Client: “I am tired of talking about my eating disorder”
Therapist: “It sounds like your eating disorder voice is getting loud again.”
Client: “I’m not restricting, but my stomach hurts really badly; I think something might be wrong.”
Therapist: “Keep eating your meal plan. The eating disorder can manifest in GI issues and we can’t feed it by restricting. You have to just stick with it. Your eating disorder is telling you that you should restrict because it hurts, but the more you stick with new foods and sit with the discomfort, the better you will feel. Just give it time.”
Client: “I am so tired and I can’t focus on work when I’m constantly feeling guilty about eating, I can’t meet the meal plan but I don’t feel like treatment will be helpful.”
Therapist: “You’re malnourished, if you keep nourishing yourself, you won’t feel as tired anymore. Don’t let the eating disorder keep you sick, ED wants you to stay at work instead of going to treatment so that you don’t recover.”
Client: (helpless in the face of power dynamics), concedes.
These are sentiments I have heard all too often in eating disorder recovery spaces, and I honestly believe they are doing more harm than good. While I believe that the sentiment that the eating disorder takes over and hijacks individual’s brain was well-intended and remains helpful in some aspects, in many ways, the field has really taken the concept and run with it. It is true that malnourishment negatively affects our relationships and our brain function. It is true that when someone has an eating disorder, it can make it so that they will do anything to satisfy the wants of the eating disorder because the eating disorder will always want to survive at all costs. The personification of eating disorders was a huge help to many people in their recovery journey’s. However, I notice in the field (and in life) that often when we find something new that works or resonates with a large group of people, it becomes not only a suggestion, but an imposition: it becomes the way we promote recovery for everyone.
Provider-Centered, Power Dynamics
In my work treating eating disorders, I notice the dissonance between the answers I have heard and been taught to relay and the changing needs of my clients. In my practice, I see over and over again, that people are no longer interested in what I call my “canned recovery answers”, they know this information and it isn’t working. In fact, it may be making things worse. There are quite a few problems I see when providers respond to client concerns with “that’s your eating disorder talking”:It perpetuates the inherent power dynamic of therapist (or provider) and client. When clients make the decision to come to therapy, it is often disregarded that they are paying for a service that is intended to help them meet their goals and move towards their own values, not those imposed by the therapist. There is an inherent power dynamic in the therapeutic relationship where the therapist is often viewed as the expert and the client is in the role of someone vulnerable, sharing their fears and whole life stories in a fairly non-reciprocal relationship. The therapist holds to power to diagnose, to pathologize, and to send someone to a facility based on their perceptions. Not only is there the therapeutic relational power dynamic, but also many times there are identity differences that create even more power and privilege dynamics. For example, a White male therapist working with a Black female client will carry not only the power of being the therapist and holding valuable information, they will also have to grapple with the historical power dynamics of patriarchal power structures and racial privilege / oppression that will show up in the room. This may look like the therapist pathologizing normal responses to trauma or racism, perpetuating stigmatizing diagnoses. This may show up in the client withholding details of their symptoms or experiences because they are afraid the therapist won’t understand them or will pathologize cultural experiences, which may be perceived as withholding or non-compliance, etc.
We take away even more agency from the individual and discourage them from practicing trusting their bodily experiences of pain and their perception of the world. The eating disorder already is associated with cognitive distortions and a view of the world that isn’t always trustworthy, and to tell clients that they are not perceiving their experiences of symptoms correctly is to diminish their ability to trust themselves and their identification of their own needs. What if we engaged in collaborative conversations that are guided by the client? Imagine how important this could be especially for clients who have experiences of trauma — they are able to take the power back in decision making, gain more of a feeling of control instead of perpetuating the taking away of control that is a hallmark of trauma. If we embrace curiosity instead of assuming we know best as the “expert providers”, then clients can have a safer space to be honest, and imagine what this does for deeper processing of eating disorder beliefs and fears, leading to longer-term recovery that isn’t based on surface level behavior management but on real, raw relationships.
“That’s your eating disorder talking” ignores the intersectional, complex contributors towards eating disorder development and recovery. When we take on an approach that focuses solely on reducing ED behaviors and changing cognitions, we miss out on a lot of the deeper work of recovery that creates eating disorders in the first place. I wonder if this is part of the reason why so many people pass along from treatment center to center, from one provider to another (and can you imagine what this does in terms of attachment trauma — being vulnerable and passed from one provider to another creates more patterns of unstable, short-lasting relationships, and doesn’t create space for individuals to learn what healthy trust looks like in longterm relationships, how to speak their needs and engage in difficult conversations and seasons of relationships). When we ignore the influence of trauma, marginalization, and oppression in body image and eating struggles, we continue the trend of shallow recovery that gets people out the door of treatment and out of providers’ liability / concern, but keeps people stuck and feeling like it is their fault. Canned recovery sounds like “once you address your eating disorder, you’ll feel more capable of doing other work” or “it is best to not engage in ED behaviors and if you want to, that is your eating disorder talking.” What if it isn’t just about people stopping behaviors and doing CBT to reframe their thoughts because I’m seeing in my practice, that this is just not enough. A happy, food freedom and “recovery is possible” just isn’t that exciting or attainable for everyone, and it is not because they aren’t “choosing recovery” or that they’re “letting the eating disorder win.” It’s because they aren’t recovering into thin bodies, and that means that recovery may lead to increased experiences of stigma and shame.
Prioritizing Individual’s Values
The world wasn’t built to celebrate or support recovery, and that is really important to sit with. Eating disorder behaviors feel good and serve a function, why in the world else would anyone use them? And that is uncomfortable for providers to sit with. Recovery does not feel better than the eating disorder for a lot of people, and that feels scary to providers because the canned answer that it’ll get better doesn’t work. Some people would rather prioritize feeling safe from bullying or name-calling in their families or access to quality medical care than recovery, which may lead to weight gain and feeling unsafe with trauma, years of paying for therapy, and losing connection, and that has to be okay. I think many of us are afraid that if we accept our client’s agency and values, then we are encouraging them. Acceptance and support of a person is not the same as encouraging. I think because this reality is so gloomy and not picture perfect, it feels too uncomfortable. If we say recovery isn’t possible, then there’s this false belief that people will just give up on recovery or therapy. But what if when we are really honest is when the healing work can more sustainably and beautifully begin. What if we allowed ourselves to sit with the discomfort of a client saying “nothing feels better than restriction” and instead of responding with “it’ll feel better I promise,” we create space for uncertainty and fear: “I don’t know if it will feel better. It might feel worse — you might be less productive, you might experience more distress around food, you might feel unsafe. And, I wonder if that means you are longing for more connection, safety, and support. I wonder if you can choose nourishment one meal at a time and know that each day or engagement in behavior gives us neutral information. What is it that you need to feel safer to do this work? Where are my blindspots? Do you want motivation to change or do you just want to feel sad, scared, and hurt?” How honest.
Getting Really Honest
Just like grief, I don’t think our canned recovery answers are working or what people need. I think many people just want to be able to be honest that they don’t want to give up their eating disorder and not be bombarded with “let’s change that thought” or “I know what is best for you and you are not well enough or capable of understanding your needs.” Instead of screaming recovery when clients whisper their hardest truths, what if we held space for the “I wish I had anorexia” “I would rather purge and hurt myself than have to feel the pain of my trauma” “I keep engaging in behaviors because I want people to care and be concerned.” Make space to pivot: instead of we have to get these cognitive distortions under control or you have to meet the meal plan or I’m sending you to treatment, “what do you want?” “What is it that I’m not hearing or assuming or imposing, how do you feel?”
Sometimes recovery won’t feel better. I’ve heard so many times that meeting the meal plan will make people feel better and I think that is more for the provider to wipe their hands of the messiness than for the client, sometimes. Also, it often minimizes and perpetuates problems that have solutions. Maybe it is ignoring difficulties with concentration and brushing them off as malnourishment. While this may be the case, what if we took those concerns seriously — assessed for ADHD or talked about other treatment options. If a client says they have chronic pain or that they aren’t hungry throughout the day, but are able/willing to eat more at night, instead of “that’s your eating disorder taking control”, what if we bring back that curiosity and work with clients instead of above them. I’m not saying nothing is the eating disorder, but I wonder if we can just… ask the client? And in this way, we bring back that agency and encourage the skill of helping them become more attuned with their body and mind; people are often more capable than we give credit for, especially when they are labeled as mentally ill or incapable of making their own decisions.
All in all, I see an overall theme here: touting recovery as possible for everyone feels easier and more hopeful. Being honest and allowing space to not know the answers and feel the grief of that is uncomfortable and scary. Hear people out, even and especially when it brings up strong feelings inside of you. Maybe some of those strong agitations are actually fears of your own recovery and curated life feeling threatened. Collaborate, engage, listen. Be open to feeling hopeless and being wrong.
I heard about this blog post during the National Alliance for Eating Disorders support group this morning. You have spoken so many truths in this one post. Thank you.