Diverging Paths of Eating Disorder Treatment: How to Treat the Chronic Eating Disordered Patient

A recent conversation with a colleague reached a sticking point: what options are there for an undernourished patient who is not able to go to a program and become nourished?

She said that she cannot work with someone who is malnourished. Since a starved brain doesn’t work, any form of therapy is ineffective and meaningless. Until the patient is ready to seek help, therapy is pointless.

I said that although that may be true, how can a clinician reject a patient because she is so stuck in her illness? Isn’t it the obligation of the treater to stand by the patient and shepherd her into beneficial care?

This conversation reflects a larger issue with eating disorder treatment. What is to be done about the people with chronic eating disorders who are unable to seek more intensive help?

Standing one’s ground about becoming nourished has its merits. Treatment will be challenging for someone who is working hard to follow a meal plan, but there will inevitably be progress. Creating new thought and behavior patterns around food naturally evolve from actively working on a meal plan. And for the clinician, it is easy to feel secure in the direction and goals of treatment. There is little risk for the therapist.

Working with someone unable to start a meal plan is a different, challenging and potentially dangerous endeavor. The risks of serious medical consequences are high. The effects of being malnourished or compensatory behaviors such as purging or laxatives are concerning. And there is no guarantee the patient will find a way to start to eat more regularly again.

This path demands patience from a therapist to tolerate a high level of illness and the brutal honesty of seeing what someone in an active eating disorder looks like. Yet the potential rewards of taking the more dangerous route are great.

The effect of standing by someone too sick to begin a path towards recovery is significant. The patient feels heard and understood. She realizes she is not a pariah but instead someone with an illness who wants and needs to get help. She starts to see that she can be cared for in her illness and she won’t be alone in the process of recovery either.

Those messages are necessary to create the trust that opens a heretofore invisible road to wellness.

So it’s not that I disagree completely with my colleague. But maybe there are multiple ways to help someone with an eating disorder see the opportunity to get better. Flexibility and the willingness to find that road are sometimes more important than anything.


Why are People with Eating Disorders Blamed for their Illness

Another component of eating disorders that differentiates them from other mental illnesses is blame. More than every other psychiatric problem, people with eating disorders are routinely blamed for their illness and their inability to get well.

Not just family and friends but even clinicians often tell the person to just eat a sandwich or drink a milkshake. The lack of compassion and limited inclination for people to even try to understand eating disorders are so powerful that it’s hard not to look for other reasons to explain hard-hearted responses.

Eating disorders are contradictory for most people. Eating is a basic component of living, not far behind breathing and sleeping. It’s anathema for people to conceive of a world in which they willfully don’t eat or purge food in some way. The instinct to tell someone just eat a sandwich comes in part from the incredulity that a person would do otherwise.

However, that reaction makes sense the first few times a person tries to understand an eating disorder. Why would family and friends continue to say the same thing months and years later? How can experienced clinicians repeat the same mantra to eating disorder patients?

Another part of the confusion is the dearth of successful treatment. Medications, by and large, are ineffective. Therapies are specialized and take a long time to have a significant impact. Moreover, not enough clinicians are experienced in treating people with eating disorders even though many people profess to have that expertise.

The decades of social pressure to be thin and diet has glamorized eating disorders. On the one hand, many people in general see an eating disorder as a prolonged successful diet. Few understand the psychological torture of the illness. On the other hand, the cultural zeitgeist professes that once someone has an eating disorder, they always will. It’s a life sentence. The concept of full recovery is one most people have never contemplated or even heard about.

All of these aspects of eating disorders leave the public with the sense that eating disorders are the person’s fault. The final blow in this scenario is that the blame ultimately disempowers the person, usually a woman, from feeling like she has any ability to get better. Since recovery involves a constant, daily fight against the disorder while attempting to tolerate the discomfort of changing an automatic behavior pattern, the blame undermines a chance at getting well.

It behooves family, friends and clinicians to scrap the assumption of blame. Eating disorders are true illnesses. The sufferers need and deserve support, comfort and compassion.


Connecting Eating Disorder Recovery with Women’s Emotions and Power

The first part of eating disorder treatment is typically focused on normalizing eating and implementing a meal plan. Regulation of food and nutrition allows the body and brain to receive adequate energy to heal and function normally again.

The second part of treatment is amorphous and more complex. The last several posts highlight, on a larger scale, how the suppression of girls’ and women’s emotions and anger is very much related to eating disorders. Thus, it’s not coincidental that recovery focuses on identification and expression of those suppressed feelings along with exploration of someone’s true identity once the eating disorder is no longer the only driving force in her life.

The true engine of an eating disorder is the obsessive, persistent thoughts about food and weight. At its worst, an eating disorder so dominates one’s mind that there is no room for all the thoughts, feelings and experiences that come from living life. Once the eating disorder thoughts begin to dissipate, the mind almost feels blank and people often find themselves longing for the old thoughts to occupy all the empty space.

It doesn’t take much encouragement or living to bring up new and different thoughts and feelings. They come automatically just by living in the world. However, the experience of true reactions to the world can be overwhelming after having been sheltered for years behind the wall of the eating disorder.

Fairly soon, the new feelings land on anger and often this anger relates to the ways in which the person has been suppressed, oppressed or kept down in some way. The reaction and feelings can be very overwhelming yet the path to recovery has to go through those very real and valid feelings.

In the context of the recent posts, this step in recovery represents the idea that eating disorders have become the newest psychiatric disorder that pathologizes girls’ and women’s emotions. The goal of recovery isn’t just to help people eat and live their lives again. The goal is to open the door to living fully and freely, including the ability to express all of one’s feelings in the world.


Anger as the Engine for an Eating Disorder

At the emotional root of many eating disorders is suppressed feelings, most commonly anger. For people taught at a young age that anger is not an acceptable emotion, food is an easily found, effective and socially acceptable way to manage emotion.

Indulging or overeating, secreting food or binging and restricting all help transform emotions into behaviors that either express feelings or numb them. As society continues to reinforce these behaviors as a viable alternative to acknowledging feelings, we collectively increase the likelihood of triggering eating disorders in those who are susceptible.

It’s also not a coincidence that most people who develop eating disorders are girls or women. As evidenced by the recent political events, anger in women is taboo in our culture. Women who express their anger are most often called names or vilified until they are able to control and channel their anger. The reality of human emotion is that no one can tamp down anger indefinitely without repercussions. 

Pushed into a corner where the reality is either express unacceptable anger or repress it, women often find themselves focusing on food behaviors or body shaming as a coping tool. The general pressure on women to eat and look a certain way only reinforces the behaviors as appropriate and meaningful. As I have written many times in this blog, the main risk factor for developing an eating disorder is food restriction or dieting, and using food behaviors to manage emotion is a first step to possibly developing an illness.

One hope I have behind the growing movement towards equality of women in the workplace and culture is the freedom for women to express their emotions, especially negative ones. Being trapped by their own feelings leaves women unable to embrace their full self. Subjugating their beliefs, thoughts and feelings for the meaningless obsessions with food and weight is a waste of time and energy. The goal is for girls and women is to be their true selves and not get lost in the inanity of an eating disorder.


Why Someone with Anorexia Should See a Doctor

For people with anorexia, one irony is that getting medical help often reinforces the illness. I will frequently hesitate before referring these patients to their primary care doctor, and this conundrum presents a complex path towards getting better.

The anorexic thoughts repeatedly tell people that they just eat a little less than others and that their medical symptoms are exaggerated. The fact that they cannot see their bodies realistically means that they think they are fairly healthy when they are actually severely malnourished.

How else can people who wear very small clothing sizes or get weak and dizzy from walking down the street believe they are healthy?

As their health continues to deteriorate, the eating disorder thoughts strengthen and convince the person their health is normal. Even abnormal tests, worsening physical health and increasingly debilitating symptoms don’t change this delusional thought. 

A confusing factor for these patients is that the human body is programmed to adapt to periods of starvation. Centuries of intermittent famine have built this protective mechanism into our DNA. Accordingly, blood tests often remain normal even when someone is severely starving. This does not reflect health but instead the body’s resilience.

Also, modern medicine is not designed to diagnose the medical problems associated with starvation. Outside of anorexia and end-stage cancer, people don’t experience chronic starvation in the first world. Thus, doctors aren’t trained to treat malnutrition and modern medical tests don’t pick up on the problems associated with starvation, especially the common cardiovascular ones which look for heart problems of the elderly, not the starved.

Because of these complications, seeking medical help often reveals little: blood tests and imaging are usually negative. Instead of receiving useful medical attention, people with anorexia end up without any useful information which then reinforces the eating disorder thoughts and leads to further slips. Unfortunately, a medical work-up can just as often lead to a relapse and hospitalization as it can medical findings.


The Flawed Messages to Parents about Food and Weight

After recently talking to an acquaintance about her daughter’s eating, I was reminded of the pressures on families to adhere to the societal mores around food and weight. It’s no wonder that so many children are essentially raised to have eating disorders.

The biggest disservice our culture provides is couching these pressures in hackneyed science and medicine. There are several examples that trick even the most well-meaning parents into questionable practices. 

The erroneous research into sugar as an addictive substance has created communal terror of this component of food. Yes, the human body is not designed to process the added sugars in all sorts of foods, but sugar is not the new cocaine or oxycodone. Understanding the risks of consuming too much sugar while also figuring out how one’s own (or one’s child’s) body reacts to sugar is important, but using this information to ban sugar from your child’s diet is troublesome. It only reinforces the child’s desire to eat sugar and creates a mystique that makes sugar the forbidden fruit and the most desired food.

The increase in children’s weight in recent years has become a public health obsession. However, the guidelines pediatricians use to manage weight as a medical indicator for health risk do not take into account the child’s overall health. As a result, many children are branded overweight and parents are charged to change that child’s eating and exercise habits or else fear the shame of a fat child. The line between fat phobia and sound medicine is not so clear. Often the well-intentioned doctor only encourages the possibility of an eating disorder.

Last adults who likely discourage peer pressure at school condone the shaming of fat children. Since being fat is considered a personal flaw or weakness, parents expect their fat children to be teased and, perhaps subconsciously, blame the child for the situation.

It’s easy to see how a child can internalize these messages about weight when they come from doctors, science, adults and peers. The message is clear: being fat is a personal flaw and losing weight is the only way to rectify the situation. Parents need to be focused on their child’s emotional and psychological well-being and not the number on the scale.


Hope: the Cornerstone of ED Treatment

Too many people with chronic eating disorders feel like they run out of options. It often takes quite a bit of time to summon up the courage to look for help and then actually get to an appointment. The shame about the illness and the fear of discussing the disorder—making it real—are overpowering. But after that first difficult step, what’s happens next?

Too often, people end up very frustrated and disappointed. Perhaps they see a clinician without much experience treating people with eating disorders. Perhaps they see someone who shames them for their illness. Perhaps they feel blamed for being sick. Or perhaps they go to treatment for a while and make no progress at all.

If that pattern happens a handful of times over a few years, it’s easy to see why someone would become demoralized and expect that the eating disorder is likely a chronic condition. As time passes and opportunities are lost, a sense of hopelessness grows even larger.

I have seen many people 10-15 years into an eating disorder in this frame of mind, devoid of hope and stuck in a cycle that feels like it will swallow their lives.

I don’t pretend to have all the answers to help these people. Sometimes they need behavioral intervention just to break the eating pattern. Sometimes they need education to understand the difference between their own thoughts and eating disorder thoughts. Sometimes they need someone to believe in them. Sometimes they need to see that love is the antidote to an eating disorder.

Most of all, the one component of treatment that is critical is hope. What these people who have struggled for years without any true progress need is hope. They need to see there is a way to recovery and that people who have been sick for years can fully recover. They need to see that the path may be hard, but someone has an idea of what that path might look like.

My wish for the many people struggling with chronic eating disorders is to know that help does exist for you. Look for the right kind of guidance and maintain hope that wellness and recovery can be in your future.