BED7787 - SECTION 4: INTERVENTION WITH THE EATING DISORDERED PATIENT
As noted earlier, the primary purpose of this course is to provide the healthcare professional with a solid overview of BED – so that the clinician may operate with some skill and knowledge when presented with a patient exhibiting signs and symptoms of an eating disorder. The primary focus will be on four distinct intervention components: 1) identifying the presence of an eating disorder, 2) assessing the type and severity level of the BED, 3) successfully engaging the patient (and her/his family) in the treatment process, and 4) where warranted, referring the patient to the appropriate level of services, from referral to individual or family therapy with an BED specialist, up to and including hospitalization in an inpatient BED unit.
Within these four intervention components, there are many skills that should already be in the repertory of every clinician. Every clinician should have a fundamental understanding of how to conduct a thorough assessment, for instance, or how to develop a trusting therapeutic relationship with a patient. Because this knowledge base is assumed, we will not spend a great deal of time here covering all of the aspects of each of these intervention areas.
(For clinicians who are uncertain of these foundation skills, or who may wish to review them in preparation for applying the principles of this course, yourceus.com offers a thoughtful and well-constructed overview in "The Fundamentals of Counseling and Treatment: Lessons for Beginning and Experienced Clinicians")
Regarding these four components of intervention, what is more important for the clinician to know is: 1) the specialized knowledge that may not be deduced or assumed from a more general knowledge base, and 2) the ways in which other, more general skills of good practice must be modified when working with an eating disordered patient.
We will begin with the two key elements at the start of the therapeutic work: developing a therapeutic alliance and identification of the BED, with special emphasis on the signs of BED for which clinicians must be on the lookout.
The Clinician's Role and the Therapeutic Alliance
When addressing BED, clinicians may face a complicated array of roles. The healthcare professional who works with BED may have to address simultaneously, or sequentially - depending on the needs of the moment - the patient in question and the family in which the patient lives.
The clinician may need to provide emotional support and guidance to the spouse, family or parents of the eating disordered patient. Simultaneous with lending support to these other parties, the clinician may be trying to engage the patient into entering into a working alliance. Even the clinician whose task will only consist of assessing the ED patient and making a successful referral to an ED specialist will need to be able to engage in the balancing of these different roles.
The clinician's goal in establishing a working alliance would be to establish the proper context for the patient to feel comfortable. The patient needs to know that the goal of the healthcare professional is to be helpful, not necessarily to strip her or him of his eating disorder in a single session. BED has an adaptive function for the patient – and this means addressing defenses and resistance that warrant respect on the part of the clinician.
If patients believe that the clinician wants to rid them of their eating disorder, they may resist and not come back for treatment (especially in the case of the private practice practitioner). If the patient feels that the clinician is interested in the patient’s experience and pain - instead of in removing the problem – he/she may be more inclined to enter into therapeutic alliance.
The context needs to be one of proper trust and appropriate dependency. This context will allow patient and healthcare professional to develop a therapeutic alliance. Once this is done, the patient and the clinician can begin to work unraveling the multiple meanings of the eating disordered behavior, thoughts and feelings.
The healthcare professional needs to figure out, as well, what are the most pressing health issues for which this patient might need immediate attention.
Identification of the Problem and Signs of BED
Unlike patients with AN or BN, patients with BED are likely to be above a normal body weight for their age or height. As we have noted, not all persons who suffer from obesity have BED, however it is sensible to look for – gently and with great sensitivity - indicators of BED in all patients for whom excess weight is an obvious problem. This is particularly relevant if the patient shows evidence of depression, prior emotional, physical or sexual abuse, and some degree of disconnection from their own feelings.
Warning signs of BED that the clinician might want to look for would include the following:
- Rapid weight gain or obesity
- Constant weight fluctuations
- Frequently eats an abnormal amount of food in a short period of time (usually less than two hours)
- Does not use methods to purge food
- Eats rapidly (i.e. frequently chewing without swallowing)
- Feeling a lack of control over one's eating (i.e. unable to stop)
- Eating alone, "secretive eating habits", hiding food, etc.
- Eating late at night
- Eating when not hungry
- Disgust and shame with self after overeating.
- Hoarding food (especially high calorie/junk food)
- Coping with emotional and psychological states such as stress, unhappiness or disappointment by eating.
- Eating large amounts of food without being hungry
- Consuming food to the point of being uncomfortable or even in pain
- Attribute ones successes and failures to weight
- Avoiding social situations especially those involving food.
- Depressed mood
- Anxious mood (131)
Clinicians may also be referred patients by internists who see the following complications - either separate from or in conjunction with observed mental health problems:
- High blood pressure
- High cholesterol
- Kidney disease and/or failure
- Gallbladder disease
- Bone deterioration
- Upper respiratory problems
- Skin disorders
- Menstrual irregularities
- Ovarian abnormalities
- Complications of pregnancy
- Depression, anxiety and other mood disorders
- Suicidal thoughts
- Substance abuse (131)
A healthcare professional needs to assess BED fully, whether in children, adolescents or adults, according to his or her expertise. In order to perform the assessment, the professional may utilize many tools. Some professionals utilize them all, while some others use only some of the tools in this list to make the assessment.
A) Individual face to face interview
B) Family interview
C) Self-administered questionnaires
E) History of Family Functioning (how has the family of the patient functioned as a family), past and present.
F) Stressors: past and present.
G) Medical History
If there are signs and symptoms that suggest the presence of an eating disorder, a comprehensive assessment done by competent clinicians will also need to include:
A) History of body weight
B) History of body dissatisfaction
C) History of dieting
D) History of behaviors intending weight control and the control of physical shape
E) Assessment of patient’s self-perception including, a history of changes in self- perception
F) Assessment of patient’s personality and, a history of psychological functioning. This psychological history needs to include checking for anxiety, depression, suicidal ideation, OCD signs or symptoms, sexual abuse, substance abuse and use of drugs to induce weight loss. It should also include getting familiar with the changes that the eating disorder may have brought on the patient’s basic personality.
During this assessment the healthcare professional needs to assess the patient’s health and mental health individually, as well as the patient's functioning as a family member and his/her ability to have and maintain friendships.
When the patient with BED is a child or adolescent, it may be helpful to gather information from other parties in the patient’s life, typically parents or other family members. The younger patient who has begun an active eating disorder may already be engaged in attempts to keep his or her behaviors secret, so other family members may turn out to be more reliable sources of information.
However, family members may have their own reasons for being resistant, such as fear or shame, and may also engage in attempts to downplay or hide the presence of these indicators. It is important to realize that information provided by a resistant family may contain some of the same distortions as information coming directly from the resistant patient. Until it is clear that the family is able to provide accurate information, an attitude of healthy skepticism is often warranted concerning the comprehensiveness of the information being given.
A quick word here on process. Because these same family members may become important partners in the patient's treatment attempts, great care must be taken during the identification stage not to move forward too forcefully if the family gives clear signals that they are not ready to fully acknowledge the extent of the problem.
Whenever the family has reached the point of acknowledging the problems, the healthcare professional may need to be available to provide support and guidance to the parents of the eating disordered patient.
One key topic to clarify with patients at the beginning of treatment is goals. Some patients come to treatment with goals that are not therapeutically indicated and with which a clinician cannot comply. The patient’s stated goals may be substantially different from those of the clinician.
A patient may want to learn how to eat food with less fat content. He/she may want to learn how to purge in a more efficient manner. He/she may want to find out how to endure more time without eating. Patients may want to learn how to lose more weight or exercise more. They may simply want the clinician to get their families to leave them alone - so they may engage in their binge eating without worries of criticism or condemnation.
However, the patient may not state these more unhealthy goals quite so frankly and directly. They may exist as part of a hidden, personal agenda that the patient partially or completely withholds from the healthcare professional. The clinician may find out in the course of treatment that what the patient wants is not weight restoration or freedom from purging. Although virtually all BED patients endure suffering and want relief from the suffering, many patients may not be able to clearly state a goal for their treatment, past the fact that they have been brought in by family members.
However, patients, sometimes using some help from the healthcare professional, will readily accept that they want to be less obsessed with food, body and weight. Being less obsessed with food, weight and body shape is definitely an important goal to have. The clinician and patient can hold on together to this goal. Many times, this goal is the first purpose that the patient and clinician share together within the treatment partnership.
Successful recovery from serious eating disorders may take from 5 to 7 years.
Source: South Carolina Department of Mental Health
When a clinician is performing an initial evaluation of an eating disordered patient – with the goal of making a successful referral and transfer of care to a BED specialist – it is not always either necessary or advisable to create detailed treatment goals with the patient. The goal can simply consist of a plan to have the patient meet further with someone who is better prepared to address the patient's concerns.
In making a determination of whether to pursue or defer the creation of treatment goals, the assessing clinician must weigh a number of factors. The patient's level of resistance must be carefully considered. The patient's ability to align with the goals of positive change must be examined. The presence of external sources of pressure and support – from family members, for instance – must be factored in.
Additionally, the clinician must be cognizant of his or her own skills or limitations in presenting treatment goals that will support motivation for treatment, so as not to make errors that decrease motivation for treatment. The treatment goals must be presented in a way that increases hope on the part of the patient that the distressing aspects of the patient's disorder can be helped, without excessively evoking the fears of the patient about becoming "fat" or losing the emotional protections that the eating problems represent.
In a manner similar to working with addicted patients, there may be stages of change the patient (and family) need to go through in order to fully engage in treatment. For those clinicians with less familiarity with the concept of stages of change within therapeutic processes, it might be helpful to familiarize yourself with the work of DiClemente and Velasquez in this area. (27) (28) As stated earlier, motivational interviewing is a useful technique for addressing resistance as patients work through these stages of change.
A more detailed look at this subject may also be found in yourceus.com's course, Motivating Substance Abusers through the Stages of Change: A Comprehensive Overview for Mental Health Professionals.
Clinicians must be aware that some patients will engage in complex bargaining behaviors as they sort through their ambivalence about treatment. They may threaten to leave treatment if they have the sense that "unreasonable" demands will be placed upon them in terms of their eating or weight control.
The use of techniques such as motivational interviewing - even at the point of gathering preliminary information - points out the overlap between the different components of intervention. Choices of how forcefully to pursue the gathering of information will affect the capacity to engage the patient in the treatment process.
Similarly, when information is being gathered from the patient, there may be indications that the patient would be receptive to input and/or education from the clinician in some or all of these areas. The clinician must be ready for this possibility, with sufficient knowledge to provide useful education about BED and the change process. This input and education may begin to set the stage for engaging the patient in treatment – and may even start the patient on the road to change.
This is the point at which the clinician must be prepared to enter into discussions with the patient concerning questions of body ideals and the complex socio-cultural factors that were previously noted. These initial discussions will need to be undertaken carefully until there is a clearer sense of the patient's overall emotional landscape. They must also be performed in a careful enough manner that it does not disrupt the development of a therapeutic alliance.
Without treatment, up to 20% of people with serious eating disorders die. With treatment, that number falls to 2-3%.
Source: South Carolina Department of Mental Health
It must always be understood that BED has adaptive functions for the patients who have this problem. Early in the process, the patient needs to know that the goal of the clinician is to be helpful, not necessarily to strip her or him of his eating disorder in one sitting. If patients believe that the healthcare professional wants to rid them of their eating disorder, they may resist and not come back for treatment.
On the other hand, if the patient feels that the clinician is interested in the patient’s experience and pain - instead of in removing the problem – he/she may be more inclined to enter into therapeutic alliance. For this reason, a key goal in terms of establishing a working alliance would be to create the proper context for the patient to feel comfortable. Once this is done, the patient and the clinician can begin to work unraveling the multiple meanings of the eating disordered behaviors, thoughts and feelings.
For younger patients who may present with BED, many times it is the family of the patient who makes the initial contact with the clinician. When working with the family, there is the same need in the early stages of treatment to balance information gathering with creating a therapeutic alliance.
Important decisions also need to be made – based on careful assessment – of how much room the clinician has to provide education and direction to a family early in the process. While some families will welcome information and want to understand the dynamics of an eating disorder, others may only want relief of symptoms and nothing to do with the treatment.
Please note one additional complication during the information gathering process. Because there are serious health problems attendant to BED, the clinician also needs to be gathering as much information as possible concerning the most pressing health issues for which the patient might need attention.
If the family is available and willing to work with the clinician, it may be able to provide more accurate healthcare information and help facilitate coordination with the patient's other healthcare provides for purposes of gathering information and providing needed care.
The skill and care with which the clinician handles this initial dialogue may begin the work of reshaping the patient's emotional landscape – even in the course of the first discussions pursuant to gathering evidence of eating concerns. On a larger scale, it will also be an introduction to the treatment process itself. The patient - and/or the family - will have an opportunity to see whether the treatment process is safe and helpful.
When some therapeutic trust has been established, and where the clinician requires somewhat more objective information about whether an eating disorder may be present, it may be helpful to consider the use of a tool specifically designed to determine the presence of an eating disorder.
However, if the patient demonstrates clear and strong resistance to even acknowledging the possibility of an eating disorder, both the timing and process of introducing these kinds of tools must be considered with great care. The need to develop a trusting therapeutic alliance must generally take precedence over depth and speed of information gathering.
Obviously, the clinician will be in a different position if she or he is a member of a team in a hospital or at an institute that specializes in working with BED than if he is in a group or solo private practice. In the first instance the clinician will have available - for both supportive and information gathering purposes - other team members, such as the psychiatrist, the psychologist, the intake nurse, other nurses in the unit if the patient is hospitalized, as well as the treating medical doctor.
On the other hand, as a solo practitioner, the treating professional would be in charge of all of the information coordination. The solo practitioner would also need to have in place ongoing resources and a referral system. Cases may range from the very mild to the very severe, where medical care might be required and referrals might need to be made fairly quickly.
With treatment, about 60% of people with eating disorders recover, and another 20% partially recover.
Source: South Carolina Department of Mental Health
As in the case of patients with substance abuse problems, patients with BED may be seen as moving through early, middle and late stages of the disorder. Unfortunately, many patients do not appear for any kind of treatment until the eating disorder has moved out of the early stage.
It is important for clinicians to know the early signs of BED, before it is too late. Detecting early signs of BED may make a huge difference in the prognosis of a patient. Studies show that early intervention in eating disorders yields more benefits than later intervention. (73) According to research, the longer an eating disorder goes on, the worse prognosis it holds. (However, as an alternate view on this issue, some studies maintain that BED runs its own course and dissipates in time.) (32)
A useful analogy when talking about early versus late intervention is the following: early intervention may viewed as saving someone from drowning in a raging ocean by stopping him or her when s/he is beginning to walk towards the water or before the water reaches his/her knees versus retrieving someone half-drowned among the high waves (late intervention).
Those who suffer from BED may act secretively, and may actively hide signs and symptoms from caretakers, except of course from obesity which may be the most obvious sign. However, it is important to repeat that not all obese individuals suffer from BED.
It is important to remember that the signs of trouble may not be apparent at first sight. However, there are trails that healthcare professionals can follow – that may help parents follow, too - to possibly help prevent the development of BED early in its inception.
Teenagers and pre-teens - before developing a full-blown eating disorder – will usually show a pattern of behaviors that may indicate the beginning of BED. Because mothers and fathers have different and unique influences when it comes to the concern of overweight teenagers, programs for intervention should target the relationship between the adolescent and the parent. (5)
Furthermore, it seems that when dealing with the assessment of binge eating in children, what needs to be taken into consideration - more than the amount of food eaten - is the feeling of being out of control that the child or youth may experience. Teenagers and children, according to this study, also eat when they are not hungry and they eat in response to emotions. (76)
Evaluation of the Level of Care Needed
When a patient comes to see you with an active eating disorder, one of the important decisions that may need to be made will involve a determination of the appropriate level of care. Typically, there will be a choice of five different levels of care: 1) Outpatient treatment with a BED specialist/group/program; 2) Intensive outpatient treatment, typically with a group or program that specializes in BED; 3) Full-day outpatient treatment; 4) Residential treatment; 5) In-patient hospitalization.
Decisions about level of care will be based upon several considerations. The most intensive levels of treatment for BED are typically reserved for patients whose binge eating has resulted in a degree of obesity that has become life threatening or disabling. There have been some publicized cases of patients whose weight has reached or exceeded 1000 pounds, and who are no longer able to get out of bed without assistance. In such instances, hospitalization is necessary during treatment for health and safety reasons.
About 80% of girls/women who have accessed mental health services do not get the intensity of treatment they need to stay in recovery.
Source: South Carolina Department of Mental Health
Patients whose BED creates other kinds of major health problems, i.e., diabetes or serious cardiac problems, and who are unable to control their binge eating with outpatient levels of support, may also be good candidates for more intensive levels of care. Such determinations would usually be made through the joint efforts of the patient's supervising physician and the clinician.
There is clearly a correlation between a person's weight and an increased risk of these kinds of health problems. However, the weight at which different individuals will begin to have life and health threatening medical problems can vary. Genetic predisposition towards health problems must be factored in, as well as other historical elements, such as the amount of "yo-yo" dieting in which the person may have engaged.
This means that the assessment process around level of care will need to be conducted with care and knowledge – and with appropriate consultation from and coordination with medical personnel who can conduct thorough health based examinations.
Another group of patients that would typically require a higher level of care would be those patients who present with other co-morbid factors that alone would usually require a higher level of care. This might include such problems as obsessive-compulsive disorder, substance abuse, severe anxiety or depression, suicidal or homicidal features, etc.
Motivation for treatment is also an important factor that is considered when making decisions about level of care. Regular outpatient treatment should be considered only when the motivation for treatment is considered good to fair. As the level of motivation decreases, then progressively higher levels of care would be indicated.
Engaging the BED Patient in Treatment
There are some complications about engaging the BED patient in treatment. First, binge eating behaviors may be very deeply engrained in the patient. If, as our best current theories propose, these behaviors serve important emotional and psychological purposes, the patient can be resistant to attempts at change.
Second, body size, body image, and disordered eating behaviors can be the source of a great deal of personal shame. Patients may have a great deal of reluctance about discussing their eating problems, and may prefer to keep the focus on other problems in their life that are less shame filled.
The ramifications of this are important. The process of engaging the patient in treatment must begin from the very first point of contact, even as one is still gathering information. The patient's resistances and defenses must be seen and understood quickly, and efforts at engaging the patient must work within the comfort zone of the patient until a solid therapeutic relationship can be formed.
One of the important building blocks of this process will consist of exploring and increasing the patient's internal motivation for change. This will not – in all likelihood – be a simple and straightforward process. From the very beginning of this course, we have noted that BED is a complex, multi-layered illness, with numerous components that factor into the patient's emotional landscape in complicated ways. Any of these components may present us with an opportunity to engage the patient and increase commitment to positive change.
However, because we do not know which specific components may present us with a "teachable moment" at which particular point in time, we must have some degree of preparation to handle them all. The information presented to this point in the course has been in preparation for understanding the "what" of this process.
In a later section, we will also provide some information about the "how" of this process, by presenting some actual dialogue that may be used by a clinician in discussions with an eating disordered patient.
Some of the information shown in the section below – and the chapter on treatment to follow - would be more likely to be incorporated into the longer term work performed by a specialist in BED, as part of the ongoing treatment. However, as stated earlier, clinicians cannot predict when there will be opening for a “teachable moment.” The successful use of the teachable moments may make the difference between a patient engaging in treatment or dropping out of treatment. This is one reason that we will include this more comprehensive presentation of material.
Unfortunately, because BED as a separate diagnostic entity is still relatively new, there is no well established, evidenced-based treatment for BED patients as of yet. Research is still trying to determine which method or combination of methods is the most effective in controlling binge eating disorder.
Please note that one of the complicating factors in determining the appropriate treatment for BED is that this disorder is likely to occur in conjunction with a number of other emotional/psychological problems. As was stated much earlier, there is a very high degree of co-morbidity between BED and various depressive and affective disorders. There is also a great deal of evidence linking family dysfunction and various forms of childhood neglect and abuse with BED.
In the next section, we will cover in more detail treatment approaches that are typically used with BED. The most common intervention used for BED patients is a combination of the following:
A. Cognitive behavioral therapy, in which patients are taught skills in reshaping their thinking and encouraged to develop more effective behaviors in order to change the way they respond to difficult and stressful situations.
B. Interpersonal psychotherapy: Method in which the patient is taught to examine their relationships with friends and family and to make changes in problem areas.
C. Medications: Antidepressants may be helpful for some individuals.
D. Self-help groups: These groups may be a good additional source of support for many.
Additionally, some medical treatments that target obesity, including the use of bariatric surgery, will be noted and discussed.
If unhealthy eating patterns develop as an attempt to respond in some adaptive way to these other emotional/psychological issues, then treatment for BED must ultimately address these underlying issues - in addition to targeting the eating patterns that may pose health risks long-term. Otherwise, the patient is likely to relapse and the binge eating is likely to recur.
Conversely, however, even if the underlying emotional and psychological issues are improved, this does not necessarily lead to an easy remittance of the binge eating tendencies. Once established as a mode of providing emotional comfort or nurturance, binge eating can be extremely persistent as a habitual or compulsive behavior. A variety of approaches for targeting habitual behaviors may be needed to address just the eating aspects of this problem.
Additionally, the presence of extra weight on a person's body may also increase the persistence of the binge eating behaviors, both because of changes in body chemistry due to obesity and the psychological complications of living in a culture that champions and celebrates thinness. For this reason, many clinicians working with BED, opt for a weight reduction treatment as a first step in targeting the problems.
The bad news on this front is that regardless of what approach these weight loss treatments do take, they have not shown a significant differential outcome between binge eaters and non-binge eaters.
It is also important to note a few facts about treatment targeting weight loss for binge eaters. Some studies suggest that that binge eaters are more apt than non binge eaters to drop out of their treatment and regain the weight. (141) However, other studies found that binge eaters and non binge eaters have similar levels of drop out from treatment.
To complicate matters further, one study found the reverse phenomenon. It found that BED status among women predicted that the patients would stick with the program. (53)
As has been noted, among the favorite treatments modalities the most common strategies were cognitive behavioral therapy, low calorie diets and appropriate pharmacology, utilizing - for the most part – antidepressants, such as SSRIs. Less commonly, behavioral therapy and interpersonal psychotherapy are used. Within cognitive behavioral therapy, the most used modalities were journals in which patients could self-monitor their food intake and their eating behavior. However, weight was not what was self-monitored.
Other approaches have included education and targeted skill building, in which patients were taught how to deal stressful situations, while taught alternative ways of dealing with stress. Another important part of their learning was how to deal with stimulus control: the intake of regular meals without forgetting what they might consider forbidden foods. Goal setting and self-reinforcement was also part of cognitive behavioral therapy. (25)
In essence, the treatments focused not on weight per se, but rather on binge eating as a disordered behavior. What patients reported was not lost weight but the frequency of binge eating. Patients reported reductions in the frequency of binge eating from 44 to 94 % and seven day abstinence rates from 28 to 80 % for those in active treatment. (25)
There are two other items of note to mention here. Treatment lengths were brief, from 10 to 16 sessions. Furthermore, there may be a difference in outcomes between group treatment and individual treatment. (25)
However, the outcome on weight loss on these studies is not encouraging and the gains made in terms of weight loss are not well maintained. There are many possible reasons why such high weight gain rates were noted in these studies. One plausible cause is that when the patients do not lose weight as they intended, they may re-start dieting once treatment is completed. As we have noted, there is evidence of a complex relationship between dieting and bingeing. A return to unhealthy or harsh modes of dieting may lead to a return of bingeing behaviors.
Another possibility is that patients were successful in reducing their binge eating behaviors, but regained weight without returning to the previous rates of bingeing. In other words, the BED was somewhat successfully addressed, but the success did not translate into weight maintenance – only improvement in terms of decreased bingeing.
This is one of the difficult issues in terms of treating BED. Is treatment successful with a reduction in bingeing – even if the patient does not significantly reduce his/her weight – or should outcome measures look at the patient's weight as the most objective indicator of success in treatment?
In the opinion of these authors, weight loss is not a criterion for successful completion of BED treatment - since people are endowed with different genetics as far as metabolism and the ability to lose weight. If the BED has decreased and the patient is eating more normally, then the problem is addressed from a psychological point of view.
Around the question of weight loss, there are other approaches that are commonly used when treating patients with BED in order to further weight loss efforts. These interventions are: Pharmacological. (31) (14), psychological (126) (129) and surgical (78)
What researchers do not know yet, is if these treatments work directly on BED or, if they work because they act at the level of appetite and/or eating patterns. (59)
One study at least has established that adding a routine of exercising to CBT in the treatment of binge eating is beneficial. In this study patients were encouraged to visit a gym for four months, twice a week. The results of this study suggest that joint CBT and exercising and extending the length of the treatment of patients enhances the outcome of the treatment. The enhancement consists in both decreasing BMI and binge eating behavior in patients. (88)
Making a Successful Referral
Once a clinician has completed a thorough assessment of the eating disordered patient and established enough of a therapeutic rapport to draw the patient into the treatment process, the clinician should be in an advantageous position to determine whether a referral to a BED specialist or BED program is warranted. If the clinician has the level of skill to incorporate best practices treatment approaches for BED into the overall treatment strategy for the patient, he or she may elect to continue working with the patient.
However, if the clinician does not feel that he/she has the appropriate level of skill, or if the patient's presenting problems with BED are serious enough to require the use of a BED specialist, a referral should be made. The transfer of this kind of case must be handled with care.
It is important to note that the time of transfer can be risky in terms of holding on to and solidifying the patient's commitment to treatment. Whereas the typical patient may have a certain measure of ambivalence about engaging in treatment, the eating disordered patient may present with a very serious level of ambivalence - if not outright resistance to or refusal for treatment.
The ambivalence may take the form of the patient looking for any excuse to discontinue the treatment process – and the "abandonment" of the patient by the referring clinician in order to make an appropriate referral may serve as just such an excuse.
For this reason, the clinician must proceed cautiously and with a great deal of knowledge and planning. The patient's feelings of abandonment and fears about beginning over with a new clinician or program must be addressed in a manner that reassures the patient and exudes confidence about the ability to effectuate a smooth transfer of care.
The clinician must always be prepared to answer any of the patient's legitimate questions about the treatment that will likely be provided by the specialist or BED program. This requires some knowledge on the part of the referring clinician about the treatment providers that will be taking over the care of the patient: what their approach might be, what their expectations might be for the patient around eating, use of a nutritionist, medication protocols, etc. It also requires some knowledge about how such practical matters as insurance might be handled.
However, the clinician must be prepared for the emergence of resistance and ambivalence as the questions are asked and as information is provided to the patient. There should be a clear focus on siding with and championing the parts of the patient that want to get better, with implied confidence concerning the patient's ability to utilize the ongoing services, and the success of an overall treatment approach.
The clinician must ultimately strike a delicate balance between providing some accurate information about what ongoing treatment might entail, and not giving so much detail that the patient feels threatened by the changes that will be sought in terms of his or her relationship with food, thereby fueling his or her ambivalence about change. If the clinician errs on the side of providing too much detail, the patient may choose not to follow through with the referral. If the clinician omits too much of what may occur in treatment, the patient may later feel betrayed as the full extent of the treatment program is revealed.
If the clinician has been successful in engaging the patient in treatment and building a generally trusting relationship as the assessment process has unfolded, it provides some level of protection against problems in this area. Still, the clinician must not let his or her attention and commitment wane as the transfer proceeds forward. Releases must be signed, contact must be made with the parties who will provide specialized treatment, and follow-up must be conducted with the patient to trouble shoot and make sure that the patient follows through with ongoing care.
If a referral is necessary, an excellent resource for BED specialists may be found at the Eating Disorder Referral and Information Center.
(International Eating Disorder Referral Organization Binge Eating Disorder http://www.edreferral.com/binge_eating_disorder.htm )
Factors to Consider When Making a Referral
If a clinician is electing to refer a BED patient 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 patient being referred:
1) Treatment style: the specialist 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 patient's cultural background, subculture, gender, religion, family and social relationships, age and developmental factors, and other contextual issues)
3) The patient's actual response to the treatment approaches being applied (with an understanding to alter approaches based upon treatment success or failure for the specific patient in question)
In order for treatment to be effective, patients 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 patient is extremely important.
Typically, retention in treatment is dependent on a combination of factors including program, clinician, and patient 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.
- Is the program short-term or long-term - based upon needs of patients?
- Is the program part of an eating disorder clinic?
- Is the program part of a dieting program only?
- Does the program work with the appropriate age and sex of the patient?
- Are there other BED patients?
- Do they put together BED BN and AN patients?
- Is the program set up to be culturally sensitive to needs of patients?
- Does the program have flexibility in its schedule to accommodate scheduling needs of patients' 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?
- Are the clinicians who provide services skilled, experienced and knowledgeable in providing treatment for BED 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 patients?
- Do the clinicians have skills, knowledge and experience in handling relevant psychosocial or medical issues in addition to the BED?
- Do the clinicians in the treatment team work well collaboratively, supporting one another in following the treatment plan?
- Does the patient have long-standing or severe problems that may require more intensive or long-term treatment?
- Does the patient have other significant dual-diagnosis treatment issues that require specific program needs?
- Does the patient have work and/or home issues that may interfere with the course of treatment, such as the presence of severe triggers?
- Does the patient have any medical issues that may affect treatment or the maintenance of improved eating and weight control issues?
- Does the patient have any cultural or disability issues that may create barriers to treatment?
- Is the patient disabled by obesity?
The next section will provide the clinician with some general information about what the treatment process may look like, including the major models for working with eating disordered patients. This base of information should help the referring clinician be better prepared to handle some of the challenges of the referral process, or to incorporate a more targeted knowledge base into the treatment process.