As a child or adolescent, it will have been left to your parents or guardians to navigate your treatment options and then your subsequent familiarity with “the system” might mean you’ve never really evaluated your treatment team as an adult.
This post gives you an opportunity to understand why treatment teams comprise specific health care providers. Hopefully that will also allow you as an adult to make informed decisions moving forward as to how you might like to pull together a treatment team to help you get to remission from a persistent eating disorder, or conversely to minimize its impact on your quality of life and overall health.
We have built a mental health care system in our developed nations that centers on psychiatry as a medical specialty. It is not possible to receive a diagnosis of an eating disorder that would allow for any kind of established treatment in the absence of a psychiatrist evaluating your symptoms and deciding upon the corresponding diagnosis.
As such, it’s likely that any treatment you have received for an eating disorder in the past involved psychiatric assessment and diagnosis.
A psychiatrist has completed a 4- or 5-year undergraduate degree followed by approximately 8 years’ post graduate training to become a medical doctor with a specialization in psychiatry.
The Diagnostic and Statistical Manual of mental disorders (DSM), created by the American Psychiatric Association (APA), itemizes mental disorders using observable and self-reported symptom checklists. Psychiatrists (as well as psychologists) depend upon this manual to identify mental disorders within patients.
Unlike many other medical specializations, psychiatry is not practiced in a universal way. There are psychiatrists who adhere strongly to the biomedical model— i.e. all mental disorders are the result of neurotransmitter and/or brain structure malfunction and can therefore be reversed or resolved through the prescribing of various classes of psychoactive drugs. However, there are also many psychiatrists who prefer psychoeducational frameworks for treatment wherein the use of psychoactive drugs is time-limited to an acute phase of the condition, if those drugs are even prescribed at all.
If your treatment during childhood or adolescence included psychoactive prescriptions (antidepressants, antipsychotics, atypical antipsychotics, anxiolytics, mood stabilizers and/or stimulants) then it’s very likely that these were not time-limited prescriptions and you may still be taking them to this day.
There is no universal truism when it comes to taking, or not taking, psychoactive drugs. It is entirely specific to your circumstances and your comfort level. In a scientific sense, there are no psychoactive drug classes that treat an eating disorder and at best they can remediate some symptoms for some patients and likely not in any sustainable or long term way either. 3
Given that several systematic reviews have confirmed the extremely limited value of psychoactive drugs for the treatment of eating disorders, then why do they remain so prevalent in inpatient eating disorder treatment settings?
“Psychotherapy continues to be the mainstay of treatment, but unfortunately, the lack of trained therapists and unwillingness of many of these patients to see a therapist puts a huge burden on the primary care physicians and pediatricians to treat these patients to the best of their abilities.” 4 [emphasis mine]
If we pause for a moment to consider the very telling observation in the above quote from one of the most recent systematic reviews on the use of psychoactive drugs in the treatment of eating disorders, then we have patients with eating disorders prescribed psychoactive drugs primarily due to the burden they place on medical practitioners. Hold that thought and I’ll circle back to it in the next section.
Psychiatrists are medical doctors and in a somewhat circular (and iatrogenic*) definition found on WebMD, they are able to monitor and treat all the medical complications associated primarily with the drugs that they prescribe to treat mental disorders. Some psychiatrists offer 10-15 minute appointments similar to those you might have with a medical doctor, while others might offer psychotherapy sessions of 40-90 minutes. Psychiatrists who offer psychotherapy sessions will have received additional training and accreditation in psychotherapy (and you would look to confirm what that training and accreditation might be in those cases).
Beyond the necessity you may have of receiving a recognized diagnosis of an eating disorder in order to receive treatment, you may choose to see a psychiatrist as an adult when pursuing remission from an eating disorder for several other reasons beyond diagnosis. You may have a very trusting and ongoing relationship with a psychiatrist that you have known throughout the years you’ve been dealing with your condition. You may want to see a psychiatrist to be carefully monitored as you choose to taper from various psychoactive drugs that you were originally prescribed as a child, adolescent or young adult. You may also want to see a psychiatrist because it aligns well with your own medical model of how you would like to have your condition treated. And there are as many other valid reasons for seeing a psychiatrist for treatment or management of an eating disorder as there are individuals with this condition too.
However, having a psychiatrist on your treatment team as an adult is something entirely at your discretion and is not a necessity for navigating the recovery or management process.
The Medical Doctor
Having a medical doctor on your treatment team as an adult is not optional; it’s a necessity. An eating disorder that has been active for perhaps more than a decade has most definitely impinged upon the overall resilience of your body and a recovery effort will likely generate significant, although usually temporary, complications that may require medical intervention as you progress through your recovery effort. And while many with persistent and enduring eating disorder behaviors can be medically stable, they are often in a frail and stable state. As such, the repair and recovery process applied to that frail system can result in suddenly having biomarkers end up all over the map. It’s important to work with a medical doctor who will take a conservative approach when it comes to intervention—what is defined as “watchful waiting.”
The most challenging aspect of finding a medical doctor who can oversee your recovery effort will likely be the pervasive cultural (and not medical, evidence-based or scientific) attitudes of fattism and healthism that infect those in medicine as much as they do the general public. For a look at the prevalence of eating disorder behaviors within the health care provider communities, please review the paper: Orthorexia nervosa I.
Fattism is the discrimination of those who are above average weight, as well as the reinforcement of class and status reflected in a person’s body weight. Healthism is the discrimination of those who are ill and the reinforcement of class and status reflected in a person’s activity level, perceived health and food choice. Both fattism and healthism are viewed as valid forms of discrimination in our society as we frame weight and illness as entirely within an individual’s control. Therefore, the presence of above average weight and/or illness confirms that the individual has failed to exert the necessary behaviors and control to ensure his or her ongoing thinness and health. As fatness and ill health are perceived as personal moral failings, our society views the existence of people with fatness or illness as reprehensible, thereby absolving ourselves of our guilt in stigmatizing, alienating and ultimately de-humanizing these individuals in our midst.
Additional papers and posts on the topic:
- Dear Doctor: Your patient has an eating disorder.
- Being Weighed: Medically sound or fattist bullying?
- Getting Ready to Recover from an Eating Disorder
- Target Weight: Recover but not too much.
The ever complexifying health care delivery system is tough enough to navigate without further dehumanization at the hands of a fattist and/or healthist physician. If you are ever advised by a medical doctor to lose weight and exercise then, wherever possible, find a new doctor. Leaving aside that no one should even place their license to practice medicine behind a treatment (losing weight) that has a 0.003% success rate 5, if the patient has a history of an eating disorder then attempting to lose weight or embark on a formal exercise regime are known triggers of relapse. Eating disorders kill between 1 in 4 to 1 in 5 patients. 6 Fundamentally, if your physician does not recognize those dangers for you, or at the very least agrees those dangers are relevant to you, then you cannot likely build any kind of professional working relationship with them at all.
However, here’s where I will circle back to the quote in the previous section suggesting that patients with eating disorders are both unable to find qualified psychotherapists and are unwilling to undergo psychotherapy.
It’s a good idea to re-evaluate your goals in some detail when it comes to seeing a medical doctor. We haven’t been taught to ask the questions “Why should I see a medical doctor?” and “What do I hope to achieve in seeing a doctor?”
To be fair on us all, the medical industrial complex in which we live in our developed nations is not particularly keen to generate that level of self-reflection and self-awareness in patients. The whole point of countless medical screenings, so-called early detection and presumptive preventative medicine is that we are to frame these things as automatic obligations we have to ourselves to practice good health behaviors in our lives. We’re not really supposed to spend too much time thinking about the “why?”
I will save it for another time to go into some of these concepts in more detail, but for this section I want to focus on the patients and their motivations.
Why do patients with eating disorders have an unwillingness to see a therapist? Beyond the confirmation in scientific literature, this is a truism I see in the majority of patients I’ve come across over the years as well.
Yes, there aren’t enough therapists available (except perhaps if you live in Argentina) and yes, cost certainly is a factor as well. But those reasons are just as likely to be deflections as they are to be real barriers. There are patients I’ve known who’ve been struggling with extremely low income levels who were able to successfully see therapists who offer sliding-scale payments; counselors who volunteer within church and community settings; on campus counselors available to university students at no charge; and group therapy options that are far less costly as well. Many patients have also been supported by family and friends able to pay for the sessions. I don’t mean to suggest that “where there’s a will there’s a way” in all cases, I am simply recommending that you dispassionately evaluate whether you cannot or will not see a therapist.
There’s a Pill for That
Medical doctors routinely end up as not merely the primary health care provider, but also as the primary mental health care provider as well—and that is particularly the case when there is a confluence of medical and mental chronic conditions at play. And as general practitioners, obstetricians/gynecologists, gastroenterologists, endocrinologists, internists, and pediatricians (among other specialties), it’s not that they don’t anticipate caring for the whole person, it’s rather that their expectation is that they can improve someone’s quality of life through the application of their particular area of expertise. There’s a lot that these practitioners can do for you during recovery or while navigating an active state of an eating disorder, and there’s equally a lot that is utterly beyond their scope of practice.
In order to partner effectively with your doctor, you need to understand your own medical mind and how much you may have unwittingly sipped from the medical industrial complex Kool-Aid. Biomarker screening and tests can backfire for those with anxiety disorders (an eating disorder is an anxiety disorder). Monitoring biomarkers (blood pressure, blood glucose levels, electrolyte and mineral levels, resting heart rates and the like) can end up being just the kind of distraction and delay tactic that allows you to keep practicing and reinforcing eating disorder behaviors. If the biomarker results are all normal, then that can misguidedly provide you with an argument that the eating disorder behaviors are essentially harmless. As I’ve discussed in several other papers here on this site, catabolism is largely responsible for biomarker results during active restriction that appear normal. 7 Unfortunately, it’s an illusory and finite state wherein the patient can maintain a frail stable state and then suddenly it will deteriorate hard and fast when the process of destroying one’s own cells to release energy into the body (catabolism) runs out of cells to destroy. Conversely when biomarkers suggest that things are now amiss, the anomalous biomarker itself becomes the focus of treatment rather than the underlying condition causing the anomaly in the first place.
Wherever possible don’t inadvertently rope your doctor into avoiding the elephant in the room (i.e. the eating disorder behaviors). Consider sharing the following post with your doctor whether you are pursuing active recovery or are looking to manage an active eating disorder: Dear Doctor: Your Patient Has an Eating Disorder.
There is no pill to treat an eating disorder. There are certainly pills and injections that can treat biomarker results and some of those pills and injections might also improve your quality of life. But it’s up to you to be realistic and to ensure you don’t use your medical practitioner as a psychotherapeutic surrogate.
When it comes to understanding your own medical mind, consider looking out the book: Your Medical Mind: How to Decide What Is Right for You. There is no hierarchy of better or worse approaches to medical treatment. However, whether you are someone who feels more comfortable with high levels of monitoring and intervention or not, recognize that having an eating disorder gets in the way of honestly knowing your medical mind in the first place.
Your medical doctor cannot replace the psychoeducational training and support you need whether you are attempting recovery or living with an active eating disorder. If you are avoiding psychotherapeutic help all while regularly seeking out medical advice, then you are likely setting you and your medical doctor up for a frustrating and deteriorating professional relationship. The medical industrial complex has set up the patient for unrealistic expectations regarding the pursuit of her or his health outcomes. Some physicians believe in the medical industrial complex tenet that health is always attainable and intervention is always warranted and others know this belief to be largely misguided. But who wants to argue with a patient who insists upon tests and treatment when, as the expert, you know better?
You need a medical doctor on your treatment team whether you’ve been navigating (and plan to continue to navigate) an active state of the eating disorder, or whether you are now navigating a recovery effort. However, do make every effort to understand your health goals and preferred approach. Avoid the pitfalls of either using your medical doctor as a psychotherapeutic surrogate, or anticipating your medical doctor can cure your condition. Your doctor can assuredly support complications that may occur in recovery and can improve quality of life outcomes as well; but it benefits you greatly to have a realistic understanding of how little treatment is available for your underlying condition (the eating disorder) beyond psychotherapeutic treatment.
Resting and re-feeding alone will not provide you with the skills to maintain full remission. Brain retraining is something that is as important as rest and re-feeding during recovery and it’s the one thing you continue to apply as you practice remission for the rest of your life. I often get asked “Can I recover without seeing a therapist or counselor?” and if that’s a question on your mind, then investigate where that question comes from by asking the following questions of yourself:
“I haven’t seen a therapist so far and I’m not in remission from my eating disorder, so why would I avoid trying a new approach that might provide success when I know the current approach has failed?”
“All the scientific evidence from the past 30 years confirms that an eating disorder is a neurobiological condition wherein several psychotherapeutic approaches have clinical evidence for their ability to move the condition into complete remission. Why am I resistant to using the clinically evident treatment options available?”
A therapist is the most critical member of your treatment team whether you are working towards full remission as an adult, or whether you are navigating an active state of the condition. If you have absolutely confirmed that you cannot (do not have the financial wherewithal to) see a therapist, don’t despair. You can continue to investigate low-cost to no-cost options in your geographic area; ask family and friends for the financial help to see a therapist; and clear out your library shelves of any self-help workbooks on treatment approaches such as dialectical behavior therapy, cognitive behavior therapy, exposure and response prevention, eye movement de-sensitization and reprocessing, yoga breathing exercises, mindfulness-based stress reduction, etc.
Qualifications and accreditation for therapists varies from one country to the next. As you know, accreditation exists solely for the purpose of providing the patient with legal recourse if the treatment does not meet the standards to which the practitioner has been required to adhere. Accreditation is important for that reason, but don’t confuse accreditation with competence or excellence.
Beyond that, your government may have regulated the practice: requiring that those who practice are specifically accredited and in good standing with their particular college or association.
It’s good to first familiarize yourself with the regulations associated with your particular geographic area for psychotherapy options. In most countries, a registered clinical psychologist has a PhD or PsyD and accreditation involves additional supervised practice along with ongoing education, liability insurance and etc. And in most countries, no one can call themselves a clinical psychologist without such qualifications and accreditation either.
Counselors may or may not be regulated in your geographic area (they are here in my part of Canada). Life coaches are usually not regulated, but many voluntarily join self-regulated associations. All colleges and associations are self-regulating for the most part, whether the government has chosen to regulate membership to those colleges and associations for the purpose of practicing within their jurisdiction or not. What this means is that practitioners might even be found criminally negligent under the law and yet the college in question chooses to keep the practitioner in good standing and therefore legally able to practice their profession.
It’s distressing to realize that criminally negligent practitioners might still be able to legally practice, but it’s mercifully not too common. I mention this because the pursuit of improving your health and mental health outcomes necessarily means a certain level of vulnerability and it’s good to remember that the certificates on the wall don’t give you license to turn your brain off and assume all will be well.
Wherever possible have a trusted family member or friend to whom you could relay the contents your interactions with your treatment team. I’m not suggesting you need to share details that you privately share with your therapist or counselor, but rather you occasionally speak about the contents of what your therapist or counselor is advising and recommending when it comes to your treatment. This suggestion obviously applies to interactions with all your treatment team members as well.
Your instincts will inevitably tell you when things are amiss for you and when you should perhaps find another practitioner. The problem is that you are quite likely going to second-guess those instincts and that’s where your trusted family member or friend comes into the picture.
It’s difficult to find the right therapist or counselor however it can help buoy you up in the search if you remind yourself that everyone finds it difficult to get the right match. It’s not just you.
And the entire discussion in the previous section about the utter inappropriateness of having your medical doctor advise weight loss, “healthy dieting,” or exercise regimes goes triple for any therapist or counselor you might engage. Their job is to provide you with the tools and techniques to address anxiety in and around your need to approach food and eat.
As for treatment modalities (approaches), you may find you get the most from working with a therapist trained in multiple modalities as she or he can tailor things to your specific needs. You’ll find more details in the Psychology section on this site when it comes to treatment modalities that have evidence of their usefulness in treating eating disorders (also look out the UCSD EDC Conference material as well).
Dietitians and Nutritionists
A fundamental aphorism is that food is never more thought-consuming than when you have little to none available. An eating disorder is a special kind of hell in that food, for most with the condition, is never in short supply but the drive to avoid food (as the misidentified threat) makes it an imposed lack of food.
The brain has a very powerful and distributed system designed to keep you energy-balanced. The brain also has equally powerful and distributed structures designed to keep you well clear of potential threats. An eating disorder ends up as an endless Godzilla vs. MUTO battle between these two systems. Once food is embedded as a threat within the treat identification system of the brain, then the drive to avoid food battles it out with the drive to maintain an energy-balanced state in the body.
Most individuals with an eating disorder are drawn to working with dietitians and nutritionists. Endless discussions about food, food choice, food options, macronutrients, good and bad foods, foods to eat in moderation, what kinds of moderation, food intolerances, food allergies, innumerable gastrointestinal symptoms and their relevance for further dietary tweaking…all act as futile attempts to resolve the battle of the monsters.
It’s all too easy to rope any of your treatment team members into diversionary tactics to keep avoiding food. Just as you can have your medical doctor burn out trying to improve your quality of life in the absence of you working with a therapist; you can also burn out your dietitian or nutritionist in similar ways.
It’s not your fault that you misdirect your treatment team members—the Godzilla vs. MUTO battle positively compels you to do so.
Let’s look at what dietitians and nutritionists are about and what they can reasonably do to support you whether you are pursuing remission or dealing with an active eating disorder.
Credentials and Such
Again, check out the education, credentials and regulatory oversight in your own country to determine whether your country distinguishes between dietitians and nutritionists.
In most countries, dietitians are regulated and nutritionists are not. There are laws restricting practitioners identifying themselves as dietitians or registered dietitians. To do so, they must have licensed status within a dietitians college in their geographic area of practice.
However, these colleges (just as with physicians, psychiatrists, psychologist etc.) are all self-regulated. The oversight of these practitioners’ licensed statuses is the sole purview of the regulatory college in question. As such all health care practitioner colleges and associations have a fundamental conflict-of-interest: they have a responsibility to their members to protect their members’ ability to earn a living all while ostensibly protecting the population at large from substandard practitioners. An educated patient will recognize this inherent conflict-of-interest and understand that these regulations and credentials don’t exclusively protect them from potential harm—caveat emptor.
A registered dietitian has a bachelor’s degree in food and nutrition, as do many nutritionists. The prospective dietitian must then pass an entrance exam and enter a dietetic internship program that involves several hundred hours of practice under supervision. Upon completion of the internship they are eligible to seek licensing within the College of Dietitians to attain registered dietitian (RD) status.
Variably, a registered nutritionist might be regulated in your geographic area or not. But for the most part there are certificate programs and a host of holistic nutritional associations and institutes that will register those who wish to practice as nutritionists. Most certification involves a 1- to 2-year program. However, some nutritionists will have PhD’s in nutritional sciences, so the educational backgrounds can be all over the map in this field.
Having a Dietitian or Nutritionist on Your Team
Unlike the necessity of having a medical doctor and therapist on your treatment team as an adult with an eating disorder, involving a dietitian or nutritionist is not necessary.
There are many patients I know who have worked with truly exceptional and brilliant dietitians and nutritionists. These patients credit their dietary practitioners with their current ability to maintain complete remission of their eating disorder. If you are lucky enough to find them, then of course you would continue working with them.
However, there are a few serious drawbacks to involving a dietitian or nutritionist on your treatment team. First and foremost, their education is steeped in unscientific cultural norms of both fattism and healthism. The nutritional sciences reflect little scientific practice or discipline at present. The vast roster of dietitians and nutritionists out there will squat firmly on the misguided approach to eating disorders of “recover but not too much.” If you are attempting to minimize the impact of an active state of the condition, then working with a dietitian will likely be of more value to you than if you are actually attempting to pursue complete remission. Registered dietitians have a good handle on addressing nutritional deficits and deficiencies that appear with many chronic conditions, including active eating disorders.
Secondly, as absorbed as you might be with food, nutrition, macronutrients, intolerances and the like, you likely also recognize that anyone with a history like yours might also be drawn to a professional career that would support that ongoing focus and interest. It appears as though practitioners specializing in the treatment of eating disorders have eating disorders themselves at about the same rate as the population at large. 8 And that translates to between 1 in 4 to 1 in 5 practitioners that you might hire who will have an eating disorder (or a history of an eating disorder). I’ll discuss the possible pros and cons of this fact in the final section of this paper.
If you are considering adding a registered dietitian to your treatment team, then it will be to you to determine whether you are inadvertently reinforcing the Godzilla vs. MUTO immobility and indecision that are the markers of needing to eat and yet responding to food as a threat (keep in mind you will not likely frame your experience of an eating disorder as responding to food as a threat because the response happens in areas of your brain to which you have little conscious connection). Talking about food, reviewing menu plans, discussing gastrointestinal symptoms, and generally doing anything and everything around food while failing to approach and eat food, will reinforce eating disorder behaviors. When you work with a dietitian who is willing to keep you focused on the practice of approaching and eating food, then you have a powerful ally in having Godzilla (if we use the analogy that this monster represents your drive to stay energy-balanced) ultimately overcome the misidentification of food as a threat (a MUTO controlled by misguided forces, if you will).
Whereas nutrition for otherwise healthy individuals lacks evidentiary context for morbidity and mortality outcomes; there are solid systematic reviews associated with nutritional support for those managing existing chronic or acute health conditions. And while an eating disorder is a chronic health condition, it is primarily an anxiety disorder more akin to phobias—and as such it is a mental health challenge wherein balancing macronutrients and negotiating intake through exchange systems are not as critical as simply eating all the food all the time. If you have comorbid health conditions (such as perhaps multiple sclerosis, lupus systematic erythematosus, degenerative congenital conditions, etc.) then a dietitian may help you navigate maintaining an optimal quality of life. But remember that nothing kills like an eating disorder, so there has to be a compelling reason to risk worsening the symptoms of an eating disorder (through restriction of food groups etc.) in the interests of improving the symptoms of another co-existing condition you must navigate.
Other Health Care Practitioners and Treatment Goals
Any additional alternative or complementary health care providers can form part of your treatment team if you wish. You might also be seeing several medical specialists in addition to your primary medical doctor. The more health care practitioners involved in your care, the more you need to make sure everyone stays on the same page—and that’s not their job, it’s yours. In order to ensure your health care providers stay aligned with your treatment goals, you first need to know what your treatment goals are.
And that’s hard to do if you are experiencing ambivalence about what you really want to achieve. If you are not sure whether you want to reach full remission or whether you want to try to minimize the health and quality-of-life impacts of an active eating disorder, look out a therapist or counselor who is specifically trained in motivational interviewing. It’s a treatment approach specifically designed to uncover what you might really want to achieve. For many, even thinking about the option of remission or management of the condition generates a strong desire to avoid the entire topic. If that’s the case for you, then find a therapist with experience in treating anxiety disorders and let them know you are too agitated to even spend much time contemplating the options you face.
Once you have decided what your treatment goals might be, then you are ready to pull together your treatment team. Write out your treatment goals and share them with all of your treatment team members. Remind all of your treatment team members that upholding these treatment goals is hard for you because you face that inner battle of one survival mechanism (energy balancer) pitted against another usurped/misapplied survival mechanism (food as a threat). Ask them to help you be accountable for the ways in which this might lead you astray.
Here is the questionnaire that might help you to uncover whether you are, or are not, inadvertently undermining your stated goal of reaching remission:
- Have I committed to pursuing full remission by ensuring I have a medical doctor and therapist or counsellor regularly involved in my treatment and progress?
- Have I identified the ways in which I might have unrealistic expectations of what my treatment providers can actually offer me?
- Have I specifically involved any health care provider wherein I am unconsciously using them to delay and avoid my need to rest, re-feed and retrain my behaviors to the anxiety I experience in and around food?
- Have I continued to see any health care provider even as I recognize it is not maximizing my ability to reach my stated goal of getting to remission?
Indecision is a decision. The decision you make if you don’t pursue full remission or conversely actively manage the condition so that you can maximize quality of life and minimize complications, is one of maximizing complications and minimizing quality of life. Being too anxious and distressed to contemplate the reality of an eating disorder actively running your life, sentences you to the worst of what the eating disorder can dole out. As mentioned above, if you think you are in that space right now, then seek out a therapist to address your indecision.
Actively managing an eating disorder is not an inferior space, much as the narrative of recovery dominates all mental health and chronic health spaces right now. Even if you sense that others do not share your opinion of managing an eating disorder as being worthwhile, know that your innate value as a human being is utterly intact. And while I tend to take a more circumspect view of pharmaceutical options and 12-step (and be prepared for some profanity), this book is overall a very refreshing take on purposefully choosing the path of living with a condition rather than chasing so-called happy end states: F*ck Feelings.
Here is the questionnaire that might help to uncover whether you are, or are not, inadvertently undermining your stated goal of actively managing your eating disorder to minimize complications and maximize quality of life:
- Have I understood all the ways in which my day-to-day function will include levels of anxiety and discomfort if I am to actively manage a state that drives me to avoid distress at all costs?
- Am I inadvertently using any health care practitioner on my treatment team as a surrogate for psychoeducational training?
- Have I ensured I regularly work with a therapist to help address and increase my distress tolerance?
- Am I and any of my treatment team getting distracted with symptoms and biomarkers to the detriment of always recognizing that an active eating disorder is the underlying cause?
- Am I realistic about what my treatment team can and cannot do as the impacts of the condition inevitably mount over the years?
- Am I continuing to see any health care provider despite the fact that I believe they have classified me as “treatment resistant”? If so, have I confirmed this belief by asking them outright? And if the answer is yes, then have I fired said health care provider to source someone new?
Family and Friends
Wherever possible don’t make your family and friends part of your treatment team (assuming you are an adult). Maintain the locus of control (whether you are pursuing recovery or actively managing the condition) of your treatment goals between you and your professional health care providers. It’s best not to make family or friends responsible for representing Godzilla (energy balance) on your behalf. Let your spouse, partner, roommate, family member be your spouse, partner, roommate and family member.
As much as you might be tempted to do so, don’t ask of your loved ones to have them provide permission for you to eat, rest and otherwise support your treatment goals on your behalf. It’s a great idea to have them remind you of your treatment goals, but not to represent them during those times when you are tending to side with MUTO (the misapplied threat response system).
What you don’t want them to say: “It’s okay to eat the spaghetti,” “I’m so proud of you for resting completely today,” “Yes you had a big lunch but that’s not a reason to not eat dinner.”
What you do want them to say: “Are you struggling right now to side with your treatment goals? Would you like me to re-read them out to you?” And ideally you want them to respond to all your questions that represent eating-disorder driven anxieties with that same statement every single time.
Yes, there will be many a time where you would truly want to walk over broken glass just to have your loved one or friend take the lead and absolve you of having to do battle yourself. But the essence of the battle is that you will feel distressed, afraid, agitated, frustrated and feel a tremendous pull towards avoidance and you will be the one who must eat the food and rest in spite of all those thoughts and feelings. As much as it might wondrously ease the anxiety in the short term if your loved one takes the reins and tells you what to do, it’s just another insidious avoidance tactic driven by the threat response system that only serves to reinforce the behaviors that have got you where you are in the first place.
Stuff Experts Say as Experts vs. Human Beings
Everything that comes from the mouth of an expert/health care practitioner is never 100% expert advice. In fact, doctors, nurses, dietitians, therapists, naturopaths, massage therapists, and the like all spout many things to patients on any given single visit that is decidedly not expert advice.
Expert advice is ideally rooted in clinical evidence and first-person empirical experience. So, when a surgeon who has performed hundreds of vasectomies lists the peer-reviewed published data on the number of operations that result in any adverse outcomes and then lists his own rate of complications to number of operations performed to a patient contemplating said surgery, that is quintessential expert medical advice.
But if said surgeon then speaks about having suffered from depression and how helpful an antidepressant has been for him in treating the condition, is that expert medical advice? No, it’s not. That’s stuff human beings regularly relay to each other as just plain old people.
Because we live in a society steeped in fattism and healthism, if you are navigating recovery from an eating disorder, or managing an active state of the condition, you have to become your own expert in identifying when you are not getting expert advice.
If any health care practitioner recommends you restrict food intake or food groups, or that you implement a regular exercise regime, that is not expert advice. Ever. If you need to understand all the ways in which these assertions are just stuff people say, rather than any kind of scientifically-backed expert opinion, consider reading the papers under Obesity and Papers on this site.
If you are unsure as to whether your health care practitioner is offering up an expert opinion, or just saying stuff as a human being, then ask: “Do you have any clinical papers you could point me to on that topic?” The onus is on your health care provider to offer up evidence (just as with the example provided above of the urologist specializing in vasectomies).
Having a Treatment Team Member with First-Person Experience or Not?
This is a particularly contentious topic. Most of the focus has is on how practitioners in the eating disorder field with first-person experience, navigate their rights and obligations to themselves and their clients.
While there is a solid body of clinical data and research on the challenges and benefits of having a history of an eating disorder as a practitioner and treating those with eating disorders, there is not much in the way of actual patient experience.
Culturally, we believe that first-person experience renders someone more empathetic. There’s no clinical evidence to prove or disprove that belief at this point. And while surveys indicate that patients believe they will be better helped by those with first-person experience (in the same condition the patient is navigating), there are no retrospective investigations on whether actual patient outcomes support that belief.
Unfortunately, it seems recently as if more focus is being placed on the practitioner point of view rather than actual client or patient experience. However, it’s understandable given that the discussion is taking a legal turn and that likely isn’t in anyone’s best interests (practitioners and clients alike). 9 Divulging your own history with a mental health condition when you specifically treat patients with the same mental health condition is a quagmire of conflict and professional ethics that is only pushed underground when governments decide to require by law that practitioners divulge such histories.
It’s true that those with health concerns may need more protection under the law than those without because, whether it’s physical or mental or both, it’s hard when your energy is diverted into navigating your condition to also advocate easily for yourself and your best interests. However, legally requiring that practitioners divulge their health care histories and further considering banning them from practicing in the area in which their personal histories overlap, will serve to disempower patients and stigmatize practitioners.
The goal of this entire paper is to hopefully help patients identify the limits of what their practitioners can and cannot offer (assuming basic competency and capability) and to maintain accountability and responsibility for your own goals as a patient at all times.
I think requiring of practitioners that they divulge their first-person experiences with health care and/or mental health care doesn’t increase protection for a patient and assuredly invades the privacy of practitioners and their rights to that privacy.
Having a practitioner with a history of an eating disorder may be the best thing for you, the worst thing for you, or be absolutely immaterial either way. You are the patient and it’s your call. It’s your practitioner’s right to choose to divulge a personal history or not. That means it will remain with you (and your trusted family members or friends as advisers) to judge their usefulness to you based on their performance associated with your treatment interactions alone. And that’s ultimately fair on everyone.
Substandard, incompetent, damaging and even dangerous treatment won’t be rooted out by assuming that anything in a practitioner’s past renders them more or less capable. And the fact of the matter is that what is one patient’s brilliant care experience is the next patient’s substandard waste of time treatment.
If you happen to be a patient/practitioner yourself, then it will be to you to differentiate when you represent yourself as a practitioner and when you do so as a patient.
Delay, Manage It, or Pursue Remission
Your treatment team is your responsibility to hire (and fire) as you see fit. It’s your responsibility to measure their performance against your treatment goals and to check in with them and your trusted family members and friends to ensure your goals are realistic (although you ultimately decide what’s realistic and they provide input only).
As an eating disorder is an anxiety disorder, the drive will be to keep delaying, distracting and avoiding. And maybe that’s what it needs to be for you at this point. But make a commitment to yourself to force a periodic revisit of whether you want to keep putting it all off. Reinforcing the anxiety through avoidant behaviors generates deeper patterns that get harder to retrain the more years that go by.
Commit to making definitive steps towards managing its active presence in your life even if those steps seem modest at first. As an example: “January 1 I will tell my doctor I have an eating disorder and that I’m not yet ready to do more than just be honest about it.” Or, “I will begin keeping a journal of my daily exercise routine and pledge never to increase the intensity or duration from here on out no matter how much I might feel the need because of food intake variation.”
I tire of the dogma I am seeing in the recovery narrative across social media these days. The fact of the matter is that the camp that insists full remission is always possible and the camp that insists it is absolutely not possible for many, are both right.
If you think you can absolutely reach full and permanent remission you are as right and wrong as if you happen to think you can never reach full remission. And I will call you out on both counts.
Mute the either/or discussion altogether. Hold within you the unknowable and equivalent possibility and impossibility of it all and how it changes over time as well.
Remission is a practice with no end state while you are alive. It would be impossible to delineate the point at which managing an active state of the condition ends and the practice of remission begins.
Just keep trying and striving and be as true to your goals as you can be from one day to the next. Your treatment team can help you with that and if they can’t, get a new treatment team.
[*] Iatrogenic: (harm or death) induced inadvertently by a physician or surgeon through medical treatment or diagnostic procedures.
1 Keel, Pamela K. "Update on Course and Outcome in Eating Disorders." International journal of Eating Disorders 43, no. 3 (2010): 195-204.
2 Gorla, Kiranmai, and Maju Mathews. "Pharmacological treatment of eating disorders." Psychiatry (Edgmont) 2, no. 6 (2005): 43.
3 Milano, W., M. De Rosa, L. Milano, A. Riccio, B. Sanseverino, and A. Capasso. "The pharmacological options in the treatment of eating disorders." ISRN pharmacology 2013 (2013).
4 Gorla, Kiranmai, and Maju Mathews. "Pharmacological treatment of eating disorders." Psychiatry (Edgmont) 2, no. 6 (2005): 43.
5 Anderson, James W., Elizabeth C. Konz, Robert C. Frederich, and Constance L. Wood. "Long-term weight-loss maintenance: a meta-analysis of US studies." The American Journal of Clinical Nutrition 74, no. 5 (2001): 579-584.
7 Casper, Regina C., Barbara Kirschner, Harold H. Sandstead, Robert A. Jacob, and John M. Davis. "An evaluation of trace metals, vitamins, and taste function in anorexia nervosa." The American Journal of Clinical Nutrition 33, no. 8 (1980): 1801-1808.
8 Barbarich, N. C. "Lifetime prevalence of eating disorders among professionals in the field." Eating disorders 10, no. 4 (2002): 305.