BETHESDA, MD. — A multidisciplinary approach to treating eating disorder patients can help to prevent relapse when the treatment team works closely with family members and other concerned individuals, speakers from Johns Hopkins University said at the annual conference of the National Eating Disorders Association.
It's important to use the approach even when a multidisciplinary professional team is not available because of geographic isolation or because a patient has limited resources and insurance coverage, said Dr. Angela S. Guarda, director of the eating disorders program at Johns Hopkins Hospital in Baltimore.
To prevent relapse in patients with anorexia nervosa or bulimia after they return home, clinicians should incorporate strategies that address patient and family behaviors around shopping, eating, and food preparation, Dr. Guarda said. They also need to replace the time spent on eating disordered activities with more age-appropriate and functional behaviors.
The Hopkins program requires new patients to bring a close relative to the first appointment. After the end of the evaluation, the family member is invited to join the session, and the treatment plan is discussed with both the patient and family.
“We initially meet separately with the patient and the family to take a history and to address the issues that relate to the patient's eating disorder,” said Josie Bodenstein, a social worker at Johns Hopkins. “The goal is to educate the family, to diffuse feelings of blame or responsibility for the eating disorder, to listen to their respective viewpoints, and to help parents become part of a unified team in assisting their child to change her behavior.”
“Patients and families must understand that unless you change your behavior, you won't be able to correct your eating disordered thoughts and feelings,” Dr. Guarda said. “Treatment is a process of conversion—from seeing dieting as the answer to recognizing it as the problem.”
Discussions with patients include making patients realize that it is normal to have ambivalent feelings toward change, to relapse on the road to recovery, and to be initially dissatisfied with the changes to their bodies. Body dissatisfaction typically lags behind behavioral change by several months, Dr. Guarda said.
Despite the reluctance of some therapists to weigh patients for fear of encouraging focus on weight, it is critical to weigh patients at weekly office visits. “We are very explicit with patients that we require [weigh-ins] in order to treat them. You don't treat hypertension without checking a patient's blood pressure; why would we treat anorexia nervosa without checking weight?”
Many patients with eating disorders have problems with preparing meals and eating in social settings, which can be isolating and result in occupational and educational limitations. Eating disorders can “freeze” a person's developmental progress, resulting in impaired formation of identity and intimate relationships, and difficulty in separating from parents, according to Dr. Guarda.
“It's important to educate parents about grocery shopping,” because eating disorder patients often want to be involved in planning family meals, the grocery shopping list, and anything related to food, said Sandra Kirckhoff, a nurse on the inpatient unit in the eating disorders program. Adolescent patients can request some nondiet foods, but they should not be in charge of doing the shopping or making menus or lists.
Families should try to eat balanced meals together at a table, with no one eating diet food. After-meal activities can help to prevent purging, strenuous exercise, or guilt from feeling full.
At various points during a patient's treatment, clinicians may have to assess the family's mealtime behavior, parenting skills, and assist them in setting firm but supportive limits on disordered behavior and to carry out the roles assigned to them by the treatment team. This may involve having the family practice designing menus, going to the grocery store, and eating at a restaurant together. Family members must show a united front in setting limits on the patient's behavior and in following through with consequences, Ms. Bodenstein said.
“When lines get blurred, roles become unclear, and progress stalls or regresses; it can be helpful to use a behavior contract … to make explicit what everybody's role is,” said Dr. Graham Redgrave, assistant director of the eating disorder program at Johns Hopkins.
During hospitalization, Hopkins clinicians do not allow any arguments over whether something should be eaten or not, Ms. Kirckhoff said. Nurses supervise meals and encourages patients to eat all of their food. Each patient is expected to eat like a normal weight, nondieter, to consume a range of foods, and to stop all exercise if on weight gain. Team sports and weight training are introduced after patients reach their target weight. The staff also teaches patients to determine appropriate portions for weight maintenance by eyeballing portions, not measuring them.