Body Image Work in Eating Disorder Treatment

Body image thoughts are almost always the hardest part of any eating disorder recovery. Although not everyone has these thoughts and may have other difficult parts of recovery, body image tends to be a big challenge to address.

First, body image is subjective. Even if clinicians can counter body image norms in many different ways, these data points aren’t very convincing. Besides, we process our own body image very differently from other bodies. There is some compelling research to show that processing one’s own body image uses non-visual brain centers. So body image is likely more about self-perception than it is about what we see in the mirror. It’s hard to convince someone to see themselves differently when they aren’t even seeing themselves at all.

Second, body image and weight are markers for people to assess their success or failure. Each morning on the scale or each day trying on an outfit is a referendum. Is today a good day or bad day? Can I feel good today or need I feel awful? Too many people with eating disorders conflate appearance with well-being in a very automatic, unconscious way. Taking away this assessment would leave them with no way to function that day.

Third, body image is everywhere. We are bombarded with media and photos of people all day long. When body positivity was prevalent, at least some of those bodies were not extremely thin. In the GLP-1 era, bodies are all extremely thin again in media and even in shrinking celebrities, family or friends. It’s hard to address body image when the world presents a very different message.

Work on body image takes a circuitous route. The focus in recovery must be more profound from the start and center on what matters in life, whether that is work, family, friends or community. People in recovery need to look inward and find a path that matters to them which, to start out, is at least as important as body image.

At first this new path may only compete with body image rights for attention. Through the process of getting well, a new focus can begin to replace and hopefully supersede the all consuming body image thoughts.

In the end, the body image concerns can still exist and insert itself into one’s consciousness. There is a big difference between intermittent body thoughts and an all consuming focus. Life needs to mean more than distorted and disturbing body image thoughts and be about other things that matter a whole lot more.

Eating Disorder Treatment Reimagined: Proper Diagnosis and Treatment of All Associated Illnesses

Eating disorders primarily are seen as psychiatric disorders in the medical system. Even though much of the treatment focuses on stabilization of food and health, which are necessary components of treatment, the success of long-term treatment rests in the hands of mental health clinicians.

There are a number of factors which led to this clinical decision: the lack of knowledge about the biological causes of eating disorders, the social construct and expectations around food and weight and the cultural dynamic of thinness which handcuffs women.

Reservoirs of health insurance money engendered a recent takeover of the eating disorder treatment field by private equity companies. Accordingly, the system is even more organized around ineffective mental health treatment and less about healing and getting well. Any progress integrating medical and mental health treatment is not a priority at the moment.

Years of experience treating people, primarily women, with eating disorders revealed to me that there are a host of misunderstood, complex illnesses for many people with chronic eating disorders.

The cohort of patients who typically fall into eating disorder symptoms without much volition and stay very sick often don’t benefit from current eating disorder treatment. It may very well be that these people are treated for a psychiatric disorder when the primary issue also includes an underlying medical problem that is not addressed.

In recent posts, I have written about EDS, MCAS and other disorders that appear to be linked with eating disorders. These illnesses are some of the medical struggles people with eating disorders face without any diagnosis or treatment from doctors. People with chronic eating disorders also can have hormonal disorders, swallowing disorders, neurological disorders and many other issues. Rarely are the medical issues treated. Instead, doctors blame all physical symptoms on the eating disorder, and thus on the patient, for not getting better.

What needs to be considered for people with chronic eating disorders is to include medical screening in a comprehensive treatment plan for these patients.

Outpatient treatment with therapy and nutrition counseling is critical for recovery. Food stabilization and therapeutic work around learning how to live without the eating disorder remain essential to get well.

However, too many people stay sick, and providers tend to give up in one way or another so these patients only blame themselves for their illness and become hopeless. These outcomes are inexcusable.

Doctors need to be more involved in all elements of eating disorder treatment for these patients to get well, and the field needs to consider all other medical illnesses and incorporate a wider net of diagnosis and treatment to help more people truly get well.

New Directions for the Medical Treatment of Eating Disorders

There is a sweeping change coming to eating disorder treatment in the near future. The connection between the onset and severity of eating disorders and an assortment of vaguely defined illnesses is likely to play a role in early diagnosis and care for people with eating disorders, especially anorexia. If there is enough interest in the medical field, these new changes may profoundly change the scope of eating disorder treatment from purely psychological to a combination of medical and psychological conditions.

Some patients with eating disorders respond quickly to standard eating disorder treatment. Many of these patients seek treatment early, more often exhibit binging and purging symptoms and have thoughts mostly focused on weight before seeking any treatment. Regulation of meals, education about diet culture and prioritization of health and well being, all central to standard treatment, can right the course fairly quickly.

These patients are a substantial population of the people getting help for an eating disorder, but they are not even the majority.

A large percentage of people have intractable symptoms not focused on food and weight which are the core factors in their eating disorder. In addition, they often develop symptoms for a multitude of other reasons unrelated to diet culture and have unexplained and often ignored medical symptoms that are deemed unrelated.

As I have written about in this blog recently, a host of other medical illnesses appear to have some connection to eating disorders, especially anorexia. The most common ones are Ehlers Danlos syndrome, mast cell activation syndrome and general inflammatory/autoimmune symptoms. The first is a genetic variant which leads to looser connective tissue, the second a varied illness with multi-organ effects and the third consists of chronic pain and discomfort. They are minimally researched, and the medical establishment shows little interest.

A final common diagnosis connected with the above is hypersensitivity, a vague title meant to indicate acute sensitivity to sensory input and emotional input. The symptoms of this condition play a role in the extreme difficulty and pain some people experience upon eating, but there is even less information about this condition.

These four together don’t generate much interest from the medical community yet impair the lives of so many women and are strongly linked to eating disorders.

Many medication treatments are now options for people with these symptoms: low dose naltrexone (an anti-inflammatory), many mast cell medications such as Cromolyn, cetrizine and famotidine and even very low dose GLP-1’s being studied for severe anorexia.

The progress in diagnosis and treatment thus far is nonexistent, but some providers have begun to look for new ways to approach chronic eating disorders.

I hope we clinicians look back at the blame I wrote about in the last few posts as a sign of ignorance and instead begin to show interest in some of the underlying medical issues related to eating disorders. Current eating disorder treatment guidelines help some people, but we need better options for a large number of people seeking help.

The Antidote to the Three False Beliefs of Eating Disorder Treatment

The three false tenets of eating disorder treatment—blame, “full recovery” and ultimatums—are an unfortunate byproduct of poor clinical decision making that causes more harm than good. The three falsehoods often become foundational beliefs for people with eating disorders and cause significant psychological harm to patients seeking help. As a result, patients need therapy to recognize the beliefs as false and reverse the detrimental effects on their own recovery.

First and foremost, no one ought to blame themselves for an eating disorder. Many factors lead to the start of an eating disorder, and they all have one thing in common: no one chooses to get sick. People surreptitiously fall into disordered behavior like restricting, overexercising, binging or purging and find that the physical and emotional effects of these actions are very powerful. These behaviors may lead to an emotional release, physiological improvement in symptoms or even relief from the effects of an undiagnosed medical issue. Every single person in treatment needs to know the eating disorder is not their fault.

Second, everyone’s path to get well is individualized. I often lay out broad strokes of what recovery looks like when I first meet patients, but those are only general suggestions of the paths people take. There is no right way to get better with one correct end result. Life in recovery still has the ups and downs of anyone’s life but is no longer dominated by the torturous thoughts and behaviors of an eating disorder. The idea of a “full recovery” only places more blame and shame on the person already struggling and doesn’t reflect the reality of getting better.

Last, there is no place for threats in recovery. If clinicians are unsure how to help a patient, it’s the responsibility of the provider to look for help, not to place that onus on the patient for not getting better fast enough.

The through line of these three erroneous beliefs about eating disorder treatment uncovers the consistent message of blame on the patient for having an eating disorder and for not getting better. Treatment focused on blame insists that there is only one way to get better. Either the plan works for you or it’s your fault.

Healing from misguided treatment necessitates a clear message: blame and shame don’t belong in any eating disorder treatment setting. The antidote to this approach of poor care is treatment grounded in compassion, kindness and sincerity.

At the heart of an eating disorder is the internal critical voice telling someone how they are a horrible, despicable person. The message from providers needs to reinforce the opposite so the person knows they are good and instead are sick and need help in order to get well.

It’s not a lot to ask of any provider, yet it’s often hard to find kindness when seeking help for an eating disorder. This clear approach to eating disorder treatment and to the person struggling can go a long way to help people get well.

Ultimatums Don’t Work in Eating Disorder Treatment

Eating disorders are considered difficult to treat. Several factors such as our collective obsession with food and weight, the entrenched nature of eating behavior, disordered or not, the strong connection between eating disorders and identity and the underlying medical issues all create a tangled web once treatment starts that many people call difficult.

As a result, ultimatums either to eat more or go to residential treatment have long been a staple in eating disorder treatment. The premise is that a patient needs a concrete goal to attain with clear consequences, if not punishment, if they fail. Ultimatums end with either the treatment team summarily dropping the patient or the patient complying. Some people see compliance as a good outcome to stabilize nutrition and health but at the expense of autonomy and psychological growth needed to get better from an eating disorder.

Clinicians benefit greatly from ultimatums. They feel as if they are standing up for what is best for the patient and simultaneously holding their ground for the right next step. Clinicians can escape a situation they’re not sure they can handle in a way that is completely accepted in the treatment community. They feel absolved of any responsibility and can fully hold the patient accountable for their decisions.

In my estimation, clinicians benefit greatly from ultimatums. After trying as hard as they believe they can, treatment providers have an easy escape hatch in order to end the therapy unscathed and feel little remorse for the outcome.

Ultimatums give little solace or hope to the people seeking help. There are three clear ways patients suffer when ultimatums are a part of the protocol.

Patients understand that the ultimatum implies that the lack of progress is their own fault due to not trying hard enough. The clear message is that an eating disorder is not an illness but a choice, and true recovery demands the patient just try harder.

Second, patients realize they can’t trust their providers. If the team were on their side, patients would be able to be honest about the strong pull towards eating disorder thoughts and symptoms and how and why it is incredibly difficult to get better. It’s harder to trust a team willing to use the information patients share as part of a threat to stop treatment.

Last, patients learn through an ultimatum that they are truly on their own. More than food or weight, eating disorders provide a failsafe, reliable source of comfort and support. The emotional benefit of the eating disorder thoughts and behaviors provide comfort in ways people can’t. Recovery means learning how to find imperfect comfort elsewhere and understanding how and why relying on people creates a much more fulfilling life. Ultimatums make it clear that providers can’t even provide support so how can anyone else help.

When clinicians feel the urge to use an ultimatum, they need to look inward as to why they are feeling so hopeless and powerless to help the person with an eating disorder. The multitude of layers to an eating disorder are incredibly complex. Any therapy deeply involved in treating someone with an eating disorder will become difficult and even frightening to a provider.

Clinicians can look for outside help, seek second opinions or consultations, dive deeper into the complexity or find medical help to ensure the patient is stable while treatment progresses. Looking to an ultimatum to solve this personal dilemma always prioritizes the provider’s concerns over the patient’s needs.

Recovery from an Eating Disorder is Different from “Full Recovery”

For many years, the term recovery described the process of getting well from an eating disorder. The all encompassing concept reflected a person engaged in treatment with the end goal of living a life no longer dominated by an eating disorder and with the freedom of making one’s own choices about how to live.

Coined in substance abuse treatment, recovery speaks to a state of mind for both the patient and treatment providers of a similar goal: to disempower the eating disorder over time and open doors to a fuller life. Recovery implies progress and hope. The term reflects a years-long process which can ease the discomfort of the hard days by remembering the positive changes happening over time.

The private equity-funded eating disorder treatment programs co-opted the term and changed it in subtle but profound ways. People are much less likely to talk about recovery anymore and instead to proselytize about “full recovery.” I use the quotations intentionally because this concept itself is erroneous and changes the meaning of the term and the connotation of recovery as a whole.

“Full recovery” means the holy grail, the pot of gold at the end of the rainbow, the fantasy that a life completely free from the eating disorder is imminently and immediately available if you only try hard enough. Clinicians at programs can use this term to browbeat patients to comply with rules or to shame them into believing they are the problem, not the illness itself.

There are several problems with this idea. First, hard work in treatment does not land you in a fantasy world where the eating disorder is wiped clean and magically disappears. Recovery is a process over time and the eating disorder will recede but there is no nirvana at the end. Second, life is always complicated and messy so people almost always experience eating disorder thoughts even when they are well but know the thoughts can’t derail their lives anymore. Third, at the heart of the term is promising the impossible, a time when the eating disorder just goes away because one works “hard enough.”

Rather than promote the reality of the process of recovery and the true nature of the daily struggle of getting well over time, “full recovery” implies that if you try hard enough now, you’ll find a world where life is just easy and simple, where you get everything you want easily. Life is never that way, and it’s cruel, if not sadistic, to promise something that does not exist and use that promise to coerce people to follow guidelines.

Fundamentally, the term only reinforces the feeling of blame that surrounds people with eating disorders. Since they didn’t try hard enough, it’s their fault they didn’t get better. And on top of that, they should be ashamed of themselves for not getting better.

We need to return to the idea that recovery is a long process that focuses on stabilizing food, learning about the emotional and psychological forces hidden by the eating disorder, discovering who you are and finding how to live in the world. It’s not easy and takes time but will allow the person to live their own life not dominated by the thoughts and actions of an eating disorder.

Blame Has No Place in Eating Disorder Treatment

The inception of blame as a pillar of an eating disorder is rooted in our collective idealization of thinness. Body size and shape has become an ever more central factor in defining achievement and success, control and determination, willpower and attention. Society dictates that we should all strive to be as thin as possible at all cost. Any failure is our own fault.

The issue in eating disorder treatment is the expansion of the idea of blame about not being thin enough to blame about all different types of disordered thoughts and behaviors. The types of blame providers use morph throughout treatment to match the current symptoms but inevitably point back to personal failure as the cause of the disorder itself and the reason for any obstacle towards getting better.

A person with an eating disorder is blamed for being vain to want to be thin, even though our entire culture focuses on weight and thinness; blamed for having thoughts to restrict or believe they are fat even though these experiences are practically universal; blamed for debating controversial topics around body in session even though that type of discussion is integral part of any therapy; blamed for not being able to eat a full meal plan or avoid behaviors even though that’s exactly why they are seeking help in the first place, and blamed for almost every other part of their illness and treatment.

The blame that starts with idealizing the unattainable goal of perfect thinness expands to all aspects of an eating disorder so that the illness itself becomes a reservoir of endless blame and often self-hatred.

It’s clear to me that openness in treatment towards understanding the person seeking help is necessary to understand the nature of their eating disorder and also the torment of being endlessly ignored and misunderstood. Treatment needs to involve the psychological wellness of the person in a kind, generous and caring way. Without that step, any chance at improvement is impossible.

Many people without this support talk about being labeled chronic which is intended to instill more blame and hopelessness, but how often does this label only reflect inadequate and uncaring treatment?

Blame does not belong in eating disorder treatment any more than it does in any psychiatric treatment. People with eating disorders ended up in their illness, like anyone else, without intention, and they need help. Our society has both increased the incidence of these disorders through a culture of chronic dieting and then coined a label to isolate a swath of our population and saddle them with an illness without much of a path to recovery.

Every person with an eating disorder has their own experience that led them to be sick, to their trials of treatment and to a course of healing. There is no place for blame but only for understanding, help and the hope that they can live they want to live.