Access to Eating Disorder Treatment, Part II

The increased access to eating disorder treatment had a particularly significant effect during the pandemic. In many ways we—patients and clinicians—are all fortunate for the changes in the treatment landscape which occurred the years prior to COVID.

The incidence of eating disorders rose dramatically during the pandemic. Many people have theories about the cause in this rise including worsening mental health, social isolation and the inundation with social media images in the first year of the pandemic. The possible causes matter less than the response.

Even just a few years before 2020, the eating disorder community lamented the enormous shortage of treatment centers. There were few options across the country. Many areas of the country had no options at all. The result was that a large percentage of people with eating disorders never sought or found appropriate care.

In 2020, there were often long waitlists for treatment. However, the key point is that those people could find treatment even if they had to wait. In addition, the plethora of treatment centers also led to more clinicians in the community with experience either working in or with those centers. Thus, patients in the community were more likely to be diagnosed and appropriately treated during the rise in cases during the pandemic.

To be clear, I do not work with any of the national companies running treatment programs, nor do I have any stake in their success.

I have seen the changes in the eating disorder treatment landscape in the past two decades. Many clinicians reflexively lament the financial companies which have corporatized treatment, and those criticisms are valid. But any clinician who remembers the lack of options for care needs to admit that there is more access to care than ever before. Let’s hope these changes continue to add value to patient care and also to decrease the overall stigma around eating disorders.

Escaping the Eating Disorder Prison from the Pandemic

The increased incidence of people developing or relapsing with eating disorders during the pandemic is well documented.

One fundamental cause is the lack of external structure during the periods of isolation. Without any interruptions, people whose eating disorders have very rigid rules experienced a hardening of those rules. Nothing interfered with the rigidity, and the eating disorder became more powerful than ever.

For many at this point, some life experiences have returned thereby creating an external structure again. However, after most of the last two years trapped in the limitations of the eating disorder world, returning to the real world is very difficult.

Although this may constitute a relapse, a better description is the increased power of the eating disorder rules and the confinement within the limitations of the illness. The result is a newly imposed prison by the eating disorder even while the prison of the pandemic is no longer as all encompassing.

People trapped in their eating disorder have forgotten how to be flexible enough with food to see friends, go out to a meal, attend a function or even break up their day by having plans. The mundane elements of a regular life seem impossible since they interfere with the minute and powerful rules established by the eating disorder.

Experiences that were well within someone’s grasp prior to the pandemic now appear to be far out of reach.

The treatment is clear and very important. Exposures to these new events and facing the barrage of eating disorders thoughts in the process are imperative. Anyone trapped by their eating disorder needs to begin to push back against these rules and not let the eating disorder remain dominant in the face of opportunities to resume some form of normal life.

The urge to put off these challenges will be great. Heeding the urges will only harden the behavioral changes of the pandemic and make them more challenging to overcome.

Recognizing the urgency of the situation is necessary. The changeable nature of the pandemic can’t be a reason to allow these behaviors to continue. Exposure to new experiences, breaking eating disorder rigidity and trying to experience life again are all critically important.

Why Access to Eating Disorder Treatment Matters

The drastic changes in eating disorder treatment in recent decades has been extraordinary. The first treatment centers were based in a few hospitals across the country in the early to mid-80’s. The next two decades saw the rise of independent residential treatment centers often founded by recovered clinicians. The last five years introduced the corporatization of programs into national institutions.

A relatively obscure set of diagnoses have turned into a cultural touchstone and now big business. But the question that remains is how to give the best care to people struggling with eating disorders.

The most recent corporate model for treatment provides more access to care but much less personalized and less experienced care. Centers have opened up across the country and are then staffed often with relatively new graduates.

The overall trend of treatment has led to increased opportunity to find help and that’s extremely important, but that care is, on the whole, less effective overall. A corporate structure can’t provide the same individualized care as a stand alone center.

The complaints about the new business model in the eating disorder treatment community abounds. After being spoiled by personal, caring providers, the transition to a corporate approach is hard to swallow. But the transition also reflects a growing need. The incidence of people with eating disorders who need help continues to grow. And the population of these people has spread beyond the community who first got sick and includes all different kinds of people from all different kinds of backgrounds. Eating disorders know no bounds.

It was only a few years ago when residential treatment was a luxury afforded only to people who lived in the right part of the country and who had the financial means to afford it. The corporate model has spread this treatment more broadly geographically and accepts many insurance plans. Accordingly, access to care is now possible for many more people who need it. It’s hard to complain about that.

What’s also hard to fathom is that the US appears to have more treatment for eating disorders than many other countries. Having spoken to people with eating disorders from the UK, Germany, Mexico and Australia—all places with access to good health care—treatment was hard to find in their countries. In fact, people from many other countries come to the US for residential treatment because there is no similar option at home.

Although it’s easy and reasonable to point out the flaws in the eating disorder treatment industry, the value of adequate, accessible care is very high. People in need deserve care.

The True Shame about Binge Eating Disorder

People with Binge Eating Disorder (BED) frequently wait many years before first seeking help. It’s not uncommon for people with BED to have struggled with the eating disorder for 15-20 years. Even though the most recent DSM finally included BED as a definitive diagnosis, the recognition and treatment of this disorder are still very limited.

There are several reasons this is the case.

The first is that anorexia and bulimia are still considered the only true eating disorders. Based on decades of exposure in the media, these two diagnoses remain most visible as eating disorders and most acceptable diagnoses in this culture to allow people to seek treatment.

Second, fatphobia continues to be central not just in our society but also in the eating disorder treatment world. People with BED are often in larger bodies and the false statement that only people who are underweight can have eating disorders remains very strong.

Third, these two factors only increase the amount of shame people with BED experience. The overall cultural message is that BED is a personal failure and lack of willpower, not a true illness. The diet industry exploits people with BED and robs them the ability to seek help earlier on their lives. All these pressures stop people with BED from even realizing there is help to find.

The most unfortunate part of this scenario is that BED is also the most easily treatable of all eating disorders. Cognitive Behavioral Therapy is very effective in rooting out the thought and behavior patterns of binging. The treatment can quickly enable people to understand the pattern of binging, see the emotional roller coaster that triggers binges and apply new strategies to regulate eating.

Overall, the eating disorder treatment community needs to be sure people are aware of the BED diagnosis and seek appropriate care. The real shame is the unnecessary suffering of so many untreated people with BED.