Adults or young adults: treatment for a restrictive eating disorder

Where can I get help on adult treatment for someone with anorexia?

At present my expertise is mostly on children and adolescents, though I do speak to a number of parents of university-age people.

Adults who embraced the strengths of adolescent treatment

For approaches that are similar to the resources I value for youngsters, but made to work for independent adults, I recommend Tabitha Farrar's website, podcasts and discussion groups. You will find quality information and real positive action you and your son or daughter can take.

Also packed with resources is Gwyneth Olwyn's website

I love the insightful account from a 40-yr old: 'Reflections on my recovery at 40 – a journey with my parents' who used her parents for the same kind of support a teen needs.

Check out @recovering_nomad on Instagram or her website

If you registered for FEAST of Knowledge 2022 then you will have access to a fantastic session where adult Shira Rosenbluth describes how her friend Lauren Muhlheim (a therapist I often quote) helped her meal by meal.

And see this guest post on my site: 'I'm not a tortured soul. I just needed to eat!' where an adult used lockdown to get her parents and sister to 'magic-plate' her.

Most of the above is for anorexia, but there are always useful overlaps with other eating disorders involving restriction, fear of weight, over-exercise.

Hope for better adult treatment: Temperament-Based Therapy with Supports

I am excited by Temperament-Based Therapy with Supports (TBT-S), for any age. The person with the eating disorder has support people (parents, friends etc) that they chose to help them throughout the treatment, guided by clinicians. The stance seems to be genuinely respectful and empowering of all those involved. I say more and guide you to the TBT-S manual here.

A family-based approach for adults

Indeed there are plenty of adults who recovered with the help of their own parents, and there's been some research on adapting FBT for young adults. From my Bitesize audio collection: “I was desperate for my parents to feed me”:

Everyone can learn a lot from Emily Boring, in her mid-twenties, describing her state of mind when she's been underweight and comparing it with her ease of life and freedom of thought after treatment and weight recovery. I love this piece of hers, as well as her two-part interview on a podcast. If you registered for FEAST of Knowledge 2022 then you'll have access to another excellent talk from her.

Is anorexia treatment for children and adolescents different from treatment for adults?

Yes, it's very different. And that is a shame. It's not evolved the way adolescent treatment has, and I hope that will change.

For a review of the research on treatment for adults, see Glenn Waller (2016), ‘Recent advances in psychological therapies for eating disorders

Adult treatment emphasises psychological approaches, getting the patient to be motivated to get well, to gain insight, and to work on their recovery on their own, with weekly outpatient appointments. 

There can be a lack of ambition in getting them to fully recover, possibly because a fair number of adult patients are chronic sufferers.

Often treatment for anorexia stops before the person has reached a normal weight, and people are left to their own devices before they're well enough to take care of themselves.

Sometimes treatment stops because the adult is kicked out for lack of sufficient motivation.

If weekly outpatient appointments don't work, in the US there are partial hospitalisation programs (PHP) and in some countries (including the UK) there are day treatment programs. People get help to eat several meals a day, but are often required to muster some willpower back home alone. Again, they may get kicked out if that fails.

Some adults can be in limbo until they get 'sufficiently' ill to be admitted to an inpatient unit, where there is more robust help to get them to eat, stop exercising and purging, and gain weight. If they can't eat and are very ill, the mental health act kicks in and they are tube-fed — if necessary against their will.

In adult treatment, parents or partners tend to be held at arm's length, on the basis that the patient must have motivation and autonomy and self-responsibility. So the family has to watch helplessly while the person restricts. Then if the person gets worse, a hospital will take away their autonomy and do the very things that the family members could have done months before.

With most adult treatments, if there is any 'family therapy', it looks at the interactions between family members, on the basis that dysfunctional relationships may have caused, or may be maintaining the illness. When I talk to parents in this situation, they generally feel blamed, disempowered and helpless, and it may become even harder for them to help their child eat at home.

The picture is a lot more positive with children and teens, thanks to research on a totally different concept of family therapy for anorexia. On this site, when I talk of 'family therapy', I refer to an evidence-based approach whereby parents are part of the team and are empowered to take charge of meals and of normalising behaviours. The standards of many countries make this approach either highly recommended or mandatory, as the first approach to try. The beauty of it is that this treatment does not require the child or teen to have motivation or insight, and it addresses the biological aspects of an illness that cannot be healed while the body and brain are malnourished. My book, my 'Bitesize' audio collection, and this website, are designed to help you support your child in this way.

There are good chances that family therapy for eating disorders, or some variant of it, could help people beyond their teen years. See my article 'Young adults with anorexia: family-based treatment for 17-25 year olds'.

An all-age treatment service

Some eating disorder services treat all ages, which means that adults benefit from the best treatment principles used for teens. From a therapist on a video interview I did : "A colleague of mine said, it's brilliant because they actually get better!"

The best evidence for adult treatment methods

The NICE guidelines make recommendations based on a detailed review of the research.

For adults with anorexia they recommend just three approaches:

  • CBT for eating disorders (which I describe here)
  • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
  • Specialist Supportive Clinical Management (SSCM)
  • If none of those three are acceptable or effective, the next best option is eating-disorder-focused focal psychodynamic therapy (FPT).

There is not enough research for a family-based approach or for Temperament-Based Therapy with Supports (TBT-S) to feature in these recommendations.

For bulimia and for binge-eating disorder in adults, NICE recommends a guided self-help programme, possibly with brief supportive sessions, and if after four weeks this proves unacceptable, contraindicate or ineffective, then CBT is to be offered.

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