The Context of Eating Disorder Diagnosis and Treatment

The overlap between culture and psychiatry is profound and always has been since the inception of the field. The dearth of scientific information to diagnose and treat mental illness combined with societal bias mean that psychiatry relies heavily on social values and cultural norms to determine treatment. Although other fields of medicine change from social impact, none do so more than psychiatry.

The definition of mental well being changes through generations. Success can mean many things: professional success, completing an education, a steady job with a family, a thin enough body, the ability to study or work 12 hours per day for weeks and months and years, or spiritual awakening. And the ideal mental state to attain many of these goals is extremely different.

Accordingly, dysfunctional mental states change drastically as social norms change. Odd or unusual behavior that is seen as mental illness now may have been adaptive in smaller, isolated villages centuries ago. A slow and steady temperament may be beneficial in some communities and seem as a sign of a learning disorder in others. Inattention that is a hindrance in school can be more creative and inspirational in times of societal distress. A thinner body may be ideal in certain towns and a sign of illness in a different community even in the same state.

As these norms change, psychiatry changes as well. Without a clear way to diagnose and treat illness, mental health professionals need to consider the world each patient lives in when thinking about diagnosis. What is considered an eating disorder now may not have been twenty years ago.

The point of this blog post is not to discount psychiatry and mental illness at all. However, we all need to be sure not to conflate psychiatry with clearcut science. The scientific data about the safety and utility of medications or research into best practices when treating eating disorders are sound. The philosophical and moral values about how to proceed in recovery is not only dependent on the person’s medical and psychological state but also on their background and community. Our individual mental health demands context in order to be defined correctly.

The Broad Changes Occurring in Eating Disorder Treatment

The changes in treating people with eating disorders have been dramatic in recent years. Several differences in how we as a culture approach mental health have opened the door to very new ideas about diagnosis and treatment.

First, mental health is a much more accepted part of overall health. We discuss our psychological and emotional well being as something to be monitored, addressed and taken seriously. The idea that we should tough out difficult experiences and ignore our emotional selves is not the only way to function anymore. Awareness increases the likelihood that family or friends will notice changes in eating behaviors or emotions and say something a lot sooner.

Second, knowledge and education about eating disorders are much more available and prevalent. Mental health awareness is a part of this change, but in addition most people know what eating disorders are and many more people have experienced someone close to them who has struggled with one. Social media exposes people to eating disorders much more regularly, and younger people have a larger breadth of knowledge not just about eating disorders but also diet culture and fat phobia.

Third, the expansion of care with many more treatment programs, virtual programs and clinicians for people with eating disorders makes it possible to be diagnosed and treated much earlier in the course of the illness. Since so more options now accept insurance, many more people have access to care. Treatment options means many people can get help and find a path to recovery sooner in their illness.

Compared to the relatively recent past, these changes are shocking to consider. The majority of people with eating disorders used to struggle for years before figuring out a diagnosis, let alone find any professional help, but that path is much less common these days. I am much more likely to see a young patient who understands their issue and the help they need than a patient ten years older coming to treatment for the first time.

This post reflects an important aspect of mental health care, namely how psychiatric diagnosis and treatment changes with cultural changes in our society. I’ll talk more about that in the next post.

The Contradiction Between Love and Perfectionism in Eating Disorders

The last few posts reviewed some central parts of the psychological underpinnings of an eating disorder and, accordingly, aspects of treatment that help people fully recover. Finding purpose, self-worth and a philosophy to make life meaningful are true antidotes to perfectionism, self-hatred and purposelessness.

At the time, I was very clear about how people with eating disorders often felt unlovable but was unsure as to how to couple this experience more fully with recovery.

In the last two decades, the pressures on women grave grown and changed in ways that have been instrumental in the explosion in the incidence of eating disorders. The contradictory messages of being both extraordinary and mediocre, perfect and one of the group, exemplary and also humble easily conform to perfectionism around food, body and weight. These impossible expectations both in their behaviors and in their food and bodies for women fit neatly into the paradigm of traits that create an eating disorder.

What underlies these impossible expectations is the feeling of never being good enough at anything—a tenet of the thought process of an eating disorder. In addition, never feeling allowed to reach a reasonable goal translates into never feeling lovable or worth loving. If love demands perfection, then no love ever seems reasonable or deserved. Love needs to reflect the feeling of being good enough, not being perfect, just as recovery implies doing well enough both with food and in life.

The learning process of understanding love distinct from perfection starts in therapy. Someone in the throes of an eating disorder and the concomitant perfectionism can’t see outside that bubble. Therapy that balances the idea of love for who you are instead of what you accomplish or what you represent can change the fundamental idea of what love is and is a key to recovery.

Expanded Treatment Options for Eating Disorders

Coaching and meal support are two relatively new and important signs of progress in eating disorder treatment. One theme throughout this blog describes the experience that eating disorder thoughts are ever present in a person’s life, and treatment needs to find ways to counter the thoughts and behaviors much more regularly during the day.

I have written about using daily food logs as a primary way to enable patients to face their thoughts and feelings. This treatment plan continues to work very well.

Coaching and meal support offer a different way to provide more help through the day. These modalities focus on extra time with a clinical provider either around daily activities or at meal and snack times.

The provider can interrupt entrenched eating disorder thoughts and behavior patterns and increase the time a patient can try to change these patterns rather than reinforce them. The result is that treatment plans extend into more parts of the day and give the eating disorder less leeway and freedom to dominate a person’s life.

For coaching and meal support to be effective, the patient needs to be far enough along in recovery to be willing to hear the messages around eating more consistently and why the eating disorder can be so destructive. If a patient is so fixed on staying sick, extra support still won’t make much of a dent.

These expanded options in treatment allow for providers to create a much more specific plan for each patient. Therapists, dietitians, groups and outpatient programs used to be the only available options. Now coaching, meal supports, online groups, mentors and a variety of mixed programs offer so many more ways to get well.

The Existential Nature of Eating Disorder Recovery

The last few posts circle a pressing issue in modern day life, especially post-pandemic life. It’s more common for us to be home now and feel comfortable in an increasingly virtual world. As much as we have the luxury and convenience of having everything at our finger tips, there’s something fundamental to the human experience that is slowly fading from our lives.

One element we are missing is social interaction. Virtual relationships certainly do matter and saved us all through the pandemic. However, we are biologically built to be social beings. Extensive research shows that our health and well-being benefit enormously from in person contact, something we are slowly agreeing isn’t as important anymore.

On a more profound level, engaging with the world enables us to find meaning and purpose in our lives in a way that virtual life cannot replace.

Eating disorders create purpose, meaning and structure to people’s lives. The day revolves around how to eat, how to move and how to plan each and every day. It’s clear every night if the day was a success or failure based on the philosophy and morals of an eating disorder. The eating disorder brings pain but also enables people to find a sense of purpose, safety and even calm.

If we retreat to the virtual world, the structure of an eating disorder becomes even more appealing. Diet culture, the exercise industry and the wellness cult draw us further into these depths and away from lives with meaning. The media easily confound any sense of direction in life through endless advertising and images that associate food and weight with personal value. Individual choices drown when faced with the overwhelming messages about health and thinness. And social media imprint a profound sense of inadequacy about who we are and how we live.

The cure to most of these ills is out in the world. Purpose and meaning come largely from relationships. We find our best selves learning from others and celebrating the complex, emotional and new experiences in our daily lives.

In order to decrease the incidence of eating disorders, our society needs to prioritize interaction and relationships enough for people to find identity and meaning outside themselves. It’s not a small task but a necessary one.

Our Intentions About Food Matter

People who come to see me for help with their eating disorders often ask me how I eat and how I think about food. Years ago when first asked this question, I was taken aback, but I have thought quite a bit over time as to why this question is so important. Now I try to answer honestly either about what I might have eaten in any given day or how I approach food in general. As a result, I try to look into all the ways I approach food and how my experience might help guide people in recovery.

This question gets to the heart of dealing with food in our world as it is. There is no clear way to think about and approach food. We aren’t equipped to handle the endless array of food at our disposal, as I mentioned in my last post. The media noise about dieting, “healthy” food, irresistible food and weight is extremely loud while the silent whispers of a more balanced way to think about food and body are barely audible.

For the first time ever as humans, the fortunate of us expect to be able to follow hunger and fullness cues and desires to figure out a way to eat without a care of a future without plentiful food at our disposal. Even for those of us who don’t have eating disorders, eating is complicated and laden with many contradictory impulses.

Many if not most people use the messages in the media to eat based on some ambiguous sense of doing the right thing balanced with their own desires. Some people use exercise as a way to justify eating (food as “fuel”) while others focus on the kinds of food they eat (or don’t eat) either as a way to eat ethically or to focus on perceived health benefits.

We all may look for the right way to eat, but more than anything I think we are searching for a structure to help us eat regularly and in a way that feels good physically and emotionally. And more often than not, the media have an enormous impact on how much time and effort we put to our food.

I often answer the question in a few parts. During the week, my food is fairly consistent without too much variation since this way of eating needs less attention so I have more energy to focus on the weekdays. The weekends tend to be a time of more food pleasure either around foods I enjoy, being with others or cooking. The balance between routine, ensuring there is time and attention to meals even on busy days and enjoyment is a pattern that has worked for me and is often a helpful guide for many people to begin to figure out the place of food in their lives.

The Role of Mass Media in Self-Worth

The first and possibly most important step to avoid the pitfalls of how food and body play an outsized role in modern life is actually not related to food. Instead, we all need to focus on the elements of who we are and what we value in order to put food and weight in their proper place.

In many ways, food and body are defaults to represent self-worth and life priorities. There is an abundance of evidence to show that dieting, body focus and eating disorders arose in large part due to the inception of mass marketing. Only through the creative but insidious generation of images that pervaded our culture did these issues emerge. As media continues to grow and spread into every facet of our lives, we all struggle not to embrace food and weight as imperatives for a meaningful life.

I don’t mean to imply that food and weight haven’t had their place throughout human history, but media allows messages and images to spread much more widely and powerfully than ever before, and, as social beings, we are not wired to ignore the messages.

The only way to push back against the powerful societal messages is an active, directed approach. We need to spend time thinking about, considering and engaging with values and morals that are most important to us. We need to make decisions about how we want to eat for our own well being whether it’s based on how we feel, what we enjoy or the role food plays on our lives.

We need to embrace images of all sorts of bodies to counter the pervasive messages around thinness. We need to see the positive in our physical selves, our bodies and our appearance. We need to look for messages from people who think about and view bodies as beautiful in all shapes and sizes.

If we are passive about how we consider ourselves as humans, we remain very susceptible to the idea that our self-worth is based solely on food and body. But we also are very adaptable so making time to create our own sense of selves and our own thoughts about food and body that can counter the effects media has on each and every one of us.