The Discovery of Self-Worth

Much has been written by acclaimed clinicians who treat people with eating disorders about the desire to disappear. One central wish for many people who suffer from these illnesses is to fade away and simply vanish from the world. The mere act of starvation is the process of wasting away in order to take up less physical space, but the wish to be gone represents more than that concrete manifestation.

The underlying tenet of this fantasy is the concept of not having personal value as a human being. For most people, a sense of self-worth pervades the way everyone goes through the world. Waking up and living each day implies a sense of meaning and value. Meaningful relationships or even simple, human interaction give a sense of purpose to our days. There are many more ways people see their increased value but I  am trying to point out the most basic self-worth we have as human beings. 

There are more subtle ways people express how they value themselves. Speaking up for your own wishes or rights is a way of expressing self-worth. Emphasizing self-care can send a message to yourself and others of valuing yourself. Talking about one's life day to day implies value in the quotidian tasks. Even the basic concerns like sleeping and eating show a sense of value in ensuring one's body is prepared for the day. 

People with eating disorders can have trouble with all of these things: speaking up, self-care, taking about oneself and ensuring basic needs are met. 

The result of struggling to prioritize these concerns represents the figurative process of disappearing. Even if the eating disorder does not cause a literal disappearance or diminishing, the psychological underpinning of these illnesses is one's own disappearance. 

In terms of support and treatment, the implications for these truths are very clear. Therapy, but also support from friends and family, needs to emphasize self-worth in the world.

Personal characteristics and positive traits that may be obvious to most people are almost impossible for someone with an eating disorder to see. That person may need their own positive attributes repeated dozens of times before they start to process the information. Self-deprecating comments need to be contained and questioned again and again. It's critical to identify these thoughts as untrue and caused directly by the eating disorder. 

Although the actual causes for the intense self-negation for someone with an eating disorder are varied, figuring out that cause is not always necessary or central to treatment. It maybe useful for some people, but the important idea is to undermine those thoughts and help the person to find their own voice and learn to see themselves clearly in the world.


Regret has no Place in Eating Disorder Recovery

A confusing part of treatment for an eating disorder is the need to avoid certain feelings. That is not the usual method therapy applies and seems counterintuitive for a set of illnesses that enable people to avoid feelings. The underlying reality is that certain feelings reinforce a sense of hopelessness which can sabotage any real attempt at recovery. 

The most insidious of these feelings is regret. In the safe confines of the eating disorder mindset, all decisions about food are paramount and, accordingly, everything becomes secondary to the primary goals laid out by the illness. It's problematic that many of those other concerns are much more important when it comes to daily living than the short-sighted, fruitless tasks of an eating disorder. 

But understanding the power of an eating disorder means making sense of this powerful driving force. The thoughts feel incredibly meaningful and give order and structure to the scary emotions, relationships and decisions that are a part of every day life. 

Even a small step away from the eating disorder can open a person's eyes quickly. That immediate awareness, like a screen suddenly lifting, illuminates the emptiness of life run by an eating disorder and the missed opportunities that abound during the years lost in illness. 

It's tempting to follow that path of regret both for the patient but also in therapy. Mourning and a sense of loss are often critical parts of adult life and are very hard for even people who are emotionally healthy. The pain and struggle are easily avoided in the daily routine so any therapist would feel compelled to explore these emotions. 

For people with eating disorders, regret is a bottomless pit of shame, a detour right back into the self-loathing that can start a full relapse. Recovery takes so much attention and focus on current emotions and on each meal and snack. Sometimes, hope can be hard to find in the daily slog but a sense of purpose or at least delayed promise can serve as enough drive just to get through each day. 

That amount of resolve cannot withstand a period of dwelling on loss. That time has passed and reviewing the pain wrought by the eating disorder leads to a strong urge to rely on the illness to cope with the emotions. 

Once the person is ready to face the sense of loss, life has already taken over. Moments of regret might pop up at times, but the pressing moments of life instead take center stage. 


Ownership of Eating Disorder Recovery

The eating disorder thoughts, as I have written many times in this blog, are incredibly powerful and often just feel like thoughts. Distinguishing eating disorder thoughts from one's own is critical for recovery, but the process is not linear. It takes time and practice to learn how to do so reliably. That interim can be a risky time for relapse despite the real desire the person has to get well. 

This transition also marks a shift in the personal ownership for the recovery process. Before this time, the therapist, family or friends stand firmly for health while the person suffering can only blindly follow the eating disorder. The thoughts are too internalized and strong to resist.

The ability to have a moment of perspective about the eating disorder thoughts creates a new situation. All of a sudden, there is a choice whether or not to follow the thoughts. Having the moment does not mean the power to choose differently right away, but it does mean the path out of the illness is possible for the first time. 

During this time, the person with an eating disorder starts to take ownership of the recovery process. It truly becomes their own, and it's crucial to start to take on that mantle. Because distinguishing the two thought patterns is so new, it's a risky proposition. Owning the process opens the door for worsening symptoms and a fall into relapse with much less oversight. 

The hardest part for others to accept is that the risk is worth it. True recovery must mean the person not only takes ownership for her health but for her life. Successful treatment cannot leave that person unable to function in the world as an independent adult.


The Internal Suffering of an Eating Disorder

The emotional suffering someone with an eating disorder endures can be hard for others to comprehend. An illness wrapped up in the most basic human function as eating perplexes even the most compassionate person. However, the fascination that comes with explaining the ins and outs of having an eating disorder glosses over the crux of the problem: the overarching experience of internal suffering. 

As much as someone with an eating disorder does not want to discuss food, weight and body image, the most shameful component is the eating disorder thought process. Early in the illness, these thoughts are comforting and readily accepted as one's own. They simplify the complexities of daily life into rigid rules about food. Following them carefully leads to immediate success and, through weight loss, elicits praise from others. 

Time reveals the truth about the thoughts. They limit life experience greatly, interfere with psychological and emotional maturity and isolate the person from family and friends. By the time these truths become evident, the person is locked in the prison of the thoughts, unable to break free without a significant commitment of time and energy to learn a new way to navigate life. 

The compassion someone with an eating disorder most needs is for these thoughts. The psychological component of an eating disorder is comprised of relentless thoughts and compulsions to follow rigid, nonsensical rules of eating. Not doing so leads to punishing thoughts and even the experience of screaming in one's head. One and all, people with eating disorders describe these thoughts as extremely painful. 

It can be hard to imagine what that suffering feels like, yet attempting to do so shows a more profound sense of compassion and even an attempt at empathy. There is nothing more powerful a therapist, family member or friend can do to show true love and support for someone in recovery.


Personal Connection in Therapy

There is a piece of advice I give people who contact me for referrals. Even in a city like New York which has a large number of mental health professionals, it can be hard to find trained, experienced therapists who treat people with eating disorders. These qualities are necessary but not sufficient to choose the best therapist for each individual.

The advice is simple: make sure you like and feel comfortable with the therapist from the start. Everyone describes the experiences of clicking with a person when first meeting. Whether it is related to personality types, background or common interests, the reasons are not always clear but the feeling is universal. 

After finding a few referrals for experienced therapists, the best next step is to trust your instincts. Talking about food and eating disorder symptoms will be a very personal and vulnerable time. There will be ups and downs, starts and stops.

The sense of a true connection with the therapist will make the difficult steps easier to manage. Believing there is something important in that relationship creates a bond that can begin to challenge the tenacity of the eating disorder and present a road to recovery. 


The Importance of Present-Focused Treatment for Eating Disorders

Current trends in therapy reflect a thought process favored in the general community: mindfulness. Originally coopted from Eastern philosophy and Buddhism, the concept of being present and mindful rails against the Western, and especially American, mentality that striving for the future brings satisfaction and happiness. 

An eating disorder thrives on a mind always looking ahead to the next best thing. As long as the attention remains elsewhere, the eating disorder thoughts easily dominate any thoughts in the present and focus on maintaining the obsessive, rigid eating patterns at all costs. 

Clinicians who treat people with eating disorders agree that insight into personal emotional struggles and interpersonal dynamics have their place in therapy but will not be the cornerstone of effective recovery. Meaningful sessions can occur for months or years with no appreciable change in the illness. 

What is often mistaken for lack of motivation or drive in someone in recovery is in fact a lack of focus on the present. The energy and attention needed to challenge the eating disorder thoughts at every meal and snack and every moment in between are critical but exhausting parts of real recovery. The automatic response to listen to the eating disorder comes with slipping into the illness but, in that moment, also leads to palpable relief. 

Present-focused treatment leads to discomfort in two ways. First, the person will be more able to think and feel clearly with better nutrition. For someone used to being disconnected due to starvation, this experience is very challenging. Second, the fears and insecurities that come with facing the aftermath of the eating disorder are emotionally challenging and threaten to push the person back into focusing on the future, thereby returning to the confines of the illness.

The key is to stay in the present despite these experiences and to use therapy to get support managing them rather than use therapy for less necessary insights. 

Most therapists agree that the best way a patent can stay in the present is through support. Regular contact with the treatment team combined with support from friends and family who understand the illness work best. It is most helpful when daily interactions reinforce the need to stay in the present and remain focused on the challenges each day, not the goals and changes that may come down the line. 


The Role of Transitional Programs in Recovery

One of the changes in recent years in eating disorder care is the advent of transitional living centers. 

Residential programs are a central part of treatment but have several limitations. One major concern is that very few patients can stay long enough to receive the full benefit of the treatment.

The longstanding malnourishment and diminished health from an eating disorder remain even after 6-8 weeks of residential care. Since prolonged starvation is the main catalyst for persistent eating disorder thoughts, every patient who leaves treatment after a short stay is at significant risk for relapse. 

The typical reason people leave treatment is related to health insurance coverage. The companies, wary of the prohibitive cost, monitor health changes every day during a patient's admission and determine criteria to insist upon discharge as quickly as possible. 

Often the medical monitoring in a residential program--less than a hospital but still very complete and costly--is unnecessary for many patients after 6-8 weeks. The high rate of relapse shows that day treatment programs are not sufficient either as the step down from residential. 

Transitional programs provide an alternative to bridge the difficult gap from residential to outpatient treatment. Patients live in a setting with other people in recovery and with recovery coaches who are available twenty four hours per day. There is constant support and the expectation that each person will follow their meal plan. 

Daytime hours however are flexible. Patients can attend outpatient treatment programs or transition to volunteer or part-time jobs. The experience allows a more steady and less suddenly shift from the inpatient bubble to the various stresses and uncertainties of daily life. 

As of now, transitional programs are connected to individual residential programs and are not generally covered by insurance. It would behoove the eating disorder treatment world to offer transitional living as a viable and cost effective strategy to treat chronic eating disorders and increase the likelihood of recovery.

Extending the period of regular nourishment and improved health increases successful recovery dramatically, and transitional programs can be a key part of that process.