It's not just genetics
One of these days, I will start a “Grey’s take on the Maudsley Method” series. Not because I think that it’s wrong or right, but just because I think it’s really interesting and have a lot to say about it.
In the meantime though, I want to highlight a quote from Laura Collins’ article, “The size of the trigger or the speed of the bullet?”
An eating disorder is not a sign of deep wounds, but some people do have deep wounds, and it makes recovery harder.
I’m curious — this this a “duh” statement for everyone treated with the Maudsley Method? Because it basically goes against all of my inpatient and outpatient treatment, formal education, and research. Just to quote a few of the institutions, professionals, and resources I’ve had experience with:
“Eating disorders are serious health- and life-threatening physical disorders that usually stem from some underlying emotional cause.” – The Renfrew Center
“Genetics make the gun, environment loads it, and that an experience of unbearable trauma is what actually pulls the trigger.” – Lui, Aimee. Gaining: The Truth About Life After Eating Disorders.
“Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes.” – National Institute of Mental Health
If you don’t see my point by now… it’s that I have always been told, eating disorders are not about the food. They’re a symptom, coping mechanism, etc. of something else.
That said, I don’t think that everyone has trauma… I’m not a fan of repressed memory therapy, because I think a lot of it is made up (or generated in the process). Ruminating on traumatic events prolongs mental illness. You can’t change what happened to you when you were three. This is all true… but I also think that some people are using food to subconsciously avoid feelings/situations related to previous trauma, and in those cases, they need to be resolved in therapy.
I like Aimee Lui’s perspective on the matter. You NEED the genetic component to develop and eating disorder. They don’t really just happen to people. Even if you have the genetic component, though, growing up in a wonderful environment can be protective. I refuse to believe that you just inherit the anorexia gene and you’re doomed for a life haunted by an eating disorder (and if that’s the case, then I should never have children given my family history). There IS a strong genetic component… but in all these genetic studies, you also have to consider environment! Chances are, these kids are growing up with semi-similar relationships as their parents did. There are just too many variables.
Anyway, I think that given genetics, environment CAN be enough… but for many people, it’s the unbearable stressing event that pushes them over the edge. Those are the people with the trauma history. So, regardless of whether or not you have a history of trauma, you at least have underlying relationship/environment issues to address
I’m flattered to be mentioned in your blog!
Can I clarify the way I look at this? I don’t see the issue as genetics Versus environment – it is both, of course. I think the genetics is far more of an influence, and I think environment includes nutrition and prenatal conditions and STRESS which changes the biology of the body.
But here’s the biggest thing: just because something is biological/genetic doesn’t mean it is unavoidable and untreatable. EDs are completely treatable, and full recovery is absolutely the goal. And treatment isn’t all biological – you need skills and a healthy environment to recover and avoid relapse.
In other words, we don’t disagree as much as you might think!
I’d encourage you to look into the Maudsley approach a little more closely, particularly the writings of Drs. Lock and le Grange. You might be surprised to find that they do NOT claim that it’s “just genetics” (or biological/genetic) at all. Further, weight restoration is just the first of three stages of treatment. The second centers on the adolescent resuming healthy eating in an independent way. In the final stage facilitating healthy adolescent development is central. This might involve any number of issues, depending on the individual. In addition, any co-morbid illnesses need to be addressed.
I think there is often focus on the first part of family-based treatment because parents are involved in helping the patient to restore weight and this sets FBT apart from other treatments. But there really is more to it than that. Unfortunately, the Maudsley approach is sometimes wrongly dismissed as a “feed-em-and-forget-em” treatment and that is simply NOT what FBT is.
There’s a lot of interesting work related to AN’s contributing factors (I prefer that term to “cause”) so I hope we will soon know more about etiology. In the meantime we need to muddle through as best we can.
I don’t see eating disorders as “about” anything, actually, any more than pneumonia or schizophrenia or autism are “about” something. We don’t understand them very well, and it’s probably true that there is no one cause but rather a perfect storm of causes that must come together. Genetics is absolutely part of the picture; temperament probably is too; environmental triggers, almost certainly. But you can add those three things up in an infinite number of ways. So I think it’s important to not make blanket statements one way or another.
If you’re interested in reading our family’s story of using the Maudsley method, it’s at http://www-news.uchicago.edu/citations/06/061126.legrange-nyt.html.
Laura –
I’m flattered to have you reading my blog, and apologize in being so delayed to reply to your comment.
You’re right, maybe we don’t disagree as much as I originally thought. I think that the original quote, “An eating disorder is not a sign of deep wounds” is a pretty controversial point, though. Maybe it’s not a sign of TRAUMA… but I would consider it a significant sign of something… something that isn’t right and either cannot be expressed or mentally/emotionally dealt with in another way.
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Jane –
I think that in my attempt to highlight the “there is no underlying psychological cause” theory leaned a little too much on the biological component. Sorry about that.
What shocked me in my original quote was the “it IS about the food” approach. In a hospital, refeeding starts on day #1… that’s not step 2 after psychological progress has been made. It’s refeeding AND therapy, though… and my understanding of step #3 of the Maudsley approach (correct me if I’m wrong), is that therapy focuses on resuming normal, non-ED life–rebuilding a social life that you might have lost while isolated in your disorder, joining activities, building relationships, etc–not really addressing any “underlying contributing factors” of the disorder.
I agree that this is a very interesting topic and field of research…
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Harriet –
I remember reading that article a little while ago when it was published, and hope that your daughter is still doing well.
I don’t think that you can compare anorexia to pneumonia or autism (I’d have to give schizophrenia a little more thought). I hear people compare it to cancer all the time… but eating disorders are NOT like cancer. Cancer is a disease; anorexia is a disorder. I think that eating disorders are most comparable to addictions (although again, not many holes in that comparison), and addictions are more than biological. The difference between someone who does and doesn’t become an alcoholic is biological, but SOMETHING usually drives that person to drink in the first place. EDs may not be “about” anything, but they are related to something. For those with the genetic predisposition, they are (poor) coping mechanisms. I think that they have some psychological function– unlike pneumonia.
I’ve never ever heard “there is no underlying psychological cause” from a Maudsley researcher or practicing family-based therapist. I have heard things like “We don’t know what complex factors contribute to EDs but we need to get on with treating them as best we can. Parents can be a resource in helping their child.”
FBT is not a rejection of therapy, but a type of therapy. Even in the earliest stage it’s not solely about food. (If adequate calories were enough to take care of AN then hospital refeeding programs would have great success rates.) Even in the weight restoration phase there are important psychological factors. Calm, compassionate, consistent support while externalizing the illness is key. There’s a lot of attention given to parents working together so they are on the same page in supporting their child and helping her eat. Siblings are encouraged to support their brother or sister, but are relieved of the burden of responsibility for refeeding. The adolescent’s independence in other areas continues so that she can stay engaged in the healthy aspects of her life. As recovering kids take over independence and learn to manage, they do so as they go about their lives at home amid their normal stresses and strains of everyday lives. This kind of support makes a difference. For example, there are studies showing that when parents doing FBT aren’t able to refrain from criticizing their child, the children don’t do as well in recovery (not too surprising to me.)
As to what stage 3 of Maudsley looks like I imagine that it varies quite a bit by individual. In general FBT is a pretty minimalist treatment (and it shows good results in randomized controlled studies of kids who’ve been sick for less than three years) but I think any responsible therapist would make a referral (or continue therapy) if a patient wasn’t fully recovered. I don’t think FBT intends to ignore patient concerns or issues–whether they are typical adolescent issues, co-morbidities, anxiety or feeling out of control of one’s life. In my daughter’s treatment her thoughts about AN were not pushed aside or ignored but were discussed as part of her recovery.
Somehow i missed the point. Probably lost in translation
Anyway … nice blog to visit.
cheers, Vying
im sorry but to miss the point is irrelevant to even commenting on this blog, to miss the shameless comment that ” not a sign of deep wounds” is ludicrous. Deep wounds are not deficient to sexual or physical abuse. To rape yourself of your own self worth and love is a penetrating wound that takes vigorous action physically and mentally. Are we ever completely “fixed” of debilitating habitual inclinations. Maudsley pulled me from the throws but those neurobiological and psychological matters are still universal in my continuing recovery.