The Political and Social Biases of Eating Disorder Treatment, Part I

Not much has been written about why most people with eating disorders are women. The standard explanation is that the pressure of thinness and dieting is much stronger for girls and women. Since undereating is the number one risk factor for developing an eating disorder, this explanation has some merit. However, it feels like a facile and elusive way to understand a much more complicated situation. 

Psychiatry has often used certain diagnoses to explain women’s emotions. Hysteria, fainting spells and erotic fixation are examples of ways the mental health establishment has attempted to silence and pathologize women’s human reactions, whether emotional or sexual.

The question psychiatry and the eating disorder treatment world needs to address is whether eating disorders represent the newest way to silence women.

First and foremost, I know these illnesses are serious and real, much as the other illnesses I mention above are real. In no way do I doubt the severity of these disorders.

The problem is how psychiatry uses these illnesses to quiet women and explain away valid emotions women express.

For instance, most psychiatrists can compete their entire residency training program learning very little about how to treat people with eating disorders. This is odd considering how prevalent eating disorders are in this country. Accordingly, most eating disorder treatment exists as privatized business outside of the medical establishment and one that very often excludes the treatment of men. In fact, many eating disorder treatment programs openly endorse a feminist slant to their treatment, politicizing the existence of eating disorders. 

Sometimes, as most laypeople assume, eating disorders stem from a desire to look a certain way in order to invite attention to physical appearance. Much more frequently, eating disorders serve as a way to be more invisible either by being very underweight and resemble a young girl or by being overweight and effectively invisible in a fat phobic world.

I have written extensively about the treatment of eating disorders and said multiple times how the core of treatment involves close personal connection and that the antidote to an eating disorder is love.

These facts and treatments are very different from the treatment of any other mental illness such as schizophrenia or bipolar disorder. Clearly, there is a strong social component to this illness, and one aimed specifically at women.

The difficulty with these revelations is how to address them. I’ll write more about this in the next post.

Facing Eating Disorders as True Medical Illnesses

By considering the reality that eating disorders can be fatal, it’s hard for a loved one or clinician to ignore the severity of these illnesses. It’s too easy for people to minimize eating disorders as extreme diets or a passing phase to lose weight, but there is a stark difference between some weight fluctuation and serious medical illness. 

People with eating disorders find that their lives are taken over by the thoughts and behaviors. Attending to work or schoolwork becomes more difficult. Friendships tend to go by the wayside. One’s personality fades in order to accommodate the eating disorder. Any life goals that seemed important don’t matter in the same way anymore.

Someone may get distracted by a diet or weight loss plan for a few weeks and become upset once the period ends, but that person isn’t likely to lose track of everything and everyone that matter in life. The obsessive focus on eating disorder goals is all that is important to a sick person. This singleminded goal combined with the loss of everything relevant to that person are the key distinctions between an eating disorder and a diet.

Once that line is crossed, loved ones and clinicians need to stress the severity of the condition. Without adequate treatment, eating disorders can be chronic, even life-long illnesses, and compromise quality of life and longevity.

Treatment is not a guarantee of health and recovery and tends to take time, but minimizing the illness and avoiding necessary steps to get help can be dangerous. The risks to health and living a full life are great. Stressing this reality can make a difference in the long run.

Mortality and Eating Disorders

Eating disorders are so often misunderstood by laypeople. It’s too easy to chalk up the food behaviors to a desire to lose weight and disregard the severity of the symptoms. 

What’s even harder to comprehend is how these illnesses are not only debilitating but can be lethal.

I focus more often in this blog on the eating disorder behaviors and the psychological component of these disorders. Just as important in managing eating disorders is taking care of the medical complications. 

Purging and laxative abuse can lead to electrolyte abnormalities which cause two serious long term medical issues. The first is an abnormal heart rhythm from a low potassium level which can lead to death. The second is kidney dysfunction and even kidney failure necessitating kidney transplant. 

Starvation can cause poor function in many organ systems: metabolism, temperature regulation, heart function, brain function including cognitive symptoms and emotional dysregulation, bone marrow suppression leading to susceptibility to infection and anemia and the list goes on and on. The true takeaway is that starvation can cause any system to shut down. Whichever part of the body is more vulnerable is the one likely to shut down first. 

And even more central is the hopelessness many people feel when in the throes of an eating disorder. Being so trapped makes many people feel helpless enough to consider or even attempt suicide.

The combination of the myriad medical consequences of eating disorders and suicidal thoughts makes an eating disorder much more than a desire to lose weight. It’s crucial to take these illnesses very seriously and understand how often an eating disorder can take a life.

Two Things to Look for in Eating Disorder Treatment

Even though the prevalence and severity of eating disorders has become clear to clinicians and laypeople, it remains very difficult to find skilled practitioners who can assess these illnesses and find he best course for treatment.

There is no clear license or certificate that proves competence in treating eating disorders, so there is no deterrent for anyone to hang out a shingle as a specialist.

For patients and families, the result is frequently a haphazard search for an able caregiver with multiple ineffective or failed attempts. Anyone would quickly get frustrated and demoralized by the process.

Understanding eating disorders doesn’t just mean being familiar with the physical symptoms and effects of eating disorder behaviors. More important is what people with eating disorders call “getting it:” a crucial understanding of the eating disorder thought process that drives the illness.

Most people with eating disorders light up when a clinician understands these thoughts. It means they won’t feel different and alien. They won’t need to explain every thought and action. They’ll be able to talk freely and know they will be understood and won’t be judged. The result is a truly open forum of conversation.

Understanding the thought process is necessary but not sufficient. The second critical aspect of a clinician is hope for improvement and change. Instilling true hope that there is a path out of the confusion and torture of an eating disorder is a critical step in starting recovery. The hope cannot be hollow but has to reflect real experience and confidence.

Once a patient or family finds both understanding and hope, a therapeutic relationship can have real meaning. It can jumpstart a new path in life and meaningful change.

Some Ways that Residential Treatment Works

Due to the proliferation and corporatization of residential treatment centers, the caliber of the admissions staff at these programs staff has declined. They are no longer compassionate outreach but largely an arm of the corporation. This change has made it even more important for clinicians to assess when and why a patient needs to consider this level of care.

Looking for a quick fix or magic cure is the worst reason to consider residential treatment. Used as a tool in recovery, this path can can be very beneficial. Having unrealistic expectations only makes the time, energy and expense used feel like a waste.

There are several clear reasons to look into residential treatment. And it’s only worth pursuing this option when there is a clear purpose in mind. 

The most obvious reason is a patient who is medically unstable due to the eating disorder. A program can normalize food and help the person regain medical stability quickly.

When someone becomes unable to function in their life professionally, academically or personally, residential treatment can be a reasonable choice. The consistent food and stable environment can normalize the body and brain and enable the person to resume their lives and be more able to work on recovery.

A third clear reason for residential treatment is someone who is very stuck in the cycle of their illness. Even if the person functions well enough, it may be clear that the eating disorder is very limiting and outpatient treatment won’t be able to break the cycle. The combination of a new food pattern and a new environment can alter a very destructive cycle and open the door to being able to challenge the eating disorder more directly.

Finally, some people need to better understand the philosophy of recovery. Some programs offer not only stabilization but a new way to conceive of how recovery progresses. This new mindset can open up a patient whose thoughts have become very fixed and rigid.

Although this list is not exhaustive, it highlights some clear indications for residential treatment and the potential benefits. What brings these different options together is a very clear goal for the treatment. The purpose of residential is to try to achieve certain specific goals, not present the idealistic and unrealistic goal of full recovery.

The Mistake of Blaming Someone for their Eating Disorder

Unlike many other chronic illnesses, families frequently become very frustrated with their child who has an eating disorder. Once the illness is out in the open, even for supportive families who find sufficient treatment options, it’s hard for families not to resort to blaming their child for not getting better.

Families and loved ones may get angry but don’t blame someone for getting other chronic illnesses yet almost universally blame for someone for not recovering from an eating disorder.

Although the lack of understanding around mental illness can lead to blame, this dynamic is even more pronounced for eating disorders.

The difference can easily be summarized by a common refrain heard in treatment: no one understands. This seeming complaint is actually much more complex and subtle because it hints at the depth of the misunderstanding of eating disorders.

People without eating disorders just eat meals and eat food. Although they may worry about food components and their own weight, eating itself is not a fraught endeavor. People with eating disorders suffer enormous ambivalence, struggle and suffering with every bite of food, even every thought about food. Their entire day is loaded with painful struggles about what to eat or not eat and about their body. The extent of this suffering is unfathomable to even the closest and most educated family members.

So when a child is getting help and trying hard but still slipping regularly in the process of recovery, this is not an example of failure. To the contrary, this is the arduous process of recovery.

During those difficult moments, blame will only serve as another roadblock on the path to getting well. Compassion and love are by far the most helpful responses to the challenges in recovery, even when it is the hardest feeling to summon.

Families need to work hard to avoid blaming their child for an eating disorder. It’s an illness like any other.

The Void after Normalizing Eating Behaviors

Eating disorders typically start in adolescence or early adulthood. Food manipulation and overvaluing weight are important to people at this stage of life but not nearly as all encompassing as they are for people with eating disorders.

Thinking too much about food and weight represents a way to feel calmer or more secure for a stage of life that is very uncertain. Looking a certain way of managing food appear to be superficial tools to find comfort.

For people with eating disorders, these tools become the sole important aspect of their lives. The thoughts are so dominant that all other parts of life become irrelevant. It is worth sacrificing anything and everything in order to achieve the goals the eating disorder sets forth.

The total obsession about food and weight has unforeseen repercussions in recovery. As someone begins to learn how to counter the eating disorder thoughts and make changes in behaviors around food, they start to realize that they are unsure what else to think about or focus on. The concept of other interests or goals has long since been ignored and replaced by food and weight.

This realization is often accompanied by a sense of emptiness and loneliness. Without guidance to know how to face this terrifying prospect, it often feels simpler to lean back into the eating disorder. The person may not even want to return to those thoughts and symptoms. The vast expanse of an open day of thoughts and feelings seems too overwhelming to have it any other way.

After successfully changing eating patterns, recovery needs to switch gears and focus on rebuilding an internal and external sense of what life means. Many recovery philosophies have an existential bent for this reason.

At any age, the person in recovery will need to look at themselves and their own lives and start a crash course in emotional and psychological development.

As hard as this step can be, it also will be very rewarding. Being willing to look at oneself opens the door to a full life. The desire to learn and grow, weathering the excitement and pain that comes along with it, does enable the person in recovery to fully find a way out.