HDRM: Strengths and Weaknesses
In many ways there is nothing special about the HDRM protocol for treating an eating disorder. There is no magical treatment out there, as anyone with an eating disorder tends to already know. Eating disorders are known in the medical and psychiatric businesses as “refractory,” or resistant to treatment. Yet untreated, they progress to serious disability and early death. In other words, the treatments on offer today, including HDRM, fall well short of an as yet unknown cure but they are out there doing their best to try to stem the tide of disability and early death.
As with all other treatment protocols, HDRM will be very well suited to some and not to others. You will find in Treatment Options information on all the other common science-based protocols out there and are encouraged to assess what approach seems to fit best with your treatment goals.
In the twelve years to date that patients have been applying HDRM, there are clear successes and failures in the same range as is seen with FBT. Here are the strengths and weaknesses associated with applying HDRM when considering the other options out there:
HDRM is designed for adults living in community. While it can be applied in acute inpatient settings, it is best suited for either post-release from an inpatient program, or for adults living independently (either alone or with a partner, friends or family). It can be applied for minors still living with their guardians at home, but this is a condition that tends to reinforce food avoidance by having patients think it is best to hide the symptoms from others and to try to “recover on their own.” While HDRM is designed to be a patient-led treatment option, it is not meant to be a secret treatment option. We encourage adolescents and adults alike to involve their nearest and dearest.
The patient has to be comfortable either counting calories, or else having someone who lives with them, or a dietitican, build out the meals to match the minimum intake guidelines in HDRM. For some patients, calorie counting is is nightmare but people with eating disorders are the only people who overestimate what they think they are eating (by as much as 30%). There is no other way to ensure those minimum amounts are getting eaten every day except that someone is counting. However, meal plans developed by a family member or dietitian that meet the minimum intake (and are designed for excess) are a good workaround.
The patient has to have a support structure in place to a) give into extreme intake of food, and b) deal with the distress (both physical and emotional) that approaching and eating large quantities of food will generate. In the Minnesota Starvation Experiment the return to pre-starvation intake of food did not help the subjects recover. They were continuing to deteriorate until such time as the reseachers provided unlimited amounts of food. There was a multi-month protracted period for the subjects of extreme refeeding where upwards of 10,000 calories were consumed in a day. The references on that are found within the Phases of Recovery. For the body to recover from an energy deficit the minimum guidelines in HDRM are utterly insufficient; they are the jump off point to a period of extreme refeeding.
HDRM recognizes that a patient’s weight will never reflect whether there is an energy deficit in the body or not, and therefore it has a greater success rate than all other treatment protocols for the 60% of patients with active eating disorders who do not meet the weight criteria for focusing on refeeding and restoring energy.
Patients get stuck in cycles of temporary improvements and deterioration with all other treatment protocols because weight is considered the definitive marker for having completed the treatment program. For the vast majority, the weight target leaves them both underweight for their natural set point and severely energy depleted as well. While relapse can happen for patients applying any treatment protocol including HDRM, HDRM is a practice of unrestricted eating for life that mimics what those who don’t have eating disorders do naturally.
Unrestricted eating is what those without eating disorders naturally do, even as we live in a culture that has everyone cycling through the latest diet. Diets fail precisely because people without eating disorders have systems that ensure they return to an energy balanced state. The greatest weakness of HDRM is that it is not aligned with the cultural dogma that losing weight signifies health and success. HDRM calls out the healthcare professional communities that struggle to determine when they are spouting dogma and when they are practicing evidence-based medicine. What this means is that your doctor, nurse, therapist, dietitian, nutritionist, physiotherapist, spiritual adviser, family, neighbour and strangers on the internet are all going to advise you to recover but to not get fat or lazy while doing so. This is HDRM’s greatest strength: it rests on the research and not the dogma. Just because our culture has absorbed the juggernaut funding engine that has us believing the weight loss and wellness industries are based upon some kind of scientific evidence does not mean the evidence is really there. It’s not.
Most patients contemplating HDRM are going to need to wade through the reams of referenced materials and that is why this site exists— as a synthesis of the what the evidence tells us about resting and refeeding as a real way to get an eating disorder into complete remission. Everyone contemplating HDRM combs through the evidence on this site with a very fine tooth comb. They have all the requisite questions and doubt and they scour the internet to learn about others’ experiences using HDRM.
Patients with eating disorders tend to be the most intelligent, inquisitive and analytical group that I’ve come across within the mental healthcare field, as a generality. And you will have to depend upon your own decision-making skill and instinct to embark upon any treatment for an eating disorder.
Finally, despite our best efforts to understand chronic illnesses, eating disorders included, there is absolutely no assurance that what is known to work for others will work for you. All I can do is give you as much as I’ve managed to amass here on the topic, and you take it from here.
