Do you need talk therapy in order to weight restore from Anorexia?

Do you need talk therapy in order to recover from Anorexia?


The short answer here is “No.” You do not need talk therapy in order to reach full remission from Anorexia. However, you might want it, in which case you should have it.

Before we get into it, remember that weight restoration is one step in recovery, and re-wiring mental processes is another. For some people, natural re-wiring happens with weight restoration alone. For others, more focus on mental re-wiring is needed after weight restoration to achieve full remission. Hence, we cannot really have a blanket statement answer to this question because the path to full remission looks different for each individual.

With that said, here is a blanket statement. Weight restoration is the vital ingredient that everyone needs. That means eating a lot of food. If you are not yet weight restored, anything that you are doing other than eating should be in place only if it helps you eat more. Eating food is a priority.

(This blog is about medical rehabilitation in Anorexia i.e. weight restoration. It is not about trauma and Anorexia, or any co-morbid disorders that you might have as well as Anorexia.)


In order to reach medical stability from Anorexia you have to fully weight restore. If you can eat the amount of food that you need to eat in order to weight restore, and if you can combine that with mental rewiring aka eliminating all restriction and compulsive behaviours, then you will reach full remission. You may not “need” anything or anyone in particular in order to be able to do these things  — other than food of course. A talk therapist is not going to be there at breakfast and help you put your fork to your mouth, chew and swallow (however a meal support coach, family member or friend could be).  But … therapy might help you deal with the anxiety and fear that comes up as a result of doing so. It can also help you with the process of neural rewiring alongside weight restoration. 

Some people find that therapists that focus on effective behavioural change are extremely helpful to them. A therapist specialising in CBT, CRT, ACT or DBT who has an extensive understanding of eating disorders can be useful in helping you overcome negative thought patterns and actions.

I asked the question “have you used therapy and have you found it helpful?” on Facebook and the Slack group. Some of the responses I got I have anonymously placed below. The answers there, alongside my own opinion shaped this blog. My own opinion is mostly influenced by the experiences of my coaching clients and friends who have had therapy for an eating disorder. Having never had talk therapy in any form myself, I do not have personal experience to relay. That doesn’t mean I don’t have pretty strong opinions on it. 😉

Cognitive Behavioral Therapy (CBT)

For CBT, CBT-BN and CBT-E, the underlying notion here is that overvaluation of shape and weight and controlling shape and weight is at the core of all restrictive eating disorders. Thus, CBT works to counter this. I am sure that you can see that this could be helpful, as can I. However, some CBT therapists subscribe to the idea of discouraging patients from eating anything other than their prescribed meal and snack times, and this I generally disagree with for a person with a AN or BN as it promotes restriction.

I also disagree with the premise that over-evaluation of shape and weight are at the core of all restrictive eating disorders. While I agree that these are often the most obvious symptoms, I believe that these are symptoms of an eating disorder, rather than the cause. To an extent, they are also symptoms of society, and the implicit bias towards thin is nothing unique to the eating disorder population. For a person with an eating disorder the strengthening of these weight biases are symptoms that arise once energy deficit has triggered the eating disorder. I also observe that in myself and many others, weight restoration remedies these biases somewhat. Hence I think that CBT is best used after or alongside weight restoration to help with any remaining negative thought patterns.

Having spoken to a number of adults with Anorexia who have tried CBT in the past, one thing that has been said to me a lot is that while CBT didn’t help some people with weight restoration, it did provide them tools for life in terms of coping with anxiety and challenging negative thoughts.

So yes, CBT can be helpful, but weight restoration has to come first, and unless you are working with a CBT therapist who understands the nature of restriction and the importance of unrestricted eating, you can get in trouble when that comes up.

For example, one of my clients found that her CBT therapist was helpful for body image concerns, but had to end up asking her to not talk about food or get involved in the eating side of things because the therapist was unwittingly telling her to restrict by indicating that she should not eat between her planned meals and snacks. This was because the therapist was concerned doing so would lead to binge eating behaviors, a notion which is grounded in fear and opposes the very natural physiological response to starvation. That is, to eat a lot of food. Okay, in truth this has happened with more than one of my clients.

So while CBT therapists can be helpful in some areas, they can be unhelpful in others. I  think that a lot of this comes when therapists try and treat eating disorder patients according to the manual — which in CBT-E Stage One is to establish “regular eating” and not allow for eating more than the meal plan — rather than listening to the individual or helping that person challenge the restrictive urges.

If a person in recovery from Anorexia is wanting to eat more food they should never be told that is wrong. All this does is enhance their fear of their own hunger.

 

Dialectical Behavioral Therapy (DBT)

(For some reason I always read “dialectical” as “diabolical.” I think if it was called Diabolical Behavioral Therapy I might have been tempted to try it myself)

DBT works on helping people accept change. It uses both cognitive and behavioral therapies to help people adopt healthy coping mechanisms. The core components are mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation. It can help you learn how to relax, and chose alternative ways of dealing with stress.

I do think that DBT can be helpful for many people. I also think that mindfulness is helpful for life in general. I’m not sure it helps greatly with weight restoration. I can’t hurt … or maybe it can if it distracts away from the focus on weight restoration.

In a similar vein as my comment above I believe that the majority of the stress that people with Anorexia experience is due to … having Anorexia. Thus, long-term remission (medical stability and coming out of energy deficit) works wonders. I also found that when I was in energy deficit, I simply could not engage my brain in mindfulness. My brain didn’t want to think about relaxing, it wanted to think about food. Probably because it knew my body was starving. It is hard to be zen when one’s body is starving.

Mindfulness doesn’t help all people in all situations. For some of us, mindfulness at mealtimes is the last thing that we need. I needed mindlessness at mealtimes — I needed distraction. For the first year when I refed myself I did so with a crossword or a sudoku puzzlebook with every meal to distract me enough to stay (relatively) calm. If I thought about the food the anxiety was too high.

 

Acceptance and Commitment Therapy (ACT)

ACT combines acceptance and mindfulness therapies alongside commitment and strategies to achieve behavioral change. I’ve heard quite good things about ACT, as people say that it helps them find positive thoughts about themselves and therefore makes them more motivated to help themselves recover. Rather like connecting with one’s purpose in life.

This is one sort of talk therapy that I think can only really does good. Helping someone find a reason to live can’t ever be a bad thing. But … so long as that warm and fuzzy is followed up with eating food.

I like this comment from a person on Facebook as I think it succinctly sums up ACT:

“ACT helped me because it made me identify what was important to me and I couldn’t have what was important to me or what I valued unless I gained weight and kept it on.”

I think anything that can help someone find a nugget of motivation to recover should be treated like gold dust. Recovery when motivated versus recovery when not motivated are worlds apart. That is not to say that recovery when motivated is easy. It’s not. But we are all smart people, and when motivated to recover we will find our path there someway, somehow.

 

Psychoanalysis/Psychodynamic therapy

It is no secret that I am furiously opposed to psychoanalysis for Anorexia treatment. We do not need to dig deep into our souls and search for an “underlying reason” as to why we are starving ourselves. The reason that we starve ourselves is Anorexia. In the same way the reason a person with cancer has cell growth is cancer.

The underlying premise that “truly eating-disordered individual has a history of disturbances in early relationships, leading to a lack of security and pronounced difficulties in trusting others, and in simply being an authentic individual in the presence of others,” makes me want to vomit. It is not only complete bullshit, it is insulting.

Here is another psychoanalytical gem relating to eating disorders: “It is this profound underlying personality pathology that necessitates prolonged treatment for any hope of amelioration.”

Excuse me?

I say that having an eating disorder says nothing about you as a person in the same way having a broken leg or cancer says nothing about you as a person. It is an illness, a disease, a physiological disruption caused by a pre-programmed genetic response to prolonged energy deficit.

Psychodynamic therapy confuses symptoms with causes; is based on theory rather than data; wrongly accuses a patient’s family for the illness; places meaning where there is none; and worst of all causes physical and mental damage by prolonging the time between diagnosis and weight restoration.

What vexes me something chronic, is that there is little evidence to show that psychotherapy is successful for eating disorder recovery. Yet, it was grandfathered in yonks ago and like a turd that won’t flush, we can’t seem to get rid of it.

Never mind the fact that now we know better. Never mind the evidence-based treatments have proven themselves to actually work. Never mind the patients who are screaming out that analyzing their past is not helping them put food in their mouth. Never mind that parent’s of patients are showing the industry that they are the biggest most effective resources when treating a child with Anorexia and far from the cause of the illness. Never mind all that. Psychoanalysis was there first, so we’ll all just have to put up with it.

No.

There are not many things that I am so utterly opposed to as the notion that psychoanalysis has a place in eating disorder treatment. Much of my resistance probably comes from working with adults with long-term eating disorders as I do. I have worked with a number of people in their 30s, 40s and 50s who were diagnosed with Anorexia in their early teens. They were treated with psychotherapy at that time, and thirty years later they are sicker than ever. They were stuck in an office with some nosey shrink asking them about their relationships with their parents. Their parents were excluded from the process and even blamed for the illness. Had they been treated with nutritional rehabilitation aka FOOD and given effective support for overcoming restrictive thoughts and behaviors I believe that they would have made it to full remission half a lifetime ago. This makes my blood boil. It makes me so angry I can barely type.

Psychoanalysis makes me so livid I am going to stop writing about it.

 

The therapeutic alliance

I have been told a number of times by people who have tried various types of therapy that the therapist is the most important part, rather than the type of therapy that therapist practices. So having a therapist who “gets” you, and makes you feel understood is the most important thing. I agree on some levels that it is the individual therapist that makes the difference.

I don’t know how I feel about this really. I mean, of course everyone likes the feeling of being understood, but I think that has to be coupled with that person influencing you to change the behaviors that you are seeking to change. Otherwise it is a nice experience, yet still an ineffective experience. Warm and fuzzy is all very well, but is it helping you put on weight?

For example, if someone has been working with a therapist for 3 years, and not made any significant progress in weight restoration, I would argue that regardless of how much the client and therapist get along, it is not an effective eating disorder recovery relationship.

On the flip side, someone can be being put through a strong and compassionate FBT-type recovery and hating every moment of it but gaining weight. I would argue that this is far more effective, will take much less time to get the person weight restored, and will therefore reduce the severity of the effects of malnutrition etc. This would be my preference. It might not be popular with the client at the time, but most of us look back on the influences that forced us into weight restoration with gratitude when we are in full remission. When we are in full remission. If full remission is not reached, it doesn’t work out so well.

With adults, they have to get along with their therapist or they simply will not go. However, sometimes I think that this can get in the way a little. An example of what I mean here would be the person who has not made any weight restoration progress, but likes her therapist and therefore sticks with her and doesn’t make the changes that are needed.

Additionally if a therapist can help a person want to recover and want to have a life without Anorexia, then that ultimately will lead to them being more successful and determined and able to cope the the anxiety of eating. Anorexia recovery is hard. The more motivation to get to full remission we can gather the better in my book! Whatever works for you to do that … run with it!

If it works: keep it — if it doesn’t work: trash it

You are an individual, and what works for one person may not work for you. To that point, some aspects of therapy may work for you, and others not so. You can pick and choose. You can pick and mix also. There is no straight path to recovery; it is a ton of learning, tweaking, trying. If you are picking and choosing, your intention has to be solid, and by that I mean you have to understand that if your resistance to someone or something is because you are scared that they will get you to gain weight, then you may have to dig deep into the healthy brain in order to keep yourself there. Tap into that motivation and grit your teeth.
If something is helping; use it. Anorexia recovery is a long and exhausting process and you should take all the help that you can get.
If something is not helping; stop it. Anorexia is a long and exhausting process and you cannot waste time or energy on things that are not working.

I have known people who have been in therapy for Anorexia for years and not progressed, but been told that they are being resistant to treatment if the express that said therapy is not helping them. I strongly disagree. An individual approach has to be taken in order to find what is right for the person. An agile approach has to be taken in order to make changes needed so time is not wasted for that person. We have to be responsive and learn from experiences so we can sift out what works for us to get us where we want to be.

This also means treating the individual even if doing so means you have to drop your own preconceptions or beliefs. To this end, I vow that if someone comes to me and tells me that psychotherapy helped them weight restore and reach full remission I will accept that worked for them. (gulp)

This goes for evidence-based practices too. For example, for some families it is impossible for them to succeed with FBT due to the dangerous level of resistance and/or other psychological problems and therefore additional help has to be given. We have to be able to think outside the box more and get realistic not idealistic. 

There is no right or wrong answer here. But it should not be assumed that seeing a therapist is essential to recovery. The only essential ingredients are food and determination, but that is not to say that additional ingredients won’t make the process more palatable.

 


Note: After reading all the replies I have had to this question: My god I am glad I have never been in therapy. But then I am so cynical and gobby that probably the therapists are better off without me. I would be a disastrous patient!


 

CBT-E… at least 30 sessions. Whilst it did not get me to a place of recovery a couple of years ago, I learnt loads in the way of CBT techniques which I find I use every day – very helpful for life in general – esp with anxiety / challenging negative thoughts etc. (which in turn have an impact on eating). But now I am focusing again on ED recovery I can translate those skills back to challenging ED thoughts and behaviour.
As well as this CBT-E provides a framework for understanding ED behaviour and how this can perpetuate.

 

I was given some sort of dream  regression thing………..bear in mind this was  1983…..;-)……CBT  yes   gained    insight  from that…..  a chiropractitioner  said she   could help unblock   my channels  by    sorting my spine out………  no effect……….. having a  dietician  who was in control and    helped with the weight gain feeling when i was  an IP, she  was FAB…..art therapy…. useless…… transactional analysis ,ho hum…….   traditional psychiatrist, good  but not practical. my GP being  direct  and   giving me  facts  and  figures  worked a treat when my  bloods went  cock a  hoot.

 

honestly the best therapy was the therapist. Obviously some therapies give us better tools than others, but the therapeutic alliance for me was key. Does this person understand me, believe in me, and see in me what I can’t? In studies, despite the therapy, the therapeutic alliance is shown to be the largest factor in determining the success of therapy. As for specific types of therapy, absolutely without a doubt, meditation and mindfulness. Mindful-Based Stress Reduction.

 

I’ve had CAT and my therapist refuses to talk about food or how to move forward even though I’m really motivated but need some support. So CAT is a nice chat but not what I have needed whilst underweight, perhaps later on when weight is stable. Although that is my personal opinion

 

A behavioral approach of rewards and consequences/ level systems where you earn privileges based on meeting weight goals was effective short term but not in the long run because it becomes a game to the ED and you do what you have to do to get out only to slip back to old patterns. I found a CBT approach of reframing helpful but ultimately it came down to maintaining a more healthy weight for a long period of time that was most effective. I never “talked” my way out of anorexia

 

I find DBT and the core concept Linehan underlines in her ‘life worth living’ as a recovery goal for treatment refractory versions of the illness to be a helpful tool!

 

Outside of DBT, two other things were hugely helpful: long-term meal support, and group therapy for women in recovery focused on building life skills, like money management, romantic relationships, dealing with clothes, etc.

ACT and motivational interviewing, group therapy, IFS individual therapy, meal support, DBT, relapse prevention

Just general therapy with someone who helped me build my self love muscle through parts work, CBT, radical loving acceptance on her part.

 

I have found ACT (acceptance and commitment therapy) the most helpful. Art and music therapy have also been very powerful in learning to express my emotions and feelings. I have taken hours and hours of dbt and haven’t found it very useful in my recovery.


Let’s start with what hasn’t helped me (nor do I see it listed often here…) but seems to remain standard of care:

1. CBT
2. “Tough Love”

Though dry and boring, the elements of DBT skills I’ve been exposed to have helped cope with crises… I haven’t done a DBT Intensive, just “psychoeducational” groups and skills classes in treatment centers.

Sensory-based interventions (occupational therapy, expressive arts therapies, & movement) have helped me stay engaged in treatment.

Mind-body (yoga, meditation, massage); coaching; & meal support were what helped me gain outside of 24/7 forced protocols. After yoga, I crave nourishment. After massage, I would notice an inclination to self-nurture.

NEW FED TR has given me steady hope through the last 2 years of this exhausting marathon: understanding why my brain is off, distraction -AND- reaction skills, experiential / metaphorical versus just didactic education, meal support, movement, and PLANNING AHEAD!

So far, I haven’t maintained any gains other than the ability to stand back up and to “never give in” … Steady hope has come from NEW FED TR. I wish The Center’s PHP reflected the same approach!

Anything with MORE DOING and less thinking, unless it’s thinking through limited options for decisions to ACT upon and planning ahead.


I’ve been to every level of care except residential, and PHP has been great because I’m surrounded by other fighters who embrace and support me, a dietician who is helping ME create a meal plan that fits my needs while matching with my personality so I have the best chance for success and therapists who teach us relevant information that has helped me so much. This morning was horrible for me, but when I applied what I’ve learned and allowed my team and group mates to support me I was able to finish all my meals and end the day with lots of laughs and smiles. At the end of the day I get to go home and practice what I’ve learned in “real life” rather than being stuck in a hospital. Having the right support group and treatment team on a regular basis is making a huge difference for me and I can finally feel the potential for recovery:

 

I’m finding my most recent outpatient therapist most helpful. Mostly talk therapy, cbt, some skills based, focus on my values and living a healthy young adult life. Talking about my stressors, OCD triggers etc. I think there’s a time and space for talking about your values and having support to do that. To be afraid and still choose what’s best for your recovery with loving, tough support is crucial. My current therapist now is saving my life. Providing hope and support during the times that seem so hard. But I will admit that it is only effective when I am nourished and following my meal plan. I also believe you reach a point where you finally start fighting for yourself and not doing this just so you don’t upset the people that you love. I’ve tried doing it that way and it never lasted. That’s been huge for me. Recognizing that I want my life to look different for others but also for myself. Anorexia makes life so small, when you recognize that I think true growth can happen in therapy.

CBT didn’t help me at all, DBT was only helpful in he short term. EMDR was EXTREMELY helpful for me- definitely most affective for me.

I do want to add that I don’t think any of the therapy I have done directly assisted in helping with weight restoration or improve restricting habits. In my experience that was only improved by sitting at the table and just doing it (eating). Therapy has helped some by addressing other components, like anxiety and dealing with emotions.

 

I think what my best, most effective therapist did was find a way to utilize my strengths to help me move towards recovery. So much of what my first therapy experiences focused on were what I was doing wrong- eating too little, exercising too much, studying/working too much, being too much of a perfectionist. Which isn’t to say you should ignore those, but it’s easy to lose sight of what characteristics can also help you recover. For instance, I really like routine. So I started pre-planning meals and snacks the night before. I still do it, because it works. I’ve Incorporated more flexibility, but the same principle applies. This also helped with general self-acceptance.

 

I have been lucky enough to experience some really wonderful talk therapist, but they did not help me put on weight. I think talk therapy is really useful just to have the support and feeling less alone, but not when they try to dig through your whole life story. I just want someone to be there for me. I’m still looking for someone that meets my needs at this point, as I believe I need a combo of meal support and talk therapy. I wish there were more groups, as in person peer support can be great, but also triggering. I think my dog therapists give me enormous comfort and support. I like art therapy sometimes. Yoga/movement therapy helps IP. In residential the most effective group therapy sessions were ones where I was just surrounded by people feeling like shit, and the group therapist just letting us play games/play with chalk, f-around, and be around supportive people while trying to not feel like dying after a meal

Relaxation therapy . Fun but useless. Talking through non existent trauma the therapist insisted I had. Worse than useless and caused ME trauma. Some kind of talk psychotherapy that seemed more like coaching and trying to figure out why I kept up ED behaviors. Mostly useless. Only ONE therapist who was really a relationship counselor ever had a tiny hit of insight into ED when she advised, once, That i should try to eat breakfast. A snack. Lunch and a snack when I got home to avoid binging. Useful. It’s cringeworthy really. Oh a first doctor who told me how to diet! The 90s were fun.

I’m finding my most recent outpatient therapist most helpful. Mostly talk therapy, cbt, some skills based, focus on my values and living a healthy young adult life. Talking about my stressors, OCD triggers etc. I think there’s a time and space for talking about your values and having support to do that. To be afraid and still choose what’s best for your recovery with loving, tough support is crucial. My current therapist now is saving my life. Providing hope and support during the times that seem so hard. But I will admit that it is only effective when I am nourished and following my meal plan. I also believe you reach a point where you finally start fighting for yourself and not doing this just so you don’t upset the people that you love. I’ve tried doing it that way and it never lasted. That’s been huge for me. Recognizing that I want my life to look different for others but also for myself. Anorexia makes life so small, when you recognize that I think true growth can happen in therapy.

 

I have had a variety of outpatient treatments: Clinical Psychologist – useless, made me feel worse (due to scraping the barrel for the ‘root cause’ of my AN, when really it is – as we have all been discussing earlier – biological); Clinical Psychiatrist (my consultant at the OP unit) – useful when giving me straight facts about how my physical health was in serious danger; not useful in terms of her lack of ‘bedside manner’, which constantly reminds me that she treats me as an anonymous number and follows a text book treatment plan (involving the useless psychotherapy) at all times; Dietician – utterly useless, gave me an unachieveable diet plan and then seemed to give up on my and  told me to go and eat bananas. The most important thing I want to say about my treatment, if it is relevant for your article, is how terrible the unit (an NHS specialist eating disorder unit) was when I first got referred: I went my initial appointment with the consultant, with a very low BMI, and was told that she would be able to start regular appointments with me from that day forward, however, there was a 3-month-ish waiting list for appointments with the psychotherapist. During this time – on repeated appointments with the consultant – she told me to ‘REMAIN THE SAME’ in terms of my eating/exercise behaviours, as without psychotherist intervention I ‘SHOULD NOT ATTEMPT TO CHANGE MY BEHAVIOUR, EVEN FOR THE BETTER’. And, what, obviously, did AN do? It latched onto this opportunity to make me get worse and worse, convincing me I need to remain  ill enough to warrant treatment. Of course, I ended up losing lots more weight, getting more poorly than ever, on the brink of enforced IP (which I managed to avoid by the skin of my teeth, somehow, despite almost being sectioned). During this agonising 3-month wait, the consultant repeatedly told me not to try and change my behaviours, even though I was deteriorating rapidly in front of her.

 

I would have to agree with a lot of what has already been said. I have a wonderful psychotherapist now. We do a lot of inner work and cultivating self compassion/love, and opening awareness. I find it helpful and deeper than just the DBT skills that I have done in programs. I also see a therapist and we mostly just do what I would describe as talk therapy as there is no “DBT” “CBT” or other labelled techniques used. I find these helpful now as I am learning more about myself and why I cling so tightly to my ED. However, this did not help in weight restoration part, I have been involved in therapy all along but much too ill to change my behaviours. I had to be hospitalized and go to ED programs (where they did DBT which I can’t tell if it was helpful bc it worked in the early stages or if it was just the fact I was in a program where I had to eat? Hard to tell…) anyway, either way I had to get nutrition and restore weight in a structured setting before any therapy would even mildly help! Nothing was working at all until I was forced (for lack of a better word) to get nutrition into my body. For me, it had to be in a hospital setting. Now, AEDRA is working wonders! I am afraid I would have relapsed by now had it not been for my coach supporting me through meal times and talking me through the process of transitioning to eating at home on my own! I find meal support to be the most helpful (esp when it is not my family) to keep me on track.

 

We had “therapy” for our daughter, who is now in solid recovery. Most of it was useless…especially when delivered by people who had no training in EDs? I mean WTF? They all wanted to focus on her trauma and her messed up child hood which she would now laugh at!Most wanted us parents WAY out of the picture. Right? In the end she will say it was us parents who delivered the final blow to ED.

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About Tabitha Farrar

I work as Head of Marketing for a software startup in Boulder. As a recovered Anorexia sufferer, I advocate for proper understanding of eating disorders in my spare time. On that note, I wrote a book about my own journey into eating again called Love Fat.

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