What Does Forgiveness Mean (in eating disorder recovery)?

This topic runs the risk of devolving into a self-help diatribe but also touches upon something fundamentally necessary for full recovery. People commonly mistake the motivation for having an eating disorder as vanity and competition. I have tried to describe how someone with a chronic eating disorder actually exists in a very different internal world. The reality of feeling trapped by shame, self-criticism and suffering lacks any of the perceived mastery of food and glamour of being thin. For a patient to embrace the concept of a world without interminable mental torture, she needs to consider two steps towards forgiveness: choice and regret. The inability to accept either one inevitably limits the possibility of full recovery.

When someone gets sick, the initial human but often futile response is to find blame. Who caused this to happen and why? There are a few controversial exceptions: lung cancer, drug abuse, obesity-induced diabetes--illnesses seemingly caused by personal choice. And that includes eating disorders. A group of students in the lunch line or colleagues at the water cooler all too often gossip about the girl who's too thin. The implication is that she can choose to start eating and she would be fine. And if that girl dips her toe in the water of the illness and then proceeds to dive in head first, to everyone around her she chose to develop an eating disorder. Granted, she could have been a confused and scared 14 year old girl with no one to turn to, but, in the eyes of her family, friends, treatment team, in the eyes of the world, she is surely responsible. She wasn't stricken with an illness; she chose her own affliction.

What is similar about illnesses that blame the patient is that society has a role in the initial exposure. Although someone chooses to smoke and smoking causes cancer, that person--usually a young person with poor judgment--does not believe it will lead to a lifelong addiction. Moreover, how can it be legal for a lethal substance to be legally sold and marketed, especially to those most vulnerable? If our society promotes thinness and weight loss as a necessary part of being a successful woman, a percentage of girls who do go on a diet or throw up their food will end up with an eating disorder. The values of an era define the social illnesses of the time and are inherent in the disorder itself. So that even with these issues clearly laid out, even if the patient brings them up herself in treatment, escaping blame for the eating disorder remains a challenging leap in recovery. Indeed, the cause and effect appear to be one and the same.

The experience of having an eating disorder is centrally a mental exercise. Since emotion and personal connection is stripped from her life, the patient exists largely through her painful, harsh, punishing thoughts. In a world where every negative emotion or thought can be diagnosed and medicated away, the societal norm is that thoughts can and should be contained and eliminated. Any unwanted thought that lingers and, heaven forbid, leads to action, is a sign of weakness. Even the central mechanism of the disorder--not just the cause and effect--reinforces the idea that having an eating disorder is a personal choice.

Forgiveness starts with true recognition of how powerless the patient has been to the whims of the eating disorder. The driving force to remain stuck and spinning in the world of disordered thoughts and behaviors has been impossible to escape. I have discussed in previous posts why someone who experiments with disordered eating might become sick and why an acute eating disorder becomes chronic. These factors remain out of the patient's control. Our society has created a world to lure young people into an eating disorder and provided few means of escape. The seemingly controllable thoughts are actually the critical symptom of the disorder. The burden of personal responsibility for the eating disorder is the communal tactic to fob off our own responsibility of sacrificing so many young women. And the myth that all of these girls chose this disorder is debunked by the fact that society paints them into a corner. What other choice do they have?

When a patient begins to concede she is powerless and may not control the illness, she unleashes a torrent of regret. A glimpse of recovery makes the years trapped in the disorder even more painful to remember. To imagine there was a way out all that time makes the cycle of the illness even more pointless. How does one reconcile those lost years and begin the struggle to find a new path in life? Having been grounded in an excruciating present, the past looks like a tunnel of loss too deep to even contemplate, let alone mourn.

Unfortunately, although therapy can often make headway in reducing the sense of blame, I have found that directly facing a mountain of regret can backfire. For women who are smart and motivated and who have allowed themselves lofty but attainable goals, fully reconsidering the past is a sobering task. Instead of having years to reevaluate their future, the sudden revelation they are not to blame opens up the immediacy of the state of their lives today. There is no easy way to handle such a shift in self-perception and personal direction. I think people who do find full recovery tend to use a moderate amount of denial of the enormity of the change in order to function each day. They try to stick with the transition in the moment and work to lessen the punishing thoughts and incorporate a new self-identity. By staying present, they don't dwell on the past. The regret still lies under the surface and frequently is discussed in therapy but rarely takes over. In this way, the mourning is protracted but tolerable and doesn't impede movement forward.

The recognition of being powerless and of the sense of loss is a bitter pill to swallow after riding the high of food mastery for so long. These changes highlight the slow descent into mediocrity--a word frequently used by patients in recovery and uniformly despised. The eating disorder makes people feel special, even as its appeal diminishes over the years. The next post will address the importance of mediocrity and specialness in recovery.              

Shame and eating disorders

The experience of shame is a part of the human condition: we all eat the apple from the garden of Eden at a very young age. Children experience shame of their bodies or their behavior without the perspective to comprehend what it means. This shame--in its primal form--is deeply buried within an eating disorder. The obvious shame of being sick is one facet, but at the center is something truly existential. People with eating disorders feel like there is something really wrong or even, in the most simplistic term, bad at the core. The irrefutable existence of this badness makes the eating disorder feel like a just punishment. The problem in treatment is that the source of shame is both fully accepted by the patient but also completely elusive. There is nothing to point to or home in on because--and this is where the logic of the eating disorder becomes a house of cards--there is nothing there. The shame and the central badness are one and the same. Rather than searching for a source for the shame, the therapy needs to find out why and how the shame took over in the first place and then expose it to the patient. If the shame was planted there first, then the patient unknowingly created a world to justify her false reality. Recovery can feel like a complex knot to untangle.

In treatment, shame creates a barrier which stops the patient from being able to talk freely and to be herself. Everyone knows what it's like to feel inhibited. Imagine having a secret so large, so abhorrent that revealing anything about oneself will lead to catastrophe. Imagine not knowing exactly what that secret is except that letting one's guard down will without a doubt reveal everything to the world. Imagine knowing that one is an absolutely awful person but pretending to be someone else will keep the charade of life going. Imagine always feeling like you're one step from losing everything. Living in such a precarious world can--too most people--seem surreal: constantly putting on an act, being terrified of being found out, never being yourself and never-ending shame. But this is the world that traps someone with an eating disorder. Under these circumstances, the punishing eating disorder completes the circle and feels like just retribution for just being allowed to live.

The first step towards addressing the shame is to break the almost delusional cycle. Even though the logic of the eating is precarious, the shame and punishment feel completely deserved. The therapist can start to question these deeply-held beliefs. What makes you so bad? What are you being punished for? What makes you different from everyone else? By gently probing the thought process, the therapist pokes holes in the eating disorder mantle. Patients have never spoken about the shame with anyone so it can be a revelation to actually question the eating disorder in any way. Often the effect is surprisingly brisk and empowering.

But the shame cannot instantly wash away and leave good self-esteem and well-being in its wake. Once the logic breaks down, patients are confused that the shame lingers and are furious that the requisite punishment continues. Eating the forbidden fruit may have shattered eternal bliss, but the process doesn't happen in reverse. The work in therapy involves looking for a new reflection of oneself. With no other way to process thoughts and feelings in the world, we all revert to the default self-image. The long-term goal is to build a structure that explains how to live in a world not dominated by shame.

The bigger revelation is that the shame was never warranted, and years were spent enduring an illusory punishment. Many people, faced with this shock of reality, find themselves quickly hidden behind the shame and the eating disorder again. The process of nurturing a new self-image necessitates intense feelings of vulnerability and discomfort--experiences that until now were avoided at all costs. Trust in oneself and in the treatment is crucial to take the first steps away from shame and from this badness. This post highlighted several important issues in eating disorder ecovery related to shame--namely feeling special and trust--and these will be further discussed in upcoming posts. But for a new way of seeing oneself in the world to fully take, the next step is forgiveness. That will be the topic of the next post.