Healing the Trauma of Residential Treatment for Eating Disorders

People in recovery from eating disorders often need to address the trauma of being in treatment programs in order to fully get well.

Hospital stays and residential treatment are often, but certainly not always, a necessary part of recovery. Critical medical issues need attention and sometimes a hospital stay is necessary. When people experience prolonged, severe eating disorder symptoms, residential treatment may be the only way to normalize eating enough to continue down the path of recovery.

Patients who understand their illness usually agree when it’s time to go into treatment as well, even if they are reluctant.

The trauma of being in treatment can stem from being forced into the program, especially if the patient is young, but often trauma occurs even when the patient decides to seek help themselves.

Treatment programs render the patient powerless and helpless. They have to stay on the physical premises and are only allowed out on arranged outings. They must eat what is in front of them, no matter how frightening or overwhelming the experience, five to six times daily. They need to tolerate any changes in their bodies, no matter how sudden. For the first few weeks, they cannot even go to the bathroom themselves for fear they may engage in eating disorder behaviors.

In addition, patients need to adhere to these rules while attending individual and group therapy sessions where they are expected to talk about deeply personal and sensitive topics. It’s hard enough to broach those topics in the best of circumstances, let alone when the person is locked away without any rights, independence or agency.

Weeks or months of being trapped without any say and forced to do the terrifying act of eating many times per day while one’s body changes, often very quickly, is frequently traumatizing.

The expectation after treatment is that patients will continue their meal plan, ignore the emotional fallout of weeks or months in treatment and recover swiftly.

Clearly there is something missing in this plan for eating disorder recovery.

After discharge from treatment, patients need to start to talk about their experience immediately. Not only is it harder to eat without being forced to do so, but a common response to being so powerless is to assume power back with eating disorder symptoms. Paradoxically, the traumatic experiences reinforce the eating disorder itself. Patients need to talk through their experience and feelings immediately in order to not fall into the most common pitfall after discharge.

In addition, discharge plans from treatment need to focus on the food in a compassionate and supportive way. The draconian methods used in programs will backfire in the world. Force does not create an path to recovery.

Last, patients need to know they will be in charge once they are out in the world. The experience of being trapped and overwhelmed renders people scared and alone. Retreating to the eating disorder feels like the only way to regain any sense of safety and security.

This topic is even more important with the growth of treatment programs in recent years. Therapists need to be ready and capable of ensuring patients get compassionate care after discharge from programs.

The Existential Nature of Eating Disorder Recovery

Treating eating disorders frequently leads to an existential conversation. There are many theories why recovery inevitably lands in discussions of the meaning of our lives. Nevertheless, the work of getting better apparently necessitates delving into why we are here.

In part, people with eating disorders are very coherent and clear in all other aspects of their lives outside of their own food and weight. The symptoms of every other psychiatric illness bleed into daily components of human life, but eating disorders are much more circumscribed. The result is that someone with an eating disorder can have a lucid, insightful conversation about their illness even when they are struggling to get better.

No matter how they start, eating disorders become the foundation of the meaning of life. Success is determined by the actions of that day: food eaten in the day, the number on the scale, avoiding food behaviors, the number of steps, to name a few. Or the eating disorders provide emotional needs not found elsewhere: comfort, companionship, guidance or praise.

Stepping away from an eating disorder and attempting to live without the feedback and direction the illness provides instantly leads to questions about what life means. The eating disorder provides clear answers about what makes life worthwhile. The immediate question is why else does life matter when the eating disorder begins to seem meaningless?

For most people, recovery cannot exist in a vacuum. People who try to change their behaviors, without any other part of life providing value, don’t see a reason to continue the hard work of recovery. They peek out at the world, perceive only emptiness and dive headfirst back into the disorder.

Successful recovery demands that other parts of life start to matter as well. As the eating disorder behaviors and thoughts recede, the person often finds they are drawn to focus on and think about these other facets of their existence. At first, that may mean broadly talking about what matters in life, but the transition is not fluid or easy and almost always torturous and challenging. Missing and grieving the distance of the eating disorder feels painful, and figuring out how else to live is complicated and confusing. It’s hard to start with no idea about how to live after having a guiding light one’s entire life.

These conversations need to give room for the uncertainty of our existence to remain a focal aspect of getting better. The existential nature of recovery is one we all find familiar. We all face the reality of our existence, and any therapist can identify with the fears of trying to find meaning in our lives.

Even more, the goal of thinness has a powerful place in generating meaning even outside of eating disorders. It would behoove us as a culture and country to rethink thinness as an accomplishment that gives meaning to our lives. A cultural phenomenon is now a capitalist boon to several powerful industries. We all need to recognize there has to be more to life than a number on the scale.

The Risk of Referring to Eating Disorder Programs too Quickly

The growth of residential eating disorder treatment in recent years expands access to care in ways that were unimaginable a decade ago. Programs accept many insurance plans. There are so many more programs across the country. I look back at posts on this blog from a decade ago, and one main takeaway is how few options there are for treatment. What a needed and rapid change!

Availability of treatment for a broad swath of people with eating disorders is a huge relief. I have spoken about many of the concerns about these programs—many of which are now owned by private equity companies—but it’s important to recognize the benefits as well. Many more people sick with eating disorders can receive adequate and timely care.

An unexpected result of these improvements is a more myopic view of eating disorder treatment for outpatient clinicians. Before, referrals to “higher level of care,” i.e. treatment programs, were held at a higher threshold. The limited availability of programs made this referral more of a last resort.

With so many programs accessible and covered by insurance, it’s a lot easier for treatment teams to consider a program even after someone struggles for a brief period of time. There is less patience on the whole in outpatient treatment for patients to have a chance to try new ways to get well. Treatment programs can stop an immediate slide in symptoms, which often puts the clinicians’ minds at ease when facing a patient not doing well.

Programs may excel at making people eat, gain weight and regain health; however, in a bubble protected from the outside world, patients don’t learn how to cope with life while maintaining recovery. Cycling in and out of programs typically leads to patients who are demoralized and lose any sense of who they are outside the eating disorder. Too many of them lose hope for recovery.

The hardest part of recovery is the work done out in the world, not just the eating but dealing with the feelings that arise when eating behaviors are stable. That’s the work people in recovery need help with the most.

A treatment team needs to be able to tolerate the ups and downs of recovery in the world in order to let the patient know she has the support to get well. Clinicians need to remember it’s also their job to tolerate when a patient struggles. Resorting to treatment programs too quickly only reinforces the hopelessness of recovery rather than the projecting the belief and confidence that getting better is really possible.

Metabolism in Eating Disorder Recovery

Our genetic makeup plays a large role in how eating disorders develop and an equally large role in recovery.

The most important risk factor for an eating disorder is an extended period of food restriction. Surviving a dearth of food has been necessary for human survival, so genetic encoding and inheritance of these metabolic adaptations enabled humans to still be here.

People can survive famine by both slowing metabolism to function on little food or binging when food is plenty to live on the energy stores for as long as possible. Many people have both genetic predispositions and some have neither.

People trigger these tendencies with dieting. Once engaged, the metabolic changes don’t always turn off so easily. Even when food is aplenty, once adaptive metabolic behaviors start, they won’t necessarily stop which leads to anorexia or binge eating behaviors. In these cases, the behaviors are an adaptive response to food restriction that persists for our survival.

In recovery, people switch from disordered eating to eating regularly, hopefully on a consistent basis. At some point, our metabolism recognizes that food is now available and can adapt to the new energy available and abandon strategies to cope with food deprivation.

For some people, metabolism adjusts quickly and returns to baseline function that would have existed without an eating disorder.

For many people in recovery, metabolism won’t adjust so fast. Once triggered, metabolism sometimes is primed to expect another famine on the horizon. It does make sense that if one prolonged period of food restriction happens, our bodies will protect against the next period that may very well arrive. This is a clear and evident survival adaptation.

However, for people recovering from an eating disorder, it’s a challenge because the adaptation in metabolism leads to a period of weight gain not commensurate with food intake. Body image is hard enough to tolerate in recovery and even harder when weight gain does not match the meal plan.

Metabolism usually does respond over time by gradually resuming pre-eating disorder function or a lot closer to that function. Some people benefit from medication that communicates to your body that food is now plentiful and will continue to be available.

These metabolic changes through an eating disorder and recovery and the differences people experience in their bodies all reinforce how eating disorders are genetic adaptations triggered by food restriction. A significant part of recovery is recognizing that healing means listening to your body and what it needs. Without trusting your body to heal, recovery isn’t possible.

Stop Blaming People with Eating Disorders

The ultimate paradox of eating disorders in our society is the disdain we have for people suffering with them. We live in a culture obsessed with thinness, dieting and “healthy” eating, yet the most common response we have to people with eating disorders is “why can’t you just eat the food?”

As I have written extensively in this blog, the most important risk factor for developing an eating disorder is dieting. We are all genetically programmed to respond to prolonged restricted eating differently, and many of us respond by developing eating disorder behaviors.

Despite the fact that our society focuses so much on weight and food restriction, people who have eating disorders are almost always blamed for their illness. It’s difficult for people to have the kindness and compassion people with eating disorders need and deserve to get better. Instead these patients are faced with an endless barrage of anger and blame which only intensified the already harsh, critical thoughts central to an eating disorder, as I wrote about in the last post.

So many treatment approaches to eating disorders use blame and anger as a supposed therapeutic technique. Treatment teams often use ultimatums to attempt to force people to get well or else terminate treatment. Hospitals tie patients down or lock them alone in rooms to force them to comply. Clinicians harp on patients to “want to get well,” as if getting better is simply a matter of will. Medical care doesn’t usually punish people for being sick but that’s incredibly common for people with eating disorders.

The key to moving forward in eating disorder treatment is simple: understanding, care and kindness.

People with eating disorders need to be heard and understood. Rather than telling people what to do, clinicians, doctors, family members and friends need to be quiet and listen. Given time, people will find their voice and learn ways to express themselves.

Eating disorder thoughts are very harsh and cruel. People struggle to ignore the loud thoughts in their head and try to take steps towards wellness all day. Kindness and compassion serve as bulwarks to keep going forward.

The shift from blame to kindness can enable people to feel supported in recovery. Rather than reinforce the hypocrisy in our society of blaming those with eating disorders, let’s try to be kind and chart a new path to being well.

The Negative Thoughts of an Eating Disorder

One almost universal part of an eating disorder is the internal monologue both around food and negative thoughts about oneself. The intrusive thoughts about how to eat and how to look are relentless and exhausting. Even more insidious and destructive are the negative thoughts about oneself.

These thoughts typically are categorical negative statements about who the person is. They can vary from you’re fat to you’re ugly or stupid or useless or a terrible person. The list goes on, but these thoughts loudly reiterate that, in one way or another, they are a bad person.

Even if the person with an eating disorder tries to counter these thoughts, the repetitive, forceful nature of the thoughts often triumphs.

The origin of these thoughts often precedes the eating disorder itself whether based on prior traumatic experiences, lack of attention to personal and emotional growth or external negative reinforcement through one’s life events. The eating disorder behaviors both provide momentary relief from the negative thoughts and, afterward, reinforcement for the deep sense of shame of being a bad person.

Being trapped in an eating disorder for years solidifies a binary way of seeing oneself, either good or bad, but mostly bad. The eating disorder thoughts provide a simple, black and white framework to understand and assess one’s identity. Since these thoughts dominate the internal mind of someone with an eating disorder, there isn’t much mental space to learn a more nuanced way of understanding who they are.

Accordingly, eating disorder recovery involves a profound exploration of one’s understanding of identity. As the old negative thoughts are stripped away, people first often experience a void in their mind. Gradually, recovery can focus on how to better understand who they are as a person, what they think and feel and how they want to live.

It is imperative that the therapist have an open, nonjudgmental stance to help explore this growing identity and understand how to nurture a caring, curious way to learn about oneself.

At first, this part of recovery can be overwhelming if not frightening. Over time, the idea of learning about who you are begins to be exciting and revelatory that life can feel so different and new.

The Only Real Nutrition Advice to Follow

The newest battle to stop the continued explosion of eating disorders in our society is against Ozempic, but the endless war has many fronts.

The medical establishment continues to vilify obesity at every turn, now even recommending Bariatric surgery to children. The diet industry capitalizes on our fears by rebranding every few years, currently expounding upon the benefits of “healthy eating” and intermittent fasting. The pharmaceutical industry, like a siren song, promises the newest wonder drug for weight loss, Ozempic. The food industry creates addictive, non-nutritious foods or diet foods to tempt us from every angle. And the fashion industry, despite valiant attempts to promote body positivity, still values the thinnest models first.

Amidst so much noise, one basic question that arises regularly in eating disorder recovery is this: what is normal eating?

Too many industries and too many capitalist pressures make this question difficult to answer, but there are a few clues.

The most savvy professors of nutrition and reporters laid out clear guidelines years ago which remain sacrosanct in eating disorder recovery treatment.

First, eat all variety of foods. We humans are omnivores who are at our best when we eat all different kinds of food. We need the various nutritional elements, vitamins and minerals we get from eating lots of different things. Our digestive systems vary as well, so we all do best with different types of food and will get everything we need from a varied diet.

Second, eat mostly real food. The food industry has created an endless assortment of processed foods and packaged foods. These items are very convenient and heavily marketed. In addition, people with eating disorders are focused on calories and often prefer foods with clear nutrition labels. However, these foods are not real food. They have some nutritional value, but our digestion was designed to eat real food and our bodies are actual healthiest when given actual food not made in a factory.

Third, be sure that a good part of your food includes fruit and vegetables. Intentionally, there is no exact amount that is best, but the overall guideline is perhaps a quarter to a third of your intake can be from fruits or vegetables. Too few limit the nutrients needed, and too many limit the more substantial food our bodies need to survive.

Truly, these are the only guidelines. All further information has limited research and reflects individuals’ preferences or opinions rather than the data from actual clinical studies. If only recommendations could be clear and straightforward and not disguised by the barrage of messaging about health we endure each and every day.