How Someone with an Eating Disorder Can Feel Seen

So many people with eating disorders don’t feel seen and heard in their lives. Eating disorder symptoms provide relief by numbing, comforting and validating parts of themselves. The end result is that the eating disorder can assuage the emotional pain that results from feeling so invisible.

Although this experience is not universal for people with eating disorders, many people feel terribly alone.

I have written many times how the eating disorder can be a salve against this emotional pain and can be a means to feel companionship and reliability as well.

The path to recovery needs to include meal plans, external factors that matter to the person and a team of clinicians who the person trust and who cares for them. But eating disorder recovery needs something more fundamentally human than that too.

People with eating disorders struggle so much with the balance between a professional and personal relationship in therapy. For people who have felt so unloved, they have a hard time balancing what they actually need with the circumscribed, limited therapy relationship. As real as the connection is, it’s hard not to feel even more heartbreak and loneliness as a reaction to the boundaries imposed by the therapy relationship.

Yet the connection and care of the therapy relationship are critical to any true recovery. To do such incredibly hard work, the person needs to know that they matter to someone.

Granted, it’s easy for the therapist to envision the therapy relationship as a springboard to find that kind of love in a relationship without limitations. That’s easier for the therapist to lean on and potentially more satisfying for the patient too.

But that’s just an easy out. The therapy relationship still is meaningful, very real and ultimately the catalyst that leads the way to get better. The limitations and emotional pain that ensue also need to be addressed since this experience in therapy highlights much of what led to the eating disorder in the first place.

The answer isn’t clear. Even if the boundaries exist, the relationship for someone who has never mattered before is a transformative experience and invaluable. Plus, this is an intensely personal relationship. There is no clear advice that makes it any easier. The goal is to find one’s way, value how much the relationship brings and find gratitude to have found a relationship that makes it possible to live in this new way, one where the eating disorder isn’t dominating everything in life. Moreover, hope for the future can pave the way forward.

Eating Disorder Recovery and the Impossible Magic Cures

Eating disorder treatment involves two central pillars to recovery. The first step is regulating meals with a structured meal plan that can stabilize the digestive system and also calibrate hunger and fullness cues. The second step is to identify emotions and then work on ways to experience, validate and manage those feelings without using the eating disorder.

These two parts of eating disorder treatment don’t, and for the foreseeable future won’t, change.

The complex interplay of the psychological and physiological cues that regulate our eating patterns are largely innate and outside the purview of conscious thought and intent. Eating enough food for survival is an ingrained primal urge we share with all living beings. When we have enough food, the hunger drive is weak enough that we can delude ourselves into thinking we control how we eat. That changes quickly when our bodies are starved.

In the modern world, access to so many foods designed to be addictive combined with the powerful food industry leaves us vulnerable to a system intended to make us associate food with emotion and comfort. The fat phobic culture adds to the lure of food by demonizing being fat and eating “unhealthy” foods, thereby creating a way for children and adolescents to work out their negative feelings through food.

We are pressured to connect food and emotion both through industry and through cultural fat phobia. The result is a high likelihood that people will have disordered thoughts and behaviors around food and, largely based on genetic predisposition or less fortunate circumstances, an eating disorder.

Recovery needs to undo the psychological and behavioral patterns and rewrite the myths about food and weight drilled into people when they’re young. This work is hard and needs repetition but can be successful. People do get better from eating disorders all the time. I have written many posts in this blog that explain the path to get well.

There are also capitalist drives intended to take advantage of people desperate to get help. These industries promise an easy but ultimately unsuccessful fix that only demoralize and even re-traumatize people already suffering with an eating disorder.

Eating disorder treatment programs offer the illusion of a cure but provide a stopgap measure of stability, at best. The services are run primarily by inexperienced clinicians with misleading if not cruel messages that eating disorders are the patient’s fault. In addition, they offer no plan for continued recovery after discharge.

The diet industry benefits from the numerous studies that show that diets don’t work. The business model is that their services never work. People will always come back since the companies know that what they offer is never a cure and often only worsens the eating behaviors. Similarly, GLP-1’s offer a seeming cure for all eating woes. In addition, they are now available to anyone who wants them without medical supervision. There are enough stories online to convince people with eating disorders that these medications will cure them. Despite all the benefits of these new medications, they don’t cure eating disorders.

The path to recovery remains as possible as ever. People do get better. The steps still involve a meal plan, consistent support through a treatment team and resiliency. Many industries know how desperate people are to find a solution to their eating woes, body image thoughts and eating disorders and how susceptible they all are to supposed cures. I advise people to avoid any seemingly miraculous cure. The path towards recovery has not changed.

The Ongoing Need to Eradicate Blame from Eating Disorder Treatment

In recent decades, eating disorder treatment opened up access to care and improved the initial diagnosis by primary care doctors and pediatricians. Awareness has clearly increased, and doctors who see people with an eating disorders have resources for referrals. That’s a great improvement.

What has not changed is the overall mindset and morality about the diagnosis and towards patients, even among health care professionals.

Since the advent of the eating disorder diagnosis in the early 1970’s, clinicians remain perplexed about the cause and persistence of eating disorder behaviors. For people with little familiarity with these illnesses, it’s unthinkable to struggle with restriction, binging or purging, especially after months or years of treatment.

Incredulous as to what motivates people to continue the symptoms, clinicians and laypeople fixate on the myth that people are to blame for their illness. In this line of reasoning, eating disorders expose weakness or a lack of willpower in the individual—still the most used trope in recovery. Any failure to get better is the fault of the patient. Any medical symptom is caused by the eating disorder. The emotional and physical pain wrought by the disorder deserves no compassion and only further blame, insult on top of injury.

Blaming patients for their illness is a convenient way for clinicians to absolve themselves of any responsibility to help people get well. There is no need to think outside the box or consider other possible directions in treatment or to posit new ideas for causes of the illness.

The current business model for treating eating disorders is successful and lucrative. The philosophy is buoyed by a culture used to forging a connection between weight and self-reproach. The population with eating disorders are more likely to opt out of destructive treatment than fight back against an ineffective and often destructive system.

Creative options for care exist, and I have been writing about them in recent months. There is little appetite within the eating disorder field to look outside the current guidelines for treatment and care. Medical diagnoses that may be related to eating disorders don’t get any attention from a psychologically oriented community. The people who don’t get better are labeled chronic without much thought given to improving treatment for them.

In time, I suspect many eating disorders are likely to be seen as medical in nature. Research into the hormonal balance of gastrointestinal and metabolic functioning, a haywire allergy/immune system and misfiring of hunger cues likely will change the landscape of eating disorder treatment.

There will certainly be a psychological component to almost everyone’s eating disorder, but medical knowledge and interventions will help with diagnosis and a higher rate of successful treatment. Blame has no place in eating disorder treatment, and time will prove that to be true. 

Taking a Step Back: the Reality of Eating Disorder Recovery

Reviewing this blog from the past year, I wrote a lot about new avenues in the treatment of eating disorders. The new medications that affect our gastrointestinal system and the confluence of medical syndromes in eating disorder patients that doctors know little about dominated my thoughts.

The purpose of these alternate ideas is to improve treatment success for people with eating disorders. Even with adequate care, too many people still don’t get better. Many do, but the goal is recovery for all.

In that vein, I have started to look elsewhere, not for a new magical cure but for adjunctive treatment options that might increase the success and well being for people seeking help.

However, I do believe I left out the crux of treatment, or at least implied that the hard work is avoidable, if these other therapies are appropriate. The hard work actually remains the centerpiece of any true recovery.

The process of finding a committed, knowledgeable and well-suited treatment team is still paramount.

The struggle to eat one’s meal plan day in day out still is crucial for anyone to get better.

The daily obsessive thinking about body image will still be a very challenging and necessary part of the process of getting well.

And the healing of one’s body as it becomes accustomed to regular nutrition and improved health needs to be a top priority.

No new medication, no alternate diagnosis, no change in metabolism is a magical fix for eating disorder treatment. No matter the initial cause of the eating disorder—be it a general inflammatory syndrome, dysfunction in the gastrointestinal hormonal system, longstanding trauma or any of the myriad causes—recovery takes the same course. A thorough diagnosis and treatment plan may take these other issues into account, but recovery is still a challenging process. There are no shortcuts.

As I enter the new year working to expand treatment options for people with eating disorders, it must be clear that recovery is still a hard, long road. I just want the end of that road to be as successful as possible for everyone.

Accepting the post-GLP World

GLP-1 medications change the entire landscape of how we think about food, weight, our bodies and our health. Even more relevant to this blog, eating disorders are now perceived differently as well.

Any one person’s opinion about the benefits or risks of these medications is conjecture and largely irrelevant, including mine. We are all going through a cultural transformation that extends well beyond health. The tectonic shift in perception about our bodies is more to the point.

Thinness is back in. Any sense of body positivity or a generous understanding of the variability of the human body is out.

The pressure to be thin is stronger than ever, and the cost to do so irrelevant. Since GLP-1’s are available for a few hundred bucks per month, anyone inclined to take them can have them. And if anyone has any personal sense of what is best for one’s health, the current cultural trend demands you take them. What else could be more important?

Also the medical establishment is lying by acting as if we are predominantly taking these drugs to improve our health. Of course, some people do have meaningful health benefits: lowered blood sugar, decreased inflammation, lower alcohol cravings and improved cardiac risk, to name a few.

However, the true customers finding the medications are the healthy people who want to lose weight, pure and simple. That’s where the true profit comes from. That’s what is changing our cultural landscape because GLP-1’s have become the newest addition to medicine-adjacent, “healthy” treatments like Botox, plastic surgery, IV vitamin treatments and now GLP-1’s.

We all need to accept that the collective obsession with thinness landed us here. Experimenting with medications often prescribed by clinicians online who barely know the patent and have little justification to do so except for financial gain is risky business. Our health care system for actual illness has many inherent problems, but the self-care industry is thriving.

People with eating disorders will now include those with little or no treatment who choose instead to take these medications. They may seek help once the medications don’t work well. They may experiment with the drugs to try to manage their eating disorder. They may develop an eating disorder by using the drugs.

No matter how it plays out, GLP-1’s are part of the American zeitgeist and will affect all parts of life and continue to alter how eating disorders exist in our world. The first step is to accept this reality and move forward. I certainly have in ways I incorporate these drugs into my practice, work with people on them and find new ways to help navigate a world dominated by weight loss drugs, for better or for worse.

Shame and Our Bodies in Modern Culture

The shame many people experience about weight and body is a crushing burden. They live their lives with the unwavering belief that their body is unhealthy, unattractive and unlovable. They interact with others always feeling less valuable. These thoughts plague them every minute of every day.

In most posts in this blog, I write about body shame with respect to people with eating disorders. That feeling is central to the hold eating disorders have on a person’s life.

The shame people with eating disorders feel is often shared by others. Women and men, young and old, people of all different sizes experience enormous shame about themselves embodied by their physical being.

Recent posts highlight the fine line between an eating disorder and a body lauded by society. The external validation or vilification doesn’t always affect the internal experience people have about their body. Shame often exists no matter how the world reacts to one’s body.

To be clear, I don’t mean to compare the extreme hatred people with eating disorders can feel about their body with the more common pervasive shame. However, discussing widespread shame makes it easier to explain how common self-hatred is.

Our physical selves represent what we show to the world. Without knowledge of the other person, people can assess, judge, criticize or praise anyone’s body.

Our culture now and for many decades values thinness over almost anything. Thinness represents success and diligence, willpower and determination, financial means and the luxury of time and attention to oneself. Thinness is not the number on the scale or solely a measure of vanity. Thinness represents a moral high ground that can be the means to feel superior to others.

Anyone who perceives their body or their lives to be less than ideal can immerse their sense of failure and loss into body shame. Peers, media of all kinds, family and even doctors reinforce the idealization of thinness. Medications beckon people to inject themselves with the hope of an ideal body. Body shame is an accepted way of being in the world.

The purpose of a social construct built around shame is to keep people in line. Those in charge, supported by success and financial backing, can keep a stronger hold by propagating shame as a way to make money and exploit negative feelings about oneself for personal or corporate gain. Personal well-being does not satisfy the greed of various industries which use our collective self-reproach to induce us to spend money hoping to find a reprieve from the shame.

It’s hard to know where education can make inroads into all of our shame. Medicine has little evidence to support the connection between larger bodies and poor health. In fact, there’s more evidence that smaller bodies lead to more health issues with age. Small changes for body positivity pale in comparison with overvaluing thinness. Food, fashion, diet and exercise industries all benefit enormously from our desire to feel better by losing weight. And the newest availability of weight loss drugs adds a new wrinkle to the desire for thinness.

Perhaps the goal is to find value in ourselves in new ways. We can’t win the thinness argument, but we can agree that love, compassion, kindness and care lead to more happiness than focusing on weight and body. We can look for new ways to find joy in a world bent on profiting from our misery.

People who recover from an eating disorder go on an existential journey to find themselves and meaning in their lives. Creating new ways to cope with emotions and with life’s travails forces anyone in recovery to take a hard look at what matters. People who venture down this path often end up better equipped to handle the cultural shame so many of us endure. Escape from shame entails finding a new and different way to live, one that values things that truly matter in life.

Why are Eating Disorder Diagnoses so Fluid?

Diagnoses in psychiatry change over years and even generations to reflect the role mental illness plays in our culture. Some changes are due to a better understanding of an illness. Other times the diagnoses reflect a new social construct around a mental disorder, changes in the social structure or treatment trends that lead to increases in specific diagnoses.

Eating disorder diagnoses change over time as well. More recent trends include the misdiagnosis of depression or anxiety as an eating disorder or the expansion of the diagnoses to accommodate the larger number of treatment centers seeking to fill their beds. The ease of access of GLP-1 medications leads to more self-diagnosis of “food noise” as a different kind of eating disorder and as a way to justify taking these new drugs.

These are just examples of how diagnosis changes over time and how the concept of eating disorders remains fluid rather than a fixed concept, largely due to changing external circumstances rather than a fundamental change in the illness.

The borderline between an eating disorder and a supposedly healthy person is narrow in our culture. The drive for thinness implies that health, beauty and success are synonymous with a low weight. However, the line between these purportedly positive attributes and an illness is not always easy to define.

Psychiatrists try to define an eating disorder diagnosis based on the number on the scale, a certain amount of disordered behavior or the overall level of disordered thoughts about food and weight. However, many people who seem to fall into the socially admirable category don’t seem all that different from the people who are deemed sick.

Often the difference is context. Does the person have family who assess the situation as an illness or an achievement? What is the opinion of the pediatrician or primary care doctor who does the first assessment? What is the role of that person in their family of origin? The answers to these questions can determine the outcome: either a functional person with disordered thoughts and behaviors or extended stays in eating disorder treatment. The difference is not diagnosis but context. Few mental illnesses rely on external circumstances as the crux of the issue.

With current trends leaning towards extreme thinness again, there is much more acceptance of thinness as the goal rather than a sign of being sick. Because so many people are underweight due to the GLP-1’s, it is harder to differentiate the unwell versus the well. Without other markers for achievement, weight has become the default indicator of wellness again. There is no medical justification that people losing weight are healthier, but all cultural trends overvalue size and health, so anyone losing weight receives accolades across the board.

Eating disorder diagnosis is as much a cultural construct as it is a psychiatric disorder. There are many people who clearly have eating disorders and struggle to get well. The clearest diagnoses involve addictive-like behavior around food, intractable intrusive thoughts, trauma and often primary medical illness like MCAS. However, the number of people who don’t fit these categories but also dilute the severity and understanding about eating disorders is vast.

In trying to be clearer about diagnosis, the term eating disorder ought to reflect the cause of the illness, the severity of the symptoms and the types of experiences more specifically. These changes involve further research into possible underlying causes and incorporating changing trends around food and weight.