Proponents of evidence-based treatment argue that clinical psychologists are scientists, that psychotherapy is (or should be) based upon scientific theory, and therefore therapists must use the best available scientific evidence in their practice of psychotherapy. They argue that the public must be protected from therapies which are not evidence-based, as such therapies may be ineffective or harmful.

Opponents of the evidence-based practice movement argue that psychotherapy is an art rather than a science, and that the essence of what they do – the “human element” – cannot possibly be manualized or subjected to clinical trials. Opponents are typically therapists who practice relationship- or insight-oriented approaches. They see their work as diametrically opposed to the principals of evidence-based practice.

I understand and appreciate the arguments of the opponents, and I do believe they have some valid points. However, I have established my professional identity as a strong proponent of evidence-based treatment.

When you visit a physician for an illness and she prescribes a medication, you can safely assume that the medication has been FDA-approved for your particular illness, that it is likely to be effective, and that it is unlikely to seriously harm you.

Imagine the following scenario: Drug A was used to treat Illness X twenty years ago. Then, ten years ago, clinical studies showed that Drug B is significantly more effective than Drug A in treating illness X. A physician, Dr. Dolittle, continues to prescribe Drug A for Illness X because he really believes it works, and because he was taught that Drug A works well when he was a medical student 20 years ago. Dr. Dolittle does not inform his patients that Drug B exists, because he doesn’t believe it will work for them and he has no experience with it.

The scenario described above would not happen in medicine, would it? And if it did happen, Dr. Dolittle would be reprimanded by the medical board and may have his license revoked.

Believe it or not, this scenario happens in psychology all the time. Most people outside the field would be shocked to learn that the majority of psychological treatment out there is NOT evidence-based.

I have seen patients who underwent years of psychodynamic therapy for severe depression, without getting any better, without being told about cognitive-behavioral therapy (CBT) and without being referred to a psychiatrist for a medication evaluation. I have seen patients with anxiety disorders whose psychiatrists have prescribed multiple medications for them, never once referring them for psychological treatment, without ever mentioning that CBT at least as effective, if not more so, than medication for most anxiety disorders. I have seen patients who suffered from eating disorders for many years, who have seen many therapists, who have had multiple stints in residential treatment and have taken numerous medications, but were never restored to their ideal body weight and never provided with the support they needed to eat properly. And finally, a substantial portion of my case load is comprised of teenagers with eating disorders who have experienced months or years of ineffective, non-evidence-based treatment. The families of these teenagers were never informed about Family-Based Treatment (FBT), which is the only empirically-supported treatment for adolescents with eating disorders. Their parents discovered FBT on their own through desperate late-night internet searches.

These patients are pleasantly surprised to see how quickly and dramatically they improve with evidence-based treatment. They are also angry that they were not provided with, or at least informed about, effective treatment from the start. I believe that all patients and their families deserve to be fully informed about the range of different treatment options available to them, including evidence-based treatment. I do believe that there is a place for non-evidence based treatment, but patients and families should know from the outset what they are getting.

Evidence-based practice is not about using treatment manuals verbatim, or only relying upon randomized clinical trials. Treatment manuals are necessary for research and dissemination, but they are not intended to be followed verbatim with every patient in the real world. Manuals don’t treat patients – they merely provide a guide and a plan of action which may be revised and altered as needed for each unique patient. The basic principles and techniques of the treatment are the brick and mortar; the details of each room can and should be tailored to the individual.

Clinical psychology is a science, but it is not as precise as the so-called “hard sciences” like physics or mathematics. The brain is too intricate; human behavior too complex to be boiled down to immutable formulas. There is, and always will be, room for intuition, creativity, spontaneity, and that intangible “human element” that cannot be manualized or subjected to laboratory research. But the evidence base is there, so we owe it to our patients and to our profession to use it. Otherwise, we are no better than Dr. Dolittle.

NEDAW is a public health initiative designed to educate people about eating disorders. While I applaud the good intentions and effort that go into planning and executing NEDAW, I will not be participating in any of the events. I do not believe that the messages conveyed during NEDAW are particularly helpful: instead of correcting the myths and misconceptions associated with eating disorders, NEDAW just seems to perpetuate them.

For example, the National Association of Anorexia Nervosa and Associated Disorders (ANAD) posted the following on their website in under the heading Eating Disorders Awareness Week 2012:

“Through intentional activities, conversations and events we can all help create an environment that redefines outdated thinking, reduces the stigma associated with weight, body shape, or size, and inspires someone to reconsider an unhealthy attitude or behavior.”

There are several assumptions imbedded in this sentence:
• The environment causes eating disorders by making people feel dissatisfied with their bodies.
• People develop eating disorders because they are insecure, vain, shallow, appearance-focused, or overly influenced by the media.
• By altering the messages people receive from their environment and eliminating the “thin is in” culture, we can prevent or cure eating disorders.
• Overcoming an eating disorder is about reconsidering unhealthy attitudes or behaviors.
• If you have a friend or family member suffering from an eating disorder, you should try to inspire him/her to reconsider his/her unhealthy attitudes and behaviors.
• The unhealthy attitudes and behaviors associated with eating disorders are willful and consciously chosen.

Of course, none of these statements are explicit, but they don’t need to be – the public will draw these conclusions on their own.

I wholeheartedly agree that our culture is toxic and that the messages we receive about body image, beauty, food, and sexuality are horrific and damaging. I do not object to these principles at all – quite the contrary – but I do object to focusing on these messages during National Eating Disorders Awareness Week.

The current public health message associated with eating disorders awareness week is something akin to “Girls are dying to be thin, so let’s all love our bodies!” The themes of NEDAW revolve around thinness, body image, and the media. The concept of psychiatric illness is lost. Of course, it does not help that most eating disorder treatment professionals, eating disorder organizations, tabloid magazines, and recovering eating disorder patients espouse the same body-image centered messages.

I would like to change the public health mantra to something along the lines of “Eating disorders are highly heritable brain-based illnesses with severe psychiatric and medical symptoms.” My ideal public health message for EDAW would also contain the following points:

• Most symptoms of anorexia nervosa and bulimia nervosa are triggered or perpetuated by malnutrition. For those who are biologically vulnerable, dieting can trigger a cascade of self-perpetuating symptoms which lead to life-long psychiatric disability or death.
• Body dysmorphia is a symptom, not a cause, of an eating disorder. It is not present in all eating disorder patients, and it bears little relation to the typical woman’s body image distress.
• Early, aggressive intervention offers the best hope for full recovery.
• An eating disorder is a brain disease, not a weight problem.
• There are a variety of methods for treating eating disorders. Most of the eating disorder treatment available is NOT based on current science or evidence-based practice. Patients and parents must be proactive in finding effective treatment.
• Anosognosia – a neurologically-based inability to recognize one’s illness – is a symptom of Anorexia Nervosa. Therefore, patients should not be expected to “want to get well.” It is up to the patient’s loved ones and clinicians to ensure that he/she gets appropriate treatment as soon as possible.

These are the points that the public needs to hear. These are the points that will truly change the way eating disorders are perceived.

There are many eating disorder treatment professionals out there who will participate in a NEDAW walk or rally, or wear a “Love your body” T-shirt, or attend a screening of “America the Beautiful,” and then head to the office to practice outdated, ineffective treatment.

Next week, I will be promoting eating disorders awareness by providing my patients with the most current, evidence-based information and treatment, and by spreading scientifically-sound information through my blog and through my conversations with people. Please join me!

Recently, these words were uttered to me over the phone by an adult with Anorexia Nervosa (AN) who was desperate for help. A successful professional and devoted mother to three young daughters, she, like so many who suffer from AN, seems to “have it all.” Her husband was aware of her illness – he had attended a few therapy sessions – but it was never discussed openly. Although he was terrified that she would die, he had no idea how to help her. In fact, he had been advised by her former treatment providers that he should not try to “fix” her – that was her job. Like most men, he was begging for something concrete, a specific job to do, something to latch onto and work towards to help save his precious wife.

“I know my life inside and out,” this woman told me. “I have so much insight. It just hasn’t gotten any better.”

If someone has been in therapy for 18 years – or even 18 weeks – there should be marked, measurable improvement. Even 18 days into treatment, there should be something concrete – a written treatment plan, psycho-education for the patient and family, recommendations of reading materials and resources, development of specific goals. There should be hope. Psychotherapy research has shown that the instillation of hope – which is one common factor present in all types of psychological treatment – is the predominant mechanism of change in the first few weeks of treatment.

If someone who is suffering from a life-threatening, soul-killing mental illness for 18 years without making any improvement, where is the hope? How can someone possibly have hope that their condition will improve when they have been dutifully going to therapy with eating disorder experts for almost two decades? In the amount of time it takes to raise a child from birth through high school graduation, there has been no measurable change. Can you imagine such an interminable, grueling, agonizing battle?

In these chronic cases, inevitably the patient begins to blame herself. Her family, once supportive and nurturing, becomes paralyzed with guilt and fear, with anger and frustration. They, too, lose hope.

Let me tell you this: if you have been in treatment for 18 years, 18 months, even 18 weeks, and your condition has not improved, TREATMENT HAS FAILED YOU. No matter how long you have suffered, no matter how many treatment programs you’ve been through, or how many therapists you have seen, or how many relationships have been destroyed by this horrific illness, THERE IS HOPE.

New science offers hope for people with AN. We know so much more now than we did even 5 years ago. This new knowledge is power – it is ammunition against even the most severe, chronic, “treatment resistant” cases.

If you have been in treatment for a significant period of time without improvement, please do not blame yourself. It is your treatment team’s job to help you get well. Even if you don’t want it. Even if your motivation wavers. Even if you are ambivalent about change. These feelings are symptoms of the illness, and you deserve treatment regardless. If your therapist is kind and warm and empathic and you have wonderful relationship, that is terrific – but these things alone will not get you well.

You need a treatment team that will stand up to AN; a team that will insist upon prompt nutritional restoration, achievement of your optimally healthy body weight, cessation of eating disorder behaviors, skills to cope with unhealthy thoughts and negative emotions, and treatment of any comorbid psychiatric conditions.

If your clinicians have not been able to help you, I beg you, I implore you, to find a second opinion. Find a third, fourth, fifth opinion if needed. You deserve effective treatment, and you need something concrete – a specific plan – to help you reach full recovery.

It seems that there are quite a few ineffective therapists who treat eating disorders (ED’s), and this is particularly dangerous given that EDs have such a high mortality rate and are associated with many medical and psychiatric complications.

I have had the privilege of working with many ED patients and families who have received ineffective or actively harmful treatment in the past. In talking with these patients and families about their prior treatment experiences, I have come to recognize many red flags that are very commonly associated with ineffective or harmful ED treatment.

Red Flags re: Etiology
1.) The professional informs the patient or family that the ED is “not about the food.”
2.) The professional informs the patient or family that the ED “is about control.”
3.) The professional is not knowledgeable about recent science regarding the etiology of EDs.
4.) The professional emphasizes psychosocial “causes” of EDs (e.g., family dynamics, societal pressures, identity issues) while ignoring, discounting, or minimizing the genetic and biological underpinnings.

Red Flags re: Family
1.) The professional blames the parents (either subtly or overtly) for causing or “contributing to the development of” the patient’s ED.
2.) The professional advises the parents: “Don’t be the food police.”
3.) The professional does not keep parents of minor patients (< 18 years) fully informed and actively involved in their child’s treatment.
4.) The professional views parents with suspicion or keeps them at arm’s length, without reasonable cause.

Red Flags re: Treatment
1.) The professional is not knowledgeable about evidence-based treatment for EDs.
2.) The professional cannot, or does not, explain the treatment method she uses and / or the rationale behind it.
3.) The professional recommends or allows individual psychotherapy without ongoing nutritional restoration, weight restoration, and medical monitoring.
4.) The professional is very interested in exploring “underlying issues” in an acutely symptomatic patient.
5.) The professional insists on addressing the patient’s co-morbid conditions without also (either first or simultaneously) addressing the ED symptoms.
6.) The professional has never heard of Maudsley / Family-Based Treatment (FBT), or has heard the term but knows nothing about it.
7.) The professional asserts that Maudsley / FBT “will not work” for this particular patient, without giving a convincing explanation for this assertion.
8.) The professional blames the patient (either subtly or overtly) for having an ED.
9.) The professional advises parents to send their child or adolescent away to a residential treatment center without first trying Maudsley / FBT, unless it is clearly contraindicated.

Red Flags re: Recovery
1.) The professional asserts that the acutely ill patient “has to want to eat” or “has to want to recover.”
2.) The professional emphasizes the adolescent or young adult patient’s need for control and independence as more important than her recovery from ED.
3.) The professional sets or allows a target weight range based on population indices (e.g., BMI of 18.5) or percentiles (e.g., 50th percentile for age/height) without consideration of the individual patient’s build, weight history, or optimal weight.
4.) The professional declares the patient “recovered” based on weight alone, without regard for her behavior or mental state.
5.) The professional asserts that one never recovers from an eating disorder.

This list of red flags may be useful when you are looking for or ruling out a professional or treatment program based on information on their website; it may also be useful in interviewing potential new therapists. If you or your loved one have been in treatment for a while without making progress, you can also use these red flags to help you assess the situation and determine whether to go elsewhere for a second opinion.

My advice? If you see one or two of these red flags in your therapist or treatment program, investigate and proceed with caution. If you see three or more, find a new therapist.

There is a pattern I have observed in a few of my patients – they disappear from treatment for several weeks or months at a time, and then call me in crisis needing an appointment ASAP. They get stabilized, start feeling better, disappear from treatment again, neglect their mental health, and show up in crisis weeks later. This is not good mental hygiene.

What is mental hygiene? I view mental hygiene as preventative medicine for your brain, just as biannual dental checkups are preventative care for your teeth and annual physical exams are preventative care for your body. Many medical crises can be averted by getting regular check-ups and aggressive treatment for medical problems as soon as they are identified, along with good nutrition and regular physical activity.

While most people take their sanity for granted, those who have been diagnosed with a mental illness cannot afford to do so. Achieving and maintaining good mental health requires a daily practice of mental hygiene which includes the following 10 components:

1.) Regular therapy sessions. Seeing a therapist regularly helps keep you accountable and on-track with your wellbeing. It is helpful to discuss your problems with someone who has a thorough knowledge of your history and can help you identify areas for continued growth. Sessions should be held at least weekly during the acute phase of illness, but may be spaced out to once or twice a month after stabilization.

2.) Adequate sleep. While individual sleep needs may vary, most adults require 8 hours of sleep per night for optimal functioning. Adolescents require at least 9 hours. It is best to sleep a full 8-10 hours at night rather than napping during the day, which can actually increase fatigue. Before you say “well, I get 7 hours and that’s close enough,” consider this: a cumulative sleep deficit of even 30 minutes a night increases the risk of depression, impairs concentration, and contributes to daytime fatigue.

3.) Regular exercise. Getting at least 30 minutes of physical activity 4-6 days per week helps to boost mood, relieve anxiety, and increase energy. New exercise trends come out every week, but it really doesn’t matter what type of exercise you do. Just move.

4.) Good nutrition. Proper nutrition involves eating, at a minimum, three balanced meals per day, with snacks in between as needed. A balanced diet incorporates a wide variety of foods including carbohydrates, fats, proteins, fruits, and vegetables. I also recommend supplementing with a daily multivitamin and Omega-3 essential fatty acids. The brain requires sufficient calories in order to function properly – 20% of the calories we take in are used for brain activities – so a reduced calorie diet is harmful to your mental health. The brain is made of fat and runs on glucose, so it is not surprising that both low-fat and low-carb diets have been linked to depression.

5.) Avoidance of harmful substances. Don’t use illegal drugs. Don’t use prescription drugs unless they were prescribed for you. Don’t use over-the-counter drugs unless you really need them. I recommend avoiding alcohol if you fall into any of the following categories: you have a personal or family history of alcoholism or addiction; you take psychotropic medication; you have a chronic health condition; or you are under 21. If you do not fall into any of the aforementioned categories and you decide to drink alcohol, drink responsibly and moderately. Many people who suffer from depression find that alcohol exacerbates their depression (it is, after all, a depressant). If you drink caffeine, do so in moderation – excessive caffeine use can exacerbate anxiety and insomnia. If you need 7 cups of coffee just to get through the day, you are either sleeping too little or doing too much.

6.) A reasonable schedule. Being over-scheduled contributes to excess stress and anxiety, while being under-scheduled can lead to boredom, isolation, and depression. Many of your waking hours will be spent in structured, mandatory activities such as school or a job. Each person’s ideal balance of school/work hours will be different based upon their individual needs. That being said, no one does well working 100 hours a week or sitting at home all day for an extended period of time. Taking too many classes or working too many hours is exhausting and draining, and leaves little time for important self-care activities.

7.) Adequate “down time.” A reasonable schedule (see above) will allow for adequate sleep as well as unstructured “down time” to be by yourself, decompress, and regroup. Individual needs for down time may vary, but as a general rule I recommend 15-30 minutes per day. Down time may be spent taking a bath, reading for pleasure, watching TV, or something similar.

8.) Stress reduction activities. I recommend adopting a regular pattern of relaxation / stress-reduction activities which may include one or more of the following: yoga, meditation, deep breathing, progressive muscle relaxation, or massage.

9.) Social support. Robust mental health requires steady, reliable social support. It is important to have at least one person who is close to you whom you talk to on a regular basis. This may be
a spouse or significant other, a best friend, a parent, a sibling, or relative. It is also important to be a part of a larger community, such as a club, a church, a team, an extended family, or a close-knit workplace.

10.) Pleasurable activities. A good life involves a balance of things you “have to do” and things you “want to do.” It is the “want to do” activities that make life worth living. Spend some time each week pursuing a hobby or doing something that you really enjoy. I recommend scheduling pleasurable activities at least once per week.

Does this sound daunting? Perhaps it does if you have been neglecting your mental hygiene. But these basic principles can have a dramatic impact on your mental well being. If you want to feel good, you must treat yourself well. If you want to prevent a mental health crisis, you must practice good mental hygiene. Trust me – it is much easier and far less disruptive to prevent a mental health crisis than it is to pick up the pieces afterwards.

There is no doubt that the ideal female body is much too thin and unrealistic for the vast majority of people. And yes, the majority of girls and women, as well as many men, aspire to be thinner and attempt to diet in order to lose weight. But the thin ideal plays a different, and more peripheral, role in AN than most people think.

The thin ideal does not cause AN. Contrary to popular belief, AN has existed for centuries, long before television or internet or fashion magazines, long before thinness was associated with attractiveness or health. Girls do not “become anorexic” in order to look like supermodels. Many girls have tried to “become anorexic” and failed. You cannot choose to “become anorexic” any more than you can choose to become schizophrenic or autistic or epileptic. It is impossible to develop AN if you do not have the genes for it. Dieting, while ubiquitous in American society, does not cause AN. In fact, it’s quite the opposite – dieting reliably predicts weight gain. At least 95% of dieters regain all of the weight they lost within a few years, and research suggests that the rise in obesity in recent decades is at least in part the result of repeated dieting.

Although the thin ideal does not cause AN, it impacts AN in other very important ways:

• It delays diagnosis and treatment.

Since the population is so consumed with dieting and losing weight, children and adolescents in the early stages of AN are usually praised for their willpower around food, for their strenuous exercise regimens, for their avoidance of “fatty foods.” Parents, friends, and even pediatricians will commend kids for losing weight and compliment them on their slim appearance. In their own zest for thinness, adults seem to have forgotten that it is neither normal nor healthy for a child or teenager to lose weight. In this “thin is in” culture, a patient’s AN is often not recognized until he or she is emaciated and visibly ill. By that point, the illness is very entrenched and treatment is much more difficult. It would save so much time, energy, suffering, and money (yes, money) to diagnose and treat AN at its first manifestation, before it spirals into dramatic weight loss.

• It prevents full recovery.

Clinicians often set a target weight range that is much too low for full physical and mental recovery. Eating disorder thoughts and behaviors, as well as the associated anxiety and depression, begin to melt away only when a patient has reached and maintained his or her unique optimal weight range.

Clinicians themselves are often so afraid of weight gain that they settle for, or even worse, actively encourage patients to stop at, a “low normal” weight. We seem to have forgotten that there is a natural diversity of body sizes. Some people are genetically built to be thin; others to be average; some to be muscular; some to be stocky; some to be large-framed. Each individual is optimally healthy at his or her ideal weight range.

Recovering patients who have reached that magical BMI of 18.5 (at which they are no longer considered “underweight” on the charts) are often complimented for their thinness, which is considered desirable and attractive and healthy. The thin ideal feeds into patients’ disordered belief that they should maintain a “low normal” weight even if their own body is healthiest at a higher weight.

• It exacerbates patients’ suffering.

The ever-present chatter about diets and calories and weight loss and exercise programs creates an unhealthy environment for recovery. When the vast majority of the population is trying to eat less, exercise more, and lose weight, it exacerbates the suffering of a patient who has received doctor’s orders to eat more, exercise less, and gain weight despite her compulsive urges to do the opposite. Patients who do achieve their healthy weight goals tend to see themselves as colossal failures – unattractive, ugly, and disgusting – as they have moved away from the societal ideal that everyone else is striving to achieve.

• It trivializes the illness.

As a result of our society’s thin ideal, patients with anorexia are often viewed as vain, superficial, spoiled rich girls who starve themselves for the sake of beauty and fashion. Anyone who has witnessed AN up close will testify that nothing could be further from the truth.

• It creates an environment of fear and guilt around food and fat.

Most people these days make moral judgments of themselves and others based on dietary intake and body size. How many times have you heard people say things like: “I was so bad last night – I had 2 cookies” or “I was really good yesterday – I only had a salad for lunch.” Extreme fear of eating and gaining weight is a symptom of AN. So is extreme guilt after eating, or when not exercising. This societal moralizing around food and weight validates the symptoms of AN in its early stages and triggers their recurrence when a patient is trying to recover.

If our society’s ideal female body were a plump, voluptuous figure, would AN still exist? Absolutely. Would the incidence of AN be reduced? Probably not. But I believe that patients would be diagnosed sooner, treated earlier, restored to higher (and healthier) weights, and feel somewhat less triggered to restrict after remission. Perhaps the public would also be more apt to see AN for what it really is: an agonizing, life-threatening mental illness that destroys a person’s physical and emotional health. The broader context in which AN occurs would be less validating of the anorexic symptoms and more supportive of full recovery.

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.

The need to create theories arises most often when the reason or cause of an event or circumstance is not readily apparent. For example, in ancient Greek mythology, the god Apollo rode his chariot across the sky every day, carrying the sun from east to west. Now we have modern science to explain the earth’s rotation on its axis every 24 hours, thus creating the appearance of the sun moving overhead from east to west, so the myth of Apollo is no longer necessary.

In modern times, science has replaced mythology and theory as our means of understanding various phenomena. While modern science has helped us understand many phenomenon, we still do not know what happens to us after death. This explains the popularity of major world religions which offer theories to answer these questions, such as heaven in Christianity or reincarnation in Hinduism.

In contrast to physics, chemistry, and biology, which have existed for millennia, psychology is a relatively new science. Relatively little is known about the causes of, and effective treatments for, mental illnesses. Therefore, numerous psychological theories have been proposed over the past century in attempt to explain psychological disorders. For example, in the 1950’s mental health professionals believed that autism and schizophrenia were caused by emotionally frigid “refrigerator mothers.”

With the advent of better science in recent decades, we have learned that parenting style plays no role whatsoever in the development of autism nor schizophrenia. While the precise causes of these brain disorders are unknown, we do know that autism and schizophrenia are neuro-biological disorders with strong heritability components, and that the patient’s parents can be extraordinarily valuable resources in treatment if they are given the right professional support.

While our current understanding of mental illness is in its infancy, recent scientific research has shed some light on factors that influence the development of mental illnesses. We also have some scientific data demonstrating that certain types of treatment are more effective than others for certain populations. In light of our current understanding of the etiology and effective treatment of mental illness, I am profoundly disappointed when I read about well-meaning but misinformed psychologists who cling to antiquated theories of mental illness and practice antiquated treatments.

For example, psychologist and author Judy Scheel, Ph.D., LICSW, believes that eating disorders are rooted in unhealthy or disrupted attachments to parents. In her recent Psychology Today blog post, she writes:

“For many individuals, eating disorders are attempts to fix externally what is internally vulnerable in an individual. Yet the cause of an eating disorder can often be traced back to attachment patterns that are weak or failing in childhood, which leave someone vulnerable to a whole host of self-esteem, self-worth and relationship issues later in life.”

This theory has a familiar odor. It reeks of refrigerator mothers, castration anxiety, and unconscious conflicts. In 1950, this was all we had. But now, in 2011, we know so much more.

Why do some psychologists cling to antiquated theories which have been disproven? Similarly, one may ask why many people cling to the theory of creationism when we have solid scientific evidence to support evolution. For some people, the notion that “we came from monkeys” is insulting and offensive and clashes with their existing belief system. The story of creationism is a foundation of Judeo-Christian religions, and (at least in its literal interpretation) is incongruent with Darwin’s theory of evolution.

The same is true with psychological theories. Many people who have been trained in psychodynamic or relational approaches feel that the new science runs counter to everything they have been taught and undermines the type of treatment they practice. They cling to their theories and defend them with religious fervor. The new science threatens their religion.

The problem here is that psychology is not a religion; it is a science. In the United States, we all enjoy freedom of religion – the freedom to believe whatever we wish and practice any religion we choose without persecution. We should not have freedom of science. As experts in the field of psychology with doctoral-level degrees, we should not have the freedom to write and publish whatever we happen to believe, and practice whatever method of treatment we wish, without accountability.

I was a graduate student relatively recently (2001 – 2008), and I was taught many things in my training that I no longer believe to be accurate. This is not a failure of my training; this is a reality of an evolving science. New developments occur in medicine all the time, and physicians who have been in practice for 20 years have had to learn and re-learn new ways of practicing as the science of medicine has evolved. This is expected. It is taken for granted by most patients.

As psychologists, we have a responsibility to educate ourselves about the latest scientific developments in our field and utilize our expertise to help people in need. Clinging to unproven theories, in the face of new science, is irresponsible, lazy, and potentially harmful. When challenged on their ideas, many old-school psychologists will use phrases such as “everyone’s opinion is valuable” or “can’t we agree to disagree” or “there is no right way to treat eating disorders” or “I feel unsafe.”

Here is the problem – this is not group therapy. We cannot sit around and validate one another’s feelings and hold hands and sing Kumbaya. Yes, all people are equal, but all ideas are not equal. Some ideas are supported by reliable scientific evidence and others are not. There may not be one right way to treat eating disorders but there are many wrong ways, and there are methods and techniques which clearly work better than others for most people.

We must let go of unhealthy, dysfunctional attachments to old ideas. Clearly, these attachments to antiquated theories contribute to the development of unhelpful psychotherapy. Perhaps today’s unhelpful psychotherapy is an attempt to validate one’s early training.

Let me explain. First, there are no good data to support the popular notion that the prevalence of AN has increased over the past few decades (in contrast, the prevalence of bulimia nervosa and binge eating disorder has skyrocketed in recent decades, but that is beyond the scope of this post). Most data in fact suggest that the incidence of AN has remained constant throughout recorded history. Second, we do not yet know how to prevent AN, nor do we know whether AN is possible to prevent.

We do know that children are being diagnosed with and treated for AN at much younger ages now compared to a generation ago. Research has also shown that the prognosis for AN is inversely correlated with age and duration of illness prior to the start of effective treatment. In other words, the younger the patient, the better her chance for full recovery.

The 5th and 6th grade girls who are diagnosed with AN today would most likely have developed AN anyway, but in previous generations the illness would not have been triggered, diagnosed, or treated until later in adolescence, when it is more difficult to treat. Therefore, I view younger age of onset as a positive thing.

AN is triggered by an energy imbalance – that is, a period of time in which a person’s caloric intake is lower than her body’s energy needs. My theory is that kids are developing AN at younger ages because there are more opportunities for energy imbalance to occur in younger children now compared to generations past.

Several factors contribute to this trend of children developing AN at younger ages:

1.) National hysteria about the “obesity epidemic” and well-intentioned but misguided government programs aimed at children.

Children who are predisposed to AN tend to be anxious, sensitive, perfectionistic, rigid, and overly compliant with rules. These are the kids who actually take the “obesity prevention” messages to heart and follow them to the letter. They avoid “unhealthy foods” (e.g., those high in calories) in favor of “healthy foods” (e.g., those low in calories and fat), thus creating a negative energy balance and triggering AN. The irony here is that it is very unhealthy for a growing child to eat a low-fat or restricted-calorie diet.

2.) Earlier puberty.

This generation of children tends to enter puberty earlier than their parents or grandparents. The hormonal changes of puberty, combined with the increased energy needs of the pubertal growth spurt, provide a perfect opportunity for a negative energy balance. Add to that the tendency of girls to begin dieting to counteract their body’s pubertal changes to conform to the thin ideal, and you have a perfect storm.

3.) Participation in intense athletics at younger ages.

It used to be that athletically-inclined kids did not begin intense athletic training until high school. These days, 6-year-old kids begin practicing for their sport multiple nights per week and traveling to games on the weekends. These kids have extremely high energy needs, as they must consume enough food to fuel their sports in addition to keeping up with normal growth and development. Kids who are predisposed to AN are not able to eat enough to fuel their body’s needs. Further, thinness is considered an advantage in many sports such as gymnastics, track and field, cross country, dance, cheerleading, and diving.

4.) Increased stress.

The modern lifestyle is fast-paced, rushed, overscheduled, and pressured for all of us, even children. Every time I listen to an elderly person talk about their childhood, I am struck by how different life was in the 1940’s and ‘50’s and how much more laid back things were for children then. Stress can trigger loss of appetite, which creates a negative energy balance, which can be the beginning of AN in a vulnerable child.

5.) Decrease in family meals.

For a number of reasons, including busy schedules, families are eating together less often now. If a young child is responsible for fixing her own breakfast, packing her own lunch, or microwaving her own dinner, it is much easier for her to skip meals or restrict her food intake without her parents knowing.

6.) Ignorant pediatricians.

In most cases, pediatricians are the first healthcare professionals to spot (or miss) early signs of an eating disorder. I cannot count the number of patients I have seen whose pediatrician was completely unconcerned by a child or adolescent’s weight loss or failure to gain weight. They will often say things such as “Don’t worry, she’s still in the normal weight range for her age” or “she could lose 10 more pounds and still be fine.” Even worse, many pediatricians will congratulate a child for losing weight. It is as if pediatricians have become so consumed with “fighting childhood obesity” that they have forgotten that kids are supposed to grow and gain weight from birth until age 20. Weight loss is not normal or healthy for any child or adolescent. Generations ago, people understood this, and any weight loss in a child was cause for alarm. You know how grandparents always want to feed you a lot, and say “you’re looking thin” as if it were a bad thing?

Like many diseases, AN in children presents differently than in teens or adults. Here are some key differences I have observed in the young children I treat:

1.) Young children are much less likely than teenagers to fall into AN through dieting. In little girls, the negative energy balance is more likely to result from unintentional weight loss through illness, athletic training, or “healthy eating.”

2.) Fear of fat, drive for thinness, and body dysmorphia – which are considered the hallmark cognitive symptoms of AN – are often absent in young children. Eating provokes extreme fear and resistance, but they often cannot articulate why.

3.) Young children are more likely to present with dehydration as well as malnourishment. Whereas teenage anorexics drink large quantities of water, diet soda, and black coffee, little kids sometimes cannot grasp the concept of calories. Many little kids with AN will fear and avoid anything that enters the mouth- including water, gum, vitamins, and medicine.

4.) Teens and adults with AN usually have a list of “safe foods” which are low calorie and low fat – such as salads, fruit, rice cakes, and nonfat yogurt – and they tend to fear high calorie foods such as ice cream and pizza. However, sometimes young children’s food rules and food fears make no caloric sense. For example, I have worked with children who will willingly consume any beverage, including milkshakes, but who refuse to take a bite of solid food, even a carrot stick. Other kids will have a narrow list of safe foods which are familiar but not low-calorie (e.g., chicken nuggets, pop tarts, and grilled cheese sandwiches).

5.) Young children become medically and mentally unstable much more quickly than teenagers. Post-pubescent teen girls and women, even slender ones, start out at a higher body mass and have reserves of fat. Prepubescent children are already light and very lean. A loss of even a few pounds is enough to cause severe medical problems and extreme cognitive distortions in a child. It is not uncommon for a child to go away to summer camp completely healthy and return three weeks later in grave danger.

6.) It is easier for young children to externalize their illness. They often describe feeling “taken over” by a voice or by some evil force beyond their control. They love to name their illness and refer to it in the third person, unlike teenagers who tend to balk at this exercise, or who experience their illness as more ego-syntonic. My young patients have come up with various names for their illness – the monster, the beast, the devil, Scary Larry, and Voldemort are a few that come to mind.

In my experience, young children tend to make a full recovery more quickly and more easily than teens or young adults. Because they fall into AN so quickly and because they are still so dependent on their parents, they are brought into treatment very early in the course of the illness. Their AN thoughts and behaviors are not as engrained as, say, a 16-year-old who has suffered from AN for two years.

Young children are more dependent on their parents than teens. Thus, it is far easier for both parent and child to adjust to the “magic plate” technique of parents preparing and supervising all meals and snacks – this is not so different from what most parents do for their healthy 10-year-olds anyway. It is extremely difficult for teens and especially young adults to accept the amount of parental support and supervision required for successful re-feeding.

I love treating little girls with AN. Each time I get a call from a terrified parent whose little girl who is showing signs of AN, I breathe a sigh of relief, grateful that they have come to my attention so early in the course of the illness. Although these children and their families are in for a harrowing journey, I have complete confidence that they will defeat the monster. These kids can enter their teen years fully recovered and able to enjoy high school and college unencumbered by this horrible illness.

“Looking for psychologist and psychiatrist in Atlanta for student entering freshman year at Emory. Bipolar disorder diagnosed in February 2011; has been stable on new meds since suicide attempt in June. Patient is very insightful but needs close monitoring.”

“Need treatment team in Boston for incoming freshman at Boston University with 4 year history of bulimia and major depression. Weight is normal but patient engages in binge/purge symptoms 3-4 times per week. Patient has delightful personality but is very entrenched in ED symptoms.”

“20-year-old patient with anorexia nervosa, social anxiety, and OCD just released from our day treatment program needs multidisciplinary treatment team in Chicago as she returns for her junior year at Northwestern University. Patient was discharged at 90% of ideal body weight and is compliant with meal plan. Needs nutritionist, psychologist, psychiatrist, and internist familiar with EDs.”

“23-year-old patient with major depression and alcoholism is entering graduate school at UMass Amherst and needs treatment team. Has 2 months sobriety.”

As I read vignettes such as these, I can’t help but wonder whether it is in the best interest of these vulnerable young people to be away at college. Adjectives like “compliant” and “insightful” and “delightful” seem to be inserted to justify the decision to send the patient away to school and/or to entice clinicians to take on these challenging cases. Qualifiers like “2 months sober” and “90% of ideal body weight” do nothing to quell my apprehension. Frankly, they frighten me more.

Let me be frank: a psychiatric diagnosis is a game changer. Any artificial deadlines, such as an 18th birthday or the start of the school year, are irrelevant. Psychiatric disorders are serious, potentially disabling (think major depression, which is a leading cause of lost productivity in the workplace), even deadly (think anorexia nervosa, which carries a 20% mortality rate). Individuals with psychiatric diagnoses can and do recover and go on to lead productive, fulfilling lives, but this requires prompt, effective treatment and a supportive, low-stress environment for a sustained period of time.

The transition to college presents numerous challenges to even the healthiest and most well-adjusted young people: leaving their hometown, family, and friends; living independently in a different city or state; adjusting to dorm life; navigating new peer relationships and social pressures; managing one’s time and money; choosing a career path and taking academically rigorous courses; assuming full responsibility for nutritional intake, sleep schedule, physical activity, and medical care.

Let’s face it: the typical college lifestyle does not promote physical or mental health. Late nights spent studying or partying, daytime napping, chronic sleep deprivation, erratic eating habits consisting mostly of processed snacks and caffeinated beverages in lieu of balanced meals. Most college students drink alcohol socially, and many drink to excess multiple times a week. Widespread use of illicit drugs as well as rampant abuse of black market prescription drugs as study aids (e.g. Adderall) or sleep aids (e.g., Xanax) is a mainstay of university life. Casual sex with multiple partners, often unprotected and usually under the influence of alcohol, is the norm on most campuses.

Navigating these challenges successfully requires a certain level of mental and emotional stability. Maintaining good self-care in an environment where virtually everyone else practices unhealthy habits requires a maturity and strength of character that is beyond the reach of most 18, 19, and 20 year olds.

I have treated patients before, during, and after college, and have counseled their parents throughout this process. I worked at three different university counseling centers during my doctoral training. During that time I worked with dozens of students struggling with psychiatric illnesses and gained an intimate understanding of what universities do, and don’t do, to support students with mental health problems.

Now, as a psychologist in private practice near two large universities, I treat a number of college students as well as high-school students who hope to go away to college in the near future. I also have a few patients who had attempted to go away to college in the past, but experienced a worsening of symptoms, a full-blown relapse, or in some cases life-threatening complications which rendered them unable to live independently. These are young people who have returned home to the safety of their families and are now going through treatment to repair the damage with hopes of living independently in the future.

I have developed the following professional recommendations for parents of young people with psychiatric illnesses based on these clinical experiences as well as the latest scientific research:

1.) If your child is a junior or senior in high school and hopes to go away to college in the future, begin working with her and her treatment team now to establish criteria to assess her readiness for going away to college. I recommend collaboratively establishing a written plan which includes specific, measurable criteria which the child must meet before she is permitted to leave home.

2.) If your child has had life-threatening symptoms (suicide attempt, drug/alcohol abuse, eating disorder), ensure that her condition is in full remission for at least 6 months prior to letting her go away to college. For example:
- A child with bipolar disorder should have at least 6 months of mood stability without any manic or major depressive episodes.
- A child who has attempted suicide should have a minimum of 6 months without any suicidal behaviors, gestures, or urges.
- A child with a substance abuse problem should have at least 6 months of complete sobriety.
- A child with anorexia nervosa should have at least 6 months of eating independently without restriction while maintaining 100% full weight-restoration with regular menstrual periods.
- A child with bulimia nervosa should have at least 6 months of normalized eating with complete abstinence from all binge/purge behaviors.

3.) A young person going off to college should have, at most, minimal or mild mental/emotional symptoms. For example, a child with an anxiety disorder who has occasional panic attacks, or who feels somewhat anxious at parties around new people, may be able to function well at college, but a child who has panic attacks multiple times a week or who avoids most social situations is not yet ready to go away.

4.) Ensure that your child has effective tools to manage any symptoms that may arise. This may include CBT or DBT skills to manage feelings of depression or anxiety.

5.) Work with your child and her treatment team to develop a self-care plan that includes plenty of sleep, physical activity, time management, and balanced meals and snacks at regular intervals.

6.) Do not rely upon university services (student health center or student counseling center) to provide therapy, psychiatric, or medical services for your child. University counseling centers are not equipped to manage the needs of students with major mental health issues. Most student counseling centers are over-worked, under-staffed, and underfunded. By necessity, most have limits on the number of sessions each student can attend, and most will not support parental involvement in treatment decisions or even communicate with parents at all.

7.) Prior to your child’s departure for college, establish a treatment team off-campus.
- Interview the clinicians over the phone and schedule a family meeting in person with the clinician before the school year starts, during the time you are helping your child move into the dorms. If the clinician is reluctant to talk with you over the phone or refuses to meet with you in person, this is a red flag.
- I recommend selecting a clinician who welcomes individualized, appropriate parental involvement in college students’ mental healthcare. This means working collaboratively with parents based upon the individual patient’s needs in light of her diagnosis, history, and developmental stage, irrespective of her chronological age.
- Ensure that your child signs releases of information allowing you to communicate with the clinician regarding your child’s care (law requires that persons over 18 must provide written permission for a mental health professional to release information to anyone, including parents).
- Use the initial family meeting to provide the clinician with any relevant history about your child’s condition. Written psychological evaluations or discharge summaries from previous treatment providers are very helpful in this regard.
- Work collaboratively with the new clinician and your child to establish frequency of contact, and nature of communication, between you and the new clinician. For instance, I often work out a plan wherein I call parents every two weeks, or once a month, with a general progress report on the patient, without revealing the specific content of sessions (e.g., “Mary is adjusting well to dorm life. She’s had some mild anxiety but she seems to be managing it well.” Or “Annie has been struggling with an increase in depressive symptoms over the past week. I will keep you posted and notify you right away if there is any indication of suicidality or deterioration in functioning.”) Be very clear about the type of information that will be shared between clinician and parents. It is important for the patient to establish a trusting relationship with the clinician and to feel secure that, in general, “what happens in therapy stays in therapy.” It is equally important for the parents to be reassured that they will be notified promptly if the child’s condition deteriorates.

8.) Have a safety net in place. Decide exactly what extra supports will be provided, and under what circumstances, if the child should experience an increase in symptoms while away at college. For example: an increase in symptoms lasting longer than one week may result in the child coming home for the next weekend, or perhaps a parent would travel to stay with the child in a hotel for a week or two.

9.) Have a plan B.
- Work collaboratively with your child and her new treatment team to establish what conditions would warrant a more serious intervention.
- Some situations, in my opinion, warrant a medical leave and an immediate return to the safety of home. For example, a suicide attempt or gesture, an episode of alcohol poisoning, a weight loss of more than 5 pounds (in the case of anorexia nervosa) or a recurrence of binge/purge symptoms lasting longer than a couple of weeks (in the case of bulimia).

10.) Always remember, and reiterate to your child: whatever happens is feedback, not failure.
- A medical leave of absence is not the end of the world. Nor is it permanent. It is simply an indication that your child temporarily needs more support than can be provided in the college setting. It is no different from a young person taking a leave of absence for major surgery or cancer treatment (try getting that done in the student health center!).
- Many young adults recover more swiftly from a relapse compared to the first time they were ill – the benefit of maturity and the motivation of wanting to return to college and independent living can be very helpful in this regard. If your child does well at home and recovers from the relapse, she may be able to return to school away from home the following semester or the following year.
- Depending on the circumstances and the course of your child’s illness, it is possible that the best scenario for her would be to live at home and attend college locally, or transfer to a school in-state and come home each weekend. Again, this is not the end of the world. If her recovery is robust after college, she will still have the opportunity to go away to graduate school or start the career of her dreams somewhere else.

Attending college is a privilege and a gift, not an inalienable right. It is not something that one must automatically do right after graduating from college. Living away from home, apart from one’s primary support system, to attend a faraway school is a privilege unique to American culture, and is not a prerequisite for success in any way. In most other countries, young people who do attend college (and not everyone does) do so locally while living at home until they are married.

Take your child’s psychiatric diagnosis very seriously, and do the right thing for her health. As her parent, it is not only your right but your duty to make these decisions, and you should be supported by a treatment team that empowers you to do so.