Can Bariatric Surgery Cause an Eating Disorder?

Repeated experiences seeing post-Bariatric surgery patients are perplexing and disturbing to the clinician who treats people with eating disorders. Obesity is clearly a significant health issue in large parts of the world; however, permanently altering someone's gastrointestinal anatomy to make possible longterm starvation is a destructive and counterproductive solution. 

The grand experiment of culturally sanctioned starvation has caused multiple chronic medical problems, number one on the list being eating disorders. The result of idealizing the extremely thin has been to encourage and blindly support constant dieting and starving. 

We have learned that people have a varied but ingrained and largely genetic response to chronic starvation. The most common response is overarching hunger that usually triggers one form of eating disorder symptoms or another. 

Bariatric surgery often causes a form of binge eating. Most people can starve for 6-9 months and lose a significant of weight before the starvation response takes over and the uncontrollable urge to eat dominates one's thoughts and actions, thereby leading to binging. 

The solution, as with all eating disorders, is to start by normalizing a meal plan. Consistent nutrition signals the body and mind that the famine is over so normal body function can resume. Doing so will gradually let the starvation response subside. 

What's particularly concerning is the medical community's reaction to these cases. Uneducated in eating disorders, most doctors are perplexed by these symptoms. Bariatric surgeons continue to encourage starvation and weight loss, while the Bariatric nutritionists do not consider changing their recommendations for prolonged malnutrition. Endocrinologists encourage medications to treat the increased hunger. No one considers the effect of chronic starvation, largely because thinness is of primary importance. 

The Bariatric community needs to team up more closely with eating disorder clinicians in order to better understand the repercussions of these surgeries. Curing obesity by causing an eating disorder is certainly not a viable means of treatment.


Can People with Eating Disorders be "Treatment Dependent"?

I heard a new term in the treatment of people with eating disorders this week: treatment-dependent patients. I was flabbergasted by the judgment and blame associated with this label, especially since it came from a program well versed in the need for kindness and compassion. 

The overt message appeared to be that patients should not be dependent on their treatment to get well while the implied message is that chronicity of an eating disorder is the patient's fault. 

For those who read my blog, it's clear that dependence on treatment is a necessary part of recovery. The eating disorder serves as a constant companion, comfort and salve for all the events of daily life. Weaning oneself from such a critical part of life demands a drastic shift in lifestyle. Depending on treatment can be a bridge towards learning how to depend on close relationships in daily life while learning how to eat normally again. That dependence makes the eating disorder less necessary over time. The relationship serves as a jumping off point for independence, not a reason to remain ill. 

The chronicity of an eating disorder is not the failure of the patient. The implied message is that the person just needs to try harder or to learn to stand on her own two feet. Anyone knowledgable in eating disorder treatment knows this message only sends someone to relapse because it reinforces self-criticism and self-blame, the cornerstones of the eating disorder.

The eating disorder thoughts and behaviors become so ingrained and automatic that only sustained support to change these patterns over time will have an impact. Urging someone to just figure it out implies a lack of ability on the treatment providers to manage the illness. 
This is certainly not the first time I have heard clinicians blame the patient for her illness. Usually inexperienced therapists will state uneducated opinions which only show a lack of understanding of the nuances of eating disorders. That's not surprising since it is hard to find thorough training for treatment of these illnesses. 

However, the term treatment-dependence comes from an established and esteemed organization. When patients are blamed for their illnesses, it's time for the treatment providers to delve into their own motives to be sure they have the clarity needed for this type of work.


Surviving the Pressure to Diet, Part II

The ideas of the individual diet and the pressures to constantly diet from the last two posts open the door to a new philosophy of not just eating disorder recovery but eating in our current environment. 

The concept that there is one correct way of approaching food, body and health contradicts everything we know about the human body. Although we all have the same organs and function similarly, our genetic differences underlie a vast range of traits from appearance to personality to our unique fingerprint to organ function. 

In other words, we are each our own person. The collective attempt to universalize food choice and metabolism as if we are all the same rails against these truths about humans. 

I have written extensively in this blog (post1, post2, post3) about the societal pressures which have encouraged these falsehoods to pervade our world. The media pressure for thinness, the diet industry, the pervasive food industry and weak regulatory system (influenced largely by industry lobbying) have all weakened the clear message from science: we are each an individual human. 

And so the philosophy that will counteract these pressures has two parts: learn about your own body and life is more important than food. 

Well-being and health have many components, and one is food and nutrition. Although there are some basic facts about nutrition that matter for us all, for example eat a variety of food and eat real food, what works best is the individual diet. Learn what types of foods work best for you, the way of eating that fits your digestive system and meal sizes that help you function at your best. For people with eating disorders, there will be a period of following someone else's plan to relearn how to eat first, but others can start to learn about their own bodies right away. 

Second, despite the pressure to prioritize food, spending an enormous amount of time on food and weight wastes time better spent on living. People with eating disorders or those with disordered eating know that obsessions about food can consume one's internal world.

It's so important to make sure life--family, relationships, work, hobbies, interests--matters more than simply thinking about body and food. Life leads to more satisfaction every single time.


The Individual Diet: Just One Person at a Time

Part II of surviving dieting will come next post in order to spend a few moments on a new and crucial line of research related to both eating disorders and the societal understanding of metabolism and weight. 

A recent article explained some new findings about the treatment for obesity which turn the common notions about dieting and food choice on their head. The underlying message is that all meal plans and all foods are not equal for everyone. The variability of digestion and gastrointestinal endocrinology between people means that various foods do not have absolute value. Instead diet options need to be tailored to the individual. 

This is new, profound information for the lay person and confirms that considering all food to be equal to all people seems absurd.

We all look different. We all have different physical, intellectual and social skills and weaknesses. We all have different vulnerabilities in the world. Why would our biological response to food be universal?

The specific research quoted here focuses on the body's immediate endocrinological response to a meal. Specifically, how fast does an individual release insulin--the hormone that informs the body it is time to utilize new energy that just entered the bloodstream. The article proposes, based on clearly described data, that this variability in a biological response to food indicates that different meal plans are necessary for different people. 

It is new for any treatment plan, medical or otherwise, to approach obesity, eating disorders or even improving one's overall diet from an individual perspective. All diet advice is general, as if one person or plan can assert a diet that will help all people. More importantly, the desperation of the public to find an ultimate solution to food leads many people to follow these unreasonable expectations to their ultimate failure. 

Instead, it behooves the medical community, clinicians who treat eating disorders and the public to heed the message behind this article. The point of any attempt to improve one's health through a new diet is a personal endeavor. There is no right way. There is a meal plan that will improve one's own health, and the goal is to seek a way of eating that allows each individual to live their life fully feeling healthy and strong. 


Surviving The Pressure to Diet, Part I

For adults and children, the concept of dieting or restricting eating for health reasons is commonplace and even considered healthy. A part of modern day living is to constantly monitor and reconsider which foods should be eaten and which avoided. Our general appetite for more nutrition news is seemingly insatiable. 

Unfortunately, when these studies are fully evaluated, it's clear that they do not represent trustworthy science. There is no regulation of this information, and anyone is allowed to impart their own personal wisdom as fact in a new book, diet or food fad. 

The result is a world where it is virtuous to follow any diet without considering the validity of the recommendations or the health of the suggestions. Even the medical field tends to be unclear as to how to change eating behaviors since doctors themselves have minimal training in nutrition. 

Diets rarely consider some basic facts about our bodies, nutrition or metabolism. We focus mostly on calories and ignore other critical pieces of information such as essential items of nutrition necessary for healthy body function. We don't take into account the variety of foods necessary for general health. We also do not consider that changes in metabolism almost always, in countless studies, lead to a reversal in weight loss from every diet. How can a society supposedly grounded in science be so willing to forgo reason and diet incessantly when all evidence points to failure?

Therein lies the confusion. We all diet when reliable data points to its failure. We even encourage or turn a blind eye to dieting children until a real problem, such as an eating disorder, presents itself. 

A final issue is that all this dieting has increased the incidence of eating disorders significantly in the last forty years, yet no one seems to acknowledge this change. 

Three pieces of information can help explain why an entire society continues to make the irrational decision to diet without even considering the consequences: the desire for thinness at all costs and as a panacea for our daily woes; the collective panic over endless supplies of processed, irresistible food; and the total lack of protection by industry or regulatory agencies from the massive change in available foods in recent decades. 

I have written about these concerns in this blog before, and nothing has changed in recent years. This post serves as a bridge between the risks of starvation and the ways to combat the societal pressure to diet. The next post will focus on ways to rethink and revise our thoughts about dieting. 


The Risks of Dieting and Starvation

The model in the last post described a three step process to explain the cause of an eating disorder: genetic predisposition, environmental trigger and emotional/psychological stimuli. Although the first and third part of the model increase the likelihood greatly of illness, there is no chance an eating disorder will occur without the trigger of starvation. 

It remains somewhat controversial to view dieting and undereating as a necessary part of the evolution of an eating disorder. Dieting and losing weight are seen as a beneficial and even health-promoting parts of modern life. The increased concern over obesity and the incessant focus on thinness make dieting a cornerstone of our daily life. Dieting has become the de facto answer to many medical ills. 

Yet no one speaks of the medical risks of dieting and chronic starvation. Various diets of 1200 calories per day, half of which often comes from a shake made of processed protein powder, are commonplace. Starving all day in order to wait and eat at night is considered virtuous. The diet industry is a booming business. 

This message seeps down to children and adolescents who easily fall into the trap of dieting and soak up the praise that comes with weight loss while nobody seems to worry about the risks associated with a malnourished child. 

The immediate risks, including lack of energy, slowed thinking or weakened organ function, do not come to mind when we think about a diet. Instead weight loss is blindly equated with health.

But dieting also triggers ingrained biological adaptations to starvation, the body's protection against times of famine. The adaptations include obsessive thoughts about food and weight, slowed metabolism to conserve energy and the preservation of essential body functions at the expense of less necessary ones. The basic functions include cardiovascular function, maintenance of core temperature and basic organ function but sacrifices muscle mass, higher level brain function and reproductive capability. It's like the body running on a backup generator. 

This metabolic shift is the key to the illness model. It is the trigger. If someone rests in starvation metabolism for too long, they run the risk of triggering a longterm, adaptive shift into starvation metabolism, essentially a semi-permanent state to survive famine. In modern life, this mental and physical shift isn't based on actual famine. The food is still all around us. But starving for long enough can trigger the thoughts of an eating disorder if someone is so predisposed. That is the central risk. 

When dieting was not pervasive in our culture, this risk was minimal, but recent decades have made dieting almost a rite of passage. All of a sudden, we all are exposed to this risk, we all try to diet and starve at some point, we all test to see if we have a genetic predisposition to an eating disorder. And we all do this without any understanding of the risk we are taking.

Instead when a child or adolescent turns out to have an eating disorder, the general consensus is to throw up our hands in confusion, but the number one risk for developing an eating disorder is that first step to start a diet.

The implications of what this knowledge means for adults and children will be the focus of the next post.


The Causes of an Eating Disorder

Patients, parents, family and friends find solace in asking how an eating disorder starts. Often what makes an eating disorder last is more important for treatment than why it started, but figuring out the initial cause does two important things: creates a story that helps someone make sense of their lives and provides underlying clues for therapy. 

I have written at length about the number one cause of an eating disorder: dieting and starvation. Taking in significantly less food than one needs for an extended period of time triggers the innate human response to famine. Metabolism slows, organs function efficiently but less effectively, unnecessary body function is sacrificed. If this time persists, brain changes occur which include decreased cognitive function, obsessive focus on food and increased attention to body shape and weight. The number one reason for the skyrocketing incidence of eating disorders in recent decades is widespread sanctioned dieting, especially in children and adolescents. 

The second cause for an eating disorder is genetic predisposition. Not all kids and people who diet end up with an eating disorder. In fact, the large majority don't, even if many of them stay focused on food and weight into and through adulthood. A certain percentage of people have an innate response to eating disorder symptoms, largely a strong biological and seemingly chemical response to the eating disorder symptoms. Prolonged starvation, binging or purging can all trigger powerful chemical responses in the brain that are very calming and, for those are predisposed, almost addictive. In addition, the rigid rules and routine of an eating disorder create calm and safety not as an immediate response but as a longterm salve to the uncertainty of daily life. People who combine the trigger of starvation with the powerful biological response to the behaviors are at higher risk for an eating disorder. 

The third component of the cause of an eating disorder is emotional. Kids who lack love, warmth and attention feel as if they have found a panacea in an eating disorder. The almost magical trick of having figured out food--whether through prolonged starvation or a method of eating and purging l--and the positive feedback of being thin replace the emotional pain of feeling unloved and worthless. This experience can range from seemingly benign neglect to emotional or physical abuse to traumatic experiences. The severity of the experience tends to correlate to how much the emotional cause contributes to the eating disorder. 

These three components of the cause of an eating disorder do not factor in equally. For some the genetic component is the main instigator of the eating disorder and for some a traumatic childhood is. For most though, the eating disorder started because all three potential reasons came together in such a way that led to the person falling into this illness.

Most people find comfort in having an explanation as to why their eating disorder started. This conversation can be hard but it helps push aside the shame associated with the illness and give the person enough agency to continue taking steps in recovery.


The Food Journal: Five Years Later

I wrote in one of the earliest posts in this blog about the food journal. The reason to revisit this topic is the increasing feedback from the clinical community that the journal is more than a tool and actually a necessity for recovery. Many other clinicians see the journal as a key difference between those in recovery and those who aren't. 

The journal represents a daily external mechanism to see one's daily intake of food and share that with someone focused on helping with recovery. This explanation encompasses the three important aspects of the journal. 

First, the journal is a means to externalize the thoughts of the eating disorder. The act of writing the journal is a daily exercise in separating oneself from the eating disorder thoughts by processing food in a new and different way. Encouraging separation from those thoughts is a critical part of recovery. 

Second, seeing the day's food written out enables each person to see realistically the food intake for that day. Rather than allow the eating disorder thoughts to confuse and cloud that reality, there is no hiding from the words on the page. 

Third, the act of sharing the journal is a daily step of allowing someone else to help. It's a sign each day of committing to recovery and using relationships to move into a place of health and wellness and not become lost in the distorted priorities of the illness. 

The food journal is one of the hardest things for someone in recovery to complete regularly. Writing about food and showing that to someone else is very exposing and activates the shame that is a common stumbling block.

In addition, food is the most intimate of subjects for someone with an eating disorder so sharing that information opens the door to a very intense and close bond, something that feels intimidating when the illness remains so strong. 

It's important to recognize the food journal as a cornerstone of treatment. Writing and sending the journal each day are not just useful steps but instead are clear markers of recovery and need to be a central part of any effective treatment.


Therapy as the Central Focus of Psychiatric Treatment

It is rare that psychiatric research makes the headlines two weeks in a row. The current news discusses the results of a large study on schizophrenia, which, along with anorexia, have the two highest mortality rate of any psychiatric illness. 

The study reports that low dose medications plus regular psychotherapy is more effective than high dose medication alone. 

This is shocking news because psychiatry has hung its hat on medications as the best form of treatment for this illness with hope for more thorough pharmacological cures in the future. The NIMH funded study has clearly proven otherwise. 

Psychiatry has worked hard to find a place in the scientific world by relying on brain science and medications as the best hope for the future. Our limited understanding of the brain may be the reason this supposition is unrealistic. Perhaps it's a matter of time before brain science leads to simple pharmacological cures.

But there is also the possibility that the complexity of our brain doesn't lend itself to quick fixes. So much of our miraculous central nervous system is attuned to interaction with the environment, especially other people. Psychotherapy, a treatment that grew out of, at least in part, the lack of other viable alternatives, may be grounded in something very real and, at its core, scientific.  

In other words, the most potent tool to change brain function may be relationships themselves. 

This new study about schizophrenia and last week's conclusion about eating disorder behaviors as habits have one key similarity. Brain behavioral patterns, once established, are ingrained and difficult to change. Repeatedly research studies have shown that therapy is as effective or more effective than medications for almost all psychiatric illnesses: schizophrenia, eating disorders, depression and anxiety disorders. 

It's a novel idea to approach psychiatric treatment with the expectation that establishing effective, meaningful relationships is at the root of change with medications as an important but secondary tool. Although medication may play a role, relying solely on pharmacology does not have a good track record. 

Heeding the recent news means focusing on the therapy relationship first and foremost as the step into wellness.


Are Eating Disorders Habits?

A new study that received national media coverage uses brain scans to interpret the underlying intention of eating disorder behavior. The researchers' conclusion seems reasonable based on the limited scientific data and on corresponding clinical information: eating disorder symptoms are habit rather than willpower.

The current societal bent towards describing eating patterns as willpower stems from persuasive marketing by the diet and food industry for decades. Rather than understand the complex, innate nature of hunger and fullness, these industries surround us all with irresistible goodies and then perpetually blame us for not resisting them, thereby increasing profit. 

This mistaken understanding bleeds over into the general public's concept of eating disorders with two mistaken ideas: restricting food is about willpower and these people suffering from eating disorder are not sick but have actually mastered the ability to resist hunger.

Nothing is further from the truth. 

Clinicians who treat people with eating disorders will not find anything ground breaking in this study. It is the clever translation of accepted clinical knowledge into a simple research study, namely that the thought and behavior patterns of an eating disorder are habit.

This core knowledge does inform the treatment and recovery from an eating disorder. Simply educating a person about the risks of an eating disorder and explaining the health benefits of normal eating never influence recovery. Neither of these facts can change a habit. 

Two aspects of recovery are necessary to put into place a process that will change ingrained habits. That process is slow and arduous but, with consistent practice, will lead to new habit formation. 

The first step is accountability. Someone else other than the person with the eating disorder needs to be aware of the day-to-day events around food. Habits are by definition largely unconscious behaviors. If there is minimal conscious thought about the habit, the behaviors will not change. Accountability forces the person to pay conscious attention and make an active decision to continue the behaviors or not, thereby addressing the conflict around continuing the habit and recognizing the consequences.  This conscious experience already starts to break the circuit in the brain reinforcing the habitual behavior by inserting debate over whether or not to engage. 

The second component of treatment is behavior replacement. If there is no thought process or new behavior to change the habit, then there is no way anyone can resist doing the same thing every day. In terms of brain science, this means reinforcing a new brain circuit will weaken the old one.

The combination of a conscious decision to choose the habit combined with an alternative behavior that feels within their grasp gives the person with an eating disorder a reasonable chance each day to learn a new habit. 

The media coverage that eating disorders have nothing to do with willpower is important and necessary. This information already informs a large part of successful eating disorder treatment and gives the clinical community an opportunity to educate the public about this growing problem in our society.


Reflection on First Consultations

I wrote in this blog a long time ago about the first step into eating disorder treatment and wanted to review some of the key points.

It typically takes years for people to reach out for help and can often take a few tries before committing to really get well. The result is that first appointments are critical to help someone start the road to health. 

Much has been written about how to engage someone with an eating disorder and for good reason. Experienced clinicians know how difficult it is to transform a consultation into steps towards recovery. 

Unlike most initial consultations, gathering all the facts is not the most critical part of the initial appointment. There will be time to sort through details and understand the facts. This first meeting must emphasize the reason for meeting. After years of illness, what has led to following through with getting help? Namely, what has changed to make this session possible?

It's often a difficult question to answer, but the purpose is to consider what might have begun transforming in that person to want to address a longstanding part of her life.

A marker of success of that first appointment is to help the person have enough perspective on her life to consider herself separate from the eating disorder for a moment and realize that recovery is deeply connected to that separation. 

Looking back at recent posts in this blog, I realize the existential component of recovery begins from the first appointment. Reflection on one's own value and purpose underlies the first session and emphasizes the most difficult part of treatment: finding meaning outside of the eating disorder. 

Stepping into treatment is a courageous act that needs to be matched by direction and courage from the clinician as well.


Existentialism and Recovery, Part 3

Modern life does not often force us to rethink our basic philosophy years into adulthood. There are certain circumstances--such as illness or tragedy--that do so, but many of the comforts of the western world mean basic necessities are a given.

Granted, it is easy to be lulled into a deep sense of complacency and live out our days, and many of us do live that way. However, the process of eating disorder recovery mandates a profound inward exploration.

Meaning for someone with an eating disorder always revolves around food and weight. Whether positive or negative, food and weight are the primary aspects of life that matter. Everything else is secondary.

It often takes years to realize that prioritizing food and weight pushes everything else down the list. There is no room for meaningful life changes in these circumstances. That realization is usually very painful because it begs the question of what is lost by ignoring so much of life for the disorder. It's often a triumph of the mind to even engage in this conversation.  

At this point any discussion of recovery has to avoid the discussion of regret, bitterness or unfairness. These feelings or thoughts may have a role in the long run but threaten the real discussion of life right now. An existential discussion must focus on what is important at the moment, how to start down a path that will make those things possible and how the eating disorder limits living one's life fully. 

But the discussion has no clear guidelines. There is no specific type of therapy or plan that makes a conversation about the human condition any easier. I, like any other therapist or any other person, am just another human engaged in this challenging and scary topic.

But an honest, heartfelt, genuine experience discussing these issues can make several things clear. Life cannot move forward without changes in priorities. This is our chance to live. Decisions we make now matter more than anything. 

The final aspect of existentialism lies in living in the present moment. Eating disorder thoughts co-opt one's mind to spend the present focused only on food and weight. Any other thoughts are relegated to the future, which is put off indefinitely.

All we have is now, and blind pursuit to remake the past or focus on the future clears the way to ignore the present. In recovery, eating sufficiently means facing the thoughts of the illness now in order to live in a new way. It's a leap of faith to trust that this new direction will create true, deeper meaning in life.


Existentialism and Recovery, Part 2

The rules and laws of an eating disorder give order and direction to one's life. Even if the end result is punishing and unpleasant, there is something powerful to ending a day knowing you have done everything correctly. 

The sense of purpose to eat less, lose weight and follow the rules solves the existential struggle for many people with eating disorders. It's such a relief to escape the tyranny of judging the value of life and instead rely on food and weight as clear markers of success and failure. 

Describing an eating disorder as a calling or set of rules to live by is incredibly confusing for non-believers. How can food and weight replace all the other aspects of life that matter?

Fundamentally, these disorders create an entirely new world to escape to. The rules are clear. The purpose every day is obvious. The reason to live and strive self-evident. There are other people in the world who become so attached to a movement or cause that it justifies their existence so why not an eating disorder?

What the mental health world seems to have trouble seeing is that eating disorders could just as well be a movement. In fact, that component of eating disorders reveals itself in pro-Ana and pro-Mia websites. I don't support them at all as I have written many times in this blog, but the belief system of an eating disorder can be that powerful. 

Take away this purpose to live and the existential crisis of recovery is evident. Years of having a clear reason to live cannot just disappear overnight. The sense of loss of a direction and also the thought that this direction has never been as meaningful as it appeared are enormous. 

The process of recovery must allow for the breadth and scope of reevaluating the most basic and most potent aspects of life. Relationships, family, love and career all become secondary to the eating disorder when someone is sick. Disobeying the rules by eating and nourishing one's body begs the question of why bother even considering either one? What is the purpose of eating like everyone else and still living each day? Are these other aspects of life worth fighting to get well?

The answers aren't obvious or clear. I don't pretend to know why each of our lives matter. A psychiatrist or clinician can have those conversations but cannot pretend to know the answers. 

The next post will delve more deeply into these questions, not for answers but to explain why the conversations are so important.


The Role of Existentialism in Recovery

Eating disorder recovery is, by its nature, an existential exercise. Once someone has found an answer, if imperfect, to so many personal struggles through the disorder, it feels impossibly hard to give up that success for the uncertainty of daily life. The underlying questions behind the painfully difficult stages of treatment are what is the purpose? Why should I go on?

There are a series of trite answers that minimally trained clinicians or poorly run programs use. It's fairly common for these practitioners to label this ambivalence as a psychological obstacle and to end treatment until that person is "ready" to comply with all the conditions set for recovery. 

These rigid guidelines reveal the discomfort therapists or programs have for painful existential crises that create deep ambivalence and painful decisions of the value of life without the eating disorder. 

The only way to process this confusion is through it. There have been moments in recent decades when psychotherapy and psychoanalysis have embraced the philosophy of existentialism, but recent years instead leaned towards short-term cognitive therapy: face the thoughts and feelings, place them in an organized structure and fix the problem. This approach has a lot of merit, even in the treatment of people with eating disorders, but is completely invalidating for those deeply struggling with the meaning of their own life. 

Because eating disorders grow with the burgeoning identity of the sufferers, there is a complex interweaving of oneself and the illness. The subtlety and compassion needed to be willing to see this conundrum are very significant.

The next few posts will outline what this existential crisis looks like and how it is at the heart of eating disorder recovery. Few illnesses intertwine so closely with emotional and psychological maturation. Undoing and then reconfiguring the sense of oneself are heady and very challenging endeavors.


The Discovery of Self-Worth

Much has been written by acclaimed clinicians who treat people with eating disorders about the desire to disappear. One central wish for many people who suffer from these illnesses is to fade away and simply vanish from the world. The mere act of starvation is the process of wasting away in order to take up less physical space, but the wish to be gone represents more than that concrete manifestation.

The underlying tenet of this fantasy is the concept of not having personal value as a human being. For most people, a sense of self-worth pervades the way everyone goes through the world. Waking up and living each day implies a sense of meaning and value. Meaningful relationships or even simple, human interaction give a sense of purpose to our days. There are many more ways people see their increased value but I  am trying to point out the most basic self-worth we have as human beings. 

There are more subtle ways people express how they value themselves. Speaking up for your own wishes or rights is a way of expressing self-worth. Emphasizing self-care can send a message to yourself and others of valuing yourself. Talking about one's life day to day implies value in the quotidian tasks. Even the basic concerns like sleeping and eating show a sense of value in ensuring one's body is prepared for the day. 

People with eating disorders can have trouble with all of these things: speaking up, self-care, taking about oneself and ensuring basic needs are met. 

The result of struggling to prioritize these concerns represents the figurative process of disappearing. Even if the eating disorder does not cause a literal disappearance or diminishing, the psychological underpinning of these illnesses is one's own disappearance. 

In terms of support and treatment, the implications for these truths are very clear. Therapy, but also support from friends and family, needs to emphasize self-worth in the world.

Personal characteristics and positive traits that may be obvious to most people are almost impossible for someone with an eating disorder to see. That person may need their own positive attributes repeated dozens of times before they start to process the information. Self-deprecating comments need to be contained and questioned again and again. It's critical to identify these thoughts as untrue and caused directly by the eating disorder. 

Although the actual causes for the intense self-negation for someone with an eating disorder are varied, figuring out that cause is not always necessary or central to treatment. It maybe useful for some people, but the important idea is to undermine those thoughts and help the person to find their own voice and learn to see themselves clearly in the world.


Regret has no Place in Eating Disorder Recovery

A confusing part of treatment for an eating disorder is the need to avoid certain feelings. That is not the usual method therapy applies and seems counterintuitive for a set of illnesses that enable people to avoid feelings. The underlying reality is that certain feelings reinforce a sense of hopelessness which can sabotage any real attempt at recovery. 

The most insidious of these feelings is regret. In the safe confines of the eating disorder mindset, all decisions about food are paramount and, accordingly, everything becomes secondary to the primary goals laid out by the illness. It's problematic that many of those other concerns are much more important when it comes to daily living than the short-sighted, fruitless tasks of an eating disorder. 

But understanding the power of an eating disorder means making sense of this powerful driving force. The thoughts feel incredibly meaningful and give order and structure to the scary emotions, relationships and decisions that are a part of every day life. 

Even a small step away from the eating disorder can open a person's eyes quickly. That immediate awareness, like a screen suddenly lifting, illuminates the emptiness of life run by an eating disorder and the missed opportunities that abound during the years lost in illness. 

It's tempting to follow that path of regret both for the patient but also in therapy. Mourning and a sense of loss are often critical parts of adult life and are very hard for even people who are emotionally healthy. The pain and struggle are easily avoided in the daily routine so any therapist would feel compelled to explore these emotions. 

For people with eating disorders, regret is a bottomless pit of shame, a detour right back into the self-loathing that can start a full relapse. Recovery takes so much attention and focus on current emotions and on each meal and snack. Sometimes, hope can be hard to find in the daily slog but a sense of purpose or at least delayed promise can serve as enough drive just to get through each day. 

That amount of resolve cannot withstand a period of dwelling on loss. That time has passed and reviewing the pain wrought by the eating disorder leads to a strong urge to rely on the illness to cope with the emotions. 

Once the person is ready to face the sense of loss, life has already taken over. Moments of regret might pop up at times, but the pressing moments of life instead take center stage. 


Ownership of Eating Disorder Recovery

The eating disorder thoughts, as I have written many times in this blog, are incredibly powerful and often just feel like thoughts. Distinguishing eating disorder thoughts from one's own is critical for recovery, but the process is not linear. It takes time and practice to learn how to do so reliably. That interim can be a risky time for relapse despite the real desire the person has to get well. 

This transition also marks a shift in the personal ownership for the recovery process. Before this time, the therapist, family or friends stand firmly for health while the person suffering can only blindly follow the eating disorder. The thoughts are too internalized and strong to resist.

The ability to have a moment of perspective about the eating disorder thoughts creates a new situation. All of a sudden, there is a choice whether or not to follow the thoughts. Having the moment does not mean the power to choose differently right away, but it does mean the path out of the illness is possible for the first time. 

During this time, the person with an eating disorder starts to take ownership of the recovery process. It truly becomes their own, and it's crucial to start to take on that mantle. Because distinguishing the two thought patterns is so new, it's a risky proposition. Owning the process opens the door for worsening symptoms and a fall into relapse with much less oversight. 

The hardest part for others to accept is that the risk is worth it. True recovery must mean the person not only takes ownership for her health but for her life. Successful treatment cannot leave that person unable to function in the world as an independent adult.


The Internal Suffering of an Eating Disorder

The emotional suffering someone with an eating disorder endures can be hard for others to comprehend. An illness wrapped up in the most basic human function as eating perplexes even the most compassionate person. However, the fascination that comes with explaining the ins and outs of having an eating disorder glosses over the crux of the problem: the overarching experience of internal suffering. 

As much as someone with an eating disorder does not want to discuss food, weight and body image, the most shameful component is the eating disorder thought process. Early in the illness, these thoughts are comforting and readily accepted as one's own. They simplify the complexities of daily life into rigid rules about food. Following them carefully leads to immediate success and, through weight loss, elicits praise from others. 

Time reveals the truth about the thoughts. They limit life experience greatly, interfere with psychological and emotional maturity and isolate the person from family and friends. By the time these truths become evident, the person is locked in the prison of the thoughts, unable to break free without a significant commitment of time and energy to learn a new way to navigate life. 

The compassion someone with an eating disorder most needs is for these thoughts. The psychological component of an eating disorder is comprised of relentless thoughts and compulsions to follow rigid, nonsensical rules of eating. Not doing so leads to punishing thoughts and even the experience of screaming in one's head. One and all, people with eating disorders describe these thoughts as extremely painful. 

It can be hard to imagine what that suffering feels like, yet attempting to do so shows a more profound sense of compassion and even an attempt at empathy. There is nothing more powerful a therapist, family member or friend can do to show true love and support for someone in recovery.


Personal Connection in Therapy

There is a piece of advice I give people who contact me for referrals. Even in a city like New York which has a large number of mental health professionals, it can be hard to find trained, experienced therapists who treat people with eating disorders. These qualities are necessary but not sufficient to choose the best therapist for each individual.

The advice is simple: make sure you like and feel comfortable with the therapist from the start. Everyone describes the experiences of clicking with a person when first meeting. Whether it is related to personality types, background or common interests, the reasons are not always clear but the feeling is universal. 

After finding a few referrals for experienced therapists, the best next step is to trust your instincts. Talking about food and eating disorder symptoms will be a very personal and vulnerable time. There will be ups and downs, starts and stops.

The sense of a true connection with the therapist will make the difficult steps easier to manage. Believing there is something important in that relationship creates a bond that can begin to challenge the tenacity of the eating disorder and present a road to recovery. 


The Importance of Present-Focused Treatment for Eating Disorders

Current trends in therapy reflect a thought process favored in the general community: mindfulness. Originally coopted from Eastern philosophy and Buddhism, the concept of being present and mindful rails against the Western, and especially American, mentality that striving for the future brings satisfaction and happiness. 

An eating disorder thrives on a mind always looking ahead to the next best thing. As long as the attention remains elsewhere, the eating disorder thoughts easily dominate any thoughts in the present and focus on maintaining the obsessive, rigid eating patterns at all costs. 

Clinicians who treat people with eating disorders agree that insight into personal emotional struggles and interpersonal dynamics have their place in therapy but will not be the cornerstone of effective recovery. Meaningful sessions can occur for months or years with no appreciable change in the illness. 

What is often mistaken for lack of motivation or drive in someone in recovery is in fact a lack of focus on the present. The energy and attention needed to challenge the eating disorder thoughts at every meal and snack and every moment in between are critical but exhausting parts of real recovery. The automatic response to listen to the eating disorder comes with slipping into the illness but, in that moment, also leads to palpable relief. 

Present-focused treatment leads to discomfort in two ways. First, the person will be more able to think and feel clearly with better nutrition. For someone used to being disconnected due to starvation, this experience is very challenging. Second, the fears and insecurities that come with facing the aftermath of the eating disorder are emotionally challenging and threaten to push the person back into focusing on the future, thereby returning to the confines of the illness.

The key is to stay in the present despite these experiences and to use therapy to get support managing them rather than use therapy for less necessary insights. 

Most therapists agree that the best way a patent can stay in the present is through support. Regular contact with the treatment team combined with support from friends and family who understand the illness work best. It is most helpful when daily interactions reinforce the need to stay in the present and remain focused on the challenges each day, not the goals and changes that may come down the line. 


The Role of Transitional Programs in Recovery

One of the changes in recent years in eating disorder care is the advent of transitional living centers. 

Residential programs are a central part of treatment but have several limitations. One major concern is that very few patients can stay long enough to receive the full benefit of the treatment.

The longstanding malnourishment and diminished health from an eating disorder remain even after 6-8 weeks of residential care. Since prolonged starvation is the main catalyst for persistent eating disorder thoughts, every patient who leaves treatment after a short stay is at significant risk for relapse. 

The typical reason people leave treatment is related to health insurance coverage. The companies, wary of the prohibitive cost, monitor health changes every day during a patient's admission and determine criteria to insist upon discharge as quickly as possible. 

Often the medical monitoring in a residential program--less than a hospital but still very complete and costly--is unnecessary for many patients after 6-8 weeks. The high rate of relapse shows that day treatment programs are not sufficient either as the step down from residential. 

Transitional programs provide an alternative to bridge the difficult gap from residential to outpatient treatment. Patients live in a setting with other people in recovery and with recovery coaches who are available twenty four hours per day. There is constant support and the expectation that each person will follow their meal plan. 

Daytime hours however are flexible. Patients can attend outpatient treatment programs or transition to volunteer or part-time jobs. The experience allows a more steady and less suddenly shift from the inpatient bubble to the various stresses and uncertainties of daily life. 

As of now, transitional programs are connected to individual residential programs and are not generally covered by insurance. It would behoove the eating disorder treatment world to offer transitional living as a viable and cost effective strategy to treat chronic eating disorders and increase the likelihood of recovery.

Extending the period of regular nourishment and improved health increases successful recovery dramatically, and transitional programs can be a key part of that process.


The Combination of Support and Love to help Someone in Recovery

A message to the family and friends of a loved one in recovery bears repeating. The most important thing to say at all times is the following: I love you and support you no matter what.

Based on the premise of the last post, it feels imperative to explain how to put that information into practice. A common way to help people through challenging experiences is to praise their progress and achievement. These statements provide both acknowledgement of the hard work and recognition of the results. 

Extension of this kind of support appears on the surface to apply to someone with an eating disorder. It's not clear at all why a simple vote of support and confidence would be harmful, but it is. 

The eating disorder not only represents a way of facing food in daily life but also a way of navigating the world and of understanding oneself. As an all encompassing philosophy of living, the eating disorder thoughts have been the structure influencing the person's thought process and decisions every day. 

Choosing to ignore the thoughts and live as someone without an eating disorder may be a new and compassionate way to see oneself, but it is also excruciating because it means stepping away from a way of life that is safe and into the vast unknown. There may be the opportunity for love in the world without an eating disorder but it feels vulnerable and scary. 

Words of encouragement only reinforce the fear and exposure of steps into recovery. Telling someone they ate well or look good or have been really present in life may all come from the heart, but these statements reinforce the terror of being in recovery. Acknowledging the real steps into wellness is hard to do but it is especially hard to realize others see it as well. 

Reminding the person she is loved and has support in this scary environment provides different support and something much more needed. These words reinforce the opposite of the eating disorder, love, and help the person understand that even in recovery, she will be ok.