What map for finding ways out of the territory of eating disorders?

What map should we use to find ways out of this territory of eating disorders, a map that takes advantage of all the natural resources, shortens travel times and reduces risks?

The problem we deal with in this article is the one that arises when an eating disorder (ED) takes hold in a person and/or in a family. These disorders take various forms: anorexia nervosa (AN, 1 to 2% of female students), bulimia (BN, 3 to 5% of women) or eating disorders not otherwise specified (10 to 15% of women), that is to say those that do not meet all the criteria to be diagnosed as AN or BN, but present a good number of their characteristics. The factors common to all these disorders are an extreme preoccupation with weight and body image, and repeated weight-control practices.

What elements should be taken into account to understand the problem?

The following data, obtained in 1994 (2), should be kept in mind:

These data allow us to conclude that among the factors predisposing to the development of this problem are certainly:

The multidetermined nature of EDs means that none of these factors produces the disorder on its own. In each case, a singular combination is required of predisposing factors, precipitating factors (an increase in the stress proper to the life cycle, strict diets) and perpetuating factors (repeated weight-control practices: fasting, binge eating, purging, and their physiological and psychological sequelae).

Attempted solutions

Following our map, what we have just described as the factors of the ED could also be called the attempted solutions people use to solve the problem. Precisely, the problem (the need to control weight and figure) is perpetuated by the weight-control practices that seek to solve it: caloric restriction or strict diets, which lead to starvation if they are “successful,” or to binge eating as a natural physiological reaction to compensate for deprivation. Binge eating, in turn, leads to self-induced vomiting or to taking laxatives and/or diuretics as a psychological reaction to regain control, which legitimizes the start of a new cycle and, consequently, the loss of control.

The logic of the problem and beliefs

To continue the journey with our map, it is essential to discover the logic that links the problem to the attempts to solve it, because it is in this cognitive space that we will have to operate for actions to change. Seeing what is happening differently makes it possible to do something different about it.

Let us get acquainted with some of the individual, family and/or social beliefs on which the people involved rely to put this type of solution into practice:

• “Thinness is happiness, it gives you everything. Fatness is deplorable, it deprives you of everything.”
• “Control and self-discipline are expressed in Not-eating. Eating is synonymous with failure. If you respond to hunger, you lose control completely.”
• “My body betrays me.”
• “Recognition and affection depend on the shape and size of my body.”
• “Thin people are more popular and more successful.”
• “Men prefer them thin.”
• “I can’t rest until I have a perfect figure.”
• “Eating non-diet food in front of others is shameful, it changes my image.”
• “Being thin is a matter of willpower; obese people eat more than thin people.”
• “Obese people have more psychological problems than non-obese people and die younger.”
• “Treatments based on prolonged diets are effective,” etc.

From the family point of view, the ideas that support the actions seem more closely linked to:

Issues unresolved by the parents in managing their own body image, of which they are sometimes little aware, so that, on the one hand, they criticize their daughters’ physical appearance and push them to diet, but become contradictory when, frightened by the results the daughters obtain in their desire to please them, they find themselves obliged to hold them back.

Historical issues linked to this particular daughter, by which the current situation is justified or by which it is hoped that it will change: “poor thing, she has never been able to…,” “since she was born, she’s been the most fragile”; “she has never caused us any problems, she’ll get through it,” “I’m confident, she’ll get out of it on her own.”

The very onset of the disorder, which in fact alters previous ideas and interactions: “poor thing, she’s ill”; “I couldn’t eat like that either”; “nothing will make her change her mind”; “she always does whatever she pleases”; “I’m convinced I can’t help her,” etc.

First intervention: cognitive change

The first recommended intervention for producing the cognitive change that will make it possible to modify habits consists in giving the basic information that sheds light on the direct relationship between weight-control practices and the maintenance and worsening of the symptom, and which, at the same time, warns of the seriousness of the situation if it continues without being resolved. This reality is “hard,” it is not subject to redefinition and, given the risk to which the patient is exposed, it cannot be avoided. It is a matter of giving the family tools for change, a key function of the therapist.

The second intervention is almost simultaneous and consists in putting in place a physician responsible for the organic dimension, when there is none. Usually, in cases of AN, it is not the patients who consult, but their parents or the significant persons responsible for them. Passing this information on to them almost always makes possible a radical change in the ways of coping with the situation. They can begin to take things in hand more effectively, accompanied by the professionals, who give the instructions from a more peripheral position and, for that reason, one less exposed to confrontation from the patient.

In cases of BN and other varieties of ED, this information, conveyed through psychoeducational groups, usually counterbalances personal beliefs and those acquired through the media to such an extent that, once the cycle of five meetings is over, the state of the symptom shows a very significant reduction. From this experience, the treatment to be followed is redesigned, and it generally continues with structured family containment, with nutritional re-education with a specialist in the matter, and with the recommendation to join a peer group, designed for learning to solve problems, and not only eating problems.

All the work is done in close communication between the different professionals involved (general practitioner, nutritionist, gynecologist, psychotherapist and psychiatrist, when there is one), trying to ensure that it is, in one way or another, the professional toward whom the patient and/or the family have the strongest motivation who leads the strategy devised. For example: if the only reason the patient agrees to consult is to “get her period back,” we will then seek to mobilize motivation through the gynecologist, who is, in fact, the one with the most power to convince her. Or it will be the family therapist who is the explicit axis when the family arrives with the conviction that it is a psychological problem, even though the therapist’s first task is to convince them that the patient will get better by eating, or by giving up diets in order to put an end to the binge eating.

Designing the intervention

Finally, it is important to stress that, in our view, there are two fundamental axes along which the intervention is designed:

The idea is to go from less to more and, if hospitalization or day hospital are unavoidable, it is recommended to reintegrate the patients gradually into their family and social environment, in the shortest possible time. It is fundamentally in their own environment that the best possibilities for recovery are found; not occupying a central place in the recovery process makes the parents feel powerless, with the waste of resources that this implies.

We believe it is our duty to ensure that the therapeutic intervention (the journey through the troubled territory) is as brief as possible, and that “being in treatment” does not end up becoming a way of life or a substitute addiction.