People with eating disorders have often intertwined their identity and sense of who they are with their illness. Even calling it an illness can be frustrating to hear. It doesn't feel like naming a disease but instead seems like a personal attack on one's character.
For people with this conception of their eating disorder, there is no clear distinction between the illness and themselves. Any interaction is, by definition, an interaction with the eating disorder.
This fact makes looser boundaries in therapy tricky. Openness in treatment is effective in large part by communicating that the personal connection is between the therapist and the patient, not her eating disorder. This concept can feel not only abstract but almost impossible to those who view the eating disorder as an integral part of themselves.
In this scenario, the closeness and connection in the therapy relationship, which is very real, either leads both parties to ignore the presence of the eating disorder altogether, thereby colluding with the illness, or to work around it with little success, ignoring the elephant in the room.
If the looser boundaries enable the person to see how limiting the eating disorder can be and how much it interferes with living life fully, then the therapy can start to create enough distance from the illness to separate it from identity.
If the person cannot pull away from the eating disorder, the relationship begins to feel hollow. A connection built on the foundation of an eating disorder will not have enough solid ground to continue unless the goals shift away from recovery.
It is a painful realization to know that therapy has made a difference in someone's life yet has been unable to separate that person from her illness. Because of the looser boundaries and the intensity of the connection, the emotional fallout from this realization can be strong. In what seems like a last gasp, the power of the moment can sometimes galvanize the treatment to have a more profound impact. It is critical never to lose hope, neither therapist nor patient.
The end result is that the therapy relationship has to be a true bond to have success in treating an eating disorder. The subtle ways an eating disorder clings to a person, an insidious virus boring into her life, are so hard to overcome. The boundaries, openness and trust are all crucial pieces of recovery. There are risks in that type of treatment, but the potential benefits far exceed the downside.