Treatment for eating disorders

There is effective treatment for eating disorders. However, someone cannot receive appropriate treatment in a wholly passive manner and yet still recover, as might be the case with some physical illnesses. Struggling out of an eating disorder must be an active process on the part of the sufferer, even though others may help a great deal. Treatment should help the sufferer to define and to tackle the tasks of recovery herself.

Most people who find themselves with an eating disorder have very mixed feelings. On the one hand, they hate their present state; on the other, they fear changing it, because change may seem to threaten instability and a loss of control. The sufferer is caught up in a vicious circle and the easiest thing to do in a vicious circle is to stay within it.

Breaking out is always demanding. It demands courage and faith. Whatever approach is used, the overall aim of treatment must be to promote sufficient understanding, confidence and a sense of safety to enable the sufferer to change.

In many ways anorexia nervosa and bulimia nervosa are similar disorders, and the general tasks of recovery apply to both. However, there are differences in how these tasks are achieved. So, not surprisingly, the typical treatment advocated for the two disorders will differ although there are many elements in common.

It is important to emphasise that the following is only an outline of the current treatments. This does not mean that these treatments are perfect or will work for everyone. Some people recover without professional help, while a few fail to recover even though they have been through extensive treatment.

BULIMIA NERVOSA

The mainstay of treatment for bulimia nervosa is some sort of short-term psychotherapy, or ‘talking treatment’. This involves the patient meeting with a therapist for a series of conversations, each typically lasting between half an hour and an hour. In this case short term means therapy involving between 12 and 24 sessions spread out over three to six months. There are often follow-up appointments at much longer intervals.

There are different kinds of psychotherapy. Probably the most successful in the treatment of bulimia nervosa is cognitive– behavioural psychotherapy, or CBT.

As the name suggests, CBT is focused upon both the problematic behaviours and the ideas (cognitions) that support them. The therapist works with the patient to reduce undesired behaviours, such as bingeing and vomiting, and to build up healthy alternatives such as eating more regularly. The patient is usually asked to keep a detailed diary so as to monitor the relevant behaviours and the thoughts and feelings that seem to trigger them. As the problematic behaviours become less frequent the patient and her therapist can begin to see the wood for the trees. The ideas and beliefs that maintain the disorder become more evident and accessible to scrutiny and change.

If all goes well the last phase of the treatment is focused much more upon managing issues such as self-esteem than upon weight and eating control. CBT emphasises the need to find new ways of tackling present problems rather than speculating about why they developed. It recognises that what sustains a problem now may not be what caused it in the first place. Furthermore, it sees the present as more open to scrutiny and change.

Other types of psychotherapy can be used in the treatment of bulimia, although there is less evidence for their effectiveness. Some types of psychotherapy are very similar to CBT, whereas others are quite different. Some concen­trate much more upon issues of current relationships. Still others, called psychodynamic therapies, are focused upon exploring links between the current symptoms and issues in the past, and tend to invoke the importance of uncon­scious mental processes. At present, we cannot be absolutely sure which kind of therapy is best in any one case.
However, some direct attention to the issue of eating does seem to be sensible and is supported by the evidence. In the terms outlined above, it makes sense that all three tasks should be addressed.

Hospital admission

Most treatment for bulimia nervosa takes place on an outpatient basis. However, some people may benefit from hospital admission. This may be especially useful if bulimia is only one of several problems that feel out of control. For instance, the woman may be drinking exces­sively, taking drugs, shoplifting or experiencing impulses to harm herself. This is sometimes called multi-impulsive bulimia. Special inpatient programmes exist for bulimia in general and such complicated bulimia in particular. These can be helpful but their advantages over simpler treatments have not yet been clearly proven.

The same goes for other special regimes that are built around the so-called Twelve Step programmes. These are based on ideas similar to those used in Alcoholics Anony­mous and some approaches to drug dependence. How applicable these are to eating disorders is a matter of debate.

Dealing with depression

In many cases bulimia nervosa may be accompanied by clinical depression, and antidepressant drug therapy may be very useful. Antidepressants are not ‘pep pills’ and are not addictive. They can help when someone has symptoms of depression, such as low spirits, poor sleep and reduced vitality. It is possible that some antidepressant drugs also have a direct effect upon the bulimic symptoms. This seems to be a modest effect, however, and in most cases medication alone is not adequate treatment for bulimia nervosa.

When additional help is needed

Sometimes the sufferer makes great progress in separating weight and eating from wider issues. However, she may find that these issues are still causing problems or are associated with other kinds of distress or problematic ways of coping. For instance, she may be clinically depressed or drinking excessively. If so, therapy may need to be adapted and often extended.

Hospital admission may be recommended to help her cope with crises or to help gain some initial sense of control. Even when there are no major complications, some people decide that they want more wide-ranging psychotherapy to explore their feelings after they have overcome the particular disorder of bulimia nervosa.

Sometimes people need a good deal more than short-term psychotherapy. Others recover using a self-help approach in which they follow advice given to them in written form with or without some face-to-face sessions with a therapist. And it must be remem­bered that some people recover without any outside help at all.

ANOREXIA NERVOSA

The treatment of anorexia nervosa is usually more prolonged than that of bulimia nervosa. It may take months and years rather than weeks and months. This is partly because the person with anorexia nervosa has the initial task of restoring her weight and then learning to maintain it once restored. Furthermore, once an individual has developed full-blown anorexia nervosa the degree of entanglement is usually much more profound although there are exceptions to this rule.

For the person trying to escape from anorexia nervosa the first of the three tasks of recovery – regaining lost weight – tends to loom large. It also ‘looms large’ for those around her. The emaciation of those with severe anorexia nervosa is so pressingly evident that it may come to dominate the picture and sometimes it is appropriate that it should do so. However, the second and third tasks are every bit as important in the long run. Any treatment programme that neglects them is unlikely to be effective.

Help from psychotherapy

Most treatment for anorexia nervosa can take place on an outpatient basis. As with bulimia nervosa, the core treatment should involve some kind of psychotherapy which enables the patient to feel safe enough to change. Cognitive–behavioural techniques may be used or more exploratory styles of a psychodynamic kind.

Often some kind of monitoring of weight and eating is incorporated into the therapy. The therapist or a colleague may need to advise the sufferer on how to change her eating habits. This is not because the task is complex or difficult, but because the patient needs to feel safe when performing the simple act of eating and choosing what to eat. She has to borrow confidence from someone whom she can trust.

The important thing is that the whole process helps the individual feel confident enough to let go of some of the exaggerated control that she is exerting upon herself. This control is both dietary and psychological, so the process of psychological change depends in part on physical change. Sometimes the task of gaining weight proves too difficult, and the patient remains stuck in her behaviour or even deteriorates. A more intensive treatment situation may be required, and hospital admission needs to be considered.

When hospital treatment is needed

Admission to hospital can be frightening. Ideally the patient needs to decide for herself that it is the way forward. The best reason for admission is that the patient herself wants to change but cannot do so except with constant, round­the-clock support. Again the aim should be to promote a sense of confidence, trust and safety.

If the sufferer feels that she is being bundled into hospital, for instance because her health is endangered, she may feel even more out of control. In these situations people are liable to panic. If it is the patient who is panicking, she may make the right decision and go into hospital but often her resolve will waver before long. If it is the family or the doctors who are feeling that there is no choice but hospital treatment, a battle may ensue.
Such battles between a patient with an eating disorder and those who are trying to help her are sometimes difficult to avoid. However, they usually make matters worse. The patient may find initially that she had mixed feelings about going into hospital, but pressure from others frees her whole­heartedly to oppose them. It is easier to battle with others than it is to have a battle raging within oneself.

Very occasionally compulsory admission under a provision of the Mental Health Act may be sought on the justification that inpatient treatment is required to save the patient from serious deterioration of health or even death. However, such situations are best avoided if at all possible. Those involved with the sufferer need to try to cherish and work with the more positive aspects of her feelings.

Admission to hospital should provide a good setting for tackling all three of the tasks of recovery. Probably the best chance of this happening is if the sufferer is admitted to a unit specialising in the treatment of severe anorexia nervosa. Most specialist inpatient services are located in psychiatric hospitals or in the psychiatric units of general hospitals. Unfortunately there are rather few of these, and there may often be a difficult choice between admission to such a specialist service far away or to a more local but less specialised psychiatric or medical unit.

Hospital treatment is usually geared towards encouraging the patient to gain weight. Often a target weight is set and the person aims to reach and then maintain this weight. In most cases the patient achieves this by eating substantial, healthy meals. Special food supplements may be useful, but techniques such as tube feeding are hardly ever justifiable.

Most inpatient treatment regimes have their own rules and regulations about eating. Many of these are essentially arbitrary but make the whole experience more predictable, and predictability can bring a sense of safety. It helps the patient feel that she will be prevented from overeating once she starts. The details of the regime, the confidence of the nursing staff and the general emotional setting can all help her to feel safe enough to eat.

The more specific, psycho-therapeutic treatment needs to continue alongside the weight restoration regime and indeed should continue long after weight is regained. As the patient gains weight she will need an opportunity to talk openly about her thoughts and emotions. Furthermore, restoring body weight only marks the start of another phase of recovery rather than its completion. In fact, restoring weight may often seem to be the easiest part of recovery to both the patient and those who are trying to help her.

The role of the family

For younger patients with anorexia nervosa who are still living with their parent or parents, family therapy of some kind is often thought to be useful. This may be addressed to all three of the tasks of recovery. For instance, the family may be asked to take responsibility for feeding their child. More often, family therapy involves trying to understand and change the emotional issues that have become entangled with weight and eating.

Where to get help

A variety of different people and services offers treatment for eating disorders. The family doctor (GP) will be the usual first contact for someone who is seeking help. Sometimes the GP is able to provide all that is required, but often referral will be made to a more specialist service.

In some parts of the country there are services devoted to the assessment and treatment of eating disorders. Some of these will be able to deal with the full range of eating disorders of every type and severity. Others are suitable only for the less severe.

An important issue is the extent to which the person or service is able to provide assessment, monitoring and intervention for both the psychological and the physical aspects of the disorders. A general physician may feel comfortable treating the physical problems but less so with the psychological ones. A psycho­therapist may have the reverse problem. What is important is that, somehow, all the necessary aspects are sufficiently addressed.

Usually within the NHS, help for eating disorders is offered within the mental health services which tend to be organised into multi­disciplinary teams. In addition to the medically qualified psychiatrist, nurses, clinical psychologists, occupational therapists and social workers will be involved. This pooling of available skills often helps, although the key contact may still be with just one person. Patients who are in their mid-teens or younger would normally be offered help within Child Psychiatric Services.

Self-help organisations

Another important resource is the self-help groups which are widely available throughout the country. These can provide useful infor­mation, advice and support for both sufferers and their families. Most would claim to be a complement rather than an alternative to professional help. Many are organised by the Eating Disorders Association, the address of which is given at the end of this book.