Rewards Matter for Eating Disorder Patients

By Vicki Berkus M.D., Ph.D., CEDS, Remuda Ranch Medical Advisor

People who are struggling with their eating disorders (ED) and refusing to cooperate in treatment often need rewards they can work toward. Being in treatment would be hard for anyone; but, it’s especially hard for adolescents and for those who don’t yet have coping skills or a mind that’s fed well enough to fully function.

Privileges as Rewards

To encourage patients to follow their treatment plans, most programs use levels of activity as rewards. Anything that patients tend to look forward to–going on outings, going to a movie, more exercise time, eating somewhere other than the treatment group table for a meal—can serve as motivation for patients to adhere to their treatment regimens.

I used to be stopped in the hall by my patients with requests. “Can I _________?” they would say. They couldn’t help themselves. The idea that their entire treatment team would have to make the decision, not just me, was not in their thoughts at the moment of the request.

I decided to come up with a system that would help them know exactly what they needed to do to earn one of the privileges they wanted.

Actions Replace Words

I would have patients fill out a “request sheet” every Monday. On the sheet they were asked to write down what they wanted to do most at the end of the week – exercise more, go on an outing, etc. They also would have to write down what would be required for them to be allowed to do what they asked. (e.g., eating 100 percent for the three days prior to the activity, or not needing to be reminded to limit their movement when sitting.)

Depending on each patient’s need, the clinical team would either set the criteria for them or the patient would sit with the therapist to develop the criteria. Either way, the patient knew and agreed upon exactly what they needed to do on their part to get the added perks.

I was amazed at how quickly their behavior changed. Instead of finding me and putting a lot of energy into “making their case,” they would get excited for the change and for the challenge of meeting their goals. They would then hear from the clinical team by Thursday what the weekend would look like in terms of activities and changes.

It sounds simple but ED patients are adept at holding onto the yardstick that compares their peers’ eating disorder behaviors to their own. The ability to put on “emotional blinders” and focus on their treatment is just not in their skill set in the beginning of treatment. Having structured reward systems help them to achieve that focus.

A Team Approach

It is important for treatment teams to be consistent with patients and for each team member to be fully up to date on the latest information about their behavior and their risks. Patients need to know that the team members have access to their daily behaviors including, meal consumption, fluid consumption or daily weights. They also need our united front on the decisions we make that have such a significant impact on them during their treatment.

At Remuda Ranch at The Meadows, we use a consistent team approach every day and work with each person individually based on their strengths. With the support of our teams, our patients achieve much greater success toward their recovery.
If you would like to find out more about Remuda Ranch, please call 866-390-5100 or contact us.

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A Story about a Cat - Remuda Ranch Eating Disorder Treatment Program

By Vicki Berkus M.D., Ph.D., CEDS, Remuda Ranch Medical Advisor

I have learned that I will not win a “battle of wills” against a patient with an eating disorder.
They have perfected setting rules for themselves and the last thing I want to do is give them more rules. I also don’t expect a new patient to immediately trust me; I know that I need to earn the trust. If a patient refuses to talk about their eating disorder or refuses to tell me what they would be willing eat, I start by finding a way to get them to just talk—about anything.

A Story about a Cat

One of the most difficult patients I’ve met in my career actually said to me, “Dr. B, don’t look at me. I don’t deserve to be looked at.” Where do you start from there?

This patient was extremely shut down. The only thing she was willing to talk about was her cat. So, we visited about her cat for a while. Once she started to relax, I asked her if she would be willing to imagine that her cat had an eating disorder and write a story about it.
She did an amazing job! (I tried to get it published but no luck.) She was able to clearly and beautifully articulate her own fears and feelings as long as she was able to imagine that it was all about the cat.

Finding a Way through Shame

I had another patient who was 16 and had lost her hair and her teeth to her disease. She refused to talk about her eating disorder. So, I asked her what she would like to talk about.

She told me that she would talk about her heroin use but not her eating disorder.
So, we started there. Not long after, she told me she had dropped out of high school because the kids would snatch off her wig and laugh at her baldness. She was filled with shame and guilt. As a result, she had only eaten one piece of hard candy, ½ cup of yogurt, and a half of bagel each day for the last year. It can be hard to imagine someone needing that kind of control.

Eventually, she was able to start talking about her eating disorder, but we had to go at her pace. To push her too far too fast might have ruined any chance I had at developing a rapport with her.

Meeting Patients Where They Are

The hardest part of our work as eating disorder professionals is establishing relationships with our patients that allow trust to develop. I frequently start by asking them what they would be willing to try. It may be a smoothie or a quarter cup of a supplement like Ensure or Boost. It may be talking about a beloved pet, or a co-occurring disorder rather than the eating disorder itself.

I also try to provide patients with the information they need in order feel ready to try. For example, if their fear of eating includes fear of the pain that they feel in their GI tract when they eat, I will talk to them about how together we can address the pain and come up with a plan to make it less painful. I will also often order abdominal films for patients so they can look at it and see why they are not “going to burst” with one more mouthful.

Most importantly, I try to remember that with each suggestion I make, the eating disorder is pushing the patient to make the opposite decision. It will take the entire treatment team to help the patient through this difficult phase of their recovery.

Remuda Ranch Can Help

One of the most important goals to achieve while in treatment is to learn how to live life with your Eating Disorder (ED). Remuda Ranch at the Meadows uses a 45-day curriculum to teach the skills you will need to live with ED and move toward life-long recovery. Call us today for more information: 866-390-5100.

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