Relationships are the Foundation of Full Recovery

Therapy is central to the treatment of most psychiatric disorders but is even more so to the recovery of people with eating disorders. As trends in therapy focus more time on techniques and tools, the nature of the therapeutic relationship might get brushed aside. It’s crucial to make sure the relationship itself does not lose its place as a part of growth and healing.

Tools and techniques play a large role in eating disorder recovery as well. When someone has an urge to engage in any eating disorder behavior, the ability to turn to another action until that urge dissipates is necessary to make progress. That step is very hard and takes repetition and perseverance.

Similarly, eating regular meals regulate the gastrointestinal system to become accustomed to consistent food through the day. Using techniques to stay focused on eating through the day can be very helpful too. The physical cues for hunger and fullness ensue and give a person in recovery new ways to conceive of eating and thus reinforce the need and ability to continue new behaviors.

However, eating disorders also encroach on psychological and emotional development. At the start of the illness, eating disorder thoughts and behaviors replace all other possible ways to face emotions and reactions to daily life. The eating disorder is so powerful, so numbing, that there is no reason to even search for other ways to cope with being human. An eating disorder feels like a panacea to the travails of life while simultaneously extracting the joy, growth and connection that makes life meaningful.

In many different ways, relationships that are connected and true provide an antidote to the dullness of life with an eating disorder. For many people, the therapy relationship can be the first exposure to that sort of connection.

Any relationship that begins to compete with an eating disorder must, first and foremost, engage with the true sense of the person hidden behind the eating disorder. Only after one finds and connects with their true self can a person in recovery chart a course that escapes the eating disorder’s clutches fully. There has to be something more powerful and more important in a person’s life to consider letting go of a set of calming rules and structure. Invariably, personal connections make the biggest difference.

Recovery involves these two pieces—techniques and relationships—working together to form a new path in life. Once each person starts their new path, the directions splay in all new ways because recovery itself means becoming your own self and living your own journey.

The Financial Industry Interest in Eating Disorders

As I reviewed the last post, I neglected one way in which capitalist tendencies undermine the ability to find eating disorder treatment. The food, diet and health care industries collectively convince us to blame ourselves for any perceived shortcomings about food and body and then to purchase the wares to either remedy the problem or drown our sorrows. I neglected to mention the finance industry which cynically exploits mental illness for financial gain.

Many years ago, private equity companies bought up and expanded substance abuse treatment centers. Although the access to treatment centers improved, the intention of the industry growth was to create profitable enterprises to take advantage of health insurance benefits. Much of the data accumulated show how these clinics make unsubstantiated medical decisions to keep patients longer. The decision making process chose financial gain over patient well being.

The eating disorder treatment center model has started to look a lot like substance abuse treatment and became too tempting for the finance industry to ignore.

Residential treatment centers were, not long ago, places for intensive emotional work, soul searching and a safe place for people, primarily women, to find a path towards healing and recovery. Frequently, the programs were run by people who themselves had recovered from eating disorders and used their own personal experience combined with clinical knowledge to create centers with exceptional clinical care.

The rapid expansion of treatment programs by financial firms reeks of a quick grab for money. Although access to care had been a significant problem for years, opening many programs with poorly trained staff is not an improvement. The growth continues and the benefit from these programs decreases with each step while insurance money lines the private equity coffers. There isn’t enough focus on quality of care and too much focus on profit.

The limited benefit of residential programs makes the path towards recovery complicated. It’s harder to recommend residential programs than it used to be. Online outpatient programs have unclear value even though they do provide a needed service. Outpatient treatment is much easier to find but not sufficient for many people.

The problem of limited access has transformed into a struggle to find appropriate and educated providers. It is perhaps an improvement and also a sign of the times: medical care is increasingly driven by the patient, aka the consumer, who makes semi-educated decisions based on the limited information online. These are the overall trends in medical care but they are concerning for eating disorder treatment.

The Core Issue of Eating Disorders: Shame

A cornerstone to eating disorder treatment is addressing shame. For the majority of eating disorder patients, the rules, rigidity and behaviors of an eating disorder serve to cover up underlying, painful negative feelings about one self. Staying preoccupied and busy within the confines of the eating disorder hides the deepest feelings of shame about one’s body and oneself.

Beginning to uncover shame starts with an open and honest discussion of the eating disorder symptoms. Typically, secrecy surrounds the disorder not only because secrecy increases the power of the illness but also because it hides the shame. Speaking frankly about symptoms as part of the illness dispels the initial surface shame that’s paralyzing.

Eventually, eating disorder therapy shifts towards shame not only about body and self but often to other parts of one’s life. These causes are myriad and varied such as lack of emotional support, struggles to find a way through puberty, a dearth of individual recognition to create a sense of self or trauma.

The original causes will need different levels attention depending on the severity of the issue, but the severity does not change the nature of eating disorder treatment. Exposure of the illness and the feelings and experiences underneath can take away the engine that has driven the eating disorder for so long: shame.

We live in a world driven by shame in many ways, especially around body. There is little acceptance of bodies as they are and little admiration for all the types of bodies we as humans have. There is also little respect for the miraculous way our bodies can survive difficult times and thrive when given the chance. Our eyes look for criticisms and flaws, not for joy and gratitude.

The capitalist marketplace does not help. The food industry plies us with addictive foods; the fashion industry floods us with underweight models; the diet industry shames us to always feel fat and unworthy, and the medical industry lures us with magic weight loss drugs while also shaming us to change behaviors.

Our culture is designed to use shame to increase our desire to consume. Economic needs overcome personal well-being time and again.

It’s a large hurdle to overcome. The steps forward entail finding one’s self-esteem and confidence elsewhere. With personal well-being as a bulwark, each of us can try to ward off shame and live as our true selves.

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.