If you are seeking help for yourself or a loved one with an eating disorder and want to receive the best possible care, there are a few things it might be helpful to know. It’s tricky to determine what “best possible care” or “best practices” means when it comes to psychological treatments for eating disorders. By “psychological treatment” I mean individual, family, or group psychotherapy targeting eating disorder symptoms—not medication treatment.
No one would argue with the statement that clients seeking psychological treatment for an eating disorder should receive the best possible care. These days, multiple treatments are available for many people with eating disorders. There can be different routes to improving a person’s eating disorder symptoms. The question is, which is the best approach to start with for a person with a given condition? Each person is unique, so of course treatment decisions need to be tailored to each client’s needs.
How do we Know What Psychological Treatment is Best for Each Individual?
The good news is that eating disorders are treatable, and there are a number of psychological treatments that have been shown to be effective in reducing and eliminating eating disorder symptoms. Here are some things to keep in mind.
First, not all psychological treatments are equally effective. No single psychological treatment is failsafe and helps everyone with a given eating disorder, much as everyone wishes it were the case. People—and their eating disorders—are complicated, and a simple fix rarely exists. As a result, therapists and clients must determine what psychological treatment to use in a given situation.
Second, not every psychological treatment approach that may be available has undergone the scrutiny offered by carefully designed research studies. Actually, most haven’t. Results from a survey of 118 community psychotherapists in the province of Alberta, Canada, showed that many therapists provided elements of psychotherapies recommended by evidence-based practice guidelines to clients with eating disorders (von Ranson, Wallace, & Stevenson, 2012). However, therapists rarely provided complete treatments as they had originally been tested, and instead mixed techniques and approaches.
There has been a movement in recent years toward using scientific knowledge to guide practice, including in mental health, but not everyone is on board with this trend. Many join me in arguing that it is critical that we use research findings to point us toward specific psychological treatments to help an individual overcome an eating disorder (e.g., Lilienfeld et al., 2013). Research shows that some psychological treatments work for more people, on average, than others, and so provide logical starting points. As time passes, research evidence about what treatments work continues to evolve, and new research findings point us in new and occasionally unexpected directions.
Why Should we Rely on Research to Guide Treatment Decisions?
So why is it essential to rely upon research wherever possible when making decisions about which treatment to use? Because, to put it simply, we humans are fallible. What we believe is true—such as that treatment X is the most effective for problem Y—does not always turn out to be actually true when we use rigorous scientific methods to examine the question. Researchers have shown that, when making decisions, humans tend to fall prey to biases of which they are unaware. No one is immune from these biases. No amount of experience or skill prevents us from having such biases. Research evidence provides the best form of guidance for making complex decisions such as which psychological treatments has the best odds of helping someone, including for an eating disorder. They reduce reliance on our fallible judgment.
Randomized Controlled Trials
Randomized controlled trials (RCTs) are the gold standard of evidence for identifying effective treatment approaches. This research strategy involves strictly controlling as many aspects of a study as possible to increase our chances of making correct inferences about how effective a particular treatment approach is. An RCT involves randomly assigning patients to treatment conditions, using trained therapists who follow a treatment manual to ensure they are providing treatment using the same principles and techniques, and providing treatment to people who are experiencing the same problem. Expert researchers who don’t know which treatment a person is receiving track individuals’ symptoms, diagnoses, and other outcomes, such as quality of life. All these steps are taken to identify if a treatment actually improves one’s symptoms, and if so, how well it helps.
Effective Psychological Treatments for Eating Disorders
It is expensive and time-consuming to design and carry out RCTs. As a result, only a few psychological treatments for eating disorders have been tested in this fashion. For eating disorders, RCT findings have supported the use of the following psychological treatments:
- cognitive-behavioral therapy for bulimia nervosa and binge eating disorder
- interpersonal psychotherapy for bulimia nervosa and binge eating disorder
- family-based treatment for adolescents with anorexia nervosa
In each case, multiple RCTs have shown that these treatments are more effective for alleviating symptoms of these problems than another treatment, or no treatment at all (von Ranson, Wallace, & Stevenson, 2012). Confidence that a specific psychological treatment will help improve a person’s symptoms rises when RCT evidence supports its use, as long as the treatment provided is identical to the one found effective via an RCT.
The Research-Practice Gap
Physicians routinely use findings from RCTs and other systematic research to guide their practice. However, despite the best of intentions, few counselors from all disciplines follow an evidence-based approach to providing psychological treatments for eating disorders (von Ranson, Wallace, & Stevenson, 2012). This divide between researchers’ and practitioners’ views is called the “research-practice gap.”
Both practitioners and researchers want to alleviate suffering in individuals with eating disorders and their families. The relationship between researchers and clinicians goes both ways: research studies often aim to solve clinical problems, and clinicians can benefit from the knowledge that rigorous research provides in identifying effective psychological treatments. Collaborations between therapists and researchers can be credited for helping move the field of eating disorders forward.
Why Might Therapists Not Use Research to Guide Their Practice?
There are different reasons why psychotherapists often do not base their choice of psychological treatments for eating disorders on research evidence.
Psychotherapists must consider many different pieces of information when determining how to approach the treatment of a client with an eating disorder, and so clinical decision-making is complex. Finding and considering research evidence of course adds to the complexity.
It is a time-consuming process for practitioners—in mental health as well as other health care fields—to take up new methods and approaches with their clients. It can be difficult to obtain training in and apply new therapeutic approaches.
It is sometimes argued that it is limiting to rely upon RCTs when providing psychological treatments to clients with eating disorders. That may be true, but providing the best possible treatment for an eating disorder means also ensuring that a treatment does not cause harm. Research provides the best way to distinguish among helpful, neutral, and harmful treatments. In addition, it’s important to have a Plan B (that is, another treatment approach) if the first treatment approach does not result in symptom improvement within approximately four weeks.
It is also sometimes argued that manual-based treatment is inflexible, but this is actually a myth. Skilled therapists can apply manualized treatment as deftly as other forms of treatment, because manuals are guides rather than “cookbooks.” Clinical skill and acumen is needed to effectively deliver any psychological treatment, including ones based on treatment manuals.
Not all psychological treatments are equally acceptable to a client, and they aren’t one-size-fits-all, so flexibility is needed. How should you proceed when the best-supported psychological treatments are inappropriate or unavailable? This question raises other questions. Most importantly, what counts as evidence? For instance, the wisdom and judgment of an experienced therapist is often persuasive. However, as invaluable as clinical experience can be, it does not substitute for research evidence in selecting a treatment.
Probably Effective Psychological Treatments For Eating Disorders
How much evidence is sufficient to merit recommending a treatment as effective? At least one study has shown that each of the following psychological treatments is “probably effective” (Wallace & von Ranson, 2012):
- cognitive-behavior therapy for relapse prevention for anorexia nervosa, once weight restoration has been achieved
- motivational interventions for anorexia nervosa, bulimia nervosa, and binge eating disorder
- specialist supportive clinical management for anorexia nervosa
- focal psychoanalytic therapy for anorexia nervosa
- behavioral weight loss for binge eating disorder
- dialectical behavior therapy for binge eating disorder
- cognitive-behavior therapy via guided self-help for binge eating disorder
So How Do You Find the Best Possible Care For An Eating Disorder?
In sum, when seeking psychological treatment for an eating disorder, educate yourself about the available options. Make sure you understand what the diagnosis is. Look into the psychological treatments listed above, starting with the established treatments. Also, don’t be shy about asking lots of questions of potential therapists, including about the psychological treatment approaches they use. For example, ask about the therapist’s education and training, including details of what their training consisted of. Extensive, focused training that included therapy supervision by an expert would be ideal; by contrast, if the therapist has read a book, they may be familiar with an approach but does not make them expert in it. What treatment approaches has the therapist used with similar clients? What is the rationale for the treatment approaches they use? Ask questions about the research basis of the treatment they propose. How effective is the treatment they use or are proposing? How do they know it is effective? If there is no RCT research available on the treatment model a therapist proposes to use for an eating disorder, ask the therapist how they would proceed. How would they judge if the treatment approach was helping? Remember that RCT research tests a specific form of treatment, so it is that treatment in its entirety—and not a shortened variation—that has been shown to improve symptoms.
Having received answers to questions like these, you will be better prepared to make an informed decision about the therapist and psychological treatment that is best for you or your loved one.
Lilienfeld, S. O., Ritschel, L. A., Lynn, S. J., Brown, A. P., Cautin, R. L., & Latzman, R. D. (2013). The research-practice gap: Bridging the schism between eating disorder researchers and practitioners. International Journal of Eating Disorders, 46, 386-394. doi: 10.1002/eat.22090
von Ranson, K. M. (2015). Clinician delivery (or not) of evidence-based treatments. In T. Wade (ed.), Encyclopedia of Feeding and Eating Disorders. Singapore: Springer Science+Business Media. doi: 10.1007/978-981-287-087-2_78-1
von Ranson, K. M., Wallace, L. M., & Stevenson, A. (2012). Psychotherapies provided for eating disorders by community clinicians: Infrequent use of evidence-based treatment. Psychotherapy Research, 23, 333-343. doi:10.1080/10503307.2012.735377
Wallace, L. M., & von Ranson, K. M. (2012). Perceptions and use of empirically-supported psychotherapies among eating disorder professionals. Behaviour Research and Therapy, 50, 215–222. doi: 10.1016/j.brat.2011.12.006.
About the Author
Kristin von Ranson is an Associate Professor of Psychology at the University of Calgary. Her research there focuses on eating disorders, body image and related issues. She also co-chairs the Research-Practice Committee of the Academy for Eating Disorders.
Written – 2016