How to Find Good Virtual Treatment for an Eating Disorder

Initially, virtual treatment was part of the necessary changes to continue any therapy during the worst parts of the pandemic. Now virtual work has become the norm.

Prior to the pandemic, I had written many posts about one of the biggest issues in treating eating disorders: access to care. There weren’t enough clinicians or programs to go around even in the most populous parts of the country, let alone in more rural areas.

Virtual work opened up opportunities for people to seek care much more widely, a needed change. As new virtual opportunities for care expand, the possibility that everyone can get help might be realized.

Expansion of care exposed another issue in eating disorder treatment, namely the quality of care. There is no standard training, certificate or degree for treating people with eating disorders. While virtual access improves, more clinicians are necessary, and the likelihood of inexperienced treatment providers in unsupervised settings increases dramatically.

Online treatment varies from therapy to all day programs to weekly coaching programs. The expense of treatment is high, and the ability to assess its efficacy very limited. In addition, programs that include meal support have an even higher bar to climb because tracking whether someone finishes a meal is even harder on a video call.

Grappling with the virtual landscape demands an even higher level of vetting by the patient to be successful. These are some ideas to consider and ask directly when making decisions about care.

First, ask providers and programs about their credentials. Any virtual treatment needs to start with well trained professionals with successful clinical practices who have the expertise to navigate helping people recover online.

Second, have a conversation about how any treatment works virtually and how the program adapts to online work. This modality can be very successful but not as a virtual version of the same treatment. The explanation of the differences will reveal how thoughtful the provider is.

Third, it’s essential that any treatment uses criteria to assess progress and has a plan at the ready for virtual work to be successful. Many providers and programs will say that if their treatment doesn’t work, they’ll recommend a “higher level of care,” a euphemism that the clinician does not know what else to do. Asking for more specific guidelines will be revealing of the person’s overall thoughts about treatment.

Virtual care fully enacted during the pandemic is here to stay. The pros of this work outweighs the cons. Seeking the best virtual care tasks patients to ask the right questions to ensure the treatment is effective.

Traversing the Altered Landscape of Eating Disorder Treatment: Overview

The pandemic changed the already confusing eating disorder treatment world immeasurably. The demand for treatment remains extremely high, and the avenues to find appropriate care are increasingly difficult to find.

A few major changes have had the most impact, and I will use the next few posts to discuss all the issues in detail. This post will focus on the few biggest ones.

The first big change is that virtual mental health treatment is quickly becoming the norm. In eating disorder treatment, virtual work is particularly hard since eating food together is an integral part of much of the work. Deciding whether virtual work can be helpful and when in person work is essential can be complicated.

The second change is the extraordinary array of options. The explosion of treatment programs, in person and virtual, therapists, coaching, support networks and mentor programs is dizzying. The number of clinicians professing eating disorder expertise is extraordinary, and there is no degree or certificate to prove any experience at all. Choosing providers has become very complex.

The third change is the enormous growth in residential programs funded by private equity firms. These programs are run at the corporate level by experienced clinicians and financiers aimed at growth, profit and eventually selling the company. Many of the day to day clinicians are inexperienced people early in their career and often at their first job. Some of them are excellent, but the varied skill levels are hard to assess. Providing the need for access of care is a boon to many but also has come at a cost.

These are the three most pressing changes to eating disorder treatment. I’ll discuss each one in more detail in the next several posts.

Psychedelic Medications in Psychiatry: Early Thoughts

Psychedelic drugs now used as psychiatric medications are a wave of the future. Psychopharmacology is effective and safe for many people, but there is still a significant number of people who get little or no benefit from this form of treatment. Any new direction for helping people with mental illness is intriguing and important.

Ketamine is already available and can be used by infusion, nasal spray, intramuscular injection or lozenge. Psilocybin should be available at some point in 2023.

The early data about both medications are very promising. People with many mental illnesses including depression, OCD and PTSD appear to derive benefit from the psychedelics. Although people who work with these medications report benefit for even more disorders, there isn’t enough known yet to substantiate the claims.

Unlike psychiatric medications, psychedelics don’t directly reduce symptoms. Instead, they increase brain plasticity—the flexibility of the brain to break stuck routines and change automatic thoughts and reactions. The effect of the medications is more effective when the program includes mental exercises or writing that enhances and focuses on changing certain patterns in the brain. For instance, trauma therapy using psilocybin shows significant promise.

Of note, there is no clear benefit for these medications for people with eating disorders, though any peripheral benefit for other psychiatric symptoms can benefit eating disorder treatment.

It’s crucial to note that psychedelic medications don’t follow the typical FDA method of approval for new drugs. And once approved, there is no clear method of treatment either. Psychiatrists cannot just prescribe the medications and pharmacies do not dispense the drugs. Ketamine is prescribed in specific clinics and can even be ordered as a lozenge on various websites without medical supervision at all.

The lack of regulation, unclear medical follow-up and minimal guidelines for use make it important for anyone using these medications to find a reputable source for attaining and using them. The patient has the responsibility to search for the safe and effective way of trying the medications and of assessing its benefit.

Psychedelic medications are an exciting new direction for psychiatry. The holes in care for mental illness demand new options to help those undertreated by the current available options. As long as a patient is educated and clear about their decisions, these new medications can be a very effective alternative. However, it’s important for patients to heed the risks and work with knowledgeable doctors through the process.

The Current State of Body Positivity

There appear to be signs that the movement towards body positivity and embracing all body types is fading. There are still models and actors in different bodies, more than there were a few years ago: thinness is not yet supreme again. However, the cultural pressure to consider all body types isn’t as strong, and people are more willing to accept celebrities losing weight publicly again.

Body positivity gained traction on social media. Younger generations saw different bodies on TikTok and in advertising. Evidence overwhelmingly shows that visual exposure to all body shapes and sizes quickly changes our perception of what is typical and also attractive. As long as the cultural norm is thinness, our minds quickly learn and absorb the expectations of how bodies ought to look. When we are exposed to all body types, the desire and aura of thinness diminish quickly.

The culture of body size matters for people with eating disorders. The more one is bombarded with thinness, the more likely an adolescent is to diet. In the developmental search for identity, teenagers look to culture to dictate what is desirable. They are susceptible to trends and are very likely to try out norms dangled in front of their eyes on social media.

As I have written here many times, dieting is the number one risk factor for developing an eating disorder. The movement away from body positivity means an even higher incidence of eating disorders.

Never have teenagers had more influence on current culture. They can quickly create a trend on social media which influences public opinion and cultural expectations. Before media preceded and created the public response to new ideas, but now they are symbiotic.

So the most likely way to ensure body positivity doesn’t fade is to encourage the younger generation to support the attractiveness of all bodies and ignore ideals for thinness. Only time will tell if the strategy can be effective. I certainly hope it is for that generation’s sake.

A Guide to Starting Eating Disorder Therapy: Beginning with Hope

An experienced, compassionate clinician needs to consider hope from the first minute of a consultation. Yes, understanding the person’s complete history and background is important, but from the introduction to treatment, the tone is set for how therapy progresses, and no treatment will make progress without hope.

The myths about eating disorders are in the background of any therapy. A patient will most likely think how can this new treatment help me? Is there any chance of really getting better? Will this person truly understand the nature of my eating disorder and what I struggle with every day? Why will this time be any different?

A therapist must realize these thoughts dominate the mind of the person you are just meeting. Even if they don’t state a word about the future, their expectation is the confirmation of the hopelessness they have likely felt throughout much of their clinical experiences.

But the sense of hope can’t be forced or unsubstantiated. There are some people for whom hope is not recovery but stabilization of the eating disorder to build a future, and that’s a very real accomplishment. The hope needs to be borne out of true beliefs the clinician has about this person, their eating disorder and realistic goals for the future.

At first, the hope stems from the therapist listening with an open mind, learning in detail about their eating disorder and asking questions that imply how things might change. Typically, one can reinforce positive experiences in the past, note treatment not considered yet or emphasize strong elements of motivation. The therapist’s initial approach to the session will communicate the direction therapy can take right away.

These immediate actions and initial plans need to be proactive so the person knows the treatment will be collaborative. They can’t feel alone anymore.

Communicating hope from the start is remarkably helpful and effective in laying the groundwork for successful treatment. This path needs to be integrated immediately into any new therapy.

Reclaiming Goals, Wishes and Desires in Recovery

Eating disorders usually begin at a formative stage of life, typically between childhood and early adulthood. Since these illnesses are all consuming—physically, psychologically and emotionally—many stages of personal development and growth halt or slow considerably when someone is sick.

The physical limitations can result in slowed growth, delayed puberty and organ system dysfunction. Despite the severity of the symptoms, the large majority of physical effects reverse quickly with adequate nutrition. Moreover, the physical concerns rarely cause people to lose hope.

The emotional and psychological results of an eating disorder cause more psychic pain for people and lead to enduring hopelessness. It’s easier for people with eating disorders to lead a semblance of a typical life into their early twenties. They can go to school, socialize appropriately and develop friendships around shared activities. The eating disorder numbs emotions and limits the depth of connection with others, but the lack of emotional development is largely hidden—both to the person with the eating disorder and others—earlier in life.

In early adult life, the social and emotional deficits become more evident. The eating disorder consumes the majority of one’s thoughts and leaves little room to explore emotional experiences and deepen relationships. Socializing typically involves eating, and these events are fraught with fear, not with an opportunity to connect with others. Relationships are not possible unless the eating disorder plays a large role in the bond. Those connections can never be that powerful.

Suddenly, people with eating disorders feel very different from others, left behind. And the road to restarting psychological development necessitates getting better from an eating disorder which has been intimately woven into daily life from a young age. People experience this situation like a trap: getting better means facing the struggle around food and body, and life events can’t happen unless one gets better.

The road forward looks impossible. It’s easy to become hopeless.

The therapist has a critical job early in therapy to explain how psychological and emotional development can restart at any age and can catch up very fast. Much as physical limitations from the eating disorder heal, so do psychological limitations. As the eating disorder symptoms recede, a person in recovery can take on personal challenges and move forward. A new task at age 17 is much easier even a few years older because the brain has finished critical developmental stages. So the social and emotional changes can happen very quickly.

Hopelessness in this case is borne out of the false idea that one can never catch up in life. Having missed critical years, the future is hopeless. This myth could not be more false. Tackling eating disorder symptoms opens the door to personal growth and the ability to forge ahead and create the life one wants.

The next post will address how therapy itself can disempower the hopelessness borne out of diet culture and the idealization of thinness.

Hope at the Start of Eating Disorder Treatment

I see hope in eating disorder treatment as integral to its success and woven into many parts of the process.

The first step is a clear, logical, reliable plan to start treatment. Initially, the approach needs to be concrete and specific to allow for a sense of accomplishment and the establishment of a team focused on recovery.

Although the DSM uses a list of symptoms to describe and diagnose eating disorders, the criteria don’t explain the confusing and tricky elements of how these illnesses work. A clinician can ask a series of questions and write an elegant medical note about someone’s eating disorder without a true picture of what any one individual’s daily struggle looks like.

The only way to establish a mutual understanding of an eating disorder is a food log. The log creates a way for clinician and patient to talk about food and elucidate the details of how the eating disorder works.

Fairly quickly, the timing of food each day, gaps in time between eating, the size of meals or snacks, urges to use behaviors and emotional triggers for symptoms become clear in the log very quickly. A therapist can ask specific questions that help the patient better understand how they are tricked into the same patterns by the eating disorder and also how to start to alter the patterns.

The log also creates a bond between therapist and patient. By having the log to examine together, the eating disorder feels separate from the patient, an entity between the patient and therapist which they can discuss honestly, openly and without judgment. Suddenly, the shame isn’t so present, and the goal of working together on getting well is paramount.

Last, that feeling of together, of not being alone, in the struggle to get well is the first glimmer of hope. The changes to daily behaviors may be small at first, but the log implies that the patient will have help directed at the most difficult moments of the day and that the therapist will be involved immediately in the actual behaviors themselves.

The next post will address identifying emotional and psychological development that never happened because of the eating disorder and how restarting this development generates hope.

The Basis of all Successful Eating Disorder Treatment

The most common response I receive from people who find my blog is the message of hope. Even with the widespread content about eating disorder recovery in social media, many people, especially those suffering for some time, long for a reason to believe things will improve.

With more information and education easily available about eating disorders, the implicit message is that people with an eating disorder can’t really get better. Recovery is a term that promotes the concept of a lifelong struggle. Widespread myths about these illnesses is that fully getting better isn’t an option. And the broadening community of people online with eating disorders don’t offer an exit strategy: once a member, always a member.

The loss of hope in eating disorder treatment over the last decade stems from two disparate pressures. First, the desire to find an identity is ever-present. Many young people with varying levels of severity of eating disorders organize their identity around the illness, which is an easily way to belong, especially online. Second, the venture capital intrusion into the eating disorder treatment world means replicable, oversimplified and mediocre care. The end result is less effective treatment. Without any clear hope of getting better, programs inadvertently encourage personal identification with the illness and even less of a drive to search for a different life.

The course of an eating disorder is variable. Many people recover either fully or partially early on in the illness. Even though symptoms linger for many, they can function well enough in life while connecting with the eating disorder identity. They typically expect to be sick forever.

For those with a more intractable eating disorder, social media identity and average clinical care make the future seem hopeless. They hope for a substantiated by a path towards getting fully well. They can’t find this information anywhere.

The reason I started this blog was twofold: to outline my thoughts about eating disorder treatment and to spread the message that people get better. I’ll review the ways people really can get better in the next few posts.

The Role of Body Size in the Treatment of Restrictive Eating Disorders

An important new clinical question is how to diagnose and treat people with restrictive eating behaviors, psychological focus on weight loss and obsessive thoughts about food and weight in people who are not extremely underweight.

This week’s New York Times article discusses a new consideration in the diagnosis among providers and the possible acceptance of a more inclusive diagnosis. The unfortunate and inaccurate diagnosis of “atypical Anorexia Nervosa,” as the article suggests, will only feel dismissive and shameful to all people who are trying to fully grasp the severity and significance of their illness, no matter their body size.

The central issue is the lack of creativity and limited diagnostic categories for people with eating disorders. Over many years, I have seen people exhibit the same food restriction with extreme variability in weight. People in large, medium, small and emaciated bodies can all have very similar symptoms.

Each person is genetically programmed to respond to starvation and malnutrition in different ways. These metabolic changes induced by anorexia are the body’s attempt to survive a severe, prolonged famine. The resulting body size reflects how that body can survive such an assault.

However, it is naive to assume that everyone with restrictive eating behaviors but in different size bodies will experience their eating disorder the same way and respond the same treatment.

Because anorexia has a strong cultural association, people assume anorexia only applies to someone who does not eat and has an emaciated body. Because of the increased pressure for thinness and almost universal belief that dieting or undereating is virtuous and supposedly healthy, almost everyone risks inducing an eating disorder. Chronically underfeeding one’s body is the number one risk factor for an eating disorder, no matter the reason for restricting food.

But people who restrict in larger bodies will be misdiagnosed and often judged for their body size no matter how little they eat. And those in emaciated bodies often receive attention and even praise for the result of their eating disorder. The psychological ramifications of body size is very significant to an eating disorder and to the path of treatment and recovery.

Moreover, the physiological adaptations that lead to larger or smaller bodies when restricting are very different. Our metabolism can respond in many ways to adapt to the lack of food, and the overall course of treatment needs to be tailored to each person’s biological response to the illness.

No one can predict how a body will respond to severe restriction. The focus of diagnosis and treatment needs to be on behavioral, psychological and medical symptoms and include the effects of body size and weight as a part of the treatment. Discounting body size as a factor in eating disorder treatment is ignorant and misguided.

Eating Disorders and our Nervous System

A relatively new direction in psychotherapy is the discussion of our nervous system. Words such as activation and dysregulation of our nervous system describe increased anxiety or the experience of shutting down in response to external or internal emotional triggers.

Discussing our nervous system incorporates the idea that some responses to our lives are driven by ingrained reactions, not emotions or fear.

The referenced nervous system is the autonomic nervous system, an automatic and unconscious part of how our body functions. The autonomic nervous system regulates brain and body activity in response to threat and safety and changes how our body reacts to these different scenarios.

The key is that these nervous system reactions are automatic. Although we may create a logical explanation as to why we react the way we do, the story matches but does not explain the physiological and emotional response. Our bodies instead are programmed to respond to stress or safety in specific ways, but not the same ways for everyone.

Focus on the connection between the autonomic nervous system and mental health revolves primarily around the treatment for trauma. The underlying point is that the ways our bodies react to trauma are protective: we activate our fight-or-flight response or shut down in order to avoid as much harm as possible during the traumatic experience. The new theory helps people understand why their body reacted to trauma the way it did, how this response is protective and the cause of their current symptoms.

My question is how does the autonomic nervous system relate to eating disorders?

First, most eating disorder symptoms replicate the experience of shutting down. Restricting food, binging and purging all induce the feeling of shutting down our vigilance and cognitive abilities thereby numbing emotions and connections in the world. Eating disorders trigger a part of the autonomic nervous system that protects us by shutting down. When emotions or agitation are too strong, the quick fix of eating disorder symptoms can powerfully access shutting down.

Recovery and treatment demand being present, as I have written about extensively in the blog, and also emotional attunement with others, another core part of the autonomic nervous system. The vulnerability of the heightened awareness of being alive and connected to others often overwhelms people in recovery. The temptation of shutting down can be so powerful and lead to slips or relapse.

Even this simple framework opens up many questions. Is there a component of attunement and alertness that is overwhelming for people who get eating disorders in first place? Is there a predilection to seek the numb feeling of shutting down? Does the pull to shutting down reflect a reaction to prior trauma or to a life experience? Are people with specific types of autonomic nervous system more prone to eating disorders?

This new theory about mental health is applicable and useful for eating disorders. New conceptualizations of eating disorders are necessary. The current clinical approaches are often punitive and not helpful. Perhaps theories about the autonomic nervous system will open new doors to eating disorder treatment and care.

Separating the Forest from the Trees in Eating Disorder Recovery

A colleague and mentor of mine, who has treated people with eating disorders long before I started, said that it’s important to remember that these patients have never really been seen or heard. The experience of therapy that will most help them get better is feeling seen and heard for the first time.

As the eating disorder treatment world expands with residential programs, IOPs, meal supports and all sorts of groups, clinicians need to remember this tenet of recovery.

Patients almost always fell into their eating disorder by accident. A combination of the draw of dieting and weight loss, the accidental discovery that eating disorder symptoms serve a powerful emotional purpose and a genetic predisposition lead people into a cluster of symptoms that takes over their lives.

As the illness grows in mental and behavioral scope, the person finds themselves trapped in a life dictated by the demands and emotional rewards that come from following the eating disorder rules and behaviors.

However, this new world does not allow for the connection, affirmation and love one can find in relationships. The eating disorder serves as the arbiter of daily decisions, the guiding light for what is right and wrong and the ultimate assessment of your value as a person.

We are social people whose health and well being necessitate safe and secure interpersonal attachment. Without the ability to form strong connections, the eating disorder deprives people of not just continued nutritional sustenance but the source of emotional sustenance too.

Therapy is often the first time many patients find someone who sees them. The experience of someone listening to what you have to say, valuing your thoughts and feelings and exploring the true elements of what makes you the individual you is transformational.

Of course, eating disorder treatment must include normalizing meals and snacks, yet the importance of strong emotional bonds combined with the experience of being seen and valued is just as crucial to recovery. With all the new changes in eating disorder treatment, it’s important not to ignore what getting better really means.

Virtual Eating Disorder Treatment

Eating disorder treatment, like so many elements of health care, has adopted the virtual treatment model wholeheartedly. Virtual treatment programs, virtual meal support and access to care all around the country are increasingly prevalent and accepted. State licensing programs and insurance coverage are reassessing previous regulations. The lack of access to eating disorder care throughout the country is a relic of the past.

Virtual treatment was present before the pandemic and has taken on an ever increasing share of overall clinical care. The treatment community is in the process of transforming the care we provide and adapting effective methods to remote work.

The overall benefit of virtual care is straightforward. Most important is access to care throughout the country. Remote and rural areas used to have no care for eating disorders. That issue is in the past.

In addition, skipping or missing appointments is much less common so clinical treatment can be much more consistent. Moreover, virtual contact between appointments, important for many stages of recovery, is easily embedded into virtual care.

The potential pitfalls of virtual care are less obvious and important for the clinical eating disorders world to grapple with.

First, the screens create not only a physical distance but also an emotional one. The connection between clinician and patient is so important for recovery as I have written about extensively here. Developing that therapeutic bond is harder virtually. The screen creates distance that sometimes can be hard to cross.

Second, it’s easy for people to hide online on many different ways: hiding food, hiding feelings, hiding fears. Bridging the virtual gap is always possible and demands a different way of approaching treatment, an added vigilance of the clinician and increased awareness to piece together clues that are often more obvious in person.

I strongly advocate for virtual treatment and am positive the increased access, no matter the platform, will be beneficial for many people. In trying to explain some of the benefits and pitfalls, I hope the treatment community continues to figure out the best ways to make virtual care effective.

Eating Disorder Therapy Must Start with the Food

There are so many different directions to take when seeking treatment for an eating disorder. Even ten years ago, the options were so much more limited. Now there are many clinicians (even if it’s not always easy to find someone taking new cases), treatment programs and a variety of support networks online.

When making the decision about the first step, one element of the treatment is necessary: talking in depth and specifically about the food. Many patients I have seen worked in therapy for years making significant progress their lives. Unless the therapy focuses on part on the food, eating disorder symptoms just don’t change.

Of course, addressing the food is one of the hardest steps in recovery. To a person, people with eating disorders feel that discussing their food is the most exposing, most vulnerable thing they can do. So the clinician needs to gently urge people to understand why it is so important and also so hard to talk about the food.

If the food remains a secret, the thoughts and behaviors also remain hidden and outside the purview and potential benefit of therapy. Exposing the eating disorder thoughts and behaviors reveals the feelings covered up by the eating disorder and gives the therapy a chance to help find new ways to manage these emotions.

The willingness to discuss food is the most courageous step someone with an eating disorder can take in therapy. Freedom from these illnesses demands exposure of the symptoms and a desire, no matter how difficult, to let go of the needed comfort and safety.

Any successful therapy must address the food and will subsequently open up the possibility to learn new ways to live and thrive without the eating disorder.

Eating Disorder Classification Does Not Work

The diagnostic classification of eating disorders is problematic. Anorexia, Bulimia and Binge Eating Disorder are the only accepted diagnoses, yet many people with eating disorders, especially those struggling for many years, only fit into the box of Eating Disorder, Unspecified.

It may seem like these diagnoses shouldn’t be very important, but insurance companies insist on a diagnosis for reimbursement and treatment. Since insurance has so much power to dictate medical care, the diagnosis does matter.

Moreover, the diagnosis helps define the problem and lay out a clear path for recovery. Even if the clinical team insists that the diagnosis does not reflect the severity of the disease or importance of recovery, an unspecified diagnosis feels demeaning and dismissive and often decreases the motivation for a patient trying to take their illness seriously.

The diagnostic criteria need to take into account the shift in symptoms through the course of an illness in order to help describe the various disorders more clearly. For now, the classification only describes the earliest symptoms of illness.

For instance, people with anorexia in the first couple of years meet the criteria for weight and eating behaviors, but many fewer continue to do so for five years or more. The body biologically tries to survive the illness by finding ways to compensate for long-standing food restriction or by slowing metabolism to conserve energy. Thus, people with chronic anorexia usually don’t meet the weight criteria after a number of years, a very demoralizing and misleading change. However, even through these adaptations, it’s clear to any clinician the person still has anorexia, just in later stages.

The same can be said about all eating disorders in many different ways. The diagnoses don’t distinguish the myriad ways eating disorder present and persist.

Formally clarifying the distinction between stages of illness would not only be illuminating but also help patients better understand their diagnosis and how to conceive of treatment.

The best next steps in diagnosis would be to create stages of illness that allow people to recognize their diagnosis and also where they are both in the course of the disorder and in recovery.

What it Takes to Really Get Better from an Eating Disorder

Eating disorders usually start at a young age and become a central part of how a person functions early in the development of our identity.

The eating disorder rules organize daily life around food and weight, sets a clear and definite idea of right and wrong and helps life make sense at a confusing developmental period.

Eating disorder symptoms serve as an easy and effective way to manage feelings and calm oneself down during periods of distress.

Eating disorders become central to identity. It’s acceptable to conflate an eating disorder with personal goals, personality and a legitimate organizing force in life.

By the time the eating disorder becomes a problem, one’s entire life and self-image is organized around this illness. In fact, the eating disorder often doesn’t feel like an illness. Questioning the eating disorder usually feels like a personal attack instead.

Recovery doesn’t mean getting better from a long-standing illness to most people. It feels like tearing away the fabric of their being. It feels as if clinicians are asking them to remake themselves, to start from scratch.

So getting better from an eating disorder only begins with a stable meal plan, regular meals and snacks. Recovery quickly becomes more of an existential crisis, a journey to figure oneself out and to throw out the old theories.

Anyone starting recovery, and any clinician embarking on this path with a patient, needs to be aware of how disorienting and exposing recovery feels. Getting better means opening up some of the deepest personal spaces and looking at the raw emotion and fears that are revealed by the end of eating disorder symptoms.

The process of recovery demands respect, empathy and creativity. The path often leads to unexpected places, figuratively and practically, and can end up at unpredictable realizations about life.

Only with a knowledge of recovery and a willingness to explore what the person needs to face, without judgment or criticism, can someone find their way to being truly well and to being truly themselves.

Body over Mind: Accepting Recovery

The false premise of anyone with an eating disorder is that our mind can control our bodies. The truth is that our bodies always win.

The glorification of thinness and dieting is pervasive in our society. Many people are shocked when they realize everyone doesn’t ascribe to the philosophy of dieting and weight loss. In fact, many people consider other things more important than weight and usually live happier lives. The driving force for overvaluing thinness is industry, and the business model is based on the impossible goals set forth.

We can’t ever control our bodies. Survival is the only goal for us as humans, and the most primitive part of our brains drive the hunger instinct especially if our health is threatened. Thus, diets don’t work.

Long-term restricting almost always leads to extreme hunger and binging. And our bodies determine weight based on a number of biological factors that improve our chance of survival, not based on any thoughts or desires to attain a certain weight.

The comparatively rare person with chronic restrictive anorexia appears to have a genetic variant that allows interminable food restriction. The adaptation likely enabled a small percentage of the population to survive extremely long famines and gave them an advantage in a very specific setting. Due to the advantage, the genetic variant has persisted.

Recovery from an eating disorder means accepting that our bodies determine how and when we eat. There are many ways one can attempt to trick our bodies to continue to restrict or compensate for binging. But these behavioral changes solidify the grasp of the eating disorder because the hunger only intensifies and in the end only make people sicker.

Acceptance of body over mind is humbling, but it’s the only path to recovery.

The Pitfalls of Saying “My Eating Disorder”

The concept of mental health is increasingly considered a part of our overall health. It’s high time we conceive of mental health when we think about our well being.

Once it’s easier to take ownership of our mental health struggles, people can be more transparent about taking care of themselves. That may mean being patient with ourselves during hard times, recognizing how to support others with mental health struggles or identifying our own mental illness.

The acceptance of psychiatric diagnoses and various types of treatment including medication has enabled a newer generation to equate mental health with physical health. Conversation and openness about daily psychological and emotional challenges normalize a once taboo experience.

All of the changes apply to eating disorders as well. Since shame is central to these illnesses, tolerance and understanding make it much easier for people with eating disorders to talk about their struggles and seek help. Moreover, the plethora of social media about eating disorders means you don’t have to feel alone with an eating disorder.

For young people, the evolving concept of mental health has one pitfall. It’s too easy to conflate mental illness with identity. At a time in life when people are searching for meaning and a sense of oneself, the mental health struggle itself starts to seem like the core of identity. Young people don’t talk about depression, anxiety, OCD or an eating disorder. They talk about my depression, my anxiety, my OCD or my eating disorder.

The meaning of the possessive pronoun is not just about ownership but about possession itself. The mental health issue feels like it makes the person special, makes that person who they are.

This is especially troubling for eating disorders because the illness itself is already deeply entangled with identity. A key part of treatment, written about in many places including in the blog, is to separate the eating disorder from identity.

Despite the fact that mental health needs to be just as important to people with eating disorders, it’s also critical to address that the eating disorder is an illness, not a possession or identity. The eating disorder is a mental health struggle that may be yours to face but the illness itself is not yours to own.

Dispelling the Myth About Full Recovery from an Eating Disorder

The widespread information online about eating disorders and recovery provides people suffering with these illnesses the ability to educate themselves. Access to knowledge informs people about their experience and how to get help.

The benefits of information are widespread. Patients have much more knowledge about eating disorders and treatment from the start. Research into all forms of help from medications to various types of therapy reveals many different options to get better. Broad details about clinical care gives patients the ability to express their own thoughts about the course of treatment. And educating oneself can be the best motivator to get well.

In recent years, the information available is more often from individuals rather than educational websites or non-profit organizations. Searches for eating disorders are likely to lead to Instagram influencers or marketers rather than a university hospital study or the Academy of Eating Disorders website.

Accordingly, the information people learn tends to be curated by people who may or may not be as educated about eating disorders and who may have a personal agenda. The agenda could be as simple as building a clinical practice or may reflect a personal bias about eating disorders. Since the internet equates all knowledge, people searching for useful articles can instead stumble upon biased data.

One myth that is particularly concerning is the idea that people with eating disorders will always be sick, that the best a person can do is tame the eating disorder thoughts but should expect to live with these thoughts forever. Although the belief that one can’t recover from an eating disorder is old, propagating the myth through social media runs the risk of making this idea appear to be fact.

Some people don’t get fully better from an eating disorder for a number of reasons, but the majority of people can and do get better. If people first learning about eating disorders believe they won’t get better, they approach treatment in a very different and less determined way. Armed with the myth they will never be well, these patients struggle to commit to recovery and to do the hard work needed to take on the process of recovery.

I worry that this myth is growing because more and more people grow their online presence and identity as someone who has recovered from an eating disorder but always needs to be vigilant. If people build a practice around the ever present identity of a recovered person, then being fully free of the eating disorder can jeopardize the business model. If people get well, then the practitioner needs to find a new identity to sell as part of the treatment the provide.

Although access to information can help many people learn about eating disorders and find the courage to seek help, the eating disorder community needs to be sure the goal is full recovery. Holding onto the identity of a recovered person runs the risk of helping people get better but limiting their identity to someone who is recovered. The goal of recovery needs to include becoming one’s true self.