By the time most people with eating disorders seek treatment, they have little hope their lives can really change. The symptoms and disordered thoughts are relentless and, without any perspective, it feels impossible to imagine seeing the world any other way. The impetus to seek help comes instead from either external pressure or internal desperation. So much of what I have written about recovery boils down to maintaining hope. The daily battle of questioning the eating disordered thoughts, trying to eat and engaging with the world is exhausting. Without a sense of purpose or direction, the emotional pain feels pointless. All too often, the hope dies and the treatment along with it. Dropout rates are notoriously high, so much so that just continuing therapy is a predictor of improved outcome. Circling back to hope as a touchstone--a benchmark of progress--is one of the therapist's primary responsibilities, at least until the patient feels ready to share this duty too.
Living with an eating disorder means being grounded solely in the present. The past and future are irrelevant: the thoughts about food and weight in the moment are all that matter. Any decision either follows or breaks the rules of the eating disorder. It is a success or a failure. By definition, this sense of immediacy cannot coexist with perspective--an ability to step out of the moment and see the bigger picture. And perspective is a necessary component of hope. Without that psychological and emotional distance, any progress or change gets buried under an ever-present sense of inadequacy and shame. But the immediacy that makes the eating disorder powerful is also what makes it safe. Lack of perspective means lack of an identity separate from the eating disorder and that feels special, as if the person has life figured out, as if she a free pass from the daily struggles everyone else has to deal with. Perspective means starting to disentangle the patient's own identity from the eating disorder. Even acknowledging this is a possibility has far-reaching consequences. It implies that a different path may lie on the horizon. I have mentioned several ways to gain perspective in previous posts: food journals, medical effects of eating disorders, regular review of progress and developing a meaningful therapeutic relationship. Each of these steps will cause fear and apprehension but also cultivate hope in a future of recovery.
With perspective comes a very different emotional understanding of the eating disorder. The thoughts that are so harsh, demeaning and critical remain powerful only when the patient is consumed by the urgency of the present moment. People with eating disorders are, by and large, compassionate when contemplating other people's struggles. Some distance from the eating disorder stirs up that same sense of compassion for their own plight. The conflict between these two internal reflections is a pivotal part of maintaining hope. Once the therapy touches upon compassion for oneself, distinct from pity or self-recrimination, progress becomes palpable. The therapist can regularly remind the patient of her own sense of compassion for others and the possibility of feeling that way for herself too. Hope springs from the gradual process of learning to see oneself with understanding instead of reproach.
The other important result of having perspective is how it shatters the idealization of recovery. Many patients view their own potential recovery through the black-and-white prism of the eating disorder: perfection or utter catastrophe. The fear of prolonged misery, even after starting to eat normally again, girds the patient from any sense of hope, compassion or change. With some distance from this narrow scope of the world, the prospect of recovery changes too. Life, with all of its messiness and complexity, becomes clearer and lets the patient off the hook from needing to attain perfection. As terrifying as things look from this vantage point, the therapist can help the patient learn to be grounded in this new reality and feel as if she can survive, mainly by emphasizing hope. The ability to even acknowledge a world of confusion and complexity is a phenomenal step forward. The latent desire to move away from the security of the eating disorder is the patient's own way of seeing hope for a different life.
Occasionally, a patient who has been a stalwart believer in the immediacy and identity of her eating disorder glimpses how the other half lives. After months of hearing me go on and on about perspective, hope and compassion, she will let slip a word or phrase that suggests she has been listening. It could be a side comment about the eating disorder as separate from her; or an acknowledgement that the treatment has affected her eating disorder; or a hint at the progress in recovery; or even a session with limited discussion of food and weight. At that moment, it is clear that something has shifted. Any one of these comments or omissions implies that the patient has begun to have some perspective from the eating disorder. More importantly, it shows she is ready to share the mantle of hope for recovery. Perhaps what appeared at first to be complete fantasy may indeed start to feel very real.
The next few posts will shift in a new direction. I will address the impact of media on the culture of thinness and strategies to cope with its broad influence on our lives.


Medical Complications of Bulimia

Unlike starving, the symptoms of bulimia--primarily binging, purging and laxative use--cause immediate harm to the body. No patient can deny the physical toll these symptoms take. For many, the pain and weariness is a welcome relief from the emotional misery of the eating disorder. Although most patients are terribly afraid of the potential long-term damage, they are just as likely to ignore the risks of their behaviors and signs of deteriorating health. Patients often confuse the immediate physical effects of bulimia with the chronic medical complications and thereby underestimate the serious long term risks. Like with starvation, the body has to adapt to malnutrition and nutrient deficiencies, in this instance from lack of digestion and malabsorption. Unlike anorexia, which the body has an evolutionary inclination to weather, bulimic symptoms are a trauma to endure with a cascade of increasingly toxic effects. 
The gastrointestinal system--the part of the body most immediately affected--functions through peristalsis, the muscle contraction initiated by swallowing that pushes food through the system's entire length. Binging, purging and laxatives all disrupt this muscle contraction in quite similar ways. Binging expands the stomach and slows or even stops the muscle contractions temporarily, an effect even more pronounced after purging. Laxatives actively stimulate the colon leading to forceful and often painful diarrhea. These tramuatic shocks to the GI system lead to a period of slowed peristalsis with limited digestion and constipation. After recovery, peristalsis gradually resumes; however, prolonged symptoms can impair the body's ability to return to normal function. For instance, laxatives are addictive and chronic use makes it extremely difficult to have a bowel movement without them. Persistent binging may permanently slow digestion as the stomach is regularly overwhelmed with too much food or expects the contents to be purged. Consistent purging can lead to GI reflux (the food goes backwards into the esophagus) which is experienced as esophageal pain and bleeding.
One lingering effect of bulimic symptoms is electrolyte abnormalities, most notably a low blood potassium level. Purging, laxatives and diuretics all lead to excretion of this essential mineral and a gradual decline in the blood level. Life is considered untenable as the potassium level nears 3.0, but to many doctors' shock and dismay, bulimic patients have been known to walk around with levels under 2.0. For some people, the body adapts to the low level and manages to survive, for a time, but this is the most sudden and lethal complication of bulimia. Low potassium affects the heart rhythm and can precipitate cardiac arrest. Chronic low potassium also leads to kidney damage, and patients with bulimia even end up needing kidney transplants.
These complications are the most destructive, but the list of medical complications is long and equally mind-numbing as that for anorexia: hormonal abnormalities including infertility, slowed cognitive function, breakdown of dental enamel, persistent fluid retention and swelling. Most patients sit quietly waiting for the medical lecture to be over and are too afraid to see the full impact on their bodies. Two factors can help break through the powerful denial and help patients begin to process the risks of their behaviors: fear and timing.
The most common binge trigger is fear: fear of emotions, fear of new situations, fear of people and, ironically, fear of really being hurt by the eating disorder. The last fear is pervasive but hidden deeply beneath the need to binge to survive daily life. Using this fear to chastise the patient drives a wedge into the treatment: no one recovers when being consistently hammered with clinical facts. The therapist needs to broach any discussion of medical complications from a place of genuine compassion and caring. Too often families, friends and, sadly, clinicians place the blame on the patient and undo much of the progress. By trying to understand--and perhaps imagine experiencing--these fears, the therapist can make it safe for the patient to let down her guard. Feeling understood for the first time will allow her to express these feelings and acknowledge her desire to be well and to live fully.
A therapist needs to choose the right time to discuss the medical issues. Even with a sense of safety, a mistimed discussion often becomes an ignored lecture. If a patient is feeling vulnerable and confused but also safe and understood, the medical information can get through and help her face the reality of the eating disorder. This component of therapy relies heavily on the therapeutic relationship and on the therapist's ability to surmise that the patient is ready to trust the treatment enough to face her reality.
These two posts highlight how damaging and even lethal eating disorders are. Patients and therapists are often afraid to discuss these consequences and risk overwhelming the treatment. At the same time, any therapist who avoids this discussion is remiss. Engaging in this part of eating disorder treatment successfully sidesteps the patient's most valued protector, denial, and opens the door for another deeper question. How do you maintain hope during treatment for an eating disorder? Look for the next post.