The following content may be triggering for individuals who are currently active in their disorder, and for those new to recovery. No material on this site is intended to be a substitute for professional medical advice, diagnosis, or treatment.

In our last discussion of eating disorders (ED) we explored types of ED with an emphasis on disorders with a body image component. This includes anorexia, bulimia, and binge eating disorder. Now we are going to focus on treatment options - what’s available, how treatment works, and what you can expect in the process. We’ll also consider barriers to treatment since eating disorders are among the most under-treated disorders in mental health.

Components of treatment
Successful eating disorder treatment requires a holistic focus, incorporating medical interventions for physical recovery, mental health counseling, nutritional monitoring, and often includes family education and therapy. The most immediate goals are stabilizing any medical problems that resulted from the eating disorder, including malnutrition, organ damage, and electrolyte imbalances, which is largely accomplished through restoring healthy eating patterns. 

Once clients are medically stable, the psychological and emotional treatment can begin. During this phase of treatment, clients learn a wide range of skills to help them engage with food and their bodies in healthier ways. In order to make sure new eating and body image skills stick, it’s critical to address underlying issues such as trauma, depression, anxiety, and family conflict. Different types of therapy may be used to help folks in their recovery.

Cognitive Behavior Therapy
Cognitive Behavior Therapy (CBT) is the most widely used treatment approach for ED. CBT involves identifying and changing problematic beliefs people have about their bodies and food, and behaviors that result from those beliefs. In a CBT-based program, clients will be asked to track their thoughts before, during, and after meal times to find “hot thoughts,” or thoughts that cause significant distress. Identifying problematic beliefs such as, “if I eat any cake, I’ll immediately gain weight,” can help clients challenge those thoughts with more realistic evaluations. Behavioral components of treatment generally include tracking and monitoring a variety of behaviors and learning how thoughts and behaviors connect to maintain the eating disorder. Food journaling is an example of a behavior tracking strategy that keeps clients accountable for their calorie intake, and allows the client and treatment team important insight into how stressors of daily life may be impacting food choices. 

“Caleb” had been running up to three hours per day and restricting his calorie intake since his father passed away last year. His mother noticed his weight loss and enrolled him in an outpatient CBT program at the recommendation of their family doctor. In the program, Caleb began tracking his mood and eating habits, and realized that he was most vulnerable to over exercising and skipping meals in the afternoon, when he and his father used to spend time together on the ride home from school. He learned he could cope with his grief by journaling instead of exercising. With his mom’s help, he was able to stick to the meal plan he made with a nutritionist, and began feeling rejuvenated and hopeful.

Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) uses many of the same building blocks of CBT (identifying problematic beliefs and changing behavior), but incorporates mindfulness practices and specific skills for managing distress and being more effective in relationships. DBT’s focus on improving our ability to manage difficult emotions may be the key to its success in treating ED. Rather than solely emphasizing changing problematic thoughts and behaviors like CBT, in DBT we are also encouraged to acknowledge that even our least skillful behaviors came from somewhere and likely for good reason. DBT helps clients learn to connect with their inherent wisdom while learning concrete tools to reduce eating disordered behaviors and increasing coping. 

“Cory” was binge eating weekly, consuming multiple servings of cake, chips, and alcohol in a couple of hours and feeling tremendous guilt and shame afterwards. She started a DBT group that met every week for 2 hours where she learned how to identify different emotions, use her wise mind to make choices about food, and how to be more assertive in her relationships. Each week she had a new skill to practice to help her reduce bingeing behaviors and increase healthy coping skills such as talking about her feelings with her husband. After she completed the 24 week program, she hadn’t binged in over one month.

Acceptance and Commitment Therapy
Acceptance and Commitment Therapy (ACT) is also a cousin of CBT, and shares an emphasis on the importance of thoughts and feelings on behavior. Where CBT emphasizes changing our internal experiences, ACT suggests that we can change how we interact with thoughts, feelings, and memories instead. Research indicates that many eating disordered behaviors serve to help folks avoid uncomfortable feelings. ACT directly targets avoidance and helps us see the cost associated with making choices based solely on not feeling bad. In ACT, we learn how to accept that discomfort is a natural part of life, and to commit to acting in the service of values such as honesty, kindness, adventure, or respect. Given the critical role of avoidance in maintaining many eating disordered behaviors, particularly in anorexia, ACT is becoming a preferred treatment approach.

“Gloria” had been eating large amounts of food, and forcing herself to vomit a few times a week for the past 3 months. Her chemistry teacher noticed that she would ask for a hall pass to go to the bathroom everyday after lunch, and helped connect her to an ACT program that offered Spanish-language groups after school. In the group, she realized that her bingeing and purging behaviors, while helpful for managing anxiety about school performance, were at odds with core values of personal growth and family support. She was able to commit to making choices that were aligned with nurturing herself and being present for her family and learned skills for allowing her anxieties to ebb and flow.

Family Psychoeducation and Therapy
Family therapy is often included in more intensive treatments for eating disorders to help ensure that a client’s home environment is supportive of their recovery. Well meaning family members may inadvertently become obstacles to recovery by trying to over feed, hyperfocusing on weight and food, or engaging in dieting behavior of their own. Through psychoeducation, family members can learn how to become skillful partners in recovery by helping clients follow meal plans, modeling healthy, non-restrictive eating behaviors, and generally engaging with more empathy and authenticity. For those families in which conflict is a primary contributing factor to a client’s eating disorder, therapy can help them unpack painful past experiences and communicate more effectively.

Recovery outcomes
Eating disorder recovery is seldom a linear process - slips and relapses are to be expected given the complicated nature of these disorders. US-based studies estimate that, with treatment up to three-fourths of people with eating disorders will make at least a partial recovery, meaning they may still have some mild symptoms, but without significant impairment in their ability to function. Factors that contribute to better outcomes include early diagnosis and family support. The longer an eating disorder goes untreated, the harder it will be for someone to make a full recovery.

Barriers to treatment and recovery come from internal and external sources. Similar to folks with substance use disorders, individuals with eating disorders (particularly anorexia) can experience intense resistance or ambivalence about treatment. For some folks with ED it can be next to impossible to imagine how they would manage without their eating disorder behaviors to help them cope or to help them maintain a specific weight. Treatment programs are designed to help clients with this internal conflict, but often getting someone in the door is the hardest part. 

Important external barriers include bias and access. Stereotyped images of ED generally show extremely thin women despite the fact that only 6% of folks with eating disorders are actually underweight. This mismatch in expectation and reality contributes to underdiagnosis of ED for people in larger bodies. Athletes also make up a significant portion of those with ED - their eating behaviors are often overlooked as a necessary way to maintain a competitive edge. Additionally, treatment for ED is often time intensive, expensive, and clustered in urban areas making it difficult for people and families to complete treatment while continuing to go to work and school. 

Efforts are being made to make treatment more accessible through cost saving measures such as peer support groups, online and telephone based treatment offerings, and broader insurance coverage for treatment. Many programs also offer evening treatment to help accommodate work schedules.

Committing to recovery may be one of the hardest things a person with an eating disorder ever does. Caroline Knapp, an author in recovery from ED and alcoholism describes recovery in her memoir as, “less about getting better, and more about subjecting yourself to change.”  With the right support, change is possible.

If you or someone you love is struggling with an eating disorder, help is available 24/7 by phone or online through the National Eating Disorders Association.

Written for Fitness Blender by Candice Creasman Mowrey, PhD
Licensed Clinical Mental Health Counselor Supervisor

References

Arcelus, Jon et al. “Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies.” Archives of general psychiatry 68,7 (2011): 724-31. 

Bankoff, S. M., Karpel, M. G., Forbes, H. E., & Pantalone, D. W. (2012). A systematic review of dialectical behavior therapy for the treatment of eating disorders. Eating disorders, 20(3), 196-215.

Flatt, R. E., Thornton, L. M., Fitzsimmons‐Craft, E. E., Balantekin, K. N., Smolar, L., Mysko, C., Wilfley, D. E., Taylor, C. B., DeFreese, J. D., Bardone‐Cone, A. M., & Bulik, C. M. (2020). Comparing eating disorder characteristics and treatment in self‐identified competitive athletes and non‐athletes from the National Eating Disorders Association online screening tool. International Journal of Eating Disorders, 54(3), 365–375. https://doi.org/10.1002/eat.23415

Grave, D. R., Calugi, S., & Fairburn, C. G. (2020). Cognitive Behavior Therapy for Adolescents with Eating Disorders (1st ed.). The Guilford Press.

Knapp, C. (1996). Drinking: A Love Story by Caroline Knapp. The Dial Press.

Kazerun, I. (2015). The effectiveness of acceptance and commitment therapy on improving body image of female students with bulimia nervosa. Journal of Ardabil University of Medical Sciences, 15(1), 15-24.

Manlick, C. F., Cochran, S. V., & Koon, J. (2013). Acceptance and commitment therapy for eating disorders: Rationale and literature review. Journal of Contemporary Psychotherapy, 43(2), 115-122.

Murphy, R., Straebler, S., Cooper, Z., & Fairburn, C. G. (2010). Cognitive behavioral therapy for eating disorders. The Psychiatric clinics of North America, 33(3), 611–627. 

Walsh, J. M. E., Wheat, M. E., & Freund, K. (2000). Detection, evaluation, and treatment of eating disorders: The role of the primary care physician. Journal of General Internal Medicine : JGIM, 15(8), 577-590.