Eating disorders are devastating disorders capable of causing incredible suffering and premature death.
The underpinnings to anorexia, bulimia, binge eating disorder and all the sub-clinical manifestations of these struggles are deeply rooted in our humanity, engaging with the most unconscious aspects of our nature.
No one would argue with the idea that these are complex struggles that manifest in a variety of ways with a variety of potentiating forces. The complexity often leads the sufferer, caregivers and professionals into heady and potentially misguided notions about the causal point.
As mental health professionals, we have worked almost exclusively with this population a combined 40 years. We have gone through many transformations in our understandings of the disorders and approaches to intervention. We have had to let go of many notions trained into us by books written by self-proclaimed experts, interactions with other eating disorder professionals and our own bias-driven professional views.
It is dangerous to put eating disordered individuals in a box that suggests it is driven by their psychology.
Only one in 10 individuals struggling with an eating disorder access treatment. Over the years, we have been struck by the years that some individuals will suffer before seeking help. When asked why they delayed, many answered that it was due to the shame they felt about their behavior. Often we would hear that they didn’t want to learn that their mother or father was to blame. They were afraid of being told that they are crazy.
This is one tragic result of the proliferation of the misnomer that these are psychologically driven disorders. It seems to deepen the stigma that the individual experiences.
Our current understanding is that the onset of eating disorders is NOT driven by individual psychology, but instead by a physiological response to behaviors that are intended to mitigate the relationship between an individual and food.
Our modern food supply coupled with an unhealthy cultural drive towards thinness IS at the root of the initiation of eating disorder behaviors. The diet, the skipped meal, the purging of a large meal, all done in a misguided effort to avoid weight gain, are all initial behaviors that then potentially lead to an eating disorder. What develops from these initial behaviors is rooted in our brain (mostly that very primitive part of our brain, the hypothalamus), not our psychology.
To place emphasis on our psychology is like fiddling with the thermostat in response to global climate change. It is a reaction, not a response.
It is essential that the first approach be to stop the behaviors. The importance of this cannot be overstated. Eating disorders are progressive disorders, progressively damaging to the body and potentially lethal. Time is of the essence.
And again, most professionals who have worked with eating disorders will tell you that the large percentage of mental health symptoms that appear with eating disorders, e.g. depression, anxiety, self loathing, etc., significantly diminish or ameliorate when the eating disorder behavior is managed.
Working on the psychology of an individual actively engaged in an eating disorder is like working with an alcoholic actively engaged in drinking. Psychological insight is limited when the brain is starved, muddled or otherwise compromised. Under such conditions our minds are not clear or capable of the level of insight and processing required to initiate and maintain change.
Should we then ignore the psychological symptoms that accompany an eating disorder? If we think of the psychological symptoms as noise, then it may be appropriate to reduce some of that noise and perhaps ease the main work of learning to manage the behaviors.
However, the view that the psychological is the driving energy behind the behaviors may mislead everyone involved into thinking that resolution of underlying psychological experiences will enable resolution of the eating disorder.
The inverse has been proven time and again to be true. It is the rare circumstance that psychological interventions seem to lead to a reduction is eating disorder behaviors.
A revealing study was conducted in 1944-1945 and published in 1950. The study is commonly referred to as the starvation experiment and is well documented in the book “The Great Starvation Experiment: Ancel Keys and the Men Who Starved for Science” by Todd Tucker. Many descriptions of it are accessible via an Internet search. It has never been duplicated because of the sheer agony experienced by the participants that would never be allowed today.
The study has much to offer, and the information is far too voluminous to detail in this brief column. In short, the study showed that many of the psychological symptoms commonly thought to be underpinnings to eating disorders actually were caused by the eating disorders and were mostly ameliorated upon the participants return to a healthy nutritional intake and normal weight.
Education is the essential component in intervention. Explaining why the individual is experiencing the psychological war resulting from the eating disorder is to relieve them of confusion and fear and allow them to place the emphasis on changing their relationship to food. This can most definitely be done with a nutritionist, and/or another professional with the information.
In fact, the refeeding process may require dietitian input and perhaps a physician as well. Often the nutritionist is viewed as the devil (not because they miss the point, but precisely because they get it), so it is helpful to have other professionals supporting the process.
In addition, it is helpful to have loved ones educated to ensure the message is consistent and they know how to support the process. With kids, the most promising interventions involve the family (see Maudsley Approach) who are viewed as the most capable of helping.
After regaining a sound nutritional state and the eating disorder behavior is sufficiently managed, if the individual then wants to deeply explore their relationship with their mother and father, so be it. We can, perhaps, all benefit from that exploration; or not.