Why Choose Us
A letter from the director
Walter H. Kaye, MD
For over 35 years, I have worked in the eating disorder (ED) field. As a researcher, I have published more than 300 papers. As a clinician, I have directed ED programs at the National Institute of Mental Health (NIMH) in Bethesda, then at the University of Pittsburgh, and for the past 11 years, at the University of California, San Diego. I have seen the ED field go through many changes as new research and treatments have emerged, as insurance companies increased coverage for treatment, and currently as the number of treatment centers has quadrupled.
Individuals and families now have more treatment options that ever before. While access to care is increasing, our patients and families are telling us that it is confusing and difficult to navigate the dozens of websites for various treatment programs to find help for themselves and their loved one. Our colleagues in academia and in the popular press have written about for-profit, private equity owned, franchise based treatment centers that make up the majority of ED clinics in the United States. As a university-based program, we want to help individuals be better consumers of mental health services, to discern marketing from facts and find the program that is the best fit for you and your family.
The first reason to write this letter is to provide consumers information about the causes of eating disorders and the most effective treatments, which are based on science and data. Second, to describe the ways in which we are able to provide treatment that is a scientific, evidence-based treatment that is individualized for each client.
As part of one of the world’s top research universities, we run three synergistic programs: a treatment program, a research program that develops new treatments, and a training program. Being a part of a university holds us to the highest standards of patient care and academic integrity as we strive to improve the lives of those with eating disorders—both at our facilities and around the world--through the creation, dissemination, and practice of cost-effective, evidence-based treatment. The approach in our program is to use scientific studies and data that is published in reputable journals to guide us in terms of understanding causes and treatments. The UC San Diego Eating Disorders Center is the only university-based treatment center in San Diego, and one of the largest single-site programs in the United States. Importantly, we are able to take revenue, that for-profit programs must return to investors, and instead re-invest it in our program by hiring more experienced staff and developing improved treatments.
Our program seeks to employ what is known as “evidence-based treatment” (EBT). EBTs are treatments in which published studies have shown proof that this treatment results in improved outcome. In order to provide EBTs, you must have staff that are professionally trained in the treatment in the same way in which it was researched. For example, Dialectical Behavior Therapy (DBT) is an evidence-based treatment only when it is implemented with all of the components: weekly skills groups, individual therapy with a DBT-trained therapist, nights/weekend phone coaching, and a consultation team. Providing only one component (e.g., a weekly DBT group), particularly if it is not with a DBT-trained therapist, is not evidence based. We utilize EBTs, with expertly trained staff, delivered in the ways that have been evidenced as most effective.
“The number of eating-disorder specialist clinicians who report adhering to evidence-based protocols and manuals is between 6 and 35 %. Far more clinicians report that they use (un-tested or un-supported) mixtures of some techniques that are derived from empirically supported treatments and some techniques that are not supported even at that level. Even when clinicians say that they are using an evidence based therapy, that claim should be treated with caution. For example, many clinicians who state that they are delivering CBT or FBT report that they omit many of the key techniques that make up those treatments. This omission is reflected in the accounts of eating-disordered patients reporting on the treatment that they have received, as their accounts suggest widely divergent patterns of techniques delivered.”
Some ED programs claim, on their websites, that almost all of the patients they treat show an outstanding response. These types of claims are not consistent with the published literature, which shows that, unfortunately, many with ED relapse after discharge from treatment, or have a chronic course, or even die. Although it can be tempting to believe these claims, we know that not everyone in treatment will do well after discharge – this is too difficult a disorder. If someone has truly invented a better treatment, they would explain their treatment approach in detail at industry meetings and in reputable journals. The scientific community demands that proof supporting such claims needs to be published in a reputable journal after stringent peer review. Using distorted outcome data as a marketing tool hurts the science, the families, and most importantly, the patients.
There are several issues that may inflate claims about outcome. For example, claiming improvements at the time of discharge unfortunately has little meaning, as people usually are not discharged until they are doing better. Because of the high relapse rate, what is critical is demonstrating that people can maintain good outcome months after discharge. Another issue is selective follow-up; that is, only reporting follow-up on a subset of patients. It may be that those that have good outcomes may be more agreeable to complete follow up assessment whereas those who did poorly might not complete the questionnaire, leading to very biased results. Many treatment centers display outcome data on their websites but do not submit their outcome data to peer-reviewed journals that ensure that they used scientifically sound methods. Our program publishes outcome data in well-reputed, peer-reviewed journals. And, our program is based on the literature published by other investigators to identify treatments that have some proven efficacy.
In truth, there is no single therapy or approach that is proven to work for all people with eating disorders. People with eating disorders tend to have different mixtures of symptoms, varying degrees of anxiety or depression, too little or too much impulse control, and differences in home support systems; thus we seek to tailor treatment for each person.In order to tailor treatment to an individual, it is essential to have a large staff of full-time eating disorder experts. Treatment is a major investment of time and money—an individual should not have to participate in a group that does not pertain to them (e.g., trauma, substance use, perfectionism, self-harm, etc.) simply because there is not enough staff to lead additional groups. In each of our three programs (Pediatric, Adolescent, Adult), we are able to offer two or three groups simultaneously so that individuals only go to the groups that are the most relevant to them. Most importantly, we never combine children, adolescents, and adults (we have three separate programs) because they have very different developmental issues and require different treatment approaches.
There has been substantial accumulating evidence that Family-Based Treatment (FBT), also referred to as Maudsley method, is significantly more effective than other sorts of treatment for adolescents with anorexia. Several members of our staff are widely considered experts in FBT/Maudsley and are invited to give talks and workshops on the subject worldwide.
Additionally, Dr. Ivan Eisler, the creator of the Maudsley Method, is our frequent collaborator, offering trainings to our treatment teams several times throughout the year. We also have weekly FBT workgroups for our staff and are able to film our therapy sessions (with client’s permission) to ensure that all members of our treatment team are adherent to the treatment. As discussed above, despite being the gold-standard treatment, few eating disorder clinics offer FBT to their patients and families. http://link.springer.com/article/10.1007/s11920-016-0679-0.
It is critical to note that while FBT is currently the most effective treatment, it does not work for everyone. In fact, the literature shows that 50% to 60% of individuals have a good outcome a year after treatment—leaving many patients needing more. For the patients and families who do not respond to FBT, or for whom FBT may not be a good “fit”, we integrate other forms of evidence-based treatment, such as dialectical behavior therapy (DBT), parent management training, and cognitive behavior therapy (CBT). By having a large and diverse staff, we are able to offer multiple treatment approaches and work with families to provide the best possible treatment for each patient.
Some people with eating disorders have difficulties with impulse control and report experiencing emotions more intensely than their peers. They may be over-reactive to stress or change, use drugs and alcohol to cope, and have self-destructive urges. Or they may be under-reactive to emotions and over-controlled. Brain imaging research suggest such behaviors are related to brain pathways which regulate mood and reward, and/or ability to inhibit behaviors.
We have adapted an evidence based therapy, called dialectical behavior therapy (DBT) to treat such problems in those with ED. We have separate tracks for those who may be over-reactive or under-controlled, as well as a track for those who may be under-reactive or over-controlled. I like to think of our treatment as a school for emotions, when clients work with highly trained therapists to develop more effective strategies in order to reduce relapse. DBT is a comprehensive, behaviorally-based therapy that has a large research literature to support it. In DBT, patients learn skills to cope better with their emotions, so that they don’t turn to self-destructive behaviors in an attempt to control their emotions.
True DBT—the kind with substantial evidence suggesting its effectiveness—includes DBT skills groups, a therapist consultation team, night/weekend phone coaching with their primary therapist, and special treatment strategies like diary cards, behavioral chain analyses, and family involvement. Phone coaching with the primary therapist is a vital component to effective DBT; to our knowledge we are the only eating disorders program that offers after-hours phone support with the primary therapist. The reason we offer phone support is that we want the skills clients are learning in program to generalize to struggles outside of program. DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives.
One way that we tailor treatment is to offer specialized treatment programs. In addition to having separate clinics for young children, teens, and adults, we also have tracks tailored to individual symptoms or comorbidities. A few of these specialty tracks include:
Avoidant Restrictive Food Intake Disorder (ARFID): There has been recent recognition that a substantial number of children suffer from ARFID, which can present as very picky or obsessive food choices, low or absent hunger cues, or intense fear of swallowing, vomiting, or aversive food reactions. We have developed one of the only ARFID clinical protocols and are able to create tailored treatment plans for individuals struggling with ARFID.
We also have specialty tracks for trauma, binge eating, bulimia, anorexia, males—having a large staff of expertly trained therapists allows us to run many groups simultaneously so that all groups are small and tailored to the individual’s specific symptoms and needs.
Learning to effectively use an evidence based treatment (EBT) is as complicated as learning to do brain surgery. It takes many months to years to learn complex psychological treatments. Would you go to a brain surgeon that spent a weekend learning how to operate on your brain aneurism? Thus we have constructed a system that would ensure that the therapists who were treating your children had deep training, continued supervision, and demonstrated competence.
I worked with Dr. Jim Lock at Stanford on developing a multicenter study of Family-based Therapy (FBT). Dr. Lock trained and certified Dr. Roxie Rockwell (link to bio), who is now head of our adolescent program. Training took many months of supervision, and many test cases before she was certified as a FBT therapist. In addition, Dr Kerri Boutelle (link to bio), one of our senior psychologists, has been certified as a FBT trainer by Dr. LeGrange, who has been Dr. Lock’s partner in developing and disseminating FBT in the US. Dr. Stephanie Knatz (link to bio), the lead clinician in our intensive family therapy program, has been trained by Dr. Eisler (link to bio), who is the person at Maudsley acknowledged as the principal architect of FBT and who is a visiting professor in our program at UC San Diego. Dr. Eisler hosts up to 20 days of training for our staff each year. Dr. Leslie Anderson (link to bio), who is our director of training, learned dialectical behavior therapy (DBT) at the University of Washington in Dr. Marsha Linehan’s training clinic (the creator of DBT). Dr. Anderson has adapted DBT for ED in a partial hospital setting and trains and supervises our staff.
At UCSD, we have established a training and supervision program for our staff to ensure that our clients get consistent high quality, evidence-based care. All staff, regardless of how many years they have been licensed, participate in over 50 hours per year of ongoing training with weekly didactics, workshops, and our annual conference. With client permission, we have the ability to film sessions to ensure fidelity to the evidence-based treatments. All staff also participate in weekly supervision and case review along with establishing a personal “deliberate practice”—to continually assess and improve their clinical skills.
Our most valuable resource is our staff and faculty. Eating disorders have the highest mortality of any mental illness. ED behaviors are complex and it takes many years to learn and become highly skilled in delivering evidence based treatments (EBTs). Thus the most important investment any treatment center can make is in a well-trained, full-time treatment team. Psychologists (doctors with PhD’s or PsyD’s) spend a minimum of 11 years in school and training before they are eligible to be licensed. We have 11 full-time licensed psychologists and 10+ psychologists completing their final years of training prior to licensure. Similarly, psychiatrists have a medical degree (MD) and have 12 or more years of education and training. We have 6 physicians on site with various specialties in pediatric, adolescent, and adult psychiatry. We are the only eating disorder clinic in San Diego that employs full-time physicians and psychologists; we always have a medical doctor on site and clients have daily access to their doctors.
Our entire treatment team works full-time; this ensures that patients have access to their psychiatrists, therapists, and dieticians every day. Full time staff also ensures that staff have adequate time for training, attending treatment planning, and meeting with patients and relatives. If people work part time, it is less likely that they have sufficient time for ongoing training and collaborative care.
It is with great pride that I share that we have near zero staff turnover. The majority of our staff have been here for 4-10 years, and while we add new staff each year as the program grows, we rarely need to throw a going away party! Because each and every member of our staff is such a valued part of our program, we post detailed bios for our entire team on our website describing their training and expertise. Many treatment centers publish only the bios of the executive leadership team on their websites, not the actual staff who provide patient treatment. Many programs claim to offer evidence-based treatment such as FBT or DBT, and yet the names of the therapists, or their training, is often not provided. If ED programs have staff with little ED expertise or university training, and where there is often high turnover, treatment approaches are more likely to be inconsistent and not well informed.
The bottom line is that we have highly trained staff with enormous expertise in ED treatment who have put systems in place to train and supervise staff and maintain a high level of treatment quality.
It has been common in the ED field to recommend long hospitalizations or residential stays to normalize nutrition. However there has been little data to support this approach and many people report difficulties transitioning from 24/7 care to living at home. Additionally, these are often chronic disorders and few people have the resources or desire to stay in a residential environment for many years to avoid relapse.
At UCSD we tend to treat people in a day or evening treatment (4-10 hours per day) and have them live at home or in our supportive housing with peers. We want to work with parents and significant others as allies, and help them understand ED behavior and learn strategies they could employ after discharge to reduce relapse. Living at home reduces people becoming dependent on a protected living environment and helps them learn to cope with daily stresses of life.
In our 10-hour Day Treatment (aka partial hospitalization) program, individuals receive nearly all of their nutrition in clinic, and are able to interact with the real world each evening after program. Clients are encouraged to contact their individual DBT therapists on nights and weekends to receive phone coaching if they are triggered to use ED behaviors.
Lastly, our review of inpatient and residential treatment centers suggests that many take a “passive supervision” approach, encouraging rest and relaxation, while individuals are supervised to prevent ED behaviors. In contrast, our program utilizes an “active treatment” approach where clients spend their days engaged in curriculum to learn and build skills to cease ED behaviors and prevent future relapse.
For other illnesses, we have had biological markers such as high blood sugar or high blood pressure to define an illness. It has been difficult to “measure” and understand the biology underlying human behavior because the brain had been inaccessible. Now new technologies, such as brain imaging, are providing new insights into why people have eating disorders and this is changing our concepts and treatments. That is, we now understand how powerful brain neural systems can contribute to developing and maintaining an ED. Importantly, we are using these insights at UCSD to develop and deliver more effective treatment approaches.
Many people diet in our culture, but few develop anorexia or bulimia. While culture or society often make substantial contributions to developing an ED, it stands to reason that the rate would likely be much higher if the cause was only culture and society, given the high rate of dieting in this country. Repeated studies have shown that heredity and genes are often important contributions to developing an ED. While there isn’t a gene for “eating disorders”, it seems that what is inherited are some important personality temperaments. Recent studies show that many people who develop an ED tend to have certain temperament and personality traits in childhood, long before they have an ED. For example, individuals who later develop anorexia were reported to be perfectionistic, anxious, obsessive, compliant, shy, risk avoidant, achievement-oriented, and/or picky eaters as children. It is important to note that people tend to have different patterns of these traits – but often people have at least some of these traits.
Scientific studies suggest that these traits are due to the way certain brain pathways function, and when these traits are focused on food or the body, people are vulnerable to developing an ED. These traits tend to be lifelong. I have been doing research on people who have recovered from ED for more than 30 years. People who recover often do very well in life. Many of the traits turn out to be strengths in the long run. For example high attention to detail, concern for consequences, high self-discipline, and determination to achieve all are strengths for many endeavors. We are using this information to help people find constructive coping strategies—as one father put it, “learning to use their traits for good, not ED.” Instead of a one-size-fits-all approach, our aim is to develop approaches that are tailored to specific issues. It may be that extremes of eating (restricting or binge purge behaviors) may be ways to temporarily reduce some uncomfortable feelings. Many patients describe that restricting makes them feel less anxious, or purging provides relief from overwhelming emotions. Thus a major focus of our treatment program is to help people develop constructive coping strategies for uncomfortable feelings or non-productive behaviors.
There is a critical need to develop more effective treatments for ED. This is an important goal of our program. As discussed below, our program is engaged in research on understanding how the brain works and applying this information to develop new psychotherapy approaches and finding new medications. Over the years, my laboratory has published more papers on brain imaging than any other group in the eating disorder field. One thing that is very special about our program is that we have many faculty who combine expertise in treating eating disorders with expertise in developing better treatments. Most importantly, these faculty provide clinical care to our patients, as well as train our staff.
The focus of our efforts is to understand the forces underlying behavior in those with ED. For example, how are people with anorexia able to eat a few hundred calories a day and become emaciated when most people struggle to lose a few pounds? Normally, hunger activates reward brain regions that motivate people to eat. Those with anorexia fail to have a reward response to food – no wonder they can restrict their eating. Moreover, food makes them anxious. We apply this new knowledge to our treatment program. For example, we recently published a paper summarizing new approaches to learning to deal with diminished reward and increased anxiety in the European Eating Disorder Review. (LINK) In summary, we learn from reward and punishment; if something is rewarding, we learn to do it more, and if it is punishing, we learn to do it less. Considerable research suggest that people with anorexia tend to have difficulty learning from reward, but are oversensitive to punishment. That helps explain why they are so sensitive to criticism, change, or feel like they are always making mistakes, or things are never right or rewarding for long. Parents often attempt to use reward to get their children to eat and maintain their weight, but report little success likely because individuals with anorexia have difficulty coding reward. We have developed a contracting system for families to both understand and capitalize on their child’s imbalanced reward/consequence system. This is one example of how our research program and treatment program are synergistic as we constantly develop and test new treatment to help people get better, faster, and with fewer relapses. Our research helps clients and families understand why such puzzling behavior occur and how to manage it. Our staff use this information to understand and empathize with behavior seen in eating disorders rather than blame and label those suffering as being non-cooperative or manipulating.
Some people with ED may be highly anxious, or obsessive, or have very unstable, over-reactive moods. There are limited options in terms of treatment for anxiety, OCD, or unstable moods. Talk psychotherapies can be very useful in helping people learn how to manage or tolerate these behaviors, but people entering our program have often tried such approaches for many years with little success. For some people, the addition of medications may reduce symptoms to the point where they can make better use of psychotherapy. Unfortunately, we often find patients have tried many medications in the past with limited success. We are using new understandings of brain processes to identify new medications that may be more successful. We are fortunate that we have psychopharmacology experts on our staff. Dr. Terry Schwartz, (who is a long-standing best-psychiatrist awardee in San Diego) and Dr. Mary Ellen Trunko (who is both a psychiatrist and internal medicine physician) have published a number of papers showing some efficacy for new medications in those with anxiety or emotional dysregulation in ED. In addition, we have 2 expert child and adolescent psychiatrists (Drs. Gray and Haber) who have additional expertise in ARFID and OCD disorders. It is rare for an ED program to have such full time, intensive medical and psychiatric care, but this allows us to treat severely ill patients who might otherwise require a higher level of care.
Many of the eating disorder programs in California are owned by large, out of state companies. Consequently, the management is not local or clearly identified. In comparison, we are a UC San Diego program, managed and operated solely by people who live in San Diego. You can view the training and expertise of our staff on our website (link). Because we are a university-based program, one of our major goals and responsibilities is to raise the level of mental health treatment and awareness in San Diego by providing education to the local community, and providing national and international teaching with our conferences, talks at meetings, and publications.
If you have questions or concern about treatment, we want to know about it. I encourage you to email or call me. (firstname.lastname@example.org; 858-534-8019). Similarly, the directors of our divisions want to hear from you as well. Their contact information is on our website.
We believe that we run one of the best eating disorder programs in the world; we certainly work very hard to do so. We are delighted to have other researchers and clinicians look critically at our methods and our published studies. We work hard to encourage others to adapt evidence-based treatment models as this is the best hope we have for any affected individual to recover.
UCSD is an academic center that has patient outcomes as our number one priority; while we need sufficient income to cover the cost of treatment, our main goal is to save and improve the lives of the people and families affected by these serious, genetic, brain-based and environmentally-influenced neurobiological disorders. We are here to both effectively treat your loved one with individualized evidence-based treatments and to develop and share new and effective evidence-based protocols to help all those affected by eating disorders now and in the future.
I appreciate you taking the time to read this letter. Please contact us if we can be helpful to you or your family.
Walter H. Kaye, MD