We have absolutely no idea how to treat an eating disorder.

Okay, true: there is research. There are studies and meta-analyses and case reports and all of that. It's not that the studies aren't useful, but I know very few therapists who really use these as the basis for their treatment. I have heard of and have personally met many treatment providers who say they use the acronymmed treatment in question (CBT, DBT, ACT, FBT...WTF?!?), but that's not exactly what the patient is getting. I don't think the therapist is lying, I think they don't have enough training or they pick and choose which parts of the therapy to use.

A study published earlier this year in the Journal of Consulting and Clinical Psychology noted the following:

That's even assuming a therapist actually says they use a particular treatment approach. Many times, a therapist will list that they use any (or all!) of the following: psychodynamic, feminist-relational, cognitive-behavioral, dialectical-behavioral, interperonal, equine, animal-assisted, yoga, past life regression, and a whole host of other things that I can't remember. Maybe a Magic 8 Ball or something...

Most of the time, the therapist simply picks and chooses what they "think" will work, which ends up being something like Dr. Lastname Therapy (DLT, if you need another acronym to add to your collection). As the keynote speaker at this year's International Conference on Eating Disorders pointed out , all humans are subject to errors in evaluating such things without rigorous clinical data, research, and (hopefully) a control group.

Except that most treatment-naive ED sufferers and their families don't know this. They don't know that there is zero regulation of the term "eating disorder expert." They don't know that the $1000/day treatment facility for which they've mortgaged their house a second, then a third, time does a crap job of collecting data to show that what they do actually works. Instead, they're printing glossy brochures and buying new Magic Ponies and hiring "Marketing Representatives."

I'm not dumb- I get that in the US, you need to advertise. You need to market yourself. I'm not expecting that a facility don't do that. You can deliver the best care possible, but if no one knows about it, what good will it do? Thus far, however, no one has shown in a large-scale study that residential ED treatment is really effective.

For many patients who use residential care, they've exhausted other options. Insurance kicks them out of the hospital once their blood pressure and heart rate are out of the basement. Nasogastric tubes are denied on the grounds that nutrition isn't "medically necessary" to the treatment of anorexia. {Not making that last one up...I wish I were...}They don't have family or social support to engage in the hard work of recovery. I'm not saying that residential treatment doesn't have a place in treating an eating disorder or that it's never helpful. What I want to know is whether it's helpful more often than not. For those whom it is helpful, I'd like to know who they are and why. What do they benefit from? Can we do it better? Change it to help those who weren't otherwise helped?

Again, treatment-naive people don't know this. We're so used to clinical trials in other areas of medicine that we sort of assume the eating disorder world is like that, too. And it's a brutal wake-up call when they figure out that's not how it works. 

The research literature might say that FBT is the " gold standard " for the treatment of adolescent anorexia*, but if you poll 100 therapists, you could probably count on one hand the number that use FBT as a firstline treatment for adolescent AN. Even if we take FBT out of the picture, things still look fairly grim. Anorexia has no real evidence-based treatments besides FBT, and bulimia has mainly CBT and interpersonal therapy (IPT). For the delivery of CBT, see the above study.

What we need, in my opinion, is a consensus not just on how to treat eating disorders, but what causes them. I don't mean that we create a generation of cookie-cutter therapists and therapies. I don't mean that we use just one therapy or assume that eating disorders are caused by just one thing. I don't mean we all just hold hands, sit around a fire, roast marshmallows, and sing Kum-by-ya. Disagreements are necessary to move the field forward. But when you get down to it, there is very little on which the eating disorder field agrees. At first, this made me sad. Now? It makes me really scared.

This consensus shouldn't be the final word. After all, as Victor Hugo said, "Science has the first word on everything and the last word on nothing." Our ideas about what eating disorders are and how we treat them will, of necessity, change as we learn more. That's not a weakness, that's a strength.

Even if I can't corral people in trying to reach a practical (ie, one that treatment providers in everyday practice actually use) consensus, I hope to make more people aware of the fact that there isn't a consensus. There's a massive divide among ED professionals, and it's not getting any narrower. 

I truly believe that knowledge is power. Knowing that the ED world can't even agree on what causes an eating disorder, let alone how to treat it, can be powerful. It can turn on your critical thinking skills. It can make you start to ask the right questions. Until we do, this lack of even general agreement on eating disorders will remain the ED world's dirty little secret.