Eating Disorder Recovery during the Holiday Season

The holiday season can be very hard for people in recovery from an eating disorder. They feel pressured to appear more well than they are and to put on a veneer or comfort and calm when the holiday meals elicit anything but that feeling.

Recovery and progress cannot move forward any faster because of a holiday, and the most important decision in anticipation of these days is to stay grounded in what works in recovery.

Practically, the person in recovery needs to follow their meal plan and expectations of the treatment team as a top priority. Often, this plan will mean eating at times others don’t eat or types of food other people may not be eating.

It’s also critical for people to explain to families that the plan for recovery is more important than any family tradition. The goal is not to make this specific holiday better but to pave the way for real recovery in the future.

Moments of seeming normalcy that only hide the severity of the illness perpetuate the lie that things are getting better. Transparency, even if it reveals the difficulties of recovery, is much more honest and promotes progress towards wellness.

Families can focus primarily on compassion and support. The holidays shine a spotlight on togetherness and food, both things people in recovery struggle with. The food is clearly difficult and the time together makes it much harder to hide the eating disorder. This feels very exposing for people fighting to get well. When families show love and support, the environment encourages openness and decreases the urge to hide.

Last, I encourage families to try to celebrate the gains in recovery and recognize how hard the process is. The changes someone makes in a year time might seem small, yet the work and progress lay the groundwork for more and more health and for breadth in one’s life.

The Veneer of Success Hides the Suffering of an Eating Disorder

Many people with eating disorders appear to live relatively normal lives. To the uneducated or ill-informed observer, the limitations of the eating disorder don’t diminish someone’s life considerably.

Except for the most ill, people with eating disorders can maintain careers, relationships, friendships and family. Part of what can be so confusing to many is that the only issue between health and illness is simply eating food regularly through the day.

Although eating appears to be straightforward, nothing is harder for someone with an eating disorder.

The experience of those who are sick is diametrically opposed to how the bystander views the illness. The sick feel as if their entire life has been hijacked. They are able to cobble together a life out of sheer force while constantly battling thoughts and behaviors around food which dominate their internal world. They live in a constant state of self-loathing, rumination about food and misery. Any accomplishments pale in comparison to the suffering.

The behavioral and medical components of the eating disorder are just ramifications of the powerful psychological and emotional toll of the illness.

All the success does not represent the true difficulty of surviving with a chronic eating disorder. In fact, people often feel as if they lose any sense of who they are and instead function as a puppet controlled by the eating disorder thoughts.

Compassion for someone with an eating disorder begins with understanding how powerful the eating disorder is and how hard it is to function with it every day. The more someone understands the daily struggle with the illness, the stronger they feel to fight against the thoughts and behaviors.

In addition, support involves helping someone remember who they are deep down beneath the eating disorder. Since they often lose connection with their true selves, any real relationship in the world helps them remember that there is a real person underneath the illness.

Concrete accomplishments don’t represent steps towards recovery. Escaping the relentless thoughts of an eating disorder entails daily, grueling work, and any help connecting with the deep, meaningful relationships in recovery helps a person keep fighting to get well every day.

The Truth about Full Recovery from an Eating Disorder

The notion of full recovery from an eating disorder remains controversial in the media and lay world. Eating disorders may be very specific diagnostic entities to clinicians; however, the terms are used more broadly by the public. Similarly, many if not most people see eating disorders as a way of life rather than an illness with an actual cure.

Two phenomena lead to this fallacy: clear evidence of people with chronic eating disorders and the cultural acceptance of food and weight obsession. These two realities help propagate the myth that no one can get better from an eating disorder.

The truth is that some people have chronic eating disorders they need to manage throughout their lives. Sometimes the eating disorder is disabling and extremely limiting and in other circumstances people can manage larger lives while also dealing with a chronic illness.

A significant percentage of people do fully recover, including people with all different kinds of eating disorders. These people tend to have certain similar experiences that increase the likelihood of recovery.

First, people have a higher chance of getting better the earlier they enter into effective treatment. The longer someone is ill, the more ingrained the eating disorder thoughts and patterns become. This is especially the case when the eating disorder persists in early years of adulthood and becomes a key component of adjusting to life in the world.

Second, the more fulfilling a person’s life is despite the eating disorder, the higher the success of treatment. People need to have things that matter more than the eating disorder. This enables them to deal with the persistent discomfort of eating normally because there is something else to eat for.

Third, people need to be able to believe the thoughts that counter the most basic argument of the eating disorder. These thoughts include fear of gaining weight, the need for regular nutrition and that there are other ways to handle stress and emotion. When the eating disorder is the sole way someone handles life, recovery looks much more daunting.

Last, the more support someone has in life enables recovery to proceed more smoothly. Support isn’t absolutely necessary but makes a difference so the person feels less alone.

Completely recovery is a very common end result of treatment. An eating disorder is not a life sentence despite the general belief otherwise. Getting treatment early and fully committing to the work of getting better really can pay off.

Societal Risks of Bariatric Surgery, Part II

Fat has become the evil we avoid at all costs. In our collective world of fantasy, one of only good fortune, endless riches, eternally youth, fat is the source of the evil we avoid. The dream is that remaining thin and perfecting our diet and exercise plan will allow us to revel in what was once unattainable: immortality.

Society has tacitly agreed that fat is culprit of all our woes. Accordingly, we must avoid eating fat (except fats deemed healthy) and we all just avoid fat people. As bias against race, gender and religion decreases on all fronts, bias against fat people is on the rise. They are seen as lazy, ignorant and lacking in all willpower. They represent everything distasteful in the world and must be avoided at all costs. They deserve what they have brought upon themselves.

The diet industry rests largely upon the theory of self-advocacy. With any specific diet, a person will successfully lose weight for good and transform their lives. The data proves that 98% of diets fail, so why would any new diet be more successful than the last? Since diets work by supposedly empowering people, those who fail are to blame. Certainly the diet can not be the failure.

The exercise industry is the same way. New exercise plans promise a life transformation including weight loss, new confidence and personal transformation. Lack of success is always a personal failure. The exercise program cannot be held accountable for false promises.

The medical establishment reinforces the concept of fat as the source of all illness. As doctors arrogantly explain the dubious relationship between weight and health, they offer no solutions mostly because there are no reasonable solutions to be found. Diets don’t work. Weight loss medications won’t work. Doctors easily shirk off any responsibility by blaming the patient.

Inevitably, the demoralized patient believes they are to blame for their weight and that their weight will shorten their lives considerably. The only path left is Bariatric surgery. Medicine pushes these patients towards surgery, and the centers have become large money makers for hospitals struggling to survive financially.

Perhaps Bariatric surgery is barbaric. It’s a last ditch effort to transform a person’s body and life by cutting away most of their stomach and decreasing their physical ability to eat food. The result is forced prolonged starvation: anatomical anorexia. The only way to lose weight is to create an eating disorder by any means.

If thinness is the only key to success in this world and the promises mentioned above, is it any wonder droves of people have signed up for surgery?

Watching people gradually find a way to eat again around the surgery, I have wondered what the long term results will show. I see so many patients eventually eat more regularly or overeat again after their bodies adjust to the surgery.

And how will we reassess the long term effects on so many people undergoing this procedure as they age? Surgery isn’t a permanent solution but only delays our inevitable need to face the judgment and bias around weight. It is a scary view of what the fantasy of thinness has wrought in our world.

Societal Risks of Bariatric Surgery, Part I

The medical establishment posits that Bariatric surgery is the newest and most effective way to combat issues with weight in our society. As previously explained in this blog, our bodies have adapted to the environment created by the food industry, namely processed foods meant to appeal to our most powerful tastes and that also wreak havoc on our metabolism. Rather than face the public health crisis caused by the food industry, surgery, which is now covered by insurance, is the solution of the moment.

The increase in average weight in the country is linked to worsening health. However, this link is questioned by many authorities. Movements like Health at Every Size present substantial evidence that proves otherwise. The power of the food industry has convinced society and doctors that people are to be blamed for their weight which causes poor health and that these people need help to fix their weight problem. There are medications meant to counteract this scourge which have limited benefit, but surgery is the increasingly common recommendation as a quick fix.

Bariatric surgery is essentially anatomical anorexia. Gastric sleeve surgery, the newest iteration, surgically separates 80-90% of one’s stomach leaving a very small, crescent shaped stomach. The result is the physical inability to manage no more than a few bites at every meal, at least for the first 6-12 months after surgery. The Bariatric surgical centers focus solely on weight loss. Their success is measured by the number of patients who lose a certain percentage of body weight over the first year or two. Long-term results, let alone overall health, are secondary.

But surgery essentially leads to drastic food restriction over a long period of time. By any other definition, this looks like anorexia. Any starvation, however it is imposed, can lead to very strong hunger that triggers overeating or binging. Also, restriction over a period of time leads to malnutrition no matter the weight of the person. The surgical programs don’t consider overall nutrition or the health consequences of such prolonged limited eating. Instead, they focus on improved blood sugar and blood pressure, metrics that increase insurance coverage. What benefit is there to swap one set of medical issues for another?

Based on how easy it is to sway medical opinion—the continued manipulation by the pharmaceutical industry is the clearest example, it’s not surprising that other more powerful forces have convinced medicine to take this approach to treat larger patients. But how is it that thousands of fat people blame themselves so much that they endure risky surgery time and again? Why is it that no one is questioning this barbaric practice? I’ll address this in the next post.

The Fallacy of Willpower in Eating Disorders

Clinicians regular conflate eating disorder recovery and willpower. For people with anorexia, they say that willpower is the essential ingredient to be able to follow a meal plan. For bulimia, therapists describe willpower as the main way to avoid binges. For binge eating disorder or compulsive overeating, willpower is the only way to stop eating.

All research into treatment shows that this therapeutic approach is ineffective, yet the theory is pervasive in the clinical community, to the detriment of all those seeking help.

The focus on willpower as a part of eating disorder recovery, despite its clear ineffectiveness, is due to three issues.

First, therapists struggle to manage the helplessness and powerlessness they often feel when treating people with eating disorders. Therapy may include insightful sessions, a clear understanding of the cause of the eating disorder and a definite plan moving forward. Even still, the person may make no or marginal progress. Without any clear culprit, the therapist can easily blame willpower—the patient—for the failure to move forward, absolve themselves of responsibility and avoid more frustration.

Second, the concept of willpower camouflages a therapist’s lack of knowledge or experience treating people with eating disorders. Willpower reflects an aspect of therapy called motivational interviewing first adapted for people with substance abuse issues. Although there is some benefit utilizing this treatment approach for eating disorders, the therapy does not take into account the greatest difference between the two: food. However, it’s a convenient way to explain why someone is not progressing in treatment and instead blame the patient for her illness. It behooves patient and therapist to get a second opinion or try a different course when a clinician is unclear how to proceed rather than attribute a stall in progress to a largely irrelevant treatment modality.

Third, the therapist is unwittingly reinforcing the eating disorder mindset when focusing on willpower. Since this approach is wholly ineffective, it only makes the patients feel more inadequate and more helpless. Rather than trying to find a new way the circumvent the illness, the therapist expresses frustration in the most facile way: leading the patient back to the helpless state of the illness.

When a patient encounters a team focusing on willpower as a core part of treatment, the patient ought to both confront the team about this approach and, more importantly, seek new help. Using willpower as a fulcrum to leverage recovery inevitably fails and only reinforces the illness. Better treatment exists elsewhere.

Eating Disorders vs. the Collective Focus on Weight and Food

The cultural views of weight and being fat factor heavily in the clinical approach to treating people with eating disorders. Those with anorexia are often lauded for their weight even when the illness severely limits their lives. Fat people are shamed so much they develop body distortions or eating disorders through endless dieting and even Bariatric surgery. Bulimia is sometimes seen as a necessary evil to manage weight. 

The lens through which many people understand eating disorders is itself distorted by the vilification of fat and glorification of thinness. 

In order to make more sense of eating disorders, the distinction between what these illnesses are and the societal distortions about body size and shape is critical. 

Eating disorders are characterized by abnormal eating behaviors: chronic starvation, binging, purging, excessive exercise, laxative abuse. However, the true nature of an eating disorder is psychological. Obsessive thoughts about weight, food and self-loathing dominate the minds of people with eating disorders. These thoughts make it almost impossible to live a full life. Even those who objectively seem to be living talk in secret of how much mental energy they use for the eating disorder. Their lives are not theirs to live. 

Society’s views about weight reinforce much of these eating disorder thoughts. The endless praise for thinness, pervasiveness of dieting and marketing for diets and exercise all confirm that the underlying basis for the eating disorder appears to be valid. It seems as if everyone is focused on weight and food. 

When people hear about or discuss eating disorders, the difference between our collective focus on food and weight doesn’t seem much different from an eating disorder on the surface. 

People without eating disorders may engage in these thoughts and behaviors, but their lives go on. They can let go of these thoughts, stop a diet or exercising and think nothing of it. Someone with an eating disorder cannot make these changes without the illness consuming their lives. 

Changing the obsession with food and weight is not a short-term solution because the obsession is too ingrained in our national ethos. It’s critical to recognize that eating disorders are true illnesses, many levels more severe and all-consuming than simply altering one’s daily diet. Comparing eating disorders and the general focus on food and weight completely misunderstands how severe and destructive eating disorders really are.

Present and Future of Eating Disorder Treatment

Eating disorders have complex and multifactorial causes. With our still limited knowledge of brain function, genetics, environment, behaviors and brain pathways all are part of what leads to an eating disorder. Dieting and food restriction may be the number one risk factor, but the still basic understanding of our brains leaves medicine with only a cursory sense of why and how a diet causes anorexia in one person, bulimia in another and only a few days of hunger in a third.

Since there is no standard approach to treating any eating disorder, clinicians or researchers tend to recommend treatment based on their own personal bent rather than overall knowledge about these illnesses. Some treatment is primarily pharmacological, some psychoanalytic and others behavioral or relational. The fact that clinicians have so many approaches reflects the difficulty finding adequate and successful treatment.

Some approaches seem to have benefit: high doses of Prozac for severe Bulimia or binge eating, cognitive behavioral therapy for bulimia, family based therapy for some adolescents with anorexia. However, there are no treatments known to work broadly based on repeated research studies.

These facts can be demoralizing for patients, especially those who don’t get better quickly after the first series of treatment. As they emerge from the initial shock and preliminary steps into treatment, families and patients can get bogged down in the difficulty finding the best treatment pathway, assessing the hodgepodge of residential treatment programs and combing through the informal training process for clinicians who treat eating disorders.

There is some research on the horizon that is promising. One direction is starting to delineate the hormones that modulate hunger, fullness and the gastrointestinal system. It is interesting and useful but not yet enough to lead to effective medications on the market. Perhaps these medications can open doors to at least moderating the strength of some eating disorder symptoms and improving outcomes.

In addition research into the experience of appetite and fullness in the brain is also present in academic circles, yet these neural pathways are complex and just starting to be understood.

For now, the most effective treatment aims to circumvent and weaken behavioral pathways for all eating disorders. By figuring out how to help people identify the repetitive eating disorder thoughts and behaviors and change them accordingly may be an involved and long process, but it’s one that works long-term and is effective. This therapy does the work medications may help do more quickly in the future.

The truth is that effective treatment is out there for everyone. It may be hard to find or take a long time, but it is important to keep trying and know that recovery is possible.

Why is it so Hard to Find Competent Treatment for Eating Disorders

It is notoriously difficult for people with eating disorders or for their families to find competent help in the mental health field. Despite the increasing incidence of eating disorders, the most frequent complaint I hear is how difficult it is to navigate the eating disorder treatment world.

People frequently say they have seen treatment providers who purport they know how to treat eating disorders and then turn out to have minimal experience. Over and over again, they report the ignorant things professionals have said about eating disorders. This frustration often leads to giving up and a sense that there is no real help to be found.

Even when I cannot see someone, I will try to provide connections to the eating disorder treatment world in New York. Similarly, people contact me from all over the country, and even in other countries, with the same complaint seeking any kind of guidance.

It’s confusing how a set of disorders so prevalent have such limited infrastructure in the mental health community.

There are a number of reasons for this discrepancy. First, the training programs to teach clinicians how to treat people with eating disorders are very limited and completely unregulated. The programs vary from analytic programs, short-term certificates and informal training at residential programs. All these training areas focus on their own way of treating eating disorders but don’t coordinate to teach an overview of treatment and basic knowledge about these illnesses.

Accordingly, there is no formal accreditation for clinicians to attain and advertise. Instead, any experience helping with eating disorders will do, and clinicians can say they have experience treating people with eating disorders even if that’s not true.

Similarly, most academic medical centers have limited treatment and knowledge of eating disorders as well. Instead, the mainstay of treatment is residential centers which are for profit private companies and have no motive to consider treatment and wellness as their ultimate goal. Although these programs can be beneficial, they don’t help codify a basic knowledge for clinicians in the community and don’t encourage research into best practices.

Three more social components of eating disorders make them very different from other illnesses in psychiatry. First, eating disorders are relatively new and there is a short track record for understanding and treating them. Second, treatment is difficult and frequently long-lasting, something anathema to the current mental health world. Third, these illnesses have a central medical component typically not part of psychiatric treatment. These three differences appear to have made it less desirable for the medical community to prioritize treatment for these illnesses.

The lack of formal training for and complex social aspects of eating disorders have created a void in competent eating disorder treatment. The real question is how to recognize this public health crisis (outlined in the last post) and begin to change the treatment landscape to make good treatment easier to find.

The Number One Risk Factor for an Eating Disorder: Dieting

The precipitating factor for every eating disorder is a diet. It’s not a coincidence that the number of eating disorders in this country skyrocketed when dieting became a nationwide fad in the late 1960’s and early 1970’s. As dieting continues to be regular practice for people in so many communities, eating disorders have become a larger public health problem.

Dieting over an extended period of time triggers a powerful genetic mechanism in all of us to survive famine. The human species has persevered in part because of our biological ability to adapt to limited availability of food for extended periods and utilize times of abundance wisely. 

Dieting mimics famine for our biological constitution. Thus, what we now describe as a disorder actually reflects a built-in adaptation to the lack of food. For some, prolonged dieting will trigger anorexia: the ability to survive on extremely small amounts of food and simultaneously shift all conscious awareness towards searching for and hoarding food. For others, dieting triggers a version of binging, hoarding food by eating long past the feeling of fullness and storing extra energy in our bodies. And many people diet for a few days or a week and just give up. 

The main difference between eating disorders and famine is that these adaptive measures are triggered by conscious decisions to diet rather than external environmental factors. Nonetheless, the behavioral and psychological symptoms are the activation of programmed survival mechanisms currently triggered by maladaptive means.

The lack of this basic knowledge about eating disorders frequently leads family members, friends and clinicians to blame people for their eating disorders. Rather than understand the medical explanation of an eating disorder, people become frustrated with such irrational, nonsensical behavior and simply implore the person to eat a hamburger or drink a milkshake.

Instead, recovery needs to involve an extended period of normal eating that will reassure one’s body and mind that regular nutrition is on the way: the famine is over. Once that period of eating lasts long enough, the psychological component of the eating disorder will diminish over time, with consistent psychological and emotional support.

However, it’s critical people don’t forget the only clear risk factor for developing an eating disorder: dieting.

The First Attempt to Treat Anorexia

The first appointment for someone with essentially untreated Anorexia Nervosa is a complex and intricate moment. These people are usually young, very trapped and hopeless. They frequently have met clinicians who have weighed them, threatened them, explained the dire consequences of the illness. Ultimately, these clinicians relent after facing the stubborn will of anorexia.

The longer this battle continues between a relatively new case of anorexia and ineffective professional help, the more hardened anorexia becomes and the more unwilling the patient is to be open to any help.

In addition, anorexia completely isolated this person from their lives. Although they can seemingly go to school, have friends and interact with the world, their entire mind is co-opted by obsessive thoughts about food and weight. There is no escape and the illness feels like a permanent prison.

The goal of that first meeting with someone with untreated anorexia is to try to help them feel understood and cared for. The endless string of ineffective attempts to care for them have already backfired. No one seems to understand. Everyone ultimately is the enemy and it feels like life is slipping away from them.

People who feel this way won’t benefit from an attack or a threat. They won’t respond well to a poorly conceived message that stems from fear or frustration.

They are looking somehow and someway for care and understanding, for attention and compassion, for comfort and love.

A clinician needs to understand that there are no magic answers in that first appointment. There is nothing one can say that will immediately break down this wall. That’s not the goal. The only hope is to start to find some way to show a modicum of understanding and care, to see them realistically and to meet them where they are.

The only real measure of success is whether or not there is any connection, any real human moment that transpires. This person may or may not come back again. Often sent to the appointment under duress, they assume they won’t follow up with someone they didn’t choose in the first place.

But maybe that first conversation can open a door and give this person the idea that there is a way out of anorexia. That would be a true success.

A Binge Eating Disorder Treatment Plan

Treatment for BED has some similarities to treatment for other eating disorders. Normalizing eating patterns is still a critical initial step. Thoughts about weight and food remain dominant and interfere with learning other ways to manage daily life. Shame is a central part of the eating disorder and needs to be addressed.

These are underlying aspects of any eating disorder and demand significant attention in successful treatment.

The more obvious differences center around the exact type of behaviors and around weight.

Food restriction and weight loss—focal points of most eating disorders—are lauded behaviors in our society. People with most eating disorders feel like they are engaging in behaviors considered acceptable by society since weight loss and thinness are idealized and viewed as true accomplishments in life. The effect of overvaluing thinness makes it harder to face eating disorder thoughts for many people.

People with BED experience the opposite. The pervasiveness of fatphobia means that these patients suffer from bias and prejudice in all aspects of their lives. Not only do they struggle to get well, but they also face the constant message that they are weak and incapable people.

The eating disorder symptoms are signs of their lack of worth, an erroneous fact validated by the world around them. Even eating disorder treatment can view binging from a negative standpoint rather than as a symptom of an illness.

Similarly, programs tend to focus on weight stabilization as a key to recovery, largely driven by the lure of the illusion of concrete steps towards wellness and by the number-oriented insurance companies. However, it’s hypocritical to harp on weight for people who restrict and ignore the inherent complications for people with BED in our society.

A well-conceived treatment plan for BED needs to address these two differences head on. Programs must face the complicated world we live in that includes fatphobia and body image in order to begin to create an adequate treatment plan for these patients. Similarly, clinicians need to consider how to talk about weight in different ways for people with BED and to consider any plan individually rather than use a one-size-fits-all policy, no matter the eating disorder.

The treatment for BED is often as or even more successful than for other eating disorders. The key to success is considering the true nature of this illness and create a treatment plan aimed at recovery from this specific eating disorder.

Binge Eating Disorder: the Neglected Stepchild of Eating Disorders

Binge eating disorder (BED) finally received the recognition as a true eating disorder diagnosis in the DSM in 2014 yet still seems to be the neglected stepchild of the eating disorder treatment world.

The clinical community remains transfixed by the immovable fortress that Anorexia Nervosa presents in so many patients. And the relative success of cognitive behavioral therapy for Bulimia Nervosa makes for some positive affirmation in treating these difficult illnesses.

However, BED taps into several prejudices both in the medical establishment and in our culture that sideline interest in the disorder and undermine any movement towards improved care.

First, both overeating and larger people immediately trigger the fatphobia ingrained in our culture. Eating more and being larger invoke an automatic response of weakness, inferiority and worthlessness. The kindness, compassion and understanding that are the cornerstones of eating disorder treatment often don’t break through the raw prejudices in our society.

In addition, the eating disorder treatment protocols and insurance company standards for care all revolve around weight gain. Eating a nutritious meal plan and maintaining supposedly adequate body weight are erroneously deemed the overall goal of treatment. However, this entire philosophy is not relevant for someone with BED, and there is no similar approach to helping people with this disorder.

Time and again, people with BED who enter treatment programs note that they don’t belong, aren’t truly accepted and don’t see any value in treatment not geared towards their illness.

These patients frequently remark that they cannot find an outpatient program or group designed to help them and populated with people like them. However, these patients with BED are a significant and prevalent part of the population who have eating disorders. Just in my practice alone, easily one third of my patients with eating disorders have BED.

The next post will outline the goals of treatment and what adjustments in clinical goals can help people specifically struggling with BED.

The Plight of an Eating Disorder Born before the Emergence of Treatment

People with chronic eating disorders who are age mid-40’s or older have had a very different course of their illness. Without access to treatment or even knowledgeable professionals when they were younger, they had to navigate their personal struggle on their own and find any way they could to survive.

The term eating disorder was only coined in 1973, and the first fledgling treatment modalities first appeared in the early 1980’s. However, more widespread diagnosis and treatment did not emerge until the late 80’s or early

90’s and even then only in certain urban pockets of the country.

Before then, the medical literature reports only a handful of perplexing cases largely attributed to profound neurotic complexes. The concept of a genetic or biological illness called an eating disorder was unimaginable. So the people with eating disorder flew under the radar: undiagnosed and untreated. 

People who developed eating disorders prior to the advent of eating disorder treatment found ways to cope and survive. Rather than learn about their illness start recovery, people rightly assumed this illness was their lot in life. In order to move forward, they coped the best they could and endured.

Now, later in life, some of those people have taken advantage of treatment programs but with little success. Residential treatment is aimed at young, newly diagnosed women and struggles to accommodate people with different backgrounds and courses of their illness. 

Even in outpatient treatment, these women need a different approach. Once an eating disorder has been fully incorporated into one’s identity and psyche, it isn’t easy to extricate it at all. Instead, treatment needs to adapt to the psychological reality of these women.

They have survived the all-consuming existence of an eating disorder without any prospect of help. Now, with the possibility of knowledgeable support, a clinician needs to table the idea of recovery and instead embrace the prospect of exposing the secret world of this illness in therapy. Just the step towards releasing the secrecy and sharing the details of this private world can be immensely helpful.

The goal in these instances is not the supposed panacea of recovery. Instead, treatment aims at debunking the myth that an eating disorder is a lifelong burden. Therapy can open the door to see an eating disorder as an illness that can improve with real support and help.

Positive Signs for People with Chronic Eating Disorders

People with chronic eating disorders often feel trapped and hopeless without any sense that recovery is still an option. They look into literature and treatment programs and find everything aimed at people who have just been diagnosed, not geared towards them. The path to to recovery looks very murky. It becomes very hard to imagine life without the illness.

In my work with people who are not new to treatment, I look for certain keys that point towards a likelihood of success. 

First and foremost is the existence of a life outside the eating disorder. That may entail a career, friends, a passion or close family ties. When a person has found something meaningful outside the eating disorder, movement in recovery can lead her to further engage this part of her life. She has a place to put that new energy and to escape the eating disorder.

Time of wellness during the eating disorder also is meaningful. It’s important for the person with a chronic illness to have known a period of semi-adequate nutrition, decreased behaviors and to know what it feels like to be better, even if that time is brief. This more recent memory connects them with the idea of wellness so that recovery doesn’t seem so farfetched.

Third is the ability to make emotional connections with people. Sometimes people with chronic eating disorders lose the ability to tolerate personal closeness and the development of emotional bonds. The closeness to the eating disorder replaces real relationships. Knowing that actual relationships are within the person’s grasp makes it possible to be more present in the world, a necessity in recovery.

Last, the patient has to feel able to engage in meaningful work around the food behaviors. If the thoughts and behaviors remain hidden, if that person cannot find a way to communicate and expose the eating disorder, the illness will hold into its most powerful weapon: secrecy. Openness and the ability to tolerate exposure is a critical sign that recovery is possible.

These four signs all point to the possibility of real progress to treat chronic eating disorders. This is a general idea of what parameters make recovery possible although it is not absolute: some people without any of these four strengths can get better too. However, the more a person can engage in these activities, the more hopeful the possibility of recovery.

Individualized Treatment for Eating Disorders

Treatment ultimately needs to become individualized in order for more people with eating disorders to fully recover.

As financial companies have purchased smaller eating disorder programs, profit has become the driving force for treatment. Programs have leverage, connections to insurance companies and marketing strategies that easily overrun the small programs and clinicians in the community.

The result of this sea change in eating disorder treatment is a reflexive reaction by clinicians to immediately refer patients to a treatment program. If that patient does not benefit from a program, it’s too easy to blame the patient for being intractable than to begin to create a specific program that could help this patient.

Programs provide a very specific program that entails absolute compliance with the meal program, rigid structure for daily groups and goals, adherence to weight management plans and an ability to quickly ignore eating disorder thoughts. Accordingly, people who do well at programs have eating disorder symptoms that match the overall philosophy of a program.

People with more chronic eating disorders, stronger eating disorder thoughts, binge eating disorder or more complex psychological and emotional causes for their illness often do not get much help.

There are many forms of outpatient treatment that can be more flexible. Some people cannot gain weight rapidly without immediate relapse. Others need to do more work on emotional resilience before they can tolerate substantial changes in their food. Some need to manage traumatic reactions in new ways before being ready to move forward in recovery. Sometimes it just takes longer to quiet the eating disorder thoughts.

During this transition period for patients, it remains crucial for clinicians to manage medical consequences of the eating disorder and to maintain focus on confronting eating patterns while still making changes in the meal plan. The worst slips into eating disorder symptoms might be treated medically or with short-term stays in hospitals or residential programs.

Individualized treatment always involves taking risks for patients. It means tolerating difficult stretches of worsening symptoms while trying to ensure safety and leave open a path to recovery.

Residential treatment is always a viable option. But the caring clinician needs to consider all routes to recovery to give everyone the best chance to get well.

Residential Treatment Programs for Eating Disorders are Too Restrictive

The treatment options for eating disorders remain very limited in this country. For the most part, there is one way to get help. If that doesn’t work for you, then there are very few other paths. 

Even as financial companies have bought and aggregated treatment facilities, there is no innovation in treatment, only more of the same programs. Outpatient teams funnel into residential treatment programs and their outpatient step-down plans. There are a smattering of hospital-based programs for the sickest people which are usually even more rigid and punitive. 

These programs function on a very strict model. All eating disorders are essentially treated as equal. The focus is on 100% compliance with the meal plan, weight restoration and complete acceptance of the treatment philosophy of the program. There is little room for individualized care. And if following any of these rules is impossible or even difficult, the patient is labeled intractable, ostracized and eventually moved out of the program.

As a clinician who works with people with chronic eating disorders, I am aware of how difficult and long a course of recovery can be. There rarely are easy answers. Changing long-standing eating patterns takes enormous time and effort which cannot happen in these short-term programs.

However, programs are intended to be stepping stones into more active recovery. The goals are stabilization of eating patterns, health and psychological symptoms. With those achieved, the transition into intensive outpatient treatment can be more effective.

The people who can’t benefit from programs end up feeling more hopeless and often more entrenched in their illness. The sense of failure reinforces a deep feeling of inadequacy and an internal inability to weather the storm of recovery.

The only option left is to set up a treatment team and work on the slow process of recovery on their own out in the world. This plan can be effective although the deep sense of failure from treatment only makes it more difficult.

The harder question is what other options are there for different kinds of treatment. I will start to address this question in the next post.a

The Social Isolation inside an Eating Disorder

Discussion among clinicians and patients about eating disorder treatment focuses necessarily on meal plans, health, treatment programs and behavioral change. What seems to be sidelined too regularly is the social and emotional isolation of these illnesses. In many ways, people with eating disorders end up feeling very alone and need help learning how to connect with people and build a life with relationships with people and not focused on their relationship with food.

Eating disorders may appear to be largely behavioral, but the crux of the illness is psychological. The pervasive, loud and dominant thought process of an eating disorder affects not just thoughts about food and weight but all decisions each day. Being able to choose foods that feel safe, exercise or limit time in the world to be sure no eating disorder rules are broken are the pillars of an eating disorder.

Notice what is ignored through these decisions. People with eating disorders don’t even consider friendships, relationships or true interpersonal connection. Even if they have friends and spend time with people, they universally talk about feeling alone and not having meaningful connections in their lives. Despite the yearning desire to connect, fear of breaking the eating disorder rules precludes ever prioritizing personal relationships.

The first connections that help people recover often begin in treatment. A strong bond with a clinician allows the person to remember why caring, close relationships matter. In the process of getting help for the eating disorder, patients also remember how to connect with another person and how those connections mean so much more than the eating disorder rules.

True recovery must include reconnecting in the world and forgoing the eating disorder in the process. Behavioral changes themselves may improve health and well-being, but they are not recovery on their own. People who get well relearn how to be fully in their lives and find value in other people and meaningful actions in the world, not the empty successes of food and weight.

The Core of Family Support in Eating Disorder Recovery

Normalizing eating, health and weight are the easiest part of an eating disorder for families to understand. Even though the concept of not eating regularly perplexes most people who have never had an eating disorder, the prospect of needing to regulate nutrition as a part of getting well makes sense.

However, the crux of an eating disorder is psychological and not behavioral. Although the behaviors are compulsive and destructive, the eating disorder thoughts and rules are the engine that make these illnesses so powerful.

Therapy focuses on the emotional reasons underlying the disordered thought processes, but families do not need to understand the full scope of the internal working of an eating disorder. They only need enough information to provide true support.

It’s still very complicated for families to understand that an eating disorder can co-opt a person’s mind. In all other aspects of life, a person with an eating disorder typically thinks clearly and rationally and functions like anyone else. In relation to food and weight, other thoughts and rules dominate and insist on eating disordered behaviors and actions.

Families find this concept almost impossible to understand and also terrifying to accept. No one would want to believe someone cannot think clearly about food, a basic necessity to live. Acceptance means fully believing this family member has a psychiatric disorder they cannot control. Perhaps the stigma of mental illness has lessened in recent years, yet within families it still often remains present.

The purpose of family sessions with a therapist first and foremost needs to be to reinforce the psychological nature of the illness. Fighting the eating disordered thoughts is crucial to recovery and takes a lot of hard work. If families question the validity of disordered thoughts as a symptom of the illness, then they also undermine therapy.

Families don’t need to fully understand what eating disorder thoughts are exactly or how they function. They need to know the family member does not willfully choose to engage in eating disorder behavior. The thoughts are part of an illness and the person needs help and support to get well.

Disordered Eating vs. Eating Disorders

As psychiatric diagnoses have seeped into the lay lexicon, the general understanding of the severity of these illnesses themselves become watered down. When people say they feel depressed instead of sad, manic instead of happy or OCDing instead of anxious, it’s unclear what being psychiatrically ill actually means.

Conflating daily life with mental illness is most evident when discussing eating disorders. Many people struggle with disordered eating. They fight with distorted body image and eat based on diets or fears about weight rather than based on hunger. They exercise out of guilt rather than to enjoy movement or to improve health.

And moreover, these people who engage in disordered behaviors often believe they have an eating disorder. Even though these thoughts and behaviors can be disruptive, disordered eating does not fundamentally impact people’s lives. They are still able to work, socialize and function within society even if they spend too much time thinking about food, exercise, body and weight.

People with eating disorders are not able to live a full life. And if they are able to live somewhat fully, they suffer the constant psychological and physical consequences of their illness. The eating disorder thoughts make it very difficult to focus on other parts of their life. They struggle so much to eat and to manage their body image thoughts that it impairs their ability to make plans and develop friendships or relationships.

The difference between symptoms and illness is the amount the symptoms affect one’s life. When life is disrupted and a person cannot live fully, disordered eating becomes an eating disorder.

The reason this is important is that people with eating disorders often feel misunderstood or feel their struggles are minimized when others purport to have an eating disorder. It makes truly sick people feel as if their illness is not severe. This misconception leads to worsening symptoms and relapse.

Although disordered eating can affect a person’s life, it’s crucial that the distinction between the two are clear for all people involved.

Exercise and Weight, Part II

I need to clarify that, overall, exercise is beneficial for one’s body and health. The human body is designed to work better with regular exercise in terms of managing cardiovascular health and well being. This fact is undeniable and important.

However, the other messages about exercise that have become pervasive and, for many, apparent facts that are more problematic and untrue.

The association of exercise and weight loss, equating exercise as a form of burning calories to be matched by food intake and the need for increased fitness and exercise as a sign of improvement of health all are either falsehoods or exaggerations not based on fact.

The food, diet and exercise industries benefit from making these statements appear true.

If exercise is associated with weight loss, the imperative and pressure to exercise falls on the individual. The pervasive guilt when people don’t exercise pushes them to sign up for classes, join gyms and participate in a part of life they may or may not want to but feel compelled to. But the purpose of this collective obsession is to maintain or lose weight when the overwhelming data proves otherwise.

If eating food can only be justified by exercise, people will need to rack up a certain amount of calories burned in order to feel able to eat their meals, even though the calories burned statistics on machines and various devices is not based on any biological science. Instead, people feel tethered to inaccuracies as the reason they can or cannot eat.

And with the constant personal urgency to be “healthy,” exercise is often the foundation of that philosophy. Yes moderate exercise is connected with improvement on health, but excessive exercise has no bearing on health. The connection between health and exercise is such a strong reality that people are shocked to know that only moderate exercise shows true health improvement.

These pressures around exercise, based on a series of inaccurate statements, drive a significant amount of behaviors and thought processes for many who don’t have eating disorders. The growing exercise industry benefits from an urgency people feel to exercise, and the diet and food industries also benefit from the growing obsession to seek improved health by focusing on these falsehoods. 

Without sufficient public health and medical establishment response, these falsehoods remain the only “truths” people know. Too many doctors have been brainwashed into believing the propaganda and public health campaigns are more focused on increased weight to realize the larger picture.

As long as our society is so obsessed with thinness, people are trapped in this conundrum. The real freedom is to see exercise as a part of life and to see food more clearly as a necessity to sustain life.

Exercise and Weight, Part I

The societal messages about exercise are incredibly confusing. As with nutrition, most doctors know little about the connection between exercise and health and rely on media misinformation rather than any true data. Minimally knowledgeable writers and a powerful exercise industry instead dominate our collective thoughts.

There is plenty of evidence that moderate exercise on a regular basis is better for overall cardiovascular health. Being completely sedentary worsens health and well-being.

Increased exercise or fitness does not correlate with commensurate improvement in health. It only confers improved athletic abilities.

However, the underlying message about exercise relates implicitly or explicitly to weight. No matter how people discuss exercise, they always imply that exercise is necessary to remain or get to a low weight. And by and large, these conversations lead to shame, guilt or conversely smugness.

The overall data is conclusive: exercise doesn’t lead to weight loss. For a sedentary person, exercise often leads to short-term amounts of weight loss that returns within six months. Exercise often leads to increased hunger to compensate for increased activity. Time and again, research proves that exercise does not change one’s weight.

This fact is irrefutable, yet it seems to shock anyone who hears it. Almost everyone told this information can’t believe it’s true. Instead, most people exercise out of guilt and shame and many people only feel able to eat if they compensate with regular exercise.

How has the falsehood around exercise and weight become so pervasive? What keeps people from learning the basic facts about exercise and the body’s response? I’ll talk more about it in the next post.

Body and Shame, Part III

The message that needs promotion in our culture is that girls’ and women’s self-esteem cannot be connected to body and weight. If image and looks are the most important elements of a woman and if thinness continues to be glorified, then dieting will still be a rite of passage for adolescent girls and eating disorders will continue to be an intractable problem. 

Despite the sentiment that girls are capable of choosing any profession—that they can have it all—they continue to be burdened by anachronistic mores about appearance. The two cannot exist together without severe consequences. In fact, the drive for thinness only weakens the growth of a girl or woman because the energy consumed by dieting and weight detracts from attention needed to build a full life. 

By and large, men don’t have this problem. Some men do have eating disorders and body image issues that largely revolve around the fat phobia pervasive in our society, also a pressing and important issue. But they aren’t trapped behind sexist expectations that a woman prioritize image over everything else. 

The media has created an ideal for women in recent decades of extreme thinness and a photoshopped perfect body. In other words, not only is thinness a goal, but the objective is unattainable. The drive for thinness is inevitably a setup for failure. So the result of focusing on weight is shame and failure. And that is how a significant number of women experience themselves day in day out. 

There is a growing chorus of angry women’s voices expressing outrage about the shackles of thinness and weight. From the body positive movement to the concept of intuitive eating to the food coaching movement, younger people are listening to influencers who making a difference. These voices need to penetrate communities where dieting is a part of every 13 year old girl’s development and be sure the overwrought fears of obesity don’t scare people away.

These voices need to make clear the risks of spending a lifetime suffering in shame. These voices need to make clear that all body shapes are healthy and ok. These voices need to remind everyone what is truly valuable in life.

The Root Cause of Body Image Distortion

These last two posts outlined some of the causes of body image distortion and how one’s mind can latch onto these self-images. The power of negative body image feels like a truth, a rite of passage passed down from mothers to daughters or within communities.

Because this component of eating disorders is a culturally accepted norm, changing the root of the distortion is exponentially more difficult. The outside world continues to state that thinness is a virtue, if not an accomplishment. Among women, telling one another “you look like you’ve lost weight” is still the ultimate compliment.

The task for the clinician of convincing a patient that the goal of thinness, a central part of society, is somehow false is a tall order. A therapist may be able to work against eating disorder thoughts that tell people to starve or binge and purge, but it’s a much more difficult goal to contradict the belief that women need to focus on weight loss as a sign of success.

This contradiction comes up in recovery very regularly. Even the most educated and supportive families struggle not to question their child’s meal plan and become afraid of too much weight gain. Even after years of watching their family member suffer with an eating disorder, the overall pressure for thinness can often override a person’s general health and wellness.

The drive for thinness leads to dieting, the most significant risk factor for developing an eating disorder, and also makes recovery more difficult because of the pressure not to gain weight, even if that’s necessary to get well. Trapped on both sides, people often feel most stuck because of body image distortion in their recovery. This is the last element of the illness that gets better.

Ultimately, body image distortion will only change when the cultural norm changes, something well beyond the lone clinician’s ability. This focus on weight remains a curse in our lives and especially women’s lives. Nothing will change unless the people most affected find a way to band together and insist on those changes. Life has to be more important than weight.

Body Image in Eating Disorders, Part II

The last post focused on the changes in brain processing which affect body image and the perception of one’s own body differently from others. Another equally important aspect of body image distortion is the emotional connection.

The underlying feeling behind body image thoughts is shame. Thoughts about body always revolve around never being enough: not thin enough, not shapely enough, not attractive enough. The list is endless.

Typically, these thoughts about one’s body starts around puberty when bodies change quickly and suddenly. The development of identity and self-perception occurs at the same time and often in lasting ways.

Adolescents, especially girls, still grow up with the message that their changing bodies are a source of deep shame. That shame may begin in how they are perceived with a developing body, how they dress, how they develop curves or fat in typical places for women or in the deep discomfort others, typically family, have during their development. Sometimes, the shame begins at home and other times from school or peers.

Because of the drive for thinness in our society, many children see dieting, food restriction and weight loss as a concrete way to battle against puberty and attempt to halt the changes in their body. The cultural norm of thinness naturally condones this dangerous behavior and assures teenagers that body shame is a critical part of becoming a woman.

As I have written many times in this blog, dieting is the number one risk factor for developing an eating disorder. Whether or not children become ill, for the most part, they learn about the connection between shame and body image. And the constant negative thoughts associated with their own self-image is quickly ingrained in so many girls and young women.

The new trends of body positivity, varied size models and body acceptance are taking hold. Both for the sake of avoiding eating disorders and for avoiding a lifetime of shame, let’s hope these trends make a dent in the cultural norms of the last fifty years.

Body Image in Eating Disorders: a Brain Malfunction, Part I

People with eating disorders struggle more with body image than with any other part of their illness. Even when eating behaviors have normalized, body image distortion often persists for years afterwards before fading.

The first component of body image thoughts manifests as a brain distortion. The visual image of one’s body is transformed in the brain into something very different from reality. At the most extreme, people who are very underweight see a much larger person on the mirror. Others may only see a body that disgusts them no matter its appearance.

As one’s own reflection is associated with such negative thoughts and feelings, it becomes impossible to disconnect the internal reaction from the way their body actually looks.

I have seen many people have an experience that highlights the power of body image distortions. These patients have told me that they will catch the reflection of their silhouette in a store window and not realize they are seeing themselves. In that moment, they describe having a positive feeling about that body and often a jealous reaction that they wish it was their body. Once they realize it actually is their body, the reaction immediately changes to seeing a body they hate which leads to disgust and hatred.

This moment makes clear how body image symptoms can be seen as a brain malfunction. The brain of someone with an eating disorder can process one’s own image very differently depending on the context. The exact same body can be a source of envy or the locus of disgust depending on whose body it is.

The connection of positive or negative feelings with one’s body grows from years of associations with how one feels about oneself. The core of the negative associations starts at a younger age and coalesces around body and body image through the process of childhood and into an eating disorder. The next post will focus on this process.