The term ego syntonic leaves out one psychological component of eating disorders. This term implies that the internal thought process feels like a crucial part of one's identity, but an eating disorder has a dual role in someone's life. It can be a part of identity and simultaneously feel like a separate and individual entity. A person with an eating disorder knows there are parts of themselves separate from the eating disorder but that having the thought process of the illness makes them feel safe, special and whole.
The eating disorder has two powerful distinct ways to hold onto a person. First, it can reinforce the truths of the illness, thoughts that feel like one's own thoughts: you don't need to eat like other people; you are disgusting and horrible; you cannot trust other people. Second, it can lure the person back by acting like one's best friend: just eat a little more now (and it won't become a binge); I will keep you safe and calm; you're not strong enough; and life will never be more than this eating disorder for you.
So recovery becomes very tricky and painful when it means losing a life philosophy and your best friend at the same time.
Once someone begins to doubt the truths of the eating disorder and the relationship with it, therapy can become a relationship that helps her challenge the disorder more fully. The person needs to hear over and over again how the eating disorder lies, manipulates and sabotages. The illness only makes someone starved, sick and isolated. The promise of safety and security camouflages the truths of isolation, misery and despair.
It's infuriating and sad for a person in recovery to face these truths day after day. The repetition of the reality of the eating disorder and their lives unleashes a startling amount of denial and anger and runs the risk of alienating that person from treatment.
At the same time, identifying this reality day after day chips away at the ego syntonic experience of an eating disorder and leaves a wake of anger needed to face the hardship of the daily work of recovery.
The eating disorder thoughts are then replaced with a series of difficult emotions.
One is regret of years of illness and the denial carefully crafted and protected by the eating disorder. Although sadness about lost time is very real, regret tends to be a bottomless pit the eating disorder uses to cause great despair and then reinforces the illness through learned helplessness.
Another emotion is anger at the person continually pointing out the reality of the eating disorder, the therapist. If the patient has created a world where no one knows the extent of the illness, the person who does know becomes a threat. The moment that therapy punctures the denial can feel like the therapist's fault, rather than a peek into the true nature of their life. Sharing that reality, rather than blaming it on the messenger, creates a mental framework to challenge the ego syntonicity of the disease.
Fear is the third important emotion. Typically, this person has little experience in the world without the illusory protection from the eating disorder. So basic facts of daily life seem daunting. This again encourages reliance on the eating disorder and learned helplessness. Understanding the reality that people face fears each day just by getting up and living is important. Also, it's instructive to see that real relationships provide support to handle the stresses of each day in a way that opens up possibility as opposed to the prison created by the eating disorder. There are no right and wrong answers in the world without the eating disorder. Instead life is about trying your best each day and tolerating the events and emotions of being human.
This understanding of how someone breaks through the philosophy and lies of an eating disorder also explain how friends and family can be supportive. In these relationships, a patient can learn how people can provide support, care and love in ways an eating disorder never can. It's not a family's or friend's role to reinforce the nature of the eating disorder that dominates therapy. Without the structure of a treatment relationship, facing the denial head on only alienates the patient from her life. Consistent care and support continue to remind the person through experience what the eating disorder has taken from her and how much she wants a life free of illness.