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.

The Three False Beliefs in Eating Disorder Treatment

The last few posts outlined my thoughts about how and why the eating disorder epidemic remains so strong and influential over decades. Social forces use psychiatric labels to systematically reinforce these illnesses to disenfranchise an entire group of people.

Theories are one thing, but the more important question for a clinician is what to do with these concepts.

There are several ways the eating disorder treatment community reinforces these beliefs and allows clinical acumen to support the sexism and bias inherent in these illnesses.

I’ll flesh out my thoughts about the three most important problems inherent in eating disorder treatment in the subsequent posts but will outline them here.

The underlying factor uniting these three is the lack of compassion, understanding and care at the center of these supposed clinical interventions. If mental health treatment is supposed to start from a place of openness and kindness, how can it be that the central tenets of eating disorder treatment ignore this sentiment completely?

The idealization of thinness implies for all people that thinness is within your grasp, a goal attainable with the right amount of will and perseverance. If you don’t reach the goal, then it is your fault. Eating disorder treatment adheres to this misguided belief by positing that eating disorders are also your fault. If you don’t get better, then you haven’t tried hard enough. Although psychiatric illness is considered largely biological, mental health providers don’t seem to talk about blame for illnesses other than for eating disorders.

Similarly, treatment programs run by finance companies, as I have discussed extensively in recent posts, use not only blame but the supposed utopia of “full recovery” as the holy grail to shame recalcitrant patients into submission. Without much guidance about how to get to full recovery, nor even a realistic sense of what that means, treatment program philosophy uses this nonsensical term to instill a sense of failure and blame in all patients when they don’t rescue the impossible.

The result of the false belief is that social media and outpatient treatment revolve around a concept far afield from what getting better from an eating disorder actually looks like.

The end result of blame is the extensive use of ultimatums in eating disorder treatment. When clinicians decide a patient is getting “too sick” or “not trying hard enough,” it is considered standard of care to make an ultimatum: get better, go into treatment or otherwise you can’t stay in therapy anymore. It’s unfathomable to me that people consider this step caring and ethical when the goal of care is to help people get better. How can clinicians sleep at night when they overtly blame their patients for not getting better?

I’ll talk more about these three issues—blame, “full recovery” and ultimatums—in the coming posts. Making changes to eating disorder treatment can transform a field guided by nefarious social forces and instead focus recovery on true healing from a physical, psychological and personal place.

The Personal and Societal Parts of Healing from an Eating Disorder

In recent posts, I reflected on some of the larger social forces that have both led to the incidence of eating disorders in recent decades and impacted how these disorders are diagnosed and treated. Reckoning with the meaning of eating disorders in our society is essential, yet clinicians still need to address the symptoms of an eating disorder when someone comes to treatment for help.

First steps include assessment of the severity of the symptoms and education about hunger/fullness, metabolism and the need for energy and nutrition for overall health. Initial sessions then can focus on the means to change disorder eating patterns. No matter the larger picture, individual treatment needs to start in the same place.

However initial treatment stabilizes eating for many people, this step does not have to mean “full recovery,” the overarching promise of many programs that an eating disorder can disappear for everyone (and if it doesn’t then it’s your fault). Instead, stable eating means that someone eats enough and with enough variety to be healthy enough to move forward with their lives.

Often, treatment at this point searches for an underlying cause for the eating disorder thus implying that something external and concrete caused the problem . That is not commonly the case. The search is fruitless and not directed at the central issue.

Recent posts point out another possibility for the eating disorder in the first place. Eating behaviors or weight may instead be a means of expression, a way to say something powerful that otherwise won’t be heard. The message hidden behind the eating disorder often come from a source of emotional pain but may also be a way for others around them to understand the nature of their circumstances and the limitations they feel to move forward in their lives.

Examples can include family dynamics that scapegoat the child in the family to feel responsible for everyone’s ills or dynamics that necessitate the child care for a parent unable to take on their personal responsibility. Another possibility is a child forced to grapple with the wrath of a parent aimed at them which limits the child’s ability to focus on their own growth and development. A third may be a family with a disabled child and the sibling with an eating disorder has no room to be themselves.

There are myriad examples of scenarios where the child, much more often a daughter, finds themselves without a voice, bearing family responsibility and with an eating disorder as the only way for others to see their emotional and personal struggles.

Treatment at this point focuses on finding one’s own voice and thoughts and the means to identify, experience and express their internal world to chart a path towards living a full life. The broader social forces are at play in these individual instances, but the treatment is aimed at the person’s specific situation and finding ways for her to not feel so trapped by personal pressures. Understanding the larger implications may be helpful in the moment and helps educate the therapist to know how to proceed focusing on life change and not just food and weight.

Toggling between the larger causes of eating disorders and the individual’s need to get better is the primary experience for any eating disorder clinician. These illnesses aren’t just about food and weight, nor are they just about the social causes. They are about the combination of nuanced clinical care and understanding the root cause of eating disorders in our society.

The Return of Idealizing Thinness at All Costs

I have written extensively about the GLP-1 medications over the last couple of years because of the impact on people with eating disorders. Posts have ranged from concern about this new powerful class of medication, the ease with which people can attain them basically unsupervised, the potential benefits to some people with eating disorders and the haphazard regulation of the use of this new medical intervention.

The most significant effect of the widespread use of the GLP-1’s is the societal shift over the last few years about body and weight, especially for women. In light of the last few posts in this blog, I feel compelled to discuss the changes.

Prior to the explosion of Ozempic use, there had been a movement towards body acceptance, also called body positivity. Despite the many complicated factors about this movement, one effect for many women was the possibility of seeing their bodies, and often themselves, in a new and less critical light.

I found that body positivity enabled treatment to be more successful for many of these women with more progress than I had seen before. Instead of the constant battle upstream against the current of idealizing thinness, some women could visualize a body that did not fit the societal ideal but instead matched who they were physically as a person. The newfound freedom to see herself more clearly allowed for personal growth as well.

Ozempic and the like pushed even the most conservative women about medication to consider and often try the new drugs. Without any medical indications for use, women can easily find ways to procure them for the sole purpose of weight loss. Even though many people can’t tolerate the drugs, enough women now are in much smaller bodies and the societal pressure to be thin has rebounded very powerfully headlined by the message that weight loss is attainable for all.

Women finally seeing the possibility of settling into a place of acceptance and even comfort with their bodies now suffer with negative thoughts about their bodies and themselves again. The end of any semblance of body positivity renewed the onslaught of women’s body hatred.

I don’t think these new medications are intended for social ills. The benefit for diabetes, metabolic disorders and some eating disorders is profound. The pharmaceutical industry, however, is a for profit business so the pressure to take as much of the financial pie always wins over thoughtful and regulated use of powerful new drugs.

Patients and clinicians alike need to face the reinvigorated desire for thinness by doubling down on work aimed at giving women freedom and direction. Life needs to mean more than the number on a scale or meeting the societal norm at all costs. GLP-1’s or not, these goals can’t change. External factors will come and go. The overvaluing of body won’t stop being a way to disempower women any time soon, but treatment needs to see the barriers and continue to move forward.