James L. Sandel, MSW
James Sandel, an ordained minister, has worked in all aspects and levels of substance abuse treatment since 1986, specializing in dual diagnosis since 1997. He is currently with Family Behavioral Center in Delray Beach, Florida, which is a specialty dual diagnosis eating disorders program.
Eating Disorders: A Reason to Resume Drug Use
"Once I got into treatment and stopped using drugs, lots of hidden stuff started bubbling up. One of the most important was my realization that my first addiction was to food…specifically, sweets. I know it was an addiction because I used to binge. As a child, I even stole money to get candy. My drugs of choice later turned out to be speed and cocaine, both appetite suppressants, so when I got to treatment, I was still thin. No one suspected I was a binge eating disorder. No one looked too closely at the issue of eating disorders at all. Well, what happened was, once I didn't have my drugs anymore, I turned back to food again, and quickly became obese. I eventually returned to using drugs." - Larry S., recovering addict
This is, sad to say, a story all too often heard within the recovering fellowships. A newly recovering patient in a treatment program may have an eating disorder that has gone inactive due to her drug use. After all, a person who is obsessed with body image could hardly find a more effective solution than various drugs that suppress appetite. So long as the drug addiction is active, it is improbable that anyone is going to notice an eating disorder, unless one is floridly bulimic to the extent that others become aware of constant bingeing and purging.
Because of the denial and delusion that is part and parcel of every addiction, the patient herself may even be unaware of a previously active eating disorder, especially if it involved only restricting rather than the more obvious bingeing and purging. In this, they are much like trauma survivors, whose core issue remains very undercover. They are very secretive, seldom volunteering that, "Oh, and by the way, I think I also have an eating disorder." Even substance abuse treatment programs that are conscientious enough to assess incoming patients for eating disorders often miss them unless they are currently active. The reason is very simple: the patient is an inaccurate historian. In other words, they lie. They don't admit to the use of laxatives or appetite suppressing drugs. They are ashamed of the bingeing and purging. They are not forthcoming, and are not likely to be until the eating disorder is out of control, they are hospitalized, or concerned and observant parties intervene.
For the substance abuser and those in the business of treating him, this constitutes a huge problem. While the drug addiction is being treated, and the addict is remaining abstinent, it is nearly a foregone conclusion that the unidentified eating disorder will sooner or later reactivate. If this happens during the course of treatment, and the clinical staff and fellow patients are observant enough, it can often be identified and ultimately treated (although probably in a different program that specializes in eating disorders). The most serious danger is that, even if active, the eating disorder doesn't intrude enough to be noticed, and the patient makes it through treatment without anyone realizing what's really going on. Often enough the patient herself remains unaware, and the most dangerous cases are where the eating disordered behavior doesn't resume until the patient has discharged from treatment altogether.
More often than not, the recovering addict who resumes restricting, bingeing or bingeing and purging, will ultimately end up, and usually in a relatively short time, returning to drug use. After all, the eating disordered behavior was either unnecessary or nearly invisible in the soothing chaos of the drug addiction. Appetite suppression and purging through drug use was the magic bullet for the anorexic or bulimic. Return to drugs is almost a certainty, and the cycle begins all over again. And it will continue until someone identifies the real relapse as being associated with an eating disorder, and the patient comes to terms with this core issue, which may, after all, be the primary diagnosis.
Estimates vary, but nearly everyone agrees that at least ten percent of those seeking treatment for drug addiction can be diagnosed with an eating disorder. Yet, addiction treatment programs don't identify anywhere near this number. Given the level of denial, the secretiveness born out of shame, and the paucity of clinicians well-trained in eating disorders, it is little wonder that such patients slip through the cracks.
Clinicians need to acknowledge that eating disorders are reaching epidemic proportions in the United States, and that chances are excellent that those on their caseloads may be afflicted with this health and life threatening illness. We all need to pay much closer attention to the eating (or not eating) patterns of those trudging the road of recovery. We in the business of treating addictions need to become especially alert to any small warning signs and develop treatment routines that tend to reveal emerging eating disorders.
For the private practitioner providing individual therapy, becoming educated in the signs and symptoms of eating disorders is the basic solution. This, in turn, will hopefully allow the clinician to identify an eating disorder within the context of the therapeutic alliance. In a controlled, residential treatment environment, there are a few simple strategies that can be implemented.
1. Require all patients to attend every meal. Pay attention to patterns of excuses for not attending meals.
2. Monitor what each patient eats (or doesn't eat) at every meal.
3. Note complaints of patients feeling bloated or nauseous.
4. Be alert for patients secreting food in their residence or smuggling in restricted food items.
5. Set strict limits on bathroom time.
6. Be alert for patients disappearing immediately after a meal.
7. Monitor patients for excessive exercise.
8. Listen for tell-tale statements like, "I'm just not hungry."
We are acting irresponsibly and serving our clients poorly if we do not educate ourselves to identify eating disorders. They depend on us to provide them with the very best opportunity for long term recovery. They pay us for competent services. If we fail them due to insufficient education or training, or even worse, unwillingness to probe more deeply to uncover hidden issues, we are not only betraying the patient, but our own integrity.
© 2003: (Rev.) James Sandel, M.S.W. All rights reserved
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