The Context of Eating Disorder Diagnosis and Treatment

The overlap between culture and psychiatry is profound and always has been since the inception of the field. The dearth of scientific information to diagnose and treat mental illness combined with societal bias mean that psychiatry relies heavily on social values and cultural norms to determine treatment. Although other fields of medicine change from social impact, none do so more than psychiatry.

The definition of mental well being changes through generations. Success can mean many things: professional success, completing an education, a steady job with a family, a thin enough body, the ability to study or work 12 hours per day for weeks and months and years, or spiritual awakening. And the ideal mental state to attain many of these goals is extremely different.

Accordingly, dysfunctional mental states change drastically as social norms change. Odd or unusual behavior that is seen as mental illness now may have been adaptive in smaller, isolated villages centuries ago. A slow and steady temperament may be beneficial in some communities and seem as a sign of a learning disorder in others. Inattention that is a hindrance in school can be more creative and inspirational in times of societal distress. A thinner body may be ideal in certain towns and a sign of illness in a different community even in the same state.

As these norms change, psychiatry changes as well. Without a clear way to diagnose and treat illness, mental health professionals need to consider the world each patient lives in when thinking about diagnosis. What is considered an eating disorder now may not have been twenty years ago.

The point of this blog post is not to discount psychiatry and mental illness at all. However, we all need to be sure not to conflate psychiatry with clearcut science. The scientific data about the safety and utility of medications or research into best practices when treating eating disorders are sound. The philosophical and moral values about how to proceed in recovery is not only dependent on the person’s medical and psychological state but also on their background and community. Our individual mental health demands context in order to be defined correctly.

The Broad Changes Occurring in Eating Disorder Treatment

The changes in treating people with eating disorders have been dramatic in recent years. Several differences in how we as a culture approach mental health have opened the door to very new ideas about diagnosis and treatment.

First, mental health is a much more accepted part of overall health. We discuss our psychological and emotional well being as something to be monitored, addressed and taken seriously. The idea that we should tough out difficult experiences and ignore our emotional selves is not the only way to function anymore. Awareness increases the likelihood that family or friends will notice changes in eating behaviors or emotions and say something a lot sooner.

Second, knowledge and education about eating disorders are much more available and prevalent. Mental health awareness is a part of this change, but in addition most people know what eating disorders are and many more people have experienced someone close to them who has struggled with one. Social media exposes people to eating disorders much more regularly, and younger people have a larger breadth of knowledge not just about eating disorders but also diet culture and fat phobia.

Third, the expansion of care with many more treatment programs, virtual programs and clinicians for people with eating disorders makes it possible to be diagnosed and treated much earlier in the course of the illness. Since so more options now accept insurance, many more people have access to care. Treatment options means many people can get help and find a path to recovery sooner in their illness.

Compared to the relatively recent past, these changes are shocking to consider. The majority of people with eating disorders used to struggle for years before figuring out a diagnosis, let alone find any professional help, but that path is much less common these days. I am much more likely to see a young patient who understands their issue and the help they need than a patient ten years older coming to treatment for the first time.

This post reflects an important aspect of mental health care, namely how psychiatric diagnosis and treatment changes with cultural changes in our society. I’ll talk more about that in the next post.

The Contradiction Between Love and Perfectionism in Eating Disorders

The last few posts reviewed some central parts of the psychological underpinnings of an eating disorder and, accordingly, aspects of treatment that help people fully recover. Finding purpose, self-worth and a philosophy to make life meaningful are true antidotes to perfectionism, self-hatred and purposelessness.

At the time, I was very clear about how people with eating disorders often felt unlovable but was unsure as to how to couple this experience more fully with recovery.

In the last two decades, the pressures on women grave grown and changed in ways that have been instrumental in the explosion in the incidence of eating disorders. The contradictory messages of being both extraordinary and mediocre, perfect and one of the group, exemplary and also humble easily conform to perfectionism around food, body and weight. These impossible expectations both in their behaviors and in their food and bodies for women fit neatly into the paradigm of traits that create an eating disorder.

What underlies these impossible expectations is the feeling of never being good enough at anything—a tenet of the thought process of an eating disorder. In addition, never feeling allowed to reach a reasonable goal translates into never feeling lovable or worth loving. If love demands perfection, then no love ever seems reasonable or deserved. Love needs to reflect the feeling of being good enough, not being perfect, just as recovery implies doing well enough both with food and in life.

The learning process of understanding love distinct from perfection starts in therapy. Someone in the throes of an eating disorder and the concomitant perfectionism can’t see outside that bubble. Therapy that balances the idea of love for who you are instead of what you accomplish or what you represent can change the fundamental idea of what love is and is a key to recovery.