THE MISSING LINK
Have They Truly Given up or Have We Given up on them? If you have ever heard someone who has known or worked closely with the eating disorder population you may hear them say that they are: manipulative, deceiving, fake, sneaky, attention seeking, obsessive compulsive and so much more. This population of clients is unique in that treatment may not only fail to work but treatment itself could add “fuel to the fire” so to speak. After battling with anorexia nervosa as a young child and working hands on with this population I feel as though in many cases we as therapist are not treating these clients as seriously as we should. After seeing some adults in the hospital who had an eating disorder for fifteen plus years I began to wonder what is going wrong with the system. One particularly distinctive feature is its tendency to run a chronic course. When patients present for treatment they typically give a history of many years of unremitting symptoms, and studies of their subsequent course reveal a low rate of full recovery. (Fairburn et al., 2003, p. 103)
Before I go into the failure of treatment for this population I want to describe what extreme obstacles counselors will encounter when working with them. As in many mental disorders the client must be willing to change in order for change to actually occur. The problem is that people suffering from eating disorder in most cases are in such extreme denial that changing is not an option at first. “Problems such as denial or minimization of the eating disorder, lack of motivation for change, treatment resistance, and lack of insight are common, and techniques that can diminish or eliminate these challenges are sorely needed.” (Michel, 2002, p.470)
It is very important when helping one suffering from an eating disorder to get the family involved. I personally feel it is a family disorder and the eating disorder is just that particular family member’s way of showing something is wrong in the family dynamics. Many families are in denial and do not want to admit that someone in their family has a mental disorder. “In addition, it is not unusual for family members of those afflicted with eating disorders to deny a problem, minimize the eating disorder, and or display treatment resistance.” (Michel, 2002, p. 470) In some cases education is the key to overriding the obstacles of the family of this population. Even if the family is not willing to own up to the family origins of the disorder it is extremely important to engage them in the treatment process. (Wilson, Vitousek & Loeb, 2000)
Of all the treatment of this client population Cognitive Behavioral Therapy has shown to work better then other types of therapies. (Fairburn et al., 2003) However, “Little is known about the optimal treatment of Anorexia Nervosa.” (Wilson, Vitousek & Loeb, 2000, p. 572) “Most of the few controlled trials have failed to demonstrate differential effectiveness for any modality, with a minority of patients showing full symptom remission.” (Wilson et al., 2000, p. 572) Although some treatments work the question is for how long. One of the main issues I saw from my experience working at the Institute of Psychiatry in CharlestonSouth Carolina was the inability for the patients to stick to the treatment program because of the lack of insurance funds. Recommendations of extended inpatient treatment imply an enormous financial burden for families and health care systems. After the maximum 28-day stay many plans permit, patients are discharged to resume spaced therapy sessions- and not infrequently readmitted for a second round as soon as the next annual period begins. (Wilson et al., p. 565) Many of these clients come to the hospital with out nutritional sound bodies and are incoherent and unable to participate in therapy due to lack of nutrition. This poses a major problem because as soon as the treatment is beginning to make a difference the client is put back out into the community or back into the dysfunctional home where the problem persist. This of course is the unfortunate cycle that many other mental disorders encounter throughout treatment.
Here is a hypothetical example that resembles some of my patients from the hospital I worked at. Twenty-year old S has been suffering from anorexia nervosa since the age of nine. She has been in and out of six different intensive inpatient hospital eating disorder programs, she has lost complete contact with her family because the burden was too hard for them to bare, she is physically unable to work because she is wheel chair bound do to her weak body and finally her insurance has completely run out. What now? Where does she go for hope?
People who suffer from eating disorders are expected to start out patient therapy as soon as they are at a healthy weight. This in my opinion is too sudden of a transition. The failure to give them time to develop motivation is left out. “Motivation to change is adversely affected, too, by the fact that people with anorexia nervosa frequently describe their disorder as fulfilling a protector or guardian role in their lives.” (Michel, 2002, p. 473) The disorder, especially for those who have been suffering for many years, becomes their best friend and in some cases their only friend. Ending this unhealthy “relationship” is very frightening for some.
From my research, personal and work experience I feel there is a missing link. First and foremost the education needs to be increased especially for those working with this population. For example, many feel that eating disorders are solely about body image and media. These negative aspects do not help the situation and do contribute to low self-esteem however they are not they do not address the underlying issues at hand.
The issues underlying eating disorders are not about food, weight and body shape. Disordered eating behavior is a means of distracting oneself from, and coping with intolerable emotions, problematic life circumstances, and the absence of a sense of self. (Michel, 2002, p. 471) The focus on recovering nutrition is of course life or death with anorexia nervosa. However, realizing that it runs deeper then food will make a huge difference in their recovery.
The missing link as stated earlier is the link between inpatient and outpatient treatment. At my job at the Institute of Psychiatry I worked with both inpatient and outpatients and saw that taking a patient from twenty-four hours a day observation and care and putting them out of their own or with their families set the stage for failure. My proposal is a type of halfway house. One where twenty-four hour care was provided yet with more freedom. Then slowly and I mean slowly, as progress developed weekend stays away could occur and so on. This would also give the families some time to come in to the halfway house for group sessions see how to go about caring for their loved ones etc. It would give the clients with out families or who lived alone time to really gain confidence in their recovery before going back out into the community. The people in the community that have battled with eating disorders and are successfully living life again can come to the halfway house for groups to share their stories, much like Alcohol Anonymous. This halfway house would provide a step down instead of a fall.
I realize that this plan is not perfect and much thought and research would have to occur before action yet the idea of the missing link is something to think about with many mental disorders being pushed aside due to poor funding. Eating disorders are serious, deadly and hard to treat but there is hope. Our job as counselors is to provide hope not sit back and pretend that it exists.
References
Fairburn, C. G., Stice, E., Cooper, Z., Doll, H. A., Norman, P. A. & O’Connor, M. E.
(2003). Understanding Persistence in Bulimia Nervosa A 5-Year Naturalistic
Study. Journal of Consulting and Clinical Psychology, 71, 103-109.
Michel, D. M. (2002). Psychology Assessment as a Therapeutic Intervention in Patients
Hospitalized With Eating Disorders. Professional Psychology: Research and
Practice, 33, 470-477.
Wilson, G. T., Vitousek, K. M. & Loeb, K. L. (2000). Stepped Care Treatment for
Eating Disorders. Journal of Consulting and Clinical Psychology, 68, 564-572.
Hypothetical Models
Treatment Plan Today: The Never Ending Cycle
Inpatient (Max: 28 days)
Relapse
Intensive Outpatient (30 days)
Outpatient (20 days)
Ideal Treatment Plan of Hope
Inpatient (28 days)
Transferred To An Intensive Halfway House For As Long As It Takes
Intensive Outpatient
Outpatient
Continues to come to group meetings to support others who are fighting the battle!!!!