By: Melissa Gerson, LCSW
In my work as the Clinical Director of a specialized eating disorder treatment center, on occasion I will meet individuals who continue to struggle with severe anorexia after having received multiple treatments over the span of years. Severe and enduring anorexia, also known as Longstanding Anorexia Nervosa (L-AN), is often associated with poor quality of life, resistance to treatment and treatment failures. Often, individuals suffering from L-AN will report that they feel disheartened by their failed treatment attempts, report negative treatment experiences and a sense of skepticism about services and recovery, altogether. Specialist Supportive Clinical Management (SSCM) is a novel treatment approach that has been gaining ground within the field. It has now been reviewed by professionals and compared to alternative interventions such as CBT. Specialist Supportive Clinical Management is well-suited to clients with L-AN as it is developed around a central principle of aligning with a client’s goals and supporting them as willingness and resistance ebbs and flows. As defined in an article published to International Journal of Eating Disorders, SSCM “is an outpatient treatment that could be offered to individuals with anorexia nervosa in usual clinical practice by a provider trained in the treatment of eating disorders. It combines features of clinical management and supportive psychotherapy.”
Researchers of SSCM found it limiting that in most studies, traditional interventions such as CBT, group therapies, nutritional treatments (e.g. dietary counseling, nutritional advice) and family therapy are evaluated. Beyond these studies, little is known about the effectiveness of psychotherapy treatment for L-AN and there have been few attempts to identify or develop novel treatment methods. It was here in this small space that a manual for SSCM was developed. SSCM is composed of two major components; Clinical Management and Supportive Psychotherapy.
This term has been conceptualized by researchers as “good-quality care, delivered by a competent clinician with our without the addition of any specific treatment regimen.” The lack of specific treatment regimen is supported as the article claims “There is mixed evidence about whether more specialized psychotherapies or treatments confer added benefit to good clinical management. Differences in outcome between known effective treatments and good clinical management may be small or negligible.” Clinical management includes education (symptoms and diagnosis, etiology, warning signs of illness recurrence, prevention strategies and what will happen if it is left untreated), care, and support, and fosters a therapeutic relationship that promotes adherence to treatment. For individuals with anorexia nervosa, treatment emphasizes the resumption of normal eating and the restoration of weight. A main goal of the clinical management component is to establish a stable rapport and therapeutic relationship with a client as that relationship promotes adherence to the treatment regimen and compliance in taking medications. An important factor that will enhance the effectiveness of clinical management is an open discussion about fears or prejudices on the part of the client as they relate to mental health care. It will also be important for the client to present their ideas as they differ from those of the clinician. Sharing the diagnosis with the patient in this way enables the clinical to provide, and the patient to receive, ongoing care and treatment.
The delivery of information and psychotherapy within SSCM must be done in a supportive manner. Supportive Psychotherapy is best defined by L. Luborsky (1984) as “demonstration of support, acceptance, and affection toward the patient; emphasis on working together with the patient to achieve results; communication of a hopeful attitude that the goals will be achieved; respect of the patient’s defenses; and focus on the patient’s strengths and acknowledgment of the growing ability of the patient to accomplish results without the therapist’s help.” Supportive psychotherapy has a conversational style, using techniques such as active listening, verbal and nonverbal attending, open questioning, reflection, praise, reassurance, advice, and therapist self-disclosure.
Phases of Treatment:
SSCM is divided into three phases. Phase one includes a patient orientation to SSCM, identification of target symptoms and goals for weight gain and normal eating. The features are agreed upon by both parties. Middle phase includes the ongoing monitoring of target symptoms and support/encouragement. The final phase involves discussion of issues related to termination and planning for the future. In this particular clinical trial, sessions were scheduled 1x per week for 20 weeks. It is important to note that the time frame for SCM is flexible, and therapy contracts are re-negotiable.
Throughout the course of treatment the provider maintains that the client must stay medically stable throughout but otherwise, is largely responsive to the client. While a main focus of treatment is weight restoration, it is not the primary focus. Instead, the focus is on improving quality of life and in doing so, invariably eating, food and overall health are addressed in a way that may be experienced as far less threatening for the client. Physical status is evaluated throughout via weigh-in’s and blood test monitoring in addition to the delivery of nutritional education and advice.
How does this differ from other therapeutic interventions?
SSCM was specifically designed so as not to overlap with the key features of CBT or IPT. As practiced in this clinical trial, supportive therapy allows discussion of personal concerns and issues on a session by session basis and as identified by clients as opposed to challenging irrational beliefs (CBT) or focusing on interpersonal issues as facilitated by the therapist (IPT).
While further research of this promising therapy is warranted to evaluate the effectiveness of SSCM, it is an important tool for clinicians to evaluate as it may impact their clinical treatment of L-AN.
McIntosh, V., Jordan, J., Carter, F., McKenzie, J., Bulick, C., Joyce, P., (2006) Specialist Supportive Clinical Management for Anorexia Nervosa. International Journal of Eating Disorders, 39:8 625–632.
Luborsky L. Principles of psychoanalytic psychotherapy. New York: Basic Books; 1984.
About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.