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Treatment of Bulimia Nervosa

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Bulimia nervosa (BN) is a dangerous and potentially deadly disorder, affecting more than 5.2 million people in the U.S. alone. (1) Thankfully, there are many treatments for bulimia nervosa that can help heal this illness before it’s too late.

Treatment of Bulimia Nervosa

Levels of Care for Bulimia Nervosa

With bulimia nervosa, as with most other eating disorders, there are varying levels of care that can help a patient on their path to recovery.

Which level of care a patient receives depends on several factors, including the severity of the case, the stability of a patient’s mental and physical health, and available options.

Inpatient

Inpatient programs represent the most intensive form of treatment for bulimia nervosa. They can be voluntary or involuntary and are typically only administered in extreme cases, such as when a patient:

  • Needs life saving interventions
  • Exhibits signs of suicidal ideation
  • Has rapidly worsening symptoms, such as drastic weight loss in a short period of time (2)
  • Shows signs of a physical or mental health crisis (2)

Patients stay in a hospital or treatment facility full-time, where they can be actively monitored by healthcare professionals and have access to medical care 24/7. Stays are typically around two weeks or less, and the focus is often on stabilizing a person who may be in immediate need of help.

The type of care a patient receives at an inpatient program includes:

  • Lifesaving medical interventions, if necessary
  • Individual, group, or family therapy sessions
  • A physician-developed care plan, which could include
  • Medication routines
  • Additional therapeutic recommendations
  • Nutrition counseling
  • Supervised daily meals and snacks
  • Coping skills development

Residential

Residential treatment is often considered a “step down” from inpatient care. It’s best suited for patients who:

  • Are medically stable or have had immediate physical health needs met
  • Could still benefit from around-the-clock medical care and monitoring

Patients still live at a facility, but the environment is more home-like than hospital-like. Treatment options are similar to those administered in inpatient care, but with more focus on establishing long-term goals and healthy routines.

Residential programs can also offer many benefits for patients who didn’t require inpatient care treatment, including:

  • A regimented schedule that emphasizes structure and healthy routines
  • Living away from their regular environment, which often includes a number of triggers or temptations

These programs require a much longer stay than inpatient care. Many residential programs have no prescribed length, with patients potentially staying in the facility for several months before feeling ready to leave. (3)

Partial Hospitalization Program (PHP)

Partial hospitalization programs (PHPs) are sometimes known as “day programs,” due to their structure: a patient commutes to a hospital for treatment, often between five or six days a week, then returns home in the evenings, after their sessions.

PHPs represent a transitional phase in treatment, allowing a patient to continue receiving regular care and guidance from healthcare professionals, but giving them the opportunity to begin practicing their new, healthier skills and routines at home.

This level of care is often considered a good match for patients who:

  • Can still benefit from daily mental health check-ins
  • Have trouble maintaining school, social, or work schedules due to their eating disorder
  • Sometimes see a relapse of bulimia symptoms
  • Have adopted different extreme weight control techniques, including limited food intake or extreme exercise (4)

Types of treatment in these programs often include: 

  • Supervised meals and snacks
  • Nutritional counseling
  • Medication management
  • Ongoing individual, group, or family therapy sessions

The frequency of these visits and the length of the program are also determined on a case-by-case basis, but the program often lasts around 5-6 weeks. (4)

Intensive Outpatient (IOP)

As they continue on their recovery journey, many patients transition from PHPs to intensive outpatient care (IOP). 

These programs offer many of the same benefits as partial hospitalizations but are carried out on a less intensive schedule. Programs run for just 3-5 hours per day, as opposed to the all-day sessions of PHPs. (5) Patients also usually receive treatment between 3-5 days per week. (5)

Patients are typically enrolled in these programs once they:

  • No longer need daily monitoring or mental health check-ins
  • Have their bulimia symptoms under sufficient control
  • Are ready for a return to school, work, and social situations
  • Feel dedicated to their continued recovery 

IOP programs feature the same type of meal planning, nutrition education, and medication management options as PHPs. Most programs also require at least one day a week of individual, group, or family therapy.

But to encourage their patients’ progress, many IOPs include offsite outings to help develop management skills. And their less-intense schedules allow patients to start returning to a more proactive routine by resuming activities like work or school. 

Outpatient

The final step in many types of bulimia nervosa treatment plans is outpatient care. Making the transition to this important final step is often a group decision, based on input from: (4)

  • Healthcare facilities
  • Eating disorder specialists
  • Health insurance providers

The patient is also involved in the decision-making process and is typically asked to talk about:

  • Their detailed personal history
  • Any past or present bulimia symptoms they’ve struggled with

Once they’re ready to make the transition, people participating in outpatient treatment will live full-time at home and be responsible for all their own dietary decisions.

That’s not to say they’re not in need of any support. Indeed, most people—including those who aren’t struggling with an eating disorder—need some outside help from time to time.

Most often, outpatient treatment looks like one or more therapy sessions per week, which could entail individual, group, or family counseling, and additional nutritional education or medication management.

Most importantly, patients at this stage have often embraced their recovery journey and are committed to continue working on healing.

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Psychotherapy for Bulimia Nervosa

Most patients seeking treatment for bulimia nervosa will undergo some type of psychotherapy. The term represents a variety of treatment approaches No single type of care is better or worse to help people struggling with bulimia. Each simply tackles the issue in a different way.

Acceptance and Commitment Therapy (ACT)

Each word in acceptance and commitment therapy (ACT) represents an important aspect of this mental health practice. 

The overall goal is teaching patients to “go with the flow” when encountering unpleasant or unhelpful thoughts, rather than spend precious energy on fighting or eliminating them. When these feelings surface, ACT patients are encouraged to accept them, let them go, and move on. 

To help with this tricky concept, ACT focuses on six major tenets, including: (6)

  • Acceptance: Allowing inner-thoughts to occur without actively trying to change or ignore them
  • Cognitive defusion: Seeing oneself and one’s inner-thoughts as separate entities
  • Self as context: Seeing one’s thoughts as separate from one’s actions
  • Being present: Staying mindful of external surroundings and conditions
  • Values: The areas of one’s life worthy of protecting or cultivating through action
  • Commitment: Dedication to changed and healthy behaviors

Acceptance and commitment therapy has also been known to increase mental flexibility. This is often an underlying problem with bulimia nervosa that, if improved, can help manage anxiety and depression. (7)

Cognitive Behavioral Therapy (CBT)

By far the most frequently-recommended treatment for people struggling with bulimia nervosa, cognitive behavioral therapy (CBT) centers on the idea of changing unhelpful or distorted thinking patterns.

This is achieved by essentially “rewiring” the brain, breaking up neurological pathways that have been built around unhelpful thoughts or behaviors, and constructing new, healthier paths for those thoughts to take instead.

CBT programs typically follow a pre-prescribed path, with several major areas of focus, including:

  • Identifying negative thoughts and maladaptive behaviors
  • Learning and practicing new coping mechanisms and skills
  • Setting future and long-term recovery goals
  • Learning problem-solving techniques to protect new thought patterns from overwhelming stressors
  • Self-monitoring work, such as daily journaling, to stay on top of one’s current mental condition

These methods have proven successful for many types of disorders and have been especially helpful for people recovering from bulimia nervosa. (8)

Cognitive Remediation Therapy (CRT)

Originally developed to help people recovering from brain injuries, cognitive remediation therapy (CRT) has been developed to help people overcome eating disorders, including bulimia nervosa.

Typically a more short-term treatment, this type of therapy also focuses on building new thought patterns within the brain but does so by employing different types of “games,” puzzles, or problem-solving techniques, including: (9)

  • Changing the order of an established routine
  • Sitting in different places at mealtimes
  • Using dominant or non-dominant hands to complete different skills
  • Switching attention back and forth between two different categories of things

Patients are then encouraged to connect changes they see in response to these games to changes they can make in other areas of their lives, such as the maladaptive behaviors that help sustain an eating disorder.

Usually employed in conjunction with other types of therapy, such as CBT, cognitive remediation therapy has also been known to help increase mental flexibility.

Dialectical Behavior Therapy (DBT)

Almost like a mix of ACT and CBT, dialectical behavior therapy (DBT) focuses on promoting acceptance of and tolerance for distressing circumstances. DBT also teaches patients how to proactively change some thoughts and behaviors.

It uses several techniques to achieve this, including: (10)

  • Mindfulness: Encourages patients to stay in the moment, even if that moment isn’t pleasant
  • Distress tolerance: Builds up stress management by teaching skills for handling crises
  • Interpersonal effectiveness: Teaches patients how to assert themselves in relationships, in positive and healthy ways
  • Emotion regulation: Focuses on first identifying emotions, then working to change or cope with unhelpful ones

Courses of this therapy are usually longer-term, and patients take home skill-building “homework assignments.” As for results, DBT has shown some promising potential in helping people who struggle with bulimia nervosa. (11)

Exposure Therapy

Exposure therapy operates similarly to how it sounds. It helps people by getting them to directly face their fears. 

Patients are intentionally introduced to items, activities, or situations they struggle with in order to break patterns of avoidance or apprehension. When used to help treat bulimia nervosa, exposure therapy may confront patients with certain foods, mealtime routines, or other typical difficulties.

Patients can also be “exposed” to these things in different ways, including: (12)

  • In vivo exposure: The direct, physical confrontation of a feared item
  • Imaginal exposure: A vivid imagining of the feared item, situation, or activity
  • Virtual reality exposure: An encounter that takes place using virtual reality simulators or other types of technology
  • Interoceptive exposure: Getting someone’s body to create harmless but feared sensations–for example, someone with a panic disorder may run in place to experience a rapid heartbeat 

While a majority of this work may involve tangible objects or physical confrontation, much of the therapeutic effect of exposure therapy goes on under the surface, with these incidents helping remodel what are, in many cases, automatic or even subconscious responses.

Group Therapy

Another aptly-named type of psychotherapy, group therapy involves one or more therapists working with several people at once. 

Sessions can be open, with new participants welcome to join any time, or closed, and accessible only to invited members. Groups can also include strangers, family members, or members of the same treatment program.

Typically, people are assembled or come together to tackle the same types of problems. This can be achieved in a group therapy setting through a number of techniques, including: (13)

  • Cognitive behavioral groups: Focus on reinforcing changed behaviors or emotional responses
  • Interpersonal groups: Center on the importance of interpersonal relationships, social interactions, and support networks
  • Psychoeducational groups: Primarily teach about different disorders and coping mechanisms
  • Skills development groups: Help develop social skills
  • Support groups: Bring people in various stages of recovery together to encourage and inspire one another, plus broaden support networks and outreach options

Aside from a source of socialization, group therapy sessions can also help by providing:

  • A sense of catharsis
  • An opportunity to help others
  • A larger/different perspective
  • A sense of belonging
  • A safe space to practice new skills

Interpersonal Psychotherapy (IPT)

Interpersonal therapy (IPT), as its name suggests, focuses on examining how a person’s interpersonal relationships and social interactions may be affecting them or their disorder.

There are several different variations of IPT, but, generally, they all work to educate a patient about their own thoughts and feelings, as well as thoughts and feelings of others. Some versions also incorporate strategies for people who tend to hold back or avoid their emotions.

Most forms of IPT will help a patient sort their relationships into four major categories, including: (14)

  • Grief: The relationship with a loved one who has passed away, or otherwise moved out of someone’s life
  • Role dispute: The discordant connection that exists when the patient and their loved one have different expectations of their relationship
  • Role transition: The transitional role a person has when undergoing significant life changes, such as getting married, getting divorced, or becoming a parent
  • Interpersonal deficits: The difficult relationships a person might have when they have trouble adequately or properly expressing their emotions

Interpersonal psychotherapy typically helps a person sort through these issues with a short-term and largely pre-prescribed program.

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Nutrition Counseling and Meal Support

Bulimia nervosa can be a tricky disorder to navigate, since there are a number of varied but related areas of concern. 

Aside from helping a person understand their own thoughts and behaviors and their relationships with others, therapists also must help a patient heal their relationship with food. And, unfortunately, in many cases, a patient’s diet must be dealt with first, to stabilize their physical health before mental health work can even begin. 

That’s why most levels of care for bulimia nervosa include nutritional counseling and meal support. 

A registered professional–a therapist, nutritionist, or nurse–administers nutrition counseling. The focus is on education, with practitioners helping a patient learn more about: (15)

  • The types of foods and drinks a body needs to be healthy
  • How the body uses different vitamins, minerals, and nutrients
  • How to plan meals to ensure these needs are met

Nutrition counseling also educates individuals on the mental aspect of eating, including topics like:

  • How eating habits can be linked to emotions
  • How to recognize and overcome fear of certain foods/food groups
  • Why even “feared” foods can be healthy

Hand-in-hand with these nutritional counseling lessons often comes meal support. This type of care is a bit more hands-on. Practitioners sit with patients through meals, offering support and encouragement to follow the “four c’s”:

  • Remaining calm while eating
  • Being confident about diet choices
  • Being consistent with healthy diet choices
  • Having compassion for oneself
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Experiential Treatments for Bulimia Nervosa

Experiential treatments for bulimia nervosa help a person heal by getting them out of their mind and into their body. This can be done through a number of mediums, including:

  • Art therapy
  • Dance therapy
  • Music therapy
  • Psychodrama
  • Wilderness therapy
  • Recreational therapy
  • Yoga therapy
  • Adventure therapy

These types of treatments work by helping someone struggling with bulimia nervosa feel—or, in the case of psychodrama, act out—their feelings, rather than analyze or talk about them.

Experiential treatments can be immensely beneficial, allowing patients to tap into their “right brain,” the side more responsible for imagination, intuition, and the senses. This can help them “turn off” their conscious brain, leading to the access—or even discovery— of deeper feelings than they’d otherwise be able to articulate.

Experiential therapies can also help both the patient and their therapist gain a different perspective on things and give them access to an entirely new type of vocabulary to express their emotions.

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Treating Bulimia Nervosa at Within Health

Sadly, bulimia nervosa is a dangerous disorder that can end in death. But it doesn’t have to be.

It is entirely possible to stop bulimia in its tracks and start down the path to healing. In fact, one recent study found that up to 68% of patients with bulimia nervosa had recovered from the disorder within 10 years of first seeking help. (16)

That may sound like a long time, but it’s worth a lifetime. And it’s never too late to start.

You can find help and treatment for bulimia nervosa at Within Health.

Every patient’s experience with bulimia is unique to them. So we create individual treatment plans for each of our clients. We aim to support our clients with bulimia by helping them learn to embrace flexibility around food and eating, explore what emotions may be driving their disordered eating patterns and accompanying compensatory behaviors, rediscover their bodies’ innate hunger and fullness cues, and enjoy food and healthy social eating rituals again.

Our bulimia treatment program consists of three levels of care:

  • Partial hospitalization program
  • Intensive outpatient program
  • Outpatient program

The level of care required for an individual living with bulimia will be determined depending on the severity of restricting and purging, overall health and wellbeing, and a person’s specific needs. 

Our multidisciplinary team of experienced psychotherapists, dieticians, nurses, and other mental health professionals not only provides cutting-edge treatment, but also unconditional compassion, support, and understanding whenever you need it.

We know how hard it is to seek help for bulimia, or any eating disorder, so we ensure you will not have to go through recovery alone. Supported group meals and group psychotherapy are there to make you feel like you’re part of a community, no matter what your gender identity, ethnicity, sexuality, or age, and reassure you that your struggle is not yours alone.
At Within Health, help is available wherever you are, whenever you need it. Call our team to learn about the first steps.

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Frequently asked questions

Resources

  1. Authored by Editorial Staff. (2018, November 7). What are the real facts about bulimia? American Addiction Centers. https://americanaddictioncenters.org/bulimia-treatment/facts-and-statistics 
  2. Authored by Editorial Staff (2021, October 13). Inpatient vs outpatient bulimia treatment. American Addiction Centers. https://americanaddictioncenters.org/bulimia-treatment/inpatient-outpatient
  3. Differences between inpatient vs residential treatment. Pasadena Villa. (2020, October 11). Retrieved from https://www.pasadenavilla.com/inpatient-vs-residential-treatment/ 
  4. Levels of Care in Eating Disorder Treatment. National Eating Disorders Association. (2020). https://www.nationaleatingdisorders.org/sites/default/files/NEDA%20Webinar%20Levels%20of%20Treatment.pdf
  5. What is Intensive Outpatient Treatment for Eating Disorders? Center for Discovery Eating Disorder Treatment. (2021). https://centerfordiscovery.com/blog/intensive-outpatient-treatment-eating-disorders/
  6. What Is Acceptance and Commitment Therapy (ACT)? VeryWell Mind. (2021, September). https://www.verywellmind.com/acceptance-commitment-therapy-gad-1393175
  7. Acceptance and Commitment Therapy as a Treatment for Anxiety and Depression: A Review. Psychiatric Clinics of North America. (2017, December). https://linkinghub.elsevier.com/retrieve/pii/S0193953X17300771
  8. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research. (2012, July). https://link.springer.com/article/10.1007/s10608-012-9476-1
  9. Cognitive Remediation Therapy (CRT) for Anorexia Nervosa. VeryWell Mind. (2020, December). https://www.verywellmind.com/cognitive-remediation-therapy-for-anorexia-nervosa-4003481
  10. The Application of Cognitive Remediation Therapy in The Treatment of Mental Disorders. Shanghai Arch Psychiatry. (2017, December). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5925589/
  11. Van Dijk, S., Jeffrey, J., & Katz, M. R. (2013). A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Journal of Affective Disorders, 145(3), 386–393. https://doi.org/10.1016/j.jad.2012.05.054
  12. What Is Exposure Therapy? American Psychological Association. (2017, July). https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy
  13. What Is Group Therapy? VeryWell Mind. (2021, July). https://www.verywellmind.com/what-is-group-therapy-2795760
  14. What Is Interpersonal Therapy (IPT)? VeryWell Mind. (2021, August). https://www.verywellmind.com/interpersonal-therapy-1067404
  15. How do you treat an eating disorder? Kelty Mental Health Resource Center. (2022). https://keltyeatingdisorders.ca/treatment-options/nutritional-counselling
  16. Given time, most women with anorexia or bulimia will recover. Massachusetts General Hospital. (2016, December). https://www.sciencedaily.com/releases/2016/12/161220140917.htm


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