Boundaries and Eating Disorder Therapy, an Overview

Traditional psychotherapy focuses a lot of attention on creating boundaries in the therapeutic relationship. This concept applies to concrete measures such as a clear beginning and end to the session and rules about contact between appointments. There are also more gray aspects to boundaries such as the therapist sharing personal information or ensuring the limits of the personal connection in therapy so the treatment can focus on the well-being of the patient. 

Many books and articles delve into the effects of setting boundaries, and newer therapeutic orientations explore the benefits of looser boundaries. The evolution of the meaning of this term in recent years reflects changing attitudes and expectations for therapy in people's lives. 

Certain illnesses such as eating disorders force the therapist to take a closer look at the boundaries in treatment, especially when present attitudes about the therapy relationship do not coincide with the most effective care.

The psychological component of an eating disorder is relentless. The thoughts to restrict food or binge, buoyed by the constant need to lose weight and the feeling of inadequacy, press to the fore of one's mind over and over again.

The only way to placate them appears to be engaging in the eating symptoms. Struggling against those thoughts to try to follow a meal plan and then manage the feelings that surge forward when not numbed by eating disorder symptoms can feel like a never-ending battle. 

The most successful treatment for eating disorders involves regular contact between the patient and treatment team. The person needs very regular support in order to successfully confront the eating disorder thoughts throughout the day.

In order to be available enough for recovery, therapists often loosen the boundaries significantly. This change undoubtedly has an effect on the therapy but also gives the person the support necessary to be able to continue effective recovery. 

In treatment that works, the therapist-patient relationship strengthens considerably and may even become very personal even though the boundaries of a professional relationship remain clear. This dichotomy can be confusing and is even a point of contention within the community of clinicians treating people with eating disorders. 

The next two posts will present the pros and cons, respectively, for loosening the boundaries in therapy for an eating disorder and explain how this component of treatment is critical to meaningful recovery.


What does "Enabling" mean in Eating Disorder Recovery?

During a conversation with a therapist last week, we stumbled upon a word used often in treatment with questionable relevance to eating disorder recovery: enabling. 

This word, first linked to recovery from substance abuse, is used widely with varied meanings. It is not a clinical term but instead a warning to family, friends and clinicians about relationships with people struggling with addiction. 

The original meaning refers to the support of the faulty reasoning of a person consumed by addiction. This definition has merit. The thought process of someone lost in addiction can transform logic and reason into the means to continue the troubling behaviors. Loved ones and clinicians need to point out the discrepancy even if that leads to conflict. 

This meaning of the word can apply to people with eating disorders as well. Eating disorder thoughts can be very tricky and convincing, even as they lead directly back to using symptoms. Agreeing with faulty logic does not help that person continue a road to recovery but very much the opposite. 

As the term has moved into the lay lexicon, the meaning of enabling has morphed into something more insidious. It is used to discredit all thoughts and logic of someone who is ill, even when the person's thought or opinion has nothing to do with addiction per se.

Granted, this is a fine line, but completely disempowering a person attempting recovery is not supportive either. With this expanded definition, enabling can mean that agreeing with anything at all that the person says is a mistake, rather than applying the term only to thoughts related to the addiction.  

This expanded definition is the one most often applied to eating disorder recovery. Clinicians or family can immediately and irrefutably disagree with any decision the person makes about her next step by implying that it is enabling. Thus, the patient loses faith in all of her thoughts and does not learn how to trust her emotions and instincts in the long run. 

People with eating disorders, as opposed to those with substance abuse, struggle to find their own voice in the world. Using a term thoughtlessly that discredits their feelings and opinions counters much of what true recovery needs. There will be many situations when eating disorder thoughts do dictate decision making, but relying on the term enabling to insist the ill person is always wrong is not helpful either.


The Role of Medication in Eating Disorder Recovery

The focus in psychiatry in the last couple of decades has switched to psychopharmacology. The combination of the burgeoning field of brain science and the powerful draw of the pharmaceutical industry lured budding psychiatrists from the world of psychoanalysis into neurotransmitters and SSRI's. Although there are pockets of devoted psychoanalysts and therapists in the country, psychiatry has been increasingly pigeonholed into a drug dispensing field. 

That message is very clear to people searching for help with mental health concerns. Many patients express surprise that any psychiatrists do more than write prescriptions, even when that pertains to treating people with eating disorders. 

Not infrequently, new patients with longstanding chronic eating disorders search for help online to make a new, brave attempt at health and recovery. More often than not, the appeal to expose themselves again to the pain and challenge of trying to get well is the possibility of a new effective medication.

When I see people in this situation, I try to convey the message that there have been no breakthroughs in the treatment for eating disorders. Recovery is still hard work and requires the patience to weather the ups and downs of learning how to eat again and to manage the tenacious eating disorder thoughts, but I quickly learn that these patients have already been down that road. I find it hard to deter them from looking for the magic bullet, namely a new medication cure. 

Despite the promises made in print ads, photos of people magically cured by a drug and the occasional unlikely anecdote, medications do not provide immediate relief from mental illness, especially from the suffering of an eating disorder. If a medication can ease anxiety or depression somewhat during recovery, then it might help open the door to improving the symptoms. It is crucial to understand the value of medications in recovery and not be wooed by false promises. 

That being said, finding the path back into treatment can very much start someone towards recovery. My goal is to realistically chart that path and help the person who bravely stepped back into treatment to use that momentum to make real changes. Taking the step to seek help, in any way that transpires, is paramount and something to be proud of.

Disappointment that medication is not a panacea does not have to deter that person from a new step towards wellness. Recovery can come at any age and at any stage of the illness. Hope does not have to hinge on a magic medication but instead on the real decision to re-enter treatment.


Changes to the Fashion Industry in France

new law described in the New York Times is making its way through the parliament in France could set new, stringent regulations against extremely thin models and retouched fashion photos.

The law would mandate that models meet BMI-determined weight criteria and be deemed healthy by a doctor before being allowed to work. Violation of these provisions would lead to a hefty fine and possible jail time for the offenders. In addition, all photos that are retouched would have to be labeled as such in any magazine. 

The purpose of the law is to "fight malnutrition," as stated by the main proponent for the law. It's clear that this law is meant to reduce societal encouragement of extreme weight loss and to penalize media which idealize sanctioned starvation. 

The one statement in this article which did not support the law said that the effects might oversimplify what causes anorexia, but this person is completely mistaken. As I have written here many times, starvation is the first step towards an eating disorder. It triggers the starvation response, a predetermined reaction which may lead to an eating disorder. Discouraging dieting can decrease the incidence of eating disorders.

This regulation is no panacea. The weight restrictions will still leave models looking unnaturally thin but not skeletal. The societal effect of the industry will persist. 

But what is crucial here is the message. For a government to sanction against the freedom media has over determining the norms of body shape and size is very significant. The statement tells its people that the persistence of extremely underweight models is not just detrimental but illegal. There are boundaries in terms of what is acceptable for fashion companies to promote through its business. 

It's notable that the pervasive effects of industry are starting to receive government attention. A larger step would be to address this attention to the effect of the food industry. The fact that these companies are allowed to sell food that has had such negative effects on a population's overall health without any government regulation is shocking.

It is time for people to understand that much of the blame for the drastic change in overall nutritional health does not lie with individual, as industry would like us all to believe, but with business and advertising.


The Fear of Spring and Warm Weather

The approach of spring is generally a time of hope and excitement. After months of hibernation combined with the dark and cold, the long days and warming sun tend to inspire a sense of good things to come. 

But for people with eating disorders, the warm weather only evokes anxiety and dread. The insistent thoughts to lose weight grow in strength, and the fear of summer clothes escalates. It's a time of year when the eating disorder thoughts feel even more justified and the inclination to restrict food or do what it takes to lose weight feels most important. 

Body image thoughts, often the most rigid and inflexible of all eating disorder thoughts, feel even more true in the spring. The absolute necessity to create any sense of comfort through weight loss often seems like the only escape. The warm weather gives rise to the foreboding sense of exposure and vulnerability. 

I find that it is very difficult to break through all of these thoughts and feelings of someone with an eating disorder. The most effective way to help someone is to find perspective from the experience.

Each person will have had to face the spring before. Each spring elicits the same feelings and fears. The key is to recognize that the rounds of torture through restricting, binging, purging and any other symptoms do not actually help in the end.

Any short term comfort from hiding in the eating disorder is an attempt to stave off the fear that the warm weather brings. But the symptoms provide no real relief. 

Sometimes the panic about the coming summer is so great that it is very difficult to find that perspective. But even reiterating the fact that allowing the eating disorder symptoms to ramp up will not make this time of year any easier can helpful. 

The purpose of leaning on perspective is to bring back compassion into one's thought process. The eating disorder thoughts are punishing and cruel. Perspective brings with it distance, and through distance one can find compassion again. Kindness towards oneself is always the best first step away from the eating disorder.


Vyvanse Approved for Binge Eating Disorder

A medication, Vyvanse, approved in the last few weeks for Binge Eating Disorder (BED), ought to be cause for celebration. There just are not many options to treat binging. Yet my first reaction is concern and trepidation. 

This medication is a stimulant initially marketed and approved for Attention Deficit Disorder. It is effective and safe for this disorder. A once daily, long-acting alternative to Adderall and Ritalin, Vyvanse was a welcome addition to this class of psychiatric drugs. 

One of the most common side effects of stimulants is appetite suppression, the purported effectiveness of Vyvanse in BED. Since children often take stimulants, decreased appetite can lead to weight loss, malnutrition and medical issues. Adults often see this side effect as an added bonus, which only increases the appeal and risk of stimulant usage. 

My first concern is that the side effect of appetite suppression is now touted as a potential cure for binge eating, which is patently untrue. These medications can be used to stop binging that is particularly dangerous in the short-term but no more.

Like most side effects, loss of appetite tends to wear off as someone takes Vyvanse regularly.  The binging returns soon enough as appetite returns to normal, unless the patient receives alternative treatment. Vyvanse is a bandaid in this instance, not a cure. 

My other concern is that Vyvanse is an addictive medication. In other words, people develop a tolerance to the drug so that they will experience withdrawal if it is stopped abruptly. Also the initial effect tends to wear off and necessitates an increased dose for the same effect. 

When used for ADD, the doctor can increase the dose until it is effective. Since Vyvanse actually treats the symptoms, the effects will usually be long-lasting. When used for BED, Vyvanse diminishes appetite only as a temporary side effect, so increasing the dose is inevitable when appetite returns to normal.

Continually searching for an effective dose will lead some people to seek higher doses, increasing the chance of taking too much medication. There is no benefit to replacing binging with prescription medication abuse. 

The shortage of effective medications for BED is clear to patients and physicians. However, a government agency cannot justify approving an addictive medication with extremely limited use for binge eating as a viable treatment alternative.

It's better to increase awareness and develop more treatment options than propagate false hope. 


The Miracle of Human Metabolism

The other topic of the radio show I mentioned a few posts ago is concerned with digestion and metabolism of processed foods. The doctor in that show speaks with authority about how digestion and metabolism are different with these foods as opposed to foods found or grown in the environment.

Specifically, he describes how processed foods are immediately available for digestion and absorption which leads to instant changes in blood energy levels. There is increasing evidence that the complex hormonal regulation of blood energy struggles to adapt to these new foods. More natural foods provide a buffer to delay and slow absorption, something our digestive system depends upon for normal regulation of blood energy. 

The doctor's step towards vilifying processed food and added sugars though is unrealistic. From his vaunted perch, it would be more helpful to discuss how to live in a world with our current food supply. Being able to eat processed foods in moderation is a cornerstone in modern life, but it's also crucial to understand why the majority of one's diet needs to be real food for our bodies to function normally. 

People generally think about metabolism in terms of burning energy. The goal in this rubric is to maintain a high metabolism to keep weight down; however, this is not the true definition. The pressures from the food and diet industry intend to place blame on the individual while hawking products that lead to weight gain. 

Metabolism is the bodily function that digests food, turns it into usable energy and transports the energy to parts of the body that need it. It is a complex interplay of the endocrine and gastrointestinal system which maintains healthy function throughout the body.

Our conscious part in this system is to eat regularly and eat predominantly a varied diet of real food. People like the NYU nutritionist Marion Nestle have written at length about what that means, but it's not about following the most recent fad, just following logical conclusions. 

The purpose of reflecting regularly in this blog about metabolism is for readers to understand and admire the way our bodies use food and energy in complex and amazing ways. With that knowledge, we can try to avoid the current trends and pressures about food and just do the basics each day. That's true for everyone, those with or without an eating disorder.