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.