Long-Term Treatment of Eating Disorders: Tools for a Journey

I have been a practitioner in the subspecialty of eating disorders since 1982. Like most readers of EDR, my practice has not been exclusively the treatment of eating disorders but also includes men and women with a range of mental health concerns. Working with eating disorders has taught me many important lessons about mental health in general, not the least of which is that full recovery from the designated problem for which the person enters treatment may be an elusive goal.

Nonetheless, there is reason to be optimistic, because the majority of persons who seek our help can and do improve. Indeed, many patients are remarkably resilient and inspirational to get to know as they share their stories and make use of some of the tools we offer. Working with eating disorders has also raised my awareness about the many persons in our culture who do not carry an eating disorder diagnosis but still struggle with psychological symptoms related to body image, appearance and aging, food and nutrition, and self-esteem that is centered on external markers of success.

Students and staff members in my practice have noticed the same theme. “Nearly everyone who comes to see me has some kind of body or eating issue,” they exclaim, and then add, “I don’t think I would have tuned into it if had I not worked with at least a couple of clients with eating disorders in my training.” Clearly, the treatment of eating disorders has much to teach each of us about the deeper struggles with psychological pain and psychophysiological problems of the body that are translatable to other mental health concerns. And, notably, these deeper struggles often find remedy slowly, with ‘tincture of time’ and with the avid listening skills of a concerned therapist.

Unfortunately, time for listening now appears to be in short supply. There are many reasons for this in our culture, which are beyond the scope of this short essay. Suffice to say that when a person does not quickly get better from a prescribed intervention, we therapists are apt to blame ourselves and to feel diminished, which is one factor in what some authorities call ‘compassion fatigue,’ or burnout. When we read case studies or research reports, we tend to deny the backstory and end up feeling insufficient to our task. To our detriment we overlook the number of dropouts from even the most well-conducted research and the treatment chapters and failures that likely occurred before a given patient made a positive shift in remedying her symptom. In any given article, quantifiable, positive results become inflated in our minds simply by neglecting obvious facts right before us. For example, this can be the sheer number of patients who do not respond to an intervention because to be published the authors must conclude that what they did worked, and worked well enough to merit citation in a statistically significant way.

The grave difficulty with ‘negative data’ going underreported in the medical literature has recently come to light for prescribers of psychopharmacological agents, like me. Patients are now asking questions and saying no to taking medications because they read widely that the results are not as robust as we were lead to believe from the medical literature over the past 3 decades, and these patients want to avoid the long list of potential side effects that go along with ingesting a pill or elixir. Still, many people do receive lasting benefit from medication, so the point is not to throw out the baby with the bathwater, but rather to be extra vigilant about taking what we read or learn in any format as holy writ. But when facts change, as they often do, one must change one’s mind; back-peddling is never easy. Consider “everything provisionally and questioningly” advised the 18th Century philosopher and polymath Michel de Montaigne,¹ sound advice for maintaining respectful doubt and open-mindedness when the path of least effort augurs for premature closure and certainty.

What can be said of psychopharmacology overselling itself must be thought about across the board in rendering psychotherapy because our evidence base will always be more complicated than in general medical practice. We treat a whole person, not just a disease entity. When we truly listen, we become embroiled in an imbroglio of an individual’s conflicts, worries, losses and grief, choices, and questions about what ultimately leads to greater satisfaction and meaning in life. As I have written elsewhere,^2,3 it is these very issues that also undergird and “feed” eating disorders but that can go unheard and hence unheeded in psychotherapy.

As important as biological, cognitive, and cultural factors are in capturing a partial rationale for the initiation and continuation of an eating disorder, tenacious symptoms are likely to stick around (as they so often do) until the patient’s other problems with living are also given voice and worked on. And when this happens, the therapist has yet another problem to bear – how to define one’s usefulness to a human being who has otherwise improved significantly symptomatically. Many solid eating disorder therapists seek consultation at this time in the treatment. Their story goes something like this: “My patient is so much better. He isn’t starving himself. He has stopped purging. He binges less often. He has gained weight…I feel as though I should be out of a job yet he continues to come… Why is that? What am I doing wrong? What have I missed? I feel that I am taking a fee for not doing anything at all. ”

To this my answer often is, “You are not failing him, but you think you are. Continue to sit there, listen, and be content with ‘not doing anything at all’ for a while longer.” This remark is intended to reduce the therapist’s inner critic and to give permission to simply allow oneself to be fully human with another human being, to encourage psychological pain to emerge and to speak for itself. Only then can we begin to hear what is going on beneath the surface that continues to ensnare the individual. Doing ‘nothing’ is always something bigger than what it appears to be on the surface, so I hasten to further explain, “By tuning in to just a couple of the themes of a few sessions, we will formulate a hypotheses of why he continues to come and to need you. Then we will test it out in real time – by asking him indirectly what he gets from you and the safe environment of your office and the space you give him.” The next phase of therapy will then be less driven for control or mastery of a particular symptom and more guided by inferences derived from tuning into the inner turmoil that the patient may be valiantly struggling to bring to light.

[In Part 2, in the next issue, Dr. Zerbe outlines four major principles for treating patients who need longer-term psychotherapy or who tend to stay in our practice for at least a year.]