I often hesitate to make broad, sweeping claims about the nature, cause, and experience of eating disorders and disordered eating. However, if there is one thing I feel absolutely certain saying about these disorders, it is that they are incredibly complex and multifaceted with no “one-size fits all” solution. So, I was quite excited when I came across a recent article by Michael Strober and Craig Johnson (2012) that explores the complexity of eating disorders and their treatment. Both authors have significant clinical experience treating eating disorders.
This article uses cases studies, literature, and the authors’ collective clinical experience to respond to some of the key controversies surrounding anorexia and its treatment. Among the major controversies that have come to light of late, they focus on two:
- Genetic/biological causation (Biologically-based mental illness – BBMI)
- Family-based treatment (FBT) as the best form of treatment for adolescents
The authors’ exploration of these topics supports an overall argument: focusing on singular explanations and solutions for anorexia, particularly through the vehement defense of any particular approach, obscures the complexity of the disorder, as well as the processes and skills required for effective treatment. This complexity needs to be taken into account in order to derive truly effective methods for treating diversely presenting disorders. After contextualizing their argument for deeper, more complex understandings of AN and improved clinical skills in treating AN, Strober & Johnson conclude the article by suggesting benchmarks for treating AN.
CONTROVERSY AS A CONVERSATION CATALYST
Far from suggesting that the controversies that emerge surrounding eating disorders in general and AN in particular are to be avoided and neatly cleared up, the authors argue that disagreements and discussions around the etiology and treatment of these disorders have helped to illuminate areas for new and improved learning.
Importantly, the authors note that they do not necessarily disagree with the recent focus on BBMI and FBT; they are simply urging a softening of the staunch reliance on these paradigms to the detriment of all others.
As readers might be aware, explanations of anorexia have become increasingly focused on genetic/biological factors. Treating anorexia from a gene-centric point of view has led, among other things, to the suggestion that until weight is restored, psychological treatment is futile.
While there is evidence that points to improved capacity to do the psychological work involved in recovery once weight is restored, the authors take issue with the clinical practice of not initiating this psychological work until weight gain has occurred. Therapy and psychological work need not wait until the patient has gained weight, they argue.
REIFICATION OF GENETICS
While randomized controlled trials are often heralded as the gold standard in any kind of scientific field, and rightfully so, an overreliance on randomized controlled trials (RCTs) and genetic studies may result, the authors suggest, in a “reification” of results of such studies. This may result in overlooking “clinical wisdom” that has not been tested. Though evidence may be strong for a particular form of treatment, it does not mean that this treatment type is the be-all and end-all for all individuals with AN.
As Strober & Johnson suggest, many questions remain, including why treatment is not effective for all individuals, why clinical practice does not always match up with research evidence, and why little discussion has centered around the diverse skills required for effective treatment of AN.
As the authors suggest, there is strong evidence for the inherited influences involved in the development of AN. I’m certainly not a geneticist or neurobiologist, but I can grasp the convincing nature of the evidence pointing to strong links between genes and AN.
However, just as an overreliance on any particular form of treatment can lead to unexpected negative consequences, over-relying on the view of AN as a “brain disease” can obscure the social factors that interact with biology to lead to various outcomes for individuals predisposed to AN.
The authors make a number of key suggestions that help to clarify the gene/environment interaction involved in AN:
- Genes and environment are correlated and neither fully explains or causes eating disorders:
- Individuals with a genetic predisposition may both seek out and “invite” certain social environments, which lead to the expression of the characteristics to which they are predisposed
- Genes and environments can both co-occur and/or clash, at different moments in an individual’s development
- Brain circuitry adapts to the environment
- Stress (for example, exposure to negative experiences during childhood) can precipitate neurochemical changes, which shape and change different areas of the brain
- Environmental stress leads to over-sensitivity in the brain’s fear-generating areas; on the flip side, these structures can be calmed by caring rearing environments
- An individual’s social world has a strong influence on behavioural outcomes
- Epigenetics explores how environment can “pull the trigger” of particular genes, beginning even before birth
The authors’ discussion of the interaction between genes and environment is detailed and intriguing; I was encouraged by the suggestion that both positive and negative environments can play into biological processes. Too often, I think, studies focus primarily on the negative, and I found this positive slant to be encouraging.
In short, Strober & Johnson argue that clinicians (and individuals in general) need to take into account at least 3 factors in understanding AN:
- Rearing environment
- Larger social context
Without an understanding of these factors, treatments will inevitably come up short. As the case studies in this article illustrate, “symptoms of psychological illness do not exist in an impersonal vacuum,” and relying solely on biological explanations fails to generate solutions that can be discussed and understood by families and sufferers.
EXPERIENCE, SKILL, AND COMPLEXITY
Another central element of this article is the focus on the importance of effective training for practitioners who will be dealing with these complex disorders. The authors take up a discussion of the tradeoffs involved in determining the appropriate course of care for individuals with AN. They argue that clinicians must become aware of the key debates in understanding and treating AN, as well as the science that underlies them.
Parents and patients, too, need to be informed (presumably by treatment teams) about the roles of environment and biology. I particularly appreciated this suggestion; too often, it would seem, patients and parents are kept in the dark, and may come to understandings of AN that are, at best, partial. Environmental impacts on AN may be ignored out of a fear of parent-blaming, which the authors suggest is misguided.
Looking to the interaction between biology and environment does not vilify families, but underscores the importance of attending to dynamics in the sufferer’s environment, which may sustain the disorder or inhibit recovery. Overall, the authors make the argument that despite all the incredibly interesting and important scientific progress surrounding AN, the importance of skillful, intuitive and decisive clinicians.
Obviously, given the complexity of AN, it is not easy to determine benchmarks for the course of treatment.
The authors point out several key considerations to be taken into account:
- Mild symptoms that persist in the face of overall improvement/stabilization must not be ignored
- Limited early weight gain may limit possibilities for what is achievable in outpatient settings
- Single interventions are generally unsatisfactory
- Therapist inexperience can itself cause harmful effects
- The longer the illness persists, the worse its impact on physical and mental health
While benchmarking may be helpful in terms of deciding on inpatient/outpatient care and course of action, without a strong treatment team with adequate experience and understanding of the complex processes at play in AN, they may not prove useful.
With the caveat that their suggestions for benchmarks are a frame of reference rather than empirically based solutions, the authors propose several scenarios and benchmarks. These benchmarks center largely around weight gain or loss, and vary based on the patient’s age and course of illness.
I won’t give detailed explanations of the benchmarks here, but if you are interested I highly recommend reading the full article. Suggestions are made, too, for ways that therapists can respond to patients and/or families who reject the recommendation that care be increased.
Overall, this article does an excellent job at highlighting the complexity of AN. The suggestions Strober & Johnson make provide a strong case for the importance of acknowledging this complexity, and the authors argue for the importance of well-informed, well-coordinated treatment for eating disorders.
They also acknowledge the constraints placed on caregivers and clinicians, which is an important consideration to make; treatment is obviously not accessible to all, nor is it always available at the time it is perhaps most needed. While it is great to make recommendations for finding clinicians with the most experience and best intentions, this kind of exceptional care is obviously not accessible to all, for myriad reasons ranging from finances, to lack of diagnosis, to long wait lists, to geographical location, and the list goes on.
The authors also do a fantastic job, in my opinion, of acknowledging both the agency and the incredible struggles faced by individuals with eating disorders and their families. I always appreciate articles in which the authors’ obvious passion for improving care and outcomes for eating disorders shine through, and this article was no exception. This was particularly clear in the way that the authors articulate the need to make information about the complexity of disorders more readily available not only to practitioners, but also to families.
Strober, M., & Johnson, C. (2012). 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 International Journal of Eating Disorders, 45 (2), 155-178 DOI: 10.1002/eat.22005