The Food Journal: Five Years Later

I wrote in one of the earliest posts in this blog about the food journal. The reason to revisit this topic is the increasing feedback from the clinical community that the journal is more than a tool and actually a necessity for recovery. Many other clinicians see the journal as a key difference between those in recovery and those who aren't. 

The journal represents a daily external mechanism to see one's daily intake of food and share that with someone focused on helping with recovery. This explanation encompasses the three important aspects of the journal. 

First, the journal is a means to externalize the thoughts of the eating disorder. The act of writing the journal is a daily exercise in separating oneself from the eating disorder thoughts by processing food in a new and different way. Encouraging separation from those thoughts is a critical part of recovery. 

Second, seeing the day's food written out enables each person to see realistically the food intake for that day. Rather than allow the eating disorder thoughts to confuse and cloud that reality, there is no hiding from the words on the page. 

Third, the act of sharing the journal is a daily step of allowing someone else to help. It's a sign each day of committing to recovery and using relationships to move into a place of health and wellness and not become lost in the distorted priorities of the illness. 

The food journal is one of the hardest things for someone in recovery to complete regularly. Writing about food and showing that to someone else is very exposing and activates the shame that is a common stumbling block.

In addition, food is the most intimate of subjects for someone with an eating disorder so sharing that information opens the door to a very intense and close bond, something that feels intimidating when the illness remains so strong. 

It's important to recognize the food journal as a cornerstone of treatment. Writing and sending the journal each day are not just useful steps but instead are clear markers of recovery and need to be a central part of any effective treatment.

Therapy as the Central Focus of Psychiatric Treatment

It is rare that psychiatric research makes the headlines two weeks in a row. The current news discusses the results of a large study on schizophrenia, which, along with anorexia, have the two highest mortality rate of any psychiatric illness. 

The study reports that low dose medications plus regular psychotherapy is more effective than high dose medication alone. 

This is shocking news because psychiatry has hung its hat on medications as the best form of treatment for this illness with hope for more thorough pharmacological cures in the future. The NIMH funded study has clearly proven otherwise. 

Psychiatry has worked hard to find a place in the scientific world by relying on brain science and medications as the best hope for the future. Our limited understanding of the brain may be the reason this supposition is unrealistic. Perhaps it's a matter of time before brain science leads to simple pharmacological cures.

But there is also the possibility that the complexity of our brain doesn't lend itself to quick fixes. So much of our miraculous central nervous system is attuned to interaction with the environment, especially other people. Psychotherapy, a treatment that grew out of, at least in part, the lack of other viable alternatives, may be grounded in something very real and, at its core, scientific.  

In other words, the most potent tool to change brain function may be relationships themselves. 

This new study about schizophrenia and last week's conclusion about eating disorder behaviors as habits have one key similarity. Brain behavioral patterns, once established, are ingrained and difficult to change. Repeatedly research studies have shown that therapy is as effective or more effective than medications for almost all psychiatric illnesses: schizophrenia, eating disorders, depression and anxiety disorders. 

It's a novel idea to approach psychiatric treatment with the expectation that establishing effective, meaningful relationships is at the root of change with medications as an important but secondary tool. Although medication may play a role, relying solely on pharmacology does not have a good track record. 

Heeding the recent news means focusing on the therapy relationship first and foremost as the step into wellness.

Are Eating Disorders Habits?

A new study that received national media coverage uses brain scans to interpret the underlying intention of eating disorder behavior. The researchers' conclusion seems reasonable based on the limited scientific data and on corresponding clinical information: eating disorder symptoms are habit rather than willpower.

The current societal bent towards describing eating patterns as willpower stems from persuasive marketing by the diet and food industry for decades. Rather than understand the complex, innate nature of hunger and fullness, these industries surround us all with irresistible goodies and then perpetually blame us for not resisting them, thereby increasing profit. 

This mistaken understanding bleeds over into the general public's concept of eating disorders with two mistaken ideas: restricting food is about willpower and these people suffering from eating disorder are not sick but have actually mastered the ability to resist hunger.

Nothing is further from the truth. 

Clinicians who treat people with eating disorders will not find anything ground breaking in this study. It is the clever translation of accepted clinical knowledge into a simple research study, namely that the thought and behavior patterns of an eating disorder are habit.

This core knowledge does inform the treatment and recovery from an eating disorder. Simply educating a person about the risks of an eating disorder and explaining the health benefits of normal eating never influence recovery. Neither of these facts can change a habit. 

Two aspects of recovery are necessary to put into place a process that will change ingrained habits. That process is slow and arduous but, with consistent practice, will lead to new habit formation. 

The first step is accountability. Someone else other than the person with the eating disorder needs to be aware of the day-to-day events around food. Habits are by definition largely unconscious behaviors. If there is minimal conscious thought about the habit, the behaviors will not change. Accountability forces the person to pay conscious attention and make an active decision to continue the behaviors or not, thereby addressing the conflict around continuing the habit and recognizing the consequences.  This conscious experience already starts to break the circuit in the brain reinforcing the habitual behavior by inserting debate over whether or not to engage. 

The second component of treatment is behavior replacement. If there is no thought process or new behavior to change the habit, then there is no way anyone can resist doing the same thing every day. In terms of brain science, this means reinforcing a new brain circuit will weaken the old one.

The combination of a conscious decision to choose the habit combined with an alternative behavior that feels within their grasp gives the person with an eating disorder a reasonable chance each day to learn a new habit. 

The media coverage that eating disorders have nothing to do with willpower is important and necessary. This information already informs a large part of successful eating disorder treatment and gives the clinical community an opportunity to educate the public about this growing problem in our society.

Reflection on First Consultations

I wrote in this blog a long time ago about the first step into eating disorder treatment and wanted to review some of the key points.

It typically takes years for people to reach out for help and can often take a few tries before committing to really get well. The result is that first appointments are critical to help someone start the road to health. 

Much has been written about how to engage someone with an eating disorder and for good reason. Experienced clinicians know how difficult it is to transform a consultation into steps towards recovery. 

Unlike most initial consultations, gathering all the facts is not the most critical part of the initial appointment. There will be time to sort through details and understand the facts. This first meeting must emphasize the reason for meeting. After years of illness, what has led to following through with getting help? Namely, what has changed to make this session possible?

It's often a difficult question to answer, but the purpose is to consider what might have begun transforming in that person to want to address a longstanding part of her life.

A marker of success of that first appointment is to help the person have enough perspective on her life to consider herself separate from the eating disorder for a moment and realize that recovery is deeply connected to that separation. 

Looking back at recent posts in this blog, I realize the existential component of recovery begins from the first appointment. Reflection on one's own value and purpose underlies the first session and emphasizes the most difficult part of treatment: finding meaning outside of the eating disorder. 

Stepping into treatment is a courageous act that needs to be matched by direction and courage from the clinician as well.