In my first year or two after residency (St. Louis Park Medical Center), I was assigned to see a woman in her late 20’s who had an eating disorder. No one else wanted to see her. I had attempted to treat a few patients with anorexia nervosa in my residency.
But, she had bulimia – not anorexia nervosa. She did not starve herself, but would eat excessively and then cause herself to vomit. I knew nothing about bulimia (back then it was not a formal diagnosis), and I could find only three articles about the illness published in psychiatric journals. I tried to treat her weekly in outpatient psychotherapy, but she often failed her appointment. She later explained that she skipped appointments if she had continued to binge and vomit. She was ashamed.
She became a pattern. I interviewed young women with this disorder. Bulimia had suddenly become common, treatment seemed ineffective, and few other clinicians were interested in treating such patients. I met with some colleagues, and we planned to deliver an 8-week group therapy. We thought we had little to lose, since it was better to fail once a week [the group] rather than 6-8 times per week [individual therapy]. The meetings went pretty well, although patients needed to continue treatment beyond the scheduled number of meetings. So, we repeated the group on a weekly basis, although the other three clinicians discontinued their involvement.
I kept adding and subtracting treatment aspects to the group. Sometimes we discussed activity, such as how to plan meals or exercise. Occasionally, outside experts met with the group, and other times we read relevant literature together.
Very importantly, each patient set a clear weekly goal. This activity took place in the last 15 minutes of each group. We learned that the goals should be specific, measurable, obtainable, relevant, and time-based. Saying that her goal was to care about meals or relationships was too vague. Instead, helpful goals would be ones such as …
I will eat at least two breakfasts per week
I will not vomit after 7:00 pm five days per week
I will tell my husband
I will not exercise for greater than 40 minutes four times per week
I wrote down the goals, and also read the goals from the previous week. New goals were usually based on the response to the previous goal.
The group became very effective, although patients usually needed to stay for months. Thus, I needed to start a second group per week, and eventually three per week [each group 90 minutes of duration, late in the afternoon].
Many of the patients had low self-esteem. One particularly memorable incident involved one of these patients who told me directly that I was 15 minutes late for the 4 PM Group for the last three weeks. She stated that it was very embarrassing to make an excuse every week to leave her job early. The least I could do was to leave my office on time, which was just down the hall, and get to the group on time. I did not need to be 15 minutes late. I did not make excuses, and I stated that she was correct and I would be on-time in the future. This patient improved significantly. Because of that successful experience, she began to stand up to her boyfriend and her mother, and had healthier, assertive relationships. When she improved sufficiently to discontinue group therapy, she told the other group members about her assertiveness with me. Of course, the other group members realized that they had to stand up to me also!
There started to be some national meetings about this subject and I met a very good psychiatrist who lived in Boston. Now and then we would call and share our insights.
Helping people with bulimia was one of the best parts of my practice.
I never effectively treated patients with anorexia nervosa. One patient with the diagnosis of anorexia, who did get much better, probably had severe depression rather than classical eating disorder. Her weight had fallen to 58 pounds.
Things changed when I was elected to the Board of the clinic, and it was hard to have administrative meetings in addition to late-afternoon group therapy. I handed the groups off to another clinician.