Charting Changes in Diagnosis and Treatment
Reprinted from Eating Disorders Review
March/April Volume 25, Number 2
At the International Association of Eating Disorders Professionals (iaedp) meeting February 27-March 2, at the TradeWinds Island Resort, St. Petersburg, FL, more than 500 attendees were challenged with new treatment approaches, compelling patient histories of recovery, and the latest findings from genetics research. The conference theme, “Waves of Change,” reflected the rapidly changing field of eating disorders diagnosis and treatment.
A New Center Focusing on Family Therapy
Craig L. Johnson, PhD, FAED, CEDS, Chief Clinical Officer at the Eating Recovery Center, Denver, presented on the use of family-based therapy (FBT).
In his keynote presentation and at a three-part workshop, Dr. Johnson told attendees about a number of well-known treatment models, including Structural, Systematic, Maudsley and FBT. New technologies are helping families find sources of support among themselves, said Dr. Johnson, who has been treating eating disorders patients for more than 30 years. He then described the development of family therapy and the role of advocacy groups from the 1960s through 2010.
Data from several studies, particularly the NIMH Collaborative Study by Lock et al. (Int J Eat Disord 2012; 45:202) have shown that with behavioral family therapy adolescent patients had lower treatment dropout rates, lower rates of relapse, and patient and parent satisfaction with treatment was good. Overall, FBT was superior to comparison interventions at the end of therapy and follow-up.
Dr. Johnson listed four positive predictors for successful FBT: younger teens (15 years of age or younger), a shorter duration of illness (less than 13 months), mild-to-moderate weight loss (89% of ideal body weight, or IBW), and parental expressions of warmth. Conversely, negative predictors for FBT included a history of low weight (<80% of IBW), older teens with a longer duration of illness, and psychiatric comorbidity. Other factors with negative effects included high levels of parental criticism and patients’ failure to increase their weight by about 3% shortly after the beginning of therapy. Patients with obsessive-compulsive disorder and those from non-intact families need more treatment, he said.
Eating Disorders Pose Challenging Legal and Ethical Issues
John Dolores, JD, PhD, Director of the Center for Hope of the Sierras, Reno, NV, noted that clinicians treating clients with eating disorders must deal with unique legal and ethical issues surrounding confidentiality, informed consent, protection of medical records, and multiple relationships with other medical professionals. One challenge is keeping up to date with the legal aspects of care and also with changing technology.Dr. Dolores also pointed out that ethical codes vary among various professional organizations, such as the American Psychiatric Association, the American Medical Association, and the National Association of Social Workers.
Some practice pointers for inter-professional relationship ethics include: obtaining releases for all procedures, contacting each department to obtain records, discussing the diagnostic impression, and developing a treatment plan. It is important to be clear and consistent about who is the client and what is your role as clinician and therapist, he added.
Dr. Dolores also touched upon the Omnibus Rule involving the Health Insurance Portability and Accountability Act (HIPAA) and the Code of Federal Regulations (CRF) 42 CFR, for Substance Abuse and Confidentiality. The Omnibus Rule, which went into effect in late September 2013, prohibits selling patient health information unless authorized, expands reporting duties, and allows stricter penalties for violating patient confidentiality. These regulations dictate who has access to individual patients’ health information (no one unless specifically authorized) and includes stricter penalties for not complying with the regulations and wider reporting duties.
Dr. Dolores told workshop attendees that it is important to use an evidence-based approach for informed consent. For example, when discussing treatment options with a client, it is important to disclose the effectiveness of the treatment based on empirically validated research, instead of using the old phrase, “In my experience…” And, when non-empirically validated treatment is offered, this should be disclosed to the client, and alternative treatment options discussed. The agreement about consent to the treatment must be reasonably understandable to the patient. For compulsory treatment, the patient’s identity must be protected. He added that “A signed form is not a substitute for consent.”
As for medical records, a client cannot dictate what goes into the medical record. He advised attendees to use comprehensive documentation, including the rationale for treatment selected and why an alternative treatment or treatments were not chosen. Other recommendations included the fact that medical records should reflect professionalism and relevancy to the case. Records should be accurate and never tampered with. Follow-up information should also be in the medical record, he added.
The process of terminating tratment is another challenging area. Some justifiable reasons for terminating treatment include the fact that the client is not benefitting from treatment and may be harmed by it. Or, the client no longer requires treatment, or has threatened the provider and/others. In contrast, “abandonment” occurs when needed treatment is inappropriately halted. Clinicians should also make sure to discuss financial issues in advance. Termination calls for reasonable notice, which is usually considered to be about 30 days, and the treatment recommendations, resources, and medical records are part of the documentation needed to accompany treatment termination.
When the patient terminates treatment in a non-crisis situation, all of the steps for physician termination apply, except the 30-day notice. In addition, when the client is in a crisis situation, the provider must act to resolve this crisis if possible.
Dr. Dolores also touched upon the importance of securing email systems with an organization’s IT professionals, and applying reasonable safeguards to Internet communications. Encryption is particularly important in client-to-client communications, he said.
Eating Disorders, Self-Harm, and Trauma
According to John L. Levitt, PhD, Clinical Director at Linden Oaks Hospital, Naperville, IL, when a patient has an eating disorder combined with a history of trauma and self-harm, clinicians have to work with the “darker side” of a patient’s profile, including dissociation, intense self-loathing, anger, and hatred. The key is to use a treatment approach that is both flexible yet structured enough to guide clinical decision-making because it will be necessary to treat both the eating disorder behaviors and the darker and more challenging emotional states. Dr. Levitt has treated such complex patients for more than 30 years.
At a workshop, Dr. Levitt noted that the Structural Process Model empowers such patients to learn ways to take control and to eventually discover their own healthy power and control. As Dr. Levitt explained, empowerment is not something the therapist does to the patient; instead, it is the result of repeatedly observed, discussed, and enacted interactions that lead to the patient discovering his or her own power and capabilities. In this way the patient becomes the “expert” in his or her recovery
The focus is also on the role emotions may be playing because emotions directly or indirectly impact our relationship with ourselves, our environment, and with others, he said. For patients with eating disorders with self-injury, substance abuse, and traumatic disorders, their emotions are often a mystery. Dr. Levitt said the Structural Process Model uses education and training to help organize the therapeutic environment in ways that make sense to the patient. Patients learn to use their own thoughts, skills, and abilities to accomplish their goals. At the same time, Dr. Levitt said, that the therapist has to respect patients’ right to decide not to change.
Therapy also is focused on helping patients learn to self-regulate and to use self-care, which is regularly discussed and focused on and actually used as a metaphor for recovery. Patients are repeatedly encouraged and directed to be actively involved and to be their own guardians. Dr. Levitt said, “We want to help the patients to establish how the behaviors and patterns fit into their lives, and to examine their purpose and meaning for the patient.” And, he said, the goal is helping patients understand that when discussing their patterns, this refers to all of the compensatory behaviors used to self-regulate, and these are not discrete or separate entities.
Dr. Levitt also noted that clinicians must ask themselves some difficult questions when first confronted with such patients. They must be prepared not to treat a patient but also not to “dump” them on colleagues just because the patient is difficult. Another misstep is to treat a patient for a time who really should be receiving treatment in another setting. Other difficult questions a clinician must address are: Can one ethically and legally agree not to treat a patient? And, if the clinician agrees to treat the patient, what approach will be taken? Since not all patients should be treated when they first present, it is important to assess whether this is a patient to take on or continue with, and to have identifiable criteria at the beginning, Dr. Levitt said. One must also carefully assess whether a patient is prepared to change or is merely contemplating it. What are the options to not receiving treatment, and what is the risk in managing the patient? Final critical questions a clinician must ask are: Am I prepared to work with this patient for potentially long periods of time and to experience the onslaught of their pain, terror, and anxiety?
The Father-Daughter Relationship in a Developing Country
Faced with a lack of resources, two eating disorders professionals from Jamaica demonstrated some of the innovative ways they approach and treat eating disorders patients. Jamaica has no eating disorder treatment centers, and only three only three specialists are trained to treat eating disorders.
In their workshop session, Caryl James, a clinical psychologist and eating disorder specialist at the University of the West Indies, Mona, Jamaica, and Abigail Natalie Harrison, a consultant pediatrician and adolescent medicine specialist at the University of the West Indies, noted that in addition to the lack of resources, many professionals, such as Jamaican sociologists, for example, do not recognize there is a problem. In addition, cultural myths work against diagnosis and treatment.
Jamaica is primarily a matriarchal country, Drs. James and Harrison said, and although the mothers were very adept at providing normal care for their sons and daughters, they were largely unable to effect lasting change in their children’s eating disorder. However, once Drs. James and Harrison approached the fathers and involved them in their children’s care, treatment was more successful. Once the fathers realized the children were ill, they connected and cooperated well with the therapists.
(In the next issue, more highlights from the iaedp meeting, including on binge eating disorder, Acceptance and Commitment Therapy, and the challenge of treating binge eating disorder.)