Anorexia, Treatment of a Complicated Illness.

Each client tends to be more different than similar, and the development trajectory for each client is complex. Most anorexics will move into bulimia, while many bulimics who get under control will attempt to restrict; therefore, one common feature of the illness is that over-control eventually leads to out of control, and getting under control results in over-control.

The Potential for Combination of Disorders

The vast majority of anorexics and bulimics likewise, manifest sexual over control and out of control difficulties. In their disease, they are unaware of cues for appetite or satiations. In a similar manner, the cues for sexual appetite are confused. Once they are eating and re-fed, often they will experience sexual arousal, but the ability to use those cues to make sexual decisions is blurred. These primary interactions with others are geared to avoid disappointment, as well as to please. It is as if they do not have a core sense of self to know or determine what they deserve, so they make decisions regarding their wants in relation to not displeasing others. Unfortunately, sex, for the sake of the other can be disastrous, since it typically feels like an assault to the body when there is little desire combined with intense fear. The result of these juxtaposition and disconnections is a pattern of sexual behavior that is out of control, many patterns in a short span of time, while simultaneously experiencing low desire as even sexual aversion. When they do find a partner who is desirable after their body is too traumatized by prior objectification and bypassing to respond.

Attachment Issues at the Center

The critical difficulty or deficiency, at the core of the eating symptom, is the capacity to relate and form attachments to other people. The eating disordered client often feels a sense of being alone even with people and friends when in the restriction phase. One might say: non-consuming consumes them. In the binge state, they may become too close or too needy, which results in being rejected or hurt eventually. Again, over-control leading to out of control. The etiology of this pattern seems related to the early attachment patterns blueprinted in the first two years of life. When fearful children either cling (anxious attachment) or if over time experience rejection when they move-towards, they quickly learn to avoid, becoming angry, aggressive or inhibited. Some children also develop patterns of disorganization, with both some clinging and avoiding. This latter pattern resembles the eating disorder client, restricting: avoidance, and bingeing: clinging. These early attachment patterns quite likely are at the core of the eating, bonding, and sexual symptoms of the adult. For this reason, we focus on attempting to change attachment patterns in order to facilitate resolution of the illness. Our experience is that even when there is success in control of symptoms using behavioral therapies, relapse often is triggered by loneliness, or pain from relationships. Under stress, the client returns to the established way of coping, unless they have learned to use relationships with self and others to regulate their emotions.

The Relationship to Self

Changing attachment patterns begins with helping the client develop a relationship with themselves. This sounds a bit like a cliché, but literally the client needs to develop internal communication and listen to their inner voice related to what they want and need without judgment and with compassion. In the past, the likelihood is that the internal relationship has been one of negation, invalidation, and emotional brutality. So, attention, acknowledgement and care is no small change. Once this shift begins to permit the turning to the self in distress, the development of renewed trust, in their own intuition and wisdom, takes place. They can then more safely make choices to allow others in, while operating in the outside world, and do so with improved self-efficacy and competency. The development of healthier boundaries is both a requisite and by-product of this unfolding process, resulting from enhanced clarity regarding what they actually want and how to say yes and no, while not disqualifying their own needs or compromising self-respect.

Re-Building from the Ground Up

To know self however, they must walk through their development without omission of the painful, shameful or overwhelming aspects nor of the beauty, courage, or capacities that are intertwined with these and establish a cohesive and coherent story about their life experiences. They examine and reexamine how they experienced childhood and adolescent events and the effects on them, through their adult self-perspective. They reexamine how they established trust, esteem, intimacy, power and control and consider values clarification related to their core beliefs in relation to others. They question whether their conclusions and attributions were truly accurate. This also requires trauma resolution work since often patterns of thinking are arrested at certain ages by traumatized experiences. Reworking of the trauma by the adult allows for a better way of being in the world without the residual paralyzing fear and numbness that restriction attempts to offset or disguise.

During this period of recovery, it is necessary to practice abstinence from intimate relationships, abstinence from sexual behavior, and to adhere to a structured meal plan established by the dietitian. Over time, the abstinence can be steadily lessened but the main principle is to move slowly.

“Violent delights have violent ends and become loathsome in their own deliciousness,” say Shakespeare, which translates into loving moderately. As most of us have learned from experience, relationships with others, when they are healthy, strengthens ones sense of safety.