Eating Makes Recovery so much Harder

Eating disorders are classified as psychiatric illnesses for good reason. Although the physical symptoms are most obvious to the outside world, it's the inner psychological turmoil that causes the most pain.

The outward physical manifestations of eating disorders tends to overshadow the true nature of these illnesses. Starving or purging food distracts people from recognizing that beneath eating symptoms are far more insidious psychological symptoms. The medical effects of eating disorders often disturb clinicians and scare doctors away from treating these patients but also stops even the treaters from seeing the inner world of a sufferer. These illnesses cause chronic physical symptoms, and anorexia has the highest mortality rate of any psychiatric diagnosis. And the cure looks so simple as to be ludicrous, just eat.

To anyone watching a person in recovery, it's evident that eating isn't easy at all. Each bite is excruciating; each plate of food is an obstacle of epic proportion; each moment is dominated by fear of the next meal or snack. Eating a meal is a ritual that happens several times per day. Whether for pleasure, work, celebration or sustenance, food represents a mundane part of life to those who are well. The experience of terror around food mystifies even the most open-minded, compassionate person who doesn't have an eating disorder.

Understanding the true inner struggle of recovery necessitates a big step in logic. The eating disorder symptoms appear to be the biggest hurdle in treatment. Avoiding restriction or purging or over-exercise, a person in recovery starts to physically look better to the outside world. Normalized weight and energy makes concerned family and friends take a deep breath of relief.

The reality of recovery is much different. Once a patient starts to eat and avoid behaviors of the disease, things start to get really hard. Just when everyone stops worrying as much, the person in recovery needs a lot more comfort and support.

The easiest way to imagine the psychological symptoms of an eating disorder is to think of a repeating loop of thoughts in one's mind. The thoughts are an endless string of criticisms and punishments. These thoughts can attack every step the person takes: every comment, every decision, every opinion.

The result is to quash any meaningful aspect of this person's life. If ever an ounce of positive experience sneaks past the filter of these thoughts, the endless loop returns to the most effective punishment: food and body. Feeling guilty about eating food or ashamed of one's appearance will always stop any movement towards positivity and trap the person in the negative, critical loop of the illness.

There is only one way to calm the punishment: the eating disorder symptoms. Starving, binging or purging will make the thoughts stop for a moment and give a few minutes of peace. So the symptoms are the only thing that provides any relief to someone in the throes of an eating disorder, and eating is the only way to get better. The result is doing something many times per day that will get you well but makes you feel worse in the moment each time. Meanwhile, everyone who is supportive thinks things are better, yet the sick person just feels really bad. No wonder recovery gets so much harder.

Regular professional help will reinforce to the patient that this step in recovery is always very difficult. However, educating family and friends is crucial at this stage of treatment. While getting better, the person needs to reach out for support and work on building personal relationships. Those connections help loosen the grip of the eating disorder. It's critical for those close to the person in recovery to work hard to understand what makes eating so hard. The supporters need to regularly express love, compassion and understanding for the emotional struggle to try to live each day without engaging in the eating disorder symptoms. Doing so helps the person feel supported in the struggle to get well and comforted by the repeated recognition that even though eating each day is very, very hard, it's also the only way to get better.


The Challenge of Compliments for a Person in Eating Disorder Recovery

Compliments generally have a universal effect on people. They smile, feel better about themselves or feel more connected in the moment. Families and friends, recognizing the challenges in recovery from an eating disorder, want to acknowledge small successes and encourage their loved ones through the process. Yet compliments to a person in recovery usually backfire. The patient tends to feel worse afterwards and pull away from the relationship, a confusing response to a gesture of love and caring and, in light of my recent posts about relationships and intimacy in recovery, somewhat paradoxical. But a more careful understanding of the social dynamics of a compliment explain the situation more clearly.

In order for a compliment to be helpful, the receiver has to be able to do several things. First, she has to believe the statement comes from someone being genuine. Second, she has to understand that the statement might very well be true. Third, she must allow the closeness that comes with accepting the statement and must allow herself to express the vulnerability of gratitude. In other words, the seemingly automatic and easy responses to a compliment don't come naturally to someone with an eating disorder.

Wary of relationships, the person in recovery isn't facile at believing a positive statement from someone else can be authentic. It's hard to imagine a compliment is real when one's internal thoughts are constantly negative and critical. If a positive comment doesn't represent true caring, the next alternative is to assume the other person has an agenda. The internal criticism can cook up many stories to explain the comment from wanting something in return to veiled competition. Sizing up another's motivation for a compliment will only reinforce the negative thoughts associated with the eating disorder and confirm the world is just as harsh and cruel as the disease itself.

Even more difficult for a patient in recovery is to assume the opposite of the critical thoughts, that a compliment may in fact be true. A lot of work in recovery is explicitly geared towards imagining a positive statement about oneself is true. At the core of the illness is the absolute belief that one is a horrible person. Although the patient can live in the world and fake being "normal," a word frequently used by people with a chronic eating disorder, the underlying identity is a complete negative self-image. There are almost no positive thoughts to find in someone with longstanding illness. And so it takes time, patience and a lot of repetition to begin to replace those critical, automatic negative thoughts. Positive comments from others seem irrelevant, not connected at all to the identity of the sick person, and learning how to accept and believe these statements is a central part of recovery.

The last step in accepting a compliment is the hardest. The social norm in responding to a positive statement is a subtle but powerful engagement. The complimenter is extending a hand and showing some personal vulnerability with the praise. Compliments generally come with eye contact and an expectation of a response. The complimentee is likely surprised and will smile and be gracious. That response necessitates returning the eye contact, a smile and an extension of the vulnerability by allowing a moment of connection, likely leading to a sense of emotional closeness. For many reasons, this short, subtle exchange taxes the patient's ability to engage in the intimacy of relationships, something that generally terrifies someone in recovery from an eating disorder.

Left without the natural response to help a loved one in recovery, family and friends can feel powerless to say anything. A compliment pushes the person away and any even subtly critical comment certainly hurts. Yet not saying anything at all will send the message that one doesn't care. Often, emotional distance in all relationships precedes the step into recovery so these once close relationships are already strained and much more distant than in the past, a fact that puts significant pressure on making communication work. Confusion and tentativeness are the most common response for loved ones close to the person in recovery. 

The best approach is to continue to compliment the loved one while also recognizing how difficult that interaction might be. It's best to preface the statement by saying a compliment is on its way or that this statement might not be so easy to hear. This will give the person a moment to prepare for the emotions that follow. Even commenting that it might be hard to believe the statement will help the person feel understood. Steps forward in recovery can be challenging and the process of improvement leads to mixed feelings, as I have written often in this blog. Sensitivity to the challenges in recovery, even in something as hard to understand as taking a compliment, will only help the person in recovery continue down that path and feel supported and loved.


The Role of Weight Loss in the Treatment of Binge Eating Disorder

Binge eating disorder (BED) is a newly accepted diagnosis in the DSM-V, the most recent update to the guidebook for mental health. Accordingly, the clinical approach to BED is under increased scrutiny. Treatment using food journals and cognitive behavioral techniques to break the cycle of binges remains the gold standard, but the official diagnosis will generate increased attention and funding to investigate the differences between BED and other eating disorders. It's a relief for clinicians that the committee revising the manual acknowledged the reality and prevalence of BED and put the spotlight on improving care for these patients.

With that controversy in the past, another debate is in the forefront of BED treatment: weight. Patients with anorexia are clearly underweight, whereas those with bulimia range between underweight and normal weight. Treatment of these two illnesses include weight restoration and improved health and nutrition. Binge Eating Disorder is the first eating disorder diagnosis likely to cause weight gain. Eating disorder clinicians, thrust into the obesity debate, are unsure how to respond. The greatest risk is that the overarching societal focus on weight overrides the best clinical approach for these patients.

People with BED are just as focused on feeling overweight as those with other eating disorders and erroneously view weight loss as the solution to all their problems. The problem is that clinicians may agree because these patients usually are overweight and not focus on eating disorder treatment.

The result of weight obsession in BED patients is serial dieting followed by worsening relapses of binging and, ironically, subsequent weight gain. The pattern isn't all that different from all serial dieters except for the two things that make BED an eating disorder: binging rather than overeating in response to dieting, and the internal punishing dialogue, discussed at length in this blog, present in all eating disorders.

In anorexia and bulimia, much of the focus in therapy stems from feeling fat even when normal weight or very underweight. Accordingly, treatment involves challenging the obviously distorted thoughts about body and weight and linking these thoughts with the self-loathing associated with the eating disorder. Countering the distorted thoughts is easier when it's clear the patient isn't overweight at all: the fat thoughts are a distortion, the punishment meted out by the eating disorder.

In a patient with BED, the practical thoughts about being overweight are often true, and the societal focus on obesity reaffirms these same punishing eating disorder thoughts as occur in anorexia and bulimia. It's much harder to convince a patient with BED that the fat thoughts are distortions if the person is overweight. Being overweight, to the sick person, confirms that the person is truly horrific and that weight loss is the only way to recover. This scenario complicates treatment greatly, namely forcing the therapist to confront the thoughts about weight not as a distortion but as a tool the eating disorder uses to worsen the cycle of symptoms.

When weight loss is central to BED therapy, the course of treatment quickly goes awry. The message received by the patient is that weight is the only real problem and the most shameful part of the illness. Immediately, everything else will be secondary, and the punishing thoughts become more true. The practical result inevitably is more hateful feelings that trigger more binging and continued weight gain. Just as in other eating disorders, if weight and body image are taken seriously, rather than as distortions of the disease, treatment won't work. Effective treatment includes normalizing eating with a meal plan while focusing on avoiding triggers for binges and countering the punitive thoughts of the eating disorder.

But any patient with BED will quickly point out the obvious: obesity has serious long term health consequences. No clinician can refute this statement, so it's too easy to find the conversation steered to weight loss as a primary goal of treatment. Unlike any other eating disorder, even drastic measures like Bariatric surgery often enter the discussion. At this point, the underlying emotional and physiological reasons for the binge eating, a core aspect of treatment, are secondary. The eating disorder has hijacked the conversation. As with every quick fix, the scenario will fail and trigger another slip into worsening binging. 

Early on, the clinician needs to point out that BED is another eating disorder with the same eating patterns and same punishing thoughts of all eating disorders. Even if BED leads to weight gain, the goal of treatment has to be eating disorder recovery to make any headway. Focusing on weight, which certainly is affected by these illnesses, reaffirms a central tenet of the disorder and always worsens symptoms. When the patient tries to explain the health concerns of being overweight, it's important to acknowledge these statements are true but also to point treatment in a direction that can lead to improvement in the patient's quality of life.

Normalizing eating while stopping binges will lead to weight loss. Addressing the emotional triggers for binges while encouraging compassionate thoughts about oneself are central to effective therapy. To help patients with BED, clinicians need to ignore to obesity epidemic swirling in society and focus instead on what's best for this cohort of patients: treatment for their eating disorder.