When Psych Students Attack

When I get disheartened about the state of ED treatment I try to take heart in the hope that newer generations of better-trained clinicians will clear out the old thinking and improve things.

But maybe not:
Family-based treatment for anorexia? - Student Doctor Network Forums

"I think that method only works for a small, small, special subset of anorectics....When you consider that anorexia often develops out of family conflicts, etc, I don't think that method would work."

"I think this method would crash and burn with 90% of them. Enmeshment and familiar conflict are often a large contributing factors to the development of an ED".

"...only the very tame cases, and the ones that aren't rooted in the traditional pathology, but more in the societal pressures, etc. I would never recommend it, but some do."

Yes, "some do." Like the APA, the AAP, the ADA and the NIMH. Like the ED clinics at Stanford, the University of Chicago, Duke, Columbia, and the UC San Diego. Like most leading eating disorder researchers. That Family-Based Maudsley treatment isn't widely available, despite the research behind it, is because of antiquated notions of family pathology and the condescending attitudes of clinicians who continue to "think" things like the above. It's frightening.

Comments

  1. I find it disheartening and discouraging to read things like this. These student doctors misunderstood the basic story (they assumed for some reason no pediatrician was involved, which couldn't have been further from the truth) and come with so many preconceptions and assumptions it's hard to know where to start breaking them down. The assumption of sexual/physical abuse in families with e.d.s--well, that says it all, doesn't it? Haven't we all faced this kind of prejudice and assumption?

    I thought we'd come a long way. I still hope so. But boy, this is ugly. And misinformed.

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  2. Don't take SDN to be characteristic of future doctors at all. It's well known to be a particularly silly type of forum, where the most obnoxious 21-year-old medical students have fun writing inflammatory comments about subjects about which they know nothing. Most of us are not like that!

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  3. These medical students are sadly misinformed about anorexia. It makes me wonder what the state of education is in medical schools today on the whole subject of eating disorders. For example, to what extent do recent research findings work their way into the curriculum? Perhaps the medical student who posted above could talk about the training most doctors are receiving in this area. I'd be very interested to hear. Thanks

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  4. It is my impression from talking with doctors that that there IS no training around eating disorders in med school.

    Correct me if I'm wrong.

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  5. I'm with Harriet on the state of training around eating disorders in med school - in the UK there IS none, even in psychiatric modules unless the student specifically chooses to study the area. I was talking to a fellow carer whose healthy daughters are both medical students and neither of them has studied eating disorders AT ALL in their careers - and one of them has just qualified.

    I have to say that I wasn't THAT horrified by the debate. As the med student said, this type of forum usually brings out the combative nature in students who like to debate. Yes, old, worn out theories are trotted out, but genuine information, particularly about the Lock and LeGrange trials is also in there. The article has sparked off a genuine debate, which can't be bad - now all Harriet needs to do is to write another one directed, not at the thinking general public, but at that strange breed, the med student ;-)

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  6. It troubles me less that there is little training for general practitioners than the fact that those without specific training go ahead and treat people with EDs anyway. This is like having podiatrists treat brain tumors.

    The best comment on that discussion was the one who said they he refers ED patients to specialists because it is out of his comfort zone.

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  7. Here in the UK those without training have to treat EDs anyway - no one else is going to. The NICE guidelines give full responsibility to GPs for identifying and referring. YES, the fact that GPs don't go on training courses and don't seem to be terribly committed to this specialised area of work is a concern - but then again no one ever asked them if they wanted this responsibility. Unclear guidelines and lack of local resources mean that generalists very often get left treating those for whom there aren't the resources to go round - and those who refuse to see the specialists ;-]

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  8. I think they had a point, in that:

    1. Maudsley has not been proven effective for older adolescents or adults. That is not to say it hasn't WORKED on older adults, as Maudsley Forum can testify to a variety of cases -- just that it has a lower success rate. This HAS been proven in medical study.

    2. Refeeding ALONE is dangerous in low weight anorexics. The guidance of a dietican is needed and psychiatric team. I have read the Maudsley Manual and I think a team approach is recommended with the parents as part of the team. Too often I read of people on the forum lacking medical experience and a team to monitor refeeding in a child with a dangerously low BMI.

    4. They are correct in that not all symptoms are not a product of starvation. Certainly they are aggravated, but these are not cured upon weight restoration -- even long term weight restoration. Some is personality and some certainly MAY BE caused by environmental influences.

    5. You cannot ignore emeshment and family conflict as a contributer to an ED. There is research tied to these findings. Does this mean Maudsley will not work -- no.

    I guess the end conclusion is there are pros and cons to EVERY treatment. And yes there are STUPID treatments out there, but Maudsley is not the only effective treatment. Only one of many.

    A :)

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  9. Also, I think the ball game changes so to speak, when you are dealing with an older AN adult than an immature child.

    My therapist once said, "A teen with AN has NOTHING to lose. An adult has everything to lose."

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  10. Also, I think the ball game changes so to speak, when you are dealing with an older AN adult than an immature child.

    My therapist once said, "A teen with AN has NOTHING to lose. An adult has everything to lose."

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  11. A:),
    I will confess that reading that exchange I was filtering to focus on certain things. I was seeing all the incorrect beliefs and assumptions about families and about Maudsley. The "90%" and the "small, small subset" and the assumption of family pathology.

    You, I think, are also doing some filtering. You are focussing on adults, for one thing, and they weren't. And neither do I - when we are talking about Maudsley I am by definition talking about dependent adolescents. I am also assuming the patient is not medically unstable, because then they should be in the hospital.

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  12. And just because the success rate *may* be lower with adults and older adolescents--and we really don't know that because there are no good studies yet--doesn't mean it's not an appropriate treatment. When you look at the absolutely pathetic recovery rates from "traditional" treatments--how can med students or anyone else possibly just rule out a whole treatment modality? Do they really think 33% recovery rate is acceptable? My god.

    I am so frustrated by this debate I could scream. In fact I think I will.

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  13. Hi a:)

    Could you post the cites to the scientific studies that support your five points? This is really interesting.

    Thanks so much.

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  14. Don't have much time. . .

    But, (if you will allow me Laura) I will start with refeeding complications -- Obviously there are many, but one medical article put it best. . .

    Department of Clinical Neuroscience, University of North Dakota School of Medicine and the Neuropsychiatric Research Institute, Fargo, North Dakota 58103, USA . mitchell@medicine.nodak.edu

    PURPOSE OF REVIEW: This review focuses on recent publications concerning medical complications in patients with eating disorders, including anorexia nervosa and bulimia nervosa. RECENT FINDINGS: Recent literature continues to reflect that multiple organ systems are frequently affected by eating disorders. The literature underscores the frequently cited risk of premature death in those with anorexia nervosa. A plethora of dermatologic changes have been described, some signaling serious underlying pathophysiology, such as purpura, which indicates a bleeding diathesis. Much of the literature continues to delineate the fact that diabetic patients with eating disorders are at high risk of developing diabetic complications. Gastrointestinal complications can be serious, including gastric dilatation and severe liver dysfunction. Acrocyanosis is common, and patients with anorexia nervosa are at risk of various arrhythmias. Low-weight patients are at high risk for osteopenia/osteoporosis. Nutritional abnormalities are also common, including sodium depletion and hypovolemia, hypophosphatemia and hypomagnesemia. Resting energy expenditure, although very low in low-weight patients, increases dramatically early in refeeding. SUMMARY: Medical complications are common and often serious in patients with eating disorders, particularly those with anorexia nervosa.

    PMID: 16721178 [PubMed - indexed for MEDLINE]

    http://www.ncbi.nlm.nih.gov/pubmed/16721178?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

    Have to run to dinner

    More later

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  15. a : ( is settin up the same straw man that the poster on the SDN forum did. FBT does not proceed without medical oversight for refeeding complications and other physical health issues. Posters on SDN seemed to assume the NYT article's author (and perhaps other FBT families) did not consult medical professionals. As the author has clarified for us, that is not true in her daughter's case. Medical oversight is a part of FBT. Posters who suggest that this isn't true show their ignorance or (and I think this is more likely) disingenuously raise specious arguments to discredit an approach they dislike.

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  16. Hi a:) I don't think anyone denies that there are medical issues involved in refeeding and that the supervison of a medical doctor is necessary. That's all part of FBT/Maudsley therapy. But your five points are different. I really do hope you go back and look again at the research. In particular, what is the "medical study" that "proves" Maudsley is not effective for older adolescents? Or the research proving that AN is "tied" to enmeshment? I'm willing to have an open mind, but you've got to provide evidence if you are going to change my mind. I've spent hundreds of hours reading the scientific literature and I've never come across scientifically reliable studies concluding anything like what you are saying.
    There's only speculation, but that's not a basis on which to design a therapy for a potentially life threatening condition.
    What matters in the end is what works in treatment, and what doesn't. Every responsible researcher in the world seems to agree on the need for prompt refeeding and weight restoration as a necessary part of recovery. It will likely take a long time to restore and maintain a healthy weight. The question, then, is how it gets accomplished. In the real world, if the parents don't participate, it's not going to happen. Very few people can afford to pay a hospital or residential treatment facility to refeed their child for several months on end. And how does prolonged confinement in a hospital setting affect the psychological development of adolescents? Very few if any people with AN can refeed themselves. Visits with a therapist won't refeed the child either. So if the parents don't take charge, refeeding likely won't happen, the sufferer will continue in a state of semi-starvation, and she might even die. What do you (and the geniuses on SDN) propose as an alternative to having the parents take charge of refeeding? And again, if your alternative is so good, where are the studies showing it works? I'm screaming too, along with Harriet.

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  17. To respond to the comment that said that ED's are not covered in medical school:

    We have some teaching about eating disorders in the first two years (classroom-based learning) at my medical school. These included a couple lectures by psychiatrists, and a lecture from a recovered anorexic about her personal experiences. In the third and fourth year (clinical-based learning) there is a mandatory psychiatry rotation which would include exposure to all major illnesses for which patients are hospitalized which would generally include eating disorders.

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  18. Can you post this series of comments on SDN? Is that possible? I think it might give people a little something to think about and 'chew on'.

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  19. Anon, Again,

    My post was NOT complete or I would have included more studies and information. I'm kind of angry I did post because I would have preferred NOT to make a fool of myself.

    I concede to Laura that if professionals are involved, the child is a younger adolescent, not medically unstable, Maudsley is often very effective. I guess my filters were on too Laura!

    However, I'm just saying there are other types of effective treatment. Day programs and hospital based inpatient programs (with good follow up) are very effective for older ANs.

    Why is it so difficult to believe that Maudsley is not the ONLY anorexia/bulimia treatment?!

    Yes there are some bogus therapies out there, and attempting to "talk" to the patient while they are underweight simply doesn't work, but I have seen MANY people recovery without Maudsley and with traditional ED programs (i.e - inpatient stay --> day patient stay --> intensive aftercare program --> community based help).

    I think there is a danger in seeing Maudsley as the ONE way and making assumptions that ALL other forms of therapy are useless.

    I'm sorry if I've offended anyone. My goal was not to insinuate that Maudsley was not at all effective, but that there are also other ways.

    I didn't expect hostility in response.

    A :)

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  20. Hi A:),

    I don't think anyone here is arguing that Maudsley is the only way. Not at all. I think what you're hearing is frustration with the lousy recovery statistics from other treatments, and also the frustration that comes with the instant dismissal of family-based treatment that you read on the SDN listserv and so many other places.

    I don't think there are lots of other effective treatments, though. That's the thing. Recovery statistics aren't very good overall--less than 50% recovery, and often you're talking about a course of disease that lasts 5 years, 7 years, 15 years. I don't consider that effective. Do some people recover in traditional settings? Absolutely. Are those settings ideal? No way. I'm sure you know yourself the cycle of relapse-recovery-relapse that comes of treatment in many IP settings. Patients never get to true healthy weight, they're released and expected to manage their own eating way before they truly can, they lose weight, relapse, and the whole thing starts over again. It breaks my heart.

    Does Maudsley work for every single family? Nope. But it works for many many families. To dismiss it out of hand like the posters on the med students listserv is to come at the issue with preconceived notions and blinders in place. So far the outcome studies on Maudsley show 80 to 90% percent recovery rate 5 years later. There is no other treatment that is nearly as effective at the moment. Is it good enough? No, and that's why NIMH is funding multiple studies right now on this. But for now it seems, going strictly by the numbers, to be the best treatment we've got in many cases.

    I don't feel hostile to you and I'm sorry if I seemed hostile. I do feel hostile to people like the psych students who speak out of arrogance and ignorance and who thereby condemn too many people to needless suffering.

    Rant over. :-)

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  21. A : (

    You didn't get hostility in response. You received requests to justify your stated points with the "research" you mentioned.

    Again, you're setting up a straw man. I've never heard anyone--including leading experts on family-based therapy--say that Maudsley is (or ought to be) the only treatment option. Indeed, given the scarcity of of FBT treatment provider and the fact that the VAST majority of treatment is not family-based your worries about it being seen as the ONLY treatment are really quite odd. (Once parents have decided to pursue FBT it is natural that they would seek support and remain firm in their commitment to compassionately follow through with treatment.)

    You seem to have some misunderstandings about the approach. FBT is not simply refeeding. Restorative nutrition corrects problems, both physical and mental Issues, including the family conflicts or environmental issues you mention, are addressed in the later stages.

    I'm not at all offended but I'm not at all convinced either that you understand FBT or that your points are valid research-demonstrated findings (rather than the clinical lore that comprises most of ED literature.)

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  22. I unintentionally ommitted the text in caps from my post above. "Restorative nutrition corrects problems, both physical and mental, THAT RESULT FROM MALNUTRITION. AFTER THAT PHASE OTHER ISSUES, including the family conflicts or environmental issues you mention, are addressed in the later stages."

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  23. Dear a:) It was not my intent to be hostile, but I do feel strongly that for the sake of accuracy and integrity statements about what "medical studies" "prove" should be backed up with citations. For example, you say it has been "proven" in a "medical study" that Maudsley has a "lower success rate" for older adolescents. I think you should give a citation to a reputable study if you are going to make that statement. I must say that I have never seen a field of science or medicine where speculation and wild hypothesizing is more rampant and tolerated than with respect to eating disorders. It's as if the normal rules of science and good clinical practice are suspended and everyone is invited to a free-for-all. Wild guesses get repeated time after time and after awhile hypotheses become accepted wisdom just because they are repeated so often, without any scientific basis. This kind of pseudoscience would never be tolerated if we were dealing with any other illness, such as cancer. Those who suffer from anorexia deserve better.
    And med student, I appreciate hearing about the state of medical school education. It sounds like the average med student and doctor receives maybe a half dozen hours of education and training on the subject of eating disorders. Compare that with many of the parents who post on this site. They not only have studied the most up-to-date and sophisticated scientific literature for, in some cases hundreds or thousands of hours, but also have had direct up-close personal experience with AN. To put it bluntly, we know a lot more than most general practitioners and many of the folks who post on SDN. So when we are told to "turn the problem over to the professionals" we have a right to ask questions and expect good, evidence-based answers and treatments, not obsolete folklore that passes as science.

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  24. "Why is it so difficult to believe that Maudsley is not the ONLY anorexia/bulimia treatment?!"

    I think this gets to the heart of the debate here. No one said that. I don't know anyone who believes that.

    The condescending and uniformed dismissal of FBT by those students is an attitude that parents face all too often. All I want is for families to have the option. To be informed of their options, and have FBT available from clinicians who understand it and believe it can help.

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  25. That Maudsley was less effectvie for older adolescents. . .

    I participated in a Maudsley study -- our therapist was the inpatient director of a hospital based program and working directly with Locke and all that in the states. The study was a joint effort and was being replicated in many hospitals. . .

    I heard this from him and I'm assuming since he is also a professor at the university of toronto, that he is correct. . .

    I don't know -- most of what I have heard has been through psychiatrists who have treated me. And I don't think someone who is an advocate for Maudsley (as is this dr) would lie.

    "There are limitations to family-based treatment for anorexia nervosa in adolescents. For example, data from the Maudsley studies show that this approach is less effective for older adolescents (>18) or adults, adolescents who are chronically ill or those who binge and purge. In addition, highly critical families may not respond to the whole family treatment model and need alternative versions of family treatment to succeed. "

    This is written by Locke, -- an article rather than a study -http://www.childresearch.net/RESOURCE/NEWS/2001/200104.HTM

    A

    Bruch H: Eating Disorders: Obesity, Anorexia Nervosa, and the Person Within. New York: Basic Books, 1973.

    Dare C, Eisler I: Family Therapy for Anorexia Nervosa. In Garner DM, Garfinkel PE (Eds.): Handbook of Treatment for Eating Disorders, (2nd ed.). New York: The Gilford Press, 1997.

    Eisler I, Dare C, Russell G, et al.: A five year follow-up of a controlled trial of family therapy in severe eating disorders. Archives of General Psychiatry 1997; 54: 1025-30.

    Gull WW: Anorexia nervosa (apepsia hysterica, anorexia hysterica). Transactions of the Clinical Society of London 1874; 7: 222-228.

    Lock J, Le Grange D, Agras S, et al.: Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: The Guilford Press, 2001.

    Minuchin S, Rosman BL, Baker BL: Psychosomatic Families: Anorexia Nervosa in Context. Cambridge, Mass: Harvard University Press, 1978.

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  26. Gull, Minuchin, and Bruch were wrong about family pathology. The other people you cite specifically dispel those ideas in their work.

    You cite Eisler, so let me point you to what he says on the video available on my site.

    The older patients described above are a small subset of patients. Most ED patients, especially in AN, are diagnosed as adolescents living at home with less than 3 years of illness.

    Yet critics concentrate on the patients who are older and sicker - ones who have worse outcomes with any treatment. Patients who might have been treated earlier and more effectively.

    Criticizing Maudsley based on a population it is not meant to be used with would seem to be a conclusion in search of a question.

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  27. True Laura,

    I really don't want to argue with you.

    The older patients are a small group -- yes that is true. And tend to be stuck in the illness etc.

    I am not critizing Maudsley. Just stating that there are varying degrees of effectiveness depending on the individual, length of illness, etc.

    Don't be angry

    A

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  28. Who's saying that Maudsley is the one and only treatment option? You're arguing against a point NO ONE has made--fabricating it out of thin air apparently. Why bother? Surely you must know that all parents have been exposed to the option of conventional ED treatment. Again, it comprises the vast majority of what is available. Can you imagine that it's been overlooked by anyone? I don't see how it could happen. I am less upset than ever by the kind of silliness on we see on the SDN thread (though I do hope they learn a bit more) because parents are finally becoming aware of their options. They have an opportunity to assess treatment options and DECIDE which therapist/approach will work for them (just as you would have to if you had an adolescent daughter with AN.)

    And who's angry? I think most FBT parents are used to these types of arguments and aren't especially bothered, as once treatment is underway they are more focused on their recovering children. Honestly, they are so common they are boring. Please don't worry that you've upset anyone who is helping their child recover--I sincerely doubt that you have.

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  29. Anon

    "You're arguing against a point NO ONE has made--fabricating it out of thin air apparently. Why bother? Surely you must know that all parents have been exposed to the option of conventional ED treatment."

    I understand your point, but you could be less rude about the delivery. This blog and Harriet's is about the only place where I DARE to express a contrary opinion.

    I'll admit, I am defensive about traditional treatment because Maudsley did not work for my family and my stable recovery was largely dependant on a program I entered that got me to 105% of an ideal body weight and continues to follow me each day in their afterprogram.

    The program was also largely based on recovering under your own intiative as adults. All were very committed to recovery and are doing well at normal body weights which are not minimums.

    This may have obstructed my view. My point was always that other forms of treatment can also work though I think my experience is based on adult treatment which may be where my perception is skewed.

    I'm sorry if I came across as ignorant

    A

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  30. I was emphasizing my point since you seemed to miss it the first time.

    I would imagine there are many, many, many places that you could DARE to express an opinion contrary to FBT (like the SDN--ha, ha). Maudsley is far from the dominant treatment in EDs although there are now a few resources available for FBT parents.

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  31. "I would imagine there are many, many, many places that you could DARE to express an opinion contrary to FBT (like the SDN--ha, ha)."

    I am not a member of the SDN as I am not a medical or psych student. I wouldn't post there because I am not nearly knowledgeable enough. I only have my treatment experience and the medical studies I have read via the internet.

    And yes, I find it hard to express my opinion -- I would love to just agree with you all just to feel better. I thought this was a safe place but maybe not?

    A

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  32. I doubt that agreeing with things you don't believe would make you feel better.

    If you express your opinion then it only seems fair that others have the opportunity to express theirs. What's unsafe about that?

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  33. Well, I guess I percieve your "expressing your opinion" as an attack. I think if we are going to debate or discuss it could at least be polite.

    I'm not sure whether I am right or wrong about this.

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  34. a,

    No attacks. I care about you and so do others here. You must understand that parents of eating disordered children and teens come in for an awful lot of criticism and hostility. This is a safe place for us, too. But we're on your side.

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  35. Wow - what a debate. I woke to 18 e-mails, most of them from this post.

    I LOVE the fact that people are debating these issues although I hope that the at times heated nature of the debate hasn't hurt anyone.

    For me, I'm going to go back to the original comments that Laura has linked us to.

    Are they REALLY that hostile? These are medical students (like a:) I haven't joined them but actually that is at least in part because I can't work out how to rather than because I'm not qualified - although I'm certainly not;-)).

    Doctors are different from the average person. They HAVE to be. When someone collapses in the theatre, do they call out for a therapist or an experienced parent? NO, they call for a doctor. Doctors deal with life and death on a daily basis. In order to survive they do develop a self-confidence that appears somewhat arrogant - if I have a heart attack I want the most self-confident doctor I can find thank you - I'll criticise him or her for attitude AFTER they've resuscitated me.

    Given the nature of the forum I actually think that the debate is quite balanced. They do seem to have misunderstood Harriet's original article in thinking that she worked without medical support - it would be good if one of us could get on there to correct them - but the moderator sets them straight on the nature of the established "Maudsley" (although one could spend hours debating that term in the first place) treatments stating that "In my experience with families using Maudsley, their team is readily available and supportive of the parents". One poster - a new member - states that she uses "Maudsley" within the treatment centre in which she works. She does make the point "it's only appropriate in certain situations and with proper external supports". Having failed at Maudsley at least in part because of the inadequate external support I say a resounding YES to that.

    I find the fact that these med students (who I note are joined by a few psychology rather than psychiatry students) are debating Maudsley (or eating disorders in general) highly encouraging. If they fight over the effectiveness of one method against another it means they know that there IS hope and that there ARE effective treatments - so much better than the attitude I have come across in a few older doctors which goes along the lines of "these things are untreatable so why bother" - an attitude that used to be fairly common in cancer at one point too.

    Now to have another go at working out how to join them - I wonder what they'd think of the French treatment Laura has posted about above? As someone who is facinated by the economic history of medicine the financial implications of each treatment is something I'd like to see debated by med students. Sometimes doctors like to think they are above economics but there's evidence from Chaucer and before that that is complete rubbish.

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  36. A:), I'm not angry. Sometimes indignant, but only at some ideas - not angry at you. I actually think this kind of exchange is NECESSARY because most people in the ED world talk past each other and don't engage. I'm impressed and thankful to you for speaking up and engaging. I admire you!

    It is probably impossible for you to share the context, for parents, of these types of resistance to Maudsley. All of us have fought so hard just to get the topic raised.

    Marcella. !!!!
    Yes, it is that hostile, I think. To follow your analogy, if I had a heart attack at the theater I would want the physician to revive me, not the popcorn salesman, but in this case the students are selling popcorn. The "only for the few" and "enmeshed" stuff is just plain wrong - their confidence should be earned with good training, not based on damaging presumptions.

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  37. I am fascinated by the emotional response the SDN site has created. The debate can only highlight the ignorance of subscribers and hopefully stimulate further reading and discussion on the topic of FBT and Maudsley.

    Surely it's up to parents who have experienced treatment from a variety of perspectives, including M to stand up and be part of the training schedule for trainee practitioners. Attending several lectures does not constitute being an expert in the field of ED.

    Practitioners are hesitent to quote success rates for traditional treatments (because there aren't any?). Surely there is a duty of care in their job description which says 'they will offer the best possible care to the patient'. Part of that duty has to be research into what has been the most successful form of treatment. To date M/FBT wins hands down. In determining the success rate there are several factors which need to be considered.
    1). Severity of the diagnosis on a scale of 1 - 10.
    2). Duration of illness prior to commencement of treatment.
    3). FBT support and parent determination to follow the programme.
    4). Co-Morbidity or underlining pathology.

    The need for follow up/alternative treatment modalities could then be determined.

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  38. I still think they either should be referred to read these comments or our comments posted on their site. That would be something that could effect change.

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  39. a,
    Some might perceive your assertions about enmeshment and family conflict to be impolite or a judgement about families ("attack" seems to go a little far--we're all people writing a few words on the internet not knife-wielding maniacs.) Put the shoe on the other foot for a moment--this goes both ways.

    Marcella,
    I think that they were pretty hostile. Clearly some were misinformed about the basics of the approach. A good chunk of the criticism revolved around the idea that medical oversight isn't involved and suggested that Maudsley=refeeding. If these people believe that they are really too ignorant to have any sensible type of discussion. And someone who claims to be a researcher says that "I think this method would crash and burn with 90% of them". FBT is one of the very few types of therapy that has outcome data--I'd like to think someone who calls himself a researcher would READ it. And Therapist4Change does seem quite hopeless even though s/he is not an older doctor but a mere student "For many, this is a life-long struggle, and trying a quick fix is not really realistic."

    No big deal if these people express themselves directly to parents who seek care for their kids since parents (in the US anyway) can look elsewhere.

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  40. "anne said...
    I still think they either should be referred to read these comments or our comments posted on their site"

    Make it so, Anne! Go for it.

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  41. The December 2007 issue of the American Journal of Psychiatry has an article entitled "Anorexia Nervosa." It is written by Evelyn Attia and Tim Walsh, both professors at the College of Physicians and Surgeons at Columbia University. They are also leaders of the Eating Disorders Research Unit at New York State Psychiatric Institute. Here's some of what they say:
    1. "All current treatment guidelines for anorexia nervosa emphasize weight restoration. There is no clearly defined algorithm for how to accomplish this goal, although common practice includes the selection of the least restrictive treatment setting that is likely to be effective." To me, this means the top priority is to restore weight in the least restrictive setting. That usually means within the family. Even if hospitalization is required, the hospital will only partially restore weight. Then the insurance companies kick the patients out -- before full restoration -- and the family needs to take over with full restoration and maintenance. There is no other option, other than starvation. When Therapist4Change writes: "The re-feeding process should be done in a hospital or in-patient unit .... PERIOD" he or she is dreaming. That's not a realistic option, even if it were desirable (which it is not). I'm repeating myself, but I'll ask again: if the parents don't take charge of refeeding, who will? Is Therapist4Change saying that if hospital or inpatient refeeding is not available, the sufferer should be left to starve on her own? Please answer.
    2. Attia and Walsh go on to write: "Weight restoration is generally associated with improvement in a variety of psychological areas, including mood and anxiety symptoms." This conclusion is supported by the many, many parents who have posted on the forum. Would Therapist4Change forego weight restoration and instead use talk therapy with a severely malnourshed patient in an attempt to improve mood and anxiety? If so, why? Has talk therapy ever been shown to improve mood or anxiety in a malnourished patient?
    3. Finally, Attia and Walsh discuss Maudsley treatment. They write: " a family-based approach appears promising for children and adolescents with anorexia nervosa; family therapy has been reported to be superior to individual therapy in two randomized controlled trials for adolescents with anorexia nervosa." This conclusion has also been reached by many, many of the leading scietific researchers in the world, including Jim Lock at Stanford and Daniel Le Grange at University of Chicago, who have had so much more experience than any of the SDN students, that any right-minded person would conclude that a Maudsley/FBT approach should be considered first in every case and rejected only for compelling reasons. So when one of the SDN posters says he or she would "never" recommend Maudsley/FBT, I think it's fair to say he or she is taking a postion that is wildly outside the mainstream of current thought among the leading scientists and researchers in the field.
    It's distressing to me that these students are expressing such adamant opinions based on so little knowledge and experience. To me, it represents dysfunctional thinking. If a parent were to express such uniformed ideas, they would be labeled as dysfunctional by just about any therapist. If these student docs go on to practice medicine or therapy with the style of thinking they have demonstrated, they are likely to commit malpractice repeatedly and endanger the health and lives of countless people. Maybe that's why my earlier posts have come across as hostile.

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  42. 1) SDN does not a group of medical doctors.

    2) It is an internet FORUM!!! Not expert medical advice.

    3) Relax

    4) The way these posted comments were taken out of context is sicken to me. it leads to false information (i.e. a medical student said...). It is simply not true. You know no ones credentials!!

    5) "When Psych students attack" come on, sounds like a bad reality show.

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  43. Hey all, Therapist4Chnge here, Senior Moderator from SDN. I think it is very important to have places to share ideas and experiences, as no one has an all-encompassing experience. It is also important to understand where people are coming from, because that will greatly influence their perspective on an area.

    I’ve been involved in ED and body image work for the past 7-8 years, and it is my area of research and clinical expertise. I’ve been fortunate to work in both research and clinical settings (in-patient and out-patient), and I have been able to work closely with individuals and families effected by EDs and related challenges. I actually have an organization that I started awhile back that eventually will provide out-reach education for professionals and community members. StrugglingWithFood

    I think where Maudley is effective is in recognizing the importance of family involvement, though other treatment models also include the family, though at different levels of participation. Instead of getting off on my views of Maudley, I’d like to respond to some of the comments/questions here.

    Laura: Bruche's writings on the possible family influence on the development of an eating disorder can seem accusatory, though it isn’t about blaming but learning how early childhood experiences can influence a person later on in life.

    “The older patients described above are a small subset of patients. Most ED patients, especially in AN, are diagnosed as adolescents living at home with less than 3 years of illness.”

    This is actually incorrect, as there are a great number of adults who struggle with EDs, many of which weren’t realized until more recently. There is more of an awareness now in younger people, with some particularly scary trends that are happening very early on (8-12 yr old), though the <18 are not the majority of the population seeking treatment.

    Laura: Treatment effectiveness is quite splintered because of the complexity of each individual's situation, so it hard to general a treatment model.

    The role of enmeshment is well founded in the literature and in clinical practice, and it definitely needs to be considered in treatment. It obviously isn't a factor in all cases, but it is definitely present in many.

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  44. Anonymous: "Therapist4Change does seem quite hopeless even though s/he is not an older doctor but a mere student "For many, this is a life-long struggle, and trying a quick fix is not really realistic.""

    I take a bit of offense to ‘mere student’, as I have more training and experience in this area than most general professionals (going on 8 years), though that is neither here nor there. As for your comments, it isn’t that I’m hopeless, I just understand that for many this *IS* a life-long struggle, and that there is still a great deal of work that needs to be done to properly address treatment and hopefully recovery from EDs. My particular area of interest is in the more severe cases, so a lot of my comments are in regard to those people, and not someone who may be closer to the beginning of their ED and/or less severe presenting symptoms.

    Anonymous: "The re-feeding process should be done in a hospital or in-patient unit .... PERIOD" he or she is dreaming. That's not a realistic option, even if it were desirable (which it is not). “

    Let me clarify my statement…if someone requires moderate to extensive re-feeding (<70% of their ideal body weight), a hospital or in-patient unit is the best place for them, as medical complications are much more likely to be present. Once the person is medically stable then the remainder of the weight-restoration can be done in a different setting. In a compromised state, adding weight too quickly can be just as problematic (or moreso) than dropping weight….which is why there should be 24/7 care. Not everyone can go this route, so alternative routes are needed, but many people underestimate the risks involved in not handling this part of the process under the close supervision of professionals.

    Anonymous: I'm repeating myself, but I'll ask again: if the parents don't take charge of refeeding, who will? Is Therapist4Change saying that if hospital or inpatient refeeding is not available, the sufferer should be left to starve on her own? Please answer.

    It depends on the setting, but in an ideal setting a nutritionist and supporting medical staff will be in charge of re-feeding, at least to a point where the person is back to a place where they can better function and take care of themselves. Minors add another level of complexity to the equation, but many of the same challenges are present.

    Re-feeding is merely one step in the process, and the in-patient setting provides all of the other support services that out-patient may or may not provide.

    As for starving….of course they shouldn’t starve. Many parents struggle for many years trying to help their children (either young or grown), but that often isn't enough. It isn't a failure of the parents, but instead a result of the ED that they need additional support.

    I understand not everyone can seek treatment, so other avenues need to be explored. There are support groups, local programs, and related services that can be used, and I hope they *are* used. The family is an important aspect of recovery (particularly for minors), but there are many challenges that come along with what some (myself included) may see as duel relationship roles for the parents.

    Anonymous: You are correct that nothing on SDN should be construed as medical advice. It would be unethical to give medical advice. Anyone seeking medical advice should go see the appropriate health care professional in person for evaluation and treatment.

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  45. SwF,

    Welcome to the conversation, and thank you for coming. I respect it.

    Unsurprisingly, we don't agree on several points - and there's not need to repeat myself on enmeshment and Bruch and evidence-based practice; my views are well known.

    But I will address the age issue. The number of adult sufferers is directly related to failed diagnosis and treatment in adolescence. Society failed those patients - let's not condemn another generation of young people to chronic illness and ruin the lives of another generation of families.

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  46. Hello Therapist4Change,

    I'm glad to hear from you on this thread. I'd like to answer some of *your* statements now.

    You say you have 8 years' experience, mostly with more severe cases of anorexia. There is a world of difference between chronic adults and adolescents with anorexia. That's not my opinion, by the way, but a direct quote from Daniel Le Grange, who heads up the University of Chicago Eating Disorders program and who wrote the treatment manual and parent guide to family-based treatment.

    I do know this from my own experience, as the mother of a 14-year-old who developed such severe anorexia so quickly that she wound up in intensive care. We were told by all the doctors, she will never recover, she will need 7 or 8 years' treatment, she'll be in and out of hospitals, she is sicker than anyone we have ever seen.

    All of these comments were made out of ignorance--ignorance of the disease as it manfests itself in adolescence. Ignorance of the other treatment options. I know many, many families who have put their children--children like my daughter--into Rogers and other IP programs, and whose children deteriorated. Got sicker. Went downhill. On the other hand, I know many, many families who have used FBT and, like us, helped their children recover within a year. I submit to you that you are simply not well informed about this population, and I wish I heard in your comments and on the SDN thread an openness to learning about the things you do not know. No doctor can know everything. The good ones understand that they must keep learning throughout their careers.

    Anonymous is correct in saying that to say recovery can happen IP is unrealistic. When we looked at IP for our daughter, we were told our insurance would cover $6,000 of treatment. (We live in one of the many states without mental health parity; even those that have it often exclude e.d. treatment, as I'm sure you know.) Treatment in the IP setting would have cost $1,000 a day, conservatively. My daughter wound up needing to gain 45 pounds, because she grew 4 inches during re-feeding. By my estimate, her full recovery IP would have cost us $359,000. All I can say is, Are you dreaming?

    That begs the question of whether IP would have been the best choice for her. Her peers who wound up IP learned some lovely e.d. strategies, including water loading (one girl nearly died of it), weights in the bras, cheek stuffing, and, oh yes, using their index finger to great effect. Of those who have been weight restored through IP, many are still struggling with exchanges and calorie counting meal plans that they learned in IP and are now rigidly afraid to deviate from.

    You haven't been there. We have. I can tell you right that a support group isn't going to help at 8 p.m. when your child has been screaming at the dinner table for hours and refusing to eat. A support group isn't going to cut it when your child bangs her head on the wall so often and so hard that she blacks both her eyes. "Related services" do not begin to do what it takes to help a teen who's going downhill fast from anorexia.

    You say, "Of course they shouldn't starve." I say anything less than full nutrition and recovery is starving--starving the brain and the body. How many times have I heard from professionals like yourself, "It's not about the food" or "Don't be the food police." Well, it IS about the food when you're starving, or even just a little too thin, when it comes to anorexia. And if you have so much experience working with AN patients then surely, surely you know that someone with AN eats with tremendous psychic difficulty. That she CANNOT "just choose" to eat. That it is cruel to expect it, as cruel as expecting a schizophrenic to "choose" not to hear the delusions that affect her.

    I don't mean to be hostile, truly. But I know all too well that had we listened to the "experts" my daughter would still be fighting for her life instead of a happy, healthy, fully recovered 17 year old.

    The reality is that for adolescents, very often weight restoration *is* 99% of the recovery process. Of course once someone has been chronically ill for a number of years, things get much more complex psychologically as well as physiologically. The whole point of FBT is to prevent this snowball from starting down the mountain. Because once it does, as you no doubt know, it's virtually unstoppable.

    Please, please, please, I beg you, educate yourself a little more. Look into the research on adolescents. Don't generalize from chronically ill adults to all patients. Open yourself to new ideas. And don't undereestimate the power of a parent's love. You're foolish if you think e.d. professionals can do a better job with this than parents working with medical professionals.

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  47. laura: I'd love if EDs can be identified early on, before they can be deeply ingrained. I think the more education and awareness of EDs, the better chance we have to stop the vicious cycle.

    harriet: I need to run to a meeting, but I'll try and get back to this tonight, as I'd like to respond to your post without being in a rush.

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  48. Strugglingwithfood,
    My experience is similar to Harriet's. My daughter's presentation was severe--HR 42, orthostatic, lanugo, too depressed to speak--after less than 2 months of restriction. She's recovered using FBT with the support of a some really caring professionals. Your notion that FBT is for "tame" cases is off base. There IS research--randomized controlled studies--that I view as a far more reliable source that your "thinking" that the method would crash and burn with 90%. You're right that re-feeding is just part of the process. In FBT it is only the first of three phases.

    Unlike Harriet, I don't mind being hostile. I hope that you never treat adolescents with eating disorders. If you do I hope you have the honesty to tell their parents that you "would never recommend" FBT and let them make their own judgement. Don't kid yourself that anyone takes SDN seriously as medical advice. I'm inclined to agree with A Med Student's assessment above that "It's well known to be a particularly silly type of forum" and that "most of us aren't like that."

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  49. Anon,

    I think that although you have different views you COULD be polite.

    "Unlike Harriet, I don't mind being hostile."

    There is a difference between stating your opinion and just straight attacking. You ONLY know as much about this person as they posted -- who are you to be making judgements.

    As strongly as you feel as a parent, I think this debate degenerates when someone begins to act rudely.

    There are many different opinions regarding ED treatment. As a parent, you have one -- and I am so happy that you have found a style of treatment which works for your daughter. I know Maudsley did not work for me and traditional hospital based treatment did. My parents would advocate for traditional treatment just as you advocate for Maudsley for this reason.

    Different experiences colour peoples opinions regarding treatment.

    Can we please put aside our differences

    A

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  50. No, I won't put away my differences. I don't think that serves anyone. No one, least of all me, has ever suggested that there ought to be one form of treatment, as I have said repeatedly. I don't have a problem with treatment options at all.

    This isn't about advocacy for a certain treatment IMO. It's about a student who prefers to ignore research (though s/he claims to special in AN research) and state statistics ("90% would crash and burn" based on what he "thinks." A student who assumes the worst of a parent, like the NYT author--suggesting she proceeded with no medical oversight. I think that ought to be challenged.

    If the blog administrator has a problem with my comments she's free to delete them. If you or anyone doesn't like them they don't have to read them.

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  51. Then what is your problem Anon?

    I think everyone has agreed here that;
    1. Maudsley works and is effective for many
    2. It is not the only form of treatment, etc.

    The only points that were touched upon that seem to make people upset were true and;
    1. Often severely underweight sufferers need to be hospitalized.
    2. Maudsley MAY not be appropriate when dealing with families with abuse issues or substance abuse, etc. (other complicating factors).

    In an article I stated previously outlines this. It WAS WRITTEN BY JAMES LOCKE. I put that in caplocks because people seemed to be more interested in attacking HIS sources than the author.

    "There are limitations to family-based treatment for anorexia nervosa in adolescents. For example, data from the Maudsley studies show that this approach is less effective for older adolescents (>18) or adults, adolescents who are chronically ill or those who binge and purge. In addition, highly critical families may not respond to the whole family treatment model and need alternative versions of family treatment to succeed. ""

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  52. This is ALL I have been trying to say all along!

    Yes, Maudsley is not the PERFECT treatment but it is a great treatment. . .

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  53. But that's not what some others on this thread have been saying. And it's certainly not what the undereducated folks on the SDN listserv said. As Therapist4Change has said, s/he thinks Maudsley is appropriate only for "the very tame cases, and the ones that aren't rooted in the traditional pathology." S/he goes on to say, "One of the biggest mistakes people make is that they think it is about the food. IT ISN'T." (not my caps)

    Well, it certainly is about the food. Have you ever read the Minnesota Starvation Study, T4C? Check it out. The healthy male volunteers in the study exhibited all the psychological and emotional signs of anorexia after being starved and then re-fed. Many people with AN are misdiagnosed with depression, OCD, etc. while they are malnourished, at a time when it's ALL about the food, or the lack thereof. You cannot diagnose pathology, OCD depression, anxiety, etc. until weigh has been restored and stabilized for a period of a couple of months.

    What else has T4C said. Oh yes: "The familiar roles in families of anorexics are frequently dysfunctional, and adding more layers to that through this method . . . it seems pretty counter-intuitive."

    I think you speak without knowledge, T4C. Most researchers are now aware that the so-called anorexia family pathology is a construct that comes from the fact that families that seek treatment for a child with AN are already in crisis and are already behaving in unusual ways. I defy you to find a family who's gone through this who doesn't look pathological at moments. It's part of the disease. You cannot fairly judge a family by how they present in the office with an AN child.

    So no, I don't think we're all in agreement on these points at all--not here on Laura's blog and certainly not in the real world.

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  54. Well, by the time I'd gotten home from work and seen Laura's "go for it, Anne!", Marcella had already gone for it (thanks, Marcella--it didn't occur to me that a parent might be able to log onto a medical students site). I couldn't believe how the number of posts had grown!

    As much of a heated exchange as it's become, I think that's healthy. We need to be heard--on all sides. I think too often family voices get silenced--by the illness itself and sometimes by professionals treating it. Mine was. I was so afraid to say the wrong thing and make the illness worse. I actually recall being told to say nothing, to just listen to my daughter when she was inpatient. I don't have a problem with listening--but I also had a need, and a right of my own, to be heard. And, had I listened to her, she might still be starving. I think I do--and did back then-- listen to her, the real her. I just refused to listen to the illness from the very beginning.

    And you know what else? When treatment costs thousands and thousands of dollars (and this is NO exaggeration), we--as paying consumers of a service--should have rights. The right to know what we are buying, to question what we are getting and it's effectiveness, to question the costs even, to ask about alternatives, to not be belittled as 'dysfunctional' and as causing the 'problem' for our child. We should be treated as equal members of a wellness team for our child. We should not be kept in the dark about treatment or denied access to medical records for our minor children. We should be allowed to see our children daily when they are inpatient. We should be treated with respect and dignity just as the patient should.

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  55. Well, by the time I'd gotten home from work and seen Laura's "go for it, Anne!", Marcella had already gone for it (thanks, Marcella--it didn't occur to me that a parent might be able to log onto a medical students site). I couldn't believe how the number of posts had grown!

    As much of a heated exchange as it's become, I think that's healthy. We need to be heard--on all sides. I think too often family voices get silenced--by the illness itself and sometimes by professionals treating it. Mine was. I was so afraid to say the wrong thing and make the illness worse. I actually recall being told to say nothing, to just listen to my daughter when she was inpatient. I don't have a problem with listening--but I also had a need, and a right of my own, to be heard. And, had I listened to her, she might still be starving. I think I do--and did back then-- listen to her, the real her. I just refused to listen to the illness from the very beginning.

    And you know what else? When treatment costs thousands and thousands of dollars (and this is NO exaggeration), we--as paying consumers of a service--should have rights. The right to know what we are buying, to question what we are getting and it's effectiveness, to question the costs even, to ask about alternatives, to not be belittled as 'dysfunctional' and as causing the 'problem' for our child. We should be treated as equal members of a wellness team for our child. We should not be kept in the dark about treatment or denied access to medical records for our minor children. We should be allowed to see our children daily when they are inpatient. We should be treated with respect and dignity just as the patient should.

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  56. True harriet,

    I hadn't studied the comments as in depth as I thought and I THOUGHT we were agreed on some main points.

    I do believe that Maudsley can work for cases that are not "tame" and that family dysfunction is not a hallmark of anorexics life, though in SOME cases it may be a contributing factor. . .

    Maybe treatment in the US is different than in Canada. . . My parents have certainly never been blamed for my AN -- in fact the first thing they were told was that it was NOT their fault -- this is in EVERY program I have been in no matter the philosphy.

    I really know little about "treatment centres" in the US which seem to have some very different ideas than Canadian hopsital based programs. As we don't pay for our healthcare, I also can't relate to the consumer aspect of American healthcare.

    I'm thinking the experiences of ALL of you parents must have been very different than my family's experience. . .

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  57. No problem here. Again, I never said Maudsley was a magic bullet or the best treatment for every sufferer. Glad to hear you're doing well after the treatment you received. I'm very aware of Lock's work (it's spelled without a final "e" by the way) and agree with his conclusion. You're arguing against something I never said ("Maudsley's perfect".)

    I don't think anyone disagrees that hospitalization is sometimes medically necessary (you're aware that the Maudsley is a hospital, right? And that the first studies were conducted with hospitalized patients.) No one is upset about the idea that FBT doesn't fit everyone. The SDN poster wrote that s/he would "never recommend" FBT. So who's making the one size fits all statement?

    I can't be any clearer than I was above. My problem is with personal impressions being cited as facts (90% would crash and burn) and the denigration of the NYT author's family (setting up the straw man of lack of medical oversight) and the absolute ruling out of FBT as a possiblity.

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  58. Harriet: Different treatments work for different people. I stand by my comments that I wouldn’t refer to a Maudley Model because I believe it does not properly account for duel relational roles for the parents, transference / counter-transference, and it can further contribute to enmeshment issues and/or other relational deficits. It is a model flaw, and if I think any treatment will be detrimental to a person, I won’t suggest it. If they really are set on going, I’ll refer them to someone else as I wouldn’t feel comfortable referring to a MM program.

    You seem to be taking my comments as a personal commentary on *your* situation, which is not the case. I am speaking in a general sense about the treatment process, re-feeding, etc. You seem to be generalizing your belief of the effectiveness of IP on your personal situation, instead of seeing your personal situation as one instance that may or may not be representative of a larger trend. I am not discounting your experience, but one size does not fit all.

    As for picking up behaviors…..people do it, both healthy and unhealthy. It is up to the person to decide whether or not they want to acquire healthy or unhealthy behaviors. There are endless Pro-Ana and Pro-Mia sites out there, so if a child/adult wants to find new information, they will find it.

    Exchanges, when paired with education, can be used to guide nutritional planning, though ultimately they should be used as a concept and not just rigid guidelines. A nutritionist can use the exchanges and make changes as necessary. Ultimately it is a way to learn what encompasses a healthy meal, and what each person’s body needs.

    Support groups are just that….for support and not for therapy. They are not a supplement for treatment, but they can be helpful, especially during the step-down process.

    Conceptually I get where you are coming from with, “anything less than full nutrition and recovery is starving”, because a person may need that kind of mindset to avoid the slippery slope, but rigidity and black and white thinking is not always our friend.

    As for the ED being about the food or not….it isn’t *just* about the food/starvation, because when there is weight restoration the symptoms DON’T disappear. The thoughts, urges, feelings, etc are still present and need to be address. The ED behaviors are symptomatic of other issues, so until the other issues are addressed, the symptoms will most likely be present. This is most likely a place where we should just agree to disagree.

    I am open to more reading and research…..please feel free to suggest anything you think would be helpful in this area.

    My comments are not *just* for chronic treatment. Many of the same issues (like addressing the symptoms not the problem) are present in new and chronic cases.

    As for a parent’s love…I don’t doubt it can have a profound effect on a person and can be a true asset during the process, but I completely disagree that a parent can do BETTER than a professional in regard to overall treatment.

    Anon: As for my “90%” comment…it obviously wasn’t a fact or citation (as I would include a reference), so please don’t treat it as such. I was merely commenting on the high failure rate of the treatment models referenced throughout the literature.

    I think you are also taking things too personally. I am not ‘assuming the worst of a parent’; I openly acknowledge the importance of the parents throughout the process.

    I take offense to your assertion I ‘ignore’ the research just because I don’t agree with MM programs. I can post a number of useful references if that would be more helpful, though I didn’t want to clutter up this discussion with a bunch of citations.

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  59. harriet: The ED symptomatology may add fuel to the fire, but most of the times the foundation for the ED was set long before the family presents for treatment, as the ED symptomatology is *not* solely about the food. The manifestation of ED symptomatology is traditionally a reaction to underlying issues and is often the vehicle for expression of these issues, and is not merely a learned behavior.

    This is not a condemnation of the family, but it is a recognition that there were things during childhood or another time that contributed to the development of an ED.

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  60. anne: I agree with your sentiment about being on the team, having things clearly explained, etc. Having the parents on board is vital, and anything that can be done to help facilitate that should be done.

    anon: I stand by my comments. I think the model is flawed and fails to recognize important aspects that may not be beneficial to the patient. There are a number of other models that can better address these areas of concern.

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  61. Strugglingwithfood:
    You don't know what you're talking about. I too hope you never treat any adolescents. You're dangerously misinformed and so full of yourself you can't hear anything anyone else is saying.

    You're damn right it's personal--have you any children? I can assure you, it's plenty personal when it's your child. But I'm not just talking about myself here. Your blatant disinterest in and disregard for solid evidence-based research is profoundly telling. Until you "choose" to be less ignorant I'm afraid this conversation is pointless.

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  62. As this conversation winds down, I just want to thank every one of you.

    Parents need to know that the antiquated, discredited, damaging mindset of clinicians is still alive and well - even among some of the newer generation treating our children. But just because it persists doesn't mean we have to desist. We have to have these very exchanges with the clinicians we encounter - we have to choose clinicians who ARE reading the research and engaging in the dialogue in their own profession over this.

    When I spoke with Dr. Eisler earlier this year about this issue he expressed dismay and surprise that some clinicians were still using Bruch et al's work in this way. Watch the video clip on this site for his comments.

    The families of schizophrenia patients, autism families, even relatives of TB patients have seen this sort of assumption of family pathology and patting parents on the head saying "let us take care of this" before. It faded with the light of science and common sense.

    This will fade, too, and for the leaders in the ED world it already has. It will take us, the parents, to move that forward by speaking up - sometimes even with hostility - when we need to.

    A:), I'm not angry! Keep asking, keep explaining, stay engaged!

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  63. This is exactly what I ran into when my daughter was inpatient. It left me bewildered and angry. And it's why I'm still dealing with 'fall-out' from my daughter almost 5 years later. Part of her blames us. Part of her feels we 'did too much' and 'were babying her'. I still don't believe it. But, it saddens me greatly that SHE does. How wonderful it would have been to have had Maudsley support and *even* and agnostic view of cause. How wonderful it would have been for someone to have told her then "trust your parents" and "this illness is not your fault, much of it is biological".

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  64. mom of recovered AN daughter10:03 AM, January 10, 2008

    Strugglingwithfood.com said "As for the ED being about the food or not….it isn’t *just* about the food/starvation, because when there is weight restoration the symptoms DON’T disappear. The thoughts, urges, feelings, etc are still present and need to be address. The ED behaviors are symptomatic of other issues, so until the other issues are addressed, the symptoms will most likely be present. This is most likely a place where we should just agree to disagree."

    The thoughts, urges, feelings, etc DO disappear with weight restoration. I have seen it in our own family, as well as others. The snowball effect of restriction and ritualistic behaviors as well as OCP/OCD and perfectionist behaviors, rigidity, anxiety, etc. were a result of my daughters starvation, not the cause of it. Her initial weight loss was caused by over exercise because of an intensive training program she was involved in. Not everyone in the program ended up with ED. It was practically accidental, but once her BMI fell, her brain went haywire. Before I knew it, she was malnourished and covered with lanugo and she was *unable* to eat. We had to intervene as a family and MAKE her eat. She could not choose to eat on her own until her weight was restored. The process was very difficult, but she went back to normal -eats all foods without fear, etc. We did "refeeding" at home under a doctors supervision. I realize this is anecdotal, but strugglingwithfood, honestly, you need to open your mind. Perhaps this is what you would consider a "tame" case, but what if we had wasted time trying to figure out the "why" based on the assumption that there was some underlying family pathology or groundwork laid that caused the ED. There wasnt, and she is recovered - without a hospital or a bunch of psychobabble.

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  65. It definitely was an interesting conversation. I wish you all and your families well.

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  66. StruggleingWithFood,
    I, too, hope you never treat any an kids. You have dismissed a possible treatment route that has been proven to save lives and reduce years of suffering--and yet you have no experince with it. Firing our useless therapist was the best move we ever made. Our daughter slid quickly into ed after cutting out 'junk food' while preparing for sports camp. A 12 lb weight loss turned a happy, popular, carefree child into a total wreck. Our therapist kept trying to figure out what happened to our daughter. We listened to all sorts of psycho babble about our daughter being afraid of her breasts, too close to us, afraid of boys, something happened to her, etc etc. Afraid of her breasts? Are you kidding me? This girl was scuba diving with sharks only weeks before. The only thing that happened to her was that she read a book that said real athletes don't eat junk food and so she changed her diet. She kept losing weight while we listened to nonsense. Then my until my research found Locke's book and Laura's site. It was then that I realized that nothing had happened to her except unfortunate genetics and biochemistry. Sadly, there are no Maudsley therapists around here. We went it alone and refed our daughter with her ped. support only. Now she is happy, healthy and weight restored. She is back to being a normal teenager. Nobody had to 'unmesh' her or any other BS. The were no issues to resolve because the issues were caused by the biochemical imbalance of the ed. Up close and personal, it was obvious to me that my daughter did not chose to have an ed any more than we caused it.
    The thing I really don't understand is why younger doctors are not looking more closely into the biology of eds. There is new research out there. There is evidence of people getting well. I am a professional engineer and I read everything I can in my field. I don't dismiss anything new out-of-hand. I keep up with all of the latest research. Why is it that so few pysch doctors are willing to consider biological causes for eds but still dust off copies of Bruch?
    And yes, I am angry. I am angry that attitudes like yours persist, that so many other kids will continue to suffer for years, that there were no professionals to be found to help our struggle and that my daughter suffered needlessly while some fool tried to persuade us not to do the one thing that made her well--feed her!

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  67. Strugglingwithfood said: "The ED symptomatology may add fuel to the fire, but most of the times the foundation for the ED was set long before the family presents for treatment, as the ED symptomatology is *not* solely about the food. The manifestation of ED symptomatology is traditionally a reaction to underlying issues and is often the vehicle for expression of these issues, and is not merely a learned behavior."

    I've just stumbled on this discussion late this morning. I cannot help but to respond to the notion above.

    SWF points out repeatedly that refeeding is treatment of symptoms rather than addressing the underlying problem. And SWF is exactly right when saying the psychological symptoms are not merely learned behavior. However, she's (he's?) tragically off the mark when failing to take into account that anxiety, depression, irrationality, hypersensivity (both bodily and emotionally), paranoia, marked irritability, obsessionality, violent reactions, delusions and disturbances (including mental, visual and auditory delusions and disturbances), compulsive behaviors, self-harming behaviors, etc. . . are all among the medically recognized symptoms of advanced malnutrition and starvation, and many be symptoms of short-term, but profoundly disruptive, malnutrition. There is more to this list, and I've included no strictly physical symptoms here.

    Now SWF may not know this, but information on the psychological effects of seriously compromised nutrition can easily be found in all sorts of places. I first saw it in my Human Anatomy and Physiology Textbook from a 200-level human anatomy class I took years ago. A few Google searches later I saw that this information is widely known across many disciplines. I found pretty darn consistent information from general medical literature, nutritional literature, mental health literature, alternative medicine information, traditional eastern medicine information, and orthomolecular medicine literature. Even the ancient Greeks knew it.

    So, which ED treatment method is really only treating the symptoms? No one thinks that a diabetic in the throes of serious blood sugar imbalance, even though he may be irrational, combative, and impulsive, needs talk therapy before they need their blood sugar stabilized. No one thinks that a person in chronic pain who is severely irritable, depressed, and possibly even prone to self-harm needs therapy to uncover underlying issues before they need pain meds. And why does no one think this? Because these are recognized psychological symptoms of the biological issue at hand, and they typically resolve once the issue is corrected.

    THIS is my complaint. Why is it that some conditions rightly have clinically accepted psychological consequences due to body chemistry, yet a set of conditions/diseases that necessarily include either starvation or a profound disruption of nutrition are considered to be the result of emotional problems and have little or nothing to do with food taken in or retained? EVEN if the patients primary presenting symptoms are low weight and/or a refusal to eat appropriately?

    To make the current clinical situation even more aggravating, researchers agree that EDs have a clear genetic predisposition--and AN even moreso than BN. THAT means the predisposition is biological, period. And yes, practically everyone agrees that while biology loads the gun, environment pulls the trigger.

    What does this mean day-to-day in the real world? Well, the researchers are still on the fence, here. But the overwhelming majority clearly notice that going on a diet, or participation in body-conscious yet physically demanding sports, or severe stress, or even an illness are very frequently precursors to the development of AN (to use AN as the example). Do you know what all these things have in common? They can all put a person at clear risk for not meeting the body's nutritional needs for a period of time. Malnutrition and starvation can result. Square that if the patient is in or approaching puberty which requires a big upswing in incoming nutrition.

    Why are the old-school-trained therapists of the world so adverse to considering this? Why are the medical doctors still referring people to them in the early stages especially? It would seem merely silly if it weren't so damaging.

    I do not think that ED sufferers can't stand to benefit from smart, focused, talk therapy. From what I've read, I think CBT is even better in many cases, but, I think that many sufferers can and ought to make use of GOOD therapy in the process of getting on with their lives. See, many of these individuals carried around the vestiges of the biological problem that became an ED for a while before the ED surfaced officially/clinically. These biological vestiges carried psychological ramifications, and many sufferers learned to deal with the world through this slightly skewed filter. I can only assume that some coping strategies in sufferers could be refined to their benefit at least.

    One might also note that in psychological studies, organic childhood anxiety is so far the only risk factor that has been reliably indentified for AN in adolescents. And of course, there is a huge range for this condition. Many sufferers did not meet the criteria for "clinical anxiety" before onset of the ED. But if someone learns her coping skills (or even develops coping habits) in an even slightly skewed internal environment, these skills may not be in the person's best interest on a go-forward basis. By all means, we should equip these patients better whenever it's needed.

    Yes, ED symptomology may well add fuel to the outwardly obvious fire, qand in my experience it does so in spades. But it does not follow that a clinician or parent should stop trying to feed a sick sufferer who is unable to eat on his or her own. Setting a broken bone often hurts more than breaking one, and more than the injury hurts a couple of days later. A shot of penicillin usually makes the patient feel worse that night and the next day, but after that the healing begins in earnest. Even well-warranted psychotherapy often makes the patient more unsettled, more anxious, more depressed at first. And this is one of the tenents of 5the theraputic process, and thoroughly described in the literature. Severely depressed patients are at higher risk of suicide at the beginning of medication and healing than prior or later. ED patients are unable to eat on their own until well after complete weight restoration that is healthy for their height and age has been maintained for several weeks at least. Someone must insist on nutrition on their behalf int he meantime.

    WHY is everyone so afraid of pissing off an ED patient? Admittedly, it's a tough illness to deal with and treat, but it's not exotic. It's not even considered rare anymore, and it may be on the rise. We've learned to selectively poison people with cancer and we call it chemotherapy and/or radiation treatment. We've even gotten patients and their families to accept this course of treatment as a given. Why on earth is feeding a starving parient so radical?

    M.

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  68. Ack! Typos abound!

    Sorry!

    M.

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  69. Oh, amen, sister. Never mind the typos.

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  70. Therapist4Change and others in the old school don't understand that the talk therapy they use actually undermines refeeding. It encourages sufferers to want to break away from the supposed "enmeshment" with parents. And it convinces parents that they need to back off and allow their adolescent more independence. Both of those phenomena make it harder to accomplish refeeding. What results is prolonged malnutrition and serious, even permanent, harm. So the objection to the old school is not just that it's been shown by a half century of experience to be ineffective, but that it's actually conterproductive and dangerous.

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  71. I guess this thread will eventually come to a close if only because there must be some kind of technical limit as to how many replies a blog post can get before it seizes up altogether.

    I'd just like to thank all those who've taken part. It's been fascinating. I personally probably look at the matter from a slightly different perspective than some in that I haven't experienced "traditional" therapy - indeed I'm not sure that it IS traditional in our country (the UK) - rather like turkeys and cranberries, psychoanalysis is a foreign import here and treatment for ED's (and other illnesses) probably has a slightly different history.

    Like A:)'s parents, we were introduced to the Maudsley Method first and we failed. I'd HATE to have had the kind of experiences you did Anne, and can quite see why many here emphasise the harm that can be done in looking for causes and treating the family as if their pathology was obviously to blame rather than getting on with the job in hand and re-feeding. However, WE needed more help than the basic Maudsley Method was able to give us, and I shall be FOREVER grateful to the very traditional (in British terms)hospital who did re-feed our daughter when we couldn't. For ME some of the cautions that Pinguin on the psychstudents board has posted about Maudsley (I don't have his/her permission to copy them here so I won't but do go and read them if you are interested) DO resonate.

    I'd also like to apologise here for initially misunderstanding the nature of the students on the other board - they are not Medical students training to be cardiologists or General Practitioners - they are all training for some kind of psychology/psychiatric social work/possibly psychiatry. They WILL therefore have a different perspective than those concentrating on the biology of illness - after all as one poster raised in a thread on the board, if the biologists "win" totally in the argument about treatment they'll be out of a job ;-) I guess if we want to find out what young medics in the more biologically orientated areas of medicine think we will have to search for another kind of forum,

    I think the field NEEDS debate, yes, perhaps even NEEDS conflict and it's a GOOD sign (perhaps it's a bit like that infamous "Stage II in re-feeding that Lask and Bryant-Waugh describe) that this area isn't being neglected but debated and studied and fought about. Much more qualified individuals than I have likened it to debates in the field of cancer and that for me brings a lot of hope. In the bad old days cancer was considered incurable so patients were sent home to die and the only people doing research were a few boffins in corridors. Then new treatments brought better results, encouragement and yes, money and, terrible though the disease still is, there is now so much more hope. May this happen with eating disorders too.

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  72. First off, I never denied the biological aspect and influence of starvation, though my assertion is that in many cases the underlying issues were present before starvation was reached, and they were just enhanced once starvation was established, so once weight restoration is accomplished, there are still issues left to address so the cycle does not start again. There are cases where starvation was the primary cause of the other related symptoms, and weight restoration can get things back to normal, but I do not see this group as the ‘majority’ when it comes to EDs. Weight restoration in regard to starvation excludes most of the other ED patients (most bulimics, most ED-NOS’ers, Pica, etc).

    As for talk therapy’s role in the re-feeding process…..

    Talk therapy during re-feeding offers the person an avenue to express their thoughts, feelings, and experiences around the re-feeding process. Obviously cognitive functioning will vary during this process, so some adjustments may be made during the process (supportive interventions at first, and then transitioning to more process oriented interventions), but talk therapy during the re-feeding process is VITAL to recovery. The issue of “you can’t just make them eat” was broached earlier in the discussion, and this is why there needs to be talk therapy, so the person can express themselves and their feelings verbally, so they do not keep in their feelings. Failure to properly express themselves can often be a catalyst for future ED symptom activation/relapse.

    My reference to Bruche was more about general conceptual models of ED origins, though there is still a place for psychodynamic work in the treatment of EDs.

    Teatment settings, orientations, and interventions will vary, based on the ED and specific person.

    For talk therapy I utilize methods from a number of orientations: Cognitive, Cognitive-Behavioral, Dialectical-Behavioral, and Psychodynamic, with the variance being on what is best for the case. In addition to talk therapy, other interventions are needed to help ensure against relapse (nutritional counseling, medication management, physical assessment, etc). Nutritional counseling alone will not suffice, except in cases where starvation was the primary catalyst, and I believe that to be quite the minority (anectdotal evidence from above not withstanding).

    The use of talk therapy is in intricate part of recovery, and failure to utilize it usually brings relapse. Pike et. all (2003) did a study on the effects of Cognitive-Behavioral Therapy during post-hospitalization with AN, and they found some positive results.

    Pike, K.M., Walsh, B.T., Vitousek, K., Wilson, G.T., & Bauer, J. (2003). Cognitive behavioral therapy in the post-hospital treatment of anorexia nervosa. American Journal of Psychiatry.160 (11), 2046-2049.

    OBJECTIVE: This study provides what the authors believe is the first empirical evaluation of cognitive behavior therapy as a posthospitalization treatment for anorexia nervosa in adults. METHOD: After hospitalization, 33 patients with DSM-IV anorexia nervosa were randomly assigned to 1 year of outpatient cognitive behavior therapy or nutritional counseling. RESULTS: The group receiving nutritional counseling relapsed significantly earlier and at a higher rate than the group receiving cognitive behavior therapy (53% versus 22%). The overall treatment failure rate (relapse and dropping out combined) was significantly lower for cognitive behavior therapy (22%) than for nutritional counseling (73%). The criteria for "good outcome" were met by significantly more of the patients receiving cognitive behavior therapy (44%) than nutritional counseling (7%). CONCLUSIONS: Cognitive behavior therapy was significantly more effective than nutritional counseling in improving outcome and preventing relapse. To the authors’ knowledge, these data provide the first empirical documentation of the efficacy of any psychotherapy, and cognitive behavior therapy in particular, in posthospitalization care and relapse prevention of adult anorexia nervosa.

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  73. There is a plethora of other research out there that supports talk therapy’s place in ED treatment and recovery. There is some recent research that supports a modified version of cognitive-behavioral therapy in persons suffering from anorexia nervosa (Garner et. al., 1997). The books should all be available at local libraries, and the journal articles should be available online through local libraries.

    Bruch, H. (2001). The Golden Cage: The Enigma of Anorexia Nervosa. Harvard University Press. Boston.

    Garner, D.M., & Bemis, K.M. (1982). A cognitive-behavioral approach to anorexia
    nervosa. Cognitive Therapy and Research, 6, 123-150.

    Garner, D. M. & Garfinkel, P. E. (1985). Handbook for psychotherapy for anorexia nervosa and bulimia. New York: Guilford Press.

    Garner, D.M., Vitousek K.M., Pike, K.M. (1997). Cognitive-behavioral therapy for anorexia nervosa, in The Handbook of Treatment for Eating Disorders, 2nd edition.( 94-144). Edited by Garner DM, Garfinkel P.E. New York, Guilford.

    Johnson, C. (1990). Psychodynamic Treatment of Anorexia Nervosa and Bulimia. Guildford Press. New York.

    As for bulimia, there is research supporting a psychodynamic approach (Johnson, 1990), as well as Dialectical Behavior Therapy (Garner, Vitousek, & Pike, 1997).

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  74. I think you're missing the point, struggling. No one here is saying talk therapy is useless. What we--what I am saying is that talk therapy by itself is useless without the weight restoration component for anorexia. I'm all for people getting to express themselves; my d did therapy during re-feeding (along with weekly visits to pediatrician and psychiatrist--where you all got the idea that we had no medical professionals involved I do not know) and I think those sessions felt good to her. But without my husband and me insisting that she eat, and her eating, the talk therapy would have been pretty damn useless.

    You write: "Nutritional counseling alone will not suffice, except in cases where starvation was the primary catalyst, and I believe that to be quite the minority (anectdotal evidence from above not withstanding)."

    Where's your evidence? You "believe" that to be the minority and write scornfully of anectdotal (sic) evidence, yet provide no evidence of your own.

    And as for bulimia, did you not see the results of the recent 5-year NIMH study on FBT and bulimia in adolescents? It's extremely successful. Blows away the competition.

    Parent of adolescents should not settle for anything but the most effective treatment . . . which, in the case of both anorexia and bulimia, means family-based treatment.

    One reason FBT isn't always successful is because of the very attitudes you embody and how they translate into lack of support for parents. And it really doesn't take that much, struggling. A phone call a week from someone who's been through it can be enough to help parents and their team be successful. I can't help wondering if part of the resistance here from folks like you is that there isn't a ton of money to be made--no exorbitant IP admissions or hospital stays, no weekly $400/hour psychiatrist's visits. Solid support from a Maudsley therapist, and/or a supportive pediatrician, and the support of other parents. Hmmm.

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  75. When considering treatments parents may wish to consider available outcome studies. It gives a starting point to make decisions.

    For anyone interested in a comprehensive look at treatment efficacy this report linked at EDC is available free and full text.

    http://www.eatingdisorderscoalition.org/reports/reports.html

    Here's an abstract to a shorter article that examines randomized controlled AN treatment studies.

    Int J Eat Disord. 2007 May;40(4):310-20. Links
    Anorexia nervosa treatment: a systematic review of randomized controlled trials.

    Bulik CM, Berkman ND, Brownley KA, Sedway JA, Lohr KN.
    Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7160, USA. cbulik@med.unc.edu
    OBJECTIVE: The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed evidence on efficacy of treatment for anorexia nervosa (AN), harms associated with treatments, factors associated with treatment efficacy, and differential outcome by sociodemographic characteristics. METHOD: We searched six major databases for studies on the treatment of AN from 1980 to September 2005, in all languages against a priori inclusion/exclusion criteria focusing on eating, psychiatric or psychological, or biomarker outcomes. RESULTS: Thirty-two treatment studies involved only medications, only behavioral interventions, and medication plus behavioral interventions for adults or adolescents. The literature on medication treatments and behavioral treatments for adults with AN is sparse and inconclusive. Cognitive behavioral therapy may reduce relapse risk for adults with AN after weight restoration, although its efficacy in the underweight state remains unknown. Variants of family therapy are efficacious in adolescents, but not in adults. CONCLUSION: Evidence for AN treatment is weak; evidence for treatment-related harms and factors associated with efficacy of treatment are weak; and evidence for differential outcome by sociodemographic factors is nonexistent. Attention to sample size and statistical power, standardization of outcome measures, retention of patients in clinical trials, and developmental differences in treatment appropriateness and outcome is required.
    PMID: 17370290 [PubMed - indexed for MEDLINE]

    Recent randomized controlled studies of CBT, interpersonal therapy and non specific supportive clinical management show that non specific supportive clinical management showed better results than the other two therapies. This article is available free and full text online.

    Am J Psychiatry. 2005 Apr;162(4):741-7. Links
    Three psychotherapies for anorexia nervosa: a randomized, controlled trial.

    McIntosh VV, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, Frampton CM, Joyce PR.
    Department of Psychological Medicine, Christchurch School of Medicine & Health Sciences, P.O. Box 4345, 4 Oxford Terrace, Christchurch, New Zealand. virginia.mcintosh@chmeds.ac.nz
    OBJECTIVE: Few randomized, controlled trials have examined the efficacy of treatments for anorexia nervosa. Cognitive behavior therapy and interpersonal psychotherapy are effective in a related disorder, bulimia nervosa. There are theoretical and treatment indications for these therapies in anorexia nervosa. METHOD: Fifty-six women with anorexia nervosa diagnosed by using strict and lenient weight criteria were randomly assigned to three treatments. Two were specialized psychotherapies (cognitive behavior therapy and interpersonal psychotherapy), and one was a control treatment combining clinical management and supportive psychotherapy (nonspecific supportive clinical management). Therapy consisted of 20 sessions over a minimum of 20 weeks. RESULTS: For the total study group (intent-to-treat group), there were significant differences among therapies in the primary global outcome measure. Nonspecific supportive clinical management was superior to interpersonal psychotherapy, while cognitive behavior therapy was intermediate, neither worse than nonspecific supportive clinical management nor better than interpersonal psychotherapy. For the women completing therapy, nonspecific supportive clinical management was superior to the two specialized therapies. CONCLUSIONS: The finding that nonspecific supportive clinical management was superior to more specialized psychotherapies was opposite to the primary hypothesis and challenges assumptions about the effective ingredients of successful treatments for anorexia nervosa.
    PMID: 15800147 [PubMed - indexed for MEDLINE]

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  76. "talk therapy by itself is useless without the weight restoration component for anorexia."

    harriet: Where did I ever say that weight restoration wasn't important? Obviously it is needed.

    "Where's your evidence? You "believe" that to be the minority and write scornfully of anectdotal (sic) evidence, yet provide no evidence of your own."

    If it were the majority, you would see ED symptom extinction in more of the cases across the board, as weight restoration is a part of every ED treatment.

    The NIMH study compares FBT to SPT (Supportive Psychotherapy), which is described as: "SPT focuses on the individual and does not specifically address the eating disorder " (pulled from the abstract). My reference to contributing factors is not at the expense of addressing ED symptoms, but merely one small part of the orientations mentioned above. SPT is not a mainstream mono-therapy commonly utilized to treat EDs; it is typically used for things like adjustment disorders.

    Your assertion that, "the most effective treatment . . . which, in the case of both anorexia and bulimia, means family-based treatment" is far too generalized. It may work for *some*, but far from all; in addition to not being widely supported nor applicable to most EDs. EDs come in all shapes and sizes and the primary challenges vary greatly, so FBT may be appropriate for some, but I'd caution anyone reading to understand that there is no magic bullet or treatment, and many times multiple treatments are needed to address the issues. There are many adolescents suffering from EDs out there who don't have a problem with eating, so support around eating would not help them, as their issues reside elsewhere. How would FBT address them? How about adolescents who don't have functional relationships with their parents? How about adolescents with co-morbid diagnosis that are not related to their ED...how does FBT treat them? Obviously "the most effective treatment" is not FBT in all cases.

    As for your implication that professionals do this for the money, that is quite rude and reflects poorly on you. People who do this work don't make big bucks off of the people they treat. Most of us do it because we want to help people. Money is made in business and finance, not in therapy.

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  77. Here's what I would have liked in retrospect: I would have liked to have kept my daughter at home. I would have liked to have known about Maudsley. I would have liked a Maudsley team in place. I would have initially liked counseling support FOR MYSELF (this board did not exist at the time) to keep me on track, to support me and my husband, to educate ME about this illness and what to expect so it didn't "cow" me.

    My daughter was one of those that did have pre-existing anxiety and--yes, still struggles with it. I would have liked an easier time gaining access to a child psychiatrist when I first realized she was exhibiting signs of anxiety (5th grade). Child psychiatrists are not easy to come by and I had to call MANY practices before finding one (the ONLY one) that would take her on. I would have liked to have been taken seriously by teachers, by counselors and by doctors when I expressed concern about her anxiety (she was a 'good' little girl and student. I was likely seen as an overly concerned parent).

    And, yes, there has been place for for therapy in her life, to help her deal with her anxiety in a healthier way. Post weight regain, I might add. Without blaming anyone I might add too.

    So, I am not anti-therapy. It just depends very much on when and very much how it is done.

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  78. The American Psychiatric Association issued its Practice Guideline for the Treatment of Patients With Eating Disorders (Third Edition) in June 2006. Under the heading "Choice of specific treatments for anorexia nervosa" the FIRST item is "nutritional rehabilitation." It notes that "Weight gain results in improvements in most of the physiological and psychological complications of semistarvation." The next section in the Guideline is "psychosocial interventions." There, the Guideline concludes: "For children and adolescents, the evidence indicates that family treatment is the most effective intervention. In methods modeled after the Maudsley approach, families become actively involved, in a blame-free atmosphere, in helping patients eat more and resist compulsive exercising and purging." The Guideline notes: "Attempts to conduct formal psychotherapy with starving patients who are often negativistic, obsessional, or mildly conginitively impaired may be ineffective."

    Not to belabor the point, but the SDN posters who say the they would "never recommend" the Maudsley approach and that it would "crash and burn with 90% of them" have not done their homework. Have they even read the APA Guidelines, which are available for free on the APA website?
    Finally, those who subscribe to the discredited "enmeshment" and family dysfunction models not only don't have evidence to support what they are doing, they cannot, in my opinion -- because of their prejudices -- create the "blame-free atmosphere" that is needed for effective treatment.

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  79. One thing to bear in mind is that FBT is not a rejection of therapy--it's a TYPE of therapy. It's not simply weight restoration--all eating and no talking. I'd recommend maudsleyparents.org as a resource for those wanting to learn more. The article "Maudsley Misconceptions" might be of special interest.

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  80. I doubt I will be able to change your thinking on all this, SwF, but for the benefit of bystanders:

    The Golden Cage was written in 1978, not 2001, and it was not science it was anecdotal.

    You can't pick random old work out of context, you have to look at the most recent analyses of the data available. Anonymous posted the Bulik review information and it is not only up to date it is the state of the art in the field.

    If you are going to cite studies, you can't just reject the conclusions of the current leaders in the field. They've read Bruch and Garner -- and Kaye and Johnson and Fairburn -- and come to very different conclusions.

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  81. Speaking of picking and choose references, Anon's reference omitted the following statement from the APA Guidelines:

    "For adolescents treated in inpatient settings, participation in family group psychoeducation may be helpful to their efforts to regain weight and may be equally as effective as more intensive forms of family therapy"

    As for the "conclusions" in the field, the problem is that there AREN'T conclusive findings in regard to AN treatment as a whole, and most of the research is for small N and very narrowly defined populations. A review of methodology is needed to tease our treatment methods for particular cases, which is why PROFESSIONALS utilize the most APPLICABLE research to each case, not just the most RECENT.

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  82. PROFESSIONALS utilizing the most APPLICABLE research don't dismiss entire treatment approaches in their chosen field.

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  83. Hi "struggling with food." I just went on your website, strugglingwithfood.com That pretty much explains everything. As you say, you are currently in training, and not licensed, so "take my words with a grain of salt." You also admit yours is "not a medical site and should not be treated as such." And while you posted above that ED's are your "area of research," your website includes no original research on anorexia whatsoever, or on anything else. So I guess I'll take you up on your offer. I'll take everything you've said with a grain of salt. And if you ever do become licensed, I hope you don't treat anyone with anorexia. Unless you learn a lot more.

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  84. I appreciate that you took the time to visit my side project. I never claimed nor implied to offer medical advice, as that would be unethical. My research is still in the works, as these things take time...just ask any professional.

    The tone and venom of your post let's me know that your agenda isn't in discussion but in negativity and catharysis of anger, so I'll leave it at this.

    To everyone else, thank you for a lively discussion. I took down a number of citations I found on maudsleyparents, and I look forward to evaluating their research.

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  85. SWF - Why dont you add a link for the Maudsley website to your anorexia resource page and let people make thier own decision.

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  86. Hi, this is a different anonymous from the one who has been posting earlier

    I want to address something strugglingwithfood said


    "Exchanges, when paired with education, can be used to guide nutritional planning, though ultimately they should be used as a concept and not just rigid guidelines. A nutritionist can use the exchanges and make changes as necessary. Ultimately it is a way to learn what encompasses a healthy meal, and what each person’s body needs."

    I am currently in a program with exchanges and I agree with Harriet. It makes me worry when I go one tally over, even if it is so much as a carrot. I have had tons of education about the tally system and how if I go over a little bit it's ok, but I think it has made my thoughts about food even more rigid.

    Secondly

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