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.


The Combination of Support and Love to help Someone in Recovery

A message to the family and friends of a loved one in recovery bears repeating. The most important thing to say at all times is the following: I love you and support you no matter what.

Based on the premise of the last post, it feels imperative to explain how to put that information into practice. A common way to help people through challenging experiences is to praise their progress and achievement. These statements provide both acknowledgement of the hard work and recognition of the results. 

Extension of this kind of support appears on the surface to apply to someone with an eating disorder. It's not clear at all why a simple vote of support and confidence would be harmful, but it is. 

The eating disorder not only represents a way of facing food in daily life but also a way of navigating the world and of understanding oneself. As an all encompassing philosophy of living, the eating disorder thoughts have been the structure influencing the person's thought process and decisions every day. 

Choosing to ignore the thoughts and live as someone without an eating disorder may be a new and compassionate way to see oneself, but it is also excruciating because it means stepping away from a way of life that is safe and into the vast unknown. There may be the opportunity for love in the world without an eating disorder but it feels vulnerable and scary. 

Words of encouragement only reinforce the fear and exposure of steps into recovery. Telling someone they ate well or look good or have been really present in life may all come from the heart, but these statements reinforce the terror of being in recovery. Acknowledging the real steps into wellness is hard to do but it is especially hard to realize others see it as well. 

Reminding the person she is loved and has support in this scary environment provides different support and something much more needed. These words reinforce the opposite of the eating disorder, love, and help the person understand that even in recovery, she will be ok.


The Opposite of an Eating Disorder

A somewhat corny phrase has popped into my mind recently about recovery. On the surface, it appears that the cure or the opposite of an eating disorder is eating regularly and maintaining health, yet a more true statement in my experience is that the opposite of an eating disorder is love. 

These illnesses promise a utopia of sorts when someone fully dives into them. The rules and strict guidelines of an eating disorder provide a powerful feeling of safety and comfort, something coveted by most people suffering with them. The uncertain and unmanageable aspects of life, both external circumstances and internal thoughts and feelings, become irrelevant compared to the reliability and consistency of the eating disorder. 

The reality of these rules is a life of isolation. There is no room for friendships, relationships or, most importantly, love when the eating disorder blocks any path towards meaningful connection. Real love and caring are fraught with land mines: vulnerability, feeling misunderstood and being hurt. The eating disorder causes suffering but with no surprises, and the benefits are clear. 

It may be obvious that the love from an eating disorder is lonely and hollow. An eating disorder cannot replace the true connection from another person but merely distract the sufferer from her pain. 

Recovery involves engaging with people directly, not from behind the veil of an illness but in a true and genuine way. A sensitive and emotional person will struggle at first with the raw vulnerability that comes with opening up to others and caring about building relationships. However, even a few positive steps in a friendship are often enough to remind the person of what she has been missing. 

Through this experience of love, recovery can take significant steps forward. The thoughts and behaviors of an eating disorder may be ingrained, but the pull of true connection serves as enough of a carrot to take the meaning and power away from the benefits of an eating disorder and make the struggle of recovery worth it.


Thoughts about the Transition from Residential to Outpatient Treatment

One of the rockiest parts of eating disorder recovery is the transition from residential treatment back into real life. Navigating that step plays a large role in the benefit the inpatient experience can give. 

Although treatment programs provide many necessary and valuable opportunities to help people challenge the eating disorder thoughts, certain parts of the illness lay dormant.

Ultimately, all food decisions are made by the program, so the internal struggle between restricting food and eating a sufficient meal is moot. Regular nourishment and improved health both substantially decrease the eating disorder thoughts, but the insidious urges to follow a trail back into illness remain. 

Treatment programs attempt to inculcate patients to sign on fully to recovery, to believe in their desire to be well, as a hedge against the inevitable return of these thoughts after discharge. This dynamic sets up a confusing and somewhat unrealistic situation upon re-entry into the world. 

The crux of a sufficient discharge plan lies not with the perfect arrangement of treatment providers. A well designed plan with gradual step down from more to less intensive outpatient programs combined with an experienced, caring and communicative team does not guarantee full recovery. The likely success of the transition rests instead with a plan to face the ambivalence, confusion and daily struggle to contain the eating disorder thoughts, a very individual and personal effort. 

Two aspects of treatment at this stage are critical. 

The first is the openness and honesty of the patient in treatment. The track record of anyone who entered residential treatment shows that battling the thoughts alone will lead to a likely relapse. Any way to be open about that daily struggle with any part of the treatment team means the person is not facing recovery alone. In and of itself, this openness changes the dynamic of daily life. 

The second is transforming ambivalence of recovery from another shameful or guilt-inducing part of this illness--a mental state likely to encourage relapse--into a natural part of the process. The idea of leaving behind something that has been a central coping mechanism and a source of individuality, despite the obvious negative effects as well, is very difficult. It's natural to experience mixed feelings when going through a deep, emotional and personal change. 

The transition from residential to outpatient treatment remains complex and challenging. Openness and acceptance of the ambivalence will help make this step even more successful for patients.