Food Journals

The food journal is a simple, effective but underused tool in eating disorder treatment. Both clinicians and patients balk at incorporating the journal into treatment. Therapists consider it too simplistic to be effective. They fear the therapy will not address the patient's underlying emotions or believe only nutritionists should discuss food. Patients are too ashamed to discuss specific food choices or find the daily journal too cumbersome. When both therapist and patient really sign on for the food journal, the treatment feels like it has taken a shortcut to trust, honesty and progress. By addressing food from the start, the journal can be the catalyst for real life changes.

The food journal itself includes the date and time of eating, specific foods and amount eaten, whether the meal is overeating or a binge and the thoughts and feelings at that time. If possible, each entry should be written at the time of the meal. The format of the journal can be a chart, narrative, or daily emails, but I am always surprised by creative ways a patient will write her journal. The best option is the one that works for the patient. The journal can be in any form as long as it gets done. In the session, the therapist and patient review the journal and learn how to work together to understand the eating disorder, a process based on Cognitive Behavioral Therapy or CBT.

The essential component of CBT--a mainstay for eating disorder treatment--is the food journal. This approach involves identifying patterns between eating disorder thoughts and behaviors, increasing awareness of these patterns and devising methods to change them. The biggest problem with CBT is commitment to the journal itself. While this type of therapy can be very effective, there is little guidance on how to ensure the patient completes the journal.  Often, what is missing is a sense of urgency. What is the purpose of recording her food daily? Why should she bother? She needs to know and truly understand that the journal can be the bridge to hope and then recovery by addressing the most insidious and powerful part of any eating disorder, secrecy.

Because patients feel intense shame about themselves and the symptoms, hiding the disorder feels like the only option. Each and every subsequent slip into the symptoms induces more guilt. Each time, she says, will be the last. Each time only reinforces the need to remain hidden until the eating disorder goes away. This vicious cycle makes her feel more and more isolated from family and friends and increasingly hopeless about her life. The therapist needs to break through the cycle to help her believe she is capable of eating in a different way and becoming free from the overwhelming hopelessness.

How can a food journal change anything? I hear that question every time I mention it. First, the journal establishes a consistent, daily connection between therapist and patient. Moreover, the communication in therapy starts with the biggest secret in her life--things she frequently has never told anyone before--behaviors around food. This is a huge leap for the patient and a huge responsibility for the therapist, but these steps are necessary because eating disorder treatment needs to tackle the secrets directly. The patient cannot be alone anymore.

The journal means honesty for the patient with her therapist and with herself. This can be a remarkably liberating experience after years of feeling captive to the cycle of thoughts and behaviors. Instead of deluding herself that each day will be her last eating disordered day, she has a partner to help demystify and change her relationship with food. The sense of collaboration transforms the immediate experience in therapy for the patient. Regular talk therapy can feel like an inquisition which only reinforces her sense that she is broken. The journal can change that. It is the physical object the team--patient and therapist--can look at and learn from together. The therapy is not judgmental but objective, and the goal of each session is to learn how to do the work of treatment together? It means the patient has the answers too; she is no longer powerless. So many patients avoid treatment because the shame is overwhelming, but here the shame is secondary to the collaboration. The shame is transformed into trust and a renewed hope for the future.

This entire post reveals a fundamental difference between eating disorders and other mental disorders. No other disorder becomes a way of life so powerful, so shameful and so secretive that it can consume a patient entirely. No other disorder is highly praised by society. No other disorder arose from nowhere less than forty years ago. The next post will begin to consider these differences and the bigger question: why is this disorder different from all other mental disorders?

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