A Parent Primer for First-Time Eating Disorder Diagnosis

This time of year is a common one for high school and college students to first be diagnosed with an eating disorder. The stress of the end of the first semester of a new school year can exacerbate already existing tendencies to turn to food for comfort and lead to a true disorder. For college students being on their own for the first time is also a reason for the descent into more severe eating behaviors.

Families now confronted with getting help for their child can be overwhelmed by the maze of treatment and the confounding task of getting adequate help for a sick child.

The first step for any family is to find a trusted clinician knowledgeable about several components of these illnesses. The person must be versed in the diagnosis of an eating disorder, capable of assessing the severity of the symptoms, connected enough to assemble a team and aware of the positives and negatives of all treatment modalities.

Beware of practitioners who solely urge one form of treatment, especially if that option is a hospital or residential treatment program. That choice can frequently be best for someone newly diagnosed, but the proliferation and directed marketing of new programs can influence clinical decisions and cloud clinical judgment.

Programs can lead to quick return of adequate nutrition but also can trigger a quick relapse for two reasons. The first is that programs tacitly promise an immediate cure. Without a treatment team back home, it is easy to turn to the residential program for guidance even after discharge and not find ways to reconnect with the world. Second, patients can wish to relapse to return to the safety provided by living in a caring and nurturing bubble protected from the stress of life. Instead of getting better, it perpetuates the desire to hide away from the difficult obstacles of recovery ahead.

The important step as a family is to assemble a treatment team of experienced clinicians whom the family can trust. Even if that team quickly decides upon residential treatment, the family can focus efforts on recovery in the real world. Any inpatient setting is only a stopover to improve nutritional status and health, not a place for full recovery. The family can also turn to the team for support and ensure the primary support is accessible in daily life and not just the duration of a residential stay.

Last it is important to know full recovery is the goal and very attainable. The myth that no one gets better from an eating disorder is pervasive in our society. Getting the right help for the patient, learning about how to provide family support and coming together as a family all are crucial to help the child get well.

The Ill-Fated Merger of Finance and Eating Disorder Treatment

As more financial investment pours into the eating disorder residential treatment industry, it is a relief to know there are more options for patients who need intensive help. However, clinicians are left with several questions and concerns about the intention and skill of these centers. 

The first pressing question is the effect on the quality of treatment when financial personnel run a sensitive and challenging clinical endeavor. The quick proliferation of treatment centers means hiring and training of less experienced people hastily in order to staff new programs quickly. Clearly, this can affect the quality of treatment.

Second, it’s very possible that the bottom line will lead to sacrifices of the more nuanced and crucial aspects of treatment that distinguish an excellent program from one that checks all the boxes of an adequate one. Focusing on running a business successfully is often at odds with clinical care. 

Third, the expansion of marketing of these programs may very well attempt to convince clinicians to utilize residential programs when other clinical options are preferable. The treatment community has to be reflective enough not to be swayed by shiny new promotional materials. What’s best for the patient must remain paramount. 

It’s concerning that the influx of money and power may very well corrupt a clinical endeavor driven by passion and determination to serve a community of sick people not treated well by the medical establishment. The likelihood is that savvy investors will capitalize on access to funds from a wealthy constituency willing to pay for treatment at the places deemed the best. 

The most insidious result of the newfound changes in the eating disorder residential treatment industry is the increased admission of adolescents to programs. Although some teenagers get very sick, many kids first diagnosed can recover quickly when families initially become aware of the problem. However, these kids are so susceptible to experiences and their egos are still so malleable that immediate long term care as a first line defense may very well set them up for a longer course of illness. I’ll expand on this idea in the next post.

The Truth about Nutrition Labels

Understanding why nutrition labels became ubiquitous has to start with a brief history lesson. One of the reasons urban areas could grow so quickly in the mid-twentieth century was the increased availability of mass produced food. At the time, packaged foods and the concomitant ease of food shopping seemed like a wonder of the modern world.

However, the change in the types of food available to the masses also included diets largely consisting of processed foods, a completely new food group for people to eat. Medical data over time started to show the detrimental effects of manmade foods such as margarine and how the increased salt or sugar intake of processed foods has long term health effects. Regular foods don’t have the same ingredients, ease of digestibility or addictive quality of processed foods, and our bodies react very differently to these foods. 

Once medicine brought to light the risks of processed food, government regulation moved in to try to slow down the exploding food industry. One result was the suggestion of dietary recommendations, the food pyramid (recently replaced by the food plate) and mandatory nutrition labels on packaged foods. Granted, the food industry lobbies have altered the government recommendations, yet there is still a component of the federal guidelines meant to inform and protect the population.

What the government regulators have struggled to incorporate is the drive for thinness and pressure of the diet and, more recently, exercise industries which use nutrition labels to their own advantage. The labels were meant to be guidelines that would help consumers recognize foods made with chemicals or with hidden calories from factory processing. Instead, labels and serving sizes enable people at the mercy of the drive for thinness to justify restricting their food intake and feel compelled to constantly diet.

The other confounding factor has the been the overemphasis of weight in the government regulation of food. The data about weight and health is very limited, yet diet and exercise industry representatives continue to help urge the public to be scared of weight gain even though chronic dieting is an equal if not more insidious aspect of modern life. Chronic dieting is the cornerstone of eating disorders, disordered eating and our collective obsession with weight and food as I explained in detail in a previous post.

The sole purpose of nutrition labels is to recognize foods as more or less processed and help people identify foods that are more real. In today’s world, it’s impossible to avoid some processed food and there is no evidence that eliminating all processed foods is necessary. The goal of a balanced diet is moderation and variety of all things.

However, there is no use in obsessively reading labels to determine how many macronutrients one eats in a day, a normal serving size or for calorie counting. The regulations around nutrition labels allow so much room for error that these data are useless for any individual dietary choices and only serve to confuse the true reason label became a federal regulation in the first place.

The Dangers of Nutrition Labels

It would have been difficult to predict the cultural impact of nutrition labeling on foods. At first, transparency of ingredients and additives seemed like a win for the consumer. As processed foods became a universal part of one’s diet, people needed to know what they were eating. Over time research has shown that many manmade ingredients were not particularly good for one’s health.

However, government regulators could not have foreseen how labels might pervade the daily intake and food decisions of a large majority of the population. Without adequate knowledge of general points of nutrition and of nutritionism (the faulty philosophy of nutrition based on building blocks, i.e, fat or protein, rather than real food), it’s incredibly hard to make sense of the information on the labels.

Even more confusing is that children are often taught about biological macromolecules through food labels, equating this information with scientific facts. Food labels have transformed from corporate transparency into false nutrition and dietary law for much of the population.

Too many people assume calorie facts on food packaging is absolutely true. They don’t realize that the information only needs to be within 25% of the actual value. Also, companies can determine serving sizes based on how best to sell product. There is no regulation to create serving sizes that people would actually eat. And the percentages that labels apply to the daily overall diet only approximate a general idea of human needs. Using this data as a hard and fast rule often only encourages dieting.

The immediate benefits of assessing packaged foods has instead turned into a supposed guidebook for food choices and dietary consumption. People who have grown up with food labels are much more likely to count calories, consider dietary choices based on macromolecules rather than food and assess healthy food choices through food industry-devised data.

The next post will give some guidelines about how to use the nutrition labels effectively.

The Halo Top Curse

In light of the upcoming Thanksgiving holiday, I felt the urge to rant about the most recent egregious exploitation by the food industry: Halo Top ice cream.

From a marketing standpoint, the new, low calorie ice cream is an absolute success. The brand is easy to find everywhere and is the most talked about new ice cream in a long time.

The unfortunate news is that the brand has taken an incredibly cynical approach to our food culture. It markets itself as the easy way to eat an entire pint of ice cream guilt free. It encourages people, especially women, to feel free to eat an excessively large amount of ice cream either as dessert or, better yet, as a meal replacement. It feeds the guilt of a generation of women constantly torn between endless dieting and liberation from our culture of thinness.

Rather than enable a feminist escape from the exploitative pressures of modern culture, this brand attempts to box women into the shame of eating ice cream indulgently while preserving the desire for thinness.

As a last insult, the brand doesn’t divulge the possible side effects of overeating the artificial sweeteners in Halo Top: gastrointestinal distress and diarrhea.

In the eating disorder treatment world, the brand encourages binging, discourages eating meals and real food and condones eating behaviors that reinforce these illnesses.

That we live in a culture which allows marketing of explicitly damaging brands is abhorrent. It is one thing to market cheap food alternatives and another to exploit the psychological and emotional vulnerabilities of our society for a profit.

Does an Eating Disorder Make You Special?

One reason for the rise in eating disorders in recent decades is the fundamental need to be special in modern life. As longterm health improves, lifespan lengthens and basic life essentials are taken for granted, first world populations have much more time and energy to expend elsewhere.

Striving to be exceptional appears to be one of the most common ways people have found a life purpose. Not infrequently, this common desire to be special is diverted to particularly unimportant goals. One such goal is thinness.

For many people with eating disorders, the goal of thinness feels paramount in life. Achieving it often leads to overwhelming praise, increased opportunity and the promise of a greater life. Whether or not this goal promotes obsessive thinking about food, eating disorder symptoms or extended misery is besides the point.

The idea of giving up on thinness as a primary goal feels like failing on many levels. Not only does surrender mean disavowing the collective fallacy that thinness has true meaning in life, but it also allows for the difficult concept that we are all average.

Ultimately, being human implies being one member of the large dominant species on earth. We can find special parts of any person, especially anyone we are close to, but with eight billion people on the planet, not one of us is truly unique. Using weight and thinness as markers of being special looks absurd in light of the larger scope of humanity.

Past the immediate horror of admitting mediocrity is the relief of just being a person. The incredible pressure to be something more than yourself makes each day so much harder. The unnecessary goal of manipulating food in order to weigh a certain amount only limits how fully a person can live.

If living means developing relationships and trying to develop meaningful activities or work, then expending energy on food and weight has no true purpose. None of us are remembered for how we eat or what we weigh.

The drive for thinness is linked to the drive to be special. Rearranging our priorities, even in a world where so much is given to us easily, is a critical step in limiting truly unimportant goals from dominating our experiences.

The Reality of Medications and Eating Disorder Recovery

A conversation I recently had with the editor of an eating disorder content website highlighted a fallacy about medications and treatment. The editor spoke about how hard it is to find an in-depth, definitive article regarding all different types of psychiatric medications and eating disorder treatment. His concern reflected a deep misunderstanding of the role psychopharmacology in recovery.

The research into medications and eating disorders is extremely limited. The only illness researched with any depth is anorexia but with very disappointing results. No medications have shown to be effective for this disorder.

As I wrote in the last post, a few medications have shown some benefit for binge eating disorder, but even those articles have very few subjects and are of limited utility.

Medications are primarily of value when treating other psychiatric illnesses that are primary, in other words independent of the eating disorder, usually depression or anxiety. 

There are individuals who benefit from medications for various eating symptoms, but the overall psychiatric literature does not point to medications as a central part of treatment.

The problem with a supposed definitive article about this aspect of treatment is that it would be inherently misleading. The underlying message would be that medications can have a significant impact on recovery when reality and research prove otherwise.

Medications and Eating Disorder Treatment

The central components of eating disorder treatment are meal planning and therapy, both individual and group. Medications play a peripheral role but can be important in certain circumstances.

Medications are most effective for comorbid psychiatric problems, especially when they are separate from the eating disorder. Treating depression and anxiety alleviates symptoms that typically exacerbates the eating symptoms and allows for more direct focus on recovery.

Seeing a psychiatrist knowledgeable enough to tease apart depression and anxiety secondary to the eating disorder, which typically respond less well to pharmacological intervention, and psychiatric symptoms separate from the eating disorder will help streamline overall progress in recovery.

Medications directed at the eating disorder symptoms have more mixed results.. The research into psychopharmacology for eating disorders is limited but gives a few important results dependent on diagnosis.

Despite the most rigorous research, no medication has proven to be effective for anorexia at this point. Many medications used in psychiatry, and some outside the purview of the field, have been studied to no avail. Even antidepressants tend to have no impact on people with anorexia who are depressed. The overall effect on the brain from starvation appears to trump all other interventions. The essential part of recovery is nutrition.

The most successful effect of medications is for bulimia and binge eating disorder. High dose SSRIs such as Prozac or Zoloft can be very effective for the sickest of these patients who binge at least twice daily almost every day of the week. Medications tend to reduce symptoms by about half after six weeks of treatment. Topamax, an anticonvulsant, also has benefit for people binging frequently but with less robust research results.

For the large number of patients with symptoms not easily categorized in one of the limited eating disorder diagnostic options, there is minimal evidence of benefit of medications. Treating underlying psychiatric problems can be beneficial, and attempting to use medications can have a moderate impact on progress, especially for adjunctive symptoms.

One last benefit of antidepressants is actually via a side effect. Most SSRIs can diminish the intensity of emotional reactions, a side effect called emotional flattening which often leads people to stop taking the drugs. For patients early in recovery who feel often unbearable emotional intensity, this side effect can be beneficial. The decreased intensity temporarily helps people stay on course with the food plan and tolerate the intensity of nourishing their mind. It is an often ignored but very useful pharmacological choice.

Psychiatric medications play a peripheral but often important role in recovery. Seeing a doctor versed in less common aspects of psychiatric care for eating disorders can be helpful to see alternative benefits of medications or to separate primary from secondary psychiatric symptoms related to the eating disorder. When the psychiatrist is integrated as part of a treatment team, the patient will always get the best results.

Residential Treatment Programs or Corporations

There are several posts in this blog about how to choose the level of treatment: hospital, residential program, day program or outpatient team. When residential seems to be the best option, choosing the right program has become increasingly difficult in recent years.

The trend in the residential treatment model in the last five years is concerning and creates a dilemma for families and clinicians. Venture capital companies have bought the most successful residential programs and aggressively expanded their reach in recent years. The increasingly corporate approach to eating disorder treatment combined with the shift in philosophy from clinical care to financial gain has greatly changed the landscape.

I don’t want to ignore the benefits though. There are many more programs accessible to patients and families than there were before. These new companies have tried to expand and replicate the successful treatment models created by the parent companies and founders. The resources for clinicians have multiplied greatly. For instance, the number of outpatient programs in the New York City metro area has multiplied several fold in the last decade.

The problem with the corporate takeover in the eating disorder treatment world is that a plethora of programs doesn’t increase the likelihood of recovery. The most successful programs created an environment of clinicians and programming that helped patients see the path of recovery. From the initial intake coordinator to every staff member of a program, each person had the clear motive of enabling recovery.

Now the staff and leadership of eating disorder programs are charged with building a company and, more importantly, a brand. The focus is to make sure clinicians know the outreach team and the name to increase referrals. Rather than hearing from the clinical staff, I am much more likely to be enticed to a free expensive dinner than to be lured by their clinical competence. Where does recovery fit into the business model?

For patients and families, the key to this decision is to learn about the individuals who run and work at each specific program. Even these financially driven companies hire excellent, caring clinicians. If those carers run an effective program, the clinical care will help people start down the road to recovery. Word of mouth can lead people to the best decisions for their care and hopefully drown out the flashy marketing that has unfortunately clouded those seeking help for their eating disorder.

The Importance of Personal Growth during Eating Disorder Recovery

The last post reviewed the often ignored fact that the path from starting treatment to full recovery is long. Patients, family members and friends want treatment to be successful in a few weeks or a few months. A prospective patient’s mother recently asked if a few weeks would be sufficient for recovery, and it was a shock to have to say not just a few months but several years were necessary to really get well. 

The thought patterns underlying an eating disorder are ingrained around food, a very automatic aspect of our daily lives. The more unconscious thoughts and behaviors are, the harder they are to change. Our minds typically focus conscious attention on less quotidian tasks and leave the typical daily necessities on autopilot mode. Shifting attention to change automatic thoughts and behaviors is not a priority for brain function so the steps in recovery, even if they appear simple to the outsider, require an enormous amount of attention and time. 

However, during the process of transforming the automaticity of the eating disorder behaviors, life doesn’t stand still. I am often hesitant to explain the length of treatment necessary for full recovery because people instantly believe life will remain the same during the entire course of treatment. After years of suffering, it is so hard to imagine getting well that it’s expected that one would believe nothing changes at all until there is a miraculous rush to being cured and recovery is complete.

The truth is that life can and often does change drastically during the course of recovery. Full recovery entails not only normalized eating patterns but complete remission of the disordered thoughts as well. During this period of treatment, life continues to grow and change in positive ways.

Normalizing eating will enable patients to be more present in their lives and more able to excel and grow both professionally and personally. There will be opportunity to deepen friendships and start relationships. Returning to school or furthering one’s career become much more feasible. And growing confidence in oneself opens doors to new ideas and directions in life.

Concurrently, life changes make it seem more important to face the deeper, more insidious components of the illness. As the person sees the myriad ways the eating disorder undermines daily life, the determination to face difficult parts of recovery grows.

Recovery is not a switch from sick to well. It is a gradual process. Most importantly, life continues during this time. If it takes years to get well, life grows and changes during that time. Unlike many illnesses, one doesn’t just get cured. Recovery is a process one needs to live through. And doing so makes it clear why this treatment works.

The Long Road of Eating Disorder Recovery

The standard approach to a medical problem is to see a doctor, get a diagnosis, follow through with treatment and get well. This reasonable approach to care for an illness is commonplace but creates miscommunication and confusion around eating disorder treatment and recovery.

If the symptoms of an eating disorder revolve around disordered eating, then recovery should be simple: eat regular meals and snacks and get well. And if the treatment is difficult, then the person just needs to try harder. People erroneously believe that any stumbling blocks must be the fault of the sick person, not a sign of an intractable illness.

This approach to recovery makes sense to someone with limited knowledge about eating disorders. Eating is a staple of every day of life, no less important than sleeping or breathing. But for someone with an eating disorder, meals are fraught with so much stress and anxiety that it feels more like a prison.

Moreover, eating disorder thoughts and behavioral patterns are largely ingrained and unconscious. Even people who are very focused on food but not ill don’t think that much about how or when or what they eat. This may be a controversial concept, but it’s necessary to talk to someone with an eating disorder to understand what it means to think about food and only food all day long. 

The process of changing such ingrained, automatic thoughts and behaviors takes time. Families want people in recovery to get better quickly. There should be a marked change within months, if not weeks, and recovery should be mostly completed within a few months. Sadly, this is not what recovery looks like for almost everyone in treatment.

The process typically takes several years from two to even 7-10 for full recovery. Since the steps are gradual, there is improvement within a few months, but ups and downs are a necessary part of relearning how to think about, approach and eat food in one’s life.

I often hesitate to tell people how long recovery takes, perhaps not to scare them off at the start of a long road. But there is a point where this knowledge is crucial. Committing to the entire process of recovery means embracing this path to living a full and meaningful life, not losing oneself in the minutiae of food, weight and misery forever.

The Secret Life of an Eating Disorder

People with eating disorders become masters of hiding and secrecy. This behavior doesn't represent a pattern of deceit or a change in character. In fact, most people with eating disorders have a strong conscience that judges every step and action and even every thought harshly. 

Instead the shame and compulsive behaviors lead a person to hide their true feelings and constantly put on a show to the world as if everything is fine. And the majority are remarkably successful at portraying themselves as well while suffering greatly with their illness. 

This split between the private and the public self is a common experience for most people. Everyone knows that there is a difference between how they are at work or out of the house as opposed to their personality at home. But for people with eating disorders, this divide is much greater. 

In order to make up for the shame and humiliation of the eating disorder, people tend to overcompensate in the world. They tend to be people pleasers to an extreme and try to help and support others while projecting an image of someone whose life is completely in order. 

But the effect of this outside persona is to reinforce the internal shame of the reality of struggling so much with the eating disorder symptoms. This dichotomy leads to a feeling of being trapped in the illness. 

The juxtaposition between the outside and the inside creates a deep sense of being a fraud. That reality reinforces the need to hide and protect a secret life the eating disorder needs to flourish. The more a person can successfully inhabit these two worlds, the more entrenched an eating disorder becomes. 

Accordingly, successful treatment must open up these secrets as completely as possible. Digging into that private world uncovers the shame and also helps separate the sense of being a fraud from the illness itself. When someone has help and support to uncover the divide between the private and public worlds, the power of the eating disorder diminishes significantly. One immediate goal of treatment is to take away the secrecy and privacy of the illness. Without that power, the path towards recovery opens up.

Finding Hope in the Hardest Moments of Eating Disorder Treatment

Helping people with eating disorders who are also severely hopeless and suicidal doesn't mean just sending them to a hospital. It is important to recognize how serious the suicidal thoughts are while simultaneously seeing that developing trust in treatment is the only way to make progress. 

Many patients with eating disorders are scared to bring up suicidal thoughts to their treatment team. Not infrequently, the team responds by immediately recommending hospitalization or even calling 911. As much as I respect the need to focus on patient safety, everyone is different. Often, overreacting sends a message to the patient not to reveal their deepest and most painful thoughts and feelings. As I have written many times in this blog, secrecy strengthens the eating disorder. 

If the patient is imminently planning on committing suicide, then it is important to consider all options. But if the person has thoughts without any immediate intent, the next step is to try to talk more openly about these thoughts. The hopelessness and suicidal thoughts are almost always a window into the most powerful parts of the eating disorder, and exploring these thoughts can be an important step towards recovery. 

The circular reasoning of an eating disorder leaves patients trapped. It feels impossible to change eating patterns, challenge the thoughts and live a fuller life. The eating disorder thought process is intent on blocking all avenues of escape. After years of being trapped in this maze, it is common for patients to think that ending their life may be the only way out. 

Revealing that level of desperation can be a sign to a clinician that perhaps there is an opening for change. It is important to engage both practically and emotionally with this hopelessness and challenge the false beliefs of the eating disorder. It's hard to face that fear of change, but it is also possible to summon the courage to live life differently and alter deeply ingrained patterns. 

Sharing the intensity of hopelessness is often a sign of impending movement in recovery. Safety is clearly a priority but so is respecting the openness and trust in treatment along with acknowledging that clear, consistent support makes even he most challenging steps possible.

Eating Disorders and Suicidal Thoughts

Eating disorders are relentless mental illnesses. The struggle and suffering that stem from both the physical starvation and the mental torture are exhausting. People who have not had much treatment and don't know what the recovery process looks like can become very hopeless. The severity of the despair can sometimes lead to suicidal thoughts and even suicide. 

Three components of eating disorders increase the risk of hopelessness and suicidal thoughts for people with eating disorders. 

The first risk factor is secrecy. The eating disorder thought process involves a constant need for secrecy. Only in private can someone fully engage in the eating disorder. This urge often leads to lying and hiding in order to create time and space for the illness and the behaviors. Since most people with eating disorders are straightforward and direct, the secrecy creates a sense of hopelessness and despair based on behaviors anathema to their true selves. The idea that the illness leads them to behavior so out of character opens the door to feeling hopeless that life can ever change or be different. 

A deep sense of shame, something I have explored many times in his blog, creates a thought process of feeling intensely negative thoughts about oneself. Years of reinforcing behaviors and thoughts can create a hopeless feeling of being trapped in this shame with no way out. Shame is often a feeling that inundates all other feelings about oneself. Buried in shame, someone with an eating disorder typically feels very hopeless. 

Most people will seek treatment at some point, but the kind of therapy they receive makes a difference as to whether this cycle of hopelessness continues unhindered or comes into question. Seeing a clinician with a profound knowledge of eating disorder thoughts quickly makes a sufferer imagine that the secrecy, shame and hopelessness may very well be unfounded. It makes the idea and process of recovery realistic. On the other hand, a session with a less experienced clinician can only confirm these fears thereby strengthening the hopelessness and suicidal thoughts. 

Suicidality is a common and very serious component of chronic eating disorders. It is the absolute responsibility of the treatment community to provide solace and guidance to find a way out of this desperation towards treatment and recovery.

When to Choose Residential Treatment

One difficult decision in eating disorder treatment is whether or not to go to residential treatment. The factors around patient safety, the course of recovery and the anxiety of the clinician all make the process tricky. 

The number one reason for someone to go into treatment is patient safety. If an eating disorder has led to medical instability, organ damage or significant functional impairment, then the recommendation for inpatient treatment is clearcut. More often than not, any treatment team can come to this conclusion fairly easily. 

Many situations do not present such clear alternatives. When a patient has been in treatment for a period of time without making much progress, the choice of a higher level of care, clinical jargon to mean day treatment or residential treatment, becomes an option on the table. Frequently, the suggestion for more care comes from frustration of the treatment team around the lack of progress rather than a clear indication or need for residential treatment. The idea is that more treatment will kickstart the recovery process and lead to more rapid improvement. However, there is little evidence that this clinical step is successful. 

Another reason clinicians recommend inpatient treatment is the discomfort of the team with the level of a patient's symptom use. Even if that person is functioning and is medically stable, many clinicians struggle with the anxiety of seeing a chronically ill patient. Recommending residential treatment may be a salve to the concern of the clinician, but the key question is whether or not it is beneficial to the patient. 

Instead there are a few questions that would behoove a clinician or team before suggesting inpatient treatment. First, if the patient is at significant medical risk or is minimally functioning, then residential treatment is an option. If someone has not had good experiences with inpatient treatment before, then it is crucial to have specific reasons to consider this option and why it would be different. All clinicians and teams must assess their own fears and anxieties before suggesting inpatient treatment. Last, a team must have clear and reasonable goals for this step in recovery. Unrealistic expectations or even imagining a panacea that sets up the patient for failure are ways to absolve oneself of responsibility, not a benefit to the patient. 

Inpatient treatment is an option for the process of recovery. It must be considered carefully and clearly. The expense in time and energy is significant. This step should never be considered without clear and reasonable intention and assumption of the gravity of the decision.

Facing Eating Disorder Delusions, Part II

Internalizing the idea that the eating disorder creates a false world of beliefs is a significant step in recovery. But delusions, by definition, feel like reality to the person who has them, so questioning that reality is a monumental step forward. 

By and large, people with eating disorder delusions live in a world founded on these beliefs. If these thoughts come under question, one's entire belief system and even the structure of daily life has to be reevaluated. 

It is rare that adults are forced to reassess the way they live their lives. Catastrophic events can force adults to do so, like war or natural disaster or financial ruin. Social changes such as divorce or the loss of a loved one can also make adults rethink their lives. But most adults live in a world of set values and mores. They don't need to question the fundamental rules of the world they live in. 

There comes a point in recovery when people are capable of identifying and questioning the delusions of their eating disorder. They may not always want to question them because it is painful to recognize the lies that have governed their lives; however, they also know that living according to these lies is too destructive to continue. 

For them, facing the delusions is akin to completely reassessing their world and the foundational beliefs of their lives.  This is often the most important step in treatment. It enables people to see a life that is fully recovered and much more full.

As scary as this new world looks, reminding the person that disavowing these long held, false beliefs will create a truer and complete life will enable the person to take large steps in recovery. Above all, emotional support and compassion are the key to facing the delusions and entering a new world.

Eating Disorder/Healthy Self Dialogues

There are many ways to approach the delusional thoughts but only one appears to be consistently effective. In order to use this method, the person already needs to understand that the eating disorder thoughts are delusional and also at least acknowledge that more logical thoughts exist and would encourage recovery. With that foundation, treatment can move forward. 

The core piece of this step in therapy is to create an internal dialogue between the eating disorder thoughts and the healthy thoughts. The ed thoughts have usually felt completely true and also secret for a long time. Exposing them can be emotionally challenging and even scary to admit openly. The healthy thoughts often feel forced and unsure. It takes time for these thoughts to start to seem true and supplant the eating disorder thoughts. 

It is also important that both sets of thoughts come from the person struggling with the eating disorder. It's counterproductive for the healthy thoughts to come from someone else. The purpose of the exercise is to practice and express the healthy thoughts and learn to associate oneself with a new way of thinking. 

An example of the dialogue can start with the idea that one shouldn't have lunch. 

Ed: You don't need lunch today. You're not hungry. 

HS: Food is a part of recovery. Hunger is not the issue. Eating to live is the issue. Following the meal plan is crucial to get well. 

Ed: You're already fat. You don't need food. 

HS: Without food you just end up getting sicker and unable to live your life. 

Ed: But you want to be skinny. That's most important. 

HS: You've done that before. Then you end up in treatment and unable to make friends or do anything. Life is much more than starving. 

Typically the dialogue leads to the conclusion that the eating disorder thoughts only want the person to live for the illness itself. There is no purpose beyond that and it leaves no meaningful life in its wake. 

Although this is a hard part of recovery, it is crucial to help combat longstanding delusional beliefs. Making these changes and doing the consistent work is a big part of the reason people can fully recover.

Facing Eating Disorder Delusions, Part I

Typically delusional thoughts are fixed beliefs about the world that someone is convinced are true but that are clearly false. More often than not, these beliefs are so prominent and so all consuming that they significantly disrupt the person's life and relationships. 

Sometimes the delusions can be circumscribed, for instance focused solely on one person or one event happening in the world. In these circumstances, the delusions only come to light when the specific target is discussed. 

Delusions in an eating disorder are both circumscribed and also internal. The fake beliefs about food and weight only pertain to that person and not others. In addition, the thoughts are shrouded in secrecy and rarely come to light. Unlike almost all other delusions, they only are revealed when questions probe enough to elicit the beliefs. 

Yet these delusions are so powerful that they affect most decisions every single day and profoundly limit how someone lives their life. 

Eating disorder delusions come in two similar patterns. First they can revolve around severe limitations of foods that one can eat or the amount one is allowed to eat. Breaking these laws around food actually feels like doing something absolutely horrific, something illegal that deserves punishment.

The delusions can also revolve around a belief that the person either has never been sick with an eating disorder or has never been very sick despite clear evidence that proves otherwise. Some people with clear organ damage or even at risk of dying still believe they are well. 

It's important to recognize that these are thoughts someone with an eating disorder absolutely believes are true. They are not just passing thoughts. This is often what makes understanding these illnesses so hard. 

Questioning delusions is very difficult. Directly confronting them typically fails immediately and brings any trust in a relationship into question. The way to challenge these fixed thoughts is to essentially build a case against them.

By amassing evidence that shows how these delusions are false, one can begin to bring to light the lack of data to prove these thoughts are true. Even with overwhelming evidence, it can continue to be hard to escape a delusion. It often takes months of questioning the thoughts to weaken them in time.

Gradually, the most important step is to help the person herself begin to question the delusions directly. I'll discuss that more in the next post.

Delusional Eating Disorder Thoughts

The large majority of people with eating disorders seem fairly well and functional on the surface. Although the physical and psychological effects of the illness are rampant, most people can engage in conversation, hold down a job or go to school and maintain stable enough connections in the world. 

The juxtaposition of someone who appears well but actually suffers from a serious disease is confusing for many people. It contributes to the difficulty many have with believing an eating disorder is a life threatening illness. 

To those unaware of the nature of eating disorders, recovery could easily just mean starting to eat normally, as if the symptoms are a choice. That's the primary misunderstanding which explains why it's so hard for laypeople to comprehend the nature of these illnesses. If getting well were a choice, eating disorders wouldn't exist in the first place. 

What lies underneath the seemingly normal facade is a thought process that drives the eating disorder. These thoughts make it a powerful and destructive illness. Distinguishing between clearly delusional eating disorder thoughts and healthy thoughts is extremely confusing for people in recovery. The process of recovery is largely about learning to identify and ignore the eating disorder thoughts. However, disregarding thoughts that have structured daily life for years takes time. 

For the purpose of this blog, I will call these thoughts delusional. Clinically, a delusion is a fixed false belief. In the case of eating disorders, a common delusion is, for example, "I can't be thin enough" or "this crash diet will finally stop the binging" or "I'm really fine even though I feel weak and dizzy" or "I'll just use laxatives one more time." 

The next few posts will explain in more detail what the delusional component of an eating disorder entails and the process of learning how to ignore them and move ahead in recovery.