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Anorexia nervosa: behavioral treatment ANOREXIA NERVOSA: BEHAVIORAL TREATMENT
Having a contract reduces the "arbitrariness" of treatment and makes it easier to accept. The rules are codified, written down, and stored away someplace-somewhat like the Constitution. The patient might argue about how to interpret those rules, or how they should be enforced, but she can't dispute that they exist.
Of course, it's important to work with patients to help them overcome their fears and anxieties. I tell them, "Look, I know this whole situation is pretty scary. But we want to help you. Of course we want you to gain weight, but that's really your responsibility. We're not going to be spies and monitor every mouthful you eat. But if you find you're having trouble, we'll have someone sit with you and help you get through the fear. Yes, we need to give you enough calories so that you begin to gain weight, but we don't want to go too fast. We're not here to just fatten you up and send you on your way. We want to help you gain weight in a healthy and calm manner, so that we can begin to find out what's really troubling you deep down inside."
The food journal provides clues about strategies that might work. Anorexics might not be ready to fill out such sheets, especially at first. They dwell on food constantly anyway; writing it all down might just make them more anxious (that can be true for bulimics, too). If they feel that way, I don't push it. Sometimes keeping a journal focusing just on feelings and events (not food) can be useful.
A journal can provide a vivid record of the patient's thoughts and feelings about her situation. By examining these thoughts, we can often reveal distortions in the way the patient perceives and interprets events in her life. Cognitive therapy, which I will discuss in just a moment, is a good method for correcting such distortions.
In the final phase, we concentrate on helping the patient maintain her weight within the target range. We reinforce normal eating habits and look ahead to her continued recovery as an outpatient.
Before sending her home, we work out a plan to monitor her weight. We agree on who should do the weighing-a doctor, a nurse, her parents. She understands that if her weight drops below a certain limit, she will have to come back to the hospital.
A word about outpatients: It is possible to set up a contract with anorexics treated outside the hospital, even though they are not being monitored twenty-four hours a day. Usually such contracts set lower goals for weight gain-say, between one and two pounds a week. In family therapy sessions we work out the system of rewards and penalties. The parents may agree, for example, that if the patient fails to meet her target, they will suspend her allowance or ground her.
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WEIGHT LOSS
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