Don’t Blame the Eating for Everything!

Eating disorder thoughts typically weave into a person’s identity and feel inextricable from oneself. These disorders start at formative ages when identity develops. Other people react strongly to the eating disorder, only reinforcing the concept to a younger person that the disorder represents more than just a set of rules around eating but a way to define oneself. Often, the internal and external reinforcement create a profound identification with the essence of an eating disorder and leave little room for other forms of self-exploration.

Treatment feeds into this mythology by conflating the person and the illness. Unlike most psychiatric disorders, clinicians typically blame people with eating disorders for their illness and misconstrue difficulty following a meal plan with willful disobedience. For a young person trapped and confused in the mental maze of an eating disorder, blame for the illness confirms that this illness is who they are.

Attempts in treatment to separate the eating disorder from the person run through most plans for recovery. Therapy theories reflect the concept of the separation of the eating disorder voice from one’s own voice. Recovery refers to an ideal, a fantasy really, that life after recovery is idyllic once the eating disorder disappears.

In the process of this artificial definition of recovery, therapists in the eating disorder field often overlook one common theme for people with eating disorders: they don’t feel seen or heard. Being in a body approved or noticed by others or eating in a way that gets attention is the only way many people with eating disorders experience being seen. Take that away and they feel like they have nothing and are nobody. To the individual trapped in an eating disorder, getting better doesn’t feel like a choice.

The various treatment approaches using different types of behavioral therapy, meal planning, inpatient or outpatient programs or different types of trauma work are not likely to address the fundamental issue in eating disorder recovery. Each person struggling to move forward feels trapped behind the illness and all the ways they feel seen, access comfort and feel secure through the illness. In order to come out from behind that screen, therapy needs to focus on helping the person feel understood and heard and to learn who they are beneath the illness and treatment.

Each concern someone has can’t just be another eating disorder thought. Everything they feel can’t be fixed by eating more. All their life experiences can’t be the result of being stuck in an eating disorder.

Each person with an eating disorder has feelings, thoughts, preferences and ideas. Everyone struggling with an eating disorder is a legitimate person who needs to be treated as such.

Yes, clinicians can be concerned about the health and well-being of people with these illnesses because of the medical consequences in addition to psychiatric ones. The treatment team still has an obligation to remember this is a real person trying to get better from a real illness. Silencing them with endless blame for their daily experience in the illness only makes them sicker. Our job, first and foremost, is to listen.

The Best Course for Eating Disorder Treatment in the Current System

The plethora of treatment options and modalities obfuscate the clear and effective protocol to treat someone with an eating disorder. It’s too easy to get lost in all the ways to get help, yet what works hasn’t changed at all.

Various new programs and offerings create a confusing breadth of ways to consider treatment. Online partial hospitalization or outpatient programs, virtual team treatment, new supposed medication cures and even text therapy businesses make it hard for the newcomer to find a treatment path that can lead to recovery.

The combination of virtual mental health care that arose during the pandemic and the entrance of finance companies angling to capture some of the health insurance market share has put the health of eating disorder patients on the back burner.

Outpatient treatment entails a primary therapist well versed in the course of eating disorder recovery, not someone who dabbles in these illnesses, a dietitian knowledgeable about meal planning for eating disorders and also experienced with nutrition therapy and a primary care doctor to track any health concerns in the process. Sometimes a short-term group therapy or more specialized doctors are necessary. Psychiatric medications are often a part of treatment as well.

Choosing a team of providers with enough expertise to chart a course towards wellness is critical. In addition, recovery is a personal and emotionally intense experience; thus, patients need to prioritize finding clinicians with whom they feel safe and comfortable.

Because recovery is so hard, people unconsciously find ways to hide, and learning how to be open is an important part of getting well. Virtual work has become the norm for so many people, but it is very easy to hide behind a screen. At least for part of the treatment, meeting in person always benefits recovery.

When outpatient treatment isn’t sufficient, residential programs and hospital-based support are necessary. There are a handful of hospitals with experience treating people with eating disorders, and patients should seek this places out for optimal care. The landscape of outpatient programs has been transformed by venture capital funds. My recommendation lately is for shorter stays at residential centers, one to two months, during which patients put together an outpatient team for the transition back to their lives. Most residential programs are no longer set up for longer stays but instead help restore enough nutrition to do the true work at home.

Despite the changing eating disorder treatment field, I would advise patients seeking care to follow these guidelines. Ignoring the calls from well-funded companies luring people into their programs is wise. It still may take some work to find the best fit for each individual person, but the time invested is worth the outcome.

Eating Disorder Treatment After the Demise of Body Positivity

The onslaught of GLP-1’s in our culture has left the body positivity movement in the distant past and reignited the drive for thinness.

The growing movement of acceptance of all different body types, especially in women, had opened the door for new directions in eating disorder treatment. Body image distortion, the most persistent and stubborn symptom of any eating disorder, was a bit less powerful when the cultural acceptance of varied body types grew. People were more likely to consider different clothing sizes and less ashamed of the changes in their bodies that accompanies recovery.

The new class of medications promoting weight loss and the micro-economies around them spawned a renewed and even more powerful focus on thinness. People who never had eating disorders suddenly lost extreme amounts of weight. Influencers peddling body positivity suddenly showed up dozens of pounds smaller. Any variation in model body shapes vanished.

Amidst the about face in media images of women’s bodies, the eating disorder treatment world has backtracked greatly. Patients with all sorts of eating disorders, and in all shapes and sizes, gravitated shamelessly to finding any way to procure these drugs. Physicians and various medical-adjacent industries prescribed them readily, often with minimal or even no clinical indication.

The drive to find eating disorder recovery disappeared behind the promise of weight loss, minimal “food noise” (euphemism in the eating disorder world for any sign of hunger) and a magical cure for any eating disorder.

It has been harder as a clinician to encourage people down the emotionally challenging and time consuming journey of recovery. More and more people seek this new magical cure and are less likely to acknowledge and seek actual help for their eating disorder.

As the GLP-1’s lead to food restriction and potentially induce an eating disorder, even in those never sick before, I wonder what kind of devastation these drugs may leave in their wake. I have touted the potential uses of these drugs in recent posts because I don’t want to dismiss new, powerful drugs with clear medical benefit, but I am just as concerned about the negative outcomes.

My focus now is to acknowledge these new medications and recognize their benefit in manipulating the gastrointestinal hormonal system. However, the clinical community must also focus on eating disorder treatment that has not changed.

Clinicians who treat people with eating disorders need to stay true to treating this population. No medication has ever cured an eating disorder, and GLP-1’s are no exception. People who benefit from these drugs have already made headway in recovery. Eating disorder treatment entails the hard work of therapy, meal planning and food counseling with a dietitian and a long term process in order to help people get well.

The Use and Misuse of GLP-1’s for People with Eating Disorders

The new GLP-1 agonist medications are a live experiment due to the widespread use, and misuse, of these drugs. Here are my most recent observations and recommendations based on reviewing current research, communication with colleagues and clinical observations of patients with eating disorders.

First, the best approach to the medications is to start low and go slow. Some people even need to start at doses lower than recommended by the pharmaceutical company and often stay at very low doses. The benefits of the lower doses are fewer side effects, more longstanding benefit and time for one’s body to adjust to the metabolic changes. Going too fast leads to more side effects, especially nausea and constipation, which can build over months or even years and lead to necessary discontinuation of the drugs. The drugs work best when the intended use is for gastrointestinal hormonal imbalance.

Second, people on these medications need to have normal hunger cues and be able to eat regular meals. When hunger is suppressed, people end up restricting food and losing weight due to having less food than they need. This strategy is never sustainable as anyone knows who has an eating disorder. Food restriction leads to ongoing medical issues and rebound hunger, if not binging, thus perpetuating the binge and restrict cycle.

Third, the medications are ultimately hormonal in nature, not specifically weight loss drugs. They work by affecting hormones and adjusting how the gastrointestinal system works. At doses that are too high, they can lead to food restriction and severe weight loss with no long term benefit. The mentality one uses to approach the GLP-1’s is critical. They are medical interventions to be used judiciously, not miracle weight loss drugs.

Last, it’s very important that people with eating disorders don’t use these drugs to remain at weights lower than their body can manage. The end result is slower GI system, muscle wasting and many other effects of drug-induced anorexia.

These conclusions reflect my current understanding of the guidelines most useful for people with eating disorders considering GLP-1’s. There is no doubt these drugs are here to stay so a thoughtful, curious and cautious approach is necessary to use them safely. More information is on its way in the coming months.

The Existential Part of Eating Disorder Recovery

The expansion and monetization of eating disorder treatment has led to a primary focus on concrete steps and goals in recovery. Insurance companies demand practical goals for reimbursement, and the corporatization of treatment means less individualized care.

I believe strongly that behavioral therapy is a necessary component of early recovery and has a role in later stages as well. However, in the current jargon, full recovery indicates freedom from food and body thoughts without addressing the element of identity. If treatment doesn’t involve steps to separate oneself from the illness, it’s impossible to be free to live life fully.

Eating disorders encompass disordered eating, compensatory behaviors, body image thoughts and the all consuming experience of one’s mind being taken over by these demands. Recovery needs to help people find themselves beneath the all consuming nature of the illness.

Early recovery must normalize eating to insure one’s body gets the food it needs throughout the day while also minding the emotional and psychological turmoil that ensues. This part of getting well is always hard and is a necessary first step but is just that: a first step.

Treatment that began early in the eating disorder epidemic took the history of mental illness into account and recognized the existential component of treatment. Eating disorders grew out of the cultural imperative to be thin combined with the advent of mass media outlets spreading images of thinness throughout the country.

No one could predict the effect that sanctioned dieting combined with the idealization of thinness could have on a society. As social media made it easier to spread images and messages that propagate dieting and thinness, eating disorders have become endemic.

The nature of eating disorders and the media machine driving them necessitates a deeper dive into one’s identity for true healing. An eating disorder is now considered a widely accepted definition of identity in this culture. It’s easier than ever to eat well enough and be recovered while continuing to base one’s sense of self on the disorder itself.

An existential search for meaning can be painful at times. The work of therapy examines the core sense of oneself and reckons with the underlying thoughts of person, motivation and meaning. This exploration points the person in a direction of how to live life and what truly matters.

The process of pulling away from the safe identity of the illness and identifying the less sure but more genuine idea of being a full person allows someone to fully get well. Without the need for the eating disorder as a pillar of identity, there is much less reason for the eating disorder to linger.

If treatment ignores the key existential step in recovery, wellness simply means eating enough but still creating self around the empty meaning of food and weight. There has to be more to life than that.

Don’t Lose Sight of What Works in Eating Disorder Treatment: Part II

The current eating disorder treatment protocol is focused on weight, meal plans, higher level of care and, sadly, liability. People seeking help confront a tricky dynamic in which their health and well being are not always primary.

In addition, the capitalist effect on mental health treatment affects eating disorder treatment too. Various therapy services and even text therapy allow for easily switching therapists and substituting a professional friend for true therapeutic work.

In this climate, the value of the therapeutic relationship is easily lost. Much has been written for decades about the value of a therapeutic relationship with clear boundaries of time, role and intention. The relationship is open and connected but allows for vulnerability and exploration that modern life rarely affords. In this relationship, the openness allows for the type of therapy that is very helpful for recovery.

Eating disorders, especially anorexia, represent a source of safety and comfort for many people. Food restriction often serves as a means of security and certainty in a world that is anything but. Following the food rules, monitoring effects on weight and making decisions based on the eating disorder represents a source of calm, something that often feels impossible to resist.

Early studies into treating people with anorexia focused on developing a therapy relationship that might circumvent and eventually disempower the eating disorder. Finding new sources of calm through relationships and connection, so the theory goes, could begin to compete with the emotional security of the illness.

Much evidence supports this idea, yet the eating disorder treatment community continues to move towards solely cognitive based therapy or reflexive inpatient treatment for people not sick enough to merit that level of care.

The effect of more surface level care combined with unnecessary residential treatment sends people the wrong message. Full recovery doesn’t entail embracing the illness and creating identity through treatment. Instead, being well needs to encompass identity outside of recovery or illness. Identity can come from within and develop through connectedness in the world.

The treatment community can offer a more complete and fulfilling idea of recovery by returning to some of the basics of helping people with eating disorders. Understanding what people with eating disorders need to get well is a necessary part of treating this group of people.

Don’t Lose Sight of What Works in Eating Disorder Treatment: Part I

All the changes in the eating disorder treatment field distract clinicians from the basic, most effective ways to help people with eating disorders. While access to care and outcomes matter, all those in the field still need to rely on therapy approaches that work.

With that in mind, I think it’s worth revisiting the tried and true ways to treat people with eating disorders lest we forget what types of therapy really help people get well.

Any type of binge eating disorder, including Bulimia Nervosa, Binge Eating Disorder, Compulsive Overeating and Night Eating, responds best to Cognitive Behavioral Therapy (CBT). The first studies that proved how effective CBT is for these disorders were in the 90’s, and nothing developed since is more helpful.

CBT entails writing a detailed log each day of what one eats, whether or not the eating is disordered and, most importantly, the thoughts and feelings around each time one eats.

The log is the centerpiece of the treatment. Assessing the log each session unearths a multitude of critical information about the eating disorder and charts a path to recovery.

First, looking in detail through a day can reveal what thoughts, behaviors and feelings foreshadow a binge. The most likely causes are undereating through the day, emotional triggers or situational triggers. Even though patterns of eating that lead to binges are often similar, each person learns how their individual eating disorder works.

All this new information makes clear the options to circumvent binges. Adding food at certain times of day or acting on feelings in advance are the most common examples of what can change the course of the day. Each step forward empowers the person to see they are not trapped in the binge cycle indefinitely.

Once the eating pattern normalizes, CBT gradually transitions towards the working in new thoughts and feelings around each meal as binging subsides and in everyday life. The therapy can both curtail binging while assessing what someone needs to face other parts of life without returning to the eating disorder. Awareness of thoughts and feelings enables people to learn about themselves and how to cope in new ways.

The path of recovery may seem straightforward from the above summary, but there are always ups and downs in eating disorder recovery. CBT gives a direct route to getting well and makes clear the steps to get there.

All clinicians in the eating disorder field need to remember that CBT works for any binge or overeating disorder and not get distracted by all the new programs. The focus needs to be on helping people get well.