Nursing Strategies for Treating Eating Disorders: A Review

Statement of the Problem and Significance

One of the most widespread and substantial health dilemmas in the Western world, in general, and in America, in particular, is the eating disorder. Nurses have developed several strategies for treating eating disorders among both young and old members of the population. This paper assesses the effects of some of these treatment strategies on the medical complications associated with eating disorders.

Eating disorders are not a new health concern — people of all ages have long suffered from these conditions. For instance, Shisslak, Crago, and Estes (1995) studied the spectrum of eating disorders and found that adolescents face a much greater risk of developing one. While eating disorders span a broad range, two forms are particularly prevalent in Western societies: anorexia nervosa (AN) and bulimia nervosa (BN). The existence of both disorders poses a significant challenge for the nursing profession, as the problem has been observed to escalate year after year (Shisslak, Crago, & Estes, 1995).

Bunnell, Shenker, Nussbaum, Jacobson, and Cooper (1990) compared and contrasted sub-clinical and formal eating disorders. Their results revealed that 35% to 50% of girls surveyed had been suffering from partial eating disorders, and that partial eating disorders were present in a higher proportion than complete eating disorders. The study also found that as adolescents grow and develop, it is highly likely that their partial eating disorders will develop into a full-fledged syndrome (Bunnell, Shenker, Nussbaum, Jacobson, & Cooper, 1990).

Bruch (1973) argued that eating disorders are most prevalent among adolescents, particularly during the period in which they are developing their sense of independence, mastery, and capability — a process crucial to acquiring adulthood and gaining freedom from parental control. Abraham and Llewellyn-Jones (2001) further revealed that the over-perception of body mass among children is the underlying issue driving eating disorder behavior, predominantly in the Western world.

Telch and Agras (1996) studied the influence of emotions on obese individuals and found that people who engage in binge eating do not experience anorexia nervosa — because their body mass index (BMI) exceeds 17.5 — nor do they experience bulimia nervosa, because they do not employ unsafe weight-control techniques. The results suggest that binge eaters use food to regulate mood or manage complex emotions, predominantly unhappiness, irritation, and feelings of inadequacy (Telch & Agras, 1996).

These studies, along with numerous others, have established that eating disorders represent a major health concern for the nursing profession. It is imperative that appropriate skills and strategies be developed and practiced so that successful, productive outcomes can be achieved. Nurses have demonstrated considerable commitment in this regard, producing several treatment options and anchoring their practice in both guiding principles and the enduring foundations of their profession. Among all treatment strategies employed, some naturally yield greater success. The aim of this literature review is to assess the most relatively successful strategies employed by nurses in treating eating disorders.

Eating Disorder Treatment Through Education

Huon, Braganza, Brown, Ritchie, and Roncoloto (1998) studied dieting-induced eating disorders in detail. Their results revealed that while several programs are operated through the American healthcare system, very few empirical studies have documented their success and productivity. Research has been carried out in diverse locations, though schools and hospitals have been the most common settings. The results also indicate that risk factors for eating disorders — including those addressing health problems and associated risks — should be incorporated into programs operated by nurses throughout America. Many studies have found that education and knowledge about health risk factors can redirect people's attitudes toward their eating habits (Huon, Braganza, Brown, Ritchie, & Roncoloto, 1998).

On the other hand, many studies have downplayed the role of education in producing behavioral change around eating habits, on the grounds that transforming behavior does not necessarily increase knowledge, or vice versa. Several programs have been initiated that include education about the consequences of unhealthy eating habits in order to address eating disorders; however, most have not yielded positive results. For instance, Carter, Stewart, Dunn, and Fairburn (1997) studied eating disorder prevention and treatment programs, adding a cognitive-behavioral dimension to their education curricula in an effort to alter clients' thinking about food and body image. Unfortunately, while the program showed efficiency at the end of the intervention compared to baseline, dietary self-control actually increased above baseline scores at the six-month follow-up. It is worth noting here that Huon et al. (1998) cautioned against education programs that may inadvertently motivate the very behaviors they aim to eliminate — much as drug prevention programs have long been considered to enhance drug use rather than reduce it.

Eating disorder programs operated by nurses not only target dieting practices but also address psychological factors such as body dissatisfaction and negative body image. Winzelberg, Taylor, Sharpe, Eldredge, Dev, and Constantinou (1998) evaluated a computer-mediated eating disorder program and found that women could use computer-based tools to improve body image and reduce body dissatisfaction. The researchers hypothesized that results might have been stronger had there been greater oversight, as subjects completed only 50% of the software program.

Springer, Winzelberg, Perkins, and Taylor (1999) studied the effects of a body image curriculum for college students. Their research demonstrated the success of an educational program on body image delivered on a university campus. The content covered biological, historical, and developmental perspectives on body image without focusing on personal transformation. Significant pre-test and post-test differences were recorded: the program decreased attitudinal and behavioral risk factors associated with eating disorders without altering BMI or self-esteem. The researchers attributed their results to a deliberate decision to exclude information on nutrition and weight management from the curriculum.

Education and awareness about healthy and unhealthy eating habits and their consequences are important components of holistic eating disorder treatment — including programs that incorporate hypnosis. Patients are helped to see the broader picture and to think about long-term outcomes. They are also made aware of the productive results achievable through consistent dietary control. Fiona Mantle (2003) provides an in-depth view of treating people with eating disorders through hypnosis: "Treatment of the person with an eating disorder centers on encouraging an achievement and acceptance of a weight which lies in the normal range or a higher realistic weight if the person is obese. Patients need to relearn normal eating and gain insight into their eating behavior and why it is persisting. Nutrition education and dispelling myths about food and eating are necessary, as is appropriate lifestyle modification. A major aim is to get the patient to desist from potentially dangerous eating behaviors, part of which requires dealing with underlying problems" (Fiona Mantle, 2003).

Another objective of hypnosis-based treatment is helping patients manage their eating behavior rather than aiming for an outright cure. Nurses and researchers alike recognize that it is not feasible to eliminate all eating disorder behaviors entirely. As Mantle (2003) explains: "The overall aim of treatment is not necessarily to cure the condition but to control it, since the eradication of all eating disordered behaviors is unrealistic and the goal of therapy is the maintenance of healthy, controlled eating patterns (Comma 1992)" (Fiona Mantle, 2003).

Eating Disorder Treatment Through Hypnosis

Initially, nurses focus on the patient's abnormal eating habits and behaviors so that they can employ various techniques to restore healthier patterns. Sometimes nurses use behavioral techniques without cognitive behavioral therapy; at other times, they combine both. The mode of treatment depends on the nurse's clinical assessment of the individual patient. Mantle (2003) describes common behavioral techniques used in this context: "Behavioral techniques might include simply not buying trigger foods or avoiding certain shops; that is, building up new habits to replace existing ones. Another example would be modifying eating behavior such as eating in the same place each day, or concentrating solely on eating and not watching television at the same time" (Fiona Mantle, 2003).

Research has shown that people will change their eating habits once they understand the advantages and disadvantages of their current behavioral patterns. At the same time, since eating habits are learned, they can also be unlearned — though the process may take considerable time. As Mantle (2003) notes: "Eating behaviors are learned behaviors; therefore they can be unlearned, although this can take some time. Rehearsal, age progression, or assertiveness training may be used. Control of binge eating may include eating regular meals, avoiding addictive foods, instigating a controlled binge, and delaying tactics" (Fiona Mantle, 2003).

Treatment results can only be achieved when patients are willing to acknowledge that they have a problem with eating behavior. Nurses have frequently observed that patients deny their eating disorders and therefore continue engaging in problematic behavioral patterns, endangering their renal, cardiovascular, and endocrine systems. Therapists have developed strategies to help individuals overcome this resistance. As Mantle (2003) explains: "Many eating-disordered patients tend to be resistant to treatment. They deny that they have a problem and it is necessary to devise an eclectic approach to treatment tailored to suit the individual.... Given the high hypnotisability of most eating-disordered patients, the adjunctive use of hypnosis is very appropriate. A number of uncovering techniques such as ego state therapy, age regression, age progression, and idiomotor signaling can be used to identify the origin of the patient's disordered cognitions and emotional conflicts which are precipitating their associated eating disorders" (Fiona Mantle, 2003).

Nurses have also learned that poorly organized therapy sessions can cause patients to lose hope and become discouraged. Today, considerable care is given to structuring competent sessions. Nurses think, act, and speak in ways that relate directly or indirectly to the patient's growth and development, employing various hypnotic techniques. As Mantle (2003) asserts: "Hypnosis may also be used to help patients develop feelings of control and mastery over their thoughts and behaviors. Cognitive and behavioral techniques for weight management have increased efficacy when combined with ego strengthening, imagery, systematic desensitization, and cognitive restructuring... because of the need for control within this patient group, the use of indirect and permissive suggestions for trance are more effective since they serve to enhance rather than challenge the patient's need for control" (Fiona Mantle, 2003).

Nurses exercise particular care when working with patients who have restrictive eating habits. Among the most valuable contributions of hypnosis in this context is its ability to address low self-worth and distress. As Mantle (2003) writes: "Because of their extreme need for control, restrictive eating patients make poor subjects for hypnosis. Patients who binge and then purge are more extroverted and are more highly hypnotizable than restraining anorectics. However, it has been shown that hypnosis can be effective in treating underlying problems of self-confidence, low self-esteem, stress, and depression. Of particular value is the Calvert-Stein technique for anxiety, as well as rehearsal, under hypnosis, of such techniques as self-talk, safe-place imagery, and social phobia management" (Fiona Mantle, 2003).

Conclusion and Recommendations

It is clear from the above that eating disorders represent one of the most widespread and consequential health challenges in the Western world, and in America in particular. While nurses throughout the Western world have developed a range of strategies for treating eating disorders across all age groups, efforts to curb this growing health concern remain inadequate. This paper assessed the effects of several treatment strategies on the medical complications associated with eating disorders.

To summarize the findings, only a limited number of eating disorder prevention programs have been rigorously evaluated. Of those assessed, education-based interventions — particularly those centered on dieting and dietary self-control — have tended to produce counterproductive results. Programs that address negative body image from a theoretical and developmental perspective have shown the greatest potential. However, nurses have often been reluctant to implement such educational programs with adolescents and children. That said, two comprehensive programs examined here — hypnosis-based treatment and the CMCD continuum of care — have demonstrated real promise. The CMCD, in particular, has proven highly effective in designing and executing a complete program for children and adolescents with eating disorders.

Eating disorders are multifaceted and deeply entrenched behaviors that function as part of the patient's psychological defense structure, making them especially difficult to treat. Standard treatment procedures may nonetheless be enhanced through the adjunctive use of hypnosis, even though patients vary considerably in their level of hypnotizability. Whether hypnosis can serve as an effective preventive intervention when predisposing factors are identified early remains an area requiring further research, as current standard intervention strategies appear to be of limited value in this regard. A carefully controlled clinical examination of hypnotic interventions, compared against appropriate control groups, could yield meaningful evidence as to whether hypnosis genuinely offers a protective function in eating disorder prevention.