African-American Women and Eating Disorders: Depression, and the Strong Black Woman Archetype

Vol. 30 / No. 5 — Eating Disorders Review

By Carolyn Coker Ross, MD, MPH, CEDS

While eating disorders have long been considered a “white woman’s problem,” recent findings show that eating disorders are becoming a major health issue for black women. Black women are sometimes assumed to be less susceptible to body dissatisfaction, based on the notion that African-American culture embraces larger or curvier body types than does the dominant culture. While some research does suggest that AN is less common in black women than in white women,1  recurrent binge eating occurs at higher rates in black women than in white women.1

An example of this trend is described in a recent article by Stephanie Covington Armstrong, in which she shares her own battle with emotional eating.2 According to Armstrong, a breakup with her first boyfriend triggered memories of her childhood trauma of sexual abuse. This then brought on extreme yo-yo dieting, and later led to anorexia and bulimia. When her anorexia was at its worst, she starved herself for weeks. During her bulimic stage, after stuffing down large quantities of food, Armstrong used laxatives and exercise to try to combat the calories. She kept her struggle hidden for three years before being confronted by her sister, with whom she shared a home.

Although Armstrong’s experience is consistent with research showing that binge eating or emotional overeating is often used as a way to cope with difficult emotions triggered by past trauma, like childhood mistreatment, clinicians rarely assume that eating disorders are a problem for black women. Additionally, there are several other factors that affect black women in terms of trauma and coping that may be overlooked or disregarded but that have an undeniable effect on their health.

The Role of Stress

Problematic eating patterns may develop in response to stress, and existing eating disorders may be worsened by stress. African-American women are more likely than their white counterparts to experience poverty,3 a major, pervasive source of stress. They are also confronted with the stressors of racism and microaggressions. Black women are greatly affected by discrimination and sexual harassment in the workplace,4 and they may have limited avenues for effective recourse. Disordered eating can arise in part as a way of coping with the stress of living and working day after day in unwelcoming, hostile environments.

Black women experience depression at higher rates than do white women.5 A study of depression and coping behaviors in adolescent black and white females found that those who reported higher levels of depression were more likely to experience an eating disorder. Women who reported recurrent binge eating had especially high levels of psychological distress.6 Depression and eating disorders intensify one another in a vicious cycle. While binging may temporarily relieve unwanted feelings, the weight gain that affects some women with binge eating caused by long-term bingeing can increase feelings of depression.

The Effects of Trauma

Binge eating and overeating are often used as ways to cope with difficult emotions triggered by past trauma. Trauma can be caused not only by acute events such as assault but also by threatening circumstances or long-term situations. Thus, while childhood abuse or neglect is traumatic, so are foster-care placements and domestic violence. The illness, addiction, or absence of a parent or other primary caregiver can also be traumatic: it can also cause lasting interpersonal problems as a function of attachment style. Furthermore, a woman may experience multiple types of trauma in her lifetime.

Survivors of trauma are typically hypervigilant, always on the lookout for the next threat. This continual feeling of tension is uncomfortable, and trauma survivors often engage in some sort of self-soothing behavior in response to the discomfort. Binge eating, emotional overeating, and eating addiction are common reactions, particularly among black women. Some women with past or present trauma may have used food throughout their lives as their only reliable source of pleasure or comfort.

Stress and trauma can cause neurological changes in the brain that increase the risk of binge-eating and compulsive overeating. The cortisol and adrenaline released as part of the stress response interferes with development of other parts of the brain, especially those areas associated with judgment and impulse control. Both prenatal stress and early life stress can increase the risk of developing an eating disorder, addiction, and obesity.7  Exposure to stress early in life can result in more difficulty managing stress later and in regulating emotions throughout life, as well as a predisposition to mood disorders, impulsivity, and compulsivity.

How can clinicians do a better job of detecting and treating eating disorders in black women? Improving care starts with conceptualizing disordered eating not as a preoccupation with appearance but rather as a strategy for coping with the patient’s stress, depression, and trauma.

Rising Rates in Eating Disorders and Depression 

The Undercurrent of Racism 

In a study conducted in 2008, researchers found that black women reported more comfort with being overweight, and were more likely to report themselves as underweight when they were actually in the normal range.  Researchers suggested two reasons why black women may look at weight standards differently. One reason is that black women may be distancing themselves from the unrealistic weight standards of the white culture. The other reason may be due to lingering historical depictions of black female slaves as heavy, sexless, and deviant. These findings suggest that the effects of racism from the past and present, and the trauma associated with racism, may play a critical role in black women’s health. Past historical depictions and the trauma associated with racism must be considered when dealing with and effectively treating eating disorders in the black female population.

The Strong Black Woman Archetype

There are certain characteristics many black women imbue that may shed light on why they are more prone to certain health issues. In Superwoman Schema: African American Women’s Views on Stress, Strength, and Health,Cheryl L. Woods-Giscombé, PhD, RNsuggests that health issues facing black women may be explained by how black women cope with stress.7  When it comes to health-related issues, stress plays a major role in the development and proliferation of illness and disease. How black women have been conditioned to cope with stress from life experiences relies heavily on this strong black woman archetype, or Superwoman role.  

Difficulty Accepting Help from Others

The strongest characteristic in the strong black woman (SBW) archetype is difficulty accepting help from others and feeling the need to be very independent for fear of getting hurt. In a study conducted in 2000, young black women often used the word “strong” to describe themselves. Women who embraced this SBW image said they maintained a strong sense of self in spite of the issues they faced. In another study in a demographically diverse sample of 48 African-American women, all eight focus groups reported it was not uncommon for them to protect themselves by putting up defenses. This occurred either because they did not know how to accept help or they felt their vulnerability or dependence on others might lead to getting hurt. The participants in this study also reported reluctance in expressing emotions or seeking assistance from others because of past experiences of being let down by family members or friends. When they do seek help, they often rely on a strong sense of faith or on religious outlets such as their community church to help them overcome challenges and to remain strong in the face of adversity.

Another key characteristic of the SBW is the role of nurturer. Women who take on this role not only feel responsible for the family, but for the black community at large. They also tend to take on the dominant role in intimate relationships, and this is most prevalent in the role of the single black mother.  Black women also reported feeling a responsibility to meet everyone else’s needs before their own, and often took on multiple roles and responsibilities and had difficulty saying no even if they knew that they were overcommitting.

Interestingly, the women in Woods-Giscombé’s study made connections between the health issues they were facing and this Superwoman role. Many reported stress-related health behaviors like emotional eating, smoking, and avoiding caring for their own needs. They also reported physical health issues such as migraines, hair loss, panic attacks, and depression.

Addressing the Whole Person

Eating/food addiction and eating disorders are not really about food at all; they are about emotions. African-American women may adopt cultural values that put them at higher risk for emotional eating — and also make it more difficult for them to seek and accept help for the problem. They may use food to numb their emotions or to distract them from life issues.  Like a beach ball held under water, emotions that are repressed may resurface with a vengeance, often in another form, such as overeating.

Integrative medicine has much to offer all women, including African-American women, when it comes to recovery from eating disorders. Problems such as binge-eating, emotional eating, anorexia and bulimia or compulsive overeating arise in a context of complex, interconnected factors, so it makes sense to take an integrative approach to treatment.

When you are working with African-American clients, it’s important to explore their history of trauma, as identified in the Adverse Childhood Experiences study.  The client cannot change a difficult past, but she can change how she cares for herself in light of her experiences. Similarly, she can’t change her body, but she can transform her relationship to her body. Unlike other compulsive behaviors, eating is not something a person can be abstinent from. A new, healthy relationship with food must be established.

Levels of Change

Clinicians can help clients recover from disordered eating by guiding them through the following levels of healing. Healing from an eating disorder involves five levels of change:

1. Letting go of superficial behaviors, such as dieting, restricting, and obsessing about food — because these behaviors do not solve the problem of out-of-control eating, and only function as a distraction from the underlying emotional issues.
2. Learning new ways to cope effectively with stress, and beginning to acknowledge and express the painful emotions that may have been driving the eating disorder.
3. Developing body awareness, reconnecting with sensations, and learning to see the body as a source of wisdom rather than as a recalcitrant adversary that has to be “whipped into shape” or “kept in line.”
4. Letting go of core beliefs (such as “It’s not safe to trust other people”) that no longer serve a positive purpose, and cultivating new beliefs that are accurate and functional in the present (such as “I can trust that certain people in my life truly want the best for me”).
5. Discovering ways to satisfy the profound human need for authenticity and meaning, because these experiences are essential to a good life, and also because they serve as natural positive reinforcers and help heal the brain’s reward system. This is about satisfying the soul, not the scale.  The client may view this as her spiritual self, the person God or spirit created her to be.

As clinicians, we are more effective in helping our clients when we take a holistic view of their lives. It is critically important that all clinicians work to understand the whole experience of their black female and male clients, including not only their physical health but also their emotional lives and the many particular ways in which the stresses of racism, discrimination, poverty, trauma, family disruption, and adverse childhood experiences can contribute to disordered eating. It’s imperative that we recognize the potential causes and symptoms of eating disorders in our African-American clients, so they do not suffer alone.

References

1. Ives A. What You Need to Know About Eating Disorders.Ebony. Retrieved http://www.ebony.com/wellness-empowerment/eating-disorders-health#axzz4mTPm4Dcj
2. Offutt MR. The Strong Black Woman, Depression, and Emotional Eating. Scholar Commons: University of Southern Florida. 2013: 1-113. Retrieved http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=5935&context=
3. Anda RF, Williamson DF, Spitz AM, Edwards, Koss MP, Marks JSW. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med.1998; 14:245.
4. Striegel-Moore RH, Dohm FA, Kraemer HC, et al. Eating Disorders in White and Black Women. Am J Psychiatry. 160:1326-1331.
5. Striegel-Moore RH, Wilfley DE, Pike KM, et al. 2017. Recurrent Binge Eating in Black American Women. Arch Fam Med. 9:83-87.
6. Ives A. What You Need to Know About Eating Disorders.Ebony. (http://www.ebony.com/wellness-empowerment/eating-disorders-health#axzz4mTPm4Dcj)
7. Offutt MR. The Strong Black Woman, Depression, and Emotional Eating. Scholar Commons: University of Southern Florida. 2013: 1-113. (http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=5935&context=etd)
8. Woods-Giscombé CL. Superwoman Schema: African American Women’s Views on Stress, Strength, and Health. Qualitative health research. 2010; 20:668-683. doi:10.1177/1049732310361892.

Suggested Reading

University of Michigan Poverty Solutions. 2017. “Poverty in the U.S.” http://poverty.umich.edu/about/poverty-facts/us-poverty/. Accessed December 18, 2017.

Krieger N, PD, Waterman C, Hartman, et al. 2006. “Social Hazards on the Job: Workplace Abuse, Sexual Harassment, and Racial Discrimination – A Study of Black, Latino, and White Low-Income Women and Men Workers in the United States.” Int J Health Services. 2006;36: 51.

Centers for Disease Control and Prevention. 2010. Current Depression among Adults – United States, 2006 and 2008. Morbidity and Mortality Weekly Report.  59 : 1229–35.

Offutt MR. 2013. The Strong Black Woman, Depression, and Emotional Eating.” Graduate dissertation, University of South Florida. http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=5935&context=etd

Su X, Liang H, Yuan W, Olsen J, Cnattingius S, Li J. 2016. “Prenatal and Early Life Stress and Risk of Eating Disorders in Adolescent Girls and Young Women.”Eur Child Adolesc Psychiatry25: 1245.

Thomas MB, Hu, Lee TM, Ming HU, Lee TM,Bhatnagar S, Becker JB.Sex-Specific Susceptibility to Cocaine in Rats with a History of Prenatal Stress. Physiol Behav. 2009;97:270.

Enoch MA 2011. The Role of Early Life Stress As a Predictor for Alcohol and Drug Dependence. Psychopharmacol. 2011;214: 17.

Warren BL, Sial OK, Alcantara LF, et al. Altered Gene Expression and Spine Density in Nucleus Accumbens of Adolescent and Adult Male Mice Exposed to Emotional and Physical Stress.Developmental Neuroscience. 2014; 36: 250.

Thompson BW. A Way Outa No Way: Eating Problems among African-American, Latina, and White Women. Gender and Society.  1992;6: 546.

Eating Disorders and College Students

Eating Disorders and College Students

By Sydney Brodeur McDonald, Ph.D., LCP

Kayla* was a 19-year-old sophomore art student who garnered the attention of her professors and was thought of as a protégé in the expression of abstract images. She was quiet with pink streaks in her hair, she wore layers of clothes and sometimes seemed to disappear into her own internal world. Mentors at times wondered if she was too thin, but her work was impeccable and they had no idea how to express their concern. She suffered a cardiac arrest in her studio at the art school on a Tuesday night and with her, her art died.

Kayla had struggled with anorexia in high school and never fully recovered, and her relapse went unaddressed in a college environment because her eating disorder bloomed and gained strength in her isolation.

Eating disorders have a very high mortality rate relative to other mental health disorders, and they thrive on secrecy. Contrary to popular belief, eating disorders are not a choice and the illness is often accompanied by distorted beliefs about food and body shape and size. Eating disorders are cunning, manipulative and self-protective making it all the more difficult for the person suffering to independently reach out for help.

According to the National Center for Education Statistics, in 2016 41% of all US adolescents aged 18 – 24 were enrolled in a college or university. This number has increased by 16% since 1970, and this shift has changed the experience of university life, including the extent and availability of student support services such as counseling centers and student health. College can be an exciting time marked by exponential personal growth, social and education knowledge acquisition, and entry into adulthood. However, it is also a vulnerable stage of life, and a time when young people are at risk for an eating disorder developing or worsening. While approximately 6% of women on college campuses meet criteria for anorexia or bulimia, as many as 40% report body image concerns, weight management behaviors and out of control eating (Schwitzer & Choate, 2015). In other words, social pressures, burgeoning identity, and first tastes of independence combine to create the perfect conditions for disordered eating.

Further, western cultural idealization of a thin frame is an added complication for college students today, and while faced with these often unattainable ideals, college students are also in an environment where regular well-balanced meals are rare, binge-eating and drinking is normalized, and diet mentality is rampant. This creates a risky environment for a cycle of binge eating, weight gain, dieting, body image disturbance, and disordered eating cycles. As many as 36 – 50% of adolescent girls diet and, of these, NEDA reports that 35% of “normal” dieters progress to unhealthy dieting, and of those, 20-25% develop partial or full syndrome eating disorders.

Meanwhile, the landscape of college mental health has shifted considerably in the past two decades. While enrollment has exponentially increased, so has the demand for support services such as counseling, but for most universities, the demand far exceeds the available resources. For example, between 2011 and 2015, Virginia Commonwealth University’s counseling center experienced a 45% increase in the number of students seeking counseling services. The impact of this increase is significant, and while accessing college mental health is a priority, it also means that the availability of ongoing services for students is scarce. According to the Center for Collegite Mental Health (CCMH), most college counseling centers are beginning to move to a triage model of mental health and focusing their efforts on crisis intervention, brief counseling, and referral to community providers. Also according to CCMH, the average number of appointments attended by students in a college counseling center is 4.55.

Contrast this with the typical length of outpatient treatment for patients with eating disorders, for which estimates range from 30 sessions to seven years. This essentially means that college students with eating concerns are unlikely to receive adequate treatment at their college counseling centers. However counseling centers can assist with early identification and be an entry point into appropriate outpatient services or higher levels of care.

Early identification of eating disorders is critical in order to effectively prevent the potentially life-long impact of the disease on the body and brain. Malnutrition can lead to bone density loss, suspend brain development, interrupt reproductive processes, and more. Without prompt and sufficient treatment physical consequences can be irreversible. Furthermore, eating disorders can negatively impact social, psychological, and academic functioning. Treating people who are struggling with the onset of symptoms of an eating disorder as quickly as possible and at the highest level of care needed likely leads to the best possible outcome for those students. Early identification through student health, residence halls as well as university counseling services are likely the best way to ensure that young people do not struggle unnecessarily.

Strategies to Support Students with Eating Disorders or in Recovery: 

1. Educate students with a history of disordered eating/eating disorders, along with their parents and treatment teams about the risk of relapse that entering college presents.
2. Ensure that students with a history or current struggle with disordered eating are equipped with a treatment team (RD, MD, psych provider, and therapist) with scheduled appointments before beginning college.
3. Parents and college students should not expect that the university resources will be sufficient if someone has an active eating disorder or an eating disorder in remission.
4. Provide resources for understanding warning signs and strategies for early identification and intervention to professors, residence life personnel, and other university support providers.
5. Align universities with ED support networks and provide them with resources for understanding the first signs and efforts of early identification.
6. Assist university counseling center staff with developing a network of external providers experienced in treating eating disorders so that the referral process is as seamless as possible.
7. Train residence hall personnel and other front line staff to know how to intervene with students who are struggling with eating concerns or body image issues.

*Name changed for privacy

Veritas Collaborative can partner with your university counseling center, providing assistance in efforts around early identification and the referral process. For more information, please contact admissions@veritascollaborative.com or (855) 875-5812.

About the author:

Sydney Brodeur McDonald, Ph.D., LCP is passionate about providing best-practice, research-informed and multiculturally competent treatment to patients and their families suffering from eating disorders.  She is committed to increasing access to effective treatment, training professionals to deliver gold-standard care, and empowering them to be the best providers and people they can be. Before joining Veritas Collaborative as the Senior Director of Clinical Services, she served as the eating disorder specialist and Associate Director for Training at University Counseling Services at VCU.

What It's Like to Fall In Love When You Have an Eating Disorder

By Becky Curl June 30, 2019

My eating disorder was my first real relationship. I spent my days consumed by it and the hold it had over my life. Night and day, day and night, my anorexia was there by my side. Instead of a warm embrace at night from someone I loved, I felt its grip tighten over my bones while I struggled to find solace in my sleep. I did not love myself, and I feared that my obsession with my outward appearance would forever be the only one by my side.

People like to tell you that in order to be loved by someone else, you have to love yourself first. How toxic it is to make someone feel as if they are unworthy of being loved because of their own struggles with their mental health. We all deserve to feel love, even if we can’t quite love ourselves yet. I often could not see my own beauty, but luckily, one day, you did.

You were the first person to show true romantic interest in me. I couldn’t believe that love was finally happening for me, after all of these years of feeling so alone. You were patient and kind with me when it came to my eating disorder. You accepted that big fancy dinners and ice cream dates might never be something we could enjoy together. I shared more of my body with you than with anyone I ever had before, and I do not remember ever feeling uncomfortable in your presence. You brought me peace and love, and I thought that maybe I had finally found my person.

I am not sure how I ignored the signs so easily, when there were sirens blaring all around me. You broke up with me and not just because you found someone else. You were frustrated with my eating disorder and the fact that you couldn’t take me out for dinner like all of the other girls. You didn’t know what to do with me. I was boring, awkward, and not someone you wanted to spend your free time with anymore. The comfort I found in you was decimated, and again, I was back in the arms of my eating disorder.

I struggled for years after you left to jump back into a dating scene that looked like a war zone to someone struggling with an eating disorder. How could I go out for drinks when they had so many calories? How could I go out for dinner and eat in front of a stranger? How could anyone ever want to be with someone as disgusting as me?

Every time I thought I met someone, it always fell through. Until one day, I finally met you.

You were all in before I even had a chance to show you the darkness I kept so well-hidden. I did not realize it then, but I had finally found someone more toxic to be with than my anorexia. At first, you were supportive, understanding. But soon, my eating disorder began to fuel the fire that would eventually destroy us.

I was in love with you, and I like to think that you were in love with me, too. For the most part, you were very patient with me and my need to take things slowly. I have never loved my body, so how could anyone else? The idea of someone seeing you naked is one of the worst things someone struggling with an eating disorder could ever imagine. During one of our most intimate moments, just when I was finally beginning to feel comfortable enough to share myself with you, you saw my body and told me that I was disgusting.

Complete and utter devastation. Shame. Those are just the highlights of the way you made me feel that night. How could someone I love so much and who loved me so deeply see me as so repulsive? I know that I will never see my own body for what it really is, but having the person you love tell you that your body is disgusting is enough to fuel your self-doubt forever.

It took me a long time after that night to feel comfortable enough to share myself with you again. I wish I could say the next time went any better, but all you did was solidify how much I hated myself and how much I was beginning to hate our relationship. Some days, you told me I was too thin. Others, you told me I needed to start working out. You didn’t like the way my clothing fit me. And you certainly did not want to stay with someone who couldn’t even take care of themselves. Eventually, I left you, but not without emotional scars I fear will never fade.

When you love someone, you decide to love them for their good and their bad. And while you may not condone the bad, you certainly should never shame them for it. Shame never saved anyone. Patience, understanding, and support are what those of us struggling truly need.

So what is it like being in love when you have an eating disorder? It is like you are drowning and can see the hand trying to pull you back out, but no matter what you do, the current keeps pulling you under. It’s like finding the light only to be cast back into the darkness because the flame didn’t last as long as they said it would. It is like fighting a battle, but forgetting what side you are rooting for because sometimes, everything feels wrong. You never know when love is real, and you never trust anyone to stay. You are afraid for how they will react when they see you for who you really are, so you do your best to hide yourself from them. But sometimes the hiding is what makes them leave in the first place. You start to wonder if love just isn’t in the cards for you. But then you remember that you used to think you would never make it to the other side of your eating disorder. You used to think that recovery would never be for you. We become so used to finding comfort in the toxic because sometimes the toxic choice is the easiest one that we forget that a little bit of fight can yield beautiful results.

Loving someone with an eating disorder means loving a person who cannot love themselves. It means supporting a person who sees a different image reflected back at them. But just imagine the strength of that person you are loving. To get through every day hating what you see reflected back at you, but persevering because you know there has to be something better than how things are right now. That is true strength. And love needs a strong foundation to blossom and thrive.

Being in love when you have an eating disorder makes a challenging aspect of your life come center stage. But love is also the way out of your pain. So please, fall in love. Feel loved. And don’t be afraid when the first few don’t work out. Because if your eating disorder has taught you anything, you know that you are stronger than you ever thought possible. Don’t let it or anyone else’s toxic love convince you otherwise.

Different Approaches to Weighing Patients

Vol. 30 / No. 4 — Eating Disorders Review

Patient wishes overruled established treatment guidelines.

A recent study sought to uncover reasons that clinicians regularly fail to weigh patients appropriately during cognitive-behavioral therapy (CBT) for eating disorders. Drs. A. Daglish and G. Waller of Sheffield University, Sheffield, UK [see also article on abbreviated CBT elsewhere in this issue] evaluated patient- and clinician-based reasons this occurs (Int J Eat Disord.2019. June 7. doi:101002/eat.23096 [epub ahead of print]).

After surveying 74 clinicians who practice CBT, using case vignettes that varied in patient diagnosis and distress levels, the two researchers found that clinicians were more likely to weigh patients with anorexia nervosa than to weigh patients with bulimia nervosa, but less likely to weigh those who were distressed at the idea of being weighed.

Clinicians who thought weighing was helpful were more likely to do so. The authors note that their recruitment strategy may have tended to attract participants already predisposed to weighing.  Moreover, it seems possible that such a survey might bias reporting toward what is perceived to be best (rather than actual) practice. In each case, actual rates of weighing could be lower than described. The authors suggest these findings call for enhanced training and supervision around the benefits of open weighing of people in eating disorders treatment.

Peer Mentoring Program Yields Positive Results

Vol. 30 / No. 4 — Eating Disorders Review

A pilot program in Australia helped both mentors and mentees.

A “mentor” is someone who teaches or gives help and advice to a less experienced and often younger person. This very modern word goes back to the ancient Greeks and to a character, Mentor, a trusted friend and advisor to Odysseus in Homer’sOdyssey. This concept has reached across the ages and now is found in most specialties, particularly education and social work. A pilot study in Australia recently evaluated a peer mentor program for “mentors,” persons recovered from an eating disorder, and “mentees,” individuals who currently had an eating disorder (J Eat Disord. 2019. doi: org/10.1186/s40337-019-0245-3).

In this pilot study, Dr. Jennifer Beveridge and co-workers at Swinburne University of Technology, Hawthorne, Australia, and St. Vincent’s Hospital, Melbourne, Australia, recruited 30 mentees and 17 mentors for a peer mentoring program. The mentors were all recovered from an eating disorder for at least a year, and for study purposes were staff members at St. Vincent’s Hospital, employed specifically for the program.  Mentees had current eating disorders, and had actively transitioned out of an inpatient treatment program but remained in outpatient treatment for their eating disorder.

The program consisted of 13 sessions given over 6 months. The participants completed the EDE-Q and measures of quality of life, mood, and perceived levels of disability. Semi-structured interviews were conducted for qualitative evaluation of the overall program. An individualized Wellness Plan was designed for each participant.  The mentors all attended separate bimonthly group supervision sessions, where the participants received further education, including training, and peer support.

Thirty participants (28 females and 2 males) agreed to participate in the study. The mentees ranged in age from 18 to 50 years (median age: 28 years). Most mentees (28)  had diagnoses of anorexia nervosa, 1 was diagnosed with bulimia nervosa, and 1 had other specific feeding or eating disorder (OSFED).Eight withdrew during the study, due to need for overseas travel, moving, returning home to a regional area after treatment, and lack of motivation to continue with the program.

Improvements noted at the end of the study

Over the time of the study, the mentees increased their body mass index (BMI, mg/kg2), in contrast to the typical weight loss reported after discharge from treatment. They also had improvements in eating disorders symptoms over the course of the study, including improved mood, less disability, and improved quality of life.

Overall, the mentoring relationship was a positive experience for both mentees and mentors. The mentees reported feeling inspired by their mentors, and that the sessions were much more relaxed and nonjudgmental than treatment sessions. However, the mentors themselves had increases in the EDE-Q Global Eating Concern and Shape Concern scores, though none reached the pathologic range.  Dr. Beveridge reported, “Qualitative results highlighted that the mentoring relationship was a positive experience for both mentees and mentors, instilling an increased hope for recovery in mentees and an opportunity for mentors to reflect on their own recovery with increased confidence.”

This strategy has been shown to be helpful in mood disorders and although results were mixed, deserves further attention for EDs as well.

Eating Disorders Treatment and Concomitant Substance Use among Teens

Vol. 30 / No. 4 — Eating Disorders Review

The combination can affect completion of outpatient treatment.

Chemical dependency and eating disorders commonly co-occur. This produces many challenges; for example, ED programs tend to be uncomfortable with clients with addiction, and addiction programs are often uncomfortable dealing with clients with eating disorders. It appears that treating one problem at a time does not work optimally.

A 2015 study published in the journal Psychiatry Researchfound that more than 13% of female patients with bulimia also had a substance use disorder. About one-third of men and 7% of women diagnosed with the binge-eating/purging type of anorexia met the criteria for alcohol dependence.

Adolescent patients with substance abuse and eating disorders have different characteristics and are more likely to drop out early from eating disorder treatment, according to a team of researchers from Montreal. Dr. Ryan Kirkpatrick and psychologist Linda Booij, associate professor of psychology at Concordia University, Montreal, and their colleagues investigated whether teens with eating disorders who used substances responded better to outpatient treatment compared to teens with eating disorders who did not use substances (Int J Eat Disord. 2019. Doi:10.1002/eat.23017 [E-pub before print].

Dr. Kirkpatrick and colleagues specifically wanted to study teens who used drugs, tobacco, or alcohol socially (off and on), without developing addictions or showing problematic behavior. One goal was identifying teens at greater risk of dropping out of treatment or those who might need a more specific form of treatment. The study group included about 200 teens who received outpatient treatment at Hotel Dieu Hospital at the Kingston Health Sciences Center, Montreal.

Heeding warning signs that can improve outcome

As previously described in the literature, teens who used substances were more likely to have bulimia nervosa or binge/purge type anorexia nervosa. They also reported that teenagers who used substances before entering treatment regularly used more self-harming behaviors, like cutting, and displayed more impulsivity.  However, the two groups showed similar severity of eating disorders. As noted earlier, dropout was higher in the substance use group.

These findings might help clinicians be more alert to the possibility that a teen with substance use is more likely to drop out of treatment early. More broadly, the results raise the issue of refining eating disorders treatment to improve their fit for people with co-occurring EDs and substance disorders.

Ten-Session CBT Proposed

Vol. 30 / No. 4 — Eating Disorders Review

A shorter period of CBT might reduce costs and make treatment available to more patients.

During a plenary session at the 2019 ICED meeting in New York in March, Glenn Waller, DPhil, of the Department of Psychology at the University of Sheffield, Sheffield, UK, described a 10-session cognitive behavioral therapy (CBT-T) program that he and his  colleagues have recently developed.

Dr. Waller pointed to the ICED conference theme, “Start Spreading the News,” and asked where the news is coming from and where is it going. “We should be listening,” he said.  “We have effective but not perfect therapies; these could be better,” he added. Dr. Waller and colleagues have developed a shortened form of CBT that is showing early promise. He added some key (and perhaps provocative) points contrasting traditional psychotherapy and CBT-T:

1. More therapy does not make for a better outcome, according to Dr. Waller. He said, “Typically, if we do wait for patients to spring into action in bulimia nervosa, the number of sessions is usually a mean of 45. This is twice the recommended number of sessions.”
2. Manuals improve outcomes but many clinicians don’t even pick them up; “we still rely on osmosis,” he said.
3. Therapists don’t need specific training for a specific disorder.
4. Most therapists are over-trained for what they do.
5. If he had his choice, Dr. Waller said, he would develop treatment models that don’t rely on over-trained, overly expensive therapists. More therapy doesn’t make for better outcomes, he added.

Dr. Waller said that CBT-T began as a result of many frustrations, especially from poor attention to patient outcomes.  One of the questions his group and others have had to face was how to get patients into therapy quickly and effectively. A faster turnover was needed to deal with resource limitations, where lengthy waiting lists keep people from receiving needed treatment.

To test the efficacy of CBT-T, Dr. Waller and colleagues recently treated 93 non-underweight adult eating disorder patients. These patients received a protocolized 10-session program of CBT, which was delivered by clinical assistants, under supervision (Int J Eat Disord. 2018; 51:262).  By the end of their therapy 31% of the patients had dropped out. Statistically significant changes in EDE-Q Global and subscale scores as well as ED behaviors were seen at the end of treatment and at a three-month follow-up.  The authors note the magnitude of change was in the range seen in studies of more traditional CBT approaches. (More recently, Pellizer, Waller, and Wade [Eur ED Rev,2019, epub ahead of publication] reported a second trial of 52 individuals treated by 6 different trainees, with similarly encouraging results.)

Dr. Waller and his colleagues were pleased to find that the shorter-term CBT showed similar efficacy as that reported in larger, separate studies of longer-term therapy, and it could mean reduced patient costs and improved access to care. He added, “We initially thought that shorter treatment would not be as effective, but patient experiences were generally very good. Briefer therapy can work just as well as longer therapy. Now we have to transmit the news: we as clinicians can be more treatment-resistant than patients are, and we need to spread the news to patients and others that briefer treatment is better.”

These results should prompt discussion and perhaps reconsideration of treatment models for eating disorders. Can some therapies be shorter? Which individuals might benefit, and which need longer treatment?  And, finally, while short-term outcomes are encouraging, is long-term outcome similarly positive?