Eating disorders

Treatment techniques for adolescents with eating disorders

By Carolyn Costin, MA, MEd, MFT

I have often said that if you can treat eating disorders successfully, you probably can treat almost everything, and if you are successful at treating eating disordered adolescents, you can treat anything.

Adolescents feel immune to the consequences of their behaviors. They see themselves as immortal. Combine this with the ambivalence in all eating disorder patients about giving up their eating disorder, and any therapist is in for a complicated, challenging, and frustrating task. Nevertheless, I love my work.

I love working with this population because it keeps me on my toes, searching for creative interventions and innovative techniques. Below are a few strategies I use with the eating disorder adolescent population that I have found useful over the last 25 years.

Letter from a friend

I have found it useful to find out who my patient's best friend is and get permission to call or e-mail that person asking them to write me a letter about what it is like to have my patient as a friend. What would they like her to know and understand? What are her strengths and weaknesses? What would you wish that she would understand? I tell friends that it is up to them if they want me to show my patient the letter or just summarize it.

I have found this to be extremely useful in confronting patients with the reality of the effect their eating disorder has on people they care about. They will usually take this feedback much better from friends than from their parents.

Role reversal

I often have my adolescent patient and one of her parents switch roles, playing each other for part of the session. Then I ask various questions. In the example below, my patient's name is Karen and her mother's name is Emily.

To Karen's mother (who is playing Karen):

"So Karen, how do you think the week went?" or "Karen, is there anything you feel like you need to talk to your mom about?" or "Karen, how did you do with food this week?"

To Karen (who is playing her mother, Emily):

"So Emily, how do you think Karen did this week?" or "Emily, did anything come up this week that you'd like to discuss?"

After spending some time in reverse roles, I then ask both mother and daughter to share how accurate the information given was and how each felt about doing the role play. They are allowed to make corrections of things that were wrong and add what may have been omitted. I usually find that this builds greater empathy between family members and improves communication.

Family group food activity

In family group, I often like to do an experiential activity. This particular one involves food. I bring into the multi-family group a variety of foods. A sample list looks like this:

• Wheat Thins
• salad dressing
• peanut butter
• apple
• cookie
• cheese
• rice cakes

I put all the food into the middle of the room on the floor with the group sitting around the food. I then ask everyone to just write down whatever comes to mind regarding each food item. This is a great exercise to process. The patients usually use words for foods like cookies or cheese with a lot of emotional content like "disgusting", "scary", "fattening", "out of control", "frightening", etc. Parents rarely use these words and often say things like, "Oh, I like that brand of cookies" or "Cheese goes well with crackers" or something less emotionally laden.

I ask the group to share their answers, patients and parents alike. Then I ask for comments. We process how different patients react simply to these foods' being in the room. I then explain that all these things they've written on paper are the kinds of things going on in their minds at mealtime.

Family meals supervised

If I do a supervised family meal, I think it is very important that the therapist eat the meal too. I don't like the outside observer stance. I think that it's best to have the situation be more like normal eating. In normal eating, no one is sitting, watching or taking notes. The therapist helps decide the meal ahead of time, making appropriate meals for individual patients according to where they are in their recovery. Eating low-fat foods is fine for the early stages of treating severe restrictor anorexia nervosa. In the later stages I would be including more challenging foods. Getting patients to eat is the primary goal initially. Also, I like to help them overcome their fear that all food, any food, will make them gain weight. If we respect that our patients have a phobia about eating, then it helps us realize that starting off with all "scary", high-fat foods is not only unreasonable, but I think it's cruel. I have had no problem with most patients starting this way and gradually adding more variety and higher fat meals and menu items. The therapist helps the family with how to communicate during the meal and helps to model how to be firm but empathetic with the patient.

This technique is tricky and should be used only at certain times with certain patients. For some patients, setting up a family meal too soon only reinforces their ability to use this as a means of rebellion. I have had many patients who could eat properly with me or other staff members, only to regress in their eating with their parents. There are several psychodynamic reasons for this. One main reason is that girls with anorexia nervosa unconsciously use the illness as a way to rebel and as a way to get needs attended to. They believe that, as several patients have actually said, "If I eat, well, then my family will think I'm okay. They won't know that I still have a lot of pain and problems inside."

There are many other reasons why patients will eat poorly in front of their parents even when they are doing better in treatment. To push family meals in some cases reinforces the need for the eating disorder behaviors.

I love working with eating disorder adolescents and their families. The above are just a few of the techniques I use. If anyone wants more information about any of these techniques they can email me at mntc@montenido.com.

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Carolyn Costin
Clinical Director
Monte Nido Residential Treatment Facility