Food is to insight as insight is to....

I'm having an interesting conversation with a clinician.

I told her that I think of active restriction/bingeing/purging as I would shooting heroin: therapy is inappropriate while high. She found that a provocative idea.

I said I wished therapists would refuse to engage in ongoing therapy with a patient who is actively 'using,' and she felt that was wrong: that very useful therapy can go on without weight restoration.

This is probably a matter of emphasis between us. She's a therapist whose tools are rapport and building insight in patients.

I'm a parent. I saw first-hand that our daughter displayed lots of insight even when entirely unable to sustain herself nutritionally. Insight didn't help her. And I saw how full nutrition alone brought her reasoning to a place where her insights were in line with her actions - and to a place she engaged quite successfully in therapy.

I'm curious: parents, do you find it provocative to suggest that therapy in the absence of nutritional rehabilitation is like doing therapy while high?

What role did insight have in your loved one's recovery?


  1. Well - this is probably an issue of semantics. I found therapy to be essential while my son was still malnourished and restricting or "high." But I'm not sure how much good it did him individually. For our family, and for us as parents helping him, it was essential.

  2. To me it's sort of like "what came first, the chicken or the egg?" I'm not sure there's a correct answer to your question. I think it depends on how severely malnourished the person is. If the person is too weak to get up and do anything, then I think food is necessary first.

  3. I found that therapy during malnourishment was very helpful for our d but must add that we have had a very dedicated,amazing Maudsley-trained therapist who has been our guiding light and saving grace during this difficult phase. The weekly appointments is what kept our d moving forward and my sanity..

  4. Just to clarify, I'm asking about therapy WITHOUT nutritional restoration. Therapy ALONE.

  5. Without Nutrition restoration and just Therapy ALONE,It DOESN'T Stand a Chance and would be a waste of time........

  6. My only problem with this argument as you know, is that it can leave uncooperative patients with no treatment at all - not that bolstering the ED's deception that everything is fine would do either.

  7. In answer to your actual question - no I don't think that it is provocative to suggest that therapy in the absence of nutritional rehabilitation is like doing therapy while high - I just have a problem with the way our adult mental health care system here suggests that addicts, alcoholics and anorexics can and should take full responsibility for their own recovery and that it is OK to tell vulnerable people to go away and think about it and "come back when you are ready" - what if they don't come back - who's going to notice? Not the busy therapists - maybe that's a job for the coroner. (I realise that I am now the one who's being provocative)

  8. I totally agree,Marcella. When I hear people say that addicts and alcoholics or anorexics need to choose to get better, I cringe. Imagine how many people could be helped if their FAMILIES were told, "you must choose to help your mate/son/daughter/parent get better. They need your support now."

  9. I'm not certain how comparable this is really because I'm not underweight but I'm actively bulimic and don't really get the nutrition I should. Don't eat that much that has anything worthwhile in it and when I do it comes back up. I have lots of insight and it does nothing. Absolutely nothing. My therapist keeps telling me the insight I've got is the first set but what use is the first step when there's no second step. I was better a while ago when my parents monitered me totally- was unable to binge or purge- but since I've been alone my insight has been useless. I'm glad it seems to have helped some people though.

  10. L,

    Your comment is dead on. I had insight for years, but it really didn't do me any good. I stayed sick.

    And for those who say that insight is enough, I'm just curious: how has insight benefitted your recovery? Are you further along because of it? Obviously, insight has helped me now that I'm no longer really malnourished, but has insight decreased your symptoms? Made you happier? More functional?

  11. Much of my own "insight" that I offered was about needing potassium and fat in a diet and how honoring oneself was law. We found a T to be unnecessary after a brief trial period in which we found the same problem you are addressing Laura. When one is deeply entrenched they need a rope(nourishment and a plan), not a promise to be led out if they share "why" and "how" they fell in the hole. First we pull em up....then if they need to make some life changes so they can avoid the "hole" we can offer them a place for guidance and a magic wand/*. I'm not sure this even has to be in the form of therapy though I know some swear by it. We found ourselves to be fairly capable of talking and laughing about ways we do things, figuring out how to make changes that served us best. Funny, we never heard from the place which cared so much after her week of IOP or the miserable T she had for a brief period.

  12. Hmmmm

    This is an interesting topic -- you always bring up an interesting debate Laura.

    I think that there is a difference in FOCUS of therapy when the individual is malnourished/ill -- and there is also a difference age wise.

    In children, I would go for nutrition 100%. I don't know if they are capable of understanding their disorder (if it does indeed make sense) or appreciating what they are losing if they remain ill. They cannt be responsible for themselves because even under NORMAL conditions, they are not responsible for themselves. This is where Maudsley makes sense.

    However, this changes in the field of chronic/adult anorexia. I think for adults with eating disorders, therapy can be helpful even while malhourished -- the goals may be working on motivation for change, coping at the current state, searching for alternative coping strategies to the eating disorder etc, readiness for treatment rather than insight. . . The therapist can act to prepare a client for treatment or to faciliate the treatment process while refeeding occurs. Therapy is not always digging into the past.

    That said, is the goal of outpatient interpersonal therapy to stop symptoms of an eating disorder and help the individual recover -- No. A more intensive program is needed to do this.

    Don't discount interpersonal therapy on the basis that it does not provide "full recovery" -- there are still obvious benefits.

    I'm tired, so I may not have worded this the way I wanted to. . .


  13. I like the idea of full nutrition first, but I think until a plan is in place to provide that, then the current type of treatment needs to remain.

    For instance, our health care system is sucks. But I'd never advise that we just do away w/ it. We need to change it. Talk therapy is all some have. It's not enough, but many believe it's better than nothing.

    I wish Maudsley was more widely accepted and that more drs and therapists provided it (and I wish I wasn't so terrified of giving it a try...). But until then, I wouldn't want what is available taken.


  14. I come to this discussion as a therapist rather than a family member. I think it is important to think of therapy as purposeful and goal-oriented and as such, someone in the therapy, whether the individual and/or family, needs to want help and be willing to struggle to solve problems. Regardless of the eating-disordered patient's age, the order of addressing problems should be the same --- first nutritional, weight and behavioral rehabilitation -- and then cognitive and other remaining psychological issues. While it is tempting to have "insightful conversations" prior to true behavioral and weight change, the results of these conversations is usually unproductive. Problems which require insight also require brain power which is severely compromised with low weight and malnutrition. While tempting to avoid the conflict involved in pushing for weight and nutritional restoration, it is really essential -- in its own right and for the productive resolution of other problems. That being said, it doesn't matter if the IP is a customer for help or just their family is ---- it is merely important that someone is willing to make things better, practically no matter what it takes. And when that decision is made, recovery occurs.

  15. Anonymous therapist
    Are you saying that you would treat a situation in which one member of the family was desperate to work with you but the adult sufferer wasn't? If so, how?

  16. As someone in her 20s who is on the other side of recovery now, I must say that therapy saved my life. My doctor saw things that I was not well enough to see, and has been amazing. I got sick in my mid 20s, so I'm coming from a different angle than you with your child, but I do have to defend therapy and say that, though I understand what you're saying, going every week kept me alive. And eventually, once I was eating enough, it is helping me to thrive.

    The focus should be on finding someone AND something that helps the sick person feel like life is worth it, without the ED. The ED is an addiction and a high, but I think of it more as an abusive boyfriend or girlfriend. That's really what it feels like when you're in it - like you know it's bad for you, but the good feels SO good, and you don't want to know and are scared to know what life without it would be.

  17. Therapy alone was all I had, both in a disordered state and when I was pursuing recovery. Without it, I know I would still be sick.

  18. Fascinating!

    One thing I didn't anticipate is that people would read the question as if the idea was "therapy only" or nothing. Or as a criticism of therapy.

    I wasn't thinking either. I don't want to take away people's therapy: I want to make sure they are getting nutrition at the same time.

    The arguments for therapy being better than nothing strike me as analogous to "well if you don't eat then at least drink water."

    Water is necessary, but without food it only prolongs the agony and worsens prognosis.

  19. From Anonymous therapist to Marcella:
    I regularly work with adult ED patients who are unable to accept help but whose families are willing to use their leverage to convince their loved one to participate in the treatment. As such, I then see a whole family or a husband and wife and I work pretty much like I do when I see younger adolescents and their very worried and willing parents. My thought is that I just need someone who wants my help and then I can help them to help their ED family member. I've had great success and for many years. Hope that answers your question!

  20. Oh we've been there i.e therapy not related to food and not working on eating either. My bulimic D became more and more depressed and suicidal. If we hadn't shifted away to an eating approach she would be dead - no question.

    My AN S found insight without reason and therefore believed the father blame thing. He was unable to put it into context and realise although maybe not great parenting it wasn't actually bad (not much different from his peers)he had a father who loved him. Even in recovery this relationship is suffering from the DAMAGE caused.

    I STRONGLY believe nutrition makes the difference with counseling focusing on eating management both for patient and family. Learning to work together to manage the current crisis and understand together about the disorder.

    As they slowly recover and return to life they can tackle the anxieties / depression etc.

    My S wanted to get well but still made no progress until focus shifted from his "anxiety and learning to live in the moment" to eating.

    My D never believed she was ill so we - eventually-used our leverage to insist on "eating" help. She made more progress in 3 months than the previous 6 years.

    However, my S benefited from counseling (as well as eating support) when still underweight but was closer to normal.
    Unfortunately my D won't revisit the counseling after years of weekly psychiatric and psychological before learning to eat. She is now in a place where it would be helpful but she is 'burnt out" (her words) and has lost faith in it.

  21. Hey, even Freud recognized that insight is not a cure, right!

    So the first thing question to my mind, is the patient suffering from anosognosia or impaired insight due to ED or concomitant comorbidities (shout-out to CA for the post on insight deficits and mental illnesses and addictions)? If the answer to that is yes, then it seems unlikely that insight-based therapy will be effective unless and until that deficit is corrected.

    Now, the sticky wicket is of course that insight is really hard to quantify & test. Also, many clinicians - and family members! - fail to appreciate the difference between won't self-evaluate and CAN'T. And perhaps worst of all, there seems to be a general under-appreciation of how important this kind of self-awareness actually is to healthy happy functioning in "normal" people, much less to full recovery.

    Interestingly, I just read a New England Jnl of Medicine review of a book I can't wait to read: "The Insanity Offense: How America's Failure to Treat the Seriously Mentally Ill Endangers Its Citizens" By E. Fuller Torrey. 265 pp. New York, W.W. Norton, 2008. From what I can gather, the POV of the author is that we (U.S.A.) do not do a good job treating patients who have anosognosia or insight deficits. The author traces this to the reaction to the forced institutionalization and other horrors historically practiced on the mentally ill. In the move to restore humane treatment to such people, though, perhaps the baby was thrown out with the bathwater, because the argument can be made that autonomy is granted to people who really can not function independently, as judged by the harm they represent to themselves and others. The author also seems to argue that we are not agressive enough in treating and restoring mental health.


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