Eating disorders begin at a particularly vulnerable time of life. Adolescence revolves around conflict, namely the push for independence vs. the yearning for the safety of childhood. The urge to break new ground and become a separate person combined with the still immature understanding of identity often leads a confused teenager to simple, even comical, shifts in their persona. No reasoning can dissuade the adolescent bent on fashioning themselves an acting prodigy, an expert on political debate, the ultimate savvy socialite, the IT guru or just plain right about everything. The sudden changes in identity, the need to be instantly best at something, the urgency and totality of every self-invention all represent the desire to solve the problem and become someone else, as if identity can be chosen in a moment.
But that's exactly what an eating disorder can do. The eating disorder gives instant purpose in many ways. First, the power to manipulate your body is clearly prized in society. The disorder creates a long list of rules about how to live life: all decisions are made based on when, how and what to eat. The comforting and even superior feeling of having a way to live and a physical identity to cling to is incredibly satisfying. Suddenly, the desire for identity is complete. With the onset of symptoms comes attention and praise. A potentially life-threatening, debilitating illness can be the envy of everyone, at least for a moment or two.
What passes for a magical identity in adolescence is an albatross in adulthood. When identity forms around an eating disorder, the complex and mature inner sense of who we are never comes into being. Linking identity to the goals of an eating disorder leaves a hollow, empty feeling inside. The power to manipulate one's body and the eating disorder rules appear meaningless when the internal struggles change after adolescence and into adulthood.
However, if someone is still stuck in the illness come young adulthood, there is no easy way out just because one's psychology no longer needs the eating disorder. The urgency to find a new philosophy of life isn't enough to escape an eating disorder, and life without the eating disorder feels impossible, as if the core of one's being is being taken away. So the most common result through young adulthood is that identity and the eating disorder fully merge.
A clinician needs to be aware of this psychological process. The patient may be clear about wanting to get better but may not understand that their identity is so tied up with the illness. No one can get better when they are the eating disorder. When the behavioral and psychological symptoms appear to be very fixed, therapists often ascribe stalls in recovery to low motivation. The frustrated therapist's message boils down to: "If you would just buck up and eat, you will get better."
More often, the attachment to the disease as identity makes clear, visible progress so terrifying that the person ends up paralyzed. The desire to get better has little effect in the face of losing who you are. The best analogy is the child sports star suddenly unable to play or the child actor whose career dries up. An eating disorder feels like an achievement in adolescence. It's an accomplishment to have conquered food and body when so many others struggle with weight and self-image every day. Eating and having a normal body feels like letting go of the only true achievement in life. From that vantage point, getting better isn't about motivation. It's about losing your one anchor and entering a terrifying unknown.
The work in therapy is to separate identity from the eating disorder. This concept may make sense abstractly but is harder to imagine practically. The truth is that after years of being sick, the patient does have an identity and personality separate from the eating disorder. That's clear to anyone who knows the person. But identity is not what others see; it's what you see in yourself. The clinician's job is to repeatedly point out what other people see instead. Helping the person see themselves through someone else's eyes can gradually shift identity as well. The goal is to recognize that the internal identity of the eating disorder is, and always has been, false.
Starting to question our being is the hallmark of adolescence. Even a few years later in life, the disorientation of such urgent self-reflection is more daunting, the pull back to what we know even stronger. When the source of safety is a tenacious illness, the process of forging a new identity is even more frightening. For the gradual separation of identity from disorder to last, therapy must use the person's outside life to reinforce the false safety of the illness. Engaging friends and family in the process will allow the patient to understand that others see a very different person than she imagines. When trying new activities or meeting people in new situations, each opportunity calls into question whether identity is really just the eating disorder. By applying constant pressure to the assumption that the eating disorder is everything, the therapy can gradually drive a wedge between patient and illness and open the door to different expectations in life.
The next post will address more practical steps to separate identity from the eating disorder.