The Role of Coping Skills in Eating Disorder Treatment

Eating disorder treatment programs focus a significant portion of education in recovery on coping skills. These tools don't always translate easily from a closely monitored program into the real world. As a psychiatrist and therapist who works with many patients just discharged from a program, I help people negotiate the transition back into their lives and have worked hard to make sense of how coping skills can be constructive in recovery. I think the idea is useful but could also benefit from some clarification.

The concept of coping skills has a research foundation and therefore a pertinent beginning. The cognitive behavioral therapy model--the most used modality to treat eating disorders--helps patients identify moments in a day when they become vulnerable to eating disorder symptoms, mostly binging or restricting. Once the pattern and triggers are clear to the patient, the next question is obvious: what do I do next to stop the behaviors? Therapists don't always have the answers. It's easier to identify the patterns than it is to break them.

The default answer is to use coping skills. Effectively, this means sit with the urges to do eating disorder behaviors and distract yourself with a variety of mundane activities until the urge passes. It's assumed the urge will pass. This assumption is a result of the original research used to support CBT, first performed in mice, supported by increasing knowledge about brain function then applied to humans. The research conclusion is scientifically robust yet simple: one's urge to do something (drink alcohol, perform a compulsion as in OCD, avoid a scary place, use ED symptoms) will diminish if one can push through the anxiety and urges over a period of time, generally weeks. The gradual decrease in anxiety is called habituation.

With handy research in mind, the next goal of treatment is delaying the symptoms in any manner possible. Coping skills tend to be typical daily activities that pass the time: walking, reading, seeing a movie, calling a friend, painting your nails. Without other alternatives, most patients will try the coping skills with varying success depending on their progress in recovery. It's rare that someone doesn't throw up their hands and say, "There's got to be something better than this in treatment." But that's not necessarily the case. 

Treatment programs have, for obvious reasons, much more success stopping the eating disorder behaviors than outpatient options. It's much harder to follow through with the symptoms when you're being watched 24/7. So people in treatment programs have hours during the day when they have to sit with the urges and can't do anything about it. This provides ample time to practice coping skills. But these opportunities are just practice. It's only the real thing when doing the eating disorder symptoms is a viable option. That transition from the constant observation of a program to freedom in the real world makes applying coping skills tricky. 

I very much respect and use the concept in treatment. When eating disorder behaviors are routine, changing them, as with changing any ingrained behavior pattern, takes one's full attention and requires a long period of discomfort. Habituation seems to occur faster in some situations than in others, and eating may be too innate and ingrained a behavior to change quickly. In truth, using coping skills is a kinder term for white-knuckling it. But any recovery from an eating disorder requires it.

What the use of coping skills points out to me is the weakest link in the recovery. When someone is able to identify risky periods during the day, the points of vulnerability--the times when the eating disorder threatens to take over--become apparent. It's critical to realize that failing at coping skills is not failing at recovery. It just points out where work needs to happen in treatment.

There is a certain kind of learning through repetition, namely slips into eating disorder symptoms, that happens back in the real world outside of a residential treatment program. Those times when coping skills don't work typically point out where someone doesn't yet believe or understand the psychological adjustments necessary to push through the urges. Examples are not being able to eat enough to satisfy hunger or the inability tolerate being full or the fear of gaining weight or not being "small" anymore. If a significant amount of time in therapy is devoted to arguing or bargaining around these issues, then it's clear what the snag is. Meal plans and adequate nutrition aren't bargaining chips or variables. They're the only way clinicians can track medical stability and progress in recovery and the only path towards recovery. Although there are different, often creative, ways to reach these goals, in the end they must be met. 

Coping skills work best once a patient and therapist are on the same page with these central aspects of recovery. Then there's a purpose to experiencing long periods of discomfort or even pain. Once the eating disorder thought process is no longer primary in someone's self-assessment, white knuckling it becomes a difficult but necessary part of getting well.


A New Take on Identity and Eating Disorder Recovery

Far From the Tree, a true masterpiece of a book written by Andrew Solomon, addresses the link between identity and various illnesses and disabilities for children and their parents. I can't do justice to the work, but his thesis has clear implications for people with eating disorders and is very relevant to this blog.

In fact, he briefly addresses anorexia and bulimia, referencing pro-Ana and pro-Mia websites as examples of activist movements for people with illness or disability. However, he quickly dismisses the premise because eating disorders are fatal and thus cannot compare to similar movements such as for deaf people or dwarfs. 

To be fair, Mr. Solomon didn't research eating disorders in the way he so thoroughly did the other issues chronicled in his book. He may have been better off leaving this one alone, but he does touch upon something critical and confusing about how eating disorders are linked to identity.

The controversial eating disorder websites are certainly dangerous, and supporting an eating disorder as identity only increases the morbidity and mortality of these diseases. But in light of the topic of identity, the pro-ED sites also reinforce two things necessary for successful recovery. First, much as the other illnesses Mr. Solomon discusses, people with eating disorders did not choose their disease and don't choose to stay sick any more than someone with Down's Syndrome or cerebral palsy. Second, unlike these other issues, people with eating disorders can get better but the process involves relinquishing the core of identity since adolescence--the opposite of the premise of the book.

Mr. Solomon draws the reader in to story after story of heartbreak, resilience, transformation and acceptance. After hundreds of pages, it's exhausting but exhilarating to realize these stories could go on ad infinitum. A crucial part of each person's path is acceptance of the limitations of the illness combined with taking pleasure in what life can still offer. Implied in acceptance is coming to terms with the identity of the disability or illness, both for the person afflicted and for the parents.

There is a clear demarcation here between eating disorders and the illnesses described in this book. Chronic eating disorders always intertwine the thoughts and behaviors of illness into identity, inextricably and with finality. The result is that the person feels bereft even at the thought of letting their illness go.

Recovery involves stripping away all sense of oneself so that this person can start over, raw, unprotected and very much alone but with the hope of a life free of this terrible affliction. Disavowing one's identity for anyone discussed in Far From the Tree is denial and leads to an extremely limiting life. Doing so with an eating disorder is a painful but necessary step in recovery.

The activism in the eating disorder world must explain that recovery involves relinquishing identity to start over. Learning how to live without one's guiding force, destructive though it was, is a tall order. Recovery means creating a new self and life, not just eating more food.