How to Prevent an Eating Disorder from Becoming Chronic

The last two posts made a few things clear. Almost everyone is exposed to the risk factors for developing an eating disorder: dieting and adolescence. In addition, most people have an evolutionary predilection towards starving or binging. The combination of these variables leads some people into the prodrome, the precarious mental state that precedes the eating disorder, and then into the illness itself. There are two critical questions to answer in order to fully understand the prodrome: who recovers from early illness? and how to prevent the progression to a chronic disorder?

I don't want to minimize any stage of an eating disorder. The symptoms hijack the patient's life and overturn any semblance of a stable family. However, the early stage of an eating disorder is critical because there is still a significant chance of full recovery.  Eating disorder treatment for patients in the acute, early illness involves weight restoration, normalizing eating and a return to regular life. For most patients, this transition is very hard but often a relief from the physically and emotionally punishing cycle of the illness. For most, this treatment is enough. The difference between recovery and chronic illness is comorbidity--the presence of another psychiatric disorder in addition to the eating disorder. When the eating disorder masks the comorbid disorder, normal eating leaves the patient fully exposed to the comorbid symptoms. In fact, the eating disorder becomes a very powerful and successful coping mechanism for the underlying problem. Following the rules of the eating disorder gives a sense of control and satisfaction. The world is ordered and makes sense. The other disorder makes little sense and has no rules. Under these circumstances, the patient with comorbidity will choose the eating disorder, essentially the lesser of two evils. After "failing" at treatment, this patient will quickly be labeled chronic.

The most common comorbidities are trauma, depression and anxiety. A history of abuse, particularly as a child, contributes to a strong need to hold onto the eating disorder. Like an abusive parent, the eating disorder provides both comfort through eating and punishment through the  internal monologue that is harsh and unrelenting. The  eating disorder hides her fear that she will be subjected to more trauma. This calms the feelings and memories of the abuse and structures the patient's adult life. Depression and anxiety often accompany the descent into the illness, but a minority of these patients have severe depression or anxiety as the primary symptom. In these circumstances, fully treating the comorbid symptoms will also largely cure the eating disorder. Conversely, untreated or undertreated depression or anxiety will lead to chronic illness: the eating disorder helps the patient manage her other symptoms.

There is one more category of patients who become chronic. I will label them as the "delusional" type. Here the comorbidity could be seen as part of the disorder, but I prefer to label this aspect of the illness as separate from the eating disorder itself. The delusion reflects the patient's inability to differentiate between the most punishing and extreme thoughts and behaviors of the eating disorder and reality. There are many examples: some patients literally see themselves as 100 pounds heavier in the mirror, some are convinced they have eaten calories when they drink water or even by watching others eat, others truly think the eating disordered thoughts will punish them, some don't believe they are sick at all. These patients lack the perspective to see the disordered thoughts as part of the illness. Recovery makes the patient feel as if she will lose herself. Her identity is woven into the disorder so that she does not know herself without it. Needless to say, the treatment course is significantly prolonged.

What can be done to prevent the patient from developing a chronic eating disorder? A thorough initial evaluation followed by a  comprehensive treatment plan will identify those people at higher risk to determine who needs treatment for the comorbid illness as well. This involves trauma therapy concurrent with eating disorder treatment
or comprehensive treatment for depression and anxiety. For the patient with a delusional comorbidity, the treatment is more complex. This patient may end up in several rounds of treatment, often both inpatient and outpatient, before she is accurately diagnosed and finds the right help. The key to success is a strong therapeutic bond which can generate the internal motivation and courage needed for the patient to question the delusions. In addition, the treatment must nurture the growth of the patient's identity separate from the eating disorder. This is no easy task but is critical for real recovery. The delusional comorbidity also can break down even the most supportive families. Their role is to work hard to find the best help for their daughter. Participating in the eating itself is almost always  counterproductive unless supervised and instructed by the treatment team. However, families can and must provide emotional support and compassion through the treatment. The process is long and arduous, and families themselves may need support to handle their own frustration.

Writing about this critical part of the evolution of an eating disorder has led me to address the role of the family. Most patients in the prodromal stage are in their teens or early twenties and are still dependent on the family for support. The next post will address the best ways for families to support the child with an eating disorder.

Hunger and Fullness

Hunger and fullness are the internal cues we use to regulate eating. They are also what our current culture of abundance of food and obsession with thinness looks to exploit. Last, they are what goes awry in an eating disorder. Relearning these cues is a cornerstone of eating disorder treatment.

At the most basic level, hunger is critical to our survival. It is clear that identifying hunger and acting on it is necessary to avoid starvation and death, both as an individual and as a species. Most of us feel mild hunger on most days, but hunger need not be a regular part of daily life for a majority of the population anymore. Experiencing hunger seems more like a social statement--or even a medical condition--than an evolutionary necessity. But forced hunger and starvation are very different. Prolonged hunger leads to a primal, visceral response which includes obsessive thoughts about food, a voracious ability to eat endlessly, cravings for odd food combinations, mindlessly performing strange food behaviors and a complete loss of rational thought around the social norms and propriety of eating. In other words, anyone who is chronically starved exhibits the symptoms of anorexia nervosa. This point highlights another curious aspect of eating disorders. Anorexia looks more like an adaptive mental state in starvation than a psychiatric illness.

It is less clear what role fullness, or satiety, plays in our lives. Historically, eating until one was full, very full, was looked upon as socially correct behavior. If there was an erratic food supply, eating a lot was a way to store energy for the future. Eating large amounts and gaining weight was a sign of prosperity and wealth. The expression of love and caring in many cultures is through providing food and eating together, usually to excess. Similar to anorexia, overeating or binging looks like an adaptive response to an environment with excess resources: eat and eat and eat. It is a physiological response to help avoid hunger in the future.  Calling it a binge is a new classification of an old, adaptive behavior. Any compensatory action to repair the "damage" done by the binge, i.e. purging, are panicked responses to the social judgment and perceived consequences of the binge. Fullness has no clear relevance to survival. There has been little reason to hone our instincts to identify fullness, at least until now. Bombarded with a neverending supply of food crafted to appeal to all of our senses, fullness is now necessary to avoid overeating and obesity. In that vein, fullness is not adaptive at all. It is a social construct created because of our ideal of thinness and a culture serving up endless quantities of food. Our society acts as if fullness is a natural instinct, and by extension a failure for those who cannot recognize it, not an ingenious way to place responsibilty for the obesity epidemic upon the individual.

Like all adaptive, evolutionary traits, hunger and overeating are exhibited along a spectrum. Some people will experience the starvation response more quickly and profoundly while others can tolerate hunger and function. Some will gorge around excess while others will not be capable of overeating. From an evolutionary standpoint, this variability within a population ensures the survival of a species. Certain people will survive in famine and others will prosper in times of excess. In modern times, these traits transform from evolutionary traits into eating disorder risk factors. Suddenly, people who can withstand hunger try a diet and find that their tolerance for hunger is rewarded by society and by the internal, visceral high of starvation. Others who have the adapted trait to overeat when food is abundant find that the food industry products trigger a primal craving, such as sugar cravings or carbohydrate cravings. In our current culture, it is a short leap from evolutionary leanings to a full-fledged eating disorder.

If risk factors for an eating disorder are adaptive traits, where does that leave those most susceptible? If we live in a world with food aplenty and processed food designed to appeal to our most basic desires, how can those susceptible not get an eating disorder? How effective can intuitive eating--a treatment designed to help us get back in touch with our internal sense of hunger and fullness--successfully compete with evolutionary adaptations? These are sobering thoughts. They leave eating disorder treatment in a bind between our most basic instincts and the missteps our society has made about how we handle food.

Although I am tempted to address the larger picture first, I want to stick with the original point of writing this blog: the treatment plan. So the next post will look at the transition from adaptive response to eating disorder. As I described in the last post, it is called the prodrome.

What Makes Eating Disorders so Different

Every eating disorder starts with a diet. Most diets peter out when the person gets too hungry, but sometimes it leads to a different kind of hunger, one that triggers a cascade of largely physical reactions that can result in an eating disorder. But the hunger can be of many kinds. Perhaps it is a type of high, emotional but also psychological, from feeling as if one has mastered food. Or maybe it is an all-consuming hunger that makes one want to eat and eat and eat. Maybe the hunger becomes irrelevant because it feels so good to lose weight. For these people, once the hunger takes over, there is no turning back.

What other mental disorder starts with a choice, a seemingly innocuous choice, that spirals out of control? Maybe it even starts with a thought: I want to lose weight. Moreover, what adolescent girl--and, more often these days, boy--doesn't try dieting at some point? Does that mean everyone is exposed to the trigger for an eating disorder? Does that mean anyone can get an eating disorder?

It's hard to imagine having this discussion about any other mental disorder. Psychiatrists talk about a prodrome, a cluster of symptoms which appear to herald the onset of a psychiatric illness. The prodrome for an eating disorder could just be adolescence. Our culture extols the ability to remain thin and eat little in a world of abundance of all kinds of food. No one is more vulnerable to cultural mores than teenagers. When everyone is exposed to an environment ripe for developing an eating disorder, it begins to feel like everyone who is predisposed to get one will.

Although the mental health world has adapted over the last century to different conceptual frameworks for illness, psychiatric symptoms have remained fairly consistent: anxiety, depression, delusions, hallucinations. They have all been documented under one name or another and can be traced through the evolution of psychiatry, but eating disorders only entered the mental health lexicon in the last few decades. The almost meteoric rise from newly described illness to national obsession occurred within a generation, or perhaps two. The discipline is still trying to catch up on all levels: diagnosis, treatment programs and even basic treatment success.

Sometimes, I even wonder if eating disorders are really mental disorders. Maybe they belong to a whole different class of illness, the result of a broader national miscalculation which has exploited a cornerstone of human survival. Our food supply has been transformed in recent decades. Agribusiness and processed food, primarily using corn and soy, has provided our society with an abundance of food for the first time in the history of humans. The US makes almost twice as much food as the people living here need. We have gone from a people seeking enough food to survive to a world with, in theory, more than enough for everyone. Food changed from an urgent necessity to a continual choice. We can find anything we want to eat at any time. This means survival on a global scale but at what price? Our hunger was adapted to a world with a more limited supply of food, and we are ill-equipped to cope with such a plentiful environment. Hunger was a visceral, physical signal to the body to get food. Now many people experience hunger infrequently. Instead we are pushing new boundaries: either how much we can eat, what is our capacity, or how much can we withstand hunger with food all around us. There never has been the need before to adapt to times of plenty. Like it or not, this is our grand experiment.

Every person born today lives in this new world. Each person and each child has to learn how to balance hunger and fullness in the constant presence of food. No one knows how an entire country will handle hunger when faced with more than enough food, and not just food but all types of tasty and tempting food. This is food an entire industry spends enormous amounts of time and money developing to appeal to our most basic senses. The industry has worked hard to find food that will override any rational desire to stop eating. The result has been disastrous: rising rates of obesity, a steep increase in eating disorders, ineffective government iniatives to promote nutrition, and the exploitative food industry.

Re-reading this post, I realize there is a lot more to discuss in each point. The next few posts will explicate these thoughts in more detail. If these are the current conditions which exposed our evolutionary weaknesses to food and hunger, who among us ends up with an eating disorder? What makes those of us susceptible? Look for the next post.

Food Journals

The food journal is a simple, effective but underused tool in eating disorder treatment. Both clinicians and patients balk at incorporating the journal into treatment. Therapists consider it too simplistic to be effective. They fear the therapy will not address the patient's underlying emotions or believe only nutritionists should discuss food. Patients are too ashamed to discuss specific food choices or find the daily journal too cumbersome. When both therapist and patient really sign on for the food journal, the treatment feels like it has taken a shortcut to trust, honesty and progress. By addressing food from the start, the journal can be the catalyst for real life changes.

The food journal itself includes the date and time of eating, specific foods and amount eaten, whether the meal is overeating or a binge and the thoughts and feelings at that time. If possible, each entry should be written at the time of the meal. The format of the journal can be a chart, narrative, or daily emails, but I am always surprised by creative ways a patient will write her journal. The best option is the one that works for the patient. The journal can be in any form as long as it gets done. In the session, the therapist and patient review the journal and learn how to work together to understand the eating disorder, a process based on Cognitive Behavioral Therapy or CBT.

The essential component of CBT--a mainstay for eating disorder treatment--is the food journal. This approach involves identifying patterns between eating disorder thoughts and behaviors, increasing awareness of these patterns and devising methods to change them. The biggest problem with CBT is commitment to the journal itself. While this type of therapy can be very effective, there is little guidance on how to ensure the patient completes the journal.  Often, what is missing is a sense of urgency. What is the purpose of recording her food daily? Why should she bother? She needs to know and truly understand that the journal can be the bridge to hope and then recovery by addressing the most insidious and powerful part of any eating disorder, secrecy.

Because patients feel intense shame about themselves and the symptoms, hiding the disorder feels like the only option. Each and every subsequent slip into the symptoms induces more guilt. Each time, she says, will be the last. Each time only reinforces the need to remain hidden until the eating disorder goes away. This vicious cycle makes her feel more and more isolated from family and friends and increasingly hopeless about her life. The therapist needs to break through the cycle to help her believe she is capable of eating in a different way and becoming free from the overwhelming hopelessness.

How can a food journal change anything? I hear that question every time I mention it. First, the journal establishes a consistent, daily connection between therapist and patient. Moreover, the communication in therapy starts with the biggest secret in her life--things she frequently has never told anyone before--behaviors around food. This is a huge leap for the patient and a huge responsibility for the therapist, but these steps are necessary because eating disorder treatment needs to tackle the secrets directly. The patient cannot be alone anymore.

The journal means honesty for the patient with her therapist and with herself. This can be a remarkably liberating experience after years of feeling captive to the cycle of thoughts and behaviors. Instead of deluding herself that each day will be her last eating disordered day, she has a partner to help demystify and change her relationship with food. The sense of collaboration transforms the immediate experience in therapy for the patient. Regular talk therapy can feel like an inquisition which only reinforces her sense that she is broken. The journal can change that. It is the physical object the team--patient and therapist--can look at and learn from together. The therapy is not judgmental but objective, and the goal of each session is to learn how to do the work of treatment together? It means the patient has the answers too; she is no longer powerless. So many patients avoid treatment because the shame is overwhelming, but here the shame is secondary to the collaboration. The shame is transformed into trust and a renewed hope for the future.

This entire post reveals a fundamental difference between eating disorders and other mental disorders. No other disorder becomes a way of life so powerful, so shameful and so secretive that it can consume a patient entirely. No other disorder is highly praised by society. No other disorder arose from nowhere less than forty years ago. The next post will begin to consider these differences and the bigger question: why is this disorder different from all other mental disorders?

Diagnosis

The first eating disorder diagnosis, Anorexia Nervosa, was described in 1973. In the DSM-IV-TR, there are only two accepted diagnoses--anorexia and bulimia--and a grab bag classification called eating disorder not-otherwise-specified (EDNOS) for everything else. There is a lag between relevant diagnoses and the steep rise in the incidence of eating disorders and eating disordered syndromes, and this lag makes the current system essentially irrelevant for treatment. Many other diagnoses have been suggested: binge eating disorder, night eating syndrome, orthorexia, purging disorder and compulsive overeating. The psychiatric community has had difficulty codifying these symptoms into disorders largely because they are a social phenomenon or perhaps even a lifestyle choice. Due to multiple individual and societal pressures, manipulating food has become a way of life. As is evident from my previous posts, I believe these symptoms only lead to isolation and misery, but the purpose of this current post is to present an eating disorder classification system.

When it comes to treatment, only two variables really matter: the length of the illness before effective treatment and the most prominent symptom of the disorder. If effective treatment starts within the first five years, then the goals are to stabilize eating, normalize weight and return the patient to her pre-eating disorder way of life. At this point, she will more easily fall back into her natural eating patterns and her natural social patterns. Treatment is likely to be more successful and more uniform no matter the diagnosis. Her eating disorder will only be a coping strategy, not yet a lifestyle. She will be able to join her peer group relatively quickly in terms of education, friendships and relationships. Even though a significant minority of these patients will become chronic, expecting success can turn around even the most gravely ill patient early in the course of the disorder.

For people with chronic eating disorders, usually five years or longer, recovery for the patient feels more like introducing a new way of living. The eating disorder has become a buffer between herself and the world. What appears to the outsider to be liberation from the symptoms can feel oppressive, exposing and terrifying to the patient. After a lengthy illness, she can rarely fall back into pre-eating disorder living and feels as if she has fallen too far behind her peer group to ever catch up. Sadly, the benefits of remaining sick often look more appealing.

The core of successful treatment with chronic patients is personal connection. If she can break down the barrier of the eating disorder and connect in any relationship--in her life or in therapy--she can start to realize and want what she is missing. That desire and motivation is crucial to have any chance at success. The therapy relationship itself is often the critical tool that can break the hold of the disorder. The means of finding connection depends not on
diagnosis but on the primary symptom of the disorder: starving, binging and purging (vomiting, laxatives, diuretics, over-exercising etc.) or overeating.

People with chronic eating disorders almost always fall into the diagnosis EDNOS. Few people sick longer than five years are able to sustain the same symptoms. As her body adapts to the disorder, she needs to find new symptoms to survive, ie binging to compensate for long-term starvation or laxatives when she can no longer vomit. These adaptations don't change the primary symptom, and the psychological key to recovery lies in that core symptom.

People whose prominent symptom is starvation have tied up their entire identity in the ability to control hunger and remain thin. Society has lavished her with praise. She has figured it out. Everyone is incredibly jealous. Even though starvation has always curtailed any other accomplishments, nothing surpasses the ability to master food. The attachment is so powerful, she will often overlook severe medical complications to continue to starve. The key to opening the door to treatment is to unlock her isolation and sadness. By connecting in a relationship, usually in therapy, she can remember how alone she is and how much she sacrifices to continue starving. The road to
treatment is long and arduous, but sometimes the desire to survive and truly live can gradually overcome the satisfaction of the illness.

For patients who primarily binge and purge, the disorder most closely resembles an addiction. The chemical high a patient experiences from binging and the release of purging only leads to a craving for more. Often, she feels powerless to experience eating any other way. The shame leads to the need to hide so even those closest to her may not suspect she has an eating disorder. The key to treatment begins with forging a new connection with herself. Exposure of all of her eating behaviors, binging included, in therapy in a detailed food journal is essential. As the patient gains some perspective on her disorder and begins to have success with normal meals, she loses both the cravings to binge and the internal sense of shame. Reconnecting both to herself and the people in her life provides essential feedback to continue down the road to recovery.

Overeating presents the newest, least studied and most controversial group of eating disorders. Food journals can certainly help distinguish overeating from binging and expose the level of shame associated with eating. Since these patients frequently have a lot of knowledge about nutrition, education is not a critical component of treatment. What makes these patients controversial is that the illness is a national phenomenon with political, industrial and psychological causes. For now I will focus on the psychological root. These patients have disconnected on a larger, societal level, and the treatment needs to bring them back to their own daily lives. In our community, people who are obese are often ignored or even invisible. They feel disempowered, desexualized and even dehumanized, almost as if they do not deserve the same rights as others. For many patients, this isolation provides security. The isolation limits the closeness in relationships and the expectations that might be imposed on them. The public scrutiny and judgment can reinforce their extremely low self-esteem. Food itself both provides both solace and punishment. These patients need to want to be part of the world again and to believe they deserve connection, respect and love. They are usually very aware of their isolation but do not believe it could be any different. It can be a lonely life, and the goal of treatment is to provide hope again, perhaps enough to reassess her relationship with food, her life and herself.

Food journals work their way into all categories of diagnosis independent of the duration of illness and primary eating disorder symptom. I will elaborate on the utility and benefit of journals in the next post.

Psychiatric Medications

Psychiatric medications have become a national obsession. Everyone seems to believe there is a pill to cure all of our woes. That is no different when it comes to treating eating disorders. Often patients come to treatment looking for the pill that will make their eating disorder disappear. They go away terribly disappointed.

Psychiatric medications do have a role in eating disorder treatment, but a limited one. Although the majority of patients end up taking medications, the patient is rarely aware of what the goal of treatment really is. I wonder if the prescription is almost a reflex response--thoughtless and automatic--because the psychiatrist doesn't know what else to do.

Let me be clear. Medications do not cure eating disorders and rarely even treat them directly. Instead they can treat the secondary symptoms of anxiety and depression and sometimes reduce the eating behaviors. Before a prescription is written, every patient needs to understand that medications play a secondary role in treating eating disorders. If a patient is considering taking a medication, she needs to know the goal of treatment, target symptoms and the time frame to assess the effectiveness.  To get more specific, it makes the most sense to break eating disorders down by behavior categories: restricting, binging, overeating and obesity.

Restricting behaviors--controlled starvation--usually fall under the diagnosis of Anorexia Nervosa but can also encompass a wider range of symptoms such as purging, chew-spitting, diet pills and laxative abuse. The psychological effects of starvation are very powerful and include depression, anxiety and obsessive-compulsive symptoms. Medications will not change the desire to restrict or change the desire to be thin, but antidepressants are often prescribed to treat the depression and anxiety. The obvious point is that food will work much better than any medication. Although starvation reinforces the obsessive thoughts, obsessive-compulsive symptoms often predate the eating disorder. High doses of antidepressants--usually SSRIs--can lessen the intensity of these thoughts and make it easier for a patient to eat. Since the medications take two to three months to work, it is critical to start all components of treatment right away and not wait for the  medication to take effect.

Binging disorders can include Bulimia Nervosa, binge eating disorder or other binging syndromes such as night eating disorder. These disorders can also lead to secondary depression and anxiety symptoms and are often treated with antidepressants. Once again the eating disorder symptoms are the primary cause of depression and anxiety. Eliminating the behaviors will be much more effective than any medication. There are two critical differences between binging and restricting disorders. First, there are medications proven to cut down binging: once again high dose SSRIs. Most of the research studies have shown that frequent binging can be cut in half after about eight weeks of treatment. The patients in these studies typically binged several times daily. Less is known about medications for people with more mild symptoms. Topamax--a medication mainly used to treat seizures--has more limited evidence to treat binging. Patients request it because weight loss is a common side effect and frequently cannot tolerate it because slowed and confused thinking is another common one. Neither of these medications are particularly effective without a complete treatment plan. The second difference is that a handful of patients with binging disorders actually have primary depression. This group usually has a strong history of depression in their family and longstanding depressive symptoms that don't fluctuate with the ebb and flow of the eating disorder. In these cases, the eating disorder will get much better when the depression is treated.

The mental health world has only just begun to try to treat compulsive overeating and obesity. Only binge eating disorder is even being considered as a psychiatric diagnosis for now, but I have gotten more calls about overeating than anything else over the past year. Most of the patients who come for an evaluation have a long history of overeating and have made multiple attempts at weight loss including diets, nutritionists, obesity specialists and exercise. This is often the last stop before bariatric surgery, and many of these patients hope there is a magic pill which will rescue them from their long struggle. Unfortunately, that pill does not exist.

Overeating can sometimes mask depression, bipolar disorder or anxiety, and treatment with the right medications can open the door to success with food as well. But those are the rare cases. The only other psychiatric medications used are appetite suppressants that are uniformly addictive so that the immediate success only leads to many more complications in the long run.

These medications, primarily Adderall and Ritalin, are the most challenging aspect of psychopharmacogical treatment of all eating disorders, not just overeating or obesity. Stimulants are usually used to treat Attention Deficit Disorder but are also used as a secondary treatment for depression. Patients often start these medications for one of these diagnoses but are lured by the side effect of powerful appetite suppression. All of a sudden, patients feel like they have found the magic pill which helps them not eat and not think about eating. This is not a cure but can feel like a huge weight has been lifted. For the doctor, this seemingly miraculous effect gives one immediate satisfaction. It is too easy to imagine a patient  truly cured and even to forgo the long, but necessary, real treatment. The biggest problem with stimulants is they are very addictive. Physically, a patient will have withdrawal if she stops the medication but will also become tolerant: you need more to get the same effect. As a patient needs a higher dose, the side effects get worse and scarier such as severe heart problems. Psychologically, a patient will feel like she cannot function without the medication. Rather than learn how to face the eating disorder, the pill becomes the only tool to combat the illness. Then she will continue the medication, at any cost. The final take home message is use stimulants with caution to treat an eating disorder.

Clearly, psychiatric medications are of limited benefit in treating eating disorders, but this discussion also highlighted another messy topic: the different diagnoses of eating disorders. Stay tuned for the next post.

Choosing a Therapist

The relationship between therapist and patient is the foundation of any successful eating disorder treatment.  All of the anxiety, fear, anger and hope reside in that relationship. No treatment can move forward without a therapeutic bond that works. There is so much weight on the choice of the therapist but how does a patient know she has found the right one?  There are no directions, there is no checklist, no magic wand that confirms this is the one. The only guide is the almost mystical idea of a good "fit" between therapist and patient.  To make it even harder, an eating disorder makes someone doubt everything about herself, yet choosing the right therapist is based on trusting oneself. So the best advice is to ignore the eating disorder and trust your instincts.

No wonder this decision is so daunting.

Here are five important clues a patient can identify even after one session. These clues will help guide a patient in the right direction and are closely related to traits important in an eating disorder therapist.

The best place to start is to ask a few questions right after the  first session.  Did the therapist really listen and try to understand? Did the therapist think she knew everything already? Did the session feel like an awkward and forced exchange or a real conversation between two people?  In other words, the patient should feel like she just had a good conversation, not a psychological evaluation.

The next question to ask is how knowledgeable and experienced the therapist seems to be.  It is worth asking about the therapist's training and experience treating people with eating disorders. This information is important but far from enough. The best gauge is to ask for a treatment plan. Both the answer and the way the answer is given are important. The treatment needs to be specific and include members of the treatment team, goals for how to handle food, reduction in symptoms and the expected time frame to see results. The answer should come easily and naturally: the patient needs to feel the therapist can handle the treatment and has successfully treated patients before.

Eating disorder treatment demands flexibility. As a patient starts to get better, the therapy will need to change considerably by providing different types of support through different stages of treatment. There are many small but critical variables in an initial session such as where to sit, how to pay and how often to meet. Negotiating each seemingly minor issue is a clue. The easier each step felt, the more likely the therapist is flexible.  Using this flexibility will indicate if the therapy can become a true collaboration. The therapist knows how to treat people with eating disorders and the patient knows herself. This foundation of mutual respect and a flexible relationship starts right in the first session. If it is not there, it is very unlikely to develop.

This relationship will be a very important part of a patient's life. She will spend a lot of time with the therapist and invest time, energy and money so it is important to assess the therapist as a person too. Did you like the therapist?  Is this someone you want to get to know?  Could you trust this person?  A first appointment can be so stressful that a patient might ignore her own instincts. It's okay to put these thoughts together later and not know right away.

Invariably during a first session, a patient asks me if I think she can really get better. Struggling with an eating disorder day after day leads to feeling trapped and hopeless. After all, people who don't understand often say no one should feel so confounded by food! Eating disorders are much more complex, but our society floods us with simple ways of handling food and only makes someone with an eating disorder feel more hopeless. Coming out of a first session, a patient needs to feel hope again. She needs to believe her life can really change.

These five attributes--a therapist who is real, knowledgeable, flexible, likeable and hopeful--are a place to start in choosing the right person. It is better to plan to pay attention ahead of time: write these questions down and check the list right afterwards. Once the therapist is in place, often the next big question is treatment with  psychiatric medications: whether to use them, what they do and will they work.  Look for the next post.