The Importance of Relationships and Closeness in Eating Disorder Recovery

One difficult part of recovery from an eating disorder is letting people close again. It's hard to tell which comes first: the illness or the lack of intimacy. Being so sick at a young age with an obsessive disease completely eliminates any ability for closeness, but, for some, the eating disorder replaces the need for relationships by providing reliable comfort and solace. The food, or starvation, has a powerful calming effect that for the time replaces the need for others in life. No matter the type of eating disorder, recovery necessitates finding close relationships again in order to help the person both find connection, a vital part of being human, and remember what the illness has taken away.

The transition from isolation to intimacy is rough and rocky. The eating disorder may be punishing, treacherous and dangerous but, above all, it's reliable, and that's very hard to give up. Starving or binging and purging or overeating all lead to predictable comfort and effectively numb any feelings from day to day life. The calm may be brief and followed by guilt and anger, but in the moment the symptoms feel worth it. Life stops for a moment. The escalating swirl of emotions and frustrations of daily life, which overwhelms someone with an eating disorder, temporarily fades. All that's left are the simple rules of an eating disorder and the powerful chemical brain effects created by the symptoms around food.

But no one recovers alone in a bubble. Without relationships and support, the internal urge to return to the eating disorder is too strong, and a slip or relapse is all but inevitable. What confuses many people, both those recovering and friends and family, is why relationships feel so hard.

It's not obvious why an illness focused on food and weight has anything to do with closeness and intimacy. The confusion can easily trigger disputes and arguments. Often people accuse those in recovery of being too sensitive and needing to develop a tougher skin. Another common complaint is that the person isn't being honest or forthright. Even if these comments are meant to be helpful advice, anyone in recovery would interpret the statement as, "You're too much of a bother for me."

Although the solace from the eating disorder symptoms are short-lived and ultimately unsatisfying, it's very consistent. This known quantity helped eliminate two dangers of being close to others: dependence and disappointment. Most people in recovery find those feelings unbearable, largely from a lack of experience. Years of isolation limited their ability to learn how to navigate these normal parts of relationships. Similarly, people in recovery haven't had any practice expressing their emotions or frustrations to others. And so family and friends try to engage with the person in recovery as if they haven't been sick. Expecting someone with a broken leg to run five miles the day after the cast comes off is completely unrealistic. Similarly, it takes time to understand and handle the ups and downs of close relationships. Finding comfort in closeness with others is something to get used to, not an automatic experience. Expressing emotions or needs clearly in a relationship takes practice. Patience, kindness and understanding go a long way to expedite the process.

The caring from another person feels terrifying and miraculous to someone in recovery. Having been so alone, hopeless and lost, the person has gotten used to loneliness and feeling misunderstood. The illness has consumed their mind and taken even the closest people away. The fear of getting close and then losing the intimacy back to the illness is overpowering. Every misstep feels like the end of the relationship. Any trust feels like it will be instantly taken away. Every moment of caring feels fleeting. Any disappointment seems to foreshadow the end of this brief respite from the disease. It's easy to minimize the magnitude of each moment. Building relationships over time will gradually ease these fears and allow stability of community to replace the shaky foundation of the eating disorder.

The best advice both for the person in recovery and friends and family is patience. Starting to eat means feeling less numb to the world. Every moment of daily life is raw and intense. Each interaction in a relationship feels fraught and fragile. The urge to go back to the familiarity of the illness is ever present. Sustained patience and and understanding of the process of relearning how to live and love without the eating disorder is what the person in recovery needs. That room to learn, grow and get better is often the difference between aborted treatment and full recovery.

The Facts about Food, Hunger and Weight: Why so much food makes us so sick

While the only solution to the growing public health issue of obesity and disordered eating remains willpower and healthy eating, the problem grows unabated. Shifting responsibility from agribusiness, food conglomerates and regulatory agencies to the individual strengthens the foundation of our collective struggle and leaves us nothing to grasp onto for relief. Doctors recommend ineffective solutions; experts blame the lack of willpower; and science searches for the biological or genetic cause. But it seems as if the answer to facing this world of food is right under our noses.

We have created a world of paradoxes and just sit back and watch how our population goes haywire. The first world is inundated with food, much more than we could ever consume. Food companies exploit scientific and psychological knowledge of food preference to create treats we are programmed to desire. Meanwhile, cultural touchstones present slim figures as the panacea for our woes, a body shape most of the population cannot attain without starvation. We all stand by while experts sanction severe diets as if this is normal behavior.

And our minds and bodies pay the price. We are plagued with guilt and shame, tricked into thinking willpower can override hunger, as we indulge in treats unaware that we are powerless to do otherwise. We chronically starve under the pretense of a sanctioned diet, supposedly doing the right thing, and wonder why we are always so hungry and unable to stop eating. The hunger triggers food obsession and slowed metabolism, and we are shocked when we keep gaining weight and develop diabetes. The system is rigged but no one seems to understand.

There is no one piece of the puzzle to vilify. The whole system is broken. The fix lies in changing the conversation enough for people and society to listen and start to shift our priorities.

From the start, that means education. Without the basic knowledge, we are so easily duped that we sit around blaming ourselves for the disastrous scenario. The basic knowledge will help us understand why we can't accept the current food situation and, in our own small way, will help us understand how to change our own perspective and behavior around food.

The three critical components of education are the biology of food and weight, the myth of willpower and the nonsensical media chatter about food which leads us to blame ourselves.

The biology is simple. Although there is plenty of complex and fascinating science, the layperson only needs to know the basics. Food is necessary for human survival. Our instincts tell us to eat to survive and to eat more when there is surplus and to eat even more when we have been hungry. Historically, the periods of abundance of food have been scarce, and there has never before been a time of endless supply. Even though times have changed, our innate response to food hasn't. Believing we can control all food intake is patently false. Our biological instinct to eat can't be changed. It's a fact of being human we need to respect and not expect to magically override.

Similarly, weight is not a variable we have ultimate control over. The number can shift with fluid changes, hormones and even external factors like seasonal changes. Our bodies allow this value to move to maintain our health, not at our whim. It is one of many components that our bodies adjust for our well-being. The idea that we are solely responsible for the number on the scale based on food intake and exercise is absurd. Basing one's self-image on the number on a scale is a losing battle that ignores the reality of how our bodies function.

The concept of willpower is only effective for a population ignorant of how our body manages hunger and weight. The industries that rely on our ignorance reinforce the false hypothesis. The myth of willpower states that we have the mental ability to restrict what we eat, avoid mouthwatering treats and maintain a too low body weight. The biology of hunger and weight clearly prove otherwise. No perfect diet, newly identified nutrition culprit or Bariatric surgery will overcome our biology.

If biology trumps willpower and our society sets us up for failure, then none of the media information makes sense. Self-help books, supposedly proven diets, medical recommendations and government-sponsored programs encourage behavior that relies solely on willpower. The information is false and leaves us flailing purely focused on our own sense of failure because even the mentally strongest person cant seem to override biology. The only way to manage the media message about food and weight is to ignore it and remember how our bodies truly respond to food.

The basic information about the human response to food and hunger is humbling. The expectation that we all have ultimate control over eating and weight, although pure myth, has a profound effect on our sense of ourselves. It's comforting to believe the answer is within our grasp but ultimately demoralizing to realize we have been duped. Accepting our need for regular meals through the day, a variety of food and a weight range that may be higher than the social norm is a significant first step. The belief that food and weight can't be our top priority may be disorienting at first. It's a leap of faith to know that, with all the advances in modern life, we have it completely wrong when it comes to food and weight. Culture and tradition planned for regular, hearty meals through the day. That pattern stabilized hunger and weight and also trained our minds and bodies to expect food and to learn regulate hunger and fullness accordingly. Modern life has tried to phase out hunger and been wholly ineffective. If we respect our human nature around food and weight and work to incorporate regular meals throughout the day and listen to hunger, we will have much more success in the world of plentiful food than we do now. Knowledge, including debunking all the current false beliefs, followed by new eating behaviors will help us all avoid the pitfalls around so much food.

A Full Assessment of the Hard-Line Approach to Eating Disorder Treatment

The frustration and confusion in treating people with eating disorders allows clinicians to adopt a wide range of therapeutic approaches. Yes, patients do get better and recover, but there is little consensus or evidence of a reliable and effective treatment to get them there. Instead, therapists cobble together a mixture of available options to find a personal style that works. The lack of effective standard guidelines and an accredited subspecialty leaves patients at a loss to find expert clinicians and to assess their competence.

One resulting dilemma among treaters is the theoretical difference between compassion and even love as a source of recovery versus the hard line, best described as "eat or else." These two theories hold sway in the clinical community and often divide a treatment team and limit effective care.

The philosophy of compassion is one I have written about extensively in this blog. The psychological thought process of an eating disorder relies heavily on an internal, critical monologue. The thoughts berate the patient in every aspect of life and curtail any pleasure from even small parts of daily existence. The criticism focuses primarily on food and weight but can encompass most of one's day and cause endless misery. The theory behind compassion is that kindness, forgiveness and caring counters the psychological underpinnings of the eating disorder and presents the patient with an alternate mindset of how to live. At first confused or even angry at the compassion, the patient gradually begins to accept the connectedness and positivity and to recognize the critical thoughts, once confused with identity, as a core symptom of the illness.

The hard line philosophy originated with the clinical application of theories used to treat people with drug addiction and alcoholism. Viewing eating disorders as a subset of substance abuse, therapists insist on regular meals and a weight goal as a mandatory part of treatment. If a patent cannot reach the goal, the team sets a deadline to either eat meals and stop purging behaviors or reach a specific weight. The punishment of not doing so is termination of treatment until the patient is ready to comply with the recommendations.

There are two important points to support this model. First, outpatient treatment with a patient who is malnourished has significant limitations. When someone remains so sick, the brain cannot function well, and therapy cannot be nearly

as effective, and for some completely useless. The body also physically continues to deteriorate, and many clinicians believe that treating a patient under these conditions is akin to enabling a chronic and often fatal illness.

Second, this line of reasoning implies that recovery and eating will be very hard, and there is no point waiting for an epiphany, in or out of therapy. In order to fully recover and get well, every patient must go through the emotionally and physically painful process of eating again and reacquainting the body with regular meals and snacks every day. Learning to face the food and the feelings and experiences that come with eating will always be hard. The hard line approach emphasizes that recovery must come with nourishment, and there is no better time to start than now.

The difference between these two philosophies, in my opinion, is not related to the course of recovery. Patients who find a treatment team with either approach can get well. However, the message underlying that process leads to two diverging ways to live afterwards.

The hard-line approach certainly encourages autonomy, self-determination and the critical importance of eating. A patient who responds to this thought process will bring to many components of life the urgency just to push through, an admirable trait but one that still condones or at least tolerates the critical thoughts of the eating disorder. What this approach ignores is the patient's need to look inward not for guts and determination, something many eating disorder patients have in spades, but for love and kindness.

The goal of treatment is a full recovery and a full life, but the hard line approach neglects to address what a full life means. It means a generosity of spirit, a desire to help others as well as yourself and an ability to take pleasure in the small things around us every day. It must embrace a positive outlook on the identity of the recovered person and the ability to receive and truly feel compliments and care from others. It must allow the person to depend on others and not feel alone in the world anymore, no longer isolated by the punishing thoughts of a horrible illness.

The compassionate philosophy of treatment of eating disorders remains more murky and thus more complicated. Tolerating the severity of symptoms and the medical and psychological sequelae of chronic illness is no easy feat for patients, families or clinicians. At times, it feels like delay or just treading water for long periods of time. However, staying the course with unlimited caring reinforces the concept that only a turnaround in how the person views oneself will lead to a true recovery. Identifying and healing from the eating disorder thoughts must accompany eating and physical well-being in order to attain a full life. Even though the hard-line can get the job of nourishment and weight restoration done, that just isn't enough to get people well.