6 Things Eating Disorders Treatment Often Gets Wrong

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Anorexia nervosa is one of the most pernicious diseases around. People who develop it are sick, on average, for four to seven years. A third never recover. Ten percent die from the disease, either from malnutrition or from suicide.

Some of these depressing statistics can be chalked up to the nature of the illness. But too many of them come from misconceptions and wrong-headed ideas about anorexia and what it takes to recover. Too many nutritionists, dietitians, therapists, and psychiatrists still prescribe treatments that are outmoded, outdated, not evidence based, and often just plain wrong. In fact, I doubt there’s another area of medicine that’s so rife with inaccuracies, old-fashioned perspectives, and out-and-out errors.

Here are 6 of the most common and dangerous misconceptions I’ve seen in eating disorders treatment. If you’re working with professionals who are telling you any of these things, you need a new treatment team.

1. Psychological treatment leads to recovery. Many practitioners see psychotherapy as the first step in treating eating disorders. The reality is that when you’re deeply malnourished, your brain doesn’t work right. All the talk therapy in the world won’t do diddly when you’re literally starving. When my daughter was sick we wasted precious health-care dollars and time on ineffective and expensive visits to psychiatrists and psychologists. Patients and their families need professional support, of course. But that support should be aimed at restoring lost weight and normalizing eating first. Physical recovery always comes before mental/emotional recovery.
2. The lower the target weight the better. Our culture is intensely fatphobic, and one consequence of that stigma is that practitioners often want to set target weights as low as possible. “Don’t worry, we won’t let you gain too much weight” is a mantra I’ve heard over and over, both from my own daughter’s treatment team and from other families.There’s a big difference between a weight that’s not medically dangerous and a weight that supports true recovery. The only way to know if a target weight is high enough is to see what happens after a patient has been there for a while. In my experience, people in recovery often wind up at BMIs in the upper end of the “normal” range. (And don’t even get me started about what a crock BMI is.)
3. Numbers are everything. Some numbers are clearly important in recovery; people with anorexia need to gain weight and re-nourish their bodies. But they don’t need to get trapped in rigid meal plans or discuss calories. While it’s true that people with anorexia are keenly aware of the calories and nutritional content of every bite, emphasizing that awareness only feeds into the eating disorder thinking. It reinforces the idea that calories must be counted, foods must be measured exactly, exchanges must be consumed precisely to a plan. Treatment should work to quiet the constant awareness of calories and exchanges rather than bolster it.
4. Families have no place in treatment. Many of the early researchers and clinicians in the eating disorders world believed (without any actual evidence) that families caused and exacerbated anorexia and other eating disorders. Hilda Bruch, author of The Golden Cage, painted a particularly damning picture of the parents of anorexic patients, describing them as overcontrolling, smothering, and destructive. Bruch and other practitioners advised that patients be physically and emotionally removed from their families, in a move that became known as a “parentectomy.” More recent studies have shown that families play a hugely important role in helping children, teens, and young adults recover. Except in very rare cases, families should always be part of eating disorder recovery efforts.
5. People with anorexia must choose to eat. Eating disorders have often been perceived as lifestyle choices rather than serious illnesses, and some eating disorders professionals have contributed to this dangerous misperception. In the DSM-IV anorexia was defined as a refusal to eat, and treatment often required sufferers to choose, prepare, and consume their own food. In my experience, it’s not that people with anorexia refuse to eat; they can’t eat. They’re caught in deep compulsions and terror around food, eating, and weight gain, and suffer enormous guilt, anguish, and self-recriminations when they do. It’s not only unkind to ask people with anorexia to voluntarily eat enough to recover; it’s impossible for pretty much everyone, which explains in part why pretty much everyone relapses over and over. It’s much kinder and more effective to relieve sufferers of the responsibility for choosing to eat until they are physically recovered and well on the way to psychological recovery.
6. Only underweight people can be diagnosed with anorexia. Too often, those who start at higher weights are praised for their weight loss rather than treated. As psychologist Deb Burgard has said, “We diagnose as eating disorders in thin people what we prescribe in fat people.” Anorexia can affect people at any weight.

For more information visit the Maudsley Parents website, the National Eating Disorders Association website, or check out Brave Girl Eating: A Family’s Struggle with Anorexia.