Editor’s Note: This post does not address all the various approaches and models when it comes to eating disorder treatment, but rather outlines a few methods. We plan on posting follow-up pieces that will further expand on other eating disorder treatment options. Please note that Adios Barbie does not endorse any specific approach or model, but instead, we aim to provide our readers with a variety of tools and a range of perspectives so that they can make informed choices. ~Sharon

By Valerie Martin

When Adios Barbie approached me about writing a piece on methods of eating disorder treatment, I simultaneously had two reactions: “Cool, something that I am passionate about and actually do for a living… of course I’ll write about it!” and “Oh no. There are so many great things already written about this by people way more knowledgeable and experienced than me. What could I possibly add to the discussion? And if I have to introduce each method, I won’t be ever able to do it without spending 20 hours I don’t have researching and citing articles and books and OH NO…”

Hi, my name is Valerie and I’m a recovered anorexic.

I am a therapist (LMSW, to be precise) so you might think I’d know too much to fall into my own mind traps, but it turns out I’m also human. And although I am recovered from my eating disorder (ED), I’m definitely not recovered from perfectionism (or its bedmate, black-and-white thinking), a highly common personality trait in people with anorexia. So, instead of continuing to let my Ghosts of ED Past win on this one by continuing to put off writing this post, I finally decided I’d hang up on my inner perfectionist and just write about my own experiences on both sides of the ED treatment. If you’re looking for a comprehensive overview of treatment approaches, check out The Eating Disorder Sourcebook by Carolyn Costin or Integrated Treatment of Eating Disorders by Kathryn Zerbe. I’m going to speak to the therapeutic side so just keep in mind that is only part of the equation, along with psychiatric care and nutritional support from a Registered Dietitian.

Separation from the Eating Disorder 

This one is more philosophy than specific method, but I wanted to include it first because I believe it sets an incredibly important foundation for ED recovery and ties in to overall self-esteem building. Unless you’re already pretty ED savvy, you’re probably wondering what the heck I’m referring to in the title of this post, “Telling Ed to F off.” So let’s start there. One of the most popular books in the ED recovery world is Jenni Schaefer’s already-classic Life Without Ed in which she shares her journey of recovery alongside her co-author and therapist Thom Rutledge. Jenni writes about how one of the significant “aha” points in her recovery was when Thom put an empty chair in front of her and told her to talk to Ed – her eating disorder (empty chair work is a Gestalt therapy technique.) After wondering for a moment if Thom needed therapy himself, Jenni went for it and saw the method to the madness, or the value in separating her true self from her eating disorder and beginning to distinguish the separate voices.

Where I work, most of our ED clients also have addiction issues, and we use the disease model of addiction, which includes the idea that there is the person, and the disease within the person (see below for more details). Just like cancer is not all that defines Lance Armstrong, if addiction is also a disease, it is not all that defines a person. And the same goes for eating disorders, though try telling that to someone in denial of her ED or in the early stages of treatment. For many people with ED, it becomes their best friend – their Mia or Ana[1] – the most important priority in life. So the idea of separating it from some other “true self” is both terrifying and critical.  This is one of the most important things I see women in treatment do every day: begin to distinguish their healthy recovery voice from “Ed’s voice” and start talking back. Each person’s  “disease” may look different. Maybe one person’s disease is alcoholism, bulimia, and anxiety. And if she can begin to learn (perhaps for the first time) that there is a beautiful, pure core to her being – her authentic self – that is NOT her alcoholism, bulimia, or anxiety – then she can have a real reason to begin healing. Even therapists who don’t adhere to an addiction treatment model can benefit from helping a client separate her authentic self from the eating disorder.

Empty chair work is just one experiential way of reinforcing this separation. There are also great journaling exercises (dialoguing with Ed, writing letters to and from Ed), art therapy activities, and many other ways of doing this. Separating from the disease is a process, not an event, so it takes time, and it relies on some of the other techniques I’ll talk about below (in addition to good old-fashioned soul searching).

Cognitive Behavioral Therapy (CBT)

Most people have had at least a little exposure to CBT, and there’s a good reason for that. Since its emergence in the late 1970s (when it was originally developed by Aaron Beck for treating depression), CBT has been one of the most widely researched psychotherapy techniques ever, and it’s proven to be an effective treatment method for many types of psychological disorders. (Insurance companies just love those words “evidence based treatment”!) The basic premise is that a clinician trained in CBT can help clients learn to recognize cognitive distortions (including negative core beliefs) and choose not to act on them, even replacing them with more positive and reality-based thoughts and beliefs which will ideally lead to healthier behavior choices.

In my personal experience, the effectiveness of CBT depends significantly on the personality of the individual in treatment. Even the most intelligent of people are prone to cognitive errors like black-and-white thinking, overgeneralizing, and personalizing.  I gained a lot from CBT in my personal recovery from anorexia (no pun intended), and research shows it’s actually even more effective for bulimia and binge eating disorder.[2] However, people with very strong eating disorders often need a lot more than CBT to make progress in recovery. I’ve worked with many clients who say, “I know intellectually that my hatred toward my stomach or believing this one meal will make me gain weight are irrational, but that doesn’t change the way I feel.” For some in the field, this is seen as CBT’s big weakness: that it’s based more on logic and thought than on emotions. For some types of people, that may work pretty well and CBT may be a big contributor to their recovery. But for others, CBT may only be a small drop in a huge bucket, and getting these clients “out of their heads and into their bodies” may bring much greater success. I like how Carolyn Costin sums why including these ideas in ED treatment is so important:

“Regardless of theoretical orientation, most clinicians will eventually need to address and challenge their clients’ distorted attitudes an beliefs in order to interrupt the behaviors that result from them. If not addressed, the distortions and symptomatic behaviors are likely to persist or return.”

Dialectical Behavior Therapy (DBT)

DBT is one of my favorite treatment methods because, in my experience, it’s incredibly effective for a wide range of disorders and makes a tangible impact on both thoughts and behaviors. DBT uses a Zen Buddhist foundation and combines some of the techniques from CBT with interpersonal therapy. Marsha Linehan originally developed it for working with clients diagnosed with borderline personality disorder and other individuals with high impulsivity and self-destructive tendencies. A significant component of DBT is skills training (in both the group and one-on-one setting), and one of the things I love most about DBT is that it concretizes the whole idea of “coping skills.” I feel like by the time clients get to treatment, they hear “healthy coping skills” and roll their eyes, thinking, “sure, I could just go take a bath or listen to music, but I highly doubt that’s going to keep me from purging or drinking.” And aren’t they right? I find that DBT skills often give a name and visual to concepts that are otherwise pretty “obvious” and this helps them become more tangible and easily accessible. For me, certain catchy phrases can go a long way. For example, I joke that I have to use my DBT phone sometimes to “hang up on that thought.” I literally say out loud to myself “hang up” and something about visualizing. By saying it out loud, it helps me actually stop the destructive thought in its tracks. I also love “shelf it” for issues/feelings that you can’t deal with in the moment but need to come back to later instead of just stuffing them down and “forgetting” about them.

I could go on and on about DBT, but it basically boils down to four focus areas: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotional Regulation. Each area has its own distinct skills, acronyms, and homework assignments, with the goal of helping individuals tolerate and accept the present moment rather than run from it. For the anorexic client, it could mean “radical acceptance” that a “healthy weight” is outside the realm of what they consider to be attractive. DBT also focuses on helping clients become more aware of and connected to their feelings. Part of the “dialectical” in DBT means holding two truths that 1) we must accept our feelings because we cannot control the emotions we feel, and 2) we can learn healthier ways to respond to our feelings so we don’t have to stuff them or act out in ways that are self-destructive or harmful to others and our relationships with them. On my to-read list currently for DBT and eating disorders is Jennifer Taitz’s new book, End Emotional Eating: Using Dialectical Behavior Therapy Skills to Cope with Difficult Emotions and Develop a Healthy Relationship to Food.

The 12-Step Treatment Model

Many people in ED treatment (me included) believe eating disorders are process addictions. A “process addiction” (as opposed to a substance addiction) is simply an addiction to the rewards of certain behaviors such as gambling, sex, spending, eating, purging, etc. If you’ve ever been or known a gambling addict, a compulsive spender, or a binge eater, you’ll know that the attachment to the behavior is so strong that it truly becomes an addiction. And notice that even with the binge eating example, the addiction is still to the behavior of eating, not the food itself.

So it only makes sense that the most widespread and successful recovery program for addiction – Alcoholics Anonymous (AA) – would provide the model for a similar program for ED, Eating Disorders Anonymous (EDA.) At the treatment center where I work, we use the 12-step model (including AA, NA, EDA, SLAA, etc.) because we find that our clients benefit tremendously from it, and the worldwide network of support groups is a built-in (and FREE) continuing care support as the client steps down from residential treatment into Intensive Outpatient (IOP) and then regular outpatient treatment. So for us, 12-step is a no-brainer. At the time of my own ED recovery, I had no exposure to 12-step, and I wish that I had. I love a lot of the old 12-step adages, and one of my favorites is, “If you could think your way out of this, you probably would have by now.” It goes along with Step 1, admitting you are powerless over (alcohol, your eating disorder, gambling, etc.) Even if your ED has already wrecked utter havoc on your body, your relationships, your finances – that is not enough to stop the power of addiction. Willpower (trying harder to stop) alone is not enough.  Witnessing someone surrender their disease is so powerful and almost palpable. It’s that moment where a person says, “I just can’t do this anymore. My way isn’t working. Take it. I need help.” I will never forget the first time I surrendered my ED (even though I didn’t know it was called “surrender”) and came clean to my Mom, handing over my thinspo printouts and crying my eyes out as I told her how miserable and alone I felt that this was all I cared about in life anymore.  (Notice I said the first time, because surrendering is often something you have to do again and again, almost daily in early recovery.) That moment changed my life forever, but it was only the beginning.

I love that the 12-step model acknowledges imperfection, necessitates connection, encourages fearless introspection, and applauds asking for help. Another key element of 12-step that I didn’t realize at the time was actually a crucial element of my recovery was connecting to a higher power. A Geneen Roth workshop and a few of her books got me started along my spiritualpath, which I believe is one of the reasons that after that point, I never looked back and haven’t relapsed for almost seven years now.12-step is NOT just for highly religious people, either. For some, a “power greater than you” might look like your treatment team, family, or friends.

Click here to read the 12 steps of EDA. You might have also heard of Overeaters Anonymous (OA). There are some philosophical differences between OA and EDA that are covered succinctly at this blog and here at EDA’s website.

I could write about at least a dozen more treatment methods including equine therapy, interpersonal therapy, internal family systems therapy, dance movement therapy, and more… but that’s all I have room for today! If you’d be interested in having me write about a particular method in more detail, please leave a comment. I’d especially love to hear from anyone who’s been through ED treatment and what you found most effective for you.

I look forward to hearing from you!