by Dr. Sarah Ravin. F.E.A.S.T. Advisor
Special Essay for F.E.A.S.T.
March 2009 NEW: SEE UPDATED POST A DECADE LATER!
As a therapist with a special interest in adolescent eating disorders, I first learned about the Maudsley Method in 2004 during my clinical training at the Children’s National Medical Center’s Eating Disorders Clinic in Washington, DC. Working on a multidisciplinary team of physicians, psychologists, and nutritionists, I treated many young patients and their families with great success using the Maudsley Method. Working at Children’s was a fantastic experience for me, and since my rotation there I have been passionate about promoting and practicing evidence-based treatment for eating disorders.
Sadly, my other experiences in eating disorders treatment have not always been positive. Quite frankly, I’ve been appalled by the current state of eating disorder treatment in this country, particularly in light of all the scientific research that has emerged within the past few years on etiology and effective treatments.
I am young and relatively new to the profession, having only received my Ph.D. six months ago. I am not yet licensed, as Florida state law requires 2,000 post-doctoral hours for licensure as a psychologist. My youth and relative inexperience have often placed me in the precarious position of educating my older, licensed colleagues about the Maudsley Method as well as research on the genetic and neurobiological factors associated with anorexia nervosa and bulimia nervosa. Most of my professors and clinical supervisors in graduate school had never heard of the Maudsley Method. Many of my colleagues who treat eating disorders cling to antiquated notions about their supposed causes, and their approaches to treatment are ineffective as a result.
I have heard colleagues – licensed professionals with specialties in eating disorders – ridicule the Maudsley Method in very much the same way that the rest of us ridicule scientology or voodoo. I have heard them scoff at the parents of college students with anorexia nervosa for being “too involved.” As if there were something pathological about taking all necessary measures to ensure that your 21-year-old daughter who is 500 miles away at college, suffering from a life-threatening mental illness, gets the appropriate treatment.
Viewing these moments as golden opportunities, I politely correct their misunderstandings, citing empirical research as well as my own clinical experience. My participation in these discussions is not always welcome. These clinicians may have been in practice longer than I have been alive, but they are wrong, and people suffer and die as a result. I was groomed as a liberal feminist and trained as a scientist-practitioner. I have a mind and a mouth, and I don’t hesitate to use either one. It is against my nature, my training, and my conscience to be an apathetic bystander. I approach everything with an open mind as well as a healthy degree of skepticism. I don’t back down.
Through my clinical work with child, adolescent, and adult eating disorder patients at various levels of care, I have found that the underlying principles of the Maudsley approach – externalizing the illness, disputing the myths that patients choose the illness or that families cause it, education about the genetic and neurobiological roots of the illness, emphasizing the importance of full nutrition and medical stabilization as the first step in treatment, and tackling emotional and psychological issues after weight restoration – are extremely helpful, regardless of the patient’s age and regardless of whether an individual or family-based treatment approach is employed.
At the start of treatment, I make a point of providing patients and their families with sound scientific data on eating disorders. Almost invariably, patients and their families report feeling comforted and relieved to have this information. For example, the mother of one of my adult patients with anorexia once confessed to me that family weekend at her daughter’s previous treatment center was tantamount to “The Stoning of the Mothers.” After nine years of insufficient and ineffective treatment, this mother and her daughter were both helped enormously by evidence-based psycho-education and treatment. It was as if, suddenly, something just “clicked,” and everything made sense. Released from endless cycles of blame and futile searches for a “root cause” while trapped in a malnourished haze, mother and daughter were both comforted to learn that anorexia nervosa is a biologically-based brain disorder, not a choice, and not the result of bad parenting. Treatment was neither quick nor easy, but at least the patient, her family, and I were united in fighting a common enemy – the eating disorder.
This mother and daughter had been in the trenches of anorexia nervosa for nearly a decade, and they were just now beginning to find a way out. It angered me that this family had not been given this vital information sooner. It saddened me that the patient had lost so many years of her life to a treatable brain disease which had most likely caused irreversible damage by now. But most of all, it irked me that so many professionals who treat eating disorders are either unaware of this information or are somehow averse to disseminating it to the very individuals who need it most – patients and their families.
I am committed to staying abreast of the latest research on the etiology and effective treatment of eating disorders. After a thorough review of the research and several years of supervised clinical experience treating eating disorder patients, I have absolutely no doubt that eating disorders are biologically-based mental illnesses that are triggered by an energy imbalance – either through dieting, increased exercise, illness, or failure to consume enough calories for one’s energy needs. For certain individuals who possess a genetic predisposition, the illness is perpetuated by malnutrition and reinforced by the temporary respite from anxiety and depression that the sufferer feels while restricting. Unfortunately, our society’s glorification of thinness, combined with the ubiquity of dieting and exercise in western culture, has created a bit of nonchalance surrounding these severe and life-threatening illnesses.
I am confident that, within my lifetime, more convincing and definitive research will emerge to convince all clinicians what I already believe to be true. How delightful it would be, a generation from now, to reflect on the state of eating disorders treatment in 2009 with shock, incredulity, and laughter? Let us not forget that, just a generation ago, homosexuality was considered a mental illness, schizophrenia was treated largely with psychoanalysis, and autism was presumed to be caused by cold, unaffectionate “refrigerator mothers.” As for the common notions espoused by many well-meaning but misinformed clinicians – that eating disorders are caused by the media, by enmeshed families or controlling parents, by a fear of growing up, by sexual abuse, or by a need for control – I predict that these ideas will retire along with the therapists who preach them. Collectively, we will realize that while these phenomena may be correlated with eating disorders in many cases, they do not cause eating disorders, and uncovering them is not a magic bullet for recovery. These archaic notions will be replaced with better science and more effective treatment.
Let’s say, hypothetically, that controlling parents cause eating disorders. Or that media images which glorify thinness are responsible for eating disorders. Or that anorexia nervosa is caused by a desire to remain childlike and avoid growing up. Even if these things were true (and there is no reliable scientific evidence that they are), the first priorities in treatment should still be nutritional rehabilitation, weight restoration, and medical stability. Why? Because the patient’s normal adolescent development depends on it. Because the patient’s mind has been hijacked by an eating disorder which has impaired her ability to think rationally and process emotional information. Because research has consistently shown that many of the physical and mental symptoms of eating disorders are caused or exacerbated by malnutrition, restrictive eating, bingeing, and purging, and that these symptoms diminish with normalized eating and weight restoration. Because spending more time at a suboptimal weight, or engaging in food restriction, binge eating, or purging, is causing more physical and emotional damage. Because a weight-recovered, medically stable eating disordered patient who is receiving full nutrition is better equipped to explore and process the issues that may have triggered eating disorder symptoms in the first place.
I am not entirely sure why many clinicians work with patients on developing insight and searching for a root cause early in treatment, prior to nutritional restoration and medical stability. We still do not know the causes of many types of cancer, but cancers are treated aggressively as soon as they are diagnosed. A surgeon will operate on a patient to remove a tumor regardless of whether he knows what caused it. It is tragically comical to imagine a doctor and patient searching for the cause of the tumor while it metastasizes.
For now, let’s go with what works best. The proof, if you will, is in the pudding. With treatment as usual, recovery from an eating disorder takes 5-7 years. In my opinion, this is because only the most ineffective treatments are employed first. It is standard practice for clinicians to treat patients as young as 11 or 12 years old on an individual basis while excluding the family. It is also standard practice to charge young anorexic and bulimic patients with the daunting and terrifying task of monitoring and regulating their own food choices. This is cruel and unusual punishment. If you asked an alcoholic to spend her days at a party with an open bar, what would you expect to happen?
If a 12-year-old child insisted upon eating nothing but French fries and candy, or if a 16-year-old had a few beers each morning before school, parents would be expected to intervene immediately and would be considered negligent if they didn’t. Why is it such a revolutionary idea to encourage, or insist, that families take responsibility for nourishing their ill child? Why must we wait for a patient to choose recovery before intervening? Why is imminent medical danger a prerequisite for hospitalization? Why are multiple failed stints at outpatient treatments required for insurance companies to pay for residential treatment?
As a general rule, I am all in favor of the American values of free will, self-determination, independence, and rugged individualism. But an adolescent who is consumed by the hell of an eating disorder is not able to make healthy choices for herself. She is not independent and she does not have free will. She is completely and utterly consumed by the eating disorder, which places an indefinite moratorium on her physical, mental, emotional, social, and sexual development.
Here’s the way I see it. A person with active anorexia nervosa or bulimia nervosa is drowning in a freezing ocean. School A (the psychodynamic school of thought) proposes that you talk with the drowning person about how she is feeling and help her to explore the issues in her past that have gotten her into the water or interfered with her ability to swim. Once she develops this insight, she will swim safely to shore and avoid the water in the future. School B (the cognitive-behavioral school of thought) proposes that you send a swimming instructor into the water to teach her how to swim. School C (The Maudsley approach) sends a lifeboat to the drowning person, pulls her aboard as she is thrashing about (despite her protest and resistance), and rows her safely to shore. After she has been medically cleared and has recovered from the effects of hypothermia and near-drowning, she begins to take swimming lessons with a certified instructor. Once she has mastered the skill of swimming and can keep her head safely above water, she begins to process the experience of near-drowning, she explores the factors that brought her into the water, and she learns ways of avoiding a similar predicament in the future.
Is it any wonder that up to 20% of patients treated in school A end up drowning? Patients treated in school B fare somewhat better than those in A, but they often have difficulty learning to swim. Arguably, a person drowning in a freezing ocean is not the best candidate for swimming lessons. Granted, patients in school C struggle immensely for a brief period of time. They may topple the lifeboat, injure the rescue crew, or pull others down with them. In their frantic struggle to survive, they may not be able to heed the crew’s instructions. They cannot carry on a rational conversation, and they cannot express their needs the way the rest of us can. But they’re drowning, and ultimately they want and need to be rescued.
In this media-saturated world of constant communication, we are typically alerted to a celebrity’s pregnancy within the first trimester, and we learn of a politician’s DUI arrest on the 11:00 news the very day it occurs. And yet, it takes many years for research findings to be integrated into clinical practice. This frightens me.
I live and work in an area that is saturated with mental health professionals in general and eating disorder specialists in particular, but there is an unfortunate dearth of evidence-based and family-based treatments. It is my mission to remedy that.
I would like for medical schools, as well as graduate programs in psychology, counseling, and social work, to provide scientifically-sound information on etiology and effective treatments for eating disorders. I would like to see affordable, evidence-based treatment available locally for every child, adolescent, and adult who develops an eating disorder. I would like for eating disorder symptoms to be treated aggressively and effectively, immediately after diagnosis. I would like for all insurance companies to provide unlimited coverage for eating disorder treatment at various levels of care, for as long as it takes for the patient to achieve full recovery. I would like to see a dramatic shift in societal attitudes about eating disorders. These are my hopes as I embark on my career as a clinical psychologist.
Dr. Sarah Ravin received her B.A. in psychology from Smith College and her Ph.D. in clinical psychology from American University. Dr. Ravin has been licensed as a Florida Psychologist since April 2010. As a therapist in Coral Gables Florida, she provides evidence-based treatments for adolescents and adults with eating disorders, including Maudsley family-based treatment, cognitive-behavioral therapy, and dialectical behavior therapy. Contact Dr. Ravin at [email protected] or visit her website at www.drsarahravin.com for more information.