Why cause matters - nature and nurture

It gives me fits when people profess not to care about the cause of eating disorders. Or, in what I see as a weasel defense, people say "eating disorders are caused by a combination of factors" but then go on to tell you which one they think it really is. Even the Maudsley literature is "agnostic."

But cause does matter. Treatment is determined by what you think the cause is, or isn't. And we all know it. That is why Dr. Insel, head of NIMH, lamented in September that what ED treatment you get has more to do with who you consult than the nature of your own disease.

And yes, I believe in what Dr. Cynthia Bulik says about this: it isn't nature VERSUS nurture, it is nature AND nurture. But people use that wiggle space to insert their proportions to that and to put in a whole lot of stuff in the environment category that just doesn't belong there.

Environment is nutrition, prenatal exposures, diseases, co-morbid psychiatric conditions, stress - as well as a ridiculous media, overanxious moms, abuse, misogyny, and social ills. Saying 'environment' is so broad we can drive a truck of donuts through it. Or rice cakes.

Whether EDs are a choice or a tendency or a set of traits or a discrete biologically determined illness matters to your insurance agency as well. And at $1K+ a day for whole-hog (sorry!) treatment you better bet it matters to families what insurance pays for.

People have a lot of investments, literally, in what they believe causes EDs.

If you know me, you know I lean toward a 90/10 ratio of biology/environment. And the environment, in this case, is the avalanche of support for dieting. I flip the ratio when it comes to treatment, strangely enough: I think 10% of recovery is the full nutrition part and 90% is maintaining and reinforcing an environment which is emotionally supportive, firm against the disease, and teaches skills to prevent relapse. Both factors are necessary, but not sufficient, on their own.

That environmental 90% requires enormous and unyielding resources from everyone involved. Although there are families who can do it all on their own - they shouldn't have to. Insurance should, in the interests of long-term health AND their own balance sheet, fully cover therapy and nutritionist support and psychiatric services and inpatient treatment and hospitalization for AS LONG AS IT TAKES. Just as they would for a tumor, kidney disease, or asthma.

Families have taken on the insurance industry successfully on treatment, like the Westin family in Minnesota, but they LOST their daughter first. Some families in New Jersey are banding together to get full coverage for EDs and taking on the term "biologically based," as are others. The Eating Disorders Coalition and the National Eating Disorders Association are also fighting for legislation that will move mental health parity forward.

Cause matters. Ask your providers where they stand.


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