Eating Disorders

An eating disorder is not, at its root, about food. The food is the surface. The food is the thing the disorder uses, the way a fever uses the body's temperature — the fever is not the infection, and the food is not the disorder. The disorder is the relationship, and the relationship is the thing this book is about: the relationship with food, and the relationship with the body, and the way those two relationships, when they are disordered, become the way a person tries to manage a life that has become unmanageable.

The title of this book says that the relationship must be identified, and the word "must" is deliberate. The relationship must be identified because the relationship, unidentified, runs the disorder from beneath, and the running-from-beneath is the thing that makes the disorder so hard to change, and so easy to relapse from, and so deadly in the cases where it is not addressed. The identification is the first step of the recovery, and the recovery, for most people who get adequate care, is real, and the real is the thing this book is a guide to.

This is a clinical book, written from fifteen years of practice with people who arrived describing themselves as "having a problem with food," or "struggling with body image," or "not eating right," and who, in the work, turned out to be in relationships with food and with their bodies that were, in clinical terms, disordered, and that were, in human terms, consuming their lives. The book is built on the understanding that the eating disorder is a relationship — a learned, patterned, deeply ingrained way of relating to food and to the body that serves a function, and that the function, understood, is the key to the change.

Who This Book Is For

It is for the person who has begun to suspect that their relationship with food is not the relationship other people have. The person who thinks about food more than they think about anything else, who eats and then feels the shame, who does not eat and then feels the triumph, who has the body that they are at war with, who has the mirror that they avoid, who has the scale that runs their morning, who has the clothes that they cannot wear, who has the social situations they cannot enter because of the food. It is for the person who has been told they are "fine" or "healthy" or "just disciplined" and who knows, in the place where the truth lives, that the relationship is not fine, and that the discipline is a disorder wearing a costume.

It is also for the clinician who works with these patients, and for the family member who is watching someone they love disappear into the relationship. The patterns are recognizable, the mechanisms are understood, and the treatment, described in the later chapters, is effective. The book is a map of the territory, from the relationship to the disorder to the recovery.

What This Book Is Not

This book is not a diet book. It is not a guide to eating "right," or to achieving the "right" body, or to the "right" relationship with food as defined by any particular nutritional philosophy. The disorder is not solved by the right diet, because the disorder is not a dietary problem. The disorder is a relationship problem, and the relationship, addressed, is the thing that lets the eating take care of itself, in the way that the eating takes care of itself for people who do not have the disorder.

This book is also not a substitute for the clinical care that eating disorders, in their moderate and severe forms, require. Eating disorders are, among the mental health conditions, the ones with the highest mortality, and the mortality is real, and the real is the reason that the care, for the moderate and severe cases, is the care that includes medical monitoring, nutritional rehabilitation, and psychotherapy, often delivered by a team. This book is a guide to understanding the relationship and the recovery, written so that the person in the relationship can participate fully in the care, and so that the person supporting them knows what to expect. Nothing in this book is a replacement for that care.

The Two Relationships

The book is built on the recognition that the eating disorder is, at its core, two relationships that have gone wrong, and that the two relationships, addressed, are the thing that the recovery is built on. The first is the relationship with food. The second is the relationship with the body. The two are connected — the disordered relationship with food is very often a response to the disordered relationship with the body — but they are distinct, and the distinction matters, because the recovery must address both, and the addressing of one without the other is a recovery that will not hold.

The relationship with food, when it is disordered, is the relationship in which food is not simply food. Food is the enemy, or the comfort, or the control, or the proof, or the punishment. Food is the thing that is monitored, counted, restricted, binged, purged, hidden, hoarded, feared. The relationship is not the relationship of a person who eats when hungry and stops when full. The relationship is the relationship of a person for whom food has become the central organizing principle of the life, and the centralizing is the thing that narrows the life, and the narrowing is the thing that makes the disorder a disorder.

The relationship with the body, when it is disordered, is the relationship in which the body is not simply the body. The body is the project, or the enemy, or the measure, or the shame. The body is the thing that is monitored, weighed, measured, criticized, hidden, punished, displayed. The relationship is not the relationship of a person who lives in their body as the house they live in. The relationship is the relationship of a person for whom the body has become the central problem to be solved, and the centralizing is the thing that makes the body the enemy, and the enemy is the thing that the disorder is built on.

The Function the Disorder Serves

The disorder serves a function, and the function is the thing the recovery must understand, because the recovery that does not understand the function is the recovery that removes the disorder without replacing the function, and the unreplaced function is the thing that pulls the person back to the disorder. The function, very often, is the management of feelings — the feelings that the person does not have another way to manage, and that the disorder, through the restriction or the bingeing or the purging or the body-focus, provides a way to manage. The disorder is the coping, and the coping, understood, is the thing that the recovery must replace with a coping that works better and costs less.

The function can also be the control. The life that feels out of control, the emotions that feel out of control, the relationships that feel out of control — the disorder offers the control, in the one domain the person can control: the intake, the weight, the shape. The control is real, in the sense that the person can exert it, and the real is the thing that makes the disorder feel like a solution, and the solution-feeling is the thing that makes the disorder hard to give up, because the giving-up is the giving-up of the control, and the control is the thing the person does not have another way to have.

The function can also be the communication. The disorder, for some, is the way the pain is expressed — the pain that has no words, the pain that the body expresses through the starvation or the bingeing or the weight. The disorder is the body's way of saying what the mouth cannot, and the saying, understood, is the thing the recovery must find another way to do, and the finding is the thing that lets the body stop saying it through the disorder.

The Identification

The identification of the relationship is the first step, and the identification is the thing this book is a guide to. The identification is not the diagnosis, though the diagnosis is part of it. The identification is the recognition, by the person in the relationship, that the relationship is disordered, and that the disorder is not a personal failing but a pattern that has a function, and that the function, understood, is the thing that can be addressed. The identification is the beginning of the recovery, and the recovery, for most people who get adequate care, is real, and the real is the thing the whole book is pointing toward.

If You Are in Crisis Now

A note, before the chapters, on safety. Eating disorders, in their severe forms, are medical emergencies. If you are experiencing medical instability — fainting, chest pain, severe dizziness, irregular heartbeat, inability to keep food or fluid down — go to an emergency room now. If you are having thoughts of harming yourself, call or text 988 (the Suicide & Crisis Lifeline, available 24/7 in the United States). The chapters will be here when you are safe. The safety is the floor. Nothing in this book works without it.

The chapters that follow are the conditions, the assessment, the treatment, the recovery, and the life — the architecture of the work, in the order it is usually done. The relationship is the foundation, and the foundation is the thing the rest is built on, and the rest, built on the foundation, is the thing that lets the person move from the disorder into the relationship with food and body that is the recovery, and the recovery is the life this book has been pointing toward. Begin.

To understand why the relationship with food and the body gets disordered, you have to understand how the disordering happens. The disordering is not a choice. It is not a vanity. It is not a sign that the person is shallow, or weak, or attention-seeking. The disordering is the result of a convergence — of biology, of psychology, of culture, of experience — that produces, in a susceptible person, a relationship with food and the body that becomes the way the person tries to manage a life that has become, in some way, unmanageable. This chapter is about the convergence, because the convergence is the thing the recovery must understand, and the thing the recovery addresses.

The Biology

The biology is the first, and it is the first because the biology is the thing that makes the person susceptible, and the susceptibility is the thing that the other factors act on. The biology includes the genetics — the eating disorders run in families, and the running-in-families is, in part, the genetics, and the genetics are the thing that sets the baseline of the risk. The biology includes the neurobiology — the brain systems involved in appetite, reward, anxiety, and impulse control, which function differently in the person who develops the disorder, and the different functioning is the thing that makes the disorder, once begun, hard to stop, because the stopping requires the overriding of the systems that the disorder has co-opted.

The biology is not the destiny. The person with the genetic risk does not necessarily develop the disorder, and the person without the genetic risk can develop the disorder, because the biology is one factor among several, and the several, converging, are the thing that produces the disorder. But the biology matters, and the mattering is the thing that destigmatizes the disorder — the person who develops the disorder is not morally defective; they are biologically susceptible, and the susceptibility, acted on by the other factors, is the thing that produces the disorder.

The Psychology

The psychology is the second, and it is the set of traits and patterns that make the person vulnerable to the disordering. The traits include the perfectionism — the high standards, the self-criticism, the all-or-nothing thinking that turns a single deviation from the plan into a total failure. The traits include the anxiety — the baseline of worry, the difficulty tolerating uncertainty, the nervous system that is easily overwhelmed. The traits include the impulsivity, in some forms, and the rigidity, in others. The traits include the difficulty with emotion — the trouble identifying, tolerating, and expressing feelings, which leaves the feelings to be managed through the behavior, and the behavior, for the susceptible person, is the eating behavior.

The psychology is not the flaw. The traits are real, and the traits, in other contexts, are strengths — the perfectionism, channeled, is the thing that produces excellence; the anxiety, managed, is the thing that produces caution; the rigidity, applied, is the thing that produces consistency. The traits become the vulnerability when they meet the other factors, and the meeting is the thing that turns the trait into the disorder, and the turning is the thing the recovery must address, not by eliminating the trait but by changing the trait's relationship to the behavior.

The Culture

The culture is the third, and it is the environment in which the susceptible person lives, and the environment is the thing that provides the content of the disorder — the specific way the disordering expresses itself, which is, in our culture, overwhelmingly about thinness, weight, and the control of the body. The culture is the one that equates thinness with virtue, and weight with moral failure. The culture is the one that sells the diet, the supplement, the program, the surgery, as the path to the life. The culture is the one that comments on bodies — the bodies of children, the bodies of adolescents, the bodies of adults — as though the body were a public object to be evaluated, and the evaluating is the thing that installs, in the susceptible person, the sense that the body is the problem, and the problem is the thing the disorder offers to solve.

The culture is not the cause, alone. Many people live in the culture and do not develop the disorder, because the culture is one factor among several, and the several, converging, are the thing that produces the disorder. But the culture matters, and the mattering is the thing that explains why the disorder, in our time, is so common, and why the content of the disorder is so consistent — the thinness, the weight, the control — across the people who develop it. The culture provides the script, and the susceptible person, given the script, performs it, and the performing is the disorder.

The Experience

The experience is the fourth, and it is the specific events and circumstances that trigger the disordering in the susceptible person. The experience can be a diet — the innocent, culturally-sanctioned diet that, in the susceptible person, becomes the restriction that becomes the disorder. The experience can be a loss — the death, the breakup, the move, the change that overwhelms the person's coping and sends them to the disorder as the way to manage the overwhelm. The experience can be a trauma — the assault, the abuse, the violation that the person tries to manage through the control of the body, and the control is the thing the disorder offers. The experience can be a transition — the puberty, the college, the marriage, the new job, the life change that the person navigates through the disorder, and the navigating is the thing that makes the disorder feel like a solution.

The experience is the trigger, and the trigger is the thing that activates the susceptibility, and the activation is the thing that produces the disorder. The trigger is not the cause, alone — the trigger, without the susceptibility, does not produce the disorder. But the trigger, in the susceptible person, is the thing that starts the disorder, and the starting is the thing that, once started, the disorder's own momentum takes over, and the momentum is the thing that makes the disorder hard to stop, because the stopping requires the interrupting of the momentum, and the interrupting is the thing the recovery must do.

The Convergence

The convergence is the thing that produces the disorder, and the convergence is the coming-together of the biology, the psychology, the culture, and the experience, in a person, at a time. The convergence is not the person's fault. The convergence is not a choice. The convergence is the thing that happens, to a susceptible person, in a culture that provides the content, at a time that provides the trigger, and the happening is the thing that produces the disorder, and the disorder, produced, is the thing the recovery must address.

The understanding of the convergence is the thing that destigmatizes the disorder, and the destigmatizing is the thing that makes the recovery possible, because the person who understands that the disorder is a convergence is the person who can work with the recovery, rather than against themselves for having the disorder. The convergence is the cause, and the cause, understood, is the thing that points to the treatment, and the treatment, built on the understanding, is the thing that lets the person move from the disorder into the relationship with food and body that is the recovery.

The Momentum of the Disorder

The disorder, once begun, has a momentum of its own, and the momentum is the thing that makes the disorder hard to stop, even when the person wants to stop. The momentum includes the biological momentum — the starvation, the bingeing, the purging, the restricting, each of which changes the body and the brain in ways that reinforce the behavior, and the reinforcing is the thing that makes the behavior feel necessary, and the necessary-feeling is the thing that keeps the behavior going. The momentum includes the psychological momentum — the disorder, once it is the coping, becomes the only coping the person has, and the only-ness is the thing that makes the giving-up of the disorder feel like the giving-up of the only way to manage the life. The momentum includes the social momentum — the disorder, once it is the person's identity, becomes the thing the person is, and the being-the-disorder is the thing that makes the recovery feel like the loss of the self, and the loss-feeling is the thing that keeps the person in the disorder.

The momentum is the thing the recovery must interrupt, and the interrupting is the thing the treatment is built to do. The interrupting is not the willpower. The willpower, alone, does not interrupt the momentum, because the momentum is stronger than the willpower, and the stronger is the thing that makes the willpower fail, and the failing is the thing that makes the person feel weak, and the weak-feeling is the thing that reinforces the disorder. The interrupting is the treatment — the medical, the nutritional, the psychological — and the treatment, done well, is the thing that interrupts the momentum, and the interrupting is the thing that makes the recovery possible.

The chapters that follow are the conditions, the assessment, the treatment, the recovery, and the life — the architecture of the work, in the order it is usually done. The convergence of this chapter is the foundation, and the foundation is the thing the rest is built on, and the rest, built on the foundation, is the thing that lets the person move from the disorder into the recovery, and the recovery is the life this book has been pointing toward.

This chapter is the clinical map. It is not a diagnostic manual, and reading it will not diagnose you. What it will do is give you the patterns and the language to recognize what you are looking at — in yourself, or in someone you are trying to help — and to know, with enough clarity to be useful, whether the relationship with food and the body has crossed the line from the difficult to the disordered, and what the care on the disordered side of the line looks like.

The distinction matters. The relationship with food and body that is difficult — the occasional diet, the body dissatisfaction, the wish to be different — is not, in itself, a disorder, and treating it as one can do harm — can medicalize a relationship that is meant to be worked with, not treated. But the relationship that has become disordered is a clinical condition, and failing to treat it as one does harm too — can leave a person in a disorder that the passage of time alone will not resolve, and that the disorder, untreated, will worsen. The line between the two is not always clear, which is why the assessment in the next chapter is its own chapter, but the patterns in this chapter will help you see which side of the line you are closer to.

The Spectrum

The eating disorders exist on a spectrum, from the disordered eating that does not meet the full criteria for a disorder to the severe, life-threatening conditions that require hospitalization. The spectrum is real, and the spectrum is the thing that makes the line hard to draw, because the disordered eating can slide into the disorder, and the slide can be gradual, and the gradual is the thing that makes the crossing of the line hard to notice, by the person or by the people around them. The spectrum is also the thing that makes the early intervention possible, because the disordered eating, caught early, is easier to address than the full disorder, and the easier is the thing that makes the early intervention worth doing.

Anorexia Nervosa

Anorexia nervosa is the disorder of restriction. It is the relationship with food in which the intake is severely limited, and the limiting is driven by the fear of weight gain and the pursuit of weight loss, and the driving is the thing that produces the weight loss, and the weight loss is the thing that produces the medical instability, and the instability is the thing that makes anorexia, among the mental health conditions, the one with the highest mortality. The signs include the restriction, the weight loss, the intense fear of weight gain, the disturbance in the way the body is experienced (the body that is experienced as larger than it is), and the medical consequences of the starvation — the cold intolerance, the lanugo, the loss of menstrual periods, the cardiac changes, the bone loss.

Anorexia is treatable, and the treatment — which is described in the treatment chapter — is the thing that, for most people who get it, produces the recovery. The barrier, as with all the eating disorders, is the person's relationship with the disorder, which is often the thing the person does not want to give up, because the disorder is the thing that feels like the solution, and the giving-up feels like the loss of the solution. The treatment, done well, is the thing that addresses the relationship, and the addressing is the thing that makes the recovery possible.

Bulimia Nervosa

Bulimia nervosa is the disorder of the binge and the purge. It is the relationship with food in which the episodes of binge eating — the eating, in a discrete period, of an amount that is large, with the sense of loss of control — are followed by the compensatory behaviors — the vomiting, the laxatives, the exercise, the fasting — and the following is the thing that the person does to undo the binge, and the undoing is the thing that produces the cycle, and the cycle is the thing that runs the life. The signs include the bingeing, the purging, the preoccupation with food and weight, the shame, the secrecy, and the medical consequences — the electrolyte abnormalities, the dental erosion, the esophageal damage.

Bulimia is treatable, and the treatment — cognitive-behavioral therapy, specifically — is among the most effective treatments in psychiatry. The barrier is the shame, which is the thing that keeps the disorder hidden, and the hidden is the thing that delays the care, and the delay is the thing that lets the disorder worsen. The treatment, done well, is the thing that breaks the cycle, and the breaking is the thing that lets the person move from the disorder into the recovery.

Binge Eating Disorder

Binge eating disorder is the disorder of the binge without the purge. It is the relationship with food in which the episodes of binge eating occur, with the sense of loss of control, but without the regular compensatory behaviors, and the without is the thing that distinguishes it from bulimia. The signs include the bingeing, the loss of control, the eating when not hungry, the eating alone, the shame, the distress, and the medical consequences — the weight gain, the metabolic changes, the conditions associated with the weight.

Binge eating disorder is treatable, and the treatment — the therapy, the medications, the behavioral interventions — is effective. The barrier is the shame, and the shame is compounded by the culture, which stigmatizes the larger body, and the stigmatizing is the thing that makes the person with binge eating disorder feel that the disorder is the evidence of their failure, rather than the condition it is. The treatment, done well, is the thing that addresses the shame and the behavior, and the addressing is the thing that lets the person move from the disorder into the recovery.

ARFID and the Other Specified Disorders

The eating disorders are not only the three named above. Avoidant/restrictive food intake disorder (ARFID) is the disorder of restriction that is not driven by the weight and shape concerns — the restriction driven by the sensory sensitivity, the fear of aversive consequences, the lack of interest in food. The other specified feeding or eating disorders are the conditions that do not meet the full criteria for the named disorders but that are, in their impact, disordered. The conditions are real, and the conditions are treatable, and the treatment is the thing that, for most people who get it, produces the recovery.

The Comorbidities

The eating disorders very often co-occur with other conditions — the anxiety disorders, the depressive disorders, the substance use disorders, the trauma-related disorders, the obsessive-compulsive disorders. The co-occurrence is the rule, not the exception, and the rule is the thing that makes the assessment, which the next chapter is about, so important, because the treatment plan that addresses the eating disorder without addressing the comorbidities is a plan that will leave the person still stuck, and the still-stuck is the thing that makes the relapse likely, and the likely is the thing the whole-picture assessment is built to prevent.

The Overlap and the Whole Picture

The most important clinical fact in this chapter is the same as in any chapter on mental health: the conditions co-occur, and the whole picture is the thing the treatment must address. The person who comes to care is very often carrying an eating disorder and an anxiety and a depression and a trauma history, all at once, all entangled, each feeding the others. This is not a sign that something is especially wrong. It is the ordinary presentation of an eating disorder when it has become entrenched, and the treatment plan that addresses one and ignores the others is a plan that will leave the person still stuck. The assessment, which the next chapter is about, is the mapping of the whole picture, and the treatment, which the chapter after that is about, is the addressing of it — all of it, together, in the order and the way that the evidence supports.

The treatment begins with the assessment, and the assessment, in this work, is the identification of the relationship — the relationship with food, the relationship with the body, the function the disorder serves, the conditions that co-occur, the medical status, the history, the supports. The assessment is the map, and the map is the thing the treatment plan is built on, and the plan, built on the map, is the thing that addresses the whole picture, and the addressing is the thing that lets the person move from the disorder into the recovery.

This chapter is for the person who is about to be assessed, and for the person who is doing the assessing, and for the family member who is trying to understand what the assessment should cover. It is not a substitute for the clinical encounter. It is a guide to what the encounter should include, so that the person in it can participate fully, and so that the assessment, when it is done, has produced the map that the work requires.

The First Question: Difficult or Disordered?

The first question of the assessment is the one from the last chapter: is this a difficult relationship with food and body, or has it become a disorder? The question is answered by the impact — is the relationship consuming the life, or is it a part of the life? — and by the behaviors — are the behaviors present that define the disorders, and are they present at the frequency and intensity that cross the line? — and by the medical status — has the relationship produced the physical changes that indicate the disorder? The difficult relationship that is a part of the life does not need clinical treatment. The relationship that is consuming the life, or that has produced the defining behaviors, or that has produced the medical changes, does.

The assessment does not rush this question. The person who is in the disorder is often the last to see it, because the disorder is the thing that feels like the solution, and the solution-feeling is the thing that hides the disorder from the person in it. The clinician takes the time to understand the relationship, the behaviors, the history, the impact, and the understanding is what produces the answer, and the answer is what the rest of the assessment is built on.

The Relationship with Food

The assessment maps the relationship with food in detail. The questions cover the intake — what is eaten, when, how much, with what rules. The questions cover the restriction — what is avoided, why, with what fear. The questions cover the bingeing — the episodes, the triggers, the sense of control. The questions cover the purging — the methods, the frequency, the function. The questions cover the rituals — the things the eating must be done in a certain way, the rules that govern the food, the rigidity that is the thing that makes the relationship disordered. The detail matters, because the detail is the thing that reveals the relationship, and the relationship, revealed, is the thing that points to the treatment.

The Relationship with the Body

The assessment maps the relationship with the body. The questions cover the body image — the way the body is experienced, the accuracy of the experience, the distress the experience causes. The questions cover the weight and shape concerns — the preoccupation, the checking, the avoidance, the comparing. The questions cover the body behaviors — the weighing, the measuring, the mirror-checking, the body-monitoring that is the thing that runs the life. The questions cover the history of the body — the development, the changes, the comments, the experiences that shaped the relationship. The detail matters, because the detail is the thing that reveals the relationship, and the relationship, revealed, is the thing the treatment must address.

The Function the Disorder Serves

The assessment explores the function the disorder serves, because the function is the thing the recovery must replace. The questions cover the feelings — what feelings does the disorder manage, and how. The questions cover the control — what does the disorder control, and what would feel out of control without it. The questions cover the communication — what is the disorder saying, that the person cannot say another way. The questions cover the identity — what does the disorder give the person, that they fear losing. The exploration is the thing that reveals the function, and the function, revealed, is the thing the treatment plan must address, because the treatment that removes the disorder without replacing the function is the treatment that will not hold.

The Medical Status

The assessment covers the medical status, because the eating disorders are medical conditions, and the medical status is the thing that determines the level of care. The assessment includes the weight, the vital signs, the labs, the ECG, the bone density, and the other markers that indicate the medical stability or instability, and the markers are the thing that determines whether the care can be outpatient, or whether it must be intensive, or whether it must be inpatient. The medical assessment is not optional, and the not-optional is the thing that the person in the disorder must understand, because the medical consequences of the eating disorders are real, and the real is the thing that makes the medical monitoring a part of the care, and the part is the thing that keeps the person alive to do the recovery.

The Comorbidities

The assessment screens for the comorbidities — the anxiety, the depression, the substance use, the trauma, the other conditions that so often co-occur with the eating disorders. The screening is the thing that reveals the whole picture, and the whole picture is the thing the treatment plan must address, because the plan that addresses the eating disorder without the comorbidities is the plan that will leave the person still stuck. The comorbidities are not separate; they are part of the same picture, and the picture must be whole for the treatment to work.

The Safety

The assessment covers the safety, always, because the person with an eating disorder is at elevated risk, and the risk is real. The assessment asks, directly and with care, about the thoughts of self-harm, about the medical symptoms that indicate emergency, about the person's capacity to keep themselves safe. The asking is not the thing that creates the risk. The asking is the thing that makes the risk addressable, and the addressing is the thing that keeps the person alive to do the work the recovery requires.

If you are reading this as the person being assessed, and you are asked about safety, answer honestly. The clinician is not judging you. The clinician is doing the thing that keeps you safe, and the safety is the floor the rest of the treatment stands on. If you are reading this as the family member, and you are worried about the safety of the person you love, ask. The asking is hard, and the asking is the thing that gets the help, and the help is the thing that saves lives.

The Map

The assessment, done well, produces a map — of the relationship with food, the relationship with the body, the function, the medical status, the comorbidities, the safety, the supports, the history. The map is not the treatment. The map is the thing the treatment plan is built on, and the plan, built on the map, is the thing that addresses the whole picture, and the addressing is the thing that lets the person move from the disorder into the recovery. The next chapter is the treatment, and the treatment is built on the map, and the map, if you are the person being assessed, is yours — to understand, to question, to use. Ask for it. Understand it. It is the beginning of the work, and the work, done, is the thing that gives you back to yourself.

The treatment is the work, and the work, when it is done well, is the thing that produces the recovery — not the will to eat differently, and not the desire to feel differently about the body, but the specific, evidence-based interventions that address the relationship, the function, the behaviors, and the conditions that the assessment mapped. This chapter is the treatment, in the practical, clinical detail that the person receiving it and the person supporting it can use. It is not a manual that will teach you to do the treatment yourself. It is a guide to what the treatment is, so that the person in it knows what they are doing and why, and so that the person supporting them knows what to expect and how to help.

The Foundation: Medical and Nutritional Stabilization

The treatment does not begin with the psychology. This is the first and most important thing to understand, and it is the thing the patient who wants to rush to the "real work" most needs to hear. The treatment begins with the medical and the nutritional stabilization — with the restoration of the body to a state where the brain can do the psychological work, because the brain, starved, cannot do the work, and the cannot is not a weakness; it is a physiology. The starved brain is the brain that cannot think flexibly, cannot regulate emotion, cannot challenge the thoughts, and the cannot is the thing that makes the psychological work impossible, and the impossible is the thing the stabilization addresses.

The stabilization includes the medical monitoring — the vitals, the labs, the ECG, the weight — and the monitoring is the thing that ensures the safety, and the safety is the floor. The stabilization includes the nutritional rehabilitation — the structured, supported, gradual restoration of the eating patterns, and the restoration is the thing that restores the brain, and the restoring is the thing that makes the psychological work possible. The stabilization is not optional, and the not-optional is the thing that the person in the disorder must understand, because the stabilization is the thing that makes the rest of the treatment work, and the work is the thing that produces the recovery.

The Evidence-Based Psychotherapies

The psychological treatment is the work that the therapies are built for, and the therapies — cognitive-behavioral therapy for eating disorders, family-based treatment for adolescents, and others — are, in their essence, structured ways of helping the person identify and change the thoughts, the behaviors, and the relationship patterns that the disorder is built on. The work is hard. It is the work of facing, in the therapy room, with the clinician, the things the disorder has been organized to avoid — the feelings, the fears, the body, the food — and the facing, done in the right way, in the right doses, with the right support, is the thing that lets the relationship change.

Cognitive-behavioral therapy for eating disorders is the therapy with the most evidence, and the therapy is the thing that, for most people who complete it, produces the recovery. The therapy includes the regular eating — the structured, supported restoration of the pattern, which is the thing that breaks the cycle of the restriction and the bingeing. The therapy includes the challenging of the thoughts — the food rules, the weight concerns, the body image distortions, which are the things that run the disorder, and the challenging is the thing that weakens the thoughts, and the weakening is the thing that makes the behavior change possible. The therapy includes the exposure — the gradual, supported facing of the feared foods, the body, the situations, which is the thing that reduces the fear, and the reducing is the thing that lets the person live without the avoidance.

Family-based treatment is the therapy with the most evidence for adolescents, and the therapy is the thing that empowers the family to be the primary agents of the recovery, and the empowering is the thing that makes the recovery happen, because the family, supported and guided, is the thing that can restore the eating, and the restoring is the thing that makes the rest of the recovery possible. The therapy is not the blaming of the family. It is the mobilizing of the family, and the mobilizing is the thing that, for adolescents, produces the best outcomes.

The Medications, When Needed

The medications have a role, and the role is worth naming clearly, because the person with an eating disorder is often carrying, alongside it, a clinical anxiety or a clinical depression, and the conditions, when they are present, benefit from the medications that treat them. The SSRIs and other medications, prescribed by a psychiatrist, are effective for the comorbid conditions, and the effectiveness is the thing that lowers the background arousal enough that the therapy can do its work. The medications are not a treatment for the eating disorder itself, in most cases, and the not-a-treatment is the thing that must be understood, because the medications alone, without the therapy and the nutritional rehabilitation, do not produce the recovery. The medications are a support, and the support is part of the whole, and the whole is the thing the treatment plan addresses.

Addressing the Function

The treatment includes the work of addressing the function the disorder serves, because the function, unaddressed, is the thing that pulls the person back to the disorder. The work includes the development of the alternative coping — the skills, the practices, the ways of managing the feelings that the disorder managed, and the development is the thing that gives the person another way, and the another-way is the thing that makes the giving-up of the disorder possible. The work includes the exploration of the control — what the disorder controls, and what the person can control in a way that costs less, and the exploration is the thing that opens the alternatives. The work includes the communication — the finding of the words for the things the disorder said through the body, and the finding is the thing that lets the body stop saying them.

The addressing of the function is the thing that makes the recovery hold, because the recovery that removes the disorder without replacing the function is the recovery that leaves the person without the coping, and the without-the-coping is the thing that makes the relapse likely, and the likely is the thing the function-work prevents. The function-work is the thing that turns the recovery from the absence of the disorder into the presence of the life, and the presence is the thing the recovery is for.

The Body Image Work

The treatment includes the body image work, because the relationship with the body is the thing the disorder is built on, and the relationship, unaddressed, is the thing that maintains the disorder. The body image work includes the challenging of the distortions — the body that is experienced as larger than it is, and the challenging is the thing that brings the experience closer to the reality. The work includes the reducing of the body-checking — the weighing, the measuring, the mirror, and the reducing is the thing that reduces the preoccupation, and the reducing is the thing that frees the life. The work includes the body acceptance — not the love of the body, which is too much to ask, but the acceptance, which is the thing that lets the body be the house the person lives in, rather than the project the person is at war with.

The body image work is hard, because the body is the thing the culture has taught the person to be at war with, and the war is the thing that has been running for years, and the ending of the war is not a single act but a practice, and the practice, done over time, is the thing that changes the relationship, and the changing is the thing that makes the recovery real, and the real is the thing the whole treatment is aimed at.

The Time and the Outcome

The treatment takes time, and the time is measured in months to years, not weeks, for most people. The stabilization, the therapy, the function-work, the body image work — each takes its time, and the time, given, is the time that produces the recovery. The recovery is not the end of the relationship with food and body — the relationship, reformed, is the thing the recovery is — but it is the end of the disorder running the life, and the end of the running is the beginning of the life, and the life is the thing the whole book has been pointing toward. The treatment is the door. Walk through it, with the team, at the pace the work requires, and the life, on the other side, is the life that is yours to live, with the food and the body, finally, as the things they are, rather than the things the disorder made them.

The last chapter is the life. The treatment described in the previous chapters is the treatment of the disorder, and the treatment, for most people who get it, produces the recovery — not the end of the relationship with food and body, which is the thing the recovery is, but the healing of the relationship, which is the thing that lets the person live. The living is the subject of this chapter, and it is, in some ways, the hardest chapter, because the life in recovery is not the life the person had before the disorder, and the building of it is a work that the treatment supports but does not do for you.

The Relationship Healed

The first thing to understand about the recovery is that the relationship with food and the body is not eliminated; it is healed. The recovery is not the absence of the relationship. It is the presence of a different relationship — a relationship in which food is food, and the body is the house, and the neither is the central organizing principle of the life. The food, in recovery, is the thing that is eaten when hungry and stopped when full, and the eating is not the thing that is monitored, counted, feared, or punished. The body, in recovery, is the thing that is lived in, and the living is not the thing that is weighed, measured, criticized, or hidden. The relationship, healed, is the relationship that is not the disorder, and the not-the-disorder is the thing the recovery is.

The healed relationship is not perfect. The recovery is not the absence of the thoughts — the thoughts, the food rules, the body concerns, return, especially in stress, and the returning is not a relapse. The recovery is the presence of the relationship with the thoughts — the thoughts, noticed, are the thoughts that can be challenged, and the challenging is the thing that keeps the thoughts from running the behavior, and the keeping is the thing that makes the recovery hold. The recovery is the practice, and the practice, done over time, is the thing that keeps the relationship healed, and the healed is the thing the life is built on.

The Life That Is Not the Disorder

The life in recovery is not the life that was before the disorder, and the mourning of the life before is part of the work. The person who had the disorder before the disorder began is not the person who has the recovery after the disorder ends, and the not-the-same is the thing that must be grieved, and the grieving is the thing that makes the new life possible. The new life is the life that includes the recovery, and the recovery is the thing that shapes the life, and the shaping is not a diminishment; it is a deepening, and the deepening is the thing the disorder, ironically, made possible, because the person who has been through the disorder and the recovery is the person who knows, in a way the person who has not cannot, the value of the ordinary relationship with food and body, and the knowing is the thing that makes the ordinary precious, and the precious is the thing the recovery gives.

The life is built, in recovery, around the things that are not the food and the body. The relationships, the work, the interests, the passions, the contributions — these are the things that the life is built on, and the building is the thing that the recovery makes possible, because the disorder, when it was running, left no room for the building, and the no-room is the thing the recovery opens, and the opening is the thing that lets the life be built, and the building is the thing the recovery is for.

The Relapses and the Maintenance

The recovery is not a straight line. There are hard days, and hard weeks, and the contexts that trigger the old patterns — the stress, the loss, the transition, the body change, the life event that activates the old coping. The activation is not a relapse. It is the course of a pattern that was deeply installed and that leaves traces, and the traces, activated, are the thing the skills the treatment taught are for. The person who feels the old pattern activate uses the skills — the regular eating, the challenging of the thoughts, the reaching for support — and the skills, used, settle the activation, and the settling is the thing that confirms the recovery, and the confirmation, repeated, is the thing that makes the recovery hold.

If the activation does not settle — if the old pattern returns and stays, if the recovery feels like it is slipping — the treatment is still there. The clinician is still there. The team is still there. The tools are still yours, and the returning to them, in the hard time, is not a failure. It is the maintenance of the recovery, and the maintenance is the work, and the work is the life, and the life is the one you are living, with the food and the body, finally, as the things they are, and the as-they-are is the thing the whole book has been pointing toward.

The Identity Beyond the Disorder

The recovery requires the building of an identity that is not the disorder, and the building is the work of the life. The person who has been the disorder for years — the person whose identity was the restriction, the bingeing, the body, the weight — is the person who, in recovery, must build an identity that is something else, and the something-else is the thing the recovery makes possible, and the possible is the thing the life is built from. The identity is built through the doing — the relationships, the work, the interests, the contributions, the things that the person does that are not the disorder, and the doing, accumulated, is the thing that builds the identity, and the identity, built, is the thing that holds the recovery, because the person who is something other than the disorder is the person who does not need the disorder, and the not-needing is the thing that makes the recovery last.

The People

The recovery is lived with the people, and the people are the recovery, in the way that the people are always the recovery. The disorder isolated. The recovery, in part, is the re-entry into the rooms the disorder withdrew from — the meals, the social situations, the relationships, the life. The re-entry is not easy. The people who did not have the disorder do not fully understand the recovery, and the not-understanding is its own kind of loneliness, and the loneliness is part of the work. But the people, even imperfect, even not fully understanding, are the thing that the life is made of, and the re-entry, over time, is the thing that lets the life open back up.

The people who are also in recovery — the support group, the therapy group, the community of people who have been through the disorder and the recovery — are a particular gift. The shared recovery is the recovery that is understood, and the understanding is the thing that the not-understood recovery most needs. The support group is not for everyone, and the support group that is right is the one that fits the person, and the finding of it is worth the effort, because the recovery that is shared, in the right way, with the right people, is the recovery that holds, and the holding is the thing the whole book has been pointing toward.

A Final Word

The eating disorder is a relationship, and the relationship, identified, is the thing that can be addressed, and the addressing is the thing that produces the recovery. The recovery is not the absence of the relationship. It is the healing of the relationship, and the healing is the thing that lets the person live, with the food and the body, as the things they are, rather than the things the disorder made them. The recovery is real, for most people who get adequate care, and the care is the thing this book has been a guide to, and the guide is now yours, and the recovery is now yours, and the living of it, with the food and the body, finally, as the things they are, is the thing that begins.

You did not choose the relationship that became the disorder. You can choose, in the moment you reach for help, to do the work the recovery requires. The help is there. The treatment works. The life in recovery is the life that is waiting, and the waiting is the thing this book has been honoring, and the honoring is the thing the book is, and the book is now yours, and the life is now yours, and the living of it, with the food and the body, finally, as the things they are, is the thing that begins, in the way that all of it begins, with the next meal, and the next breath, and the next day. Live it. The disorder is not the end. The recovery is the rest.

— Dr. David K. Lubega, LICSW, LCSW-C