I understand what you’re saying, but still see some elements of the treatment as problematic. Re: giving the patient tools to deal with family rather than directly helping the family… While I agree that learning to deal with a less-than-perfect family is important, I also think that a little family / significant other therapy can go a long way. Family therapy also provides a “safe” place for difficult conversations that may have to take place. Additionally, being the one with the ED, you don’t necessarily have much credibility. To use a personal example, when I first explained to my fiance that being the food police was NOT helpful, he didn’t know whether or not that was me talking or the eating disorder. All it took was my therapist telling him that it was more important for him to model healthy eating than to monitor my eating to straighten everything out.

Sure, learning tools for dealing with difficult environments is vital. You can’t change the world — only your reaction to it. However, I think family/significant other therapy is kind of a best case scenario. If there ARE situations or relationships that you can change/improve, then why not directly work on that?

I’m curious when you say, “Chances are that the favourable family environment cannot be upheld in the long run, thus reducing chances for long term improvement.” Why do you think that? I would argue (although without having done any research on the matter) that when families DO make the necessary changes, then they can stick. I think it’s the families that can’t/don’t make the changes hurt recovery–but that it’s pretty apparent during therapy which families those are.

I’m particularly interested in your last statement: “In addition to that, this approach would reduce dependence on a treatment friendly environment, thus reducing the risk of an increase in symptom severity over time.” I don’t think that limiting the availability of the “treatment friendly environment” is really a helpful move. There are some individuals who definitely become so used to the treatment world that they can’t (or are too scared to try) function in the real world… but I would argue (again, need to research this) that this is more often the case with individuals that hop from inpatient to inpatient hospitalization for years and years — not so much with outpatient treatment professionals. A good team is going to know how to downgrade treatment when appropriate. Plus, I think that some dependence is necessary. Heck, my old nutritionist would have probably loved it if I depended more on her to control my meal plan… rather than fighting her or trying to make my own independent (and ED-influenced) decisions. The word “depending” has a negative connotation to it (needy, unable to function on own, absolutely reliant, etc.)… but part of asking for / receiving help is depending on someone else to help.

The goal is to be able to thrive on your own without relying on a dietitian and/or therapist… and I think that most approaches to therapy have this same goal in mind. I just don’t think that by limiting all help from the very beginning that you are going to get there. Maybe at the end of 20 sessions you are NOT depending on your therapist — but you’re not turning to her for help when you need it, either.

Lastly, I’m curious how dependence on a “treatment friendly environment” is related to the “risk of an increase in symptom severity over time” ? Are you saying that increased dependence on professionals increases the severity of symptoms? That just doesn’t make much sense to me.

Thanks for your thoughts, Esse! You make some good points.