In Depth with Professor Richard Newton

Professor Richard Newton:

My name is Richard Newton. I’m a professor of psychiatry at Monash University and I also work as a Clinical Director of a mental health service here in Victoria.

Sam Ikin:

This month’s Let’s Talk In Depth takes us into the mind of one of Australia’s most experienced eating disorder clinicians. I had the privilege of spending some time with Professor Richard Newton when we explored how eating disorders almost always occur with other mental health conditions. He also took me through how eating disorders used to be treated back in the bad old days. Suffice to say, I’m glad that people like Richard have been there and done so much hard work to improve the outcomes of people who experience eating disorders, even though we’ve still got a long way to go. We’ve come a long way. Richard also serves on the Boards of both Butterfly and Wandi Nerida, Butterfly’s Residential treatment centre on the Sunshine Coast.

Richard:

I’ve been working in eating disorders since the 1980s and back in the 1980s, people with eating disorders were essentially treated in a very coercive patient model of care. The whole field of binge eating disorder was very poorly understood and treatments were pretty miserable.

By and large, cooccurring mental health issues is the rule, it’s very, very unusual in my experience for people with an eating disorder to only have an eating disorder, essentially because eating disorders are driven by very often by low self-esteem, high levels of anxiety, high levels of emotional sensitivity and experience, as well as depression and obsessive-compulsive disorder. There are also previous experiences of trauma, often of different types, over a long period of time. So, you know, one of the challenges of working alongside people with eating disorders, to help them recover, is to identify which co-occurring mental health issues really require a specific therapeutic focus, and which co-occurring issues, if you manage to help the person recover from their eating disorder, will actually improve as the eating disorder improves. Because of course a lot of co-occurring mental health issues are actually as a result of the effects of starvation, the effects of binge eating, the effects of the metabolic instability that’s associated with purging and etc. Of course, some co-occurring mental health issues are somewhat to very effectively mitigated and reduced as far as the person with an eating disorder is concerned by their eating disorder. If you feel empty and hopeless and despairing and one of the things that you can do to is to nurture yourself by eating, then you eat.

One of the things that binge eating does is it helps people fill themselves with something even though it then becomes quite an aggressive self-harming, hurtful attack on themselves. Again, because it’s driven by that low self-esteem and guilt and sense that the person is to punish themselves, but that’s an example of how an eating disorder can actually manage some of the co-occurring mental health issues around it. If you’ve been depressed or very, very anxious for all the time that you can remember, and if you lose weight that depression and low mood becomes flat and blunted, then that may be the best you felt in your mood for a very long time. That’s a direct result of starvation. And so, for some people, the eating disorder appears to be a solution to some of their co-occurring mental health issues when no health professional has been able to help them. And I think that adds to people’s reluctance to try recovery because they’re so anxious that some of this other stuff will come back.

Sam:

It just makes so much sense. I’ve spoken to a lot of people in recovery who had to deal with the fact that they grieved the eating disorder, they missed it, they really missed having that in their life. And I guess what you just explained kind of explains that.

Richard:

I think it explains some of it, but also having an eating disorder, it’s something that people can rely on. You know, some people talk to me very much about is the one thing that they can look to when they’re unsure of who they are unsure of their place in the world, they’re unsure of what people expect of them, they’re not sure how they affect, how they are interpersonally and socially. The eating disorder gives them a whole set of rules that they can measure themselves against and gives them some sense of certainty, some sense of achievement. All of those kinds of things, when you’re trying to help people find a way to recover, I think you absolutely have to validate some of the functions that the eating disorders serves in their life and then explore with them other ways that they may be able to achieve those functions that are better for them. Because ambivalence and being intensely ambivalent about recovery is usual. I don’t know that I’ve ever met anybody with an eating disorder—and that might be because people come to see me when they want to get better—but even in circumstances where people haven’t necessarily voluntarily come to see me. But if you listen carefully to people and explore things with them, everybody that I’ve ever spoken to would prefer not to have an eating disorder if they could find a way out of it that met their other needs.

Sam:

Is the incidence of co-occurring mental health conditions across eating disorders any different to any other mental health conditions?

Richard:

That is a great question and a really good point because of course co-morbidity or co-occurring issues are very common across everything. Substance use is common amongst anxiety disorders, bipolar disorder, schizophrenia, anxiety is ubiquitous. Everybody has some experience of anxiety, it’s whether or not it’s a problem. But I think the evidence is really quite strong that in eating disorders, those co-occurring mental health issues are unusually highly prevalent. Depression has rates of up to 80%. Whereas in the general population depression with other illnesses might be 20-30%. There are higher rates of trauma than the general population, much higher rates of anxiety, much higher rates of psychosis. And then people there is really quite a significant, not high, but quite significant co-occurrence of schizophrenia and other psychotic like illnesses alongside eating disorders. And that’s unusual. And, of course, one of the things that we should talk about is the so-called personality disorders. While you’re thinking about problems with impulsivity, problems with emotional disregulation, problems with despair and hopelessness and managing how you respond to distress, those things seem to be at much higher rates in people with eating disorders than in the general population. So depression, anxiety, OCD, very high rates PTSD…

And, of course, one of the things I was hoping to talk about because it’s so big in my mind at the moment is post-traumatic stress disorder. We think about PTSD as being something that people who have been in combat, or first emergency responders, might have, but it’s actually common in people with recurrent episodes of other traumas, sexual trauma, physical trauma, et cetera. And one of the things I think we don’t talk about is the trauma of being unwell as a cause of PTSD. And also, the trauma of getting treatment. People talk about their experiences of treatment of eating disorders. So many of them describe very clear-cut PTSD symptoms, flashbacks, recurring nightmares, and avoidance of treatment, not just because of that ambivalence that we’ve spoken of, but also because they genuinely and realistically experienced trauma in the treatment experience.

Sam:

It sounds like safety and that feeling of being okay in recovery or in trying to find recovery is a massive thing. And while we’re on that, can you take us through what are the best practice approaches for treatment at the moment?

Richard:

That’s such a huge question. Treatment of what Sam? The co-occurring mental health issues? Treatment of the eating disorder?

Sam:

I guess if you just treat the eating disorder, then you are in in most cases not helping that person to recover because there’s the other conditions that are not being treated, I guess. What do you recommend?

Richard:

By and large, if you can help somebody improve the anxiety management skills and abilities around the eating disorder, then that will generalize out into helping them with anxiety in other areas. Some of that anxiety might still need some specific treatments. But essentially, a kind of cognitive, behavioural, mindfulness-based approach to anxiety management, where people learn those self-management skills is core to treating depression, which is also so extraordinarily common. That’s much trickier because it’s so debilitating, just as anxiety is. It can be, as you know, a life-threatening illness, but the treatment of depression usually requires a combination of talking therapy, whether it’s CBT other dynamic therapies and sometimes antidepressants. And if somebody is very physically compromised, either metabolically because of bingeing and purging or particularly compromised because they’re very underweight, then it’s almost impossible for the depression to really lift.

Whether it’s with psychotherapy or drug treatment, until they’ve managed to reverse at least some of the effects of starvation on the brain, if somebody puts on weight, for example, with anorexia nervosa, it’s very common for them to become more and more anxious and more and more depressed. Paradoxically, that actually is the time where treatment of depression can be very successful. Whereas when people are very metabolically compromised treatments for depression are really hard. So, the depression, anxiety, substance use problems which are very common actually can be done in parallel to the eating disorder.

Richard:

The parallel treatments might be, you know, I’m a big fan of the AA12 step model, I think it works for an enormous number of people. It’s the original peer led treatment in the world. You know, AA was all about peers, helping each other get better with experience. We don’t think like that so much because you cannot abstain from food. So, the abstinence model does not work for eating disorders, because if you don’t eat then you die. But the abstinence model can work for substances.

Sam:

I was just going to say, that’s part of the problem. I’ve been through AA many times, and you know I did not have the success that I was hoping for, but I know plenty of people have gone through AA and it helped them immensely.

Richard:

Because it’s so successful for so many people, you have to give it recognition. I used to work in Scotland when I was younger, with the Scottish council for alcohol, and that was an alternative approach to a providing people with peer counselling, to help them find non abstinence approaches to their alcohol or substance use also, which was really effective. So, what I guess I’m saying in terms of the eating disorders is that if you have a co-occurring substance use disorder, then it needs to be addressed in parallel. I often think about these things is, you know, as left foot forward, right foot forward, left foot forward, right foot forward, you kind of shuffle along, doing a bit of work on the co-occurring issue, then a bit of work on the eating disorder until you get to the point of full recovery. But you cannot ignore co-occurring substance use if it’s present, it requires treatment, and peer support is really helpful, whichever way you go.

Sam:

And that’s just exposing yourself to other people who are experiencing similar issues. Not everyone’s the same. But, yes, that’s something that we found out through the journey of this podcast as well. Just the idea that talking helps.

Richard:

Absolutely right and Sam, you know, you’ve talked about the AA model a little bit.

Sam:

I think for me the abstinence was the sticking point, because abstinence for me is something that is a massive trigger.

Richard:

One of the things that I wonder if we should talk about is the public health messaging around obesity in the space of co-occurring issues, because the public health messaging around obesity, I think is a co-occurring issue. I think is a really good example of how when we set people up to restrict or to be restrained in their eating, then you set them up for a whole range of feelings of deprivation, non-nurturing, you know, it’s enormously triggering for many, many, people, for the population as a whole. We’re telling people in a world of massive plenty—our world in Australia is a world of massive plenty—and we’re designed to eat everything that we can in that setting so that we’re fine for later when there’s not so much food about. But that bit of the equation no longer applies to us. And so, we are all restraining ourselves almost at every eating episode. And when we’re told that we need to restrain ourselves more, because otherwise there will be this massive public health issue of obesity, I think it actually sets up a paradoxical response with overeating and guilt etc. I don’t think that’s just in people who may be vulnerable to eating disorders. I think it’s actually in the general population, it makes the general population also eating disordered. I don’t know if you’ve got any thoughts about that.

Sam:

I think that a lot of it comes from a place of, you know, of genuine concern about the health issues caused by obesity and those are undeniable. You can’t deny those things, but at the same time, I don’t know, it’s a very fine line to walk. There are, I believe, a very large portion of the population who absolutely it won’t work for and, you know, everyone knows about calories in calories out. Everyone, there’s not a single person in the world that doesn’t know that’s how it works.

Richard:

We’ve got to be thinking about this differently because our messaging tends to play the person, you’re eating too much, you know, you need to take more control, you need to be more restrained because it plays on the person. So many vulnerable people end up developing an eating disorder. So, there is a societal issue here that, as you say, it’s complicated. But we’ve not got it right yet.

Sam:

Look, I feel like we’ve got a whole another episode in that. But let’s wrap it up. Can I ask you for, what are your tips for somebody who is experiencing an eating disorder as well as a few other co-occurring diagnoses. What’s the first thing that they should be doing?

Richard:

Well, I think the first thing would be to always to have an expectation of full recovery. I love that phrase. Full recovery, full citizenship, people with an eating disorder and co-occurring depression, anxiety, substance use, bipolar disorder, OCD, whatever it is, it’s all treatable. With good quality therapy to engage with and work towards it will all get better. So have hope, have an expectation that things will really recover, but know that it makes things a bit more complicated, and it may take a bit more time, it may take a bit more fiddling around with medication. Have faith in that process because it does work.

And, in the meantime, do all the things that, you know, I’m sure everybody says about working hard on both the eating side of things. But being kind to yourself, allowing yourself to have these other things rather than blaming yourself for having all of these problems. And know that as you recover, and as you work through all of the things that need to be worked through across these different diagnoses. I don’t know, it’s trite, but people get so much better when they recover from an eating disorder. You wouldn’t wish an eating disorder on anybody, but goodness me, the process of recovery can be so transformative.

Sam:

Thank you so much for joining us. We’ve gone well over time, but I really do appreciate your time, Richard, thank you very much.

Richard:

Okay, don’t worry, Sam, thank you for having me.

Sam:

If you’re a health professional interested in further education about eating disorders, you can contact the NEDC at nedc.com.au or ANZAED at anzaed.org.au for more training. If you work with young people, Butterfly’s Prevention Services, run training webinars. Look under the Schools and Youth Professionals tab on the Butterfly website. If you’re a clinician and you’d like to be listed on the Butterfly Referral Database, please contact Butterfly at referraldatabase@butterfly.org.au. Remember help is available for anyone struggling with an eating disorder through the Butterfly Helpline on 1 800 ED HOPE that’s 1 800 33 4673. And for more resources check out butterfly.org.au. If you liked this episode of the Butterfly podcast, you might want to write a review, leave us a rating wherever you get your podcasts, we would really appreciate it. And remember, as always, please share it with a friend. I’m Sam Ikin. The Butterfly podcast is an Ikin Media production for Butterfly Foundation.