What “Getting It” Really Means?

A common concern for people in recovery from an eating disorder is that clinicians, family or friends “get it.” People in treatment understand what this means implicitly and are often frustrated with those in their lives who don’t get it. But it’s often difficult to explain exactly what this term means and sometimes those in recovery feel misunderstood even by having to explain the term in the first place.

There are few other illnesses for which understanding the experience is so central to providing support.

The core reason for this unique component to eating disorders is the fact that the internal logic of an eating disorder is so unintuitive, confusing and often shameful. Eating meals is a basic function of human life. We are all born with the unconscious drive to eat because it’s synonymous with survival. Hunger is a sensation even babies are keenly aware of and it can take over our conscious wishes when it gets too strong. Hunger is tied to our most primal instincts.

Eating disorders by definition lead people to ignore hunger cues and eat instead based on the rules of the eating disorder. The urge to restrict food, lose weight, eat to excess or intentionally purge food makes no sense to those who don’t have an eating disorder.

Eating is a basic human need. Thus, an uninformed person will often suggest someone with an eating disorder should just “have a milkshake” or just eat “normally” as if a simple suggestion about eating will just solve the problem. Nothing makes someone with an eating disorder feel less understood and more alone.

In order to “get it,” a person without an eating disorder needs to understand that all typical thoughts about food and weight are not relevant. They need to start over and realize that the eating disorder provides a completely different framework to approach food.

There are many other basic assumptions of an eating disorder that differ completely from typical eating: food is scary; eating needs to be prescribed and limited; you don’t need food; you’ll just purge anyway; I need to lose weight no matter what, and I might as well just binge now. The list of these assumptions is very long and replaces all other thoughts about food for someone with an eating disorder.

In the end, recovery necessitates identifying all these underlying thoughts, combatting them with one’s newly formed thoughts about food and well being and constantly trying to replace the disordered thoughts with a new way to approach food and life. This internal battle takes months or years to lead to full recovery and is really what “getting it” is all about.

So supporting someone with an eating disorder means listening and learning about how an eating disorder works. That approach of openness and the willingness to learn opens the door to “getting it.” Nothing will help the person in recovery feel more understood and supported and that’s what matters most.

Treatment for Binge Eating Disorder

The most effective tool to treat Binge Eating Disorder (BED) is the food journal combined with Cognitive Behavioral Therapy (CBT). This is an old treatment model developed over twenty years ago that still is not standard of care despite the long history of effectiveness. In a field with a relatively low success rate in treatment, any researched and proven approach needs to be the first line in treatment.

The therapy was first adapted by C. Fairburn in his book Overcoming Binge Eating written in the 1990’s. Patients complete a daily food journal including writing about thoughts and feelings around the time of each meal or snack. The therapist uses this information to take a number of important steps to normalize food, decrease binges and understand how to avoid binges in the future.

First, the therapist points out the long stretches of time a patient does not eat or eats very little. Working to eat regularly through the day decreases how often the patient gets very hungry, the most important trigger for a binge. After years of binging, restricting begins to seem like a necessary compensatory behavior. But regular eating, even when binges do occur, is necessary to regulate hunger.

Second, as the patient eats in a more sustained way through the day, binges decrease significantly for most people. Subsequent binges are almost always triggered by emotional reactions to life. The thoughts and feelings section of the journal can reveal when an emotional trigger begins to surface and how it leads to a binge. CBT helps link the thoughts and feelings with the behaviors and connect how a binge develops for each patient. This knowledge is a critical part of learning how binges come about.

With this new information, a patient can recognize familiar feelings sooner. Then the next step is to find new ways to manage these emotions and not subconsciously end up binging to cope with the feelings. Interventions like journaling more in depth about the feelings, ensuring adequate food when in an emotional state or connecting with people to discuss the feelings can all stop the seemingly inevitable path from emotions to a binge.

For many people, even a few months of CBT can lead to a significant decrease in binging. After this success, typically a patient’s emotional experiences or personal concerns come to the surface. No longer buried under the shame and relentlessness of the binges, the emotions that arise lead to personal growth which was otherwise impossible.

This work does not need to happen in person to be successful either. Virtual work can be just as effective as long as the patient is committed to the therapy.

My hope is that CBT gets more attention as the standard treatment for BED. It really is effective and needs to be a critical part of anyone’s training to help people with this disorder.

The Risks and Benefits of the Online Focus on Food and Weight

The changes in eating disorder treatment discussed in the last post also reflect changes in the ideas of food and eating for a younger generation.

The flood of TikToks by people with and without eating disorders reinforces the idea that food choices and identity are almost synonymous. Normalization of the link between food and self is a sign of how society has begun to blur eating disorders and uses food as a sense of identity.

Rather than using these tools to find a new societal direction, they seem to have solidified the idea that food and weight are paramount in our society, thereby encouraging dieting and the risk of developing an eating disorder. 

The combination of social media and our isolation caused by the pandemic has only accelerated the chatter about food, body and identity. Body positive movements continue to grow so all the messages isn’t negative. However, there are two central dangers to this trend.

The first is that true, serious eating disorders are marginalized more and more. There is still a significant percentage of people who seek help who have serious eating disorders. These illnesses need to be diagnosed and treated. Experienced clinicians can differentiate between identity struggles around food and eating disorders. Appropriate treatment is critical early for these patients to have a chance to get better. It’s necessary that the growing trend around identity and food doesn’t stop these people from getting help.

The second critical change is that more isolated younger people see food and weight as a way to grow a sense of self and identity. Most of them won’t develop eating disorders, but they will be misled into believing that food and weight are appropriate and effective ways to grow psychologically and emotionally.

The explosion of content online about food, weight and eating disorders can consume much of one’s day and fill the space left by loneliness and isolation. The messaging is powerful and the communities strong and vocal. The new online treatment programs also make it seem that speaking up about food and weight is a worthy goal in and of itself. 

Certainly there is value in countering the food, diet and exercise industries but not at the expense of one’s own development.

Part of what needs to be communicated to younger people is that escaping food and weight does not mean solely jumping on the bandwagon. It also means leaving that world behind in order to focus on personal growth in all aspects of life and to find meaning elsewhere outside the inevitable emptiness that remains when food, weight and eating disorders are the focus. Recovery is a means to an end and that end is living life.

Thoughts about the Changing Face of Eating Disorder Treatment

Starting the new year, I have had broader thoughts about the eating disorder treatment field and growing industry rather than on the individual level.

The trend of venture capital-backed treatment companies expanding throughout the country now dominates the industry. Virtual treatment programs, a new option in the years before the pandemic, are exploding and even luring people who have long been in private practice. Psychology Today, the easiest resource to find treatment, lists many clinicians who indicate that eating disorders are part of their treatment expertise, but there is no license or coursework that exists to prove this specialty. 

The result is that the growth in treatment options continues to veer away from medical, research proven treatment towards capitalism and marketing. 

Overall, there are two ways to look at the broadened access to eating disorder treatment. On the one hand, the increased incidence of eating disorders during the pandemic has led to a much higher need for treatment, more than private practice providers could handle. On the other hand, these new ventures are often run by people with limited experience treating people with eating disorders. The lack of any clear standard of care enables the various new treatment options to operate without any real oversight or regulation. 

I go back and forth between concern about the overall quality of care and the need for access. It’s easy to err on the side of quality and criticize these new ventures, but in the end I think that is shortsighted and a backwards way to approach a field that does not stop changing and growing. 

When I compare the treatment options in the US to barriers patients of mine have faced all through Europe, I quickly conclude that it’s better to have imperfect options than none at all. Patients who sought help in their home countries originally found there was no help and they had to manage on their own. Living in the US now, they unanimously prefer some options to none.

It’s also critical to realize that the large majority of the new surge in eating disorders stems from the social isolation and fears driven by the pandemic. These newer cases will, for the most part, be less complicated simply because eating disorders of shorter duration are usually easier to treat. The longer the eating disorder exists, the more hardened it is in someone’s life. So online programs or the treatment options run by less experienced clinicians can be very effective for the majority of these cases. 

Perhaps that is the model of the future. Early or less severe cases of eating disorders can be treated in these broader programs and the more challenging or longer lasting cases can see individual teams in private practice.

No treatment model will be perfect. As long as we live in a world of diet culture, glorified thinness, a powerful food industry and the bombardment of body images on social media, the incidence of eating disorders will remain high. If this new model offers treatment to the largest number of people, that has to be a positive thing.