Philosophy and Approaches to Treating Eating Disorders

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DISEASE/ADDICTION MODEL

The disease or addiction model of treatment for eating disorders, sometimes referred to as the abstinence model, was originally taken from the disease model of alcoholism. Alcoholism is considered an addiction, and alcoholics are considered powerless over alcohol because they have a disease that causes their bodies to react in an abnormal and addictive way to the consumption of alcohol. The Twelve Step program of Alcoholics Anonymous (AA) was designed to treat the disease of alcoholism based on this principle. When this model was applied to eating disorders, and Overeater's Anonymous (OA) was originated, the word alcohol was substituted with the word food in the Twelve Step OA literature and at Twelve Step OA meetings. The basic OA text explains, "The OA recovery program is identical with that of Alcoholics Anonymous.

We use AA's twelve steps and twelve traditions, changing only the words alcohol and alcoholic to food and compulsive overeater (Overeaters Anonymous 1980). In this model, food is often referred to as a drug over which those with eating disorders are powerless. The Twelve Step program of Overeaters Anonymous was originally designed to help people who felt out of control with their overconsumption of food: "The major objective of the program is to achieve abstinence, defined as freedom from compulsive overeating" (Malenbaum et al. 1988). The original treatment approach involved abstaining from certain foods considered binge foods or addictive foods, namely sugar and white flour, and following the Twelve Steps of OA which are as follows:

TWELVE STEPS OF OA

Step I: We admitted we were powerless over food–that our lives had become unmanageable.

Step II: Came to believe that a Power greater than ourselves could restore us to sanity.

Step III: Made a decision to turn our will and our lives over to the care of God as we understood Him.

Step IV: Made a searching and fearless moral inventory of ourselves.

Step V: Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

Step VI: Were entirely ready to have God remove all these defects of character.

Step VII: Humbly asked Him to remove our shortcomings.

Step VIII: Made a list of all persons we had harmed, and became willing to make amends to them all.

Step IX: Made direct amends to such people wherever possible, except when to do so would injure them or others.

Step X: Continued to take personal inventory and when we were wrong, promptly admitted it.

Step XI: Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Step XII: Having had a spiritual awakening as the result of these steps, we tried to carry this message to compulsive overeaters and to practice these principles in all our affairs.

The addiction analogy and abstinence approach make some sense in relationship to its original application to compulsive overeating. It was reasoned that if addiction to alcohol causes binge drinking, then addiction to certain foods could cause binge eating; therefore, abstinence from those foods should be the goal. This analogy and supposition is debatable. To this day we have found no scientific proof of a person being addicted to a certain food, much less masses of people to the same food. Nor has there been any proof that an addiction or Twelve Step approach is successful in treating eating disorders. The analogy that followed—that compulsive overeating was fundamentally the same illness as bulimia nervosa and anorexia nervosa and thus all were addictions—made a leap based on faith, or hope, or desperation.

In an effort to find a way to treat the growing number and severity of eating disorder cases, the OA approach began to be loosely applied to all forms of eating disorders. The use of the addiction model was readily adopted due to the lack of guidelines for treatment and the similarities that eating disorder symptoms seemed to have with other addictions (Hat-sukami 1982). Twelve Step recovery programs sprung up everywhere as a model that could be immediately adapted for use with eating disorder "addictions." This was happening even though one of OA's own pamphlets, entitled "Questions & Answers," tried to clarify that "OA publishes literature about its program and compulsive overeating, not about specific eating disorders such as bulimia and anorexia" (Overeaters Anonymous 1979).

The American Psychiatric Association (APA) recognized a problem with Twelve Step treatment for anorexia nervosa and bulimia nervosa in their treatment guidelines established in February 1993. In summary, the APA's position is that Twelve Step based programs are not recommended as the sole treatment approach for anorexia nervosa or the initial sole approach for bulimia nervosa. The guidelines suggest that for bulimia nervosa Twelve Step programs such as OA may be helpful as an adjunct to other treatment and for subsequent relapse prevention.

In determining these guidelines the members of the APA expressed concerns that due to "the great variability of knowledge, attitudes, beliefs, and practices from chapter to chapter and from sponsor to sponsor regarding eating disorders and their medical and psychotherapeutic treatment and because of the great variability of patients' personality structures, clinical conditions, and susceptibility to potentially counter therapeutic practices, clinicians should carefully monitor patients' experiences with Twelve Step programs."

Some clinicians feel strongly that eating disorders are addictions; for example, according to Kay Sheppard, in her 1989 book, Food Addiction, The Body Knows, "the signs and symptoms of bulimia nervosa are the same as those of food addiction." Others acknowledge that although there is an attractiveness to this analogy, there are many potential problems in assuming that eating disorders are addictions. In the International Journal of Eating Disorders, Walter Vandereycken, M.D., a leading figure in the field of eating disorders from Belgium, wrote, "The interpretative 'translating' of bulimia into a known disorder supplies both the patient and therapist with a reassuring point of reference. . . . Although the use of a common language can be a basic factor as to further therapeutic cooperation, it may be at the same time a diagnostic trap by which some more essential, challenging, or threatening elements of the problem (and hence the related treatment) are avoided." What did Vandereycken mean by a "diagnostic trap"? What essential or challenging elements might be avoided?

One of the criticisms of the addiction or disease model is the idea that people can never be recovered. Eating disorders are thought to be lifelong diseases that can be controlled into a state of remission by working through the Twelve Steps and maintaining abstinence on a daily basis. According to this viewpoint, eating disordered individuals can be "in recovery" or "recovering" but never "recovered." If the symptoms go away, the person is only in abstinence or remission but still has the disease.

A "recovering" bulimic is supposed to continue referring to herself as a bulimic and continue attending Twelve Step meetings indefinitely with the goal of remaining abstinent from sugar, flour, or other binge or trigger foods or bingeing itself. Most readers will be reminded of the alcoholic in Alcoholics Anonymous (AA), who says, "Hi. I'm John and I am a recovering alcoholic," even though he may not have had a drink for ten years. Labeling eating disorders as addictions may not only be a diagnostic trap but also a self-fulfilling prophecy.

There are other problems applying the abstinence model for use with anorexics and bulimics. For example, the last thing one wants to promote in an anorexic is abstinence from food, whatever that food might be. Anorexics are already masters at abstinence. They need help knowing it's okay to eat any food, particularly "scary" foods, which often contain sugar and white flour, the very ones that were originally forbidden in OA. Even though the idea of restricting sugar and white flour is fading in OA groups and individuals are allowed to choose their own form of abstinence, these groups can still present problems with their absolute standards, such as promoting restrictive eating and black-and-white thinking.

In fact, treating anorexia patients in mixed groups such as OA may be extremely counterproductive. According to Vandereycken, when others are mixed with anorexics, "they envy the abstaining anorexic whose willpower and self-mastery represent an almost utopian ideal for the bulimic, while binge eating is the most horrifying disaster any anorexic can think of. This, in fact, constitutes the greatest danger of treatment according to the addiction model (or the Overeaters Anonymous philosophy). Regardless if one calls it partial abstinence or controlled eating, simply teaching the patient to abstain from binge eating and purging means 'anorexic skills training'!" To resolve this issue it has even been argued that anorexics can use "abstinence from abstinence" as a goal, but this is not clearly definable and, at least, seems to be pushing the point. All of this adjusting just tends to water down the Twelve Step program as it was originally conceived and well utilized.

Furthermore, behavior abstinence, such as refraining from binge eating, is different from substance abstinence. When does eating become overeating and overeating become binge eating? Who decides? The line is fuzzy and unclear. One would not say to an alcoholic, "You can drink, but you must learn how to control it; in other words, you must not binge drink." Drug addicts and alcoholics don't have to learn how to control the consumption of drugs or alcohol. Abstinence from these substances can be a black-and- white issue and, in fact, is supposed to be. Addicts and alcoholics give up drugs and alcohol completely and forever. A person with an eating disorder has to deal with food every day. Full recovery for a person with an eating disorder is to be able to deal with food in a normal, healthy way.

As has been previously mentioned, bulimics and binge eaters could abstain from sugar, white flour, and other "binge foods," but, in most cases, these individuals will ultimately binge on any food. In fact, labeling a food as a "binge food" is another self-fulfilling prophecy, actually counterproductive to the cognitive behavioral approach of restructuring dichotomous (black-and-white) thinking that is so common in eating disordered patients.

I do believe that there is an addictive quality or component to eating disorders; however, I don't see that this means that a Twelve Step approach is appropriate. I see the addictive elements of eating disorders functioning differently, especially in the sense that eating disordered patients can become recovered.

Although I have concerns and criticisms of the traditional addiction approach, I recognize that the Twelve Step philosophy has a lot to offer, particularly now that there are specific groups for people with anorexia nervosa and bulimia nervosa (ABA). However, I strongly believe that if a Twelve Step approach is to be used with eating disordered patients, it must be used with caution and adapted to the uniqueness of eating disorders. Craig Johnson has discussed this adaptation in his article published in 1993 in the Eating Disorder Review, "Integrating the Twelve Step Approach."

The article suggests how an adapted version of the Twelve Step approach can be useful with a certain population of patients and discusses criteria that can be used to identify these patients. Occasionally, I encourage certain patients to attend Twelve Step meetings when I feel it is appropriate. I am especially grateful to their sponsors when those sponsors respond to my patients' calls at 3:00 a.m. It's nice to see this commitment from someone out of genuine comradery and caring. If patients who begin treatment with me already have sponsors, I try to work with these sponsors, so as to provide a consistent treatment philosophy. I am moved by the devotion, dedication, and support that I have seen in sponsors who give so much to anyone wishing help. I have also been concerned on many occasions where I have seen "the blind leading the blind."

In summary, based on my experience and my recovered patients themselves, I urge clinicians who use the Twelve Step approach with eating disordered patients to:

• Adapt them for the uniqueness of eating disorders and of each individual.

• Monitor patients' experiences closely.

• Allow that every patient has the potential to become recovered.

The belief that one will not have a disease called an eating disorder for life but can be "recovered" is a very important issue. How a treating professional views the illness and the treatment will not only affect the nature of the treatment but also the actual outcome itself. Consider the message that patients get from these quotes taken from a book about Overeaters Anonymous: "It is that first bite that gets us into trouble.

The first bite may be as 'harmless' as a piece of lettuce, but when eaten between meals and not as part of our daily plan, it invariably leads to another bite. And another, and another. And we have lost control. And there is no stopping" (Overeaters Anonymous 1979). "It is the experience of recovering compulsive overeaters that the illness is progressive. The disease does not get better, it gets worse. Even while we abstain, the illness progresses. If we were to break our abstinence, we would find that we had even less control over our eating than before" (Overeaters Anonymous 1980).

I think most clinicians will find these statements troubling. Whatever the original intention, they might more often than not be setting up the person for relapse and creating a self-fulfilling prophecy of failure and doom.

Tony Robbins, an international lecturer, says in his seminars, "When you believe something is true, you literally go into the state of it being true. . . . Changed behavior starts with belief, even at the level of physiology" (Robbins 1990). And Norman Cousins, who learned firsthand the power of belief in eliminating his own illness, concluded in his book Anatomy of an Illness, "Drugs are not always necessary. Belief in recovery always is." If patients believe they can be more powerful than food and can be recovered, they have a better chance of it. I believe all patients and clinicians will benefit if they begin and involve themselves in treatment with that end in mind.

SUMMARY

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The three main philosophical approaches to the treatment of eating disorders do not have to be considered exclusively when deciding on a treatment approach. Some combination of these approaches seems to be the best. There are psychological, behavioral, addictive, and biochemical aspects in all cases of eating disorders, and therefore it seems logical that treatment be drawn from various disciplines or approaches even if one is emphasized more than the others.

Individuals who treat eating disorders will have to decide on their own treatment approach based on the literature in the field and their own experience. The most important thing to keep in mind is that the treating professional must always make the treatment fit the patient rather than the other way around.

By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

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