The Trauma of Forced Treatment for People with Eating Disorders

Forced treatment has been a component of eating disorder treatment since its inception. The concept of a treatment intervention began in substance abuse treatment and transferred primarily to severe cases of Anorexia Nervosa.

The theory behind an intervention is that a central facet of the illness is denial. The person has little if any insight into the problem, minimal desire for change, if any, and significant risk of medical symptoms or even fatality.

Forced hospitalization feels like the only option for families in this situation as they fear for the safety, health and even life of their loved one. With encouragement from professionals, families, often reluctantly, agree to take this drastic step.

The intervention undoubtedly leads to short-term relief. The person is temporarily safe. Their medical and psychiatric conditions improve from nutrition, and the family hopes that the intervention predicts healing and recovery.

However, people with anorexia forced to eat will comply in the short-term, but that nutrition will not change the core beliefs of the disorder about food restriction and weight loss. Rarely, an early intervention can reverse the course of the illness, but much more often this step hardens the eating disorder thoughts and behaviors as a reaction to being trapped to do the action most abhorrent and terrifying to them. Even though families may even not feel like there is a better solution in the moment, interventions are far from a panacea.

One major risk of forced treatment is the traumatic effect on the patient. They will feel as if they are being forced to do the one thing that every part of their being is fighting. The thoughts are so strong to restrict and each bite, each snack, each meal can cause extremely painful emotional responses. For others who don’t have anorexia, the pain caused by forced eating is hard to imagine.

As the person endures the food and weight gain that follows, many feel traumatized by the experience. They feel they are forced to do something extraordinarily painful day after day for months with minimal understanding or compassion. They feel abandoned and betrayed by their loved ones and locked up in a tortured environment for months on end.

The younger the patients, often the more traumatic the responses.

The result is not only hardened eating disorder symptoms but trauma symptoms such as constant reminders of the treatment, nightmares and fear of the people they love most.

Seeing patients years out from their experience still having trauma symptoms certainly makes one question the benefit of forced treatment.

The trauma caused by forced treatment is one the eating disorder treatment community needs to grapple with and needs to stop.

When forced treatment is needed to save someone’s life, then thoughtful steps to mitigate the potential trauma need to be considered. If that means shorter term care to stabilize someone medically rather than months of treatment, that may be a more humane and compassionate step to consider. Any intervention must take into account the risks from the start.

The Causes of Trauma Caused by Residential Treatment

At an eating disorder clinician holiday party last week, an outreach representative from a venture-owned eating disorder treatment program approached me. As she discussed the changes in her program, she focused on how beautiful the new outpatient facility is, as if a new renovation were the best selling point for comprehensive eating disorder care.

The obvious takeaway is that the monetization of eating disorder treatment has supplanted the need for effective and compassionate treatment.

But my mind drifted instead to an ignored topic in eating disorder care: trauma caused by residential programs and hospital programs.

To be clear, many people receive substantive, effective care at these programs, even the ones backed by financial companies.

Many people, especially young people and adolescents, also have traumatic experiences at treatment programs which cement the power of the eating disorder and layer an unnecessary and entrenched mental health issue which makes recovery much harder. A traumatic treatment experience often leads people to stop seeking care completely. Destroying trust in the treatment process forces patients down a path of a chronic eating disorder and little chance for recovery or even relief.

Sometimes a treatment program won’t be helpful and that’s ok. But no treatment should be traumatic and worsen a patient’s illness. That’s unacceptable.

The next few posts will focus on various ways residential and hospital-based programs are traumatic. I’ll also focus on ideas to limit this horrible and avoidable damage.

The posts will discuss the following ideas: forced treatment stays, treating patients like children, relentless focus on weight in recovery, ensuring programs have adequately trained supervisors and creating a standard for adequate education and experience.

The Place of Eating Disorders in the History of Psychiatric Illnesses

Psychological maladies have shifted due to cultural changes in the history of the last two centuries. The psychological and emotional struggles are consistent, but the physical symptoms associated with that stress change due to new societal norms and expectations.

There have been various symptoms over these years as a result of stress and anxiety: fainting spells, prolonged periods of weakness, “hysteria,” mental breakdowns, self-harm and now eating disorders.

The sharp rise in the incidence of eating disorders in the most recent decades reflects the transition of psychological symptoms in the climate of diet culture. The extreme focus on thinness encouraged young people to diet in order to manage their emotional struggles, and dieting is the number one risk factor for developing an eating disorder.

Like all of the manifestations of emotional issues, addressing the physical issue will uncover the psychological ones. However, eating disorders are different.

For the other issues, working on the emotional piece can eliminate the physical symptom almost immediately. For eating disorders, the fundamental change in eating disorder behaviors doesn’t change so easily.

The disordered way of eating is often ingrained quickly for people with eating disorders as a way of coping through the numbing effect of the symptoms and the powerful, unconscious eating routines that can be comforting.

Once the mind and body adjust to a new way of eating, even a disordered one, it takes an enormous amount of work to make a new eating pattern stick. As the person finds new ways to cope emotionally with the struggle that led them to the eating disorder itself, they also need to relearn how to eat. The process of figuring out how to eat can take a long time and a lot of effort.

The epidemic of eating disorders stems from the transition of emotional struggles to the newest cultural phenomenon: diet culture. As it turns out, reversing eating disorder symptoms take a lot more time and effort than reversing other physical manifestation of other psychological problems in past generations.

Support for People in Recovery During the Holidays

This time of year is among the hardest for people with eating disorders. Holidays focus on food as a central part of the celebration with much fanfare and little escape. The result is extremely high anxiety for people with eating disorders combined with feeling an enormous amount of exposure and pressure.

Since there is no way to change the nature of the holidays, how can people with eating disorders and their family and friends make the time of year more manageable?

First, people with eating disorders can try to prepare by telling themselves some facts about this period of time. As hard as it seems, the time is short and will end soon.

Second, the internal pressure is almost always harder and more intense than the external pressure.

Third, have a plan to take breaks and to designate one person at the holiday to be the person to rely on for support. Feeling less alone makes this time a bit easier.

Friends and family can support people with eating disorders first and foremost by being kind and understanding. Eating disorders are so isolating, and any attempt to provide support without judgment goes a long way.

Checking in with the person to see how they are helps a lot as does distracting them by having a conversation about something else or taking a walk.

Ultimately, all support from a kind place is the most important support.

In the end, preparing for this time of the year can make the holidays more manageable for people in recovery. Now would be the time to strategize how to make things easier during this period.

Rethinking the Classification of Anorexia Nervosa

In the last post I mentioned how social media has increased communication and awareness about eating disorders and has led to new ideas about adjunctive diagnoses and treatment. The broader knowledge has also led people to seek help earlier and had a significant impact on the classification of eating disorders, Anorexia Nervosa specifically.

Years ago, I wrote a series of posts about the difference between acute and chronic Anorexia. At the time, those posts reflected the awareness and stigma about eating disorders, both of which limited early diagnosis and treatment.

Overall knowledge about eating disorders is much more broad now, especially for the younger generation. In addition, this generation is very focused on mental health with much decreased stigma about seeking diagnosis and treatment.

Accordingly, people with eating disorders look for treatment much earlier, often before they meet criteria for a full-fledged disorder. Anorexia in particular is much more easily treated before the eating disorder thoughts blend with a person’s own thoughts and before the behaviors become central to one’s well-being.

People so early in their illness almost never sought diagnosis and treatment so early in the past. As expected, the patients who get help earlier often recover quickly and fully.

In my mind the phenomenon of earlier diagnosis of Anorexia diagnosis points to a new way of classifying this illness into three stages.

Early stage Anorexia Nervosa can denote patients with symptoms for less than two years and whose eating disorder thought processes are not as entrenched. Immediate and intensive treatment can lead to a faster and long-lasting cure.

Middle stage Anorexia Nervosa identifies people with at least two years of illness and much more defined psychological identification with Anorexia. Disentangling eating disorder thoughts and actions is much more complicated and likely needs more time for treatment and recovery.

Late stage Anorexia Nervosa is a small subset of people with minimal or no change over many years of treatment and no interest in recovery. Management of the disorder keeps medical symptoms stable and helps people function as well as possible.

The middle group is still the largest percentage of people and can itself be broken up into several stages. The first group is the newest and represents the most significant change that arises from the increased communication about eating disorders in social media.

How are Patients Driving Changes in Eating Disorder Treatment

The last post reviewed the connections between Anorexia Nervosa and several chronic medical and psychological illnesses. The reason I felt compelled to write the post is that clinical assessment of people with Anorexia now necessitates considering a variety of other concomitant illnesses. It felt important to highlight some of the relatively recent changes in eating disorder treatment.

However, the driving force for these changes is not from the medical or psychological field. Instead, social media and information by laypeople have opened the door to different avenues for diagnosis and treatment—certainly a new direction for medical care in its entirety.

One entrenched issue with eating disorder care is the reflexive conclusion clinicians draw to attribute all medical and psychological phenomena to the eating disorder. It’s all too common for eating disorder patients not to be diagnosed with other conditions because clinicians blame everything on the eating disorder. So patients end up searching for ways to explain their medical symptoms since they are often ignored by doctors.

Moreover, the eating disorder community is disjointed enough such that communication about clinical findings tends not to be shared in a useful way. Treatment programs see people for relatively short stays and don’t communicate well with outpatient teams, as I have written about extensively here. Hospitals also function separately. And clinicians in an outpatient setting function for the most part independently. Poor overall communication about diagnostic trends won’t move the needle for new concepts in eating disorder treatment.

But now patients have a way to communicate with each other, post on social media, create videos for hundreds or thousands of people to see. In other words, patients can much more easily create communities, share ideas and begin to explore connections between eating disorders and other illnesses than clinicians.

Therefore, the clinical community is playing catch-up with laypeople’s theories. We are learning how ADHD works for people with eating disorders, adapting assessment for autism in adults and finding referrals for inflammatory diseases and MCAS. And this feels like only the beginning.

Let’s hope sharing of information helps clinicians chart a course for more successful treatment as well so people don’t have to suffer alone so much anymore.

New Developments in Chronic Anorexia

In recent years the correlation between Anorexia Nervosa and several groups of illnesses has become evident. Uncovering these connections, for the most part, can’t be found in medical journals. Most of the discussion occurs in lay writing and especially on social media.

However, as a clinician treating people with eating disorders, I can’t ignore the clear connections between Anorexia and these illnesses even though a clear path to diagnosis and treatment remains elusive.

The first set of connections is between Anorexia, Attention Deficit Disorder (ADD) and Autism. There is a set of people with chronic Anorexia who tend to have some if not many symptoms of the latter two disorders. The information often feels validating for people who have struggled with Anorexia and felt unlike many patients and often felt ignored for their differences.

There is no clear guideline about how to treat these patients differently at the moment other than to treat the ADD and give guidance for understanding autism and looking into ways to understand how and why relationships may feel different for these patients.

One compelling theory is that these patients with Anorexia may have a specific genetic variant that increases the likelihood of all three disorders. At this point, it is only a theory, but even the possibility of a genetic cause can be helpful for many people.

The second illnesses connected with Anorexia are a set of inflammatory and autoimmune disorders. The inflammatory diseases largely center around MCAS (Mast Cell Activation Syndrome), an illness defined by a hyperactive inflammatory response to stimuli that can cause widespread inflammation, pain and swelling throughout the body.

For some people, they also develop undefined autoimmune symptoms. Autoimmune disorders are defined by the immune system misidentifying parts of oneself as foreign and then attacking one’s own body. For many people with eating disorders, these symptoms remain undefined rather than turning into common autoimmune disorders such as Rheumatoid Arthritis or Lupus.

Treating MCAS or autoimmune symptoms has standard protocols that can be followed just as for patients who don’t have Anorexia. Diagnosis and treatment can bring a lot of relief which helps patients have energy to focus on recovery.

There are also many theories about the connection between inflammatory symptoms and Anorexia, but none of these thoughts have any scientific or medical evidence as of yet.

One critical difference between these two sets of illnesses is how they connect with food restriction. The first set of symptoms are present with or without the eating disorders. However, eating can sometimes unmask inflammatory symptoms which are possibly suppressed by food restriction.

Putting together the information connecting Anorexia and these various illnesses can begin to inform clinicians about the medical and genetic causes for eating disorders. Clinical research will need to take these connections seriously first and begin to study them before there are any clear changes in clinical treatment.

Each Person has a Unique Path to Recovery

In many past posts, I have written about important elements to successful eating disorder recovery including food logs for accountability, regular contact with a provider to consistently counteract eating disorder thoughts and a meaningful connection with a therapist.

These parts of recovery remain essential but also are not a bellwether of success or failure in treatment. They are essential for most treatment but not enough to get well.

Just as central to the process of tackling an eating disorder is the individual and personal component of treatment. After the initial, universal steps of recovery such as stabilizing eating, any road to get well is a very individual experience.

As comforting as it might be, clear and consistent steps that guarantee recovery don’t exist. Each person needs to use the support they have and the structure they learn to figure out how to get well.

Since an eating disorder becomes the foundation of one’s identity, the process of extricating oneself from an eating disorder must allow for the exploration of who each person is.

And the individual herself can begin to learn their likes and dislikes, their internal emotional world and their desires in the process of getting well.

No treatment guidelines or overall recovery plan will dictate how getting well looks for each person. Recovery uncovers who each person truly is, and treatment needs to leave room and freedom to explore, not create a false path to become the person a provider might mold or create.

Therapy which leads to a successful recovery is open ended, creative, free but often frustrating. The therapist must allow for fits and starts, confusion and missteps, anger and connection. What remains constant is acceptance, understanding and freedom without judgment.

Creating space to grow and learn works best in that environment and leaves little room for an eating disorder tho thrive.

The Profound Challenges of Eating Disorder Recovery

Clinicians, including me, often lay out the broad strokes of eating disorder recovery when someone is first starting treatment. The steps often include at first some form of higher level treatment like the hospital, residential treatment or outpatient group programs. Following the initial stabilization of food intake and medical health, the longer and more challenging part of recovery involves an outpatient team with one or several appointments per week. This stage of recovery reinforces regular eating and focuses on the emotional and psychological transformation that inevitably comes with meaningful recovery.

The second part of treatment sounds clear and streamlined. It is anything but. As difficult as the initial food stabilization can be, the personal transformation that accompanies a new life in recovery is inevitably a lot more challenging.

As a clinician, I know that any new patient who is truly engaged and determined to take the path of recovery will reach many points along the way of frustration, sadness, confusion and loss. And even if I describe what this course may look like, no words can prepare someone for the feelings of going through this existential, deeply felt and often wrenching change.

Eating disorders don’t simply comprise a series of eating behaviors and thoughts about food and weight. They represent a philosophy about how to live, about what feels truly meaningful and a moral guide to what is right and wrong. Since eating disorders usually start at a young age, people tend to develop their understanding of themselves and the world through the lens of the eating disorder beliefs.

Hence, recovery demands shedding one’s full understanding of how to live and necessitates starting fresh almost creating a new sense of identity. It’s hard to conceive of reimagining who we are after years of developing an identity based on the life and values we already know. No other recovery means starting over in quite the same way.

A clinician’s role is not to devise a new identity, explain new values or imply they know better. Instead, the clinician needs to be along for the ride and ready to embrace any feelings and experiences the person in recovery goes through and concomitantly provide comfort, support and understanding.

Life with an eating disorder will always be limited in scope and devoid of space for true connection and meaning. The eating disorder takes up so much energy and time that there is no room for a more complete life experience. The road to recovery is not an easy one, but it does make possible the ability to create one’s own sense of meaning, not just the eating disorder’s, in one’s life.

What People in Eating Disorder Recovery Value Most

Compassion and kindness need to be present in eating disorder treatment. Increased awareness and knowledge about eating disorders have helped lead to earlier diagnosis and treatment but haven’t helped family, friends and sometimes even clinicians remember that eating disorders are psychological illnesses, not merely a measure of willpower.

Many people expect that once someone is getting experienced help for their eating disorder that improvement and recovery aren’t far away. It’s hard to recognize that being in treatment is only a first step.

For so many medical conditions, treatment leads to improved health and the resumption of normal life. Eating disorder treatment instead results in a long process of recovery and many profound changes not just in how one eats but also to the core being of that person.

Since eating disorders become a focal point for one’s identity, getting better also means unwinding what feels like an inextricable sense of oneself and creating a new identity. That change takes time and enormous effort. Recovery is not a matter of days or weeks but instead months or years.

True support for someone in recovery needs to be grounded in patience, kindness and compassion.

Patience allows the person to believe getting better isn’t a race against time or a constant feeling of failure. Instead, recovery is a journey of self-discovery and self-care that leads to a new and improved way to live.

Kindness will give the person in recovery a new way to consider treating themselves. Instead of the harsh, critical thoughts of the eating disorder which always reinforce the feeling of not being good enough, kindness can introduce the concept of caring for oneself emotionally in addition to physically.

Compassion reminds everyone that an eating disorder is an illness that happened to someone and was not a choice. Recovery from an illness deserves compassion for the pain and suffering caused by the illness and love and support for the patience needed to find health and internal peace.

Frustration, disappointment and struggle are always going to be a part of recovery. For the people truly providing support for someone working hard to get well, patience, kindness and compassion will serve as cornerstones to a path to a new life.

The Context of Eating Disorder Diagnosis and Treatment

The overlap between culture and psychiatry is profound and always has been since the inception of the field. The dearth of scientific information to diagnose and treat mental illness combined with societal bias mean that psychiatry relies heavily on social values and cultural norms to determine treatment. Although other fields of medicine change from social impact, none do so more than psychiatry.

The definition of mental well being changes through generations. Success can mean many things: professional success, completing an education, a steady job with a family, a thin enough body, the ability to study or work 12 hours per day for weeks and months and years, or spiritual awakening. And the ideal mental state to attain many of these goals is extremely different.

Accordingly, dysfunctional mental states change drastically as social norms change. Odd or unusual behavior that is seen as mental illness now may have been adaptive in smaller, isolated villages centuries ago. A slow and steady temperament may be beneficial in some communities and seem as a sign of a learning disorder in others. Inattention that is a hindrance in school can be more creative and inspirational in times of societal distress. A thinner body may be ideal in certain towns and a sign of illness in a different community even in the same state.

As these norms change, psychiatry changes as well. Without a clear way to diagnose and treat illness, mental health professionals need to consider the world each patient lives in when thinking about diagnosis. What is considered an eating disorder now may not have been twenty years ago.

The point of this blog post is not to discount psychiatry and mental illness at all. However, we all need to be sure not to conflate psychiatry with clearcut science. The scientific data about the safety and utility of medications or research into best practices when treating eating disorders are sound. The philosophical and moral values about how to proceed in recovery is not only dependent on the person’s medical and psychological state but also on their background and community. Our individual mental health demands context in order to be defined correctly.

The Broad Changes Occurring in Eating Disorder Treatment

The changes in treating people with eating disorders have been dramatic in recent years. Several differences in how we as a culture approach mental health have opened the door to very new ideas about diagnosis and treatment.

First, mental health is a much more accepted part of overall health. We discuss our psychological and emotional well being as something to be monitored, addressed and taken seriously. The idea that we should tough out difficult experiences and ignore our emotional selves is not the only way to function anymore. Awareness increases the likelihood that family or friends will notice changes in eating behaviors or emotions and say something a lot sooner.

Second, knowledge and education about eating disorders are much more available and prevalent. Mental health awareness is a part of this change, but in addition most people know what eating disorders are and many more people have experienced someone close to them who has struggled with one. Social media exposes people to eating disorders much more regularly, and younger people have a larger breadth of knowledge not just about eating disorders but also diet culture and fat phobia.

Third, the expansion of care with many more treatment programs, virtual programs and clinicians for people with eating disorders makes it possible to be diagnosed and treated much earlier in the course of the illness. Since so more options now accept insurance, many more people have access to care. Treatment options means many people can get help and find a path to recovery sooner in their illness.

Compared to the relatively recent past, these changes are shocking to consider. The majority of people with eating disorders used to struggle for years before figuring out a diagnosis, let alone find any professional help, but that path is much less common these days. I am much more likely to see a young patient who understands their issue and the help they need than a patient ten years older coming to treatment for the first time.

This post reflects an important aspect of mental health care, namely how psychiatric diagnosis and treatment changes with cultural changes in our society. I’ll talk more about that in the next post.

The Contradiction Between Love and Perfectionism in Eating Disorders

The last few posts reviewed some central parts of the psychological underpinnings of an eating disorder and, accordingly, aspects of treatment that help people fully recover. Finding purpose, self-worth and a philosophy to make life meaningful are true antidotes to perfectionism, self-hatred and purposelessness.

At the time, I was very clear about how people with eating disorders often felt unlovable but was unsure as to how to couple this experience more fully with recovery.

In the last two decades, the pressures on women grave grown and changed in ways that have been instrumental in the explosion in the incidence of eating disorders. The contradictory messages of being both extraordinary and mediocre, perfect and one of the group, exemplary and also humble easily conform to perfectionism around food, body and weight. These impossible expectations both in their behaviors and in their food and bodies for women fit neatly into the paradigm of traits that create an eating disorder.

What underlies these impossible expectations is the feeling of never being good enough at anything—a tenet of the thought process of an eating disorder. In addition, never feeling allowed to reach a reasonable goal translates into never feeling lovable or worth loving. If love demands perfection, then no love ever seems reasonable or deserved. Love needs to reflect the feeling of being good enough, not being perfect, just as recovery implies doing well enough both with food and in life.

The learning process of understanding love distinct from perfection starts in therapy. Someone in the throes of an eating disorder and the concomitant perfectionism can’t see outside that bubble. Therapy that balances the idea of love for who you are instead of what you accomplish or what you represent can change the fundamental idea of what love is and is a key to recovery.