How Does Eating Disorder Therapy Work?

August 07, 2023

When someone is struggling with their mental health, the first recommendation they often get is to see a therapist—and often, that’s just what they need. But with eating disorders, the role of therapy is more complex. Eating disorder therapy is an integral part of treatment, but it’s not the only part, and it often looks different than people might expect. Here’s a look at the unique role eating disorder therapy plays in treatment.

Understanding the role of eating disorder therapy in treatment

People are often surprised to learn that therapy isn’t usually the initial, primary focus in eating disorder treatment. That’s not to say that those who are struggling can’t get started with therapy right away; but in order for treatment to be effective, they’ll likely need to work with other providers and focus on other areas in the beginning.

There are a few reasons for this. For one, eating disorders emerge out of a constellation of neurological, genetic, and environmental factors, and so conventional talk therapy isn’t likely to move the needle toward recovery, at least at first. Usually, it makes more sense to begin with behavioral interventions that can help those struggling address some of the physiological and habitual aspects of the eating disorder. This, in turn, paves the way for eating disorder therapy to be more productive.

Then there’s the reality that therapy just won’t work well on a malnourished brain. Regardless of whether or not a patient is underweight, if their eating behaviors are disordered, their brain is likely malnourished. A malnourished brain doesn’t think clearly or take in new information well, and those who are malnourished are more likely to be anxious and have trouble paying attention. This means it’s extremely difficult to make any real progress in eating disorder therapy until eating habits are normalized.

Equip therapist Lainy Clark points to another hurdle that comes up in eating disorder therapy: anosognosia. “You might expect that in eating disorder treatment, someone who’s suffering will meet with a therapist on their own for an hour or so every week and after some time emerge all better,” she says. “But history has shown that this is an ineffective—and at times, nearly impossible—way for folks to recover. That’s because of anosognosia, or a person’s lack of insight into their need for help. They don’t believe they’re sick. This ambivalence can make it difficult to engage in on-on-one therapy and even more difficult to implement changes.”

None of this is to say that therapy doesn’t have a role in treatment—in fact, eating disorder therapy is crucial, it just doesn’t take center stage during the first steps of recovery. At Equip, adult patients will begin seeing a therapist right away, whereas young patients who are doing family-based treatment (FBT), will usually only start seeing an individual therapist after they’ve made behavioral progress. In either scenario, the first focus is always to normalize eating habits, restore weight (if needed), and stop eating disorder behaviors.

After those aspects have been addressed, the focus can shift to individual eating disorder therapy. In eating disorder therapy, providers work with patients to continue to improve their symptoms, help them build skills, explore the emotional and psychological aspects of the eating disorder, and address any co-occurring conditions. Says Clark, “one-on-one therapy does become a bigger part of treatment when patients are weight restored and the anosognosia is no longer wreaking havoc.”

What are the goals of eating disorder therapy?

The end goal of eating disorder therapy is, of course, to help patients achieve recovery. The way therapy accomplishes this goal will shift based on a patient’s individual needs and where they are in their treatment process. At first, eating disorder therapy is often focused on addressing a patient’s struggles with food and sticking to their meal plan. Once eating has become less of a struggle, the scope and goals can both widen.

Equip Research Intern Bek Urban explains that initially, her eating disorder therapy sessions centered around how she was doing with eating disorder behaviors, but over time, the range of what she discussed with her therapist expanded greatly. “I was surprised at first, because I expected to sit and talk about food and exercise the whole time I was in therapy. Instead, my therapist worked with my dietitian to make sure those things were taken care of, which let us focus on other things in therapy: things like processing trauma, body image, fear of change, and practical day-to-day stuff about how life would be different in recovery.”

Some of the potential goals of eating disorder therapy include:

  • Developing skills to manage mealtime distress. There are a wide range of different techniques that people struggling can call on to make eating easier. This might include mindfulness practices, distraction, or writing down negative thoughts, among others.
  • Becoming more in tune with emotions, mood, and how they impact eating. Often, our emotions impact us in ways we don’t even realize. By tuning into the relationship between eating and mental state (for instance, noticing that anxiety sparks an urge to restrict), patients can make more mindful choices in the moment.
  • Learning coping strategies to replace eating disorder behaviors. Eating disorder behaviors are often coping mechanisms gone awry. Eating disorder therapy can help patients build healthier coping mechanisms that help eliminate the need for the eating disorder.
  • Spotting unhealthy habits and working to replace them with healthier ones. Therapists can help patients see patterns that are perpetuating the eating disorder or causing distress—like scrolling fitness accounts on social media, or fixating on what other people are eating—and brainstorm healthier alternatives.
  • Improving relationships. Loved ones can’t cause an eating disorder, but tough interpersonal dynamics can be a barrier to recovery. Eating disorder therapy can help patients and their loved ones better understand each other and find healthier ways to communicate. This not only makes life more pleasant for everyone, but also protects against relapse by helping the patient build a strong network of support.
  • Exploring underlying causes. While eating disorders never have just one cause, therapists can work with patients to identify some of the psychological roots of their disorder, like low self-esteem, trauma, or anxiety, for example. They’ll then use evidence-based modalities to help patients address these issues.
  • Treating co-occurring conditions. Eating disorders often come with one or more co-occurring conditions, like depression or anxiety. Therapists can work with patients to tackle these conditions alongside the eating disorder.
  • Discovering life beyond the eating disorder. Therapists can help patients set goals beyond those involving weight or eating behaviors. They work with patients to explore their hopes and dreams outside of the eating disorder—moving abroad, starting a company, writing a book—and help them envision a path to get there. “Therapy provided me a place to practice being me for the first time, and opened doors to a reality I couldn’t imagine before,” says Urban. “So much of my life before therapy was focused on coping through my eating disorder and not being who I am. Therapy allowed me to explore what I wanted to do with the huge part of me that was opening up as the eating disorder shrank.”

How eating disorder therapists work with the rest of the treatment team

Because eating disorders affect many aspects of a person’s life—physical, nutritional, social, emotional, psychological—effective treatment requires a multidisciplinary care team to address each area. For most people seeking treatment, this means pursuing eating disorder therapy while also seeing a dietitian and having periodic check-ins with a medical provider.

The coordination between providers depends on the type of treatment a patient is getting. In an ideal world, all of these providers would be regularly checking in with one another to ensure everyone is on the same page about goals, concerns, and the patient’s progress—but unfortunately, in traditional treatment there often aren’t open lines of communication between providers. At Equip, every patient is matched with a dedicated team that includes a therapist, dietitian, medical provider, and mentors who have made it to the other side of recovery. Because all of our providers are Equip employees, they are one cohesive team, allowing care to be both coordinated and collaborative.

“The value and support of the multidisciplinary care team is immeasurable. It’s a major benefit for therapists,” says Clark. “Eating disorder therapy in many other settings can feel isolating, and therapists often shoulder the burden of a person’s mental well-being and progress, or lack thereof.” She says that being able to work closely with other providers helps therapists feel more supported and leads to better care for the patient.

What modalities are used in eating disorder therapy?

There are several different effective therapeutic approaches in eating disorder therapy. The specific approach (or approaches) a therapist chooses to use will depend on the patient’s diagnosis, symptoms, age, personality, family dynamics, and more. At Equip, our therapists use a variety of different evidence-based approaches, tailoring treatment to each patient’s unique needs.

The modalities we most commonly use are:

  • Cognitive behavioral therapy for eating disorders (CBT-E): CBT-E is the leading treatment for eating disorders in adult populations. Using a detailed view of their daily habits, thoughts, and emotions, therapists work with patients to identify behavioral triggers and find more adaptive ways of coping with them. CBT-E differs from regular CBT in that it addresses certain eating disorder-specific challenges, like food and body image.
  • Dialectical behavioral therapy (DBT): “Dialectical” refers to accepting that two opposing realities can exist at once, and DBT focuses on helping people manage this through both acceptance and change. With eating disorder therapy, this means learning skills and strategies to manage big emotions that can trigger eating disorder symptoms. While there’s still research to be done on the effectiveness of DBT for eating disorders, initial studies are promising.
  • Exposure and response prevention (ERP): Originally developed to treat OCD, ERP focuses on helping patients overcome fears and triggers through exposure. For eating disorder patients, that might mean fears around certain foods or food-related situations, social events, exercise, or any other situation that evokes a strong anxiety response. Research is still emerging on using ERP for eating disorders, but evidence suggests it can be effective.
  • Temperament-based therapy with supports (TBT-S): TBT-S acknowledges and treats the brain- and personality-based factors that might contribute to an eating disorder, helping patients identify the temperament traits behind their behaviors and find healthier, more productive ways to channel them. For example, a therapist might work with a patient to redirect their perfectionism toward a creative project or career goals rather than their eating disorder. Initial research has shown TBT-S to be an effective treatment approach.

Often, family therapy is also an important part of eating disorder treatment, especially for younger patients. This is particularly true in family-based treatment (FBT), where family members are at the center of treatment, but it can be equally helpful for all eating disorder patients. Bringing family members—or chosen family, friends, or other important people in the patient’s life—into treatment helps patients address challenging relationships and bolster their support network. This is incredibly important not just during treatment but afterward, when a patient’s friends and family will be the first line of defense against relapse.

Eating disorder therapy isn’t one-size-fits-all. A good therapist will work with the patient and the rest of their treatment team to find an approach that works, and change or add modalities based on the patient’s progress and their needs.

How to get started with eating disorder therapy

If you or your loved one is struggling with an eating disorder, it’s important to get help, whether that means getting an assessment from your doctor or reaching out to an eating disorder treatment provider. If you decide to seek treatment through an eating disorder program, like Equip, you’ll automatically be connected with a therapist who specializes in eating disorders. At Equip, all of our therapists have extensive experience treating all eating disorder diagnoses and co-occurring conditions, and we take care to match each patient with the therapist who we think will be the best fit.

If you’re seeking eating disorder therapy on your own, there are few questions you should ask as you choose a provider:

  • What is their training? Most graduate programs for therapists don’t include extensive eating disorder education, so it’s important to find someone who has received additional training.
  • Do they understand the importance of coordinated care? Even patients who aren’t enrolled in an eating disorder treatment program need to be supported by a whole team, not just a therapist. It’s important to find a therapist who not only understands the role of the dietitian and medical provider, but also knows how important it is that they communicate regularly with them.
  • Do they treat co-occurring conditions? Effective eating disorder therapy often requires that therapists address co-occurring conditions like anxiety or depression, so it’s vital to find a provider who is comfortable treating multiple diagnoses at once.
  • How do they make you or your loved one feel? “Be patient, be picky, and advocate for your needs,” Urban advises. “Therapists are humans like everyone else, and you won’t always get along with every therapist you meet. It’s not uncommon to just not mesh well with a therapist, even if they’re a perfect fit for someone else. And that’s okay!”

Lasting recovery is possible for everyone struggling with an eating disorder, but it’s hard work. Eating disorder therapy is an essential part of that work—not only for helping to stop destructive behaviors and silence the eating disorder voice, but also to help open the doors to a brighter, bigger, and bolder future. “I wouldn’t live the life I have now without the support of the therapists I had before, during, and after treatment,” says Urban. “Therapy was a space that would welcome all of my fears and all of my joys as I learned to live without my eating disorder.”

This article originally appeared on the Equip blog.