Trust in Eating Disorder Treatment

Relationships are the fundamental but unreliable cornerstones of daily life. We need people to chat with about the weather, people who will care about our problems, people who we just can't stand, people we nod hello to in the corner store, and above all people we love. Unexpectedly, trust is at the heart of not just the most intimate but all of these relationships.

Trust implies reliability. In any relationship, it is comforting to know what to expect, whether it is the daily chat about small things, the almost imperceptible nod of recognition or the hug that confirms you're not alone. In our increasingly isolated world, more and more common wisdom points to loving yourself first, yet so much of our self-image stems from the relationships we take for granted in our lives from the deepest to the most superficial. That foundation acts as confirmation that our own self-image is accurate and as a springboard for challenges we face each day: successes, failures and the critical feeling that we belong.
Learning to rely on an eating disorder means losing faith in human relationships. The eating disorder symptoms are always reliable. The immediate benefits are very predictable. Life, painful as it is, moves forward in a highly structured fashion. The experience of living with an eating disorder is a bold rejection of personal relationships and even the concept of trust entirely. Some people completely isolate themselves and others just keep their friends or even boyfriends at bay because the disorder remains paramount.
In addition to reliability, the second and more hidden benefit of the eating disorder is its availability. Unlike any human relationship, the disorder and symptoms never let you down. Any disturbing event, feelings or even thoughts can be eliminated by listening to the eating disorder and doing what it says. Unlimited access to such a powerful way of life is hard to replicate. No single person can be so available and so reliable. Existing alone in the world demands that the person handle the discomfort of feeling emotions and find the patience to let these experiences pass, both daunting tasks.
For any patient to embark on the process of recovery, she needs to reconsider her belief in trust and relationships again. I have written at length about the importance of the relationship between the patient and therapist in eating disorder treatment, specifically how that relationship can provide hope, direction and motivation to move a patient away from the security of the disorder towards a fuller life. The intimacy combined with self-reflection in therapy can help a patient question the truths that the eating disorder stands by: the certainty of her negative self-image and the fact that she must live life on her own and trust no one. But just the step of questioning these beliefs--which have been written in stone for years--begins the process of trusting in the therapy. And that means considering the unthinkable: learning how rely on others for a different view of herself and a new way to live. 
Once a patient begins this shift in her mindset, the treatment becomes a trial run for building relationships in life. That means learning what availability and reliability mean in personal relationships. The eating disorder literature postulates that the relationship in therapy needs to be nurturing but also gently authoritative. I have always understood these traits to represent those of a kind mentor who gives caring, firm advice. But these traits have also felt limited, as if the treatment were a revolving door, as if the therapist shouldn't really care too much. In order to compete with the eating disorder, the therapy--even better, the treatment team as a whole--needs to understand what it's up against. The team needs to work hard to provide reliable and available care to have any chance of competing. Although consistent, effective work in treatment can establish both of these in the session, that leaves many, many hours in the week when the person is still very alone.
In all of those free hours, a patient can start to drown in the eating disorder again. The thoughts of doubt turn back to shame and finally to an overwhelming surge of emotion. These experiences, many patients have told me, just don't usually happen to someone with an eating disorder. Before long, even the most motivated patient will cede to the inexorable pull back to the symptoms. For patients who start to believe in recovery and the therapeutic relationship, the goal is to learn how to hold onto the idea of recovery and the relationship as a buffer--at times even a buoy--to survive the onslaught of the disorder. Then the therapy can begin to provide comfort even outside the sessions. More often than not, contact outside the therapy is critical, by phone, email or even texting. Almost always, when the patient begins to think treatment can be reliable and available in a different but meaningful way, the patient is overwhelmed with the fear that the therapist doesn't really understand or care and even that the relationship isn't real.
What does a therapist say to that? When the therapy is bounded by a financial agreement and (hopefully) clear limitations, what defines real? Moreover, this line of reasoning is the last resort of an eating disorder, backed into a corner, saying, "I don't trust you and I don't trust anyone!" Although the therapeutic relationship is unique, this belief--so strong and dominant in the mind of an eating disorder--repudiates how we all function in this world. How can a relationship not be real? But there is a quieter voice behind this absolute saying something very different. This voice, the thoughts and feelings of the person behind the disorder, wants desperately to be seen and heard and cared for, but it also believes the relationship will ultimately be disappointing and eventually just vanish. After the internal torture by the disorder, the patient is terrified to trust anyone again. Each small step strengthens her belief in the therapy and in her ability to lead her life without the buffer of the disorder but also intensifies the terror of believing in trust and relationships again. The fragility of human relationships seems to pale in comparison to the certainty of the disorder yet also makes the patient feel real and human again. The ultimate goal is to reopen the visceral power of personal connection for the patient, and, hopefully, to make her feel alive again.  
The next post will reflect more concretely on how therapy can even begin to replace the availability of the eating disorder. This topic, not often discussed among therapists, is contact outside of therapy, and, more generally, the complicated nature of boundaries in eating disorder treatment.

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