Treating Co-Occurring Eating Disorders and Drug Addiction

Written By: Kansas Cafferty, MA, MCA, CSC, MFTI, LAADC Date: June 15th, 2011. Topic: Eating Disorders.

With increasing prevalence, addiction treatment programs are finding themselves approaching a new challenge in their milieus. It is yet unclear whether eating disorders are occurring at higher rates of frequency or if we are just getting better at identifying and assessing for them (Holderness, et al., 1994). Regardless of the answer to this question, those who treat this common co-occurrence are often in need of additional support and training. Unfortunately, what we do not know can seriously harm our clients with eating disorders.

Addiction treatment programs, in general, are ill-equipped to properly treat clients with serious eating disorders. For many of our clients, this will ultimately result in a chemical relapse post-treatment, as the structure and approach often falls short of addressing the dysfunction that is pervasive in the client’s life. Clients are seen as resistant and defensive, difficult to treat, and often labeled “borderline” when we fail to adequately address this problem area.

Imagine trying to treat a heroin addict who was smoking marijuana after every meal or snack of every day. Imagine the lack of progress this person might display in treatment. Fortunately, we are able to identify this quite easily with drug testing. This is not the case with an eating disorder, but the result is much the same. The client is off the chemicals but is “using” in the sense that they are in a pathological relationship with a maladaptive coping response that triggers neuro-chemical reward pathways in the brain. As this maintains a vibrant and active old brain, and diminishes the capacity of the prefrontal cortex to be the modulator of behavior, emotion and personality, we see what appear to be pervasive personality problems, resistance and lack of progress.

The old school of addiction treatment continues to use confrontation as the primary tool of intervention for the behaviors viewed as resistant. When a person with an eating disorder experiences this style of counseling, they will typically experience judgment and ridicule and be triggered into further eating-disordered behavior. Of course, this prompts more confrontation from the counselor, which results in the perpetuation of symptoms.

Eating Disorder Support

Appropriate treatment of eating disorders can be given in an addiction treatment setting, but some of the following issues must be supported. If they cannot be, it is unethical to continue treatment and the client should be referred to a facility that is equipped to offer this kind of support.

• Bathroom protocols, such as monitoring an hour after meals
• Meal-time support: no calorie counting, no food talk at meals and offering emotional processing of meals
• Eating disorder specialists on staff
• Regular training for direct care staff
• Blind weights for medical monitoring
• A registered dietician
• Meal planning
• Supervised food exposure such as gardening, cooking, restaurants
• Challenge foods
• Caring, non-judgmental staff
• Eating disorder-specific therapy (Substituting “purging” for alcohol while doing an AA 1st step is not treatment for an eating disorder)
• Intense medical monitoring of shifts in weight, electrolyte unbalancing (can lead to heart attacks) and even bone density scanning, when indicated
• Body image support

This is not a comprehensive list of supports, but it is a great start. The field of addiction treatment, while well-meaning, has at times caused more harm to our clients by failing to address these significant needs. Where support, love and affirmation would have provided relief for our clients from a preoccupation with food and eating patterns, the field has historically confronted the illness aggressively and caused more damage to an already fragile sense of self-worth. It is up to us to learn the best practices for treating these deadly diseases, or it is incumbent upon on us to refer our clients out.

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