Goals for Treating People with Chronic Eating Disorders

A discussion of goals has to start by addressing the obvious question: can people with chronic eating disorders recover? The answer is an unequivocal yes. The deepest fear for anyone who has been sick for many years is a lifetime sentence to an eating disorder. Unless the clinician directly faces this concern, every patient will leave assuming the worst. Thus, it's essential that a discussion of goals explicitly puts recovery at the top of the list.

The second assumption someone with a chronic eating disorder will likely make is that the stated goal of recovery is just a lie created to give false hope. Who in their right mind would think someone can get better after five, fifteen, twenty five years of a brutal illness? Yet those people can and do get better. The road to recovery is long and hard and painful, punctuated by too many moments when all feels lost. A constant theme in therapy must be repeating the idea that recovery is a real option and that a life not plagued by this illness possible.

Recovery, however, cannot be confused with paradise or nirvana. Anyone who has struggled with a chronic illness will be affected by that experience throughout their lives. They can get well but will always have a different perspective of life. They need to be prepared to face their own life circumstances, persevere and move forward, and not think they can rewind life to what they envisioned before the illness. It's crucial to build resilience into the goals of treatment early and represent recovery as a life not completely dominated and controlled by the eating disorder symptoms, not the imagined life they might have led were they not sick.

With these guidelines, the therapy needs to narrow down from large scale expectations to day-to-day goals. Two aspects of chronic eating disorder treatment are central to understand to establish feasible goals. First, the patient is bombarded by thoughts and instructions by the eating disorder itself all day long. These commands, from thoughts to restrict to urges to binge to constant confusion about what to eat, occupy far and away the majority of mental energy of someone with a chronic eating disorder. It's practically a miracle they can do anything else in a day. These thoughts are all consuming, very unpleasant and impossible to ignore. The eating disorder thoughts easily drown out the few sessions or hours of treatment per week. Whereas more limited treatment can reverse an eating disorder earlier in its course, therapy for a chronic eating necessitates daily, constant intervention to make a dent in the relentless illness. Second, these thoughts become the person's identity. After years of living through constant eating disorder thoughts, it becomes very hard to differentiate between the eating disorder and oneself. 

Since no therapy can last all day, every day, the therapist and patient need to collaborate to extend treatment into a daily intervention. Trying to force this treatment into the standard treatment protocol leads to sure failure. A team cannot present an immediate food plan and expect a person sick for many years to make instant changes because they are suddenly more motivated. Eating disorders are just too tenacious to let go because the ill person wants to get better. The clinicians and patient need to explore the nature of the eating disorder and look for loopholes, ways to insert new thoughts and actions into each day. Through more communication via more hours in treatment, food logs, journaling, emailing or texting, the team can be in regular contact so the patient isn't alone with the illness all day long. Creating a new environment in which several people are putting their minds and time into changing a longstanding pattern of illness opens a new door to recovery.

In this circumstance, the practical goals come into clearer focus: stay in touch regularly, communicate through the day, watch for signals or patterns of distress and create and try out new behaviors to replace the eating disorder. The therapeutic effect of these changes is profound and necessary to be sure treatment heads towards recovery.

It's usually eye-opening for a chronically ill patient to see any change in the eating disorder behavior from simple interventions. That first blush of progress begins a new path of recovery. The psychological imprint of years of an eating disorder feels untouchable, yet the start of relationships that may affect the illness is revelatory. It opens that person's mind to possibilities long forgotten. From the therapist's perspective, the person's identity has completely merged with the eating disorder. One doesn't have anorexia or bulimia; one is anorexic or bulimic. The process of separating identity from the eating disorder is critical to successful treatment because it allows in real hope for recovery once again. Yet it's also the most challenging. The next post will address this topic in detail.