The primary aim of this study was to explore the views of homeopaths about their experience and treatment of clients with eating disorders such as anorexia and bulimia. The intention was to reveal the challenges, outcomes and pitfalls of working with individuals with enduring eating disorders and to discover if homeopaths believe homeopathy to be effective in treating the whole person; the symptoms of the eating disorder both mentally and physically.
A constructivist, grounded theory approach was taken and semi-structured interviews were undertaken with homeopaths who have experience in treating people with eating disorders. Data was analyzed using thematic coding.
Findings suggest that it is necessary for homeopaths to distinguish between eating disorders of long standing and short term disorders. Short term disorders have different implications in that they are often easier to deal with. Disorders of long standing have far-reaching implications in practice. In depth knowledge is required of eating disorders in general as well as of the therapeutic relationship in particular. Managing this group of patients is different from other patient groups, and it asks of the homeopath to be very aware of boundaries and professional limitations. Patient choice is perceived as vital for effective treatment. Patients need to be willing to commit to and engage in the process. Furthermore, dealing with maintaining causes and relapses can be challenging. Homeopaths need to have an awareness of the socio/cultural contexts affecting patients with eating disorders and be able to assist in the management of triggers and relapses. Findings also suggest that treatment can have an effect on all levels; mentally, emotionally as well as physically.
Eating disorders are becoming an increasing problem in the western world with up to as many as 1 in 3 girls showing symptoms of some kind of eating disorder (Fløe & Madsen, 2005). According to the Danish Department of health (1999), the death rate for anorexics is 9 times the rate of people the same age and is attributed to complications from starvation or suicide. Anorexia nervosa has the highest mortality rate of any psychiatric illness (Treasure, 2007; Birmingham & Treasure, 2010).
Resent research suggests that although bulimia and other non-specified eating disorders are often viewed as less severe, individuals with bulimia or such non-specified eating disorders have elevated mortality risks similar to the level found in anorexia nervosa (Crow, Peterson, Swanson, Raymond, Specker, Eckert & Mitchell, 2009).
Despite all this, not much in the way of treatment is on offer for this neglected group of patients and it is notable that research on the subject both in conventional and complementary medicine, is conspicuously lacking. When examining the subject carefully it appears that there is great confusion about the whole subject of eating disorders. This is confirmed by patients’ statements that they feel not to be understood (Andersen, 2009; Lassen, 2008; Sørensen, 2004).
There is anecdotal evidence in the homoeopathic literature that increasingly people seek homoeopathic treatment for these disorders (Snowdon 1999; Maslan, Nd). To date, however, apart from one study on the homeopathic treatment of binge eating disorder, there has been a paucity of research in this area. The primary aim of this study was to explore the views of homeopaths about their experience and treatment of clients with eating disorders such as anorexia and bulimia. The intention was to reveal the challenges, outcomes and pitfalls of working with individuals with enduring eating disorders and to discover if the homeopaths find homeopathy effective in treating the whole person; the symptoms of the eating disorder mentally and physically.
Attitude and treatment
According to patients suffering from eating disorders there is a tension between the patients’ own understanding of their disorders, the conventional attitude towards and definition of eating disorders and their ensuing treatments ( Hvid, 1998; Lassen, 2000; Skårderud, 2001; Sørensen 2004). According to Lassen (2008), a psychologist who herself suffered from bulimia for 10 years and who has much experience in treating patients with eating disorders, it is very important which attitude one takes towards an eating disorder. If one looks upon the disorder as being strictly about an erroneous diet or a bad habit then a change of diet is a sensible solution to the problem. But, if it is viewed instead as being an externalisation of existential suffering, then it is necessary to deal with the problem entirely differently. Interestingly, Lassen (ibid.) explains that most people with an eating disorder or a weight problem try to treat themselves and the most prevalent treatment is – the diet. This may be explained by the reinforcement and emphasis which is put on the actual diet in our present time. As one patient with bulimia put it: ” I did not know what to seek help for and the sad thing was I thought the solution to the problem was to become thin” (Sørensen 2004 p. 11).
This is mirrored in the Danish Health Department’s leaflet on eating disorders, which is intended to support people with eating disorders as well as their relatives and to enable people at risk to realize and acknowledge their condition. In the same leaflet, however, they encourage weight regulation as it is healthy. In this way they send out mixed messages and are in fact moving the boarders between health and disease.
At any one time approx. 50 % of women are on a diet in Denmark which is likely to result in an eating disorder (Lassen ibid; Petterson ibid). According to Petterson (1999) this bears witness to the fact that women in certain professions dare not become fat, because if they did perhaps they would not get a job or they would not keep it. The traditional method of treatment of anorexia nervosa in conventional medicine has been one of focussing on the weight gain and in many hospitals the treatment has been based on a system of “punishment and reward” according to the weight loss or gain respectively (Fløe & Madsen 2005).
The study of the literature and of biographies of those who have suffered or suffer from anorexia or bulimia shows one of the most striking things to be the matter of choice. On the one hand they describe how they are caught by the disease, but on the other hand how they choose not to do anything about it (Lassen, 2008: Sørensen, 2004) One mother writing about her daughter’s life with anorexia even describes how her daughter “chose death” (Dunbar, 1986).
Common to the persons who have had anorexia or bulimia is the fact that they themselves say that the illness is not about food. The food is just a symptom covering what is going on underneath (Lassen 2008; Sørensen 2004). They also make quite clear that they are not “cured,” they have learned to live with the symptoms of the disease and they get relapses which they use as guidance for situations that they need to be particularly aware of.
Sørensen (2004 p.11) describes bulimia as “the art of eating and throwing up.” “By thinking about food it becomes possible not to think about oneself and one’s feelings which I did not dare accept. By thinking about food I avoided thinking about the problems and solving them.” (Sørensen, 2004 p. 56) and further: “You have to dare feel the pain, the sadness, the happiness, the love, yes everything to do with feelings, because that is what an eating disorder is really all about: FEELINGS.”
According to Sørensen (2004), when one has no self confidence, when one dare not live or believe in the future, a vacuum arises that yearns to be filled with something else like food. To fill that vacuum with food gives a false sense of security which is possible to relate to. A recurring theme through autobiographies from people with bulimia is a common desire to detect and understand the feelings that make the vacuum arise in the first place. Bulimia becomes a sign that something is not quite how it should be.
Often there is a difficulty in accepting the fact that there is a problem. The main point that is emphasized by both patients with anorexia and bulimia is the fact that they are not understood by other people (Andersen 2009; Lassen 2000; Sørensen 2004)
During a visit to the doctor after having fainted from starvation during her anorexia, Sørensen (2004 p. 46) describes the conversation with the doctor: “Then she said something I really hope she has regretted: “Well, take yourself home and get something nice to eat and if you are not better in a week then feel free to call again.” I felt so let down, eventually I had pulled myself together to see the doctor, to elaborate on my innermost feelings and then she tells me to go home and eat!”
But the first criteria for an effect of treatment is the free choice” (Lassen 2008 p.15). Patients with anorexia are usually under 19 when they come, but those who suffer from bulimia or obesity often come of their own free choice, but much later in life.
According to Lassen (2008), it is necessary to look at the whole; all the factors that make a person – not only the diet, but the person who eats the food, the person’s self-conception, and the circumstances that have formed that person’s self-concept, life and eating strategies.
In all the clinical trials the researchers, without exception, call for a greater knowledge-base and a better understanding of eating disorders. The problem that seems to be appearing from the research is the difficulty in combining the physical side of the disorders with the mental aspect of them, and this is probably why it has been so difficult in conventional terms to grasp and treat the diseases.
This again may be one reason why eating disorders have warranted so little interest in terms of conventional research.
As Konrad (2007) pointed out “it may be possible to re-feed the anorexic person or teach them to eat, or reinforce their control and maintain their level of food balance, but so far nobody has been able to make the anorectic person feel good about herself.”
“As eating disorders include both psychological and physiological components, appropriate management of these disorders requires input from a number of disciplines working together in a coordinated manner, following an integrated programme” (Loria et al 2009, p. 558). Fennig and Hadas (2010), point out that too much emphasis is still put on the eating behaviour itself and since the risk of suicide is so great due to depression, they stress the need to detect and treat the depression, as the depression seems to amplify illness severity. However, even in the trial by Loria et al (2009), in which they acknowledge the necessity of directing the treatment of eating disorders at different levels, the greatest emphasis is put on the nutrition programme in which the focus is on “achieving healthier habits and modifying eating behaviour” (ibid. p. 558).
Of the few trials on anorexia, two randomised controlled trials (RCTs) that incorporate the use of family therapy seem to come up with the best results.
Correlations showed that adolescents who gained more weight in the early sessions (69%) were more likely to agree with the therapist on the goals of the therapy (p<0.02) and stay with it (ibid, 2006). It is, however, a small trial with 40 patients in the study, but subsequent studies on the same topic have yielded similar results (Zanadin et al 2007). The overall outcomes of both studies are good. In the other study on family therapy 75% of patients reported no anorectic symptoms at all after 5 years; only 8% have relapses and there are no deaths (Eisler et al 2007).
However, according to Guarda (2007): “Evidence-based data on treatment interventions for anorexia nervosa are scarce and methodological problems afflict the few published, controlled trials.”
With respect to most studies on eating disorders, there seem to be a few design problems. Generally, there seems to be a lack of consensus in the field (Guarda 2007; Southgate, Tchanturia & Treasure, 2009), both in regard to definitions of psychological and physiological criteria for recovery, symptom remission, problems about other forms of treatment, co-morbidity, target weight and prognosis which makes it very difficult to compare the different studies.
The quality of evidence therefore is generally weak and the trials are difficult to reproduce.
Furthermore, studies suggest that people with eating disorders do not turn up for help with the treatment of an eating disorder, but rather for symptoms secondary to the eating disorder (Hay, 2007).
One clinical study that stands out is the study on binge eating disorder and homeopathy carried out by (Jacobs, 2001). In this study there is an emphasis on the physical as well as the mental and emotional plane. According to Jacobs (ibid. p. 22):
“Homoeopathy may help on several planes simultaneously. The simillimum aims to address the low self-esteem, fears and obsessions and restore the appetite to normal, while healing any physical and psychological consequences of such a disorder.”
The homoeopathic perspective
Usually, homeopaths look at the underlying reason for the individual to become ill in the first place, whatever that might be, and a homeopathic approach to treatment would invariably involve a holistic assessment of the patient.
Looking at one of the few single cases of anorexia nervosa available in homoeopathic literature by Montani (1999), it becomes apparent that when the patient started feeling better, she started gaining weight, the menses returned, her anxiety disappeared and the other physical symptoms disappeared, and not least, her diet became stable. A single case cannot qualify as scientific evidence (Thompson 2004) even if the results are mirrored in other similar cases, for example in a case study reported by Crump (1995). However, when successful treatment by homeopaths are reported in a number of cases (Fixen 2006), (Lefevre 2005), it might suggest that further investigation is warranted into this as a potentially effective healing modality.
The patients themselves seem to regard the disorders as an externalisation of existential suffering, whereas the help they get seems to spring from a treatment based on the first attitude, in this way reinforcing the vicious circle of the disorders and resulting in a tension between the patients’ understanding of themselves and the ensuing treatment.
Theoretical framework and epistemology