I’ve noticed a recent trend in the clients that I’ve been working with. Many of them have had serious, clinical eating disorders in the past, which they previously received treatment for. Although they recovered in a medical sense (no longer displaying the clinical symptoms of an eating disorder according to the DSM), they end up in therapy years later for behaviours and thoughts that feel eerily familiar and harmful.
By digging around in what has unfolded in the years between treatments with these clients, a couple of themes have emerged:
For some, there doesn't seem to have been enough time in treatment for emotional, spiritual, and existential healing to occur and so bigger fears, feelings, and questions underpinning the original eating disorder (ED) remain. This could happen for various reasons: maybe the client left treatment because it didn't align with their values, because they couldn't financially continue, or because they weren't quite ready to 'go there'. Sometimes the reason is more systemic and due to limited public health funds. Regardless, when these factors aren't adequately addressed it leaves room for previous ways of coping through food to slowly re-emerge.
For others, the previous treatment had not focused enough on building adequate skills, coping strategies, and knowledge to return to a world saturated with unwell messages about food and bodies. As a result, the client may have left previous treatment only to fall back in to a diet-mentality, leaving them at risk for body dissatisfaction, dieting, and future relapse.
Now, in defence of any previous treatment my clients may have received, the non-diet and Health at Every Size (HAES) approaches have only recently emerged in a more mainstream way and there’s still so much work to be done to truly integrate it in to foundational approaches to ED treatment. HAES is basically the flip side to the fear-mongering and fat-phobic discourse that accompanies diet-culture - but please don't think that it's advocating for obesity. Rather, it draws from evidence-based research to advocate for respect, compassion, and equality for people of all shapes and sizes. It highlights the inequalities and privilege that is embedded in the idea that we need to look a certain way (be a certain weight) in order to be 'healthy', and it encourages people to engage in true body positivity - which has no 'but's' or exceptions. The current cultural discourse shames and blames people for being fat and obese, and research has shown that this type of weight-stigma has significant negative health consequences - which are akin to those reported as being obesity-related. If you want to learn more about HAES, the research underpinning it, and some FAQs click here.
Secondly, conceptualising ED recovery in a standardized way is nearly impossible as it looks a feels different for each individual – and yet, many treatment models need to conceptualise recovery in a particular way in order to receive funding and monitor progress, which again is totally understandable. So I’m not saying that previous treatment was wrong or bad, but rather I want to highlight that there have been treatment advances and paradigm shifts that need to be integrated and made more widely accessible for individuals seeking holistic support.
All of this being said, as I explain to my clients, my job is not only to support them to recover from their disordered eating, but also to be sure that they are well equipped to return to living in a diet-culture. Before we complete therapy, I make sure that they have tools to challenge unrealistic ideals, to push back against the pressure to change their bodies, and to maintain nurturing and compassionate relationships with themselves, food, and their bodies going forward in life. So, in clinical terms, I believe that incorporating a non-diet approach to ED treatment contributes to relapse prevention. I would even go as far as saying that it's necessary for a full recovery in our current socio-cultural landscape.
With this being said, my goal isn't to push my values and beliefs to my clients. Whilst it goes without saying that I don’t endorse weight loss in my practice, for moral and ethical reasons, my hope is that my clients who complete therapy with an intact desire to lose weight can, at the very least, question this desire and understand what drives it prior to choosing whether to act on it and how. I respect their decisions either way, because the last thing I want to do is pressure anybody in to a way of living that doesn’t make sense for them... but at the end of the day, an educated choice is always more empowering than automatic or fear based action. And I believe that having an understanding of diet-culture, the diet-mentality, and a HAES approach to wellness can equip them to do just that x