What is the best therapy - what works?

As a general principle, we choose what are generally referred to as evidence based therapies to guide us in developing treatment programs. Evidence based means that there is a body of research literature that supports an approach in terms of there having been a demonstration of effectiveness using the scientific method of investigation.

The Cognitive Behaviour Therapy model of Fairburn and Cooper has come to be viewed as the "gold standard" as an approach that is primarily intended for binge eating and bulimia, although one can apply the general outline to anorexia as well. There is less evidence that this approach is effective with anorexia, so far, but there is no protocol for psychotherapy for anorexia, and it does address some of the issues that anorexia has in common with bulimia and gives a rational structure to the psychotherapy being conducted.

A second model that can be applied is that of Prochaska and his colleagues as it pertains to stages of change. This material has only recently been receiving attention in the eating disorder literature, but has actually been around for some time. It allows us to address the issues clients present in light of how ready they are to actually change those behaviours. Pushing people into action before they are ready for such action reduces the probability of a successful outcome.

A third model that can be effective is that of solution focused therapy in general. When applied, this results in collaborative goal setting, and reduces resistance to treatment (as does attention to Prochaska's stages). Effective goal setting is a key component, as is attention to what has been working, rather than attention to what has not worked, and seems better than continued attention to the persistence of symptoms.

A fourth element is not really a model, just an application of attention to a list of coping skills for stress management. The skills should all be evidence based, and therefore it is reasonable to make sure that individuals have those skills in their repertoire. Relaxation training, assertiveness skills, effective use of social support, journal writing, and expressing emotions are examples of such skills.

Interpersonal therapy has also shown itself to be quite effective as an approach. The focus here has been on bulimia, although attention to the application of elements of this approach to anorexia is beginning.

Family therapy has been undergoing several changes over the past few years. A new, and apparently more effective approach has been gathering considerable attention lately. The work of Psychologists Christopher Dare in England, James Lock and Stuart Agras in California and Daniel Le Grange in Chicago have presented a break from the traditional approach to family based treatment of anorexia in adolescent girls. In this approach, parents are seen as the most useful resource in their treatment. Outcome studies have been very promising, with a lower relapse rate, and a shorter time to recover. Best of all, the client need not be hospitalized.

Intervention should be evidence based as much as possible, to give clients the best shot at recovery, as well as the best expenditure of their money if they are self-paying. Twelve step programs have little evidence based literature for bulimia, although there do seem to be some anecdotal reports success, and none for anorexia, where it is contraindicated as an intervention approach. Response prevention, although it is widely used in treating bulimia, has little support in the literature, and there is recent evidence that it may add nothing to the CBT approach, which is already known to be effective. Rapid refeeding in treating anorexia is also only weakly supported in the treatment of anorexia, despite the widespread use of such an approach. The role of medication in treatment is also quite limited in terms of what has been demonstrated to be effective. Beyond the demonstrated effectiveness for fluoxetine (Prozac) in the treatment of bulimia, there is poor to no support for most other medication. As research continues in this area, one expects that there will be further positive outcomes, but the sum of all the considerable research in the area so far has been disappointing.

The following reference list is not exhaustive, but does reflect many of the points made above. What it really does reflect is some of the literature that guided the development of the philosophy we follow at Westwind.
Apple, Robin and Agras, W. Stewart , (1997) Overcoming Eating Disorders. Client Workbook, USA, Greywind Publications Inc
Agras, W. Stewart and Apple, Robin, F., (1997), Overcoming Eating Disorders: A Cognitive Behavioral Treatment for Bulimia Nervosa and Binge Eating Disorder. A Therapist Guide, USA, Greywind
Publications
Benson, H.,(1996), Timeless Healing: The Power And Biology Of Belief, New York, NY, Simon and Schuster Inc.
Cooper, P. J. (1995), Bulimia Nervosa and Binge Eating: A self-help guide using Cognitive Behavioral Techniques. London, Robinson Publishing Ltd.
Domar, A.D. and Dreher, H. (1996) Healthy Mind, Healthy Woman. New York, NY, Henry Holt & Company.
Fairburn, C., (1995), Overcoming Binge Eating, New York, NY, Guilford Publications Inc
Fairburn, C. and Brownell, K.D. (2002) Eating Disorders and Obesity: a comprehensive handbook (2nd ed.), New York, NY, The Guilford Press
Hall, Lindsey and Cohn, Leigh, (1999), Bulimia: A Guide to Recovery, 5th ed., Carlsbad, CA, Gurze Books
Heymann, Jody (1995) Equal Partners. A Physician's Call for a New Spirit of Medicine. New York, NY, Little, Brown and Company.
Lock, J, LeGrange, D. , Agras, W.S. & Dare, C., (2001), Treatment Manual for Anorexia Nervosa: A Family Based Approach., New York, NY, The Guilford Press
Mehler, P.S. and Andersen, A. eds.(1999) Eating Disorders: A guide to medical care and complications. , Baltimore, MD, The Johns Hopkins University Press
Meichenbaum, D. and Turk, D. C. (1987), Facilitating Treatment Adherence. New York, NY, Plenum Press.
McFarland, Barbara. (1995). Brief Therapy and Eating Disorders. San Francisco, CA, Jossey-Bass Publishers.
Mitchell, J. ed. (2001) The Outpatient Treatment of Eating Disorders: A Guide for Therapists, Dietitians and Physicians. University of Minnesota Press
Nash, Joyce D., (1999) Binge No More; Your Guide to Overcoming Disordered Eating, Oakland, CA, New Harbinger Publications, Inc.
Prochaska, J.O., Norcross, J.O. and DiClemente, C.C. (1994) Changing for Good. New York, NY, Avon Books.
Schmidt, Ulrike & Treasure, Janet, (1993) Getting Better Bit(e) by Bit(e), Hove, East Sussex, UK, Psychology Press Ltd.
Striegel-Moore, Ruth and Smolak, Linda., (2001) Eating Disorders: Innovative Directions in Research and Practice. Washington, DC, American Psychological Association
Tobin, David., (2000) Coping Strategies Therapy for Eating Disorders. Washington, DC, American Psychological Association
Vandereycken, W. and Beaumont, P.J.V. (1998) Treating Eating Disorders: Ethical, Legal and Personal Issues. Washington Square, NY, New York University Press.
Villapiano, M. and Goodman, L., J. (2001) Eating Disorders: Time for Change. Philadelphia, PA, Brunner-Routledge.