely to notice an eating disorder until it is in its advanced stages. Thus, you cannot always trust your child’s pediatrician to spot a problem. I have had many patients whose physicians have completely overlooked telltale signs such as weight loss, missed menstrual periods, or failure to grow. Consider taking your child to a pediatrician or adolescent medicine physician who specializes in eating disorders. Remember, trust your parental instincts. If you think there is something wrong with your child, you are probably right. It is far better to intervene immediately and later discover that everything is fine, rather than waiting until your child is in the acute phase of a life-threatening mental illness.
• If you intervene at the first sign of an eating disorder, your child may not meet full criteria for anorexia nervosa or bulimia nervosa. Thus, she may be diagnosed with Eating Disorder Not Otherwise Specified, or she may not be diagnosed with an eating disorder at all. This does not mean that your child’s problem isn’t serious or that immediate, aggressive intervention isn’t necessary. It simply means that your child is in the beginning stages of what is likely to become a severe, life-threatening mental illness if left untreated (or improperly treated). Your child is most likely to achieve complete, lasting recovery treatment begins immediately, rather than waiting for her to develop full-syndrome anorexia nervosa or bulimia nervosa and the myriad of psychological and physical problems these illnesses entail.
• If your child has been in therapy for a while and she continues to restrict her diet, lose weight, binge, or purge, therapy is not working. In early recovery, it does not matter if your child has a good relationship with her therapist, enjoys speaking with her, or trusts her. The therapeutic relationship is only therapeutic insofar as it promotes health, wellness, and recovery. Insight, self-exploration, and rapport are useless in the wake of malnutrition. Speak with your child’s therapist about taking a different approach. If your child’s therapist refuses to talk to you, or if you are not satisfied with the results of treatment, find a different therapist.
• Seek evidence-based psychological treatment for your child and your family. Most therapists, even ones who specialize in eating disorders, are not up-to-date on the latest research and most effective treatments. I have worked with many families who have taken their child to multiple eating disorders specialists over a period of several years and seen no symptom improvement whatsoever. This is usually because the therapists were not aware of recent scientific research on eating disorders and were not using evidence-based treatments. For children and adolescents, the strongest evidence base is for Maudsley Family-Based Treatment (FBT). Maudsley FBT is a highly practical, empirically-validated treatment method which empowers the family to help the patient recover and focuses on immediate restoration of nutritional and physical health before tackling psychological issues. Research has shown that 75-90% of adolescents treated with Maudsley FBT recover within 12 months and maintain their recovery at 5-year follow-up. In contrast, traditional treatment generally takes 5-7 years and only 33% of patients achieve full recovery.
• Remember that you are an essential member of your child’s treatment team. Your child’s treatment will be most effective if you are fully informed and actively involved. Interview any potential physicians, dieticians, therapists, and psychiatrists without your child present before your child meets them. Make sure that you are comfortable with their philosophy of eating disorders and their approach to treatment. Insist on being informed about your child’s progress in treatment and ask what you can do to help her recover. If the therapist will not inform you or include you in treatment decisions, find a new therapist.
• Recognize that your child’s eating disorder is neither her fault nor her choice. Do not wait for her to “choose” recovery, because she can’t. It is your job to choose recovery for her until she is well enough to take ownership of her treatment. Try to separate the disorder from the child you know and love. She is in there somewhere, and some day, she will thank you.

Force feeding?

The idea of force-feeding in eating disorder treatment is highly controversial. It is ironic that the idea of requiring sustenance, which all living things need to survive anyway, has the power to create such extreme revulsion. Perhaps it is not so surprising that old-school treatment professionals object to force-feeding. You know the types – those who believe that eating disorders are “not about food,” that sufferers are the victims of over-controlling parents or a size-0 obsessed society or a fear of growing up. The idea that eating disorder patients have willfully chosen self-starvation, and will begin to eat again once their “underlying issues” have been resolved, follows logically from these unsubstantiated theories.

What really boggles my mind is that the very mention of force-feeding creates a visceral reaction even in well-informed clinicians who practice evidence-based treatment and parent advocates of Maudsley Family-Based Treatment. These individuals are fully aware that eating disorders render victims temporarily unable to nourish themselves, and they know from empirical literature and personal or clinical experience that re-feeding is the essential first step in successful eating disorders treatment. To me, it seems to follow logically from this knowledge that most patients with eating disorders cannot choose to eat and therefore must be forced to eat in order to recover. And yet, when confronted with the term “force-feeding,” Maudsley parent advocates and clinicians reframe the statement or circumvent the issue altogether. For example, a parent advocate whom I greatly admire states that “It is not forcing them to eat, it is letting them eat and live.” A clinician who practices Maudsley FBT writes that “Describing what we do in the Maudsley approach as “force feeding” is very misleading and I hope that we are able to continue to get the word out that this is a misconception.”

Most families encounter extreme resistance during re-feeding. I have heard stories of previously sweet, compliant, well-behaved young girls hurling swear words and spewing horrid insults at their parents during re-feeding. I myself have been on the receiving end of my share of f-bombs and hateful remarks from patients when I maintain an uncompromising stance of full nutrition and complete weight restoration. I have heard stories of girls running away from home, throwing ravioli across the room, smashing plates, locking themselves in rooms, and attempting to jump out of moving vehicles – all in response to the intolerable anxiety of re-feeding. And these scenarios are the norm, not the exception. I believe that families need to be fully informed of what is likely to happen during re-feeding so that they can prepare themselves to deal with what lies ahead. They need to know that what they are encountering is not evidence that they are doing something wrong, but rather is par for the course with this illness. But I digress.

The process of re-feeding an anorexic very often involves force. It has to, because most anorexics are not able to eat unless they are given no other alternative. In hospitals, this may require nasogastric tubes or IV nutrition. In residential or day treatment settings, it may involve earning privileges by finishing meals. In home-based re-feeding, it may involve not leaving the table until the meal or snack is 100% complete. The patient cannot choose to eat, but she will eat when she is forced. And she absolutely must eat a sufficient amount and variety of foods in order to recover. For those who have never experienced or witnessed the agony of an eating disorder, the idea of forcing someone to eat may sound inhumane. For those of us who have been in the trenches, we know that it is quite the opposite.

Our society values an individual’s right to make her own decisions. Respect for individual autonomy and self-determination is a cornerstone of democracy. In addition, our society embraces paternalism, which is the belief that it is ethical, at times, to intervene in the life of another person who does not desire such intervention because intervening will protect the person from harm, much in the way a loving father would intervene against his child’s wishes in order to protect the child. Our healthcare system and our government embrace the ethics of self-determination as well as the ethics of paternalism. For example, mandated reporter laws require physicians, therapists, social workers, and teachers to report cases of suspected child abuse and elder abuse, even if the victim doesn’t want the abuse to be reported. Laws allow for the temporary involuntary hospitalization of individuals who are suicidal, homicidal, or floridly psychotic. Many newer state laws require drivers to wear seatbelts and to abstain from text-messaging while driving. Hospitalized patients who engage in self-injury are forced into physical or chemical restraints. Children are forced to attend school at least through the age of 16. Suffice it to say that our great country, which was founded on the values of liberty and independence, recognizes that autonomy is not limitless. Children are forced to get an education and forcibly removed from abusive or neglectful homes. People are forced into hospitals for their own protection when they are a danger to themselves or others. Drivers are forced to wear seatbelts and forced to wait until they reach their destination before sending that oh-so-important text message.

Remember the 13-year-old cancer patient who skipped town with his mother last spring in order to escape court-ordered chemotherapy and radiation treatment? Well, the police eventually found him and forced him into treatment. He has just finished his last round of radiation and he is now cancer-free. This boy’s type of cancer has a 90% cure rate in children when treated with chemo and radiation. His doctors reported that he probably would have died if he hadn’t received these treatments.

Anorexia nervosa is also deadly and disabling disorder. Research shows us that most cases of adolescent anorexia nervosa can be successfully treated with a combination of full nutrition, weight restoration, family support, and evidence-based psychotherapy. Without treatment, or with “traditional” treatment which doesn’t aggressively push full nutrition, only 33% of patients ever fully recover.

I think I understand why people are frightened or repulsed by the idea of force-feeding. The idea of pushing full nutrition immediately after eating disorder diagnosis is still controversial, and to many people, the word “force” seems punitive or even abusive. It may conjure up images of physical torture and it may seem to conflict with the aforementioned democratic values. Eating disorder treatment should never be punitive or abusive (although it may feel punitive and abusive to the patient). Re-feeding is only one component of successful treatment. Cognitive, emotional, and behavioral symptoms and co-morbid conditions must be addressed as well. We all want to help patients recover rather than inflict further anguish. The illness itself is pure hell, and the recovery process can be even worse. But allowing the patient to engage in eating disorder symptoms is far more inhumane than force-feeding a patient to save her life, improve her health, and propel her towards full recovery.

Perhaps we are splitting hairs or just arguing over semantics. The American Heritage Dictionary provides several definitions of the verb “force,” including 1.) to compel to perform an action, 2.) to move something against resistance, and 3.) to produce with effort. Anyone who has witnessed, experienced, or been involved with the process of re-feeding an anorexic would undoubtedly agree that it involves 1.) compelling them to perform an action (eating), 2.) moving against resistance (the eating disorder thoughts, feelings, and behaviors, and 3.) an extreme amount of effort for both the caregiver and the patient. Call it whatever you want – supported nutrition, letting them eat, helping them recover, empowering parents to combat eating disorder symptoms – all of these labels are quite accurate and descriptive. So is force-feeding. And I don’t believe it is a bad thing.

Confidentiality in Adolescent Psychotherapy

Confidentiality is a cornerstone of the therapeutic relationship. The ethics of my profession require that all communication between my patients and me remains confidential. In other words, I cannot disclose the information a patient reveals in session, or my own impressions about a patient, to anyone without the patient’s explicit written consent. Of course, there are exceptions to the rule. I am a mandated reporter of child abuse, and if a patient is imminently suicidal or homicidal, I have a duty to notify the appropriate parties in order to save the patient’s life and protect the public. But these scenarios are relatively uncommon.

Undoubtedly, confidentiality is an important, if not essential, therapeutic tool. Patients are far more likely to enter therapy, and to be completely honest and forthcoming in therapy, when they know that “what happens in therapy stays in therapy.” I am honored and humbled, though not necessarily surprised, when a patient tells me that I am the first person she has ever told about a particular trauma, event, thought, or feeling. A therapist’s office is a safe place in which a patient can express anything and everything without fear of judgment, alienation, or other negative repercussions. Through this vulnerability and brutal honesty comes an opportunity for growth and meaningful change.

However, confidentiality is not without its problems. For example, psychologists often struggle with decisions as to whether to disclose information about adolescent patients to their parents. On the one hand, parents have a legal right to obtain health care information regarding their child, and they are technically the “holders” of any privileged communication between their child and her therapist. On the other hand, adolescents can undoubtedly benefit from discussing certain personal issues with a nonjudgmental third party outside their family, and they are less likely to raise such issues with their therapist if they know that the information will get back to mom and dad.

I know of some psychologists who share very little with the parents of their adolescent patients. After all, they argue, the primary developmental tasks of adolescence include separation from family and establishment of an independent identity. These psychologists believe that they are respecting the adolescent’s burgeoning sense of identity by excluding parents from treatment. They also believe that they are nurturing the therapeutic relationship by refusing to disclose all but the most essential information to an adolescent’s parents. Many of these therapists believe that the parents are guilty of causing or contributing to their child’s problems, and thus are best kept out of the treatment picture. As a result, many parents of adolescent patients are relegated to the role of chauffeur. They drive their child to her appointments and pay for her treatment without ever knowing what is going on in those sessions. Imagine how disempowering it must feel for a parent to be relegated to such a role.

To be sure, psychologists who practice this way make many valid points. However, I have a different perspective on my role as a therapist and on the role confidentiality plays in my work with adolescent patients. Consequently, I approach the issue of confidentiality with adolescent patients differently. Empirical research has demonstrated, and my own clinical experience has confirmed, that adolescent treatment generally works best when parents are fully informed and actively involved, and I communicate this point to my adolescent patients and their parents at the start of our work together. I am relatively unconcerned when I meet an adolescent patient who lacks insight or motivation or who resists treatment. I am very concerned when the parents of an adolescent patient are unwilling, unmotivated, or unable to play an active role in their child’s treatment.

When I work with adolescents with relatively normal social or developmental concerns (e.g., grief, problems with friends, sexuality, stress management, body dissatisfaction), parents play an important, though relatively minor, role in treatment. In these cases, the work is primarily between the adolescent and me. Even so, I involve parents in the initial evaluation, treatment planning, and discharge planning; I provide them with empirical literature on their child’s problem and the treatment approach I am using; I provide them with guidance as to how they can support their child at home; and I invite them to call me or schedule an appointment with me at any time if they have questions or concerns about their child.

In my work with adolescents with mental illnesses, parents play a central role as indispensable members of the treatment team. I take an authoritative stance regarding my knowledge of, say, major depression or anorexia nervosa, while also maintaining humility by respecting parents’ judgment and intuition regarding their child. I may be the expert on mental health, but they are the experts on their child.

Adolescents who are struggling with serious mental illnesses, such as bipolar disorder, major depression, anorexia nervosa, and bulimia nervosa, require treatment which is more intensive and more comprehensive. These patients need their parents to play an active role in managing their symptoms and creating an environment which is conducive to recovery. In order for parents to do this, they need to be informed about their child’s symptoms and progress. While I certainly do not share everything a teenage patient says in therapy with her parents, I do provide her parents with the information they need in order to help her get better.

The parents of adolescents with mental illnesses are often overly stressed, worried, isolated, and confused. These parents need considerable support, encouragement, and guidance as they learn to cope with their child’s illness and support her through her recovery. This one of the reasons why I am so fond of family-based treatment: I get to empower the family to support the patient, drawing upon the parents’ intimate knowledge of and investment in their child. Instead of pulling the patient away from her family, I strengthen her natural support system, which makes intuitive sense to me. After all, therapy is time-limited. Family is forever.

Family members are also vital in preventing relapse, as they are generally the first people to notice a change in their child’s mood or behavior. Equipped with the right knowledge and skills, parents can intervene immediately and help to pull their child back from the brink of relapse, often preventing the need for future treatment.

Does involving family members in treatment damage my relationship with my adolescent patients? In the short term, it often does. Keep in mind, though, that some families bring their adolescents to me after an unsuccessful course of traditional individual therapy in which the patient had a very special, exclusive relationship with her therapist (who may have implicated her parents in the etiology of her problems) but made no meaningful progress whatsoever. My therapeutic relationship with adolescent patients is certainly important, but it is far less important than strengthening her relationship with her family and taking the necessary steps to help her recover. As adolescent patients progress through recovery and gain more insight, they gain trust in me and in their parents. They gain faith in the recovery process, and most of them are grateful for the fact that their parents and I worked collaboratively to help them. As much as they may resist it, adolescents need boundaries and limits, and they need adults to work together on their behalf.

By involving parents so heavily in an adolescent’s treatment, am I disrupting the processes of separation and individuation? In the short term, yes. I would argue, however, that cutting, starving oneself, engaging in unprotected sex, and throwing up after meals are not acceptable ways of exerting control or establishing identity. The supposition that a certain unhealthy behavior serves a valuable emotional or developmental purpose does not justify allowing that behavior to go unchecked. It is the mental illness which hinders adolescent development, not the treatment. Adolescents struggling with crippling depression or anxiety, erratic mood swings, self-injury, or life-threatening eating disorders are unlikely to blossom into well-adjusted, independent young adults without significant support. Empowering an adolescent’s parents to help her overcome a mental illness is ultimately very respectful of adolescent development – it allows the patient to recover within the safety and security of her natural environment so that she may one day live independently, unencumbered by mental illness.

For these reasons, my relationship with the parents is just as important as my relationship with the adolescent patient. Parents need to trust my judgment and treatment methods. They are, after all, entrusting me with their child’s health and bright future. I believe that I earn parents’ trust by maintaining open lines of communication between us, by providing them with empirically-sound literature on their child’s condition and the treatment approach we are taking, by respecting their parental instincts and taking seriously their experiences with their child, by supporting them emotionally, by absolving them of guilt and self-blame for their child’s disorder, and by empowering them to take constructive action.

Maudsley Is As Maudsley Does

Those who know me professionally are well aware that I am an advocate of the Maudsley Method of Family-Based Treatment and that I use this approach to treat my adolescent patients with eating disorders. What they may not know is that Maudsley principles pervade my treatment philosophy for eating disorder patients of all ages, regardless of the treatment approach I employ with them. For example:

• I always externalize the eating disorder and teach my patients to do the same.
• I firmly believe that patients do not choose eating disorders and that parents do not cause them. I make this point explicitly to patients and their families at the start of treatment and as many times as necessary throughout the course of treatment.
• I explanation the etiology of eating disorders as follows: We don’t know definitively what causes eating disorders, and for the purposes of this treatment, the cause isn’t terribly important right now. The most recent scientific research suggests that eating disorders are biologically-based, genetically-transmitted mental illnesses which are triggered by an energy imbalance (for example, through dieting) and perpetuated by malnutrition, with emotional stress (e.g., anxiety, OCD, depression) as an aggravating factor. I mention all of the common myths about the causes of eating disorders (e.g., the media, fear of growing up, need for control, overbearing parents) and dispute each one of them.
• At the start of treatment, I provide patients with psycho-education about the central role of full nutrition, weight restoration, and cessation of binge/purge behaviors in recovery.
• Whenever possible, I involve family members (parents, siblings, spouses, girlfriends, boyfriends) in the patient’s treatment to some extent. In some cases, family involvement may be as simple as providing family members with psycho-education, literature, and internet resources on eating disorders. In other cases, family members may participate in the evaluation or attend some therapy sessions with the patient. Regardless of the patient’s age, I like to empower those who live with her (parents, spouses, significant others) to provide meal support and help stop other symptoms such as excessive exercise, bingeing, and purging.
• I view family members as essential members of the treatment team who can provide nutritional, practical, and emotional support to the patient as she recovers.
• I make physical health (including full nutrition, weight restoration, elimination of purging and other unhealthy behaviors) the most immediate priority in treatment.
• I help patients re-learn how to eat properly on their own once they are physically healthy and psychologically prepared to assume this responsibility.
• I treat patients’ other disorders (e.g., depression, OCD, anxiety) and address their developmental, familial, and interpersonal issues after physical health has been achieved.

In my view, these principles are equally applicable for children, adolescents, college students, and adults. They apply when I am doing individual therapy using a CBT, DBT, ACT, or IPT approach. They apply when I am doing couple’s therapy when one partner has an eating disorder. And, of course, they apply when I am doing Maudsley Family-Based Therapy.

These principles are a central part of my professional identity. I stand behind them when I am giving a lecture, doing a presentation, conversing with colleagues, speaking to potential clients, talking about work with family and friends, or even answering the questions of acquaintances who are interested in what I do.

To date, the Maudsley approach has only been empirically-supported for adolescents with anorexia nervosa and bulimia nervosa. However, preliminary data suggest that Maudsley may be equally effective for pre-adolescent children and young adults. Regardless of what the eventual published data may say about broader applications of Maudsley, I will hold fast to these principles. At least until science or experience convinces me otherwise.

Informed Consent

The American Psychological Association’s ethical guidelines require that psychologists obtain informed consent for treatment from all patients and parents of minor patients. But what does it mean for consent to be truly informed?

In standard practice, informed consent generally amounts to a frazzled patient or harried parent signing a consent form after a perfunctory glance. Patients and parents are often in crisis when they first present for treatment, and signing the form is just one more hoop to jump through before getting into therapy. Most therapists’ consent forms cover business procedures and confidentiality issues. This is important information, but does it amount to truly informed consent?

I don’t think so.

I believe that the APA’s ethical guidelines should be revised to require full disclosure in informed consent for psychological treatment. Specifically, therapists should be required to disclose 1.) The patient’s diagnoses and explanations of these diagnoses, 2.) What factors caused or contributed to the patient’s illness, as evidenced by the most recent empirical research and the clinician’s informed judgment, 3.) What treatment methods are available for treating the patient’s condition, 4.) Which of these methods are evidence-based, 5.) Which method(s) the therapist will use, 6.) Why the therapist has selected these methods, 7.) The anticipated course of treatment and prognosis, based upon recent empirical research, and 8.) Scientifically informed, practical resources (e.g., books, articles, websites) on the patient’s condition and the type of therapy that will be used. For patients under 18, all of the above should be explained to the parents and to the child, using language appropriate to the child’s age and developmental level. Finally, parents should be provided with guidance as to how they can help their child recover. I’m talking about specific recommendations, not just blanket statements like “be supportive.”

In my consent for therapy forms, which patients (and parents of minor patients) read and sign before meeting with me, I specify the types of treatment I use, all of which are evidence-based. After the evaluation, I provide patients(and parents of adolescent patients) with empirical research on their particular disorder, as well as information on the efficacy of various types of treatment and who recommends these treatments (e.g., APA, Society for Adolescent Medicine, etc.). I explain the type of treatment I recommend for them, why I have selected this type of treatment, how it works, and what to expect on the road to recovery. If there is a type of treatment that is likely to be effective for the patient but that I do not offer (e.g., psychiatric medication, residential treatment), I provide them with referrals to these types of treatments and explain why I think they would be beneficial. At this point, the patient has all of the information she needs to make an informed choice about treatment.

Most patients seeking therapy, and most parents seeking therapy for their children, are not aware that there are different types of psychological treatments with varying degrees of efficacy. I think most people outside of the field assume that therapy is therapy and that therapists are pretty much interchangeable, like dentists or surgeons. Many people assume that as long as you like your therapist and feel comfortable with her, that’s all that matters. While the therapeutic relationship is undoubtedly a critical aspect of treatment, there are other factors to consider in selecting a therapist. Often times, people want to see a psychologist with decades of experience. This is an understandable, albeit unreliable, method of seeking good treatment. The older, more experienced therapists were trained decades ago in theories that have since been discarded, in therapeutic methods with no scientific backing. Sometimes they become set in their ways of practicing, clinging to old theories like religious dogma in spite of evidence to the contrary. Granted, many experienced therapists have kept up with recent developments in the field and have educated themselves. Sadly, many have not.

Informed consent in therapy is complicated by the fact that different professionals have vastly different, and often contradictory, views on the causes of various mental disorders and how best to treat them. To make matters worse, the public has access to a tremendous amount of information on mental health issues through the internet, much of which is either unsubstantiated or patently false. Consequently, many patients arrive in our offices with deeply entrenched false beliefs about their illnesses. As professionals, it is our job to set the record straight.

I have had a number of patients come to me seeking therapy for the first time after being unsuccessfully treated for anxiety or depression by their primary care physician. I use the term “treated” very loosely here – their doctor spoke with them for a few minutes and wrote them a prescription for a low dose of antidepressants or sleeping pills, only to follow up with them a year later. They were not informed about evidence-based psychological treatments. They were not informed about behavioral methods of treating insomnia. And of course, they were not informed that their dose of Prozac is far too low to have any therapeutic benefit. Similarly, I have had patients come to me after years of therapy for depression or self-injury who have done endless amounts of exploration into the supposed causes of their supposed issues, without ever learning the skills they need to recover.

Parents of eating disordered children have come to me for Maudsley family-based therapy after months or years of unsuccessful therapy, after multiple hospitalizations and stints in residential treatment. These families were never informed about the Maudsley Method by any of their child’s previous treatment providers. These parents, desperate to help their children, did their own research on the internet late at night, sifting through the mounds of information to try to find the one thing that would save their child’s bright future. I’ve seen patients, who have been through years of eating disorder treatment with other professionals, who have never once been told that they have a biologically-based, genetically-transmitted mental illness which is neither their fault nor their choice.

Parents of eating disordered children have a right to be informed about the Maudsley Method at the time of diagnosis. The research is clear that Maudsley is the most effective treatment for adolescents with a short duration of illness who are still living at home with their families. For various reasons, Maudsley is not the best choice for every patient or family. Nonetheless, families have the right to know it exists and to decide for themselves whether they wish to pursue it. Patients with depression, anxiety disorders, and personality disorders have the right to be informed about evidence-based treatments such as CBT, DBT, and ACT. Many lives, many years of chronic illness, and many dollars spent on ineffective treatments could be saved if patients and parents were fully informed about evidence-based treatment options from the outset. If a patient has cancer, it is her physician’s duty to inform her of the various life-saving treatment options, some of which may be available in that physician’s office or the local hospital, and some of which are only available in the nearest major city. Why should psychology be any different?

10 Common Mistakes in Eating Disorder Treatment

Eating disorders are notoriously difficult to treat and have the highest mortality rate of any psychiatric illness. With traditional treatment, average time to recovery is 5-7 years, relapse is the norm, and many patients continue to suffer from chronic physical and mental illness for decades. Fortunately, new research has shed light on how we can help patients recover more quickly, prevent relapse, and live healthy, fulfilling lives. Below are 10 of the most common mistakes I’ve observed in the treatment of eating disorders.

1.) Setting target weight too low.

Physicians and dieticians will often set a patient’s minimum target weight at the low end of the statistically-determined “ideal” range. The minimum target weight thereafter becomes the maximum allowable weight in the patient’s mind, and she will do whatever she can to avoid going above it. There is no such thing as a universal minimum target weight. People vary dramatically in terms of body build, muscle mass, bone structure, body shape, and natural weight. Professionals need to take these factors into consideration when setting target weight ranges. The minimum target weight is often not sufficient to promote brain healing and repair the damage caused by malnutrition. “Out of immediate medical danger” does not translate to optimal physical and mental health. Many patients are left to struggle with ongoing depression, fatigue, anxiety, and preoccupation with food and weight because they haven’t reached their optimal body weight.

For children and adolescents, setting minimum target weight too low is especially dangerous because it fails to take into account the natural growth and physical development that occurs throughout adolescence. The ideal weight for a 13-year-old is not ideal for a 22 year-old. A 13-year-old patient who becomes fixated on her “minimum target weight” and maintains such a weight for a number of years is placing an indefinite moratorium on her physical, psychological, and sexual development. Another problem that is particularly disconcerting is that the minimum target weight set by professionals is often significantly lower than the patient’s pre-eating disorder weight, even if the patient was at a healthy weight before. Think about the subtle message this sends and how the ill patient may interpret it: “You were too big before, so you were right to start dieting.” This just feeds into the eating disorder. We need to send a different message: complete weight restoration is not negotiable.

2.) Discharging patients from inpatient or residential programs prematurely.

By “prematurely,” I mean several things: before the patient has reached her ideal body weight, before she has developed the skills to manage her symptoms, before other comorbid conditions have been diagnosed and treated, before the patient’s family has the knowledge and tools they need to support continuing recovery, or before a solid relapse-prevention plan is in place. According to my standards, then, the majority of patients are discharged prematurely. With treatment as usual, relapse is the norm, and repeated admission to hospitals and residential facilities is expected. It doesn’t have to be this way, and relapse may not be such a major problem if patients were treated fully and successfully the first time around. Of course, this will require healthcare reform and better insurance coverage in order to pay for a much longer duration of treatment, but I digress.

3.) Blaming parents for their child’s eating disorder.

Parents have traditionally been excluded from their children’s eating disorders treatment in large part because professionals have blamed them for causing the eating disorder. This viewpoint is based in psychoanalytic theory, not empirical fact, and to date there has been no reliable scientific evidence that parents cause eating disorders. Blaming parents is harmful to the entire family. It disempowers parents, angers and confuses the patient and her siblings, and interferes with the recovery process. Only a generation ago, parents were blamed for causing their children’s autism and schizophrenia. We now know that these illnesses are biologically-based brain disorders, and the idea of a “refrigerator mother” causing her son’s autism is ludicrous. I look forward to the day when the general public has the same sentiment about parents causing eating disorders.

4.) Failure to involve parents and other family members in the patient’s treatment.

Parents have a right and a responsibility to be fully informed and actively involved in their child’s treatment. Imagine how confusing and disempowering it is for parents to drop their child off at various appointments without being informed about the treatment and without being given an opportunity to ask questions, voice their concerns, or help with the recovery process. Likewise, adolescents have a right to have their parents fully informed and actively involved in their treatment. No child would have to manage cancer or diabetes independently. Why should it be any different for eating disorders? The research clearly indicates that involving parents in an adolescent’s eating disorder treatment dramatically increases her chance of full recovery.

Some therapists argue that involving parents in an adolescent’s treatment is counterproductive because it interferes with the adolescent’s burgeoning autonomy and encourages the family unit to remain enmeshed. In reality, the opposite is true. The eating disorder itself is disruptive to normal adolescent development and causes the patient to remain dependent on her parents. Family-based treatment approaches, such as the Maudsley Method, are first and foremost respectful of adolescent development. These approaches empower parents to help their children recover so that they may return to normal adolescent life, unencumbered by the illness.

5.) Basing interventions on unsubstantiated theories about the causes of eating disorders.

Our ideas about etiology inform our treatment approach. Consequently, incorrect assumptions about eating disorders tend to result in ineffective treatment. Let’s say, hypothetically, that controlling parents cause eating disorders. Or that media images which glorify thinness are responsible for eating disorders. Or that anorexia nervosa is caused by sexual abuse or is rooted in a desire to avoid growing up. Even if these things were true (and there is no reliable scientific evidence that they are), the first priorities in treatment should still be nutritional rehabilitation, weight restoration, and medical stability. Why? Because the patient’s life and health depend on it. Because research has consistently shown that many of the physical and mental symptoms of eating disorders are caused or exacerbated by malnutrition, restrictive eating, bingeing, and purging, and that these symptoms diminish with normalized eating and weight restoration. Because spending more time at a suboptimal weight, or engaging in food restriction, binge eating, or purging, is causing more physical and emotional damage. Because a weight-recovered, medically stable eating disordered patient who is receiving full nutrition is better equipped to explore and process the issues that may have triggered eating disorder symptoms in the first place.

6.) Viewing the patient’s symptoms as rationally chosen behaviors.

Recent research suggests that eating disorders are genetically-transmitted, biologically based mental illnesses, just like bipolar disorder and schizophrenia. No one would choose the agony and suffering of an eating disorder. I think the general public may get confused about this point because, for healthy people, eating and exercise are voluntary behaviors that are largely under conscious control. For eating disorder patients, restrictive eating, fasting, excessive exercise, bingeing, and purging are compulsive behaviors brought about by a brain condition, perpetuated by malnutrition, and aggravated by emotional stress.

Not only is it incorrect to view eating disorders as choices, but it is dangerous as well. It leads to blaming patients for their illnesses, trying to talk them out of their symptoms, and giving them the responsibility of choosing recovery. Almost invariably, people with anorexia are not able to choose recovery because denial and lack of insight are hallmark symptoms of the illness. People with bulimia are more likely to acknowledge their disorder and enter treatment voluntarily, but they are often unable to interrupt the binge/purge cycle without a major intervention and significant support from others. Insight and motivation are not prerequisites for entering treatment, restoring weight, or stopping unhealthy behaviors. Rather, increased insight and desire to maintain health are natural consequences of full nutrition, improved brain health, abstinence from eating disordered behaviors, and good therapy.

7.) Overemphasizing psychological recovery while underemphasizing physical recovery.

I am not entirely sure why many clinicians work with patients on developing insight and searching for a root cause early in treatment, prior to nutritional restoration and medical stability. We still do not know the causes of many types of cancer, but cancers are treated aggressively as soon as they are diagnosed. A surgeon will operate on a patient to remove a tumor regardless of whether he knows what caused it. It is tragically comical to imagine a doctor and patient searching for the cause of the tumor while it metastasizes.

One of the earliest things we’re taught in our clinical training is how to build a positive, trusting relationship with the patient. If the patient doesn’t trust us and feel comfortable with us, the therapy won’t work. Indeed, psychotherapy research across various disorders and types of treatment has demonstrated that the therapeutic relationship is a very powerful predictor of outcome. However, the therapeutic relationship is more complicated in working with eating disorders because success in therapy requires that the patient do the exact opposite of what her disorder wants: eat more and gain weight. Early in treatment, it often seems as though maintaining a positive therapeutic relationship and helping the patient recover are mutually exclusive. So often, well-meaning eating disorder therapists work hard early on to gain a patient’s trust and build a positive therapeutic relationship in the hopes that the patient will eventually develop the insight and motivation to address her symptoms. While this rapport-building is going on, the patient is becoming sicker, weaker, thinner, more depressed, and more entrenched in her symptoms. Allowing the patient to marinate in malnutrition and continue to engage in her symptoms delays recovery, increases her risk of medical complications, and prevents her from being able to engage in the psychological work of recovery.

The therapeutic relationship is only therapeutic insofar as it facilitates health, growth, and recovery. I have found that my relationships with patients improve naturally, and dramatically, once they are no longer engaging in restricting, bingeing, or purging. I would much rather have an angry, tearful adolescent patient hurl vile words at me as I’m pushing full nutrition and weight restoration than a quiet, sweet adolescent patient who enjoys talking with me as her health declines and her vital signs dwindle.

8.) Overemphasizing physical recovery while underemphasizing psychological recovery.

This is the polar opposite of #7. It happens far less often that #7, but it does happen. Full nutrition, weight restoration, medical stability, and cessation of binge/purge behaviors are absolutely necessary, but not sufficient, for recovery. Restoring physical health is only the beginning of a long, difficult process. The psychological aspect of eating disorders cannot be ignored or minimized. Patients need low-stress environments and lots of support from loved ones. Most patients need psychotherapy to address anxiety, depression, perfectionism, social concerns, body dysmorphia, and other issues that may have contributed to the eating disorder. Therapy can help patients develop the skills they need to manage their emotions, cope with stress, stay healthy, and prevent relapse. Some patients need psychiatric medication to treat comorbid conditions such as ADHD, OCD, or major depression. Fully addressing the patient’s psychological needs, as well as her physical and nutritional needs, gives her the best shot at lasting recovery.

9.) Failure to intervene immediately, and aggressively, at the first sign of weight loss or change in eating or exercise behavior.

The research is very clear on this point: early intervention predicts better prognosis. We should not wait for a teenager to develop full-blown anorexia nervosa or bulimia nervosa before stepping in to help her. We should not wait for her to drop to 15% below her ideal body weight, miss 3 consecutive menstrual periods, or develop a dangerously low heart rate. We should not wait until she has binged or purged twice a week for three months. Let’s step in when she is 1% below her ideal body weight, when she has missed one menstrual period, when she has purged one meal. Better yet, let’s step in as soon as we notice body image concerns, changes in eating or exercise habits, or excessive preoccupation with body weight and shape.

10.) Using physical appearance or statistically-determined BMI charts as definitive measures of physical or mental health.

There is a common misconception that all people with eating disorders are emaciated. This is not necessarily true. Certainly, individuals in the acute phase of anorexia nervosa are often shockingly thin. However, most people with eating disorders don’t “look sick.” Individuals with bulimia are usually of normal weight. People with anorexia who are at or near their ideal body weight, but still actively struggling with eating-disordered thoughts and feelings, generally “look normal.” Further, it is impossible to tell whether a person is underweight simply by looking at them. Because ideal body weights are highly individualized based upon bone structure, muscle mass, body shape, and weight history, a person may fall within the “ideal” BMI range and still be significantly malnourished or dehydrated. The danger in using physical appearance as a gauge of mental or physical health is that people who “look normal” may be overlooked. Their eating disorders may not be as easily detected and may not be taken as seriously. These patients don’t believe they deserve treatment because they’re not thin enough, not sick enough, not worthy enough. As professionals, we must not fall prey to this distorted thinking.