A strengths-based approach to eating disorder recovery

There are very few practitioners outside of the eating disorder specialty who can effectively identify patients who need help and treatment, said Amy Pershing, LMSW, ACSW, at the 2019 Institute for Functional Medicine Annual International Conference in San Antonio, Texas.

An eating disorder is a relationship with food, weight, or exercise that is used to meet needs other than the needs these things can truly fulfill. It is a serious mental illness, Pershing said.

People never choose an eating disorder. Eating disorders cause extreme distress. They rob sufferers of most of their energy, attention, and focus. No one with an eating disorder can simply stop the behaviors. Willpower has nothing to do with it. No matter how difficult, people are terrified to let go of the eating disorder. For those with eating disorders and trauma, the eating disorder allowed them to survive.

Patients with an eating disorder might show signs of low self-esteem, significant social anxiety, fear of judgement, perfectionism, or a high need for achievement, control, or approval. They may have a history of trauma. Substance use disorders are more common. They may have a secondary chronic illness, such as diabetes, Chron’s disease, or irritable bowel syndrome. A family history of addictions or mental health issues is possible. Dancers, models, actresses, military personnel, athletes, and weightlifters are statistically at a higher risk for developing an eating disorder, Pershing said.

Eating disorders are often viewed as narcissism. Eating disorders are not about vanity. People with eating disorders have very low self-esteem, Pershing said. Perceptions of binge eating increases stigma of obesity. Those with an eating disorder are the target of more blame than other psychological disorders.

People may not look like they have an eating disorder, and it could still be very serious, Pershing said. People of all sizes have eating disorders, and they are only prevalent in cultures that value thin over health. Thin is not healthy for every body, only bodies designed to be thin. Further, body size is not an accurate indication of health, Pershing said.

Eating disorders are incredibly complex. Causes and paths are unique to each person. Eating behavior exists on a spectrum. Position on said spectrum can be fluid. The spectrum of eating and related disorders includes:

• Binge Eating Disorder
• OSFED
• Bulimia Nervosa
• Anorexia Nervosa
• Orthorexia
• Rumination Disorder
• PICA
• Avoidance/Restrictive Food Intake (AFRID)
• Sub-clinical food/weight obsession

Anyone can get an eating disorder, Pershing said. Females may be more likely to develop some types of eating disorders, but in general any body size, body type, race, culture, age, sexual orientation gender identity, or economic class.

“We have to expand profoundly who we think can develop an eating disorder,” Pershing said.

Eating disorders can be a form of safety through control of chaos, self-punishment, allowing a way to right wrongs, distraction, boundary setting, soothing, rebellion, freedom, reward, emotional regulation, and biological response to restriction. Family characteristics, trauma, and genetics and increase likelihood of developing an eating disorder, Pershing said.

The formal definition of a diet is any time a person manipulates foods food for the purpose of weight loss. Typically, it involves sustaining hunger and stopping eating prior to fullness. Diets and “beauty” culture are prevalent, with 75 percent of adolescent girls dieting by the age of 16, 50 percent by the 11, and 35 percent by the age of 10. Diet and beauty is an $80 billion industry.

Dieting is a gateway behavior to eating disorders, Pershing said. 81 percent of 10-year-olds are afraid of being fat and 51 percent old 9-and 10-year-old girls feel better about themselves if they are on a diet. In addition, 35 percent of “normal dieters” progress to pathological dieters.

Pershing said dieting doesn’t make biological sense. Fundamentally, our bodies don’t know the difference between a diet and a famine. When we go on a weight loss plan that involves either significant caloric reduction, or tolerating hunger for a sustained period, we experience key survival-based biological changes that drive us to seek food, she said.

Research shows between one-third and two-thirds of dieters regain more than they lose. Three quarters to 90 percent regain at least the amount originally lost within two years; 95% of dieters regain all weight lost within three years; paradoxically, adolescent girls with elevated scores on dieting scales are at increased risk for future onset of obesity...indicating that dieting predicts weight gain in adulthood; adolescents using weight control practices at Time 1 increased their BMI  by about one more unit than adolescents not using any weight control behaviors and were at approximately three times greater risk for being overweight at Time 2.

Weight stigma is defined as bulling, teasing, negative body language, harsh comments, discrimination, or prejudice based on a persons’ body size or weight. It reflects three basic assumptions, that thin is always preferable, thin is always possible, and thin people are better people, Pershing said. Weight discrimination occurs more frequently than gender or age discrimination. The stigma has a dangerous impact.

But how do we help build strength and create resiliency? Pershing says we must define recovery from a strengths-based vantage point; build a recovery team; treatment paradigms and modalities; address underlying pathology and trauma activation; address diet mythology and mentality; challenge the culture of weight stigma and heal body distortions.

Recovery from an eating disorder means an increasingly peaceful, self-directed relationship with food and movement, based on physical desire, nutrition, health and wellbeing, Pershing said. It may or may not mean a complete cessation of behaviors. Psychologically, it is about being able to look with growing compassion at one’s inside and outside, past and present, and for one’s unique journey with food and weight. It is learning to trust one’s voice, in body and spirit, and to fight back when we feel shamed or diminished. And perhaps most critically, it is about allowing oneself, as is, to be seen and loved by safe others, and to love them back. It is coming to learn that healthy connection, finally, is both possible and abundant, Pershing said.

An ideal treatment team may include the individual, family, psychotherapist, medical professionals, psychiatrist, and a nutritionist. Psychological treatments range from psychodynamic, IFS/trauma-informed, family/couples and group therapy, HAES-informed nutrition counseling, psychopharmacology, alternative therapies such as yoga, art, and writing, mindfulness therapies, and sensorimotor therapies.

Attuned eating and movement is a health philosophy based on the premise that becoming attuned, on all levels, to the body’s needs for food and movement allows for maintenance of a healthy weight, as defined by the body, a decrease in food and weight obsession, a decrease in overeating or binge eating, and a more peaceful relationship with one’s physical body, Pershing said.

Pershing says to let go of the dieting paradigm that says weight loss is necessarily possible, aesthetically preferable, and intrinsically healthy. Challenge the moralization of food and relearn and honor body cues for food such as hunger, fulness, and the physical impact of specific foods. Understand the critical role of satiety. Learn the body’s unique needs and rhythms and be able to anticipate. The body knows best in terms of weight. Comfort from food is not pathology, it is one tool in a toolbox. Attuned eating is so important, and can be scary for patients, Pershing said.

Regarding attuned movement, Pershing said to reclaim movement. Don’t exercise to lose weight. One day is independent of any other. All movement matters to your body. We may go through periods of more or less movement, and that is okay. There is no shame if you never exercise again. As with food, movement must come from care for your body, not shame or an attempt to “fix” it. The focus is not on being thin, but living an embodied life.

We also need to let go of the weight stigma in recovery. Pershing offers five focus points for inner healing and social change:

• RECOGNIZE the many messages directed toward women about beauty, and how many of our thoughts and actions revolve around appearance. Put this into action with a media fast.
• REFLECT on what impact narrow beauty ideals have had on your life and take inventory of the time, money and energy you dedicate to appearance concerns.
• REDEFINE beauty and health for yourself in more empowering ways by consciously focusing on how you feel and what your body can do. Set fitness and activity goals and skip the weight and appearance goals.
• RESIST harmful messages in order to take your power back by turning away from the messages that spark body anxiety, speaking up about harmful media and talking to friends and family about more than their outward beauty.
• RISE with RESILIENCE by responding to shame-inducing disruptions in ways that exercise your mental, social, spiritual, and physical power, rather than distracting, hiding, or fixing yourself to cope with difficult experiences.

In addition, for clients struggling, Pershing suggests the following Hungerwise Attuned Eating Program principles:

1. Accept your size. Love and appreciate the body you have. Self-acceptance empowers you to move on and make positive changes.
2. Trust yourself. We all have internal systems designed to keep us healthy —and at a healthy weight. Support your body in naturally finding its appropriate weight by honoring its signals of hunger, fullness, and appetite.
3. Adopt healthy lifestyle habits. Develop and nurture connections with others and look for purpose and meaning in your life. Fulfilling your social, emotional, and spiritual needs restores food to its rightful place as a source of nourishment and pleasure.
4. Find the joy in moving your body and becoming more physically vital in your everyday life.
5. Eat when you’re hungry, stop when you’re full, and seek out pleasurable and satisfying foods.
6. Tailor your tastes so that you enjoy more nutritious foods, staying mindful that there is plenty of room for less nutritious choices in the context of an overall healthy diet and lifestyle.
7. Embrace size diversity. Humans come in a variety of sizes and shapes. Open to the beauty found across the spectrum and support others in recognizing their unique attractiveness. 

"Healthcare professionals can have a tremendous impact on clients," said Pershing. "They need to listen and understand and get them the correct treatment, and for patients that can mean the world." 

Editor’s note: This article is part of Integrative Practitioner’s live coverage of the 2019 Institute for Functional Medicine Annual International Conference. For a full list of coverage, click here.