types of treatment for eating disorders

The Team Approach for eating disorders
Eating disorders are multidimensional syndromes that oft en require treatment
from multiple disciplines: psychology, medicine, nutrition, and psychiatry.
Practitioners need to communicate regularly with one another to pool their
assessments and impressions of clients and to make united decisions about
type and duration of treatment. Operating as a team also helps to counteract
the splitting and denial that characterize students with these disorders.
Practice guidelines for the treatment of eating disorders were generated
and revised by a task force of the American Psychiatric Association (1993,
2000). Th e guidelines were based on extensive interviews with clinicians and
reviews of the scientifi c literature. Th ey refl ect the fi eld’s collective expertise physiological and psychiatric status. Treatment strategies should be informed
by these guidelines.
By virtue of requiring multidisciplinary care, eating disorders present an
exacting challenge to college health centers, which oft en must treat students
with limited resources. College health centers must identify and monitor students
with eating disorders, introduce them to psychotherapy, and arrange
ongoing care for them off -campus.
Individual Treatment for Anorexia Nervosa
Psychotherapy alone has little eff ect on anorectics who are markedly malnourished.
Th e negativistic mindset and depressed and irritable emotional state
of a starved person render exploratory work nearly useless. On the contrary,
nutritional rehabilitation, oft en in a hospital setting, is required for severely
underweight anorectics. Such rehabilitation helps to mitigate symptoms of
obsessiveness, rigidity, and depression, and in so doing, enhances receptivity to
psychotherapeutic interventions. On-campus nutritionists can do nutritional
remediation with students who are both motivated and medically safe.
Patients with anorexia are able to benefi t from psychotherapy once they have
initiated weight gain and are no longer medically compromised (American
Psychiatric Association, 2000). Many clinicians who specialize in psychotherapy
with anorectics use concepts of both interpersonal theorists, most notably those
of Bruch and Crisp, and cognitive-behavioral techniques.
Bruch (1978) believed that anorexia emerged from dysfunction in the
mother–child dyad. Specifi cally, she believed that the defi cits in self-awareness
and competence that characterize anorexia are the outcome of maternal misattunement
and failure to promote autonomy. Suffi cient maternal perceptiveness
of children’s internal states is necessary, she argued, for children to come to
know their own impulses, feelings, and bodily sensations. Such self-knowledge,
which she termed “introceptive awareness,” is what guides children to
act eff ectively in the world. Maternal affi rmation of child-initiated actions is
also necessary for children to develop a sense of agency. In contrast, chronic
maternal misattunement and discouragement of independent strivings leave
children confused about their internal experiences and ill-equipped to meet
their own needs.
According to Bruch, the clinician’s role is to remedy anorectics’ defi –
cits by fostering introceptive awareness and encouraging expression and
autonomous action. For example, one clinician sensed hurt and anger from
a student who repeatedly fell into protracted silences in sessions and said
only, “I’m blank.” Th e clinician shared her hunches and urged the student to
tend to and voice what she felt at these times. Gradually, the student began
to know and practice conveying what for many years she had not allowed
herself to experience.

Crisp (1980) saw anorexia as a defense against an avoided family problem,
such as sexual abuse or a strained marital relationship. According to his
view, puberty, with its attendant biological urges and separations, threatens to
accentuate the unresolved problem and destabilize the family. Th e anorectic
halts maturation to rein in her impulses and to maintain the existing, albeit
fragile, family structure. Treatment involves helping the anorectic tolerate the
anxiety and interpersonal consequences of moving away from the stasis of
self-starvation toward psychobiological growth.
CBT aims to enlist the anorectic as an active collaborator in treatment,
since accurate self-report data are essential to this approach. Motivation must
therefore be assessed and usually strengthened through an analysis of the
drawbacks of continuing with the disorder. Weight- and food-related distortions
can then be addressed through monitoring of symptoms and psychoeducation
about chronic undereating and the futility of dieting behaviors.
Patients are also urged to experiment with making the behavioral changes
they fear, such as normalizing eating patterns and weight. Later stages of
CBT include examining the multiple functions of symptoms and challenging
internalized cultural values (Garner, Vitousek, & Pike, 1997).
Most college counseling centers are able to off er only short-term psychotherapy.
Because the average duration of anorexia is 7 years and rates
of full recovery are modest, what can be accomplished in college settings is
limited. Nevertheless, introducing ways of thinking about and ameliorating
their symptoms can help ready students for ongoing treatment. For example,
students may be encouraged to attend closely to their internal experiences,
including sensations of hunger and fullness, and to use those experiences to
guide behavior. Students may be asked to consider the possibility that their
disorder is connected to a larger family problem. Th is may open up inquiry
about family vulnerabilities and patterns of avoidance to be pursued in ongoing
treatment. Self-monitoring and behavioral experimentation, even on a
short-term basis, can also help clarify diagnoses and chip away at students’
denial. Whatever the approach, therapists who convey interest in students’
internal workings and initiate behavior change off er anorectic students
much-needed responsiveness and hope.