Monte Nido Vice President of Clinical Programming Keesha Amezcua, MA, LMFT, CEDS continues her series this week on the 8 Keys book by Gwen Grabb, LMFT and Monte Nido Founder Carolyn Costin with the 3rd key. In her writing, Keesha explains how this key stresses that the eating disorder is not just about the food, and the ways this is put into practice in treatment at Monte Nido.

Almost every person who has struggled with an eating disorder has been berated by a, often well-meaning, loved one to “just eat a cheeseburger already”. Key 3, which stresses that eating disorders are not just about the food, is the antidote to those comments. This is what makes healing from an eating disorder so complex. Key 3 can help create discussions that explore the range of complex multi-faceted meanings of eating, food, weight and shape.

This is the key where therapists get to pull out all the knowledge they used in graduate school; digging deeper into the underlying issues that result in food and exercise behaviors. In the absence of healthier, more adaptive coping skills, an eating disorder can develop as a way to manage stress, anxiety or depression, family dynamics, cultural pressures and traumatic experiences, among other things. There can also be biological factors contributing to a person’s eating disorder. Therefore, we can’t assume that just reestablishing someone’s relationship with food can heal his or her eating disorder completely. This is why there continues to be such debate in the field about evidence-based therapies and best practices for treating these disorders. If there was one right way, one clear winner in how someone can without-a-doubt get well, every treatment program would look the same and there would be less need for research and conferences. There are obviously some treatment modalities that have proven to work better with certain demographics and diagnoses; but still, those do not give us absolute certainty that a person will recover. Therefore, we continue to utilize an eclectic group of therapies to get at these underlying issues.

Key 3 is not intended to negate the importance of nutritional stabilization; this is addressed in another key. It does make clear that solely addressing the food, in the absence of exploring other psychological issues misses the mark. We can talk about food all day, every day, for a year and not see someone truly progress toward recovery. Someone can restore his or her weight, but if he or she hasn’t explored what was underneath the restricting and weight loss there is a good chance recovery will be short-lived. We need to understand what function or set of functions a person’s eating disorder has served. As clinicians, we have to identify these functions in order to help our clients get their needs met in more adaptive ways. A conversation about kale will only get you so far. Only discussing donuts can be a dead end.

One assignment that Carolyn and Gwen discuss in the 8 Keys book, which Carolyn had initially written about in her first edition of Your Dieting Daughter, is the “Real Issues” assignment. There is a list of 13 proposed issues to provide a jumping off point for clients to delve into what’s really going on underneath their fear of food or their over-attachment to it. This list covers the basic categories and can help a therapist determine what therapeutic modality might best address what’s going on. Is there a need for more psychodynamic work? Family systems? Existential? Feminist theory? Narrative therapy? ACT? DBT? Perhaps some specific trauma work needs to happen via CPT or EMDR? All the while we continue to utilize the CBT techniques as I’ve previously discussed.

It’s not just about the food. This makes this work exciting, ever changing, always challenging and forever interesting. It is also what makes an individual’s recovery unique and lasting.

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