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The Treatment of Eating Disorders in Occupational Therapy
Rosemary Crouch1 and Vivyan Alers2,3
1 School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2 Occupational Therapy private practitioner, Midrand, South Africa
3 Director, Acting Thru Ukubuyiselwa NPO, Johannesburg, South Africa
Introduction
Throughout the past decade, the occurrence of obesity in children and adolescents has increased together with emphasis on diets and weight loss. The changing epidemiology of eating disorders shows a higher prevalence in males and minority populations in the USA, with a prevalence in younger ages (younger than 12) and the emergence of eating disorders in other countries where they were not seen previously (Rosen and American Academy of Pediatrics 2010). Younger patients with eating disorders more often show premorbid psychopathology (depression, obsessive–compulsive disorder or other anxiety disorders), and binge/purge behaviour is unlikely. Faster weight loss occurs in younger patients (Rosen and American Academy of Pediatrics 2010). Athletes and performers may be at risk of developing partial-syndrome eating disorders.
An eating disorder not otherwise specified (EDNOS) (American Psychiatric Association (APA) 2000) diagnosis was more prevalent than anorexia nervosa and bulimia nervosa. This occurrence is explained in the DSM-5 where the information suggests that a significant portion in this category were binge eating disorder. Thus, the DSM-5 has approved binge eating disorder as a category on its own (APA 2013). Binge eating is now in a category of its own and is more severe than overeating. It is also associated with significant physical and psychological problems.
The aetiology of eating disorders is multifactorial (genetic, social, behavioural, familial); thus, treatment is required to address these issues. Physical problems include gastrointestinal complaints; hypothalamic suppression causing amenorrhoea; skin, hair and nail changes; endocrine abnormalities; and low bone mineral density. Dilutional hyponatraemia (‘water loading’) may be done to misrepresent weight at outpatient visits (Rosen and American Academy of Pediatrics 2010). Social and behavioural issues are influenced by the micro (personal), meso (community) and macro (societal) environments when the person feels developmentally vulnerable.
Schwartz cited in Carnabucci and Ciotola (2013, p. 23)
Maudsley Hospital in London has developed specialised family-based interventions for patients with eating disorders. Loeb and le Grange (2009) stated that family-based treatment was effective with anorexia nervosa patients younger than 18 years old and it reduces binge/purge behaviour in bulimia nervosa patients. The National Institute of Mental Health (2012) states that psychotherapy may be individual, group or family based to help address the psychological reasons for the illness.
In the USA, the Renfrew Centre has residential and non-residential facilities. Their facilities have four goals of comprehensive treatment:
- Stabilise and engage. Initially to focus on re-establishing physical and nutritional health and to engage the patients to develop their commitment and motivation for treatment.
- Trust and experiment. Therapists and peers support and encourage patients to begin making significant changes in their eating-disordered thoughts and behaviours. This leads to experimenting and exploring new relationships with food and their bodies.
- Learn and practice. Progressing through treatment, patients work with their treatment team to recognise new challenges for practice and preparation for future everyday situations in treatment or after discharge.
- Maintenance and relapse prevention. The goal of treatment is to develop skills and strategies to manage eating-disordered thoughts and behaviours. Maintaining and strengthening the recovery process involves continually addressing the ongoing issues with self-esteem and relationships (Renfrew Centre 2013).
Treatment and recovery is a long-term process. Relapses are an expected part of recovery, and the person is encouraged to use alternative options to assist again in recovery. The emphasis is for the relapse to become a learning experience rather than a sign of failure (Carnabucci & Ciotola 2013).
Occupational therapists treat patients with eating disorders through occupational group therapy in the inpatient situation and later follow them up into the community. According to Herpertz et al. (2011, p. 1), ‘Bulimia nervosa and binge-eating disorder can usually be treated on an outpatient basis, as long as they are no more than moderately severe; full-fledged anorexia nervosa is generally an indication for in-hospital treatment’. It is a challenging area in which to work because of the intensity of treatment by the multidisciplinary team, the extremely fixed body image disturbance on the part of the patient, the resistance to treatment, the deceit and lying which occurs behind the scenes and sadly the loss of patients who starve themselves to death. Counselling (supervision) and support is required for staff as a built-in service. Often, extra training is required, which also encompassed handling of the family who care for the patient.
Recent research into the condition of eating disorders encompasses anorexia nervosa, bulimia nervosa, binge eating disorder, overeating disorders and night-binging disorders. The DSM-5 includes binge eating disorder and revisions to the diagnostic criteria for anorexia nervosa and bulimia nervosa and incorporates pica, rumination and avoidant/restrictive food intake disorders (APA 2013).
Criteria for suspecting an eating disorder are (Herpertz et al. 2011, p. 5):
- Low body weight
- Amenorrhoea or infertility
- Dental damage, especially in young patients
- Worry about body weight even though it is normal
- Unsuccessful attempts to lose weight in patients who are overweight or obese
- Gastrointestinal disorders that cannot be ascribed to another medical cause
- Delayed growth in children
- Parents worried about their child’s weight and eating behaviour
Multidisciplinary approach to the treatment in the field of eating disorders
The Johns Hopkins Eating Disorders Program in Baltimore (Johns Hopkins Medical 2013) discusses the treatment of persons with eating disorders and states that the interdisciplinary team consists of nurses, social workers, occupational therapists, dieticians and other specialists. The primary goals of their programme are to ‘restore the functional capacity, to normalise the eating patterns, and to improve the quality of life of our patients’ (p. 1).
Occupational therapy within the team
‘The benefit of occupational therapy for clients with eating disorders revolves around issues of occupational functioning’ (Kloczko & Ikiugu 2006, p. 64). The University of Toronto (2009) describes a day in the life of an occupational therapist working in an inpatient eating disorders programme and states that an important part of the occupational therapist’s role is to normalise the patient’s eating programme. This would include ‘grocery shopping outings, meal preparation sessions, supervised meals, and meal and snack outings’ (p. 1). This emphasis may vary according to the team approach to the treatment of eating disorders.
Emphasis is on occupational group therapy, which is often within the cognitive behavioural framework or emotional-focused therapy, and these groups must be led by an experienced occupational therapist with a thorough training and background in occupational group therapy.
It is important to note that adolescent patients with eating disorders should be treated separately from adult patients because adolescent patients have unique problems which must be addressed in combination with the treatment of their eating disorder.
Individuals suffering from eating disorders seldom seek treatment themselves. The individual suffering from anorexia nervosa often does not see his/her behaviour as problematic or may be deeply afraid of weight gain. The individual suffering from bulimia nervosa is often too ashamed about his/her behaviour and the stigma attached to seek help. In determining the treatment plan, the therapeutic team thus needs to consider that the treatment is often lengthy and the individual’s motivation to change is important (Szabo 2009). The focus of treatment is in changing behaviour and to assist with shifting the individual through the stages of change. It has been documented that the therapeutic relationship needs to be collaborative rather than confrontational (Barlow & Durand 2005; Szabo 2009).
There are two key focus areas in the treatment of both anorexia nervosa and bulimia nervosa: firstly, changing the nutritional behaviour, thereby stabilising the individual’s eating patterns, and, secondly, cognitive restructuring, normalising the individual’s thoughts and intense fears. These will then in turn create a positive influence over the individual’s physical and emotional needs. With anorexia nervosa, the initial priority is to restore weight, whereas with bulimia nervosa, it is to eliminate the binging and purging behaviour (Barlow & Durand 2005; Szabo 2009). The cognitive behavioural approach is widely recognised as being effective in challenging the negative beliefs the individual has about himself/herself, which assists in maintaining the disorder. This approach also facilitates the individual’s learning about his/her weight and body image (Barlow & Durand 2005; Szabo 2009).
When an individual suffers from an eating disorder, any previous ability to engage in healthy roles and occupations is compromised by a preoccupation with the eating disorder and all the rituals and behaviour involved in the disorder. His/her previous balanced lifestyle that incorporated healthy occupations of engaging with work or school activities, socialising, constructive use of leisure time, volunteer work and spending time with family and friends slowly disappears as the eating disorder consumes more and more time and focus. This continues until the individual is completely preoccupied by the eating disorder and becomes unhealthy. It is therefore the occupational therapists role to re-establish a balanced lifestyle that supports normal, healthy, client-centred occupations and promotes activities health (Sheppard Pratt Health System 2013).
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