Eating Disorder/Healthy Self Dialogues

There are many ways to approach the delusional thoughts but only one appears to be consistently effective. In order to use this method, the person already needs to understand that the eating disorder thoughts are delusional and also at least acknowledge that more logical thoughts exist and would encourage recovery. With that foundation, treatment can move forward. 

The core piece of this step in therapy is to create an internal dialogue between the eating disorder thoughts and the healthy thoughts. The ed thoughts have usually felt completely true and also secret for a long time. Exposing them can be emotionally challenging and even scary to admit openly. The healthy thoughts often feel forced and unsure. It takes time for these thoughts to start to seem true and supplant the eating disorder thoughts. 

It is also important that both sets of thoughts come from the person struggling with the eating disorder. It's counterproductive for the healthy thoughts to come from someone else. The purpose of the exercise is to practice and express the healthy thoughts and learn to associate oneself with a new way of thinking. 

An example of the dialogue can start with the idea that one shouldn't have lunch. 

Ed: You don't need lunch today. You're not hungry. 

HS: Food is a part of recovery. Hunger is not the issue. Eating to live is the issue. Following the meal plan is crucial to get well. 

Ed: You're already fat. You don't need food. 

HS: Without food you just end up getting sicker and unable to live your life. 

Ed: But you want to be skinny. That's most important. 

HS: You've done that before. Then you end up in treatment and unable to make friends or do anything. Life is much more than starving. 

Typically the dialogue leads to the conclusion that the eating disorder thoughts only want the person to live for the illness itself. There is no purpose beyond that and it leaves no meaningful life in its wake. 

Although this is a hard part of recovery, it is crucial to help combat longstanding delusional beliefs. Making these changes and doing the consistent work is a big part of the reason people can fully recover.

Facing Eating Disorder Delusions, Part I

Typically delusional thoughts are fixed beliefs about the world that someone is convinced are true but that are clearly false. More often than not, these beliefs are so prominent and so all consuming that they significantly disrupt the person's life and relationships. 

Sometimes the delusions can be circumscribed, for instance focused solely on one person or one event happening in the world. In these circumstances, the delusions only come to light when the specific target is discussed. 

Delusions in an eating disorder are both circumscribed and also internal. The fake beliefs about food and weight only pertain to that person and not others. In addition, the thoughts are shrouded in secrecy and rarely come to light. Unlike almost all other delusions, they only are revealed when questions probe enough to elicit the beliefs. 

Yet these delusions are so powerful that they affect most decisions every single day and profoundly limit how someone lives their life. 

Eating disorder delusions come in two similar patterns. First they can revolve around severe limitations of foods that one can eat or the amount one is allowed to eat. Breaking these laws around food actually feels like doing something absolutely horrific, something illegal that deserves punishment.

The delusions can also revolve around a belief that the person either has never been sick with an eating disorder or has never been very sick despite clear evidence that proves otherwise. Some people with clear organ damage or even at risk of dying still believe they are well. 

It's important to recognize that these are thoughts someone with an eating disorder absolutely believes are true. They are not just passing thoughts. This is often what makes understanding these illnesses so hard. 

Questioning delusions is very difficult. Directly confronting them typically fails immediately and brings any trust in a relationship into question. The way to challenge these fixed thoughts is to essentially build a case against them.

By amassing evidence that shows how these delusions are false, one can begin to bring to light the lack of data to prove these thoughts are true. Even with overwhelming evidence, it can continue to be hard to escape a delusion. It often takes months of questioning the thoughts to weaken them in time.

Gradually, the most important step is to help the person herself begin to question the delusions directly. I'll discuss that more in the next post.

Delusional Eating Disorder Thoughts

The large majority of people with eating disorders seem fairly well and functional on the surface. Although the physical and psychological effects of the illness are rampant, most people can engage in conversation, hold down a job or go to school and maintain stable enough connections in the world. 

The juxtaposition of someone who appears well but actually suffers from a serious disease is confusing for many people. It contributes to the difficulty many have with believing an eating disorder is a life threatening illness. 

To those unaware of the nature of eating disorders, recovery could easily just mean starting to eat normally, as if the symptoms are a choice. That's the primary misunderstanding which explains why it's so hard for laypeople to comprehend the nature of these illnesses. If getting well were a choice, eating disorders wouldn't exist in the first place. 

What lies underneath the seemingly normal facade is a thought process that drives the eating disorder. These thoughts make it a powerful and destructive illness. Distinguishing between clearly delusional eating disorder thoughts and healthy thoughts is extremely confusing for people in recovery. The process of recovery is largely about learning to identify and ignore the eating disorder thoughts. However, disregarding thoughts that have structured daily life for years takes time. 

For the purpose of this blog, I will call these thoughts delusional. Clinically, a delusion is a fixed false belief. In the case of eating disorders, a common delusion is, for example, "I can't be thin enough" or "this crash diet will finally stop the binging" or "I'm really fine even though I feel weak and dizzy" or "I'll just use laxatives one more time." 

The next few posts will explain in more detail what the delusional component of an eating disorder entails and the process of learning how to ignore them and move ahead in recovery.

The Role of Medications to Treat Binge Eating Disorder

Unlike people with other eating disorders, those with Binge Eating Disorder often contact me solely to talk about medications. Sometimes they want to meet to discuss medication options or even, if they live outside of New York, ask to speak on the phone for a few minutes. 

There is a widely accepted view that medications are unlikely to be a significant part of treatment for other eating disorders, but the idea that medications can temper, if not cure, binge eating is pervasive. 

From a clinician's point of view, treating binge eating is similar to treating other eating disorders. The focus on a combination of normalizing eating patterns while zeroing in on the emotional and psychological manifestations of the illness is paramount. There is no evidence that medications help binge eating any more than other eating disorders. 

Seemingly, the media and lay knowledge of eating disorders categorize binge eating as something different. It represents, in our current culture, a flaw or a sign of weakness. As medication has become more central to psychiatric treatment, it is natural to assume there must be medication to fix this core craving or, as some falsely describe it, lack of willpower. 

The reality is that binge eating is one of a variety of biological and psychological adaptations to chronic undereating. We are all programmed to respond to prolonged starvation, i.e. dieting, in different ways. For some people, the starvation mechanism cascades into compulsive starvation and leads to anorexia. For some, the diet ends abruptly and leads to normal eating. For others, it triggers binge eating which can lead to bulimia, binge eating disorder or a variety of compensatory mechanisms to deal with overeating. 

Ultimately, the course of treatment needs to be the same. And a key component of treating binge eating disorder is to take the shame away from binge eating and follow a comprehensive treatment plan rather than a pharmacological magic fix. It's not a flaw but part of an illness.

Weight Bias and Biology

The idea that our bodies know how to function also applies to people who are overweight. They experience overwhelming pressure from society, friends and family to lose weight with the often unspoken message that their weight is a sign of their own weakness and slothfulness. 

The drive for thinness and dieting is usually even more pronounced for those who are overweight. The diet industry plies the public with unsubstantiated miracle fixes for weight loss and happily reaps significant profit on the misery of others. Meanwhile, the government, medical establishment and even close family and friends all support these endeavors as signs of self-care or even self-love. The promulgation of an endless search for the pot of gold at the end of the rainbow all to satisfy the misguided idea that weight is both a manipulatable data point and a sign of virtue is abhorrent. 

The accepted messages about food and weight can easily become personal rebukes of those who are overweight and even open the door to widespread, accepted prejudice. If the person is misled into conflating self-worth and weight, they are susceptible to all types of bias and mistreatment. 

Meanwhile, the human body functions solely on biological terms, irrespective of the current societal norms around weight. As I have written extensively in this blog, weight is not commensurate with health, and there are ample data to prove this point which is summarily ignored by the powerful diet industry. 

All the noise around weight and virtue drowns out the facts. Our bodies know how to manage hunger and food. Given the necessary diet, humans can live and thrive. Weight is but one data point of many that the body works to keep within a range commensurate with health, and the range is largely predetermined by our genetics. Our body size and shape are part of our inherent nature, not signs of personal virtue. 

First and foremost, food and weight are not indicators of our worth as a person. The message of biology trumps all other specious explanations of health and weight. This message needs to be trumpeted and spread to counter the overarching and destructive falsehoods spread by the diet, food and exercise industries.

The Central Myth of Eating Disorder Thoughts

A refrain of eating disorder treatment is your body knows how to function. Give it enough food and it will take care of itself. The saying begins to be trite the more often one hears it, but the challenge is to recognize how profound it really is. Ultimately, believing this simple message can help someone with an eating disorder discount the majority of what any eating disorder thoughts deem as true. 

Food is a biological necessity for life, as crucial as oxygen, water and sleep. However, of these absolutes, only food is so mutable to allow for someone to attempt to constantly manipulate and adapt their food choices. 

The confusing messages society consistently supports is that one's diet is something to work on and perfect. There's a widely accepted belief that choosing food wisely, if not perfectly, will transform weight and health, if not the course of life itself. Meanwhile, the body will digest, absorb and utilize the energy from food in its own way no matter what one eats. Weight is a data point the body manages for health and wellbeing. And the vagaries of daily life are not related at all to what one decides to have for lunch. 

The best argument to use against exaggerated, if not magical, thoughts about food and diet is that food is a basic necessity of life. Biology dictates what our body needs and how it functions. Our life course and decisions are what we can all try to affect and move through. Expecting food choice to fix life's problems means ignoring one's realities. And our lives need as much attention we can give them.

The Separation of Meaning and Weight

People engaged in recovery from an eating disorder comment on how personal and how philosophical the process is. They marvel at their internal growth and maturation and at how their view of themselves and the world has transformed. 

In the same breath, they often ask why eating disorder recovery needs to be this way. If eating disorders are largely destructive behavioral patterns, why can't behavioral treatment lead to health and wellness?

The answer lies in the fact that ingrained food behaviors tap into our basic human drive for survival. Accordingly, deeply rooted food behaviors function within the oldest and least conscious parts of our brains, parts we share with much more primitive living beings. And so once food behaviors are fixed, changing them becomes overwhelmingly difficult. The patterns exist in the least accessible parts of our psyche. 

As I wrote in the last post, once the survival instinct transitions to diet and weight management, it starts to feel as if maintaining a certain weight is as urgent as our survival. Once that instinct is triggered, changing the association is very challenging. 

The key to creating a meaningful life, one not dominates by the endless search for the perfect diet, exercise plan and weight, lies in the most successful eating disorder treatments. Although the severity of the medical and psychological risk is much greater for people who suffer from these illnesses, the methods used to change profoundly ingrained food behaviors are relevant for both. 

The medical or purely practical approach to treating people with eating disorders is hardly ever successful. Short-term improvement in health belies the course of the eating disorder. Inevitably, the eating disorder thought process hardens when someone is forced to make behavior changes. It may appease clinicians to blame the person for her illness in this situation, but the clear problem remains in the treatment decisions. 

Treatment directed towards a fuller recovery combines refeeding and improved health with a consistent message of creating a meaningful life. Using our conscious brains to introduce and reinforce the need for useful activities, important relationships and intrinsic personal value creates a foundation to combat the eating disorder thoughts.

The psychological process of recovery involves replacing the old eating disorder thoughts about food and weight with a  new philosophy focused on meaning and relationships. As the new philosophy strengthens, the old eating behaviors lose steam and normal food patterns dominate. 

Applied to the general world focused on weight and appearance, the message that dieting doesn't work is too practical. There is no personally meaningful voice or system to replace the incredibly powerful diet, food and exercise industries. It's not a surprise that even those fed up with living their life for weight loss turn to Bariatric surgery for relief rather than a compassionate and kind approach the identity and life. 

The messages competing with the seemingly perfect life of diet and exercise need to find their way into our daily awareness to be effective.