Treatment & recovery
Recovery from an eating disorder will never be easy, never be short, and never be painless. The gaining of weight, or relinquishing of unhealthy eating behaviour is a slow, long, arduous struggle full of emotional turmoil. The strength and mental willpower an individual needs to break free from their illness is immense. An individual cannot recover without support and guidance. For some, breaking free from an eating disorder may be their toughest challenge in life. They will feel lost, alone, and vulnerable.
Recovery is complex. Not only does an individual have to rebuild their body physically, they also have to rebuild themselves psychologically. They have to find the necessary skills and tools to cope with life and its resulting emotions without depending on their eating disorder.
A regular and balanced eating pattern needs to be established and underlying emotional problems need to be explored, addressed and resolved. Weight gain in anorexia, or breaking the binge-purge cycle in bulimia, are both long processes. Setbacks are common and at times, progress is invisible, but recovery is achievable.
There is considerable evidence to show that the earlier treatment begins, the more successful it will be, but the first signs of an eating disorder are subtle and are often meticulously concealed by the sufferer (see signs of an eating disorder page).
The longer an individual lives in secret with their illness, the higher the chance it will plague them for the rest of their lives and that treatment will be less successful. With time, distorted body image and low self-esteem become deep-rooted behaviours and habits become ingrained, and feelings and emotions fixed. The treatment response of adults with anorexia is much less positive than for adolescents: only about a third are in remission after one year of specialist outpatient psychological treatment and up to 50 per cent of those who remit, relapse, many within the first year after treatment.
Specialised services for eating disorders offer the best support: however, many parts of the UK have little or no designated NHS specialist services for eating disorders.
This means that many anorexia patients in particular are often admitted to and spend lengthy periods of time in non-specialist units. It is estimated that 35 per cent of people with anorexia seen in non-specialist child and adolescent mental health services are admitted to hospital, whereas for those who are seen in specialist adolescent eating disorder services, the admission rates are around 10 per cent.
The Section of Eating Disorders and other research groups are constantly developing and trialling new treatments, and developing ways those treatments can be used by non-specialist health professionals. Visit our research pages to find out more about our work in this field.
Guidelines on treatment for eating disorders provided by the National Institute for Health and Clinical Excellence tell you what you can expect from the NHS. Please visit NICE for a downloadable leaflet.
For further information about treatment and recovery options can be found below:
First step: acknowledging that eating is a problem
The role of GPs
The first, and perhaps most difficult step in treatment, is for the individual to acknowledge that eating is a problem. They have to want to change their life and give up their illness. Ambivalence will lead to an incomplete recovery or relapse.
People with anorexia nervosa highly value their undernourished state and are typically reluctant to contemplate change. In contrast, family members are usually desperate for change. This discrepancy, together with the often life-threatening nature of the illness, makes treatment of anorexia an extremely challenging task.
Many young women with bulimia do not acknowledge there is a problem because they are ashamed about their abnormal eating habits. When Princess Diana publicly spoke about having bulimia, many more women sought help: a study of the numbers of women visiting their GPs to talk about their eating disorder showed the total increased when reports of Diana’s battle with bulimia hit the headlines in 1992 – and began to fall again after her death in 1997. It is now estimated that only one in 10 adolescents with bulimia seek help.
A GP is normally the first point of access to NHS services. He or she will be able to confirm the diagnosis of an eating disorder, assess its severity and evaluate the best course of action.
From this point, most individuals are referred to a psychiatrist or a psychologist, or to a community mental health team (see Getting help pages). Some areas of the country have specialist eating disorders services, but many do not.
Research has shown that people with anorexia consult their GP significantly more often than other people over the five years prior to diagnosis with psychological, gastrointestinal or gynaecological complaints.
A single consultation about eating or weight/shape concerns is a strong predictor of the subsequent emergence of anorexia.
There are sometimes considerable delays between first contact with a GP and the point where appropriate help becomes available and it is important that families are persistent in their request for referral.
Inpatient treatment and day care
More often than not, someone with eating disorders will see a therapist who may be a nurse, psychiatrist or psychologist on an outpatient basis. Their weight will be closely monitored.
For anorexia, treatment will include helping to devise a comfortable and safe weight-increasing diet.
In bulimia, the focus will be on dispelling the conviction that eating three meals a day, without the use of weight controlling measures, will lead to weight gain.
There may be sessions with a psychotherapist who will aim to help an individual express their emotions and feelings without using food.
The idea is that an individual will be helped to come to terms with any problems they may be avoiding and learn how to cope with stress, anxiety, guilt or negativity in a less destructive way.
If outpatient treatment is proving unsuccessful, or if the psychiatrist or psychologist feels a greater level of support is needed, someone with anorexia may be admitted to hospital, either to a non specialist or specialist bed. Day care or inpatient beds are available in specialist eating disorder units.
Day care means patients attend the programme for a few days a week, but spend nights at home.
Inpatient care means they remain in hospital full time. Days consist of regular and supervised meals and snacks, with trained nursing staff offering encouragement and support to master high levels of anxiety and the refeeding problems that can arise. Care is individualised and it may includes restrictions on exercise, supervision with nursing staff after meals to prevent vomiting and restricted access to kitchen and food supplies to stop bingeing. Food is interspersed with an intense therapy programmes, including group therapy with other patients, individual therapy and family therapy, involving parents, siblings and partners and which focuses on the cognitive emotional and interpersonal factors that maintain the disorder.
New forms of treatment
There may be a range of treatment approaches, including:
- motivational therapy,
- cognitive behaviour therapy,
- interpersonal therapy,
- drama therapy,
- art therapy, and
- occupational therapy
One of the aims of any sort of therapy is for the individual to be able to reflect clearly on their thoughts, emotions, and state of mind, and to understand its strengths and weaknesses and work with it for optimal function. Different treatments use different strategies for reaching this understanding.
For some people, using words and talking is important. For others, using movement or other forms of expression can help emotional understanding and processing. It is not easy to predict what will work, when and for whom. Often for severe cases that need inpatient treatment, a variety of strategies are used.
For bulimia, cognitive behavioural therapy (CBT) is the psychological therapy most often used and guided self-care using CBT techniques is often the first step in treatment. Self-monitoring techniques, such as food diaries and thought records, are widely used.
Working with families
New forms of treatment are being developed and tested by the Section of Eating Disorders and other research groups. Visit our research pages to find out more about new treatments being developed and tested.
In outpatients we offer MANTRA (Maudsley Model of Anorexia Treatment for Adults). In inpatients we offer Cognitive Remediation treatment (CRT) or Cognitive Remediation and Emotional Skills Training (CREST).
These therapies involve tackling the factors that researchers have found instrumental in the maintenance of anorexia:
Another new set of therapies is for people with bulimia or binge eating disorder and includes on-line cognitive behavioural therapy and a novel group-based therapy (Emotional and Social Mind Training).
- perfectionist/rigid personality traits;
- anxious/avoidant personality traits;
- different ways of processing thoughts and emotions;
- beliefs about the value of self-starvation in helping them manage difficult emotions and relationships; and
- an inadvertent unhelpful response of people close to them who may want to be supportive, but do not know how to.
Support for care givers
Most good practice in the UK recognises that it is helpful to work with the family as a team to overcome the problems caused by the eating disorder.
The exact way in which this team work occurs varies and depends on the patient (it is more usual to work closely with the family in younger cases) and the therapeutic team – some units have family therapy, others offer parental counselling with our without specific advice for carers, others offer family group treatments.
We know from our research into the treatment of adolescents that targeted family based interventions, aimed at mobilising the family’s own resources, are an effective alternative to inpatient treatment for younger people with anorexia, lead to high rates of long term recovery and low rates of relapse. Most of the work on developing family based treatments for anorexia was originally undertaken by researchers working at the Institute of Psychiatry , Psychology & Neuroscience and Maudsley Hospital.
However, they may be various reasons why families are sometimes not involved in treatment. There may have been unsuccessful or aversive family therapy in the past; the patient may feel that she is being selfish in asking the family to come, and that the illness is her responsibility and must cope alone; the patient may have communication problems and find the transition from a parent/child to adult/adult relationship difficult; there may be unrealistic expectations of change. In the long term, it is important for families to attempt to help rebuild an individual’s self-esteem, and to encourage honest and open expression of thoughts and feelings in all family members.
The Maudsley Method
We use a variety of means to give parents, siblings and families the information and skills that they need to support and guide the person with an eating disorder through to recovery. The intensity of this varies with the severity and duration of the illness.
We run 2-4 day training workshops and for others, books DVD and internet training methods are used. These have been developed by work over the years with carers and patients and collectively they are known as ECHO- experienced carers helping others.
Continuity of care
This is a form of family therapy developed and evaluated between 1970 and 1980 at the Maudsley Hospital.
The Maudsley Method of working with the family was found to improve the outcome for adolescents who had had anorexia nervosa for less than three years.
The original Maudsley Method was less effective for families with an older child or those with a protracted illness, so the treatment has been modified over time for these groups and has led to the development of multi-family therapy.
This can be a problem if someone needs high intensity care not available locally. Another problem is that it is common for someone with an eating disorder to be attending university away from home. Most universities have student counselling services and a student health facility. It is usually possible to contact the department of student counselling through student welfare. There may also be university based self help-groups. Student counselling usually requires the person with a problem to make the first move. It is a sensible precaution to alert the student GP service that your child has an eating disorder, and if necessary, they can be asked to monitor medical risk.
Given the typical age of onset of anorexia, people often move from child and adolescent to adult services, or between home and university health services. This can result in fragmented or suboptimal care. Likewise, transitions between specialist inpatient and follow up care may be poorly conducted.
Sometimes, the strength and power of an individual’s eating disorder is extreme.
The eating disorder impairs the individual’s ability to make rational decisions about their treatment.
It is therefore occasionally necessary, when life or health is at risk, to admit a patient to hospital to be treated and compulsorily fed under the Mental Health Act.
Is it possible to recover from an eating disorder?
After intensive treatment, an individual may find it helpful to join a self-help group in the community.
beat can give information about a network of self-help groups throughout the country. It also runs a telephone support line, gives support and advice to carers, and runs an informative website with contact details.
It can be difficult to maintain the changes after inpatient treatment. We have found that sharing skills with carer givers can help the transition to the community and can improve wellbeing for patients and care givers. Another novel solution is the use of internet-based support, which is becoming increasingly popular in the field of eating disorders.
The Section of Eating Disorders has extensively evaluated this approach in adolescents and adults with bulimia and we have also trialled its use in relapse prevention treatment of people with severe anorexia with good effect .
Many people are able to make a recovery from the physical, psychological and social repercussions of an eating disorder. However, many are unable to shake off all their abnormal attitudes to food, eating and body size and shape.
Even after a two to three year period of recovery, relapse can occur, particularly after stressful events, or if weight loss has been triggered: after childbirth, for example, when there is increased stress of a new baby combined with weight changes after birth.
However, people who have gone through recovery are often aware of the danger signs and can stop the illness getting a severe grip on them. Other people continue to have rather rigid eating habits and never eat as much or as freely as others.
Many people have unrealistic expectations and think they can recover from the illness after a few months. Unfortunately, once eating disorders have taken hold, you need to think in recovery in terms of years rather than months.
On average, it takes six years to recover from anorexia. After five years, approximately half of people with anorexia will have recovered, 30 per cent will remain quite severely affected by their illness and 20 per cent will be underweight and without their periods.
People who have recovered from eating disorders often talk of the experience as a journey, or a long process of change during which they learn new, healthy coping mechanisms in place of dysfunctional ones they had previously relied on.
The more weight that has been lost and the more extreme the emaciation, the longer the recovery takes. Similarly, recovery is much harder the longer the illness has gone on before treatment starts, and if the illness has failed to respond to several attempts at treatment.
Those individuals who had childhood problems such as school refusal and emotional problems, or who find it difficult to make friends, or who have experienced family difficulties, find it harder to make a recovery.
Research with people who have made a full physical recovery in terms of weight gain and reproductive function shows that there are residual abnormalities in their response to stress.
It is uncertain whether such abnormalities preceded the illness and were part of the risk factor to develop the illness, or if they are a scar from the illness.