Author: Johanna Marie Mcshane
Published in: Eating Disorders The Journal of Treatment and Prevention
Volume 14, Issue 4 September 2006, pages 341 - 347
Abstract
Clinicians treating anorexia often report that myriad and diverse attempts at treatment are met with resistance by patients, and are ultimately unsuccessful at fostering change. Many approaches to treating anorexia view the disorder as a kind of invader who must be combated and eradicated in order for the individual to recover. In this article the author proposes that such approaches fail to acknowledge fundamental aspects of the relationship between an individual and her anorexia, and that they ultimately impede or obstruct recovery. It is argued that a diplomatic approach similar to those used in resolving geopolitical conflict is more effective.
Introduction
Anorexia Nervosa is a potentially life-threatening psychological illness that is often thought of as difficult to treat and resistant to change (Couturer & Lock, 2006; Goldner, Birminghan & Smye, 1997; LeGrange & Lock, 2005; Stice, Orjada & Tristan, 2006; Lock, LeGrange, Agras & Dare, 2001). While there is consensus that, left untreated, anorexia nervosa can cause significant damage to an individual's health, myriad views exist as to the nature of the disorder: Is it an addiction? Is it a biochemical imbalance? Is it a personality trait? Is it a coping strategy?
As a psychotherapist treating people with eating disorders, I have noticed an intriguing and consistent theme extant among many clinicians, patients, and their families. People suffering from anorexia, as well as those who care about them, and those who attempt to treat them, often view the anorexia as an enemy, a powerful force that has invaded the individual. Consequently, they see recovery from this eating disorder as dependent on achieving victory in a battle between good (the person) and evil (the anorexia). Given the damaging effects of an eating disorder, it is not difficult to see how someone might come to this conclusion and subsequently prepare themselves for an intense battle.
I myself have, at times, felt anger towards the disorder, felt the urge to demonize it, to talk to my patients about conquering or eradicating it. Such a polarizing view is seductive. It gives an impression of clarity, that one side is good and the other bad, and that recovery, while perhaps difficult, is a basically clear, uncomplicated path. It affords a structure to treatment in which you always know where you stand: against the anorexia. But I believe that to hold this adversarial stance not only misses a fundamental aspect of an individual's relationship with her anorexia, but ultimately impedes or even precludes recovery.
It is worth noting here that anorexia is indeed an intra-psychic process, not a separate entity. However, both clinicians and individuals who have the disorder often see it as separate, particularly within this invader/enemy conceptualization (Hendricks, 2003; Hornbacher, 1998; Levenkron, 2000; Maisel, Epston & Borden, 2004; McFarland, 1995; Schaffer, 2003; Siegel, Brisman, & Weinshel, 1997). While I believe that ultimately the goal of recovery is integrative, there is significant benefit at times to working with the anorexia as a distinct aspect of the individual.
When I first began working with individuals who suffered from anorexia I, too, saw the disorder as an invader and as something to be vanquished. My interventions centered around fighting the anorexia. I encouraged patients to feel superior to their disorder when they combated it or hadn't let it win or get the better of them by intimidating them into not eating, or by convincing them that they were fat or worthless. These types of interventions gave me the impression that I was doing something to help my patients. They also appeared to give my patients something concrete they could do in order to feel as though they were helping themselves.
We went along like this for awhile; myself, my patients, and their anorexia. My attempts to help, while earnest and seemingly rational, were for the most part, not, getting us anywhere. Sometimes the approaches were helpful, and it seemed as if my patients were winning the war. Sometimes patients might have periods of feeling stronger than their disorder and of getting the upper hand, which subsequently gave them confidence and hope. Often, though, after repeatedly trying to fight their anorexia, I saw my patients become increasingly anxious, frustrated, and eventually hopeless. They believed the anorexia was winning and that they would never rid themselves of this devastating disorder.
Most distressing, the more we attempted to work in this way, the more entrenched the patient's eating disorder seemed to become. Instead of making the individual better, we often appeared to be making her worse. It was as if the more we fought the anorexia the more determined it became to resist our efforts. We were inadvertently creating resistance within the individual (interestingly, more than one of my patients reported she felt a “civil war” inside of her), and this was fatiguing, confusing, and demoralizing. I began to feel we must be missing something.
I began to question the usefulness of the conceptualization of recovery from anorexia as having a military solution. Senator George Mitchell (1999) had just written a book about his work as a mediator for the Ireland peace process. As I read his descriptions of how he worked with the various parties involved I couldn't help but think of my patients and their anorexia. He wrote of his attempts to get seemingly disparate, opposed, even polarized parties to be willing to interact and communicate with each other. He wrote about these parties' profound animosity towards each other, and their perpetration of immeasurable violence against each other over a long period of time. He recounted the deeply ingrained nature of the hatred, fear, and mistrust between these groups of people. And, he wrote of the processes of opening up dialogue between these parties.
I hadn't considered a diplomatic approach. My patients and I had been highly invested in the idea that we would fight to the death with the anorexia (kill it before it killed the patient). Mitchell wrote about finding commonalities between parties. I hadn't entertained the idea that there might be commonalities between an individual and her eating disorder. I surely had not thought there would be any way they could work together to solve what might be common problems.
This new line of thought forced me to look closer into the role anorexia plays in an individual's life. It had long been my belief that anorexia functioned as a coping skill, a way to mitigate emotions to make them more tolerable. But I hadn't sufficiently appreciated what I might call the work ethic of the eating disorder; that (speaking of the disorder again as if it were a separate being) it was, in its very limited and one-dimensional way, wholly committed to helping the person deal with her life. When looked at in this way, it was clear that both the individual and her anorexia had a common goal: managing and surviving life. The anorexia's role was to protect the individual by blunting her emotions, therefore sparing her from having to bear the full brunt of her feelings. The individual had somewhere along the way become afraid that she could not manage the intensity of her emotions and had unconsciously developed the anorexia as a way of doing so.
I could now see the individual and her anorexia as allies of a sort. And I could see the damaging elements of the eating disorder as by-products of the disorder, not as its intent. Anorexia was designed to save someone, not destroy her. Since there was clearly a common goal, survival of the individual, I thought that perhaps both sides could be persuaded to work together to some degree, instead of using their resources against each other.
Senator Mitchell writes of looking for common ground; if not shared goals, then at least places where all parties could relate in some way to each other. To ascertain what these might be, he had to find ways of beginning and maintaining communication between the parties, as well as maintain their interest in the process. One way he achieved this was to employ trust-building and confidence-building measures. Each party would offer something in good faith, for example, a temporary cease-fire, to the other parties. Those involved would gain confidence and trust in the word of the others by observing that pledges were upheld. This strategy seemed to fit with recovery from anorexia. Perhaps if the eating disorder could gain confidence that the individual could actually handle her emotions, it might not feel the need to be so active in her life (which would ultimately decrease her symptoms).
I imagined a confidence building measure for the individual might be to attempt to let herself feel an emotion, for even a few seconds, no matter how frightening this might be. The anorexia could watch for itself and gain confidence that the individual had been able to experience the emotion without falling apart. This process would have the effect of promoting confidence in the individual, since she would have succeeded in feeling an emotion without becoming harmed by the experience, and it would promote confidence in the anorexia that it need not step in so quickly to assist the individual when she was encountering emotions.
One of the ways anorexia appears to help lessen an individual's exposure to emotions is by distracting her before she realizes she is experiencing a feeling. Confidence building measures are useful here also. It seems the anorexia distracts the individual by pelting her with thoughts about body shape and size, about the dangers of food, and about the benefits to self-worth of abstaining from food. One of the interventions I make is to have a patient become suspicious about any thoughts she is having related to these issues. We focus on reasons the thought might have come into her consciousness at that particular moment, and what function they may be serving. Generally (usually after lots of practice), the patient becomes aware that just before the thought appeared, she began to have an emotion she found difficult. It was as if the anorexia, sensing her impending discomfort, derailed that emotional process by inserting these other thoughts. While distressing, the negative thoughts about her body were more tolerable than whatever emotion she had been about to encounter. Over time as my patient and I develop her confidence that she can handle emotions, the frequency and intensity of these body size and shape thoughts decreases. It is as if the anorexia becomes increasingly convinced that she can tolerate her emotions and therefore does not feel the need to distract her from her experience.
Mitchell wrote about the necessity of a constant process of gestures between parties in order to solidify trust. This is relevant in recovery from anorexia also. It is only in repetition and practice that confidence gets built. Furthermore, this is not always a linear proposition. There are setbacks along the way. The individual once again gets frustrated and wants to attack her eating disorder. Or she again begins to view the anorexia as attempting to ruin her. Mitchell also noted a dynamic cycle of emotional and psychological states on the part of all parties regarding the peace process. In the process of recovery I observe my patients' frequently shifting experience of ambivalence, hopelessness, despair, emerging strength, frustration, re-commitment, uncertainty, hope, and faith in the process, just to name a few.
Senator Mitchell acknowledged that peace must be continually attended to; it is a dynamic as opposed to static state. It must be carefully tended and, especially at the beginning, it can easily slip away. In both geopolitical conflict resolution and recovery from anorexia, parties must constantly challenge themselves to maintain the gains they have achieved. Reverting to old thoughts and beliefs can happen quickly and subtly (Sharkey-Orgnero, 1999). By committing to recovering from her eating disorder, the individual commits to a long-term process of not just achieving internal peace, but of becoming a caretaker of the peace.
As a therapist I was particularly interested in Senator Mitchell's role as mediator. He characterized his job as providing structure and containment for all parties and setting out rules and guidelines for negotiations. He made it clear his role was neither to impose his own beliefs on any party nor to attempt to get those involved to resolve their conflicts in a way that he might agree with or desire. His investment was in helping all sides come to agreements that were meaningful to them and that they therefore could live with, not getting them to adopt what he might believe should be done. He realized that if he tried to impose his own beliefs on the people involved, they would never trust him, and the opportunity for peace would be lost.
As a psychotherapist I consider it my job to set out parameters and to provide an atmosphere in which dialog can potentially occur. I do not see my role as getting my patient to see things my way, or to believe what I might believe. People in general, and certainly those with eating disorders, are stubbornly attached to the idea of freedom and independence. Though a patient may appear to be in agreement with the ideas of the therapist, if she does not herself believe these ideas, she will eventually resist them and rebel.
Because of the life-threatening nature of anorexia, I sometimes become worried, and consequently impatient, about the rate of change. It is difficult to refrain from saying, “you just need to eat” or “don't you understand that you could die?” Mitchell wrote about his frustration and discouragement, and about times when he felt the entire process might dissolve. He wrote of the fatigue he experienced at points throughout the process, a feature worth acknowledging in treating individuals who suffer from anorexia. There is uncertainty involved at many places along the way. I find that I am not immune from many of the same emotional states that my patients experience. I, too, have periods of frustration, uncertainty, and discouragement. I also find that I experience re-committing to the process just as my patients do.
This diplomacy-based approach to working with people who suffer from anorexia has seemed odd to many of my patients, at least in the beginning. They are not expecting me to have anything but abhorrence for their anorexia. I have received many a bewildered look as I talk about having a deep understanding of why they have developed anorexia and why they are likely invested in keeping it around. The look becomes increasingly incredulous as I describe my respect for the disorder and what it has attempted to do, and as I speak of my desire to work with the anorexia instead of against the eating disorder. This idea seems to catch my patients off-guard, and it begins to get them to think about themselves and their disorder in a different way.
Among the myriad benefits of working with anorexia from this perspective, there are two that I have found particularly rewarding. First, individuals who have anorexia tend to have significant levels of anxiety. This is generally true in their lives, and it is specifically true regarding pursuing help for their eating disorder. I have found that a major contributor to this particular anxiety is the fear that someone is going to try to take the anorexia away before the person feels prepared for life without it (which is exactly what people often anticipate will happen in treatment). Given the investment the individual has in her disorder, having it suddenly taken away with nothing to replace it would be a terrifying idea. Within the diplomatic-approach conceptualization of treatment and recovery, I can genuinely assure the individual that I will not be attempting to extricate her disorder without her consent. I also can help her understand that resolving the anorexia will be a process, and that as we traverse that process she will gain the requisite confidence that she can live quite successfully without the disorder. This is generally a great relief to my patients. It allows them to feel relatively in charge of the recovery process and affords them a feeling of stability. Subsequently, they tend to be more willing to come to treatment, and better prepared to make use of treatment.
Second, working within an approach where all sides are treated with respect and are afforded an opportunity to be heard allows for understanding to develop. Clearly, understanding the issues involved is helpful. But, more importantly, understanding offers the opportunity for development of compassion and empathy. Individuals with anorexia tend toward self-loathing. They have little patience for the idea of gentleness or compassion towards themselves.
However, over time, as we begin peace talks between the person and her eating disorder, she eventually begins to view aspects of herself as deserving of compassion, not hatred and hardness. She comes not only to understand but to appreciate the role the eating disorder has played in her life. I believe this evolution is the essential factor in recovery. Without compassion and empathy the individual views disparate aspects of herself as vile, incoherent, and unreasonable, and she tries to combat them and dissociate from them, as did the parties involved in the conflict in Ireland. But as compassion and empathy towards the self develop, the individual becomes increasingly committed to her health and well-being. She can appreciate the efforts of the anorexia, but she no longer feels the disorder must be actively used. She has gained confidence that she can bear all her emotions and deal with her life on her own.
In effect, all parties win. The anorexia has grown to trust that the individual can manage without its assistance, so it is willing to lessen its hold on her. The individual has grown to trust that she can indeed manage without the help of the eating disorder, so she does not need to remain as attached to the anorexia. At that point, from a symptomatic point of view, the eating disorder appears to have been eradicated. In reality, the individual and her anorexia agreed to negotiate, came to understand and appreciate each other, and found a way to mutually resolve the issue of how to assist the individual in tolerating her emotional experience.
REFERENCES
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