Treating Eating Disorders in Adolescents
Updated: Dec 19, 2021
Dr. Tara Deliberto's TREATING EATING DISORDERS IN ADOLESCENTS: EVIDENCE-BASED INTERVENTION FOR ANOREXIA, BULIMIA, AND BINGE EATING comes out this Thursday, 8/1, from New Harbinger! Although this might not be a book a regular person would normally stop to pick up, it's already gotten a lot of positive buzz within the medical community for its holistic approach to recovery and groundbreaking integrative program (drawn from several different evidence-based therapies) and is the Amazon #1 New Release in Cognitive Behavioral Therapy.
Tell us a bit about you and what you do.
Sure! I'm a psychologist with a job that looks different than what most people might imagine. I work at NewYork-Presbyterian Hospital with people diagnosed with eating disorders who currently need what is referred to as a "higher level of care" (e.g. inpatient hospitalization). Rather than attending therapy once per week, the patients with whom I work need care every day at a hospital from a specialized multi-disciplinary team to foster both physical and psychological recovery from eating disorders. Several years ago, I opened and directed a "partial hospitalization program" or PHP where adult patients come in for treatment from 8:00am-3:00pm, Monday through Friday. This program offers patients an opportunity to either step down from inpatient care or prevent hospitalization.
Currently, I am an assistant professor at Weill Cornell Medicine, the medical college of Cornell University, working in the program at NewYork-Presbyterian that I created, training advanced doctoral students as well as post-doctoral fellows. In this role, I teach an eating disorders seminar at the hospital that all staff members and students at the hospital are welcome to attend. While carrying out my roles as a hospital psychologist, administrator, and teacher, I worked on creating a new treatment approach called Integrative Modalities Therapy (IMT) for eating disorders along with my colleague, Dina Hirsch, PhD.
How did you put together the research for this book and what made you realize that you should write it?
Ironically, I spent my first four years of training with the thought "I want to treat everything but eating disorders because they’re just too difficult." I know a lot of clinicians think the same. But when I saw the state of things, I felt entirely differently. In fact, the treatment landscape for people with eating disorders – the deadliest of mental illnesses - was so bleak that felt compelled to devote my career to helping improve the quality of care. Then, clinicians started enthusiastically treating borderline personality disorder because they loved learning DBT. It was clear that the same needed to be done for eating disorders.
The journey of creating IMT started years ago when Dina Hirsch, PhD, was my supervisor at a partial hospitalization program for adolescents with eating disorders at NorthWell Health. I was fairly new to the treatment of eating disorders at the time and was shocked to find that there was simply no evidence-based treatment material written for use with adolescents with eating disorders. The modus operandi was to use repurposed material for adults with other disorders such as anxiety or borderline personality disorder. I remember saying to Dina, "We have to do better than this!" She agreed. Later that day, we were in a required meeting and I passed her a note with the sketched out plan for IMT I had been mulling over since the prior year. Unlike anyone else I told about this idea in the past, Dina immediately encouraged me to follow through with it.
Right away, we started creating group material rooted in either previously published evidence-based treatment manuals or one-off interventions described in research papers. We also started writing similar material for use with parents/carers in our family meetings as well as with patients in our individual therapy sessions. Over time, the collection of interventions – what we now called Integrative Modalities Therapy (IMT) - amassed into three separate works for use in groups, family sessions, and individual therapy.
Others in the field started to express interest in using our materials. Some clinicians even started translating them into other languages for use with their patients. This type of feedback quickly signaled to us that we had been creating a flexible and scalable treatment for eating disorders in adolescents that others perceived as rather easy to administer in both hospital and outpatient settings. It also became apparent that IMT could be used as a tool to train clinicians in geographical regions where eating disorder specialists were sorely lacking. I then started to think that maybe this could be the treatment that interested clinicians in the treatment of eating disorders. Understanding the potential for IMT to help, we set out on a mission to see it published and disseminated, hoping to contribute to the efforts made by those in our field to improve care.
What makes the type of treatment outlined in your book different from what is already out there?
IMT is rather different than what is out there for several reasons, some of which are likely surprising. As mentioned above, IMT is chiefly different than what exists in that it includes handouts/worksheets steeped in evidence-based treatments for adolescents. To our knowledge, nothing like this existed before IMT. It is also different from any other type of manualized treatment we know of in that there are interventions designed for three separate types of therapy settings: individual, group, and family therapy. Lastly, unlike other treatment protocols, IMT is designed to be used very flexibly. Each handout contains an intervention for a specific issue a patient may or may not face. As such, each patient gets a different set of treatment materials depending on what they need.
In a similar vein, does the flexibly of IMT's material (e.g. that is can be used in inpatient settings) set is apart from other treatments currently available?
Yes! Absolutely. Specifically, IMT is rather different in that it was created for use in inpatient, residential, and day treatment settings, as well as in outpatient settings. Most treatment manuals seem to be written specifically for use in outpatient settings. Due to factors such as the medical precariousness of our patients, however, many people with eating disorders are treated at higher levels of care (e.g. hospitals, residential programs, etc.). Considering that 1) other manuals are written for use in outpatient, and 2) a large and important portion of eating disorder treatment is delivered at higher levels of care, there was a big disconnect between what was available and what is needed. For instance, when an adolescent with anorexia nervosa is healthy enough to be in outpatient care, family therapy is absolutely essential. The outpatient manual, therefore, prioritizes interventions with the parents/carers. At higher levels of care, however, the patient is attending treatment groups all day with peers. Patients, therefore, need standardized evidence-based materials to be administered during those times.
Are the symptoms of eating disorders signs that can be easily are ignored or dismissed by sufferers or their families? Would you say it is more common for teenagers to suffer from an eating disorder now than it was 10 years ago, 20 years ago?
Both people with eating disorders and their families are often completely unaware of the illness. Eating disorders are different than most other types of mental illnesses in that they are considered to be “egosyntonic.” This means that a patient does not present as wanting to recover from the illness. Food restriction, for instance, may be viewed by patients and//or their families as “healthy,” rather than as part of a life-threatening mental illness. As such, people with eating disorders may present as being unmotivated or unwilling to change behaviors they perceive as healthy. Similarly, family members may also present as unwilling to aid a person with an eating disorder in recovery if the perils are not fully understood.
Other patients and family members, however, do recognize eating disorder behaviors as problematic, but do not feel equipped to address it for variety of reasons. For instance, when confronted about the illness (e.g. a family member prompts more food to be eaten at a meal), a person with an eating disorder may have an explosive reaction, resulting in the family member drawing the conclusion that “it is not helpful to interfere.” In IMT, a behavior that is aimed at / results in others withdrawing support (e.g. having an explosive reaction), is referred to as an “eating disorder protective behavior (EDPBs).” Despite knowing that a problem exists, family members can become conditioned to ignore the eating disorder when people engage in EDPBs. Without having the skills to address the problem nor knowledge of how to access resources, many family members simply abandon efforts to intervene, feeling helpless.
Especially considering the variety of factors preventing people with eating disorders and their families from recognizing the illness, it is up to clinicians to know that eating disorders are life-threatening illnesses that require immediate psychological, psychiatric, and medical treatment. Of note, eating disorders are much more common than even ten years ago. In fact, a recent study showed that the number of eating disorders cases has doubled in recent years (Galmiche, et al., 2019). Research is also is showing that people of all genders, ethnic backgrounds, ages, and socio-economic statuses have eating disorders. In short, because eating disorders are 1) ego-syntonic, 2) life-threatening, 3) have a rapidly increasing incidence, and 4) impact people from all backgrounds, we strongly recommend that all people presenting for therapy should be screened for eating disorders.
Can you tell us a bit about IMT and its mission?
With IMT - a curated collection of evidence-based interventions – we hope to help patients develop skills, support families, and provide a way for clinicians in the trenches to communicate core treatment concepts. We also hope to attract new clinicians willing to treat eating disorders, so that more treatment options are available to patients. In short, our mission is to help close the treatment gap.
What do you hope your book is able to change in the medical community?
Globally, I hope that IMT will help improve care for people with eating disorders. By making eating disorder treatment more approachable to clinicians, I hope that professionals will learn more about eating disorders and how to treat them. In particular, I hope that clinicians in rural areas learn how to use IMT so that people who currently do not have access to eating disorder treatment can receive it. If IMT can do any of this, all of the effort in creating this treatment will have been worth it.