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ABN8595 - SECTION 6: THE TREATMENT PROCESS

 

Overview of the Components of Treatment

As we have previously noted, the role of most of the clinicians taking this course will involve assessment and referral of the eating disordered client. A successful referral, or transfer of care, to either a specialist in eating disorders or to an eating disorders program will require that the referring clinician have some knowledge about the treatment program and services that will likely be offered to the client.

We will therefore begin to inform the clinician on this arena with a general overview of services that the eating disordered client can likely expect as a part of an overall treatment plan. We will then go into some more detail on various aspects of this overall treatment plan.

Different specialists and different eating disorders programs will provide a range of services incorporating a number of different theoretical orientations. The informed clinician will have a clear sense of: 1) What the different models of treatment are; 2) Which of those treatment models represent best practices from an evidenced based standpoint (i.e., have they been validated as effective by the most recent research; 3) Which treatment approaches have been proven to be most effective for which types and levels of eating disorders, including those that exist with co-morbid conditions.

Treatment with the eating disordered client will generally include a number of different components, such as:

1) Individual therapy

2) Family therapy and/or contact/education

3) Group therapy and/or peer support

4) Nutritional/dietary counseling

5) Medication and medication management

If the client's weight has reached a point where it is potentially threatening to the client's life or health, treatment may include some additional and more intrusive components:

6) Medical supervision

7) Involuntary feeding

 Clients with co-morbid disorders may also receive additional services to target those problems 

8) 12-step support for substance abuse problems

9) Other supportive services as needed

 

Decisions about what components of treatment to include will be based upon factors such as the client's pathology, body weight, health and motivation for treatment. The decision to involve family or other adjunctive parties will be determined by whether such activities are seen as supportive or destructive to overall treatment.

 

Eating Disorders Factoid

Young girls have indicated in surveys that they are more afraid of becoming fat than they are of cancer, nuclear war, or losing their parents.                                    

Source: National Eating Disorders Information Centre of Canada (Citing Berzins, L, Dying to be thin: the prevention of eating disorders and the role of federal policy, an APA co-sponsored congressional briefing, 1997)

 

Factors that Create Successful Treatment

When referring a client for specialized services, the referring clinician has to factor in several additional elements that will determine whether the specialist or treatment facility will be the right fit for the client being referred:

1) Treatment style: the therapist or treatment team needs to feel comfortable and familiar with the chosen method.

2) It is important to take into account the context in which the eating disorder is taking place (including the client's cultural background, subculture, gender, religion, family and social relationships, age and developmental factors, and other contextual issues)

3) The client's actual response to the treatment approaches being applied (with an understanding to alter approaches based upon treatment success or failure for the specific client in question)

In order for treatment to be effective, clients must be successfully engaged in treatment, and they must be willing to remain in treatment for a sufficient amount of time that positive change can be created. This means that the choice of a clinician or program for the eating disordered client is extremely important. 

Typically, retention in treatment is dependent on a combination of factors including program, therapist, and client characteristics, and these variables need to be addressed in any type of treatment, perhaps taking into consideration the following items that help determine the "fit" of the program.

 

Program

Is the program short-term or long-term - based upon needs of clients? 

Does the program work with the appropriate age and sex of the client? 

Is the program set up to be culturally sensitive to needs of clients? 

Does the program have flexibility in its schedule to accommodate scheduling needs of clients' work and home life?

Does the program address relevant psychosocial or medical issues in addition to the primary problems? 

Does the program offer a variety of approaches to the clinical problems, with flexibility in designing individualized treatment plans? 

Does the program offer flexibility in terms of fees and payment, so that the program will be affordable?

Therapist(s)

Are the clinicians who provide services skilled, experienced and knowledgeable in providing treatment for eating disorders and in handling problems with resistance and lack of motivation? 

Are the clinicians culturally sensitive in their approaches?

Are the clinicians able to demonstrate flexibility in their approaches to handle the changing circumstances and treatment needs of the clients?

Do the clinicians have skills, knowledge and experience in handling relevant psychosocial or medical issues in addition to the eating disorders?

Do the clinicians in the treatment team work well collaboratively, supporting one another in following the treatment plan?

 

Client

Does the client have long-standing or severe problems that may require more intensive or long-term treatment?

Does the client have other significant dual-diagnosis treatment issues that require specific program needs?

Does the client have work and/or home issues that may interfere with the course of treatment, such as the presence of severe triggers?

Does the client have any medical issues that may affect treatment or the maintenance of improved eating and weight control issues?

Does the client have any cultural or disability issues that may create barriers to treatment? 

 

Eating Disorders Factoid

Only about 1 in 10 people with eating disorders receive treatment.

Source: South Carolina Department of Mental Health

 

Three Major Models of Treatment

There are three major models to the understanding of eating disorders. They will be examined individually for purposes of clarity. As in other areas of mental health, treatment approaches for eating disorders have changed and evolved with the passage of time. More longstanding approaches have been extensively studied and validated by both use and research.

As new understandings arise from research, they are incorporated into the body of knowledge from which clinicians formulate their treatment strategies. Some of the newer – and less well validated – treatment approaches will also be examined in this section.

Please be aware that most eating disorder specialists today use a combination of approaches, predominately based upon two of the three major approaches we will study in this section, i.e. (psychodynamic and cognitive approaches). In applying these two approaches, the clinician understands the conflicts the patient brings psychodynamically, and helps the patient address his or her cognitive distortions, particularly as they relate to body image and the importance of meeting body ideals. 

Please note what will not be covered in this section. Because families represent a vital part of the support system for eating disordered clients – particularly pre-adolescents and adolescents – family therapy is frequently some component of the overall treatment approach. With adults who suffer from eating disorders, treatment may also include couples counseling.

It is assumed that clinicians will have familiarity with both family therapy and couples counseling. For this reason, we will not focus on these modalities in this section.

 

Eating Disorders Factoid

 Americans spend over 40 billion dollars on dieting and diet-related products every year.

Source: National Eating Disorders Association (Citing Smolak, L. National Eating Disorders Association/Next Door Neighbors Puppet Guide Book.)

 

The Psychodynamic Model

A psychodynamic understanding of eating disorders understands the problems primarily as signs and symptoms of internal turmoil and conflicts. The roots of this approach go back in time to the early days of psychoanalysis and the work of Sigmund Freud. However, Freud's original conceptualization has of course evolved, as later research and newer schools of thinking have modified some of the key principles from his original theories.

Psychodynamic understandings of eating disorders today, like traditional psychoanalysis in the past, emphasize that symptoms are expressions of inner conflict. Modern psychoanalysis, however, does not see instinctual life as the predominant driving force in human conflicts. 

Depending on the orientation, and school of thought, an eating disorder may be viewed as arising from the following scenarios:

 

  1. A) Needs that went unmet may – at a later time - give place to eating disorders. This could be represented, for instance, by the subset of housewives who stayed home, cut off from their real needs, a sense of meaning and purpose, and from larger communities that could provide support.
  1. B) Conflict about dependency needs. Eating disorders, according to this view, would be an outcome of premature and forced independence. Some feminist psychoanalytic thinkers believe that certain women (and men in a different manner) have been thrust into premature emotional independence, before they were ready to handle the difficulties of handling complex adolescent or adult challenges on their own.

 

This premature emotional independence, according to this view, may be responsible for many emotional and psychological problems of both women and men.

  1. C) A woman’s or a man’s conflict about his or her role in our society. This could be represented by the men who in the last decade are faced with more fluid and less stereotypical roles than they had in the past, yet feel more pressured and less certain about their social role.

A Psychodynamic understanding of eating disorders still believes that  . Food and body have unconscious meanings. For this model, it is necessary to understand such meanings – and reduce or remove the conflicts - in order to relate to body and food freely. 

In this model, it is not a specific food that makes a person binge or starve; it is the meaning of the food and the meaning of eating or not eating that drives the person to engage in the dysfunctional action. In other words, the food itself is not what is addictive; rather the meaning of the food - and the act of eating, not eating, purging, chewing and spitting, hoarding food, bingeing that - drives the unconscious choice of actions.

Unconsciously, eating could become a forbidden action or an overly satisfying action. When it is performed it becomes either a binge, or a total avoidance of food, depending on the disorder and what the patient is expressing though it.

A modern psychodynamic understanding of eating disorders includes the role of gender, society and context. The therapeutic work, however, still lies in the uncovering and reconfiguring of the unconscious thoughts and conflicts with regard to the eating disorder.

  

Eating Disorders Factoid

91% of women recently surveyed on a college campus had attempted to control their weight through dieting; 22% dieted "often" or "always".

Source: National Institute of Mental Health (Citing Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3))

 

 

Cognitive Behavioral Model

The cognitive behavioral model emphasizes changing the eating disordered behavior through addressing the thought patterns that underlie both the uncomfortable feeling states of the client and the maladaptive behaviors. A pure cognitive model is not interested in the unconscious meaning of eating, body, or self.

According to this model, attitudes about food and body image are changed by addressing the cognitions that prompt the disordered thoughts, unhealthy feelings, and choices of behaviors.

The following are some of the cognitive distortions addressed by cognitive behavioral therapy:

Dichotomous thinking (black and white thinking): i.e., if I eat one cookie or one slice of pizza, I can binge because I ruined the whole day. 

Personalization: i.e., they are all looking at me because I am flabby and fat and out of shape.

Catastrophysing: i.e., if I lose control one time, I am a loser and an out of control person.

Magnification: i.e., when I cannot eat exactly what have planned for a meal, my life is ruined.

Arbitrary Inference: i.e., people who are thin get the nice boyfriends so I need to be thin to get a nice boyfriend.

Overgeneralization: i.e., If I don’t eat healthy I will get cancer like uncle x who ate a lot of fat in his diet.

Superstitious Thinking: i.e., if I don’t do my 200 abdominals everyday there will be a horrible consequence coming.

In this model, the therapist helps the patient by reframing her thoughts. The patient learns how to approach food in a calm and prescribed manner. The patient learns how to talk herself out of thoughts that set her up to eat in an unhealthy manner either before eating, or while she is in the middle of a binge or restraining.

Cognitive therapy has proved to be very efficient with bulimic individuals, especially during the beginning of therapy. It helps individuals stop the binge and purge cycle faster than other models.

A recent variant and extension of CBT called Dialectical Behavioral Therapy is currently receiving study for use in treating eating disorders, particularly with regard to Bulimia. This treatment approach, developed by Marsha Linehan (66) - originally for use with Borderline Personality Disorder – has shown some promise in work with bulimic clients. (81)

This approach combines elements of cognitive behavioral therapy with interpersonal skill building, increasing tolerance for distress, and targeted work on the development of better emotional self-regulation, incorporating the use of a technique called "mindfulness". Mindfulness is a gentle and supportive approach for learning how to remain in the present – even when that present is painful due to intense emotional material - and is helpful to people with emotional dysregulation in terms of minimizing defensiveness and maximizing a sense of self-efficacy.

Because the research has not yet provided conclusive evidence of the effectiveness of this approach for work with eating disorders, but still is in the investigative stage, it should not be considered in the mainstream of treatment approaches. However, DBT has been reasonably well validated for work with Borderline Personality Disorders (BPD). Since there is a considerable amount of overlap between BPD and eating disorders, DBT should be considered a valid option for eating disordered clients who also exhibit BPD.

 

Eating Disorders Factoid

13% of high school girls engage in purging behaviors, such as self-induced vomiting or laxative use.

Source: Academy for Eating Disorders (Citing Maine, M Body Wars: Making Peace with Eating Disorders,2000, Gurze Books.)

 

Disease Addiction Model

This model has been in place for Alcoholics since the 1920s. Overeaters Anonymous uses the same principles as Alcoholics Anonymous, including the use of a 12-step approach. Overeaters Anonymous helps people with eating disorders deal with their compulsivity with food by helping them gain control. Additionally, many treatment programs that offered inpatient and intensive outpatient substance abuse services extended their approaches to clients with AN and BN.

For clients with BN or Binge Eating Disorders, this model views food as an addictive substance, and asks people to stay away from particular foods that are believed to be addictive. According to this model, addictive foods include foods that are high in fat, sugar and carbohydrates. In this model, people with eating disorders are seen as recovering but never fully recovered.

For other clients suffering from AN, this approach focuses on the changes in brain chemistry experienced by the eating disordered client as they withhold food. Some studies suggest that brain chemistry associated with eating – through endogenous opioid receptors - approximates the chemistry seen with the use of addictive substances. Recovery, the theory goes, would then be created through the application of principles used in substance abuse recovery.  

Based upon this theory, researchers have been experimenting with the use of Naltrexone – an alcohol and heroin anti-craving medication that works on the opioid receptor sites in the brain – to address certain of the eating disorders. Some research does suggest that Naltrexone may decrease bingeing and reduce purging in patients with BN, as well as in patients with a bingeing subtype of AN (51).

However, there are weaknesses to this model. First, it was developed to work on narcissistic males who needed to become aware of their shortcomings and of the ways they brought suffering upon others without taking responsibility for it themselves; therefore the model asked them to surrender to a higher power.

This is a different population that the majority of women and men who suffer from eating disorders who, if anything, need to have their self esteem pumped up and realize that everything that happens around them is not their responsibility. By seeing food as an addictive substance, this model does not help people deal with food in any other manner than by avoiding it. This specific model does not deal with the underlying issues that drive people to certain foods, because it views those foods as addictive. 

Overall, the trend appears to be moving away from a primary reliance on models of addiction to treat eating disorders. Outcome studies have been less favorable to this mode of treatment, and the theoretical underpinnings for using this model are unproven and much called into question. (113) 

However, many professionals believe that this approach does hold some useful components that can be incorporated into an overall treatment strategy. In 12-step programs, other people with similar problems – but who are more advanced in their recovery - are available to provide support to those who feel symptomatic at any time of the day or the night. This support reduces social isolation and impedes the ability of the client to engage in distorted thinking about their eating approaches.

There are other components of the addiction model that may have some applicability to work with eating disordered clients. A relapse prevention plan, for instance, is a useful tool for eating disordered clients. This tool helps a client to examine and prepare for events and "triggers" that lead to therapeutic regression. This tool will typically incorporate psychodynamic, cognitive and solution focused approaches as it attempts to provide a supportive structure for the change process.

The use of the relapse prevention plan engages the client in identifying the events or "triggers" that might lead to episodes of bingeing or food restriction. These might be external events, or they might be internal challenges. The patient is encouraged to work with the clinician to develop short-term and long-term solutions that will allow the client to prevent the triggers from setting off unhealthy behavioral choices.

In the process of working on a relapse prevention plan, the clinician is helping to empower the client by having the client name their triggers, understand how their triggers work, and find solutions that protect them from their triggers. There are aspects of this that strongly support the cognitive and behavioral work that is a strong component of the overall treatment approach, in addition to increasing client responsibility for their overall well being. 

For more information on the use of a relapse prevention plan, you may want to go to www.cenaps.com.

Additional Approaches: Interpersonal Therapy 

Another recent addition to the models used to treat eating disorders is Interpersonal Therapy (IPT). This model focuses on the resolution of conflicts in interpersonal relationships. The theory underlying this approach is that much of the emotional distress leading to the development of an eating disorder can be traced back to conflicts in important interpersonal relationships. When skills for managing those interpersonal relationships are improved, the level of emotional distress diminishes, and the client is more easily able to control his or her eating.

Evidence from some controlled clinical trials suggests that IPT may demonstrate some effectiveness in improving the outcome for clients with Bulimia Nervosa. (111, 112)

Additional Approaches: Ego Oriented Individual Therapy

According to Lock & Le Grange, authors of Help your Teenager Beat an Eating Disorder (68), there are concerns about the viability of psychodynamically oriented individual therapy for eating disordered clients. However, there is one type of individual therapy that they recommend as being beneficial to treat patients with eating disorders.

This approach has been developed by Arthur Robin and colleagues at Wayne State University in Detroit. The approach is called ego oriented individual therapy (EOIT). This approach aims at helping adolescents with eating disorders with maturational issues. (92) EOIT focuses on building ego strength, increasing autonomy skills, and increasing insight around a variety of complex maturational issues. 

As we have discussed earlier, the combination of problems held by eating disordered clients may include difficulties in navigating complex feelings and the skills to manage intra-psychic and interpersonal matters around these complex feelings. EOIT may be more helpful in targeting the developmental difficulties that are often exhibited by clients with eating disorders.

A clinical trial comparing family therapy and EOIT showed that family therapy patients did better at the end of treatment. However, one year after, at follow up, there were no differences in how patients were doing in both approaches. In EOIT, parents too, were very involved in their children's treatments, although they were not in charge of their meals or in charge of not allowing them to binge or purge. (92)

 


Eating Disorders Factoid

Research dollars spent on eating disorders for the period up until 2003 averaged $1.20 per affected individual, as opposed to $159.00 per affected individual for schizophrenia.

Source: National Eating Disorders Association (Citing Hoek, H.W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders)

 

The Role of Family Involvement in Treating Eating Disorder

Over the years, there has been considerable disagreement about the role that parents should play in the treatment of children with eating disorders. At times, the philosophy has been to exclude the parents from the treatment, based upon a variety of theories, including one that suggests that eating disorders have arisen from over-enmeshed family systems.

Other clinicians have argued that it is impossible to change the client's disorder without parental involvement. The aforementioned Dr. Lock and Dr. Le Grange would support this position. They advocate for deep involvement from parents during the teenager's treatment. They argue that parents are not asked to abandon their children when they have any other disease, however they say parents are asked to stay on the sidelines when it comes to AN or BN. 

In their book, Dr. Dr. Lock and Dr. Le Grange advocate that young teenagers need their parents to consistently keep with the program of eating healthy when they leave the hospital. Parents, they say, should be on the same page as far as what they expect their teenage child to consume and must firmly ask him or her to do so. This approach is a behavioral approach.

According to Dr. Lock and Dr. Le Grange eating disorders treatment must respond to complicated thoughts, behaviors and even medical complications. Parents should be allies in their adolescent’s treatments because they are the ones that know their child best, and because they are the ones that live with the adolescent after discharge from the hospital. (68)

These authors draw the conclusion from several studies they reviewed. Unlike the family therapy of the 70’s the family therapy the authors propose see nothing pathological with the families. They use the families as experts and allies. Their approach sees families as an important resource.

In their studies, individual therapy was compared to family therapy in 21 teenage girls with AN. In this study the girls were treated either with supportive individual therapy or with family therapy (as both authors understand family therapy).

At the end of one year of outpatient treatment, 90% of the adolescents who received family treatment had a good outcome, as compared to 18% of adolescents who were assigned to individual therapy. In follow up, those who did well after one year maintained their improvements after five years. There were other control trials that also used the Maudsley Family therapy model to treat teenagers with AN. Results were generally consistent with Lock and Le Grange's contention that family approaches are important in working with eating disorders. (92, 62)

Lock & Le Grange believe that psychodynamic psychotherapy is too unstructured for eating disorders. This approach does not have specific goals and may be too lax, according to these authors, for eating disordered patients. As previously noted, they do acknowledge the efficacy of individual therapy when it is structured as EOIT. Studies do support that EOIT can be successful in creating changes within family systems that support progress in eating disorders. (92)

The take home message that the authors would like to give is that parents' involvement in eating disorders is extremely important during treatment.

They also believe that it is extremely important to detect eating disorders as early as possible. It is also paramount that professionals detect medical issues that may be present in an eating disordered patient.

However, the final report card on family therapy versus individual therapy is not yet in. Some research indicates that family therapy may be more effective for early onset and short history anorexia, while individual therapy may be more effective for patients with late-onset anorexia. (24)

Pending further – and more conclusive research – it is probably best for a referring clinician to prepare a client and his/her family for some degree of family involvement in treatment. When a client and his/her family has been successfully engaged in treatment and a successful referral has been made to the eating disorders specialist, additional assessment work can be undertaken to determine the best course of treatment in this area.

 

The Role of Medication in Treating Eating Disorders

Another issue that clinicians may need to prepare clients for is the use of certain kinds of medications in combination with psychotherapy. While it will be the responsibility of the treating clinician or treatment team – after a referral is made - to provide the client with more detailed information about what medications might be used – including when and why – it is important for the referring clinician to be prepared to answer some rudimentary questions about the use of medications as a part of treatment.

To begin with - as we have noted a number of times in this training program - there are many disorders that exist co-morbidly with eating disorders. Mood disorders, anxiety disorders, OCD, and borderline personality disorder are just a few that we have addressed in this regard. When co-morbid conditions exist, medications for those conditions may be prescribed as part of the overall strategy for treating the eating disordered patient.

In such instances, the supervising physician or psychiatrist will be utilizing the medications in much the same manner as for any client that presents with a mood disorder, anxiety disorder, etc. The education provided to the patient would not differ greatly from what would be given if an eating disorder was not present.

However, as Carolyn Costin points out, eating disordered clients frequently struggle with issues of control and low self-esteem. (15) The idea of taking medications presents them with a challenge, as it is an indicator of something being wrong with them, of their having flaws and imperfections. This suggests that the education about the possibility of medications must be approached very carefully and very gently, lest the idea of taking medication scare them away from the treatment that they need.

There are also times when medications may be used to treat the eating disorders directly. This is where some specialized knowledge must be known by the referring clinician. The long and the short of this knowledge is as follows: SSRIs medications – particularly fluoxetine (Prozac) - have been shown to be effective in a reduction of symptoms in Bulimia Nervosa for many patients, but Anorexia Nervosa has been seen as being relatively resistant to treatment with antidepressants. (15)

However, the research on SSRI medication for AN may be somewhat more complex than this. At least one study has shown that SSRIs may be useful for treating AN provided that it is introduced after nutritional rehabilitation and weight restoration has occurred. In such instances, the medication appeared to be effective in preventing a relapse of anorexic behaviors. (56) Another, more recent study, however, produced the opposite result. The study did not find any significant difference between SSRIs and a placebo in terms of relapse prevention for patients with AN. (107)

Other antidepressant medications are sometimes used to treat eating disorders, including the TCAs and the MAOIs. However, the frequency and severity of side-effects for these medications make them less appealing alternatives to the SSRIs, which are generally believed to be at least as effective, with better side effect profiles.

Medications to influence appetite and medications that work on the body's mechanisms for satiety have not been shown to be particularly useful. (15) As previously mentioned, naltrexone is also being explored as a possible approach for reducing the addictive-like elements that occur in AN, with some research indicating some promising potential. (51) Until research is clearer in this area, naltrexone is not likely to be a first line approach for most clinicians who treat eating disorders.

As difficult as this is to consider, it is important for the referring clinician to stay up to date on changes in knowledge concerning the uses of medications for eating disorders, as it is with the uses of medications in other areas of treatment that may involve life threatening circumstances. Because mortality rates are so high with anorexia – and because resistance to treatment can be so strong - there are special obligations to operate with the best knowledge available.

 

Nutritional Counseling

Clinicians need to be prepared to deal with the issue of nutritional counseling when dealing with eating disorder patients. In general patients with eating disorders - especially those who suffer from anorexia nervosa - get very anxious at the thought of using a nutritional counselor. The thought of being mandated how much to eat makes patients who suffer from eating disorders very anxious because it takes away from their main mode of coping.

Different patients will react with varying degrees of discomfort and resistance to the news of nutritional counseling and to the nutritional counseling itself, according to their level of pathology and co-morbidity. However, the referring clinician would do well in remembering that all eating disorders patients use eating - and not eating - as the main strategy to fend off unpleasant feelings and strong emotions.

Most eating disordered clients – at least, in the USA – spend some energy in a struggle with issues of control and feeling fat - no matter their actual weight. The idea of eating in a prescribed manner presents them with a formidable challenge. The amount of the challenge they feel when faced with food is an indicator of their level of pathology. This suggests that the education about the possibility of nutritional counseling needs to be approached very carefully and very gently, lest the idea scare them away from the treatment that they need.

While it will be the responsibility of the treating clinician or treatment team – after a referral is made - to provide the client with more detailed information about nutritional counseling– including when and why and for how long it may be needed – it is important for the referring clinician be prepared to answer some rudimentary questions about how patients may need to eat, what the food intake may be, or if they would need to see a nutritionist as a part of treatment - especially if a the patient will go into an inpatient–eating disorders unit.

Referring clinicians may need to prepare the families to know that the nutritional counselor may ask them a certain level of involvement for the treatment to succeed.

Sometimes, nutritional counseling needs to be used to treat the eating disorders directly and right away, as when anorexics need to gain weight to merely function or when bulimics need to stop the cycle of bingeing and purging. At other times, nutritional counseling can be introduced slowly after the patient has gotten used to the other elements of the inpatient unit.

In many instances, eating disorder centers allow the patients to prepare their own meals and to be involved in the purchasing, preparing and cooking of their meals. Other centers are stricter, and patients need to eat the servings that are prepared for them. In both cases nutritionists need to be prepared to face angry clients who are unhappy with the food choices or the amount of calories the food contains.

The referring therapist will need to explain which kind of center the patient may be going into, if the patient wants to know. Some patients may need to be reassured that they will not be allowed to balloon up. Others might need to be reassured that they will not be allowed to go hungry. Referring clinicians would do well to avoid making promises about any outcomes.

 

The Role of the Nutritionist in Treating Eating Disorders

Another component of treatment that may need to be addressed when referring a client for treatment is what part will be played by a dietician or nutritionist. The referring clinician can help improve the odds of successful treatment by helping patients forge a positive relationship with the nutritional counselor, and avoiding potential pitfalls that may come from the patient's tendency to engage in (in object relations terms) splitting.

Although today, more than ever, many people are interested in healthier eating, the eating disordered patient does not have a clear idea of what healthy eating is. Moreover healthy eating can camouflage disordered eating. Eating disordered patients may need to be given a realistic view of what a regular portion looks like.

They may also need to be educated about the relationship between food intake and their eating problems. This would include agreements that they must eat 3 regular meals and 2 snacks per day, and/or that they must not go more than 3–4 hours without eating. To avoid these rules may mean running the risk of bingeing and feeling out of control. The nutritional counselor will teach patients how to do food exchanges and help them understand what food groups to add or subtract to have definite outcomes as far as energy or satiety goes.

However, the use of a nutritional counselor may also be a tricky addition to the treatment of eating disordered patients, especially in the case of ED NOS, where there is not a clear cut case of AN or BN. Patients who do not suffer from a full blown eating disorder may hide behind the use of a nutritionist to avoid finding out their own likes and dislikes in terms of food. They may also hide behind rules in order to avoid learning about their own physiological rhythms (hunger versus satiety).

Part of recovering from an eating disorder is learning to eat according to one's hunger in a manner respectful of ones physiology and taste. The journey into recovery includes eating in a safe manner that follows no strict rules. The use of a nutritionist is advisable for certain eating disorder cases and only if the nutritional counseling will end up in freeing the patient in terms of food consumption.

A nutritionist dealing with eating disordered patients need to be specialized in this field. It is not advisable to refer eating disordered patients to nutritionists who lack specialization in working with eating disorders.

 

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