On Assessment, Treatment and Referrals
1. Getting an Insider’s Help
An unconventional and very effective suggestion for professionals to get quick, accurate assessments and effective, long-term recovery support for potential food addicted patients and clients is to cultivate a relationship with a local member of a food-related 12 Step fellowship who has long-term stable abstinence and recovery from food addiction. It may take some time to identify and recruit such a person, but those who have done it usually say it is time well spent. There are at least three reasons:
First, food addicts who are still active in their addiction are notorious for lying about– or just omitting – key information about their disease. Bulimics will often not tell their doctor about their bingeing or purging; when asked directly about these subjects many will blatantly, often convincingly, lie. Obese patients going to therapy for their weight often will not mention the behavior about which they are most ashamed; when the counselor says, “We have to get at the underlying issues about why you eat,” they will be perfectly happy neither to mention what they are eating nor how much they are eating for months or years in therapy. Strangely, when talking to a recovered food addict who shares their own personal story, this same person who lied to a professional to whom s/he was going for help will now share openly and with relief that s/he have done the same or similar things with food. Moreover, in the instance where the active food addict is still in denial, the recovered food addict more often than not be able to tell. All this produces more reliable information quite efficiently for the professional.
Second, food addicts whose disease has progressed to a critical level are often hopeless. They have heard all the statistics about secondary health problems associated with obesity and with the statistical likelihood of early and more painful death. They have probably tried to lose weight and maintain a healthy weight loss more times than they can remember; what they do remember with increasing distress is how regularly they have failed. Some are too embarrassed or too concerned with hurting their doctor’s or dietician’s feelings to be honest about this. If they are honest, they will say that they are quite certain that they will not be successful with the diet their professional suggests. Or, another part of addictive denial, they will forget that diets – or diets and therapy – have not worked, so they will eagerly jump in and give it another try. Gratefully, this all looks different when they talk with a recovered food addict who was, in the not too distant past just as hopeless for very similar reasons, and is now a shining example of success.
Third, and possibly most important, a recovered food addict can be a guide for your patient in the complex world of 12 Step and other peer support recovery on food. There are now over a dozen food related 12 Step fellowships: which are strongest in your local area? And which are most appropriate for food addicts at different stages of the disease? Within the largest of the 12 Step fellowships, Overeaters Anonymous, there are dozens of different definitions of abstinence. How does a new person distinguish between these? How does one “surrender” when different members give such a broad range of advice? Finally, what if a person new to OA or one of the other 12 Step organizations does not find a sponsor they can work with? What if the program doesn’t seem to work? Without an intermediary, the physician or dietician has little option but to take their patient’s word, “That program doesn’t work.” Or “It doesn’t work for me.” A recovered food addict who knows the local recovery community can be very helpful to the newcomer and, if “it doesn’t work”, can often put the newcomer’s experience in context for the professional.
There are usually a number of long-time recovered food addicts available who will consider it in the interest of their own recovery to be of help. The professional needs only make the effort and take the time to find them.
2. Doing a Formal Assessment
We are in a time similar to the 25 years of so prior to the 1960’ s when professionals were learning more and more about alcoholism and drug addiction, but the health establishment had yet to formally establish a diagnosis of a chemical dependency. Food – more specifically, addiction to one or more specific foods or volume of food in general – is not yet approved as a substance use disorder in the DSM of the American Psychiatric Association or sanctioned by the American Medical Association and other major health organizations. Treatment follows diagnosis, however, and if someone needs to be treated as food addicted in order to recover, they need to be assessed as such. You can contribute to this effort by writing a lettter here.
We now have a peer-reviewed food addiction assessment instrument, The Yale Food Addiction Assessment. Any professional can give this to a client and help them understand the interpretation.
There are also four self-assessment tools used by professionals in the section For Addicts The first is a general food addiction self-assessment. The next three also for separate self-assessments regarding the questions: Are you a Normal Eater? Are you an Emotional Eater? (If so, are you Anorexic, Bulimic and/or a Binge Eater?) And Are you a Food Addict? (If so, at what stage?) These distinguish between the distinct diseases of obesity, eating disorders and chemical dependency on food – critical distinctions in proposing treatment.
Some professionals may prefer using the self-assessment questionnaires developed over time by the 12 Step organizations.
3. Treatment by the Non-Specialist Health Professional
There are four tasks that every Physician, Dietician and Therapist needs to be able to do: I) educate their client about obesity, eating disorders and food addiction, II) help their client assess themselves and, if appropriate, give your own opinion, III) encourage middle and late stage food addicts to consider developing more peer support, e.g. food-related 12 Step fellowships and help your client work through problem in effectively using these organizations, and IV) make referrals to food addiction professionals and food addiction treatment programs when appropriate.
Step I: Educate. This website is one good place for a client to start educating themselves about food addiction. You might suggest they go to the sections on “Questions and Answers” and/or “For Food Addicts.” If you have developed a long-time, stably abstinent food addict as an ally, you might suggest that your client call this person. There are also several good books in the “For Food Addicts” section. Many like to start with Kay Sheppard’s Food Addiction: The Body Knows or Debbie Danowski’s Why Can’t I Stop Eating? If someone is interested in “dieting”, you might suggest Anne Katherine’s Your Appetite Switch or Dr. Neil Bernard’s Breaking the Food Seduction. For men who would like to hear it from another man, Michael Prager’s Fat Boy, Thin Man, is excellent. For those with a spouse or child, Fat is A Family Affair by Judy Hollis would be a good introduction.
For those more socially inclined, you might suggest they try a 12 Step meeting; a common suggestion is “go to six meetings before you make any decisions.” In this case, you might suggest they get a copy of the basic text for addiction recovery, Alcoholics Anonymous, and read the “The Doctor’s Opinion” and first 164 pages of the text or the OA interpretation of this, The Twelve Steps and Twelve Traditions of Overeaters Anonymous. Any one of these would be a good introduction for you as a professional if you are not familiar with food addiction.
Step II: Assess. If you have a recovered food addict ally, you might suggest that your client do an initial self-assessment by talking to the long-timer. You could also use one of the several assessment tools discussed above. One thing to note is that denial is a part of the disease of food addiction just like any other addiction, so at first a client might put themselves in the category of “Normal Eater” or “Emotional Eater.” If so, you can encourage a normal eater to try dieting. Any healthy diet will do. If they are food addicted and at all advanced in the disease, they are not likely to be successful for more than a year – possibly much less. You can encourage the emotional eater to keep a feeling diary or work with a therapist; a therapist who uses the books of Geneen Roth – Breaking Free of Compulsive Overeating or Women, Food and God – would have an interest in this work. You might give a client serious about working on underlying issues one to three years. If your client comes back from their experiment still overweight, you might simply ask, “How did it work?” For the food addict, food is often the best teacher.
For food addicts, assessment is often one part rational analysis and several parts breaking denial. The work of the doctor, dietician and therapist is often one of helping a possible food addict find and accept the truth for themselves. This does not mean that the professional should not give his or her opinion. Just the opposite. The straight forward diagnosis of chemical dependency on food by a health professional is often an important part of the denial breaking process.
So, what are some simple things the health professional can look for? First, take a history. If there is a fair amount of obesity or alcoholism or drug addiction in the family, your client may be genetically predisposed to food addiction. Second, ask for their earliest memory of overeating. If the memory is especially vivid and it contains some of the more common addictive foods – sugar, excess fat, salt, caffeine, flour – they may have been chasing the memory of that food high ever since. Third, if there is inordinate resistance to trying to eliminate offending foods, i.e., chronic binge foods, for even a short while, you more likely have a food addict than a normal eater. Then, of course, there are the formal assessments like the previously mentioned Yale Inventory and/or, if you have an ally, the intuitive sense of a recovered food addict. If you are not sure, you can suggest they go to a food addiction professional for a full assessment.
Note: Many, if not most, middle and late stage food addicts who are unable to achieve and maintain needed food abstinence, present as having a trauma-based eating disorder, too. In these types of dual diagnoses, the rule in addiction treatment is to start by addressing the bio-chemically based chemical dependency and teach feeling skills as needed to developing alternative coping mechanisms for difficult emotions than using food and compulsive eating behaviors when abstaining from binge foods. It is beyond the scope of this section to deal with this important, often critical, aspect of food addiction treatment at this time. We will focus on the basics of treating food as a substance use disorder when it is the primary or only diagnosis.
Step III: Treat. If you and your client are in agreement that food addiction is a likely possibility, the best way to find out is to have the person treat themselves as if they were food addicted. If life gets better and, if they are obese, weight goes down, this is the real test. Medicine is a pragmatic science; if the treatment works, then the diagnosis it was predicated on is usually considered true – at least until it is stops working. The principles of food addiction treatment are actually quite simple:
a) Food addicts need to abstain from their trigger foods and binge foods completely to eliminate cravings.
b) Food addicts need to ask for and accept help to the degree they have lost control.
c) Food addicts need varying level of support for withdrawal and detoxification.
d) Food addicts who are unable to achieve and maintain abstinence, need higher levels of structure and support.
e) Food addicts need a process for challenging and breaking their own food addiction denial.
The problem is not in deciding what to do, it is finding the acceptance of the reality of food addiction and the willingness to do whatever it takes to be and stay well.
Abstinence first, absolutely. You may be able to find an appropriate food plan for a food addict simply by having them list their binge foods and having them take these foods out. The food plan should then be shown to a doctor or dietician who knows not just food addiction but all other aspects of nutrition such that the food plan is appropriate not just to treat your client’s chemical dependency but also other food related health issues. Dietician Theresa Wright has written an excellent workbook for developing an individualized food plan for a food addict; it is called Your Personal Food Plan: A Basic Food Plan for Recovery from Addictive and Compulsive Eating Behaviors. See also, A Food Plan as a Spiritual Tool by Phil Werdell.
Surrendering to support. Most food addicts want to be able to deal with their eating and weight on their own. Few want to admit that self-reliance has failed them. It is the nature of all addictions, though, that the disease becomes stronger than the individual can cope with by their own reason and self-will. Some can be physically abstinent pretty much on their own for a while, but few real food addicts can do this for long. Some need just the help of family and friends or a recovery buddy. Others need regular professional support of a counselor or weekly recovery group. Many need more substantial support: this is where the food related 12 Step fellowships are so valuable – they bring together self-assessed food addicts in meetings and with a program which has worked for almost all addiction including food. For some, like those who can’t get sober just by going to A.A., they need professional treatment.
Support for Detoxification. The physical and emotional aspects of withdrawal are quite different for specific foods and for specific individuals. Some do not experience detoxification at all. Others have headaches, fuzzy thinking, periodic cravings, insomnia or sleepiness for one to several days. They need be told that this is quite common during the period of acute withdrawal; as with other addictive substances, the addicts experience in abstinence sometimes gets worse before it gets better. Of course, all headaches and all other symptoms are not necessarily withdrawal. Other previously hidden illnesses can be experienced when a food addict eliminates their most common binge foods. Some food addicts in 12 Step fellowships find it useful to go to more meetings or even stay with an abstinent peer for a few days. Those not a member of one of these fellowships can ask a family member or friend for specific support during the period of acute withdrawal just as they might do if putting down cigarettes.
There are many middle and late stage food addicts who need a more formal kind of structure and support to get though acute detoxification. One of the major hospital-based treatment programs for food addiction in the 1980’s and 1990’s experienced about 10% of the therapeutic community members deciding to leave Against Medical Advice (AMA) during the first week when food addiction withdrawal symptoms can be strongest. Professional and community interventions were an important part of the program, and more than half that announced they were leaving AMA changed their minds. Since 1995 residential workshop-based programs like ACORN’s Primary Intensives have proved highly successful in helping those unable to achieve and maintain abstinence in therapy or in 12 Step program – but not needing hospitalization or direct medical supervision – develop a rigorous abstinence in five to seven days. One of the suggestions for those wanting to leave these workshops before they are over is to agree in advance to stay just one more day. Hundreds of participants have said this one suggestion probably got them through detoxification and into the beginning of their first stable abstinence.
Note: There is clinical evidence that compete detoxification from food addiction, just as in alcoholism and other drug addictions, can take three to six months. This corresponds with the suggestion in many 12 Step programs that those starting abstinence anew consider going to 90 meetings in 90 days. While not everyone probably needs to do this, those with more advanced food addiction and/or those more sensitive to biochemical withdrawal speak highly of these practice – especially after they had done it themselves.
More Structure and Support. Just as some food addicts need structured support to detoxify, there is a principle in food addiction recovery, just as in alcoholism and other drug addictions, that those have trouble with abstinence and recovery surrender to more structure and support. Here are some quite common examples in ascending order:
- Some early stage food addicts notice that they not dealing with sugar or other foods well and that they cannot seem to use them in moderation: they decide on their own to eliminate them from their diet.
- An article or self-help book – or a recommendation from a family member, friend or health professional – open some people to the idea of completely abstaining from binge foods. Then they just do it.
- When some are given a suggestion or diagnosis of food addiction, they are not convinced or find that for many reasons they are unable to do it. They need regular meetings with a physician, dietician or therapist.
- When individual counseling does not work, a good next step is group support. This might be a peer support process like a 12 Step group or a food addiction recovery group led by a professional.
- Like alcoholics and other drug addicts who need a detoxification program, there are many food addicts, like those mentioned above, who do not find stable abstinence and recovery until they are supported in a 24/7 residential detoxification. In food addiction, this can include experiential education about recovery.
- For a substantial group – one to two thirds – a week-long workshop may not be enough: they need a longer treatment program – some out-patient and other in-patient like the programs at Milestone, Turning Point of Tampa, Shades of Hope, or ACORN’s year-long Living in Abstinence program. There currently is no primary hospital-based food addiction program, though many do need this level of care because of the critical level of their disease and because of secondary illnesses and co-diagnoses which need direct medical supervision.
- For those food addicts with multiple treatments already, there is a need for long-term care like half-way houses and food addiction friendly recovery homes. Some of these cases are just in need of their first addiction model treatment.
Most health professional are not able to provide all these levels of care within their own practice, so at some point, they need to be prepared to refer their chronically active food addicts out for more specialized – i.e., more structured and more supportive treatment. (See next section.)
Note: All of the levels of food addiction programs have already been proved successful for some food addicts, including many of the most chronic relapsers. There were dozens of primary hospital-based addiction model treatment programs for food addiction twenty years ago. Thousands of today’s long-time recovering food addicts in and out of the food 12 Step fellowships are alumnae of these programs. The major private insurance companies made decision behind closed doors to stop re-imbursement for most of these programs starting about twenty years ago. This was when there was no scientific evidence of food addiction or outcome studies showing that the addictive model of treatment works for chemical dependency on food. A public call from professional and from food addicts and their families could open them again; they are needed in great numbers.
Challenging Food Addictive Denial. The chapter “More About Alcoholism” in the basic textbook of Alcoholics Anonymous (AA) begins:
Most of us have been unwilling to admit we were real alcoholics. No person likes to think he is bodily and mentally different from his fellows. Therefore, if is not surprising that our drinking careers have been characterized by countless vain attempts to prove we could drink like other people. The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistent of this illusion is astonishing. Many pursue it into the gates of insanity or death.
We learned that we had to fully concede to our innermost selves that we were alcoholics. This is the first step in recovery. The delusion that we are like other people or presently may be, has to be smashed.
Change the word “drinking” to “eating” and “alcoholism” to “food addiction” and you will find that this analysis fits very well for those who are chemically dependent on food.
Alcoholics with their second or third DUI, this time having injured others and themselves, will often argue with great personal conviction that they know that they are not alcoholic, that next time they will not drink and drive or, if they do, they will be able to control drinking and their driving. How different is this from the food addict starting to lose toes because they keep eating sugar; the woman with high blood pressure and high cholesterol even on medications saying she will moderate her eating of bread and butter and of deserts – this time; the morbidly obese man saying that he feels fine, that his extra weight just makes him more of a man, that it is no one else’s business what he eats.
These food addicts often have the same D2 dopamine gene marker as is found in many alcoholics and drug addicts. They show the same brain scan aberrations after eating sugar-fat-and-salt foods – or after just seeing a picture of their favorite fast food that alcoholics and drug addicts exhibit in when they use – or just imagine – their drug of choice. Many of these food addicts will admit to hiding food, lying even to their closest family and doctor about their eating, bingeing behind closed doors, feeling shame and guilt and declaring they will never do this again – just like alcoholics and drug addicts. Most telling, when they have been detoxified from their binge and trigger foods and gone to any length to sustain food abstinence, these same food addicts will – often to their own surprise – find that their physical cravings for food decrease, that after of period of complete detoxification , their thinking and physical symptoms will just disappear, that almost mysteriously after a longer period, they will simply no longer want the foods they were previously willing to literally die for – just like alcoholics and drug addicts.
For those health professionals wanting clinical case studies, there are thousands. For those wanting outcome research, this too is available. The next step is for these health professionals to present this information – and the possible medical implications – to their obese patients who will not – or cannot – follow medical advice. It is possible, they need to say, that some of their patients are experiencing biochemical food addiction denial, and if they are not able to overcome it by themselves, may need the added structure and support of food addiction treatment. Doing all this is a way physicians, dieticians and therapists can do their part in challenging food addiction denial.
Note: For those interested in moving towards more effectively treating the food addicts within their practice, there are four specific suggestions, each taking an increased investment of time, energy and commitment:
i) commit to further study of food addiction and its treatment and to bringing continuing education about the latest developments to your colleagues and employees,
ii) identify one or more long-time recovering food addicts first as a resource to your own education, then as a health resource to your patients,
iii) consider ways to restructure your practice to better treat chronic conditions like diabetes, heart disease and addictions, e.g. the suggestions of David Spero in Diabetes: Sugar Coated Crisis – who gets it, who profits and how to stop it,
iv) invest in training for yourself and/or other members of your team in the areas of food addiction.
4. Making Referrals to Food Addiction Professionals and Addiction Model Treatment
In developing referrals, the first question is: how do you identify health professionals who really understand food addiction? Here are a few basic ways:
- Do they clearly understand the difference between obesity, eating disorders and chemical dependency on food?
- Do they assess for different stages of food addiction and have stage appropriate treatment?
- Do they treat food addiction as a substance use disorder, i.e., complete elimination of major binge foods?
- Do they educate about the nature of addiction and, in particular, that reason and unaided will become defenseless against food addiction?
- Do they have an understanding of the different food related 12 Step fellowships and how to identify good recovery locally?
- Do they have a strategy for effectively confronting food addiction denial individually and in groups?
- Do they have a positive track record in terms of successfully working with food addicts?
There are a number of individual professionals and treatment programs which we currently recommend.