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Metamorphosis: Long-Term Therapy with Young Adults

One of the most rewarding aspects of my job is the opportunity to engage with patients in long-term therapy.  In my practice today, I have a number of patients who began treatment with me years ago, in adolescence, and are now in their 20’s.  These patients first presented in my office with their parents during middle school or high school, suffering from severe eating disorders or depression or debilitating anxiety or, in some cases, all of the above.  Some entered treatment kicking and screaming; others reluctant but resigned; still others wanting help and suffering desperately but requiring immense parental support to stay afloat.

 In many cases, these adolescent patients received intensive Family-Based Treatment for six months or a year or more.  In other cases, the teenage patients received individual Cognitive-Behavioral Therapy with active parental involvement.   All of them made substantial progress in treatment.  The majority recovered fully from their initial presenting diagnosis.  Those who have not recovered fully are doing significantly better, living independent, fulfilling lives, but still experiencing symptoms and receiving ongoing care to keep their illness at bay.  Now, years later, some of them continue with weekly therapy sessions.  Others come in once or twice a month, or perhaps biannually like dental cleanings (we call this “mental hygiene”).  Still others elect come in on an “as needed” basis, scheduling a few sessions here and there to help them cope with life events, navigate relationships, manage stress, or deal skillfully with bouts of depression or anxiety. 

What unites these incredible young men and women is the fact that they have taken full responsibility for their well-being.  They have chosen to engage in long-term individual therapy as an act of self-care.  Through their adolescent suffering, they have become acutely aware of their susceptibility to mental illness.  They are choosing to receive therapy not only to prevent relapse of illness but also to pursue optimal health.   Many of these young adults have chosen to abstain from drugs and alcohol, even as their peers regularly smoke pot and drink to excess.  Many of them have adopted consistent home practices of meditation or yoga.  They make conscious, health-promoting choices when it comes to sleep, nutrition, stress management, and physical activity.  When faced with an important decision about which graduate program to pursue, which job offer to take, which city to live in, or even which person to date, they carefully consider the impact of these choices on their quality of life.

Engaging in long-term therapy with patients like these involves a number of gradual but significant transitions for all members of the therapeutic relationship: the patient, the parents, and me.   For the parents and for me, there is the progression from the crisis management of an acutely ill adolescent to the joy of stepping back into a supportive role for young adult in his own quest for greater levels of well-being.  The parents and I often begin our relationship communicating multiple times per week to put out fires and to ensure that we are in lock-step as we form a circle of safety around a suicidal or eating disordered patient.  As the patient gradually assumes responsibility for her own well-being (which often takes several years for those with adolescent-onset mental illness), communication between parents and me subsides into an occasional email or phone call.   The patient is now a much healthier, more mature young adult, and is trusted to schedule, attend, participate meaningfully in her own therapy sessions.  In many cases, she pays for her own treatment as well.

The therapy itself goes through a significant evolution as I shift from being directive and prescriptive, setting firm limits around dangerous or debilitating symptoms, to engaging with the patient in deep psychological work and collaborative goal setting.  For the patient, there is the very welcome shift from being told what she must do, in therapy and at home, to deciding what issues are important to her and taking the initiative to seek support, both therapeutic and familial, in achieving personally relevant goals.    For the patient, this shift brings with it a transformation from a defensive posture (as evidenced by panicking, shutting down, or lashing out in therapy and at home) to a stance of openness and receptivity (as evidenced by increased self-disclosure and self-awareness along with the display of more vulnerable emotions). 

I cannot begin to describe how rewarding it feels to support a frightened, malnourished, deeply depressed teenager as she blossoms into a healthy, confident, independent young woman who is attending college or graduate school in another state, working at an exciting full-time job, getting married, or giving birth to her first child.  It is fulfilling beyond words to join with young adult patients in the journey of long-term wellness as they clarify their personal values, decide who they want to be in this world, and take concrete steps towards achieving their dreams.

Those of you who have engaged in long-term therapy, either as a therapist, as a patient, know well how deeply personal and meaningful these relationships can be.  There is a level of emotional intimacy that surpasses even that between spouses, between parent and child, or between the best of friends.   In many ways, engaging in long-term therapy with self-motivated young adults is the polar opposite of Family-Based Treatment (FBT) for Adolescent Anorexia Nervosa.   For most patients in my practice, the former would not have been possible without the latter.   

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The 4 P’s of Mental Health Treatment

I like to conceptualize the etiology and treatment of mental illness using the framework of the 4 P’s: predisposing factors, precipitating factors, perpetuating factors, and prognostic factors.

Predisposing Factors are risk factors which create vulnerability to developing a particular illness.  

Examples of predisposing factors:

Why are they important?

Predisposing factors are important in helping individuals and their families understand their vulnerabilities and in alleviating the guilt, shame, blame, and stigma surrounding mental illness. Once families learn that the patient did not choose to develop this mental illness and the parents did not cause it, they have more energy to devote to recovery.

A word of caution: Predisposing factors are probabilistic, not deterministic.  In other words, having one or more predisposing factors for a particular mental illness does not mean that developing that illness is inevitable.  It simply means that vulnerability is heightened.

Precipitating Factors, known more casually as “triggers,” are events or circumstances that immediately precede the development of a disorder.

Examples of precipitating factors:

  • A loss of some sort (e.g., breakup of a romantic relationship, death of a loved one) often precipitates the onset of depression.
  • An energy imbalance (e.g., consuming fewer calories than one expends) almost always precipitates the development of anorexia nervosa or bulimia nervosa
  • A stressful situation (e.g., final exams in high school or college) may precipitate the onset of an anxiety disorder

Why are they important?

Awareness of the factors that have precipitated a mental health diagnosis is an important part of assessment. Relapse prevention planning, which typically happens towards the end of treatment, should help the patient and family develop awareness of the most common precipitating factors for their particular illness(es) so that  they can avoid those precipitating factors when possible, or be prepared to approach them skillfully and mindfully, with ample supports in place, if they are unavoidable.   

A word of cation: Precipitating factors are not the same as causes.  The majority of individuals go through multiple stressors in their lives without developing a mental illness.  A genetic predisposition is necessary, though not sufficient, for the development of a mental illness. 

Another word of caution: Discussion of precipitating factors shouldn’t be a major focus of treatment.  Once a disorder is set in motion by a perpetuating factor, the disorder takes on a life of its own and becomes self-perpetuating.  It ceases to be “about” that precipitating factor.

Perpetuating Factors are events or circumstances that keep an illness in motion, or those things that cause symptoms to continue occurring over a period of time.

Examples of perpetuating factors:

  • Malnutrition, weight suppression, excessive exercise, and binge/purge behaviors perpetuate an eating disorder. 
  • Environmental stressors, such as a highly rigorous academic environment, social exclusion or bullying, or elite athletic training, may perpetuate an anxiety disorder.   
  • All forms of anxiety are perpetuated by heightened physiological arousal and avoidance. 
  • Irregular sleep schedules, social isolation, and habitual use of marijuana are common perpetuating factors for depression.
  • Distorted patterns of thinking perpetuate most mental illnesses.  

Why are they important?

Most successful mental health treatment is focused on identifying and modifying perpetuating factors. Most, though not all, perpetuating factors are modifiable and can be changed through cognitive or behavioral interventions. 

A word of caution: The most powerful perpetuating factors are often those that directly impact physiology and brain function. For example, starvation is a powerful perpetuating factor in anorexia nervosa, and sleep deprivation is a powerful perpetuating factor in depression. A brain that is malnourished or severely sleep deprived is unlikely to respond well to psychological interventions. Cognitive perpetuating factors, which are also important, can be addressed most effectively later in treatment, after basic physiological function has been restored.

Prognostic Factors are factors which help to determine the eventual outcome, or prognosis, of treatment.

Examples of prognostic factors:

  • Early diagnosis and prompt intervention are positive prognostic factors.
  • Receiving evidence-based treatment is likely to shorten the duration of illness and increase the likelihood of achieving full recovery .
  • Dropping out of treatment prematurely reduces the likelihood of full recovery.
  • The presence of strong social support from family and friends increases the likelihood of full recovery and reduces the risk of relapse.
  • Full weight restoration, and maintenance of optimal body weight over time, dramatically improves the prognosis for anorexia nervosa.
  • Relapse prevention planning improves long-term prognosis by reducing the risk of relapse and guiding the type and timing of intervention if the patient begins to struggle again.
  • Practicing consistent self-care habits, including good sleep hygiene, regular exercise, and balanced nutrition, improves the prognosis for most illnesses.

Why are they important?

Prognostic factors are important to share with patients and families so that they can work together with treatment providers to create the best possible treatment outcome.  Prognostic factors are relevant at the time of diagnosis (to help patients and their families act swiftly and choose evidence-based treatment), during treatment (to instill hope when treatment gets difficult and inspire everyone to stay the course rather than dropping out prematurely) and at the end of treatment, when relapse prevention plans are created. Prognostic factors are also important after treatment ends, as they relate to sustaining continued recovery and well-being.

A word of caution: prognostic factors, like predisposing factors, are probabilistic, not deterministic. Having positive prognostic factors does not guarantee a good outcome. Positive prognostic factors merely increase the statistical likelihood of long-term recovery and reduce vulnerability to relapse.

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Updated Summary of Treatment Outcomes

Since opening my private practice in 2009, I have been privileged to work with over 300 individuals and families, providing consultation, evaluations, and treatment for a variety of mental health conditions.  I believe in being transparent and straightforward about the services I provide and why I provide them.  Individuals who are seeking mental health services for themselves or for their children have a right to know what treatment with a particular provider will actually be like, how long it will last, what outcomes they can expect, and what factors contribute to a more or less favorable outcome.

To this end, I collect detailed information on my patients’ treatment outcomes and publish the results on my blog.  Here is an updated summary of treatment outcomes for the disorders I most commonly treat.  For more detailed information on the types of treatment provided and treatment outcomes in my practice for each of these disorders, click on the category heading.

Treatment Outcomes for Anorexia Nervosa

  • 50% of patients who entered treatment with me completed a full course of treatment with me. 26% dropped out of treatment prematurely.  22% were referred to other providers who could better meet their needs.  3% moved to other geographic locations during treatment.
  • 97% of patients who completed treatment achieved full remission. The remaining 3% achieved physical remission.
  • The majority of patients who completed treatment did so in a time frame of somewhere between 7 months and 2 years.
  • A full course of treatment required, on average, 27 sessions over the course of 17 months.
  • Patients with co-morbid conditions, such as anxiety disorders or depression, required more sessions, on average, than those without co-morbid conditions.
  • All patients who completed treatment achieved 100% full weight restoration, as indicated by a return to their pre-AN percentile patterns of growth for height and weight.
  • Average time to achieve weight restoration was 3.6 months.
  • Patients who recovered with individual therapy took longer, on average, to achieve weight restoration than those who recovered through Family-Based Treatment (FBT).
  • Patients receiving FBT were almost twice as likely to recover as those receiving individual therapy.
  • Patients receiving individual therapy were almost twice as likely as those receiving FBT to drop out of treatment prematurely.
  • Individuals with restrictive Anorexia Nervosa were twice as likely to achieve full remission as those with binge-purge Anorexia Nervosa.
  • For treatment drop-outs, there was a significant correlation between length of time spent in treatment and progress made. All treatment dropouts who were in treatment with me for at least 2 months had made significant progress towards treatment goals at the time of drop-out.  Patients who dropped out of treatment after one month or less had not made any progress at the time of drop-out.

 

Treatment Outcomes for Bulimia Nervosa

  • Over half of patients with bulimia nervosa (54%) discontinued treatment prematurely after making significant progress towards treatment goals, but prior to achieving full remission.  15% percent of patients were referred to other treatment providers or types of treatment that could better meet their needs, after making little or no progress in treatment with me. 8% of patients moved to other geographic locations and were thus referred to providers near their new homes.  23% of patients completed a full course of treatment with me.
  • Of those who completed a full course of treatment, 100% achieved full remission from their eating disorder.
  • A full course of treatment required, on average, 13 sessions over the course of 5 months.
  • Patients who took Prozac during treatment were more likely to achieve full remission than those who did not take medication.
  • Patients with a prior history of Anorexia Nervosa were less likely to recover from Bulimia than those who did not have a prior history of Anorexia Nervosa.
  • The presence of a comorbid diagnosis was not related to likelihood of achieving full remission from Bulimia.
  • Level of family involvement in treatment was not related to the likelihood of achieving full remission. This finding is in stark contrast to my outcomes for Anorexia Nervosa, in which family involvement was strongly correlated with positive treatment outcome.

Treatment Outcomes for Mood Disorders

  • Only 18% of patients who presented with a primary diagnosis of a mood disorder completed a full course of treatment with me. 50% discontinued treatment prematurely for unknown reasons, 15% moved to other geographic locations, and 18% were referred to other providers who could better meet their needs.
  • Of those who completed a full course of treatment with me, 83% achieved full remission from their mood disorder and the remaining 17% made significant progress towards their treatment goals.
  • Length of time to complete treatment varied dramatically (from 1 month to 3 years) based on individual needs, symptom severity, and progress. On average, a full course of treatment required 23 sessions over the course of 16 months.
  • High levels of family involvement predicted treatment completion and full recovery for adolescent patients but not for adult patients.
  • Patients who were self-referred were more likely to complete treatment and achieve full remission than those who were referred by another professional.
  • Predictors of less favorable treatment outcomes included hospitalization during treatment and taking psychotropic medication during treatment, most likely because these variables are markers for more severe forms of mental illness.
  • The following variables did NOT predict treatment outcome: age at intake, gender, ethnicity, duration of illness, diagnosis (type of mood disorder), presence of co-morbid diagnoses, rate paid for services, type of treatment received with me, or history of hospitalization prior to starting treatment.

Treatment Outcomes for Anxiety Disorders

  • Half of patients who entered treatment for anxiety disorders completed a full course of treatment with me.
  • Of those who completed a full course of treatment, 88% achieved full recovery and the remaining 12% made significant progress towards their treatment goals.
  • Length of time required to complete a full course of treatment varied dramatically from 1 month to 19 months, with a median treatment duration of 3 months.
  • Of those who discontinued treatment prematurely, 63% had made significant progress towards their treatment goals as of their final session with me, and the remaining 37% had made some progress.
  • Predictors of positive treatment outcome included high levels of family involvement in treatment, younger age at intake, shorter duration of illness, being self-referred to my practice, paying full rate for services, and having good attendance at therapy sessions.
  • Predictors of less favorable treatment outcome included presence of a comorbid diagnosis, taking psychotropic medication during treatment with me, and being referred to my practice by a psychiatrist.

General Conclusions

  • Across diagnostic categories, less than half of patients who enter treatment with me complete a full course of treatment with me.
  • I tend to set the bar high for my patients, striving to engage them and help them continue to progress until they reach full remission.
  • Many individuals and families decide to discontinue treatment after making significant progress towards treatment goals, but prior to achieving full remission.
  • I hope that those who discontinue treatment after making significant progress, but prior to achieving full remission, continue to move forward and eventually achieve full remission with the support of their families and/or with other professional supports.  My primary goal in working with families is to empower the parents to help their child.  My goal is to become obsolete for that particular family.   For this reason, when a family reaches a point where the parents are confident that “We’ve got it from here!” and my involvement is no longer necessary, then I have done my job well.    Therefore, dropping out of treatment prematurely, after making significant progress in treatment, may not necessarily be a negative thing.
  • Across all diagnostic categories, patients who complete a full course of treatment with me do very well in recovery. The vast majority achieve full remission from their illness.

 

 

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End of Treatment Outcomes for Patients with Bulimia Nervosa (2009 – 2017)

The following is an analysis of all patients who presented for treatment with a primary diagnosis of Bulimia Nervosa between the start of my private practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who were currently in treatment with me as of spring 2017 or later were not included in this sample.  Patients and families whom I saw only for evaluations or consultations rather than treatment were not included in this sample.

Description of the Sample

This sample includes 13 individuals, all female, who were between the ages of 14 -27 at the time of their initial evaluation (mean age = 19).   Duration of eating disorder prior to starting treatment with me ranged from 1 month to 11 years, with a mean duration of 3.5 years.  Nearly half of the sample (46%) had a prior history of anorexia nervosa prior to beginning treatment for bulimia with me.   More than ¾ of the sample (77%) had a secondary diagnosis, with the most common being Major Depressive Disorder, followed by ADHD and Anxiety Disorder Not Elsewhere Classified.

Description of the Treatment

Number of sessions attended ranged from 2 to 35, with a mean of 15 sessions.  Duration of treatment ranged from 1 month to 28 months, with a mean duration of 8.8 months.  Over half of the sample (54%) took psychotropic medication during their treatment.

All patients under the age of 18 had moderate or high levels of family involvement in their treatment.  For patients over the age of 18, the degree of family involvement was determined by the patient’s living situation, family circumstances, and preferences.   Among adults, 57% had no family involvement and the remaining 43% had some degree of family involvement, ranging from low (participation in at least one session and/or some phone contact with me outside of sessions) to high (participation in most or all sessions).

Sixty percent of patients under the age of 18 received Family-Based Treatment for Bulimia Nervosa (FBT-BN).  The remaining 40% of patients under 18 received Cognitive-Behavioral Therapy (CBT) with a moderate to high level of family involvement, meaning that a parent or guardian participated in many or most of the sessions.   Patients over age 18 received CBT, with an integration of Dialectical Behavior Therapy (DBT) skills for mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.

Approximately 62% of the sample paid full rate for services.  The remaining 38% received a reduced rate based on financial need.

Status at End of Treatment with Me

Twenty-three percent of patients completed a full course of treatment with me.  Of those who completed a full course of treatment, 100% achieved full remission.   A full course of treatment resulting in full remission required an average of 13 sessions over the course of 5 months.

The rate of attrition (treatment dropout) in this sample was very high.   Over half of patients in this sample (54%) discontinued treatment prematurely after making significant progress, but prior to achieving full remission.  Fifteen percent of patients were referred to other treatment providers or types of treatment that could better meet their needs, after making little or no progress in treatment with me. Eight percent of patients moved to other geographic locations and were thus referred to providers near their new homes.

For complete definitions of terms such as “full remission” and “significant progress,” see this blog post from 2013.

Predictors of Positive Treatment Outcome

  • Completion of a full course of treatment was the strongest predictor of positive outcome. 100% of individuals who completed a full course of treatment achieved full remission.
  • Patients who took Prozac during treatment were more likely to achieve full remission than those who did not take medication.
  • Shorter duration of illness prior to beginning treatment with me was associated with greater likelihood of full remission. Patients who achieved full remission had been suffering from an eating disorder for an average of 3.3 years, whereas those who did not achieve full remission had been suffering for an average of 5.3 years.

Other Observations

  • A prior history of Anorexia Nervosa was associated with lower likelihood of achieving full remission from Bulimia Nervosa.
  • Presence of a comorbid diagnosis was not related to likelihood of remission.
  • There was no significant difference in treatment completion or remission rates between patients who paid full rate for services vs. those who paid a reduced rate based on financial need.
  • Degree of family involvement was not related to likelihood of treatment completion or full remission. Individuals were able to achieve full remission with varying levels of family involvement, from no involvement to involvement in every session.  Likewise, individuals dropped out of treatment at similar rates regardless of degree of family involvement.   In contrast, among my patients with Anorexia Nervosa, family involvement was strongly related to likelihood of treatment completion and full remission.

 

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End of Treatment Outcomes for Patients with Anorexia Nervosa (2009 – 2017)

Description of the Sample

This analysis includes all patients with a primary diagnosis of Anorexia Nervosa (AN) who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.  Patients and families whom I saw only for evaluations or consultations rather than treatment were not included in this sample.

The sample includes 60 individuals (93% female) who ranged in age from 10 – 37 years old, with a median age of 16 and a modal age of 13.  The majority of patients identified as Caucasian (69%) or Hispanic (29%), with less than 3% identifying with other racial/ethnic groups.

Twenty percent of patients in this sample met criteria for the Binge-Purge Subtype of AN, while the remaining 80% had Restricting Subtype.

Half of patients in this sample had a comorbid diagnosis.  The two most common comorbid diagnosis were  ADHD and Major Depressive Disorder, with 13% of patients meeting criteria for each of these disorders.

Duration of illness before beginning treatment with me ranged from 2 months to 21 years, with older patients, on average, having been sick for a longer duration of time.  The mean duration of illness before entering treatment with me was just under 3 years.

Most patients had a history of unsuccessful outpatient treatment with other providers prior to beginning treatment with me.  In addition, 28% percent of patients had a history of hospitalization for AN prior to beginning treatment with me and 15% had a history of residential treatment.

Ten percent of the sample paid a reduced rate for services due to financial need.

What follows is a summary of treatment outcomes.  For a more detailed description of treatment outcomes for patients with AN, click here.

Description of Treatment Received

  • 95% of child and adolescent patients received Family-Based Treatment (FBT).  The remaining 5% received individual therapy.
  • 40% of patients over age 18 received FBT, either alone or in conjunction with individual therapy. The remaining 60% received individual therapy.
  • Some adolescent FBT patients received individual therapy for a co-morbid condition after their course of FBT was complete.
  • All patients received medical monitoring by their physician during treatment with me.
  • 58% of patients took psychotropic medication at some point during their treatment with me.
  • Average number of sessions attended was 23.
  • Average duration of treatment was 13 months.

Reasons for Treatment Ending

  • 50% of patients completed a full course of treatment with me
  • 26% dropped out of treatment prematurely
  • 22% were referred to other providers
  • 3% moved to other geographic locations during treatment

Treatment Completion

  • 97% of patients who completed treatment achieved full recovery. The remaining 3% achieved physical remission.
  • The majority of patients who completed treatment did so in a time frame of somewhere between 7 months and 2 years.
  • A full course of treatment required, on average, 27 sessions over the course of 17 months.
  • Patients with co-morbid conditions required more sessions, on average, than those without co-morbid conditions.

Weight restoration

  • All patients who completed treatment achieved 100% full weight restoration, as indicated by a return to their pre-AN percentile patterns of growth for height and weight.
  • Average time to achieve weight restoration was 3.6 months.
  • Patients who recovered with individual therapy took longer, on average, to achieve weight restoration than those who recovered through FBT.

Treatment Dropout

  • 26% of patients dropped out of treatment prematurely.
  • Patients receiving individual therapy were almost twice as likely as those receiving FBT to drop out of treatment prematurely.
  • For treatment drop-outs, there was a significant correlation between length of time spent in treatment and progress made.
  • All treatment dropouts who were in treatment with me for at least 2 months had made significant progress at the time of drop-out.
  • Patients who dropped out of treatment after one month or less had not made any progress at the time of drop-out.

Status at End of Treatment with Me

Recovery status was assessed for each patient as of his/her final session with me, regardless of the reason for treatment ending.  The statistics listed below are for the entire sample of patients, including those who completed a full course of treatment, those who dropped out prematurely, and those who were referred to other providers due to a geographic move or a need for a different level of care or type of care.

  • 48% had achieved full recovery
  • 2% achieved physical remission
  • 22% made significant progress
  • 5% made some progress
  • 18% made no progress
  • 3% regressed

Predictors of Positive Treatment Outcome

  • Completion of a full course of treatment: 97% of those who completed treatment achieved full remission.
  • Younger age (Children under 13 had the highest rates of full recovery, followed by adolescents ages 13-17).
  • Patients receiving FBT were almost twice as likely as those receiving individual therapy to achieve full recovery.
  • Males were more likely to achieve full recovery than females.
  • Patients with Restricting Anorexia Nervosa were more than twice as likely as those with Binge-Purge Anorexia Nervosa to achieve full recovery.
  • Patients taking psychotropic medication during treatment were somewhat more likely to achieve full recovery than those who did not take psychotropic medication.
  • Patients who paid full rate for treatment were somewhat more likely to achieve full recovery than those who paid a reduced rate due to financial need.
  • Caucasian (non-Hispanic) patients were somewhat more likely than Hispanic patients to achieve full recovery.
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End of Treatment Outcomes for Patients with Mood Disorders (2009 – 2017)

Description of the Sample

This analysis includes all patients with a primary diagnosis of a mood disorder who participated in an evaluation followed by a minimum of one therapy session with me between the start of my practice in 2009 and spring 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

The sample includes 34 individuals (29 females and 5 males) who ranged in age from 12 – 59 years old, with a median age of 20.  The majority of patients in this sample (65%) had a primary diagnosis of Major Depressive Disorder.   Other primary diagnoses included Unspecified Depressive Disorder, Bipolar Disorder, Mood Disorder Not Otherwise Specified, and Persistent Depressive Disorder (formerly known as Dysthymia).

More than half of these patients (56%) had a secondary diagnosis.  The most common secondary diagnoses were anxiety disorders. Other secondary diagnoses in this sample included ADHD, eating disorders, and PTSD.

Approximately 30% of the sample had a history of psychiatric hospitalization, most commonly for suicide attempts or suicidal ideation, prior to staring treatment with me.

Description of Treatment Received

The length of treatment varied dramatically, from one week to 3.7 years.  Number of sessions attended also varied dramatically, from 1 session to 135 sessions.  The broad range of treatment duration and sessions attended reflects the reality that some individuals decided not to proceed with treatment after one or two sessions, whereas other individuals attended sessions off and on, as needed, for the duration of their high school or college years.  The average duration of treatment was 11.9 months and the average number of sessions attended was 28.  So, a typical patient with a mood disorder attended approximately 28 sessions over the course of one year.

The type of treatment received was tailored to the individual patient, based on his or her presenting symptoms, circumstances, age, and preferences.  Forty-one percent of patients received Cognitive-Behavioral Therapy (CBT), 18% received a Dialectical Behavior Therapy (DBT) skills-based approach (NOT a comprehensive DBT program), 30% received integration of CBT and supportive counseling, and 11% interpersonal psychotherapy or supportive counseling.

Level of family involvement varied depending on the patient’s age, presenting symptoms, preferences, and living circumstances.  For the purposes of this assessment, high level of family involvement means that at least one family member attended all or most sessions with the patient.  Moderate level of family involvement means that family members attended some sessions and maintained ongoing communication with me throughout treatment.   Low level of family involvement means that at a family member was involved in the evaluation and/or at least one session, but most sessions were individual.  Among all patients in this sample, 18% had a high level of family involvement, 21% had a moderate level of family involvement, 18% had a low level of family involvement, and 44% had no family involvement.  Degree of family involvement was higher, in general, for adolescent patients than for adult patients, with all patients under age 18 having at least some family involvement in their treatment.  Fifty percent of adolescent patients (under age 18) had a high level of family involvement, while 42% had a moderate level of family involvement and the remaining 8% had a low level of family involvement.

Nearly ¾ of patients saw a psychiatrist and took psychotropic medications during treatment.  Nearly ¼ of patients were hospitalized during treatment, most commonly for suicidal ideation or suicidal gestures.

Treatment Completion and Recovery Rates

Of all patients who began treatment with me for a mood disorder, 15% achieved complete recovery, 24% made significant progress, 41% made some progress, 15% made no progress, and 6% regressed.  For a detailed description of what terms such as “complete recovery” and “significant progress” mean, please see this blog post from 2013.

Eighteen percent of patients completed a full course of treatment with me.  Completing a “full course of treatment” was defined as a mutual ending in which the patient, his/her family (in cases where family was involved) and I mutually agree that treatment goals have been met and treatment is no longer needed.  Of these “treatment completers,” 83% achieved full recovery and the remaining 17% made significant progress towards treatment goals.

The length of time required to complete a full course of treatment varied dramatically from person to person, depending on symptom severity and progress in treatment.  Time required to complete treatment ranged from 1 month to 3 years, with a mean of 16.6 months.  Likewise, number of sessions required to complete treatment varied dramatically between individuals.  Number of sessions attended for treatment completers ranged from 4 – 96 sessions, with an average of 23 sessions.  So, on average, individuals who were most successful in treatment (e.g., those who completed treatment and achieved full remission from their mood disorders) attended an average of 23 sessions over the course of 16 months.

Fifteen percent of patients moved to another geographic location during their treatment (either to attend college or to live elsewhere permanently), prior to completing a full course of treatment with me.  As of their last session with me, 60% of these “movers” had made significant progress in their treatment and the remaining 40% had made some progress.  These individuals were referred to other treatment providers in near their universities or new homes for continued treatment.

The dropout rate for patients with mood disorders was fairly high: 50% of patients discontinued treatment with me prematurely.  As of their last session with me, 18% of these “discontinuers” had made significant progress towards treatment goals, 59% had made some progress, and 24% had made no progress.   On average, individuals who discontinued treatment sooner made less progress, while those who remained in treatment longer made more progress towards their treatment goals.   Three quarters of the individuals who made no progress dropped out of treatment after just one or two sessions, and the remaining one quarter dropped out after 5 sessions.  In contrast, those who made significant progress prior to dropping out of treatment attended an average of 20 sessions.

I do not have data on what happens to patients after they discontinue treatment, so this is purely speculation, but I believe several factors contribute to the high dropout rate among patients with mood disorders.  First, depression frequently interferes with a person’s motivation and ability to carry out tasks, and tends to make people hopeless and pessimistic.  Individuals with these symptoms may have a more difficult time persisting towards a goal, such as scheduling appointments and continuing with treatment over a number of months, and they may feel less hopeful about having a positive outcome in treatment.  Second, some patients and families may be satisfied with “good enough,” and may drop out of treatment after making good progress but before achieving all treatment goals.  In contrast, I have high standards for my patients: I believe that full recovery is possible for most people, and when full recovery does not seem achievable, then a full and meaningful life with well-managed symptoms is an alternative good outcome.  I work diligently with patients and their families in pursuit of these goals.

Eighteen percent of patients with mood disorders were referred to other clinicians who could better meet their needs.  I made these referrals when a patient was not progressing in treatment, and when it did not appear likely that they would make progress in the near future.  As of their last session with me, 17% of referred patients had made significant progress, 33% had made some progress, 17% had made no progress, and 33% had regressed.

Predictors of Treatment Outcome

Not surprisingly, completion of a full course of treatment emerged as a strong predictor of positive treatment outcome.  83% of individuals who completed treatment achieved full recovery, while the remaining 17% made significant progress towards treatment goals.  None of the individuals who discontinued treatment prematurely achieved full recovery.

Another strong predictor of positive treatment outcome in this sample was referral source.  Eighty percent of individuals who achieved full recovery were self-referred (e.g., they found my practice through an online search), while the remaining 20% were referred by word of mouth (e.g., by a friend).    In contrast, none of the individuals who were referred to my practice by their psychiatrist, pediatrician, or another therapist completed a full course of treatment or achieved full recovery, although a number of them made significant progress.  My interpretation of this finding is that individuals who proactively sought my services of their own volition may be especially dedicated to improving their mental health, more invested in their treatment, and thus more likely to persevere through a full course of treatment and achieve recovery.   In the case of self-referred adolescents, their parents were the ones who actually brought their children to treatment.  These parents, on the whole, were particularly attuned to their child’s needs and struggles, researched their child’s symptoms and the variety of treatment approaches available, sought my services proactively, and were especially motivated to help their child recover.  Perhaps this parental conscientiousness, attunement, and empowerment helped facilitate recovery for their children.

Level of family involvement in treatment predicted treatment completion and full recovery for adolescent patients but not for adult patients.  All of the adolescents who completed treatment and recovered had moderate or high levels of family involvement.  In contrast, 75% of the adults who completed treatment and achieved full recovery had no family involvement in their treatment, while the remaining 25% had a low level of family involvement.

Individuals who took psychotropic medication were somewhat less likely to recover than those who did not: 40% of individuals who achieved full recovery were taking medication during treatment, whereas 76% of individuals who did not achieve full recovery were taking medication during treatment.  It is unlikely that taking psychotropic medication caused patients to have a worse outcome.  I believe the most likely explanation for this finding is that taking psychotropic medication is a marker of severity: individuals with more severe forms of mood disorders (e.g., Bipolar Disorder, Severe Recurrent Major Depressive Disorder) are more likely to need medication and are perhaps less likely to achieve complete remission of symptoms.

Hospitalization during treatment emerged as a predictor of less favorable outcome.  None of the individuals who were hospitalized during their treatment with me completed a full course of treatment or achieved full recovery.  It is unlikely that being hospitalized actually caused patients to quit treatment or caused them to make less progress in their treatment.  It is more likely that hospitalization, like taking psychotropic medication, is a marker of severity, and those individuals with more severe illnesses are less likely to experience complete remission of symptoms.

The following variables did NOT predict treatment outcome: age, gender, ethnicity, duration of illness, diagnosis, presence of co-morbid diagnoses, rate paid for services, type of treatment received, or history of hospitalization prior to starting treatment.

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End of Treatment Outcomes for Patients with Anxiety Disorders (2009-2017)

In an effort to improve the quality of services I offer, and in the service of full transparency to those who seek treatment, I am committed to compiling and sharing outcome data every few years on the patients I have treated.   The last time I compiled and shared my treatment outcome data was in 2013, so it is time for another round, this time with a larger sample to describe.

Description of the Sample

This analysis includes all patients with a primary diagnosis of an anxiety disorder who participated in an evaluation followed by a minimum of one therapy session with me at any time between the start of my private practice in 2009 and spring of 2017.  Given that this is an analysis of end of treatment outcomes, patients who are currently in treatment with me were not included in this sample.

This sample includes 16 patients, all female, who ranged in age from 10 – 42 years old, with a median age of 20.

Description of Treatment Received

Seventy-five percent of these patients were treated with Cognitive-Behavioral Therapy (CBT), while the remaining 25% of patients were treated with supportive or client-centered therapy.

Length of treatment and number of sessions attended varied considerably among these individuals.  The vast majority of patients were in treatment with me for somewhere between 2 – 19 months and attended somewhere between 3-17 sessions.   The median duration of treatment was 4.5 months, and the median number of sessions attended was 12.

Degree of family involvement varied based on the patient’s age and living circumstances.  All patients under age 18 had at least a moderate level of family involvement, and 83% of patients under age 18 had a high level of family involvement.  Patients of college age had low- to moderate levels of family involvement, and most adult patients in their 30’s and 40’s had minimal, if any, family involvement.

Forty-four percent of patients were taking psychotropic medication, prescribed by their psychiatrist, during their treatment with me.  None of the patients in this sample were hospitalized during the course of their treatment with me.

Treatment Completion and Recovery Rates

Of all patients who entered treatment with me for anxiety disorders, 44% percent recovered completely from their anxiety disorder, while 38% made significant progress in terms of reduction of symptoms and improvement in functioning, and 19% made some progress towards recovery.   In sum, all of the patients in this sample made at least some progress towards their treatment goals.  For a detailed description of the criteria used to determine “full recovery,” “significant progress,” and “some progress,” see this blog post from 2013.

Half of the patients who entered treatment with me for anxiety disorders completed a full course of treatment.   Completing a “full course of treatment” was defined as remaining in treatment until the patient, her family (when involved), and I collaboratively agreed that treatment goals had been met and further treatment was not needed.  The number of sessions required to complete a full course of treatment ranged from 3 – 25 sessions, with a median of 4 sessions.  The duration of treatment for those who completed a full course of treatment ranged from 1-19 months, with a median duration of 3 months.  Of those who completed a full course of treatment, 88% achieved full recovery and 12% made significant progress since starting treatment.

The remaining half of patients did not complete a full course of treatment with me, either because they quit treatment prematurely, they moved to another geographic location, or I referred them to another clinician.   Among those who did not complete a full course of treatment, 63% had made significant progress in their recovery at the time they left treatment with me, and the remaining 37% had made some progress.  It is important to note that I do not have data on what happens to patients after they leave my practice, so these treatment outcomes are based on an assessment of the patient’s symptoms and functioning as of the last session they attended with me. It is possible that some individuals who left treatment prematurely achieved full recovery later on their own, or in treatment with another clinician, after leaving my practice.  It is also possible that some individuals experienced a worsening of their condition after leaving treatment.

Predictors of Treatment Outcomes

A high level of family involvement in treatment emerged as the strongest predictor of successful treatment outcome.  100% of patients who had high levels of family involvement in treatment completed a full course of treatment and achieved full recovery.

Completion of a full course of treatment was the second strongest predictor of successful outcome. 88% of patients who completed a full course of treatment achieved full recovery from their anxiety disorder.  The remaining 12% of treatment completers had made significant progress since the start of treatment.

Younger age was also a predictor of successful treatment outcome.  Younger age was strongly correlated with both high family involvement and completion of treatment.

Other factors associated with successful treatment outcome include shorter duration of illness, good attendance at therapy sessions, paying full rate for services, and being self-referred to my practice.

Not surprisingly, discontinuing treatment prematurely was associated with less favorable outcomes.   Even so, 63% of individuals who discontinued treatment prematurely had made significant progress since beginning treatment with me, and the remaining 37% had made some progress.  These data indicate that the majority of individuals with anxiety disorders experienced significant benefits from treatment in terms of reduction of symptoms and improvement in functioning, whether or not they completed treatment a full course of treatment.

Other factors strongly associated with a less favorable treatment outcome included the presence of a comorbid diagnosis, taking psychotropic medication during treatment, and being referred to my practice by a psychiatrist.  Interestingly, these three factors were strongly correlated with one another: all of the individuals who were referred to my practice by their psychiatrist were taking psychotropic medication and 80% of individuals referred by their psychiatrist had comorbid diagnoses.

The following factors were modestly associated with less favorable treatment outcomes: older age, longer duration of illness, lower levels of family involvement, poor attendance at therapy sessions, and paying reduced rate for services.  Again, these factors tended to co-occur with one another, and also tended to co-occur with the three negative prognostic factors listed above.

These statistics reflect overall trends, not absolutes.  Some individuals in this sample did achieve full recovery despite being adults with long duration of illness and no family involvement, or having other characteristics typically associated with less favorable treatment outcome.

For a more detailed description and interpretation of these statistics, click here.

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There’s an App for That!

Technology can be used in a variety of ways to enhance mental health and aid in recovery from psychological disorders.   For example, patients can use smart phone apps to help them track moods and symptoms, implement coping strategies, and reach out for help from clinicians and peers when needed.   Most evidence-based, behaviorally-oriented treatments for mental health problems – such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) – require some degree of self-monitoring.  These types of treatments also strongly encourage daily practices to enhance well-being, such as journaling, identifying and challenging negative thoughts, diaphragmatic breathing, or mindfulness meditation.

Most of the teenagers and college students I work with are far beyond the old pen-and-paper logs and worksheets I was trained to use during graduate school.  It seems there’s an app for everything these days, and so many of these apps are relevant to mental health and wellness.  Today’s young people organize their lives on their smart phones anyway, so it is only natural that we would look to the smartphone to help them self-monitor their symptoms, complete their therapy assignments, and keep track of the strategies they use to help themselves.

There are literally hundreds, if not thousands, of apps that are useful to people with mental health conditions.  Here are a few of my favorites:

The Recovery Record app helps patients with eating disorders self-monitor their meals and snacks as well as thoughts, feelings, and urges that arise around food.

The Insight Timer app offers a meditation timer, thousands of free guided meditation tracks, groups for like-minded meditators, and the ability to track quantitative statistics such as how many minutes the user spends each day in meditation.

DBT Diary Card and Skills Coach is an electronic version of the Diary Card used in standard DBT practice, which helps the patient track target behaviors and utilize DBT skills from the modules of Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.

The nOCD app helps patients with Obsessive Compulsive Disorder implement their exposure and response prevention treatment while compiling objective, real-time data on their experience.

I am a firm believer that what transpires in the therapist’s office is only a fraction of the treatment package.  Most of the healing process results from consistent changes that patients and their families make on a daily basis at home, at school, and in various social settings.   Thanks to modern technology, individuals who are committed to improving their well-being are now able to hold new tools, literally, in the palms of their hands.

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After Weight Restoration: Mindfulness for Body Image

There are some people with Anorexia Nervosa (AN) who continue to struggle with significant body dissatisfaction well after their weight has been fully restored and normal eating patterns have been established. For these individuals, mindfulness can be a powerful tool to help them make peace with their bodies.

Jon Kabat-Zinn, creator of the Mindfulness Based Stress Reduction program for treating depression, defines mindfulness as: “the awareness that emerges through paying attention, on purpose, in the present moment, non-judgmentally, to the unfolding of experience moment by moment.”

Although mindfulness has its roots in ancient Buddhist philosophy, it is not a religious practice in itself. Mindfulness can be practiced formally, through mediation, or informally, by learning to be mindful while performing everyday tasks.

Research has demonstrated that mindfulness can reduce the tendency to react emotionally and ruminate on transitory thoughts. It follows, then, that mindfulness – especially with its focus on acceptance and non-judgment – may help people let go of negative thoughts about their bodies.

Yoga, a mindful form of movement with benefits for both physical and mental health, can help alleviate the mental symptoms of eating disorders. A randomized controlled trial of adolescents undergoing treatment for anorexia nervosa, bulimia nervosa, and other eating disorders found that adding yoga to a teen’s treatment plan helped to reduce food preoccupation, body dissatisfaction, and eating disordered thoughts. In recent years, many treatment centers have added yoga to their programs.

I often recommend yoga to my newly weight-restored patients as a means of reconnecting with their bodies, reducing stress, and improving physical fitness. Recovering people frequently enjoy yoga even more than they expected to. As one of my college-aged patients told me: “When I was really sick with Anorexia, I felt like my body was something I had to beat into submission. Now, I feel like my body and I are on the same team.”
That is the essence of yoga – a union of body and mind.

Mindfulness has become very popular in the field of mental health. The newer third wave behavior therapies, including Acceptance and Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT), and Mindfulness-Based Cognitive Therapy (MBCT) all contain a core component of mindfulness. These mindfulness-based treatments have been adapted specifically for targeting body image.

Anyone with a book or a computer can begin practicing mindfulness for body image. It does not require a therapist or other trained professional. There are plenty of self-help books and internet resources on this topic:

ACT For Body Image Dissatisfaction
Living With Your Body and Other Things You Hate
The Free Mindfulness Project

Many of my patients in their late teens and early 20’s find that taking a mindfulness approach to their body image is more helpful than a simple cognitive-behavioral approach. Letting go of the struggle, and accepting their bodies as they are right now, brings a sense of peace and contentment which is quite the opposite of the constant struggle of an eating disorder.

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After Weight Restoration: CBT for Body Image

As noted in my previous blog post and the comments that follow, full nutrition and weight restoration will often reduce or eliminate the body image disturbance that plagues so many people with Anorexia Nervosa (AN). This is one of the many reasons why it is essential for AN treatment to require full nutrition and prompt weight restoration.

On the other hand, some people with AN continue to experience intense body dissatisfaction after weight restoration. In these cases, Cognitive-Behavioral Therapy (CBT) can help improve body image and reduce suffering.

In order for CBT to be effective, the patient has to have some motivation to engage in the treatment and some desire to improve her body image. The patient also needs to have the insight to understand that her body itself is not the problem, so changing her body weight or shape is not the solution. Rather, the problem is that she has some negative thoughts, feelings, and behaviors related to her body that cause her to suffer. It is those negative thoughts, feelings, and behaviors that will be the targets for intervention. The insight, motivation, and judgment required for effective body image treatment is yet another reason why this intervention is most effective after full weight restoration.

Many of the CBT-informed interventions for body image are similar to those that are effective in treating anxiety and depression. Consider the following:

Cognitive Restructuring
This involves identifying and challenging distorted automatic thoughts related to one’s body image. Examples of distorted automatic thoughts include: “My thighs are enormous,” “I’m the fattest person in this room,” or “Everyone is staring at me because I’m huge.”

The patient may need some help identifying distorted thoughts because they may seem normal or accurate to her. Once she is able to identify a distorted thought as such, the patient is asked to keep a log of the thoughts as they occur. With the help of the therapist, the patient then learns to identify patterns of distorted thoughts, challenge her own thinking, and generate more rational thoughts to replace the distorted ones.

For example, “Everyone is staring at me because I’m huge” contains distortions of over-generalization and mind-reading. Is EVERYONE really staring at you? No. In a room of 30 people, maybe 2 are looking at you. That isn’t everyone. Do you know for sure that they think you are huge? No, because they didn’t say anything of the sort. Why else might they be looking at you? Maybe they like your shirt.

Exposure and Response Prevention
This involves systematically desensitizing the patient, little by little, to her body image fears for the purpose of improving her quality of life. For example, if the patient loves the beach but can’t bring herself to go because she is ashamed of her body in a bathing suit (this is a frequent scenario in my South Florida-based practice!), the therapist may begin by helping her create a hierarchy or “ladder” of challenges increasing in difficulty. The patient would need to “master” each task before moving on to the next one.

For example:
1.) Go to the beach with your best friend at a time when very few people are there, wearing a shirt and shorts over your swimsuit.
2.) Go to the beach with your best friend at a time when very few people are there, wearing just shorts over your swimsuit.
3.) Go to the beach with your best friend at a time when very few people are there, wearing just a shirt over your swimsuit.
4.) Go to the beach with your best friend at a time when very few people are there, and spend 2 minutes wearing just your swimsuit.
5.) Go to the beach with your best friend at a time when very few people are there, and spend 10 minutes wearing just your swimsuit.
6.) Go to the beach with your best friend at a time when very few people are there, and spend an hour wearing just your swimsuit.
7.) Go to the beach with your best friend when many other people are there, and wear a cover-up.
8.) Go to the beach with your best friend and spend 2 minutes wearing just your swimsuit.
9.) Go to the beach with your best friend when many other people are there, and spend 10 minutes wearing just your swimsuit.
10.) Go to the beach with your best friend when many other people are there, and spend an hour wearing just your swimsuit.
11.) Go to the beach without your best friend and wear a swimsuit the whole time.

Environmental Alterations
Once a patient is able to recognize patterns in her negative body image thoughts, she can choose to focus her attention on people, places, and activities that promote positive thoughts and feelings, while reducing or eliminating the negative influences. For example, if a patient has a friend who engages in a lot of “fat talk,” the patient may be assertive with this friend and ask her to stop talking this way around her, or she may decide to stop spending time with this particular friend and hang out with more supportive friends instead. Likewise, if following fitness Instagram accounts makes the patient feel badly about her body, she may decide to stop following these accounts.

Along these lines, many patients find it helpful to donate their outgrown, tight-fitting, or unflattering clothes to charity. The feeling of tight clothes on the body, or the sight of too-small clothes hanging in the closet, can be very triggering. Most people feel much more confident wearing comfortable, flattering clothes.

Eliminating Body Image Rituals
Some people engage in “body checking” rituals, which may be anything from measuring their wrist circumference with their fingers, grabbing the flesh of their belly, spending excessive time in front of the mirror, or trying on 10 different outfits before finding one that looks “just right.” These types of rituals may reduce anxiety in the short term, but they end up becoming self-perpetuating and increasing body dissatisfaction in the long-term.

CBT for body image can be done with a CBT-oriented therapist who has experience working with eating disorders and body image concerns. In my practice, I sometimes use CBT for body image in weight-restored patients with AN after their family has completed a course of FBT (only if it is needed and requested, of course!). I also use it in patients with Bulimia Nervosa (BN) or Binge Eating Disorder (BED) after eating patterns have been normalized, and with non-eating disordered patients who suffer from anxiety or depression and also happen to have struggles with body image.

However, improving body image does not necessarily require a therapist’s help. A motivated patient may be able to utilize these interventions on her own, or with the help of a parent, using internet resources or a guided self-help workbook. I often recommend Thomas Cash’s The Body Image Workbook, 2nd Edition.

There are other interventions for body image derived from 3rd wave behavioral therapies such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). These will be the topic of my next post.