Eating Disorder Treatment Today: Healthy Bodies Come First

Douglas Bunnell, PhD, clinical director of the Monte Nido treatment center for eating disorders, discusses the latest thinking in intervention, and it begins with getting patients medically healthy—back to a stable weight. Then, the family needs to work together to provide the psychological stability that helps young people with eating disorders maintain that health.

The foundational first step in treatment is to really reestablish nutritional and medical stability, and that’s sort of code speak for helping patients gain weight if they’re significantly underweight or stop the binging and purging. Because we know that those symptoms in and of themselves dysregulate people’s physiology and dysregulate their emotional stability and so forth.

You really have to be careful not to make a lot of inferences about emotional state until you’ve really dealt with the nutritional and medical issues. So one of the things that’s happened in the past 10 years in the field is that we’ve shifted from seeing symptom change as something that will follow emotional development to symptom change really needing to be what proceeds and sets the stage for emotional development or recovery. And so the treatments that we see now as being evidence-based really for the most part function and focus on helping people make actual changes in their eating behavior first.

Even if the inside and the emotional sort of appreciation isn’t catching up right away, you need a healthy, well-fed brain in order to do effective psychotherapy. You think about psychotherapy being something where you’re looking for patterns and making connections and doing some abstract conceptual work around yourself, taking different perspectives about yourself, you can’t do that if you’re starving. And I think the field has really shifted to really appreciate that.

So you look at treatments that are really in the books now as evidence-based in the field, cognitive behavioral therapy particularly for bulimia nervosa, and family-based therapy or Maudsley therapy for teens with anorexia. One of the things they have in common is they’re really focused on making real changes in nutritional and eating symptoms right away. In some ways that’s the core of the whole approach, putting the family back in charge of helping the child usually restore weight and get healthy again. And really the premise for that is if you help your child do that, her natural development is going to take care of a lot of the other psychological aspects. So the real key to recovery is getting that nutritional and weight stability back online.