From Chief Clinical Officer, Doug Bunnell, PhD, CEDS
There is an enduring misconception that eating disorders are simple and relatively benign illnesses. Some of these misconceptions have significant implications for how parents respond, both practically and emotionally, to their child. The complexity, ambiguity and intensity of these disorders can leave families feeling overwhelmed and anxious and, unfortunately, many even feel responsible for creating the disorder. Making informed decisions about treatment options is challenging, especially when your child is threatened by a dangerous disorder. When looking for an eating disorder program that specializes in treating adolescents, you will want to consider asking these questions of a residential provider.
An appreciation for the complexity of eating disorders is especially critical when evaluating treatment program options. It is often difficult to assess whether any particular program has the resources, sophistication, and clinical experience to develop and deliver a comprehensive treatment plan that addresses the multiple factors that drive any individual’s eating disorder. While there is often a natural and understandable interest in identifying the issues that created the eating disorder in the first place, research and clinical experience point to the necessity of focusing on the factors that are actually maintaining and sustaining the disorder in the present moment. A focus on these immediate maintaining factors is a key element of effective treatment.
Developing a comprehensive treatment plan requires careful and thorough assessment of the six key dimensions. Within the first days of admission, each adolescent and her family participates in a detailed assessment process. Nutritionists review the teen’s dietary and growth history, food preferences and disordered eating behaviors and establish an initial plan for normalizing eating behaviors and re-establishing nutritional stability. Our psychotherapy team and psychiatrists conduct a thorough review of each individual’s temperament, personality and cognitive styles. Families provide historical information and perspective on their child’s developmental and relationship histories. Psychiatric evaluations assess the degree to which underlying mood and anxiety issues may be contributing to the adolescent’s eating disorder. These evaluations also explore family histories of mood and anxiety disorders in order to clarify the importance of these potential maintaining factors.
Helping adolescents to recognize, challenge and change their beliefs about the positive benefits of their eating disorder is critical for building motivation and commitment to recovery. Assessing motivation is critical but never sufficient. Motivation and commitment are built on actual behavior change. Treatment challenges, sometimes referred to as therapeutic exposures, create opportunities to practice, encounter challenges, adapt and learn. While many of these challenges address food and eating behaviors, we also look to create individualized challenges to help adolescents learn how to manage emotional intensity. These challenges are the foundation for our clinical programming and the real engine for change and recovery.
In summary, Clementine programs have a formal process for making careful and thorough assessments of the six key maintaining factors and develop a thorough and nuanced conceptualization of how the treatment team understands the role of those factors. We stress the importance of providing parents with multiple opportunities to discuss and explore this conceptualization with their adolescent’s treatment team.
Dietary Restriction and Disruption
Re-establishing a normal pattern of eating is the foundation for effective treatment and recovery. Many of the cognitive, emotional and even interpersonal features of adolescents with eating disorders reflect the destabilizing influence of inadequate nutrition. Food is, in fact, the most important psychotherapeutic agent in the treatment of eating disorders. Restoring medical, physiological, and nutritional stability sets the stage for helping adolescents and their families address other barriers to recovery.
Temperament and Personality
Certain temperament and personality traits create and sustain a risk for eating disorders. Some of these traits, particularly perfectionism and a tendency to avoid change or potentially harmful experiences, are particularly common in adolescents with eating disorders. Emerging work on the neuroscience of eating disorders indicates that that people with eating disorders may have characteristic variations in the way they experience and respond to reward, novel stimuli, social interactions and complexity. Treatment can help modify and moderate these traits and unique variations by helping adolescents discover and practice ways to manage emotionally challenging experiences, both at the dinner table and in their lives in general.
Having a child with an eating disorder can be frightening. Families often move through predictable stages of frustration, argument, powerlessness, and anxiety as they try to adapt to the sometimes inexplicable feelings and behaviors associated with their adolescent’s illness. For too long, these predictable reactions were viewed as factors that caused the eating disorder. We now know that they are much more likely to be understandable responses to dealing with an adolescent’s potentially life threatening illness. Helping families identify these patterns and develop new ways of communicating with their adolescent can have a profound impact on recovery.
Anxiety and Mood
Current research underscores the close relationship between eating disorders and anxiety disorders. Many teens with eating disorders may have pre-existing histories of diagnosed or under-diagnosed anxiety disorders. It is clear that anxiety and associated mood disorders including depression and mood instability can perpetuate an eating disorder. For many individuals, the eating disorder behaviors and rituals have evolved as methods for dealing with emotional distress. While anxiety and depression will typically diminish with nutritional stabilization, it is often essential to develop specific treatment strategies, both psychotherapeutic and medication-based, to target this maintaining factor.
Beliefs about the Positive Effect of the Eating Disorder
One of the most challenging aspects of eating disorders is the extent to which the disordered thoughts, feelings and behaviors are seen as things that enhance and solidify a sense of competence, accomplishment and identity. For adolescents with eating disorders, the consolidation of these “positive” aspects of the eating disorder into an eating disorder “identity” may be less entrenched than in adults with eating disorders. But beliefs in the benefits of thinness, restriction, exercise, self-discipline and the sense of social approval for the accomplishment of weight loss all can work to reinforce a reluctance to make changes in the ED behaviors. This ambivalence is an essential feature of the illness, not a conscious or deliberate choice. Helping the adolescent work through this ambivalence, and the family to develop strategies for working with an adolescent who is reluctant to change, must be a key focus of treatment.
Avoidance of Emotional Intensity
Avoidance of emotional intensity is increasingly seen as one of the most critical factors underlying eating disorders and other psychiatric illnesses, anxiety based disorders in particular. Rituals, obsessive and compulsive behaviors, and many of the behavioral features of eating disorders help individuals manage emotional distress and intensity. Effective treatment needs to incorporate individualized and thoughtful experiments in which the adolescent works through a graduated series of encounters with situations that are likely to cause anxiety. These challenges will always include food and eating situations but it is important to identify other areas, such as social situations, that need that same level of graduated exposure.
What Should Parents Expect from a Treatment Program
These six key maintaining factors can also serve as a program quality checklist for parents who are trying to evaluate whether any particular program has the conceptual and programming complexity to address their adolescent’s illness. Programs should have a formal process for making careful and thorough assessments of these six factors and develop a thorough and nuanced conceptualization of how the treatment team understands the role of those factors. Parents should expect an opportunity to discuss and explore this conceptualization with their adolescent’s treatment team.
A clear conceptualization becomes the foundation for the adolescent’s treatment plan. There should be specific plans for addressing each of the contributing factors; this would typically include a clear plans for nutrition, medical management, psychiatric assessment and medication if indicated, family therapy, and individual psychotherapy. But parents should also be provided with a clear road map of the specific plans for each of those different modalities; what are the goals and what are the markers and signs that their child is making progress, in the immediate and longer term?
Family support and relationships are fundamental for recovery; parents should be seen as full partners in assessment and treatment planning. Programs need to provide a careful and respectful assessment and plan for addressing any communication patterns that have developed in response to their adolescent’s eating disorder or, in some cases, for any pre-existing family circumstances that may have contributed to their adolescent’s eating disorder process.
But families are also seeking treatment. Family therapy and family education will help identify and modify communication patterns that may complicate or inhibit the family’s ability to provide calm, clear and consistent support for their adolescent’s recovery. But parents often need support for their own distress as well. Parent-only groups provides a space for addressing the practical and emotional challenges of taking care of a loved one with an eating disorder.