Evidence Based Treatment and or Verses the Human Experience
Who then do manual based treatment approaches benefit? Clearly, they are useful for some patients in reducing life-threatening symptoms. Time-limited, concrete, step-by-step approaches also benefit insurance companies who are eager to sign on to anything that they can use to justify providing limited and reduced payments to patients. Researchers in the field of eating disorders who are eager to find a cure or cures for eating disorders are also keen on relying on outcomes that supports concrete treatment; quantitative studies are always way more easy to use to “prove” efficacy than qualitative studies.
Kathryn Zerbe, MD, a psychiatrist, specialist in eating disorders and author stated, “We clinicians who treat eating disorders in the 21st Century, find ourselves in a unique and privileged position. Discoveries in genetics, in biological therapies that will hasten weight restoration and prevent relapse, and in adjutants to our psychotherapeutic procedures will likely strengthen what we can now offer our patients by way of therapeutic support. The keystone of such an integrated treatment, however, will always be the patient’s unique life story.
It is the “patient’s unique life story” that often hangs on the periphery of treatment, yet it is this life story that provides the substance and details, the guiding forces in treatment. For all of us relationally oriented therapists who treat eating disorders, hang in there. Approaches to treatment based on understanding cause from psychological, interpersonal, cultural and biological perspectives are regaining momentum over those that focus solely on biological and cultural influences. We are moving back in the direction of nurture while not ignoring nature. Just as we guide patients to not see life in all or nothing terms, perhaps practitioners need to take a bit of the same advice. It seems too often that we “forget” about the mind and choose the brain when we find ourselves relying too heavily on research. It is nature AND nurture. Maybe we need to rely on those factors that cannot be easily quantified – the human experience, perceptions and relationships when thinking about the etiology and treatment of eating disorders.
Yackobovitch-Gavan, Ph.D., et al. An integrative quantitative model of factors influencing the course of anorexia nervosa over time. International Journal of Eating Disorders. Vol 42. May 2009. Pp 306-317.
Zerbe, Kathryn, MD. Integrating Treatment Interventions: five points to enhance clinical practice, part 2. Eating Disorders Review. Vol, 19. November/December 2008. Pp. 1-2.
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We know that recovery from Anorexia Nervosa usually takes a really long time, if recovery occurs. A variety of treatment approaches are increasingly available and research continues in order to advance our understanding of cause and in finding more effective treatments. CBT (Cognitive Behavioral Treatment), IPT (Interpersonal Treatment), Family Treatment (i.e. Maudsley), SSCM (Specialist Supportive Clinical Management), BT (Behavioral Treatment & medication) are just a ‘few’ of the so called “manual based treatment approaches,” which were created based on the outcome of many a research study. Manual based treatment refers to treatment that is formulaic in design – a step by step, time limited approach generally focusing on symptomatic relief, change in eating attitudes and behavior, and restoration of weight. Family therapy is utilized in some of these approaches in order to provide support to their loved one while recovering. Family members are often “instructed” to take on an active or passive role, depending on the treatment approach, regarding handling of food and communication about food. Rarely do these approaches deal with family dynamics outside of the realm of the eating disorder.
Yackobovitch-Gavan, et. Al. reported that determining appropriate intervention strategies perhaps ought to consider the factors that contribute to recovery. These factors are based on conditions that were present prior to onset of the disorder and course, duration and outcome of treatment. Recovery and remission are considerably different. According to Couturier and Lock, remission relates to symptoms, which are no longer present for a least a brief period of time. Maintaining behavioral and psychological remission for a significantly longer period of time is defined as recovery. Yackobovitch-Gavan focused on remission. They highlighted several variables, which were consistently shown to be associated with NON-remission from Anorexia Nervosa. Their findings showed that,
“…The combination of pre-morbid variables (the occurrence of sexual abuse during childhood, history of problematic premorbid social relationships), past clinical ED-related (vegetarianism), and non-ED related (an overall anxious temperament) variables, and treatment-related variables (more hospitalizations because of AN and a longer during of ambulatory treatment following the hospitalization), and a lower BMI (body mass index) at onset, has an excellent potential to predict NON-remission from Anorexia nervosa.
Many mental health professionals who treat eating disorders generally agree that the reasons why someone develops an eating disorder are complex and truly unique to the individual.
There is an inherent contradiction in accepting that if non-remission from Anorexia Nervosa is predicated on a variety of “predisposing and unretractable conditions, then how can a formulaic approach be beneficial, especially ones that exclude any procedures for addressing premorbid conditions?
Clearly, practitioners need to employ concrete methods to curtail and/or reduce symptoms; a patient’s medical stability is often at risk if symptomatology is not reduced. A formulaic approach in this regard can be highly useful and potentially effective for many. However, if there is merit to Yackobovitch-Gavin’s findings, as I am inclined to agree, then the complexities in understanding and treating eating disorders require significantly more than a formulaic approach.
