The Process of Becoming

A few months ago, I wrote about the difficulty a parent faces in raising a child in a world preoccupied with food and weight. The message that thinness and food restriction is a panacea for all the ills of childhood and adolescence is ubiquitous. A diligent parent is hard pressed to compete for airtime with the less appealing alternatives of family meals and traditional recipes. The age-appropriate drive for identity and individuality has become its own market-driven brand, and various forms of media have leapt on the bandwagon by adjoining the disordered eating and body image chic into a boondoggle for their bottom line.

Exposure is the first-line risk factor today's children face for developing disordered eating and perhaps an eating disorder. Offering the alternative story of food as shared time in the present and connection with a venerable past may not eliminate the risk--a veritable impossibility at this moment--but does give our children another point of view. Even if this proposed sanctuary from the relentless pressure to conform is soundly rejected, children won't quickly forget--they know all too well the norms they are railing against. In fact, rejection in and of itself can be the highest form of flattery from a child.

The last few posts add a different, and less obvious, dimension to a child's risk of becoming lost in the morass of food and weight. This has to do with personal story. In childhood and adolescence, one's story is tied to the family story with the child's occasional sidebar noted and retold (and, to the child's chagrin, often re-imagined) by the parent. A teenager will strive to find new storylines, hide them from meddling parents and keep and preserve them like secret treasure. These forays into personal narrative are baby steps to developing a sense of themselves and, within reason, need not just to be tolerated but cherished by parents. To prize the process of transformation of the child into an adult sends a clear and different message: I won't interfere with your becoming.

That remains the ubiquitous role for a child in the family: a sense of promise. The story of a child is about what is to be more than what is. Parents and children alike gloss over the daily routine to create the fantasy and hope of what this child might one day become. How many times does a child hear, "What do you want to be when you grow up?" The dreams and hopes only reinforce the urgency of a teenager to become, but in hindsight the trumped up (and often embarrassing) storylines of an adolescent dissolve not behind what that child has become but behind the internal process of becoming. The true gift a parent or adult can give--the exigencies of being with an adolescent notwithstanding--is to allow this process to unfold.

The world of thinness and food restriction is especially appealing to the child who combines the process of becoming with the urgency to become someone else. This child feels deeply the sense that she will not be satisfied with any of the choices around her because she herself is not and cannot be enough. She needs not just a new storyline but a new identity to hide behind, with new goals to attain. The problem, of course, is that many, if not most, teenagers fall into this category for a time, and many subsequently fall under the sway of dieting and weight loss.

But most adolescents avoid the fall into the abyss of an eating disorder. The need to become someone else and the burning self-loathing abate enough so they can return to the process of becoming again. The tipping point appears to relate to expectations. In the eyes of parents, the media and the world around them, teenagers know that the process of becoming no longer ends with reasonable goals. It's the rare throwback of a child who is searching for stability and comfort and whose success means education and a steady paycheck. The urgency to become famous, notable or otherwise special has become the de facto goal for all children. The covert message is that becoming the next music star, movie icon, writer or athlete is within everyone's grasp.  And how much of these outlandish expectations is supported by parents' unfettered hope for vicarious stardom? As the dreams dissolve into fantasy, the true test is whether the child can return to her fledgling story. If it is intolerable to become mediocre--as I described in a previous post--dieting and weight are ready to represent both the pinnacle and the end of becoming.

The next post will talk about what parents can do specifically for children who combine internal drive with a world of unrealistic expectations. How does a parent cope when that child does not meet her own expectations?

Personal Story

We all need a narrative of our lives, something that creates a picture of who we are and where we have come from. It keeps us in the present moment and connects us with our place in the world. 

For people with an eating disorder, their own story was abruptly halted when they first got sick. One step towards health is to circle back to that time and resume the narrative with a simple question: what caused the disorder in the first place? Since patients so often feel robbed of the time taken from them, piecing together the story is of the utmost importance. It is a way of reclaiming that lost time. The immersion in the isolating world of the eating disorder erases both identity and personal narrative. Picking up the pieces and retelling that story over and over again until it is right are a means to recover.

Practically, this means a significant portion of therapy involves looking back. The girls who first started to get sick seem so different from the women escaping the disorder years later. Those girls were in the throes of adolescence. They were inundated with the physical and emotional shifts in their lives. They battled the cravings for independence while clinging onto the lack of responsibility and freedom of being a girl. Whether they stumbled upon the high of a diet or the release of a purge or whether someone introduced them to it, these girls were much too young, confused and desperate to know what was happening. It can be hard for an adult struggling to recover not to get angry at that girl and at herself. Shouldn't she have known what was coming?

In hindsight, the answer is clearly no. However, after years of being sick, it is a big hurdle for the person in treatment to accept the utter confusion and helplessness of the girl who got sick. But that acceptance is a crucial step towards restarting one's story. It is much easier to avoid these painful memories altogether and instead stay focused on the search for a straightforward, simple cause of the eating disorder. In fact, the burning desire to answer that question can take on symbolic meaning. People often think the answer will cure the eating disorder in the magical way an adolescent mind works. I wish that were the case. Realistically, the answer will help someone stop blaming themselves and try to see how this painful experience was both an abyss she never saw coming and a trap she did not know how to escape. More to the point, she needs to see that the disorder has become part of her story.

Needless to say, a patient in recovery wants to eliminate the disorder and never look back. The idea that it actually needs to be incorporated into the story is never welcome news. Answering the question is supposed to put the experience to rest once and for all. Instead, the treatment begins to review the painful memories of the transition from adolescence into the disorder--the time when the narrative stopped--and from that point formulate the rest of the story up to the present moment.

But from the perspective of treating and also preventing eating disorders, I find myself circling back to a related but different question: why are more and more women derailing their own life story and curtailing their own personal momentum by turning to food? For these girls who first got sick, there are places in which threads of each individual story blend into a larger theme. I have tried to address some of the societal changes that preceded the increase of eating disorders and disordered eating such as the change in food supply, loss of a food community, increased freedom and opportunity for girls and the media's influence on weight and self-worth. In upcoming posts, I want to use the knowledge, perspective and experience of those stories to address the girls at risk now. What can be done to help those girls susceptible to falling into an eating disorder? How can their narrative withstand the bumps and continue without a long detour into food? Why do girls turn to food to create their own story? What other options do children and parents have?

I want to start the next post addressing the role personal story and narrative have in children's lives and what purpose an eating disorder psychologically and emotionally serves in that regard.  

The "Real" Relationship in Therapy

One difference between normal relationships and therapy is the clinical scrim that blocks the patient from knowing the therapist as one would an acquaintance, friend or family member. Starting with the almost silent, omniscient analyst in classical Freudian psychoanalysis, the theoretical foundation of therapy began with the patient's responses and reactions to a relatively blank slate. The trove of adaptations to the initial psychoanalytic model either justify a small amount of visibility through the screen or enable the therapist to hide behind a systematized (the current code word is evidence-based) technique. No matter the newfangled, popular approach, there is one question that lingers in any patient's mind: is this relationship real?

There are two general ways to answer this question. In traditional treatment, the therapist will ask the patient what triggers the question and what are the underlying motivations and feelings behind it. In evidence-based treatment, the answer is that the question is moot: the stated objective is solely to minimize or eliminate distressing symptoms.

Most clinical literature about eating disorder treatment recommends a completely paradoxical approach. The emphasis from the outset is that the relationship in therapy needs to be real and that self-disclosure--a nifty bit of psychological jargon ripe for (mis)interpretation--is not just advisable but necessary for treatment to be helpful. Necessary! How can something considered strictly forbidden since the inception of psychotherapy suddenly be essential for psychological disorders only first categorized a few decades ago?

I remember reading articles about being "real" in eating disorder treatment for the first time without fully taking in the subversive context. To the therapy universe, this is heresy. But it certainly explains a few things. If the experts agree that eating disorder treatment must flout the most basic tenets of traditional therapy, no wonder most therapists have so much trouble treating people with eating disorders. If these experts really have tapped into the well of recovery, no wonder eating disordered patients in treatment focus on the question whether the relationship is real. Nothing has ever been real for them except for the disorder itself.

I have written about most of the reasons why therapy in this context needs to be different, but they bear repeating. Patients with eating disorders have trusted no one but the disorder so the therapy relationship has to be meaningful, powerful and real to break through that barrier and open the door to even contemplating recovery. With a keen ability to read others and to be excellent caretakers, patients will almost instantly recognize a lack of genuine interest or a therapist hiding behind a professional wall and respond in kind by retreating behind the eating disorder. A patient, embarking on true recovery, needs to believe in something previously impossible: a real connection with someone--in this case the therapist--and that can't happen behind the therapeutic screen. Moreover, one of patients' common complaints about previous therapists is that they just weren't real, they just didn't care. And that's where the clinical literature has it right. Patients with eating disorders have withered under the assault of worthlessness and self-criticism unless they constantly engage in the symptoms, but somehow they feel cared for by the disorder itself. And a patient needs to know she can find that elsewhere. As a therapist, being real means more than following some guideline in a book. You really have to care.

An ethical therapist with no experience with eating disorder treatment will no doubt shudder after reading this post so far. The exhortation to dive in headfirst, arms open wide, feels like a recipe for disaster. The clinical, personal, theoretical and legal reasons to stay firmly, safely behind the scrim look very good on paper and moreover won't jeopardize a bustling practice. The psychological term--written and vehemently argued about through generations of therapists--is the boundary crossing. In the most general terms, this means neglecting the therapeutic frame I mentioned in the last post. Practically speaking, the result is the transformation of the professional relationship into a personal one. The steps that lead towards crossing that line always seem innocuous at first: extending a session a little longer or spending some time discussing the therapist's personal problems. (Just watch the first season of the TV show In Treatment for a textbook case.) The worst scenarios involve the transition to a fully personal relationship or even a romantic one. No matter the transgression, what links these examples is that the therapist's needs and desires come first. The ultimate responsibility of the therapist is to remember that she has her personal life outside the office. Really caring for the patient as a therapist means NOT letting the patient take care of you.

Without the natural give and take of relationships, without the potential to care for each other, with clear boundaries in place, the most basic question still looms: how can this relationship be real? Yet, when the therapy works and the patient does truly feel cared for and starts to get well, it is impossible to see it as anything but real. Effective, meaningful therapy is, in many ways, a re-experiencing of past relationships in the context of something both cathartic and brand new. In eating disorder therapy, this concept helps a patient remember and relive distant relationships in which she was allowed to be herself. So the artificial boundaries actually enable a patient to return to a time before the eating disorder took over, a time when she really could be herself.

When two contradictory experiences in therapy--creating artificial boundaries along with a "real" relationship--feel simultaneously possible, I try to think outside the box of therapy to all the types of relationship we experience in our lives. The idea is to draw on the concept of therapy as a re-experiencing of prior relationships and use those experiences to better understand the moment. The only other relationship that combines the deeply felt caring with strict boundaries is that of a parent and child. When this relationship works well, the parent cares deeply and powerfully for the child but needs to draw strength and support from elsewhere. Relying on the child like an adult stunts psychological and emotional development immeasurably. In no way does therapy compare or replace the parent-child dynamic, but the powerful healing that takes place in eating disorder treatment does tap into a similar experience. Freed from caring for the other person, freed from the tyranny of the disorder and free from self-punishment as the only source of solace, the patient can restart the emotional and psychological process of knowing herself. In an environment where she can be real and true and honest, she gets the chance to continue her own personal development which was stopped by the presence of the disorder in her life.

Of course, the relationship is real. But real not just for now because this isn't meant to be a blip in the course of a lifelong tragedy. This is meant to help her feel real for good.

In recent posts, I have written more about how a chronic eating disorder leads to the derailing of one's psychological and emotional development. Several older posts have referred to the risk factors for developing an eating disorder. I want to switch gears in the next post and start a series of posts about children’s susceptibility to disordered eating and eating disorders and ways to avoid this fate.