This article is written with mental health and healthcare providers in mind. If you’re not a provider, you’re still welcome to read along, just know the content is tailored to a clinical perspective.
You know what you’re seeing: food rituals, rigid routines, emotional avoidance. The question isn’t whether it’s an eating disorder. It’s how to treat it most effectively. Do you stay the course with outpatient care? Push for deeper emotion-focused work? Refer to a higher level of support?
Most clinicians understand that eating disorders are about more than food. What’s more challenging is recognizing when emotion-regulation patterns — avoidance, numbing, rigidity — signal the need to shift the clinical approach.
In this Weekly Education Talk installment, we’ve adapted insights from a presentation delivered by Ruth Flynn, MA, on behalf of The Renfrew Center, the first residential treatment facility for eating disorders in the U.S.
The session explored Renfrew’s integrated treatment model, combining relational-cultural therapy (RCT) and the Unified Protocol (UP), and how emotion-focused, transdiagnostic frameworks can enhance treatment planning and referral decisions. This article reflects those insights, helping clinicians recognize key inflection points as well as how therapeutic trust, language, and structure shape the trajectory of recovery.
What Contributes to an Eating Disorder?
Eating disorders are complex and multifactorial. They can emerge at the intersection of social norms, psychological vulnerability, and biological predisposition — and often persist because they serve a powerful emotional function.
Socio-Cultural Factors:
- Diet culture and the glorification of thinness
- Narrow beauty standards, especially exacerbated by social media
- Societal values that prioritize appearance over internal qualities
- The belief that dieting equates to wellness or discipline
Psychological Factors:
- Low self-esteem or perfectionism
- Difficulty identifying and expressing emotions (alexithymia)
- Impulsivity or limited distress tolerance
- Co-occurring mental health conditions
- Trauma histories or invalidating environments
Biological and Familial Factors:
- Genetic predisposition
- Family history of eating disorders or substance use
Eating disorders can hide in plain sight, with behaviors misread as healthy discipline or wellness. For larger-bodied individuals, weight stigma contributes to underdiagnosis. And high-functioning patients — academically successful, socially engaged — often delay detection because their symptoms “don’t look severe.”
Denial, secrecy, and shame further obscure the picture. Unlike substance use, disordered eating often doesn’t lead to immediate social or legal consequences, making it easier to conceal, even from oneself.
Diagnostic Features: What We Miss When We Stereotype
A full diagnostic assessment should consider a range of behaviors and presentations:
Anorexia Nervosa:
- Restriction of intake and food group elimination
- Food rituals or rigidity around eating rules
- Compulsive body checking or weighing
- Onset often occurs in adolescence, but not exclusive
- May shift into other ED diagnoses later in life
Bulimia Nervosa:
- Disappearance of large quantities of food
- Fluctuating weight patterns
- Bathroom use immediately after meals
- Use of laxatives, diuretics, or exercise for purging
Binge Eating Disorder:
- Eating large amounts rapidly or in secret
- Loss of control during eating episodes
- Preoccupation with planning binges
- Difficulty recognizing hunger/fullness cues
Avoidant/Restrictive Food Intake Disorder (ARFID):
- Picky eating to an extreme degree
- Fear-based food avoidance (e.g., fear of choking)
- Sensory aversions, especially around texture
- No body image concerns — not rooted in weight fear
Other Specified Feeding or Eating Disorder (OSFED):
- Restriction without full AN criteria
- Purging without bingeing
- Chewing and spitting, food rituals
- Discomfort eating around others
- New restrictive diet trends, especially if rapidly adopted
These categories are fluid and often overlap. OSFED in particular is easily missed — behaviors are socially normalized or hidden, especially in patients who don’t match conventional images of “thinness” or visible distress.
What Eating Disorders Are — and What They Do
Eating disorders aren’t simply about food, weight, or appearance. They are often about function — providing a sense of control, escape, or numbness when distress feels unmanageable. Behaviors like restriction or bingeing aren’t irrational; they often emerge as survival strategies, particularly when patients lack safer, more integrated ways to regulate emotion.
Comorbidities are common, including depression, OCD, anxiety, and PTSD. One study of more than 2,400 individuals hospitalized for an eating disorder found that 97% had one or more co-occurring conditions.
But many individuals don’t receive these diagnoses until their eating disorder is stabilized. In practice, the eating disorder can obscure the clinical picture. Patients can’t fully access their internal world until the behavior is no longer shielding them from it.
The Role of Avoidance in Eating Disorder Behavior
Disordered behaviors can offer immediate relief from what patients can’t yet name: sadness, shame, rage, fear, or grief. In this way, the eating disorder becomes a mode of experiential avoidance — an effort to suppress or escape distressing emotions, memories, or bodily sensations.
This avoidance may look different depending on the patient: high-achieving, externally composed, and even emotionally articulate. But when treatment presses into themes of vulnerability, shame, or uncertainty, emotional engagement may falter — not due to resistance, but because it’s still unsafe to feel.
Importantly, this emotional detachment isn’t static. With the right interventions, patients can shift from ritual to recognition — from reacting reflexively to responding with awareness.
Bridging Models: Relational Work and Emotion-Focused Interventions
The Renfrew Center’s integrated model combines relational-cultural therapy (RCT) with the Unified Protocol (UP), a transdiagnostic framework for treating emotional disorders. While RCT fosters trust and mutuality, UP provides structure for emotion regulation.
The Unified Protocol targets:
- Increasing emotional awareness and literacy
- Reevaluating maladaptive cognitive patterns
- Interrupting avoidance and suppression
- Building tolerance through exposure
- Promoting psychological flexibility
Together, these approaches support the goal of helping patients move through distress, rather than around it.
The ARC of Emotion
Understanding emotion as a process helps clinicians and patients identify intervention points. The Unified Protocol uses the ARC model:
- A = Antecedent: What happens before the emotion arises
- R = Response: The emotional, physiological, and behavioral response to the antecedent
- C = Consequences: What happens next — behavior, interpretation, further emotion
By mapping this process with patients, clinicians can help them track patterns, identify triggers, and experiment with new responses. The ARC also supports emotional exposures — a core intervention in UP.
Emotional Exposure as a Tool for Reconnection
Emotional exposure is the process of gradually and safely engaging with distressing internal experiences. This might include:
- Naturalistic exposure (real-life challenges such as eating in front of others or attending a triggering social event)
- Imaginal exposure (visualization, such as recounting the experience of a food-related panic)
- In vivo exposure (planned exposures, such as incorporating fear foods into sessions)
- Interoceptive exposure (inducing physical sensations to build tolerance, such as breathwork or fullness)
Exposure is not a one-size-fits-all tool. It must be personalized, consent-based, and supported by a strong rapport. But over time, it helps patients learn that distress isn’t a threat — and that they can survive what they once avoided.
From Insight to Shift: Signs of Clinical Progress
This exposure framework isn’t always linear — and it doesn’t always produce immediate behavioral change. But progress may show up in subtler ways:
- Naming emotions with increased specificity
- Pausing before acting on urges
- Reflecting without spiraling into shame
- Asking for support or sharing internal states spontaneously
- Tolerating “gray area” experiences without reverting to black-and-white thinking
Patients begin to reclaim emotional range and recognize that the behaviors that once “protected” them now obscure their growth.
Language, Bias, and What We Don’t Say Out Loud
As patients develop emotional awareness, our own awareness — especially of the language we use — becomes equally essential.
When working with individuals navigating deep shame, body image distress, or early-stage readiness for change, language matters. Not just what we say, but how we say it, and what we unintentionally signal in the process.
Even the most compassionate clinicians can reinforce harmful narratives if we’re not mindful of cultural norms and implicit bias. In fact, it’s often not what we say to patients — but what we say around them — that carries weight.
In everyday conversation, consider:
- Avoiding weight-centric praise (“You look great — have you lost weight?”)
- Steering away from “good” or “bad” food language — both about their food and your own
- Resisting casual comments about your own body, diet, or exercise habits
- Not assuming that patients want to lose weight, even in higher-weight bodies
- Being curious about food rituals or avoidance without moralizing or projecting intent
This kind of linguistic hygiene doesn’t just benefit patients with known eating disorders — it creates a safer therapeutic environment for all patients, many of whom are silently navigating their own body image struggles, disordered eating, or cultural trauma around food and weight.
As always, cultural humility is key. It’s not about being perfect — it’s about being aware.
When to Consider a Higher Level of Care (HLOC)
Some patients can’t begin emotion-focused work until they’re medically or behaviorally stabilized — and recognizing when that threshold is met is part of what makes ED treatment so complex. Knowing when to escalate care isn’t just a matter of clinical metrics; it’s a relational decision that must be made with attunement, trust, and clarity.
Referral to a higher level of care (HLOC) may be appropriate when:
- Symptom frequency increases (e.g., purging multiple times per week)
- Emotional or behavioral dysregulation interferes with daily life
- There’s significant weight fluctuation or medical instability, regardless of BMI
- The patient’s distress tolerance is so low that emotional exposures are retraumatizing, not therapeutic
- Labs or vitals suggest physiological compromise
- Safety concerns (e.g., self-harm or suicidal ideation) emerge
For clinicians, this can be a difficult conversation, especially when patients are academically driven, outwardly functioning, or highly ambivalent about treatment. But the goal isn’t to “pause” life for care. The reality is that life is often already on pause because of the disorder. Framing treatment as a way to return to life — rather than delay it — can be a powerful shift.
When recommending HLOC, consider:
- Expressing curiosity without judgment
- Using medical analogies (“If this were cancer, would you wait to treat it?”)
- Reinforcing the patient’s strengths and validating their resistance
- Offering hope that this isn’t the end of therapy — it’s a new phase
- Committing to continuity: “I’ll be here when you’re ready to return”
As always, a team-based approach is ideal. Collaborating with dietitians, PCPs, psychiatrists, and (when available) Certified Eating Disorder Specialists (CEDS) helps ensure consistency and support during transitions in care.
The Shift Toward Awareness
Eating disorder behaviors often persist because they work — until they don’t. When patients begin to move beyond avoidance, they’re met with what the behaviors were shielding them from all along.
That’s when the work deepens.
By shifting the clinical focus from behavior to emotion, we offer more than symptom relief. We offer patients the tools to stay with themselves through the full arc of feeling, and the possibility of a life no longer ruled by avoidance.
Weekly Education Talks is a blog series from Rivia Mind spotlighting clinical insights from our provider team and partners. This article is based on a presentation delivered on behalf of The Renfrew Center and reflects our commitment to evidence-based, relationship-centered care for every patient and provider.
References:
- Anti-Diet: Reclaim Your Time, Money, Well-Being, and Happiness Through Intuitive Eating by Christy Harrison MPH RD
- The F*ck It Diet: Eating Should Be Easy by Caroline Dooner, Harper Wave
- Sick Enough: A Guide to the Medical Complications of Eating Disorders by Jennifer L. Gaudiani
- Almost Anorexic: Is My (or My Loved One’s) Relationship with Food a Problem? (The Almost Effect) by Jennifer J Thomas Ph.D., Jenni Schaefer
- Eating in the Light of the Moon: How Women Can Transform Their Relationship with Food Through Myths, Metaphors, and Storytelling by Anita Johnston Ph.D.
