Treatment Notes

What's the "Take Away"?

"How do I get a client to come back after the first session?" I could see the genuine concern in this therapist's eyes as she asked the question. "I see many young men and women who know they cannot go on binging and purging like they do", the therapist went on to say, "but very often, they don't come back after the first session".

Motivation for recovery from an eating disorder is a critical factor for successful treatment. We will discuss ways to facilitate motivation for recovery in a later post. Here is one simple thing you can do to "plant the seed" for continuing care. It's called the "take away factor". Giving your clients something they can bring away with them from their first session allows them to have tangible information to which they can refer as they deliberate the decision of whether or not to commit to treatment. Of course many factors will influence their decision, and for some, the timing may just not be right. But you can offer your clients some "food for thought" that may affect their motivation and "readiness to change" (also a subject for a later post).

Some helpful "take away items" you may wish to consider include:

• an informative brochure about eating disorders (click here for an example of one for purchase from NEDA)
• Eating Disorders Today, a helpful, quarterly newsletter for patients and their loved ones written both by professionals and by those who have recovered from an ED
• a free catalog of books and videos that focus on eating disorders and recovery
• your business card with contact phone number and/or e-mail so they can ask you any questions which may arise in their decision-making process.

Patients and their families will have many questions as they ponder making a commitment to treatment. It may not seem like much, but giving a few "take away" items that address frequently asked questions, provide perspectives about recovery from former patients and their families, and highlight materials that address a wide range of recovery topics can go a long way to helping someone feel as though they have options, direction, initial answers, and hope - a very positive outcome for a first session, and a great way to begin!

For more information, or to suggest a blog topic or ask a question about "Treatment Notes", you can contact the author at mail@drshepp.com.

The New Generation of Eating Disorders

When was the last time you asked your clients about their on-line activity? You know, you really should- especially if they may be at risk for an eating disorder. An estimated 200 million Americans and 700 million people worldwide access the Web for information and two-thirds of Internet users report seeking health-related information on-line. Studies show that more than half of those who search health-related content on the Web are between the ages of 18 and 29. Tens of thousands of websites contain information about eating disorders - many of them, such as www.bulimia.com, provide helpful information to patients and consumers wishing to learn more about these conditions. Unfortunately, many of them do not. In fact, for our new generation of techno-savvy consumers, there is reason for concern.

As I wrote about in a 2007 issue of The Los Angeles Psychologist, (Download l.A. Psychologist article 3-07.pdf), the new millennium has seen a surge of Web content that promotes an eating disorders "counter-culture", one that disseminates inaccurate, misleading, and even dangerously provocative misinformation about these illnesses. You may have heard of them. They are called "pro-ana (pro-anorexia) and pro-mia (pro-bulimia) websites. You may have seen your clients wearing colored bracelets, symbols of their "membership" in these on-line communities - red for pro-ana, purple for pro-mia, green for pro-E.D.-N.O.S., or black, for pro-self-injury. "Surely you can't be serious", you may be thinking. But, sadly, I am.

Visitors to these websites are mostly teenage girls who engage in unhealthy dialog about eating disordered behaviors and the pursuit of "the perfect body". It is not unusual to find images of waif-thin men and women posted for "thin-spiration". Web-hosts of these sites alarmingly promote denial of symptoms, promote eating disorders as a "life-style choice", and encourage hiding eating disordered behavior from family and friends.

A recent study in Pediatrics found that teens who look for eating disorders information on-line are more likely to be hospitalized for their condition than those who do not seek web-based eating disorders information. Perhaps that is because 96% of teens who used pro-E.D. sites reported getting new weight-loss techniques or "tips" about eating disordered behaviors. A study published in the September, 2007 issue of International Journal of Eating Disorders showed that viewers of pro-E.D. websites report lower self-esteem, perceived themselves as heavier, and said that they were more likely to think about their weight in the near future. This was just after a single viewing of these websites! And most of sites are certainly not just innocent attempts at catharsis. Pro-ED web-hosts usually post "disclaimers" to warn visitors that the images and text they see can be "triggering" to those with "food issues".

The "new generation" of eating disorder sufferers may not be as different as they appear. Regardless of new technologies, many of these individuals simply long for connection and community. Unfortunately, too many of them find make-shift communities at these pro-ED websites. As caring professionals, we need to offer them more substantial connections and point them to healthier communities for support. Talk to your clients about their on-line communities. Encourage families to talk about it together as well. And if your clients are pat of the "new generation" of web-users, suggest sites such as www.eatingdisordersblogs.com, www.something-fishy.org, along with two websites hosted by individuals who are recovered after having been a part of the pro-ED community : www.webiteback.com and www.unitedwestarvenomore.com.

Postscript note: In February 2008, in the U.K., 40 MPs signed a motion urging government action against pro-ana sites. The motion was timed to coincide with the UK National Eating Disorder Awareness Week. In April, 2008, a French bill was proposed which would outlaw material which "provokes a person to seek excessive thinness by encouraging prolonged restriction of nourishment".

Anorexia's Extreme Methods

You have undoubtedly heard the statistic before; Anorexia nervosa has the highest mortality rate of any mental illness. Indeed, the premature death rate among people with anorexia is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population (Sullivan, 1995; Park, 2007). What you may not have known is that a large percentage of those deaths do not result from the effects of starvation, but from suicide. In fact, the rate of completed suicides among this population is more than 50 times higher than the expected rate in similar populations that don't have anorexia (Herzog, 2006, Park, 2007).

Until recently, the assumption was that higher rates of suicide among this population were a result of the increased likelihood of completed suicide by those in a severely weakened and malnourished state. Yet a 2008 study released by the University of Vermont revealed disturbing findings which indicate that anorexia patients who attempt suicide tend to use use overwhelmingly lethal methods and do so in conjunction with a low potential for being rescued.

Health-care professional who treat anorexia should be careful to recognize the higher capacity for suicide among these individuals, monitor suicide risk regularly, and be prepared to take appropriate protective action when indicated.

References: Sullivan, P.F. (1995). Mortality Rate in Anorexia nervosa. American Journal of Psychiatry, 152, pp.1073-1074.

Herzog, D. (2006). Eating Disorders: Truth and consequences. In Greenfield, L. Thin (pp.85-86). San Francisco: Chronicle Books.

Park, D.C. (2007). Eating Disorders: A call to arms. American Psychologist, 62(3), p.158.

Do Eating Disorders = Addiction?

True or False: A person with an eating disorder is addicted to food...

The answer is: False

Does that surprise you? One of the most frequently encountered misconceptions about binge eating (also called compulsive overeating by some) is that it constitutes an addiction. We hear patients say this about themselves all the time. Amy (not her real name) sat in my office just this week, Kleenex in hand, stained mascara on her cheeks, and raising her voice through her tears managed to say, "I don't know what my problem is. I eat when I am not even hungry and I can't seem to stop myself. I guess everybody has something, you know? Some people drink or smoke...I guess I must just be addicted to food."

It is true that clinically, many of the behaviors associated with eating disorders and substance abuse appear to be similar: patients report the sense of a loss of control, continue in their behaviors despite repeated attempts to change, may lie about their behaviors to avoid detection, and maintain their maladaptive behaviors despite adverse consequences. Given these observable similarities, it is understandable that many professionals have utilized the chemical dependency model to help explain the cycle of behavior frequently associated with eating disorders. However, there is little empirical support for an addictions-based treatment for eating disorders. To date, research does not support the notion of a biologically based addiction to food. Criteria such as physical tolerance, dependence, and withdrawal are not associated with food substances despite the similarities in observable behaviors among some patients.

Twelve-Step Programs: Should they or shouldn't they?

Over-eaters Anonymous (OA) is one of several twelve-step groups that has emerged over the years that attempts to help people with eating disorders. Some patients report benefit from attending groups such as OA because they provide needed structure and social support. Indeed, some patients have co-occurring substance abuse and may benefit from a twelve-step approach for that reason. However, it should be noted that OA may be contraindicated for patients with bulimia or anorexia. The abstinence model promoted by OA, along with its rigid dietary restrictions, may actually perpetuate the cognitive distortions most commonly associated with eating disorder behavior. Additionally, OA reportedly promotes the belief that "compulsive eating is a progressive illness that can't be cured but can be arrested", an assertion not supported by scientific evidence. While your eating disorder clients may need a safe place to share their thoughts and feelings about food with others who have a shared experience, be cautious to ensure that their involvement in a twelve-step program does not perpetuate the very extremes in thinking that you are seeking to help them overcome.

Welcome to "Treatment Notes"!

Hello and welcome to "Treatment Notes", the blog for professionals who wish to learn more about treating eating disorders. In my many years of speaking with other treatment providers about my work with eating disorders, when it comes those who are not eating disorders specialists, the response that I receive the most about this field of work is, "You know what I do when I get a call from a person with an eating disorder?...I refer out!" Understandable, but in many cases unfortunate.

It is true that many professional training programs do not adequately address the full scope of eating disorders assessment, treatment and prevention - given the breadth of information we receive in our training, it makes sense that there is not enough time to spend thoroughly addressing every treatment issue. Yet the by-product of this lack of information is that we have a whole host of qualified treatment providers who do not feel adequately equipped to address some of the most serious mental illnesses prevalent in our culture today.

Anorexia nervosa has the highest mortality rate of any mental illness. The risks associated with other forms of eating disorders are no less of a concern. Prevalence rates are shockingly high. The field needs more professionals who feel equipped to engage with these individuals, provide to care when they are able, or be an informed member of a comprehensive treatment team.

Is this blog meant to singlehandedly prepare you for the task? Of course not. However, there are many of you who are wanting to learn more about eating disorders, better understand their complexity, and enhance your treatment strategies with these folks. That's the purpose of "Treatment Notes" --- to address treatment considerations for non-specialists who wish to learn more about effective practice  for eating disorders issues.

This blog will share information about various aspects of eating disorders treatment. Things like: how to decide which level of care is appropriate for a patient; how to assess for eating disorder symptoms; what the current literature says about effective treatment; how to involve families in treatment, and so forth. In essence, it will attempt to answer many of the most common "What do I do when...?" questions as they relate to eating disorders treatment.

So, let's get started! I will be posting on various topics over time, but if there is a particular question that you have or a certain area of eating disorders about which you wish to learn more, feel free to contact me at mail@drshepp.com, or post a question to this blog. We'll do our best to address each question, as appropriate. If it is something outside of the scope of this blog, don't worry, I'll let you know that as well and try to direct you to the best resources available in that area.

A few things as we begin...you'll notice that I don't use the words "anorexic" or "bulimic" in my blog posts. That is deliberate. I choose to use terms such as "person with anorexia" or "binge eating disorder patient". Our clients are individuals, separate from their eating disorder, and I prefer not to label them as such. Just my personal preference. Also, (minor point) sometimes I will say patient, sometimes I use the term client. I know that we all come from various disciplines, but please roll with me on that!

Thank you for wanting to help those folks with eating disorders and welcome to "Treatment Notes"!

Treatment Notes

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