National Eating Disorders Association

Getting a diagnosis is only the first step towards recovery from an eating disorder. Once you have a diagnosis, the next step involves identifying availability of clinical resources for treatment. Several major factors will likely play a role in determining the best type of treatment for your family member:

  • Specific eating disorder diagnosis
  • Medical/psychiatric status
  • Location in the country
  • Availability of local experts and programs
  • Insurance coverage
  • Ability to pay in the absence of insurance
  • Family/patient preferences on the most appropriate type of treatment
  • Likelihood of recovery in outpatient treatment

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)

For more information on different types of treatment, see the glossary on page 41 at the end of this section.

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.

If you can’t get any referrals from your physician, there are still some ways to find good treatment providers. The following websites have lists of outpatient therapist and treatment programs that address eating disorders:

Local colleges and universities may have lists of nearby therapists for students with eating disorders, so it might be worthwhile to call their counseling or health center to ask for a referral. Larger treatment programs in your state or bordering states may also have a network of therapists and treatment providers who work with eating disorders.

Types of psychotherapy

Perhaps one of the most important considerations when you and your loved one select a psychotherapist is the type of therapy they provide. Different therapies work differently for different people, and some may be more helpful than others for where your loved one currently is in their 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.

Family Based Therapy (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.

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.

Interpersonal Psychotherapy (IPT). This is a shortterm individual psychotherapy. It is premised on the theory that interpersonal difficulties contribute to the onset and maintenance of eating disorder symptoms, and that their resolution will promote recovery. It has predominately been applied to treatment of bulimia nervosa and binge eating disorder, and focuses on interpersonal difficulties rather than behavioral aspects of disordered eating.

In addition to the above evidence-based treatments, the following (listed in alphabetical order) are commonly used to help eating disorder sufferers move towards recovery.

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.

Behavioral Systems Family Therapy (BSFT). Parents are coached to help the sufferer restore adequate nutrition and eat regular meals and snacks. BSFT also broadens the focus of treatment to include cognitions and problems in “family structure” while the parents are still in charge of the re-feeding process.

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. CRT is currently being studied to test effectiveness in improving treatment adherence in adults with anorexia; it has not currently been tested in other eating disorders.

Conjoint Family Therapy (CFT). This is a therapeutic approach that treats the entire family, including the eating disordered member, simultaneously. The premise of CFT is that the client exists within a family and spends most of their time with them. Focus is on improving family dynamics that may be contributing to maintaining the eating disorder.

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 Systems Therapy (FST). FST emphasizes family relationships as an important factor in psychological health. Therapy interventions usually focus on relationship patterns and communication rather than on analyzing impulses or early experiences that may have contributed to development of the ED. Family Systems Therapy is different from FBT in that it focuses on the interactions between family members as a way to improve eating disorder behaviors.

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 disappear with the completion of working through these issues.

Separated Family Therapy (SFT). In SFT, the adolescent is seen on his or her own and the parents are seen in a separate session by the same therapist. This differs from Conjoint Family Therapy (CFT) where the patient and family are seen together. Both are effective, but the separate parallel sessions in SFT are favored in cases where there is a high degree of hostility or parental criticism.

(some definitions adapted from FEAST’s Glossary of Eating Disorders.)

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.

Some trials of eating disorder psychotherapies are small and are not necessarily compared to other forms of psychotherapy, which can make it difficult to compare the efficacy of various treatments. Other factors that make testing ED therapies difficult include the relative rarity of eating disorders, high patient drop-out rates, and large costs. Generally speaking, CBT, DBT, ACT, and FBT are currently some of the best-studied commonly-used eating disorder treatments supported by several different studies around the world.

It’s important to remember that just because a therapy is classified 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 symptoms and psychological issues being faced by your loved one. 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. So be sure to 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.

Selecting a psychotherapist

Just as not all psychotherapies are created equal, not all therapists are created equally either. It matters less how long a specific therapist has been practicing and more on how skilled they are at treating eating disorders and how up-to-date their knowledge is.

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

Questions to ask when interviewing a therapist

  • How long have you been treating eating disorders?
  • What are your training credentials? Have you received specialized training in eating disorders?
  • Are you a member of any eating disorder professional organizations?
  • What do you think causes eating disorders?
  • What do you think needs to happen in order for my loved one to get well?
  • How will I be involved in my loved one’s treatment?
  • How would you describe your treatment style?
  • What forms of psychotherapy do you use?
  • What happens during a typical psychotherapy session?
  • How will you evaluate my loved one and develop a treatment plan?
  • What are the goals of treatment?
  • When can I start to expect seeing progress?
  • When will I be notified if my loved one is not making progress?
  • How often will progress be communicated?
  • What are the criteria you use to determine whether a treatment is working?
  • How long will you give a treatment to start working before you re-evaluate?
  • If my loved one doesn’t respond to the first form of treatment, what steps would you recommend?
  • What kind of medical information do you need about my loved one before treatment begins and as therapy is ongoing?
  • How will you work with other members of the treatment team? How frequently will you share information? How will you do this (email, phone, etc)?
  • Are you able to communicate with my loved one’s school should the need arise?
  • What are your thoughts on psychotropic medication?
  • What is the best way to communicate with you between sessions?
  • Do you charge for phone calls or emails between sessions? How is that billed?
  • How do you handle medical or psychiatric emergencies?
  • What are some warning signs of immediate danger that I should be aware of?
  • What are your criteria for moving a person to a higher level of care?
  • What is your appointment availability? Do you have evening or weekend appointments?
  • How long does each session last?
  • How frequently will you need to see my loved one?
  • How often will you meet with me/us as parents?
  • Do you accept my insurance? If not, what do you charge?
  • Do you deal directly with the insurer or do I need to do that?
  • Do you have a sliding scale?
  • When is payment due?

The availability of eating disorder therapists can vary widely depending on location, as can an individual’s insurance benefits. It may take a bit of persistence to find a treatment provider who will work well with your family, provide effective treatment, and also accepts insurance or is otherwise affordable. Many families have found that they need to travel a bit to find good treatment, but that excellent care is worth the hassle.

Medication for Eating Disorders

Besides psychotherapy, medication is probably one of the most commonly used forms of eating disorder treatment. It is rarely used as a stand-alone treatment, but generally is meant to help relieve symptoms of cooccurring disorders like depression and anxiety, as well as reduce the discomfort (physical and mental) caused by normalizing eating. Only one medication has been approved by the FDA to treat bulimia nervosa, and very few have been approved for weight management in overweight individuals. Nevertheless, medications are commonly tried in combination with psychosocial interventions for patients with the range of eating disorders.

Medication names: Generic (Brand)

Frequently prescribed for eating disorder patients

  • Selective Serotonin Reuptake Inhibitors (SSRIs)
    • Fluoxetine (Prozac, Sarafem) **This is currently the only FDA-approved medication to treat an eating disorder, and is approved for the treatment of bulimia
    • Citalopram (Celexa)
    • Escitalopram (Lexapro)
    • Fluvoxamine (Luvox)
    • Paroxetine (Paxil)
    • Sertraline (Zoloft)
  • Serotonin and Noradepinephrine Reuptake Inhibitor
    • Duloxetine (Cymbalta)
    • Venlafaxine (Effexor)
    • Desvenlafaxine (Pristiq)
  • Aminoketone
    • Bupropion (Wellbutrin, Zyban): Now contraindicated for treatment of eating disorders because of several reports of drug-related seizures among individuals with bulimia nervosa.
  • Benzodiazepines
    • Alprazolam (Xanax)
    • Chlordiazepoxide (Librium)
    • Clonazepam (Klonopin)
    • Diazepam (Valium)
    • Lorazepam (Ativan)
  • Atypical Anti-psychotic Medications
    • Aripiprazole (Abilify)
    • Olanzapine (Zyprexa)
    • Quetiapine (Seroquel)
    • Risperidone (Risperdal)
    • Ziprasidone (Geodon)

Less frequently prescribed for eating disorder patients

  • Tricyclics
    • Amitriptyline (Elavil)
    • Clomipramine (Anafranil)
    • Desipramine (Norpramin, Pertofrane)
    • Imipramine (Janimine, Tofranil)
    • Nortriptyline (Aventyl, Pamelor)
  • Modified Cyclic Antidepressants
    • Trazodone (Desyrel)
  • Monoamine Oxidase Inhibitors
    • Brofaromine (Consonar)
    • Isocarboxazide (Benazide)
    • Moclobemide (Manerix)
    • Phenelzine (Nardil)
    • Tranylcipromine (Parnate)
  • Tetracyclic Antidepressants
    • Mianserin (Bolvidon)
    • Mirtazapine (Remeron)
  • Mood Stabilizers (also used for anti-binge properties, especially those at higher weights)
    • Lithium carbonate (Carbolith, Cibalith-S, Duralith, Eskalith, Lithane, Lithizine, Lithobid, Lithonate, Lithotabs): Used for patients who also have bipolar disorder, but may be contraindicated for patients with substantial purging.
    • Carbamazepine (Equetro, Tegretol)
    • Divalproex (Depakote)
    • Lamotrigine (Lamictal)
    • Oxcarbazepine (Trileptal)
    • Topiramate (Topamax)
    • Calproate (Depakene syrup)

Other therapies to consider

Some people with eating disorders find benefit from alternative or adjunct therapies. Many of these types of therapies don’t have a lot of research supporting them, but many sufferers report finding them useful. Consult with your treatment providers and your family member to determine whether any of these might be helpful for your loved one.

  • Art therapy
  • Biofeedback
  • Coaching
  • Emailing for support or coaching
  • Equine-assisted psychotherapy
  • Eye movement desensitization (EMDR)
  • Exercise
  • Hypnotherapy
  • Journaling
  • Massage
  • Meditation
  • Movement therapy
  • Psychodrama
  • Relaxation training
  • Yoga