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After Weight Restoration: The Role of Motivation

Motivation is the process that initiates, guides, and maintains goal-oriented behaviors. It involves the biological, emotional, social, and cognitive forces that activate behavior. Basically, motivation is what drives us to act.

In eating disorder circles, motivation generally refers to an inner drive to achieve or maintain recovery. Given that anosognosia is a primary symptom of Anorexia Nervosa (AN), most patients have little or no insight or motivation while they are ill. When a person does not perceive herself as ill, she will not be motivated to recover. When a person perceives himself as superior while undernourished, emaciated, and hyperactive, he will be highly motivated to maintain his AN.

Fortunately, motivation is not necessary to begin recovering from AN. In Family-Based Treatment (FBT), motivation is neither expected nor required of patients during Phase I (re-feeding and weight restoration). So long as the parents are highly motivated to return their child to good health (as most parents certainly are), patient motivation is unnecessary.

There are two types of motivation:

Extrinsic motivation is a drive to perform an activity to attain a particular outcome. Extrinsic motivations come from outside the individual. For example, a student is motivated to study in order to earn good grades and gain admission to an elite college.

Intrinsic motivation is an inner drive to perform an activity for personal reasons, based on interest or enjoyment of the task itself. Intrinsic motivation exists even in the absence of external reward. For example, a young artist who is passionate about painting spends hours in the studio completely immersed in her art.

Parenting often involves the use of extrinsic motivation early on, as a pathway to developing intrinsic motivation. A toddler is motivated to use the toilet by getting a star on her chart; a preschooler is motivated to follow her parents’ rules to avoid getting a time-out; a teenager is motivated to be home by curfew to avoid getting grounded.

The ultimate goal of parenting, of course, is for the children to grow into independent adults who are no longer dependent on extrinsic motivation to exist in society. Eventually, the child feels intrinsically motivated to use the toilet because sitting in soiled underpants is uncomfortable; she is kind to her friends and siblings because it is the morally correct thing to do and she wants to maintain good relationships with them; she comes home at a decent hour so that she can get a good night’s sleep and function well the following day.

Similarly, a long-term goal of treatment for Anorexia Nervosa is for the patient to be intrinsically motivated to stay healthy and remain in recovery. But while we wait for intrinsic motivation to develop, it is perfectly fine and, in many instances, absolutely necessary, to impose external motivations in order to nudge the person along towards recovery.

Patients with Anorexia Nervosa often have little or no intrinsic motivation to recover during their acute phase of illness. In fact, most patients are highly motivated to continue engaging in eating disorder behaviors because there are powerful biological, psychological, and social forces compelling them to do so. For this reason, it is often essential to use extrinsic motivations of some sort to get patients to engage in recovery-oriented behavior such as eating meals, gaining weight, refraining from purging, and attending appointments with their treatment team.

Patients with AN are often compliant, rule-abiding people-pleasers. We can harness these traits in a positive way to promote recovery. It is common for patients to report that they are eating and gaining weight to make their parents happy or to please their doctors. It is even more common for patients to comply with re-feeding and maintain their ideal weight in order to avoid hospitalization or continue playing the sport they love.

Parents often worry that, if left to her own devices, their child would most certainly eat too little, exercise too much, start purging again, and fall down the rabbit hole once more. This worry is completely valid, and this is precisely why patients need a very high level of support and monitoring for a long time after diagnosis. Incidentally, the need for a high level of support and monitoring continues for much, much, much longer than what is provided by most treatment programs or paid for by most insurance companies. One of the reasons why patients need such high levels of support for so long is that intrinsic motivation is neither realistic nor possible for most patients until they are further along in recovery.

While acutely ill patients often lack the motivation to recover, many patients who are weight-restored and further along in their psychological recovery feel very motivated to stay well. I believe that there are several reasons for this shift in motivation in the later stages of recovery:

1.) The ability to think more clearly, thanks to a well-nourished brain and body.

2.) Maturity. Patients get older and more mature as they progress through recovery, and thanks to a more developed prefrontal cortex, they can think ahead, make plans, and follow through with their intentions.

3.) Perspective. Patients in the later stages of recovery have often been through hell and back. They have reclaimed their lives, and while they may not remember much of the acute phase of their illness, they know it was awful and they have no intention of going back.

4.) Parental intervention. Parents who have helped their children recover from AN tend to be extremely motivated to help them stay well. Perhaps more importantly, they feel empowered to use the tools and strategies they’ve learned through treatment to maintain an environment conducive to ongoing recovery and to set limits, without hesitation, on any behavior that jeopardizes recovery.

Motivation seems to be the natural consequence of restored health and improved insight. Once an adolescent or young adult is no longer encumbered by AN, he begins to realize how sick he once was, and how much AN ruined his life. As he returns to school, sports, hobbies, and an active social life, he begins to build a life worth living. This new life motivates him to stay in recovery and deters him from engaging in behaviors that could lead to relapse.

I have found that older adolescents and young adults are often motivated to stay in recovery in order to achieve their goals. For example, they want to go away to college or graduate school, they want to study abroad, they want to get married and have children, they want to travel the world, they want to have a rich and meaningful life that is not dominated by intrusive thoughts about carbs or calories or the circumference of their thighs.

How can you enhance motivation in someone who is recovering from AN? Well, intrinsic motivation, by definition, must grow and flourish from within. It cannot be imposed upon someone from the outside. However, there are a few things that family members and clinicians can do which may facilitate development of intrinsic motivation:

1.) Help the person build a full, rich, meaningful life.

2.) Remind the person periodically (not forcefully or frequently) that his new life would not be possible without continued recovery.

3.) Highlight and enhance the personal characteristics that have helped the person achieve and maintain recovery (e.g., “You are such a strong, courageous, dedicated person to have overcome this illness”).

4.) Help the person identify his core values and support him in living a life that is congruent with these values. What is most important in life? How does he want to be remembered by loved ones after he dies? Unless the person is acutely ill with AN, he is unlikely to say that being thin, exercising excessively, or avoiding sugar and flour his core values.

Staying focused on core values and pursuing a meaningful life are powerful motivators and potent antidotes to the anorexic thoughts that come to visit from time to time.

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After Weight Restoration: The Role of Insight

One of the hallmark symptoms of Anorexia Nervosa (AN) is anosognosia, or a brain-based inability to recognize that one is sick. For this reason, most patients have little or no insight when they first present for treatment. Even months into effective treatment, most patients with AN continue to demonstrate anosognosia from time to time, if not consistently. The irony here is that most patients with AN do not believe they are sick until after they have gotten well.

I am outspoken in my belief that insight is unnecessary, not to mention unlikely, in early recovery from Anorexia Nervosa (AN). I do not expect my patients to have any insight whatsoever early on in their treatment with me. I expect kids with AN to present in my office denying that they have a problem. Their lack of insight does not delay or undermine treatment one bit.

In Family-Based Treatment (FBT), the patient is not required to demonstrate any insight at all during Phase I (Re-feeding and weight restoration). Phase II (returning control of eating to the adolescent) and even Phase III (establishing a healthy adolescent identity) can be successfully completed with a relatively small amount of insight on the patient’s part.

The re-feeding and weight-restoration components of treatment can be achieved without the patient’s consent or compliance. Through FBT and similar family-centered approaches, parents can feed their children complete, balanced nutrition and ensure that they maintain a healthy weight for as long as necessary. In theory, a patient could exist in an externally-maintained state of physical health forever, which would be far better than suffering the long-term medical and psychological consequences of AN. But this is not recovery.

Children and younger teens tend to lack the maturity to develop good insight even after their AN has been in remission for quite some time. Lack of insight is completely normal at this stage of development, even for kids who have never had a brain disorder. It is not necessarily problematic for recovering adolescents to lack insight as long as they are living safely under their parents’ roof.

For older adolescents and young adults, however, there comes a point later in recovery, after physical health is restored and most mental symptoms have subsided, when a patient does need to develop some insight about their illness and “own their recovery.” Patients do not need insight to get well, but they certainly do need insight in order to live a healthy, fulfilling, independent life.

As a side note here, the type of insight I am referring to here has nothing to do with “discovering the root cause” or “learning to love yourself” or “finding your voice” or any of the other talking points commonly referenced in ED recovery circles. The important insights to gain, in my opinion, are the following:

1.) Acknowledging and accepting that you have (or had) an eating disorder, which is a biologically-based brain illness that you did not choose to have and your parents did not cause

2.) Acknowledging and accepting the possibility of relapse

3.) Ability to recognize eating disordered thoughts, feelings, and behaviors in yourself

4.) Understanding the necessity of maintaining full nutrition, every day, for life

5.) Accepting the necessity of maintaining your ideal body weight in order to reduce the risk of relapse

How do you help a person who is recovering from AN to develop insight? It’s tricky, and it varies considerably based upon the patient’s own unique experience of having AN. Unlike full nutrition and weight restoration, insight cannot be thrust upon someone against their will. The patient must be an active participant in the process.

I find it helpful, as a therapist, to have frank conversations with patients and their parents about the biological basis of AN, potential triggers, vulnerability to relapse, and the importance of practicing good self-care. A single conversation at the start of treatment is rarely sufficient. Instead, I integrate these conversations into most of our sessions to help the patient absorb and internalize this information. For the first few months of treatment, these discussions are primarily for the benefit of the parents, as most kids are too malnourished and shut-down to process this information. However, after weight restoration and brain healing, these discussions can have a powerful impact on recovering kids.

Parents often have these insight-building conversations with their recovering teens at home. Often, teens will get defensive, shut down, or lash out when parents bring up these topics. But sometimes kids actually listen!

Many weight-restored patients go through a phase of romanticizing their AN, longing to return to the days of extreme thinness, perpetual motion, and hyper-focus on academics and athletics. While these feelings are understandable and typical at a certain stage of recovery, they need to be counterbalanced with conversations about the negative impact AN had on their bodies, their minds, and their lives. Otherwise, it is all too easy for recovering people to view AN through “rose-colored glasses.”

Bear in mind that the development of insight can take years. Recovered teens who initially presented for treatment at age 13-14 (the typical age of onset) will often show a blossoming of insight around age 17-18, just as they are preparing to leave home for college. This newfound insight is often the result of a variety of factors, including consistent full nutrition, brain healing, normal adolescent developmental processes, maturity, frontal lobe development, and successful therapy. I have worked with many adolescents for whom this happens beautifully, organically, and right on time. These kids go off to college in other states and thrive.

In other cases, however, the timing may be far less convenient. Those who develop AN at 16 or 17 years of age may not be sufficiently recovered to develop the insight needed to manage their illness independently at that magical age of 18. Similarly, who relapse during their junior or senior year of high school may have a setback in the process of insight development and thus may not be ready for independence right after high school.

In some cases, kids are diagnosed in childhood or early adolescence but don’t receive effective treatment until late adolescence. In these cases, it may take even longer for insight to develop if the illness has become entrenched and emotional maturity lags far behind chronological age.

Further, teens who have suffered through months or years of ineffective treatment may have built up an arsenal of bogus myth-based insight that has nothing to do with the reality of their illness. For example:

• “I developed AN as a way to cope with feeling out of control in life.”

• “I have to want to get better on my own. I have to do this for myself.”

• “Re-feeding doesn’t help us discover the root cause of your illness.”

• “I am enmeshed with my parents and this is keeping me sick. I need to become more independent.”

These myth-based “insights” very often result in parental alienation and protracted illness.

As you can see, all insight is not equal. The insights worth having are those that are based in empirical science, those that empower parents to help their offspring recover, and those that serve to help patients achieve and maintain their physical and mental health while living a full and meaningful life.

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After Weight Restoration: Envisioning Recovery

In making a post weight-restoration recovery plan, I find it helpful to envision what full recovery will look like for this particular individual, and then break it down into small steps to help her achieve these ends. In my opinion, full recovery from AN involves all of the following:

• Ability to feed oneself the appropriate quantity, quality, and balance of nutrition.
• Ability to maintain one’s optimal body weight with an age-appropriate level of independence.
• Ability to accept and tolerate one’s body size, shape, and weight.
• Complete absence of eating disordered behaviors such as fasting, food restriction, binge eating, and purging.
• Ability to enjoy regular physical activity without compulsion.
• Engaging fully in all aspects of life, including school, family life, social life, and recreational activities. For older patients, this may also include employment, dating and romantic relationships.
• Freedom from constant preoccupation with food, weight, and body image.
• Mindful awareness of one’s predisposition towards AN and ability to avoid or manage potential triggers.

In my opinion, full recovery from AN does not necessarily involve any of the following:
• Ability to eat intuitively
• Ability to eat spontaneously
• Ability to eat sweets or “junk food”
• Return to the eating habits one had prior to the onset of the eating disorder
• Loving one’s body
• Not caring about one’s weight at all
• Complete absence of eating disordered thoughts
• Freedom from monitoring (for example, going for long periods without being weighed)

Of course, it would be wonderful if a person recovered from AN could do any or all of the above. If one of my patients does one of these things, I view it as a very positive sign, an indication that a person has reached a new level of freedom from AN. Parents of recovering kids often long for them to walk into the kitchen and grab a handful of chips, eat candy with abandon, or ask to go out for ice cream.

If a person in recovery does these things, that is fantastic, and it should be celebrated! Often, these things happen naturally after a year or two or three of weight restoration. But these things may not be realistic for some people with a history of AN. And if these things never happen, that is OK.

What is most important, in my opinion, is for a person in recovery to do whatever it takes to live a rich, happy, healthy, fulfilling and productive life. This is what recovery means to me.

Sometimes parents and clinicians worry that a patient’s avoidance of sweets, or inability to eat intuitively, or adherence to a structured plan of meals and snacks is “part of the disorder.” This may be true. But this is not inherently a bad thing.

Some recovered people may never want to be weighed again, because it reminds them of what it was like when they were ill. Some recovered people may resent having to eat three balanced meals every day, or not being able to diet like their friends, or not getting to participate in fasting for religious reasons like their families. Sometimes they just long to be “normal.” These feelings are completely understandable. However, this does not change the reality that people recovered from AN often have special needs which require them to be careful about their health in ways that other people are not. We cannot rewind time to the days before the illness began. We should not pretend AN never happened.

I find it helpful to assess a person’s stage of recovery using the following question:

“Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while _______________________.”

Then, fill in the blank with the issue in question to help determine whether it is in the patient’s best interest to accept it or change it.

For example:
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while also getting weighed every week at the doctor’s office? YES
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while being 5 pounds underweight? NO
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while never eating dessert or snack foods? YES
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while restricting dietary fat or carbohydrates? NO
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while being tormented by frequent thoughts about food and weight? NO
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, while wishing she had thinner legs and having occasional thoughts about restricting food? YES
• Can this person maintain good physical and mental health, and live a meaningful, productive, independent life, without being able to eat intuitively or spontaneously? YES

Keep in mind that accepting something is not the same as liking it, and acceptance does not mean abandoning hope that things will improve. Rather, acceptance is about acknowledging reality and embracing it without judgment, while doing what works, in this moment, to maintain wellness.

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After Weight Restoration: What’s Next?

Scientific research has established that consistent full nutrition and weight restoration are the essential first steps in recovery from Anorexia Nervosa (AN). A recent study by Accurso and colleagues – the subject of my previous blog post – demonstrated that weight gain is a catalyst for broader recovery in Anorexia Nervosa (AN). The necessity of normalizing eating patterns and restoring weight applies to all patients with AN: male and female, young and old, chronic and acute, inpatient and outpatient, mild and severe. While the task of supporting weight restoration in a patient with AN is daunting and exhausting, it is very straightforward.

After weight restoration, the next steps in recovery are less certain, more varied, and highly dependent on individual differences. The best way forward is often ambiguous for someone who is well-nourished but deeply entrenched in the illness. For some people with AN, weight restoration alone is sufficient to bring about full remission. But for others, weight restoration is merely the first step in a long journey towards wellness. Unfortunately, there is little scientific research to guide us in terms of how to help people with AN who are weight-restored but still suffering mentally.

Parents are often quite adept at determining what their child needs in order to move forward. For this reason, parents continue to be essential participants on their loved one’s treatment team even after her weight is restored. Although their role on the treatment team may change a bit, and their degree of involvement may be modified, they continue to be their loved one’s greatest resource in recovery.

After weight restoration, I collaborate with the patient and her family to figure out how we can work together to support her towards full recovery. This typically involves a written treatment plan that we all agree upon. I find it incredibly helpful to have a written treatment plan, as this eliminates confusion and keeps everyone on the same page, working towards common goals.

It is not always clear what the patient needs next, so treatment after weight-restoration is very often a process of trial and error. We create a plan, implement it, and see how the patient does. If she moves forward in recovery, fantastic! If she remains stuck or regresses, we reassess her situation and modify her plan based on lessons learned from her struggles.

My next few blog posts will examine various aspects of treatment and recovery for weight-restored patients with AN. Please feel free to leave a comment if there are any particular issues you’d like me to cover on this topic in my next series of posts.

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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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Effective Treatment for Bulimia Nervosa: A Good Start

A randomized controlled trial recently published in the American Journal of Psychiatry found that Enhanced Cognitive Behavioral Therapy (CBT-E) was far more effective than psychoanalytic therapy in the treatment of Bulimia Nervosa (BN).

In this study, 70 adults with BN were randomly assigned to either the CBT-E group or the psychoanalytic therapy group. Those in the CBT-E group received 20 sessions over the course of 5 months, whereas those in the psychoanalytic therapy group received weekly sessions for 2 years.

CBT-E for bulimia nervosa directly targets bulimic symptoms of dietary restriction, binge eating, and purging by modifying self-defeating behaviors, identifying and challenging distorted thoughts and beliefs about food, body shape, and weight, and learning skills to regulate moods and deal with setbacks. For example, patients learn to moderate their food intake by consuming regular, satisfying meals and snacks throughout the day rather than fasting, which often leads to nighttime binges.

In contrast, psychoanalytic therapy helps patients work through emotions and resolve inner conflicts which are believed to be at the root of their eating disorder.

After five months of treatment, 42% of patients receiving CBT-E had stopped bingeing and purging, compared to only 6% of patients in the psychoanalytic therapy group. After two years, 44% of patients in the CBT-E group had remained abstinent from bingeing and purging, compared to 15% of patients in the psychoanalytic group. It is important to note that the 2-year assessment represents a 19-month post-treatment follow-up for patients in the CBT-E group, but an end-of-treatment assessment for the psychoanalytic therapy group. Thus, patients in the CBT-E group had maintained their remission 19 months after treatment ended.

I draw the following conclusions from this study:

1.) Treatments which directly target bulimic symptoms are likely to be much more effective than treatments that deal with underlying emotions and psychic conflicts.

2.) Bulimic patients who receive CBT-E experience symptom relief much more quickly than those who receive psychoanalytic therapy.

3.) CBT-E is more efficient and cost-effective. If a psychologist charges $150 per hour, twenty sessions of CBT-E over the course of 5 months would cost a total of $3000. Weekly psychoanalytic sessions for two years would cost a total of $15,600.

4.) The benefits of CBT-E are long-lasting for those who recover

5.) Psychoanalytic therapy can be effective for a small fraction of bulimic patients

6.) CBT-E should be a front-line treatment for bulimia nervosa because, statistically, patients are much more likely to benefit from it than from other treatment approaches.

Bulimia nervosa wreaks havoc on the brain as well as the rest of the body. Insufficient or erratic nutrition caused by restrictive dieting, fasting, bingeing, laxative abuse, purging, and dehydration have a direct and immediate impact on brain function. I suspect that a primary reason for the superiority of CBT-E is that it targets the symptoms of dieting, bingeing, and purging immediately, thereby helping patients achieve medical stability and brain healing. When a person is receiving consistent balanced nutrition and keeping it down, he or she is better able to process emotions, refrain from impulsive behaviors, and do the hard work that is necessary for full recovery.

Perhaps patients in the psychoanalytic therapy group did not have the tools necessary to recover. It is one thing to gain insight into one’s emotions and beliefs; it is another thing entirely to halt a destructive and addictive cycle of restricting, bingeing, and purging.

The authors of this study conclude that it “provides one of the clearest examples of the superiority of one well-implemented psychological treatment over another.” However, CBT-E is not a magic bullet: more than half of the patients who received CBT-E did not recover. Therefore, we need to improve existing treatments for BN and develop new, more effective treatments for this devastating illness.

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Expanding Our Minds: Towards a Biologically-Based Understanding of Eating Disorders

I read the abstract of a recently published journal article which illustrates one of the major problems in the field of mental health treatment in general, and eating disorder treatment in particular. The article, authored by Jim Harris and Ashton Steele and published in the latest issue of Eating Disorders: The Journal of Treatment and Prevention is provocatively titled Have We Lost Our Minds? The Siren Song of Reductionism in Eating Disorder Research and Theory.

The authors state that, over the past decade, “the focus of eating disorder research has shifted from the mind to the brain.” I disagree with this assertion on two levels. First, the statement implies that the mind and the brain are separate entities. They are not. The “mind” is simply a range of conscious functions which are carried out by the brain: for example, thoughts, beliefs, emotions, intentions, motivations, and behaviors. These mental functions originate in the brain, are executed in the brain, and are interpreted by the brain.

Indeed, recent developments in genetics and neuroimaging techniques have allowed scientists to study the structure, function, and circuitry of the brain in far greater detail than was possible before. Researchers have utilized this new technology to generate and test novel hypothesis about the biological underpinnings of eating disorders. The results of these studies have indicated that eating disorders are genetically inherited, biologically-based brain disorders, similar to bipolar disorder and schizophrenia.

However, while research in the area of genetics and neuroimaging has proliferated in the eating disorders field, there has been no shortage of research on psychosocial factors or non-medical treatments for eating disorders, such as FBT and DBT. Contrary to Harris and Steele’s assertion, we have not “lost our minds.” We’ve simply expanded our minds and deepened our realm of investigation to study the biological underpinnings of mental functions as new technology has allowed us to do so.

Harris and Steele assert that the brain disorder model of eating disorders necessitates that treatment targets the underlying neurobiological abnormality; namely, medication. The authors then conclude that the brain disorder model of eating disorders is misguided because no pharmacological intervention has been shown to significantly benefit patients with anorexia nervosa.

This simplistic assumption and its corollary reflect a lack of basic understanding of the relationship between the brain and the symptoms of psychiatric illness. The authors fail to recognize the fact that certain non-medical interventions HAVE been consistently shown to benefit patients with biologically-based brain illnesses.

For example, it is widely accepted amongst medical and psychological professionals, as well as the general public, that autism is a biologically-based brain illness. There are no medications which have shown to consistently benefit children with autism. The gold-standard of treatment for autism is early intervention with applied behavior analysis (ABA), which is a form of behavior therapy focused on skills building, parent training, and modifying environmental contingencies. Most children with autism do extremely well with this type of treatment, and many of them can be mainstreamed in classrooms with typically developing children.

Sound familiar? It should, because that is precisely what is happening in the world of eating disorder treatment. The treatment approaches which have shown the most promise in the world of eating disorders are psychological and behavioral treatments such as Family-Based Treatment (FBT) for anorexia nervosa and Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) for bulimia nervosa.

There are a number of misconceptions about these types of treatments. For example, many people believe that FBT is merely re-feeding. This is not so. FBT is a psychological and behavioral treatment – a form of psychotherapy – and parental control of re-feeding is but one component of the first phase of this three-phase treatment model.

As another example, some people believe that CBT and DBT are merely “learning skills.” Again, this is a misconception. CBT and DBT are forms of psychotherapy which involve a relationship with a therapist who instills hope, provides support and feedback and accountability, promotes awareness of thoughts and feelings, and teaches adaptive skills for managing life’s challenges.

Contrary to popular belief, psychotherapy does not consist of lying on a couch and talking about your mother. That myth stems from psychoanalysis, an antiquated form of treatment commonly practiced in the mid-20th century which has no evidence base. Modern evidence-based psychotherapy is entirely different: it is active, directive, and believe it or not, effective.

I get a bit irritated when uninformed people make sweeping generalizations on either side of the fence, such as “psychotherapy doesn’t work for eating disorders,” or, on the flip side, “psychotherapy is the best way to treat eating disorders.” The truth is more specific: evidence-based psychotherapies are effective in the treatment of eating disorders.

From my perspective, focusing on the biological basis of psychiatric illnesses does NOT mean:

• That the illness can only be treated with a pill
• That psychological and social factors are irrelevant
• That environment doesn’t matter
• That the patient can’t do anything about it
• That the psychologist’s job is obsolete

Focusing on the biological basis of eating disorders DOES mean:

• That eating disorders are illnesses, no different from cancer or diabetes or schizophrenia
• That patients do not, and in fact cannot, choose to develop eating disorders
• That eating disorders are not caused by family dynamics or social pressures
• That prevention efforts aimed at improving body image are unlikely to be effective
• That a person must have a certain genetic predisposition in order to get an eating disorder
• That biological relatives of eating disorder patients are at risk for developing the disorder themselves
• That medication can be helpful, though not curative, in some cases
• That full nutritional restoration, and thereby correcting the brain-based symptoms of starvation, is a necessary first step in treatment
• That psychotherapy focused on resolving underlying issues or gaining insight into the origins of one’s illness is unlikely to be effective in resolving eating disorder symptoms
• That behaviorally-based psychological treatments focused on symptom management and skills building can be very effective, in large part because they change the brain
• That last century’s theories about the causes of eating disorders are inaccurate

I wish that Harris and Steele, and all professionals involved researching or treating eating disorders, could grasp these points. If the general population had this basic understanding of eating disorders, then patients and their families would be viewed with compassion and understanding rather than judgment or smug clichés (e.g. “she needs to learn to love herself;” “it’s all about control”).

The past decade represents a monumental shift in the way expert clinicians view eating disorders. In fact, it will be 10 years ago this fall that I saw my very first eating disorder patient. As a bright-eyed graduate student hungry for hands-on clinical experience, I chose a training rotation at an adolescent eating disorders clinic. On my first day at the clinic, not much older or wiser than the teenagers I was about to start treating, I was introduced to “the Maudsley Approach,” a promising new treatment method from the UK. And the rest, as they say, was history.

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Sleep and Mood Disorders: Implications for Mental Health Care

Getting enough sleep is important for everyone. Well-rested bodies and brains are healthier, more resilient, and more energetic. For those with depression and other mood disorders, getting plenty of sleep must be a priority. In fact, research has demonstrated that people with insomnia are ten times more likely to develop depression than those who get sufficient sleep. Further, new research has shown that sleep disturbances can trigger psychiatric illnesses in those who are vulnerable.

Sleep is every bit as important as medication and therapy in the treatment of mood disorders. For this reason, I make a point of discussing and monitoring sleep patterns with my patients, and I integrate sleep hygiene into their treatment plans.

A recent study financed by the National Institute of Mental Health and published in The New York Times found that a psychological treatment called CBT-I (Cognitive-Behavioral Therapy for Insomnia) doubled the effectiveness of antidepressant medication in the treatment of depression.

This was not surprising to me. I was trained in CBT in graduate school and I have seen cognitive-behavioral techniques work wonders in many of my patients. But the implications of this study, and the fact that the results have made it into the popular media, are quite significant.

One of the most disturbing and unfortunate trends in mental health care in recent years has been the overuse of psychotropic medication and the corresponding underuse of behavioral and psychological interventions. This trend is especially bothersome to me because I am keenly aware – thanks to my training and experience as a psychologist – that certain evidence-based psychological treatments are as effective, if not more effective, than medication for treating certain illnesses.

Unfortunately, most people outside the field of psychology don’t know this. Americans are bombarded daily with advertisements for psychotropic medication on television, online, and in print. It’s only natural, then, that consumers who are suffering from depression or anxiety would request medications from their doctors, even when they have a problem that can be successfully treated by other means.

Don’t get me wrong – I am by no means anti-medication. I am thankful that we have effective, relatively safe medications on the market now that can help people effectively manage serious illnesses which were once disabling. Indeed, psychotropic medication can be extremely helpful – even life-saving – for many people. My concern is that psychotropic medications are prescribed too frequently to people who may not need them, often without the necessary monitoring, and often without the corresponding psychological and behavioral interventions that have been proven effective.

As a psychologist who practices said psychological and behavioral interventions, rather than a psychiatrist who prescribes said medications, am I biased? Well, obviously. I believe in what I do and I chose this profession for a reason. But still.

My hope is that, with articles such as this one, the general public will learn that evidence-based psychological treatments exist which can reduce their suffering and improve their quality of life. I would like people to be fully informed about their options when it comes to mental health treatment. I look forward to the day when people experiencing psychiatric symptoms routinely ask their primary care physicians for referrals to psychologists who practice evidence-based treatments, rather than, or in addition to, asking for prescriptions.

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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.

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End of Treatment Outcomes for Patients with Anxiety Disorders

Since opening my practice in 2009, I have evaluated 14 patients who presented with a primary diagnosis of an anxiety disorder. All former patients who attended at least one treatment session with me following their evaluation were included in this sample (n = 9). Those who are currently still in treatment with me were not included in this sample. Please bear in mind that the results described below are specific to my practice and my patients, and should not be generalized to other therapists or other patient populations.

The sample described includes nine female patients who ranged in age from 10 to 42 years old (median age = 22). The patients’ primary diagnoses were Panic Disorder (n = 3), Anxiety Disorder Not Otherwise Specified (n = 2), Acute Stress Disorder (n = 2), Hypochondriasis (n = 1), and Generalized Anxiety Disorder (n = 1). One-third of the patients (n = 3) had a comorbid diagnosis: one had Social Anxiety Disorder, one had Major Depressive Disorder, and one had Depressive Disorder Not Otherwise Specified.

Duration of treatment ranged from one month to 11 months, with a mean duration of 5.6 months. Number of sessions attended ranged from 1 session to 18 sessions, with a mean of 10 sessions.

The primary treatment model used was individual Cognitive Behavioral Therapy (CBT). The children in this sample (n = 2) each had a high degree of family involvement, with a parent participating in part of each session. All of the college-aged patients in this sample (n = 3) were treated individually but had some degree of family involvement, with a parent participating in at least one session over the course of treatment. Amongst the adult patients in this sample (n = 4), half had no family involvement and half had some family involvement, with a loved one attending one session over the course of treatment.

None of the patients in this sample had a history of psychiatric hospitalizations before beginning treatment with me, and none of them needed to be hospitalized while in treatment with me. Forty-four percent (n = 4) of these patients took psychotropic medication during treatment. Approximately 56% of patients (n = 5) paid a reduced rate for my services based on their financial situation, and the remaining 44% (n = 4) paid my full rate.

For the purposes of this study, “full remission” was defined as complete absence of anxiety disorder symptoms in the past two weeks, along with good social, occupational, and academic functioning. “Significant progress” was defined having substantially less severe and less frequent anxiety symptoms compared to intake, along with significant improvement in social, occupational, and academic functioning. “Some progress” was defined as having somewhat less severe and frequent anxiety symptoms compared to intake, along with fair social, occupational, and academic functioning.

Forty-four percent (n = 4) of the patients in this sample completed treatment. The remaining 56% (n = 5) quit treatment prematurely. Seventy-five percent of the patients who completed treatment (n = 3) achieved full remission, and the remaining 25% (n = 1) made significant progress.

Patients who quit treatment prematurely attended an average of 12 sessions before quitting. Amongst patients who quit treatment prematurely, 80% (n = 4) had made significant progress at the time of the last session they attended, and the remaining 20% (n = 1) had made some progress. Importantly, the only individual who did not make significant progress quit treatment after attending only an evaluation and one treatment session.

In sum, patients with anxiety disorders responded very well to treatment in a relatively short period of time. All patients 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.