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.