Reflection on First Consultations

I wrote in this blog a long time ago about the first step into eating disorder treatment and wanted to review some of the key points.

It typically takes years for people to reach out for help and can often take a few tries before committing to really get well. The result is that first appointments are critical to help someone start the road to health. 

Much has been written about how to engage someone with an eating disorder and for good reason. Experienced clinicians know how difficult it is to transform a consultation into steps towards recovery. 

Unlike most initial consultations, gathering all the facts is not the most critical part of the initial appointment. There will be time to sort through details and understand the facts. This first meeting must emphasize the reason for meeting. After years of illness, what has led to following through with getting help? Namely, what has changed to make this session possible?

It's often a difficult question to answer, but the purpose is to consider what might have begun transforming in that person to want to address a longstanding part of her life.

A marker of success of that first appointment is to help the person have enough perspective on her life to consider herself separate from the eating disorder for a moment and realize that recovery is deeply connected to that separation. 

Looking back at recent posts in this blog, I realize the existential component of recovery begins from the first appointment. Reflection on one's own value and purpose underlies the first session and emphasizes the most difficult part of treatment: finding meaning outside of the eating disorder. 

Stepping into treatment is a courageous act that needs to be matched by direction and courage from the clinician as well.


Existentialism and Recovery, Part 3

Modern life does not often force us to rethink our basic philosophy years into adulthood. There are certain circumstances--such as illness or tragedy--that do so, but many of the comforts of the western world mean basic necessities are a given.

Granted, it is easy to be lulled into a deep sense of complacency and live out our days, and many of us do live that way. However, the process of eating disorder recovery mandates a profound inward exploration.

Meaning for someone with an eating disorder always revolves around food and weight. Whether positive or negative, food and weight are the primary aspects of life that matter. Everything else is secondary.

It often takes years to realize that prioritizing food and weight pushes everything else down the list. There is no room for meaningful life changes in these circumstances. That realization is usually very painful because it begs the question of what is lost by ignoring so much of life for the disorder. It's often a triumph of the mind to even engage in this conversation.  

At this point any discussion of recovery has to avoid the discussion of regret, bitterness or unfairness. These feelings or thoughts may have a role in the long run but threaten the real discussion of life right now. An existential discussion must focus on what is important at the moment, how to start down a path that will make those things possible and how the eating disorder limits living one's life fully. 

But the discussion has no clear guidelines. There is no specific type of therapy or plan that makes a conversation about the human condition any easier. I, like any other therapist or any other person, am just another human engaged in this challenging and scary topic.

But an honest, heartfelt, genuine experience discussing these issues can make several things clear. Life cannot move forward without changes in priorities. This is our chance to live. Decisions we make now matter more than anything. 

The final aspect of existentialism lies in living in the present moment. Eating disorder thoughts co-opt one's mind to spend the present focused only on food and weight. Any other thoughts are relegated to the future, which is put off indefinitely.

All we have is now, and blind pursuit to remake the past or focus on the future clears the way to ignore the present. In recovery, eating sufficiently means facing the thoughts of the illness now in order to live in a new way. It's a leap of faith to trust that this new direction will create true, deeper meaning in life.


Existentialism and Recovery, Part 2

The rules and laws of an eating disorder give order and direction to one's life. Even if the end result is punishing and unpleasant, there is something powerful to ending a day knowing you have done everything correctly. 

The sense of purpose to eat less, lose weight and follow the rules solves the existential struggle for many people with eating disorders. It's such a relief to escape the tyranny of judging the value of life and instead rely on food and weight as clear markers of success and failure. 

Describing an eating disorder as a calling or set of rules to live by is incredibly confusing for non-believers. How can food and weight replace all the other aspects of life that matter?

Fundamentally, these disorders create an entirely new world to escape to. The rules are clear. The purpose every day is obvious. The reason to live and strive self-evident. There are other people in the world who become so attached to a movement or cause that it justifies their existence so why not an eating disorder?

What the mental health world seems to have trouble seeing is that eating disorders could just as well be a movement. In fact, that component of eating disorders reveals itself in pro-Ana and pro-Mia websites. I don't support them at all as I have written many times in this blog, but the belief system of an eating disorder can be that powerful. 

Take away this purpose to live and the existential crisis of recovery is evident. Years of having a clear reason to live cannot just disappear overnight. The sense of loss of a direction and also the thought that this direction has never been as meaningful as it appeared are enormous. 

The process of recovery must allow for the breadth and scope of reevaluating the most basic and most potent aspects of life. Relationships, family, love and career all become secondary to the eating disorder when someone is sick. Disobeying the rules by eating and nourishing one's body begs the question of why bother even considering either one? What is the purpose of eating like everyone else and still living each day? Are these other aspects of life worth fighting to get well?

The answers aren't obvious or clear. I don't pretend to know why each of our lives matter. A psychiatrist or clinician can have those conversations but cannot pretend to know the answers. 

The next post will delve more deeply into these questions, not for answers but to explain why the conversations are so important.


The Role of Existentialism in Recovery

Eating disorder recovery is, by its nature, an existential exercise. Once someone has found an answer, if imperfect, to so many personal struggles through the disorder, it feels impossibly hard to give up that success for the uncertainty of daily life. The underlying questions behind the painfully difficult stages of treatment are what is the purpose? Why should I go on?

There are a series of trite answers that minimally trained clinicians or poorly run programs use. It's fairly common for these practitioners to label this ambivalence as a psychological obstacle and to end treatment until that person is "ready" to comply with all the conditions set for recovery. 

These rigid guidelines reveal the discomfort therapists or programs have for painful existential crises that create deep ambivalence and painful decisions of the value of life without the eating disorder. 

The only way to process this confusion is through it. There have been moments in recent decades when psychotherapy and psychoanalysis have embraced the philosophy of existentialism, but recent years instead leaned towards short-term cognitive therapy: face the thoughts and feelings, place them in an organized structure and fix the problem. This approach has a lot of merit, even in the treatment of people with eating disorders, but is completely invalidating for those deeply struggling with the meaning of their own life. 

Because eating disorders grow with the burgeoning identity of the sufferers, there is a complex interweaving of oneself and the illness. The subtlety and compassion needed to be willing to see this conundrum are very significant.

The next few posts will outline what this existential crisis looks like and how it is at the heart of eating disorder recovery. Few illnesses intertwine so closely with emotional and psychological maturation. Undoing and then reconfiguring the sense of oneself are heady and very challenging endeavors.


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.