Family Based Treatment for EDsResidential Treament for EDs: which is preferable?

Mental Health Eating Disorders & Body Dysmorphia
1

http://maudsleyparents.org/youngadults.html

Just had to introduce this for the sake of healthy debate. The above link is a site which talks about the Maudsley Family Based Treatment as a way of treating eating disorders. It is basically an approach in which the family of a person with EDs takes control of the eating of the person with an ED and monitors them and supports them. Similar to a way in which it might be done in a residential centre.

http://www.blog.drsarahravin.com/eating-disorders/rethinking-residential-treatment-less-is-more/

This article is quite biased in so far as the author is not in favour of residential treatments for reasons which all seem valid to me. It prefers the Maudsley approach because it allows the person with an ED to get better in the same environment in which they would have had to return to, if they were in a residential setting. The main summary of pros and cons for residential are copied and pasted below:

Residential treatment for eating disorders, as it exists today, has several benefits and several drawbacks. The benefits include:
• Supported nutrition to promote appropriate weight restoration
• Round-the-clock monitoring to prevent patients from engaging in bingeing, purging, restricting, and substance use
• Protection from self-harm and suicide
• Providing the patient with a respite from the stresses of school, work, sports, and everyday life
• Providing the family with a respite from the daily strain of caring for their loved one

The drawbacks to residential treatment, as it exists today, include:
• Prolonged separation from the family and home environment
• Prolonged absence from school, friends, extracurricular activities, and normal routines
• Exposure to other eating disorder patients, which can result in acquisition of new symptoms, solidification of identity as an “eating disorder patient,” and competitiveness with other patients about who is sicker or thinner
• Artificial environment – a “bubble” – which does not translate to real-world living
• Exposure to outdated and unproven theories about the etiology and treatment of eating disorders (e.g., blaming “family dysfunction,” search for “root causes,” exploration of supposed “underlying issues”)
• Failure to plan adequately for a smooth transition home
• Insufficient family involvement (weekly phone sessions and “family weekend” pay lip service to family involvement, but they often play the blame game, focus on presumed family dysfunction, advise parents to “back off” and not be the “food police,” and fail to educate families as to how to help their loved one recover. In essence, many family sessions send all the wrong messages and fail to send the helpful ones).
• Over-diagnosis of and over-medication for supposed comorbid disorders which are largely, if not entirely, the result of malnourishment and / or refeeding
• Attempts to use psychotherapy of any kind on patients who are not able to benefit cognitively or emotionally.

Given relapse rates, even after residential treatment, the Maudsley approach might be ideal (even for adults), if they had such a supportive and willing family. But where this does not exist, then in my opinion, something which is similarly supportive, like residential, is the next best option.

Sorry this was so long. All input welcome.

xx

2

Sreb,
I do have some thoughts, but no time right now to share..work is calling.
I will write later or in the morning...thank you for bringing up this interesting issue! Jan ♥

3

Sreb,

Whew-- Can of worms, opened! ;0)

My initial reaction... My mother's tendency to control EVERYthing, and my father's lack of emotional support, abuse, and the way in which I was prevented from showing, or feeling, emotions... All of that, and more, led to my development of an ED... I do not BLAME them... I don't believe they intended for this to happen, and I think they did the best they could, AND they did a LOT of things right! But... Eating disorders, according to my therapist, are largely the result of "nurture" vs. "nature"... So, I can't even imagine how putting my parents in charge of me and my recovery, (when they can't even have a real conversation with me about it or acknowledge the importance of therapy,) would be at all helpful... I know it's different for everyone... Perhaps it works for some... I don't know. ♥ But I shudder at the idea of attempting it myself... I need AUTONOMY from my parents... I need to learn to STOP judging myself and my life through my parents' eyes. I need to learn to feel emotions and talk about things I was never allowed to feel or discuss with them. For me, in my situation, this sounds like a recipe for disaster. My mother, on the other hand, would be THRILLED with the idea! LOL! ♥ I am a total believer in the fact that family dysfunction plays into the development of eating disorders. That people DO have root causes and underlying issues that need to be addressed. I would give ANYTHING to be wrong! Because, frankly, I'd rather NOT deal with a lot of the things I am now having to face... To look at issues that have held me in a shame-lock-down for so long that it took me a YEAR of therapy before I could utter the words to my therapist... Certainly nothing my family COULD help me face, as my current situation shows... ♥

Anyway, interesting topic... And I haven't read the article, so I hate to dump TOO much... ;0) LOL! But, it sounds messy and dangerous for me. ♥

Love you, friend!! ♥

Jen

4

Thanks for your response to this Jen.

It is really interesting as a topic. I know this approach seems to have been used quite successfully for adolescents and from what i have read, for some adults.

I think one of the reasons it works is because it does not lay the blame for eds on the parents. Be that directly or indirectly.

In all honesty, i think that eds are not really about nurture. I grew up in the same environment as all my other siblings and although there was some difference in treatment, it was very negligible. In that case, why was i the only one to develop an ed (or a 'mental disorder')? Although i believe parents have a great role in terms of how we view ourselves (self-esteem etc), i think that an ed, is just one of a host of disorders that we could gravitate towards. But it is because we have a predisposition for whatever reason (concern about our weight, previous weight related issues, teased about our weight etc). So it is like we were already on our way there anyway. Does that make sense? Like if i was a lover of alcohol, i might have been an alcoholic to deal with things rather than an individual with an ed. Or if drugs had been my poison of choice, i could have gone down that route.

Personally, i don't want my family to be that involved. But the truth is, sometimes i wish they were that involved cos i feel it may be the only way for me to get out of this sorry mess. The alternative is that i keep on going as i am and .......... only God knows.

I definitely would not encourage it in a family where parents are not nurturing. That is the main thing. That parents have a genuine concern for their children, want to see them better, are in a position to give that kind of care, are not parents who are critical of their kid or still engage in behaviours which are further likely to destabilize their child (adult or adolescent). I therefore, completely understand and agree with what you wrote concerning what would work for you, given your family history.

I do tend to find that i disagree with much of what is written about eds. But that is just my opinion. I think there is no 1 way. I think there is the possibility of recovery in different ways and this is one (albeit seemingly radical) way. I do tend to hate the focus on the root cause of the ed since i think that focuses us on blame even though, in psychotherapy speak, we then have to say, they were not to blame, they did their best etc. But in essence what we are saying is: they stuffed up. Let's call a spade a spade, as the saying goes (not sure if you have that there in the US).

Hmm, i could go on, but i won't. I respect all opinions and am really glad to read your opinion about this.

In whichever way recovery comes, i wish recovery for all of us.

Love.

Sreb

5

Sreb,

Absolutely! There is no one right way, and at the end of the day, it's recovery that is what's important. ♥ It's interesting to examine different beliefs about the subject... I can't say I agree with all you've said, but I can't presume that because it isn't right for ME, that it isn't right for SOME people. :)

I also believed that eating disorders could be about nature, and that there is a genetic component. My therapist disagrees. She explained that the development of an ED cannot be genetic, BUT some aspects that make us susceptible to developing them ARE... Sounds a bit like semantics, perhaps... She said that mental illnesses that are often co-morbid diseases, such as depression, ARE genetic. AND that people with certain personality traits are more susceptible to them as well... But, that we learn to cope with our lives through the nurture aspect... That could mean parents, I suppose, but I don't think that's the case for everyone. I know that many sufferers have experienced trauma, but not everyone. Abuse is common, but not absolute. We are also undoubtedly affected by our culture/exposure to media... In that case, media influences become part of the "nurture" piece, although there's no one to really "blame" for it...

My therapist had me write a no-send letter to my dad and share it with her last week... Even though I had no intention of ever sending it, I tried to write it as though I was going to... When I read it to her, we were both shocked at how apologetic I was. Even as I attempted to address horrible things he did to me, I almost EXCUSED him... I said things such as, "I know you were under an enormous amount of pressure at work," and, "I know you did the best you could." But the fact is clear that many of his actions, regardless of the reasons behind them, were unquestionably unjustified. And yet, my go-to reaction was to try to see beneath his obvious culpability. To find a way to blame myself. To make excuses, and thereby deflecting blame and his angry response to me... This was also a self-preserving coping strategy I developed in my childhood, and it served me well... It kept me alive. But... I MUST learn to look more objectively at certain situations. I must learn to feel what I could not acknowledge all those years ago. It's not so much about BLAME as it is recognizing and accepting the past. Accepting doesn't mean condoning, either. But, try as I might, I have been unable to move forward in my life by ignoring, deflecting, and pretending things away. Blame will not help me move forward either. But I MUST stop ignoring facts. I must learn to trust in others to be good and willing ears, because I have a LOT to say that has been kept quiet. Hidden from my parents, and necessarilly, hidden from myself.

Just my take on things... I'm a year in, and still tending to excuse abusers in my past for their treatment of me. And in effect, have found a way to blame myself for everything, i.e.: I'm too stupid, too irrational, too quick tempered, too jealous, too spineless, too ugly, too FAT, too unloveable... etc... And an eating disorder? Yet another way to try to please others, make up for what one is fundamentally lacking, and perhaps even punishing myself for being so unloveable.

Recovery... It's not a simple process, and the road is not the same for everyone. But it IS possible, whatever path you choose. ♥

Love you,

Jen

6

Well, the pros and cons you presented are valid, and I always come back to the fact that each person needs a unique approach, tailored to THEM, for recovery.
What I understand about the Maudsley approach is that it's been most effective in the adolescent population, and then, only if the 'family' unit utilizes it exactly as recommended. AND, that there has to be a phase of transition, where the responsibility for recovery is slowly given over to the person recovering. I can relate it to needing a 'cast' for a broken leg. You need it for a while, but after it's served it's purpose, it could be more harmful than helful.
More times than not, being taken out of one's environment is actually a good step in the recovery process. It's often too overwhelming to have to work recovery, yet also deal head on with normal life challenges. A nice mix is a program where you are partially doing both, yet with the option of being in a safe place to process the challenges of 'normal' life.
I think a certain treatment style may be appropriate for a while, then another style may be appropriate as time goes on...in terms of level of care, etc.
The nature/nurture issue? Highly contested, but more and more it's being shown that both areas contribute, and it's that unique combination that may cause a person to be more susceptible to developing an eating disorder.
I'm glad you brought this up....hope others will comment as well....Jan ♥

7

Hi sreb,

Wow! I can understand both the pros and cons above and they all have valid points. It all depends though...I too think it can be differant for each indicidual and their circumstances...

Each individual is differant afterall and the reasons underlying the ED are also a big part of what needs to be dealt with during recovery. Many times these reasons are partly family aswell so especially in case like that i dont know who helpful getting the family involved would be. I know if i had been living with my parents it would not have helped. My husbands support on the other hand has been a whole differant story but even that was mere emotional support, just being there and pushing me along. He wasnt so involved as it describes above, i dont know if he could have handled it. U know there is also alot of emotion involved and it complicates things...

For me having to deal with actual life and recovery has been extremely difficult. Juggling the two at times can be very overwhelming and especially at the beggining there were times i felt i was going to fall apart into pieces. I didnt have a choice though, so i took what i could and have been making the best of it. Today i start feeling and seeing the positive results and it feels good but i do know that there were times i had hoped for inpatient or for anything that could just pick me up and take me out of everything else so i could just deal with ED recovery...

I think maybe a combination would sound more helfull, if i could had had that choice...

Very interesting topic here. Thanks for posting this.

Sending Love
Andrea

8

Hmm, Jan and Andrea, you have both touched upon issues which i want to comment on: the issue of which environment it is best to recover in.

Jan, i get what you say about taking someone out of theie environment. I often think it would be better for me in so far as it would allow me to focus on recovery in a more supportive environment. My concern (which does entail some fastforwarding) is that once i was 'recovered' to a sufficient degree, i would then have to return to the environment that i left, and pick up normal life. My concern with this is that a relapse would ensue. I know that in the recovery process, the aim is to teach you new tools, but i feel like this happens in a sterilised environment. Like not the real world of the person recovering. A temporary real world albeit, but not their normal one. I feel like i need to learn how to cope in my normal environment, cos that is what i will be returning to. Does that make sense?

Like i read here on this site and all too often elsewhere, about people being in and out of treatment centres, and then relapsing some months or even a year or more after. I am in no way making a judgement about that since I know and get that relapse happens and that it is not about treatment so much as how the individual gets on in treatment but i feel like what we need most, is to learn how to cope with our everyday world within that world. I am not saying i have the answer, nor have i ever been in a residential centre so it would not be fair of me to comment on it in that way.

Andrea, i get what you mean about wanting to be taken out of your environment. I was trying to recover and get on with things as normal and at a certain point, i couldn't do it anymore. I have had to let go of everything else because physically, i am not up to it as i used to be and i think emotionally, i am pretty fragile at the moment although i do not admit that to my nearest and dearest. I think your husband's approach sounds perfect. He did not charge in saying, do this and that. I love you but you must do what i say. Instead, it sounds like he was there to hold your hand and support you as you allowed him to which i think is the approach we need as adults and sometimes adolescents.

Jen, i have tons of respect for you and for everyone on here. You have been through so much and i think that you have handled things incredibly well. I get the whole trying to excuse your parents behaviour. I have done the same. I find this helps me deal with my anger more than just saying they did this and that and then wanting to have a go at them. The other reason i do that is because our parents and others in our lives sometimes do not get that they hurt us physically and/or emotionally and also, some of them will never acknowledge or apologise. But we still have to move forward and as you say, it is about acknowledging it and then dealing with the ensuing emotions. You are getting there and i read what you write about the work you are doing and i see how committed you are to this process. You don't talk about it. You do it. There's a big difference. We are all in different places on the journey and it is good to see people at all stages.

The final thing i wanted to mention was my alarm at reading about treatment centres as profit organisations. I have no idea how things work here or in the US so i am not sure how true it is but the idea that people profit out of the misery of others would be quite alarming. There seems to be so much variation in cost that there must be some individuals or organisations who are clearly in it for the profit. Please correct me if i am making assumptions. I just want to get a clearer picture of things. Nothing i am stating is fact. I am just writing about some things i have read and hoping others can shed more light on it and contribute to the topic.

Love to you all.

In awe of you all.

Sreb

9

Sreb, my dear friend. ♥ I hope you know how much I respect you! :) You always make me think!! And I LOVE that!! ♥ You are the ultimate teacher... Challenging us all to continue learning and growing. Considering other view points is always valuable. ♥

Love always,

Jen

10

Sreb...I do agree with the concept that you present. And you are correct, we DO have to go back to real life, and be able to deal with it. For me, I was never able to go back to MY real world and deal, because parts of MY world were part of what was maintaining my eating disorder. I realized that I could NOT go back to the same environment and stay alive, yet alone stay in recovery. I had to declare myself free from my past in many ways and venture into the unknown, and virtually start over in order to truly recover. I don't believe this is true for everyone, but I do think there is merit in looking at your life situation, and searching for things in that situation which could be harmful to your emotional health. It could even be certain people. It doesn't mean they are bad people, but it may mean that for YOU to recover and stay that way, you have to change the way you interact with them, or your environment.
I have seen very few people who are suffering from an eating disorder, who are able to fully recover without having some period of time 'away' from the pressures of their life in order to fully focus on recovery. The biggest reason is to normalize eating, and interrupting a cycle of b/p, or excessive exercise, or intense restricting, etc., often does require a major intervention such as a change in environment (treatment).
I believe that the PHP program style of treatment worked for me for just the reason you state. I was in a safe environment with guidance and support, but I went 'home' at night, and had some independence. For me, I didn't go 'home, but to an apartment, but still, it was not like an inpatient facility. I guess I also think that if there are factors in your life that you are struggling to deal with, and you have the option to move away from them (physically or emotionally), for your own good, why not? NO allegiance is worth giving your life for...except the ultimate sacrifice..and that's already happened. ♥

11

Thanks Jen.

That is very kind of you. I guess i just love learning.

Jan,
I agree that a different environment is sometimes necessary. I have often done better in terms of the ED when i have been away from home. It has still been lingering but perhaps less potent than it is now.

I can completely understand how you actually could not return to your previous environment. Makes complete sense and was a wise decision even. I think the idea of going back to an apartment rather than an inpatient facility also sounds much better.

I always have concerns about inpatient and the competitiveness which can sometimes happen with eds in these environments. I am not saying it always happens but speaking from my own groups experience, it is something which can happen subconsciously.

XXX

12

Sreb,
The underlying competition is a real issue. I think the answer comes with the people in charge,and what they will allow, and how they handle such occurrences. If everyone can see that it is detrimental to EVERYONE'S recovery it can help. I never experienced this to much extent at all, after coming to the River Centre.
I think it also comes back to confronting the issue with those who are stuck in that behavior..hard, but empowering. Yes, definitely something to consider.
Thinking of you today....Jan ♥

13

The physical changes we undergo in recovery can also make it difficult to stay... Not so much because others notice and comment, but because I, for one, am always afraid of what others are thinking... That has been the hardest thing for me... I know people at school notice. I know they notice at the Y. I wish that they didn't, but it's not their fault...

I met a girl in my new Monday night support group that recently moved to Houston. She got out of treatment a few months ago and needed a fresh start. I imagine that the pressure must be even greater for those that were inpatient. I, at least, have the SLIGHT reassurance that people have watched me regain my weight gradually... ♥

Love,

Jen