People with eating disorders have often intertwined their identity and sense of who they are with their illness. Even calling it an illness can be frustrating to hear. It doesn't feel like naming a disease but instead seems like a personal attack on one's character.
For people with this conception of their eating disorder, there is no clear distinction between the illness and themselves. Any interaction is, by definition, an interaction with the eating disorder.
This fact makes looser boundaries in therapy tricky. Openness in treatment is effective in large part by communicating that the personal connection is between the therapist and the patient, not her eating disorder. This concept can feel not only abstract but almost impossible to those who view the eating disorder as an integral part of themselves.
In this scenario, the closeness and connection in the therapy relationship, which is very real, either leads both parties to ignore the presence of the eating disorder altogether, thereby colluding with the illness, or to work around it with little success, ignoring the elephant in the room.
If the looser boundaries enable the person to see how limiting the eating disorder can be and how much it interferes with living life fully, then the therapy can start to create enough distance from the illness to separate it from identity.
If the person cannot pull away from the eating disorder, the relationship begins to feel hollow. A connection built on the foundation of an eating disorder will not have enough solid ground to continue unless the goals shift away from recovery.
It is a painful realization to know that therapy has made a difference in someone's life yet has been unable to separate that person from her illness. Because of the looser boundaries and the intensity of the connection, the emotional fallout from this realization can be strong. In what seems like a last gasp, the power of the moment can sometimes galvanize the treatment to have a more profound impact. It is critical never to lose hope, neither therapist nor patient.
The end result is that the therapy relationship has to be a true bond to have success in treating an eating disorder. The subtle ways an eating disorder clings to a person, an insidious virus boring into her life, are so hard to overcome. The boundaries, openness and trust are all crucial pieces of recovery. There are risks in that type of treatment, but the potential benefits far exceed the downside.
The benefit of reconsidering the boundaries in therapy for someone with an eating disorder is straightforward. The feedback from patients and evidence of its success are both very strong.
The boundaries in therapy were originally aimed at creating an environment in which the patient can objectively analyze and understand emotions and behavior. The relatively blank slate of the therapist acts like a mirror for the patient to better understand herself. The therapist works hard to reflect observations of the patient to help her make better sense of her inner self and interpersonal relationships.
Eating disorders are almost like insidious viruses in the mind. The illness starts at a formative age when identity is still malleable and confounding. The physical manifestations of the eating disorder generate a lot of response, often positive. This feedback loop tends to reinforce the thought process of the illness and cements it as a core part of identity.
By the time the person realizes the destructive presence of the illness, the thoughts are such a central part of the self that separating the two feels like an exercise in futility.
If the therapist erects firm boundaries and invites the patient to look inward, therapy just reflects back the obvious: the patient has an eating disorder that is a strong part of identity.
Effective therapy for eating disorders needs to break down typical boundaries and create a much more genuine relationship between therapist and patient. The goal is for that connection to be established between the therapist and the healthy part of the patient, the non-eating disorder part.
This bond, a critical one to learn for recovery, allows the patient to see that powerful relationships outside the purview of the eating disorder, increase the impetus, over time, to challenge the thoughts and do the work to stick with recovery.
Patients often say that the effect of this therapy is that they feel seen or heard without the eating disorder symptoms. That feeling of recognition can serve as a strong motivation to believe true recovery is possible, a necessary component of any effective treatment.
The most significant downside of these boundaries is for the patient either slipping or in a relapse. That person has lost all connection with the healthy part of herself, the part not connected to the eating disorder. It makes it feel like any genuine connection in therapy is lost, and that loss causes enormous pain. Returning to recovery will quickly bring back the real relationship in therapy but can still take work to mend.
Traditional psychotherapy focuses a lot of attention on creating boundaries in the therapeutic relationship. This concept applies to concrete measures such as a clear beginning and end to the session and rules about contact between appointments. There are also more gray aspects to boundaries such as the therapist sharing personal information or ensuring the limits of the personal connection in therapy so the treatment can focus on the well-being of the patient.
Many books and articles delve into the effects of setting boundaries, and newer therapeutic orientations explore the benefits of looser boundaries. The evolution of the meaning of this term in recent years reflects changing attitudes and expectations for therapy in people's lives.
Certain illnesses such as eating disorders force the therapist to take a closer look at the boundaries in treatment, especially when present attitudes about the therapy relationship do not coincide with the most effective care.
The psychological component of an eating disorder is relentless. The thoughts to restrict food or binge, buoyed by the constant need to lose weight and the feeling of inadequacy, press to the fore of one's mind over and over again.
The only way to placate them appears to be engaging in the eating symptoms. Struggling against those thoughts to try to follow a meal plan and then manage the feelings that surge forward when not numbed by eating disorder symptoms can feel like a never-ending battle.
The most successful treatment for eating disorders involves regular contact between the patient and treatment team. The person needs very regular support in order to successfully confront the eating disorder thoughts throughout the day.
In order to be available enough for recovery, therapists often loosen the boundaries significantly. This change undoubtedly has an effect on the therapy but also gives the person the support necessary to be able to continue effective recovery.
In treatment that works, the therapist-patient relationship strengthens considerably and may even become very personal even though the boundaries of a professional relationship remain clear. This dichotomy can be confusing and is even a point of contention within the community of clinicians treating people with eating disorders.
The next two posts will present the pros and cons, respectively, for loosening the boundaries in therapy for an eating disorder and explain how this component of treatment is critical to meaningful recovery.
During a conversation with a therapist last week, we stumbled upon a word used often in treatment with questionable relevance to eating disorder recovery: enabling.
This word, first linked to recovery from substance abuse, is used widely with varied meanings. It is not a clinical term but instead a warning to family, friends and clinicians about relationships with people struggling with addiction.
The original meaning refers to the support of the faulty reasoning of a person consumed by addiction. This definition has merit. The thought process of someone lost in addiction can transform logic and reason into the means to continue the troubling behaviors. Loved ones and clinicians need to point out the discrepancy even if that leads to conflict.
This meaning of the word can apply to people with eating disorders as well. Eating disorder thoughts can be very tricky and convincing, even as they lead directly back to using symptoms. Agreeing with faulty logic does not help that person continue a road to recovery but very much the opposite.
As the term has moved into the lay lexicon, the meaning of enabling has morphed into something more insidious. It is used to discredit all thoughts and logic of someone who is ill, even when the person's thought or opinion has nothing to do with addiction per se.
Granted, this is a fine line, but completely disempowering a person attempting recovery is not supportive either. With this expanded definition, enabling can mean that agreeing with anything at all that the person says is a mistake, rather than applying the term only to thoughts related to the addiction.
This expanded definition is the one most often applied to eating disorder recovery. Clinicians or family can immediately and irrefutably disagree with any decision the person makes about her next step by implying that it is enabling. Thus, the patient loses faith in all of her thoughts and does not learn how to trust her emotions and instincts in the long run.
People with eating disorders, as opposed to those with substance abuse, struggle to find their own voice in the world. Using a term thoughtlessly that discredits their feelings and opinions counters much of what true recovery needs. There will be many situations when eating disorder thoughts do dictate decision making, but relying on the term enabling to insist the ill person is always wrong is not helpful either.
The focus in psychiatry in the last couple of decades has switched to psychopharmacology. The combination of the burgeoning field of brain science and the powerful draw of the pharmaceutical industry lured budding psychiatrists from the world of psychoanalysis into neurotransmitters and SSRI's. Although there are pockets of devoted psychoanalysts and therapists in the country, psychiatry has been increasingly pigeonholed into a drug dispensing field.
That message is very clear to people searching for help with mental health concerns. Many patients express surprise that any psychiatrists do more than write prescriptions, even when that pertains to treating people with eating disorders.
Not infrequently, new patients with longstanding chronic eating disorders search for help online to make a new, brave attempt at health and recovery. More often than not, the appeal to expose themselves again to the pain and challenge of trying to get well is the possibility of a new effective medication.
When I see people in this situation, I try to convey the message that there have been no breakthroughs in the treatment for eating disorders. Recovery is still hard work and requires the patience to weather the ups and downs of learning how to eat again and to manage the tenacious eating disorder thoughts, but I quickly learn that these patients have already been down that road. I find it hard to deter them from looking for the magic bullet, namely a new medication cure.
Despite the promises made in print ads, photos of people magically cured by a drug and the occasional unlikely anecdote, medications do not provide immediate relief from mental illness, especially from the suffering of an eating disorder. If a medication can ease anxiety or depression somewhat during recovery, then it might help open the door to improving the symptoms. It is crucial to understand the value of medications in recovery and not be wooed by false promises.
That being said, finding the path back into treatment can very much start someone towards recovery. My goal is to realistically chart that path and help the person who bravely stepped back into treatment to use that momentum to make real changes. Taking the step to seek help, in any way that transpires, is paramount and something to be proud of.
Disappointment that medication is not a panacea does not have to deter that person from a new step towards wellness. Recovery can come at any age and at any stage of the illness. Hope does not have to hinge on a magic medication but instead on the real decision to re-enter treatment.
A new law described in the New York Times is making its way through the parliament in France could set new, stringent regulations against extremely thin models and retouched fashion photos.
The law would mandate that models meet BMI-determined weight criteria and be deemed healthy by a doctor before being allowed to work. Violation of these provisions would lead to a hefty fine and possible jail time for the offenders. In addition, all photos that are retouched would have to be labeled as such in any magazine.
The purpose of the law is to "fight malnutrition," as stated by the main proponent for the law. It's clear that this law is meant to reduce societal encouragement of extreme weight loss and to penalize media which idealize sanctioned starvation.
The one statement in this article which did not support the law said that the effects might oversimplify what causes anorexia, but this person is completely mistaken. As I have written here many times, starvation is the first step towards an eating disorder. It triggers the starvation response, a predetermined reaction which may lead to an eating disorder. Discouraging dieting can decrease the incidence of eating disorders.
This regulation is no panacea. The weight restrictions will still leave models looking unnaturally thin but not skeletal. The societal effect of the industry will persist.
But what is crucial here is the message. For a government to sanction against the freedom media has over determining the norms of body shape and size is very significant. The statement tells its people that the persistence of extremely underweight models is not just detrimental but illegal. There are boundaries in terms of what is acceptable for fashion companies to promote through its business.
It's notable that the pervasive effects of industry are starting to receive government attention. A larger step would be to address this attention to the effect of the food industry. The fact that these companies are allowed to sell food that has had such negative effects on a population's overall health without any government regulation is shocking.
It is time for people to understand that much of the blame for the drastic change in overall nutritional health does not lie with individual, as industry would like us all to believe, but with business and advertising.