Individualized Eating Disorder Treatment

The standard treatment protocol for someone with a moderate to severe eating disorder is clear. Establish treatment with a team including a therapist, nutritionist and physician. Fully assess the medical and psychological state of the patient. Determine the appropriate level of care: outpatient team, outpatient program, residential program or hospital. Begin treatment. 

This standard approach is considered to be fairly straightforward. Like many other illnesses, the existence of a protocol implies that following the plan will lead to recovery. In the case of eating disorders, this is often not the case. 

The limited data supporting success of this treatment plan leave clinicians with their intuition and experience to make decisions rather than hard information to rely on. The promise that any step in treatment guarantees health and recovery is empty. 

The truth is that each person with an eating disorder needs an individualized treatment plan. The direction of treatment may often follow a standard protocol, but each step forward must be evaluated to see if it is right for the patient. It's not acceptable to confuse a failed treatment direction with low patient motivation. The key is to find a plan that works and not blame the person with the illness if the intervention doesn't help. 

Thus, I usually advise patients to find treatment providers they think they can trust and feel comfortable with. Also be sure this team is willing to collaborate on decision making. Having agency in one's life is essential to feel like recovery is really about wellness and life, not just following someone else's plan. Last, be sure everyone's goal is to create both recovery and a full life. Any other distractions or ulterior motives will only interfere with what recovery is all about.


Why is an Eating Disorder like a Virus?

The nature of an eating disorder is fluid and constantly changeable. Even though the thoughts and symptoms often seem fixed, any change in situation, context or environment will precipitate an immediate adjustment in the eating disorder. In this way it is like a virus in the mind, always ready to adapt to new surroundings, multiply and attack. This ability keeps the eating disorder powerful and enables it to dominate a life. 

For instance, when someone with an eating disorder moves to a new environment, the rules instantly change to suit the situation, mostly in order to maintain strict control over food. A new relationship will lead an eating disorder to find a way to inject itself into a situation. Changes in a food plan precipitate other, often hidden, changes to compensate.  

Paying attention to the subtle response of an eating disorder and fighting to avoid those pitfalls are challenging yet necessary in recovery. 

The ever-changing, insidious quality of an eating disorder demands a consistent, flexible treatment team. The people who comprise that team need to understand each other, be capable of quick response and be very familiar with each other's thought processes about recovery. There can't be a secondary agenda. The team can't isolate from each other and compartmentalize aspects of treatment. Working as a cohesive, directed unit will increase the likelihood of success and also take the responsibility of managing the team out of the patient's hands. 

From a biological perspective, a treatment team needs to mimic the effectiveness of antiviral medications. Viruses are highly adaptable organisms which can mutate in the blink of an eye to a new environment or to new medications. Any success treating viral infections stems from anticipating the likely responses of the virus to new treatment and blocking off all avenues of escape. 

The analogy is very similar for eating disorder treatment. If a clinical team can block off ways the disorder mutates, the person has a real chance of recovery. This level of success may scare some patients who aren't psychological ready for such a big step in recovery, but realizing recovery is possible can have a profound effect on even the sickest patients. 

A patient can identify a team working this well when it appears the clinicians work together fluidly and seamlessly. If a patient needs to manage the team, then there is a problem. If the team members need to spend lot of time getting on the same page, then that is also an issue which detracts from recovery and opens the door for the eating disorder to flourish. 

A treatment team is a crucial part of recovery. But finding any team isn't enough. Cohesive support aimed at cornering an eating disorder can make all the difference in true recovery.


Vocabulary of the Diet Industry: New Information or Corporate Propaganda

The purpose of diet fads is to create a novel way to approach food. If we refashion our daily diet into a prescription for health and well-being and simultaneously eliminate guilt and shame, somehow, some way our lives will magically improve. 

Typically, each successful invention in the diet industry finds new language to help rethink the role food plays in our everyday lives. It's not as if this new vocabulary alters the discussion. Instead, the shift in terminology creates the illusion of a brand new day. 

New views of a healthy diet quickly are coopted by people susceptible to eating disorders. The terminology always hides food restriction or limits under the guise of health and wellness. The insidious nature of the diet industry's mastery of marketing catches those on the brink of an eating disorder at a vulnerable moment. Swayed by the latest fad, many of them will unwittingly use the vocabulary to justify a full blown illness. 

Diet vocabulary is little more than propaganda for big business. The more new language seeps into the general zeitgeist of the culture, the more financially successful the diet. And the casualties left on the roadside are merely the necessary consequence of generating large profits. 

One latest example is the concept of clean eating. Ostensibly, this new language represents eating whole foods with limited processed foods. People can hide behind the overt definition of the term and feel fully vindicated. 

However, the word clean is loaded when applied to food. It implies that following these guidelines is inherently positive and healthy. Any other way of eating must be dirty in comparison so the combination of judgment and health appears foolproof. Feeling clean trumps the fear of judgment around food and becomes the new mantra of eating. 

New diet vocabulary only provides people a way to demonize eating and thereby justify feeling tortured by conflicting, loaded thoughts about food. Diets need to be called out for what they are: propaganda to exploit society's fear and confusion around food. Diet vocabulary is not an answer. It only creates more confusion when we all need to just learn how to eat again.


Our Collective Obsession with Weight Loss

The cultural focus on weight engulfs many people's conscious thoughts, the majority of whom do not have an eating disorder. For people whose bodies do not conform to the societal norm, and for many who cannot see their body realistically, there is a plethora of options to attempt to manipulate weight and body. The various industries, including food, diet, supplement and exercise, seek to capitalize on the intense personal need to control weight. 

Not infrequently, patients contact me or see me largely to withstand the onslaught of messages and quick fixes for weight loss. The intense pressure to look a certain way and, just as importantly, to fix problems with one's body that our society insists must exist is relentless. Our minds are bombarded with this message. Personal value seems to hinge on the expectation that we are all seeking to perfect ourselves and our weight. 

And so industries rise to offer solutions. The exercise industry continues to grow exponentially and provide a source of constant guilt and seemingly endless expenditure. The food industry pulls us between diet food and fast food like a ping pong ball. Supplements for weight loss abound. And medicine has gotten into the game from weight loss clinics to the endless stream of new obesity medications to the very lucrative Bariatric surgery centers. 

It's extremely hard to find the voice of reason. No one is saying we are wasting our time focused on body and weight. The message to live a full and productive life is nowhere to be found. 

The broader message I impart to patients who come with these worries is simple. The goal is to put the overall concern about weight into a larger context. Figuring out one's own personal needs and struggles remains paramount. Finding direction in one's life is the goal. If weight becomes the sole focus, life starts to feel like an endless rat race without a point or an end. Acceptance of one's body is difficult but a necessary goal to find out how one actually wants to live. Although this message applies to eating disorder recovery, it has true meaning for everyone in the world we inhabit.


Combatting Eating Disorder Thought Processes

The most powerful component of an eating disorder is the thought process. Unlike most illnesses, the central part of an eating disorder feels as if it takes over our identity. The thoughts become our thoughts. The rules become our rules. The beliefs become our beliefs. 

Deeply buried beneath a system that pushes someone to manipulate food in whatever way the eating disorder determines is the actual person. Those real and true thoughts and feelings are either very compartmentalized from the illness or simply ignored and not part of one's life.  

Recovery initially entails normalizing food because improved nutrition and health are crucial for any steps towards wellness. However, from the start, successful treatment needs to incorporate the concept that the eating disorder thoughts are an alien experience that severely limit personal growth, satisfaction and the true nature of life. 

It is a shock for people to realize how much they have been brainwashed by the illness. Our minds tend to be able to unconsciously accept a belief system, even if it's completely irrational or harmful, and find ways to function within that reality. Breaking through that wall to recognize the system is broken is a mainstay of recovery. 

There are three main ways to accomplish this step. 

The first is the food journal. This simple daily exercise exposes the insidious and constant nature of the eating disorder thoughts. The journal forces one to look many times per day at the painful but powerful eating disorder messages. Similarly, a small bit of perspective from this daily existence encourages the person to question if the food choices and thoughts really make sense. 

Second, the therapy needs to try to separate eating disorder thoughts from personal thoughts. Some clinicians call this distinction the difference between healthy self and eating disorder. Although the terminology may seem artificial, it's critical to start to see the eating disorder as other rather than a necessary part of identity. Once the idea of a healthy self comes into view, those new thoughts consistently question the reality of living completely in an eating disorder world. 

The last step is to use the journal and the healthy self to look more globally at life. As one begins to address a personal philosophy and overall goals, it becomes easier to see how the eating disorder will never allow anything to change in life. Other components of life, relationships, friends, work, must start to matter more and push out the eating disorder thoughts as the primary source of personal identity and accomplishment. As this process starts, it become harder to adhere to the disordered thoughts and philosophy. 

These last two posts explain why eating disorders are psychological illnesses and why clinicians and loved ones need to try to understand the complexity of the illnesses in order to be loving and supportive. Nourishment and health are critical, yet psychological change is the hallmark of full recovery. 


The Psychological Aspect of Eating Disorders

Most people, often including clinicians not knowledgeable about eating disorders, consider the physical symptoms of restricting or binging as the central element of these disorders. The psychological component of the illnesses remains confusing and elusive to most. 

People suffering from eating disorders most often perceive the eating disorder as a powerful barrage of critical and demanding thoughts that dictate daily life. The thoughts typically focus around the need to restrict food and loss weight or to find a way to justify binging no matter what. The thoughts feel so powerful and insistent that they are impossible to ignore. 

Everyone has various thoughts their head, but not everyone knows what it is like to have such powerful thoughts that run counter to one's own logic. In addition, these thoughts don't feel foreign. They feel like one's own true thoughts. 

Imagine for a moment what that last sentence means. The thoughts that serve as the engine of a destructive illness feel like one's own deep and intimate thoughts. The illness itself penetrates to the core of one's own self and literally takes it over, almost as if one has been brainwashed by the illogical, painful thoughts to manipulate food and feel sick. 

After processing this information, it becomes clearer why eating disorders are so confusing to people and why recovery is so hard. The actual symptoms make little sense to people who aren't sick, but recovery to those who don't understand simply means stopping the symptoms. In fact, families and friends usually try to make sense of eating disorders exactly with that philosophy: just eat food.

But the idea that foreign thoughts dominate one's mind and dictate how someone lives their life is anathema to how normal people live. The internal struggle between the desire to live a full life and the eating disorder determined to be thin or use symptoms at all cost leads to a fraught and challenging life. The process of successful recovery demands an enormous amount of energy separating the eating disorder thoughts from oneself  by any means necessary. True recovery means quieting the eating disorder thoughts enough to then be able to focus on life more freely. 

The next post will discuss the most successful ways to separate one's own self from the eating disorder in therapy and in practice.


Focus on Compassion and Love in Recovery

A core tenet of eating disorder therapy is to maintain sharp focus on compassion and love. Eating disorder thought processes are relentlessly harsh, critical, judgmental and downright cruel. However, these thoughts dominate the mind of someone suffering from an eating disorder and feel inescapable. 

As I have written regularly in this blog, the antidote to the thoughts is love and compassion. The instinct for loved ones is to focus on improving eating patterns, weight or physical health. Clearly, eating and health are crucial to recovery, but those comments always directly support the eating disorder. 

Rather than perceive these comments as supportive, as most loved ones imagine, they are interpreted as personal attacks against the eating disorder. Accordingly, the eating disorder thoughts only strengthen when faced with comments about food and weight. The supposed support only seems to propel a further descent into illness. 

The most helpful support that specifically counters the core values of the eating disorder is centered in compassion. Saying things like, "I love you" or "you're really doing an amazing job in recovery" convey a very different meaning. These comments penetrate through the eating disorder messages and connect more profoundly with the essence of the person suffering from the eating disorder. The effect of establishing a secure connection of love and support is what anyone suffering from an illness needs and that is even more valuable in eating disorder recovery. 

Because of the extended time eating disorder recovery takes, loved ones and friends need to keep in mind the need for compassion and love every day. It can be hard to maintain that kind of focus, yet each kind and loving word makes a difference to maintain the path to fully being well.