Mindfulness in the management of eating disorders

Abstract

K. Halmi provides an excellent summary of recent advances in the treatment of eating disorders. There are no doubts concerning the usefulness of structured units for people with anorexia nervosa and cognitive behavioral therapy (CBT) for bulimia nervosa. Structured clinical units require a multi-disciplinary (multi-dimensional) team including nurses, dietitians and psychologists, as well as social and family therapists. However, these experienced staff can be recruited only in environments where the standing of our specialty is high. Even in university hospitals, it happens frequently that nursing staff are moved periodically to other departments, so that it may be difficult to retain well trained nurses. Further, most psychiatric units are general, and to set up a specialized unit or sub-unit may not be easy. On the other hand, an intensive outpatient program or residential treatment cannot be replaced by a structured unit: all of them should be part of a comprehensive service. CBT for patients who show bingeing/purging behavior within a normal weight range has become the standard. However, there are many non-responders and premature drop-outs. Most chronic eating disorder patients have already experienced the failure of CBT throughout their long history of illness, and do not improve through short-term motivational interviewing. Transdiagnostic therapy and enhanced CBT have shown promise 1, but it remains to be documented that they are more effective than routine CBT in ordinary clinical conditions. Eating disorders arise as a way of patients trying to escape from difficulties they may have. On facing these life-threatening disorders, we must be mindful 2,3, honest, and be aware of our limitations. Structured units and enhanced CBT aim to rapidly change behaviors or patterns of thought, but chronic patients are usually extremely inflexible, and change is slow. Psychological “Judo” in motivational interviewing focuses on the patients’ “moment of inertia” to change rather than confronting their relentless pursuit of thinness. In Asia, the relationship between mother and daughter is closer than in Western countries. Even though similar percentages of eating disorder patients are impulsive 4, most patients have family support. Family support is a double-edged sword (risks of over-involvement and being manipulated), but there is the possibility that the family be truly of help. Treating eating disorders is always challenging. However, using a heavy-handed approach will make the patients more rigid. We, psychiatrists dealing with eating disorder patients, should not treat aggressively, but rather share our understanding of patients’ painful experiences and hope of recovery. It is important to develop a small-scale system that just one psychiatrist is able to run, even though it may be difficult in several contexts.