How to Find Good Virtual Treatment for an Eating Disorder

Initially, virtual treatment was part of the necessary changes to continue any therapy during the worst parts of the pandemic. Now virtual work has become the norm.

Prior to the pandemic, I had written many posts about one of the biggest issues in treating eating disorders: access to care. There weren’t enough clinicians or programs to go around even in the most populous parts of the country, let alone in more rural areas.

Virtual work opened up opportunities for people to seek care much more widely, a needed change. As new virtual opportunities for care expand, the possibility that everyone can get help might be realized.

Expansion of care exposed another issue in eating disorder treatment, namely the quality of care. There is no standard training, certificate or degree for treating people with eating disorders. While virtual access improves, more clinicians are necessary, and the likelihood of inexperienced treatment providers in unsupervised settings increases dramatically.

Online treatment varies from therapy to all day programs to weekly coaching programs. The expense of treatment is high, and the ability to assess its efficacy very limited. In addition, programs that include meal support have an even higher bar to climb because tracking whether someone finishes a meal is even harder on a video call.

Grappling with the virtual landscape demands an even higher level of vetting by the patient to be successful. These are some ideas to consider and ask directly when making decisions about care.

First, ask providers and programs about their credentials. Any virtual treatment needs to start with well trained professionals with successful clinical practices who have the expertise to navigate helping people recover online.

Second, have a conversation about how any treatment works virtually and how the program adapts to online work. This modality can be very successful but not as a virtual version of the same treatment. The explanation of the differences will reveal how thoughtful the provider is.

Third, it’s essential that any treatment uses criteria to assess progress and has a plan at the ready for virtual work to be successful. Many providers and programs will say that if their treatment doesn’t work, they’ll recommend a “higher level of care,” a euphemism that the clinician does not know what else to do. Asking for more specific guidelines will be revealing of the person’s overall thoughts about treatment.

Virtual care fully enacted during the pandemic is here to stay. The pros of this work outweighs the cons. Seeking the best virtual care tasks patients to ask the right questions to ensure the treatment is effective.

Traversing the Altered Landscape of Eating Disorder Treatment: Overview

The pandemic changed the already confusing eating disorder treatment world immeasurably. The demand for treatment remains extremely high, and the avenues to find appropriate care are increasingly difficult to find.

A few major changes have had the most impact, and I will use the next few posts to discuss all the issues in detail. This post will focus on the few biggest ones.

The first big change is that virtual mental health treatment is quickly becoming the norm. In eating disorder treatment, virtual work is particularly hard since eating food together is an integral part of much of the work. Deciding whether virtual work can be helpful and when in person work is essential can be complicated.

The second change is the extraordinary array of options. The explosion of treatment programs, in person and virtual, therapists, coaching, support networks and mentor programs is dizzying. The number of clinicians professing eating disorder expertise is extraordinary, and there is no degree or certificate to prove any experience at all. Choosing providers has become very complex.

The third change is the enormous growth in residential programs funded by private equity firms. These programs are run at the corporate level by experienced clinicians and financiers aimed at growth, profit and eventually selling the company. Many of the day to day clinicians are inexperienced people early in their career and often at their first job. Some of them are excellent, but the varied skill levels are hard to assess. Providing the need for access of care is a boon to many but also has come at a cost.

These are the three most pressing changes to eating disorder treatment. I’ll discuss each one in more detail in the next several posts.

Psychedelic Medications in Psychiatry: Early Thoughts

Psychedelic drugs now used as psychiatric medications are a wave of the future. Psychopharmacology is effective and safe for many people, but there is still a significant number of people who get little or no benefit from this form of treatment. Any new direction for helping people with mental illness is intriguing and important.

Ketamine is already available and can be used by infusion, nasal spray, intramuscular injection or lozenge. Psilocybin should be available at some point in 2023.

The early data about both medications are very promising. People with many mental illnesses including depression, OCD and PTSD appear to derive benefit from the psychedelics. Although people who work with these medications report benefit for even more disorders, there isn’t enough known yet to substantiate the claims.

Unlike psychiatric medications, psychedelics don’t directly reduce symptoms. Instead, they increase brain plasticity—the flexibility of the brain to break stuck routines and change automatic thoughts and reactions. The effect of the medications is more effective when the program includes mental exercises or writing that enhances and focuses on changing certain patterns in the brain. For instance, trauma therapy using psilocybin shows significant promise.

Of note, there is no clear benefit for these medications for people with eating disorders, though any peripheral benefit for other psychiatric symptoms can benefit eating disorder treatment.

It’s crucial to note that psychedelic medications don’t follow the typical FDA method of approval for new drugs. And once approved, there is no clear method of treatment either. Psychiatrists cannot just prescribe the medications and pharmacies do not dispense the drugs. Ketamine is prescribed in specific clinics and can even be ordered as a lozenge on various websites without medical supervision at all.

The lack of regulation, unclear medical follow-up and minimal guidelines for use make it important for anyone using these medications to find a reputable source for attaining and using them. The patient has the responsibility to search for the safe and effective way of trying the medications and of assessing its benefit.

Psychedelic medications are an exciting new direction for psychiatry. The holes in care for mental illness demand new options to help those undertreated by the current available options. As long as a patient is educated and clear about their decisions, these new medications can be a very effective alternative. However, it’s important for patients to heed the risks and work with knowledgeable doctors through the process.

The Current State of Body Positivity

There appear to be signs that the movement towards body positivity and embracing all body types is fading. There are still models and actors in different bodies, more than there were a few years ago: thinness is not yet supreme again. However, the cultural pressure to consider all body types isn’t as strong, and people are more willing to accept celebrities losing weight publicly again.

Body positivity gained traction on social media. Younger generations saw different bodies on TikTok and in advertising. Evidence overwhelmingly shows that visual exposure to all body shapes and sizes quickly changes our perception of what is typical and also attractive. As long as the cultural norm is thinness, our minds quickly learn and absorb the expectations of how bodies ought to look. When we are exposed to all body types, the desire and aura of thinness diminish quickly.

The culture of body size matters for people with eating disorders. The more one is bombarded with thinness, the more likely an adolescent is to diet. In the developmental search for identity, teenagers look to culture to dictate what is desirable. They are susceptible to trends and are very likely to try out norms dangled in front of their eyes on social media.

As I have written here many times, dieting is the number one risk factor for developing an eating disorder. The movement away from body positivity means an even higher incidence of eating disorders.

Never have teenagers had more influence on current culture. They can quickly create a trend on social media which influences public opinion and cultural expectations. Before media preceded and created the public response to new ideas, but now they are symbiotic.

So the most likely way to ensure body positivity doesn’t fade is to encourage the younger generation to support the attractiveness of all bodies and ignore ideals for thinness. Only time will tell if the strategy can be effective. I certainly hope it is for that generation’s sake.

A Guide to Starting Eating Disorder Therapy: Beginning with Hope

An experienced, compassionate clinician needs to consider hope from the first minute of a consultation. Yes, understanding the person’s complete history and background is important, but from the introduction to treatment, the tone is set for how therapy progresses, and no treatment will make progress without hope.

The myths about eating disorders are in the background of any therapy. A patient will most likely think how can this new treatment help me? Is there any chance of really getting better? Will this person truly understand the nature of my eating disorder and what I struggle with every day? Why will this time be any different?

A therapist must realize these thoughts dominate the mind of the person you are just meeting. Even if they don’t state a word about the future, their expectation is the confirmation of the hopelessness they have likely felt throughout much of their clinical experiences.

But the sense of hope can’t be forced or unsubstantiated. There are some people for whom hope is not recovery but stabilization of the eating disorder to build a future, and that’s a very real accomplishment. The hope needs to be borne out of true beliefs the clinician has about this person, their eating disorder and realistic goals for the future.

At first, the hope stems from the therapist listening with an open mind, learning in detail about their eating disorder and asking questions that imply how things might change. Typically, one can reinforce positive experiences in the past, note treatment not considered yet or emphasize strong elements of motivation. The therapist’s initial approach to the session will communicate the direction therapy can take right away.

These immediate actions and initial plans need to be proactive so the person knows the treatment will be collaborative. They can’t feel alone anymore.

Communicating hope from the start is remarkably helpful and effective in laying the groundwork for successful treatment. This path needs to be integrated immediately into any new therapy.

Reclaiming Goals, Wishes and Desires in Recovery

Eating disorders usually begin at a formative stage of life, typically between childhood and early adulthood. Since these illnesses are all consuming—physically, psychologically and emotionally—many stages of personal development and growth halt or slow considerably when someone is sick.

The physical limitations can result in slowed growth, delayed puberty and organ system dysfunction. Despite the severity of the symptoms, the large majority of physical effects reverse quickly with adequate nutrition. Moreover, the physical concerns rarely cause people to lose hope.

The emotional and psychological results of an eating disorder cause more psychic pain for people and lead to enduring hopelessness. It’s easier for people with eating disorders to lead a semblance of a typical life into their early twenties. They can go to school, socialize appropriately and develop friendships around shared activities. The eating disorder numbs emotions and limits the depth of connection with others, but the lack of emotional development is largely hidden—both to the person with the eating disorder and others—earlier in life.

In early adult life, the social and emotional deficits become more evident. The eating disorder consumes the majority of one’s thoughts and leaves little room to explore emotional experiences and deepen relationships. Socializing typically involves eating, and these events are fraught with fear, not with an opportunity to connect with others. Relationships are not possible unless the eating disorder plays a large role in the bond. Those connections can never be that powerful.

Suddenly, people with eating disorders feel very different from others, left behind. And the road to restarting psychological development necessitates getting better from an eating disorder which has been intimately woven into daily life from a young age. People experience this situation like a trap: getting better means facing the struggle around food and body, and life events can’t happen unless one gets better.

The road forward looks impossible. It’s easy to become hopeless.

The therapist has a critical job early in therapy to explain how psychological and emotional development can restart at any age and can catch up very fast. Much as physical limitations from the eating disorder heal, so do psychological limitations. As the eating disorder symptoms recede, a person in recovery can take on personal challenges and move forward. A new task at age 17 is much easier even a few years older because the brain has finished critical developmental stages. So the social and emotional changes can happen very quickly.

Hopelessness in this case is borne out of the false idea that one can never catch up in life. Having missed critical years, the future is hopeless. This myth could not be more false. Tackling eating disorder symptoms opens the door to personal growth and the ability to forge ahead and create the life one wants.

The next post will address how therapy itself can disempower the hopelessness borne out of diet culture and the idealization of thinness.

Hope at the Start of Eating Disorder Treatment

I see hope in eating disorder treatment as integral to its success and woven into many parts of the process.

The first step is a clear, logical, reliable plan to start treatment. Initially, the approach needs to be concrete and specific to allow for a sense of accomplishment and the establishment of a team focused on recovery.

Although the DSM uses a list of symptoms to describe and diagnose eating disorders, the criteria don’t explain the confusing and tricky elements of how these illnesses work. A clinician can ask a series of questions and write an elegant medical note about someone’s eating disorder without a true picture of what any one individual’s daily struggle looks like.

The only way to establish a mutual understanding of an eating disorder is a food log. The log creates a way for clinician and patient to talk about food and elucidate the details of how the eating disorder works.

Fairly quickly, the timing of food each day, gaps in time between eating, the size of meals or snacks, urges to use behaviors and emotional triggers for symptoms become clear in the log very quickly. A therapist can ask specific questions that help the patient better understand how they are tricked into the same patterns by the eating disorder and also how to start to alter the patterns.

The log also creates a bond between therapist and patient. By having the log to examine together, the eating disorder feels separate from the patient, an entity between the patient and therapist which they can discuss honestly, openly and without judgment. Suddenly, the shame isn’t so present, and the goal of working together on getting well is paramount.

Last, that feeling of together, of not being alone, in the struggle to get well is the first glimmer of hope. The changes to daily behaviors may be small at first, but the log implies that the patient will have help directed at the most difficult moments of the day and that the therapist will be involved immediately in the actual behaviors themselves.

The next post will address identifying emotional and psychological development that never happened because of the eating disorder and how restarting this development generates hope.