We CAN do Better: Co-Occurring Drug or Alcohol Dependence and Eating Disorders among Women

Did you know that among women living with a substance use disorder that up to 40%  of those women are also living with an eating disorder? (1). 

Did you know that most women are not able to find help for both disorders at the same time? (2).

There is a lack of adequate resources for women seeking treatment and there is an even bigger lack of treatment facilities that will treat both a substance dependency (drug or alcohol addiction), and a co-occurring eating disorder simultaneously (3). While many treatment providers are required by accrediting bodies or state licensing agencies to screen for eating disorders, the screenings often lack thoroughness and providers rarely have the education, training, and awareness necessary to recognize the symptoms and provide appropriate intervention. Unfortunately, due to these deficiencies, if a woman is forthcoming about her eating disorder in a substance abuse treatment facility, she runs the risk of being immediately referred out to an eating disorder program – thus, not receiving appropriate or effective treatment and making it far less likely for her to recover from both disorders at the same time. 

Furthermore, because eating disorders are not illegal, like the procurement and use of illicit drugs, many women will continue to hide their eating disorder or patterns of disordered eating from treatment providers and loved ones. While many women may be able to sustain their recovery from drugs or alcohol, they still may be living with a process or behavioral addiction, meaning that they are still coping in unhealthy ways and burdened with the fear of letting go of something that provides them with a false sense of control over their lives and bodies (4).

 It is my belief that the most concerning part of all of this stems from a general absence of understanding and awareness about women’s needs in treatment. If the owners and operators of treatment centers, state regulatory bodies, insurance carriers and other relevant agencies were truly aware of the barriers that women face when seeking and receiving treatment, then they would be motivated make the changes necessary to improve the standard of care provided, right? I know that it’s comforting to believe that perhaps those regulating the treatment industry are just blissfully unaware of the unique challenges and needs of women – however, you’d think that after years of collective experience and all the studies done for decades providing evidence to support the need for gender-specific approaches to treatment that they would have done something by now to improve standards of care for women.

 Typically, women are less likely to seek treatment for an addiction or mental health disorder than their male counterparts. When women do finally seek help, they deserve to be met with comprehensive, person-centered treatment that will provide them with the tools and resources necessary to heal from trauma, addiction, eating disorders, and other mental health disorders at once. As providers and professionals, we have myriad of research and anecdotal evidence to support what women actually need from treatment and now we must begin to put these things into practice.

We CAN do better than this. 

Here are some ways we can improve our treatment systems for women with co-occurring substance use and eating disorders:

 1.        Screening and Assessment: It is not enough to simply ask women if they have ever had an eating disorder. We live in a society that is obsessed with diet culture and reinforces patterns of disordered eating – when someone with a larger body size loses weight, we congratulate them, ask how they did it, and request dieting tips. We criticize our bodies, our diets, our exercise routines, and give and receive compliments based on external qualities. Among vulnerable populations, like women who have survived trauma or who are living with an addiction, these messages can be toxic – as many of these women do not have the tools to love themselves and their bodies and to filter out the external, unhealthy chatter from those around them and societal norms.

When screening or assessing for patterns of disordered eating or an eating disorder, we must ask direct and specific questions about the individual’s relationship with food; their typical diet and exercise patterns; and whether they have ever engaged in any eating disorder behaviors (e.g., binging, purging, restricting, over exercising, etc.). When we start to gather more information about these things, we gain insight into how we can best support the individual in need of treatment.

Additionally, screening and assessment for eating disorders among women seeking treatment for substance abuse should not stop with the intake screening or after the usual biopsychosocial assessment. This should be an ongoing process for this population, especially because when a woman enters treatment and stops using drugs or alcohol, their bodies often change significantly, which may include weight gain or redistribution. Theses changes in their bodies can be triggering for women and could motivate them to either start using drugs again to shed weight or to develop alternative means of unhealthy coping through disordered eating. Also, women may enter treatment and not be forthcoming about their preexisting eating disorder during the initial screening or assessment. These women may not disclose their eating disorder for many reasons, including but not limited to: fear of judgment; shame; fear that they will get “kicked out” of treatment for having an eating disorder; they may have a lack of awareness about the severity of their eating disorder and minimize the symptoms; or they may not be ready to let go of another coping mechanism that provides them with a sense of control over their image and body.

2.        Training and Awareness: Because women may avoid disclosing a co-occurring eating disorder for various reason, all staff and providers working with women in treatment should receive training on the signs and symptoms of eating disorders. Training promotes awareness among all staff so they can better help women in treatment. Many treatment centers report that they are unequipped to manage the symptoms of co-occurring eating disorders and while I do not support the treatment of any disorder or condition without proper training and experience, ignoring or overlooking the signs and symptoms of an eating disorder while a woman is in treatment seems more irresponsible.

 I do not expect every treatment center for women to be co-occurring disorder experts overnight; however, I do believe that treatment centers are already coming into contact with this population, whether they choose to admit it or not. Transferring a woman out of treatment for having a co-occurring eating disorder may lead a woman to believe that she is being punished, that she is unworthy, or that she is completely broken and will never find the help she needs. Not to mention the level of frustration that an individual must be experiencing when they have to go to several treatment centers to treat each disorder independently, instead of finding one treatment center that can effectively treat the root of both disorders.

 Educating treatment providers on signs and symptoms of eating disorders builds confidence and promotes awareness, which can only yield better results among the women seeking help. When staff is under trained, they may perceive eating disorder symptoms to be unmanageable and intimidating. This lack of awareness could lead to providers making fear based approaches to treatment recommendations and decisions (e.g., discharging the patient to another treatment provider or “higher level of care”); treatment teams over-pathologizing women in treatment (e.g., “she’s not a good fit for this program” or “once she gets her eating disorder under control she can get help for her drug problem”, the borderline personality disorder diagnosis); and ultimately, women are not getting the help they need to heal and find recovery. Treatment providers are already coming into contact with women living with co-occurring disorders, whether they choose to admit it or not.

The real harm in not promoting awareness about eating disorder symptoms among treatment providers is the toll it takes on the women seeking treatment.  

3. Healthy Eating and Body Image Programming: Even women seeking treatment without co-occurring eating disorders could benefit from learning how to make healthy choices that promote the healing of their bodies, while they are receiving therapy to heal their minds. Many women entering treatment for substance abuse have already been depriving their bodies of the appropriate nutrients it needs to survive by using drugs or alcohol for extended periods of time. Furthermore, most humans are never taught about nutrition, how to take care of their bodies to improve their overall quality of life, and how to develop a healthy body image.

Including healthy eating and body image related programming in all treatment settings could improve treatment outcomes by teaching individuals how to live healthier lives. Entering treatment for drug or alcohol dependence, only drinking soda, and consuming unhealthy foods with little nutritional value does not promote feelings of wellness. All individuals seeking treatment deserve the opportunity to detox the alcohol and drugs out of their bodies, while restoring the depleted nutrients, and learning how to feel better by simply increasing water consumption and making better food choices.

This is not done by labeling certain foods as “good” or “bad” but by providing individuals with the tools to gain awareness about their own internal experiences and feelings related to the food they are consuming. The general standard among treatment centers is to provide pharmaceutical remedies for quick fixes to discomfort. For example, if a patient reports that they aren’t sleeping well, they are given a prescription to sleep that usually leads them to feeling groggy the next day. While some patients can absolutely benefit from the use of pharmaceutical remedies, treatment providers should also be asking more information about the dietary and exercise habits of their patients. If a patient is drinking copious amounts of caffeine and sugar before going to bed, it is no wonder that they cannot sleep. If a patient reports that they are feeling sluggish and depressed, but primary consume candy, chips, and highly processed foods, it is no wonder they are feeling down, right? Many people entering treatment have never been taught to pay attention to how their bodies feel and how they can improve their health and quality of life simply by making different food and beverage choices. While some individuals may be unwilling to change their nutrition habits, treatment providers should still be providing education on how to make healthier food and lifestyle choices.

To treatment providers everywhere: We can do better!

 If you are seeking treatment for yourself or a loved one living with both a substance use and eating disorder, seek out a treatment center that will allow you to seek recovery from both at the same time. Remember, it’s not about the food, it’s not about the drugs or the alcohol, it’s really about the way you feel about you. It’s about having the desire to find recovery and stop living in pain. Despite any barriers that exist, there are always people who are willing to help! 

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