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.

The Simplest Tool for Recovery is the Most Effective

While working with people with eating disorders, I am reminded time and again that the most simple tool is the most effective one. Eating disorders may be known as intractable and very challenging to treat, but the food journal is a critical part of any success in recovery.

Initially, the journal provides a daily accounting of what someone’s eating disorder looks like. Although eating disorder symptoms are somewhat consistent from person to person, the exact way a person thinks about food and eats through the day can change. The eating disorder thoughts tend to be the most dominant thoughts in a person’s mind so the journal also gives insight into a day’s worth of thoughts.

Allowing a clinician to look at the journal symbolically represents an opening of the eating disorder itself into treatment. The therapist can ask specific questions to better understand the process involved and the decisions that are made by the eating disorder rules. The process of asking questions, giving answers and even making small suggestions to change the eating behaviors show that there can be a dialogue around the disorder, something usually very new to the person in treatment.

People often say to me that writing out the details of their food each day is the most personal thing they could imagine doing. The act of writing the journal and then sharing it allows for an intimacy not usually possible because the eating disorder dominates one’s life. Exposure of the central power of the illness invites change and progress.

When I think over the duration of my practice, any person with a moderate to severe eating disorder who I have seen make progress has committed to the food journal for a period of time. The tedium of writing down food combined with thoughts and feelings are worth pursuing for the true benefit that this tool provides. As long as the food journal is a part of recovery, there is nowhere the eating disorder thoughts and symptoms can hide.

The Competing Forces in the Mind of Someone with and Eating Disorder

In more severe eating disorders, there are competing forces inside the person vying to determine the course of daily life. One side is focused on living a full life replete with personal and professional goals. The other side is solely preoccupied with food, calories and, above all, weight.

Intractable eating disorders occur when the eating disorder forces dominate thinking and thereby daily decisions and behaviors. The short-term goal of treatment may be medical and nutritional stabilization, but getting better ultimately means quieting and weakening the eating disorder forces.

Similarly, developing a successful plan for recovery also involves competing forces when caring for the person with the eating disorder: compassion and firmness.

The true forces aimed at living life are grounded in the actual person themselves. That side of the person is extremely saddened and frustrated by the inability to focus on daily life and pursue long term goals. Any human being would experience powerful compassion for this person and how much suffering has come with a severe eating disorder. In the face of so much confusion and criticism during the illness, compassion provides sorely needed caring which is necessary to nourish the person emotionally back to health. It also helps bolster the energy needed to combat the eating disorder forces.

On the other hand, firmness, directness and even strength are necessary to combat the eating disorder forces. They are wily, stealthy and insidious. If subtly ignored, the eating disorder will take weakness as a sign to only push forward. Their sole purpose is to ignore actual life and magnify food and weight into the only things that matter.

The person is often ignorant of the difference between their own thoughts and the eating disorder and will take attacks against the eating disorder as personal attacks. Even in the face of this kind of rebuff, continuing to push back against the eating disorder is essential.

The combination of compassion and directness is a delicate balance. It will only be successful when a therapeutic relationship has a strong foundation of trust. Differentiating between these forces and approaching them in the correct way is the most important way to care for someone working in recovery.

Why It’s so Hard to Find Help for an Eating Disorder

This time of year seems to be a season people are much more likely to contact me to start treatment for an eating disorder. I’m not sure why I receive the most contacts in June and July, yet it appears to be the same every year.

One common refrain from these contacts is how hard it is to find clinicians who are trained to treat people with eating disorders. I often hear that people have seen several therapists, frequently for a sufficient period of time, and found the treatment to have limited focus on food and eating. After a series of failed attempts, it’s hard to keep trying.

Even if i don’t have availability, people are just as grateful to be pointed in the right direction. A true referral to someone trained to treat people with eating disorders is hard to find, even in a town like New York that is packed with mental health practitioners.

The unfortunate truth is that there is no standard certificate or training to treat people with eating disorders. Despite the increased incidence of these illnesses in recent decades, there is still no way to ascertain if someone is actually trained. Any clinician can claim the expertise and have no true training.

The same is true for psychiatrists as well. My training came from participating in the UCLA eating disorders program for two years where I was trained by doctors who helped create the field in the 1980’s. But in many ways, finding that training was just by luck.

For therapists, claiming this expertise is a quick way to increase clients. There are so many people searching for therapists who know how to help people with eating disorders that this claim will lead to increased work, even if that work is completely ineffective.

Psychiatrists tend to be much more wary about claiming this expertise. Unlike most psychiatric illnesses, people with eating disorder have many medical problems that often go beyond the knowledge base of a psychiatrist and bring more medical risk into practice than psychiatrists prefer.

Overall it makes finding experienced clinicians difficult. The key is to ask more details about someone’s training, practice and experience. It’s perfectly acceptable to know how much of someone’s practice is people with eating disorders and to know if they themselves were trained by experts. The road of treatment is hard and it has to begin with a treatment provider able to open up a path to wellness.