Anorexia nervosa is a deadly illness that must be halted and treated by any means necessary. When trying to save a life, allegiance to a singular evidence-based approach must be substituted for whatever works. As a scientific community, we must pool our resources to treat and eradicate the terrible illness of anorexia nervosa, not waste time divided by deference to opposing theories. There is so much untapped wisdom to be harnessed in every single evidence-based intervention. Curating this knowledge into a comprehensive collection of interventions has tremendous potential.
Sharing this stance, we set out to explore how different interventions could be used to help our patients. We began by distilling core concepts from family-based therapy, acceptance and commitment therapy, behavior therapy, cognitive therapy, cognitive behavioral therapy-enhanced, parent-child interaction therapy, compassion focused therapy, appetite awareness training, mirror exposure therapy, imaginal exposure therapy, in vivo exposure therapy, and cognitive remediation therapy - to name a few. Over time, a comprehensive collection of interventions categorized into three modalities - family, group, & individual - emerged. In this way, the approach we now call Behavioral Interventions, Tips, & Evaluations (BITE) was conceived.
Considering the massive integration of information involved, such an endeavor starts to sound extremely complex, and consequentially, off-putting. Quickly grasping this, we decided that BITE must be experienced as simple – for the sake of malnourished patients, distressed families, and clinicians in the trenches. As such, our number one goal became presenting clinical information and heady concepts in a crystal clear way. For guidance and inspiration, Dr. Deliberto looked to books by Edward Tufte on a topic rarely discussed in science: the art of information design. Information design is the practice of fostering understanding by presenting data both efficiently and aesthetically. Using information design techniques, we went to great lengths to make BITE content easy to understand for patients, parents, and clinicians.
Specifically regarding patients: it can be particularly difficult for people in the throes of anorexia nervosa to grasp and process information because malnourishment interferes with normal brain functioning. Consequentially, adolescent patients are often overlooked in treatment because it is all too easy for us to just communicate with the parents. But why wait to directly work with the patient until weight-restoration? Rather than seeing decreased cognitive functioning as an insurmountable obstacle, we should seek to overcome it. In part, we attempted to do this in BITE by creating handouts with fun graphics and clearly displayed information. Further, we found ways to make mindfulness exercises more concrete. For example, patients record their internal experiences on organized handouts during mindfulness practice. As another example, during the classic leaves on a stream exercise, the therapist plays nature sounds from a freely available app to help refocus the patient’s attention. In short, rather than bypassing the patient as a participant in treatment until weight-restoration, the BITE material is specifically designed to meet the patient where they are both emotionally and cognitively.
Concurrently, parents of patients often have understandable difficultly processing pertinent treatment information. In the context of having a sick child and monumental treatment responsibilities, parents are often very distressed. Therefore, it seems inefficient to rely on verbal communication alone to convey important clinical information and concepts. In therapy that uses BITE material, parents are given clear handouts, often with enumerated lists, to guide them through treatment. Rather than recommending a whole book to read, smaller amounts of relevant information is presented across multiple sessions in a way that can be referenced and reviewed as needed. We hope this to be one contribution to a growing movement of mindfully supporting parents in treatment.
BITE is also designed with the needs of clinicians in mind. We aim not only to make clinical information and concepts more understandable for parents and patients, but to improve communication among members of the patient's treatment team as well. If you have worked with adolescents with anorexia nervosa, you know how time-consuming the task of coordinating with a multidisciplinary team can be. Never having met them, you must communicate regularly with medical doctors, school psychologists, school nurses, school guidance counselors, and/or nutritionists for every patient. Plus, the outpatient therapist is charged with the task of onboarding each professional the patient brings to the treatment team. In other words, long before seeking your help, the patient has had a medical doctor - who may or may not be familiar with anorexia nervosa – now overseeing the patient’s potentially dangerous weight gain process on a weekly basis. The patient also attends a school whose staff members now need training in how to get their student with anorexia nervosa to finish eating a huge lunch five days a week. This is no small feat! In an effort to assist the eating disorder specialist, we created handouts not only meant to facilitate the communication with patients and parents, but with collaterals as well.
We also hope that BITE will be useful to non-specialists. To many mental health professionals, the treatment of anorexia nervosa remains daunting and mysterious. Only a minority of clinicians receives formal training in the treatment of eating disorders. Consequentially, the lack of professionals willing and able to treat anorexia nervosa translates into countless cases of people left suffering alone from this dangerous illness. A goal of ours is to help close this treatment gap by making treatment more approachable. With clearly defined behavioral treatment targets and practical suggestions on how to shape behavior, we hope that BITE makes the treatment of anorexia nervosa more manageable to those who otherwise would shy away from it.
In short, we hope that by compiling evidence-based interventions for anorexia nervosa, we can help to close the treatment gap, help clinicians in the trenches efficiently and effectively communicate core treatment concepts making way for individualized care, support families, help patients develop skills, and aid in standardizing evidence-based practice in the industry.
How You Can Help!
In the first five years of BITE's existence, we solicited feedback from users and incorporated it into the BITE material. Now that the material is more refined, we are seeking to publish and disseminate!
Our Mission Statement
Our mission is to optimize the treatment of anorexia nervosa in adolescents by:
- compiling evidence-based interventions
- thoughtfully ordering, visually designing, and arranging these interventions
- executing the BITE Clinician Manual and BITE Interventions Book in such a way that clearly communicates complex concepts to patients, parents, eating disorder specialists, collaterals, and novice therapists alike
- eventually making refined BITE ancillary material accessible and printable from anywhere the internet works
- seeking feedback from parents, patients, and therapists alike that will be used to direct the evolution of BITE
- potentially evolving BITE as a comprehensive evidence-based outpatient treatment for eating disorders