Dr. Phillipa Hay Explores Treatment Strategies for Bulimia

Recently, I had the distinct honor of interviewing Dr. Phillipa Hay who is Professor and Chair of Mental Health at Western Sydney University in Sydney, Australia. Professor Hay is an academic psychiatrist who is recognized internationally for her expertise in eating disorders. She has over 400 peer-reviewed publications, has written and co-edited several books, and has won several awards, including the 2015 Australian and New Zealand Academy Lifetime Achievement award. She is a Fellow of the International Academy for Eating Disorders and the founding Editor-in-Chief of the first online journal in her research area, Journal of Eating Disorders. She is also a past president of the Australian Academy for Eating Disorders.

I spoke with Professor Hay about her opinion on the best psychological treatments, the role of the family in treatment, and what kind of research and advances she would like to see in the future in the treatment of bulimia. Here is a look inside our conversation.

Will you please discuss the unique psychological, biological, and physical characteristics of someone struggling with Bulimia?

With someone struggling with bulimia, I think it's really related to their sense of identity and meaning that gets caught up with eating disorders. So they get caught up in a daily struggle of dysregulated eating or problems with binge eating and out-of-control eating that lead to emotions of despair, often self-denigration, disgust with oneself with one's eating and the weight control behaviors that then counteract the binge eating, like self-induced vomiting or taking laxatives. And that sense of blame and disgust is just very, very strong. And they get into a vicious cycle of the binge eating, the compensatory behaviors, and then that sense of themselves as being defined by the eating disorder and can't escape the eating disorder. There's also a whole range of physical effects that occur as a result of Bulimia Nervosa- as a result of the behaviors, for example, they may become very dehydrated. They may become physically unwell and need to go to hospital for replacement of metabolites such as potassium, but probably those physical effects are less impactful for the person, it is the psychological effects of the disorder that really are the key, in terms of the person's daily struggle. And when they seek help, they're really seeking help to emerge from the eating disorder, to get help to not have the eating disorder, and as that sometimes people talk to me about it to not have it as their way of coping and their way of living, and it's just not a good way of living or coping with life or its challenges.

And for those who use vomiting to purge, how and why does this behavior become habituated?

Well, it really becomes a vicious cycle, individuals have to vomit because they have that extreme fear of the impact of the binge eating, of the eating being out of control, and then their weight becoming out of control, and then themselves becoming out of control. So then they have to engage in the behavior, but people are in a vicious cycle because then that's often followed by further binge eating, further starvation, extreme fasting, and other weight control behaviors. And just getting out of that cycle is where therapy comes in. So we concentrate on helping people regulate their eating, eat regularly three meals a day to break that cycle of binge eating, and thereby reduce that fear and need to vomit after the binge eating.

And what form of psychological treatment and/or medical treatment do you see as having the best outcome?

We have a lot of research, a lot of randomized controlled trials, which indicate that certain psychological therapies have very good outcomes for people with eating disorders, and particularly for people with bulimia nervosa. And probably one of the leading ones internationally is cognitive behavioral therapy, which is a therapy that focuses on breaking those cycles of the thoughts, the emotions, the behaviors that people experience with Bulimia Nervosa. But having said that, it doesn't work for everybody, and it works better for some than for others, and we need to probably understand much better how to target the therapies to the person and really have the individual at the center of the therapy, rather than the therapy at the center of the individual, which sometimes I think we err on the side of emphasizing too much the manual and the therapy rather than the person. So where I see therapy that is most successful is one that has an understanding of the person. So you form a formulation of the person's problems of their stories, their narratives, their pathways into the eating disorder, and what for them is perpetuating the eating disorder, what are the key factors for them, and often that may be a history of trauma, which with many people these days we are now recommending they have what we call trauma-informed cognitive behavior therapy. Thus, therapy that's informed by the person's life history, by their narratives and experiences, and that I think is probably the most successful.

Can you please discuss the role and the significance of the family, particularly with children and adolescents in treating bulimia?

Well, the family is crucial, really. One's sense of who you are as a person, your identity, and your self-esteem, comes from your family and the really important people in your formative years when you're growing up. Obviously, there are many other influencers, there are your peers at school, school-teachers, there are other life experiences, but the family essentially is the main spring to setting us off on a path to adulthood. So much of our life revolves around the way we eat, the way we behave towards others, and the way we perceive and interact in our lives is determined by those experiences with the family. And one thing we've lost perhaps a little bit in recent years as a concept is family meals, families gathering together and sharing and eating together. And that is in terms of therapy, really crucial. Family meals are core to the therapy that we may offer. They also provide that validating and caring environment, which is so essential to the development of one's identity and one's sense of self.

As a recovered eating disorder recovery coach, I provide (nearly any time) virtual professional support while also acting as a mentor because I have walked their path. Will you please discuss how virtual treatment has changed the face of eating disorder treatment and your perspective on the significance of a mentor/mentee relationship for those in treatment?

This has been one of the most significant shifts in our way of thinking and delivering care for people with eating disorders in the past. Quite recently actually, probably in the past decade, I would say it's really become now seen as an acceptable, in fact, as a desirable aspect to providing care for someone with an eating disorder. I've had to say there was a time when if you were interviewing someone for a position in an eating disorder unit, you might be a bit concerned if they had an eating disorder themselves and ask them, how will you manage that? How will you cope with being a therapist for someone who also has an eating disorder? And we've really completely shifted that around. We have a program, which is one of the first programs of its type in Australia, the Wandi Nerida program in Queensland, which for the first time I saw had on its selection criteria for people to work there in therapy, having lived experience and lived expertise of an eating disorder as a desirable quality on the selection criteria. And that was just such a shift. 

We've been involved at Western Sydney in the evaluation of the outcome of Wandi Nerida. And some of the voices of people who have been to that program have really emphasized how that was a game changer for them, to go to a program where there were people who also had experienced eating disorders and not only had done so, but were there proactively to share that experience to support people, as you say, to mentor people, and to provide that peer support/peer therapy, it really gave them a sense that this was a place where they would be understood and felt understood indeed and gave them a hope, also. One of the other pieces of research we've been involved in is that one of the key things is having someone who is mentoring you, it instills hope that you can get through this.  They have got through this. You can get through this. And with their help, you will get through it.

There has been some exciting research in genetics and looking at the gut microbiome with anorexia. Are you seeing anything similar with bulimia? What kind of advances are you seeing now or would like to see in the understanding and treatment of bulimia?

Yes there has been some exciting research, and I'd have to say I think the research is still in a preliminary stage in terms of actually shifting and understanding what we actually do in terms of therapy and treatment, but it certainly is giving us insights and understanding that does modify and modulate what we do in the way we think about things for people with eating disorders and particularly that gut-brain access, and the ability to modulate your internal satiety, hunger sensations is really important. It does seem that people with eating disorders really struggle and that they lose what we call their normal ability to modulate and have a sense of how much they've eaten, when they've eaten enough, when they're full, when they're not, so that hunger satiety access. Certainly in therapy, I'm now asking people to monitor that, their hunger and satiety cues and get a much better sense of their internal ability to have a sense of when they've eaten enough or when they've not eaten enough because that is something that becomes very dysregulated with eating disorders, and it's probably where the research in the understanding the gut microbiome is really sort of helping us. In terms of eating disorders more generally, or Bulimia Nervosa, I think that the relationships between those external and internal perceptions and their modulation at the higher levels, at the levels of the frontal lobes in our brains, how we manage that. How we have a sense of being able to control, being either sometimes over controlled for people with highly restrictive eating disorders. For other people, there's sometimes too little control and that ability to modulate impulsiveness and a sense of actions that follows and emotions that we have. So what we call sort of top-down interaction of higher centers of the brain that are interacting with lower limbic system centers -those centers of emotional regulation, which are deeper in the brain. So that gets dysregulated as well, we think. And as I said, sometimes with restrictive eating disorders there's overcontrol, with Binge Eating Disorder and other disorders, there may be undercontrol, less ability to sort of modulate one's emotions and modulate impulsive actions.

So I think we are developing a much better sense of understanding of the biology of people with eating disorders and that is helping us in terms of thinking about what might be most helpful for the person in terms again, as I said, of personalizing therapy. For example, considering for an individual I if a therapy such as the Maudsley therapy for adults with Anorexia Nervosa be better? Because that really focuses on helping people with those dysregulated brain connections--helping them sort of be less controlled or more controlled using cognitive remediation therapy, that is part of the Maudsley treatment for adults with Anorexia Nervosa. So really we should be always thinking about the person and what would be most helpful for them, understanding both their life experiences and stories, but also their biology, their neurobiology, and the way their brain works.

I believe that you and I share a certain passion for improving mental health literacy regarding eating disorders. My personal goal is to implement educational programs in high schools and university campuses to increase the awareness of students and faculty while also decreasing the shame for those who may need help. Will you please share what school/campus-based public health interventions you believe are the most effective for preventing, recognizing, or increasing access to bulimia treatment with adolescents and young adults?

Internationally, the leading one really is the one that was developed by Eric Stice, at Stanford, and he's developed The Body Project, a cognitive dissonance program for students and young people to prevent, and not only prevent the onset of risk factors for eating disorders, but he's actually shown he can prevent the onset of an eating disorder, which is just so amazing to think that we can actually have a primary prevention of the eating disorder. So those programs have been highly researched. They really challenge the way people think and internalize the thin ideal and promote the young person's ability to really take charge themselves and not be overwhelmed by peer pressure, media pressure, etcetera, to engage in risk-taking behaviors that may develop into an eating disorder. Other programs that have also been effective are programs such as media literacy (e.g., the Media Smart program out of Flinders University), so really training people to be skeptical of what they see, understanding that pictures are distorted, that pictures that they see of leading models are all distorted, that they're not real. So really having that knowledge base to understand that what they're seeing and what they're being presented with is not real, it's not actually true. And it's not something that's attainable, even for real people. So those media literacy programs have also been very effective in reducing young people engaging in behaviors or thoughts that lead to an increased risk for an eating disorder. Thirdly, I think The Project EAT by Dr. Dianne Neumark-Sztainer in North America has been really encouraging young people to eat well and to be positive in terms of how they feel about themselves, their bodies, whatever size shape the body may be--to eat well, to be active, and to feel well. That has been shown to help young people prevent becoming over-concerned and also prevent other factors which we know increase the risk for people with eating disorders. So actually valuing one's body shape and weight, whatever that is, and looking after it and loving your body, I suppose, being very positive about your body whatever weight or shape it is, and being active and promoting health at whatever size you are.

You also mentioned you have a goal of mental health literacy. And I think that is also really important. I think one of the things we've found is that poor mental health literacy or people not understanding what eating disorders are has been a major barrier to people accessing care and help. And that's been both for people in the community, but also for healthcare professionals. So myths about what an eating disorder is or that people have to be so very thin to have an eating disorder, for example, have been a real barrier. And we know that early treatment and early prevention make a big difference. So getting into therapy and treatment before someone becomes extremely thin is really important because it's much more likely to result in something that they can be helped with, in a shorter period of time and don't have to spend years with an eating disorder. I see many people with eating disorders and we know this from the research as well who have had it for a decade or more before coming first for treatment. And all those years, struggling with an eating disorder need not have been there, if possibly there'd been better mental or literacy on part of both the people in the community, but also healthcare professionals. This is a problem, and we can help someone with it at an early stage. So I think that's really, really important as well.

Resources Recommended by Professor Hay:

Butterfly Foundation: https://butterfly.org.au/

Mental Health First Aid: https://www.mentalhealthfirstaid.org/

National Eating Disorders Association: https://nedc.com.au/

Author: Merrit Elizabeth, CCI Certified Eating Disorder Recovery Coach

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