People Can and Do Get Better from Anorexia

One of the hardest question I’m asked about recovery from anorexia is the following: what strategies or concepts are the most effective to combat the anorexic thoughts?

The reason this question is so hard is that there’s no simple or easy answer.

Despite decades of research into the biological underpinning for anorexia, there are no new data to use clinically that makes recovery and regular eating any easier.

Research into all different medications, including psychedelics, don’t show much benefit to make recovery different.

However, the lack of new information doesn’t mean we should disregard the decades of experience we have treating anorexia, nor the fact that treatment is much more nuanced and sophisticated than it was only a few decades ago.

First, we do know that consistent nourishment over an extended period of time will reverse the food and body thoughts for most people. Sometimes these changes are fast and other times slow.

Second, we know that regular food logs and consistent accountability helps people move forward in their lives. Recovery has nothing to do with willpower. Instead, people need external support and reminders to chip away at the power of the eating disorder thoughts.

Third, we know that treatment must include listening carefully to what people with anorexia say, think and feel. No one gets better by treating the illness and not the person. If someone in recovery is moving away from the illness and not moving towards something important to them, the changes won’t last.

Last, the process of recovery needs to center on hope. Any sense of desperation or hopelessness strengthens the illness and derails recovery.

In order to sustain hope, clinicians need to be well versed in the nature of eating disorders and recovery and to understand the ups and downs of the path to get well.

The less we all look for the magic bullet for recovery from anorexia and the more we use the available knowledge and tools, the more successful treatment can and will be.

Praise Doesn’t Feels Supportive to People in Eating Disorder Recovery

The last post about listening to people with eating disorders applies to family and friends as much as it does to clinicians and treatment.

Families often feel like their job is to monitor and assess food intake and adherence to a meal plan. Similarly, families want to reward following the treatment plan with praise. Yet this praise almost always backfires and actually strengthens the eating disorder—a fact hard for most people to understand.

The conundrum of how to support people in eating disorder recovery stems from the nature of the illness itself. The eating disorder thoughts are powerful and hard to resist. They bring comfort and a sense of accomplishment, no matter how destructive they are at the same time.

If family or friends praise progress in recovery, people with eating disorders struggle to hear the positive reinforcement as it’s intended. Instead, the praise betrays the eating disorder thoughts by reinforcing the idea that that eating normally is a failure. Other people recognize the changes and reveal the person is normal, like everyone else, something abhorrent to eating disorder thoughts. Moreover, the praise stirs up the frustration and sadness at leaving the eating disorder behind.

If instead families ask how to help or offer the opportunity to listen, people with eating disorders will likely be able to speak about how they actually feel. After being buried under eating disorder thoughts, it may take time before they feel safe to start to talk about how they’re feeling. However, without the pressure to perform and the feeling of being watched, exposed or even praised, they will feel more able to make their own decisions and not react to outside intrusions.

Of course, these thoughts don’t apply to people who are in medical danger, and the distinction between health risk and psychological stability is often not as clear as it would seem. In addition, different clinicians and families may be willing to accept more instability to provide a safe environment to start recovery. No matter the situation, an open, warm, loving environment is necessary for any successful recovery.

People with Eating Disorders Need to be Heard to get Better

If inpatient and residential treatment can be traumatizing, family based therapy doesn’t work for people 18 and over and people with eating disorders are trapped by the power of the thoughts of the illness, what are the other paths forward towards recovery?

The urgency for families and practitioners to do something, to have a concrete plan, is overpowering despite the evidence that these steps are unlikely to work after the first couple of tries. Even after many failed attempts at the options mentioned above, families and clinicians will often repeat the same plan futilely.

Increasingly, the focus of treatment is on meal plans and maintaining a symptom-free period of time at a determined weight as a magic cure. The evidence does show that remaining at a target weight long enough improves the chance of recovery. However, eating disorder thoughts often remain so strong at these weights that relapse is a common result. When this plan does not work, the patient is blamed.

Our culture tends to focus on the latest shiny object on social media and that is no doubt the case for eating disorder treatment. More and more, patients find their information about recovery on TikTok, but we have forgotten how much older information about treating eating disorders remains as useful as ever. Many of the lessons learned about eating disorder treatment in the past are fading into history.

Young people with eating disorders are often used to not being heard or seen. The eating disorder tends to be the only mode of expression younger people find effective after years of being seen as their illness rather than a real person. Expecting family and clinicians to ignore their thoughts and feelings as “just an expression of the eating disorder,” people in this situation express their frustration through even more severe symptoms until relapse feels like their only mode of being in this world.

A tried and true element of treating younger people with eating disorders is to listen to what this person is expressing through their illness and what they have to say. They feel so trapped and don’t expect anyone to care or listen to them. The isolation of being seen only as their illness leaves them no recourse to say how they feel. Really listening to their concerns can open a new path towards healing.

With treatment as an easy decision for clinicians, recovery often starts with ignoring what patients have to say. Before long, they have gone through a variety of outpatient programs and inpatient programs aimed at weight restoration only. Patients learn that the only way to be heard is through symptoms and behaviors. They learn there is no point in being honest because honesty is labeled as “the eating disorder talking.”

It would behoove families and clinicians alike to remember that people only get better from eating disorders when they are heard. Of course, food and health matter, but they are never enough to get better.

The Traumatic Effects of Inpatient Treatment for Eating Disorders

Traumatic responses to inpatient and residential treatment have many facets and interfere with one’s ability to find and commit to successful treatment. 

First and foremost, the trauma of treatment programs causes a lack of trust for clinicians. In programs, clinicians usually promise health and happiness by committing to a new meal plan, but the reality of eating and disobeying eating disorder thoughts and beliefs feels painful and frightening.

The disconnect between trust in clinicians and the outcome of following their advice convinces many patients that clinicians are not in fact to be trusted. Patients learn that it’s more advantageous to negotiate with providers rather than to trust them. The result is that the ultimate goals of the treatment team and the patient feel at odds. 

Once out in the world, trusting clinicians seems almost absurd after feeling so betrayed in programs. Without any guidance, people rely on their eating disorders, refuse to speak frankly with their treatment team and often relapse quickly. 

The experience of feeling trapped while eating and gaining weight fulfills the worst nightmare and deepest fear of many people with eating disorders. After living through such a difficult time, patients talk about reliving moments of terror in programs and how alone they felt while in treatment. Any suggestions to adhere to a meal plan or work on food consistency feel like a reenactment of treatment and engender the same feelings.

Moving forward in recovery in the world often means facing these traumatic memories of treatment first. For many people, finding a path towards a recovery entails undoing much of the effects of treatment. 

The other most important traumatic experience of programs is the drastic change in one’s body. Body image thoughts and fear of weight gain are central to most people with eating disorders. Programs often lead to a rapid change in one’s body, and handling the traumatic fallout of this transformation is painful.

For many patients, the only recourse of to lose weight as quickly as possible to regain a body that feels comfortable. Even if this impulse is not intended to lead to relapse, any attempt at weight loss triggers a relapse most of the time. 

The transition to outpatient treatment not only means learning how to eat on your own without the structure of a program. It also means facing these important traumatic elements of treatment in order to make recovery possible at all. To be clear, many people have positive and helpful experiences in treatment. Trauma is far from universal but is a real effect many people with eating disorders experience.

Healing the Trauma of Residential Treatment for Eating Disorders

People in recovery from eating disorders often need to address the trauma of being in treatment programs in order to fully get well.

Hospital stays and residential treatment are often, but certainly not always, a necessary part of recovery. Critical medical issues need attention and sometimes a hospital stay is necessary. When people experience prolonged, severe eating disorder symptoms, residential treatment may be the only way to normalize eating enough to continue down the path of recovery.

Patients who understand their illness usually agree when it’s time to go into treatment as well, even if they are reluctant.

The trauma of being in treatment can stem from being forced into the program, especially if the patient is young, but often trauma occurs even when the patient decides to seek help themselves.

Treatment programs render the patient powerless and helpless. They have to stay on the physical premises and are only allowed out on arranged outings. They must eat what is in front of them, no matter how frightening or overwhelming the experience, five to six times daily. They need to tolerate any changes in their bodies, no matter how sudden. For the first few weeks, they cannot even go to the bathroom themselves for fear they may engage in eating disorder behaviors.

In addition, patients need to adhere to these rules while attending individual and group therapy sessions where they are expected to talk about deeply personal and sensitive topics. It’s hard enough to broach those topics in the best of circumstances, let alone when the person is locked away without any rights, independence or agency.

Weeks or months of being trapped without any say and forced to do the terrifying act of eating many times per day while one’s body changes, often very quickly, is frequently traumatizing.

The expectation after treatment is that patients will continue their meal plan, ignore the emotional fallout of weeks or months in treatment and recover swiftly.

Clearly there is something missing in this plan for eating disorder recovery.

After discharge from treatment, patients need to start to talk about their experience immediately. Not only is it harder to eat without being forced to do so, but a common response to being so powerless is to assume power back with eating disorder symptoms. Paradoxically, the traumatic experiences reinforce the eating disorder itself. Patients need to talk through their experience and feelings immediately in order to not fall into the most common pitfall after discharge.

In addition, discharge plans from treatment need to focus on the food in a compassionate and supportive way. The draconian methods used in programs will backfire in the world. Force does not create an path to recovery.

Last, patients need to know they will be in charge once they are out in the world. The experience of being trapped and overwhelmed renders people scared and alone. Retreating to the eating disorder feels like the only way to regain any sense of safety and security.

This topic is even more important with the growth of treatment programs in recent years. Therapists need to be ready and capable of ensuring patients get compassionate care after discharge from programs.

The Existential Nature of Eating Disorder Recovery

Treating eating disorders frequently leads to an existential conversation. There are many theories why recovery inevitably lands in discussions of the meaning of our lives. Nevertheless, the work of getting better apparently necessitates delving into why we are here.

In part, people with eating disorders are very coherent and clear in all other aspects of their lives outside of their own food and weight. The symptoms of every other psychiatric illness bleed into daily components of human life, but eating disorders are much more circumscribed. The result is that someone with an eating disorder can have a lucid, insightful conversation about their illness even when they are struggling to get better.

No matter how they start, eating disorders become the foundation of the meaning of life. Success is determined by the actions of that day: food eaten in the day, the number on the scale, avoiding food behaviors, the number of steps, to name a few. Or the eating disorders provide emotional needs not found elsewhere: comfort, companionship, guidance or praise.

Stepping away from an eating disorder and attempting to live without the feedback and direction the illness provides instantly leads to questions about what life means. The eating disorder provides clear answers about what makes life worthwhile. The immediate question is why else does life matter when the eating disorder begins to seem meaningless?

For most people, recovery cannot exist in a vacuum. People who try to change their behaviors, without any other part of life providing value, don’t see a reason to continue the hard work of recovery. They peek out at the world, perceive only emptiness and dive headfirst back into the disorder.

Successful recovery demands that other parts of life start to matter as well. As the eating disorder behaviors and thoughts recede, the person often finds they are drawn to focus on and think about these other facets of their existence. At first, that may mean broadly talking about what matters in life, but the transition is not fluid or easy and almost always torturous and challenging. Missing and grieving the distance of the eating disorder feels painful, and figuring out how else to live is complicated and confusing. It’s hard to start with no idea about how to live after having a guiding light one’s entire life.

These conversations need to give room for the uncertainty of our existence to remain a focal aspect of getting better. The existential nature of recovery is one we all find familiar. We all face the reality of our existence, and any therapist can identify with the fears of trying to find meaning in our lives.

Even more, the goal of thinness has a powerful place in generating meaning even outside of eating disorders. It would behoove us as a culture and country to rethink thinness as an accomplishment that gives meaning to our lives. A cultural phenomenon is now a capitalist boon to several powerful industries. We all need to recognize there has to be more to life than a number on the scale.

The Risk of Referring to Eating Disorder Programs too Quickly

The growth of residential eating disorder treatment in recent years expands access to care in ways that were unimaginable a decade ago. Programs accept many insurance plans. There are so many more programs across the country. I look back at posts on this blog from a decade ago, and one main takeaway is how few options there are for treatment. What a needed and rapid change!

Availability of treatment for a broad swath of people with eating disorders is a huge relief. I have spoken about many of the concerns about these programs—many of which are now owned by private equity companies—but it’s important to recognize the benefits as well. Many more people sick with eating disorders can receive adequate and timely care.

An unexpected result of these improvements is a more myopic view of eating disorder treatment for outpatient clinicians. Before, referrals to “higher level of care,” i.e. treatment programs, were held at a higher threshold. The limited availability of programs made this referral more of a last resort.

With so many programs accessible and covered by insurance, it’s a lot easier for treatment teams to consider a program even after someone struggles for a brief period of time. There is less patience on the whole in outpatient treatment for patients to have a chance to try new ways to get well. Treatment programs can stop an immediate slide in symptoms, which often puts the clinicians’ minds at ease when facing a patient not doing well.

Programs may excel at making people eat, gain weight and regain health; however, in a bubble protected from the outside world, patients don’t learn how to cope with life while maintaining recovery. Cycling in and out of programs typically leads to patients who are demoralized and lose any sense of who they are outside the eating disorder. Too many of them lose hope for recovery.

The hardest part of recovery is the work done out in the world, not just the eating but dealing with the feelings that arise when eating behaviors are stable. That’s the work people in recovery need help with the most.

A treatment team needs to be able to tolerate the ups and downs of recovery in the world in order to let the patient know she has the support to get well. Clinicians need to remember it’s also their job to tolerate when a patient struggles. Resorting to treatment programs too quickly only reinforces the hopelessness of recovery rather than the projecting the belief and confidence that getting better is really possible.