Treating a patient with an eating disorder can often feel like walking on eggshells; it is easy to say or do the wrong thing. I’ve covered this topic in my previous posts. In my first post, I wrote about negative attitudes that health care providers often have with regard to eating disorder patients and in my second post, I covered some ways in which caring clinicians that do work with ED patients may – usually inadvertently - negatively impact treatment, often by impairing the physician-patient/caregiver relationship.
But let’s forget about clinicians for a second, what if the treatment environment itself is damaging? Could treatment itself do more harm than good?
That’s the question that Walter Vandereycken explored in this commentary article. (This interesting paper was brought to my attention by a reader – you know who you are, so thanks!)
And just to be really clear Vandereycken doesn’t mean contagious in the infectious-disease kind of way. Coming into contact with someone who has an eating disorder is not going to put you in danger of getting an eating disorder yourself.
Instead, what Vandereycken means by the use of the word “contagious” is “peer-contagion”, a phenomena that has been well documented in suicidal behaviour and self-injury. Think about copycat suicides for example: it is unlikely that a healthy individual without a history of suicidal thoughts is going to be prompted to commit suicide, but someone who is at high risk, well, that may just be enough to push them to try once more.
The notion of “peer-contagion” is meant to describe the “social learning process of imitation, identification and competition”, leading Vandereycken to suggest that “we should question the possible dangers or unwanted side-effects in treating patients together within a common therapeutic setting.”
Beside anecdotal information and opinions of professionals in the ﬁeld, three types of studies about patients’ experiences in a therapeutic setting have been found: ethnographic reports by participant observers, qualitative investigations using mainly retrospective interviews and larger scale written surveys collecting patients’ opinions in a standardized manner.
INPATIENT TREATMENT SUBCULTURE
Vandereycken recounts interesting historical cases of “a kind of pseudo-contagiousness” of eating disorder symptoms that has occurred in otherwise non-ED residential settings (I highly recommend reading the original article just for this part). But it seems that few have taken notice of the “‘dangers’ of treating patients together”.
In 2004, the principle of the British national Center for Eating Disorders, Dean Jade, made the following statement regarding inpatient treatment:
As any inpatient will tell you, a specialist unit is the best place to learn how to be really, really good at anorexia. They also breed their own subculture. Some patients have reported bullying and intimidation by the hard-core cases. If they eat anything at all, they’re called fat cows’ (Rice, 2004).
Vandereycken refers to ‘a most interesting blog’ post by an ‘astute blogger called ‘greythinking‘ that lists six different ways in which inpatient treatment for eating disorders can do more harm than good:
- exposure to the sickest of the sick
- picking up other eating disorder symptoms
- competition among patients
- unhealthy modelling
- negative attitude towards treatment and
- no life outside of the eating disorder
‘As for ‘‘breed[ing] their own subculture’’- . . . well, I’ve always said that there is an eating disorder world. You make friends in treatment. After discharge, you keep up and talk about how everyone is doing . . . is so-and-so back in treatment? I heard so-and-so is doing really poorly. Because you’ve given up school or work to go into treatment, the most interesting things going on in your life are your therapy and nutrition appointments. Everyone talks to each other about their appointments… You continue doing the same arts and crafts that you were doing inpatient. Everyone’s lives are still consumed by the eating disorder …
What do the patients think about all of this and does anyone even know or care? In large part, the answer is, well, it appears that no, most people don’t care. At the very least, it is rarely taken into consideration in studies evaluating treatment services.
And that’s the crux of the problem. To patients, what Vandereycken is writing about is obvious. DUH. But the point is, this may not be immediately obvious to treatment providers (or the size of the problem, anyway) nor is it necessarily obvious to well-meaning parents and caregivers, who think that inpatient or residential treatment is all or mostly all good.
Vandereycken summarizes the few studies that asked patients about their experiences. In all the studies mentioned in this paper, there is a common theme: positive features include support and understanding, and negative components center around competition.
- de la Rie et al (2006) found that while most patients considered specialized care to be helpful, some noted rivalry with other patients as being unhelpful
- Tierney (2008), interviewing adolescents in the UK, found that patients had difficulties with the inherently competitive nature of anorexia, the competition to be the sickest (eating the least amount or weighing the least) and the arrival of a new patient elicited the desire – a sort of nostalgia – to go back to their pre-treatment eating disorder state. There was also a fear that the new patient would judge them harshly, seeing the amount they were now eating as part of treatment (“think they were greedy for eating full meals”.)
- Colton & Pistrang (2004) also found that negative experiences in treatment included the propensity toward comparison and competition, as well as picking up bad habits (such as self-injury)
THE CONS OF GROUP TREATMENT
Is there a solution? Separating patients based on their progression toward recovery might initially sound like a good idea, but it would likely exacerbate the negative components of group treatment for those who are very sick, limiting their exposure to healthier role models.
What can be done? I am not sure. Clearly, group therapy has benefits – for me, personally, support groups were very important during my treatment, considerably more beneficial than outpatient treatment. But the caveat is that the groups I went to were voluntary. Everyone wanted to be there. And, well, we all went home after (we weren’t together 24/7). Moreover, the dynamic was never at a standstill – much depended on the facilitator and the people present. I think that prevented negative group dynamics from developing.
I got the sense of belonging, support, mutual understanding, and acceptance but almost none of the competitive and comparative aspects. Yes, individuals lost weight and it was sometimes obvious, but their presence there, being voluntary, highlighted the misery and unhappiness of their present state. It was a potent reminder of what you can lose if you don’t keep pushing yourself to try and get better. And being around individuals who were often very far along in recovery, or those who just had a few food issues, was a positive reinforcement. Unless you talked to individuals after group, there was no way of knowing how much they weigh, how much they’ve lost, etc.. Mention of numbers and specific foods were forbidden in group.
And, of course, there was none of this:
Australian researcher Warin (2005) remarked that patients laughed ‘about how they had tricked the staff through tactics [such as] hiding food in the ceiling panels, draining apple juice into bed pans that were taken away and disposed of by the nurses, and spreading butter between newspaper sheets or duvet covers’ (p. 107).
These tricks, just like the concealment of anorexic practices and pseudo-compliance with treatment, can be related to the need to create status and power in situations where they feel constrained or out of control. It may also express their need to retain an anorexic identity.
But how many cities have provide an opportunity to go to weekly (and if you want, daily) voluntary support groups? And with eating disorders, you cannot simply rely on the patients’ desire to get better and that is even when they are aware of the problem (because often, that realization comes during recovery).
So then what?
TREATMENT CULTURE AND SUBCULTURE
Vandereycken notes others’ criticisms and critiques of inpatient and residential eating disorder treatments:
Warin (2005) noticed that many inpatient programs ‘effectively reproduced and supported the many isolating practices that people with anorexia use to negate relatedness’ (p. 108).
The one thing that is missing in Warin’s analysis (as Vandereycken quoted it, I didn’t go to the original source) is the point that highly structured treatment programs are often not challenging in the right ways for patients with anorexia nervosa. The emphasis on structure, weight gain goals, numbers, controlled portion sizes, a day split into 30 minute segments, or something, may not do much to challenge the rigid anorexic mindset.
Indeed, one may even flourish in this very unrealistic setting. Stability and structure may be good, particularly for those with bingeing and purging behaviours, but the emphasis on numbers, rules and structure (albeit with the goal of “weight gain” versus “weight loss”) may actually predispose patients to relapse following discharge. It is treating rigidity with more rigidity, just reversing direction of weight changes (and weight is important, but, so is being able to let go of the rigidity and the ED mindset).
Vogler (1993) pointed out that many programs (like the 12-step program) are grounded in the notion of admitting, or assuming, “an eating-disordered” identity. It is I am anorexic versus I have anorexia nervosa. (Note, I use “anorexic/bulimic” in titles to keep it short.) Vogler views this as a form of self-stigmatization “patients can only get better if they first admit to being ‘sick’ and accept the personal weakness supposedly linked to their eating disorder“.
Vandereycken concludes with this:
[The] therapeutic practices both reﬂect and incorporate the process of social construction of an eating disorder (Hepworth, 1999). We should be aware of the various ways in which ‘the eating disordered patient’ is constituted both in terms of the patients’ self-constructions and of the constructions by healthcare workers, including the tendency of stereotyping in negative portrayals of patients as being ‘difﬁcult, uncooperative, manipulative, untrustworthy’, etc. (Malson, Finn, Treasure, Clarke, & Anderson, 2004).
Closely linked to this issue is the danger of authoritative containment of patients within a rather coercive atmosphere of a hospital unit. The more a treatment is experienced as controlling and disciplining, with nurses mainly in a surveillance role, the higher the risk of a struggle for control, leading to rebellion in patients (Ramjan, 2004; Ryan, Malson, Clarke, Anderson, & Kohn, 2006). The patients’ perception of the therapeutic alliance is a crucial factor in the process of commitment to an inpatient treatment program (Gallop, Kennedy, & Stern, 1994; Wright, 2010).
That last point is one that I, and others, have mentioned time and time again: the patient-physician relationship is of utmost importance in the recovery process.
Also, check out Vandereycken’s article on the Eating Disorders Review webpage called “How ‘Contagious’ Can Eating Disorders Be in the Eyes of the Patients?’
Readers, what negative environments have you experienced in treatment with regard to the ‘subculture’ and the byproduct of being surrounded by other ED patients? How do you think this problem can be ameliorated while retaining some of the positive aspects of group treatment?