How Therapy Separates Identity from the Eating Disorder

The process of separating identity from an eating disorder is not an intellectual endeavor. All discussing identity will do is lead to a stalemate. The illness dictates the person's every move and decision, like an oracle or a master, so discussion may be interesting but largely distraction. Moreover, perspective on one's identity is hard to come by, especially when that person is in the throes of an eating disorder.

Change will only come from action. Reinforcing the behaviors that go against the eating disorder will highlight the internal conflict between the illness and the person. No amount of discussion can make a person more aware of the powerful identification with the eating disorder than to disobey it.

The food journal, which I discussed in a post a few years ago, introduces a way to contradict eating disorder rules quickly and powerfully. Writing down meals and the rational and emotional responses to them has two immediate effects: engaging another person in the intimate details of the disorder and presenting the disorder as something separate--physically a piece of paper or an email--from oneself.

Even someone's initial reaction to the suggestion of a journal exposes the power of the illness and the fear of confronting it. Some people cannot even start the journal; some only write it for a few days while on "good behavior;" some write food but omit feelings; some write for pages and pages; some are shocked by the effect of letting someone else into the eating disorder. In every case, the effect of the food journal is indicative of how connected the person is with the disease and of the challenges that lie ahead to separate identity from illness.

At many points of treatment, the therapist has to point out new concrete steps to take such as adding in more food or adding in extra treatment. Invariably, these suggestions meet resistance. The patient knows more changes equal more time spent on recovery and more emotional turmoil. Anyone's instinct would be to push back. The therapist's job at these moments is to insist that these steps in treatment are a joint decision. The patient has to take partial responsibility for any change in treatment and to clearly state that her own intentions are different from those of the eating disorder. If the person believes the changes are enforced by the therapist, it's too easy to cling to the identity of an eating disorder. Over time, a sign of identity separating from the illness is the patient initiating discussion about new changes in behaviors.

Although certain moments of treatment are touchstones that highlight the struggle to wrest identity from the eating disorder, successful treatment is a long process. Years of embracing the eating disorder, as captive finds solace in captor, doesn't make separation easy. Even as the treatment makes clear the need to pull away from the illness and find new comfort elsewhere, it's hard to say goodbye to what had been the core of your being. Accordingly, the struggle between  actions that reflect the eating disorder's wishes and those that reflect the person's persists in a long, drawn out battle, with days and weeks leaning one way or the other. The pressure in treatment to stay the course needs to remain firm in the face of the difficult internal struggle the patient must endure.

The growth of a new identity is a slow process but it works. The immediate experience for the patient of letting go of the eating disorder will often be blankness, nothingness. Understandably, that will trigger intense fear and a desire to retreat to the illness and what is known. Even the therapist may despair at times that treatment may not follow the path to recovery. Those times of worry and fear are a standard part of treatment. Those moments aren't a sign of failure but rather signs of the challenges of recovery. Reminding the patient of the process of separating from the eating disorder and learning how to eat and forge a sense of who you are and your life course takes time. The uncertainty may be frightening but experience has proven that the effort of intense personal work bears fruit. Decades of eating disorder treatment shows that finding yourself in treatment pays off with a new and satisfying way to live.

I am not my Eating Disorder: Separating Identity from Illness

Eating disorders begin at a particularly vulnerable time of life. Adolescence revolves around conflict, namely the push for independence vs. the yearning for the safety of childhood. The urge to break new ground and become a separate person combined with the still immature understanding of identity often leads a confused teenager to simple, even comical, shifts in their persona. No reasoning can dissuade the adolescent bent on fashioning themselves an acting prodigy, an expert on political debate, the ultimate savvy socialite, the IT guru or just plain right about everything. The sudden changes in identity, the need to be instantly best at something, the urgency and totality of every self-invention all represent the desire to solve the problem and become someone else, as if identity can be chosen in a moment.

But that's exactly what an eating disorder can do. The eating disorder gives instant purpose in many ways. First, the power to manipulate your body is clearly prized in society. The disorder creates a long list of rules about how to live life: all decisions are made based on when, how and what to eat. The comforting and even superior feeling of having a way to live and a physical identity to cling to is incredibly satisfying. Suddenly, the desire for identity is complete. With the onset of symptoms comes attention and praise. A potentially life-threatening, debilitating illness can be the envy of everyone, at least for a moment or two.

What passes for a magical identity in adolescence is an albatross in adulthood. When identity forms around an eating disorder, the complex and mature inner sense of who we are never comes into being. Linking identity to the goals of an eating disorder leaves a hollow, empty feeling inside. The power to manipulate one's body and the eating disorder rules appear meaningless when the internal struggles change after adolescence and into adulthood.

However, if someone is still stuck in the illness come young adulthood, there is no easy way out just because one's psychology no longer needs the eating disorder. The urgency to find a new philosophy of life isn't enough to escape an eating disorder, and life without the eating disorder feels impossible, as if the core of one's being is being taken away. So the most common result through young adulthood is that identity and the eating disorder fully merge.

A clinician needs to be aware of this psychological process. The patient may be clear about wanting to get better but may not understand that their identity is so tied up with the illness. No one can get better when they are the eating disorder. When the behavioral and psychological symptoms appear to be very fixed, therapists often ascribe stalls in recovery to low motivation. The frustrated therapist's message boils down to: "If you would just buck up and eat, you will get better."

More often, the attachment to the disease as identity makes clear, visible progress so terrifying that the person ends up paralyzed. The desire to get better has little effect in the face of losing who you are. The best analogy is the child sports star suddenly unable to play or the child actor whose career dries up. An eating disorder feels like an achievement in adolescence. It's an accomplishment to have conquered food and body when so many others struggle with weight and self-image every day. Eating and having a normal body feels like letting go of the only true achievement in life. From that vantage point, getting better isn't about motivation. It's about losing your one anchor and entering a terrifying unknown.

The work in therapy is to separate identity from the eating disorder. This concept may make sense abstractly but is harder to imagine practically. The truth is that after years of being sick, the patient does have an identity and personality separate from the eating disorder. That's clear to anyone who knows the person. But identity is not what others see; it's what you see in yourself. The clinician's job is to repeatedly point out what other people see instead. Helping the person see themselves through someone else's eyes can gradually shift identity as well. The goal is to recognize that the internal identity of the eating disorder is, and always has been, false.

Starting to question our being is the hallmark of adolescence. Even a few years later in life, the disorientation of such urgent self-reflection is more daunting, the pull back to what we know even stronger. When the source of safety is a tenacious illness, the process of forging a new identity is even more frightening. For the gradual separation of identity from disorder to last, therapy must use the person's outside life to reinforce the false safety of the illness. Engaging friends and family in the process will allow the patient to understand that others see a very different person than she imagines. When trying new activities or meeting people in new situations, each opportunity calls into question whether identity is really just the eating disorder. By applying constant pressure to the assumption that the eating disorder is everything, the therapy can gradually drive a wedge between patient and illness and open the door to different expectations in life.

The next post will address more practical steps to separate identity from the eating disorder.

Goals for Treating People with Chronic Eating Disorders

A discussion of goals has to start by addressing the obvious question: can people with chronic eating disorders recover? The answer is an unequivocal yes. The deepest fear for anyone who has been sick for many years is a lifetime sentence to an eating disorder. Unless the clinician directly faces this concern, every patient will leave assuming the worst. Thus, it's essential that a discussion of goals explicitly puts recovery at the top of the list.

The second assumption someone with a chronic eating disorder will likely make is that the stated goal of recovery is just a lie created to give false hope. Who in their right mind would think someone can get better after five, fifteen, twenty five years of a brutal illness? Yet those people can and do get better. The road to recovery is long and hard and painful, punctuated by too many moments when all feels lost. A constant theme in therapy must be repeating the idea that recovery is a real option and that a life not plagued by this illness possible.

Recovery, however, cannot be confused with paradise or nirvana. Anyone who has struggled with a chronic illness will be affected by that experience throughout their lives. They can get well but will always have a different perspective of life. They need to be prepared to face their own life circumstances, persevere and move forward, and not think they can rewind life to what they envisioned before the illness. It's crucial to build resilience into the goals of treatment early and represent recovery as a life not completely dominated and controlled by the eating disorder symptoms, not the imagined life they might have led were they not sick.

With these guidelines, the therapy needs to narrow down from large scale expectations to day-to-day goals. Two aspects of chronic eating disorder treatment are central to understand to establish feasible goals. First, the patient is bombarded by thoughts and instructions by the eating disorder itself all day long. These commands, from thoughts to restrict to urges to binge to constant confusion about what to eat, occupy far and away the majority of mental energy of someone with a chronic eating disorder. It's practically a miracle they can do anything else in a day. These thoughts are all consuming, very unpleasant and impossible to ignore. The eating disorder thoughts easily drown out the few sessions or hours of treatment per week. Whereas more limited treatment can reverse an eating disorder earlier in its course, therapy for a chronic eating necessitates daily, constant intervention to make a dent in the relentless illness. Second, these thoughts become the person's identity. After years of living through constant eating disorder thoughts, it becomes very hard to differentiate between the eating disorder and oneself. 

Since no therapy can last all day, every day, the therapist and patient need to collaborate to extend treatment into a daily intervention. Trying to force this treatment into the standard treatment protocol leads to sure failure. A team cannot present an immediate food plan and expect a person sick for many years to make instant changes because they are suddenly more motivated. Eating disorders are just too tenacious to let go because the ill person wants to get better. The clinicians and patient need to explore the nature of the eating disorder and look for loopholes, ways to insert new thoughts and actions into each day. Through more communication via more hours in treatment, food logs, journaling, emailing or texting, the team can be in regular contact so the patient isn't alone with the illness all day long. Creating a new environment in which several people are putting their minds and time into changing a longstanding pattern of illness opens a new door to recovery.

In this circumstance, the practical goals come into clearer focus: stay in touch regularly, communicate through the day, watch for signals or patterns of distress and create and try out new behaviors to replace the eating disorder. The therapeutic effect of these changes is profound and necessary to be sure treatment heads towards recovery.

It's usually eye-opening for a chronically ill patient to see any change in the eating disorder behavior from simple interventions. That first blush of progress begins a new path of recovery. The psychological imprint of years of an eating disorder feels untouchable, yet the start of relationships that may affect the illness is revelatory. It opens that person's mind to possibilities long forgotten. From the therapist's perspective, the person's identity has completely merged with the eating disorder. One doesn't have anorexia or bulimia; one is anorexic or bulimic. The process of separating identity from the eating disorder is critical to successful treatment because it allows in real hope for recovery once again. Yet it's also the most challenging. The next post will address this topic in detail.