Active Ingredients

In eating disorder treatment, timing matters A LOT. Effective treatment requires different ingredients at various stages of recovery. Certain ingredients are essential at the very beginning of treatment but matter less towards the end. Conversely, some ingredients are unnecessary in the early stages of treatment but crucial later on in the recovery process.

To the patient’s detriment, many clinicians do not add the right ingredients at the right times in the right doses. For example, many individual therapy approaches focus initially on helping the patient develop insight and motivation to recover. Full nutrition is not required, or even encouraged, until the patient has lost a significant amount of weight.

Many clinicians are simply using the wrong recipe.

Listed below are my professional opinions on the importance of different ingredients at various stages of eating disorder treatment:

START OF TREATMENT

Essential ingredients:
1.) Immediate requirement of full nutrition, full time
2.) Supervision after meals to prevent purging (if indicated)
3.) Moratorium on exercise
4.) A complete physical exam to check for medical complications of the eating disorder
5.) Hospitalization to correct any urgent medical issues (e.g., bradycardia, dehydration, electrolyte imbalance) or to ensure patient’s safety from self-injury or suicide

Important ingredient:
1.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

WITHIN THE FIRST MONTH OF TREATMENT

Essential ingredients:
1.) Continuation of full nutrition, full time
2.) If the patient is underweight, adjustment of nutritional intake to ensure that weight is being restored at the appropriate rate (1-3 pounds per week)
3.) Continued supervision after meals to prevent purging (if indicated)
4.) Continued medical monitoring

Important ingredients:
1.) Psycho-education for the patient and family about the etiology, symptoms (medical, behavioral, and psychological), and effective treatment for the patient’s eating disorder
2.) Separating the illness from the patient (also known as externalizing the illness)
3.) Parents and treatment professionals developing a specific treatment plan and presenting a united front against the illness
4.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

MONTHS 2-6 OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Achievement of optimal body weight range
3.) Continued monitoring and supervision, as needed, to prevent purging and self-injurious behavior
4.) Ongoing medical monitoring as needed

Important ingredients:
1.) Expansion of nutritional variety
2.) Some exposure to feared foods (e.g., pizza) and feared eating situations (e.g., restaurants, parties)
3.) Parents and treatment professionals continuing to follow the treatment plan and presenting a united front against the illness
4.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

MONTHS 6-12 OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Maintenance of optimal body weight range (for patients over 21)
3.) Adjustment of optimal body weight range to account for growth and development (for patients under 21)
4.) Abstinence from binge eating, purging, and other ED behaviors

Important Ingredients:
1.) Medical monitoring as needed
2.) Re-introduction of physical exercise as patient demonstrates readiness
3.) Gradually handing back some control over food, in an age-appropriate manner, as the patient demonstrates readiness
4.) Continued expansion of nutritional variety
5.) Exposure to more feared foods and feared eating situations
6.) Parents and treatment professionals continuing to follow the treatment plan and presenting a united front against the illness
7.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

MONTHS 12-18 OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Maintenance of optimal body weight range (for patients over 21)
3.) Adjustment of optimal body weight range to account for growth and development (for patients under 21)
4.) Continued abstinence from binge eating, purging, and other ED behaviors

Important ingredients:
1.) Assessment of and treatment for body dysmorphia and co-morbid conditions (e.g., depression, OCD, ADHD)
2.) Occasional medical monitoring, as needed
3.) Continued nutritional variety
4.) Patient mastery of fear foods and feared eating situations
5.) Patient willingness to engage in treatment
6.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient motivation to recover

BY THE END OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Maintenance of optimal body weight range (for patients over 21)
3.) Adjustment of optimal body weight range to account for growth and development (for patients under 21)
4.) Continued abstinence from binge eating, purging, and other ED behaviors

Important ingredients:
1.) No more than mild preoccupation with body image, food, or weight
2.) Ability to regulate emotions and tolerate distress
3.) Ability to eat independently and self-regulate around food without losing weight
4.) Continued treatment for co-morbid conditions, if present
5.) Emotional, nutritional, and practical support from loved ones
6.) Medical monitoring annually or as needed

PRIOR TO LEAVING HOME (to attend college or live independently)

Essential ingredients:
1.) Continued full nutrition, full time
2.) Patient acceptance of her eating disorder history and life-long predisposition
3.) Patient motivation to stay in recovery
4.) Patient insight
5.) Complete abstinence from all eating disorder behaviors (restricting, bingeing, purging) for at least 6 months
6.) Maintenance of optimally healthy body weight for at least 6 months
7.) Ability to eat independently and self-regulate around food without losing weight

Important ingredients:
1.) Specific, written relapse prevention plan which is agreed upon by patient, parents, and treatment team
2.) Medical monitoring annually or as needed
3.) Ongoing treatment for any comorbid conditions
4.) Ability to care for self, regulate emotions, and tolerate distress

In conclusion, the essential ingredients of successful treatment change considerably from beginning to end. The one ingredient that remains essential throughout the course of treatment and beyond is full nutrition, full time. Medical monitoring is essential at the beginning but somewhat less important towards the end. Certain intangible factors, such as patient insight and motivation, are unimportant in the beginning but essential for independent living in recovery.