Together with members of my clinical team I recently attended the Columbia River Eating Disorder Network's annual conference, where the key note speaker was a well-known local psychoanalyst, Dr. Kathy Zerbe. who spoke on the subjects of eating disorders and obesity.
To be quite frank, what I heard left me and my colleagues deeply troubled. As a result we felt the need to initiate a broader discussion about standards of practice in eating disorder treatment. And because at the time there was very little opportunity for an open discussion of Dr. Zerbe's ideas about eating disorder treatment, we were curious to know what our fellow CREDN members truly thought of the presentation.
Let me begin by saying that we are grateful to CREDN for bringing together local therapists and providers in the spirit of improving understanding of, and treatment for, eating disorders. At Kartini Clinic we support a diversity of opinions and clinical practices (on our staff as well as within the wider provider community). Furthermore we do not claim to have all the answers when it comes to eating disorder treatment. It has been our experience that clinical innovations often require pushing the envelope of theory and practice, sometimes well in advance of supportive clinical data. And so while we believe strongly that everyone has a right to their own opinions, as a community of treatment professionals we don't believe we are entitled to our own facts.
And facts about the elements of effective eating disorder treatments do exist. Indeed they point consistently to one conclusion: psychoanalysis or other forms of psychotherapy, in isolation and without concurrent clinical management, are ineffective in treating eating disorders such as anorexia nervosa.
Considering what's at stake — the health and welfare of patients who suffer from a biological illness with a higher mortality rate than some forms of childhood lymphoblastic leukemia — as ethical providers we should insist on a standard of care that is grounded in science, not opinion. Perhaps more importantly, we should have the courage to challenge directly and openly treatment modalities that do not incorporate scientific standards.
So first, to the science.
A study published in the American Journal of Psychiatry, April 2005, looked at 56 women diagnosed with anorexia nervosa who were randomly assigned three treatments: CBT, interpersonal psychotherapies and clinical (i.e. medical/nutritional) management combined with supportive psychotherapies. The study concluded that "non-specific supportive clinical management was superior to interpersonal psychotherapy." Furthermore the eight authors of the study — among them prominent clinical psychologist Cynthia Bulik of the University of North Carolina's eating disorder program — noted that this finding was "opposite to the primary hypothesis and challenges assumptions about the effective ingredients of successful treatments for anorexia nervosa."
Indeed. It is Kartini Clinic's position that all providers should accept this challenge to past assumptions about the "effective ingredients" of successful eating disorder treatment, and openly question any treatment modality that lacks scientific evidence to back it up.
There's more. In a randomized, controlled study of family-based treatments (FBT) of eating disorders in adolescents, authors James Lock and Daniel le Grange et al., concluded that "FBT was more effective in facilitating full remission." This was published in 2010, to considerable fanfare.
In other words, we now have good evidence that certain treatments for eating disorders are better than others. We would have strongly preferred to have this perspective represented during the CREDN conference. Questions about what constitutes effective treatment really is no longer a matter of opinion, but increasingly one of clinical evidence. And whatever the merits of psychoanalysis, our position is that it has no place in eating disorder treatment, for children or adults, unless and until it can be proven to be as effective as other, known clinical interventions.
Furthermore, in my personal (Julie O'Toole's) opinion, psychoanalysis, at least as espoused at the CREDN conference last week, posits entirely outdated, and, I believe, thoroughly discredited theories of eating disorder etiology. And such theories are emphatically not harmless. Not only can they stand in the way of a child or young adult receiving adequate treatment for an illness whose lifetime mortality is 10%, but they cause parents to be so ashamed (lest others think they caused their child's illness) that they may resist seeking timely help.
This last point carries special resonance for me. I have written and talked about how parents do not cause eating disorders; in several chapters of my book Give Food A Chance I cover older paradigms, including the psychoanalytic and parent-blaming ones. I have seen first-hand how destructive and grossly unfair these notions can be to loving parents who want nothing more than to see their child recover. Recently, at least until this conference, I had started to think such paradigms were long dead and not worth re-hashing. So imagine my surprise: I had no idea that they not only still exist, but are seemingly promoted to young therapists by reputable organizations as a way to approach eating disorders! For example we heard Dr. Zerbe say, "when you see a patient with anorexia nervosa or bulimia nervosa or serious obesity ask yourself 'what is the role of sex here'?" Really? Should we ask the same question when treating schizophrenia or autism? If not, why not? Does it perhaps suggest some don't view anorexia as a biological illness despite vast mountains of scientific evidence to the contrary?
Or take the story we heard of "an anorectic [sic] person" whose underlying problem was that she identified with her father's cachexia (wasting) as he was dying of cancer. She "recovered nicely," we were told, once this underlying "reason" for her illness had been uncovered in psychotherapy. Groundless claims such as "neglectful parents and bonding disturbances between mother and child," where you could "actually see why the patient became anorectic[sic]," were offered in place of clinical evidence. Lastly, we heard of a patient who was "exquisitely on death's doorstep," having gained no weight after four years of psychotherapy.
For me the point is really this: how is it ok to treat a person for four years and watch as they become "exquisitely" on death's doorstep? Is this what we want to promote as the standard of practice in our field? I think not. In what branch of medicine (Oncology? Neurology? Pediatrics? Surgery?) would this kind of unsubstantiated clinical intervention be tolerated, much less taught to new practitioners? I have little doubt that similarly unfounded treatment methods by any other kind of "M.D." would receive a censure from the Board of Medicine.
I and my staff greatly desire an open and respectful discussion about the elements of effective treatment for eating disorders such as anorexia. We hope such a discussion will lead to better recognition of the importance of an integrated approach to treatment, one that incorporates psychotherapy along with an understanding of the biological basis of anorexia nervosa and the essential role of proper clinical (i.e. medical) management of this illness. Neither element, we believe, should stand in isolation or be presented that way in professional discussions of standards of practice in eating disorder treatment.
Dr. Julie O'Toole MD
Dr. Naghmeh Moshtael MD
Leslie Weisner LMFT
Kathy Franz LPC
Jade Buchanan LCSW
Jayotta Feimoefiafi LCSW