Current Eating Disorders Treatment Approaches: Too Narrow?

This blog post started as a short report on a workshop held at the recent Renfrew Center Foundation Conference for Professionals in Philadelphia. It was titled “Understanding the Complexities of Anorexia Nervosa and Implications for Therapeutic Management,” but many attendees knew the back story: that the workshop was prompted by a controversial paper written by its two leaders, Drs. Michael Strober and Craig Johnson.

The polarizing paper, published in the March 2012 issue of The International Journal of Eating Disorders, bears the unwieldy title “The Need for Complex Ideas in Anorexia Nervosa: Why Biology, Environment, and Psyche All Matter, Why Therapists Make Mistakes, and Why Clinical Benchmarks Are Needed for Managing Weight Correction.”

At the November Renfrew Center Foundation workshop, Dr. Strober referred to the paper’s fallout of “handwringing, angst, and statements on the (American Academy of Eating Disorders) list serve that were frank and critical.”

The paper, Strober went on to say, was prompted by his and Dr. Johnson’s increasing dismay over the “increasing reduction, narrowness and singularity of treatment paradigms.” qualities which he called “simply a marriage that does not work” when applied to treating an illness as complex and challenging as anorexia nervosa.

As your faithful blogger, I realized that in order for the Renfrew workshop contents to make sense, it would be helpful to give you some background by summarizing the academic paper the duo wrote.

So here goes. Bear with my explanation, for there really is a practical application to all of this, although I won’t get to it until my next post.

The paper took on the two prevailing treatment paradigms for the treatment of anorexia today. The first is Family Based Treatment (FBT, also known as the Maudsley Approach), which is founded on the belief that far from being the cause of their child’s disorder, parents must play a key role in their child’s recovery by refeeding their child in order to restore her or his weight.

At the same time that this widely heralded treatment has been gaining adherents in the U.S. (it originated in England over 30 years ago), many in the profession have increasingly advocated the second (and not mutually exclusive by any means) paradigm that Drs. Strober and Johnson took on, based on the importance of genes and biology in the genesis of an eating disorder. According to the proponents of this paradigm, there is irrefutable clinical evidence that eating disorders are one of many biologically based mental illnesses (BBMI for short), and they should be treated as such. You can read the American Academy of Eating Disorders position paper on the issue here.

Both in their paper and at the workshop, Drs. Strober and Johnson were at pains to acknowledge the value and importance of both treatment paradigms, even as they lamented the overly doctrinaire attitude that they say both camps have taken on.

In their paper, they noted “three worrisome trends: (1) that many therapists apparently see no place for the sort of clinical wisdom that can never be manualized [FBT is touted for its evidence-based manuals for both professional clinicians and parents on how to help reefed their anorexic adolescent or teen, and further manuals dealing with bulimia and binge-eating disorders]; (2) that the emphasis on empirically validated interventions is drawing attention away from more broad-based training experiences; and (3) that therapists who will one day encounter very ill patients are not being prepared adequately for taking on the many complex predicaments they will face.”

The paper and workshop also make a plea for appreciating the complexity of anorexia. Strober and Johnson write, “after biology, the rearing environment—the larger social context too” must be addressed, aspects of eating disorders treatment that have been devalued of late. They advocate the “common sense notion” that therapies shouldn’t overlook the parts of life that “potentially maintain or accentuate vulnerability: the family, school, or interpersonal environment.”

The family, in fact is a primary concern of the authors, who write, “The notion of stress engendered vulnerability is not at odds with treatment models that see families as critical partners in care; it argues that broad attention must be given to sources of intrafamilial strain and the need for other forms of therapeutic dialogue to reduce it.”

Although this topic may seem overly theoretical, there is actually a practical aspect to both the doctors’ paper and their Renfrew Center Foundation workshop that I will go into in my next blog post, namely their recommendations for benchmarks to help eating disorders professionals answer a question that plagues many parents and patients: “How do we know when a course of outpatient treatment in anorexia has reached the limit of benefit and we need to move to a higher level of care?”

Stay tuned for a summary of Drs. Johnson and Strober’s recommendations.