Heavy bur­den

There can be a cross­over from sub­stance ad­dic­tion to eat­ing dis­or­ders which are of­ten more dif­fi­cult to treat, writes He­len O’Cal­laghan

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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.

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