Eating Disorders- The Beginning.

My clinical expertise is in the field of Eating Disorders. I view Eating to be an area of psycho-biology that can be incredibly misunderstood, often feared and at times painfully mistreated. Part of the intention of my writing is an attempt to educate and expose the reality of Eating Disorders; the misconceptions, the fears and the shame. I will also address the good.

The fact that eating disorders are often interwoven with survival, they show resilience, intelligence and endurance. These two dueling sides create an incredibly complex issue that requires delicacy, experience, and directness to treat.

In order to begin we must never underestimate the sheer power of food in our society and culture, and the relationship between hunger and emotions. Much of our clinical training as therapists instructs us to examine the emotions that underlie behavior.

As one of my first supervisors said to me, the critical thing to look for is not what individuals say to you but to identify what they are NOT saying.

Behavior belies the picture underneath, no matter what someone is SAYING is we must believe what they are DOING.  Eating Disorders manifest in behaviors. Bingeing. Purging. Restricting. Over-Exercising. Calorie Counting. Rituals. The pattern of behaviors in eating disorders varies from person to person, but the overall picture is consistent- stable. Easily identifiable over time. However, the struggle in working with eating disorders is getting access to the emotions that are underneath the behaviors.

As is the case in all therapy the emotions are critical to the treatment. But in working with eating the path to getting to the emotions is far more complicated. Early in my career I struggled; I felt as if I was coming up against a brick wall.  No matter what I did to cajole and push patients in a starving state to talk about their emotions, the only thing they really wanted to talk about and were invested in talking about was food. And Behaviors. No matter what.

There I was sitting in the therapy room, across from someone who I knew was in agony, but I felt as if I was trying to move concrete. Pushing against something that felt like a boulder, with all my might, yet I was completely unsuccessful in scratching the surface to find real emotions. I could find anger, irritation, exasperation, and indifference, but I would not get into any real range of feeling.  We would start to explore triggers, and anger, and mothers and siblings and fathers and I would finally feel that opening, as if we were making some progress, and we would revert back to the topic of Quest Bars versus Luna Bars- which has more protein?

I began to realize that this “brick wall” I was banging against was actually quite real. In fact, I realized, there may not be any emotions underneath the food preoccupation and symptom behavior that my patients wanted to talk about. The more I thought about this, and the more research I did, I realized that I was pushing for something that not only did they not want to talk about it- IN THAT MOMENT IT DID NOT EXSIST.

 This all means- if someone is actually starving, the only thing that they are going to be able to talk about or think about is food. When I paused and turned this idea over in my head the reason why Eating Disorders are “so hard to treat” became strikingly clear. When patients with an eating disorder go to therapy it is initially a complete exercise in futility. I would equate it to walking up to someone during a drought and famine, whose entire family is on the brink of death and asking them if they have a good relationship with their parents (or children or spouse, etc.). They would look at you as if you had lost your mind. In fact, they would probably be unable to hear the words coming out of your mouth because it would be so far down on their priority list that it would not even register.

This idea that certain needs take precedence over feelings, and until those very basic needs which are integral to survival are met, the dynamic work or conceptualization of feelings underneath behavior must wait.  As a clinician who strongly believes in the relationship between emotions and behavior, I recognized that the starving brain and body were stronger than the will of the individuals who were actually starving and were certainly stronger than me.

Because I had been doing this work for several years, I knew that even if a patient was motivated and ready for change, it was nearly impossible to reverse the thought patterns, and therefore behaviors of an individual struggling with an eating disorder when they were actively hungry. I related it myself- on an infinitely smaller scale; What is my focus like when I miss lunch? How attentive am I to the issue at hand when I am hungry or thirsty? Can I focus on my children and work when I am hungry or am I more focused and attentive when I have met these needs?

When I shifted my own thought process and conceptualization to understanding that individuals simply could not think about feelings or relationships when they were focused on survival (hunger) my entire approach to my patients, and my own feelings of frustration and confusion changed. That shift I believe is when I truly began to be effective in treating eating disorders. When I met my patients where they were- which was starving.