In order to understand why eating disorders are so hard to recover from, it’s best to try to consider some basics about brain function.
Behaviors around food are among the most essential and automatic actions humans have. Like sleeping or breathing, eating enough food is necessary for basic survival, and in the end our bodies and brains are programmed to survive.
The most necessary functions are built into the automatic, unconscious parts of our brain. It is almost as if the brain doesn’t trust our more fickle attention spans with such a crucial human need.
In fact, we share the need for basic functions with all mammals, so our brains force us to act quite similarly to most animals when it comes to food, especially if our bodies are a state of malnutrition.
Higher order brain function differentiates humans from other animals. However, those cognitive processes of organization and abstract thinking don’t apply to food when it comes to survival. We can convince ourselves we get to choose how and what we eat, but that all changes if we deprive our bodies of enough food. In a state of starvation, automatic, unconscious actions demand eating food under any circumstances.
Automatic behaviors are almost a backup system to ensure adequate nutrition no matter the circumstance. Willpower or personal desire can’t withstand the urgent need for survival.
But when new patterns of behavior around food begin, even if they are disordered, they will become ingrained in the same automatic system in the brain as any food behaviors. If that means binging and purging, eating at night or eating all day, once a new pattern is set, a person must pay a significant amount of conscious attention for a period of months to start a new pattern.
It is the need for so much effort to change these unconscious patterns that makes eating disorder recovery so difficult. The process of recovery isn’t just understanding the emotional reasons for the behaviors. It’s also the difficult task of reversing longstanding neurological patterns around a necessary human function.
The initial treatment for someone with an eating disorder is very similar for everyone. It focuses specifically on normalizing eating patterns, stabilizing nutrition and promoting medical stability.
After that first step, all aspects of recovery are very much individualized based on many factors, for example, personality, age, length of illness and need for personal growth. A cookie-cutter approach to treatment after the first stage tends to be ineffective and certainly doesn’t lead to long lasting wellness.
IndividualIzed treatment needs to take into account an individual’s preferences and also the issues that are exposed by regular eating patterns. The range of issues is very broad. For some people, depression, anxiety and hopelessness are central. For others, the prospect of living an adult life is terrifying. Sometimes traumatic experiences surface, or instead the focus could solely be on personal and emotional growth.
Due the the myriad needs of someone seeking help for an eating disorder, the clinician and team need to view each person as an individual. Flexibility is a key to overall effective support rather than dogmatic rigidity. Most eating disorders already function on rules and inflexibility so recovery needs to present a different model for life.
There are two key points to note. The first is that it can be challenging to differentiate the desire for flexibility from the eating disorder thoughts attempting to sabotage recovery so joint attention by the team and patient is necessary to avoid this pitfall. Second, patients need to be sure the clinicians they see approach sessions in a way that feels real and genuine for them. If the conversations seem forced or phony, then treatment is not likely to help someone reengage in the world.
Paying attention to instincts about personal connection will go a long way to ensure treatment is successful and is right for the individual.
Understanding the complex nature of eating disorders is difficult. It’s not intuitive why someone would suddenly have difficulty eating food or start eating large quantities and throwing the food up. A person without an eating disorder approaches food and meals intuitively with little conscious thought. Even people concerned with food and weight but without an eating disorder have very automatic food behaviors. Similarly, eating disorder behaviors also become very automatic and thus difficult to change.
Recovery from an eating disorder involves paying conscious attention to change these ingrained behaviors. Although understanding eating disorders may can be hard, the methods that are effective in promoting recovery and changing behaviors tend to be very straightforward.
One tool is consistent connection between the person in recovery and people who support the process. The goal of these regular, daily contacts is to reinforce and usually reiterate the same recovery tropes to counter the constant disordered thoughts that dominate the mind of someone with an eating disorder.
The eating disorder says that food is not necessary, that the person is fat and must lose weight, that everyone else is wrong, that being alone and following the eating rules are paramount and the list goes on and on.
If there is a concurrent dialogue around recovery with people in one’s life, the eating disorder thoughts no longer have a captive audience. The statements to contradict the eating disorder are also pretty basic: food is necessary for survival; the body knows how to manage and handle food and weight; being alone with the eating disorder only leads to a small, meaningless life, and no your body is normal, not fat.
Hearing these healthy thoughts isn’t a magic fix, but the most successful therapy involves a consistent dose of these reminders throughout each day and week. A few appointments per week are no match for the relentlessness of the eating disorder. Regular reminders, usually many times per day, as a consistent part of any recovery are an important indicator of beneficial treatment.
Lately I have written about the risks associated with the takeover of the eating disorder residential treatment centers by financial investors. As the focus of care has shifted from patient recovery to financial gain, the risks and potential hazards are growing.
A foreshadowing of the possible outcomes is evident in the addiction industry. A recent episode of the podcast The Daily (search for the episode from January 18, 2018) chronicles the rise and fall of an addiction company. Started by a recovered addict eager to share his experience with fellow addicts, the company quickly grew from a small entity into a chain of centers.
Its growth was buoyed by a federal law that increased insurance coverage for mental health treatment. This influx of funds created a large cache that enabled rapid growth of the corporation. Calls to prospective clients transformed from a clinical assessment to a sales pitch. And clinical decisions similarly were tinged with the thoughts of financial gain.
The company grew until it went public and brought tens of millions of dollars into the coffers of the founder, but the slippery slope of commingling financial gain and clinical care eventually went awry.
One center decided to accept a patient too ill to be managed without more complete medical care solely to access insurance payments. The staff was unable to interpret clinical symptoms as signs of instability rather than typical withdrawal symptoms, and the patient died on his first night in treatment.
It’s not hard to see a similar process already playing out in the eating disorder treatment world, and the decisions are stark and risky. When a patient of mine goes to a residential center. My first contact is from an outreach coordinator rather than a clinician. Programs immediately urge all patients to follow the course of residential treatment and the various outpatient programs all run by the same company, ensuring insurance coverage for anywhere from six months to a year. First time diagnosis patients are given tube feedings immediately without a clear assessment of risk, a decision that increases the likelihood of readmission within the next year.
All of these decisions may have generalized clinical value, but the lack of individualized care implies insidious motives of financial gain.
The swift growth of centers and the increased corporate structure of these companies have conflated clinical decisions and financial ones. The downfall of an eating disorder company will be different from what happened to the addiction company. Eating disorder centers were often founded by recovered people who wanted to share their success with others. It’s clear that the powerful urge to heal rarely factors into the function of a corporate center. As the focus shifts from patient care to growth of wealth, only patients will suffer.
The growing community of eating disorder support by clinicians and volunteers who are recovered has been a significant change in the treatment world. On the one hand, recovered people understand how hard it is to eat each meal and snack and know what the eating disorder thoughts mean and how strong they are. On the other hand, it can be hard to assess how recovered clinicians really are and also it can be easy to conflate one’s own experience with the different paths recovery can take.
This model for recovery to include recovered clinicians is an adaptation of addiction treatment. Both 12 step meetings and many treatment programs are run by former addicts. No one understands the strength of addiction the same way. Similarly, it’s easier for a former addict to identify dangerous behavior patterns and to acknowledge the kind of tough love that is often necessary to achieve sobriety.
The models that work for addiction are often used for eating disorders, and for good reason. The behaviors are both compulsive and often driven by irresistible urges. The pattern of recovery and relapse is similar, and the patience needed to slog through the long process to wellness is comparable.
What is fundamentally different is the source of the problem. Drug and alcohol use is a compulsive behavior driven by chemical addiction and by the irresistible urge to alter your mental state; however, these drugs are not necessary for life.
In any stage of eating disorder recovery, continuing to face food and eat many times per day is critical for survival. There is no way to cut out food.
These differences are reflected in brain function as well. The knowledge of brain-based causes of addiction is focused on the surge of various chemicals that create a high. Sobriety means relying on the brain to return to normal chemical levels. Eating behavior is ingrained in the most primitive parts of our brain because food behaviors are necessary for life. Since they are so automatic and unconscious, food behaviors demand enormous conscious attention to change.
Accordingly, it can be hard for recovered clinicians to recognize how different these experiences can be for people in recovery from their own. Like any treatment provider, one in recovery must learn the breadth of eating disorder treatment. Under those circumstances, they can use both their clinical knowledge and their personal experience to best help people in need.
I have heard many people, patients and colleagues, ask why it is so easy for people to be compassionate when someone has cancer and so hard to do so when someone has an eating disorder. This comparison exposes one key hurdle in recovery.
Cancer is seen as an invasive illness, one that involves harmful cells that appear in someone’s body and puts their life at risk. We all potentially can be diagnosed with cancer and have to acknowledge this risk. There is no aspect of blame but simply the concept of fighting to live.
What makes it easy to have compassion is the apparently random nature of the illness and the universal fear of the diagnosis.
Ironically, we all can develop an eating disorder as well. If anyone is subjected to chronic starvation, they will develop disordered eating and that can lead to any type of eating disordered symptom. The incidence of eating disorders has skyrocketed due to socially acceptable starvation by sanctioned dieting. Although the collective incentive for dieting may be vanity, the reality is that individuals fall into these illnesses almost always by chance.
And once sick, people struggle enormously to fight a monstrous illness that takes over one’s mind and thoughts. Granted, it’s much harder to understand the nature of mental illness than the clear physical existence of cancer. When it comes down to the personal struggle, the fight for one’s life with what feels like an invading force, either a tumor or a strong internal voice, deserves as much compassion either way.
Clinicians, families and friends need to conceive of an eating disorder not only as an illness but of an invasive psychological process that co-opts normal brain function. Compassion makes much more sense in the context of not being to think clearly and act accordingly around a daily necessity like food. It makes the basics of each day extremely challenging. It really is a fight for one’s life.
This time of year is a common one for high school and college students to first be diagnosed with an eating disorder. The stress of the end of the first semester of a new school year can exacerbate already existing tendencies to turn to food for comfort and lead to a true disorder. For college students being on their own for the first time is also a reason for the descent into more severe eating behaviors.
Families now confronted with getting help for their child can be overwhelmed by the maze of treatment and the confounding task of getting adequate help for a sick child.
The first step for any family is to find a trusted clinician knowledgeable about several components of these illnesses. The person must be versed in the diagnosis of an eating disorder, capable of assessing the severity of the symptoms, connected enough to assemble a team and aware of the positives and negatives of all treatment modalities.
Beware of practitioners who solely urge one form of treatment, especially if that option is a hospital or residential treatment program. That choice can frequently be best for someone newly diagnosed, but the proliferation and directed marketing of new programs can influence clinical decisions and cloud clinical judgment.
Programs can lead to quick return of adequate nutrition but also can trigger a quick relapse for two reasons. The first is that programs tacitly promise an immediate cure. Without a treatment team back home, it is easy to turn to the residential program for guidance even after discharge and not find ways to reconnect with the world. Second, patients can wish to relapse to return to the safety provided by living in a caring and nurturing bubble protected from the stress of life. Instead of getting better, it perpetuates the desire to hide away from the difficult obstacles of recovery ahead.
The important step as a family is to assemble a treatment team of experienced clinicians whom the family can trust. Even if that team quickly decides upon residential treatment, the family can focus efforts on recovery in the real world. Any inpatient setting is only a stopover to improve nutritional status and health, not a place for full recovery. The family can also turn to the team for support and ensure the primary support is accessible in daily life and not just the duration of a residential stay.
Last it is important to know full recovery is the goal and very attainable. The myth that no one gets better from an eating disorder is pervasive in our society. Getting the right help for the patient, learning about how to provide family support and coming together as a family all are crucial to help the child get well.
As more financial investment pours into the eating disorder residential treatment industry, it is a relief to know there are more options for patients who need intensive help. However, clinicians are left with several questions and concerns about the intention and skill of these centers.
The first pressing question is the effect on the quality of treatment when financial personnel run a sensitive and challenging clinical endeavor. The quick proliferation of treatment centers means hiring and training of less experienced people hastily in order to staff new programs quickly. Clearly, this can affect the quality of treatment.
Second, it’s very possible that the bottom line will lead to sacrifices of the more nuanced and crucial aspects of treatment that distinguish an excellent program from one that checks all the boxes of an adequate one. Focusing on running a business successfully is often at odds with clinical care.
Third, the expansion of marketing of these programs may very well attempt to convince clinicians to utilize residential programs when other clinical options are preferable. The treatment community has to be reflective enough not to be swayed by shiny new promotional materials. What’s best for the patient must remain paramount.
It’s concerning that the influx of money and power may very well corrupt a clinical endeavor driven by passion and determination to serve a community of sick people not treated well by the medical establishment. The likelihood is that savvy investors will capitalize on access to funds from a wealthy constituency willing to pay for treatment at the places deemed the best.
The most insidious result of the newfound changes in the eating disorder residential treatment industry is the increased admission of adolescents to programs. Although some teenagers get very sick, many kids first diagnosed can recover quickly when families initially become aware of the problem. However, these kids are so susceptible to experiences and their egos are still so malleable that immediate long term care as a first line defense may very well set them up for a longer course of illness. I’ll expand on this idea in the next post.
Understanding why nutrition labels became ubiquitous has to start with a brief history lesson. One of the reasons urban areas could grow so quickly in the mid-twentieth century was the increased availability of mass produced food. At the time, packaged foods and the concomitant ease of food shopping seemed like a wonder of the modern world.
However, the change in the types of food available to the masses also included diets largely consisting of processed foods, a completely new food group for people to eat. Medical data over time started to show the detrimental effects of manmade foods such as margarine and how the increased salt or sugar intake of processed foods has long term health effects. Regular foods don’t have the same ingredients, ease of digestibility or addictive quality of processed foods, and our bodies react very differently to these foods.
Once medicine brought to light the risks of processed food, government regulation moved in to try to slow down the exploding food industry. One result was the suggestion of dietary recommendations, the food pyramid (recently replaced by the food plate) and mandatory nutrition labels on packaged foods. Granted, the food industry lobbies have altered the government recommendations, yet there is still a component of the federal guidelines meant to inform and protect the population.
What the government regulators have struggled to incorporate is the drive for thinness and pressure of the diet and, more recently, exercise industries which use nutrition labels to their own advantage. The labels were meant to be guidelines that would help consumers recognize foods made with chemicals or with hidden calories from factory processing. Instead, labels and serving sizes enable people at the mercy of the drive for thinness to justify restricting their food intake and feel compelled to constantly diet.
The other confounding factor has the been the overemphasis of weight in the government regulation of food. The data about weight and health is very limited, yet diet and exercise industry representatives continue to help urge the public to be scared of weight gain even though chronic dieting is an equal if not more insidious aspect of modern life. Chronic dieting is the cornerstone of eating disorders, disordered eating and our collective obsession with weight and food as I explained in detail in a previous post.
The sole purpose of nutrition labels is to recognize foods as more or less processed and help people identify foods that are more real. In today’s world, it’s impossible to avoid some processed food and there is no evidence that eliminating all processed foods is necessary. The goal of a balanced diet is moderation and variety of all things.
However, there is no use in obsessively reading labels to determine how many macronutrients one eats in a day, a normal serving size or for calorie counting. The regulations around nutrition labels allow so much room for error that these data are useless for any individual dietary choices and only serve to confuse the true reason label became a federal regulation in the first place.
It would have been difficult to predict the cultural impact of nutrition labeling on foods. At first, transparency of ingredients and additives seemed like a win for the consumer. As processed foods became a universal part of one’s diet, people needed to know what they were eating. Over time research has shown that many manmade ingredients were not particularly good for one’s health.
However, government regulators could not have foreseen how labels might pervade the daily intake and food decisions of a large majority of the population. Without adequate knowledge of general points of nutrition and of nutritionism (the faulty philosophy of nutrition based on building blocks, i.e, fat or protein, rather than real food), it’s incredibly hard to make sense of the information on the labels.
Even more confusing is that children are often taught about biological macromolecules through food labels, equating this information with scientific facts. Food labels have transformed from corporate transparency into false nutrition and dietary law for much of the population.
Too many people assume calorie facts on food packaging is absolutely true. They don’t realize that the information only needs to be within 25% of the actual value. Also, companies can determine serving sizes based on how best to sell product. There is no regulation to create serving sizes that people would actually eat. And the percentages that labels apply to the daily overall diet only approximate a general idea of human needs. Using this data as a hard and fast rule often only encourages dieting.
The immediate benefits of assessing packaged foods has instead turned into a supposed guidebook for food choices and dietary consumption. People who have grown up with food labels are much more likely to count calories, consider dietary choices based on macromolecules rather than food and assess healthy food choices through food industry-devised data.
The next post will give some guidelines about how to use the nutrition labels effectively.
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