Reflections On a 30-Year Career in Eating Disorders Treatment
The White House released a statement last Friday recognizing National Eating Disorders Awareness Week (NEDAwareness Week), marking the first time an administration has done so since George H. W. Bush in 1990. This declaration sends a message that we need to recognize eating disorders as mental illnesses that deserve attention. Interestingly, it was also three decades ago that I first began my career as an eating disorder treatment specialist.
Today, I want to share some reflections on what I’ve learned throughout my 30-year career in eating disorders treatment. As I do so, I also want to take a closer look at this year’s theme for NEDAwarenessWeek and consider some ways we can work together to See the Change, Be the Change.
See the Change
See the Pandemic as a Teacher
During the last few years, we have learned a great deal about what triggers the onset or worsening of eating disorders. The COVID-19 pandemic brought a dramatic increase in reported eating disorders, especially among young adults and adolescents. I’ve personally noticed this rise: I have received more calls than ever from desperate parents who are unable to find help due to treatment option shortages.
Further supporting this increase, the National Eating Disorder Association’s (NEDA) helpline calls have increased as high as 80 percent since March 2020. One study that monitored clients in both the United States and the Netherlands during the pandemic revealed an increase in restriction by 60 to 70 percent and an increase in binge eating by 15 to 30 percent. Additionally, we know that a third of Americans have reported signs of anxiety or depression since May 2020.
Given the uncertainty of our current world, it’s no wonder that everyone wants to feel better. For people with restrictive disorders, they feel better when they don’t eat. Others find overeating makes them feel better, especially when it comes to highly palatable foods. Regardless of how a person’s eating disorder takes form, it’s been a trying time. Plus, treatment centers are overwhelmed, and waiting lists for getting a placement are now the norm.
It’s no secret that social isolation and feeling trapped fosters intense anxiety in humans. Those with tendencies for obsessive-compulsive traits cling to new routines when nothing seems normal anymore. Unintentionally, these routines become out of control, leading to seriously low body weights. At that juncture, eating seems nearly impossible (more on this topic later). Those with a tendency to overeat are surrounded by stockpiles of food and also have easy access to even more food thanks to delivery apps.
In the absence of face-to-face social connection, our nervous system becomes dysregulated, and food is an easy substitute, as it uses the same neuropathways to co-regulate. During these past few years, we literally replaced people with food. Body changes perpetuated the isolation due to our social bias toward larger bodies. For others, the lack of food evoked binge eating. Food insecurity tripled during the pandemic, which reinforced the known high correlation with eating disorders. Social media use also skyrocketed during the pandemic, which in turn led to a rise in mental illness and body dissatisfaction.
One positive outcome of the pandemic was the transition to telehealth eating disorders treatment. Although most people were hesitant to make this switch, it is now a preferred method of therapy. This approach offers more opportunity and affordability. I still worry about the lack of face-to-heart connections, but time will tell.
See the Problem Through a Different Lens
New discoveries in genetics, brain-gut microbiota axis, and neuroscience have challenged the old psycho-social model of eating disorders. We now see that there are other driving forces around seemingly irrational behavior. We cannot underestimate the psycho-social vulnerabilities that prime our biological forces, but we will never see eating disorders in the same way as we did thirty years ago.
For instance, we have reconceptualized anorexia as metabo-psychiatric. Why in the world would someone starve themselves in a body that was designed to survive? We have now proven that some bodies have negative set points and a paradoxical reaction to negative energy balance. This research validates our clients’ experiences and challenges our “blame the victim” historical stances.
Positive set points act in the same way: The body’s complex metabolic systems drive behaviors that either pull our weight down to our lowest point or increase our weight to our highest weight. Genetics are a determining factor.
We have made fascinating discoveries regarding our Brain-Gut-Microbiota Axis and its influence on our mental and physical health. Psychobiotics, a new field of nutritional psychiatry that targets the microbiome (gut) to improve mental health outcomes proves to us that “it really is about the food.” In fact, we now regard food as medicine when treating eating disorders. Discoveries of gut bacteria strains that reward restrictive behaviors in anorexia and create binge cravings in bulimia and binge eating disorder began to change our lens of conceptualization.
Neuroscience discoveries have also confirmed dopamine reward pathways are highly influential in our wanting and liking of food in both restrictive and binge disorders. Although the drive for thinness is still a primary criteria for most eating disorders, which is an outcome of our weight centric and fat bias culture, it brings us to question the fragility of our biology to these social cues.
See the Truth That One Size Doesn’t Fit All
Our treatment modalities have certainly changed over the years. I was trained in the early 90’s with an addiction model of treatment for eating disorders, which faded with the introduction of Cognitive Behavioral Therapies (CBT). CBT is still regarded as the most evidence-based treatment for eating disorders. New mindfulness-based forms of CBT, including Dialectical Behavioral Therapy (DBT) and Acceptance and Commitment Therapy (ACT), have also shown efficacy.
One thing we have learned is that not all eating disorders look and act alike. Personality features and temperament influence what forms of therapies should be used. The introduction of Radically Open DBT brought to our attention that some clients need different approaches to bolster their social and behavioral deficits contributing to their ineffective coping mechanisms. Targeting impulsivity and emotional regulation aren’t necessary for everyone though. Different attachment styles or a need for trauma-informed somatic approaches continually remind us that our client’s needs come first. In other words, cookie cutter treatment plans are a thing of the past.
Another truth is that one size literally does not fit all. The belief that those with anorexia are bone thin and those with binge eating are morbidly obese is an invalidating and damaging stereotype. There are many in larger bodies suffering from the effects of starvation. Yet, they are praised for their rapid weight loss by others, including those in the medical field. I have treated post-bariatric surgery clients for severe anorexia, but they are seen as a “model client” for the surgical center.
We cannot tell anything about someone by looking at their bodies. Keep this truth in mind when complimenting someone on their weight loss or weight gain. In fact, let’s just keep their bodies out of it.
Thankfully, over the last decade, I have seen a positive shift in size acceptance and social advocacy for those in larger bodies thanks to organizations like the Association for Size Diversity and Health (ASDAH) and their Health at Every Size (HAES) Approach.
See the Parents in a Different Role for Eating Disorders Treatment
Blame the parents for an eating disorder? Not anymore. Distant fathers and smothering mothers are another stereotype that no longer fits. Family dynamics are still important, and healthy communication must be facilitated, but we now look to the parents to be a part of the treatment team.
For instance, in family-based therapy (FBT), they are the primary treatment providers. The evidence-based eating disorders treatment for those ages 8 (yes, 8) to 24 is FBT. The premise is that feeding oneself becomes a privilege when a child has not been able to maintain health with their own eating choices. Parents take back the prepping, plating, and monitoring of meals until the child reaches the stage where they are ready to transition back to making their own meal choices. I was skeptical at first, and there are always exceptions, but this treatment really does work.
For most mild to moderate cases, FBT can be a part of outpatient treatment. Due to the scientific factors mentioned previously, some severe cases have a difficult time with weight restoration outside of a residential setting, but the parent joins the child as part of the team whenever possible. Great sacrifices on the part of parents are commendable when saving their child’s life from a lethal eating disorder.
Be the Change
I’ve always prided myself as being a lifelong learner. As professionals in this field, we need to be curious about those things that challenge our conceptualization of eating disorders. There is much polarization in the field regarding brain disease versus psychosocial disorder or food addiction versus “all foods fit.” We all must find nuggets of truth in each argument and set aside our dichotomous thinking. Challenge yourself to stay up-to-date on current thinking by reading journals and attending industry conferences.
We need more professionals trained in this field, as we can no longer keep up with the demand. I also warn against taking on eating disorder clients without proper training and mentoring. It requires a specialization; don’t get in over your head. The International Association of Eating Disorder Professionals (iaedp) is dedicated to the training and certification of eating disorder professionals.
We need to keep a spirit of compassion for those suffering, their loved ones, and those treating this “sticky web” of a disorder. No one sets out to destroy their lives. Stereotypes and social biases only perpetuate existing misinformation, further hurting suffering individuals. Shame keeps this disorder hidden. Instead, we need to encourage people to seek help. It is not something that people can simply “just get over” on their own.
Be an Advocate
We require more prevention and access to treatment. Eating disorders do not discriminate. All socio-economic, cultures, races, gender, and sexual preferences are susceptible to an eating disorder. In fact, our marginalized communities are most vulnerable. We need more providers trained and recruited to treat these populations. Thirty years ago, they touted this as a white, upper middle-class problem – oh, how things have changed! It’s time to get involved and create new opportunities. Let’s point those in need to free or low-cost resources.
Visit my website to learn more about my counseling, consulting, and coaching services. In my latest book Food, Body, and Love, but the greatest of these is love, I share my personal story, my faith, and the scientific evidence revealing a “love code” that finally ends the exhaustive fight with food and body.