Raising the Bar: Competence in Outpatient Eating Disorder Treatment

When my friend and colleague, Alli Spotts-De Lazzer, M.A., MFT, LPCC, CEDS, asked me to join her in writing an article on competence for therapists treating eating disorders, I jumped at the opportunity.

Psychotherapists are ethically bound to treat within their scope of competence. Yet how does a psychotherapist determine if he or she is competent to treat eating disorders, the mental disorders with the highest mortality rates? Alli had searched for a guide or brief resource to help clinicians in training to better understand the basic knowledge recommended for treating eating disorders. To our surprise, few documents existed. Furthermore, we have both often heard that patients and families would like to feel better supported in knowing how to verify the credentials of outpatient eating disorder therapists. Many insurance companies do little vetting in choosing which therapists are listed on their panels as eating disorder treatment providers.

So we decided to create what we hoped would be a helpful document.

Alli and I each have extensive experience treating eating disorders in the outpatient setting. We come from different and complementary backgrounds. I received my original training in the 1990s in an evidence-based research lab under the direction of Terry Wilson, Ph.D, a developer of Cognitive Behavioral Therapy for eating disorders, and I have focused on evidence-based treatments ever since. Alli aligns with an eclectic approach informed by evidence-based concepts, personal experience with eating disorders and eating disorder trainings that range from Continuing Education Units to pre-licensed work at Monte Nido Treatment Center under the leadership of Carolyn Costin.

While we acknowledge that there are many possible paths to becoming a psychotherapist who treats eating disorders, we sought to answer questions including:

• What set of competencies seem necessary for therapists to know in the outpatient setting?
• What are many of the unique therapeutic needs of patients with eating disorders including anorexia nervosa, bulimia nervosa, and binge eating disorder?
• What basic knowledge and training might therapists pursue if they desire to treat eating disorders in the outpatient setting?

In addition to a mental health treatment focus, patients with eating disorders also commonly present with nutritional and medical issues that may need attention. While having well trained, collaborative team members covering medical and nutritional disciplines in a patient’s care is desirable, in a real-world outpatient setting, these team members may not always be available. Psychotherapists working in the outpatient setting who do not have well-established protocols, resources, or collaborators can be particularly vulnerable if/when issues of competence arise.

Eating disorders are psychological disorders that often come with physical, medical, or nutritional consequences and/or complications that call for acute or gradual attention. Psychotherapists, therefore, are recommended to have a basic working knowledge of eating disorder-specific domains extending beyond a psychotherapist’s traditional scope of practice and usual training. Furthermore, each major disorder – anorexia nervosa, bulimia nervosa, and binge eating disorder – can present unique treatment needs and levels of risk.

Our review of the literature incorporating both research and practice guidelines, in conjunction with our own clinical experience in treating eating disorders in the outpatient setting determined that the areas of suggested knowledge generally fell into 5 domains:

• Assessment and Diagnosis
• Medical Factors
• Nutrition and Malnutrition
• Treatment Strategies
• Multidisciplinary Collaboration and Levels of Care

Our hope is that the paper will:

• Help therapists treating eating disorders in the outpatient setting by providing accessible information and resources and assist in potentially improving the experiences of and outcomes for patients;
• Serve as a useful guide for clinicians desiring to specialize in the treatment of eating disorders;
• Assist patients and families in feeling more supported by knowledge when seeking treatment providers; and
• Possibly help to influence insurance companies in the realm of eating disorders.

We are grateful to the following colleagues who gave valuable, substantial feedback on drafts of our paper: Jennifer Thomas, Ph.D.; Charles Portney, M.D.; Stacey Rosenfeld, Ph.D.; Laura Collins; Kristine Vazzano, Ph.D.; Nina Savelle Rocklin, Psy.D; and Elisha Carcieri, Ph.D. We received considerable research assistance from eating disorders informationist, Millie Plotkin. We also thank our additional valued colleagues who provided helpful comments.

After an extensive peer-review process, the paper, “Eating Disorders and Scope of Competence for Outpatient Psychotherapists,” was accepted by and published in the American Psychological Association Journal, Practice Innovations, 2016, Vol. 1, No. 2, 89–104.