National Eating Disorders Association

Getting a diagnosis is only the first step towards recovery from an eating disorder. Treating an eating disorder generally involves a combination of psychological and nutritional counseling, along with medical and psychiatric monitoring. Treatment must address the eating disorder symptoms and medical consequences, as well as psychological, biological, interpersonal, and cultural forces that contribute to or maintain the eating disorder.  

Nutritional counseling is also necessary and should incorporate education about nutritional needs, as well as planning for and monitoring rational choices by the individual patient. There are a variety of treatments that have been shown to be effective in treating eating disorders. Generally, treatment is more effective before the disorder becomes chronic, but even people with long-standing eating disorders can and do recover.

Treatment Process

Many people utilize a treatment team to treat the multi-faceted aspects of an eating disorder. Treatment teams commonly include the following types of providers: 

  • Physician (primary care physician, pediatrician, cardiologist, etc.) 
  • Psychotherapist 
  • Dietitian 
  • Psychiatrist 
  • Additional therapists as required (yoga therapist, art therapist, etc.) 
  • Case manager at your insurance company (if needed)

A large portion of eating disorder sufferers can be treated as outpatients, so make sure that your physician has experience with these conditions. Needing to seek a higher level of care is fairly common and not a sign that recovery is impossible. A primary care physician, such as a pediatrician, internist, or family doctor, may have referrals to local therapists and dietitians who have experience in treating eating disorders, as might other specialists like adolescent medicine physicians and gynecologists. Not all areas have such clinicians available, nor are all physicians familiar with eating disorder treatment. 

For individuals struggling with anorexia, the first step is restoring normal eating patterns and returning to a healthy body weight for that person’s individual shape and size. When someone is severely malnourished, it can be hard to make use of psychotherapy as the eating disorder interferes with a person’s ability to concentrate and change patterns of behavior. 

Although there may be exceptions, eating disorder treatment generally addresses the following factors in roughly this order: 

  1. Correct life-threatening medical and psychiatric symptoms 
  2. Interrupt eating disorder behaviors (food restriction, excessive exercise, binge eating, purging, etc.) 
  3. Establish normalized eating and nutritional rehabilitation 
  4. Challenge unhelpful and unhealthy eating disorder and ED-related thoughts and behaviors 
  5. Address ongoing medical and mental health issues 
  6. Establish a plan to prevent relapse

Levels of Care

Eating disorder treatment can be delivered in a variety of settings. The list below is ordered from least intensive to most intensive treatment levels.

Intensive Outpatient/Outpatient

  • Patient is medically stable and does not need daily medical monitoring
  • Patient is psychiatrically stable and has symptoms under sufficient control to be able to function in normal social, educational, or vocational situations and continue to make progress in recovery

Partial Hospital

Patient is medically stable but:

  • Eating disorder impairs functioning, though without immediate risk
  • Needs daily assessment of physiologic and mental status

Patient is psychiatrically stable but:

  • Unable to function in normal social, educational, or vocational situations
  • Engages in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques

Residential

  • Patient is medically stable and requires no intensive medical intervention.
  • Patient is psychiatrically impaired and unable to respond to partial hospital or outpatient treatment.

Inpatient

Patient is medically unstable as determined by:

  • Unstable or depressed vital signs
  • Laboratory findings presenting acute health risk
  • Complications due to coexisting medical problems such as diabetes

Patient is psychiatrically unstable as determined by:

  • Rapidly worsening symptoms
  • Suicidal and unable to contract for safety

For more details, see: APA Practice Guidelines for Eating Disorders, 3rd Edition

Types of Psychotherapy

Perhaps one of the most important considerations when selecting a psychotherapist is the type of therapy they provide. Different therapies work differently for different people, and some may be more helpful than others, depending on the person and their stage of recovery. Reducing eating disorder behaviors is generally considered to be the first goal of treatment, and the following therapies currently have the most evidence for effectiveness. Treatments are listed in alphabetical order.

Acceptance and Commitment Therapy (ACT). The goal of ACT is focusing on changing your actions rather than your thoughts and feelings. Patients are taught to identify core values and commit to creating goals that fulfill these values. ACT also encourages patients to detach themselves from emotions and learn that pain and anxiety are a normal part of life. The goal isn’t to feel good, but to live an authentic life. Through living a good life, people often find they do start to feel better.

Cognitive behavioral therapy (CBT) and Enhanced Cognitive behavioral therapy (CBT-E). A relatively short-term, symptom-oriented therapy focusing on the beliefs, values, and cognitive processes that maintain the eating disorder behavior. It aims to modify distorted beliefs and attitudes about the meaning of weight, shape, and appearance, which are correlated to the development and maintenance of the eating disorder.

Cognitive Remediation Therapy (CRT). CRT aims to develop a person’s ability to focus on more than one thing. CRT targets rigid thinking processes considered to be a core component of anorexia nervosa through simple exercises, reflection, and guided supervision. As of 2017, CRT is being studied to test effectiveness in improving treatment adherence in adults with anorexia; it has not been tested in other eating disorders.

Dialectical Behavior Therapy (DBT). A behavioral treatment supported by empirical evidence for treatment of binge eating disorder, bulimia nervosa, and anorexia nervosa. DBT assumes that the most effective place to begin treatment is with changing behaviors. Treatment focuses on developing skills to replace maladaptive eating disorder behaviors. Skills focus on building mindfulness skills, becoming more effective in interpersonal relationships, emotion regulation, and distress tolerance. Although DBT was initially developed to treat borderline personality disorder, it is currently being used to treat eating disorders as well as substance abuse.

Family-Based Treatment (FBT). Also known as the Maudsley Method or Maudsley Approach, this is a home-based treatment approach that has been shown to be effective for adolescents with anorexia and bulimia. FBT doesn’t focus on the cause of the eating disorder but instead places initial focus on refeeding and full weight restoration to promote recovery. All family members are considered an essential part of treatment, which consists of re-establishing healthy eating, restoring weight and interrupting compensatory behaviors; returning control of eating back to the adolescent; and focusing on remaining issues.

Psychodynamic Psychotherapy. The psychodynamic approach holds that recovery from an eating disorder requires understanding its root cause. Psychodynamic psychotherapists view behaviors as the result of internal conflicts, motives and unconscious forces, and if behaviors are discontinued without addressing the underlying motives that are driving them, then relapse will occur. Symptoms are viewed as expressions of the patient’s underlying needs and issues and are thought to be resolved with the completion of working through these issues.

Evidence-Based Treatment

It is important to note that while all of these therapies are frequently used to treat individuals with eating disorders, they have varying levels of efficacy and research supporting their use. Many professionals now recommend the use of evidence-based treatment, which is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” In eating disorder therapies, evidence-based treatment usually means that the therapy has been used in a research study and found to be effective in reducing eating disorder symptoms, encouraging weight restoration in underweight patients, and decreasing eating disorder thoughts.

Classifying a therapy as “evidence-based” doesn’t mean that it automatically works for everyone; just that it works for many patients. Do some research and evaluate which types of treatments would best target the relevant symptoms and psychological concerns. Also keep in mind that not all therapists who say they utilize a type of treatment actually use it in all of their sessions. Some CBT therapists, for example, might have a primarily psychodynamic approach and only occasionally use CBT principles. Ask about how strictly the therapist adheres to treatment guidelines, what a typical session might consist of, how much training the therapist has received in this particular treatment modality, the rough percentage of patients who they treat using this form of psychotherapy, and how current their ED knowledge base is.

References:

American Dietetic Association. (2006). Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders. Journal of the American Dietetic Association, 106(12), 2073.

Dare, C., Eisler, I., Russell, G., Treasure, J., & Dodge, L. (2001). Psychological therapies for adults with anorexia nervosa. The British Journal of Psychiatry, 178(3), 216-221.

Le Grange, D., Crosby, R. D., Rathouz, P. J., & Leventhal, B. L. (2007). A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Archives of General Psychiatry, 64(9), 1049-1056.

Lock, J., Le Grange, D., Agras, W. S., Moye, A., Bryson, S. W., & Jo, B. (2010). Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Archives of general psychiatry, 67(10), 1025-1032.

Peat, C. M., Shapiro, J. R., Bulik, C. M., & Brownley, K. A. (2014, January). Evidence based treatments for eating disorders: Children, adolescents and adults. In Nova Science Publishers, Inc..

Peterson, C. B., Becker, C. B., Treasure, J., Shafran, R., & Bryant-Waugh, R. (2016). The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives. BMC medicine, 14(1), 69.

Rome, E. S., Ammerman, S., Rosen, D. S., Keller, R. J., Lock, J., Mammel, K. A., ... & Schneider, M. (2003). Children and adolescents with eating disorders: the state of the art. Pediatrics, 111(1), e98-e108.

Shapiro, J. R., Berkman, N. D., Brownley, K. A., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Bulimia nervosa treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 321-336.

Walsh, J. M., Wheat, M. E., & Freund, K. (2000). Detection, evaluation, and treatment of eating disorders. Journal of general internal medicine, 15(8), 577-590.

Wisniewski, L., & Kelly, E. (2003). The application of dialectical behavior therapy to the treatment of eating disorders. Cognitive and Behavioral Practice, 10(2), 131-138.