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.

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Tag: Maudsley Approach

Sunday, July 29th, 2012

Navigating Phase III

Last week, I blogged about navigating Phase II of Maudsley Family-Based Treatment (FBT). Today I present a roadmap for Phase III, which is equal to Phase II in its importance as well as its ambiguity.

A common but ill-informed criticism of FBT is that it only addresses eating and weight. This is a misconception. Phase I focuses on establishing normal eating habits and restoring normal weight and Phase II focuses on helping the patient eat on her own in an age-appropriate way, but Phase III has nothing to do with food or weight at all. A wonderful thing about FBT is that the life-threatening eating disordered behaviors are treated first, which frees up the therapist, the patient, and the family to focus on any remaining issues in Phase III.

The goal of Phase III is establishing a healthy adolescent identity. An eating disorder engulfs an adolescent’s identity, creates extreme stress for the entire family, and strains the relationships between family members. Phase III is about restoring healthy, age-appropriate family relationships and returning the adolescent to normal life. Anything that stands in the way of these goals must be dealt with in order for the patient to recover fully.

Phase III begins when the patient is able to eat normally, with age-appropriate independence, while maintaining a healthy weight and not engaging in any eating disorder behaviors. Essentially, once all food issues have been resolved, the patient is ready for Phase III.

The authors of the FBT manual (Locke & Le Grange, 2001) advise that Phase III entails a handful of sessions scheduled several weeks apart. In my clinical experience, many patients do quite well with just a few sessions in Phase III, but others continue to struggle with anxiety, depression, body image, perfectionism, or other problems. Therefore, I offer to provide patients and families with an extended version of Phase III when I believe it is warranted. Length of illness, severity of illness, and co-morbid conditions all influence whether a patient may benefit from more treatment than the FBT manual prescribes.

In my practice, Phase III typically addresses the following issues:

1.) Returning the patient to normal development.

An eating disorder can interrupt normal adolescent development. Often, when a patient enters Phase III, she is at the same developmental level as when the illness first began. Phase III entails helping the patient develop the maturity and social-emotional skills that were lost as a casualty of ED. Depending on the age of the patient, this may entail returning to sports or other activities, getting a driver’s license, going out with friends, dating, returning to college, or developing new hobbies and interests.

2.) Re-establishing healthy relationships amongst family members.

An eating disorder can wreak havoc on family life. It is not uncommon for spouses to have major marital conflict emerge as a result of ED. Siblings may feel neglected by their parents or jealous of the patient. The patient and her parents may develop a codependent relationship over the course of treatment, which can be advantageous in the first two phases, but must be corrected in Phase III so that the patient and parent can each return to their own lives. Healthy boundaries amongst family members can be damaged by ED, and it is crucial for these boundaries to be re-established at the end of treatment.

3.) Addressing any remaining psychological symptoms of the eating disorder.

There are numerous psychological symptoms related to an eating disorder. For example, body dysmorphia, perfectionism, poor self-esteem, anxiety, and cognitive rigidity may predispose people to AN and perpetuate the illness once it has begun. For many patients, these symptoms abate or resolve on their own during the first two phases. For many others, however, targeted treatment is needed at this phase. Cognitive-behavioral therapy (CBT) can be helpful in this regard.

4.) Working through the trauma of experiencing an eating disorder.

While many treatment programs address traumatic experiences that precipitated an eating disorder, few acknowledge that the experience of having eating disorder is itself very traumatic. Caring for a child with an eating disorder can be almost as traumatic as experiencing one. In many cases, the patient or her parents (or both) experience post-traumatic stress reactions at this point, such as disturbing nightmares, intrusive memories, and avoidance of stimuli associated with the eating disorder.

It is not uncommon for parents, drained and burnt out from the exhausting work of Phase I and Phase II, to have their own breakdowns at this point. Their child is well enough that they are no longer operating in crisis mode and they have some room to breathe. Once the survival instinct is no longer employed on a constant basis, parents have permission to experience their own reactions. Some parents fall into a depression; others feel disillusioned and cynical; still others suffer from extreme anxiety or lash out in anger. These are all normal, expected reactions to the trauma of almost losing a child. It is important for parents to get their own therapeutic support at this juncture if needed.

5.) Addressing grief.

Another often neglected aspect of eating disorder treatment is grieving what the eating disorder has taken. Not all patients and families experience this grief, but some do. I believe that when there is grief associated with the eating disorder, it should be discussed openly and addressed as part of the healing process. Patients often lose friends to their illness. They may have to take a hiatus from their favorite sport, or give it up altogether. Some patients miss a semester of school. Most are isolated from society for some time. At this stage, patients can feel the pain and injustice of losing a piece of their youth irretrievably.

Some parents may mourn the loss of their child’s innocence. They mourn the loss of life as they knew it. Many parents take time off from work and become isolated from their social circle as they help their child recover. Some parents mourn the loss of dreams they once had for their child which have been thwarted by ED.

No one emerges from the hell of an eating disorder unscathed. That said, some people are able to close that chapter in their lives and move forward, whereas others remain trapped by anger, sadness, or bitterness. It is important for patients and parents to work through their grief so that they can move forward in a life unencumbered by ED.

6.) Relapse prevention.

It is important for the patient and her parents to be aware of possible signs of impending relapse and to know what to do if these signs emerge. I find it very useful to discharge patients with a written relapse prevention plan which I have developed in collaboration with the patient and family.

7.) Evaluating the patient for co-morbid conditions.

Many patients with eating disorders experience co-morbid psychiatric conditions. Patients who continue to struggle with emotional or behavioral problems after the eating disorder has been resolved should be evaluated to determine whether they suffer from a comorbid disorder. The most common comorbid disorders are the anxiety disorders (including OCD, generalized anxiety disorder, panic disorder, PTSD, and social anxiety disorder), followed closely by mood disorders (depression and bipolar disorder). Other comorbid conditions may include autism spectrum disorders (such as Asperger’s), ADHD, substance abuse, and personality disorders.

8.) Getting the patient appropriate treatment for co-morbid conditions.

If the patient does indeed suffer from a co-morbid condition, it is important for her to get treatment for it. Treatment for a co-morbid disorder may include individual therapy, psychotropic medication, or a combination thereof. Cognitive behavioral therapy (CBT) in particular has been found to help many people recover from anxiety disorders, mood disorders, and numerous other conditions.

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Wednesday, July 25th, 2012

Navigating Phase II

There is a common misconception that Maudsley Family-Based Treatment (FBT) is all about parental control of feeding. While Phase I of FBT does require parents to take control of their ill child’s food intake to help her restore her weight, FBT also encompasses two other very important phases. In Phase II, parents return control over eating to their child as she demonstrates readiness to eat on her own. Phase III involves helping the adolescent return to normal development and establish a healthy identity.

Weight restoration is an essential first step in overcoming AN, but it is only the first step. Equally important is the ability to feed oneself properly and maintain a healthy weight independently. Without the ability to eat independently, opportunities are limited and quality of life is greatly diminished. Recovery from an eating disorder is about more than just restoring a healthy body – it is also about restoring a healthy mind and a fulfilling life.

Phase I tends to be the most tumultuous and draining for the family and the most agonizing for the patient, but the task at hand is very straight-forward: eat more and gain weight.

Phase II, however, is much more ambiguous. Parents and clinicians struggle to determine when a patient is ready to begin Phase II. The patient herself may send mixed signals – she may beg for the freedom to eat lunch in the school cafeteria and go out to dinner with her friends, but yet she is clearly unable to take a single bite of food that isn’t “required” and “supervised.” To outsiders, the patient seems normal – she looks healthy, she acts more or less like a typical teenager (in between mealtimes, at least), but appearances belie the still-raging battle in her head. Still tormented by the anorexic thoughts and compulsions, she feels torn between a wish to return to the safety of emaciation and a desire to dive headlong into the normal life she has been missing.

I use the following benchmarks to help families determine when their child is ready to enter Phase II:

• The patient has been fully weight restored to his/her historic growth curve (per pediatric growth chart percentiles) for at least a few weeks. While the FBT manual (Locke & Le Grange, 2001) recommends beginning Phase II when the patient is at 90% of her ideal body weight, I have found that the vast majority of patients are not ready for any control over their food intake until they achieve 100% of their ideal body weight. In my experience, many patients need to maintain their ideal body weight for a number of months before they are ready to enter Phase II.

• The patient’s metabolism has normalized to the point that she no longer requires a very high-calorie diet. It is hard enough for the patient to feed herself a normal meal – don’t make it even harder by expecting her to serve herself very high calorie meals.

• The patient is no longer engaging in eating disorder behaviors such as restricting, bingeing, purging, or excessive exercise.

• The patient is eating all of the food her parents provide her, in a reasonable amount of time, without much fear or resistance. [NOTE: the patient will still have some anxiety around eating at this point – that is to be expected. The point is that the patient needs to be able to push through that anxiety and eat what she needs without a struggle.]

• The family is no longer operating in “crisis mode.” The parents feel confident that they can help their child defeat the eating disorder, and the child has accepted that her parents have taken charge.

• The patient expresses readiness to assume some control over her eating and confidence that she can feed herself appropriately. [NOTE: Many patients express a desire to regain control over their eating long before they are actually ready. This premature push for independence may be partially motivated by a normal adolescent drive for freedom, but it may also be motivated by ED’s desire to restrict and lose weight. Therefore, it is a mistake to use the child’s expressed readiness as the sole criteria for entering Phase II. Rather, you want to look for the child’s expressed readiness in addition to the previous criteria.]

Here are some general principles I discuss with families to help them navigate the uneasy waters of Phase II:

• Have a vision.

I like to begin Phase II with a vision of how the patient’s life will look at the end of Phase II. By the end of Phase II, the patient needs to be able eat on her own while maintaining her weight, in an age appropriate way, in the context of her family and her normal life. All patients, regardless of age, will enter Phase II eating in the same way – with parents in control of what, when, and how much they are eating. However, the end goal of Phase II is different for a 10-year-old than for a 16-year-old or a 22-year-old. A good frame of reference in creating your vision for Phase II is to look at the amount of autonomy the patient’s friends have with regards to their eating.

For example, by the end of Phase II, a pre-teen patient should be able to eat lunch with her friends in the cafeteria at school, order from a restaurant menu, select her own after-school snack and eat it without supervision. She should be able to have a few meals and snacks at a friend’s house during a sleep-over, or spend the day away from her parents on a field trip. She should still share meals with her family each day and eat what the family is eating.

By the end of Phase II, a high-school age patient should be able to prepare a simple breakfast and lunch for herself when needed, serve herself appropriate portions at dinner, eat a meal on occasion without her parents present (for example, dinner on her own if her parents are out for the evening), and go out to eat with friends. Regular family meals are still important for teenagers so that parents can keep an eye on their child’s eating behavior, even when the teen is eating many of her meals and snacks on her own. A young adult patient who is preparing for independent living should be able to plan her menu, shop for groceries, cook for herself, and eat without parental supervision.

• Take baby steps, go very slowly, and accept that this Phase will take a long time.

In my experience, Phase II usually takes somewhere between 3-12 months, depending on the severity of illness and other individual differences.

• Accept and embrace the fact that Phase II poses an inherent risk.

Like many things in life, giving a recovering anorexic more control over her food intake involves some degree of risk. It is likely that the patient will experience struggles and setbacks during Phase II. Try to learn and grow from these slips, and help her do the same. Keep in mind that you can, to some degree, manage the amount of risk involved by ensuring that the patient is genuinely ready before starting Phase II, monitoring her closely over the course of this phase, and stepping in to help her when needed. I liken this process to helping a baby learn to walk. You wait until she is confident in her crawling. Of course she will stumble and fall, but she will grow stronger each time she pulls herself back up. And you can provide her with a soft, carpeted surface on which to practice her steps.

• Have the patient practice choosing and preparing her food under supervision before she is permitted to eat unsupervised.

I typically start Phase II by having the patient choose and prepare one snack each day under parental supervision. The parents observe the child’s food selection and gently guide her in the right direction if needed. For example, let’s say the child chooses crackers with peanut butter and puts 4 crackers with a thin coating of peanut butter on each one. The parent may say: “That’s an excellent, balanced choice, but it’s not quite enough nutrition. Let’s put three more crackers on the plate and add more peanut butter.”

I usually require a patient to have at least a week of consistent success preparing a meal/snack under supervision before moving on to the next meal/snack.

• Be systematic.

I typically coach patients to proceed through Phase II by giving back control of one meal or snack at a time and allowing the child to gain mastery of each meal/snack before moving on to the next one. For example, the child may begin Phase II by assuming control of her own after-school snack, while parents maintain control of all other meals and snacks.

• Assess progress regularly.

The patient should be weighed weekly during this phase, and family members should keep tabs on her mental state and behavior daily. If she is maintaining her weight within her healthy range, and her mood and behavior around food are good, then it is time to move forward to more independence. If her weight drops, or if she demonstrates an increase in eating disorder behaviors (even in the absence of weight loss), then it is time for parents to take back more control of her food intake.

• Take back control when necessary.

Nearly every patient has a few setbacks during this Phase. It is the parents’ responsibility, with the guidance of their clinician, to take back more control over the patient’s food when she has not been able to manage eating on her own. The step backwards is a temporary measure to help her get back on track, and she will regain control when she demonstrates readiness.

• Some patients need a gentle nudge to move forward.

While many patients are all too eager to take back control over their food intake, some become overly dependent on their parents to feed them and have great difficulty moving forward. This makes sense in light of the nature of AN – being fed by your parents is a passive process which does not involve taking personal responsibility. The “ED voice” quiets down after several months of full nutrition, and the patient is able to eat well without too much guilt when she is being “forced.” The acts of preparing one’s own food, deciding what to order from a restaurant menu, or choosing whether to have a snack when no one is watching – these are all acts of defiance against the “ED voice.” Patients are flooded with anxiety, indecisiveness, and guilt when the time comes to make these choices. It is a scary step for parents and patients alike. Some patients require lots of encouragement to become more independent with their eating. I find that it is often helpful to remind the patient of the benefits of being able to eat independently, such as spending more time with friends and doing other activities away from home. Some younger patients respond well to concrete, short-term rewards for eating independently. For example, a 6th grader who successfully manages her afternoon snack every day for a week without weight loss may be rewarded with a trip to the movies.

• Be realistic.

Many parents lament that their recovering child no longer goes out for ice cream on a whim or breezes into the kitchen to grab a few cookies or gives herself generous second helpings of her favorite meals. I advise parents that it is unrealistic to expect a recovering anorexic to eat freely or spontaneously. Some people who have recovered from AN are eventually able to eat intuitively, but not until they have been well for at least a year or two.

• Don’t force Phase II into an external timeline.

Don’t rush through this phase just so that the patient can eat lunch with her friends when the school year starts go away to college at the same time as all of her friends. The only timeline that matters is the patient’s recovery timeline, which may or may not be convenient for her (or you). Each person’s recovery moves forward at a different pace.

• Remember that whatever happens is simply feedback, not failure.

Keep in mind that the patient will probably struggle quite a bit at first. Re-learning how to feed oneself properly after a bout of AN is a very difficult task. If a patient is not able to take charge of a meal or snack, that says nothing about her character or her effort or her prognosis for recovery. It simply means that she is not ready for that step yet. Expect the patient to make mistakes, and be there to help her correct them without blame or judgment. Remember that she is doing the best she can.

• Keep things in perspective.

As challenging as Phase II can be, don’t lose sight of how far the patient has come. She is eating well, she is at a healthy weight, she is medically stable, and she is in effective treatment. In the long run, it doesn’t matter whether someone breezes through Phase II or whether it takes over a year – she’s safe, she’s physically healthy, and she will recover eventually.

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Thursday, December 29th, 2011

Red Flags: How to Spot Ineffective Eating Disorder Treatment

I have blogged before about how to choose a good therapist. In this post, I will approach the therapist selection / retention issue from the opposite side – how to spot a bad therapist. Please note that many bad therapists are very good people with good intentions. People do not become therapists for money, fame, or the recognition – most of them genuinely care about people and want to help them. By “bad therapist” I mean “ineffective therapist.”

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.

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Wednesday, July 6th, 2011

Why Clinicians Are Resistant to Maudsley FBT

Research has shown that the Maudsley Method of Family-Based Treatment (FBT) is more effective than any other treatment for anorexia nervosa (AN) or bulimia nervosa (BN) in patients under age 18. Despite this fact, many clinicians who treat eating disorders are very resistant to using FBT to treat their patients. There are a variety of reasons for this resistance – some legitimate, some personal, some inexcusable, and some bred from ignorance.

Here are some of the most common reasons why clinicians who treat eating disorders are resistant to using FBT, along with my rebuttals to each:

1.) “I work with adults. FBT is not applicable to most adults.”

While FBT has not been adequately studied in adults, the reality is that there are no evidence-based treatments for adults with AN yet. I believe that patients over age 18 need to have loved ones fully informed about their illness and actively involved in their treatment just as much as young patients. The basic principles of FBT (with some age-appropriate modifications) are now being applied to older patients with very promising results.

As Cynthia Bulik’s recent study on Uniting Couples Against Anorexia Nervosa demonstrated, the principles of FBT can be applied very successfully to adults, using spouses or significant others for support rather than parents.

Also, there is some preliminary evidence that a modified version of FBT can be useful for college-aged patients who are temporarily living at home with parents during recovery. There may very well be a time in the not-too-distant future in which a modified form of FBT is an evidence-based treatment for adults.

2.) “Some families can’t do it.”

This statement is absolutely true – some families can’t do it. However, I believe that the true percentage of families who “can’t do it” is actually much smaller than one may think. FBT can be successful in divorced families, step-families, single-parent families, families with many children, families where both parents work full time, and families in which a parent suffers from a mental illness.

The only real contraindications for FBT in patients under18 are cases in which the patient has been physically or sexually abused by a parent, or both parents are so mentally or physically ill that they are unable to care for their children. Both of these contraindications are relatively rare, and even in these cases, one would hope that the patient would be living in a safe environment with other adults (e.g., relatives, foster parents) who could participate in FBT with the patient.

What happens too often is that parents don’t purse FBT because they aren’t aware it exists, or aren’t aware of the evidence behind it. It is also common for parents to be discouraged from doing FBT with their child because the child’s clinician (who is not really familiar with FBT or who doesn’t agree with it) tells the parent that it won’t work for their particular child for some reason.

In sum, I would estimate that maybe 10 % of families really can’t do it (I have no data to support this percentage; it is just an educated guess). The majority of families can do it if they have the proper clinical support and encouragement. The majority of parents love their children immensely and will do anything to help them recover if given the opportunity. It is up to us, the clinicians, to give families that opportunity.

3.) “Some adolescents don’t improve with FBT.”

I have no counterpoint to this one. The reality is that FBT is not effective for everyone. This is not a shortcoming unique to FBT, as there are no treatments that work for 100% of patients. I doubt that there will ever be one treatment that works for everyone in the same diagnostic category, because each individual patient is unique and has their own set of circumstances. Therefore, we must continue to research other forms of treatment and work to improve upon the existing treatments. When a patient does not improve with FBT, we must offer something else – residential treatment, day treatment, cognitive behavioral therapy – whatever is most appropriate for that particular patient and that particular family.

4.) “My training and inclination is as an individual therapist. Making the switch to working with families is intimidating. Learning FBT would be like starting from scratch.”

I don’t see it as starting from scratch. Rather, I see it as adding another (very effective) tool to your existing toolbox. You certainly don’t need to abandon individual therapy just because you’ve added a new treatment to your repertoire.

While some patients will recover fully with FBT and never need individual therapy, most patients do have co-morbid disorders or other issues which need to be addressed with individual therapy. In these cases, individual therapy comes after FBT. Many times I have transitioned to individual therapy with a patient after the patient has successfully recovered with FBT. The great thing about this approach is that the eating disorder has already been fully addressed through FBT, so you and the patient can focus all your time and energy on other things, such as depression, OCD, body image issues, perfectionism, and social difficulties.

5.) “My training is in psychodynamic therapy and relational approaches. FBT is pretty concrete and behavioral. Adopting FBT would seem to remove the very things that made me want to become a therapist in the first place – the focus on depth and the therapeutic relationship.”

FBT is more concrete and behavioral than other types of therapy, and I believe that is part of why it is so effective in treating these malignant illnesses which demand immediate behavioral management in order to save the patient’s health. That being said, the therapeutic relationship is just as essential in FBT as it is in other types of treatment. The parents and the therapist must develop trust in one another, and mutual respect is key, because the parents and therapist are allies working together against the illness on behalf of the child. It is extremely rewarding to be able to offer this kind of assistance and support to terrified, confused, guilt-stricken parents, who blossom with confidence as you educate them about the illness and empower them to do what needs to be done to help their child recover.

And the kids! It is nothing short of amazing to watch the therapeutic relationship evolve and unfold so quickly as recovery progresses. In the first few sessions, the kid typically presents as catatonically depressed, curled up in a fetal position under a blanket, sobbing quietly; or the kid reacts with extreme anger and resistance, yelling and hurling insults and dropping f-bombs before running out of the room. Entire tissue boxes are gone through in one session; stuffed animals need to be placed back on the shelves after being thrown. And within a few months, the kid is smiling, laughing, so happy to see you, chattering on about their trip to Disney World or their new boyfriend or how much they love ‘90’s music exclaiming “Wow, Dr. Ravin, it must have been so cool to be a teenager back in the ‘90’s!” The transformation is astounding.

Furthermore, there is lots of room for a tremendous amount of depth when continuing to work with the patient individually after FBT has been successfully completed. In fact, is even more feasible to go into greater depth in these cases, because the eating disorder is in remission and health-threatening behaviors have long-since been eliminated, so treatment can focus exclusively on other (often more interesting!) issues.

6.) “FBT is agnostic on etiology, and I think etiology is very important.”

Yes, FBT is agnostic with regards to etiology. In other words, the clinician states clearly at the outset of treatment that we don’t know exactly what causes eating disorders, and that it is not relevant for the purposes of this treatment. I believe this agnostic stance is one of the strengths of FBT: it does not waste time on “why” but instead focuses on “how” to help the patient recover.

I agree that etiology is very important because our ideas about etiology (for better or for worse) have a huge impact on how we treat patients. Therefore, clinicians and researchers must continue to have professional discussions about etiology amongst themselves.

My concern is not the discussion of etiology amongst professionals in the field. Rather, my concerns are 1.) When clinicians have a particular presumption about etiology which is not consistent with recent scientific evidence, 2.) When that particular presumption guides the use of treatments that are less effective, and 3.) When those presumptions about etiology cause harm to patients and their families by subtly or overtly blaming the patient or the family.

In my opinion, when clinicians discuss etiology with patients and their families, these discussions should be limited to the following points:

A.) Clarifying that neither the patient nor the family is to blame for the illness.

B.) Dispelling common myths about etiology (e.g., media, control issues, overprotective parents)

C.) Discussing the “Four P’s:” predisposing factors (e.g., genetic predisposition), precipitating factors (e.g., weight loss through dieting or illness), perpetuating factors (e.g., malnutrition has a calming and mood-elevating effect on those who are vulnerable to eating disorders), and prognostic factors (e.g., importance of early and aggressive intervention, maintenance of optimal body weight).

This is all the information patients and families need to know about etiology, because let’s be frank: this is all we really know about etiology. Anything else is just a distraction.

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Sunday, May 29th, 2011

Why Psychodynamic Therapy is Harmful for Eating Disorder Patients

1.) The approach is based upon theory rather than empirical data.

Decades ago, when psychologists and psychiatrists first began treating eating disorders, psychodynamic therapy was the only tool they had. Science has come a long way since then. While there is still so much about the illness that we don’t understand, we have learned a great deal in the past decade about the etiology of eating disorders and how to treat them more effectively. Why use theory-based practice when we have evidence-based practice?

2.) It confuses symptoms with causes.

For example, one psychodynamic theory posits that girls develop anorexia nervosa due to their fear of growing up and their desire to remain child-like. In reality, the ammenorhea and boyishly-thin bodies of anorexic girls are symptoms of the illness.

3.) Insight and motivation are over-emphasized, especially early in treatment.

Insight and motivation are crucial to sustaining wellness later in the recovery process. But patients with anorexia nervosa suffer from anosognosia, a brain-based inability to recognize that they are ill. The problem with emphasizing insight and motivation early in treatment is the presumption that the patient must “choose” to get well and that, if she does not make that “choice,” no one else can make it for her. Precious weeks, months, even years are wasted trying to form an alliance, cultivate motivation, and develop insight.

4.) It presumes that the patient’s family dynamics are at least partially to blame for the eating disorder, and that correcting the family dysfunction will help the patient recover.

There is no reliable scientific evidence to support these theories. Families of eating disorder patients do typically present for treatment with high levels of conflict and tension. The conflicted parent-child relationship, however, is most likely the result of the eating disorder rather than the cause. Having a child with any serious illness creates enormous strain on even the healthiest, most functional families.

5.) It presumes that there is a “deeper meaning” in symptoms which are the result of malnourishment and/or faulty brain chemistry.

A great deal of time and money is wasted attempting to discern this deeper meaning. Meanwhile, the patient’s brain and body are failing, placing him or her at risk of permanent medical and psychiatric problems. I advise patients and families: Don’t waste time on “why.” The reality is that we don’t know exactly what causes anorexia nervosa or bulimia nervosa.

We still do not know the cause of many types of cancer, but we begin aggressive cancer treatment immediately upon diagnosis because the longer it goes untreated, the more grim the prognosis becomes. We can remove a tumor or give chemotherapy without knowing how the tumor originated. The same principles apply with eating disorders – the patient’s nutrition and weight must be normalized immediately, and dangerous behaviors must be stopped right away. The patient will benefit from these interventions, both physically and mentally – even if the “reason” for the eating disorder is unknown.

6.). Too much attention is paid to early experiences, often at the expense of solving problems in the here and now.

Psychodynamic theory presumes that psychiatric disorders stem from early childhood experiences. In reality, childhood experiences are generally irrelevant to the patient’s eating disorder. Even in instances in which early experiences are relevant to the current illness, there is no evidence that an ill patient can overcome her eating disorder “exploring” or “processing” such experiences.

7.) Too much value is placed on the relationship between therapist and patient.

While I completely agree that the therapeutic relationship is very important to the healing process (and there is solid research supporting this), I believe that this relationship must take a backseat to treating the eating disorder aggressively. This means that in order to be optimally effective, the therapist must listen to the patient’s basic needs rather than her expressed wishes (translation: the ED’s wishes), consistently nurturing her relationships with family members when she (translation: the ED) wants them to leave her the f*** alone, and setting firm limits on her ED behavior immediately rather than waiting for her to develop the motivation and insight to do so herself. In my experience, this often means that the patient (translation: the ED) will hate me at the beginning of treatment, then gradually grow to trust, admire, and respect me as treatment progresses and her brain returns to healthy functioning. Most patients eventually express gratitude for that early toughness and understanding of what had to be done, recognizing that they wouldn’t have been able to recover without it.

8.) It undermines the relationship between the patient and his or her parents.

Psychodynamic therapy involves deep exploration of childhood experiences and family relationships in attempt to uncover the seeds of the patient’s current mental conflict. The typical result of this type of therapy is that the patient begins to distrust and resent her parents for making her ill, and the parents back off even further out of fear of making problems worse. This results in further exacerbation of existing family conflict and the creation of new problems, once the patient “realizes” how pathological her family really is.

We now know, through research on family-based treatment, that empowering parents to help their children overcome eating disorders is actually the most effective way to help them recover. I believe that nurturing positive relationships between the patient and her family members is essential for full recovery and ongoing relapse prevention, as family members are usually the first to notice signs of struggle, and the first ones to intervene.

9.) It is extremely difficult to undo the damage done by psychodynamic treatment.

A substantial amount of the trauma that patients and families endure is not the result of the eating disorder itself, but rather the result of bad treatment and protracted illness. Often, patients and their families come to me for family-based treatment after months or years of traditional therapy which has not been effective. Even a newly-diagnosed patient will struggle with re-feeding, but having a history of traditional treatment makes the process much more tumultuous. It is extremely difficult for the patient to accept meal support from their parents when they have been conditioned to believe that separation/individuation issues are at the root of their illness, or that they have developed their eating disorder as a way to survive in a dysfunctional family, or that they will recover when they choose. Further, parents struggle enormously to become empowered to act on their child’s behalf when they have been blamed for causing the illness, either overtly or subtly, by their child’s previous clinicians.

10.) It does not bode well for relapse prevention.

Unfortunately, eating disorders have a very high rate of relapse, in part because the underlying biological vulnerability stays with the patient for life. In order to maintain full recovery, it is extremely important for the patient to maintain his or her optimally healthy body weight, practice excellent self-care, manage stress adaptively, and eat a complete, well-balanced diet. The beliefs that one’s eating disorder resulted from internal conflict, or that “it’s not about the food,” are not terribly conducive to these protective measures.

As science has progressed and newer, more effective treatments have been developed, there has been a backlash from the “old school.” Those who remain entrenched in outdated, unproven psychodynamic theories will defend their beliefs like a lioness defends her cubs because – let’s face it – these theories are their babies. They have built careers on these ideas; written books about them; conceptualized their own recovery through these lenses. But that does not make these theories correct, or evidence-based, or useful, or effective in treatment.

Let’s welcome a new generation of clinicians who use evidence-based treatment that strengthens family relationships, treats deadly symptoms rather than hypothesized causes, and promotes full and lasting recovery for all patients. Let’s welcome a new generation of patients and families who are not blamed for the illness, but are empowered to pursue aggressive, effective treatment upon initial diagnosis. Let’s welcome treatment that actually works and refuse to support treatment that doesn’t.

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Friday, July 9th, 2010

Controversy

I love controversy.

So naturally, I was thrilled to read the recent news article in the Sun Sentinel with a headline describing Maudsley as “a controversial treatment.”

This article gives an overview of the Maudsley Method and describes the experiences of two families – one with a 12-year-old girl and one with an 18-year-old boy – who used this approach to help their children recover from Anorexia Nervosa (AN). In a fair and balanced way, the article also lists some of the criticisms of the Maudsley Method that make it so controversial.

I believe that controversy is healthy part of living in a free society. Without controversy, there cannot be progress in the areas of ethics, morals, politics, or social norms. We must challenge old ideas and new ideas alike. We must approach life with an open mind as well as a healthy degree of skepticism. Some of the best ideas in the history of humanity, such as racial integration, freedom of religion, and equal rights for both genders, were born amidst extreme controversy. Thousands of people devoted their lives to the pursuit of these ideas. People died fighting for these causes. And to my generation, they seem so obvious and self-evident that we take them for granted.

Controversy accelerates progress in the aforementioned areas by shedding new light on old ideas. On the contrary, controversy tends to hinder progress in science. This happens because controversy over scientific ideas generally arises when people criticize or oppose scientific discoveries on the grounds of theology, politics, morality, or philosophy. Many scientific truths were initially met with extreme controversy. Galileo was tried – and convicted – by the Vatican for his scientific explanation of a heliocentric universe. And although Darwin’s theory of evolution has been almost universally supported by the modern scientific community, it was (and still is, in some communities) highly controversial for cultural, theological, and political reasons.

All viewpoints have equal merit in debating different perspectives on morality, philosophy, or politics. The winning idea is the one which is shared by the majority of people, which is then often supported by legislation and reinforced by social norms. This is what happened with racial integration, religious freedom, and gender equality. In debates over science, however, some answers are clearly superior to others. Ideas supported by scientific research are superior to ideas not supported by scientific research. Scientists conduct reliable studies, interpret the data, and present the results to their peers. Eventually, these results are disseminated into the public domain. Personal beliefs and political viewpoints and religious doctrines have no place in scientific inquiry. They obscure the truth.

In this vein, we have the controversy over the Maudsley Approach. Some clinicians say that they “don’t believe in Maudsley” just as some people say they don’t believe in God or Santa Clause or evolution. Maudsley, like evolution, is not a “belief” to be accepted or rejected. Maudsley, like evolution, is supported by a wealth of scientific literature which should be evaluated empirically and used effectively to understand and advance the human condition. To treat Maudsley as a socio-political issue like gay marriage that one sides “for” or “against” muddies the waters, misses the point, and makes one look scientifically illiterate.

Those who criticize Maudsley are doing so on philosophical, rather than scientific, grounds. They have not devised reliable, valid studies yielding data to the contrary. Rather, they cite antiquated and unproven ideas about eating disorders, they make criticisms that show a clear ignorance of the scientific process, or they ask irrelevant questions.

Some day soon, the Maudsley Approach will join the ranks of Darwin’s evolution and Galileo’s heliocentric solar system as a scientifically accepted truth. Some day soon, all therapists will approach psychology as a science – like biology and astronomy – which is guided by empirical data and impervious to personal beliefs.

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Wednesday, June 23rd, 2010

Rethinking Residential Treatment: Less is More

I am not a fan of residential treatment for eating disorders as it exists today. I am not aware of any scientific research suggesting that residential treatment is superior to outpatient treatment, with the exception of marketing materials from residential treatment centers (which have an obvious bias and financial incentive). We do know that hospital admissions and stints in residential treatment are poor prognostic factors – patients who remain at home and recover through outpatient treatment are more likely to recover than those who go through residential care. To be sure, the relationship between residential treatment and prognosis may be correlational rather than causal. Patients who are sent away to residential treatment generally have longer duration of illness, greater severity of illness, more psychiatric comorbidity, and a history of unsuccessful outpatient treatment.

There is one recently published randomized controlled trial of outpatient vs. residential treatment. Results of this study demonstrated that adolescents who were randomly assigned to outpatient treatment fared just as well as those who were randomly assigned to residential treatment. Given that outpatient treatment is less expensive and less disruptive to the adolescent’s life, the authors conclude that outpatient treatment is preferable.

I am a firm believer in evidence-based outpatient treatments which keep family members fully informed and actively involved whenever possible. Patients who receive treatment which prioritizes nutritional rehabilitation, weight restoration, and cessation of restricting/bingeing/purging behaviors as the essential first step, are more likely to achieve full recovery in less time. In an ideal situation, a skilled therapist can utilize the strengths and resources of the family and coach them in understanding eating disorders, refeeding their loved one, and interrupting her eating disorder behaviors. Families can also be coached in how to maintain a home environment which is conducive to recovery while their loved one participates in therapy to acquire healthy coping skills, learn how to prevent relapse, and manage any comorbid conditions. This is how the Maudsley Method of Family-Based Treatment works. At this time, the Maudsley method is the only empirically-supported treatment for adolescent anorexia nervosa, and has also been shown to be equally effective in treating adolescent bulimia nervosa. Empirical studies on the use of a modified Maudsley approach in treating young adults with eating disorders have not yet been published. However, anecdotal evidence suggests that many young adults respond favorably to a modified Maudsley approach – even those who have been ill for many years and have had numerous stays in inpatient or residential treatment. And, let’s face it: we don’t really have a good alternative treatment for young adults with anorexia nervosa.

The majority of patients who are treated with Maudsley do achieve and maintain full recovery. Simply put, Maudsley works, and there aren’t any great alternatives. Thus, Maudsley should typically be the first-line treatment, especially for adolescents with anorexia nervosa, and should commence immediately following diagnosis. That being said, Maudsley may not be appropriate in a minority of cases. For example, families who are unable to find evidence-based treatment providers near their home, families in which neither parent has the necessary time or energy due to very demanding careers or caring for other small children, families in which parents cannot agree to Maudsley and refuse to compromise or work together, families in which there is abuse or addiction, or families in which one or both parents suffers from a physical or mental illness which impairs their ability to parent their child effectively.

Despite the promise of the Maudsley Method, it is not necessarily effective or appropriate for all patients (this statement, while often cited by critics of Maudsley, is annoying and virtually meaningless because NO form of treatment for any psychological or medical illness is ever appropriate and effective for 100% of patients. This is not a weakness of a particular treatment method; this is just reality). For the aforementioned reasons, there is, and probably always will be, a need for residential treatment for eating disorders.

Residential treatment for eating disorders, as it exists today, has several benefits and several drawbacks. The benefits include:
• Supported nutrition to promote appropriate weight restoration
• Round-the-clock monitoring to prevent patients from engaging in bingeing, purging, restricting, and substance use
• Protection from self-harm and suicide
• Providing the patient with a respite from the stresses of school, work, sports, and everyday life
• Providing the family with a respite from the daily strain of caring for their loved one

The drawbacks to residential treatment, as it exists today, include:
• Prolonged separation from the family and home environment
• Prolonged absence from school, friends, extracurricular activities, and normal routines
• Exposure to other eating disorder patients, which can result in acquisition of new symptoms, solidification of identity as an “eating disorder patient,” and competitiveness with other patients about who is sicker or thinner
• Artificial environment – a “bubble” – which does not translate to real-world living
• Exposure to outdated and unproven theories about the etiology and treatment of eating disorders (e.g., blaming “family dysfunction,” search for “root causes,” exploration of supposed “underlying issues”)
• Failure to plan adequately for a smooth transition home
• Insufficient family involvement (weekly phone sessions and “family weekend” pay lip service to family involvement, but they often play the blame game, focus on presumed family dysfunction, advise parents to “back off” and not be the “food police,” and fail to educate families as to how to help their loved one recover. In essence, many family sessions send all the wrong messages and fail to send the helpful ones).
• Over-diagnosis of and over-medication for supposed comorbid disorders which are largely, if not entirely, the result of malnourishment and / or refeeding
• Attempts to use psychotherapy of any kind on patients who are not able to benefit cognitively or emotionally.

These last two points are particularly striking to me (granted, these problems occur with less-informed outpatient treatment as well). I have had many patients who were diagnosed with and medicated for severe mental illnesses such as major depression, bipolar disorder, or even borderline personality disorder, while they were underweight or re-feeding in residential treatment. In many patients, these symptoms decrease substantially or disappear altogether once the patient has reached and maintained a healthy body weight for a number of months. I have several patients who arrived at my office after years of ineffective treatment, with multiple psychiatric diagnoses, taking multiple medications. After weight restoration and maintenance along with evidence-based psychological interventions, these patients no longer required medication for any psychiatric symptoms and no longer met criteria for ANY mental disorder. Sometimes, less is more.

What many psychiatrists and other mental health professionals fail to understand is that all people who are malnourished or re-feeding, even those without eating disorders, exhibit symptoms that mimic certain mental disorders (see Minnesota Starvation Study). Diagnoses made while a patient is underweight or re-feeding are often inaccurate. Medicating a patient for a presumed mental illness which is actually the direct result of a malnourished and / or refeeding brain is at best ineffective and at worst quite harmful. Obviously, many patients with eating disorders do have genuine comorbid psychiatric issues, and clearly these need to be identified and treated. But even those patients with legitimate comorbidities may find that their other symptoms are more manageable, or require less medication, when their eating disorder is under control.

Nearly all patients in residential treatment for eating disorders are there because they are significantly malnourished or actively engaging in frequent binge/purge behaviors. These are patients with significant (though temporary) brain damage which renders them unable to process emotions, think rationally, perceive other people’s intentions, or think logically about food, weight, or body image. We know that this brain damage is reversible only after months of full nutrition, weight restoration, and abstinence from eating disorder symptoms. I understand the rationale that, since patients are in residential treatment, they should be given every possible type of treatment available from equine therapy to process groups to CBT to psychoanalysis to making pretty necklaces. I understand that the directors of residential treatment centers want to provide patients with every possible tool for recovery. But what if the patients are not yet equipped to use these tools? And what if some of these tools can be harmful? Again, this may be a case of less is more.

In my ideal world, residential treatment would retain the benefits it currently has while eliminating the drawbacks. Here’s how it would work:
• The immediate focus would be on full nutrition, full time so that patients can restore their weight as quickly as is medically safe and can break the binge/purge cycle (if applicable). This would include three meals and three snacks per day, carefully monitored. “Magic plate” would be employed, and patients would be required to eat 100% of their meals and snacks. There would be no “rewards” for eating well or “punishments” for eating too little. Eating disorder patients are punished enough by their illness, so the last thing they need is a punitive external measure. Rather, there would be no alternative other than to consume full nutrition, preferably through food, but otherwise through a supplement or nasogastric tube.
• Patients would be carefully monitored and prevented from hiding food, bingeing, or purging.
• Patients would be monitored for urges to self-injure or commit suicide and kept safe from any possible means of self-harm.
• No new diagnoses would be made and no new medications prescribed.
• No individual therapy, family therapy, or group therapy of any kind would be provided. However, a psychologist specializing in eating disorders would be available daily to provide supportive counseling for patients who request it.
• Patients would spend their days participating in relaxing, rejuvenating activities such as reading, watching movies, playing board games, getting massages, taking nature walks and practicing gentle yoga (when medically appropriate).
• Patients would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and relapse prevention.
• Through phone conferences and/or in-person sessions, family members would be educated about the genetic and neurobiological basis of eating disorders as well as the role of under-nutrition and compulsive exercise in the development and maintenance of these illnesses. They would be provided with scientifically valid information on effective treatments for eating disorders and skills to help their loved one continue on the path to recovery at home.
• Family members would be provided with daily updates on their loved one’s progress, regardless of the patient’s age. Family members would also be encouraged to contact the treatment center at any time with questions or concerns.
• Family members and friends of the patient would be strongly encouraged to call and visit the patient whenever possible.
• A physician would set an accurate target weight range for each patient, taking into account her pediatric growth charts, weight/build history, and genetics. The target range would represent the patients’ ideal, healthiest weight, not some arbitrary minimum BMI. Research shows that the vast majority of adult patients require a BMI of at least 20 in order to achieve complete physical and mental recovery, so that would be a good starting point.

Patients would be discharged from my ideal treatment facility only after the following criteria were met:
• The patient has achieved 100% of her ideal body weight.
• The patient eats 100% of her meals and snacks with little resistance.
• The patient reports a significant decrease in urges to restrict, binge, or purge.
• The patient is not experiencing suicidal ideation or urges to self-harm.
• The patient expresses readiness for discharge and willingness to work towards recovery.
• The family has been well-educated about eating disorders and feels confident to manage their loved one’s symptoms at home.
• The patient and her family members have collaboratively developed a specific, written outpatient treatment plan. This plan includes referrals for evidence-based psychological treatment for the individual patient and her family as well as regular medical monitoring. In addition, the plan contains specific strategies for dealing with the patient’s eating disorder behaviors and for creating a pro-recovery home environment.

Although it exists only in my imagination, I would predict that a residential treatment center such as the one I described would be more effective than most currently existing treatment centers. It would also be much cheaper, since far fewer staff would be required. Granted, patients may have a longer duration of residential treatment than they do now, since the goal is 100% weight restoration, but patients would be less likely to relapse. Since this treatment center would be cheaper anyway, and patients would be less likely to require repeated admissions, the overall cost to the patient’s family and to society would be much lower.

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Monday, June 14th, 2010

Recovery Timeline for Maudsley FBT

I recently conducted an informal survey of parents who had used the Maudsley Method of Family-Based Treatment to help their children recover from eating disorders. My intention was to gather some preliminary data on recovery milestones which I could share with patients and families who are just embarking on the recovery journey. Then I realized that other people may benefit from this information as well.

The following data were collected from parents of some of my patients (past and present) as well as from parents on FEAST’s caregiver forum, Around the Dinner Table. A total of 22 parents submitted responses. The patients (20 female, 2 male) ranged in age from 10 – 24 years when their family started Maudsley (mean age = 15.3 years).

The patients in my sample varied dramatically with regard to the length of their illness. Some parents reported that they began Maudsley within a month after their child’s first eating disorder symptoms appeared. Other parents had watched their child continue to suffer from the devastating effects of ED through many years of ineffective treatment and numerous hospitalizations before finally turning to Maudsley as a last resort.
Granted, this is not good science, but it is a start.

Length of time from onset of symptoms to beginning of refeeding
Mean = 18.8 months
Median = 6.25 months
Range = 1 – 132 months

Length of time from start of refeeding to weight restoration
Mean = 6.7 months
Median = 4.5 months
Range = 2 – 24 months

Length of time from weight restoration to acknowledgement of having ED
Mean = 1.1 months
Median = 0 (acknowledged having ED when he/she became weight restored)
Range = 0 – 16 months
(90 % of the sample acknowledged having ED at or before weight-restoration)

Length of time from weight restoration to developing motivation to recover
Mean = 4.6 months
Median = 0 months (motivation developed at the time of weight restoration)
Range = 0 – 24 months

Length of time from weight restoration to eating independently while maintaining weight
Mean = 7.8 months
Median = 6.5 months
Range = 0 – 36 months

Length of time from weight restoration to mood normalization
Mean = 3.3 months
Median = 2 months
Range = 0 – 12 months

Length of time from weight restoration to normalization in anxiety (return to pre-ED level)
Mean = 6.5 months
Median = 3 months
Range = 0 – 36 months

Length of time from weight-restoration to absence of body dysmorphia
Mean = 6.9 months
Median = 4 months
Range = 0 – 24 months

Clearly, more rigorous research is necessary in order to draw definitive conclusions. However, I’ve drawn some preliminary conclusions based on my data:

1.) The Maudsley Method can be effective for children, adolescents, and adults. It can be effective for both males and females.
2.) The Maudsley Method can be effective even for young adults who have been ill for 10 years or more.
3.) Most patients who are beginning Maudsley treatment have anosognosia – they do not recognize that they are ill and do not have motivation to recover. The patient does not have to “want to get better” in order for treatment to begin.
4.) The majority of patients develop insight and motivation to recover around the time that they reach a healthy body weight. For some patients, insight and motivation develop gradually after a number of months at ideal body weight.
5.) Patients generally require continued meal support for an average of 6 months after weight restoration.
6.) The manualized Maudsley approach (Lock, LeGrange, Agras, & Dare, 2001) recommends beginning to hand control of eating back to the patient when she reaches 90% of ideal body weight. This is probably too soon for most patients.
7.) The majority of patients must sustain a healthy body weight for 3-6 months before depression, anxiety, and body dysmorphia abate.

This is interesting food for thought (pun intended). I am interested in conducting a much larger survey on families that have used Maudsley. I’d like to gather enough participants and enough data points to be able to do some actual complex statistical analyses – maybe some ANOVA’s or multiple regressions. Through this study, I’d like to examine which variables contribute to recovery time. For example, what features differentiate patients who are able to eat independently at weight restoration vs. those who need continued meal support? What differentiates the patients whose psychological symptoms melt away with weight restoration vs. those who continue to struggle? Most importantly, I would like to use data from this future study to find ways in which the Maudsley method could be improved.

What questions would you like to see answered? I welcome any and all suggestions!

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Friday, April 30th, 2010

Everything I Need to Know I Learned From Adolescents

A 31-year-old woman named Monica recently died from anorexia nervosa (AN) following a 15-year battle with the disease. Her death is an eerie reminder of what we already know: eating disorders are dangerous, deadly, and difficult to treat. Traditional treatment for AN typically takes 5-7 years. Less than half of patients with AN will ever fully recover, and of those who do recover, one-third will relapse. Nearly 20% of patients with AN will die as a result of their illness.

Just a decade ago, only 30% of patients fully recovered, and now nearly 50% will fully recover. The reasons for the improved prognosis include greater awareness about eating disorders, which leads to earlier diagnosis and treatment, and the advent of more effective, evidence-based treatment for adolescent AN, such as Maudsley Family-Based Treatment. But early diagnosis, early intervention, and the Maudsley method primarily benefit adolescents. Consequently, I would presume that the 20% increase in recovery rates over the past decade is primarily due to the recovery of more adolescents, not the recovery of more chronically-ill adults.

Although AN typically begins in early adolescence, those who die from the disease are more often adults who have battled it for many years. The most effective course of action is early diagnosis and aggressive, evidence-based treatment as soon as symptoms appear. Unfortunately, there are countless adults with AN who have struggled for years or even decades. As of this time, there are no evidence-based treatments for adults with AN, nor are there any medications which have been proven to benefit adults with AN. CBT has been shown to be moderately beneficial in preventing relapse in weight-restored AN patients but shows no benefit in underweight anorexics.

A lot of the AN treatment offered today is outdated and ineffective. Fortunately, however, there are more and more clinicians and treatment centers who are adopting modern, evidence-based approaches to treating adolescent AN that have much higher success rates. For example, the Kartini Clinic, the UCSD 5-Day Intensive Family Program, and the Children’s Hospital at the University of Chicago have adopted a highly-practical family-based, evidence-based approach to treating adolescent AN based on the Maudsley Method.

We can learn a lot from the success of these adolescent programs. I believe that we can use the basic principles of Maudsley FBT and the philosophy of these adolescent treatment programs to develop effective treatments for adults. Medicine, psychology, and psychiatry do this all the time in the reverse; that is, they extend effective adult treatments to adolescents. If a particular medication or psychotherapy approach demonstrates effectiveness in adults, clinicians automatically begin using it in adolescents, often without any research data to support its use in this population. Clinical trials are then conducted on adolescents, and research data follows.

Consider the basic principles of Maudsley FBT:
1. Conceptualization of AN as a biologically-based brain disorder of unknown origin
2. Externalizing the illness
3. Viewing family members as vital resources in a patient’s recovery
4. Recognition that most of the symptoms of AN are direct result of malnutrition and thus will abate after weight restoration
5. Focus on nutritional rehabilitation and weight restoration as non-negotiable first priorities in treatment
6. Acknowledgment that patients with AN are unable, in the acute phase of illness, to make healthy decisions regarding food and weight
7. Coaching parents to provide emotional and nutritional support to their child
8. Addressing psychological symptoms and other comorbid disorders after weight restoration

Which of these principles are irrelevant in the treatment of adults?

I see no logical reason why we cannot use Maudsley FBT in the treatment of adults with AN. Based on the patient’s circumstance and living situation, spouses, roommates, friends, or significant others may be enlisted for meal support in lieu of parents. The specific details may need to be tweaked in order to be relevant to an adult patient’s situation, but the general principles would remain the same. After all, the physical and psychological symptoms of AN are the same regardless of whether the patient is an adolescent or an adult. AN stunts growth and development and prevent sufferers from becoming independent, fully-functional beings. Thus, adults with AN are regressed physically, sexually, and socially to the point that they often resemble adolescents anyway.

The differences that do exist between adolescent and adult forms of AN are not inherent to the disease itself or even to the age of the patient. Rather, they are imposed by society. We, as a society, have arbitrarily determined that teenagers are fully responsible for their own healthcare decisions once they reach their 18th birthday. This is the case regardless of whether the patient has an ego-syntonic, anosognosic condition such as AN which impairs their judgment and insight. By virtue of their illness, adults with AN are unable to make healthy decisions for themselves. And yet, the law prohibits parental involvement, even parental notification of treatment, unless the patient signs a release. The law clearly sides with AN, not with the patient.

Family support and family involvement are powerful predictors of good outcome. Unfortunately, most therapists consider parental involvement in an adult patient’s treatment unnecessary or even detrimental. These therapists believe that the etiology of AN is rooted in controlling parents, separation anxiety, and issues related to independence and autonomy. Thus, they keep patients separated from the very people who love them most and who may be best equipped to help them achieve full recovery. This is counterproductive because a patient’s physical and psychological wellbeing must always take precedence over the developmental issues of emerging adults which, incidentally, have never been proven to be causally related to AN. Adult patients’ lives are threatened as a result of ignorant adherence to an unproven theory.

I firmly believe that Maudsley Family-Based Treatment can be effective in young adults. In fact, I have used this approach with young adults in my practice with great success. I have seen patients who have been sick for a decade, hospitalized multiple times, and endured several courses of ineffective residential treatment finally achieve recovery as outpatients through FBT. I look forward to the day when FBT is widely available to adults, as well as adolescents, with AN.

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Tuesday, December 29th, 2009

In Defense of Helicopter Parenting

Last month, Time Magazine ran an article about the dangers of over-involved, over-protective parenting (otherwise known as “helicopter parenting” because these parents tend to hover over their children). The article is well-researched, well-written, and very interesting. As a therapist who frequently encounters this phenomenon in the parents of my adolescent and young adult patients, and as a product of this type of parenting myself, I have a few thoughts and observations on the issue.

I agree wholeheartedly with the author that today’s parents are far too over-involved and over-protective, and this is particularly true amongst middle- to upper-class families with well-educated parents. According to psychologist Eric Ericson, the primary developmental task of middle adulthood (ages 30-50) is seeking satisfaction through productivity in career, family, and civic interests. This is precisely the age at which adults are parenting young children and adolescents, and for helicopter parents, their striving for productivity is channeled into their children. Parents’ intentions are good, but the outcome can be problematic. You see, the middle adulthood psychosocial task of productivity stands in diametric opposition to the adolescent developmental task of identity formation. Children need to play, explore, relax, and interact with their surroundings in creative, imaginative ways. Adolescents need to loaf, “hang out,” date, experience “teen angst,” spend quality time with family and friends, develop their social skills, make their own choices (within reason), make mistakes, and learn from them.

Ideally, a healthy person will emerge from adolescence with a solid self-identity, resilience, confidence, good problem-solving skills, and the ability to tolerate discomfort and failure. Having worked in several college counseling centers, I can attest that many kids arrive at college without these skills and attributes. Their lives have been geared entirely towards achievement in academics, arts, and athletics, often not for the love of science or music or soccer, but because their parents pushed them and/or because they believed it would improve their chances of gaining admission to a prestigious college. Quite often, they don’t know how to structure their time, study properly, deal with disappointment, or make decisions independently. Sadly, many of them do not know who they are or what they enjoy.

Helicopter parenting has the potential to be quite harmful to children by increasing their stress and anxiety and preventing them from developing self-confidence, resourcefulness, problem-solving skills, distress tolerance skills, emotion regulation skills, and creativity. Children and adolescents are over-scheduled, over-worked, and pushed to succeed, often at the expense of their emotional health. There is not enough unstructured time for kids to play, explore, or create. There is little room for adolescent identity formation in between AP classes, Princeton Review SAT prep courses, college applications, three varsity sports, band practice, clubs, and mandatory community service hours.

These issues notwithstanding, one problem I have seen far too often in my profession is the tendency for therapists to blame helicopter parents for causing their child’s eating disorder. It is easy to look at over-involved parents and an adolescent’s misguided search for control and identity through self-starvation and conclude that the former caused the latter. But the belief that over-involved, controlling, or enmeshed parents cause children to develop anorexia nervosa (AN) or bulimia nervosa (BN) lacks solid scientific evidence. What’s worse, this belief has the potential to undermine treatment, disempower parents, confuse children, perpetuate deadly symptoms, erode physical and mental health, destroy families, and turn an acute illness into a chronic and disabling one.

There is a correlation between over-involved, over-protective parenting and the development of AN, but correlation does not necessarily indicate causation. If variable A (helicopter parenting) and variable B (child’s development of AN) are correlated, there are several possible explanations for the relationship between these two variables:

1.) A causes B
2.) B causes A
3.) Variable C causes both A and B
4.) Variables D, E, F, G, H, I, J, K, L, M, and N work together in complex ways to influence the development of both A and B.

Let’s examine each possible explanation.

1.) Explanation 1: Helicopter parenting causes children to develop AN. There is no reliable scientific evidence to support this explanation. Ironically, this explanation is touted far more frequently than the others, even by clinicians who specialize in treating eating disorders.
2.) Explanation 2: A child’s AN causes parents to become over-involved or over-protective. There is some evidence to support this explanation. If parents were not anxious, cautious, protective, or hovering before their child developed AN, you’d better believe they will be once their child becomes ill. This phenomenon is not unique to AN. Parents of children with any illness or medical condition naturally worry about their child and do whatever they can to protect her.
3.) Explanation 3: A third variable causes both helicopter parenting and AN in children. There is a wealth of evidence to support the genetic transmission of AN as well as related personality traits. The personality traits that predispose people to developing AN – anxiety, obsessiveness, perfectionism, and harm-avoidance – are largely genetic. In an adolescent female, these traits are likely to manifest as an eating disorder. In a middle-aged, middle-class, intelligent, well-educated parent, these traits are likely to manifest as over-involvement, over-protection, and over-investment in their child.
4.) Explanation 4: A complex interaction of other variables work together to produce both helicopter parenting and AN in children. This is the most thorough, and probably the most accurate explanation. As stated in explanation #3, genetics plays a major role in the development of AN. A wealth of environmental variables are also believed to influence the development of parenting style as well as AN (e.g., level of education, income, culture, peer group, family background, exposure to stressful life events).

I love working with adolescent children of helicopter parents. I require parents to be fully informed and actively involved in their child’s treatment, and helicopter parents slide seamlessly into this role. They are excellent candidates for Maudsley Family-Based Treatment because their anxiety level is high enough to propel them towards action, they thoroughly educate themselves on their child’s condition, they seek out the best treatment and resources, they are vigilant and persistent, they maintain a very high level of involvement and supervision, and they are tremendously invested in their child’s recovery. Misguided, ill-informed, old-school therapists argue that these characteristics caused the child’s AN, and they advise parents to “back off” and allow the child to make her own choices about food and weight and treatment. This approach rarely leads to lasting recovery.

While helicopter parenting certainly has the potential to cause harm, it can also be used to the child’s advantage in recovery if channeled properly. Helicopter parents tend to be wildly successful in Maudsley Phase I (re-feeding / weight restoration), and largely successful in Phase II (helping the adolescent eat properly on her own). Some of these parents are eager to step back in Phase III as their child deals with psychological and social issues and develops a healthy adolescent identity. Other parents struggle to let go when the time comes. With proper guidance from a good therapist, however, most helicopter parents can learn to manage their own anxiety enough to allow their children to blossom and develop as healthy, independent young adults. This does not come naturally for them, but never underestimate the power of the helicopter parent. If the therapist who helped save their beloved child from a life threatening illness coaches them to step back and let go, they’ll do it.

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