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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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Mental Hygiene

This post has been inspired by the absurd number of no-shows and last-minute cancellations I have had over the past few weeks, which have afforded me both the time and the subject matter to write this blog post. Yes, it’s the holiday season, and we’re all busy and stressed. You’ve got final exams and Christmas concerts and your cousins from Iowa visiting; presents to wrap and dinners to cook and trees to trim. But mental illness does not take a vacation. If anything, people with mental illnesses struggle even more than usual around the holidays. Putting mental health treatment on the back burner for the holidays – or for any reason – is a huge mistake.

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.

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The Thin Ideal and Anorexia Nervosa: It’s Not What You Think

It is commonly assumed in popular culture that the “thin ideal” is responsible for causing Anorexia Nervosa (AN). In other words, girls develop AN by embarking on an extreme diet in attempt to look like their favorite celebrity, and if we just showed “real women” in the media, AN would become obsolete.

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.