Which characteristic of the milieu is essential for clients with the diagnosis of bulimia nervosa

The literal translation of bulimia means "hunger like an ox". The diagnostic criteria for bulimia in the DSM are: 1) recurrent episodes of binge eating with a sense of lack of control occurring at least twice per week for at least three months, 2) recurrent, inappropriate compensatory behavior, such as vomiting, in order to prevent weight gain 3) and self-evaluation that is unduly influenced by body shape and weight.

Symptoms/Criteria

As outlined in the DSM, binge eating is one of the primary symptoms of Bulimia Nervosa. A binge involves eating, in a short period of time, an amount of food that is larger than most individuals would eat under similar circumstances. The food consumed during binges varies, but typically includes sweet, high-calorie foods. Binging is often characterized by rapid consumption until the individual is uncomfortably or even painfully full.

Binge episodes are often surrounded by painful emotions. Preceding a binging incident, bulimic individuals often describe depressed moods, stress, or intense hunger following dietary restraint. They try to stay in control and talk themselves into believing that they should not binge, developing increasing levels of anxiety. During the binge, there is typically a sense of lack of control and an increase in self-criticism, as well as justification for the behavior. After the binge, many individuals experience shame, guilt and regret.

Individuals with bulimia fear weight gain and typically believe they have to undo or compensate for the binge episode, so they purge what they consumed by inducing vomiting. Ironically, bingers do not recognize that most of the calories consumed during a binge remain in the body and are not reduced by purging. However, the immediate effects of vomiting include relief from physical discomfort as well as fear reduction related to gaining weight. Other purging behaviors include the misuse of laxatives and diuretics (medications that cause you to urinate), as well as excessive exercising. Individuals with bulimia may also fast and skip meals frequently in order to lose weight. When they do eat meals, they may drink large amounts of fluids, take very small portions, cut food into tiny pieces, or chew their food excessively.

Bulimic individuals believe they need to keep their embarrassing behaviors hidden from their friends and family. These individuals may avoid eating meals with others, or make frequent trips to the bathroom during or after meals. They may have a heightened desire for privacy in the bathroom or run water to conceal the sound of vomiting. Bulimic individuals may also go for unexpected walks or drives at night after meals or go to the kitchen after every one else is in bed. It is not uncommon for these individuals to chew mints or gum to conceal the smell of vomit on their breath, and they might also wear baggy clothing to conceal the size of their body.

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K. Halmi offers a comprehensive and stimulating review of the salient components of service for eating disorders. In addition to those components, and in line with acknowledging the impact of the intense counter-transference reactions evoked when treating eating disorders on treatment outcome, a supervision system is a most crucial part of such services.

In a sample of 225 Canadian psychiatry residents, for example, 28% reported that they had encountered negative attitudes of fellow students, nursing staff, physicians, or other health professionals towards patients with eating disorders 1. In a sample of 90 therapists, 31% indicated that they did not want to treat patients with eating disorders 2. These reactions arise from multiple sources, including the therapists’ and patients’ histories and personal attributes, and the activation of intrapsychic and interpersonal processes such as identification, rejection, competition, testing, projective identification, splitting, or parallel processes 3.

Working with clients with eating disorders produces all the effects frequently associated with treatment providers’ burnout, including the loss of drive and motivation, and the appearance of mental, physical, and emotional exhaustion. Moreover, health care professionals reported changes in eating habits, body image, and appearance as well as heightened awareness of food and physical health when working with patients with eating disorders 4,5.

All therapists struggle at times with emotional responses that can be either creative or destructive for themselves or their clients. Thus, a sensitive arena of supervision, where the therapists receive “good enough parenting” to heal their “wounds” and the supervisors possess a broad range of skills and personal qualities to venture into uncomfortable places with their supervisees, is crucial 6.

Moreover, a conspicuous role of the therapeutic milieu is to act as a holding environment in which staff members can be encouraged to use counter-transferential feelings as a channel for moving inward to uncover the underpinnings of their own feelings. The therapeutic milieu should become an environment that provides highly reinforcing opportunities for new patterns of thinking, feeling, and acting, as well as for the expression and examination of old patterns and motivations 4. Intervention within the milieu must interrupt the vicious cycle of malevolent transformation wherein the perceived need for tenderness in relation to the patient automatically evokes foresight of anxiety or pain on the therapist’s side. Through the appropriate interpretation of attitudes and behaviors with their transferential and counter-transferential underpinnings, milieu staff can create an environment that keeps negative phenomena in check and offers healthier alternatives for the expression of intense, yet valid, feeling states 7.

K. Halmi states that “a psychiatrist should be the captain of this multidisciplinary team”. When it comes to outpatient services, it may be argued that, although “eating disorders require treatment of a variety of conditions”, the management of such cases is a field where those with the most appropriate management skills are the most adequate answer for the captain position.

The management of eating disorders service requires coping with accumulating demands and emotional overload faced by patients, families and staff members. Thus, the captain should have, apart from clinical skills, excellent interpersonal and relationship skills, an ability to negotiate and discuss management plans with responsible clinicians, the ability to liaise with community agencies and work with them in a co-operative manner, and to use supervision, peer reviews and debriefing procedures for both clinical matters and staff issues.

These skills are acquired mainly via intuition and experience rather than via a specific professional education. Nevertheless, the psychiatrist plays a crucial role in the provision of psychiatric assessment and pharmacotherapy, and serves as a consultant to the therapists as well as to patients.

The current status quo in eating disorders services is that many are directed by professionals who are not psychiatrists. In Israel, three out of the five community-based centers for the management of eating disorders are directed by social workers or other health-care providers, and their services are well established and flourishing.

Cawley 8, discussing psychiatrist training in the 21st century, argued: “Who should lead and who should follow? Nobody can win this sort of context. Matters of responsibility and accountability are complicated, but can surely be resolved if the members of the team recognize its collective purpose and strength, and remain aware of how feeble their efforts become if they are not integrated.”

It is beyond the scope of this commentary to discuss the issue of psychotherapy for eating disorders. Nevertheless, I believe that eating disorders patients, especially those with difficulties in self-regulation and verbal communication, may benefit more when projective tools are used. Frequently the ability of our patients to profit from verbal psychotherapy is limited, due to deficit in reflective function, the acting-out nature of symptoms and because the patients may be trapped in the concreteness of body symbolism 9.

Moreover, many patients use rationalization and some do a lot of talking – distracting from the real conflict. Art therapies, biofeedback therapy and other non-verbal therapies may be superior, mainly in the first steps of therapy, to deal with the distress and internalize self-regulation more than simple cognitive-behavioral therapy.

In conclusion, in order to avoid the “revolvingdoor” when treating eating disorders in an outpatient clinic, the melody may be more important than the words themselves. How clinicians react and how they approach the illness and the clients (patients and their families) is the most precious component of the program. The challenge is to keep a tight rein on the eating disorder and nurture the patient.

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