به سوی درمان موثر اختلالات تغذیه ای: هیچ چیز مانند عمل کردن،یک نظریه خوب نیست

There is much room for improvement in the treatment of eating disorders, anorexia nervosa in particular. It is argued that for more effective treatment a radical change in thinking and doing is needed. First, the wide-spread multicausal model of eating disorders must be abandoned and replaced by (a) fundamental strategic research into the most parsimonious explanation of eating disorders and (b) interventions solely directed on the specific maintaining mechanisms. Second, evidence-based working is needed in mental health care. In daily practice, two of three psychotherapists do not treat their eating disordered patients with the best treatment available, i.e. cognitive behaviour therapy. The Dutch Ministry of Health, Welfare and Sport tried to improve the care for eating disorder patients by the nomination of several specialist hospital units. These units are, however, not selected for their treatment quality or the use of evidence-based treatment protocols. It is argued that this ministerial operation will not increase the supply of effective treatment. The Minister obviously should have done two other things to improve the amount and quality of treatment supply for eating disorders: First, she better could invest in a broad array of workshops, training and supervision programs in cognitive behaviour therapy for all psychotherapists working with eating disorders. Second, since nothing is so practical as a good theory, the facilitation of research into parsimonious models of the relevant mechanisms as well as the experimental tests of interventions on these mechanisms would have been a promising move to effective treatment.

The Dutch Ministry of Health, Welfare and Sport has a special interest in eating disorders. The minister responsible (Mrs Borst) sees waiting lists as the primary bottleneck in the care for eating disordered patients. Eating disorders are in the Netherlands as common as in other Western cultures; more than 40,000 Dutch girls and young women (year-prevalence about 2%) suffer from either Anorexia Nervosa or Bulimia Nervosa. The Binge Eating Disorder occurs in some 1% to 2% of the entire population, which amounts to 150,000 to 300,000 people in the Netherlands (SEN, 1998), whereas the exact incidence of the other eating disorders Not Otherwise Specified is not known. The severity of the disorders is substantiated by the figures on mortality: the number of patients who die of Anorexia Nervosa in the Netherlands and Germany is around 6% of the anorexia cases (Van Hoeken & Hoek, 1999 and Fichter & Quadflieg, 1999). In spite of all that, subjects with an eating disorder must wait an average of 3.6 months for clinical treatment, which can be too long in severe and life-threatening situations. For this reason, the Minister has nominated a number of general hospital units in the country as specialized in the treatment of eating disorders. In addition, she designated and subisidizes the eating disorder unit of a general psychiatric hospital for the treatment of particularly difficult and severe cases as well as for the coordination of the national treatment offer. Employees at the Dutch Ministry of Health, Welfare and Sport as well as Dutch experts in the field reason that patients with eating disorders might benefit by the current nomination of these units. They suspect that, through this action of the Ministry, the waiting lists will decrease and treatment will be more effective. However, it might be a misconception that a mere nomination of several hospital units as being “specialised” in the treatment of eating disorders will decrease the waiting lists and increase the supply of effective treatment. One of the propositions of the present paper is that the Ministerial Order bears the hazard that the supply of effective treatment will only get smaller in the end. Another central proposition is that nothing is as practical as a good theory. What will be clear later on is that the effectiveness of treatments for Anorexia Nervosa in particular is very slight. This is not at all surprising when considering the fact that there is still no explanation for why some people suffer or keep suffering from Anorexia Nervosa. In such a light, treatment quickly appears to be shooting with blanks and basically hit or miss. This is not a reproach of those providing treatment; they act to the best of their knowledge. But without a decent theory, they cannot get very far. After a discussion of the alleged multicausal nature of eating disorders in the next section, a plea is made for doing more reductionistic experiments in order to identify the real factors that cause or maintain the disorders. It is argued that experimental intervention on the identified factors should decrease eating disorder symptoms and finally may provide for better treatment methods. These ideas are occasionally related to current practical knowledge and the policies of the Dutch government.

In daily practice, only one-third of the psychotherapists treating patients with Bulimia Nervosa report using some form of cognitive behaviour therapy even though data of well-controlled empirical studies show this to currently be the preferred form of treatment for Bulimia Nervosa. Of these psychotherapists doing cognitive behavior therapy only 65% ever received training on this form of treatment. The Dutch Ministry of Health, Welfare and Sport wants to improve treatment for patients with eating disorders. Therefore, she nominated a number of general hospital units in the country as specialized in the treatment of eating disorders. However, the practise of evidence-based psychotherapy, i.e. cognitive behaviour therapy, was not a criterion for selection of these units. It was argued that a mere nomination of several hospital units as being “specialized centers” in the treatment of eating disorders will not lead to a decrease of the waiting lists and an increase of effective treatment supply. The nomination of the centers invites others to refer their patients to these centers, which means a decreased treatment supply for eating disordered patients in the numerous local Mental Health Centers. Moreover, the Dutch Ministerial action stimulates undesirable hospitalization in the specialized units. The Minister obviously should have done two other things to improve the amount and quality of treatment supply for eating disorders. First, she should have invested in a broad array of workshops, training and supervision programs in cognitive behaviour therapy for psychotherapists working with eating disorders. Second, since nothing is as practical as a good theory, she should have invested in more strategic or reductionistic experimental research which is aimed at identifying the real factors that cause or maintain the disorders. We still do not know enough about the mechanisms that maintain an eating disorder and that precisely is the reason for why treatment of eating disorders (Anorexia Nervosa in particular) is not as effective as it should be. The facilitation of research into parsimonious models of the relevant mechanisms and experimental testing of these mechanisms could have been a very effective move to stimulate more directed and effective treatment than is currently the case. The Dutch Ministry thus placed the horse behind the cart rather than in front of it. Investment of all available funds in the (assumed) expansion of treatment availability is not very efficient when there are still no effective treatments. The traffic jam behind the cart can only get longer as new patients line up (i.e. longer waiting lists). And although the possibility of the horse still being able to get ahead cannot be ruled out, the manner of working is not very handy and the flow of traffic will never be particularly smooth. A good theory of the mechanisms maintaining eating disorders is needed. When we understand how eating disorders arise or why they continue to exist, effective treatments will be more or less apparent.