Let’s Get Real About the Future of Eating Disorder Treatment; How Far We've Come - Dr. Emmett Bishop
This is the third piece of a three-part series acknowledging the serious nature of eating disorders and how little was known about helping people with eating disorders in the past.
Today’s blog shares insight. Before the 1970s and 1980s, little was known about eating disorders. Eating disorders were present, of course, but they were not identified as such or treated appropriately.
Eating Recovery Center’s Dr. Emmett Bishop shares a brief history of how far the field of eating disorder treatment has come, how therapy for eating disorders has evolved — and where the field is going:
Early 1900s – At the start of the 20th century, where today’s story begins, eating disorders were considered an endocrine disorder — not a psychiatric disease. One thing that often gets left out of the history of eating disorders is that anorexia fell under the field of endocrinology for at least the first half of 1900s. Professionals believed it to be related to a pituitary disease called Simmonds’ Disease.
“Parentectomy” was also considered an appropriate treatment for anorexia nervosa at this time and even well into the 20th century. Essentially, a person with an eating disorder would be separated from the parents as a “cure.” A receptionist who worked at my medical school had an eating disorder when she was younger, and she was removed from her parents’ home. She was then hired by the treating doctor and considered “cured” of her eating disorder. At the time, some case studies showed that patients with anorexia who were separated from their parents tended to do well. Nowadays we do the opposite — we get the parents educated and involved.
1940s – In the 1940s, illnesses that we now recognize as eating disorders — that were largely misunderstood at the time — started to be treated in the field of psychiatry.
1970s – In the 1970s, when I did my residency, the medical community was largely influenced by psychoanalytic theories regarding patients with eating disorders. In 1973, Hilde Bruch published her seminal book Eating Disorders: Obesity, Anorexia Nervosa and the Person Within.
The following year, in 1974, I saw my first patient with an eating disorder. Eating disorders were so rare at the time that my supervisor said to me, “you’ll never see another case like this.” I took a strong interest in this patient’s illness (anorexia nervosa) and started to read everything I could read about eating disorders and related issues.
In 1979, a medical student asked to do a research elective on bulimia. At the time, bulimia was not well-understood. It was not even considered a distinct illness yet — it was just a symptom observed in certain individuals.
My student found a total of eight cases of bulimia in a large database of patients and set out to intensively study these patients and the literature. The patients were similar to those described by Gerald Russell in the defining article on Bulimia Nervosa, “Bulimia Nervosa: An Ominous Variant of Anorexia Nervosa,” that year.
1980s - I decided to leave academia in 1980. We were getting flooded with patients with eating disorders in private practices. A nurse, who was in recovery from anorexia, came up to me and said, “These individuals need our help.”
At the time, back in the early 1980s, the typical treatment for anorexia nervosa was to lock patients in a Geri chair where we would feed them their meals. As you can probably surmise, this was a horrible treatment option. Knowing that we could do better, I set out to intensively research possible treatment options for people with eating disorders. Here are some of the interventions we started at the time:
- Intensive outpatient therapy
- Exposure therapy
- Group therapy, including Food Phobia groups
- Meal therapy where healthcare professionals would work with and supervise patients during mealtimes
- Cognitive Behavioral Therapy (CBT)
In the mid 1980s, hospitals started to approach me to help them start programs to effectively treat people with eating disorders. I started an Inpatient Treatment facility in Georgia and practiced there for many years.
My training was primarily in Psychoanalytic/Psychodynamic therapy — but I saw that this would not work for eating disorders. I realized that I was going to have to train myself as a behaviorist. I started researching CBT and read everything I could on this subject. But, I was also frustrated with CBT as it was hard to do with many of my patients who had certain resistant temperament and character traits. For example, CBT didn’t work well for people who had low self-directedness, a trait very common in our patients.
1990s – In 1993, we started using Dialectical Behavior Therapy (DBT) as our major treatment approach. DBT was a treatment primarily designated for borderline personality disorder, but the central feature of helping a person manage their emotions — reining in emotionally-driven behavior and helping to direct their behavior towards their goals — was proving to be very helpful for patients with eating disorders.
We noticed that our patients had trouble finding motivation to change or recover, partly because eating disorders were numbing or inhibiting emotions. For instance, an anxious person could use the eating disorder to calm down. In this way, the eating disorder was helping to manage certain difficult emotions.
We observed that if you take the eating disorder away the patient would start to feel all their emotions again — both pleasant and unpleasant emotions. So, our patients were reporting to us that when they gave up their eating disorder, they felt worse. This was a big hurdle to overcome at the time. The eating disorder was their identity.
2000s - In 2003, I moved to Denver to join Dr. Ken Weiner in a Partial Hospitalization Program for eating disorders. We started using DBT with our patients in Denver and it helped a lot with recovery.
In 2004, we piloted Acceptance and Commitment Therapy (ACT) with patients and we saw impressive results. The motivator — the key that had been missing from treatment — was helping patients identify what they really valued. Instead of just talking about getting rid of problems, we talked about moving towards what they wanted in life. Instead of being driven by their anxiety and avoidance of pain, they were driven towards their values. I’d say that this was when we really “woke up” — and treatment really improved. We would tell them, “You must move from experiential avoidance to valued living.”
Even the toughest patients, once they could identify what they valued, turned around.
Values absolutely changed the context of treatment. Patients realized then that an eating disorder was a big obstacle to valued living.
In 2008, Eating Recovery Center opened. The combined knowledge of our clinical staff helped to create a center that had a depth of expertise and could treat very severe cases.
At this time, we converted our treatment model in our adult eating disorder treatment programs to ACT. While we still use skills from CBT and DBT therapeutically, ACT provides the theoretical framework for us to understand what the processes are that help people to get well. We also focus on the caregivers and support system as the agents of change and healing through our commitment to a variety of family treatment methods (including Family Systems, Family Based Treatment, and Emotion Focused Family Therapy).
21st Century - Looking forward
While we have made many strides in working with people with eating disorders, we are still looking at a number of novel treatment options. In particular, we are looking for ways to work with what I call “outlying” patients. These individuals seem to be wired differently and do not respond to treatment as usual.
One of the possible treatments on the horizon is repetitive transcranial stimulation (rTMS) for symptoms of anorexia.
Personally, I am also very interested in learning more about assessments that can help us measure experiential avoidance — which is very common in patients with eating disorders. We have revised the Acceptance and Action Questionnaire for Weight related issues (AAQW-r) and have found it very helpful in monitoring the progress of the patient.
Today, eating disorder treatment encompasses a holistic model that addresses multiple approaches — medical, psychological, nutritional, and more. Overall, I have high hopes that we will develop more evidence-based treatment further integrating these components of recovery especially with the bright young talent entering the field.
Learn More About the History of Eating Disorder Treatment
Blog 1: Anorexia: The Deadliest Mental Illness
Blog 2: A Brief History of Eating Disorders
Blog 3: A Search for Effective Eating Disorder Treatment: How Far We’ve Come with Eating Recovery Center’s Dr. Emmett Bishop
Emmett Bishop, Jr., MD, CEDS, FAED, F.iaedp is Founding Partner at Eating Recovery Center.