I'm slowly making my whole personality "ED-therapist removes several additional support beams from previously firm understanding of quality ED-treatment."
I learned a lot from this piece and it showed me that eating disorders and treatment are even more complex than I thought--thank you.
The idea of the myth of full recovery reminds me of conversations I had a lot with people last year: I was recovering (...) from severe clinical depression and although I received good treatment there was this idea that at some point I’d be “fixed”. Last summer I started realising that in my case that’s not so. Yes, I’m loads better but depression will probably always be part of me and it will flare up from time to time. I started thinking more in terms of it being “in remission” which helped. That being said, at least with depression I don’t feel like the world wants me to fail, unlike I can imagine the experience of “recovering” from an eating disorder while being surrounded by all of this messed up messaging around food.
I had to really think about whether I would be ok if I read this (or listened to it). In the end, though, I am glad I did, and it helped to feel not alone. In fact, I cried some tears I did not even know existed for how alone and isolated I have felt in my journey with my eating disorder. Now that I'm working almost full time, I have to acknowledge that I am not fully recovered, even if I'm "weight restored." I have very restrictive rules about eating, and I cannot eat in public around people who are not family. I am running on fumes and coffee, and take long naps at 5:00 PM. I do get mental health benefits from exercising every day, but I have to also admit that I will have a great deal of cognitive dissonance if I don't. It's been more like harm reduction for my eating disorder. How many rules can I realistically set aside for myself around food and exercise while still managing to function in the workplace and as a parent? I
You're very welcome. I am in my mid-fifties and have been battling disordered eating and movement for over 40 years, so, realistically, harm reduction may be the highest level of "recovery" I'm able to achieve at this point. I wish I could declare that, after all these years, I've finally managed to conquer my own, self-directed fatphobia/anti-fat bias, but that is not the case. Maybe one day.
May 25, 2023·edited May 28, 2023Liked by Virginia Sole-Smith
I am a medical doctor accredited in Cognitive Behavioural Therapy for Eating Disorders. As discussed, there is no one size fits all when it comes to ED Treatment but CBT-ED is supposed to be collaborative not coercive and it is a good therapy to start with for most. The problems are the BMI target that we don't use at all in our practice and the "20 sessions" covered by insurance that are never enough. And there is often a need for other therapies after completing the CBT-ED protocole. and here we find a new set of obstacles: continuity of care, access to care, coverage... on top of the huge systemic changes needed.
Thank you for such an interesting and needed conversation
I will definitely read the book. I am disgusted myself by the healthcare system status but I still feel the need to defend it sometimes. The idea behind a step wise approach and limited number of sessions in CBTE, was mainly for research, training and coverage purposes. I did 2 years supervision after being accredited and it quickly became clear that we have to follow the patient’s pace since it is a collaborative non judgmental approach. But I guess it is quite therapist’s dependent.
And I really appreciated your empathy as well as cole’s for her therapist despite the shortcomings. It is an exhausting field and no one gets into ED treatment for the money, that’s for sure. And as practitioners in the field, we are all transitioning from the weight management toward a weight inclusive approach. I would like to think that we are all doing our best.
I've experienced the good, bad, and the ugly with eating disorder treatment for one of my kids, so I was eager to hear this conversation. It's cruel and shameful that our healthcare system and dominant training/supervision approaches seem so far behind what people with lived experience know to be true. Thank you, Cole, for sharing your story and educating people about the unfortunate reality of most ED treatment today.
Virginia, I'm grateful you highlighted the need for *support* during food exposures since exposure therapy can be an essential piece of recovery for many people (in other words, it's not the treatment itself but how it's delivered that can make the process either pure torment or terrifying-but-life-changing).
For anyone who has an adolescent with an eating disorder, I want to highlight what is currently considered the most effective treatment approach for that age group: Family-Based Treatment (aka "Maudsley Method"). There are so many myths and misconceptions about this approach (happy to bust those anytime), and it's a shame that people are steered away from this option rather than having it presented as a first-line treatment. There is no one-size-fits-all when it comes to ED treatment, of course—and with FBT, just as with other approaches, so much depends on the level of support provided to the family and patient during the process.
Based on our family's experience and that of many families I've worked with, I feel strongly that weight stigma is the most common barrier to a meaningful recovery (I personally tend to use the term "robust recovery" rather than "full recovery"). Emily Boring's essay on this topic is one that has helped many families face and overcome the fear of additional weight gain—her visual diagram of the "valley of illness" and the "valley of recovery" has been especially powerful for lots of folks: https://www.feast-ed.org/when-in-doubt-aim-higher-what-i-wish-id-known-about-target-weights-in-recovery/
Thank you Oona! So appreciate you sharing this resource and I'm sorry we didn't name FBT specifically in the discussion. (Maybe you need to come on so we can do whole episode about it!!)
I'm slowly making my whole personality "ED-therapist removes several additional support beams from previously firm understanding of quality ED-treatment."
So grateful to therapists like you who are working to figure out better ways!
I learned a lot from this piece and it showed me that eating disorders and treatment are even more complex than I thought--thank you.
The idea of the myth of full recovery reminds me of conversations I had a lot with people last year: I was recovering (...) from severe clinical depression and although I received good treatment there was this idea that at some point I’d be “fixed”. Last summer I started realising that in my case that’s not so. Yes, I’m loads better but depression will probably always be part of me and it will flare up from time to time. I started thinking more in terms of it being “in remission” which helped. That being said, at least with depression I don’t feel like the world wants me to fail, unlike I can imagine the experience of “recovering” from an eating disorder while being surrounded by all of this messed up messaging around food.
Such a good parallel here — and framing it as in remission does sound really helpful.
I had to really think about whether I would be ok if I read this (or listened to it). In the end, though, I am glad I did, and it helped to feel not alone. In fact, I cried some tears I did not even know existed for how alone and isolated I have felt in my journey with my eating disorder. Now that I'm working almost full time, I have to acknowledge that I am not fully recovered, even if I'm "weight restored." I have very restrictive rules about eating, and I cannot eat in public around people who are not family. I am running on fumes and coffee, and take long naps at 5:00 PM. I do get mental health benefits from exercising every day, but I have to also admit that I will have a great deal of cognitive dissonance if I don't. It's been more like harm reduction for my eating disorder. How many rules can I realistically set aside for myself around food and exercise while still managing to function in the workplace and as a parent? I
Your comment reminded me of this article I came across recently:
https://devonprice.medium.com/we-need-a-harm-reductionist-approach-to-eating-disorders-2d124db1e2e9
Eating disorders are tenacious and sneaky (and sometimes just plain hell). I wish you all the best in your recovery journey.
Thank you so much!
You're very welcome. I am in my mid-fifties and have been battling disordered eating and movement for over 40 years, so, realistically, harm reduction may be the highest level of "recovery" I'm able to achieve at this point. I wish I could declare that, after all these years, I've finally managed to conquer my own, self-directed fatphobia/anti-fat bias, but that is not the case. Maybe one day.
"It's been more like harm reduction for my eating disorder" - preach, Laina!
I am a medical doctor accredited in Cognitive Behavioural Therapy for Eating Disorders. As discussed, there is no one size fits all when it comes to ED Treatment but CBT-ED is supposed to be collaborative not coercive and it is a good therapy to start with for most. The problems are the BMI target that we don't use at all in our practice and the "20 sessions" covered by insurance that are never enough. And there is often a need for other therapies after completing the CBT-ED protocole. and here we find a new set of obstacles: continuity of care, access to care, coverage... on top of the huge systemic changes needed.
Thank you for such an interesting and needed conversation
This is very helpful context, thank you. Cole’s book includes a much more nuanced exploration of CBT for ED — def recommend it!
I will definitely read the book. I am disgusted myself by the healthcare system status but I still feel the need to defend it sometimes. The idea behind a step wise approach and limited number of sessions in CBTE, was mainly for research, training and coverage purposes. I did 2 years supervision after being accredited and it quickly became clear that we have to follow the patient’s pace since it is a collaborative non judgmental approach. But I guess it is quite therapist’s dependent.
And I really appreciated your empathy as well as cole’s for her therapist despite the shortcomings. It is an exhausting field and no one gets into ED treatment for the money, that’s for sure. And as practitioners in the field, we are all transitioning from the weight management toward a weight inclusive approach. I would like to think that we are all doing our best.
I’m really glad you are listening to Burnt Toast Dr Chidiac. Keep pressing on ditching BMI in all medicine. 💪🙏
I've experienced the good, bad, and the ugly with eating disorder treatment for one of my kids, so I was eager to hear this conversation. It's cruel and shameful that our healthcare system and dominant training/supervision approaches seem so far behind what people with lived experience know to be true. Thank you, Cole, for sharing your story and educating people about the unfortunate reality of most ED treatment today.
Virginia, I'm grateful you highlighted the need for *support* during food exposures since exposure therapy can be an essential piece of recovery for many people (in other words, it's not the treatment itself but how it's delivered that can make the process either pure torment or terrifying-but-life-changing).
For anyone who has an adolescent with an eating disorder, I want to highlight what is currently considered the most effective treatment approach for that age group: Family-Based Treatment (aka "Maudsley Method"). There are so many myths and misconceptions about this approach (happy to bust those anytime), and it's a shame that people are steered away from this option rather than having it presented as a first-line treatment. There is no one-size-fits-all when it comes to ED treatment, of course—and with FBT, just as with other approaches, so much depends on the level of support provided to the family and patient during the process.
Based on our family's experience and that of many families I've worked with, I feel strongly that weight stigma is the most common barrier to a meaningful recovery (I personally tend to use the term "robust recovery" rather than "full recovery"). Emily Boring's essay on this topic is one that has helped many families face and overcome the fear of additional weight gain—her visual diagram of the "valley of illness" and the "valley of recovery" has been especially powerful for lots of folks: https://www.feast-ed.org/when-in-doubt-aim-higher-what-i-wish-id-known-about-target-weights-in-recovery/
Thank you Oona! So appreciate you sharing this resource and I'm sorry we didn't name FBT specifically in the discussion. (Maybe you need to come on so we can do whole episode about it!!)
Any time!
Such a great message. Or really messages. And I love the Butter. Thank you Virginia
Thanks Susan!