Co-Occurring Eating, Substance Use Disorders Present Complex Challenges

Despite eating disorders and substance use disorders (SUDs) having some of the highest rates of mortality among psychological disorders, particularly when they are co-occurring, there are few evidence-based interventions to treat both conditions simultaneously.

At the Cape Cod Symposium on Saturday, Meghan Johnson, LCSW, CCS, clinical supervisor at Crossroads in Scarborough, Maine, explored the complexities of substance use and eating disorder treatment, as well as ways in which practitioners can bridge the gap between treating the 2 disorders. Prior to the Symposium, Johnson spoke with Addiction Professional about the unique challenges of treating these disorders concurrently, appropriate interventions, and the belief that co-occurring treatment can serve as a means for reducing stigma associated with SUD and eating disorders.

Editor’s note: This interview has been edited for length and clarity.

Addiction Professional: What are some of the unique challenges clinicians face when treating co-occurring eating disorders and substance use disorders?

Meghan Johnson: That’s the core question I have built my career on. I currently work in a program that supports women struggling with co-occurring eating disorders and substance use disorders. Having previously worked in each of the different populations separately, I've been able to bring the 2 together. Because of my background in treating both, I've been able to see the crossover, and that became very clear to me early on. A lot of providers don't necessarily see the similarities, and there's usually this thing that happens where clients bounce from eating disorder treatment to substance use disorder treatment back to eating disorder treatment, and it can be really challenging to help find stability when a client is always between one or the other. There are not a ton of treatment providers that offer more of an integrated care model, which has been proven to be very effective in working with this population.

One of the most challenging things is the lack of access to knowledge and education about the unique needs of these populations that have 2 different, really strong symptom presentations, and the physical needs have to take place in the treatment setting to be able to accommodate both. In my experience working with these 2 populations, they're 2 of the hardest to treat just because of the availability of their behaviors, whether it be food behaviors or substance use behaviors. A lot of research has shown that treating these separately increases the risk for lack of stabilization for either one. So if the substance use disorder treatment is going well, but the eating disorder behaviors and symptoms are active, there's a much lower likelihood of sustained sobriety or recovery. Eating disorders are also incredibly damaging to physical health, so medical providers and nutrition providers must be involved. It’s really important when treating these conditions together that you have the right resources and the right tools to be able to give effective treatment, otherwise the clients are going to continue bouncing back and forth.

Lastly, it can be challenging to treat these clients because oftentimes they don't want to work on both at the same time because these behaviors feel like something that they're relying so much on, to let go of one or the other at the same time feels pretty intolerable. Sometimes, even when we get the client into the right type of treatment, there is a lot of resistance and unwillingness to actually start to let go of both at the same time.

AP: What is that right kind of treatment? Are there clinical interventions that you're finding are particularly effective when you're treating both of these conditions concurrently? On the flip side of that, are there interventions that might be effective when you're treating someone with a substance use disorder who doesn't have a co-occurring eating disorder as well, or maybe vice versa?

MJ: Definitely. The nice thing about treating both is that a lot of the interventions that we use for each work very well together. My favorite crossover treatment is often DBT (dialectical behavior therapy) because of the ways that substance use and eating disorders both really make it challenging to regulate emotions, have healthy relationships, engage in mindfulness, and tolerate distress. The challenging piece as I've been really digging into this topic is that there's such a lack of research base for this. There are currently 3 evidence-based types of research for studies for finding interventions that treat co-occurring eating disorders and substance use disorders. This year, we saw the first qualitative data study on what these clients are actually advocating for that have gone through this parallel treatment, as we call it, when you go from one to the other, and talking about what they're really looking for in that integrated care model.

In my own experience working with this population, we have to go with what we know. Some of the more common interventions, while we're used to using them in these specific populations, when we start to look at the connections that bring the 2 together rather than what makes them different, we start to see that it's a lot of the same stuff. A lot of the function of substance use disorders and eating disorders is an attempt by the person to self-regulate. For those that are familiar with one of my favorite curriculums, which is Seeking Safety, we really get this language around people that are using maladaptive coping skills to self-regulate for trauma. In my work with clients, I adapt Seeking Safety to include language around eating disorders.

There's no evidence base for that, so it's challenging to ask whether this is this effective or not, because we just don't know. But if you see the parallels in the language, it's very clear that that both apply. Especially for our folks that have co-occurring, the substance use and the eating disorder are playing the same role—they both need to be looked at simultaneously.

Another essential intervention is always doing some work around the trauma. So often these maladaptive behaviors come up around an attempt to self-regulate the traumatic pain and the emotional pain that comes up for someone when they stop engaging in these behaviors. Safe and sober, working on their eating disorder, and treating trauma at the core of it. There are many different studies around the prevalence of trauma when it comes to eating disorders and substance use disorders, so that really needs to be addressed to find lasting stability and recovery. Regarding treatments, I do  cognitive processing therapy (CPT) with clients. There's also EMDR, somatic interventions, somatic experiencing, anything that helps to process what's coming up for the person. Seeking Safety is also a great one for individual and group work. There is a lot of crossover, but I think most providers that I know that treat one or the other just need the information about how to bring them together.

AP: How do you think that co-occurring treatment can serve as a strategy for reducing stigma that is associated with substance use disorders and/or eating disorders?

MJ: That’s something that I see a lot. As substance use providers, we're pretty used to talking about stigma when it comes to substance use. For folks with eating disorders, there's a lot of shame around the behaviors themselves. There's a lot of secrecy around the behaviors. Both presentations of these symptoms really inherently are based around this kind of shame, and stigma can be such a barrier for people seeking out treatment. So, I think through the trauma interventions and the skills-based treatments that we can use to help clients themselves deal with their own internalized stigma and internalized shame because there's a lot of that language out there. "Substance use is a choice," or, "Why don't you just eat?" People don't understand the really root function of these disorders, which is trying to manage this traumatic pain.

When we start to give the client the language to understand that these aren't things they're doing because they're choosing to do them, they're things that they're doing because they're trying to survive this traumatic pain that's coming up—it becomes a tool of survival. The first step must be empowering the client with the language to be able to understand the functions behind these behaviors that they feel so shameful or feel so stigmatized about. There's been a lot of talk in the substance use movement about moving away from stigmatizing language. A lot of people talk about people that use substances as being “dirty” and then people that are sober as being “clean,” and there's been a lot of work to really try to target that language so it is less judgment-laden and less shameful.

It's really interesting because we see the same thing on the eating disorder side, that foods are labeled as good or bad. Both have these really polar opposite ideas that inherently go into the person, "I am dirty or I am clean. If I eat good foods, I am good. If I eat bad foods, I am bad." So, the way we're working on changing the language around substance use, we can also apply to eating disorders and try to let go of this morality that comes with food because it can be so damaging for someone who's trying to really increase their intake or add variety and really take care of themselves. It gets away from that black and white thinking, which again, DBT is really helpful with tackling.

One thing I really want substance use providers to know is that the focus on cleanliness or cleanness in early recovery can be really damaging to someone with an eating disorder because we talk about, "I'm eating clean," or we talk about, "I'm only eating organic," or, "I'm only eating these certain foods," or, "I'm going on a diet," and how that psychologically can really impact somebody who's new in their eating disorder recovery. So, the same way we're trying to get away from the stigmatizing language of substance use, we also should be thinking about some of the language we might use around food that could impact someone who is judging themselves for what they're eating and struggles with an eating disorder.

AP: Was there anything else that you wanted to mention that we haven't covered yet?

MJ: Generally, anybody who's treating a substance use disorder, particularly for women, is likely also treating an eating disorder. Even the referrals I gather, the other professionals I talk to who don't specialize in this field, they're seeing it and they don't know how to treat it. And if they're not seeing it, it's just better hidden and it's definitely still there. Really recognizing that integrating these 2 disorders and finding treatment is an urgent need of the population.

I also want to mention that eating disorders and substance use disorders separately are the No. 1 and No. 2 highest mortality of all psychological disorders. When they come together, that mortality risk goes up. So, it's a very vulnerable population we're treating. Just like any other disorder, we want to have really solid, evidence-based treatment that we can offer to people that's going to work for them and help reduce their risk and help them find a better quality of life and more stability.

References

Johnson M. Exploring the complexities of substance use and eating disorder treatment. Presented at Cape Cod Symposium on Addictive Disorders; September 7-10, 2023; Hyannis, Massachusetts.