Treating eating disorders is a challenging task. I often wish eating disorders had a different name, because just as alcoholism has little to do with alcohol, eating disorders have little to do with food. Within disordered eating- food, or rather the obsession with it, is often the area that becomes the focus, in order to numb out or otherwise distract from difficult, painful and confusing emotions, including shame, vulnerability and accountability.
These emotions are abstract and can feel overwhelming. Focusing on food, weight, numbers etc., can serve to narrow the focus, taking the abstract and making it appear concrete.
Something that you will hear often related to eating disorders is that they are “about control”. That has become the standard response, and in many ways it is accurate; however, my perspective after working with hundreds of patients struggling with eating disorders over almost 17 years, is that the control factor is not necessarily about the patient having or taking control, it is more about the patient feeling controlled.
Feeling controlled is desirable for many people struggling with eating disorders and as a result, this is where we see submissive or passive (sometimes passive aggressive) and dependent tendencies emerge in the treatment process. For example, many patients with eating disorders present as very agreeable and it can be difficult to see their struggles, as opposed to the tangible collateral damage we often see with many patients struggling with chemical dependency.
This leads to a question I often receive from colleagues in the field, asking what my thoughts are on imposing strict meal plans in treatment for those who are struggling with eating disorders.
It's a great question, and one without an easy answer.
This feeling of wanting to be controlled is why many patients I have worked with over the years prefer to be told what to eat. Now, let me be clear- when I say “prefer” I don’t mean that they will drop resistance when being told what to eat, they will likely resist, but in my experience, they do want to be told what to eat. This is because being told what to eat alleviates them of the stress of personal responsibility and they can be mad at the person telling them what to eat rather than beating themselves up for having the natural urge of wanting to eat.
Many programs are aware of this, and choose to impose strict meal plans for the very reason of alleviating the suffering of the patient being self-critical around hunger or eating. I understand this drive and I have used this technique in the past, only to see short-term success and no long-term gains. An issue I have observed with this approach, is that it can create an “us against them” culture. The patient’s behaviours can travel further underground, and a cat and mouse game can ensue around “being caught”, and as a result, the patient is left feeling hostile at their supports and incapable of making decisions outside of a structured environment.
Another reason that many programs choose to impose strict meal plans is that frankly, it makes the staff feel better. When it comes to strange behaviours around food, we can quickly become co-dependent. This is because food is a basic human need and our empathic drive to help kicks in. We can have the drive to “make sure” someone is eating. I have even seen staff in treatment go so far as to tackle a patient to keep them from going to the bathroom after a meal... Many people have said to me that this is what "should" happen, to keep the patient “safe” and to keep them from “mood altering”. We think that if we block the behaviour, the compulsion will go away. This is understandable- we often make the mistake in thinking that creating simple rules will create simple behaviours. However, what we need to look at is that within these tactics, we are often just creating, or re-creating dysfunctional family system dynamics and confirming that the patient is incapable of asking for help or changing their behaviours.
We have a tendency in addiction treatment to draw a straight line between chemical dependency and eating disorders and therefore we often try to treat them the same way. While I agree wholeheartedly that there are many similarities between chemical dependency and eating disorders, there are also many differences, and I caution against being too reductionistic in the treatment approach taken. While of course, we want the patient to be “sober” from their behaviours around food- this sobriety is not the same as treating a person under the influence of drugs or alcohol, and we need to be careful to not create a false equivalency. For example, we can’t reasonably engage in insight based therapy with a person who is currently intoxicated, but we can reasonably engage in insight based therapy with someone who just binged on a box of cookies, as this gives us direct evidence of behaviours and an example to work with in the treatment process.
Many patients are very much unaware of their behavioural patterns and are disconnected from their triggers- therefore, sweeping in and totally controlling their food intake can only serve to confirm their negative beliefs, keep them passive to the process and unaware of their triggers. If we move in and control the pieces, we are missing the opportunity to support the patient to gain an understanding of their patterns and behaviours, thoughts and feelings, and further, if we remove the triggers, we do not equip them to understand the impact of their triggers, or support them in learning how to ask for help when they are in the midst of struggle.
The approach that I recommend is instead of exerting control, offer supports and open communication. Include the patient in the meal planning process, ask them their goals and how best to support them. Ask them: “when you feel supported, what are people doing?”, ask them about their most difficult times of the day, and ask them about times in their lives when they felt free from compulsion.
Include the patients fully in the process and tell them what you are seeing. I believe that one of the most important and valuable aspects of treatment is the ability to monitor and reflect behaviours back to the patients.
Instead of controlling the meals of the patients, I would rather see compassionate supports in place, collaborative meal plans and supportive monitoring and reflecting- in order to help the patient map out their behaviours and gain understanding into their underlying thoughts and beliefs.
I have found the greatest successes happen in treatment when patients feel seen, heard and valued. In my experience people are more likely to engage in the process when they feel like they are a part of the process. I have often found that our greatest breakthroughs emerged while talking about subjects that were unrelated to food, but maybe came up through noticing and reflecting upon a certain behavioural pattern that came up around meal times. Through being curious rather than directive we can move past the surface and into the core beliefs that underpin the presenting behaviours. I like to say to patients that the obsession around food isn't the issue, it's the "check engine light", indicating that something is going on that needs to be looked into.
I believe that treatment is the groundwork for gaining clarity on where a person is, what their triggers are and how their behaviours are impacting their lives and the lives of those around them. I think that it is vital to help the patient understand what their goals are and what steps they need to take in order to reach their goals. This process includes building rapport, gaining trust (teaching what trust IS), having open communication and allowing for mistakes.
*This article was originally published on LinkedIn on November 21, 2016