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Companion Guide for A Season in Hell

QUESTION 8: HOW ARE EATING DISORDERS TREATED?

People will probably want to know what could be done for Regina, were she willing to participate conscientiously in professional treatment. At this point in time the best treatments for eating disorders have not been established by well-conducted, comparative research. In fact, students who want to research the treatment of eating disorders will encounter a bewildering array of approaches, both across and within psychoanalytic, biomedical, behavioral, and cognitive-behavioral perspectives.

Based on the clinical experience of experts and on the handful of outcome studies available, it appears that the best treatment programs will have the components listed below. These components reflect one of the major themes of A Season in Hell: Eating disorders are complex because they represent the intersection of psychological, behavioral, biological, familial, and cultural issues.

(1) Assessment and treatment by a collaborative team or professionals, including a physician specializing in internal medicine, a psychiatrist, a therapist (psychiatrist or social worker) trained to help people with eating disorders, and a dietician.

(2) Careful evaluation for the presence of depression, suicidal tendencies, personality disorder, substance abuse, and sexual victimization. These problems often accompany and contribute to eating disorders.

(3) A focus on eliminating life-threatening symptoms and, just as important, developing attitudes and skills which make health more attractive than illness.

(4) Establishment of a healthy weight goal. This is a weight which (a) can be maintained by healthy eating patterns and (b) eliminates obsession with food and other starvation symptoms. Weight restoration is necessary, not only for people with anorexia nervosa, but also for some people with bulimia nervosa. Despite their culturally sanctioned slenderness or "normative" body weight, these people must gain some weight because they are dangerously below their set-point.

(5) Analysis of the patient's experiences within the interpersonal context of therapy. If done in a supportive and skilled fashion, the process of exploring the ongoing interactions between client and therapist promotes a collaborative alliance and enhances the client's receptivity to learning new ways of thinking, feeling, and coping.

(6) Procedures designed specifically to eliminate bingeing and purging. Examples include education about the cycle of bingeing, purging, and dieting; keeping records which reveal the relationships between situations, thoughts, feelings, eating, and purging; instruction in meal planning; development of "eating rituals" which reduce the propensity for mindless, impulsive consumption; imposition of increasingly long delays between eating and purging; and constructive techniques for coping with the emotions that usually fuel bulimia, e.g., anger and loneliness.

(7) Revision of distorted attitudes about food and body shape. Patients are helped to demystify food groups and to reintroduce previously avoided foods; to challenge the cultural norms which have contributed to their overvaluation of thinness; and to develop more sophisticated principles of self-control and self-defeating definitions based on dieting and weight control.

(8) Strengthening of the patient's copying skills and other healthy attitudes and behaviors. Patients are taught stress management, assertion, and problem-solving. They are also encouraged to get involved or resume involvement in exercising for pleasure (not weight management), community service, the arts, etc.

(9) Helping the family to assist in the process of recovery and future development. In some instances this will require intense therapy for the family as a whole. In all instances education and support of the family are important.

(10) Judicious use of medication for patients whose anxieties, obsessions, or depression are extreme and/or do not respond to weight restoration and cognitive-behavioral techniques.

Treatment will probably be on an outpatient basis unless (a) the individual is suicidal; (b) the combined effects of starving, bingeing, and purging are life-threatening; (c) bingeing and purging are so frequent that they completely disrupt adaptive functioning; or (d) the individual is unresponsive to appropriate outpatient care.