Utilizing an Abstinence-Based Model for Eating Disorders
Abstinence‐based treatment, derived from the Minnesota model of addiction treatment, is based on the concept that addiction is a disease, and the belief that through counseling and continued support, addicted people can recover as long as they maintain lifelong abstinence from drugs or alcohol (Spicer, 1993). An integral part of an abstinence-based treatment model is behavioral therapy coupled with the principles of Twelve Step programs.
Originally abstinence‐based treatment utilized the philosophy of Alcoholics Anonymous (AA) and targeted “hopeless” alcoholics. Later treatment centers added psychoeducation, therapeutic interventions, and peer support to complement the Twelve Step model. Over the years the focus of abstinence-based treatment has expanded to include individualized treatment planning and family involvement, in addition to consistent and frequent use of Twelve Step meetings (Iliades, 2012).
Historically, an abstinence-based treatment approach was limited to substance use as measured by the use of mood‐altering drugs. Co‐occurring disorders—including process addictions, eating disorders, and mental health issues—were not treated with this model. There was much controversy as to whether abstinence-based programs should even treat co‐occurring disorders, since they considered addicts to have pathological personalities and the tendency was to prohibit the use of prescribed medication. In the true sense, an abstinence-based model encouraged therapists to take control of clients. Through behaviorism as the preferred theoretical approach, clients were expected to act a certain way, and with the use of confrontation as the recommended counseling style. Success was measured by abstinence from all mood-altering substances and attendance at Twelve Step programs.
Studies show that more than 90 percent of drug and alcohol treatment programs in the United States are abstinence‐based, utilizing a Twelve Step program as a core principle (Lemanski, 2001; Miller, 1994). Most abstinence‐based treatment providers view addiction as a physiological, social, and psychological disease process, for which there is no cure. However, they also believe that recovery is possible through peer support and positive change. In this regard, behavioral and cognitive change occurs by practicing principles of Twelve Step programs
Though an abstinence-based model has been considered effective in achieving sobriety, with estimated relapse rates between 40 to 60 percent, it is debatable whether this would constitute successful outcomes. In addition, addicts may often be abstinent from their drug of choice, but are engaging in other addictions including process addictions, self‐harm, eating disorders or experiencing symptoms of mental health issues.
The trend may be away from abstinence‐based models and more toward harm reduction approaches such as Moderation Management, a secular, peer‐led support group utilizing a cognitive‐behavioral approach for moderate drinking. Moderation might work for some who were never drug dependent and can outgrow their negative behavioral issues. However, how does anyone know if they will be the one to outgrow their “addiction” before it is too late? Considering the toxicity and potency of drugs—including marijuana that is being laced with chemicals and other drugs—even recreational use can be fatal. There are cases of first time or moderate use that have led to overdose and death.
One of the criticisms of an abstinence‐based model is that it is not realistic to achieve abstinence when the person’s coping mechanisms have been taken away. Often this results in abstinence of one substance only to be replaced by a secondary addiction or newly diagnosed disorder, such as self‐harm or eating disorders. Young people today most often enter treatment with co‐occurring disorders, for which there is a correlation between psychiatric disorders and a high risk for substance abuse. Abstinence is held as the standard for all addictions and disorders, with specifically designed protocols to address co‐occurring disorders and emerging issues. Through individualized treatment, positive coping skills reduce symptoms while individuals identify and address their underlying core issues and take steps toward resolution through emotional expression.
How it Works
Therapists meet clients “where they are at,” allowing them full expression of their emotions through basic listening, acknowledgment, and validation, until clients feels heard and understood. Clients are encouraged to feel their emotions within their body, breathe through it, and are redirected through empowering questions that open up the realm of possibilities.
The client is “loved” by the entire therapeutic community for their uniqueness rather than viewed as pathological. Though a minimalist approach is taken with medications, they are prescribed when appropriate and as needed.
Most addicts suffer from a history of abuse, trauma, abandonment, and rejection, resulting in low self‐esteem and feelings of not being good enough and not fitting in. Until these issues are identified, addressed and resolved to the point where they are not so overwhelming, addicts will continue to resort to negative self‐destructive behaviors to avoid feeling those feelings. Negative emotional states and behavioral issues are treated as addictions, and the root of the addictive behavior is avoidance. Clients want to avoid the negative feeling which has caused them to self‐ medicate. By addressing the underlying issues, clients are able to abstain from engaging in their addictive behaviors, as they no longer have the need to ignore or avoid their pain.
Clients are held to the high standard of excellence of abstinence with substance abuse, self‐harm, suicidal ideation, and eating disorders. To endorse anything less would give users, misusers, and abusers the option to continue with their negative behaviors. However, abstinence with eating disorders is viewed very differently than any other disease or disorder.
Since according to NIDA (2012) relapse rates for addictions are similar to those for chronic diseases such as diabetes, hypertension, and asthma, relapse is not looked upon as a failure, but rather one step closer to maintaining long‐term sobriety. Sobriety is viewed as a desirable and achievable goal, and recovery is considered to be fun and rewarding, rather than a life sentence. Similarly, with eating disorders protocols are put into place to reduce negative behaviors and manage symptoms, with long-term recovery as the goal.
Bulimia, Bingeing/Purging, and Emotional Eating
Studies have shown a high occurrence of co-occurring eating disorders and substance use disorders. Perhaps not surprisingly, the highest rates of co-occurrence are seen in those patients who are in treatment. While the high rates of co-occurrence—up to 41 percent—have been observed in the literature, the exact link between substance use disorders and eating disorders or eating disorder behaviors has not been established (Grilo, Sinha, & O’Malley, 2002).
Authors Smith, Fortuna, Nosal, and Maxwell previously published an important article in this magazine (2012) regarding process addictions and the relationship between food, sugar, and substance abuse. Evidence around the use of food as self-medication and the risk of dysregulated food behaviors to recovering addicts is well established and cited in the aforementioned article.
We have embraced an expanded version of the abstinence‐based model in our work with adolescents and young adults in a residential treatment center (RTC) and intensive outpatient program (IOP). This emerging model has been redefined utilizing an integrated, holistic, individualized approach, of which the Twelve Steps are but one of the modes of treatment for substance use as well as process addictions. We have extended that approach into the treatment of patients who are exhibiting binge eating, purging, and emotional eating behaviors.
We believe that while the physiologic or pathologic links may not be established in the scientific literature to this point, the self-destructive behaviors exhibited by those with substance addictions and some eating disorders are so similar that the treatment models can, and should, have similarities.
The behaviors associated with process addictions, eating disorders being included in this category, lend themselves readily to the Twelve Step model. At the core of the Twelve Step model is Step one, where clients admit powerlessness over the substance or behavior. As with substance use, clients can’t “just stop” their eating disordered behavior. Clients will often express being unable to control the urges to binge-eat or purge. As one reviews the Twelve Steps and understands the abstinence-based model, it becomes very clear why this model can work in treatment of these behaviors. The goal of this treatment model is to address the underlying psychological basis for the dysregulated behavior—in this case bingeing or purging—rather than addressing the food behavior, per se, while maintaining a goal of abstinence from the behavior in a therapeutic environment.
One major complexity related to using an abstinence-based model in this way is the fact that food is required for survival. Client cannot avoid their triggers, not even for one day. In particular for clients with binge eating disorder or emotional eating, this poses a great challenge. This is similar to having an alcoholic have one drink every day, even during early sobriety, and expecting him or her to be able to control the drinking and not fall into the pitfall of overuse. Because of this paradox, treatment centers that employ an abstinence-based model for eating disorder behaviors must be acutely aware of the challenges that will face these clients up to six times daily when food is presented to them.
This model employs a strict, structured, and facility-specific eating disorder protocol to help clients maintain abstinence from eating disorder behaviors within the RTC environment. The eating disorder protocol includes several features, some of which are outlined here:
Abstinence-Based Eating Disorder Protocol
Nutritional and medical evaluations are done on admission.
Culinary staff is made aware of any dietary issues or special nutritional needs for new clients.
All clients are expected to sit down for their three meals each day (breakfast, lunch, and dinner) and to complete at least 75 percent of each meal.
Clients sit together at the dining table for thirty minutes following each meal.
Clients are not allowed to use the bathroom during meals and for thirty minutes following meals.
Clients who have been identified as having issues with self-induced vomiting will have bathroom monitoring such that staff will stand outside of the door during routine use of the bathroom and listen for evidence of self-induced vomiting.
Clients who have been identified as using other inappropriate compensatory measures for calorie burning (pacing, excessive exercise, and others) will be redirected at the time that the behavior is noted.
Clients will be expected to sit and finish a first serving before asking for seconds.
If clients are noted to be rushing through first servings in order to quickly obtain seconds, clients will be asked to sit patiently and wait for all clients to be done before getting seconds in an effort to reduce binge behaviors.
Clients who refuse meals will be given a smoothie with a caloric amount that is equivalent to the meal that is refused.
Clients with eating disorder behaviors will be asked to set daily intentions that relate to giving up their eating disorder behavior and will identify an abstinence date for their behavior just as clients with substance use disorders.
A Twelve Step, abstinence-based model for treatment of eating disorders has been used for many years by organizations such as Anorexics and Bulimics Anonymous, Eating Disorders Anonymous, and Overeaters Anonymous. However, this model has been slow to expand to residential treatment centers that treat clients with primary eating disorders. The majority of clients who enter treatment centers for primary eating disorders have physical sequelae of eating disorders and thus may not be able to engage in a program that requires a high level of commitment and understanding such as the one that is presented here. These clients often need nutritional rehabilitation and medical stabilization before they can participate with this type of therapeutic approach. However, the model supports a transition to an abstinence-based model once medical stability is achieved.
Additionally, as previously mentioned there is the issue of the unrealistic goal of achieving abstinence when coping skills have been “taken away.” We would argue that while the primary goal of treatment may be achieving abstinence from substances, the job of the treatment team is left undone if other maladaptive coping skills are not uncovered and treated simultaneously with the same treatment model. For instance, clients who are addicted to heroin, are in treatment, and are committed to sobriety for this addiction, but four weeks into treatment they begin the practice of self-induced vomiting. As they commit to their sobriety from substances, they look for a replacement behavior to avoid their feelings. If the treatment team either does not know about this behavior or does not address it, these clients will leave treatment in recovery from heroin use, but with a dangerous replacement behavior that they now have to manage in an outpatient setting. Alternatively, the treatment team could address the behavior and work it into the recovery process using a Twelve Step model so that those clients can rely on the strength of recovery and work to extend it into all maladaptive behaviors. This is particularly why this treatment model addresses the underlying causes and conditions, rather than just the symptoms, so that clients will not continue to develop further maladaptive behaviors.
By way of further illustration, we offer the following case studies.
Case Study #1
Kiki is a seventeen-year-old female transferred from an acute inpatient psychiatric facility for polysubstance abuse, depression, self-harm, suicide attempts, and an eating disorder requiring continued care in residential treatment. At the time of admission, Kiki reported that she struggled with an eating disorder for “a long time.” She stated that she sometimes didn’t eat for “long periods of time” and made herself throw up on occasion. Kiki admitted to purging “after every meal” at the transferring facility, but that her most recent purge was actually two days prior to admission. By way of explanation, Kiki said that she had been able to sneak to the bathroom at the previous facility and make herself throw up in the toilet.
Kiki reported poor body image and feelings of “hatred” towards her body. At the time of admission she was 5’4” and 134 pounds. She reported that her goal weight was 115 pounds, which she attained about two months prior to her psychiatric admission. Kiki was happy with her body image at 115 pounds.
Kiki was placed on the eating disorder protocol along with all other routine protocols for substance abuse and mental health treatment.
At first, Kiki appeared to be able to eat normally and there was no suspicion of self-induced vomiting behaviors. However, after approximately three weeks of admission, she was noted to be restricting particularly around breakfast time, and would refuse protein shakes when offered in place of a meal. She lost four pounds in a short amount of time and her meal monitoring and support were increased. Kiki also reported that she did throw up after eating on at least one occasion. The portion of the protocol that provided bathroom monitoring was tightened upon Kiki admitting that she had purged during treatment. Her bathroom was locked except when being used with staff outside the door.
Treatment at this time was focused around cessation of eating disorder behaviors and targeted at the underlying emotions that were leading to the need to restrict. Kiki reported intermittent dizziness, but her vital signs and lab values were completely normal throughout.
With the support of her treatment team, Kiki was able to commit to being abstinent from her self-induced vomiting behaviors and identified an abstinent date. By her discharge day, she was able to identify that she had not practiced self-induced vomiting in twenty-one days and that she was proud of herself and committed to continued abstinence from that behavior. At that time, she was identifying and crediting her higher power and prayer as her motivations for continued abstinence from both eating disorder and substance use.
After a total of seven weeks in RTC she was transitioned to IOP, where the eating disorder protocol and the abstinence-based model were continued. Her weight had been stable at 130 for two weeks prior to discharge to IOP.
Case Study #2
Jenna is a sixteen-year-old female admitted to partial hospitalization program (PHP) for depression, anxiety, and ADHD. Other possible diagnoses that had been given in the past were bipolar and borderline personality disorder. At time of admission, Jenna’s mother reported that Jenna had tested positive for marijuana and had been arrested for possession of marijuana. At the time of her initial admission, her mother was very sick and “dying of cancer.” The client’s mother reported that Jenna had “horrible eating habits—she is paranoid of fruit and won’t eat it,” but was not diagnosed with an eating disorder. There were no medications at time of admission.
Jenna initially did well at the PHP level of care and although she was interested in recovery, had trouble committing to Twelve Step meetings. After three weeks, Jenna made plans to go away for a weekend with friends to use marijuana. The decision was made to transition her to RTC. At the time of her transition, she was recorded as being 5’10” and 160.8 pounds.
Shortly after her admission to RTC she was evaluated by a registered dietician (RD) and she reported that she had been eating only one meal per day for the year prior to admission. She described herself as a lifelong picky eater who doesn’t like her food to touch and has early fullness. As her eating disorder thoughts and behaviors became apparent to the treatment team, this became a major focus of her treatment. She reported that she could eat three meals per day as expected by the program, but that this makes her feel “fat,” “gross,” and disgusting.” She reported that she is “just not hungry.”
The RD who was working with her tried to help her through these negative feelings, however, her restrictive food behaviors increased over time. Her body image concerns increased over time and she progressively lost more and more weight. Over an eight-week period of time, she lost approximately twenty pounds. At her lowest weight, her BMI was still within the normal range, but she was symptomatic with dizziness and orthostatic hypotension at her lowest weight of 138.2 pounds. The treatment team worked with Jenna within the abstinence-based model to help reduce her restricting behaviors. Over a course of several more weeks, Jenna was able to work through the program while limiting her restrictive eating behaviors. She has been able to maintain her weight at 140 pounds for four months through discharge from RTC and now within a PHP environment where she has far more responsibility for selecting her own foods.
The abstinence-based model described herein may be more applicable for clients practicing bingeing or purging behaviors, with the goal of reduced frequency and intensity of symptoms and behaviors.