MBK2003 said:
1) It's not a good idea to keep the patient in a treatment that does not have a strict treatment frame, e.g. if you don't gain 2lbs per month, I will have to end the treatment or hospitalize you. It's a big pain to be working harder than the patient on their issues.
I don't know that I agree, quite. A lot of the issues involved in treatment aren't directly related to the weight issues, and those can be worked on regardless. In fact, I'm all in favor of a treatment plan that has a therapist working on the psychological aspects, and an RD working on the nutritional rehab. (And a GP monitoring medical stability, of course.)
Honestly, I've never come across any studies showing any benefit of any medication on a low-weight anorexic.
2) Even though ED pts are often upper middle class, intelligent women/girls (for the most part) it's easy to forget that they have a serious and persistent mental illness and need the same level of psychosocial supports as the schizophrenic pts in outpt or inpt treatment.
Agreed -- with the caveat that those comments about the trauma of being a size 2 instead of a size 0 sure sounded as though you also forget that, seeing instead a shallow sort of vanity. It is a serious psychiatric disorder, and the trauma of gaining weight is very real to them. The more you dismiss that as trivial, the less effective you can be in treating them.
Here's a thought for you: say you've got a pt who is freaked out because she only got 89% on a maths test. To her, she's failed, because that's not an A, and an A is the only acceptable grade for her in math. How would you approach that issue?
4) Bulimia can be a totally different story in outpt treatment, I think in part because the behavior is so egodystonic. They may not want to gain weight, but they often are willing to do the homework and bring in the automatic thought records. I have seen amazing results with CBT for bulimic patients who suffered for 9-10 yrs and went from 3x/d binge/purge to once a month in 3 months of CBT.
My view is a little different. Maybe that's because I"ve seen those same pts six months later, when they're b/p'ing again regularly, and now think they're hopeless, because they've failed CBT?
Ultimately what it comes down to is that splitting, projective identification, and denial are a b*tch to deal with as a therapist without good supervision and a treatment frame. It's much easier to say, "As we agreed before, your failure to gain weight is an imminent threat to the treatment. Maybe you can talk about why it is that you are engaging in a behavior that threatens the very treatment you've told me so many times before is valuable to you," than "Why are you doing none of the things we discussed last week, and the week before, and the week before that?"
I'm not going to comment on this part.
Also, I've gotten better at diverting the patients from the all too frequent, "But you don't understand, I used to be a size 0 and now because of this I'm a size 2" which never is a productive topic.
I disagree. I think it can be a very productive topic -- if you use it to explore what the AN is getting out of it. Have you ever explored what these pts get out of starvation? Have you ever really listened to what they have to say? That is, listened with an open mind, and actually tried to find out what they get out of it, rather than what they think you want to hear? That's where the attitude I mentioned first can get in the way. Most of the ANs I've come in contact with are very intuitive, and pretty accurate in their assessments of treatment professionals. As you say, these are overwhelmingly smart women, with a mental illness. As soon as they sense the dismissal of their concerns, they'll shut down, and there goes effective therapy.
By the way, I've mentioned my own AN. I'll give you another hint about CBT and AN: CBT can be counterproductive for some with AN, because it has some basic similarities to AN behaviors and feelings. It might be worth exploring what AN does for these women, so that you can make sure the treatment doesn't strengthen their disorders.
