It’s no secret that I am not a fan of primarily psychoeducational interventions for people with eating disorders (EDs). It irks me that the overall theory in implementing this kind of intervention seems to be: if they only knew what they were doing to their bodies, people with EDs would take better care of themselves. Of course I take issue with this idea – if knowing that EDs were harmful to one’s health was enough to make the changes needed to not have an ED anymore, far fewer people would be struggling.
In case you don’t know what I’m talking about, a psychoeducational program is one that focuses on educating people about a mental illness, including what qualifies as pathology, what the behaviours look like, what the harms are, and what possible interventions exist. To be fair, there are not that many examples of purely psychoeducational interventions for EDs – often, psychoeducational programs precede more intensive forms of treatment or are integrated with other approaches. Still, I think it is worth exploring the theory that underlies the psychoeducation model, and how these programs might be problematic when people don’t actually have access to the interventions they want and need to actually begin working on their behaviours and thoughts.
In this post, I’ll comment on a brief report by Vandereycken, Aerts & Dierckx (2013) about patients’ knowledge of the physical consequences of EDs. In this study, the authors wanted to know more about how knowing about EDs and their consequences impacted motivation for treatment. I’ll also write about a study by Balestrieri, Isola, Baiano & Ciano (2013), who studied a 10-week psychoeducation group treatment for patients with binge eating disorder (BED) and eating disorder not otherwise specified (EDNOS).
How much do those with EDs know about the consequences of EDs?
For this study, the authors had 66 women involved in inpatient treatment for EDs in Belgium fill out a questionnaire to assess their knowledge about physical health risks of EDs. They filled out the questionnaire at the beginning of their admission to the unit and again one month later. Authors don’t describe in detail what happened in between these time points (i.e., whether there was a purposeful psychoeducational component to their program). Average age of participants was 20.8 years, and participants had been ill for 5 years on average. Thirty-three had been diagnosed with restricting-subtype anorexia nervosa, 10 with binge-purge subtype anorexia nervosa, 12 with bulimia nervosa, and 12 with EDNOS.
The questionnaire included items like:
- “A woman’s body needs a minimum of fat content to be able to menstruate”
- “Weight loss may induce dizziness (and fainting) because of too low a sugar level in your blood”
- “Regular vomiting may cause deadly complications”
Participants were instructed to answer “right,” “wrong,” or “I don’t know.” Average score was 14.05/20 (70%) at pre-test and 17.23/20 (86%) at post-test, a difference that was statistically significant. Participants mostly answered questions about fertility, hair loss, and risks of drinking too much water incorrectly. Most of the difference between the scores at pre- and post-test was related to moving from answering “I don’t know” to choosing the correct answer.
As the authors note, all of these participants had been hospitalized previously; the results clearly reveal that people admitted for ED treatment are not ignorant about the consequences of their behaviours. The authors suggest that patients may, however, think that their own case is “not that bad” or may under-value the personal risks while recognizing the risks in a broad sense – for this reason, they espouse psychoeducation as an approach to improve patient motivation.
So, is psychoeducation helpful?
Unfortunately, there are not many studies that isolate the impacts of psychoeducation – and, I’d like to note, I could not find any that acknowledged the possible problems with teaching people about the harms associated with EDs without providing recourse to treatment – a scenario I see a lot in practice but less represented in the literature.
In 2013, Balestrieri et al. conducted a 10-week intervention with 98 patients diagnosed with EDNOS or BED (91% women, 54 diagnosed with BED, 44 with EDNOS, average age 42, average duration of illness 17 years for BED and 21 years for EDNOS). Participants took part in a group oriented toward nutrition, assertiveness training, and unpacking their ED-related thoughts and behaviours. Participants simultaneously tracked their food intake and thoughts, feelings and behaviours related to EDs. Despite these additional elements, the authors labelled this a psychoeducational approach.
The authors wanted to know whether their intervention decreased binges, affected BMI, and decreased ED symptomatology as measured by body dissatisfaction and bulimic symptoms.
Notably, over 50% of patients in the control group dropped out of the study. The authors attribute this to “a well-known problem of these patients, who have poor capacity to regulate their health behaviour, unless they are heavily motivated and involved in an active treatment” (p. 50). As well, they attributed the lack of attrition in the active intervention group to motivation.
I have to ask: why do we continue to blame patients for drop out, instead of interrogating how we fail patients using the approaches we keep using? Why is “treatment failure” a personal responsibility, as opposed to a systemic one? Of course, it is partially up to the person to engage in treatment. But can we not ask ourselves why the approaches we continue to use do not work for everyone?
For those who stayed in the study, authors describe improvements in symptomatology: over 30% were no longer diagnosable with BED or EDNOS after 10 weeks. Drive for thinness did not improve, but anxiety, depression, and alexithymia did.
Another issue for me is that the authors unproblematically refer to “BMI improvement,” which is shorthand, in this group, for weight loss. The assumption appears to be that this reflects a positive outcome for BED and EDNOS, which is an assertion coloured with the idea that BMI is linked to a type of ED (i.e., that only people in larger bodies get BED in particular and that weight loss is desirable in this group).
Unlike the prior approach to psychoeducation, this one appears to be rooted more closely to skills-based training, particularly in its assertiveness component. This intervention was less about telling folks what they were doing to their bodies and more about equipping people with skills, which I would argue likely accounts for the improvements they saw.
So, is psychoeducation effective?
The short answer is: maybe, but likely only if provided with additional tools and interventions. As the first study indicates, people with EDs often already know about the consequences of their behaviours. In my opinion, we need to stop assuming that telling people all of the ways their EDs can harm them is enough to make them better. This is a fairly paternalistic way of thinking, and it feeds into the idea that people with EDs are ignorant, childlike, or always in denial of their symptoms.
Do people with EDs sometimes underestimate the severity of their disorders? Sure. Do people with EDs sometimes struggle with motivation for treatment? Of course. But, might we also, before prescribing a course of psychoeducation, consider whether:
- Treatment is available
- The treatment available fits the needs of the people seeking it
Sometimes psychoeducation, in the absence of other helpful interventions (read: ones that are in line with the personal and cultural needs of the person seeking it) seems like yet another example of how we expect people to take sole responsibility over their own health. What I mean by this is that we seem to expect that knowledge will fix everything. Despite evidence that knowledge rarely translates to behaviour change, we continue to think that people will be able to transcend environments that keep them sick.
References
Vandereycken, W., Aerts, L., & Dierckx, E. (2013). What knowledge do patients have about the physical consequences of their eating disorder? Eating and Weight Disorders, 18 (1), 79-82 DOI: 10.1007/s40519-013-0006-2
Balestrieri, M., Isola, M., Baiano, M. & Ciano, R. (2013). Psychoeducation in Binge Eating Disorder and EDNOS: A pilot study on the efficacy of a 10-week and a 1-year continuation treatment. Eating and Weight Disorders, 18(1), 45-51. DOI: 10.1007/s40519-013-0014-2
I am curious if Liz will read this post and what here comments might be. If I remember correctly, she was a fan of psychoeducation. Although I think (as far as I remember) her notion of psychoeducation was much broader than simply telling people how their ED behaviours will harm them (i.e., akin to the talk I did for NIED).
I hypothesize that these psychoeducation courses probably tend to increase guilt (“This is damaging my body, but I can’t seem to stop. Why can’t I stop even though I know how bad this is.”). Does guilt translate to motivation? It didn’t for me. I struggled a lot with how irrational my behaviours were, particularly given that I prided myself on rationality and critical thinking. (This is why knowing the biology and psychology of EDs was helpful in alleviating that guilt.) However, knowing about how damaging my behaviours were did nothing to stop me. It simply didn’t work that way in the moment, at least for me.
I also suspect some of those psychoeducation courses might be misleading (e.g., falsely telling people that purging is ineffective, for example). I do not like scare tactics or lying. The truth is that bodies do adapt to a low weight, often remarkably. The truth is that self-induced vomiting is quite effective at getting rid of calories. Scaring people into recovery is not the right way to go about it. I think the extent to which EDs affect people’s personal lives is a much bigger factor that contributes to motivation. Knowing that you are at a higher risk of osteoporosis is far in the future, but being able to go to school, have a job, go out with friends for dinner, etc., that’s all proximal.
I asked my Tumblr followers if they felt their EDs could’ve been prevented recently. You know what has been by far the most common response: Probably not, but it didn’t have to get so bad. So many stories of clinicians, therapists, teachers, nurses, parents, friends, etc., either promoting ED behaviours or denying their seriousness. In a recent response, someone commented on how their therapist accused them of lying about restricting and bingeing! Maybe we should be educating therapists instead :/.
Yeah, I think there’s a time and a place for psychoeducation – I think mostly for educating OTHERS about EDs, TBH – like, those supporting or trying to support someone with an eating disorder. In those cases, I think that GOOD psychoeducation (i.e., highlighting the seriousness without fear mongering, being too alarmist, etc.) can effectively orient people toward understanding that EDs are not some passing phase or fad diet.
I agree that psychoeducation could increase guilt/shame. For me, psychoeducation focused on the negative physical ramifications of EDs was a part of my wait list experience – they gave us psychoeducation as we waited to go into program. I hated it and got home after feeling so hopeless and depressed and bad about myself every. single. time. I suspect that for some people who are maybe less aware of the dangers of EDs or at a very early stage of ED it COULD conceivably help, but I’m not sure. I also agree that they could be misleading and employ scare tactics. For instance, I definitely learned “facts” we’ve debunked here on the blog (well, you have.. I don’t know how much I really debunk anything but probably just tie myself and others into knots) like the amount of calories absorbed prior to purging.
“Maybe we should be educating therapists instead” – yes, this. Absolutely. I’m hopeful that with the NIED strategy work, we can… I’m co-chairing the training committee and pushing for this. I’m all for education, and psychoeducation, really – just for different populations than are currently being reached. Particularly given how educating patients only presumes that they are singularly responsible for changing their circumstances.
That’s an interesting topic. The main thing that struck me is that some of the psychoeducation described is actually quite triggering (ie. more likely to make an ED worse than to improve it.)
This item in particular stood out : “A woman’s body needs a minimum of fat content to be able to menstruate”
If someone at a low weight, but who still menstruates, is shown this it could confirm their suspicions that they are still too fat.
Likewise: Weight loss may induce dizziness (and fainting) because of too low a sugar level in your blood.”
If someone is restricting, but hasn’t experienced this, they might conclude they are still eating enough – or too much.
I read a research paper recently stating that – yes – more than half of women will lose their period below BMI 19, but 25% will not lose it until they go below BMI 14. Some can even die of starvation while still menstruating.
Therefore, If psycho-education is to avoid being actively harmful it has to be slightly more clued up. “Educating” people that not all harm is visible, that menstruation is not a sign that all is OK, etc. would be more appropriate. Even if it doesn’t help, at least it won’t make things worse.
I agree that lecturing patients as if they are simply a bit stupid is really counterproductive. Some of the beliefs sustaining EDs are things like feeling ashamed, or defective, or feeling a failure for not being able to sort the problem out yourself. Any approach that treats the patient as ignorant – or merely getting things wrong – not only won’t help: it can feed into and intensify the very beliefs that caused or are currently sustaining the ED.
I agree with you Shiran.
When I wrote the post about ED awareness weeks (https://scienceofeds.org/2014/03/05/eating-disorder-awareness-week-useful-useless-or-worse/), I did come across a few mentions of the fact that standard/typical ED awareness seminars/talks actually triggered women who were predisposed to EDs/had a history of EDs:
BUT HERE’S THE REALLY IMPORTANT PART…
When it comes to program effectiveness, who target audience are really matters. Indeed, Ridolfi & Vander Wal acknowledge this:
“Mann et al. (1997) found that when women who had recovered from eating disorders presented a primary prevention session, symptoms of eating disorders actually increased among participants presumably because the presenters may have unintentionally normalized the disorders.
It could be that, or it could be what one of the participants in Ridolfi & Vander Wal’s study experienced:
‘Of the three participants who reported that the session was a negative experience, one was a woman with a history of an eating disorder who experienced negative memories while listening to the information.'”
Psychoeducation =/ ED awareness talks, but I was still reminded of this point.
Education on what happens is important, I think, but I don’t think it should be done with the intention of motivating people to get better per se. I think it should be neutral. We try to be neutral (on SEDs). I’d rather be like, ok, here’s what we know so far about resumption of menses and here’s what we know about the effect of amenorrhea on bone health and here’s what we know about metabolism in recovery and so on.
I think the assumption that knowledge about the dangers is sufficient to prevent someone from engaging in behaviours (esp. someone deep in it) is pretty unrealistic.
Lol, Tetyana, in reading your comment I realized how ironic it is for me to write a post about the problems with psychoeducation when the blog could theoretically be understood as psychoeducation. But I agree – I think there’s a difference in terms of trying to be neutral about it, not presenting things as cut and dry, and presenting the possible critiques, too.
I agree – I think there’s a certain amount of misleading information flowing around in all of this, and that it could lead people to believe they “aren’t sick enough” because of how the info is presented as cut-and-dry. The menstruation piece is a really good example of this, definitely. A lot of psychoeducation I’ve seen has been stuck in the past, still perpetuating tired ideas about what eating disorders are and who gets them, too.
“Any approach that treats the patient as ignorant – or merely getting things wrong – not only won’t help: it can feed into and intensify the very beliefs that caused or are currently sustaining the ED.” – absolutely agree with this statement. It’s disrespectful for sure – why not treat people like functioning adults instead of ignorant children? There’s no denying that sometimes people with EDs don’t act in their own best interest, but there’s no need to act as though this is always the case for everyone or that this is due to ignorance.
It is impossible to avoid discussion of any topic. Sooner or later we must ask if discussion of psycho-education is itself psycho-education? Of course it is, and by and large persons with EDs are no different from the whole population. We feed off anything that re-enforces our self-perceptions. I think the only time psycho-education can work is when the facilitators are so tuned in and skilled to be able to create a ‘Tony Robbins’ effect (this is only intended as a recognized descriptive statement that he appears to have, and not intended as an affirmation about him or his techniques). We need ‘therapists’ who accept responsibility for the outcomes of their relational interactions with others, instead of who blame the patient for failure. This is also why I agree that genetic research is a waste of time. We need therapists who have a sense of responsibility to engage and shift client’s energy by using their energetic presentations in favor of positive outcomes, not negative confirmations/conformations.