The Rebuttal to “Why Can’t You Just Eat?”

People who don’t understand eating disorders always ask someone struggling with one a simple question: why can’t you just eat?

To people versed in these illnesses, let alone those who are struggling with one, the question is frustrating, upsetting and ignorant. Being asked the same question time and again becomes truly demoralizing.

However, the question comes from a simple and logical place. People without eating disorders just eat. Even if they worry about what they eat, when they eat or their body in general, the premise of whether or not to eat is never really relevant.

The biological imperative to eat is just too powerful.

Eating disorders, by definition, indicate a strong urge to eat or not eat by other factors then hunger and fullness. These behaviors become full-fledged eating disorders when disruptive enough to interfere greatly with daily functioning in life.

Many people think a lot about their food and body. Our culture continues to greatly magnify the importance of food and weight. Capitalism and the media prey on these communal fears, with Ozempic and the GLP-1 agonists being the latest corporate cash cow for our collective obsession with weight.

And the ever present drive towards thinness means no decrease in people developing eating disorders.

The answer to the question “why don’t you just eat” is both simple and complex.

The simple answer is that you have an eating disorder which means that you have other thoughts and urges that dictate when and how you eat. And so “just eating” isn’t possible.

The complex answer is connected to what treatment means. Recovery aims to regulate eating into a pattern based on hunger and fullness and less on the psychological and emotional drives of the eating disorder. The best step for most people is to eat according to a meal plan created by a professional and to relearn hunger and fullness cues. In time the goal is to “just eat” again but that comment isn’t helpful or kind with respect to eating disorders.

A more thoughtful and education about that overused question hopefully will lead to more understanding, and perhaps even more support, going forward.

Current Anti-feminist Trends in Eating Disorder Treatment

Culturally eating disorders aren’t only mental illnesses. They represent the newest expression of suffering and oppression women experience in our society.

These illnesses are borne out of the relentless pressure for women to be thin in order to be attractive, to be employed and to be heard. Eating disorders can be seen as an expression of protest against this oppression but then become a prison of their own accord.

Over time the direction of eating disorder treatment and the cultural response to the imperative to be thin leaned into feminism and freedom.

The second generation of eating disorder treatment programs were founded and created by powerful women in recovery who themselves became the focal point of change and hope. They created worlds aimed at feeling one’s own autonomy and agency. They structured recovery around a community of women valuing friendship, connection and love, not a show of eating to prove to men how they can follow the rules.

In the decade after, the body positivity movement encouraged women to appreciate and respect their own shapes and sizes. The power of this new message stretched even to celebrities and clothing’s stores.

However, both of these steps to empower and liberate came crashing down.

Private equity bought most of the treatment programs and transformed them into money making ventures run primarily by less experienced clinicians cynically aimed at exploiting young women and insurance benefits.

Ozempic and the other GLP-1 agonists, in addition to the newer, stronger medication on the way next year, drew in women by promising a magical way to be thin. The body positivity voices have been drowned out by the lure of the weekly injection and by the unsubstantiated claims of doctors that losing weight is the key to good health.

It’s hard to watch these capitalist changes in recent years and not conclude that market forces benefit from keeping women enslaved to the goal of thinness. An empowered society of women immune to external pressures about appearance doesn’t benefit the financial goals of a male-oriented business culture.

This depressing fact does prove that the epidemic of eating disorders won’t improve without a strong feminist base to recovery. Women need to collectively remember that the pressure for thinness and the scourge of eating disorders are never in their best interest. Recovery, for the individual and the collective, begins with education, autonomy and inevitably the power to stand tall.

Eating Disorder Recovery is Grounded in Connection

The last few posts outlined new directions for eating disorder diagnosis and treatment. Conversations between people with eating disorders and the openness and ease of communication using social media open doors to new links between eating disorders and other illnesses and new treatment ideas as well.

However, it bears repeating that the psychological underpinnings of eating disorders are the most important reasons people have so much difficulty getting well.

The various emotional effects of both eating disorder behaviors and thoughts are incredibly powerful and keep people entrenched in their disorder.

Eating disorders can create excitement and also numb feelings; they can cause calming structure or deliberate chaos; they can offer clear moral guidelines for life or offer a lofty but ultimately unattainable goal.

In the end, eating disorders offer a solution to the challenges of connection in our lives. The connection with the eating disorder supplants connection with ourselves, other people, our emotions and our body. The eating disorder stops people from connecting in a true and deep way with others.

Any successful treatment needs to include learning how to connect with oneself and with others as a fundamental antidote to the allure of the eating disorder. Most people with eating disorders have had limited connection in one or all of these forms, and treatment helps them learn about the fundamental human need for connection and how to find it.

Typically, learning about connection starts in therapy. That experience is in part didactic but often it is also experiential through learning about connection through the safe and boundaried relationship in the therapy. The therapist creates a space that is safe, warm, open and validating. There needs to be room for all sorts of experiences and feelings in therapy so the person can learn to be open and accepting of their own emotional experiences and needs.

With these newfound ideas about self-worth, feelings and connection, people with eating disorders can conceive of a world less reliant on the eating disorder to satisfy those emotions.

So even though a broader idea of diagnosis will benefit many people with eating disorders, any recovery has to include profound learning about emotions and connection.

The Generator of Progress in Eating Disorder Care: Social Media

Progress in diagnosis and treatment in psychiatry historically relies on the experience and knowledge of clinicians who use their time with patients, educate themselves about new treatment ideas and collaborate with colleagues to further the field and hopefully improve overall clinical care.

Social media opens a new door to how the field progresses. Patients themselves express original ideas based on their lived experience and communicate with each other to find ways to assess and even consider new treatment for their condition. And this new path is starting to affect progress in psychiatry.

One result is to connect other medical and psychiatric illnesses to eating disorders, as I wrote about in the last two posts. People are communicating with other patients about these connections and bringing to light new ways to conceive of eating disorders.

The medical establishment, however, has not yet caught up with the findings. Clinical work remains fixed in older ways to treat eating disorders. Accordingly, patients come to treatment with new ideas about the individual symptoms and possible treatment for their own eating disorders and then try to find clinicians willing to work with them.

Social media has changed the way psychiatry is going to treat patients with eating disorders. The more difficult the disorders are to treat, the more patients are likely to look into alternative options and shop for doctors open to these new ideas.

So clinicians need to take these new concepts into account. Moreover, comprehensive assessment of eating disorders, including concomitant psychiatric and medical conditions, is imperative.

Patients will find other ways to get the help they need by cobbling together doctors who will do separate assessments and then find their own individual way to try to get well. The more clinicians band together to create a better way to assess eating disorders, the less patients will feel compelled to try to piece together their own treatment.

Treatment is no longer clinicians diagnosing and making treatment plans. The process of eating disorder treatment needs to be collaborative.

The Need for Inclusive Eating Disorder Treatment

Typically eating disorders are treated as psychological illnesses. A doctor manages any medical symptoms, lab abnormalities and medications, but the primary work in recovery is mental and emotional in nature. The root cause of an eating disorder is almost always seen as a mental health issue.

For many people with eating disorders, this paradigm is accurate. Separation and individuation from an enmeshed parent relationship, numbing of emotions from traumatic experiences and the strong desire to avoid adulthood are still common initial events that lead to an eating disorder. Treatment still needs to encompass these clinical situations.

However, more correlative data links eating disorders with other medical and psychiatric disorders—a connection elucidated in the last post. Treating these concomitant, if not perhaps causative, illnesses falls outside the purview of typical eating disorder treatment.

For instance, chronic inflammatory illnesses such as MCAS or general autoimmune symptoms may be alleviated through eating disorder symptoms. The same may be true for people with chronic metabolic issues. If these patients recover from their eating disorder, the medical symptoms return and often worsen; thus, recovery needs to address these other medical issues to allow people to recover and manage these other illnesses too.

Similarly, eating disorder symptoms may help mitigate some psychiatric symptoms for people with untreated ADHD or undiagnosed autism. Eating disorder recovery that doesn’t address these other disorders won’t be helpful for true recovery.

Eating disorder treatment not only needs to screen for other connected medical or psychiatric illnesses but also needs to incorporate a more complete approach to allow for full recovery.

The standard psychiatric treatment screens out many people with other comorbid medical or psychiatric illnesses when the approach needs to be more inclusive. These other patients deserve more complete treatment too.

A New Approach to Eating Disorder Assessment and Care

The assessment, diagnosis and treatment plan for people with eating disorders has changed dramatically in recent years.

Historically, the initial appointment comprised of a standard psychological intake followed by medical, therapeutic and nutritional follow-up. These components are still essential to any treatment plan.

Eating disorder symptoms clinically appear to be connected to other biological systems as well, predominantly metabolic, endocrine and immune (autoimmune disorder and Mast Cell Activation Syndrome). In addition, there has been more data connecting other psychiatric disorders such as Attention Deficit Disorder (ADHD) or Autism Spectrum Disorder (ASD) with eating disorders as well.

It’s unclear whether these connections are causative or even possibly point to a different way to conceive of eating disorders. Despite the lack of relevant information, diagnosing and treating these concomitant illnesses aids eating disorder treatment for many people.

A clinician now needs to take into account this entire set of medical and mental health considerations as well when developing a plan for treatment. Medicine may not yet know how and why these organ systems or psychiatric disorders seem connected to eating disorders, but distinguishing different causes and symptoms related to each person’s illness can enable a clinician to individualize treatment.

The holy grail of medical and psychological research into treating eating disorders is finding an underlying biological cause. Through such a breakthrough, the long lasting torment of these illnesses might be shortened significantly.

The ingrained behavior patterns of an eating disorder become entrenched so behavioral therapy would still be indicated, but combining a medically-informed treatment with therapy might shorten the length of care needed to get well.

A thorough assessment needs to include several elements.

1. Psychological evaluation
2. Nutritional assessment
3. General medical exam
4. Labs tailored to assess metabolic function
5. Assessment of inflammatory symptoms
6. Screening for attentional deficit or autism spectrum when indicated

The combination of a standard psychiatric evaluation plus the extended assessment for other associated conditions will help determine the best course of treatment for any individual and increase the chance for a successful outcome.

Identity Transformation at the Center of Eating Disorder Recovery

Most chronic illnesses, medical or psychiatric, have a significant impact on a person’s quality of life. Coming to terms with an illness not easily managed or cured changes how someone sees their life trajectory and future. Although an illness can become a part of the lens through which one sees the world, eating disorders are unusual in how they become tightly woven into one’s sense of self.

No matter how the eating disorder starts, the symptoms, self-image and behaviors around food become paramount. All decisions center around the convenience or difficulty of eating or around what the eating disorder seems doable or acceptable.

Inevitably, the way one thinks of themselves and leads their lives depends largely on the eating disorder. Social events, professional choices and any personal plans revolve around what is best for the eating disorder.

Since eating disorders—or at a minimum eating disorder thoughts—start at a young age, psychological and emotional development occurs with the strong eating disorder thoughts influencing every decision. One’s identity and eating disorder grow up together, connected in the overarching experience of learning about oneself.

At its core, eating disorder treatment isn’t just normalizing eating behaviors and regulating body function, nor is it simply relearning new ways to think about hunger and fullness.

Recovery involves breaking down one’s own identity and building a new identity from scratch, no matter your age or personal situation, based solely on one’s own self and not the tenets of an illness.

It’s hard enough to take the steps towards recovery let alone imagine that recovery involves such a profound and painful emotional process, one that adults rarely if ever need to consider.

Time and again, clinicians working with people with eating disorders see this trajectory. Recovery is hard work starting with eating the food and handling changes in one’s body. Understanding the internal transformation that ensues is the next big step followed by a willingness and ability to forge ahead and find that true self, separate and free of the eating disorder.