The Power of Relational Therapy in Recovery

Therapy focused on tools and techniques, as described in the last post, is a primary mode of treatment at the present moment. Often, it feels as a therapist as if referrals to programmatic treatment such as DBT, CBT, EMDR, IFS et al. are the only appropriate and recommended options for care.

As the world becomes more scheduled and filled with content, our communal focus becomes consumption rather than having the space to create and learn.

Therapy seems to be going in the same direction. All of these targeted therapies have their place, but in the end we are all individual people with our own feelings and experiences. Any steps toward healing must include the space to grow and learn and create a truer sense of who we are and what matters to each one of us.

This type of therapy also has a name: relational or interpersonal therapy. The theory of this kind of work is that creating a safe and real therapeutic relationship in which the goal is to create space for the person to grow and reflect and learn about oneself all while experiencing care, kindness and affection. This therapy can lead to true healing not just of symptoms but of the individual.

For people with eating disorders, this therapy is immensely helpful. People with eating disorders typically have a very powerful negative voice or thoughts in their mind which criticizes and berates them at every turn. They may feign happiness and smile, but most people with eating disorders go through life with the burden of negative thoughts at all moments.

Recovery stops the eating behaviors and then needs to quiet and hopefully disempower these negative thoughts. The tools and techniques mentioned above can be useful for initial steps but won’t be enough to identify and strengthen a true sense of self.

Only a strong and true bond with unconditional support really makes a long-term difference. The therapeutic relationship needs to be real and to feel real so the person knows they have the freedom to grow and learn about themselves and still feel respected, cared for and loved.

I’m a big supporter of all the tools available that can help people manage anxiety, mood regulation and other concrete symptoms. However, I believe that relational therapy is the cornerstone of eating disorder recovery.

The Swift Disappearance of Body Positivity

The trend towards body positivity and acceptance of all body types was broad and welcome but apparently short-lived. The relentless onslaught of GLP-1 agonists (Ozempic et al.) rapidly ensured that the glorification of thinness returned to the fore.

Body positivity on all media platforms, and even in clothing companies, opened the door for people to start to accept their bodies as they were made. Seeing models and influencers in all sorts of bodies and wearing all sorts of clothes was incredibly liberating for people in all shapes and sizes.

The movement lasted long enough for people with a strong negative self-image to start the process of healing. We are all inundated with images each and every day so a wider view of the human body was novel and exciting.

The GLP-1 agonists swept the country and wiped body positivity out very quickly.

Capitalism worked swiftly and at its best as the overwhelming demand for these drugs took hold. Doctors set up online rent-a-doc sites for quick prescriptions. Compounding pharmacies ramped up production to meet the demands for people who either could not find the drug in stock or couldn’t get insurance to cover it. People were willing to spend $1000+ monthly to procure the magic shots.

Such a societal craze led a majority of people to follow the trend. The need for the drugs frequently overrode any forethought into whether or not starting the medication was a good idea. There was no intention to end the body positivity movement. If there is a new and supposedly easy way to fix an old obsession, most people will forgo the new idea and reach for the quick fix. Body positivity just disappeared.

The reckoning for this communal decision is starting. People have to go off these drugs for short-term and long-term side effects. The medications often don’t work or the effects don’t last. People can’t afford to go into debt to continue the medications, and they only work if you keep taking them.

What happens next? Does everyone go on the new drugs coming out in years to come? When it becomes clear the drugs aren’t magic, do people return to focusing on thinness at all costs?

Or is it possible to return to body positivity so that this new approach to being a human isn’t just a short blip in our culture? I truly hope this last option comes true.

The Battle Between Psychodynamic Psychotherapy and Learning Psychological Tools

Psychotherapy as a whole continues to broaden from a journey of self-exploration and discovery to an “evidenced-based” program focused on scripted treatment and an accumulation of tools in the toolbox.

The shift has many causes. Insurance companies increasingly prefer the latter kind of therapy since it is time-limited and thus less expensive. The drive in the medical field to justify treatment leads to overvaluing supposed proven therapies and undervaluing long-term therapy. The social emphasis on a broader definition of psychopathology means people seek therapy to fix psychological issues rather than a means to learn more about themselves and how to live in the world. New online therapy options prefer goal-oriented sessions since no one gets a regular therapist in that setting.

I am an advocate for learning techniques and tools. Anxiety disorders, for instance, are well-suited to this type of intervention. Cognitive Behavioral Therapy (CBT) is very effective for panic disorder and OCD, and binging behaviors as well. PTSD Is best treated in part using techniques to help calm one’s nervous system.

However, there are many other reasons people seek therapy. The therapeutic relationship, in which a close, emotionally charged, vulnerable connection grows amidst clear guidelines and precautions to create safety, can be very therapeutic. This relationship is especially crucial in eating disorder treatment to help someone take often frightening steps to change ingrained behaviors.

Therapy also provides the opportunity to explore a better sense of oneself and how one interacts with people in the world. The possibility to do meaningful creative personal exploration and work is singular for many people in their lives.

The key is incorporating the newer goals of tools and structured therapy with the need for more profound and creative exploration. There is no need to pit one form of treatment against the other.

Certainly eating disorder work demands both specific tools and broader personal goals to make behavioral change. But peeling away the long-term effect of living with an eating disorder demands personal, meaningful work and change.

The Cautionary Tale of ADHD and Eating Disorders

The shift in diagnosis and treatment of Attention Deficit Hyperactivity Disorder (ADHD) in the last ten years for people with eating disorders strikingly shows how underlying bias can affect clinical care.

Until about a decade ago people with eating disorders who thought they might have ADHD were immediately branded as drug seeking for stimulants like Adderall or Ritalin. These medications are known to suppress appetite and can cause weight loss at higher doses and when abused. In fact, as many people are aware, there is a black market for these medications not just for studying in school but for weight loss.

No clinician seemed curious to know if there was a link between ADHD and eating disorders.

Instead these patients became suspicious characters, untrustworthy and hopelessly lost in their illness and to losing weight.

As I have written about recently in several posts, social media and the subsequent communication of people with eating disorders spread the word about a possible and likely correlation between eating disorders and ADHD for some, if not many, people.

Girls are frequently more overlooked for ADHD as borne out in research. Subsequently, women with eating disorders may have never been screened or even considered to have ADHD. It was more difficult to find doctors who would diagnose adults with ADHD a decade ago so these people had to move ahead without more help.

Now, many women are much more likely to wonder about the diagnosis, seek testing and possible treatment. Many of these women do have ADHD. Recent research indicates that the anxiety and agitation caused by untreated ADHD can lead to eating disorder symptoms. The numbing and calming effect of an eating disorder often minimizes ADHD symptoms. Treatment with stimulants paradoxically leads to eating disorder recovery and not weight loss.

The story of suspicion and mistreatment of women with ADHD and eating disorders is cautionary. Clinical treatment sometimes follows bias or misunderstanding which can be harmful. Intellectual curiosity and the desire to help people recover needs to be the motivating force for medical care.

Clinicians of all types need to be open to new ideas linking various psychiatric and medical disorders. A variety of ways people with eating disorders may be coping often isn’t maladaptive behavior but indicative of a mode of treatment thus undiscovered.

Eating disorders are so universal and many people may fall into eating symptoms for a number of reasons. Assumptions about a person’s intent only interfere with an attempt to find wellness. Inherent biases are everywhere and awareness of misconceptions is the best way to avoid falling to that trap for any provider.