There can be a crossover from substance addiction to eating disorders which are often more difficult to treat, writes Helen O’Callaghan
getting better, they have more interest. The eating disorder gets worse before it gets better — it’s like ‘you can take my alcohol, my drug, but keep your hands off my eating disorder.”
With an eating disorder, there’s plenty of potential for cross-over into addiction. Someone with bulimia could take up to 40 laxatives a day for example. Crosbie points to the relentless 24/7 presence of the ‘eating disorder voice’. “Sleep’s very uncomfortable for someone with anorexia. You’re talking about skin and bone against mattress. They wake up a lot and the eating disorder voice in the middle of the night is more frightening. If you have a vodka, you’ll pass out, whether you’re sore or not.”
In Ireland, just under 200,000 people experience eating disorder at some point in their life, a proportion on par with elsewhere in Europe and the US. Approximately 1,757 new eating disorder cases develop annually in the 10-49 year age group. Everybody with eating disorder is different, says Parsons, but certain personality traits are common: tendency towards anxiety/perfectionism, to black and white thinking and extreme sensitivity to how they/others are feeling.
Dr Mary Mullane, senior clinical psychologist on St John of God’s Hospital Eating Disorder Programme, says people with anorexia can be very driven, very conscientious — they have high expectations of themselves. “They’re people with lots of promise but with very strong self-criticism while being very warm to others. There’s a lot of shame about having an eating disorder, which is a barrier to seeking treatment.”
Crosbie too sees a deep self-hatred in people with eating disorder.
“It’s like ‘I can’t fix what’s on the inside, but I can change the outside’.” The new Model of Care for Ireland’s Eating Disorder Services launched in January. It’s based on a hub and spoke model — five major hubs and three minor ones for Child and Adolescent Mental Health Services (CAMHS) and four major hubs plus four minor ones for adult patients.
“Over the next five years, these hubs will have expert eating disorder teams for both children and adults,” says Parsons, who welcomes that this is a national plan with consistency and expertise at its core. Already a training programme has started.
“Somebody from each CAMHS and from each adult service have trained in the eating disorder therapies with very strong evidence base. No matter where you are in Ireland, you have access to trained clinicians with experience and expertise in treating people with eating disorder.” And for those unwell enough to need hospital admission, Parsons says there’s joined-up thinking.
“The system follows the person — there won’t be a situation where a person’s discharged from hospital and there’s no [community] service for them.” Many parts of the country have community services for eating disorder — the plan is to make this consistent nationally.
When somebody arrives for treatment, the origins of the eating disorder in the person’s life — what caused it to happen — are long gone, says Mullane. “We don’t look at causative factors but at what’s keeping it going right now. The person might desperately want to get well and recover their functioning but they’re locked in a vicious cycle of behaviours.”
CBT-E (CBT for Eating Disorders) has a strong evidence basis and Mullane says behaviour change is the lead factor in recovery. “The person assumes even a small amount of food will lead to disproportionate weight gain. There’s an assumption weight gain will be uncontrollable and unstoppable. CBT-E is about exposing people to that fear.”
But no one therapy suits everybody. Mullane points to the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) — it motivates the person around nutrition, symptom management and behaviour change. She also highlights Compassion Focused Therapy, developed by Paul Gilbert, professor of clinical psychology at the University of Derby. It targets shame and self-criticism and has been modified for treating eating disorders. “It addresses the biological, psychological and social challenges of recovering from an eating disorder.” Preliminary evidence for its effectiveness is encouraging.
Renewal runs the only 12 step Minnesota Model Extended Treatment Care programme for women in Ireland, which includes eating disorders. Crosbie trained is one of the few qualified eating disorder therapists working in an Irish treatment centre. In 2017, a new Eating Disorder Support Group was set up at Renewal. “With eating disorder patients, you have to work with their heads so their heads can take care of their bodies. You’ve got to get their cognitive voice louder than their eating disorder voice,” says Crosbie.
The NICE Guidelines, updated last year, recommend out-patient treatment as the first-line approach. But when someone’s very physically unwell, they need to be monitored medically and require residential care, says Parsons. This may also be necessary as a break for family when things are very fraught at home and “there are power struggles all over the place. You take the person with the eating disorder out of the situation to allow everyone regroup.”
Generally speaking though, residential treatment’s more about safety than recovery. “The best place for a person to recover is in their life, in their home, when they’re going to college, working, with their family, so the focus isn’t on more beds but on more services in the community,” says Parsons.
It’s “absolutely possible” to recover from eating disorder, says Parsons, who understands that one-third of people recover fully, another one-third recover to the point where they’re able to live a normal life though still with some distortion around eating/food/control. The final one-third don’t recover. “Recovery always means different things to different people.”
Caroline had to be willing to go to any lengths to recover. “That meant facing my eating disorder head-on and letting go of it. I’d developed anorexia nearly 20 years ago. When it comes to addiction, it was my first love. The alcoholism came later and as much as I loved drink, I loved my anorexia more.
“I wasn’t going to give it up without a fight. I didn’t want to give it up, I had to. I’d been told time and again that I’d have no recovery from alcoholism if I didn’t deal with my anorexia. One of my biggest turning points was when I started to separate myself from my anorexia. I used to think we were one, that I was my anorexia and my anorexia was me.
“Once I began to separate myself from it, I began to recognise how it presents itself to me in many guises and speaks to me in many ways. It mostly tells me the less I eat, the better I’ll feel. That if I maintain rigid control over the food that goes into my mouth, it means I’m in control of my life. Now I know that really I’m not in control at all, but anorexia can be very convincing.
“[Today], I mainly have an amazing and amazingly simple life, which is what’s recommended. I have a job and friends and a solid network around me at all times. I am more than OK.” * Caroline’s story features in the 2018 Tabor Group report. Her name has been changed.