Finding Effective Treatment

Seeing as I have finally (!) found a new therapist in my new location (who also accepts my insurance and is only an hour drive away), who I meet with on Saturday, and there have been several good posts about finding a good therapist and effective treatment, I decided a blog post would be appropriate.

Dr. Sarah Ravin has a list of five questions to ask a potential therapist when seeking treatment:

In regards to your question, here are the five important questions (in my opinion) that one should ask a potential therapist when seeking treatment for a serious, long-standing eating disorder:

1.) In your opinion, what causes eating disorders?

(Make sure they have a science-based explanation that involves neurobiology, genetics, personality traits, and the role of malnutrition. It’s OK if she mentions societal pressures for thinness as triggers, so long as that’s not the ONLY thing she mentions.)

2.) Describe your philosophy of treatment for eating disorders.

(Make sure she emphasizes full nutrtion and weight restoration to ideal body weight (for AN) and nutritional stability / cessation of binge-purge behaviors (for BN) as the first step in treatment. Make sure she also emphasizes the acquisition of coping skills, learning to eat healthfully and independently, self-care, treatment of co-morbid conditions, and relapse prevention)

3.) Describe your training and experience in empirically-supported treatments.

(Make sure she has some training and/or experience with CBT, DBT, ACT or other third-wave behavior therapies, and/or Maudsley FBT).

4.) How many patients with eating disorders have you treated in the past three years? How many of these patients have fully recovered?

(Make sure she’s seen at least a few other people with EDs, and make sure that the majority of them are fully recovered (or at least well on their way to recovery).

5.) What is your opinion on the involvement of family members and significant others in the treatment of eating disorders?

(If she advocates parentectomies or exclusion of family members, or implies that families cause EDs, this is bad news. If she views family members as potential emotional or nutritional support for the patient, this is good news).
If there is one word in reading about a therapist's history and treatment philosophy that gives me the heebie-jeebies and automatically makes me click "NEXT!" is this: eclectic. I shudder just typing it. To me, eclectic says "I do whatever I feel like doing" or is kind of like commitment-phobia for the potential therapist. You're a professional- tell me what works and why. There's a difference between "eclectic" and "I have been trained in approaches A, B, and C and can help tailor therapy to you and your situation." I have found a combination of CBT, DBT, and FBT to be helpful at various stages in my recovery, so I'm not all-or-nothing about types of therapy. But eclectic? Ick.

The Cleveland Center for Eating Disorders blog "Living With Food" has this advice for seeking evidence-based treatment:

1.Remember that there are very few evidence-based treatments for eating disorders. If you are not receiving cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy, or family based therapy, then the odds are very high that you are not getting evidence-based care.

2.Your primary care physician is likely to have experience with patients who have done different types of treatment in your community. Your primary care physician is therefore a critical resource.

3.When you are in a provider’s office and they are discussing care options with you, never hesitate to ask for all of the evidence behind what they are saying. At this point in time, all practitioners in eating disorder treatment should be able to back up what they are saying in a straightforward and understandable manner.

4.Finally, while doing research on treatment for eating disorders, the Internet, while helpful, may not provide definitive answers (and may be more confusing than anything). There are certain organizations that we feel are trustworthy. We highly recommend NEDA, AED, Maudsley Parents, ED Recovery, The Freed Foundation, Are you eating with your anorexic, The F-Word, NAMI, Life After Recovery, and FEAST as reliable organizations and blogs where you can learn about evidence-based care and communicate with other patients and families that may be struggling with an eating disorder.

Off course, point #2 assumes your PCP/GP isn't a total bonehead and doesn't blow off your concerns. Still, they should know something about community resources or have a referral to someone who isn't a total bonehead. When all else fails, go straight to point #4.

There are plenty of other barriers to finding quality ED care, not the least of which are: geography, therapist's availability, insurance coverage, wait lists, finances, you name it.

What criteria do you use when looking for a therapist (or what criteria would you use)? Do you have any words or phrases that are a therapist "turn off"?


Kim said...

This is really useful! I've never had a list of formal criteria to reference, but I should have! I've always gone with my intuition. There are certain styles I can't stand -- like the deep sighs, the long nodding, the soft whispering. I need someone frank and blunt and opinionated. It would be a huge turn off to me if a therapist focused on societal issues, as I give this a big eye roll. I also don't like it when therapists act like they are also nutritionists, making comments on food. Maybe this is unconventional, but I appreciate it when a therapist shares bite-sized pieces of their personal experience, whether it's ed-related or not. Mostly, I need someone to call me on my bullshit ;)

Silly Girl said...

This is so helpful. Currently, I am looking for a therapist in the area where I live and I wasn't sure what types of questions to ask. So thanks!

A:) said...

My therapist at the moment is eclectic and I like her -- I find she is the most effective therapist I have ever dealt with. She uses CBT, some psychodynamic, some humanistic, some DBT, some practical behavioural approaches as needed.

As Kim says, she is someone who calls me on my bullshit and challenges thoughts/irritional beliefs without overstepping her boundaries and becoming too forceful, etc (which has been a problem in the past).

I saw a CBT therapist for one session. The experience was bad -- she was almost TWICE the price of my regular psycholgist and she was utterly useless/manualized. She also wanted to see me TWICE/week which was ridiculous because was in intensive IOP at the time.

Evidence based therapies are good BUT the therapist NEEDS to be able to step outside the manual and apply what he or she knows. They are human as well and sometimes they NEED to be human.

I am also hesistant to see a therapist who is allied with ONE school of thought such as CBT. This is too narrow and I find these types of therapists try to force their beliefs on me regardless of whether they are correct, etc. Because the assumption is that they MSUT be correct because it is the ONE valid therapy, etc.

I remember reading a study posted on the ATDT forum which was I beleive done by Mandometer which said that non-specific clincial management was superior to most types of therapies for EDs (again, this is all memory so I may have the name wrong.) This was just where the therapist talked about day to day issues, behavioural patterns, etc and didn't dig for "core issues" or force a particualr type of therapy.

This is what I basically do with my therapist and it has been helpful for me. I talk about what I am currently dealing with in terms of stress/anxiety, etc in addition to any problems that have cropped up along with recovery. My therapist provides a sounding board and an objective/TRAINED person to give advice.

It works. Therefore that is what I believe. :)

Psychology is still a very YOUNG science and is still soft in many areas -- I think it is difficult this early to have absolute recommendations as to a particular type of therapist.


Krystal said...

Thanks for your post! With bulimia, I've had some long periods of recovery (the two times I was pregnant), but always seem to lapse back into it. I've recently been seeing a therapist who is emphatic that eating disorders are not genetic. (I was discussing the possible link between my bulimia and my father's side tendency toward alcoholism). She said it is due to the mother being so tense and stressed out when she is pregnant and it transfers to the baby. This only made things worse for me because I felt guilty for being stressed when I was pregnant with my two beautiful boys. I guess if I would have been thinking straight, I would have told her that who has ever heard of a woman who has stayed calm and serene throughout their whole pregnancy? Probably not many. . .

Anyway, this is good to hear, and maybe it is a sign because I was just doing some research for therapists in my city and was interested mainly in one who lists herself as "eclectic". Kim, I too appreciate when a therapist can share a tad bit about themselves. . .

Lou Lou said...

I have just gone to people who are the most experienced with EDs in New Zealand, there are only a few, I need a therapist who is able to explain everything to me, instead if just nodding and letting me vent the whole time, i want guidance and goals and to be given insights into why i do what i do. I have never asked enough questions and I have always gone with intuition. I am fiercly committed to recovery, i dont want them thinking they cant challenge me, because i am ready and i need a therapist who is really willing to work hard with me. i am highly responsive to therapy and I need someone who is ready to help me drive my recovery in the right directions.

Cathy (UK) said...

I agree that finding an effective therapist can be really difficult... It took me nearly 30 yrs to find one!

I agree with 4/5 of Dr Ravin's criteria, apart from number 5: "If she advocates parentectomies or exclusion of family members, or implies that families cause EDs, this is bad news."

['parentectomy' is such a silly word..]

It is NOT always the case that parents don't trigger EDs. My parents are lovely, caring people who didn't trigger my ED, but I know of a significant number of people with EDs who used ED behaviours to cope after sexual/physical abuse that occurred within the family. Imagine if those people, especially as children, were told firmly by professionals that "parents never cause EDs" - and - "your parents should engage with you in your therapy"? That person would feel seriously invalidated, misunderstood and helpless.

There are many different causes of EDs, and I do not believe that all cases have a purely biomedical and/or genetic aetiology. Some cases have a definite link to trauma/abuse and coping with PTSD. For these reasons I do not believe in 'standard' forms of treatment.

Every case is different and a good therapist will endeavour to determine what lies behind an individual's ED. Sometimes a more eclectic approach may be necessary. After all, effective, evidence-based treatments for EDs ARE few and far between.

Katie said...

A big turn off for me is anyone who insists that eating disorders have no biological component and are entirely due to childhood issues. With my current therapist, I've mostly spent sessions discussing current problems in my life and how to resolve them, although we have done some trauma based work as well. I got to a point a few years ago when I was pretty sure I understood every possible psychological trigger for my eating disorder, but still couldn't imagine surviving without it. An emphasis on science and working on my problem solving skills has been far more useful for me. It's good just to have somewhere to offload once a week too ;)

Adrianna said...

I like a therapist that is knowledgeable about co-morbid conditions and can help address them. My father, for example, struggled with bipolar disorder, ADHD, and addiction, and he could have never treated his addiction without an awareness of the other two.

My favorite approach is a combination of talking therapy and CBT. This is because you get to talk about you, your family, your symptoms, and anything you want. It addresses the whole person and the whole environment, but you are also expected to identify irrational and destructive behaviors and find ways to challenge them.

Therapists that are open to the use of therapy and medication together are important to me.

This doesn't have to do with types of therapy per se, but my therapist likes it when I bring in art, poety, projects, etc. because it can be hard to express my emotions otherwise. Then the emotions come out as we talk about what we made. It can serve as a coping skill too. My sketch pad is my pocket therapist.

The danger of talking therapy alone, ir look-backward-because-it's-caused-by-mean-old-Mommy therapy, is that it keeps you stuck in the cycle of grief, in rage, and that increases your level of stress and takes away from planning for the future.

Jane said...

Here's the study A mentioned. It's interesting (but doesn't have anything to do with Mandometer.)

Dr. Ravin said...

Cathy -

I understand your point about kids who develop EDs subsequent to physical or sexual abuse within their families. However, even in these cases, there is no reliable evidence that the parents caused the child's ED. History of abuse is a nonspecific risk factor for a variety of physical and mental illnesses - alcoholism, drug addiction, PTSD, EDs, hypertension, etc. One would never say that the cause of hypertension is child abuse - the etiology is much more complex than that. One would never say that sexual abuse causes alcoholism, but rather, that sexual abuse can trigger alcholism in certain individuals who are genetically predisposed, in the context of certain environmental conditions (e.g., a society in which drinking is common, frequent alcohol consumption in the person).

When I assert that parents don't cause EDs, that doesn't mean that some parents aren't horrible and neglectful and abusive and triggering. I'm not in any way "letting parents off the hook" for abhorent behavior. I'm just saying that their abhorent behavior is not the cause of the child's illness (although it could be a trigger, which is not the same thing as a cause). That same child would probably also be triggered into developing an ED if she were a competitive gymnast or if she were bullied at school or if she were in a high-pressure academic environment. Because all of these things are simply triggers that may cause an underlying brain disorder to manifest.

And you are absolutely right that parental involvement in a young person's treatment is not always clinically indicated. But these situations are the exceptions to the rule. It would take something as severe as a parent abusing their child, or a parent being incarcerated, or a parent being severely mentally ill themselves, for me to exclude parents from a child's treatment.

When parents are really horrible, or when parents do things that trigger ED symptoms in their kids, isn't that all the more reason to involve parents in treatment to teach them how to parent their ED child appropriately? (Obviously FBT would not be a good option in this case; I'm talking more about family therapy sessions, parent coaching, and recommending personal therapy for the parent).

Cathy (UK) said...

Hi Sarah (Ravin)

Thanks for your response to my earlier comment. I would like to emphasise that I think that the majority of your criteria are very helpful - and like you, I do believe that genetic factors account for many cases of EDs. I am sure this is true for me, because I was anxious, obsessive, perfectionistic and detail oriented right from being a small child. Furthermore, starvation strnegthened these existing traits and kept me in anorexia nervosa for many years. Re-feeding and weight gain helped many, but not all of my symptoms. I have a PhD in the Biomedical sciences and so many aspects of the biomedical model of EDs make sense to me.

However, those are my own experiences. I do know of quite a number of people with EDs who may or may not possess a genetic vulnerability to EDs, but for whom there appears to be a direct relationship between their ED behaviours and parental neglect or abuse - especially sexual abuse. These individuals describe how they 'cope' with intrusive memories of their abuse and the associated feelings by (e.g.) bingeing and purging. They often have a number of addictive/self-harming behaviours.

If a child is living in a family in which a parent repeatedly abuses them, then they may not feel able to talk about such abuse in a setting in which their family members are present. That is why, for example, we have associations such as 'Childline' in the UK, which allow abused children to talk in confidence to a trained individual.

It would be incorrect to suggest that EDs are always (or even usually) caused by such horrific issues, but sometimes there IS a direct link. The individual uses ED behaviours to cope with distress, however subconsciously. Genetics may not underpin all cases of EDs, even if it underpins the majority. Some people need specific trauma therapy to help prevent relapse into their ED.

BTW, my comment about about 'parentectomy' was not directed at you or anyone in particular. I have seen it used frequently and I wonder why people don't just write "removal from parents" or "in the absence of parents".

I have read your blog previously and I think it's great...

Dr. Ravin said...

Hi Cathy,

Thanks for your kind words about my blog.

I agree with you that sometimes people with EDs and trauma histories experience a direct link between their PTSD symptoms and ED symptoms, using ED behaviors to numb themselves or to feel something. My points, however, are that 1.) The use of self-destructive behavior to cope with trauma is not unique to EDs. Some people abuse drugs, alcohol, sex, sleeping, and cutting in the same way. So if a person experiences abuse, underlying genetic, biological, and temperamental factors must also play a role in determining whether that person will develop ED, substance abuse, cutting, PTSD alone, or no disorder at all.

I fully agree that children and adolescents whose parents have been abusive would not feel safe to speak freely in family sessions, and it probably wouldn't even be all that therapeutic. And Maudsley FBT would obviously be contraindicated in these cases. If parents were abusive and the child had an ED, I would probably work with the parents separately without the child present, while also seeing the child for individual therapy on her own. Or I would recommend residential treatment for the child. And I would get the appropriate social services agencies involved to determine appropriate placement for the child.

BTW - I think people use the word "parentectomy" (which is not an actual word, to the best of my knowledge), because it is humorous, ironic, and pseudo-medical, kind of like removing an appendix is called an appendectomy.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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