Treatment of Eating Disorders:
Help is Available

by Randy Wolthuis, Ph.D.

Asking for help can be difficult. It is not easy to admit you have a problem that seems out of your control. This is particularly true for people who struggle with an eating disorder.

Usually people keep the eating disorder, and all the behavior associated with it, a secret from others. The frantic behavior of binge eating, purging (self-induced vomiting), dieting, or excessive exercising is often frightening. It also produces a great deal of shame and embarrassment.

It is no wonder, then, that when people seek help for an eating disorder, they are fighting the secrecy that has surrounded their illness. Perhaps for the first time in their lives, they have decided to talk about what they are doing and how they have felt.

Although seeking help is often difficult, people usually feel a tremendous sense of relief once they decide to do so and have their first appointment with a professional.

Anorexia nervosa and bulimia nervosa are distinctly different illnesses. Although any treatment must be individually tailored to the specific needs of each person, there are some general principles that apply to both disorders. Because most people with an eating disorder are female, we will refer to these as female. Although less common, eating disorders are found in males, too.

A thorough evaluation from a competent and qualified mental health professional is an essential first step in treatment. Not all psychiatrists, psychologists, and clinical social workers are trained and experienced in diagnosing and treating these disorders. It makes sense to seek a qualified professional who has had such training and experience.

There are two main components for a complete evaluation of a person seeking help for an eating disorder:

• A complete medical evaluation, usually by a qualified physician.
• A thorough psychosocial assessment by a mental health professional.

Each is vital in providing the mental health professional with information that will help form a treatment plan.

The physician's medical evaluation is important because many eating disorder symptoms are potentially dangerous - even life-threatening. When a person is severely underweight and malnourished, her blood often has a diminished supply of important chemical called "electrolytes."

The most dangerous complication of repeated vomiting or laxative or diuretic use is the depletion of the electrolytes potassium, chloride, and sodium. When dissolved, these elements carry electrical charges essential for normal functioning of nerve and muscle cells.

Electrolyte abnormalities can cause fatigue, constipation, depression - even heart problems and cardiac arrest. Laboratory blood tests can help determine the blood's electrolyte levels. These tests are especially critical if a person is severely underweight or if she has frequently purged or abused laxatives and diuretics.

In addition to these dangers, eating disorders often create other medical problems that require attention. With inadequate nutrition, the brain cannot function normally. Certain vitamin deficiencies affect judgment. Seizures are more common.

There may also be digestive and kidney problems. Frequent vomiting can produce problems with gums and teeth, which can be damaged by the acidic contents of the stomach. Menstrual cycles become more irregular and sometimes stop altogether as body weight falls. In addition, recent evidence suggests an increased risk of osteoporosis (softening of the bones) among women in whom menstruation has stopped completely as a result of low body weight.

The information gathered through a complete physical examination will be very helpful to both the person seeking treatment and the mental health professional.

A mental health professional carries out the psychosocial assessment, often completed in one or two appointments. The purpose of the assessment is twofold. First, it is the initial opportunity to build a working team between the therapist and the person seeking treatment. Second, the therapist can gather relevant information such as a family history. Other important information includes educational level and performance, leisure time activities, interpersonal relationships, and a developmental history.

The therapist will be particularly interested in why the client is seeking help now, how she views the problem, and what she has done in the past to try to help herself. It is important to know a detailed history of eating and nutrition habits. The therapist will ask the person to express her view of her body and her weight.

Other questions cover any use of laxatives or diuretics, purging, binge eating, and exercise habits. The therapist also will ask about symptoms of depression and substance abuse since there is a higher proportion of these problems among people with eating disorders.

After a complete evaluation, the client and her therapist are ready to discuss treatment options. The therapist openly shares his or her perceptions of what has been learned thus far. He or she will determine the correct treatment strategy by analyzing:

• the individual's unique needs
• her age
• current family living arrangements
• duration of the disorder
• past treatment
• severity of the symptoms
• the presence of any other psychiatric problems such as depression and substance abuse
• her medical condition.

It is important that the patient and the therapist reach the decision together.

Although outpatient psychotherapy is the primary treatment strategy, other treatment options exist and often add to it. Since manypeople with eating disorders have poor eating habits and nutritional knowledge, it may be helpful to consult with a nutritionist or dietitian to work towards normalized eating.

It is beneficial to learn about the physiology of digestion and the effects of starvation, purging, and binge eating. Many are surprised to find out, for example, that in underweight people, the stomach delays its emptying to promote the maximum nutritional benefit. This produces a longer-than-normal sense of being full. This sensation is disturbing to the person with an eating disorder and discourages her from further eating. It is clear how the cycle then is likely to repeat itself.

In some cases, medication may be necessary and helpful in either reducing depression (which often accompanies eating disorders) or reducing the compulsion to binge or purge.

In addition, group therapy can provide support for a person undergoing treatment. It is an opportunity for her to share her insights and feelings with others who are also struggling. Family therapy can be helpful. It is often essential when the patient is a child or adolescent.

Finally, if a person is severely malnourished, experiences medical complications, or if outpatient psychotherapy has been unsuccessful in reversing a deteriorating physical or psychological course, hospitalization may be necessary.

While these strategies are important, individual psychotherapy is almost always the most critical method of treatment. Therapy is a relationship. Most therapists who have successfully treated eating disordered patients agree that it is the quality of the therapy relationship that is most helpful in providing relief.

It is in the context of this trusting and confidential relationship that a person with an eating disorder is, perhaps for the first time, able to speak safely to another person about herself, her fears, her sense of emptiness, her anger, her panic. When therapy is going well, she feels heard and understood. She is a part of a team working toward growth and renewed physical and psychological health.

Therapy is usually hard work. It requires people to trust and to speak about their pain, sadness, and anger. These are precisely the challenges that typically do not come easy for a person with an eating disorder. She is used to combating all her feelings with a variety of frantic symptoms such as obsessive dieting, exercise, binge eating, or purging. Therefore, confronting these feelings is usually painful and, in most cases, frightening. Yet, it is essential.

An eating disorder is more than just disordered eating. The symptoms are just the tip of the iceberg, concealing underneath them a host of feelings and thoughts the person may have hidden or ignored, perhaps for years. Most people with an eating disorder have a painfully intense sense of themselves as inadequate, unworthy, and inferior. Sometimes they are aware of these feelings. Sometimes they are not. They push these strong and painful feelings away with frantic behavior and a preoccupation with food and weight.

It is necessary, then, to gain access to these feelings by gradually giving up the symptoms that cover them up. A therapist will encourage a person with anorexia to gain a certain amount of weight as a necessary condition of treatment. Similarly, a therapist will encourage a person with bulimia to reduce the frequency of her binge eating and purging. Often therapists ask the person to record her eating behavior and the feelings associated with it to help her begin to identify patterns.

The length of treatment can vary from several weeks to several months and sometimes years. However, early in the treatment process, there should be some progress. There is more to progress than weight gain or a decreased frequency of binge eating, purging, or excessive exercising. It is just as important that the person in treatment begins to feel more calm, less frantic. She begins to develop an ability to examine and really experience her feelings without the previously overwhelming sense that she would lose control or fall apart. She begins to have a stronger sense of herself and who she is.

All of this takes real teamwork between the patient and the therapist. However, there really is hope for people struggling with an eating disorder. Although it often appears to be a perplexing and frustrating problem, it can be defeated! It may take time. It will certainly require courage to change. But the freedom and contentment that accompany successful treatment make all the hard work worth it.