People do Recover Fully from an Eating Disorder

The most pervasive myth about eating disorders is that they are chronic and never go away. This falsehood has become even more widespread through the pandemic as it has been repeated widely on social media.

When unpacked, the myth reveals fears and untruths about the role of eating disorders of our culture.

The centrality of diet culture means that dissatisfaction with weight and body are extremely common and even dominant in many communities. So the concept of restricting food, the desire to lose weight and the virtue of being thin feel like facts to many in our society. As a result, many people who don’t have eating disorders and never did have constant thoughts about food and body.

Second, even though eating disorders are so destructive and severe for many people, these illnesses are still idealized. Anorexia especially is often seen as a triumph for people who have been able to overcome hunger and “control” what they eat. The truth of these disorders is very different.

Last, the explosion of residential treatment centers has diluted the powerful message many smaller programs used to convey. Centers focus on short-term health and treatment but rarely explain and reinforce what full recovery looks like. Thus, the end result of treatment is a partial recovery without further education about how to get better.

The crux of an eating disorder is the pervasive thought process about food and body that leads to compulsive behaviors and actions. These symptoms stem from inconsistent, insufficient eating so the body does not get the steady nutrition it needs to function. Without that sustenance, eating disorder thoughts grow and thrive.

To fully recover, the patients need to follow a meal plan, eat meals and snacks in adequate amounts and spaced through the day for months at a time. The body and brain need to learn that regular, nourishing food will be the norm again. Once that pattern becomes consistent, eating disorder thoughts will fade as life intervenes and becomes the focus of each day.

When this happens over time people get well. This is the truth about recovery. The myths above reflect a lack of understanding of these illnesses and the overvaluing of thinness.

Although the path to recovery is simple, the process of doing so is very hard, if not counterintuitive. Eating disorders are defined by abnormal eating patterns. Getting better means eating normally. I’ll explain this paradox in the next post.

The Role of Residential Treatment in Recovery

It has long been assumed by patients new to eating disorder treatment that a successful stay in an eating disorder residential program is essentially a cure. The buildup to admission, the hard work in the program and the culture of “Rez” introduce the concept that treatment will help you not get better but be cured.

Nothing could be further from the truth.

Residential treatment has many benefits, and the enormous increase in the number of programs across the country in recent years has improved access for many people who otherwise wouldn’t have options for inpatient treatment.

Treatment offers a safe place to learn how to eat again, nourish one’s body consistently for weeks or months and learn the skills needed to tolerate full stomachs, digestion and weight changes. For many people these steps are extremely difficult on an outpatient basis.

But residential treatment is also a bubble, an escape from the daily challenges of life. Work, friends, family and relationships all take a backseat while people are away. They can focus exclusively on recovery and the small world in the program.

No amount of preparation in that bubble can replicate the experience of being back in the world again. Even the most successful people in residential will find the urges and desire to return to eating disorder symptoms powerful after they get home. Once they experience the intensity of their emotions about the different aspects of their lives, everyone will feel the pull to rely on these symptoms, which have been a central coping mechanism for many years. Using new ways to cope is very challenging and takes time, learning and persistence.

What will improve outcomes and recovery after “Rez?” It’s a theme I have discussed many times in this blog, and here are the three main takeaways.

First, residential is the first step in recovery and in some ways the easiest. Don’t be tricked into thinking otherwise.

Communication between the residential team and outpatient team is crucial so that the transition is as seamless as possible.

Last, eat the food. Following the meal plan no matter what leads to people really getting better. That means completing the food log, being open and honest about any symptoms and seeking help and support at every turn.

Residential treatment is a critical part of recovery for many people. The more everyone understands its place in recovery, the more people can be successful.

A Clinicians’ Responsibility in Social Media

Clinicians, coaches and recovered people explain recovery work, spread knowledge and information and promote themselves on various social media platforms. The explosion of eating disorders treatment centers, normalization of these illnesses and isolation of the pandemic created space for many different voices in the eating disorder treatment world that everyone could access easily throughout the pandemic.

What’s confusing about all these new voices is the unfiltered nature of the noise. Social media algorithms attempt to keep you on the platform. There is no way to filter all the information to spread informed, knowledgeable or even true ideas.

Many people caught in the eating disorder web on social media find themselves trapped and often convinced of the ideas presented to them over and over again. If the message is about recovery and the harm of eating disorders then that’s great. If the message is about identifying fat phobia and body positivity then that’s important too. But it’s equally likely the message will be diet focused or even pro eating disorder. Without any way to filter out the destructive or false messages, the risks of developing an eating disorder or relapse only escalate.

These concerns are pervasive effects of social media in our current culture from politics to health to the pandemic. However, the increased incidence of eating disorders in the last year and a half shed light on how dangerous this messaging is and how clinicians need to be aware of the risks.

Treatment, in all different forms, needs to incorporate a strategy to include the concerns around social media. And clinicians using social media to promote themselves need to be careful how and in what way they are seen. The lines have blurred between treatment professionals, coaches, influencers and social media stars. As much as possible, clinicians need to try to distinguish what they do and why it’s different.

The best way to support recovery in this world is to remember that self-promotion can’t be the main goal. Any social media presence for a clinician can include links to their own practice and treatment goals but also needs to be sure to point people towards real, proven information about eating disorders, treatment and recovery.

No matter how much our online presence melds with advertising and personal brand, every clinician needs to remember that treatment and helping others is the top priority.

The Role of Social Media in Eating Disorder Recovery

So many people with new eating disorders or relapses had nowhere to turn for help during the pandemic. Society shut down as we know it and access to any mental health care was severely curtailed. The eating disorder treatment world, like all health care, became instantaneously virtual with no warning and no plan. Assessment, treatment planning, residential care and outpatient treatment programs scrambled to adjust but left patients minimal options for true care.

The incidence of new eating disorders skyrocketed, but patients couldn’t find help. Clinicians had endless waitlists. Virtual programs struggled to function because eating with people in a safe setting is central to the effectiveness of treatment. Residential programs had trouble even staying open and accepting new people safely.

So many people stayed home, trapped by the coronavirus, trapped by their eating disorder, alone and scared.

Home as well, clinicians, coaches and recovered people looked for new ways to attempt to help. The plethora of Instagram dietitians, body positivity influencers and recovered people had already had an enormous impact on the vocabulary and approach to eating disorder treatment. That burgeoning world exploded during the pandemic and added TikTok as an equally powerful platform.

But the increased exposure to recovery oriented content came with the algorithms intended to push people, especially teenagers, towards posts that encourage extreme dieting, low self-esteem and thereby increased the risk of eating disorders. Research data presented to Congress this week by a former Facebook executive provides incontrovertible evidence about the destructive effects of Facebook and Instagram.

The lay of the land in the eating disorder treatment world has been forever changed.

These social media voices express a varied, powerful and resonant chorus about eating disorders, body image and recovery which all clinicians must now heed. The messages previously attributed to older media outlets are no longer easily avoidable but instead in our hands and on our screens all day long. Ignoring this new reality means missing the basic understanding of how eating disorders now exist in our culture.

Let’s hope that the experience accelerated by the pandemic and by the exposure of Facebook’s destructive business decisions help avoid an even larger uptick in eating disorders. As clinicians, we need to discuss social media as a realistic outlet to aid in recovery. Focusing on the ways to use content to encourage recovery, reinforce positive messages about body image and self-esteem and avoid triggering images and diet advice is crucial. It’s imperative for clinicians to work with this powerful tool and not demonize it or ignore it.

The next post will venture into trickier territory. What is the role of clinical work in the social media universe? Where are the boundaries between helping people get better and self-promotion?

The Triumph and Failure of Teletherapy for People with Eating Disorders

Virtual sessions, a growing trend in mental health treatment, has become the norm and frequently the only option for the past eighteen months. Video sessions had been a new direction gradually being tested and used in various settings, but the pandemic made them compulsory.

I had used virtual sessions for many years but only with long-standing patients and as part of an ongoing therapeutic relationship previously established in person. Seeing people exclusively on video was an entirely new endeavor.

Virtual treatment for eating disorders poses very specific issues not found when treating other psychiatric problems. First, for patients just starting treatment, it is much easier to hide symptoms and particularly shameful issues around their eating disorder. Second, working in person feels much more exposing for someone learning how to face the deeper shame connected with an eating disorder. And third, being in the same room with someone allows for a much more personal conversation about food, the most intimate topic anyone with an eating disorder can discuss.

However, video does have a couple of benefits, namely convenience, which makes it easier for some people to have an initial appointment, and safety since they will already be home after talking about an emotional issue and not have to navigate their way in public.

But the pandemic did not allow a gradual process to evaluate and improve teletherapy. Instead, clinicians and treatment programs dove in and found themselves often not ready or able to adapt.

The end result is decreased effectiveness of care. With the increased incidence of eating disorders and relapses during the pandemic, many people have remained ill with limited opportunity for treatment.

Since virtual therapy is so convenient, many therapists gave up their office space and some have no plans to return to in person treatment any time soon. If convenience begins to trump efficacy, eating disorder treatment may suffer further.

Two things need to happen. First there needs to be more data showing the effectiveness, or lack thereof, of virtual therapy. Second, clinicians and programs need to learn how to adapt virtual treatment in ways that improve overall care. Although the treatment continues to adapt on the fly, that slow improvement may not be enough to stem the tide of illness.

In the absence of in person treatment and due to the long waitlists for treatment programs, for many patients, especially those newly diagnosed, social media became an even more important part of the eating disorder treatment world during the pandemic. That will be the topic of the next post.

Eighteen Months Later

Eighteen Months Later

Posted 9/15/21

The incidence of eating disorders skyrocketed during the pandemic. New cases, relapses and severity of illness all worsened at a dizzying clip. Clinicians’ outpatient practices were all full. Treatment programs were virtual for a time and had endless waitlists. All outpatient treatment was virtual, and people languished at home.

Virtual treatment led to patients finding practitioners all over the country. Geography was no longer a barrier, and treatment varied accordingly since no one knew how to help people through a screen and had to learn on the fly.

The lack of a clear treatment path also meant patients looked to social media more than ever for help and advice. Instagram and TikTok became central to many people trying to find information and guidance about treatment and recovery.

Never has there been such an enormous change in the eating disorder treatment world. Even as clinicians trickle back into the office, it’s unclear what happens next. Are eating disorders a chronic, untreatable illness? A passing phase caused by the pandemic? A community to join during the most isolated months? An identity to cling to when life stopped?

The fallout from this extended transformation of eating disorders will ultimately lead to a sharp uptick in severe cases who had enormous difficulty getting help at the start of their illness. And the treatment community will need to piece together a way to salvage this treatment and help many of these patients find the path to get well.

After an eighteen month hiatus primarily caused by fear, a constant stream of people reaching out for help and weathering the worst of this terrifying time, I feel ready to embark on chronicling the ever-changing world of eating disorders and treatment.

The first posts will elaborate on the changes in eating disorder treatment and the challenges that lie ahead for those looking for recovery.

The Increased Risk of Developing Eating Disorder as an Adolescent

I am going to highlight some important posts from the past ten years and repost them over the next few months. Here is the first one about why the risk of developing an eating disorder during adolescence is so high.

Adolescence is a time of physical, mental and emotional growth. The rate of internal change is so fast that mistakes of poor judgment are inevitable. In fact, one of the last parts of the brain to mature involves planning and judgment, qualities clearly lacking for most teenagers. Combine this decision-making difficulty with the penchant for exploration and much of the risk for teenagers is perfectly clear. 

In every generation, there appears to be a new, tantalizing frontier that transforms into a universal rite of passage for adolescents. Alcohol, drugs and sex are the three most common concerns, but others have crept in like prescription pills and self-harm such as cutting. 

One of the newest adolescents crazes is the drive for thinness. With the expectation for both boys and girls to have unnaturally thin bodies, especially unnatural during the hormonal shifts of puberty, the appeal of weight loss has grown into a standard experience for teenagers. Peer pressure to restrict food, purge meals or take pills such as Adderall, laxatives or diuretics has grown almost unavoidable. Kids can find any number of weight loss guides on line as well to steer them towards these dangerous behaviors.

The thrill of seeing an effect on one's body can be exhilarating to a teenager who feels like life is an out-of-control roller coaster. The sense of pride and accomplishment, albeit one that is small and in the long run meaningless, quiets the constant feeling of confusion and replaces struggling self-worth with an immediate burst of confidence.

It's scary to reflect on just how powerful the drive for weight loss can be in adolescence and how success feels downright magical. 

As with all of the destructive behaviors for teenagers, the long-terms risks always escape their notice. 

Engaging in eating disordered behaviors, especially restricting food, sets off a cascade of biological and psychological responses to starvation.

No one can predict how each child will respond. No one knows if that child will just give up after a day or two, get caught in a cycle of restricting and overeating or be genetically susceptible to develop anorexia. But the increasingly common exposure to starvation for teenagers means those kids are more and more likely to find out. 

Until recently, no one would even consider these risks for a child. Eating meals through the day was a matter of course and the drive for thinness nonexistent. Accordingly, the incidence of eating disorders was very small, a rare and mysterious disease people fell into without any idea what was happening. That's not how eating disorders develop anymore. 

Adolescence has become a breeding ground for eating disorders, replete with friendships encouraging the behaviors, online groups dedicated to provide support and the social normalization of irrational food restriction. Just as drinking or using drugs at a young age can set that child up for much larger problems, food restriction increases the risk of developing an eating disorder. 

However, parents and adults are much less likely to worry about a teenager dieting than about using drugs. Those adults may themselves be restricting food or even encouraging the child to eat less. The social norms actually span generations, leaving teenagers without any idea their behavior is dangerous. The general obsession with thinness leaves children at sea to find a sane way to understand food and weight. 

With teenagers dieting and engaging in eating disordered behaviors, there needs to be a public health campaign to counter the false advertising of the food and diet industries. More specifically, children need to understand the risks of their behaviors and the expected norms that will keep them safe.

Adolescents won't necessarily follow the rules because that's the nature of the stage of life. However, exposure to the risks and norms will at least offer them some guidelines to either heed or ignore. It will allow them to know when their decisions are leading them into trouble. It will also give parents, even those struggling with food and weight, a means to teach their children a saner attitude about their bodies.