The Rabbit Hole: When eating disorder therapy does harm

Tabitha Farrar (Tabitha Farrar, 2023)

In typical ‘zero f***s given’ style, Tabitha Farrar slipped her new book out under the radar a few days ago. No publicity. No fanfare. Not even a publisher (this book, like all of Farrar’s work, is self-published). Yet once again Farrar gets to the heart of things in a way that no one else writing on eating disorders seems able to do.

In this succinct book, Farrar enters a land where few others would dare to tread, challenging the entire orthodoxy around the treatment of eating disorders with her central question:

Should therapy be the default recommendation for treatment of eating disorders?

Farrar is unlikely to win over many hearts and minds in the therapy industry with this book, but she is not looking for love: I don’t need or want everyone who reads this book to agree with me. My goal is to get you thinking, not to make friends.

Farrar is a disruptor, and that is no bad thing. Eating disorder recovery rates are poor by any measure. The current approach is not working. Many people are still dying, and many more are living a half life, often having been told that managing their illness is the best they can hope for. In this book, Farrar insists that we can do better.

She suggests that many therapists not only hold their patients back from recovery but actually often make the illness worse. Farrar believes that harm is being done on a massive scale in the eating disorders’ world and explains how she’s come to this conclusion, using quotes from people who have had therapy for eating disorders to illustrate her points.

I agree with Farrar that harm from treatment is widespread. In fact, I don’t know many people who haven’t been harmed in some way in eating disorders treatment. My daughter is one example. Not only was she given a low target weight by her treatment team, which kept her stuck in the ED for years, but she was told that the reason she wasn’t recovering was that her anorexia nervosa was a way of coping with depression. This then became a self-fulfilling prophecy. In my daughter’s eyes, until she recovered from depression, she couldn’t recover from her eating disorder. Or whenever she found life difficult, she turned to restriction — because her eating disorder was (to use a phrase I abhor) a ‘coping mechanism’. That must be true because that’s what a therapist told her. And they must know what they’re talking about, right?

According to Farrar, no, probably not.

Eating disorders are not a coping mechanism for anything other than an eating disorder, she writes. The behaviours are a symptom of the disorder, not a coping mechanism for something else. Restriction feels good and soothing and all that jazz because the brain rewards one for restricting because the brain is fearful of weight gain. Due to the rewarding nature of restriction, of course a person with an eating disorder is going to restrict when they want to feel better.

This book explodes this idea and other received wisdom around eating disorders piece by piece, starting with what the author sees as the confusion between cause and contributing factors:

Eating disorders are caused by a combination of a genetic predisposition, and energy deficit. Low self-esteem, negative body image, and traumatic life experiences can be contributing factors to energy deficit, in the same way that any illness that causes weight loss can be, but they are not causes.

Farrar proceeds to tackle: the psychologising of binge eating—The belief that binge eating is bad is one of the biggest barriers to recovery; the search for an underlying reason for the development of an ED and the colossal amount of time it wastes; the belief that EDs are always about trauma or control; that recovery has to take a long time; and that full recovery is not possible — an idea still shockingly prevalent and one that is not based on evidence and is obviously highly unlikely to help anyone actually recover.

I have had a therapist try and tell me that I don’t know what I am talking about and I don’t know it but I am not fully recovered, writes Farrar, who had anorexia for over a decade. I told her to prove it and she said that therapy doesn’t work like that. Well, isn’t that the truth!

I agree with Farrar that we need a revolution in eating disorders treatment. We need to look at everything differently if we are to unstick so many who have been told that they are complex, that their eating disorder is a complicated psychological issue that needs to be unpicked rather than a starvation response, that their illness a coping mechanism or a need to control something — or all the other ideas that people have come up with over the years to explain this behaviour.

People with anorexia and other restrictive eating disorders can be quite futuristic in their thought processes: always thinking about the next meal or how they will compensate for what they’ve eaten. Therapists, in Farrar’s view, are too backward looking: always searching for the imagined psychological underpinnings of the disorder, as if unearthing something in the past will magically give someone the ability to eat normally again. As Farrar explains, the brain just doesn’t work like that. The only way to change thought patterns is by challenging them over and over and over:

For our brains to learn not to be fearful we have to override our fear response consistently and frequently. This is because the brain learns via repetition. Every time you eat a “safe” food you are acting as if you are fearful of weight gain. Therefore eating safe foods actually reinforces our fear of weight gain. If you want your brain to learn not to be afraid of weight gain you have to consistently act as if you are not afraid of weight gain and this means every time you eat you should be eating something that challenges your fear response.

Farrar’s message in this book, to people working in the field, is essentially: Stop looking for reasons. Stop looking backwards. Start working on the here and now. And that means helping people to eat and helping them to change their thought patterns around food: reversing malnutrition and rewiring neural pathways through repetitive behaviour, until the brain stops seeing food as something to be feared and starts recognising it as the ordinary, essential and even joyful part of life that it should be.

I don’t agree with Farrar’s suggestion that therapists are deliberately keeping their patients stuck in treatment because of financial incentives. That may be the case for a small minority, but I think it’s more likely to be ignorance of how to treat eating disorders effectively rather than malice that is rendering treatment ineffective.

Ultimately it doesn’t really matter, though, because the outcomes are the same: many people just aren’t getting well. And if you are treating someone for an illness, getting them better should be an expectation rather than a hope. Treating the illness with confidence, from a position of understanding, should be the norm.

The field of treatment for eating disorders still doesn’t understand that eating disorders are not actually that complicated, says Farrar. They are not deeply rooted in the psyche and they are not expressions of psychological poltergeists. They are a genetically predisposed biological response to energy deficit that results in an irrational fear of weight gain.

The over-complication of treatment is the reason why, Farrar suggests, recovery rates have traditionally been so low. And the poor response to poor treatment has become the norm — patients just aren’t expected to recover so they don’t.

This book doesn’t have the backing of a big publisher, it’s not polished and it’s not professionally produced — but that doesn’t mean it doesn’t have something important to say. In fact, it should probably be required reading for anyone in the eating disorders field. Unfortunately, as this book doesn’t pack its punches it’s probable that many in the field will not be inclined to listen to its messages. Therapy is likely to be the default treatment for the foreseeable future whether we like it or not. We need therapists to be on board if anything is going to change, and perhaps a slightly more diplomatic approach might be more likely to convince therapists that they need to rethink their practice.

It is a shame that most people working in the eating disorders field probably won’t heed the advice in this book. If they did we might see fewer people struggling with eating disorders for years and decades and instead start seeing people getting over a period of illness within months and getting on with their lives.

Wouldn’t that be something.