….My own version of a “Top 10 List” of what I wish all therapists knew……

1. Patients who develop eating disorders did not choose to be sick. Also, it is very rare for them to be able to choose to get better. Some patients who are older and have some maturity may indeed be truly on board with recovery. However, most of them, including the adolescents, have no interest in giving up their ED. Treatment should be focused on using external motivation if needed (consequences and reinforcers) vs. waiting for any signs of internal motivation to change.
2. Patients who are sick with eating disorders have a brain imbalance from starvation or from severe symptom use such as bingeing and purging. This initial brain imbalance does not recover from talk therapy. This brain imbalance, however, responds to structure and re-feeding. Talk therapy comes into play once the brain is re-fed and in balance.
3. Patients who are sick with eating disorders know very well how to “talk the talk” and to please the therapist by saying what they want to hear. Do not be fooled by this “pseudo-recovery” stance into thinking there is not a raging eating disorder hidden underneath this rational exterior.
4. Patients with eating disorders are very invested in being the “good girl” but often struggle with intense rage and critical judgments of self and others. They often project these judgments onto the external world and think that others are as critical of them as they are of themselves. This personality trait often pre-dates the ED and needs to be addressed in their therapy.
5. Many therapists who enter the field of treating eating disorders do so for a reason. Some may have a history of an ED but many come with a heightened sensitivity to cultural issues that judge the female body. Many therapists have a history of dieting, being sensitive to food issues, and in general disliking their own bodies. It is a trap to think that what we as therapists may experience (“I feel fat too”,  or “I also should eat healthier”) is anywhere near the realm of what our eating disorder patients experience who are under the influence of the disease (“You are a big fat pig and you must now run on the treadmill until you drop”). We may have internalized the toxic culture but our patients are sick and are under the influence of an illness. This is a very important distinction.
6. For patients with eating disorders, it is very tempting to focus initial therapy time on figuring out the “whys” of the ED. The origins, the underlying issues, the dynamics. This is what we have been trained to do. However, the initial treatment should involve two things and two things only – 1- the re-feeding of the patient and the re-structuring of their eating behaviors and 2-effectively handling the patient’s resistance to these changes. Insight, past trauma, and psychodynamics should all be put on the back burner until the patient’s brain and body are healed from these illnesses.
7. Our views of the parents of these patients needs to completely change. Instead of seeing the parents as “the cause of the illness” we need to see them as the patient’s best shot for recovery. The parents are the “catalysts for change” that can propel the patient into recovery through structure, support, and re-feeding. Parents need to be empowered to take on this role and we need to increase our sensitivity to their own experience during their child’s illness.
8. Most of the behavioral/cognitive/ and emotional symptoms that we equate with the anorexic patient can be attributed to their physiological state of starvation. Once this state is relieved via proper nutrition, these symptoms disappear. The patients need to get to their full body weight to get this symptomatic relief. Being “10 pounds away from their goal” is unfairly placing them in an eternal limbo where they can never truly recover.
9. Fathers have a very important role in their child’s treatment. Oftentimes when a family first presents for treatment of an ED, the father is “out of the loop” of their child’s struggle.  Effective treatment requires us to empower these fathers via education and support of their own unique experience. These children need their fathers actively involved in their treatment.
10. It is a myth that eating disorder patients don’t get better. It is a myth that they will always be “a little sick”. It is a myth that treatment should take 5-7 years. These patients can fully recovery in much less time than one would think. It is our job to hold to this belief and to bring our patients to this place of truly living their lives in freedom and joy.