The Traumatic Effects of Inpatient Treatment for Eating Disorders

Traumatic responses to inpatient and residential treatment have many facets and interfere with one’s ability to find and commit to successful treatment. 

First and foremost, the trauma of treatment programs causes a lack of trust for clinicians. In programs, clinicians usually promise health and happiness by committing to a new meal plan, but the reality of eating and disobeying eating disorder thoughts and beliefs feels painful and frightening.

The disconnect between trust in clinicians and the outcome of following their advice convinces many patients that clinicians are not in fact to be trusted. Patients learn that it’s more advantageous to negotiate with providers rather than to trust them. The result is that the ultimate goals of the treatment team and the patient feel at odds. 

Once out in the world, trusting clinicians seems almost absurd after feeling so betrayed in programs. Without any guidance, people rely on their eating disorders, refuse to speak frankly with their treatment team and often relapse quickly. 

The experience of feeling trapped while eating and gaining weight fulfills the worst nightmare and deepest fear of many people with eating disorders. After living through such a difficult time, patients talk about reliving moments of terror in programs and how alone they felt while in treatment. Any suggestions to adhere to a meal plan or work on food consistency feel like a reenactment of treatment and engender the same feelings.

Moving forward in recovery in the world often means facing these traumatic memories of treatment first. For many people, finding a path towards a recovery entails undoing much of the effects of treatment. 

The other most important traumatic experience of programs is the drastic change in one’s body. Body image thoughts and fear of weight gain are central to most people with eating disorders. Programs often lead to a rapid change in one’s body, and handling the traumatic fallout of this transformation is painful.

For many patients, the only recourse of to lose weight as quickly as possible to regain a body that feels comfortable. Even if this impulse is not intended to lead to relapse, any attempt at weight loss triggers a relapse most of the time. 

The transition to outpatient treatment not only means learning how to eat on your own without the structure of a program. It also means facing these important traumatic elements of treatment in order to make recovery possible at all. To be clear, many people have positive and helpful experiences in treatment. Trauma is far from universal but is a real effect many people with eating disorders experience.

Healing the Trauma of Residential Treatment for Eating Disorders

People in recovery from eating disorders often need to address the trauma of being in treatment programs in order to fully get well.

Hospital stays and residential treatment are often, but certainly not always, a necessary part of recovery. Critical medical issues need attention and sometimes a hospital stay is necessary. When people experience prolonged, severe eating disorder symptoms, residential treatment may be the only way to normalize eating enough to continue down the path of recovery.

Patients who understand their illness usually agree when it’s time to go into treatment as well, even if they are reluctant.

The trauma of being in treatment can stem from being forced into the program, especially if the patient is young, but often trauma occurs even when the patient decides to seek help themselves.

Treatment programs render the patient powerless and helpless. They have to stay on the physical premises and are only allowed out on arranged outings. They must eat what is in front of them, no matter how frightening or overwhelming the experience, five to six times daily. They need to tolerate any changes in their bodies, no matter how sudden. For the first few weeks, they cannot even go to the bathroom themselves for fear they may engage in eating disorder behaviors.

In addition, patients need to adhere to these rules while attending individual and group therapy sessions where they are expected to talk about deeply personal and sensitive topics. It’s hard enough to broach those topics in the best of circumstances, let alone when the person is locked away without any rights, independence or agency.

Weeks or months of being trapped without any say and forced to do the terrifying act of eating many times per day while one’s body changes, often very quickly, is frequently traumatizing.

The expectation after treatment is that patients will continue their meal plan, ignore the emotional fallout of weeks or months in treatment and recover swiftly.

Clearly there is something missing in this plan for eating disorder recovery.

After discharge from treatment, patients need to start to talk about their experience immediately. Not only is it harder to eat without being forced to do so, but a common response to being so powerless is to assume power back with eating disorder symptoms. Paradoxically, the traumatic experiences reinforce the eating disorder itself. Patients need to talk through their experience and feelings immediately in order to not fall into the most common pitfall after discharge.

In addition, discharge plans from treatment need to focus on the food in a compassionate and supportive way. The draconian methods used in programs will backfire in the world. Force does not create an path to recovery.

Last, patients need to know they will be in charge once they are out in the world. The experience of being trapped and overwhelmed renders people scared and alone. Retreating to the eating disorder feels like the only way to regain any sense of safety and security.

This topic is even more important with the growth of treatment programs in recent years. Therapists need to be ready and capable of ensuring patients get compassionate care after discharge from programs.

The Existential Nature of Eating Disorder Recovery

Treating eating disorders frequently leads to an existential conversation. There are many theories why recovery inevitably lands in discussions of the meaning of our lives. Nevertheless, the work of getting better apparently necessitates delving into why we are here.

In part, people with eating disorders are very coherent and clear in all other aspects of their lives outside of their own food and weight. The symptoms of every other psychiatric illness bleed into daily components of human life, but eating disorders are much more circumscribed. The result is that someone with an eating disorder can have a lucid, insightful conversation about their illness even when they are struggling to get better.

No matter how they start, eating disorders become the foundation of the meaning of life. Success is determined by the actions of that day: food eaten in the day, the number on the scale, avoiding food behaviors, the number of steps, to name a few. Or the eating disorders provide emotional needs not found elsewhere: comfort, companionship, guidance or praise.

Stepping away from an eating disorder and attempting to live without the feedback and direction the illness provides instantly leads to questions about what life means. The eating disorder provides clear answers about what makes life worthwhile. The immediate question is why else does life matter when the eating disorder begins to seem meaningless?

For most people, recovery cannot exist in a vacuum. People who try to change their behaviors, without any other part of life providing value, don’t see a reason to continue the hard work of recovery. They peek out at the world, perceive only emptiness and dive headfirst back into the disorder.

Successful recovery demands that other parts of life start to matter as well. As the eating disorder behaviors and thoughts recede, the person often finds they are drawn to focus on and think about these other facets of their existence. At first, that may mean broadly talking about what matters in life, but the transition is not fluid or easy and almost always torturous and challenging. Missing and grieving the distance of the eating disorder feels painful, and figuring out how else to live is complicated and confusing. It’s hard to start with no idea about how to live after having a guiding light one’s entire life.

These conversations need to give room for the uncertainty of our existence to remain a focal aspect of getting better. The existential nature of recovery is one we all find familiar. We all face the reality of our existence, and any therapist can identify with the fears of trying to find meaning in our lives.

Even more, the goal of thinness has a powerful place in generating meaning even outside of eating disorders. It would behoove us as a culture and country to rethink thinness as an accomplishment that gives meaning to our lives. A cultural phenomenon is now a capitalist boon to several powerful industries. We all need to recognize there has to be more to life than a number on the scale.

The Risk of Referring to Eating Disorder Programs too Quickly

The growth of residential eating disorder treatment in recent years expands access to care in ways that were unimaginable a decade ago. Programs accept many insurance plans. There are so many more programs across the country. I look back at posts on this blog from a decade ago, and one main takeaway is how few options there are for treatment. What a needed and rapid change!

Availability of treatment for a broad swath of people with eating disorders is a huge relief. I have spoken about many of the concerns about these programs—many of which are now owned by private equity companies—but it’s important to recognize the benefits as well. Many more people sick with eating disorders can receive adequate and timely care.

An unexpected result of these improvements is a more myopic view of eating disorder treatment for outpatient clinicians. Before, referrals to “higher level of care,” i.e. treatment programs, were held at a higher threshold. The limited availability of programs made this referral more of a last resort.

With so many programs accessible and covered by insurance, it’s a lot easier for treatment teams to consider a program even after someone struggles for a brief period of time. There is less patience on the whole in outpatient treatment for patients to have a chance to try new ways to get well. Treatment programs can stop an immediate slide in symptoms, which often puts the clinicians’ minds at ease when facing a patient not doing well.

Programs may excel at making people eat, gain weight and regain health; however, in a bubble protected from the outside world, patients don’t learn how to cope with life while maintaining recovery. Cycling in and out of programs typically leads to patients who are demoralized and lose any sense of who they are outside the eating disorder. Too many of them lose hope for recovery.

The hardest part of recovery is the work done out in the world, not just the eating but dealing with the feelings that arise when eating behaviors are stable. That’s the work people in recovery need help with the most.

A treatment team needs to be able to tolerate the ups and downs of recovery in the world in order to let the patient know she has the support to get well. Clinicians need to remember it’s also their job to tolerate when a patient struggles. Resorting to treatment programs too quickly only reinforces the hopelessness of recovery rather than the projecting the belief and confidence that getting better is really possible.