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.

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