The Disgrace of Eating Disorder Treatment Programs

The last post attempted to distinguish between eating disorders and the deleterious and often traumatic effect of treatment. Clinicians often approach them as one issue, but time working with patients shows how different these two issues are.

The best place to start is to compare people with a longstanding eating disorder who have spent years in treatment to those who have not. With the explosion of private equity-funded programs, it’s harder to find people without any experience in treatment, but they do exist.

Those new to treatment have a much clearer path towards wellness. They need to be heard and to be understood as I explained in the last post. They need information about their eating patterns and how and why they have responded to food restriction over the years. They need guidance as to why this started and how to change it, if they want to. Last, they need to understand how their eating patterns are limiting and how to find what they want in life.

On the contrary, people who have spent years in programs have left behind all the original parts of their eating disorder. They are angry for having been locked up in programs, for having been treated like a child, for having been treated like a criminal, for being blamed for a problem as if an eating disorder is willful disobedience.

They are frequently obsessed with weight and calories because programs focus primarily on these factors. They want to manipulate their food to fight back against the system that has hijacked their lives for their own supposed good. They have lost hope on finding what they want in life and have internalized the idea that they are broken and have nothing left.

Treatment programs run by for profit financial companies intending to grow and sell a brand have little interest in healing anyone. Hospitals organized around the philosophy that eating disorders are a blemish on our society and need to be stamped out justify ostracizing an entire segment of people. Vilification of eating disorders pervades the broader social media world and allows people to blame this population for our own misguided obsession with food and weight.

Eating disorder treatment needs to focus on the individual first and foremost. These people, still mostly but not all women, feel unheard and unseen. In a culture that continues to idealize thinness, marginalized people fall into food restriction to seek out praise and attention. As I have written in this blog many times, the number one risk factor for an eating disorder is dieting. Many of the people looking for positive feedback by restricting food end up with an eating disorder and landing in punitive treatment.

Eating disorders are a cry for help from an isolated part of our society. We treat these people as the hysterics were treated years ago: blamed for their problems, locked up for their own good and punished until they give up any hope.

I feel so angry and powerless to make change despite treating this group of people for over two decades. I’m not sure what, but something needs to change.

Eating Disorder are About Not Being Heard

Eating disorder treatment is split between an academic and clinical focus. Research tends to look at assessment tools and perfecting diagnosis. The clinical treatment field is overwhelmed by the capitalist drive to turn a profit using health insurance payments. Individual outpatient treatment increasingly rests on virtual practices with clinicians limited in knowledge to treat people with eating disorders. The result is a wide ranging, disparate and unfocused way to help people looking for support and guidance.

Nowhere in this landscape is there a focus on the psychological and physical wellness of people seeking help.

People don’t get well using the criteria currently in vogue for assessment. So much of the focus is still on weight, daily judgment of food intake and regular threats of “higher level of care” when clinicians feel overwhelmed or frightened of a patient who doesn’t get better in a timely fashion.

People with eating disorders, for the most part, don’t feel heard or acknowledged in our society. They feel isolated and ostracized. They know they either need to fit into the box determined by external forces or be left on the sidelines.

The eating disorder, in one form or another, serves the purpose of getting the attention of those around them either by changes in their body or in their behavior. As much as treatment may be misguided and unwarranted, acknowledgement of the eating disorder expresses one’s displeasure and anger about the world in which they are trapped.

What is critical to note is that each individual does not choose this path. No one says they want to protest so they develop an eating disorder. Almost everyone falls into the eating patterns as a reaction to circumstances, experiences a beneficial physiological and/or psychological benefit and subsequently finds that they are trapped in the cycle.

Society is obsessed with thinness, so restricting food is encouraged in all communities, and these new eating patterns provide a form of expression that is otherwise ignored. Clinical research will show the genetic predisposition to eating disorders or the risk factors, but these data are not contradictory to the societal meaning eating disorders have in our world.

Attention to the individual person and their thoughts, feelings and desires can create a path for a meaningful life not lived solely through eating and weight. Similarly, opting for treatment which explicitly values the individual over food and weight will open a humane path for life to change and create a way for the person to learn to trust herself at the core.

Time and again, patients tell me that my belief in them and willingness to see them as an individual, no matter their eating patterns or weight, created the possibility for change. Ultimately, understanding people with eating disorders means understanding them fully. They are people suffering who only need someone willing to listen.

Body Image: A Symbol of Eating Disorder Treatment Gone Awry

One place to start addressing the effect of eating disorder treatment is the idea of body image. The inception of eating disorder diagnoses began with the cultural preference for thinness spread through mass media in the 1960’s and 1970’s. Classification and treatment incorporated the concept of body image as the bedrock of recovery.

Body image distortion conflated with body dysmorphia are now considered a hallmark for any eating disorder. The novel idea at the time that a person might not see their body as others do, or may in fact see a very different body, consumed the clinical eating disorder treatment world, but without nuance or creativity. It might have been helpful to consider how and why people struggled with self-image but wholly another to use body image as a way to disempower and confuse a cohort of young women.

Rather than see body image in a broader schema, treatment philosophy took the psychological experience at face value. Therapy attempted to force the person to renounce how they see themselves. Behavioral work encouraged people to do exposures to face what others considered the reality of their bodies. Therapists told people with eating disorders that they had distorted thinking about themselves and their bodies and did not truly know themselves.

However, cultural norms widely contradicted the messages from therapists. How could society value and reward thinness while treatment philosophy said the exact opposite? How could therapists seem focused on thinness themselves in their own bodies while simultaneously encouraging the people they treated to ignore the larger world completely?

The conceit of the eating disorder treatment field is to make the patient themselves feel confused if not crazy while ignoring the realities around them. In this context, eating disorder treatment appears to be almost conspiratorial, certainly not therapeutic. In no way can it be helpful to tell people not to trust themselves and learn who they are.

In this vein, the concept of body image distortion starts to have more nefarious connotations. It’s not a stretch to imagine that the mixed messages about body that women endure are intended to gaslight all women. Why should women gathering the power and momentum in all parts of our society be handicapped by the confusion around body image?

Inevitably, a substantial percentage of women succumb to these beliefs and are taken away from their own lives by years of treatment. The constant concern women feel about their own bodies reinforces the pernicious norms of self-blame and self-doubt.

I’m not sure where to take these ideas about body image in the larger scope of treating people with eating disorders. Some elements of treatment need to stand including helping people be nourished enough to live and not lose so much mental energy around food and body. I don’t believe women need guidance about how to see themselves or how to live. They certainly don’t need anyone telling them they cannot even see themselves clearly.

Anyone with an eating disorder needs help to find the path to be themselves and live the life they want. Too much attention on food, weight and body image distracts from the real issue, one that’s all too present in today’s culture: the subjugation of women through their bodies.

The Exploitation of our Youth through the Eating Disorder Diagnosis, Part I

The combination of the expansion of treatment programs and the effects of social media altered the meaning of having an eating disorder in our society.

These disorders first arose as a means for clinicians to understand the soaring rate of eating-related psychiatric symptoms starting in the late 1970’s and early 1980’s. Doctors scrambled to find ways to understand and treat people showing up in offices and at hospitals with often severe symptoms.

At first, treatment focused on hospitalization and stabilization of food intake and healing of medical symptoms. However, the lack of comprehension of how these disorders started led to an almost universal prejudice against these patients as entitled and often even feigning symptoms for attention. It was unfathomable that people would either not eat or binge and vomit unless it was volitional.

Over time, residential treatment programs, typically run by people who went through eating disorder treatment when they were younger, developed a feminist understanding to help young women find their own identity and direction in life. The philosophy was that young women were unable to find a voice in the world without action. Treatment focused on guiding women to find themselves in other ways with much more compassion and much greater success.

For a brief moment, treatment seemed like it might focus on the the real issue plaguing mostly young women seeking support and provide a community that would listen to them and validate their experiences.

The explosion of treatment centers funded by private equity ended the brief window of humane treatment and now cycles young people, women and more men, through therapy mills run by largely inexperienced clinicians and focused on reaping the reward of health insurance money.

Gone are the days of helping young people find their path in life. Instead, programs often admit people who don’t need inpatient care, cause trauma through harsh, ignorant treatment and only harden the need to find solace in other ways, largely through the eating disorder. Some programs may do good work at times, but the overall harm does not merit the few good experiences.

Social media is rife with people excoriating treatment programs and languishing behind the label of an eating disorder. These people feel blamed for their experiences, unable to find support for who they are and lost in a sea of societal scorn for their own true struggles. Ultimately, they are unable to find themselves or even find a place in the world to figure out who they are.

The deeper question is how did the eating disorder diagnosis and treatment become another means to satisfy capitalist greed? Where is the kindness and compassion for young people, still much more often young women, who are trapped in the chains of a destructive moniker? How does the eating disorder treatment field recover?

I’ll address these questions in the coming posts.

The Standard of Care for People with Binge Eating

In the last couple of years, many people seeking treatment for any binge eating (primarily bulimia, binge eating disorder or compulsive overeating) look to GLP-1 agonists medications as a way to cure their eating disorder. There may be a limited role for these medications in treating binge eating, but the mainstay of treatment is unchanged and often very successful.

Cognitive Behavioral Therapy is the central component of treating any binge eating disorder. The first step is logging food including the specifics of the meal, time of eating, whether it’s a binge or not and the thoughts and feelings around eating at that moment.

The process of logging has several key benefits: separation from the food to assess eating with more perspective, understanding the emotional and hunger cues that trigger binge eating and working together with the therapist to approach binging as a symptom that they can figure out together. Even more importantly, logging impresses upon the patient that there is a way to figure out how to stop binging.

Medications like Prozac and Topamax also play a role in decreasing binge urges but are a supplementary part of treatment rather than a cure. Working with a dietitian helps educate the patient about meal planning and the need for regular meals throughout the day to regulate hunger and fullness cues. Last, treating other concomitant psychiatric disorders, such as anxiety, depression and ADHD, makes stopping binging much more successful.

The new GLP-1 medications have confused the standard of care for binge eating. The lay concept of food noise in particular can push people with binge eating towards these medications. For laypeople, food noise means hunger caused by dieting and undereating. This new class of medication suppresses hunger for many people thereby making it easier to eat less in an unhealthy way and ignore hunger cues.

The term food noise describes very accurately the preoccupation with food that people with binge eating experience. It’s not a surprise that people with binge eating find this term validating; however, conflating food noise for someone with binge eating to food noise for someone without an eating disorder is problematic.

The biggest risk is that people with binge eating may think the GLP-1’s can cure their eating disorder and that food noise is a more universal symptom. The medications don’t treat binge eating on their own and almost always set people back who are in the process of treatment for an eating disorder and learning how to regulate their eating. Therapy and appropriate medications need to be the primary way to move forward.

The new GLP-1 medications have some limited use to treat people with binge eating, but the standard of care is very effective and must remain the first steps towards recovery. Food noise is a very apt description of thoughts around food for people with binge eating, but the term isn’t clinical and does not change how someone with binging can get better.