The Differences between ED and Addiction Treatment Philosophies. And the Pitfalls of comparing them.

I am often asked if eating disorders are addictions. I have learnt to wonder about what the question means to the person who is asking, before trying to answer it.

One of the pitfalls of comparing eating disorders to addictions ( i.e. substance abuse and dependency) is that treatment modalities, terminologies and philosophies are transferred over from the established addiction treatment world. In this article , I am going to outline some major differences between the two and identify unhelpful misunderstandings that exist in the treatment of both addictions and EDs.

Addiction treatment primarily focuses on separating the person from the substance. The 12-step model simplifies our understanding of an addiction to “a disease”. I am not sure how this term is understood by the lay person. I certainly see an addiction as a “dis-ease” with life, a lack of ease with being present to everything that adult life presents us with. The 12 steps ask for agreement that one is out of control, that one has to rely on a “higher power” and one will forever have to be vigilant about the addiction returning. The word ‘‘addiction’ is used quite loosely. An addiction to marijuana is different in quality from an addiction to fentanyl. The word is also used in relation to children and video games.

There is something condescending in the philosophy. It is true that people in the grip of an addiction feel powerless and seem to have a complete lack of agency. People do believe that they have no capacity to overcome the temptation of the moment. Familes feel powerless. And addictions destroy lives. This is true. I think the mistake is in seeing the person as eternally powerless. However, one would imagine that the intention of treatement would be to generate or restore a sense of agency. In the end nobody can sit with an adult all day and ensure that they will not reach for that substance. The adult has to be able to find that resource within themselves. Placing that resource outside of oneself leaves the person constantly reaching and white-knuckling and losing hope that they can think of themselves as anything but an addict.

There are stages of treatment and recovery. That one is not in control and one is powerless in the face of the substance is a “good starting point”. It is helpful for people to acknowledge ( not surrender) that they are not in the driver’s seat. It is an important ACKNOWLEDGEMENT. But we do not stop there.

The Problem - The client already believes that they have destroyed their family’s happiness , that they are deeply flawed and often , that everybody is better off without them. Along with an addiction comes deep shame and self-loathing. Which leads to isolation and more investment in the substance / behaviour. It is a self-sustaining cycle. Being told that one has a “disease” that requires no further explanation provides temporary relief while it is, in reality, condescending to an adult’s capacity. This lack of explanation colludes with the short-sightedness of the illness, does not invite the client to a higher level of reflection and keeps the client in a victim place. Why would a person expect any more of themselves once they are told they have a disease they cannot recover from? An adult is capable of acknowledging that they have fallen into a behaviour, that the “fall” has a pathway in (i.e. reasons ) and therefore hopefully, a pathway out. And the person, often frozen in their growth, has now to find their way to their adult self that is capable of agency and self-care. RECOVERY IS A POSSIBILITY AND AN OPTION. The pull of the old behaviour is always present in the intial parts of treatment and the client tests the edges of the therapist’s belief. Like a teenager who tests boundaries to know if his parent can be trusted. And ultimately to learn to trust themselves.

The creators of the 12 step model brought in the idea of “surrender” to shift the person’s surrender from a harmful substance to a benevolent God. It is not a bad idea on paper, as ideas go. But it is a terrible idea after a while. The person is in a constant state of surrender that does not engender agency and bodes poorly for finding their way in the world. It keeps a full-grown adult in a child place, constantly attending AA groups with a locus of control outside themselves. Recovery or abstinence is not the end goal in this model. It is abstinence. Abstinence does not necessarily lead to the development of “agency” on its own. Abstinence is simply just abstinence.

So - What about ED recovery?

I have heard people use the word “remission” to talk about ED recovery. The idea that one will “always have an ED” is a cross-over from this old AA philosophy. It treats the ED as a mysterious illness that the person has and does not really invite any elevated explanation. It is somewhat ludicrous that we rush to fix with little understanding of the cause. Because the person and the family have come to live in the immediacy of the illness, the question of “What should we DO to fix the behaviour?” is very pressing. Addiction treatment falls short in this aspect. The “solution” seems obvious. Keep the person away from the substance. Abstinence. There is not much attention paid to where the person is at, in other parts of their life and evolving a deeper understanding of what might cause a person to relapse. The ED therapist has to be vigilant to not cave to the family’s urgency and resort to quick-fix “strategies”. The same initial “triggers” of the behaviour will continue to be the triggers for relapse, if unattended to.

Addiction treatment has the luxury of considering abstinence as an option. The person white-knuckles through their abstinence from one AA meeting to another. Intention of sobriety is kept alive with “tokens” like golden stars on a reward chart in Elementary school. And when a ‘slip’ happens the person struggles with shame because they don’t “deserve” the token anymore. The lack of attention to the person’s self - agency is costly. Little attention is also paid to the profound shame that people struggle with. Since the person has surrendered to the higher power, the higher power has to “deliver” some safety from the unpleasantness of life to continue to be meaningful. But LIFE is not polite. And in this precarious balance , if the Higher Power does not protect in a moment of need, relapse is imminent. All of this is alright if AA meetings are understood to be a support group for an occasional gentle reminder of one’s intentions. AA meetings cannot substitute for treatment and sponsors cannot substitute for trained therapists.

ED treatment does not have the luxury of considering abstinence an option. Sometimes people talk about abstaining from compensating behaviours like vomiting after a meal ot abstaining from binging on certain foods. But this methodology is very naive about the complexity of ED behaviours. A person can abstain from vomiting by exercising more or simply restricting their intake. ED behaviours shape-shift to accommodate a person’s anxieties and people can lull themselves into an illusion of “recovery” because they are not doing one behaviour while ignoring that they have replaced it with others. Being told that you will have an ED forever is a poor start for treatment. Imagine the difference it can make when somebody is told unequivocally that they can recover? Imagine the effort a person will be willing to put in when they can hope that things will change and that they hold within themselves the capacity to make such other changes, in other parts of their lives? Ultimately , a therapist works with a person to help them create that broad , wide foundation that they can stand on to take responsibility for their choices and their successes. To even grasp that they have choices.

Recovery is a hard-won state where the client finally feels their agency internally and is able to look back and declare that they are not ever going back to the old ways. A state of awareness that is distinctly different from '“white-knuckling” where the person feels the locus of control and decision-making outside themselves.

The stance of the therapist - The position that a therapist holds in the room and with the process is extremely important and often not a part of the conversation. This is a mistake. It is conventional to discuss the patient and modalities of treatment ad nauseum with little attention paid to the conductor of the symphony. The reality is that much of the treatment process relies on the relationship between this particular therapist and this client. Frequent changes of therapists and / or a poor fit between the two contributes to the stuckness of the process.

It is good for the therapist to come with life experience and work experience that includes struggles , disappointments and successes that contribute to a trust in the possibility of change, a deep well of patience and tolerance for ‘slip-ups’, experience in the topic of ‘agency’ , a capacity for imagination and a certainty (acquired from experience) that recovery is possible. The stance of the therapist - a shaky stance, a confident stance, a patient stance, a “fake it till you make it “ stance - is the first step in intervention. Underestimating the significance of this is a cardinal mistake. Parents underestimate their position as the first “influencers” in a person’s life. Likewise, therapists underestimate their position as the current “influencer” in the person’s treatment. It is a position of responsibility and therapists should be willing to shoulder it. Part of that responsibility is seeking out information that will help the therapist find their trust in a person’s capacity to make change. TV shows are replete with acts of breaking barriers - people who can hold their breath underwater, running across deserts, surviving war. They are all acts of imagination followed with disciplined practice. Practicing through disappointments and failures and sad moments. Overcoming an addiction or an ED is an internal battle. One needs cheerleaders who can say that it can be done. Who know it can be done. A waffling cheerleader holds a waffling process. Doubt in the therapist’s mind that recovery is at all achievable will quickly become a certainty in the client’s mind.

Recovery is possible if it is named as the destination and the compass of the therapetic process is set in that direction at the beginning of the voyage. The map is full of diversions and speed-bumps but the compass keeps the pathway of the journey true from beginning to end. Without such a compass and a good torch to light the way, both the therapist and the client will enter a forest with nothing but a few strategies and good intentions. It is a good idea for the therapist to have travelled that forest pathway as many times as possible to be a capable guide. This is a matter of life experience and a willingness to keep learning with genuine curiosity. While we assume that curiosity is a general quality that everybody possesses, it does not often make it beyond the threshold of teenage. Somewhere along the way, many of us lose it in favour of safety. Curiosity does not always ‘kill the cat’, curiosity is just curiosity - a willingness to look and understand more wherever one hits a roadblock. Curiosity cuts through complacency and judgement. A therapist’s curiosity serves their client well.