A DOCTOR’S VIEWPOINT ON ABA
- Feb 25
- 12 min read
Excerpted with modifications from Anorexics and Bulimics Anonymous.
© Copyright 2016 by Anorexics and Bulimics Anonymous.
I am a family physician who for more than two decades has worked with people suffering from eating disorders. In this work I have had the great advantage of being a recovered anorexic myself. I was fortunate not to die from this disease, which has claimed the lives of others whose clinical pictures resembled my own. Instead I have recovered, and the story of my personal healing journey is detailed in Chapter 2.
In this first chapter I have been asked to contribute some information from a purely medical perspective, and I am honored to do so. I need issue one caveat, however, at the outset. I have found the approach of Anorexics and Bulimics Anonymous to eating disorders to be useful only with patients who have reached a level of maturity and autonomy that allows them to accept full responsibility for their illness and their recovery process. It is not appropriate for children or for young adolescents, who cannot
possibly have attained such maturity. In my practice I refer all anorexic and bulimic patients in this age group to a psychiatrist skilled in dealing with their special needs. I never attempt to treat them myself.
Readers who are concerned about minors with eating disorders are cautioned to use the content of this book with discretion. Although it may facilitate a deeper understanding of the problem of eating disorders, it is unlikely to provide any useful information leading to their solution in the case of the younger patient. In particular, parents of minor children with eating disorders are strongly advised to consult experienced medical professionals about their children.
THERAPY OF ANOREXIA AND BULIMIA NERVOSA
Current Therapeutic Approaches
The twin disorders of anorexia and bulimia nervosa have baffled and confounded medical practitioners for decades. An impressive body of literature has developed alongside a vast array of therapeutic approaches—including medication, forced feeding measures, gastrostomy, parenteral nutrition, behavior modification, confinement in hospitals and asylums, outpatient meal-support, electroconvulsive therapy, and a host of psychotherapeutic techniques.[1] Therapists in many fields have tried variously coaxing, coddling, convincing, and coercing their patients to eat in a healthy manner. They have tried reason, explanation, gentle persuasion, drugs, threats, and even physical force to control these peculiarly obstinate patients who seem bent on self-destruction.
Results of The Usual Methods
My own experience is that many of these approaches are effective for a time and that none of them work in the long run. Through the application of these methods, individuals with eating disorders may eat normally, attain a healthy weight, feel better physically and emotionally, and even come to fully understand how and why they originally developed their maladaptive behaviors. In most cases, however, they are not
released from the central crux of the disease: their mental obsession with weight, food, body image, and exercise. This leaves them predisposed to relapse. Some patients may achieve release from their obsession, only to find themselves using alcohol, drugs, overwork, sex, relationships, or gambling instead. Anything to alter their minds so they can face their lives. Often in such cases, the substitute method of psychic alteration
eventually itself becomes a compulsion fueled by a mental obsession, and as self-destructive as the eating disorder ever was.
Is Recovery Possible?
Given these facts, we are faced with a crucial question: Is true recovery from eating disorders even possible? Many of my colleagues in this field, battle-weary and jaded by their heartbreaking experience with these recalcitrant patients, shake their heads sadly at this question. No, they say, the most we can hope for, at least in chronic cases, is to help these patients cope with their dreary existence until death mercifully ensues. This opinion is remarkably similar to universal medical opinion regarding chronic alcoholism in the early 1930s, prior to the advent of Alcoholics Anonymous.
I believe that my disillusioned colleagues are correct. These patients are beyond human aid once their minds are fully occupied by the anorexic or bulimic obsession. I have seen hundreds of patients who languished in the misery of their illness for decades in spite of the best treatment by dedicated practitioners. Many experience temporary reprieves, and with each relapse sink to ever greater depths of despair. I have witnessed the deaths of many of these patients, at least half of these from suicide. No amount or combination of antidepressant medication can relieve the pernicious self-loathing generated by the entrenched obsessions of these individuals.
Nevertheless, in the past twenty-five years I have witnessed truly miraculous, enduring recoveries in the anorexic and bulimic population. I have seen people completely restored to physical health, liberated from their obsession with their bodies, free to eat normally without having to think constantly about food, free to live their lives and do their jobs and raise their families. Such recoveries have become so commonplace in my practice that I am no longer surprised by them. And it seems that such a favorable outcome is entirely independent of the age of the patient and the duration of their illness. Patients aged
eighteen and sixty recover. Those who have been ill for six months and thirty years recover. Employing the approach outlined in this book, virtually anyone can recover, even patients with coexisting mental illnesses.
Coexisting Mental Disorders
As an important aside, the recovery approach detailed in this book deals only with the disorders of anorexia nervosa, bulimia nervosa, and allied eating disorders, not with any accompanying mental illness. In my experience, such coexisting disease is frequent in the anorexic and bulimic population. Particularly common are major mood disorders, including bipolar disorder; personality disorders, especially ones with borderline and obsessive-compulsive traits; dissociative disorders; and posttraumatic stress disorder,
often resulting from childhood sexual abuse and other disruptive events in the early lives of these patients. Obviously, these concomitant mental disorders require appropriate treatment in their own right, and psychiatrists and psychologists have a vital role to play in this regard. Appropriate medication and a variety of psychotherapeutic methods can be helpful, and many anorexics and bulimics in the A.B.A. Fellowship undertake such therapy in conjunction with their Twelve-Step work. We never discourage them from doing so. Furthermore, we ensure that every individual entering the rooms of Anorexics and Bulimics Anonymous understands that our program is only intended to help her find recovery from her eating disorder and from the havoc it creates in her life.
ESSENTIAL COMPONENTS OF DEEP RECOVERY
The key elements in the remarkable recoveries I have witnessed have been simple and consistent from one case to the next. All these individuals first needed to risk letting go of their pathological eating, purging, and exercise patterns. They had to admit complete personal defeat by their disease, then come to believe that a spiritual Power greater than themselves could restore them to sanity. They needed to establish an ongoing relationship with that Higher Power and live according to its guidance. They were
required to follow a simple program of action to deal with their own emotional and spiritual ruin and with the harm they had caused others through their disease. They needed to work with other anorexics and bulimics who wished to recover, passing on their personal experience and strength. Most importantly, they needed the support of others walking the same recovery path. No one in my experience has healed in isolation.
The Physical: First Things First
Of course, anorexics and bulimics always need medical treatment to restore their physical well-being before they can follow the Twelve-Step plan outlined in this book, and the need for such treatment should never be overlooked or minimized. All of us in Anorexics and Bulimics Anonymous are aware of the physical devastation caused by these diseases. When newcomers walk through our doors, much of our early work with them is directed toward connecting them with the medical help they need. We know there is no point in talking about the spiritual message of the Twelve-Step Program to someone whose body has been compromised by starvation or by bingeing and purging, because the words would fall on deaf ears. As you read on in this book, you will notice again and again the top priority we place on physical “sobriety”— defined as adherence to nutritionally sound eating practices and initiation of return to healthy body weight—as a prerequisite to working the Twelve Steps. All are welcome, of course, to attend our meetings, no matter how sick they are. The only requirement for membership in our group is a desire to stop unhealthy eating practices. Some people attend for months or years before they finally surrender to healthful eating and become physically well enough to begin the work of psychospiritual recovery through the Twelve Steps.
We frequently refer our newcomers to physicians outside our Fellowship to obtain the medical treatment they may urgently require. Sometimes we accompany these sick members to a hospital or clinic where they can be treated for their physical complications. I have the utmost respect for physicians who are willing to treat these difficult patients, because they demand extraordinary patience, wisdom, and compassion. Many in the medical field give their all and deserve the highest commendation for their efforts. They play an essential role in the physical treatment of individuals with eating disorders.
The Spiritual: The Core of Recovery
However, for anorexics and bulimics to be healed mentally and spiritually, to be released from their deadly obsessions with food and with their bodies, I have found the usual medical and psychological interventions to be of limited use. A spiritual path of recovery is needed to heal a spiritual malady, and the Twelve-Step Program is one such itinerary. Furthermore, it is a well-trodden route, having proven effective for millions of people suffering from a variety of addictive disorders. In the Fellowship of Anorexics and Bulimics Anonymous, individuals who become physically sober are then able to work through the Twelve-Step Program, using the guidance of more experienced members. This Program leads them to profound emotional, mental, and spiritual healing.
Why Powerlessness?
Let me respond to these objections by stating that the remaining eleven Steps of the Twelve-Step Program are all about empowerment. They lead the individual to assume full responsibility for her illness and her recovery through an intensive program of action. As she works through these Steps, she discovers deep within herself a spiritual Power greater than anything she could have imagined, a Power that not only allows her to eat normally and that stops her deadly obsessions, but also one that shapes and informs every aspect of her life.
The great paradox is that she can arrive at this amazing personal power only through admitting the truth about her disease: that she is powerless over it (Step One). She can then reach out for and accept the help she needs to begin recovery. Our individual members must themselves assume full responsibility for undertaking the actions needed for recovery. No one can do this for them...and they don’t need to do it
alone.[2]
USE OF TERMINOLOGY IN THIS BOOK
Role of the DSM-IVTM
Before concluding this discussion, I wish to clarify for both lay and medical readers some of the terminology found throughout this book. I am fully conversant with the precise definitions of eating disorders found in the DSM-IVTM.[3] (For the information of the lay reader, this designation refers to a highly respected publication of the American Psychiatric Association that is widely used as a trusted handbook by psychiatrists and other medical doctors throughout the world.) However, I have found the DSM-IV definitions of eating disorders to be of little practical use to my work in this field over the past decade. Some people I have seen meet all criteria for anorexia nervosa or bulimia nervosa, while others who are just as sick do not. For example, some anorexics whose entire lives have been decimated by their disease have never met the weight-loss standards in DSM-IV. Some bulimics do not binge and purge frequently enough to earn the label of bulimia nervosa. And then there is the largely uncharted territory of compulsive eating disorder, an entity yet to be named by psychiatric texts. Of course, the DSM-IV does identify the new diagnosis of “eating disorder not otherwise specified,” a catch-all category that encompasses everyone who does not fall within the parameters for anorexia or bulimia nervosa. However, this vague diagnosis seems to be rarely heard by patients or, if heard, it is trivialized and regarded as proof of no significant pathology.
The Dangers of Diagnostic Criteria
I believe that the distinctions found in DSM-IV are not only unnecessary but potentially harmful to patients. I have interviewed many people who sought treatment for their eating disorder years earlier, only to be reassured by their physician because they did not fulfill all the qualifications for anorexia or bulimia nervosa. Regrettably, some of these individuals concluded that they were not sick after all and then went on to become more deeply mired in their disease, often devoting another decade or two of their lives to its
practice before pursuing further help. Others fled to the arms of practitioners with little or no knowledge of eating disorders who, though well-meaning, understandably missed the diagnosis in these patients. Often such therapists recommended costly and sometimes harmful approaches for the physical symptoms that resulted merely from untreated eating disorders. I have met full-blown anorexics who were prescribed highly restrictive diets to treat their fatigue and abdominal symptoms, thus aggravating their anorexic obsession and leading to dangerous further weight loss. Some patients were existing on handfuls of supplements instead of on food when they first consulted me.
We physicians might prevent such unfortunate chains of events by using broader margins in our diagnostic process. The statisticians and researchers must, of course, adhere precisely to DSM-IV, yet I wonder whether we front-line clinicians might consider approaching patients differently. Perhaps we could validate that the patient before us is truly ill even if her condition has not yet progressed to meet all DSM-IV criteria. It is generally agreed that anorexia and bulimia nervosa have the highest mortality rate of all
psychiatric disorders. It therefore seems wise to find every possible means to help a patient face her disease squarely while it is still at an early stage.
What Is She Thinking?
Anorexics and Bulimics Anonymous recognizes that the essence of eating disorders is neither body weight nor outward eating behavior per se, but rather the insanity of the mental obsession that fuels pathological eating and purging behaviors. Anorexia and bulimia are defined by what is transpiring in the mind regarding food and body image, not by the outward appearance or behavior of the individual.
A.B.A Encourages Self-Diagnosis
Furthermore, all who come to this Fellowship identify for themselves whether they belong here or not. No one weighs them at the door or demands a tally of their binges over the past week before letting them in. They are anorexic or bulimic if they say so. If they lack the true mental obsession of anorexia or bulimia nervosa, they will shortly identify this for themselves and not return to meetings. And if they do have the mental obsession, they will feel at home among us regardless of their present body size or current eating practices. Most importantly, they will have the opportunity to recover now, instead of waiting until they have lost enough weight or binged and purged enough to earn the psychiatric label. Surely this is a desirable outcome, especially for a disorder whose prognosis deteriorates rapidly with elapsed time, and in this fiscally responsible age when early intervention is regarded as one of the highest ideals in health care.
Our members identify themselves as “anorexic” if they act out their obsession through restriction of their food, as “bulimic” if they binge and purge, and as “anorexic and bulimic” if they do both. We don’t care in the least whether these labels are diagnostically correct. All that matters to us is that all people begin to be honest with themselves about their pathological behaviors, because that is what they will need to give up in sobriety. We have also happily observed that many who identify themselves primarily as “compulsive eaters” (because currently their preferred behavior is periodic bingeing or daily overeating) have found a home with us and have successfully followed our pathway to recovery. How this is possible will be made clear in Chapter 4.
WHY WOULD A THERAPIST READ THIS BOOK?
I believe that this textbook of recovery has the potential to be helpful to great numbers of people, both now and in the future. We in Anorexics and Bulimics Anonymous have stumbled across a unique approach to recovery from eating disorders that really does work. Miracles abound. Yet they rarely occur in solitude, for the Higher Power behind them works most commonly through human beings. Anorexics and bulimics need one another as well as aid from outside sources to achieve deep healing. Physicians, psychologists, dietitians, and other therapists are all vitally important. I invite all such readers to proceed through the book with open minds. You may be greatly enriched by what you are about to read.
This textbook may provide professionals with fresh insight into the true nature of eating disorders. It will also suggest novel, practical methods of intervention conducive to full recovery. Much of what you will find within these pages has never before been recorded in any medical or psychological or self-help book. I encourage everyone interested in the field of eating disorders to read this book, as it may assist many who have hitherto been groping in the dark. I trust that what follows in the next fourteen chapters will provide new light for therapists, as well as guidance and hope for those afflicted with the disorders and for their families and friends.
Joan J., M.D.
