June 4, 2011

It's about effectiveness

When discussing "evidence-based" and the tug of war over one theory over another it is easy to lose  sight of the point: effectiveness. What direction is likely to help more people do better faster?

Here's a beautiful description:
Family Based Therapy for anorexia: excellent outcomes

 "Dr. Ellen Davis, cofounder of Woodland Forge in Phoenixville, Pa., is a strong advocate for FBT. “I used to practice traditional psychotherapy with patients with anorexia,” she says, “The recovery time for most adolescents was between 2-3 years. It’s much quicker with FBT. With a younger adolescent I can move them to the point where a parent will say ‘I have my kid back’ in 9-10 months. It’s an amazing approach.”

(Though I would quibble with the bits about the "the psychological, environmental or family issues that contributed to the eating disorder" That is not part of the approach as I understand it, and that kind of wording leads back down the rabbit hole of blame and shame. A given family may have to make changes to support recovery, but not all, and just having an eating disorder diagnosis doesn't mean there was any other reason or issue or problem - usually, an eating disorder is just an eating disorder.)

10 comments:

  1. Regarding your quibble with the phrase "the psychological, environmental, or family issues that contributed to the eating disorder:"

    I completely understand your discomfort with this phrase, because when it is interpreted a certain way, it reeks of antiquated ED treatment. However, the phrase itself is not incorrect, I would just define it differently.

    In the way I practice FBT (which is close to the manualized version but not identical), Phase III encompasses the following elements:
    1.) Assessing for and treating co-morbid psychiatric disorders (which could be described as "psychological issues that contributed to the disorder")
    2.) Addressing personality issues which may fuel ED symptoms (such as poor self-esteem, perfectionism, body dissatisfaction, which may have either preceeded the ED or resulted from the ED, but either way can make full recovery more difficult)
    3.) Re-establishing healthy, age-appropriate relationships amongst family members (which I would describe as "family issues related to the eating disorder," because ED wreaks havoc on family relationships, and the whole family needs to heal from the ED)
    4.) Relapse prevention (which involves collaboratively writing a specific relapse prevention/intervention plan with the patient and family)
    5.) Changing any environmental factors that may make recovery more challenging. For example, if the patient had been involved in too many extracurricular activities which placed too much stress on her and prevented her from sitting down to a good dinner, getting enough sleep, having time to de-stress, etc. then that pattern should be changed if the patient is to achieve robust health.

    I think it would be irresponsible NOT to address the psychological, environmental, or family issues related to the ED, not because they necessarily caused the ED (although comorbid psychiatric disorders and psychological traits of the patient are usually part of the etiological picture), but because the patient is most likely to achieve and maintain robust health, without relapse, when all of these issues are addressed.

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  2. Thank you for that dr ravin. Laura, while i agree wholeheartedly with you that an eating disorder is usually just an eating disorder but that doesn't mean that the patient is just an anorexic or just a binge eater and programmes that, usually in my experience owing to lack of resources rather than lack of compassion, ignore this do their patients disservice

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  3. Dr. Ravin,
    I admire your work very much, but as a mom, I think my daughter has lost quite a bit of self esteem from thinking her eating disorder arose from a defective personality-she learned this in her treatment before we started FBT-some of these traits didn't even fit her, but she took them on anyway, as part of the overall issue of feeling bad about herself. I think we need to be very careful about calling some of these problems personality traits. As you know as a psychologist, personality and temperament are fairly stable over the lifespan and these seem to be part of the person's own soul or core value in life. Perhaps it would be better to characterize problems such as perfectionism as part of the illness, as a type of anxiety, not a personality trait? It's hard for a person to recover, maybe just too overwhelming, when their personality traits are considered to be wrong or bad. It also seems a bit like passing a judgment that just isn't helpful at all in my opinion. We need to help give confidence to the sufferers and simplify the recovery as much as possible so that it doesn't seem so hard to them...

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  4. I enthusiastically agree that if there are factors in the patient's life that impede recovery or risk relapse that they need to be addressed.

    My issue with that sentence - and the reflexive use of those terms - is the assumption that there always ARE those factors and that they ARE the real reason for the problem. Better to do what you describe, Sarah, which is individualizing the treatment to the particular patient and family and stage.

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  5. I am glad we are discussing this... Personally, I do think that environmental factors (excluding poor parenting) can contribute to the development of an ED, and that EDs don't just develop solely as a consequence of something that triggered in the brain of a person with an inherent vulnerability to EDs by energy deprivation.

    I do think that Anonymous above has a point. If an ED is seen purely as a 'brain disorder' (associated in part with personality) then this has the potential to cause the individual to feel terribly defective - which is not conducive to good mental health.

    On the other hand, I think it's a waste of time, energy and money to focus on 'ED prevention', especially when it involves eliminating thin images from the media, discussion of the dangers of Barbie, or encouraging young girls to despise thinness and thin people.

    AN has been compared frequently to autism over recent years. We now know that AN, like autism isn't caused by bad parenting and that there is evidence to suggest that AN, like autism, may be a neurodevelopmental condition (I use the term 'condition' instead of 'disorder'). Approx. 1/5 people with AN have significant autistic traits and/or qualify for a diagnosis of autistic spectrum condition (ASC) as well as AN (and note that I prefer the term ASC, as coined by Baron-Cohen, than ASD). The autistic traits prominent in AN - e.g. superior attention to detail and poor set shifting are not necessarily a disorder in themselves. In the realms of science, art and music, these traits can lead to talent, success and a positive contribution to the world. The problem occurs when an individual with such traits starts a diet, 'healthy' eating programme, or exercise regime; they find they cannot stop these behaviours and become very focused and obsessive, especially as starvation sets in.

    Bullying, abuse and social exclusion, which are commonly experienced by people with ASC can trigger anxiety and depression. If a person with ASC informs a professional that they have been bullied, abused or socially excluded and that is why they are now socially anxious, have panic attacks and feel suicidal, would it be right for the professional to ignore their client and attribute their mental health difficulties purely to their autism - when there are clear external factors?

    I guess that what I am saying is that what we are keen to call a 'brain disorder' in many people with AN is a cognitive/personality style that is not in itself 'bad', destructive or disordered. It is inaccurate and unhelpful to blame parents for causing AN. Likewise, it is unhelpful to effectively blame the patient by attributing all their mental health difficulties to a 'disordered' brain.

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  6. Anonymous,
    Of course a young person would suffer a loss of self-esteem if she is led to believe she has a 'defective personality.'. That is not useful for anyone, especially for an adolescent struggling with a serious illness.

    The personality traits I describe are not present in all people with AN, and I agree with you that there is no value in assuming every AN patient has them. Each person must be viewed as an individual, not as some anorexic prototype.

    And yes, sometimes these characteristics are not preexisting, but rather are symptoms of AN or result from it.

    That being said, many of the personality traits commonly (though not always) associated with AN can be very beneficial when the person learns to accept them, understand them, and harness them for use in positive and productive ways. For example, persistence, ambition, strong work ethic, striving for high standards, sensitivity, and attention to detail are real assets in certain professions. Most people who recover from AN go on to be quite successful in life because of these traits, not in spite of them.

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  7. Laura,

    I understand and share your discomfort with "the assumption that there always ARE those factors and that they ARE the real reason for the problem." But I don't think that assumption is necessarily implied by the phrase "the psychological, environmental or family issues that contributed to the eating disorder." Yes, some clinicians may assume that, but I certainly wouldn't, and a clinician who is truly faithful to the principles of FBT would not assume that.

    The fact that some people would make incorrect assumptions does not mean that we should stop using the phrase altogether. Just as some people misunderstand and misinterpret the term "brain disorder" (see my latest blog post), doesn't mean that the term itself is incorrect or inherently dangerous. It is false assumptions, not words themselves, that are dangerous.

    People will always "read into" other people's words and sometimes may draw incorrect conclusions; that really can't be avoided.

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  8. I agree. We should use the right terms even if others misuse them.

    But I can tell that the writer did confuse them, and that most people will:

    "work with ... family to assess what has been fueling the eating disorder"

    Here's what I call the "smell test" on writing about EDs: change the disorder to OCD, diabetes, biking injury, and anxiety - it doesn't always work, but it does sometimes clarify. If we wouldn't use the same wording with those other things, why?

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  9. The phrase was the writer's -- not Dr. Davis's. FWIW, I credit Dr. Davis for enabling me to help save my daughter's life.

    Never have I heard Ellen even suggest that parents/family contribute to the development of an eating disorder. She flatly said the opposite, in fact, to my ex-husband, who had spent two years blaming me for her AN.

    My daughter, now 19, while not symptom-free, has successfully completed her freshman year 'away' at college. I am grateful each and every day for Woodland Forge and only wish that I'd known about it 2+ years earlier.

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  10. What wonderful feedback about Woodland Forge!

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