It’s no secret that I am not a fan of primarily psychoeducational interventions for people with eating disorders (EDs). It irks me that the overall theory in implementing this kind of intervention seems to be: if they only knew what they were doing to their bodies, people with EDs would take better care of themselves. Of course I take issue with this idea – if knowing that EDs were harmful to one’s health was enough to make the changes needed to not have an ED anymore, far fewer people would be struggling.
In case you don’t know what I’m talking about, a psychoeducational program is one that focuses on educating people about a mental illness, including what qualifies as pathology, what the behaviours look like, what the harms are, and what possible interventions exist. To be fair, there are not that many examples of purely psychoeducational interventions for EDs – often, psychoeducational programs precede more intensive forms of treatment or are integrated with other approaches. Still, I think it is worth exploring the theory that underlies the psychoeducation model, and how these programs might be problematic when people don’t actually have access to the interventions they want and need to actually begin working on their behaviours and thoughts.
In this post, I’ll comment on a brief report by Vandereycken, Aerts & Dierckx (2013) about patients’ knowledge of the physical consequences of EDs. In this study, the authors wanted to know more about how knowing about EDs and their consequences impacted motivation for treatment. I’ll also write about a study by Balestrieri, Isola, Baiano & Ciano (2013), who studied a 10-week psychoeducation group treatment for patients with binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS).
How much do those with EDs know about the consequences of EDs?
For this study, the authors had 66 women involved in inpatient treatment for EDs in Belgium fill out a questionnaire to assess their knowledge about physical health risks of EDs. They filled out the questionnaire at the beginning of their admission to the unit and again one month later. Authors don’t describe in detail what happened in between these time points (i.e., whether there was a purposeful psychoeducational component to their program). Average age of participants was 20.8 years, and participants had been ill for 5 years on average. Thirty-three had been diagnosed with restricting-subtype anorexia nervosa, 10 with binge-purge subtype anorexia nervosa, 12 with bulimia nervosa, and 12 with EDNOS.
The questionnaire included items like:
- “A woman’s body needs a minimum of fat content to be able to menstruate”
- “Weight loss may induce dizziness (and fainting) because of too low a sugar level in your blood”
- “Regular vomiting may cause deadly complications”
Participants were instructed to answer “right,” “wrong,” or “I don’t know.” Average score was 14.05/20 (70%) at pre-test and 17.23/20 (86%) at post-test, a difference that was statistically significant. Participants mostly answered questions about fertility, hair loss, and risks of drinking too much water incorrectly. Most of the difference between the scores at pre- and post-test was related to moving from answering “I don’t know” to choosing the correct answer.
As the authors note, all of these participants had been hospitalized previously; the results clearly reveal that people admitted for ED treatment are not ignorant about the consequences of their behaviours. The authors suggest that patients may, however, think that their own case is “not that bad” or may under-value the personal risks while recognizing the risks in a broad sense – for this reason, they espouse psychoeducation as an approach to improve patient motivation.
So, is psychoeducation helpful?
Unfortunately, there are not many studies that isolate the impacts of psychoeducation – and, I’d like to note, I could not find any that acknowledged the possible problems with teaching people about the harms associated with EDs without providing recourse to treatment – a scenario I see a lot in practice but less represented in the literature.
In 2013, Balestrieri et al. conducted a 10-week intervention with 98 patients diagnosed with EDNOS or BED (91% women, 54 diagnosed with BED, 44 with EDNOS, average age 42, average duration of illness 17 years for BED and 21 years for EDNOS). Participants took part in a group oriented toward nutrition, assertiveness training, and unpacking their ED-related thoughts and behaviours. Participants simultaneously tracked their food intake and thoughts, feelings and behaviours related to EDs. Despite these additional elements, the authors labelled this a psychoeducational approach.
The authors wanted to know whether their intervention decreased binges, affected BMI, and decreased ED symptomatology as measured by body dissatisfaction and bulimic symptoms.
Notably, over 50% of patients in the control group dropped out of the study. The authors attribute this to “a well-known problem of these patients, who have poor capacity to regulate their health behaviour, unless they are heavily motivated and involved in an active treatment” (p. 50). As well, they attributed the lack of attrition in the active intervention group to motivation.
I have to ask: why do we continue to blame patients for drop out, instead of interrogating how we fail patients using the approaches we keep using? Why is “treatment failure” a personal responsibility, as opposed to a systemic one? Of course, it is partially up to the person to engage in treatment. But can we not ask ourselves why the approaches we continue to use do not work for everyone?
For those who stayed in the study, authors describe improvements in symptomatology: over 30% were no longer diagnosable with BED or EDNOS after 10 weeks. Drive for thinness did not improve, but anxiety, depression, and alexithymia did.
Another issue for me is that the authors unproblematically refer to “BMI improvement,” which is shorthand, in this group, for weight loss. The assumption appears to be that this reflects a positive outcome for BED and EDNOS, which is an assertion coloured with the idea that BMI is linked to a type of ED (i.e., that only people in larger bodies get BED in particular and that weight loss is desirable in this group).
Unlike the prior approach to psychoeducation, this one appears to be rooted more closely to skills-based training, particularly in its assertiveness component. This intervention was less about telling folks what they were doing to their bodies and more about equipping people with skills, which I would argue likely accounts for the improvements they saw.
So, is psychoeducation effective?
The short answer is: maybe, but likely only if provided with additional tools and interventions. As the first study indicates, people with EDs often already know about the consequences of their behaviours. In my opinion, we need to stop assuming that telling people all of the ways their EDs can harm them is enough to make them better. This is a fairly paternalistic way of thinking, and it feeds into the idea that people with EDs are ignorant, childlike, or always in denial of their symptoms.
Do people with EDs sometimes underestimate the severity of their disorders? Sure. Do people with EDs sometimes struggle with motivation for treatment? Of course. But, might we also, before prescribing a course of psychoeducation, consider whether:
- Treatment is available
- The treatment available fits the needs of the people seeking it
Sometimes psychoeducation, in the absence of other helpful interventions (read: ones that are in line with the personal and cultural needs of the person seeking it) seems like yet another example of how we expect people to take sole responsibility over their own health. What I mean by this is that we seem to expect that knowledge will fix everything. Despite evidence that knowledge rarely translates to behaviour change, we continue to think that people will be able to transcend environments that keep them sick.
Vandereycken, W., Aerts, L., & Dierckx, E. (2013). What knowledge do patients have about the physical consequences of their eating disorder? Eating and Weight Disorders, 18 (1), 79-82 DOI: 10.1007/s40519-013-0006-2
Balestrieri, M., Isola, M., Baiano, M. & Ciano, R. (2013). Psychoeducation in Binge Eating Disorder and EDNOS: A pilot study on the efficacy of a 10-week and a 1-year continuation treatment. Eating and Weight Disorders, 18(1), 45-51. DOI: 10.1007/s40519-013-0014-2