Do We Know Enough About Eating Disorders To Prevent Them?

Dr. Michael Levine, a thoughtful and well-known proponent of ED prevention efforts, asks a good question: Does Eating Disorder Prevention Work?

His recent series of posts is fascinating and rich, but has many layers that I find myself arguing about in my head so instead I will present them here.

Dr. Levine refers to two critiques he has heard of prevention work:

Nevertheless, there continue to be a number of influential researchers, clinicians, and activists who are skeptical about the possibility of effective prevention. These stakeholders in the field are concerned that prevention programming and research will siphon precious financial and other resources from basic efforts to understand and treat eating disorders. In addition, over the years several parents have challenged me by insisting that well-intentioned but misguided information aimed at prevention actually triggered their child’s ED.

I actually don't share either concern. I don't worry that prevention will take away from other ED work, for example, as in my experience these are different researchers, clinicians, and resources. I also do not share the worry about triggering EDs -- I know it seems that way to many parents but I think we make a lot of the moment WE realize our loved one has an eating disorder and what our loved one says is the reason. If all it took was one event to trigger mind-altering mental illness then that house of cards was waiting for any gust of wind.

My critique of prevention work is different. I don't think we know enough about EDs to prevent them. I don't think we know what causes them and more to the point I don't think we've parsed out the difference between symptom and cause enough to form the question.

The prevention work out there focuses on identified and modifiable risk factors, and there is some evidence that some risk factors can be successfully changed, if briefly.

But do we agree that modifying these "risk factors" prevents mental illness?

Preventing disordered eating and body image distress does not necessarily prevent the mental illness we call eating disorders. We really don't know, and we would only assume that if we agreed DE and BI distress cause eating disorders, which we don't. Those symptoms in the mentally ill may or may not have any relationship to the person's values, true desires, or environment. Like the symptoms of other mental illnesses, they don't necessarily need a reason or a cause. Like the symptoms of other mental illnesses, their severity may have nothing to do with outside influence at all.

Disordered eating and body image distress may be one thing for those with an ED predisposition and another for those without. It may be that for those without an ED predisposition you can change the course of those thoughts and behaviors, but that you are not preventing an eventual eating disorder. There's lack of clarity over whether "prevention" can serve as early intervention, or whether the illness is being delayed, or we're dealing with very different problems entirely. None of the prevention work shows that eating disorders are being prevented: only that disordered eating and body image concerns can be reduced in at risk populations. Without knowing which of those subjects would have gotten EDs without the intervention, which would take enormous sample sizes and many years of follow up, we don't know. No one could argue it is not good to make these changes for society, but if the target is mental illness it matters what we are measuring.

Levine demonstrates the ways we use the word "prevention." There is a vast difference between: "keep it from occurring" and "delay its development or minimize its severity. There's the rub. Keeping it from occurring is how most of us would use the word prevent. The latter two, delaying and minimizing, are what I would call "early intervention." And it matters. A lot. Prevention involves removing a cause. Intervention is about fixing a problem that already exists. If talk of prevention leads the public to confuse cause and symptom we risk:
  • Failing to improve society in ways that are important
  • Failing mentally ill people and their families by chasing false trails and blaming them 
I don't know if current prevention approaches are diagnostic or therapeutic. I suspect they are diagnostic: people who respond to the intervention are different than those who do not. I absolutely know, however, that prevention literature has an enormous effect on advocacy and treatment.

The weird thing is that I am a huge proponent of every single thing that is happening out there in the prevention world EXCEPT that it is being promoted as ED prevention. 

I want ALL children to have a world free of body shame and objectification. I want the full diversity of humanity to be celebrated and although this will also be a much better environment for families and clinicians to help eating disorder patients recover we have to intervene regardless of how stupid society is about body shape and weight. We do not have to and indeed CAN NOT wait.

If all the things we call "prevention" are good things in their own right -- and they are -- then we should be doing them. For all of us and for all kids. If we were doing all these things in the name of good parenting and a healthy society but did NOT sell them as eating disorder prevention then we all win, folks.

There is so much we could do for early intervention for those who are predisposed to mental illness and we are not. Hobbling them and their families with unfounded ideas about causation at the moment their loved ones need them so much, this is neither necessary nor helpful.

So we do need to talk about prevention, and have this conversation. Let's keep talking!

Comments

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  2. This could have been plucked from my own thoughts! Bravo!

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  3. So Fred, I'm not convinced that culture is part of the problem. That's one of the problems about us all discussing this issue is we don't have common ground on things like this.

    I operate under the assumption that, like OCD, eating disorder symptoms certainly reflect the culture but aren't caused by the culture. What is your belief?

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  6. OK, so Fred, let's continue this?

    What you describe could be true. I don't know. I don't know of evidence that supports this etiology. So what do we do to come together on "prevention" when we don't agree on causation?

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  7. I don't fully agree with you but that isn't what I'm talking about. I'm just wondering (not defending) if eating disorder advocacy groups (not all) but large ones such as NEDA link negative body image, fat talk, size 0 models etc. to eating disorders because they want to do something and want to point to something and say "see - that's it". If they adopt the view point that eating disorders cannot be prevented (or not easily) then that is a very scary thing and not a very positive message for a group to try to market to get funds to come in. I wish NEDA would spend more money on treatment and less on other things but if they were to abandon their message altogether about how society causes eating disorders would people really look at them and be willing to donate? I'm not arguing that they shouldn't but it would definitely be problematic to shift the focus of their organization and still remain fully funded. I think in general the public likes to view eating disorders as preventable. It's a lot less scary that way. After all then they can (falsely) say to themselves "my kid will never get it". She doesn't look at Seventeen magazine." If NEDA was to take the position that they were to only help with treatment costs, scientific research and drop the prevention piece I don't think that society at large would respond to them very well. Sadly, I think eating disorders would become a lot less interesting and people would become even more ambivalent than they already are. I'm not arguing that they shouldn't do this but I do think that sadly an organization would find it much harder to survive without this perception that it needs to create a war on society to fix the "epidemic of eating disorders".

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    1. This is going to sound completely naive, but believe it or not: THIS HAD NOT OCCURRED TO ME. It should have, though, as it makes a lot of sense. I don't know if it is conscious or not, but I think you are right that people might interpret it that way.

      For the record, I don't find it disheartening or feel less of a role -- an optimistic role -- for advocacy because I don't believe in prevention. I think advocacy for accident victims and people with OCD or issues for which there is no known prevention still have a lot of work and positivity to do.

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  8. Great blog, Laura! Great thought fightingmywayback. Thanks, Laura, for trying to get advocates on the same page by clearing away the fog surrounding the words used and clarifying the meanings. If we can all agree on definitions- THAT would be huge. We have a long way to go, but your efforts are making the road much smoother.

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  9. Thanks for this Laura! Personally, I cringe at the idea of prevention and agree with fightingmywayback that it allows people to think it could never happen in their family. The fact is that many doctors (ours included) don't know how to identify EDs in their early stages and don't know what to tell parents when they do. I would much rather have efforts be directed towards early identification and intervention.

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  10. Thanks for your blog Laura - certainly got me thinking! As an attachment-based psychoanalytic psychotherapist one area of prevention that I think is vital is supporting parents and carers to develop secure attachment bonds with their children. We know that most people with severe eating disorders have insecure and disorganised attachment styles, so this would undoubtedly be one way to reduce the risk of eating difficulties becoming entrenched.

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    1. Thank YOU, Helen. It's good for us all to talk this stuff out, right?

      You bring up a good example of where we all need to establish some common ground. You believe insecure attachment causes eating difficulties that lead to eating disorders, so you work backward to prevent attachment problems.

      I believe those attachment symptoms, when present, are symptoms not causes, and that recovery allows normal attachment to reestablish.

      Yours and my views of etiology are but two of many. How can we, as a field, find common ground together when we don't share a common view of etiology?

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  11. Does a sleep disorder come from the promotion of nightclubs on Facebook?

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  12. Does a blood disorder come from watching too many vampire movies?

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    1. I knew there was a reason I don't watch those!!

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  13. Is bipolar disorder caused by noting that one end of the may pole is stuck in the ground on Beltane?

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  14. And the last one: Are personality disorders caused by watching too much Anderson live on TV?

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    1. OK, for realz: that last one is true!

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