What Does
Recovery from an Eating Disorder Mean?
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By: Judy Scheel, Ph.D., LCSW Most outcome
studies for eating disorders focus on symptom reduction as the indicator of
recovery. In a recent article in the
“Eating Disorder Review (Gurze: March/April 08, Vol 19, No 2), Dr. Scott Crow, MD, Professor of
Psychiatry at the University of Minnesota stated in a speech made at the 2007
Renfrew Conference that focusing solely on weight restoration in Anorexia
Nervosa is “perilous” when it is considered the only variable to measure
recovery. Most behavioral inpatient
and outpatient treatment programs consider weight restoration as the prime
indicator for recovery for Anorexia Nervosa and cessation or significant
reduction in purge episodes as a measure for recovery for Bulimia. As such, they are generally able to claim
success in the short-term. Insurance
companies routinely dictate reimbursement for care based on weight and purge
activity for Anorexia and Bulimia respectively. These concrete variables (weight increase
and decrease in purging) enable the insurance company to grant or decline
continued care. Needless to say,
weight restoration is the most cost effective means for insurance companies
to cease payment of benefits; once weight has increased to the point that the
patient is out of medical danger, benefits are quickly cutback or
terminated. This is part of the issue
why so many excellent in and outpatient eating disorder programs do not have
contracts with insurance companies. What drives the
likelihood that a patient will maintain or continue to increase weight or
continue on the path of decreasing purge activity is the improvement in the
issues that underlie the eating disorder.
Dr. Crow in his presentation stated that Quality of Life and
Functional States need to be considered as well when assessing recovery in a
patient. Quality of life
includes the ability to enjoy food, having meaningful relationships,
employing solid self-care, experiencing enjoyment in life and the pursuit of
pleasurable activities, the ability to tolerate negative emotions in an
experiential way without resorting to symptoms, the ability tolerate down
time and in having good cognitive functioning (i.e. sound judgment, rational
thinking and decision making, limited distorted thinking and perceptions
about weight and body and in most arenas of life.) Functional States
include the degree of productivity and reliability at work and school and the
ability to perform to one’s capability despite “negative self-talk” (i.e. I
am too fat, I should not leave the house because I feel fat etc.) How do you know
if someone is recovered? As mental health
is a continuum, so is recovery. Let’s
give an example of Mary, a 35-year-old woman who struggled with Bulimia for
15 years and has not had any purge episodes (vomiting) for the past 6
months. Is Mary recovered? Would she be “more” or “really” recovered
if she were a-symptomatic for two years versus six months? Let’s say Mary has a triggering episode in
her life, which in the past would have led her to binge and purge, but this
time she is able to avoid resorting to past symptomatic behavior. Does this now mean that she is recovered
because she was not triggered? Let’s
say Mary is best able to remain symptom free if she does not keep any of the
food in her house that acted as triggers in the past, but she can eat some of
these foods when she goes out to eat.
Is she recovered? Let’s say she
is never able to eat any of the past triggering foods, but is able to eat a
full range of other nutritious food.
Is this recovery? If outcome
studies focus only on weight restoration as the criterion for recovery in
Anorexia Nervosa, then studies indicate great success. If treatment success is extended to include
other variables like the desire to eat, greater pleasure in life, healthy
relationships, less distorted thinking about effects of food and body image
then incidence of recovery drops dramatically. Since studies that focus on weight
restoration are generally conducted at time of discharge, success is more
likely guaranteed. Longer term recovery, which focus on weight restoration
and symptom reduction, as the only measures of outcome tend to be less
successful. Symptom reduction is
perhaps not the significant factor that predicts longer-term recovery. What predicts
longer-term recovery? The variable most
significant to those of us who provide solid psychodynamic/relational and CBT
treatment is TIME. Eating Disorders
take time, often lots of time, for recovery to be long and lasting. A sparse few published reports are
indicating that longer term and integrated treatment (therapy, nutritional
and medical care) are greater predictors of overall success; something those
of us in the clinical trenches in the treatment of eating disorders have
known for YEARS. Insurance companies,
take note! I believe, as
many of us who have been treating eating disorders for a long time believe,
that interpersonal issues, which are a cornerstone in understanding etiology
and treatment of eating disorders, can only be assessed and dealt with in a
longer-term therapy. The stronger a
patient’s self esteem and self worth and the healthier her relationships,
which take time to address in therapy, the more likely she will be to have
increased and lasting recovery Treatment
approaches continue to be multifaceted; we need to view recovery
similarly. Behavioral treatment is
only as good as the context/environment in which it is provided. Dynamic psychotherapy is weak without the
use of CBT. It is important
to remember that relapse is a |
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