Dr. Sarah Ravin - Psychologist | Eating Disorders |Body Image Issues | Depression | Anxiety | Obsessive-Compulsive Disorders | Self-Injury
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Dr. Sarah Ravin

Welcome to my professional blog. I am a Florida Licensed Psychologist and trained scientist-practitioner. In 2008, I received my Ph.D. in clinical psychology. A major component of my professional identity is staying informed about recent developments in the field so that I may provide my clients with scientifically sound information and evidence-based treatment. There is a plethora of information on the internet about Eating Disorders, Depression, Anxiety, Psychotherapy. Unfortunately, much of this information is unsubstantiated and some of it is patently false. It is my hope that by sharing my thoughts and opinions on psychological issues, with scientific research and clinical experience sprinkled in for good measure, I can help to bridge the gap between research and treatment.

Active Ingredients

In eating disorder treatment, timing matters A LOT. Effective treatment requires different ingredients at various stages of recovery. Certain ingredients are essential at the very beginning of treatment but matter less towards the end. Conversely, some ingredients are unnecessary in the early stages of treatment but crucial later on in the recovery process.

To the patient’s detriment, many clinicians do not add the right ingredients at the right times in the right doses. For example, many individual therapy approaches focus initially on helping the patient develop insight and motivation to recover. Full nutrition is not required, or even encouraged, until the patient has lost a significant amount of weight.

Many clinicians are simply using the wrong recipe.

Listed below are my professional opinions on the importance of different ingredients at various stages of eating disorder treatment:

START OF TREATMENT

Essential ingredients:
1.) Immediate requirement of full nutrition, full time
2.) Supervision after meals to prevent purging (if indicated)
3.) Moratorium on exercise
4.) A complete physical exam to check for medical complications of the eating disorder
5.) Hospitalization to correct any urgent medical issues (e.g., bradycardia, dehydration, electrolyte imbalance) or to ensure patient’s safety from self-injury or suicide

Important ingredient:
1.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

WITHIN THE FIRST MONTH OF TREATMENT

Essential ingredients:
1.) Continuation of full nutrition, full time
2.) If the patient is underweight, adjustment of nutritional intake to ensure that weight is being restored at the appropriate rate (1-3 pounds per week)
3.) Continued supervision after meals to prevent purging (if indicated)
4.) Continued medical monitoring

Important ingredients:
1.) Psycho-education for the patient and family about the etiology, symptoms (medical, behavioral, and psychological), and effective treatment for the patient’s eating disorder
2.) Separating the illness from the patient (also known as externalizing the illness)
3.) Parents and treatment professionals developing a specific treatment plan and presenting a united front against the illness
4.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

MONTHS 2-6 OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Achievement of optimal body weight range
3.) Continued monitoring and supervision, as needed, to prevent purging and self-injurious behavior
4.) Ongoing medical monitoring as needed

Important ingredients:
1.) Expansion of nutritional variety
2.) Some exposure to feared foods (e.g., pizza) and feared eating situations (e.g., restaurants, parties)
3.) Parents and treatment professionals continuing to follow the treatment plan and presenting a united front against the illness
4.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

MONTHS 6-12 OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Maintenance of optimal body weight range (for patients over 21)
3.) Adjustment of optimal body weight range to account for growth and development (for patients under 21)
4.) Abstinence from binge eating, purging, and other ED behaviors

Important Ingredients:
1.) Medical monitoring as needed
2.) Re-introduction of physical exercise as patient demonstrates readiness
3.) Gradually handing back some control over food, in an age-appropriate manner, as the patient demonstrates readiness
4.) Continued expansion of nutritional variety
5.) Exposure to more feared foods and feared eating situations
6.) Parents and treatment professionals continuing to follow the treatment plan and presenting a united front against the illness
7.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient willingness to engage in treatment
5.) Patient motivation to recover

MONTHS 12-18 OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Maintenance of optimal body weight range (for patients over 21)
3.) Adjustment of optimal body weight range to account for growth and development (for patients under 21)
4.) Continued abstinence from binge eating, purging, and other ED behaviors

Important ingredients:
1.) Assessment of and treatment for body dysmorphia and co-morbid conditions (e.g., depression, OCD, ADHD)
2.) Occasional medical monitoring, as needed
3.) Continued nutritional variety
4.) Patient mastery of fear foods and feared eating situations
5.) Patient willingness to engage in treatment
6.) Emotional, nutritional, and practical support from loved ones

Unimportant ingredients:
1.) Patient accepting or acknowledging her diagnosis
2.) Patient understanding her illness
3.) Patient insight
4.) Patient motivation to recover

BY THE END OF TREATMENT

Essential ingredients:
1.) Continued full nutrition, full time
2.) Maintenance of optimal body weight range (for patients over 21)
3.) Adjustment of optimal body weight range to account for growth and development (for patients under 21)
4.) Continued abstinence from binge eating, purging, and other ED behaviors

Important ingredients:
1.) No more than mild preoccupation with body image, food, or weight
2.) Ability to regulate emotions and tolerate distress
3.) Ability to eat independently and self-regulate around food without losing weight
4.) Continued treatment for co-morbid conditions, if present
5.) Emotional, nutritional, and practical support from loved ones
6.) Medical monitoring annually or as needed

PRIOR TO LEAVING HOME (to attend college or live independently)

Essential ingredients:
1.) Continued full nutrition, full time
2.) Patient acceptance of her eating disorder history and life-long predisposition
3.) Patient motivation to stay in recovery
4.) Patient insight
5.) Complete abstinence from all eating disorder behaviors (restricting, bingeing, purging) for at least 6 months
6.) Maintenance of optimally healthy body weight for at least 6 months
7.) Ability to eat independently and self-regulate around food without losing weight

Important ingredients:
1.) Specific, written relapse prevention plan which is agreed upon by patient, parents, and treatment team
2.) Medical monitoring annually or as needed
3.) Ongoing treatment for any comorbid conditions
4.) Ability to care for self, regulate emotions, and tolerate distress

In conclusion, the essential ingredients of successful treatment change considerably from beginning to end. The one ingredient that remains essential throughout the course of treatment and beyond is full nutrition, full time. Medical monitoring is essential at the beginning but somewhat less important towards the end. Certain intangible factors, such as patient insight and motivation, are unimportant in the beginning but essential for independent living in recovery.

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13 Responses to Active Ingredients

  1. KrisB says:

    Yes! I’ll bet it works quite well for your patients. It’s what they all need and deserve.

  2. Beautifully and clearly laid out – and fits perfectly what I’ve observed in successful treatment and recovery and clinical practice. The best of the science, and the art, of treatment!!

  3. Becky Henry says:

    Clear, concise and a breath of fresh air. I’ll be sharing this with as many treatment providers as I can to help clear up a lot of confusion especially the concept that the patient needs to be motivated or “ready” to recover. I hear it everyday…well, my child’s team said he/she isn’t ready to recover so we just have to wait till he/she is ready.

    I’ll also be sending this to those parents so they can show it to their team as they walk out the door on the way to finding a new team.
    Thank you,
    Becky Henry

  4. This list is brilliant! Perfect summary of what I’ve seen in my own recovery.

    I think insight and motivation are overrated in the beginning stages of recovery. I never wanted to get better, and yet my disease is now in remission. You don’t need to want recovery to get better, but you do need to want recovery to stay better.

    I think I need to blog on this later. <3

  5. I like how you repeatedly state full nutrition, full time.I am a dietitian and work with Eating Disorder clients. I find it is imperative that client’s have a therapist or psychologist that they work with in addition to my services as well as a MD that I can collaborate with to evaluate labs etc. Oddly, I find there a a lot of therapists who do not work with dietitians. I’m not sure if this is because they don’t have the resources?

  6. kelly says:

    What if my daughter’s progress/treatment has been intermittent or gone backwards? Is there a way to tell where she’d be on your progression?

  7. Theresa says:

    So well put! As for myself it is a day to day moment to moment kind of want to recover. I want to get better but so easier get overwhelmed by the whole thing I cave and give in. Unfortunately my insurance ill only allow me to go to one hospital for IP treatment and I dont think that is the right place for me. I cant afford the residential places although I truly believe I would benefit the most from that. The main thing for me is not to give up. I have had my disease for 25 years now and am ready to be with out it! Thanks for the in sight I will be sharing this with my family doctor too.

  8. Dr. Ravin says:

    Amy,

    In my experience, dieticians can be extremely helpful in some cases but unnecessary in others, depending on the treatment approach. I work primarily with children, teens, and college students in Maudsley Family Based Treatment (FBT). With my approach, parents choose, serve, and supervise all meals and snacks for the first few months of treatment, and I coach the parents on how to ensure that their child’s nutritional needs are met. So the parents and I collaboratively cover the nutritional aspect of treatment, making a dietician unnecessary.

    Kelly,

    If your daughter has regressed and she is actively symptmatic (restricting, bingeing, or purging), she would probably return to the start of my list. If she has had successful treatment before, though, she may progress more quickly this time.

  9. Theresa says:

    Any suggestions on what is helpful for adults who live alone with anorexia. Seeing therapist, dieticians, and doctor, but not getting anywhere. Actually had 2 therapist for a while.Sometimes I think it is hopeless..should have tried harder when I was younger.

  10. Dr. Ravin says:

    Hi Theresa,

    I believe that the most important element of recovery from AN, regardless of age or living situation, is full nutrition, full time. A person can have great therapy, dietician, medical backup, etc but none of those things will promote recovery in the absence of sustained full nutrition.

    For adults with AN who live alone, I strongly recommend enlisting the help of a loved one – a parent, cousin, boyfriend, best friend, neighbor – to live with you during re-feeding (I’m talking 6 months or so) and provide meal support to ensure that you eat what you need to recover. Perhaps you could move in with a friend or family member temporarily, or they could move in with you.

  11. Hans Stayner says:

    This truly clarified my problem, thanks!

  12. wendy says:

    I agree with Carrie that this list is brilliant and that having a concrete timeline and plans/needs for each stage in recovery is really helpful for all family members and sufferers.

    Where many clinicians get lost is the ongoing pursuit of motivation and insight too early in the treatment process.

    What I’ve seen for my young adult daughter is that she really needed full nutrition, full time, and long term maintenance for her brain to heal and readiness for any insight-oriented therapy.

    She has benefited from your structured approach with her for this process during brain healing and also for addressing comorbid disorders.

    Timing is everything and finding the right approach each step of the way is what solidifies recovery/full remission.

    You are a gem and I hope that other clinicians will read this and learn from you

  13. Theresa says:

    Thanks for getting back to me. I agree (and so did my therapist) about somebody living with with me, but unfortunately that isnt an option. I have many cats and dogs and my family members are allergic. And since I have been widowed for 2 years now the ED has really isolated me to the point of no new relationships. But thank you very much for responding. I always tell young people to deal with it then because this is noway to live your life. It really changes how you think over time. I never ever thought I would be like this. I am a nurse I should know better..tell that to the ed. So all you parents out there no matter how much you think your kids will hate you, you have to be the one. I really wish what I know now I knew 25 years ago. I have no one but myself and my brother and his family. I go there for dinner every other weekend but that just isnt enough. I will be the first to admit it I need someone in my face at times and you can only stay in the hospital so long. But on a positive note i am not giving up. I have almost dies 2 times now so there must be a reason I am around.This is truly a horrible disease.

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