FEWO Committee Report

PROMISING TREATMENT PRACTICES

Eating disorders are very complex illnesses and witnesses suggested to the Committee that there is not yet a universally effective treatment for anorexia nervosa, bulimia nervosa or binge eating disorders. However, witnesses outlined some treatments that are showing promise in certain populations. Dr. Giorgio Tasca, Research Chair in Psychotherapy Research, summarized current treatment practices:

Psychological interventions have the best evidence base for treating eating disorders. Evidence-based psychological treatments are considered by most international treatment guidelines to be the first line of intervention for most eating disorders. Treatments can be provided on an outpatient basis for less severe cases. However, specialist care is required for more severe individuals in both day treatment and in-patient programs for those who are medically compromised.

Successful treatment of eating disorders depends on a comprehensive plan that includes ongoing monitoring of symptoms and stabilizing nutritional status; psychological interventions that include cognitive behavioural therapy, personal psychotherapy, and family counselling; education and nutrition counselling; and in some cases medications.[300]

A. Cognitive Behavioural Therapy

According to Dr. Blake Woodside, Medical Director for the Program for Eating Disorders at the Toronto General Hospital, cognitive behavioural therapy (or CBT) is the “gold standard” treatment for bulimia nervosa.[301] Witnesses testified that among adults, CBT is a first-line treatment for eating disorders.[302] The goal of CBT is to train patients to understand their thought processes, how their thoughts contribute to disordered eating, and how to change their thought processes in order to change their behaviours.[303] Some witnesses also noted that dialectical behaviour therapy may be used in conjunction with CBT, particularly for people with bulimia nervosa.[304]

The problem that CBT presents for many patients is that it is a complex treatment generally delivered by psychologists, whose services in private practice are not covered by provincial health insurance.[305] This means that unless individuals have private health insurance, they must pay out of pocket, which can be a significant barrier for many people.

Dr. Woodside explained the current theoretical basis for bulimia nervosa and anorexia nervosa treatment:

The binge eating of bulimia nervosa is not food addiction. It's actually a response to starvation in the same way that if you held your breath for a minute or two you would gasp for air because you were starved for oxygen. A certain percentage of the population, about 5%, will respond to hunger with these episodes of binge eating. That makes them different from everybody else.

To treat bulimia you have to feed people. In our day hospital we feed them lunch, afternoon snack, and dinner, and teach them strategies to resist urges to binge and to purge because these things get tangled up into stressors and stuff like that. The fundamental treatment is to feed people. You eat your way out of bulimia, oddly enough. People in our day hospital service will stop bingeing in a week or two if they are able to do what we ask them to do.

The treatment for anorexia nervosa is similar in some ways. Although most people with bulimia don't like binge eating, and they'll do whatever they need to do to get rid of it, for anorexia nervosa, the decisional balance is often much more finely balanced, because the illness has advantages to the person as well as disadvantages. The fundamental thing you have to do is help people to eat and gain weight. That’s the behavioural change that has to occur first.

Then people have to address the underlying cognitive set, the way people think about weight, shape, food, and eating, which has to happen with bulimia as well. Then people have to deal with their other psychological problems that underlie or are associated with the illness. Depending on what those are, that could be the work of many years.[306]

Although CBT has been promising, the Committee heard that there is no “one-size-fits-all” treatment for eating disorders.[307] Dr. Giorgio Tasca, Research Chair in Psychotherapy Research, told the Committee that about half of bulimia nervosa patients “get better through cognitive behavioural therapy” while his estimate for anorexia nervosa patients was 25% to 30%.[308] Dr. Woodside reported that with access to some form of treatment, about 65% to 70% of people with anorexia nervosa and about 70% to 80% of people with bulimia nervosa will eventually recover.[309]

B. Family-Based Therapy (Maudsley Approach)

Many witnesses told the Committee that the most effective treatment for children and adolescents with eating disorders is family-based therapy (FBT) or the Maudsley Approach,[310] named after the Maudsley Hospital in London, England where the treatment was developed.[311] Jadine Cairns, President of EDAC-ATAC, expressed great excitement about FBT because it “really does stop the progression” of certain eating disorders.[312] The treatment appears to be quite effective for many young people,[313] although witnesses cautioned that 25% to 30% of young people do not respond to FBT.[314]

Psychiatrist Dr. Wendy Spettigue, of CACAP, suggested that one advantage of FBT is that it is inexpensive compared to inpatient treatment.[315] Although the cost to hospitals may be significantly lower, parents who have used FBT to help a child through an eating disorder testified that the treatment imposed a high financial burden on them.[316] Despite their enthusiasm for the treatment’s effectiveness, parents, including Lisa LaBorde, also discussed an even higher emotional burden:

[Parents] have to be non-negotiable brick walls of love and compassion and strength. It's a different type of parenting and nothing you've done before prepares you for it. It is counter-instinctual, rather than soothe them you have to stay steady with them through tremendous distress. Eventually you get compliance and the weight goes on, and as they get closer to health, you begin to see your child return. It takes constant vigilance. [My daughter] slept in my bed for eight months. I watched every meal go in for months. The learning curve is steep. It's hard on a family. Everybody feels it: siblings, partners, grandparents. It's a very isolating experience for families. There's stigma and shame, and most people simply don't understand. Your world becomes very small… Parents are able to do this, but they need rings of support around them. They cannot do it alone and they should not have to.[317]

Another parent, Laura Beattie, Co-chair of F.E.A.S.T. Canada Task Force, described the re-feeding process, one of the most challenging aspects of FBT:

First, I’d like you to imagine your worst fear. You can probably avoid this fear and the anxiety that it creates. We were exposing our daughter to her worst fear, but she could not avoid food or she would die. Our daughter would cry, scream, spit, hit, punch, scratch, and yell that it was too much food, that her stomach hurt, that she wanted to die. Plates of food were thrown. My daughter would fall into a catatonic state. It was like a scene from The Exorcist. Meals could take hours, but food is medicine. We learned to separate the eating disorder from our daughter. Intuitively, you do not want to see your child upset and in pain, but when we’re refeeding, there is no choice. There is no rationalizing with an eating disorder. This was not forced feeding, and it was not punitive. It was a requirement, using whatever leverage we had. Life stops until you eat. There is no option: food is your medicine. If meals are refused, then plan B is put in place: a trip to emergency for a [nasogastric] tube feed, or a call to the mobile crisis unit.[318]

Although Ms. Beattie was very frank about the stress linked to FBT, she was equally candid about her daughter’s eventual success: “Our daughter was smiling and less withdrawn at school. She began to sing again. Over the next five months, with support from FBT, and then participating in a year-long, multifamily treatment program, we managed to get my daughter’s weight restored and into recovery.”[319]

Recommendation 22

The Committee recommends that the Government of Canada should work with the provinces, territories, and stakeholders to help community programs offer integrated treatment approaches, as a recognized best practice, that include family members and people with eating disorders.

Recommendation 23

The Committee recommends that the Government of Canada should work with the provinces, territories, and stakeholders to examine as a best practice that patients be treated by multi-disciplinary medical teams with experience and expertise on treating eating disorders.

Recommendation 24

The Committee recommends that the Government of Canada consider improving research on treating eating disorders, such as deep brain stimulation and trans-cranial magnetic stimulation.

Recommendation 25

The Committee recommends that the Government of Canada work with the provinces, territories, and stakeholders to encourage relevant authorities to consider examining residential hospitalization treatment programs with the goal of ensuring that patients receive an adequate length of care in order to gain control of the eating disorder before being sent home, helping to improve conditions for a successful recovery.