Bulimia And Anorexia In A Wilderness Therapy Program: Health And Intervention

By: Michael Conner, Psy.D

Comprehensive Information: www.WildernessTherapy.Org
Mentor Research Institute
E-mail: Conner@OregonCounseling.Org
Revised: May 21, 2014


Bulimia and Anorexia are challenging and sometimes severe problems to treat in any mental health treatment setting. As many as five out of 100 females with Anorexia die from acute medical problems. Both of these disorders can produce profound and lasting damage to a person’s health.

Researchers have concluded that Bulimia and Anorexia are primarily the result of social influences and pressures in countries where a popularized body size and appearance can only be achieved through unhealthy diet and exercise. Bulimia and Anorexia are found almost exclusively in females and can be detected as early as middle to late adolescence. People who intentionally starve themselves to achieve an ideas or desirable body image suffer from anorexia (termed anorexia nervosa). The disorder, which usually begins in young people around the time of puberty, involves extreme weight loss--at least 15 percent below the individual's normal body weight. Many people with the disorder look emaciated but are convinced they are overweight. Sometimes they must be hospitalized to prevent starvation. People with Bulimia Nervosa consume food and then rid ("purge") their bodies of the excess calories by vomiting, abusing laxatives or diuretics, using enemas, or exercising obsessively. Some use a combination of all these forms of purging. Because many individuals with bulimia "binge and purge" in secret and maintain normal or above normal body weight, they can often successfully hide their problem from others for years.

According to the Diagnostic and Statistical Manual of Mental Disorders, Anorexia and Bulimia can be diagnosed at any age, but the disorder can be found in children as young 8 years old. The diagnostic criteria for these disorders have been established by the American Psychiatric Association and is very similar to the International Classification of Disorders (ICD). When a student demonstrates symptoms associated with an eating disorder, a full evaluation and diagnosis is essential. The prognosis is better when Bulimia or Anorexia is detected early and it is less favorable the longer the disorder exists and the longer it has been reinforced.

Bulimia and Anorexia, and the associated behaviors are difficult problems to address in a wilderness therapy program. In many cases, the "diagnosis" has not been made prior to admission, but the symptoms associated with Bulimia and Anorexia will become evident and more pronounced after admission. Failure to recognize and respond appropriately can exhaust field staff, diminish the benefits that other students might otherwise gain from their program and can contribute to alarming and life threatening conditions.

In the early stages, the symptoms of Bulimia and Anorexia are very difficult for parents to detect. As these disorders progress, parents, friends and care givers will usually become suspicious as they notice weight changes, preoccupations with weight and appearance, and a pattern of avoidance behaviors in which friends or family become concerned about adequate nutrition and eating patterns. In a few cases, these children also demonstrate symptoms of Depression or Anxiety disorder, a Conduct Disorder (CD) or Oppositional and Defiant Disorder (ODD). Children who become involved in drug abuse, primarily stimulants, may evidence loss of appetite and other behaviors that frequently look like Bulimia and Anorexia.

Failure to screen for, recognize and respond appropriately to Bulimia or Anorexia in a wilderness program can be disruptive to the field program, can lead to a significant health risk and can create a situation where therapeutic opportunities are lost. Many young girls with the initial behavioral symptoms of this disorder will go undetected prior to admission primarily because they hide these behaviors from parents and family members. They are generally not evident until the child is supervised continuously in a structured setting where nutrition and behavior are monitored continuously. A wilderness program is more likely to detect bulimia than a therapeutic boarding school, psychiatric hospital, residential treatment or wilderness program. In a wilderness program, a student may not demonstrate all of their symptoms until the third or fourth week.

Students with Bulimia and Anorexia have four primary problem areas. These include,

  • Control

  • Argument and Debate

  • Secretive Behaviors

  • Guilt and Shame

  • Obsession over weight

The psychological and emotional needs of children with Bulimia and Anorexia usually involve control, or more specifically, avoiding the perception of being out of control. Students with Bulimia and Anorexia are prone to view their caretakers as people who are attempting to control rather than help them. It is crucial that caregivers avoid falling into the trap of trying to control the eating behaviors of people with Anorexia or Bulimia. Care givers who attempt to reason, persuade or coerce food intake, proper nutrition and to prevent purging are met with debate, argument, deception, defiance, anger, or in some cases, self-destructive behavior. The general response toward caregivers who attempt to reason and persuade students is often resistance, avoidance or defiance. At the same time, students with Bulimia or Anorexia will make efforts to engage staff by asking questions that present the possibility of compromise, but in reality lead to arguments in which the students always wins. The resulting message to a caregiver is "I am willing to discuss my refusal to eat or my purging, but I am not going to let you stop me. I will always win the argument. I am in control of my eating and purging, not you!!" This mixed message produces frustration in peers, friends and caregivers who fail to understand the rigid and unwavering nature of the student’s obsession.

Behavior That Will Be Encountered In The Field

  • Hiding food.

  • Arguing over certain foods they can or cannot eat.

  • Comments that they are fat, unattractive and need to loose weight despite evidence to the contrary.

  • A pattern of drifting to the perimeter of the group or asking to leave the group to void their bladder soon after eating an adequate or large meal and then purging their meal without staff awareness.

  • A recurrent and increasing pattern over time of emotionality, low frustration tolerance, mental dullness, physical weakness or complaints of being cold that are the result of insufficient nutrition.

  • Arguments and pleas to staff or other students to keep their bulimic behavior secret and to keep information about their disorder a secrete from other staff and students.

  • Asserting that they can be trusted to not hurt themselves while minimizing and referring to the health education and increasing concerns about their health as stupid or unnecessary in their case.

  • Shame and guilt expressed in withdrawn and avoidant behavior that may appear shy, indignant or controlling, and may become defiant, argumentative or aggressive if ignored or challenged.

  • Obsessed thinking that borders on a fixation that is contradictory, illogical and irrational with regard to nutrition, food choice, purging, weight loss, the method and risks.

  • Exercising unnecessarily or in a secrete manner when others are not watching.

  • Attempts to form a close and confiding relationship with a staff person (usually a female) to enlist their aide in persuading other staff to allow their behavior to continue and to separate their Bulimic or Anorexic behavior and the impact of that behavior from all other aspects of their program.

  • Using defiance in terms of a refusal to eat, and then offering to eat in order to negotiate permission with the program and staff to continue partial starvation and purging.

  • Increasing motivation to purge when emotionally distressed, nervous or feeling out of control following limit setting, confrontation or feedback by staff or peers that interprets the student behavior in terms of manipulation, escape, or an avoidance.

Medical Problems

In patients with anorexia, starvation will eventually damage vital organs such as the heart and brain. To protect itself, the body shifts into "slow gear": monthly menstrual periods stop, breathing, pulse, and blood pressure rates drop, and thyroid function slows. Nails and hair become brittle; the skin dries, yellows, and becomes covered with soft hair called lanugo. Excessive thirst and frequent urination may occur. Dehydration contributes to constipation, and reduced body fat leads to lowered body temperature and the inability to withstand cold.

Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur in anorexia. If the disorder becomes severe, patients may lose calcium from their bones, making them brittle and prone to breakage. They may also experience irregular heart rhythms and heart failure. In some patients, the brain shrinks, causing personality changes. Fortunately, the later condition can be reversed when normal weight is reestablished.

Bulimia nervosa patients--even those of normal weight--can severely damage their bodies by frequent binge eating and purging. In rare instances, binge eating causes the stomach to rupture; purging may result in heart failure due to loss of vital minerals, such as potassium. Vomiting causes other less deadly, but serious, problems--the acid in vomit wears down the outer layer of the teeth and can cause scarring on the backs of hands when fingers are pushed down the throat to induce vomiting. Further, the esophagus becomes inflamed and glands near the cheeks become swollen. As in anorexia, bulimia may lead to irregular menstrual periods. Interest in sex may also diminish. Many times these people require medical attention for associated health problems that are related to loss of electrolytes, ulceration of their esophagus, deterioration of the stomach lining, bone loss, or damage to their teeth.

Program Therapeutics

Treatment can save the life of someone with an eating disorder. Friends, relatives, teachers, and physicians will often play an important role in helping the ill person start and stay with a treatment program. Encouragement, caring, and persistence, as well as information about eating disorders and their dangers, are usually needed to convince the ill person to accept help. In a wilderness treatment program, there are inherent advantages and disadvantages.

Advantages of Wilderness Treatment

Food consumption, nutrition and any purging can be monitored closely in programs that have a close supervision structure.

A reality program for counseling, reinforcement, education and social interaction can be developed and implemented more effectively than on an outpatient treatment program.

Behavioral problems can in some cases be addressed separately or along with the eating disorder.

The relationship between food, energy, stamina, physical ability, mental status and safety are clear and not ambiguous issues for students in programs that are have challenges, require initiative, are strenuous, physically demanding, have harsh environmental conditions and require teamwork.

Disadvantages of Wilderness Treatment

The physical, energy and necessary nutritional demands of a physically active program may create a high risk.

The student’s program may require exceptions which may disrupt program routines, create special exceptions and create conflict between students and staff pertaining to exceptions made in the rule structure.

The program should focus on creating choices within a reasonable and safe structure for the student's eating behavior despite the student's tendency to avoid responsibility for the consequences of their behavior. Individual therapy should monitor the obsessive compulsive aspects of the student’s behavior. Individualized rather than group treatment plans must be developed for students with Bulimia or Anorexia.

Group counseling or therapy should be supportive and exploratory. Caregivers, staff, counselors and therapists will also require support including readily available consultation with a mental health professional. A cooperative hospital or residential facility should be consulted with and made available to serve as a back-up should the student’s medical or mental status become severely compromised.

Regardless of the type of therapy used, two important issues in the program must be addressed:

  • The student may only be allowed to exercise and participate in the physically strenuous aspects of their program provided they have sufficient nutrition to do so in a safe manner.

  • Reality-oriented problem-solving and choices must be provided that are free of coercion, abuse or manipulation through guilt induction.

Students with Bulimia or Anorexia must learn how to tolerate unpleasant feelings associated with less than ideal self-image and appearance. They must also gain a sense of control and self –esteem in their life that is independent of their physical appearance. It is essential that their caregivers set boundaries and not argue with these students. Staff must be supported to respond to the student's obsession with patience, compassion and confidence. Staff should avoid discussing and debating the program’s responsibility and effort to monitor the student’s behavior. This will demonstrate to the student that the caregiver will not enter into or create power struggles. Argument with a student will only serve to reinforce the obsession and rigid stance the student is taking. Children with Bulimia must slowly learn to overcome their belief that their value and importance as a person or friend does not depend on their weight, size and shape. This cannot be accomplished through lecture and reminders. The unplanned and unstaged behavior of a caring and firm staff and the student’s peer group can communicate this more than anything. A high degree of repeated confrontation or argument from staff will only reinforce defiant behavior. The student will always "win" and remain in "control" if they simply refuse to eat or agree, or they continue to purge. In many cases, a student with bulimia or anorexia will prefer the sensation of starvation and the possibility of health problems and medical harm over the feeling of losing an argument or the belief that they are fat.

Program staff and caregivers must be able to tolerate repeated episodes in which a student will become argumentative and defiant regarding eating, assigned work activities and purging behavior. Students with severe or advanced Bulimia can demand a great deal of attention and can be disruptive to other students who become frustrated, angry or afraid for the student. Students with significant weight loss may not be appropriate or medically safe participating in a wilderness program. A significant loss of weight or overall weight less than 15% of normal weight may constitute a significant health problem.

The complex interaction of emotional and physiological problems in eating disorders will sometimes call for a comprehensive treatment plan, involving a variety of experts and approaches. Ideally, the treatment team for complex cases will include an internist, a nutritionist, an individual psychotherapist, and a psychopharmacologist--someone who is knowledgeable about psychoactive medications useful in treating these disorders. Complex or advanced disorders requiring this level of support are not realistic admissions to a wilderness programs.

To help those with eating disorders deal with their illness and underlying emotional issues, some form of psychotherapy is usually needed. A psychiatrist, psychologist, or other mental health professional meets with the patient individually and provides ongoing emotional support, while the patient begins to understand and cope with the illness. Group therapy, in which people share their experiences with others who have similar problems, has been especially effective for individuals with bulimia.

Use of individual psychotherapy, family therapy, and cognitive-behavioral therapy--a form of psychotherapy that teaches patients how to change abnormal thoughts and behavior--is often the most productive. Cognitive-behavior therapists focus on changing eating behaviors usually by rewarding or modeling wanted behavior. These therapists also help patients work to change the distorted and rigid thinking patterns associated with eating disorders.

Crisis Hospitalization

Children with Bulimia who refuse to eat for an extended time will become medically and mentally compromised. Conditions warranting hospitalization include excessive and rapid weight loss, serious metabolic disturbances, severe depression (with neurovegetative signs), risk of suicide, severe binge eating and purging, or psychosis. Most emergency departments that are medical and not psychiatric are able to recognize or respond with appropriate understanding of the needs of student with Bulimia and Anorexia. A conflict between the Emergency Department and the wilderness program is likely if the hospital does not realize that the student was being given proper care and that the program was responsive and caring toward the condition. Students with Bulimia or Anorexia are prone to sincerely fabricate and report abuse and neglect by caregivers, parents and program staff. The emergency room staff must be careful not to let the student pit the hospital staff against the student’s parents, counselors, therapists and staff in their treatment program. Primary treatment of Bulimia or Anorexia in a hospital setting is not the preferred first treatment method.

Medications

The use of medications, especially an initial trial of a medication in a wilderness program is very problematic. Starting a student on a medication, while in a wilderness settings requires that staff be trained to recognize associated side-effects and to respond appropriately. The student’s mental and medical status must be monitored. The use of antipsychotic drugs (e.g., zeprexia or respiridone) are not indicated. Monoamine oxidase inhibitors (MAOIs) have been used for students with Bulimia and Anorexia but with little success to address patients who are overly sensitive to rejection. However these drugs have potentially life threatening side effects if a student eats certain foods. Other antidepressants have also been found to be effective in reducing anxiety, depression and obsessive compulsive behavior. Brief use of antianxiety medication has been used to relieve episodic or intense anxiety. Long-term use of antianxiety medication should be considered with caution because of their propensity to reinforce medication seeking behavior and further escape and avoidance behavior. Scientists have examined the effectiveness of combining psychotherapy and medications. In a recent study of bulimia, researchers found that both intensive group therapy and antidepressant medications, combined or alone, benefited patients. In another study of bulimia, the combined use of cognitive-behavioral therapy and antidepressant medications was most beneficial. The combination treatment was particularly effective in preventing relapse once medications were discontinued. For patients who binge only, cognitive-behavioral therapy and antidepressant medications may also prove to be useful.

Recommendations

  • Prospective students for admission with an eating disorder should be carefully screened by a qualified mental health professional who is familiar with the stress and therapeutic structure of the particular wilderness program. Known cases of Anorexia or advanced Bulimia are not appropriate for admission to a long term or physically demanding wilderness program.

  • Students with Bulimia or Anorexia considered most likely to benefit from wilderness therapy must demonstrate considerable motivation to address their problems and be willing and able to co-operate in the group life of the community. Students admitted to a program should be free of medication. This will restrict admission to those without acute problems or co-morbid chronic mental illness. Potential students with Bulimia or Anorexia with a history of violent, destructive or suicidal behavior should not be admitted to a wilderness therapy program. The above requirements will severely limit the number of students for whom the wilderness option may be considered.

  • In the event that a student with Bulimia or Anorexia is admitted, or a diagnosis is made after admission, staff interactions should focus on the student's "here-and-now" program and not attempt to coerce a student to eat properly. Forced feeding or attempts to physically restrain purging behavior is illegal and unethical. Staff should also avoid arguments and power struggles that result in a defiant stance. Such interactions ultimately reinforce oppositional, defiant and obsessive behavior.

  • The program will have a number of additional clinical and administrative tasks that should be addressed. Staff will need additional training, supervision, emotional support and the availability of mental health consultation. A policy and procedure must be developed to monitor the student’s mental and physical status. Programs must be prepared to recognize that many students with Bulimia or Anorexia may decompensate and become medically unstable or at risk. Discharge without completion of the program will be necessary for some students. Parents should be informed in advance that this may occur. The program should document the student’s treatment, obtain outside consultation for the program, and obtain written approval from the parents to admit or keep students in their program.

  • Program goals for students with Bulimia or Anorexia should be in terms of supporting gains toward increased self-esteem and self-confidence that is earned through choices, and provide opportunities to gain healthy self control, express and manage emotions, minimize argument and debate, reduce secretive behaviors and reduce guilt and shame.

  • Wilderness programs are not tested or proven effective treatment methods for Bulimia or Anorexia. At the same time, there are no treatment programs that are proven more effective than doing nothing for many of these patients. There is no evidence or reason to believe a wilderness program is harmful or could in any way exacerbate a Bulimic or Anorexic condition. Placing a child in a challenging and therapeutic wilderness environment while at the same time removing the child from an environment that triggers and cues an eating disorder, or is unable to alter the course of behavior, may have therapeutic benefits.

  • Parents should become involved in treatment with a professional specialized in working with eating disorders and that professional’s involvement in program treatment planning and follow-up care should be secured. Graduation and placement in follow-up outpatient treatment, a residential treatment program or a therapeutic boarding school will be essential to maintain the gains provided by a wilderness therapy program.

Copyright 1999 - 2002, Michael. G. Conner