The Ongoing Need to Eradicate Blame from Eating Disorder Treatment

In recent decades, eating disorder treatment opened up access to care and improved the initial diagnosis by primary care doctors and pediatricians. Awareness has clearly increased, and doctors who see people with an eating disorders have resources for referrals. That’s a great improvement.

What has not changed is the overall mindset and morality about the diagnosis and towards patients, even among health care professionals.

Since the advent of the eating disorder diagnosis in the early 1970’s, clinicians remain perplexed about the cause and persistence of eating disorder behaviors. For people with little familiarity with these illnesses, it’s unthinkable to struggle with restriction, binging or purging, especially after months or years of treatment.

Incredulous as to what motivates people to continue the symptoms, clinicians and laypeople fixate on the myth that people are to blame for their illness. In this line of reasoning, eating disorders expose weakness or a lack of willpower in the individual—still the most used trope in recovery. Any failure to get better is the fault of the patient. Any medical symptom is caused by the eating disorder. The emotional and physical pain wrought by the disorder deserves no compassion and only further blame, insult on top of injury.

Blaming patients for their illness is a convenient way for clinicians to absolve themselves of any responsibility to help people get well. There is no need to think outside the box or consider other possible directions in treatment or to posit new ideas for causes of the illness.

The current business model for treating eating disorders is successful and lucrative. The philosophy is buoyed by a culture used to forging a connection between weight and self-reproach. The population with eating disorders are more likely to opt out of destructive treatment than fight back against an ineffective and often destructive system.

Creative options for care exist, and I have been writing about them in recent months. There is little appetite within the eating disorder field to look outside the current guidelines for treatment and care. Medical diagnoses that may be related to eating disorders don’t get any attention from a psychologically oriented community. The people who don’t get better are labeled chronic without much thought given to improving treatment for them.

In time, I suspect many eating disorders are likely to be seen as medical in nature. Research into the hormonal balance of gastrointestinal and metabolic functioning, a haywire allergy/immune system and misfiring of hunger cues likely will change the landscape of eating disorder treatment.

There will certainly be a psychological component to almost everyone’s eating disorder, but medical knowledge and interventions will help with diagnosis and a higher rate of successful treatment. Blame has no place in eating disorder treatment, and time will prove that to be true. 

Taking a Step Back: the Reality of Eating Disorder Recovery

Reviewing this blog from the past year, I wrote a lot about new avenues in the treatment of eating disorders. The new medications that affect our gastrointestinal system and the confluence of medical syndromes in eating disorder patients that doctors know little about dominated my thoughts.

The purpose of these alternate ideas is to improve treatment success for people with eating disorders. Even with adequate care, too many people still don’t get better. Many do, but the goal is recovery for all.

In that vein, I have started to look elsewhere, not for a new magical cure but for adjunctive treatment options that might increase the success and well being for people seeking help.

However, I do believe I left out the crux of treatment, or at least implied that the hard work is avoidable, if these other therapies are appropriate. The hard work actually remains the centerpiece of any true recovery.

The process of finding a committed, knowledgeable and well-suited treatment team is still paramount.

The struggle to eat one’s meal plan day in day out still is crucial for anyone to get better.

The daily obsessive thinking about body image will still be a very challenging and necessary part of the process of getting well.

And the healing of one’s body as it becomes accustomed to regular nutrition and improved health needs to be a top priority.

No new medication, no alternate diagnosis, no change in metabolism is a magical fix for eating disorder treatment. No matter the initial cause of the eating disorder—be it a general inflammatory syndrome, dysfunction in the gastrointestinal hormonal system, longstanding trauma or any of the myriad causes—recovery takes the same course. A thorough diagnosis and treatment plan may take these other issues into account, but recovery is still a challenging process. There are no shortcuts.

As I enter the new year working to expand treatment options for people with eating disorders, it must be clear that recovery is still a hard, long road. I just want the end of that road to be as successful as possible for everyone.

Accepting the post-GLP World

GLP-1 medications change the entire landscape of how we think about food, weight, our bodies and our health. Even more relevant to this blog, eating disorders are now perceived differently as well.

Any one person’s opinion about the benefits or risks of these medications is conjecture and largely irrelevant, including mine. We are all going through a cultural transformation that extends well beyond health. The tectonic shift in perception about our bodies is more to the point.

Thinness is back in. Any sense of body positivity or a generous understanding of the variability of the human body is out.

The pressure to be thin is stronger than ever, and the cost to do so irrelevant. Since GLP-1’s are available for a few hundred bucks per month, anyone inclined to take them can have them. And if anyone has any personal sense of what is best for one’s health, the current cultural trend demands you take them. What else could be more important?

Also the medical establishment is lying by acting as if we are predominantly taking these drugs to improve our health. Of course, some people do have meaningful health benefits: lowered blood sugar, decreased inflammation, lower alcohol cravings and improved cardiac risk, to name a few.

However, the true customers finding the medications are the healthy people who want to lose weight, pure and simple. That’s where the true profit comes from. That’s what is changing our cultural landscape because GLP-1’s have become the newest addition to medicine-adjacent, “healthy” treatments like Botox, plastic surgery, IV vitamin treatments and now GLP-1’s.

We all need to accept that the collective obsession with thinness landed us here. Experimenting with medications often prescribed by clinicians online who barely know the patent and have little justification to do so except for financial gain is risky business. Our health care system for actual illness has many inherent problems, but the self-care industry is thriving.

People with eating disorders will now include those with little or no treatment who choose instead to take these medications. They may seek help once the medications don’t work well. They may experiment with the drugs to try to manage their eating disorder. They may develop an eating disorder by using the drugs.

No matter how it plays out, GLP-1’s are part of the American zeitgeist and will affect all parts of life and continue to alter how eating disorders exist in our world. The first step is to accept this reality and move forward. I certainly have in ways I incorporate these drugs into my practice, work with people on them and find new ways to help navigate a world dominated by weight loss drugs, for better or for worse.

Shame and Our Bodies in Modern Culture

The shame many people experience about weight and body is a crushing burden. They live their lives with the unwavering belief that their body is unhealthy, unattractive and unlovable. They interact with others always feeling less valuable. These thoughts plague them every minute of every day.

In most posts in this blog, I write about body shame with respect to people with eating disorders. That feeling is central to the hold eating disorders have on a person’s life.

The shame people with eating disorders feel is often shared by others. Women and men, young and old, people of all different sizes experience enormous shame about themselves embodied by their physical being.

Recent posts highlight the fine line between an eating disorder and a body lauded by society. The external validation or vilification doesn’t always affect the internal experience people have about their body. Shame often exists no matter how the world reacts to one’s body.

To be clear, I don’t mean to compare the extreme hatred people with eating disorders can feel about their body with the more common pervasive shame. However, discussing widespread shame makes it easier to explain how common self-hatred is.

Our physical selves represent what we show to the world. Without knowledge of the other person, people can assess, judge, criticize or praise anyone’s body.

Our culture now and for many decades values thinness over almost anything. Thinness represents success and diligence, willpower and determination, financial means and the luxury of time and attention to oneself. Thinness is not the number on the scale or solely a measure of vanity. Thinness represents a moral high ground that can be the means to feel superior to others.

Anyone who perceives their body or their lives to be less than ideal can immerse their sense of failure and loss into body shame. Peers, media of all kinds, family and even doctors reinforce the idealization of thinness. Medications beckon people to inject themselves with the hope of an ideal body. Body shame is an accepted way of being in the world.

The purpose of a social construct built around shame is to keep people in line. Those in charge, supported by success and financial backing, can keep a stronger hold by propagating shame as a way to make money and exploit negative feelings about oneself for personal or corporate gain. Personal well-being does not satisfy the greed of various industries which use our collective self-reproach to induce us to spend money hoping to find a reprieve from the shame.

It’s hard to know where education can make inroads into all of our shame. Medicine has little evidence to support the connection between larger bodies and poor health. In fact, there’s more evidence that smaller bodies lead to more health issues with age. Small changes for body positivity pale in comparison with overvaluing thinness. Food, fashion, diet and exercise industries all benefit enormously from our desire to feel better by losing weight. And the newest availability of weight loss drugs adds a new wrinkle to the desire for thinness.

Perhaps the goal is to find value in ourselves in new ways. We can’t win the thinness argument, but we can agree that love, compassion, kindness and care lead to more happiness than focusing on weight and body. We can look for new ways to find joy in a world bent on profiting from our misery.

People who recover from an eating disorder go on an existential journey to find themselves and meaning in their lives. Creating new ways to cope with emotions and with life’s travails forces anyone in recovery to take a hard look at what matters. People who venture down this path often end up better equipped to handle the cultural shame so many of us endure. Escape from shame entails finding a new and different way to live, one that values things that truly matter in life.

Why are Eating Disorder Diagnoses so Fluid?

Diagnoses in psychiatry change over years and even generations to reflect the role mental illness plays in our culture. Some changes are due to a better understanding of an illness. Other times the diagnoses reflect a new social construct around a mental disorder, changes in the social structure or treatment trends that lead to increases in specific diagnoses.

Eating disorder diagnoses change over time as well. More recent trends include the misdiagnosis of depression or anxiety as an eating disorder or the expansion of the diagnoses to accommodate the larger number of treatment centers seeking to fill their beds. The ease of access of GLP-1 medications leads to more self-diagnosis of “food noise” as a different kind of eating disorder and as a way to justify taking these new drugs.

These are just examples of how diagnosis changes over time and how the concept of eating disorders remains fluid rather than a fixed concept, largely due to changing external circumstances rather than a fundamental change in the illness.

The borderline between an eating disorder and a supposedly healthy person is narrow in our culture. The drive for thinness implies that health, beauty and success are synonymous with a low weight. However, the line between these purportedly positive attributes and an illness is not always easy to define.

Psychiatrists try to define an eating disorder diagnosis based on the number on the scale, a certain amount of disordered behavior or the overall level of disordered thoughts about food and weight. However, many people who seem to fall into the socially admirable category don’t seem all that different from the people who are deemed sick.

Often the difference is context. Does the person have family who assess the situation as an illness or an achievement? What is the opinion of the pediatrician or primary care doctor who does the first assessment? What is the role of that person in their family of origin? The answers to these questions can determine the outcome: either a functional person with disordered thoughts and behaviors or extended stays in eating disorder treatment. The difference is not diagnosis but context. Few mental illnesses rely on external circumstances as the crux of the issue.

With current trends leaning towards extreme thinness again, there is much more acceptance of thinness as the goal rather than a sign of being sick. Because so many people are underweight due to the GLP-1’s, it is harder to differentiate the unwell versus the well. Without other markers for achievement, weight has become the default indicator of wellness again. There is no medical justification that people losing weight are healthier, but all cultural trends overvalue size and health, so anyone losing weight receives accolades across the board.

Eating disorder diagnosis is as much a cultural construct as it is a psychiatric disorder. There are many people who clearly have eating disorders and struggle to get well. The clearest diagnoses involve addictive-like behavior around food, intractable intrusive thoughts, trauma and often primary medical illness like MCAS. However, the number of people who don’t fit these categories but also dilute the severity and understanding about eating disorders is vast.

In trying to be clearer about diagnosis, the term eating disorder ought to reflect the cause of the illness, the severity of the symptoms and the types of experiences more specifically. These changes involve further research into possible underlying causes and incorporating changing trends around food and weight.

Vigilance and Persistence are the Needed Traits to Get Better From an Eating Disorder

Eating disorder treatment is hard because the process is long and slow and because one needs a lot of resiliency to handle the ups and downs. It’s so important not to let the harder times transform into hopelessness and instead to remember that continuing down the path of recovery leads to getting well.

The eating disorder thoughts and urges become very ingrained. All mental and physical actions around food are somewhat subconscious since we are all biologically-driven beings who the need food to survive. This fact remains embedded into our most basic essence. Even if these actions are disordered, our minds are designed to repeat food patterns over time.

Changing those patterns involves a different type of vigilance. One needs to be aware of the smallest subconscious thought that might lead to eating disorder behaviors. People in recovery often say things like: “I’ll just do this one more time” or “I’ll start tomorrow” or “nothing will happen to me if I don’t change in the next few days.”

Even though everyone in recovery recognizes these thoughts are false, the lure and comfort of continuing a known path is strong and hard to resist.

Getting better means having consistent and regular accountability combined with contact with someone who helps recognize the insidious thoughts and choose a different action.

The central tenet of this part of recovery is vigilance. Only by being vigilant each and every day can a person in recovery make long lasting changes to the subconscious eating disorder thoughts.

The second part of recovery is managing the daily ups and downs of getting better. Everyone has stretches of time when thoughts and actions start to fall into place and lead to recovery-oriented steps. Similarly, everyone has periods that feel like going back to square one.

Neither extreme is the truth. These widely different experiences reflect the challenges of recovery. The process of getting well is not linear at all. For a long middle period of recovery, people know and understand the nature of the eating disorder, how the thoughts work and ways to counter the disorder mental and physical actions. Yet they still get stuck routinely in old patterns and become increasing frustrated and, at times, hopeless.

The second tenet of recovery is persistence. Changing ingrained patterns is a lot harder than acquiring new information and understanding. These well-worn patterns of eating will only transform with persistence to translate the knowledge about recovery into action and eventually into ingrained, subconscious behaviors. With enough work over time, this change will happen.

Vigilance and persistence underlie success in getting better from an eating disorder. The combination of these two traits with the focus on recovery each day leads to truly getting well.

The Current Role of Residential Treatment for People with Eating Disorders

I have written at length recently about some of the troubling changes in the residential eating disorder treatment programs. Granted, my concerns about residential treatment have shifted during my years of practice at first from lack of access to residential care and now to the quality of care.

Because these illnesses are less of a focus to psychiatry programs across the country, eating disorders don’t have a clear, effective standard treatment plan. Thus, these programs are on their own to develop a strategy that seems appropriate. Clearly, this open debate allows programs much too wide a berth in their decision making.

Despite the varied, serious concerns, there still is a place for residential treatment for people with eating disorders. Some programs do a good enough job and many an adequate one, at least for certain patients.

The most common situation that merits residential care is a patient’s first serious episode of an eating disorder with medical consequences. If a patient is newly diagnosed, unable to curtail symptoms with sufficient outpatient care and at medical risk, then residential care is a reasonable and often necessary option. Treatment can stabilize health, provide education about the illness and inform the patient about the process of recovery. The risks are exposure to people with much more severe symptoms and the introduction of concept of the eating disorder as one’s identity.

Care needs to be taken for first time patients that they don’t end up in a revolving door of treatment. The deleterious psychological effects of ongoing residential and hospital care can cause long-lasting damage that may even outweigh the toll of the eating disorder itself.

Repeat admissions to residential care need to be considered cautiously. The risks of a first admission escalate significantly with subsequent admissions. Anyone returning to a facility needs a clear plan and hopefully a shorter time in treatment followed by a return to their lives as quickly as possible. Cycling through various programs makes people feel hopeless about their lives, unable to envision a future and identify increasingly with their illness. Outpatient clinicians must consider these various effects as much as managing the eating disorder itself.

For people with a longstanding eating disorder, programs are best used as a last ditch option. If someone is stuck in a behavior pattern with serious medical consequences, then a short term stay no longer than a month is best to stabilize the condition. There is nothing new to learn about treatment at this point, and it’s best to return to their regular lives as quickly as possible.

This post is meant to counter some of the concerns about residential treatment I have enumerated in recent months. There is a place for residential care in eating disorder treatment when considers thoughtfully and used judiciously.