Int J Adolesc Med Health 2002;14(2):269-274.
©Freund Publishing House Ltd.
The treatment of eating disorders as addiction among
adolescent females
Arthur S. Trotzky, Ph.D
The Israel Counseling and Treatment Center of the North, Kiryat Bialik, Israel
Abstract: As science and medicine enter the new millennium, the influences of genetics and
neurochemistry as high-risk determinants in the etiology and development of eating disorders are
increasingly manifest in professional literature. Eating disorders are now recognized as major medical
and psychiatric problems affecting millions throughout the world. Psychoeducational, cognitive,
behavioral, and psychopharmacologic treatments form the basis of most interventions which, for the
most part, tend to view the eating disorder as a symptom of underlying psychopathology. The Israel
Counseling and Treatment Center of the North has been treating eating disorders as addictive disease
by applying the twelve step program of the Anonymous Fellowships as an adjunct to counseling and
treatment for those who suffer from compulsive overeating and bulimia. Following the ongoing
program of interventions with adults, a counseling group for adolescent females was co-facilitated
under the supervision of the author. A co-therapist, in recovery from bulimia and compulsive
overeating, uses the twelve step philosophy and served as a role model in this group intervention.
Another sample of adolescent females was offered individual counseling adhering to the same
addiction treatment approach. Success rates were operationally defined and measured by weight loss
in the obese population and the cessation of purging behaviors among bulimic subjects for a sixmonth period. The two adolescent treatment samples had success rates of 62% and 33% respectively.
A higher success rate of 71% was observed with adult bulimic females who participated in group
counseling. A mean weight loss of 3.9 kg for the small sample of adolescents and a 9.7 kg. mean
weight loss for obese adults in treatment was reported. The theoretical basis of the addiction treatment
paradigm for eating disorders is presented. Results and problems encountered specific to treating the
adolescent population are discussed
Key words: obesity, eating disorders, bulimia, food addiction, eating addictions, Israel
Correspondence: Arthur S. Trotzky, PhD, The Israel Counseling and Treatment Center of the North,
140/27 Derech Acco, IL-27236 Kiryat Bialik, Israel. Tel: 972-4-8738021. Fax: 972-4-9530023.
E-mail: dr@trotzky.com. Website: www.trotzky.com
Submitted: January 01, 2002. Revised: January 04, 2002. Accepted: January 05, 2002.
INTRODUCTION
Many of the approaches to the treatment of
eating disorders are derived from traditional
psychological theories and systems, and
offer cognitive and behavioral interventions
as therapeutic methods for dealing with
these compulsive behaviors (1,2,3). Early
patient histories and unconscious motivations have often been presented as primary
determinants in the etiology of the eating
disorder and the consequential obesity
(4,5). Recent research has suggested a
genetic and familial predisposition in the
development of anorexia and bulimia
(6,7,8).
Certain foods have been found to affect
the neurochemical balances in areas of the
brain and, in certain individuals, certain
foods can create a craving for more in a
similar manner in which alcohol can create
2
EATING DISORDERS AS ADDICTION
craving in the alcoholic (9,10,11). Some
attention has been given to compulsive sex
and dependency in love and relationships as
other manifestations of addictive disease
displaying etiology comparable to that of
chemical addictions (12,13). Eating disorders such as anorexia, bulimia, and
compulsive overeating are seen by many
treatment providers as addictions, and
methodologies for intervention are being
adapted from other addiction treatment
paradigms (14,15).
The creation of Alcoholics Anonymous
in 1935 and the twelve-step spiritual
program provided by that fellowship has
greatly influenced the attitudes, moral
values, and theoretical approaches concerning alcoholism and the treatment of that
disease (16). The AA twelve-step program
was formulated in the United States and,
over the years, has expanded to the
treatment of other addictions in numerous
other countries throughout the world (17).
The AA program is being utilized as
adjunct therapy in many rehabilitation
centers and has been adopted by groups
such as: Narcotics Anonymous, Gamblers
Anonymous, Overeaters Anonymous, Eating Disorders Anonymous, Food Addicts
Anonymous, and by many other groups
suffering from other addictions (15,17).
THE ISRAEL COUNSELING AND
TREATMENT CENTER
In 1990, this author became the first
professional in Israel to use the twelve-step
program (18) in a rehabilitation setting. As
the first clinical director of “Gesher
L’Chaim” in Naharihya and “HaDerech” at
Kibbutz Gesher Haziv, I supervised a staff
of recovering addicts and developed a
professional program using this twelve-step
model in treating opiate addiction. In 1994,
the same twelve-step program and treatment approach was incorporated into
treatment interventions at The Israel
Counseling and Treatment Center of the
North. The center, a private outpatient
chemical dependency treatment clinic,
became the first clinic in Israel to treat
compulsive overeating, anorexia, and bulimia as food and eating addictions
following the Minnesota Model of the
United States (19) and the Promis
Rehabilitation Model in England (20).
Since 1994 women suffering from
obesity (n=409) and women suffering from
bulimia (n=169) were treated in small
group settings using the Minnesota twelvestep treatment model. In addition to the
adult treatment groups, adolescent females
(n=12) were receiving individual counseling for their eating disorders.
Because of the successes obtained with
adult groupwork using the addiction model,
it was decided to offer this medium to an
adolescent female population with the hope
of observing comparable results. Outcome
measures were operationally defined and a
group of adolescent females was formed
and underwent the same treatment
condition as the adults. A comparison of the
results is presented as well as a discussion
of the methodology and outcomes. Conclusions
and
recommendations
for
additional research, for further understanding, and for dealing with these
difficult and resistant disorders, are also
discussed.
METHOD, PROCEDURE AND PARTICIPANTS IN OUR STUDY
The participants in this study were all
interviewed and accepted to participate as a
group for the treatment of food and eating
addictions (19,20). The background of each
participant was reviewed. Family, education, army service, health problems, current
medications, and previous therapy was
taken into consideration in order to
eliminate additional diagnosis (21).
Groups were formed with ten
participants and met for a weekly, two-hour
session. The groups were controlled for age
ARTHUR S. TROTZKY
but allowed for both sufferers from bulimia
and compulsive overeating to be in the
same groups, since the theoretical approach
views both disorders as addiction. Adult
groups were on-going with a mean time
participation of seven months nine days,
and were facilitated between 1994-99
(n=578).
The adolescent group was solicited by
advertisement in the newspaper advertisements. Screening was carried out using the
same interview procedure as with the
adults. Two candidates with depression and
childhood trauma were referred to eating
disorders treatment units at the government
hospital offering psychiatric supervision
and were not accepted for the addiction
treatment group. The group (n=10) consisted of adolescent females age sixteen to
eighteen, and fully functioning in the
eleventh and twelfth grades in high school.
The adolescent group was facilitated during
the 1998 –99 academic year for an eightmonth period. During the 1997-99 period,
twelve adolescent females received
individual counseling for eating disorders
using the same addiction treatment
approach.
Between September 1994 and June
1999, 578 adults were treated at the Israel
Center and in order to evaluate the results
of treatment, they were operationally
divided into two groups: Obese (n=409)
and Bulimic (n=169). All subjects in the
obese group had a BMI (Body Mass Index)
greater than 30. All subjects in the bulimic
group were seeking help to stop purging
behavior. At the start of treatment, weights
were obtained and at termination by selfreport. For comparison with the adults and
with a similar age group, adolescent
females in individual counseling (n=12)
were operationally defined as Obese (n=9)
and Bulimic (n=3) using the same methods
as with the adult group members. Mean
weight loss was determined in the obese
groups.
3
Success in the Bulimic group was
defined as cessation of purging behavior for
a six-month period. Percentage rates were
used in comparing results. In order to test
the efficacy of the group model with
adolescents, an advertisement was placed in
September 1998 in a Haifa, Israel weekend
newspaper presenting group therapy for
overweight and/or bulimic females aged 1618 years and using an addition treatment
approach. Respondents were interviewed in
order to assure group cohesion and to
screen for possible emotional problems
requiring psychiatric referral.
The adolescent group (n=10) was
operationally defined as obese (n=8) and
bulimic (n=2). Both the adolescent group
and the adult group were co-facilitated by
an eating disorders counselor who herself
was in recovery from compulsive
overeating and bulimia, and who utilized
the twelve-step program in her recovery.
The same parameters for success and mean
weight loss were used with the adolescent
samples, and percentages were calculated
for comparisons. Both group and individual
counseling were conducted in the same
setting under the auspices of The Israel
Counseling and Treatment Center of The
North in Kiryat Bialik, Israel.
RESULTS FROM OUR STUDY
The results obtained for the adult group
were much better than those obtained from
the intervention with adolescents in
individual treatment (see Table 1.). Weight
loss was greater for adults, as was the
success rate with cessation of purging.
However, results obtained for the
adolescent group, the rate of success, and
weight loss approached those parameters in
the adult group but were not at the same
levels (see Table 2.). A much greater
difference was observed between the
adolescent group and results observed in
adolescent individual treatment (see Table
3.).
Int J Adolesc Med Health 2002;14(2):269-274.
©Freund Publishing House Ltd.
Table 1. Adult group and adolescent individual treatment. The Israel Counseling and
Treatment Center of the North, Kiryat Bialik, Israel.
Group
Numbers
Adults
Bulimic
Adults
Obese
578
169
Adolescent
Bulimic
Adolescent
Obese
12
9
Mean weight Stopped purging
loss in kilograms
Numbers
9.7
121
Success
rate
(%)
71
409
2.5
3
33
3
Table 2. Adult group and adolescent group. The Israel Counseling and Treatment Center of
the North, Kiryat Bialik, Israel.
Group
Numbers
Adults
Bulimic
Adults
Obese
578
169
Adolescent
Bulimic
Adolescent
Obese
10
8
Mean weight Stopped purging
loss in kilograms
Numbers
9.7
121
Success
rate
(%)
71
409
6.0
5
62
2
Table 3. Adolescent group and adolescent individual treatment. The Israel Counseling and
Treatment Center of the North, Kiryat Bialik, Israel.
Group
Numbers
Mean weight loss
in kilograms
Stopped purging
Numbers
Success
rate
(%)
Group
Bulimic
Obese
10
8
2
6.0
5
62
Individual
Bulimic
Obese
12
9
2.5
3
3
3
Int J Adolesc Med Health 2002;14(2):269-274.
DISCUSSION
Results seem to indicate that the addiction
group treatment intervention, which had
been effective in treating compulsive overeating and bulimia in adults, could be
utilized beneficially with an adolescent
population. In addition, the effect of group
intervention produced better results than
individual counseling for adolescent
females in this study. The addiction
treatment paradigm is able to obtain
positive results both in weight loss and in
helping to stop purging behavior in females
suffering from bulimia.
The absence of group influence might
have been a factor distinguishing results
obtained among adolescent treatment
variables. The second step of the twelvestep program emphasizes the importance of
a power other than that of personal suffering, and this certainly applies to influences
of a group (15). Individual treatment did
not provide a recovering food and eating
addict as a co-therapist and model for the
subjects, and her presence might have
contributed to the comparatively better
results observed in the group situation.
In addition to the admission of
powerlessness in step one of the twelve
steps, one must also be aware of the serious
consequences of addiction (15, 22). The
adult population has most likely suffered
consequences of overeating and bulimia to
a greater extent than adolescents, and may
consequentially be more motivated to apply
a recovery program to his or her life.
Since adolescence is a period of selfexpression and self-identification, addictive
thinking (22) may interfere with admission
of powerlessness and the need to rely on
others in order to recover (15).
As the addiction treatment model is
spiritual in nature, (18) differences in
openness and readiness to become involved
in spirituality may also be a determinant of
the differences
©Freund Publishing House Ltd.
CONCLUSION
The use of the twelve steps as adjunct
therapy in the treatment of eating disorders
has generated positive results in this study.
Effectiveness with adult group intervention
has been shown to produce less favorable
but similar results when utilized with
adolescent females. The results of this study
suggest that group intervention with
adolescent females seems to be more
effective than individual therapy in treating
compulsive overeating and bulimia.
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EATING DISORDERS AS ADDICTION
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FURTHER SUGGESTED READING
1. Black C. Double duty, dual identity:
Raised in an alcoholic/dysfunctional
family and food addicted. Denver, Co:
Mac Publishing,1992.
2. Black,C. It will never happen to me.
Denver, Co: Mac Publishing, 1982.
3. Black C. Repeat after me (2nd Ed).
Denver, Co: Mac Publishing, 1995.
4. Carnes PA. Gentle path through the
twelve steps. Minnesota, Minn:
Hazelden, 1993.
5. Christian S. Working with groups to
explore food and body connections.
Minnesota, Minn: Whole Person
Associates, 1996.
6. Cohen MA. French toast for breakfast:
Declaring peace with emotional
eating. California: Gurze, 1995.
7. Roth G. When food is love: Exploring
the relationship between eating and
Iitimacy. New York: Penguin/Plume,
1992.
8. Sacker I. Dying to be thin. New York:
Warner Books, 1987.
9. Twerski A. The thin you within you.
New York: St. Martin’s Griffin, 1997.
10. Twerski A. Waking up just in time.
New York: St. Martin’s Griffin; 1990.