The eating disorders milieu
Authors: MORIA GOLAN
Journal: World Psychiatry (2009)

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.