I will likely be working through as a series of essays as it is a very broad topic. In the past several years, as I have not really come across anything particularly new in the field of eating disorders, I have been more absent from writing here than not.
Flickr.com: Karen Horton
Since the pandemic began, I have been deeply immersed in all things SARS-CoV-2. Not only has the scientific research on this virus been enormous, but the sophisticated co-option of public health with the endless cycling of a novel coronavirus through our populations, all while leveraging the propensity we have to fall prey to coordination motivation and groupthink, give us this eyebrow-raising experiment that will continue unabated for the foreseeable future. It has been both fascinating and horrifying.
It has also, for me, generated an unexpected rethink on eating disorders. While the research in the field in the past few years has also hopped on the lockdowns-are-the-source-of-all-evil bandwagon, there has been nothing new to speak of in terms of treatment with the exception of a new darling in the field of psychology: psilocybin. So far, the actual data for psilocybin as a treatment option for eating disorders leaves me underwhelmed.
The inability to eat communally for chunks of time in 2020 and, for some, into 2021 would have exacerbated recovery efforts for those with eating disorders and the uncertainty of our world today will ratchet a desire to control things that can be controlled, such as food intake, diet choice and exercise. Therefore, I am not dismissing the confirmative studies that the pandemic has had a negative impact for those with eating disorders; it has.
Many within the eating disorder field have pivoted, as did I in 2022, into discussions on parallel challenges for those with chronic illness and other mental illnesses (see my work from 2022 here and here ). And perhaps this broadening into chronic illnesses and mental illnesses simply reflects that there is nothing new to discuss in the field of eating disorders.
Is an eating disorder responsive to some as yet undiscovered treatment? This question intrigues me and is the focus of where I will be going in these essays.
The Homeodynamic Recovery Method (HDRM) I developed a few years back had nothing new, despite the fact that many were convinced it was dangerous and life threatening to eat without restriction (with all the caveats of the risks of refeeding syndrome and that all recovery should be overseen by medical experts). Plenty of inpatient settings follow the homeodynamic approach in all but name, but patients are unable to sustain the unrestricted eating and rest once discharged from the acute phase of the recovery program.
Where my review of the research took me originally, was that in viewing the spectrum of eating disorders holistically, unrestricted eating does not apply exclusively to those diagnosed with anorexia nervosa. Orthorexia, bulimia, anorexia athletica, and binge eating disorders are merely the same eating disorder usually several years beyond the initial onset of restricted eating. So, while I perhaps framed the condition in a novel way, the bottom line was recovery was a slog of resting and refeeding without end. Most treatment modalities tend to the “recover but not too much” weight-based definition of recovery (due to fat hatred in our society of course), but fundamentally all treatment modalities look at emotions, threat responses, approaching food consistently, avoiding intense exercise and eating.
The HDRM is unremarkable when compared to any other science-based treatment modalities out there today.
As such, while I have no studies to confirm its success rate, I am confident it reaches equivalency with heavily studied modalities such as family-based treatment. In other words, little better than AA for alcoholism: a third recover, a third see no improvement and a third get worse (rough numbers).
And let’s be frank, being in the two-thirds that struggle or get worse is an awful place to be.
Now you will have to bear with me just a bit as I lay down several seemingly unrelated threads and ideas to pull them altogether.
I had a conversation with Dr. Walsh at the UCSD Eating Disorder conference a decade ago now which I have mentioned before. This is a psychiatrist from Columbia who had at that time already 30+ years as an expert in eating disorders. He had spent a lifetime being profoundly engaged in trying to find solutions for the refractory nature of eating disorders. He spoke of his sense that habit, and how habits get laid down and reinforced in the brain, played a big role in why eating disorders were (and remain) so difficult to treat. At the time it was clear to me even from my very short and limited experience in the field, that there was no question the pull to relapses and swerving from one cluster of restrictive behaviours to another seemed to be the norm and not the exception.
A few years ago, I worked at the Forensic Psychiatric Hospital in metro Vancouver and one of the senior leaders there had worked for decades in inpatient eating disorder treatment prior to taking her current leadership role. She and I chatted early on in my tenure there about my experience in the field of eating disorders and we compared notes a bit. She asked if I recalled a woman, Peggy Claude-Pierre, in BC (this was back in the 1990s) who had started to treat eating disorder patients in an unconventional inpatient facility she opened alongside her husband. I did. After huge controversy there was a 1999 decision by the licensing regional health authority to have the facility closed based on evidence that this clinic held patients against their will and force fed them.
The senior leader I worked for said that she felt Peggy ultimately had had her heart in the right place. I have ruminated over the years on that exchange, as I think that statement is ultimately the truest and yet also the most betraying aspect of all things eating disorder treatment. There is no question that the vast majority in the field of eating disorder treatment and mental health treatments in general have their hearts in the right place. And yet, the suffering of patients, the murky spaces of the ends justifying the means and even the efficiencies needed to run inpatient spaces filled with patients who almost exclusively do not want to be there, is the epitome of the road to Hell being paved with good intentions.
Okay, so now we are holding onto two concepts so far:
Eating disorders are very difficult to treat successfully and the best of the best have struggled for decades to unlock a path to better outcomes, and
Having our hearts in the right place is still leading to significant ongoing trauma and ultimate relapses for up to two thirds of all patients with eating disorders who undergo any treatment, whether evidence-based or unconventional.
While I write the next installment in this series, this is a commentary video of a Youth Olympics 2024 speed skating race and the ultimate win by China’s Yang Jingru:
You may have already seen the race as it has gotten a tremendous amount of press. There is a reason why I have included this and I will get to that in the next part of this series.