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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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Parent-Focused Treatment: An Attractive Alternative to FBT

The results of a randomized clinical trial (RCT) comparing Parent-Focused Treatment (PFT) and Family-Based Treatment (FBT) for adolescent Anorexia Nervosa (AN) were published this month in the Journal of the American Academy of Child & Adolescent Psychiatry.  As a practitioner of FBT, and as a clinician who is always looking for ways to improve patient outcomes, I read this article with great interest.

Family-Based Treatment (FBT), when applied strictly according to the manual, entails a psychologist or other mental health professional meeting with the family as a whole – the adolescent patient, both parents, and siblings – in a single session.  In contrast, Parent-Focused Treatment (PFT) involves the psychologist meeting privately with the parents, while the patient’s weight, vitals, and mental status are monitored by a nurse.

While FBT and PFT therapy sessions are conducted in different formats, the essence of the treatment – which is implemented by parents in the home – is the same.  Both treatments empower parents to work together to increase their adolescent’s food intake, restore him or her to a healthy weight, interrupt eating disordered behaviors, re-establish normal eating patterns, and return him or her to a state of healthy adolescent development.

The results of this study demonstrated that PFT is more efficacious than FBT.  At the end of treatment, patients receiving PFT were twice as likely to be in remission from AN compared with patients receiving FBT.  In addition to being published in the Journal of the American Academy of Child & Adolescent Psychiatry, the article was summarized nicely by the Murdoch Children’s Research Institute.

As I was reading this article, it occurred to me that I have been utilizing a version of PFT with some families in my private practice for years, as I have adapted FBT to suit the needs of each individual family.   For example, it is not uncommon for an adolescent patient with AN to refuse to attend some or all of the family sessions during Phase I (the re-feeding and weight restoration phase).  Personally, I have not found this to be problematic.  After all, in an FBT model, the parents are the primary agents of change in early recovery from AN.   The patient is more of a passive recipient of care – his or her job is simply to show up at the table and eat.

In my experience, most parents make excellent use of the Phase I sessions to receive support, learn more about AN, brainstorm and problem-solve, and collaborate with their spouse in the re-feeding process.  All of these things can be done with or without the child present, so long as the child’s weight is monitored weekly.  The weekly weigh-ins can be completed at the pediatrician’s office or under parental supervision at home.

As another example, many patients are so anxious about eating high-calorie foods, gaining weight, and eliminating exercise that attending sessions –during which these topics are discussed at length – is just too overwhelming.  Increasing a patient’s anxiety can sometimes be counterproductive to treatment goals.  For instance, if the patient is present during discussions of “fortifying” foods (e.g., increasing the caloric density by adding cream, oil, butter, or Benecalorie) or discussions of weight goals, this may heighten her anxiety to the point that she cannot eat these fortified foods, or she may become even more resistant to gaining weight.    For an underweight patient with AN, talking and listening are over-rated.  Eating and gaining weight are essential.

In my experience, patients who do not attend sessions during Phase I tend to have just as much success in recovery as patients who attend every single session.  Furthermore, the vast majority of the time, the kids who refuse to attend sessions in Phase I will begin to attend sessions voluntarily after weight restoration occurs and their treatment progresses through Phase II and Phase III.  By that time, most patients have the cognitive and emotional capacity to participate in their own recovery process and have some interest in getting better.

On the other hand, there are some cases in which it makes more sense to have the patient attend all of the FBT sessions, cases in which her participation in the treatment enhances her success in recovery.  Often (though not always), these are cases in which the patient is older, more independent, less cognitively impaired, less anxious, more curious about the process, and/or has some degree of personal motivation to recover at the outset.

I have also found that it is also very important for the patient to attend all sessions in cases where the parents are less willing or less able to take full responsibility for their child’s recovery.   For instance, I’ve worked with families in FBT in which both parents have active addictions to drugs or alcohol, families in which another member is coping with a health crisis (e.g., a parent with a recent cancer diagnosis), families in which the parents are going through an acrimonious divorce, and large families with many young children.   These have been cases in which the parents, while supportive in theory, were unable to invest as much time and energy into their child’s recovery as other families.  The patients from these families, in my observation, tended to be more resilient and more autonomous than other teens, likely .as a result of growing up in challenging environments.  I have observed that the adolescents in these more challenging situations have been able to (or perhaps required to) take on a greater degree of independence earlier in the recovery process.

The outcomes of this clinical trial were disappointingly low for both forms of treatment.  At the end of treatment, only 43% of patients receiving PFT had achieved remission, and only 22% of patients receiving FBT achieved remission.   Before you become discouraged, however, please allow me to explain my theories as to why remission rates were so low.

First, I believe that the poor outcomes of this study were, at least in part, due to the fact that families were randomly assigned to one type of treatment or the other.   Of course, in conducting a controlled clinical trial to study the efficacy of treatments, it is necessary to use random assignment to control for confounding variables and increase the validity of the results.  I suspect that if families were able to choose between PFT and FBT based on their own needs, desires, circumstances, and knowledge of their child, the outcomes would have been significantly more promising.  This has certainly proven to be true in my practice.

Consider the “treatment refusers” I described above, with whom I have effectively used PFT essentially by default.  On the other hand, consider the teens who come from more challenging family environments, whose participation early in treatment is instrumental to their recovery.  If the families with “treatment refusers” were randomly assigned to Family-Based Treatment, or if families with other significant challenges were randomly assigned to Parent-Focused Treatment, I suspect that the patient would be much less likely to occur.

Second, the course of treatment in this study was 18 sessions over the course of 6 months.  This sounds woefully insufficient to me.  In my experience, some patients do achieve full remission within 6 months, but this is certainly not the norm.  In my practice, most patients with AN are fully weight-restored within 3 or 4 months, but full remission of cognitive, emotional, and behavioral symptoms generally takes 12-18 months of treatment.   It is not unusual for patients to require 2 or 3 years of treatment in order to attain full remission and become ready to manage their eating independently.

I point out these time frames because I do not want patients or their families to feel discouraged when recovery takes so much longer than they expected.  The patients in these clinical trials who did not achieve full remission at end of treatment are the NORM, not the exception, and this is not due to any failure on the part of the patient or the parents.  Rather, the research study itself places unrealistic expectations on individuals with AN and their families.   Any clinician who has treated many patients with AN could tell you that full remission after 6 months is simply unrealistic for a majority of AN sufferers.  Individuals who have gone through treatment for AN, and parents who have helped their children recover, know all too well that vestiges of AN are often present for many months after weight has been fully restored.

I am confident that the majority of adolescents with AN who are not in full remission after 6 months of treatment will go on to achieve full remission within two or three years, especially when they utilize evidence-based, family-centered care.

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Weight Gain Predicts Psychological Improvement in Anorexia Nervosa

A recent study published in the journal Behavior Research and Therapy demonstrated that weight gain was a significant predictor of improved psychological functioning in adolescents undergoing treatment for anorexia nervosa (AN). In other words, adolescents who gained more weight during treatment did better mentally than those who gained less weight. This study also showed that weight gain early in the course of treatment had a greater impact on psychological recovery than weight gain later in the course of treatment.

This finding is extremely relevant not only to clinicians who treat adolescent AN, but also to the adolescent patients themselves and their families. The process of re-feeding and restoring weight often feels agonizing for patients and may cause tremendous stress to caregivers. Psychological recovery lags behind physical recovery, so patients often feel worse before they start to feel better. This study provides objective evidence that it is in the patient’s best interest – both physically and psychologically – to eat more and gain weight as soon as possible after diagnosis.

Weight gain is an essential component of treatment for patients with AN. The knowledge that full nutrition is necessary to repair the physical damage caused by AN – including weakened heart, low blood pressure, hypothermia, osteoporosis, stress fractures, lanugo, amenorrhea, infertility, and risk of premature death – helps many patients and families to persevere through the difficult days of re-feeding. Now, patients and families can hold onto hope that weight restoration will bring about psychological improvement as well. This study provides families with direct scientific evidence that gaining weight gives their loved one a greater chance of recovering mentally, emerging from the fog of depression, and reclaiming a meaningful life free from food and weight preoccupation.

Patients in this study were randomly assigned to receive either Family-Based Treatment (FBT) or Adolescent Focused Treatment (AFT). The authors of this study found that weight gain predicted psychological recovery regardless of the type of treatment (FBT vs. AFT) the patient received. This finding may be especially relevant to clinicians who treat adolescent AN using individual therapy. A common criticism of FBT (usually made by clinicians who reject FBT without really understanding it) is that it focuses on weight gain at the expense of the adolescent’s psychological wellbeing. This study clearly demonstrates that weight gain and improved psychological functioning are not mutually exclusive. On the contrary, weight gain and improved psychological functioning are strongly correlated!

It is clear that FBT supports the adolescent’s psychological wellbeing indirectly by promoting regular nutrition and steady weight gain, which help to repair the brain damage caused by malnutrition. I would also argue that FBT has a direct impact on the adolescent’s psychological wellbeing by externalizing the illness, removing any sense of self-blame the adolescent may have, supporting her emotionally, and relieving her of the burden of fighting this deadly illness alone.

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Summary of Treatment Outcomes

My blog posts from June through November 2013 have been devoted to describing my patients’ treatment outcomes. I’ve been advised that my recent posts have been too data-heavy and too detailed, but hey – that’s how I roll. I like to be thorough, meticulous, and transparent. Prospective patients and their families deserve to have access to this information. But for those who prefer brevity, I’ve summarized my treatment outcomes below. Click on the headings in bold for details.

    Outcomes for Patients with Anorexia Nervosa


Fifty-seven percent of my former patients with Anorexia Nervosa (AN) completed treatment. Of the “treatment completers,” 94% reached full remission and the remaining 6% reached physical remission. Patients required, on average, 28 sessions over the course of 17 months to complete treatment.

Forty-three percent of my former patients with AN did not complete treatment with me. Of the “treatment non-completers,” 23% were referred to other treatment settings which could better meet their needs; 15% moved to other geographic locations during treatment and thus were referred for treatment near their new homes; and the remaining 62% dropped out of treatment prematurely.

    Outcomes for Patients with Bulimia Nervosa and Eating Disorder Not Otherwise Specified


Thirty-three percent of my former patients with Bulimia Nervosa (BN) and Eating Disorder Not Otherwise Specified (EDNOS) completed treatment. One-hundred percent of those who completed treatment reached full remission. On average, patients took 15 sessions over the course of 10 months to complete treatment. Amongst patients with BN, 44% made significant progress prior to discontinuing treatment prematurely. For patients with EDNOS, 17% made significant progress prior to discontinuing treatment prematurely.

    Outcomes for Patients with Mood Disorders


Twenty-nine percent of patients my former patients with primary diagnoses of mood disorders completed treatment. Of the patients who completed treatment, 83% achieved full remission and the remaining 17% made significant progress. On average, patients took approximately 23 sessions over the course of 11 months to complete treatment.

Thirty-eight percent of mood disorder patients quit treatment prematurely, 24% were referred to other treatment providers who could better meet their needs, and 9% moved to other geographic locations during their treatment and were referred for treatment near their new homes.

    Outcomes for Patients with Anxiety Disorders


All of my former patients with primary diagnoses of anxiety disorders who attended more than two sessions experienced substantial improvement in anxiety symptoms as well as significant improvement in functioning, even if they did not complete a full course of treatment. Patients with anxiety disorders attended an average of 10 sessions over the course of 6 months.

Amongst those who completed a full course of treatment, 75% achieved full remission and the remaining 25% made significant progress.