The first priority in treating adults with anorexia is weight restoration.
According to research, enhanced cognitive behavioral therapy (CBT-E) is the most effective treatment for adults with anorexia. What we find at Columbus Park, however, is that the starved mind is not receptive to talk therapy. Re-feeding is an essential early step and, for many adults, meal support is a really effective treatment.
Adolescents with anorexia often have better outcomes than adults. The reasons are twofold. One, adults have often been sicker longer and biological changes to the brain are harder to undo. And two, adolescents respond very well to Family-Based Therapy (FBT)—sometimes called the Maudsley Approach—a particularly effective form of treatment that is difficult to use with adults.
The initial focus of FBT is weight restoration, and it’s a big reason the treatment is so effective. Parents are shown how to be emotionally supportive of their child but insistent that starvation is not an option and meals must be eaten. In effect, parents take charge of food and exercise decisions for their child. As weight is restored, we find that many other symptoms—like anxiety, depression, obsessive-compulsive behaviors and social isolation—begin to abate and are much easier to address.
FBT is difficult to replicate with adults. For one thing, over-18 adults are often living on their own and, even if they are still living at home, parents don’t have the same authority they once did. Yet without that firm hand, even the most motivated adult with anorexia can become paralyzed making decisions about what and when and how to eat.
Residential programs can achieve weight restoration with their insistence on eating, but they are very expensive and are really only appropriate for the sickest patients. Some experts in the field, like Walter Kaye MD and his team in San Diego, have tried replicating the FBT experience by organizing a care circle of friends and family to come together for a one-week intensive. Kaye’s approach—enlisting these carers to provide structure and support, particularly around mealtimes—shows a great deal of promise. And while it is a wonderful option for those with family and friends who are willing and able, it is unrealistic for most adult patients—the logistics and expense are just too imposing.
At Columbus Park, we mirror the weight restoration phase of FBT by using supported meals with our adult anorexia patients. For as many meals per week as possible, our patients eat on-site in a group setting. Job and school commitments often make attending all meals challenging, but we encourage patients to attend at least seven meals per week.
In effect, we assume the role parents have with FBT—meals are scheduled and menus are nutritious and balanced, and with enough calories for weight restoration. A therapist is present to provide support, assure meals are eaten, and help patients navigate their mealtime emotions. Our focus is on managing the intense fear and anxiety that emerge around eating while ensuring appropriate nourishment. Later in recovery, we also find some patients benefit from support in the field—like eating out at restaurants and shopping for groceries.