Virtual Eating Disorder Treatment

Eating disorder treatment, like so many elements of health care, has adopted the virtual treatment model wholeheartedly. Virtual treatment programs, virtual meal support and access to care all around the country are increasingly prevalent and accepted. State licensing programs and insurance coverage are reassessing previous regulations. The lack of access to eating disorder care throughout the country is a relic of the past.

Virtual treatment was present before the pandemic and has taken on an ever increasing share of overall clinical care. The treatment community is in the process of transforming the care we provide and adapting effective methods to remote work.

The overall benefit of virtual care is straightforward. Most important is access to care throughout the country. Remote and rural areas used to have no care for eating disorders. That issue is in the past.

In addition, skipping or missing appointments is much less common so clinical treatment can be much more consistent. Moreover, virtual contact between appointments, important for many stages of recovery, is easily embedded into virtual care.

The potential pitfalls of virtual care are less obvious and important for the clinical eating disorders world to grapple with.

First, the screens create not only a physical distance but also an emotional one. The connection between clinician and patient is so important for recovery as I have written about extensively here. Developing that therapeutic bond is harder virtually. The screen creates distance that sometimes can be hard to cross.

Second, it’s easy for people to hide online on many different ways: hiding food, hiding feelings, hiding fears. Bridging the virtual gap is always possible and demands a different way of approaching treatment, an added vigilance of the clinician and increased awareness to piece together clues that are often more obvious in person.

I strongly advocate for virtual treatment and am positive the increased access, no matter the platform, will be beneficial for many people. In trying to explain some of the benefits and pitfalls, I hope the treatment community continues to figure out the best ways to make virtual care effective.

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.

Body over Mind: Accepting Recovery

The false premise of anyone with an eating disorder is that our mind can control our bodies. The truth is that our bodies always win.

The glorification of thinness and dieting is pervasive in our society. Many people are shocked when they realize everyone doesn’t ascribe to the philosophy of dieting and weight loss. In fact, many people consider other things more important than weight and usually live happier lives. The driving force for overvaluing thinness is industry, and the business model is based on the impossible goals set forth.

We can’t ever control our bodies. Survival is the only goal for us as humans, and the most primitive part of our brains drive the hunger instinct especially if our health is threatened. Thus, diets don’t work.

Long-term restricting almost always leads to extreme hunger and binging. And our bodies determine weight based on a number of biological factors that improve our chance of survival, not based on any thoughts or desires to attain a certain weight.

The comparatively rare person with chronic restrictive anorexia appears to have a genetic variant that allows interminable food restriction. The adaptation likely enabled a small percentage of the population to survive extremely long famines and gave them an advantage in a very specific setting. Due to the advantage, the genetic variant has persisted.

Recovery from an eating disorder means accepting that our bodies determine how and when we eat. There are many ways one can attempt to trick our bodies to continue to restrict or compensate for binging. But these behavioral changes solidify the grasp of the eating disorder because the hunger only intensifies and in the end only make people sicker.

Acceptance of body over mind is humbling, but it’s the only path to recovery.

The Pitfalls of Saying “My Eating Disorder”

The concept of mental health is increasingly considered a part of our overall health. It’s high time we conceive of mental health when we think about our well being.

Once it’s easier to take ownership of our mental health struggles, people can be more transparent about taking care of themselves. That may mean being patient with ourselves during hard times, recognizing how to support others with mental health struggles or identifying our own mental illness.

The acceptance of psychiatric diagnoses and various types of treatment including medication has enabled a newer generation to equate mental health with physical health. Conversation and openness about daily psychological and emotional challenges normalize a once taboo experience.

All of the changes apply to eating disorders as well. Since shame is central to these illnesses, tolerance and understanding make it much easier for people with eating disorders to talk about their struggles and seek help. Moreover, the plethora of social media about eating disorders means you don’t have to feel alone with an eating disorder.

For young people, the evolving concept of mental health has one pitfall. It’s too easy to conflate mental illness with identity. At a time in life when people are searching for meaning and a sense of oneself, the mental health struggle itself starts to seem like the core of identity. Young people don’t talk about depression, anxiety, OCD or an eating disorder. They talk about my depression, my anxiety, my OCD or my eating disorder.

The meaning of the possessive pronoun is not just about ownership but about possession itself. The mental health issue feels like it makes the person special, makes that person who they are.

This is especially troubling for eating disorders because the illness itself is already deeply entangled with identity. A key part of treatment, written about in many places including in the blog, is to separate the eating disorder from identity.

Despite the fact that mental health needs to be just as important to people with eating disorders, it’s also critical to address that the eating disorder is an illness, not a possession or identity. The eating disorder is a mental health struggle that may be yours to face but the illness itself is not yours to own.

Dispelling the Myth About Full Recovery from an Eating Disorder

The widespread information online about eating disorders and recovery provides people suffering with these illnesses the ability to educate themselves. Access to knowledge informs people about their experience and how to get help.

The benefits of information are widespread. Patients have much more knowledge about eating disorders and treatment from the start. Research into all forms of help from medications to various types of therapy reveals many different options to get better. Broad details about clinical care gives patients the ability to express their own thoughts about the course of treatment. And educating oneself can be the best motivator to get well.

In recent years, the information available is more often from individuals rather than educational websites or non-profit organizations. Searches for eating disorders are likely to lead to Instagram influencers or marketers rather than a university hospital study or the Academy of Eating Disorders website.

Accordingly, the information people learn tends to be curated by people who may or may not be as educated about eating disorders and who may have a personal agenda. The agenda could be as simple as building a clinical practice or may reflect a personal bias about eating disorders. Since the internet equates all knowledge, people searching for useful articles can instead stumble upon biased data.

One myth that is particularly concerning is the idea that people with eating disorders will always be sick, that the best a person can do is tame the eating disorder thoughts but should expect to live with these thoughts forever. Although the belief that one can’t recover from an eating disorder is old, propagating the myth through social media runs the risk of making this idea appear to be fact.

Some people don’t get fully better from an eating disorder for a number of reasons, but the majority of people can and do get better. If people first learning about eating disorders believe they won’t get better, they approach treatment in a very different and less determined way. Armed with the myth they will never be well, these patients struggle to commit to recovery and to do the hard work needed to take on the process of recovery.

I worry that this myth is growing because more and more people grow their online presence and identity as someone who has recovered from an eating disorder but always needs to be vigilant. If people build a practice around the ever present identity of a recovered person, then being fully free of the eating disorder can jeopardize the business model. If people get well, then the practitioner needs to find a new identity to sell as part of the treatment the provide.

Although access to information can help many people learn about eating disorders and find the courage to seek help, the eating disorder community needs to be sure the goal is full recovery. Holding onto the identity of a recovered person runs the risk of helping people get better but limiting their identity to someone who is recovered. The goal of recovery needs to include becoming one’s true self.