What is Eating Disorder Recovery Really About?

Eating disorder treatment is almost exclusively focused on meal plans and weight in recent years. The end goal of recovery is settling at the correct weight, and any obstacles in that path are signs of a recalcitrant patient unable to get well.

This formulation of eating disorder recovery is a complete misconception of what an eating disorder is and how people get better.

The first step in treatment does need to be restoration of regular eating and maintaining a baseline of health. Weight is one data point in that process but far from the only one or the most important one.

Regulation of food intake and overall health are treated as the central part of recovery. Since eating disorders are the only psychiatric illness with immediate medical consequences, a risk-averse mental health practitioner might feel overwhelmed by taking on this medical liability. I agree that stability is important but not as a way to sacrifice crucial psychological parts of getting well. The limitations of mental health clinicians can’t change what’s necessary for successful treatment, not if we really care what happens to the people we try to help.

Once enough stability is established, the true work of recovery begins. As hard as it can be to stabilize food, the psychological work is always harder.

Eating disorder symptoms have many powerful effects on daily life: clear structure to the day, unquestioned feedback of success or failure, immediate numbing of emotions and complete reliability at any given moment. In a world where none of these four is a guaranteed part of life, it’s very difficult to give up such absolutes for the vagaries and uncertainty of life otherwise.

Typically, the eating disorder symptoms start at a young age. Thus, people grow up with the four cornerstone benefits of an eating disorder and organize their lives and their identity around these core beliefs.

Recovery isn’t just about eating regularly. It’s about creating an entirely new sense of self and way to cope with daily life.

No wonder recovery must take on an existential quality. No wonder the therapy relationship must be so central to this transformation. No wonder eating is not just about food but about reengineering a new identity.

At the heart of this post is the concept of what eating disorder recovery looks like. The current state of the treatment field mistakenly says that eating and weight are the mainstays of getting well. The truth is that stabilization of food and weight is only the first part.

Recovery is truly learning about oneself, building a new way to function every day and exploring and building one’s own identity separate from the eating disorder. It’s a tall order, but this process provides the ability to live a full life.

Eating Disorder Clinicians Guide: Listen to your Patients

In the early days of eating disorder treatment, the days when psychoanalysis and intensive psychotherapy still predominated mental health treatment, clinicians realized that eating disorders stemmed from a feeling of not being heard. The essence of any successful treatment started with listening to the patient. The eating disorder represented a nonverbal expression of some deeper feelings and fears that nobody would stop and pay attention.

Despite the explosion of cases in recent decades, the widespread dissemination of idealizing thinness, the takeover of treatment by private equity and the newest onslaught of GLP-1 medications to eradicate any fat in the world, the essential truth about eating disorder treatment has not changed.

Providers cling to measuring weight as a sign of health in eating disorders, reflexively recommend HLOC (higher level of care) despite the evidence that these programs seem to harm the majority of their patients and use the trope of the “eating disorder voice” to promulgate blame as the most powerful tool to cow and silence people with eating disorders.

None of these interventions involve listening.

There doesn’t seem to be much teaching or guidance for clinicians anymore to listen to their patients. People with eating disorders are still people with viable and important thoughts and feelings, values about the world and beliefs about what is more or less likely to help them. Given the limited options for care, patients often give up and understand there aren’t many places to seek help. Even a small window of hope that someone will listen in treatment inspires a desire to get well very quickly.

Eating disorders can come with many concomitant issues: traumatic events, medical issues as discussed here in recent posts or terrifying social pressures. These similarities don’t eliminate the differing needs between individuals. Each person wants to be heard in order to find a path towards getting well.

Expansion of care has been a boon for people with eating disorders. Not long ago, the lack of access to care was the biggest issue in treatment. Much of this expansion came with financial firms investing in programs for a profit, not for quality of care. The treatment philosophy can be just as cost effective if clinicians don’t follow an exact protocol but instead follow the patient, listen and help that person find a way to pursue their own goals and the life they want to live.

Granted, any treatment still needs to involve working on food plans and enabling the patient to get to a healthy place in their life. Physical health can accompany mental health when personal goals and desires are just as important as the number on the scale. Listening to people is the only way clinicians truly make a difference.

Treatment for Purging and Chew-Spitting

Purging is a common eating disorder symptom often overlooked as a pernicious and insidious behavior. Too often treatment providers are very critical of purging without understanding the true reason why some people feel a strong urge to do so. Along with chew-spitting (chewing and spitting out food), these two compulsions often linger and resurface throughout the process of getting better.

Purging and chew-spitting both typically start as an attempt to manage fear of eating what feels like too much food, whether or not it is a binge. They rarely begin as intentional but rather as a way to undo eating that feels too overwhelming and terrifying to tolerate.

Binging can be involved in the process but often is not. The compulsive behaviors become the focus of many people’s eating disorder over time and can be difficult to stop.

These two behaviors have a very powerful and immediate emotional impact. They change the person’s mood and decrease anxiety almost immediately. Not only is the food eaten part of what feels overwhelming, but the intensity of the feelings preceding the action also feels too strong to bear and is wiped away almost immediately by purging or chew-spitting.

People who find purging or chew-spitting a powerfully calming tool incorporate these behaviors as a coping strategy at a young age. Over time, both can become a seamless part of daily life. Purging is very easy for many people and involves little effort. Chew-spitting becomes something people can do, even in public, without anyone noticing.

Also because these behaviors start at a young age, they don’t find other ways to tolerate or cope with the discomfort of intense emotion. Instead, they use these actions to manage their emotional state and go forward in their lives.

One big problem is there is no incentive or desire to learn other ways to live, and these eating disorder behaviors result in larger problems over time: incompatibility with relationships, limited psychological and emotional development and intense shame and guilt.

By the time someone is ready to try to stop the behaviors, they are very ingrained and almost automatic.

The treatment for these compulsive behaviors starts with cognitive behavioral therapy, namely food logs to identify triggers for purging or chew-spitting. Following the first steps, the core work focuses on learning new ways to identify emotions, process that awareness and learn how to tolerate the internal discomfort of having these feelings.

Sometimes the treatment is straightforward if the person can identify and manage the emotions more easily. For others, the compulsions are so woven into daily life that taking away the behaviors feels like ripping away the emotional fabric of their entire lives.

In addition, trying to separate shame from the behaviors is central to the treatment. Shame almost always reinforces the actions, but these are compulsions that often feel addictive and not within a person’s immediate control. Compassion for oneself makes a big difference in learning to be patient while making changes.

Purging and chew-spitting need attention in eating disorder treatment and have clear paths toward getting well. The therapy must reinforce the concept of the behaviors as compulsions to learn about and work on with compassion. That openness will allow for an understanding conversation over time and lead the way to get better.

A Meaningful Therapeutic Relationship is the First Step Towards Recovery

Recent posts address new parts of eating disorder treatment that are on the forefront of how to recover in today’s climate: the cultural and personal effect of the GLP-1’s and the overarching changes due to private equity investment in residential programs. As critical as those topics are, nothing changes the central pillar of treatment: the strength of primary therapeutic relationships.

Starting with the dawn of modern treatment for eating disorders in the 1970’s and early 1980’s, therapists versed in care for people with eating disorders knew that recovery needed an open, trusting, profound relationship in order to start the process of really getting well.

Eating disorders in almost every iteration cause severe isolation, reliance on a set of thoughts and behaviors that are powerful but all encompassing and a litany of shame, guilt and blame from all corners of modern society. A disorder people almost always fall into at a young age creates a prison from which there appears to be no escape.

A primary relationship opens a window out of the prison and, over time, invites the person stuck in the eating disorder to try stepping outside the cell to see what life might be like otherwise.

In the daylight, life is not sunshine and rainbows. Moving away from an eating disorder allows for opportunities to grow, learn and change many elements of life, but those changes can be painful and hard at times even if sometimes the results can be uplifting or exhilarating too.

The promise of a wonderful life at the end of recovery is not even close to the truth. The possibility for fulfillment and finding meaning is within one’s grasp without the eating disorder keeping that person in prison.

The primary therapeutic relationship allows for open conversation, time to explore emotions and thoughts and the option for true growth into a person no longer mired in disordered thoughts and behaviors and instead able to engage with the world.

The treatment world is increasingly filled with residential programs run like a mill, online treatment by anonymous clinicians and virtual work which allows both sides to hide behind a screen. As much as the increased access to care is necessary, the focus of treatment must remain on the clinical relationship. Trust and care are the bedrock of meaningful recovery. Openness and honesty allow for the personal growth needed to move away from complete reliance on an eating disorder.

I will continue to address the ways eating disorders and the treatment field change since these factors affect the process of recovery greatly. However, the fundamentals of treatment remain unchanged. A meaningful primary therapeutic relationship will always be the necessary foundation to get well.