All illnesses classified as ‘mental’ are comprised of psychological, behavioral and physical components. Treatment strategies for eating disorders vary widely from psychoanalytic exploration of the emotional origins of the disorder without physical or behavioral intervention to forced tube or intravenous feeding with no behavioral or psychological work. However, despite decades of clinical research into the ideal combinations of cognitive/psychological, behavioral, and physical interventions, the mainstream evidence base is not inspiring.
One obvious conclusion to draw is that clinicians need to redouble their efforts to address the psychological components of eating disorders. However, a different reading is that the purely psychological pathway leads us down a rabbit hole. This is the claim of a Swedish treatment method that has achieved significantly more success in treating the full range of eating disorders than any other method, but that has been more or less completely ignored by the mainstream of eating disorders researchers and practitioners.
Having treated more than 1,400 patients with eating disorders (around 40% with anorexia), the Mando Clinic, headquartered in Stockholm and led by Cecilia Bergh and Per Södersten, has achieved a 75% remission rate with zero mortalities, and 90% of those who reach remission progress to full recovery over a five-year follow-up period. (1,2). These results are considerably stronger than those achieved by traditional methods used in the treatment of anorexia and bulimia. The secret to their success is treating eating disorders as disorders of eating, rather than as disorders of psychological functioning. Specifically, people with anorexia usually start off eating too slowly, those with other eating disorders typically too fast; and both groups fail to sense and respond to satiety cues appropriately.
Rather than downplaying the behavior of eating as a troublesome side-effect of deep-seated psychological disturbance, the eating disturbance is treated as the cause of the psychological disturbances. Primarily, this means normalizing patients’ eating habits using the Mandometer (from the Latin mando, I eat), an app which communicates with a scale underneath your plate and provides normal curves for eating speed and satiety cues according to which patients gradually learn to adjust both. Alongside restricted exercise and rest in warm-rooms for an hour after eating, this simple behavioral intervention is the essence of the treatment.
Dig into their treatment practices a little more, though, and it becomes clear that the Mandometer and the heated rooms are just one part of their plan. Mando’s “case managers” are clinically trained to support patients through the program in ways that the Mando team calls “just common sense,” but that would probably look very familiar to anyone who practices CBT or any other kind of practically-oriented psychotherapy. Mando therapists use behaviorist techniques like successive approximation to help patients eat. The patient might be given a plate of food without having to eat it, then be asked to put an empty fork into their mouth, and perhaps then be invited to smell the food on the fork. Verbal reinforcement, small gifts, and promises of future rewards are given at every step. They say this is behavioral and not cognitive therapy, but are the dividing lines between cognitive and behavioral really so clear? Is it even helpful to draw them?
The medium is behavioral, but the effects are also in the mind. Likewise, the Mando team explains that the heat treatment following meals not only allows the calories that would have otherwise been used for thermal regulation to be used for normalizing bodyweight but also helps lessen the anxiety that interferes with eating. Moreover, the method includes other strands like the development of ‘emotional regulation’, understanding and appreciation of one’s body, improvement of self-esteem and self-awareness, and managing social situations and relationships– all concepts familiar to any cognitive therapist working with eating disorders.
The remarkable solidity of Mando’s evidence base compared to other methods does suggest that without a central focus on the eating, nothing else works well. But the possibility remains, for example, that CBT plus the Mandometer would work even better than either in isolation. The Mando team have made this suggestion in print, and in a personal communication to me, a partner in the clinic speculated:
“CBT may be improved if it used Mandometers during the meals, allowed negotiated meal size and speed, prevented exercise, and provided physical warmth for anorexic patients. The Mando method may be improved if its common-sense therapy was given more structure via CBT training, as long as the focus remains on fostering normal eating behavior and minimizing caloric expenditure, not on resolving deep psychological problems.”
So, the real question that needs to be answered next isn’t really “CBT or Mando?” It’s “which elements of either?” Other distinctive features of the Mando method include withdrawing patients from all psychoactive drugs (80% are taking something when they arrive); the case manager eating all meals with the patient (not just watching them eat) to begin with, and later going to restaurants with them; not allowing patients to know their weight, but asking them to focus on eating and resting; and negotiating everything, so that nothing happens without patient agreement, and agreement is sought via reasoning and evidence. Which of these components are crucial, which are nice to have or incidental?
The constant feedback between mind, body, and behavior doesn’t mean that it doesn’t matter where in the system you intervene. It does mean that if you don’t observe improvement in the entire system, you probably chose the wrong place to start. And the Mando team’s claim is that the behavior is the right place to begin, that it’s the fulcrum between body and mind, between BMI and the EDE-Q. Their work reminds us that people will never get better if you pretend (and allow them to pretend) that they’re better when they’re not, which is easiest to do if you elevate one measure (often bodyweight) above all the others.
As one Mando partner put it to me, in a discussion of risk factors for relapse, “Not actually being in remission is the biggest factor for relapse risk.” And being in remission means all kinds of complex yet mostly definable things, to which eating behavior may well be pivotal. There’s lots left to learn but putting the behavioral back in the cognitive may prove to be the best starting point.
1) Bergh, C., Brodin, U., Lindberg, G., & Södersten, P. (2002). Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Proceedings of the National Academy of Sciences, 99(14), 9486–9491.
2) Bergh, C., Callmar, M., Danemar, S., Hölcke, M., Isberg, S., Leon, M., and Palmberg, K. (2013). Effective treatment of eating disorders: Results at multiple sites. Behavioral Neuroscience, 127(6), 878–889.
3) Södersten, P., Nergårdh, R., Bergh, C., Zandian, M., & Scheurink, A. (2008). Behavioral neuroendocrinology and treatment of anorexia nervosa. Frontiers in Neuroendocrinology, 29(4), 445–462.
File under: The Art of Psychotherapy
One obvious conclusion to draw is that clinicians need to redouble their efforts to address the psychological components of eating disorders. However, a different reading is that the purely psychological pathway leads us down a rabbit hole. This is the claim of a Swedish treatment method that has achieved significantly more success in treating the full range of eating disorders than any other method, but that has been more or less completely ignored by the mainstream of eating disorders researchers and practitioners.
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Having treated more than 1,400 patients with eating disorders (around 40% with anorexia), the Mando Clinic, headquartered in Stockholm and led by Cecilia Bergh and Per Södersten, has achieved a 75% remission rate with zero mortalities, and 90% of those who reach remission progress to full recovery over a five-year follow-up period. (1,2). These results are considerably stronger than those achieved by traditional methods used in the treatment of anorexia and bulimia. The secret to their success is treating eating disorders as disorders of eating, rather than as disorders of psychological functioning. Specifically, people with anorexia usually start off eating too slowly, those with other eating disorders typically too fast; and both groups fail to sense and respond to satiety cues appropriately.
Rather than downplaying the behavior of eating as a troublesome side-effect of deep-seated psychological disturbance, the eating disturbance is treated as the cause of the psychological disturbances. Primarily, this means normalizing patients’ eating habits using the Mandometer (from the Latin mando, I eat), an app which communicates with a scale underneath your plate and provides normal curves for eating speed and satiety cues according to which patients gradually learn to adjust both. Alongside restricted exercise and rest in warm-rooms for an hour after eating, this simple behavioral intervention is the essence of the treatment.
Dig into their treatment practices a little more, though, and it becomes clear that the Mandometer and the heated rooms are just one part of their plan. Mando’s “case managers” are clinically trained to support patients through the program in ways that the Mando team calls “just common sense,” but that would probably look very familiar to anyone who practices CBT or any other kind of practically-oriented psychotherapy. Mando therapists use behaviorist techniques like successive approximation to help patients eat. The patient might be given a plate of food without having to eat it, then be asked to put an empty fork into their mouth, and perhaps then be invited to smell the food on the fork. Verbal reinforcement, small gifts, and promises of future rewards are given at every step. They say this is behavioral and not cognitive therapy, but are the dividing lines between cognitive and behavioral really so clear? Is it even helpful to draw them?
The medium is behavioral, but the effects are also in the mind. Likewise, the Mando team explains that the heat treatment following meals not only allows the calories that would have otherwise been used for thermal regulation to be used for normalizing bodyweight but also helps lessen the anxiety that interferes with eating. Moreover, the method includes other strands like the development of ‘emotional regulation’, understanding and appreciation of one’s body, improvement of self-esteem and self-awareness, and managing social situations and relationships– all concepts familiar to any cognitive therapist working with eating disorders.
The remarkable solidity of Mando’s evidence base compared to other methods does suggest that without a central focus on the eating, nothing else works well. But the possibility remains, for example, that CBT plus the Mandometer would work even better than either in isolation. The Mando team have made this suggestion in print, and in a personal communication to me, a partner in the clinic speculated:
“CBT may be improved if it used Mandometers during the meals, allowed negotiated meal size and speed, prevented exercise, and provided physical warmth for anorexic patients. The Mando method may be improved if its common-sense therapy was given more structure via CBT training, as long as the focus remains on fostering normal eating behavior and minimizing caloric expenditure, not on resolving deep psychological problems.”
So, the real question that needs to be answered next isn’t really “CBT or Mando?” It’s “which elements of either?” Other distinctive features of the Mando method include withdrawing patients from all psychoactive drugs (80% are taking something when they arrive); the case manager eating all meals with the patient (not just watching them eat) to begin with, and later going to restaurants with them; not allowing patients to know their weight, but asking them to focus on eating and resting; and negotiating everything, so that nothing happens without patient agreement, and agreement is sought via reasoning and evidence. Which of these components are crucial, which are nice to have or incidental?
The constant feedback between mind, body, and behavior doesn’t mean that it doesn’t matter where in the system you intervene. It does mean that if you don’t observe improvement in the entire system, you probably chose the wrong place to start. And the Mando team’s claim is that the behavior is the right place to begin, that it’s the fulcrum between body and mind, between BMI and the EDE-Q. Their work reminds us that people will never get better if you pretend (and allow them to pretend) that they’re better when they’re not, which is easiest to do if you elevate one measure (often bodyweight) above all the others.
As one Mando partner put it to me, in a discussion of risk factors for relapse, “Not actually being in remission is the biggest factor for relapse risk.” And being in remission means all kinds of complex yet mostly definable things, to which eating behavior may well be pivotal. There’s lots left to learn but putting the behavioral back in the cognitive may prove to be the best starting point.
1) Bergh, C., Brodin, U., Lindberg, G., & Södersten, P. (2002). Randomized controlled trial of a treatment for anorexia and bulimia nervosa. Proceedings of the National Academy of Sciences, 99(14), 9486–9491.
2) Bergh, C., Callmar, M., Danemar, S., Hölcke, M., Isberg, S., Leon, M., and Palmberg, K. (2013). Effective treatment of eating disorders: Results at multiple sites. Behavioral Neuroscience, 127(6), 878–889.
3) Södersten, P., Nergårdh, R., Bergh, C., Zandian, M., & Scheurink, A. (2008). Behavioral neuroendocrinology and treatment of anorexia nervosa. Frontiers in Neuroendocrinology, 29(4), 445–462.
File under: The Art of Psychotherapy