Discussing Body Image in Eating Disorder Recovery

When discussing body image with someone with an eating disorder, the difficult concept to understand is that the person’s actual body is not the issue. As much as the conversation revolves around their actual body, it’s the body image that’s in question.

For a clinician, family member or friend, the urgency of the discussion around body is very powerful. It feels like a reasonable conversation about how the person looks and whether or not their body has changed and that it needs immediate attention.

However, the essence of body image distortion is that the person cannot really see their body. Instead, the thoughts and images in the person’s mind don’t reflect their actual body. These thoughts are dominant and painful, but there is no resolution by explaining how the thoughts are distortions or rationalizing how these thoughts can’t be true.

Body image thoughts at their core feel true. They cause so much internal stress because it’s impossible for the person to question them and see how they are false. Instead, the thoughts circle in their mind and the urgency that comes across in conversation is due to the strong desire for the thoughts to stop.

There is no reasoning that will make them go away.

The way to support someone struggling with body image thoughts is to not discuss their body no matter how frustrating that is for the person and no matter how counterintuitive it feels.

The key to this part of recovery is to focus on the fact that one’s body knows how to respond to regular food or how the person will be able to learn how to function with a body that is nourished and healthy or that the goal is to focus on living. It may seem impossible but it’s crucial to know these thoughts will diminish in time by taking these steps.

Sidestepping the need to talk about body image consistently can provide a framework that pushes aside the body image thoughts. By diminishing the importance of this distortion, the person can focus on the necessary steps of recovery and not get lost in endless ruminations.

Thoughts about Treatment of Body Image

The treatment of body image is critical to eating disorder recovery. Since the urgent desire to lose weight is central to how an eating disorder keeps a hold on someone’s psyche, loosening that grip is necessary for someone to get well. Not only does a person in recovery need to eat regularly and consistently, but they also need to be able to tolerate however their body responds and to let go of the fantasy that the goals of weight loss and a perfect body is possible.

There are several components to facing body image. The process has both physical and psychological components.

First the person needs to better understand how weight and bodies work. We are taught in modern day diet culture that our body and weight are something we can control. Thus, any change in our bodies that is unwanted is considered to be our fault.

This idea could not be further from the truth. Weight, like many other factors about our bodies, is a variable the body uses to maintain health and stability. For instance, gaining a few pounds from a salty meal is a safe way the body processes and excretes extra sodium. Weight changes reflect how our bodies respond to situations and keep us well. The idea that we manage our weight based on our food decisions each day conveniently ignores basic human biology.

Similarly, thoughts about body imply that we can see our bodies clearly and truthfully. However, it is very difficult for us to see how we look. Our brains can process other people’s bodies more clearly but have trouble seeing our own physical self objectively. And this is much more exaggerated in people with eating disorders.

Often people with eating disorders say they feel good in their bodies one minute and then horrible a couple of hours later after a meal. Clearly, a body cannot change in a few hours. Our feelings can change, but our feelings are not immediately reflected in our bodies and weight.

When people say they feel fat, they usually mean they feel an emotion that is difficult and negative. Rather than identifying and reflecting on this feeling, the emotion turns into a negative body image thought. Distinguishing between a feeling and a thought about one’s body is a big step towards facing body image.

Last, body image can be very connected to identity. The goal of reaching a certain weight or clothing size is intertwined with an overall sense of self. If weight is the only way to find a positive self-image, then the treatment goal is to create an identity outside of one’s body.

The problem with developing an identity solely around weight is that there is no room to grow as a person or even to see oneself as a whole person. If all personal goals are about the physical self then there is no attention paid to an internal self, thoughts or feelings—the things that truly make up who we are.

Working on body image is necessary for true recovery. The treatment involves a clear understanding of how weight is a part of how our bodies function, the conflation of emotions and body and the need to create an identity outside of body image. These different ways to understand and change body image can help someone go from partial to full recovery.

Eating Disorders Caused by Physical Symptoms

Although eating disorders are psychiatric illnesses, there are instances when a physical symptom causes the disorder to begin. Any symptom that leads to a prolonged difficulty eating has the same effect as a prolonged diet. Even if the food restriction is not psychological in nature, the eating disorder thoughts can arise since they are an adaptive response to food restriction, no matter the reason.

There are many examples of a symptom-induced eating disorder. Any illness that affects digestion such as Crohn’s disease, IBS or gastroparesis. People who have a problem swallowing or who regurgitate their food can develop an eating disorder. Severe constipation can make eating very difficult over time. And people who have a very limited ability to tolerate taste and texture can struggle to eat enough and develop an eating disorder.

Frequently, these people feel much more confused about how they developed an eating disorder and whether or not they even have one. At first they don’t have any of the other manifestations that come with most eating disorders and can’t easily identify with eating disorder treatment.

However, they start to have the same psychological symptoms in time: fears of gaining weight, starvation hunger and the powerful drive to eat, urges to binge and/or purge. Their symptoms begin to look more and more like an eating disorder the longer they go without normal eating.

These patients need to understand a few things that are different about their condition. They won’t need to focus as much on eating disorder thoughts at first. The physical trigger is a critical part of understanding what is happening so they need to make the best decisions to try to fix the underlying condition.

And for them quick and complete nutrition will help them get better much faster than most people with eating disorders. The psychological symptoms are usually more mild at first and they usually get diagnosed early since they are getting medical help for the primary condition. If they can nourish their bodies and minds quickly, the eating disorder thoughts will fade.

These cases are good examples of the varied ways an eating disorder can begin. Eating disorders are the brain’s adaptation to prolonged starvation of any cause. But taking into account the cause will lead to the most successful course of treatment.

The Impact of Virtual Eating Disorder Treatment

As the pandemic enters the third year, many people are taking stock of how things have changed in their lives. It’s trite these days to say things won’t go back to the way they were, but that’s the truth. And eating disorder treatment is also changed forever.

I have written about some of these changes in recent months. The increased incidence of eating disorders during the pandemic has strained the treatment community and made it even harder to find help. The growing residential treatment industry continues to be inundated with new patients. Online resources which provides more access to general care is a new, growing business. Advertising on social media has promoted the idea of health with respect to food and body.

These changes are here to stay and will only grow in the future, but nothing has led to a more profound shift in eating disorder treatment than virtual sessions and virtual clinical practices.

I and many of my colleagues had virtual sessions before the pandemic for many years. The growth of virtual care had been slow but steady both as technology improved and as the health care system accepted virtual sessions as a norm.

The pandemic led to 100% virtual care which matured this new provider system very quickly. The convenience and ease of virtual treatment appealed to both patients and clinicians. The healthcare system fast forwarded its acceptance of remote care. And treatment approaches adapted to accommodate some of the new barriers imposed by the screen. 

But what was most important is how virtual sessions have improved access. People who live in communities distant from eating disorder clinicians, students away at college or people who moved because of the pandemic suddenly had as much access as anyone. The imbalance of treatment and the dependence on location no longer applied. The seemingly unsolvable problem of access to care was solved.

It’s amazing how a crisis can sometimes reveal a solution that was right in front of our noses. And with the revelation that virtual sessions can be effective, real treatment is now available to almost anyone who needs it. That’s a true achievement in the field.