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.