Most people can describe the gist of where their eating disorder came from, what they're missing in their life and what the eating disorder does for them, but it is an intellectual exercise and often only camouflage. Fundamentally, they don't really know what will help them get better. Focused and effective treatment of people with eating disorders needs to address the painful reality that their lives are run by the disorder without disrupting the core therapeutic relationship. This demands a few critical things: consistent but not judgmental attention to eating behaviors, unwavering compassion for the trials of enduring the illness, the capacity and desire to really listen, clear limits as to what therapy can do and what it can't and, most important, patience. When one of these ingredients is lacking, the patient will quickly recognize the deficiency and react, usually by getting angry or leaving the treatment. In a larger context, the therapist's job is to figure out which of these essential components means the most to the patient. In other words, what aspect of the relationship really helps slow down or even stop the symptoms.
For people whose symptoms do get better, there is a moment--or more likely a series of moments--when they finally see and feel what it is like to let someone, initially the therapist, into their lives. In that moment, a patient, who has only let herself exist in a small world hemmed in by a ruthless disorder, can finally see the freedom that exists for everyone else. What has felt like the calm sanctuary of the disorder transforms into the lonely prison she has occupied all these years. This is the opportunity for a patient to truly see what recovery looks and feels like, to finally arrive in treatment. It can be simultaneously terrifying to acknowledge how much time has been lost and miraculous to see the symptoms as relentless but for the first time not invulnerable. And this all happens with another person, the therapist. Allowing this real connection helps the patient realize what has happened to her, what is happening and how painful it all has been. The hidden suffering, even from the patient herself, becomes a moment of shared compassion for her struggle to try to survive the illness. At that point, when the intellectual exercise becomes grounded in the reality of living with an eating disorder and in the possibility of recovery, going back no longer feels like an option.
Patients often experience these moments as an immediate reliving of the entire course of the eating disorder but from a completely different point of view. This necessitates a rethinking of what the disorder has meant all these years. Most eating disorders begin between the ages of twelve and twenty, but the time of onset has more to do with luck and opportunity--such as enough privacy to use symptoms or exposure to really learn how to do them--than anything else. The vulnerability to the illness begins much earlier, as I explained in the last post. For many people, by the time they have ridden the course from initial exposure through the powerful, painful high of the first years of the illness, they are trapped. What felt like a choice, although it never was, starts to feel like a life sentence. The main delusion of an eating disorder, and what makes it so enticing, is that the person has mastered the world of food and weight and therefore is special, but the reality is quite the opposite: she is ill and unable to truly live. By allowing the therapist in and facing this reality, the patient irreversibly shatters that delusion. Re-evaluating every moment of the entire eating disorder opens up a host of emotions. It is a rude awakening from the blinding calmness the eating disorder creates and a personal challenge to find the resiliency to face a wholesale shift in identity and self-worth.
These moments of arrival perplex me more and more. As I explained in a recent post, it has been eye-opening to realize that women with eating disorders often seem less stricken by an illness then chosen by a set of core personality traits--ones well-suited to success--combined with the conflicting expectations of society. The near universality of these powerful moments in successful therapy has the same jarring effect on my understanding of eating disorders. The moments feel remarkably similar no matter how different the person or relationship. I feel like I have witnessed the shattering of the shared delusion so many times, but how can they all feel the same? The essence of psychotherapy reinforces that all people and therapies are different, and so the sameness of these moments becomes all the more striking and has brought me to consider that the derailed development of identity and self-worth, especially in children, may be the missing link. The realizations occur when success within the eating disorder stops being synonymous with self-worth. But this means that the patient's identity must have been intertwined with food and weight long ago, well before the eating disorder started. Similarly, perhaps no true self-understanding ever started to develop, and these moments in therapy may be the first ones--no matter the age of the patient--of recognition of her own identity and value in the world.
With this foundation, these moments of arrival appear to be the formative experiences of learning to know oneself--something the influence of media has largely replaced in a child's process of growing up. If the messages and influence of the media are inescapable, then the goal is not to fight back as much as to offer viable alternatives: a way out for the young girls who see no other solution than to build an identity around food and weight. It also explains why these moments in therapy are so similar. Each moment represents a collective experience of helplessness and frustration: if living through an eating disorder--the preferred lifestyle of the times--does not work, what else is there? Living through food and weight seemed like the only way to make sense of it all.
These women have practically become the casualties of a lost art of parenting: creating hope and opportunity and individuality in kids in lieu of the current message of striving and conforming to a meaningless norm. What other value do women have in our society? Where can kids, especially girls, find role models who believe in a different kind of self-worth? What is there to strive for when the media influences our every thought and feeling? This brings the post full circle. When I wrote above about what a therapist needs to do to create an environment to promote successful therapy, I also described what children need to avoid this exact pitfall. When I suggested the therapist needs to search for what aspect of the relationship alleviates the eating disorder symptoms, I also described what children need from parents, friends and the world around them to find their own identity and their own voice and not succumb to the reductive appeal of the world of the media.
Next post, I will try to expand on how to apply the critical aspects of successful therapy to parenting about food, weight and the media.