What the Maudsley Treatment Might Mean for Adults

The Maudsley Therapy is a relatively new treatment for adolescents with Anorexia Nervosa. In a nutshell, the parents are responsible for feeding the child and finding any acceptable way to be sure she eats. The treatment team aids the parents and empowers them to leave no wiggle room for the child to continue to restrict. The parents are full members of the treatment process and an integral part of recovery.

There is nothing novel about the concept behind the Maudsley treatment. Behavioral problems in children more often than not stem from ongoing issues in family dynamics. Accordingly, treating adolescents almost always includes family therapy, and that therapy also must support the parents' authority. Although teenagers are continually working on--and pushing acceptable limits of--their independence, parents ultimately have the responsibility and ability to set rules and enforce them.

What does make the Maudsley method unique is that, unlike so much of the treatment for Anorexia Nervosa, it seems to work. This approach focuses on children early in the course of the illness, and, as I have written many times, the chance for a relatively fast and full recovery is greatest before the eating disorder has fully taken hold. Using Maudsley either after inpatient treatment or right after initial diagnosis can enable a child and family to overcome the eating disorder and its psychological and emotional causes in the initial stages of the illness. The treatment tackles the triggers in daily life and helps heal the family dynamics that may be at the core of the disorder. With the eating disorder so exposed, the child can no longer hide her feelings or her symptoms and is instantly brought back into her life and into the relationships around her. The process does not allow the eating disorder to transform from starvation into a way of life.

Any ray of hope within the professional community quickly makes its way into clinical practice. Effectively, this means that therapists will try to incorporate new, promising treatment alternatives into the process of recovery. The Maudsley method is no exception.

But there are several obstacles to adapting the treatment to adults with a chronic eating disorder. First, the patient is an adult. As I wrote in the last post, it is critical that this adult have the autonomy to make decisions about her treatment. Imposing any steadfast rules--and the fear and uncertainty that is sure to follow--only strengthens the hold of the eating disorder: the patient has no other tools to cope with high levels of stress. Second, what does relinquishing some control over food look like for an adult? Third, who is the person (or are the people) in charge of supervising the eating? And exactly what role does this person have in treatment?

The first step is one simple fundamental adaptation to the Maudsley concept. A child often has little awareness of the scope of the eating disorder, how much the illness consumes her and the long term risk to her life. Most adults with a chronic eating disorder--those without the delusional component I discussed in an early post--are much more aware of these realities. Because of this difference, a patient will often be willing to accept that, despite her resolve and motivation to get better, she cannot do so on her own. The eating disorder thoughts remain too powerful. And that means she will need help throughout the day to eat. If more structured programs have had limited long term benefit, using the relationships in her life to help her eat can not only be effective but can be appealing to the patient herself. It can offer a new alternative rather than returning to the limited and largely ineffective options she has tried in the past.

The other difference is that the patient cannot be forced to eat the way a child can. Instead, she needs first to establish the proposed changes to the meal plan on a regular basis--preferably daily to weekly--with her nutritionist. She then needs to share these changes with the designated person or people in her life who are going to help her face the eating disorder thoughts. And third, she needs to empower her helpers and herself to make these changes happen. The patient needs to acknowledge that the changes in her eating will only take place when people in her personal life are allowed to support her against the eating disorder. This person is usually a parent or friend, significant other or spouse. Under certain circumstances, the therapist can also offer this kind of support and be effective. The difference between this situation and a parent helping an adolescent is that this helper does not have the same kind of authority a parent does. Accordingly, the power to make changes comes only from the collaboration between this person and the patient herself. So the crucial component to success is the patient's ability to let people into her life. That is how the Maudsley approach is most similar for adults: it insists the patient no longer is so alone.  

After the last two posts indirectly referred to the possible role families play both in the inception of an eating disorder and in the healing process, I think the next post should focus more specifically on the family as a whole and how disordered eating and an eating disorder disrupts its function.

The Residential Treatment Option

The decision to go into residential treatment for an eating disorder is a challenging one. First and foremost, the purpose is to restore health to someone who has become too ill to function in the world. In a controlled setting, the eating disorder thoughts cannot reign unabated. The program enables restorative nutrition so that the person's body and mind can heal.

The most pressing concern is how to be sure an inpatient stay fits into the recovery plan. Eating solely to improve short-term health is of little consequence to real recovery. Although the decision to seek a residential program can be harrowing for a patient and her family, it is often followed by a sense of relief on all parts. Just the act of doing something concrete gives the illusion that full recovery is near.

Certainly for many patients, this respite can act as a springboard for more effective treatment after discharge, but a significant minority relapse and return to their pre-inpatient physical state before long. For these patients, restoration of health is not sufficient to overcome the relentless thoughts and compulsions of the eating disorder. And there are times that this sequence of events is more demoralizing than just staying the course.

For the patient with her first, second or even third episode, the professional consensus is that residential treatment is a necessary step. As I have discussed prior, resuming eating and normalizing body function can be enough to stem the onslaught of an eating disorder--especially early in the course of the illness--and to lead to full recovery. However, the patient and family need to understand the purpose and limitations of an inpatient stay, most importantly that the end result is not that the eating disorder just disappears.

Inpatient recovery exists in a bubble without any of the pressures and stresses of daily life that lead someone back to the eating disorder symptoms. On the most basic level, the patient needs to learn new ways to cope with the world and her feelings once she has returned back to her life. A clear, directed treatment plan needs to be in place long before discharge. Everyone must be aware that the inpatient program is a stepping stone towards recovery and not a magical cure.

For patients considering hospitalization after a protracted illness, the decision process looks very different. The severity of the physical symptoms takes precedence. The person's medical status needs to be the top priority because a lengthy but effective treatment does no good if the patient's health completely deteriorates during the process. Inpatient treatment becomes necessary when the person is at high risk to maintain her health and well-being, no matter the other gains in recovery.

However, people who have been struggling with an eating disorder for many years have become accustomed to feeling very ill most of the time. Because of their unusually high pain tolerance combined with the shame of being ill so long, patients find it very hard to admit to their fragile physical state. Even families begin to get used to the patient being sick. The therapist and doctor need to regularly assess the patient's medical condition and reinforce how dire her suffering is and the necessity of trying to be open about her physical state.

At the same time, after a series of hospitalizations, patients and families are aware of the limitations of an inpatient program. The history of disappointment added to growing hopelessness makes it hard to commit to such a disruptive and costly decision in recovery. Medical stability and breaking the eating disorder cycle become the only clear gains of hospitalization. But even when treatment is moving forward, a residential program can be a critical step because it may very well afford the patient more time in a stable medical state to get well. Another round of inpatient treatment often appears to the patient and family to be a futile merry-go-round rather than a part of a larger recovery, but a frank discussion about the purpose of this step often is extremely helpful. The result is to ensure that the patient's physical well-being remain a crucial part of the larger picture of recovery.

The other roadblock to making a clear and useful decision is the patient's role in the process. Someone with a chronic illness needs to reclaim some autonomy when inpatient treatment seems likely or at least a serious consideration. She can't feel like she is being shipped off to the hospital again like a child. These patients are full-fledged adults and, accordingly, can make their own decision about treatment. I have encountered too many patients well into adulthood still submitting to the will of families or paternalistic therapists who imply that having an eating disorder renders a person incompetent. There is no doubt that the eating disorder thoughts, at their most powerful, can affect someone's judgment, but almost all patients can weigh the options with a therapist and make a reasonable decision. The result is a patient who feels empowered by her own role in treatment decisions and feels much more willing to try to take an active part in making this commitment worthwhile.

The second way a patient with chronic illness takes hold of her treatment is a bit paradoxical. As I have stated before, an eating disorder effectively isolates someone from the world around them. There is no room for people and especially intimate relationships when the thoughts and behaviors of an eating disorder consume all of the time and energy a person has. One relatively new treatment program called the Maudsley method is aimed at treating adolescents with anorexia. The protocol entails the patient relinquishing all decisions about food to her parents who supervise every meal and snack and are an integral part of the treatment process at each step and each appointment.

It is a new concept to apply this approach to patients with chronic eating disorders. An adult cannot have her independence taken away, but she is also acutely aware that she cannot eat normally on her own: the eating disorder thoughts remain too powerful. The general idea is to formulate an individual plan to include an important person in her life in the daily process of eating. This is another powerful way to let someone in. I will elaborate on this idea in the next post.

Love Thyself?

"Love thyself" has become the mantra of the modern woman. According to the current gospel, i.e. women's magazines, the path to a healthy relationship is blocked until you love yourself first. But it's hard to figure out exactly what that means, although there is no shortage of people who think they've figured it out. The answer, for women who are looking for a simple fix, comes in assortment of self-help checklists meant to impart romantic enlightenment. After sifting through the blather, the only consistent message is a covert one: your personal responsibility in society is to make a relationship work and if it's not working, it's your fault. It has been all too easy for women to feel trapped in this double bind.

What has made this message so powerful and also left it relatively uncontested is the isolation of modern day life. Left alone to find their way, women are ripe for any sage advice. The media happily obliges with many--often uneducated--forays into pop psychology. The common wisdom of the day emphasizes that not just self-acceptance but self-love is essential for happiness. But a thread throughout this entire blog is that there is only one reason in our society that a woman can truly love herself: if she stays thin. So the fundamental message equates thinness with suitability as a mate, and the media's attempts to rescue women's self-image actually leads women, obsessively, back to the scale, desperate to shed the pounds that will magically land them in a happy relationship.

What's so backwards in this philosophy is that our own self-image is grounded in relationships., not in loving oneself. Historically and psychologically, that is the cornerstone of how people, and especially women, see themselves. To arbitrarily separate oneself from one's relationships is akin to tearing away the essence of our humanity.

Fundamentally, we have always had a social nature. The successes and downfalls of the human race rest largely on our sense of community, and much of our intellectual pursuit has focused on the dichotomy between our sense of individuality and our social existence.  We have attempted to understand our innate need to relate to others through philosophy in the distant past, but in the last century the mode of inquiry has been scientific, namely psychological and biological.

Some of the most basic understanding of human relationships has come from studies of the mother-child bond. Our identity originally forms in a symbiotic way with the mother. A trove of psychoanalytic research explores every nuance of a baby's transition from literally being one with its mother in utero to learning to differentiate between itself and other objects, also initially its mother. But it's startling to recognize that when a baby first looks at its mother, the baby identifies her as part of itself! And seeing oneself as an individual comes not days but a few years into life. Our sense of being independent is an outgrowth of living in the world and not at all an innate part of our psychological make-up. If that's the case, then "love thyself" as a mantra to adopt in our little bubble ignores the basic facts of our dependence on others. No wonder such an artificial way of living ends up being translated into something so concrete and meaningless as "stay thin."

Further research into child development places increasing importance on parent and peer relationships as the central mechanism a child uses to learn who he or she is. The child studies these reflections from others to learn how to become a fully independent person, also one of the goals of parenting. But if the most powerful tool to foster independence is the relationship with a child, then perhaps the goal is not complete autonomy at all. In a social society, a fully functioning adult learns to hold up her end of the relationships in her life. So the idea is to exist in a web of people and know one's place in one's own network. Maybe that's how to become a mature adult.

The difference between these two philosophies--love thyself or live in a network of relationships--can help direct a confused, at risk adolescent either towards an eating disorder or a healthy self-image. At this stage of life, a child is struggling to form an identity and, as I discussed in a previous post, is routinely trying on different hats to see if they fit. Outside of appearance and weight--things children this age universally criticize--a teenager will see little else in the mirror, so advocating the impossible edict to "love thyself" will only stoke the flame of the self-hatred.

Adolescents use all of the relationships around them to shape their sense of themselves and are susceptible to be quickly influenced by the people around them. For further proof, anyone can remember poor decisions of that time of life, and these powerfully emotional memories are always tinged with shame and the shock of being so painfully vulnerable. But these events remain defined markers of when we learned about ourselves. The positive and negative consequences of those relationships signify the process of coming to know who we are.

The critical importance of relationships to personal development in adolescence leads to an obvious step for parents. The key is to use the personal relationship with children to reflect who they are and what they mean in the world. It's a mistake to think children will acknowledge the information as an adult would. In fact, a child will look in that mirror again and again to be sure of what they saw and often challenge it for years before accepting this reflection. But if adults help the child learn who she is, then she won't end up relying on food and weight as the only barometer. We can only love ourselves as well as we have been loved. Ironically, we best see ourselves in reflections of others than in the mirror.

I want to switch gears for next time. In an early post, I discussed the pros and cons for residential treatment for eating disorders. I'm going to revisit that topic and speak about some alternate treatment ideas.

Expectations

At the end of the last post, the ideas of specialness, hope, living through the future and secretiveness--all discussed here previously--began to seem as relevant to adolescence as they do to eating disorder recovery. The question that came to mind is that perhaps the narrative of an eating disorder tends to remain stuck in the limited scope of adolescent expectations. That doesn't mean that someone with an eating disorder IS an adolescent at all but that having an eating disorder stops the personal development of how one views life's course. And then understanding the difference between the expectations of an adolescent and those of someone with an eating disorder might be a clue to help protect children from getting sick.

The state of becoming--the central theme of adolescence described in the last post--is a precious moment in life when everything seems possible for an instant.  But this developmental stage has instead become the Holy Grail, so revered that people try to extend it well past its expiration date. The sense of becoming is valuable for society at large because, by definition, it remains a brief moment in life. Teenagers embody the hope of a community for a new and improved future, but there is nothing pretty about someone in middle age working too hard to look or seem ten or twenty years younger. At some point, to have value for oneself and one's community, we all have to become something, namely ourselves.

In the world of an eating disorder, one is always becoming: becoming thinner, becoming sicker or imagining a future life when one has become well. In the end, the therapy for an eating disorder must lead to one significant transformation: from becoming to having become. A patient is so used to focusing on a future of being well and the fantasies of what life will be like that she has generally lost the ability to think and feel today, now. The end result is to completely eliminate any expectations for today and to ignore the real process of how life changes. The goal, dictated by the rules of an eating disorder, is predetermined. Each day is the same. Someone with an eating disorder continues to mature but her sense of how to become doesn't. And so expectations become almost contradictory: the aimless musings of a teenager explained by an intelligent, sophisticated adult.

But these free-floating expectations are the essence of adolescence. Suspended between an unrealistic yet somehow universal sense of promise and a tumultuous, emotional present, teenagers seem incomprehensible to any adult. They resemble wild, irrational beasts with the potential brainpower of a Nobel Laureate, the libido of a dog in heat and the emotional intelligence of an infant. The challenge of having a rational conversation can feel like learning Mandarin in one sitting. And even any linear sense of narrative is constantly being interrupted by fantasy and wild expectations. The precarious mental state and instability of a self that dominates adolescence seem to act like bait for disordered eating. As I have written in several posts, focusing on food and weight can provide order and identity to the utter confusion facing these kids. How then does a well-meaning parent talk to them in a language that will make sense? How does a parent be sure that the process of becoming lands a child squarely in the world of having become?

This is where the difference between eating disorder recovery and adolescent angst is useful. In treatment, the relationship in therapy acts like a mirror, and the patient consistently learns about herself by looking at her reflection each session. The disorder makes that image look like a monster: fat, slothful, disgusting and unlovable. Session after session, it becomes harder to believe the disorder when therapy reveals a very different self-image. The role of the therapist is to remember to state the obvious. Consistent positive feedback is  something a patient has never received and needs to hear over and over again. Patients with eating disorders have pretended to be okay while hiding the constant internal suffering. By letting their guard down and still getting regular praise--something most people take for granted--an entirely new reflection comes into focus. The subsequent confusion, emotions and dependence, previously inundated by eating disorder thoughts, represents the patient's introduction to life without the disorder. Living no longer needs to be synonymous with isolation. Being real no longer needs to mean being a burden on others but getting help and support.

The opportunity of involving all of oneself--thoughts, feelings and apprehensions--in the moment is an enormous relief for a patient unable to allow her expectations of life to mature since first becoming ill. For an adolescent, especially one at risk of perpetually becoming, the role of adults in her life is to act like that mirror. The adult doesn't need to tell or retell the child's story. The kid needs to figure that out on her own. But an adult needs to try to translate the Adolescent language (Mandarin perhaps) into something the world can understand. Although it certainly will take a few tries--and likely be very trying--a caring adult needs to show the child her reflection--with a combination of practical advice and regular positive feedback--and attempt to really understand the confusion of identity, emotion and expectations. Just as in therapy, this can create a stabilizing force. Think of it as harnessing all of this energy so it really can become ... something.

The risk of an adolescent slipping into an eating disorder, according to the above argument, hinges not just on self-esteem but on the reflection adolescents get from adults in their lives. I want to speak more about reflections and relationships in the next post.

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.

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.

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.

Reflections on Media and Eating Disorders

Using therapy as a model for good parenting is a dangerous line of reasoning and altogether inaccurate. Although effective therapy can reveal what was missing in a parent-child relationship, inflicting therapy on your children never helps. The therapeutic relationship has many boundaries and rules that render it awkward and distant yet incredibly intimate--very unlike the parent-child bond. However, those limits also make therapy safe for the patient to explore experiences and feelings that otherwise feel taboo in the outside world. The therapist--in addition to fully engaging with the patient--uses these explorations first to understand how a patient lives, feels and relates in the rest of her life and then to reflect back what it might mean about the past, present and future. This process creates a mirror for the patient to look at herself and her life in a new way, and that perspective can lead to therapeutic change. I think that the collective therapies of women with eating disorders similarly generalizes to explain why disordered eating has become an accepted way of life. Perhaps the powerful ambivalence of these women in treatment reflects a society that has trapped them within an epidemic of eating disorders and disordered eating. And perhaps the aspects of therapy that help patients find the way to moments of arrival also explain what is missing in the media-centered environment women live in--and kids grow up in--today.

Attention, compassion, listening, limits and patience. These attributes of eating disorder therapy are sufficient for successful treatment. They are also essential for parenting but  on their own represent the ineffective therapy-influenced ideal: treating kids like mini-adults. What is missing is the eternal frustration and anger that bubbles over--from parents and kids alike--when children come up against rules and limits. Kids seem hardwired to creatively challenge any boundary set in their way until the child and/or responsible adult finally gets angry. In therapy for eating disorders, personal expression of anger is almost exclusively self-inflicted since any sense of individuality, identity and self worth emanates from the success of controlling food and weight. Even experiencing anger is taboo and a sign of weakness--how can you stand up to others when it is impossible to stand up to the thoughts in your head--and leads directly to an escalation in the harsh, punishment of the eating disorder. Thus, the therapist needs to focus on compassion and kindness to counter the horror of the disordered thoughts and behaviors. The moments of arrival expose how harmful and unnecessary this punishment is and open up a world of hope, promise and emotion. There is no need for the therapist to reinforce the rules and limits children might need because the eating disorder has turned them into a prison.

The contradictory expectations of young girls--boundless opportunity combined with extreme limitations--explain how the developmental anger of childhood transforms into the punishing disorder. Girls need to strive academically, socially and athletically to achieve as much as, or even more than, boys just to prove themselves. Yet the insidious, fully accepted message of thinness and control over food is the necessary foundation to any measure of success. Fat women who are financial scions, CEOs, lawyers or doctors are still fat first. This message is a societal leash that reins in any excess confidence women may feel by demanding they strive for an unattainable goal. In addition, girls are expected to be grateful for what they have since women have never been lucky enough to have so much opportunity. Last, girls see the lives their role models lead: a frantic rush to have it all while doing nothing very well. Despite the seeming excess of opportunity, girls are fully aware of life's limitations. The promise of a wide world of options does not match the lives of women around them. With the burden of generations past, the demand for thinness and no clear path ahead, there is no room to push up against the boundaries the way boys do. Instead, an inward focus on food and weight is encouraged at an early age to channel any frustration. If striving for thinness and disordered eating provides children a solution to an insoluble reality, then it is up to parents as a whole to devise a more effective alternative.

It is all too easy for me to write a series of prescriptions for parents: support girls' self-esteem, raise sensitive, self-aware boys, make sure girls know they are loved and be sure girls know their value in the world. I certainly believe that and more, just as I know those messages--when a patient really starts to believe them--contribute greatly to eating disorder recovery. But these truisms don't address the real goal: prevention.

Life often feels like an endless series of choices. Each fork in the road closes off certain opportunities forever while opening up otherwise hidden options for the future. But progress comes from making those decisions. Trapped by unreasonable expectations and inwardly-focused anger, girls are supposed to leave all of their options open yet not make any decisions, all of which guarantees that they have none. Towards the end of successful treatment, long after the moments of arrival, the sessions are tinged with a sense of peacefulness intertwined with loss. Patients often are waiting for the next storm of recovery to weather, but it never comes. Gradually, we start to talk about acceptance of themselves and their lives. Perhaps this is who they are and their life has taken a certain path through the eating disorder in a new direction. The calm doesn't mean life will lack ups and downs, successes and disappointments, new adventures and painful losses. But those changes are now external, not reflections of the internal chaos and punishment within the eating disorder. These patients are free to foist the anger elsewhere and not suffer for it. Parents may not be able to change the conflicting pressures girls face but can work together to find new rules to play by. Feminist thought has left girls holding the imperative not to accept the world as it is, a motto distorted by the media--and condoned by society in general--into a personal attack against girls' self-acceptance. But perhaps parents can reflect a new model of life to which girls can aspire: a balance between the continued need to buck the inherent paternalism (because girls can get angry too), with a renewed focus on self-acceptance--mind, spirit and especially body.

The next post will move away from the topic of media to explore the role of shame in eating disorders.