Boundaries

Doctors and therapists are often slow to adopt new technology, so it comes as no surprise that the explosion in modes of communication has thrown medicine and therapy into turmoil. For some doctors, the refusal to use even email at all stems from the medicolegal exposure of such an accessible paper trail. Others have embraced email, Skype and texting to offer easier access for patients in need.

The reluctance of a therapist to use electronic communication has a philosophical basis. One axiom of therapy is absolute adherence to the frame: the practical structure of the relationship is critical for its success. The agreement includes the time and length of the session, the amount of the fee and mode of payment and how the session transpires. In therapy jargon, the code word for these decisions is boundaries. This used to mean limited contact outside of the therapy except for emergencies and, of course, phone was the only option. With the current, ever growing smorgasbord of modes of communication, boundaries have become much, much murkier.

Interestingly, as I discussed in the last post, the eating disorder treatment community has embraced the ease of keeping in touch with patients but not without controversy. Let me start with some positive results supported by the professional community at large. A prominent psychiatrist in North Dakota ran a study testing Cognitive Behavioral Therapy for Bulimia Nervosa via Skype and found the success rate was equivalent to face-to-face therapy. There are also pilot programs which involve sending text messages to patients with eating disorders to support them through the day. Because these studies were standardized, the texts were generic and impersonal, but the concept was very progressive. Under the guise of research standardization and academic support, these pilot studies pushed the boundaries of therapy within an acceptable framework but implied the need for further testing of these limits in typical eating disorder therapy.

In addition, I have spoken to colleagues who treat eating disordered patients, and many have significant contact with their patients by phone, email or text. However, most therapists conceal this information until they know you're a like-minded soul, and I can understand why. To begin with, the general fear of new forms of communication has plagued every step forward in technology: the telephone, television, computer and cell phone have all been branded evil in their time. That fear invades the therapy community at large. I have been questioned at length as to how text messaging a patient can be professional. I have been chastised by an inpatient psychiatrist for emailing with a patient. And this was a psychiatrist, mind you, who was all too eager to read confidential emails made available by a third party without the patient's consent! But, in my mind, the risk of exposure is far outweighed by the unquestioned benefit and progress that comes both from extra time and especially from communication that is not in person. And that is why, as complicated as the process can be, reassessing the boundaries of eating disorder treatment is so important.

I explained in the last post how a patient with an eating disorder is bombarded all day with thoughts and internal pressure to rely on her symptoms in order to live in the world. No matter how effectively and consistently the time is spent in therapy, patients will need more help to learn how to resist the urges to use eating disorder symptoms and how to use other coping mechanisms. Faster, easier and more accessible communication can aid in this process.

But another benefit to electronic communication is the obvious: it is a disembodied act. The shame of being seen and of feeling one’s body while with another person--especially in the exposed reality of therapy--inhibits more honest communication. Often the anxiety of physically being with the therapist simply shuts down the patient's ability to think clearly at all. Despite these challenges, the consistency of regular office sessions can lay the groundwork for therapeutic breakthroughs in between sessions. In a private place where the patient is not seen, the intensity of the shame diminishes, and she is able to think more clearly and express her feelings more honestly. As the therapy helps the patient separate the eating disorder from her self-worth and identity, she needs to use any opportunity to speak for herself and needs to have someone there to hear her, to mark the moment of success. These steps forward undoubtedly move recovery along faster and help the patient find new ways to counter the eating disorder on her own.

But loosening the boundaries of communication has a profound effect on the nature of treatment and the therapeutic relationship. The continuity of contact means that sessions mark the dedicated but not exclusive time of the treatment. The relationship is more natural and fluid, unlike the limited weekly allotment of most therapy relationships. The clear message to the patient is that therapy must follow her, both literally and figuratively, through the week to have any success in treatment. The expectations of the patient and therapist are significant and the commitment to the therapy and to each other must be strong because the stakes are high and the process of recovery arduous. The nature of this relationship forces the patient to reconsider her reluctance to have hope, to engage in personal relationships and to imagine a life free of the disorder. Perhaps most importantly, the loosening boundaries highlight the paradoxical (to the eating disorder) belief that the patient is a valuable, meaningful person. How else can she reconcile her vicious internal self-hatred with the reality of her treatment?

The next post will continue to discuss boundaries in the context of a question often posed by patients that I briefly discussed a few posts ago: is the therapeutic relationship real?

Trust in Eating Disorder Treatment

Relationships are the fundamental but unreliable cornerstones of daily life. We need people to chat with about the weather, people who will care about our problems, people who we just can't stand, people we nod hello to in the corner store, and above all people we love. Unexpectedly, trust is at the heart of not just the most intimate but all of these relationships.

Trust implies reliability. In any relationship, it is comforting to know what to expect, whether it is the daily chat about small things, the almost imperceptible nod of recognition or the hug that confirms you're not alone. In our increasingly isolated world, more and more common wisdom points to loving yourself first, yet so much of our self-image stems from the relationships we take for granted in our lives from the deepest to the most superficial. That foundation acts as confirmation that our own self-image is accurate and as a springboard for challenges we face each day: successes, failures and the critical feeling that we belong.

Learning to rely on an eating disorder means losing faith in human relationships. The eating disorder symptoms are always reliable. The immediate benefits are very predictable. Life, painful as it is, moves forward in a highly structured fashion. The experience of living with an eating disorder is a bold rejection of personal relationships and even the concept of trust entirely. Some people completely isolate themselves and others just keep their friends or even boyfriends at bay because the disorder remains paramount.

In addition to reliability, the second and more hidden benefit of the eating disorder is its availability. Unlike any human relationship, the disorder and symptoms never let you down. Any disturbing event, feelings or even thoughts can be eliminated by listening to the eating disorder and doing what it says. Unlimited access to such a powerful way of life is hard to replicate. No single person can be so available and so reliable. Existing alone in the world demands that the person handle the discomfort of feeling emotions and find the patience to let these experiences pass, both daunting tasks.

For any patient to embark on the process of recovery, she needs to reconsider her belief in trust and relationships again. I have written at length about the importance of the relationship between the patient and therapist in eating disorder treatment, specifically how that relationship can provide hope, direction and motivation to move a patient away from the security of the disorder towards a fuller life. The intimacy combined with self-reflection in therapy can help a patient question the truths that the eating disorder stands by: the certainty of her negative self-image and the fact that she must live life on her own and trust no one. But just the step of questioning these beliefs--which have been written in stone for years--begins the process of trusting in the therapy. And that means considering the unthinkable: learning how rely on others for a different view of herself and a new way to live. 

Once a patient begins this shift in her mindset, the treatment becomes a trial run for building relationships in life. That means learning what availability and reliability mean in personal relationships. The eating disorder literature postulates that the relationship in therapy needs to be nurturing but also gently authoritative. I have always understood these traits to represent those of a kind mentor who gives caring, firm advice. But these traits have also felt limited, as if the treatment were a revolving door, as if the therapist shouldn't really care too much. In order to compete with the eating disorder, the therapy--even better, the treatment team as a whole--needs to understand what it's up against. The team needs to work hard to provide reliable and available care to have any chance of competing. Although consistent, effective work in treatment can establish both of these in the session, that leaves many, many hours in the week when the person is still very alone.

In all of those free hours, a patient can start to drown in the eating disorder again. The thoughts of doubt turn back to shame and finally to an overwhelming surge of emotion. These experiences, many patients have told me, just don't usually happen to someone with an eating disorder. Before long, even the most motivated patient will cede to the inexorable pull back to the symptoms. For patients who start to believe in recovery and the therapeutic relationship, the goal is to learn how to hold onto the idea of recovery and the relationship as a buffer--at times even a buoy--to survive the onslaught of the disorder. Then the therapy can begin to provide comfort even outside the sessions. More often than not, contact outside the therapy is critical, by phone, email or even texting. Almost always, when the patient begins to think treatment can be reliable and available in a different but meaningful way, the patient is overwhelmed with the fear that the therapist doesn't really understand or care and even that the relationship isn't real.

What does a therapist say to that? When the therapy is bounded by a financial agreement and (hopefully) clear limitations, what defines real? Moreover, this line of reasoning is the last resort of an eating disorder, backed into a corner, saying, "I don't trust you and I don't trust anyone!" Although the therapeutic relationship is unique, this belief--so strong and dominant in the mind of an eating disorder--repudiates how we all function in this world. How can a relationship not be real? But there is a quieter voice behind this absolute saying something very different. This voice, the thoughts and feelings of the person behind the disorder, wants desperately to be seen and heard and cared for, but it also believes the relationship will ultimately be disappointing and eventually just vanish. After the internal torture by the disorder, the patient is terrified to trust anyone again. Each small step strengthens her belief in the therapy and in her ability to lead her life without the buffer of the disorder but also intensifies the terror of believing in trust and relationships again. The fragility of human relationships seems to pale in comparison to the certainty of the disorder yet also makes the patient feel real and human again. The ultimate goal is to reopen the visceral power of personal connection for the patient, and, hopefully, to make her feel alive again.  

The next post will reflect more concretely on how therapy can even begin to replace the availability of the eating disorder. This topic, not often discussed among therapists, is contact outside of therapy, and, more generally, the complicated nature of boundaries in eating disorder treatment.

Mediocrity and Specialness

I didn't think Mandarin classes for a five year old was that outlandish--why wouldn't a parent want her child to speak the family native language--until I learned the family wasn't Chinese. But then I hesitated a moment. Isn't it a parent's prerogative to want to do everything for their child? What's wrong with learning a second language? It will help in the long run with ... then I caught myself. It's just too easy to get swept up with the tide. 

There is a singularly American concept that success is measured only by being the best, extraordinary, unique. But I think the ultimate goal of this undue pressure is to be special. Our culture celebrates the accomplishments of the rich and famous and exalts these chosen ones to a class of their own. The communal desperation to be special has even transformed the American dream--originally known as hope and opportunity for everyone--into an all-out pursuit of wealth and fame. Taking this line of reasoning another fateful step, life is worthless without publicly admired success. Quality of life and meaningful experiences have been squeezed out by resume-building activities starting with children too young to understand. The underlying truth too painful for children and parents alike is that very, very few people find that kind of success in life. There is a fine line between the drive to achieve realistic goals and the absolute necessity of specialness at all costs. But for many, a moderately successful life has become simply mediocre. From what I can tell, many people believe mediocrity is a sad fate for us all.

There are few spots to fill in the elite world, and that reality starts to become clear to the adolescent. The weeding out of the undeserving begins in high school and college--a stage of life marked by the need for a concrete identifier, something that screams to the world who you are. The fear of just being you overwhelms any sensible judgment. The internal belief of immortality means no option is off limits. At a time of exploration and experimentation, the memories and experiences at this time of development often leave an indelible mark on a life but can also lead someone astray in the name of individuality and specialness. One surefire way out of the world of mediocrity is mastery of food and thinness. Nothing attracts the envious glares of other girls and the lustful stares of the boys as well. The attention is immediate and powerful and the message is clear: you truly are special. An eating disorder can catapult a teenager out of mediocrity into the promised land.

The real danger of associating an eating disorder with specialness is the effective merger of identity and illness. An adolescent grapples with a chameleon-like sense of herself. Being a teenager means putting on one costume after another, picking up bits of an identity along the way and hoping to find coherence in the end. These sudden internal shifts and endless string of poor decisions are laughable from a distance, perfectly reasonable to the child and terrifying to the adult trying to contain her. An eating disorder soaks up all the adolescent angst instantly by providing identity, specialness and coping mechanisms in a neat little package.

Many people can live in this bubble for years. The limited satisfaction and opportunities are routinely trumped by a powerful identity and point of reference. For years you really feel special by staying thin and by following your disorder. There are many pro-Ana sites that prove the power of that sisterhood. For some people the combination of a strong identity and sense of immortality sends them to the grave. Clarity never comes in time.

A moment of doubt in the eating disorder is a small step back into the terror of mediocrity. Teenagers who never experienced the liberating step into an eating disorder had to come to grips with their own mediocrity over a stretch of years. The recognition of strengths and weaknesses, successes and failures, realistic goals and outrageous expectations all aid to create a solid foundation in adulthood. Specialness and mediocrity blend into a more nuanced view of the human condition. To the person trapped in an eating disorder, mediocrity and the subsequent loss of identity feel catastrophic. She has never had to struggle with the feelings of isolation and hopelessness. She has never had to manage the intensity of emotions and fear associated with both the process of life and its defined end.

The transition from mediocrity to a realistic view of one's life often originates in the therapeutic relationship itself. The relief of fully exposing the eating disorder and all its beliefs and flaws has two important consequences. First, the patient feels as if she can stand alone separate from her disorder. Perhaps, there is more to her than the number on a scale. Second, the desire to feel special shifts from the disorder to the therapy. This is the first time the patient actually looks outside herself for guidance and restarts the process halted years ago when the eating disorder solved all of her adolescent fears. Since her peers no longer face the same identity crisis she ignored for years, she could just feel so alone that she retreats back to the disorder. But therapy can provide the mirror and feedback to start this arduous but potentially fulfilling journey back to feeling whole--and, in a different way, even special--again.

These last three posts have addressed some emotional sticking points in recovery, reasons the eating disorder just won't let go. The last post in this series will cover the topic of trust both in treatment and in life.