Eating
Disorders
By
Michelle Row
Eating Disorder Research
Phil Jones
RECOVERY
CHAPTER 4 – SCHAEFER & RUTLEDGE
1

In order to break free from the eating disorder behaviors (starving, bingeing and purging) cycle, the
individual must stay true to his/her goals, get up each time he/she fell down and never give up.

Even with the addition of new recovery tools, the eating disorder finds new methods of attack.

By separating from the eating disorder (externalizing the illness), the person can stand his/her ground.

A person with an ED tends to argue with other people about body image and eating issues, when the
person is in recovery he/she may realize that he/she is actually defending the eating disorder. In a group
of people with ED, this can become a competitive one-upping exercise. The trick is to switch the
conversation to talking about the group members in sides instead of their outsides so that the discussion
becomes more meaningful and helpful.

When the eating order is active, one’s perfectionist tendencies would beat the person down and the
eating disorder would jump in for the rescue. Separating from these cognitive distortions brings freedom
and peace.

Increased awareness during recovery allows the individual to see how fast the eating disorders enter the
individual’s mind as a coping mechanism.

Disordered eating behaviors are a way to avoid anger through numbing by starving and pushing anger
deep down through bingeing.

To move forward in recovery the person with the ED must tell on themselves to their support team, their
therapists, their doctors and their dieticians. By telling the truth, the helping professionals can meet the
client where he/she is at and truly help.

Positive guilt is the sense of shame a person feels for stepping outside the bounds of what is familiar,
when the person breaks the old rules of the eating disorder. Positive guilt is felt when a person breaks
rules that need to be broken. This guilt is like withdrawal. If the person with the ED can recognize and
celebrate this positive guilt, it means that they are taking care of himself/herself and moving forward in
recovery.

When a client begins to regularly apply what was learned in therapy to real life, it feels weird, strange or
foreign. This foreign territory of putting one’s best interests first and taking care of oneself can be very
scary.

The author experienced three phases of recovery: 1) feeling guilty 2) weird 3) amazing.

Recovery needs to be taken one step at a time.

Using the catch phrase “compare and despair” reminds the person that they need to shift his/her focus
from others back to himself/herself. Happiness is provided internally, not externally.

A person with an ED will often hear the same self-critical message replayed in his/her mind like a cassette
tape. The thoughts that occupy the most time in one’s head would take up a longer length of tape than the
ones that periodically creep in. The client pulls a piece of tape that represents the frequency of each
negative message and puts it in an envelope labelled with the thought. Then the messages take up space
in a backpack or purse rather than the client’s head. This symbolism is very powerful. When a message
runs through the client’s head, he/she pulls out the envelope and lets the message pass freely through
the mind. If a significant portion of the thought still remains in the mind, the client tears off another
appropriate length of the cassette tape and places it in the envelope.

A person in recovery s a work in progress who can always benefit from digging deep inside and getting to
know oneself better.
ADVICE FROM THE PSYCHOLOGIST

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
2
It is important for the client to define his/her recovery by identifying and describing what the person
WANTS for himself/herself.
This can be accomplished by characterizing recovery at 4 levels: 1) spiritual (sense of purpose,
connection and meaning) 2) mental (what a person is thinking) 3) emotional (what a person is feeling) and
4) physical (what a person is doing with food and exercise).
Ex. When I am in recovery from my eating disorder:
Spiritually , I ________
Mentally , I ________
Emotionally , I ________
Physically , I ________
Eating disorders are characterized by constant self-criticism. Have the client write down their top-ten
negative thoughts. Have the client use the cassette tape exercise. You can also have the client write an
alternative corresponding positive thought to counteract each negative thought (CBT). The client should
repeat these self-affirmations until they begin to believe and incorporate them in his/her life.
Email between the client and therapist can be part of therapy. In addition to emailing a daily food plan, the
client can also email internal dialogue between the client and the eating disorder to help the client
separate from the ED.
A playlist of inspirational songs can also be helpful to the client in recovery.
RELAPSE
CHAPTER 5 – SCHAEFER & RUTLEDGE

Relapse is a normal and necessary part of recovery. It is inevitable.

A person learns something from each relapse and grows stronger each time.

The author says that the part of her that holds on to her disordered eating behaviors and thoughts is her
invisible little child inside. The ED actions help the child feel secure, in control and valued. Her way to
healing involves listening to her invisible child, taking care of her and providing protection for her.

Taking responsibility for and caring for one’s inner child teaches self-compassion. This can be
accomplished by the client performing a role play in therapy or posting a picture of himself/herself on
his/her cell phone as a constant self-love reminder.

When relapse happens, it is difficult for the person to admit to herself/himself and others that her/his
recovery is not perfect.

A relapse is like a leaky roof, it must be made a priority and “do the next right thing”.

When the client feels on the verge of a relapse, calling one of his/her support team member can help the
individual avoid relapse. Connection to others provides strength to fight the relapse that isolation cannot.

There are numerous techniques that one can use to move energy in one’s body to deal with difficult
feelings. Ex. 1) Breathe in focusing on pulling positive energy (joy, happiness, love) into one’s body.
Breathe out focusing on releasing negative energy (depression, hopelessness). Just three breaths like
this can leave the individual feeling calm, peaceful and relaxed. 2) Stand in a doorway and press one’s
arms out. The resistance provided by the doorframe helps to release pent-up feelings, especially anger
and frustration. 3) Scream into a pillow as loud as one can. 4) Beat furniture with a plastic baseball bat.

These moving energy techniques are great relapse prevention tools.

When a person is in relapse, the first step is to get out of the fire. Analyzing all of the factors that
contributed to relapse is not helpful initially.
ADVICE FROM THE PSYCHOLOGIST


The client can make an Emergency 911 Card. The card includes relapse-prevention tips that have worked
in the past and a list of phone numbers for the client’s support team. The client should carry this list at all
times.
The client can intervene on his/her relapse patterns by asking the following questions:
o What are the most dangerous triggers to relapse for you?
o Do you always relapse when you encounter these triggers? If not, what are some things that you
have done to avoid relapse in these situations?
o How does relapse begin for you? With a thought? With an emotion? With a physical feeling?
o On a scale of 1 to 10 (10 being very much), how badly do you want to learn to successfully
intervene on your relapses?
o What is the one thing you are willing to seriously try for interrupting your next potential relapse?
o What are the best questions to ask yourself about relapse?
The better a person understand the patterns associated with her/his relapse, the more effectively she/he will
be able to interrupt the ED thoughts and behaviors before a relapse begins.
3

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4
The client can write a letter to himself/herself when in a solid place in recovery to be re-read when a
relapse threatens. This letter should be revised as recovery strengthens and the client gains more wisdom
from recovery.
If there are predictable times when the client is vulnerable to relapse (holidays, final exams), the client can
send his/her future self an encouraging email using a website like futureme.org
TREATMENT PHILOSOPHY AND APPROACHES
CHAPTER 8 – COSTIN

The current trend in research and clinical training for eating disorders favors evidence-based treatment.

An experienced therapist will rely on personal experience and whatever works for the client rather than
being tied to any particular treatment model.

Stabilization of a client’s medical status and ongoing medical monitoring and treatment are necessary in
conjunction with all approaches.

The therapeutic alliance is the most significant factor in treatment outcome.
Psychodynamic Therapy

Emphasizes internal conflicts, motives and unconscious forces.

If the underlying causes of disordered behaviors are not addressed and resolved, they may cease for a
time then return. Ex. Behavior modification techniques work in the short-term, but are not long-term
solutions.

Understand and treat the cause, adaptive function or purpose of the eating disorder.

Symptoms are a way for the client to express underlying issues.

The symptoms are useful to the client. The therapist helps the client to understand the connections
between his/her past, personality and personal relationships as well as how these aspects relate to the
ED.

Challenges with a solely psychodynamic approach: 1) In a client with an extreme state of starvation,
depression or compulsivity, psychodynamic therapy is ineffective. 2) Clients can spend years gaining
insight while still practicing the disordered thoughts and behaviors.

This approach has gained little empirical support. It is often used in combination with other approaches.
Cognitive Behavioral Therapy
5

Most commonly used and studied treatment approach used for ED.

Research results have been most promising for bulimia. CBT is the gold standard treatment for bulimia.

The therapist helps and individual learn to recognize cognitive distortions and either choose not to act on
them or replace them with more realistic and positive ways of thinking which shapes healthier behaviors.

Homework, journals and monitoring behavior outside of treatment are used. Educating clients about all
facets and consequences of eating disorders is stressed.

Many detailed treatment manuals based on CBT have been developed. Some clinicians find the manuals
too rigid.

Clients rely on cognitive distortions as guidelines for behaviors to gain a sense of identity, safety and
control. Functions cognitive distortions serve:
o
Provides a sense of safety and control.
o
Reinforce the eating disorder as a part of the individual’s identity.
o
Enable individuals to replace reality with a system that supports their behaviors.
o
Provides an explanation or justification of behaviors to others

Cognitive behaviors have to be challenged in an educational and empathetic way to avoid power
struggles.

Clients need to know that their behaviors are their choice, however, they are currently choosing to act on
false or misleading information and faulty assumptions.

Current research has shown that other forms of therapy are as useful as CBT.
Interpersonal Therapy (IPT)

Focuses on the links between eating disorder behavior and underlying relationship issues.

Most efficacy shown with bulimia and BED.

Clients often have a number of interpersonal problems that play a role in onset and continuation of the
ED.

The most common problems are:
o
Role disputes
o
Role transition
o
Grief
o
Interpersonal deficits in interpersonal relationships

Food, weight and shape are not discussed outside of the initial assessment. Clients are encouraged to
associate their symptoms with life experiences and interpersonal problems.

Identifying and focusing on specific problems, discussing feelings and relationships as well as using role
playing and problem solving are used in this approach.

CBT and IPT as part of an integrated, multidimensional approach is suggested by the author to treat
bulimia, binge eating disorder, and anorexia.
Dialectical Behavior Therapy (DBT)

Combines CBT and interpersonal therapy and has been gaining popularity as a mode of treatment for ED
recently.

Developed to treat people with poor interpersonal skills, extreme mood fluctuations, poor impulse control
and self-destructive behaviors.

It focuses on harmful and acting out behaviors before working on interpersonal issues. DBT also focuses
on skill building and can be adapted for ED by targeting eating disorder behaviors when setting treatment
goals and building skills in the area of nutrition and weight.

The main areas of focus in DBT are:
o
Mindfulness – awareness training – developing the ability to go inside and observe, quiet the
chatter of the mind and respond from an internal healthy self rather than react emotionally
o
Distress tolerance – help clients see that destructive behaviors are not long-term solutions.
Alternative methods for coping with painful emotions and tolerating feelings are taught.
o
Interpersonal effectiveness – successful relationships with oneself and others are modeled.
o
Emotional regulation – affect regulation – taught to experience emotions without reactivity
Addiction/Twelve-Step Model
6

Model of Alcoholism treatment has been applied to eating disorders Ex. Overeaters Anonymous (OA) –
food is the item that renders the client powerless and abstinence is the freedom from compulsive
overeating.

Research has not demonstrated the effectiveness of this treatment model.

APA’s February 1993 position states that 12-Step based programs are not recommended as a sole
approach for anorexia or an initial approach for bulimia. The APA states that a 12-Step approach can be a
useful treatment adjunct and relapse prevention.

A criticism is that this philosophy never sees as the client as recovered or disease-free.

Absolute standards and dichotomous thinking permeate 12-Step philosophy.

It is also impossible to abstain from food which is essential for survival. The key to recovery is being able
to deal with food in a normal, healthy way.

The 12-Step model can be a great means of support and recovery. Groups are free, readily available and
members give to other members through sponsorship.

Costin states “If clients believe they can be more powerful than food and can be recovered, they have a
better chance of becoming so.
Clients are more comfortable with professionals who have undergone their own recovery from an eating
disorder. They feel more understood and less judged by the treatment professional.
Treatment professionals must make the treatment fit the client.
SUGGESTED RESOURCES
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7
Duncan et al. (2004). The Heroic Client
Hubble et al. (1999). The Heart and Soul of Change
TREATMENT – INDIVIDUAL THERAPY
CHAPTER 9 - COSTIN
8

The task is freeing people from their eating disorder self and discovering the potential power,
magnificence and beauty in their authentic self.

The degree of the client’s illness is the degree to which the eating disorder self is in control.

Therapy involves providing education, insight and a corrective emotional experience. This helps the client
to strengthen their authentic or healthy self.

Clients rectify faulty thought patterns, fill in developmental deficits and internalize missing psychological
functions.

The therapist lends his/her ego and self-organization as well as capacity to anticipate, delay gratification,
use sound judgment, relate to others, regulate tension/mood, and integrate feelings, thoughts and
behaviors.

Once clients have internalized these abilities into their self-structure, they no longer need to use substitute
or self-destructive measures to meet needs or provide psychological functions.

The objective of therapy is to learn why the disordered eating behaviors developed and how its specific
behaviors serve a function.

Challenging the eating disorder self while building a relationship with the healthy self helps the client to
avoid shame and blame while still having personal responsibility.

The technique of externalization is used. Narrative therapy is the best treatment modality to use.

Role-playing techniques are vital for showing the client where he/she is stuck.

Contact and empathizing with all parts of self and reintegrating these parts into the core self is the goal of
treatment.

Clients will provide the therapist with a window in to the eating disorder self:
o
The client expresses, through actions or verbally, the ambivalence he/she has about getting
better. (The therapist points out the two selves to the client.)
o
The client demonstrates a dissociative state where a rational, healthy person knows he/she is
underweight and another part perceives himself/herself as fat.
o
The client feels that his/her eating behaviors are out of his/her control. (The therapist gets the
client to contact, transform and integrate the eating disorder self.)

Journaling assignments can help the client to access his/her eating disorder self. Dialogue between both
aspects of self can be powerful and therapeutic by getting the authentic self back in control.

Battling the eating disorder behaviors are an internal process for the client. A therapist helps the client
engage in the process.

Insight into what went wrong is not enough for people with an ED. They must learn how to develop
healthy attachments, reach out for help and learn how to solve problems differently.

The therapist helps re-parent the client until he/she gains the ability to rely on self or others rather than
the eating disorder behaviors.

An eating disorder therapist must be more active (verbal and directive) and dynamic than is necessary in
other kinds of therapy. The therapist will often stretch traditional boundaries, be more present and selfdisclose more.

Essentially, the therapist needs to provide a better relationship (or healthy attachment) than the one the
client has with her ED.

ED behaviors have served as a substitute for secure attachment.

Traits observed in anxious attachment are seen in clients with eating disorders:
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9
o
Lacking/misperceiving their own resources
o
Feeling ineffective/deficient
o
Needing to control
o
Lack of interoceptive awareness
o
Sense of inadequacy/not measuring up\
o
Insecure neediness
Eating disorder behaviors serve unmet attachment needs:
o
Starving is likely to elicit a caregiving response without the individual having to ask for help or
acknowledge any need.
o
Bingeing provides nurturing or self-soothing needs that clients do not know how to get by other
means.
o
Purging may serve as a physiological or psychological release of anger or anxiety.
o
A focus on appearance can serve as a diversion, redirecting attention from attachment needs to
more attainable goals like losing weight.

The therapist assists the client in expressing feelings, self-soothing and internal validation.

Transitional objects, such as rocks, can be given to the client as a way of staying connected to the
therapist and therapeutic work.

Clinical strategies for successful treatment:
o
Alliance and empathy
o
Deal with food and weight problems directly – don’t make assumptions, ask the client to give you
specifics about their behaviors
o
Make behavioral agreements – helps clients gain control, eventually the client can set and attain
healthy goals for himself/herself, small behavioral steps help the client recover
o
Understand ED as addictions or phobias – behaviors are used to regulate emotions. Symptoms are
self-perpetuating because they work.
o
Nurturant/authoritative therapy – nurtured and supported by the therapist with guidance and limits.
Clients need to learn the difference between self-care and selfishness.
o
Limiting control battles – the therapist establishes non-negotiable items with the client on a case-bycase basis
o
Avoid attachment to results
o
Manage resistance – roll with it
o
Patience and long-term thinking (recovery can take 2 to 7 years – stop, start, progress, slip back)

A therapist need to know when to challenge and how far to push. Working through the client’s response is
the key. (A strong alliance and a high level of trust are necessary before challenging the client.)

Every recovery is different, every individual is different.

Topics for individual therapy session:
o
Poor self-esteem/diminished self-worth (a good measure of self-esteem, yet whatever he/she does
is not good enough = low self-worth). The therapist helps clients deal with issues in the here-and –
now.
o
Belief in the thinness myth
o
Feelings of emptiness and the need for distraction
o
Black-and-white thinking
o
Desire for attention and to be special/unique
o
Need for control – the therapist helps the client face reality and see the illusion of control

Giving a list of possible issues to the client can help him/her identify areas that resonate with them.

Stages of recovery:
o
Presence of behaviors with no sense of a separate eating disorder self – the client does not accept
that he/she has an ED
o
Denial of seriousness
o
Beginning awareness of a split self – the client starts to see a healthy self and an eating disorder self
o
Active engagement with the ED self and the healthy self
o
Need for behaviors while developing the healthy self
o
Decrease in behaviors but thoughts/desire for behaviors is strong – ED self is still in control
o
General symptom control with reduced thoughts/desire – the healthy self is control
o
Control of symptoms by healthy self but remaining thoughts/desire – clients are not well enough to
stop treatment
o
Integration of ED self and healthy self – recovered, one whole self present
SUGGESTED RESOURCES

10
S. Levenkron. Treating and Overcoming Anorexia Nervosa and Related Disorders in Childhood and
Adolescence
TREATMENT – GROUP THERAPY
CHAPTER 10 - COSTIN

Group therapy is often a client’s first encounter interacting with people who talk openly about their
feelings, behaviors and fears.

Group therapy is an opportunity for people to sit in a circle with others and be fully present, listen
attentively, practice empathy and attunement and tell the truth without judgment.

When the therapist has a check-in question that all group members respond to, it acts as a “feeling
round”. It build commonality, yet separateness by seeing how many different and/or similar ways that
people can respond to the same question. The therapist can pick up on mood, tone, body language and
willingness to share from each client.

Teaching members to ask questions, be better listeners and better helpers is important in the group
therapy process. This also ensures group interaction and a high level of involvement. Individual
vulnerability and assertiveness are also stressed.

An educational component is essential in all group sessions. Topics include: nutrition, medical
consequences and assertiveness techniques.

Assignments outside of group sessions, such as journal entries, help increase learning and behaviors into
everyday life.

Topic ideas to start a group discussion:
o
What was your last ED thought?
o
What are all the good reasons you have your ED?
o
Say one or two words that describe the opposite of what you are feeling.
o
Say how or what the person on your right is feeling (To practice empathy.)
o
On a scale of 0 to 10 (0=the worst you’ve been, 10= fully recovered), what number are you right
now? What would you have to do to be a 10? How does this compare with what others have
said? Do you want to change your number after hearing what others have said, and if so, why?
o
Complete the following sentences;
An obstacle that is in my way, interfering with my recovery is_________.
A personal trait that I like about myself is __________.
A time I resisted my eating disorder was________.
What will a day in your life be like when you are fully recovered?
o
Bring in a quote, song or poem for clients to respond to:
Alanis Morisette song “That I Would Be Good”
Mary Oliver poem “The Journey”

Giving clients assignments to share in group is therapeutic and healing as members witness issues, give
feedback, empathize and challenge.

Assignment examples:
o
11
Write about what brings people closer to you and what pushes them away.
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12
o
Discuss times when you lied about your Ed and how you can avoid this in the future.
o
Write a good-bye letter to your ED self. (Then have your ED self write a letter back.)
o
List 10 warning signs that you might be headed toward relapse.
o
What client(s) in the group do you feel closest to and why?
o
Pick a situation you would like to do over, describe it, and then describe how you would have liked
it to happen.
o
Share some of the adaptive functions of you ED.
o
Describe ways in which you have instilled trust and mistrust in relationships.
ED clients often hold back and are not good at initiating taking time in group or life for themselves,
The therapist should explore group dynamics – the process (not content) must be examined. How people
behave in life is how they behave in life.
Role-play, psychodrama and re-enactment help clients practice responding to situations in healthier ways.
Group therapy serves as a microcosm for the world at large.
Group therapy helps clients feel support and acceptance, building interpersonal relations, dealing with
confrontation (about inconsistencies, self-destructive behaviors, poor or mis-communication and issues of
disagreement). Speaking truth without judgment is a vital skill that clients learn.
Mixed/heterogeneous groups can be highly successful because clients are more similar than dissimilar.
Support groups (Ex. OA) do not allow for continuity or the same kind of intimacy and depth as a therapy
group.
Cautions and concerns with group therapy that a therapist must deal with to have a successful group:
o Sharing negative ideas – It is counterproductive to give specifics about the means, the amount or
other details about behaviors that might trigger others or cause competition.
o Becoming a complaint session – a client must ask for the group’s advice and support
o Normalizing/glamorizing eating disorder behaviors
o Engaging in attention-seeking behaviors - competition
o Group members applying pressure – recovery is an individual process with varying speeds
TREATMENT - FAMILY THERAPY
CHAPTER 11 - COSTIN

The author suggests a family assessment for every client she treats which involves traumatic events,
family communication and problems and issues, especially those related to weight and appearance.

What happens in the lives of parents passes down to their children, even if no one is conscious of it.
The Maudsley Method

Effective for a select group of adolescents who have suffered for anorexia for less than three years.

Puts parents of adolescents with anorexia back in control of their child’s eating. The parent maintains a
position of boss and the therapist is a consultant.

The home acts as the hospital and the parents serve as nursing staff.

Family members have to be willing and capable of doing all that is asked, including figuring out what to
feed their child, how to feed her/him, how to spend every meal with her/him.

The parents have to get along and work together. A parent may even have to quit work to provide the
care and support needed.

The therapist’s task is to teach the parents what works with their son or daughter so that the therapist is
no longer needed.
.
13

The eating disorder family therapist helps family members learn to empathize, understand, guide without
controlling, step in when necessary, foster self-esteem and facilitate independence.

Factors that eating disorder clients find encourage successful therapy by therapists:
o
Allow all feelings.
o
Speak in the moment
o
Tell the truth without judgment.
o
Ask specific question and draw out information.
o
Don’t assume things.
o
Acknowledge client’s fear and ambivalence regarding getting better.
o
Know that it takes time.
o
Validate and acknowledge client’s experience.
o
Not emotionally connected to client’s behaviors.

When every person can tell his/her own truth, calmly with no anger or judgment, then pouses an dfamily
members can live together and work out problems harmoniously.

The therapist needs to ensure that family members accept responsibility for their own actions that
contribute to or perpetuate the ED without blame.

Help family understand the ED from the client’s point of view by getting to know and understand both
parts of the person and aligning with the healthy self

The therapist explores the impact of the illness on the family. How has the ED interfered with the feelings
and functioning of the family.

The therapist can help uncover parental expectations and aspirations. If children are rewarded for ”what
they do” as opposed to “who they are”, they may depend on external rather than internal validation. The
therapist can help families set realistic goals, especially by removing weight/shape as a focus.

Therapists help establish the client’s role in the family. Healthier and more fulfilling ways of relating to
other family members must be found.

The therapist helps to establish structure and communication within the family.

The therapist encourages family members to resist temptation to control.

The therapist also explains genetic predisposition and temperament. Craig Johnson uses analogies to
explain ED:
o
Individuals with anorexia are more like turtles:
Obsessive–compulsive
Afraid of new things
Highly rejection-sensitive
Perfectionist
Control junkies
o
Individuals with bulimia nervosa are more like hares:
Chaotic and impulsive
Novelty-seeking
More likely to take risks
Extroverted
14

Eating disorder behaviors are often the signals telling others “Help me! I can’t handle all of this, and I can’t
tell you that.”

.Numerous studies have documented a correlation between ED and a history of physical and/or sexual
abuse.

Physical and sexual abuse are boundary violations of the body, it makes sense that individuals manifest
both psychological and physical symptoms.

Family therapy can still occur without family member participation.

When the client still lives at home, it is essential to have the family attend sessions unless they are so
non-supportive, hostile, or emotionally troubled as to be counterproductive.

Education and support groups for family members and significant others are necessary for them to have a
place to talk about their fears and vent frustrations without fear of repercussions.

A therapist needs to work with family members in family therapy. The same therapist can work with both
the client and family members or separate therapists can be used by each party.

Family therapy emphasizes responsibility, relationships, conflict resolution, individuation and behavioral
change among family members.

Multifamily groups which are composed of several clients and their families/significant others can be very
valuable because family members are not emotionally tied to a person from another family and can be
more understanding. This level of increased understanding can then be transferred to one’s own family
member.
SUGGESTED RESOURCES
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
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15
Siegal, D. Parenting from the Inside Out
Costin, C.. (1997). Your Dieting Daughter
Costin, C., Borden, A., Kowalski, A., Radant, J. & Wynne, N. (2005). Books on Families and Significant
Others, Eating disorders: The Journal of treatment and Prevention
Eating Disorders Today
Ross, C. The Trauma Model
Schwarz, M. & Cohn, L. Sexual Abuse and Eating Disorders
ALTERNATIVE TREATMENT
CHAPTER 16 - COSTIN

Alternative approaches such as: acupuncture, chiropractic, herbal medicine, massage, movement
therapy, equine therapy, yoga, dietary supplements have been used with ED.

Most patients add alternative therapies to the more traditional treatments they receive. This is known as
integrative medicine.

The effect of nutrient balance on eating disorder behaviors has been documented. It includes:
o
B vitamins
o
Fatty acids
o
Zinc
o
Herbals/botanicals
o
Probiotics and digestive enzymes

Alternative therapies for treating depression have also been of benefit for treating ED.

Mind-body therapies have been effective for treating ED:

o
Guided imagery – includes stress management techniques
o
Mindful practices – meditation, prayer, focused-attention
o
Body therapies – qi gong, tai chi, yoga
o
Acupuncture
o
Massage/touch therapy - Rubenfeld Synergy Method – helps people reframe past experiences
and heal old stored-up wounds
Some psychiatrists use EEG data to identify genetic brain differences between clients to help make
objective treatment recommendations in complex biopsychosocial conditions such as ED.
SUGGESTED RESOURCES

16
Rubenfeld, I. The Listening Hand
TEENAGE TREATMENT
CHAPTER 6 – LOCK & LE GRANGE

Treatment studies providing evidence for therapies have focused mainly on people who meet the full
criteria for anorexia or bulimia.

Clinical experience shows that children should be treated for the disorder their symptoms resemble.
Outpatient Treatment
Psychological Treatments
17

Is an essential component of most treatments.

Family Treatment

The therapist focuses on how family members communicate, how they relate to one another and how
they solve problems.

The notion is that in families in which there is a member with an ED, there are certain predictable problem
areas such as:
o
Parents allow the child to function as an authority figure in the family.
o
Avoidance of addressing problems in the interest of keeping the peace.
o
Anxiety about allowing a teenager to be independent.

The focus is on family process concerns, not symptoms or symptom management.

Individual Psychodynamic Psychotherapy

Treatment focuses on the underlying issues or perceived psychological problems that may cause the ED
rather than weight and shape.

Adolescents with ED are believed to be immature and highly anxious about things such as taking up
independent roles as adults in a responsible manner.

Focus is on symptoms of disordered eating as an ineffective and dangerous strategy that prevents the
adolescent from addressing his/her real concerns and issues.

Ego-oriented individual therapy (EOIT) is used to treat anorexia. It concentrates on maturational issues
associated with puberty and adolescence.

EOIT is based on the premise that individuals are immature and unaware of their emotions, especially
strong emotions like anger and depression.

These adolescents control food and weight as a way to keep their feelings and conflicts from emerging.
They must learn to identify, define and tolerate emotions. EOIT fosters separation and individuation from
the family.

CBT assumes that the main factors involved in the maintenance of bulimia are problematic attitudes
toward body weight and shape. Attitudes lead to an overvaluation of thinness, body dissatisfaction,
attempts to control weight and shape. Dietary restriction leads to increased hunger and a higher
probability of binge eating, especially in the presence of depression. Purging is used to compensate for
excess calories consumed.

CBT changes eating patterns (3 meals and snacks daily) first and then addresses preoccupation with
shape and weight. Finally, expected issues that might lead to a return of eating problems and relapse are
addressed.

Interpersonal therapy focuses on interpersonal problems that lead to emotional problems that are
managed through the use of food.

Nutritional Counseling

Consists of meal plans, caloric recommendations, alternative food choices to meet nutritional
requirements and support for continued progress in making healthier food choices.

Research has shown that family and individual therapy are superior to nutritional counseling.

Its role is integration with other approaches.
Psychiatric Medications

Little is known about the efficacy of medications in the treatment of eating disorders.

Among adult patients, most frequently prescribed medications are:
o
Anti-depressants – mood problems
o
Low-dose neuroleptics – severe obsessional thinking, psychotic-like thinking and severe anxiety
o
SSRIs

Some patients have reported that use of these medications results in binge eating.

Clinicians hold that three meals and three snacks per day are the best medicine.
Intensive Treatments
18

Inpatient, day-patient and residential treatments ensure that the child receives treatment in a health care
facility by health care professionals for at least a large portion of each day. Varying levels of parental
consultation and involvement will depend on therapeutic approach and facility philosophy.

Inpatient treatment is indicated when a person is in urgent need of weight restoration or has acute
medical problems associated with an ED.

When weight restoration or acute medical problems have been addressed, the patient is transferred to a
day-patient program. Patient is encouraged to gain weight and eliminate other disordered eating
behaviors, yet goes home each evening and weekend.

Residential treatment functions like an inpatient program for individuals that have “failed” other treatments
and require a lengthier stay of several months.

All three treatments focus on restoring weight and stopping or significantly decreasing binge eating and
purging. Next, they help patients learn to manage continuing health on their own and help them reach an
improved understanding of why they developed o how they maintain an ED through the use of
psychotherapy.

Patients are also supported and encouraged through group therapy and, often, family therapy throughout
their involvement in the intensive treatment

Behavioral modification approaches are often used by treatment staff. Staff-imposed prohibitions and
observations are decreased as the patient demonstrates improvement. Increased patient freedom results
as he/she demonstrates a return to normal eating behaviors and weight.

A discouraging aspect of inpatient treatment is that patients may return to their pre-admission weight
within weeks of discharge.
Concluding Remarks:
19

Act early when a child shows signs of an eating disorder.

Parental involvement in all treatment modalities increases the chances of the child’s recovery.

Early and careful attention to medical problems associated with eating disorders is vital.
TEENAGE TREATMENT
CHAPTER 10 – LOCK & LE GRANGE
20

Eating disorder professionals will always have the child’s best interest at heart.

Parents will not always be in agreement with the treatment professional’s approach, but, it is important
that a way be found for both parties to stay on the same page and stay united in fighting the illness.

If the parent’s observation and concern for their child does not match with the initial professional
assessment, a second opinion should be sought.

For a treatment professional that stresses parental exclusion in treatment, the parent needs to ask the
professional about a balance between addressing the ED symptoms and exploring the underlying issues.
Ensure that ED consequences are dealt with urgently and consistently.

When a parent is given advice that he/she does not agree with, it is essential to inquire why the treatment
professional has selected option A or medication A as opposed to option B or medication B. The parent
also needs to examine the reasons for his/her disagreement. (Ex. Is the child’s eating disorder talking and
trying to persuade the parent that the doctor is wrong?)

Conflicting advice may be obtained from different treatment professionals. Because there is not a unified
treatment method for eating disorders. Parents should ask the professional why he/she arrived at their
decision, what guidelines he/she has consulted, how many patients he/she has treated this way and how
they have responded, whether this is standard practice among other professional in the field and is there
published data to support the chosen approach.

When members of the child’s treatment team are not staying in communication or are not following the
same course of treatment, it is the responsibility of the parent to bring these concerns to the attention of
all members of the treatment team to ensure consistency and to eliminate confusion. The treatment team
leader is the person to ensure that the team is following the same directives.

Persistence is of the utmost importance if treatment is to be successful. Parents and professionals must
find a way to persist to help the adolescent overcome the illness.

Parents must find their voices, make sure they remain informed and play an active part in the solution to
help their child recover from an ED.
SUPPORT SYSTEMS
CHAPTER 6 - COSTIN
21

A person does not have power over another person’s behavior.

A person only has power over what he/she chooses to do about the situation and how to take care of
herself/himself.

It is difficult to know what to do for someone you care about with an ED.

Although you don’t know how a friend or loved one will react to your concern, it is important that you
express it, offer to help and don’t give up.

Research shows that having someone who loves, believes in and does not give up on him/her are crucial
factors in the person seeking treatment and getting well.

Talk with the person you are concerned about at a time and place with no interruptions so that everyone
has time to say all that needs to be said in privacy.

Observable and non-observable signs of an eating disorder:
o
Does anything to avoid hunger and eating and feels guilty after eating
o
Is obsessive and preoccupied with food
o
Eats large quantities of food secretly and/or eats when upset
o
Counts calories obsessively
o
Disappears into the bathroom after eating (probably to vomit food)
o
Takes diuretics, diet pills, laxatives, enemas and ipecac to lose weight
o
Must earn food through exercising or exercises as punishment for overeating
o
Is preoccupied with fat in food and on the environment
o
Increasingly eliminates food groups and eats non-fat or diet foods
o
Becomes a vegetarian, but also avoids nuts, cheese, pasta, and many other foods
o
Displays rigid control around food
o
Complains of being pressured by others to eat more or less
o
Weighs obsessively, panics without a scale, is terrified of gaining weight
o
Isolates himself/herself socially
o
Substitutes sweets or alcohol for other nutritious foods
o
Constantly needs reassurance regarding appearance (self-denigrating)
o
Constantly checks the fit of a belt, a bracelet, a ring or “thin” clothes
o
Checks size of thighs when siting and space between thighs when standing
o
Uses large amounts of coffee, diet drinks, caffeine pills or other stimulants

Understand another person’s experience as she/he experiences it and convey that understanding.

Coming on too strong and demanding change may cause the person to shut down and offer no
information at all.

Asking for help is one of the hardest things for an individual suffering from eating disorders to do. Help the
individual to realize that asking for help is not a weakness and he/she does not need to handle everything
alone.

Express concern about observations and speak from your own experience (use “I” statements).

Provide information about resources for treatment.

Do not argue with the individual, but, do not give up. Expect to be rejected in the beginning because
several conversations are needed to get a person to realize or admit he/she has a problem.

Accept your limitations. There is a limit to what you can do for another person.

Often when a family member has an eating disorder, there has been a history of excessive reliance on
external achievement as an indicator or self-worth, which often fails.

Often fluctuations between parental overinvolvement and abandonment have occurred for some time,
leaving the person with the ED feeling isolated, insecure, rebellious and without a sense of self.

Parents often use overinvolvement tactics to try to gain control of an out-of-control situation when
understanding and supportive direction would be more helpful.

When a loved one is in treatment:

22
o
Be patient – there are no quick solutions
o
Avoid power struggles
o
Avoid blaming or demanding
o
Don’t ask the person how you can help – ask a professional
o
Deal with feelings of all family members
o
Show affection and appreciation verbally and physically (unconditional love, encouragement,
concern and support)
o
Do not comment about weight or appearance
o
Do not use bribes, rewards or punishments to control eating behavior
o
Do not go unreasonably out of your way to prepare special foods
o
Do not monitor his/her behavior, even when asked
o
Don’t allow him/her to dominate the family’s eating patterns
o
Set rules and say no in a caring and reasonable but firm and consistent manner
Get help and support for yourself from a support group or therapist. You need to stay healthy and strong
to be able to help someone else.
PLAY A SUPPORTING ROLE IN YOUR CHILD’S RECOVERY
CHAPTER 8 – LOCK & LE GRANGE

A parent’s role in changing behaviors is more indirect.

Involved parents make a real difference in how successfully children and teenagers negotiate their lives.

Principles for playing a supportive role:


o
Agree on the approach you will try.
o
Learn all you can about any treatment you choose.
o
Share your perspectives on your child and his/her treatment from the start.
o
Keep in frequent contact with any therapists or physicians involved in providing treatment
regarding why the disorder developed, how symptoms are currently being expressed and how
your family is currently being affected by the ED.
o
Determine how you will assess progress (improvement of symptoms and time period = agreedupon benchmark).
o
Have a backup plan.
o
Keep your child in treatment (attending treatment sessions will send a message to your teenager
that you support the treatment).
General guidelines for medical hospitalization have been published by the Society for Adolescent
Medicine and the American Academy of Pediatrics:
o
Severe malnutrition (less than 75% of ideal weight)
o
Pulse rate less than 50 beats per minute in the day, less than 46 beats per minute at night
o
Temperature less than 36.4⁰C during the day, 36.0⁰C at night
o
Orthostatic (lying to standing) systolic blood pressure greater than 10 mm of mercury or pulse
change greater than 35 beats per minute
o
Irregular pulse (QTc interval greater than .44 second)
o
Abnormal electrolytes (usually potassium less than 3.0 milliequivalents per liter)
Parental participation while their child is in inpatient treatment will help maintain the child’s gains during
follow-up after discharge. Opportunities for parents to look for:
o
Parent education meetings.
o
Observation of nursing and other professional staff.
o
Opportunities to try helping your child eat while he’s/she’s in the hospital.
o
Discussions with the nutritionist.
o
Parent support groups and therapy.

Day treatment is a good alternative to inpatient treatment – less disruption of regular family life and easier
for parents to be involved in treatment.

Single-parent families are an additional interpersonal therapy focus for the teenager with ED that involves:
o
23
Acknowledging that having a single-parent family is a problem for the teenager
24
o
Addressing feelings of loss, rejection, abandonment, and/or punishment
o
Clarifying expectations for how to relate to the absent parent
o
Negotiating a working relationship with the remaining parent
o
Establishing a relationship with the removed parent, if possible
o
Accepting the permanence of the situation