Eating Disorder Therapy Must Start with the Food

There are so many different directions to take when seeking treatment for an eating disorder. Even ten years ago, the options were so much more limited. Now there are many clinicians (even if it’s not always easy to find someone taking new cases), treatment programs and a variety of support networks online.

When making the decision about the first step, one element of the treatment is necessary: talking in depth and specifically about the food. Many patients I have seen worked in therapy for years making significant progress their lives. Unless the therapy focuses on part on the food, eating disorder symptoms just don’t change.

Of course, addressing the food is one of the hardest steps in recovery. To a person, people with eating disorders feel that discussing their food is the most exposing, most vulnerable thing they can do. So the clinician needs to gently urge people to understand why it is so important and also so hard to talk about the food.

If the food remains a secret, the thoughts and behaviors also remain hidden and outside the purview and potential benefit of therapy. Exposing the eating disorder thoughts and behaviors reveals the feelings covered up by the eating disorder and gives the therapy a chance to help find new ways to manage these emotions.

The willingness to discuss food is the most courageous step someone with an eating disorder can take in therapy. Freedom from these illnesses demands exposure of the symptoms and a desire, no matter how difficult, to let go of the needed comfort and safety.

Any successful therapy must address the food and will subsequently open up the possibility to learn new ways to live and thrive without the eating disorder.

Eating Disorder Classification Does Not Work

The diagnostic classification of eating disorders is problematic. Anorexia, Bulimia and Binge Eating Disorder are the only accepted diagnoses, yet many people with eating disorders, especially those struggling for many years, only fit into the box of Eating Disorder, Unspecified.

It may seem like these diagnoses shouldn’t be very important, but insurance companies insist on a diagnosis for reimbursement and treatment. Since insurance has so much power to dictate medical care, the diagnosis does matter.

Moreover, the diagnosis helps define the problem and lay out a clear path for recovery. Even if the clinical team insists that the diagnosis does not reflect the severity of the disease or importance of recovery, an unspecified diagnosis feels demeaning and dismissive and often decreases the motivation for a patient trying to take their illness seriously.

The diagnostic criteria need to take into account the shift in symptoms through the course of an illness in order to help describe the various disorders more clearly. For now, the classification only describes the earliest symptoms of illness.

For instance, people with anorexia in the first couple of years meet the criteria for weight and eating behaviors, but many fewer continue to do so for five years or more. The body biologically tries to survive the illness by finding ways to compensate for long-standing food restriction or by slowing metabolism to conserve energy. Thus, people with chronic anorexia usually don’t meet the weight criteria after a number of years, a very demoralizing and misleading change. However, even through these adaptations, it’s clear to any clinician the person still has anorexia, just in later stages.

The same can be said about all eating disorders in many different ways. The diagnoses don’t distinguish the myriad ways eating disorder present and persist.

Formally clarifying the distinction between stages of illness would not only be illuminating but also help patients better understand their diagnosis and how to conceive of treatment.

The best next steps in diagnosis would be to create stages of illness that allow people to recognize their diagnosis and also where they are both in the course of the disorder and in recovery.

What it Takes to Really Get Better from an Eating Disorder

Eating disorders usually start at a young age and become a central part of how a person functions early in the development of our identity.

The eating disorder rules organize daily life around food and weight, sets a clear and definite idea of right and wrong and helps life make sense at a confusing developmental period.

Eating disorder symptoms serve as an easy and effective way to manage feelings and calm oneself down during periods of distress.

Eating disorders become central to identity. It’s acceptable to conflate an eating disorder with personal goals, personality and a legitimate organizing force in life.

By the time the eating disorder becomes a problem, one’s entire life and self-image is organized around this illness. In fact, the eating disorder often doesn’t feel like an illness. Questioning the eating disorder usually feels like a personal attack instead.

Recovery doesn’t mean getting better from a long-standing illness to most people. It feels like tearing away the fabric of their being. It feels as if clinicians are asking them to remake themselves, to start from scratch.

So getting better from an eating disorder only begins with a stable meal plan, regular meals and snacks. Recovery quickly becomes more of an existential crisis, a journey to figure oneself out and to throw out the old theories.

Anyone starting recovery, and any clinician embarking on this path with a patient, needs to be aware of how disorienting and exposing recovery feels. Getting better means opening up some of the deepest personal spaces and looking at the raw emotion and fears that are revealed by the end of eating disorder symptoms.

The process of recovery demands respect, empathy and creativity. The path often leads to unexpected places, figuratively and practically, and can end up at unpredictable realizations about life.

Only with a knowledge of recovery and a willingness to explore what the person needs to face, without judgment or criticism, can someone find their way to being truly well and to being truly themselves.