The process of separating identity from an eating disorder is not an intellectual endeavor. All discussing identity will do is lead to a stalemate. The illness dictates the person's every move and decision, like an oracle or a master, so discussion may be interesting but largely distraction. Moreover, perspective on one's identity is hard to come by, especially when that person is in the throes of an eating disorder.
Change will only come from action. Reinforcing the behaviors that go against the eating disorder will highlight the internal conflict between the illness and the person. No amount of discussion can make a person more aware of the powerful identification with the eating disorder than to disobey it.
The food journal, which I discussed in a post a few years ago, introduces a way to contradict eating disorder rules quickly and powerfully. Writing down meals and the rational and emotional responses to them has two immediate effects: engaging another person in the intimate details of the disorder and presenting the disorder as something separate--physically a piece of paper or an email--from oneself.
Even someone's initial reaction to the suggestion of a journal exposes the power of the illness and the fear of confronting it. Some people cannot even start the journal; some only write it for a few days while on "good behavior;" some write food but omit feelings; some write for pages and pages; some are shocked by the effect of letting someone else into the eating disorder. In every case, the effect of the food journal is indicative of how connected the person is with the disease and of the challenges that lie ahead to separate identity from illness.
At many points of treatment, the therapist has to point out new concrete steps to take such as adding in more food or adding in extra treatment. Invariably, these suggestions meet resistance. The patient knows more changes equal more time spent on recovery and more emotional turmoil. Anyone's instinct would be to push back. The therapist's job at these moments is to insist that these steps in treatment are a joint decision. The patient has to take partial responsibility for any change in treatment and to clearly state that her own intentions are different from those of the eating disorder. If the person believes the changes are enforced by the therapist, it's too easy to cling to the identity of an eating disorder. Over time, a sign of identity separating from the illness is the patient initiating discussion about new changes in behaviors.
Although certain moments of treatment are touchstones that highlight the struggle to wrest identity from the eating disorder, successful treatment is a long process. Years of embracing the eating disorder, as captive finds solace in captor, doesn't make separation easy. Even as the treatment makes clear the need to pull away from the illness and find new comfort elsewhere, it's hard to say goodbye to what had been the core of your being. Accordingly, the struggle between actions that reflect the eating disorder's wishes and those that reflect the person's persists in a long, drawn out battle, with days and weeks leaning one way or the other. The pressure in treatment to stay the course needs to remain firm in the face of the difficult internal struggle the patient must endure.
The growth of a new identity is a slow process but it works. The immediate experience for the patient of letting go of the eating disorder will often be blankness, nothingness. Understandably, that will trigger intense fear and a desire to retreat to the illness and what is known. Even the therapist may despair at times that treatment may not follow the path to recovery. Those times of worry and fear are a standard part of treatment. Those moments aren't a sign of failure but rather signs of the challenges of recovery. Reminding the patient of the process of separating from the eating disorder and learning how to eat and forge a sense of who you are and your life course takes time. The uncertainty may be frightening but experience has proven that the effort of intense personal work bears fruit. Decades of eating disorder treatment shows that finding yourself in treatment pays off with a new and satisfying way to live.