Human Concern - centrum voor eetstoornissen behandelt álle vormen van eetstoornissen: van anorexia tot boulimia en alles wat ertussenin zit. Van dik naar dun; van veel tot weinig eten; vrouwen, maar ook mannen. Of je nu net een eetstoornis hebt of er al je hele leven mee kampt.
Weet dat we weten hoe het is om een eetstoornis te hebben, dat deze een functie en een doel heeft. Misschien kan dat je helpen om achter je schaamte vandaan te komen, je herkend te voelen en te beginnen jezelf terug te vinden.
Stichting Human Concern is een specialistische GGZ-instelling die een hoog specialistische behandeling van eetstoornissen als Anorexia Nervosa, Boulimia Nervosa, Eetbuistoornis (ofwel BED) en Andere Gespecificeerde voedings- of eetstoornis (alles wat hier tussen in valt) koppelt aan een grote mate van persoonlijke betrokkenheid en gastvrijheid.
First and foremost an increased sensitivity or predisposition in personality underlies an ED. Children who are at risk of developing an ED typically are extremely sensitive, on average more intelligent, more creative and talented in thought or action. They often have a remarkable temper, characterised by extremely extraverted or extremely subdued behaviour. These children deviate slightly from the norm, and therefore usually from the environment in which they grow up, which creates a genuine risk that their authentic characteristics will not be properly recognised and acknowledged as they grow up. The unique does not meet an unconditional mirror. Therefore it cannot accept, position, and develop itself into an autonomous identity. One’s own SELF.
The Sensitive Self I see I see what is there
Because of their extreme sensitivity, these children adapt to others from a very young age, infallibly sensing what is going on in their environment: in their family, in the classroom, in the world. Tension, noise, or issues in their own immediate world or the world far beyond that. Others’ unmet needs are picked up on, as are suppressed emotions or issues, and (unspoken) conflicts among people, religions, or countries.
Because their main focus is outward, they do not learn to attune to what is going on within themselves—needs, boundaries, emotions, etc. Therefore they will not get to know themselves sufficiently, which interferes with the development of a solid sense of self. Their SELF remains in its infancy.
The Overwhelmed Self I want I must do what I can’t
Usually these children are the first to identify something amiss in their environment. They seem to have a sixth sense for danger or injustice. In that respect they often function as antennae of a failing system, at both micro and macro levels.
Generally these children also have a strong sense of responsibility. They want to make the world a better place. They want to address the wrongs, the incongruence, the noise they sense. They feel this is their task, mission, or responsibility. However, unable to influence or solve what they intuitively hear, see, or feel, they are powerless to end situations or people’s suffering. Of course it is not their job to do so. Only the matter or person itself could. Therefore this leads to feelings of intense desperation and frustration, failure and guilt, commiseration and self-sacrifice.
The Perplexed Self I feel I sense but I don’t get
What makes it even more complex is that these children do intuitively sense lots of things from a very young age, but because of their young age they are unable to make sense of it: what causes it and how to give it meaning. The contrast between sensing and understanding is too big, which renders them confused. About the other, themselves, and the world in which they live. On top of that, being unable to exert influence over the situation frustrates them terribly, and makes them feel incredibly anxious and rudderless.
The Infant Self I miss I miss what I am not
Having been unable to develop an autonomous identity, one’s own SELF, renders these children vulnerable. They do not know how to handle life events and stress, such as being bullied, moving house, break-ups, loss, divorce, a negative remark, let alone a severely traumatic event. These types of experiences can be the cause or the last straw, triggering the onset of an eating disorder.
The Surviving Self I eat I eat which I don’t dare
Children sometimes entirely subconsciously link food and weight and how these may affect their sense of wellbeing. Initially innocent dieting attempts will go overboard because they turn out to help more than expected in dealing with difficult emotions and dilemmas. As soon as the function of food and weight in dealing with these developmental challenges is discovered, the eating disorder is born serving as a coping mechanism, also called a survival strategy. The behaviour which subsequently emerges, such as obsessing about food and weight in AN, BN, and BED alike offers the person a distraction, an outlet, but also structure and control. And security above all!
The Secured Self I will remain whom I can’t be
By ‘messing’ with food (too little, or too much) they’ll discover their ability to communicate. The ability to shape their emotions, making them disappear (fasting) or releasing them (purging). Besides, they experience a kind of power (accomplishment), support, and control (compulsion). Unable to sort out the external, they do determine this within themselves.
Through food they are creating their own small and secure internal world. A cocoon, a bubble, or a cave. There is an obvious sign on the outside. They are securing, as it were, their own SELF.
Within these secure walls, their own territory, they are asserting their autonomy, their own identity, even if said identity remains highly underdeveloped.
The Confined Self I must I will what I don’t want
However, they are also subconsciously starting to build thick prison walls. For the ED, originally a useful coping mechanism, is gradually taking on a life of its own, thriving on the lack of substantial identity and autonomy. And inside this small internal world and on this rich soil the ED is growing rapidly, taking up more and more space and control. After a while the power of the ED reaches (far) beyond the walls of the internal world. It is crossing boundaries. Entire families, relationships, friendships, treatments are dominated and intimidated by the ED.
As time goes by, the ED takes over the internal (and external) world more and more, increasingly dominantly and aggressively. Thoughts, feelings and behaviour are dictated by the ED persona, instead of the person as a healthily developed individual. The ED host starts to experience the initial ‘security’ within as more and more ‘insecure’. The secondary gain is decreasing dramatically, as the individual is now ruled by the ED instead of the other way around. He or she is no longer in charge.
The Concealed Self I seem I seem whom I am not
Their autonomy is dwindling. Their own ‘SELF’ is losing ground. And their environment is not just starting to worry, but is also feeling manipulated, controlled, attacked, forced, and terrorised more and more. The ED tentacles or roots reach beyond the body and mind of its host. They will grab anything that comes too near and poses a threat to the continued existence of the ED: parent, partner, sibling, friend, and therapist.
From bad to worse – The vicious cycle
Owing to an increase instead of decrease in internal insecurity, a more and more powerful ED is needed to recreate the (false) sense of security. However, this in turn creates more dependence and increases insecurity. Thus a vicious cycle and downward spiral are born. It works like a self-fulfilling prophecy. The person falls into a trap. The walls are closing in. Their own ‘SELF’ is getting smaller, their self-image more negative, their freedom of choice more restricted. All the while the ED is growing, eventually reaching its final stage in which the ‘SELF’ has become completely subordinated to the dictatorship of the ED. The individual, the ‘SELF’ has been taken hostage, slowly disengaging from the battlefield.
Negotiating or talking with the individual by those involved, loved ones or therapists, is becoming increasingly complicated since 9 times out of 10 the ED answers strategically. It is no longer the ‘SELF’, the healthy voice, which is represented. It is the ED and its interests. Cunningly and cleverly the ED may now even disguise itself as the ‘SELF’ in order to mislead the outside world. Its fear of exposure or threat is so great that it will defend itself by any means necessary. In fact it will strike pre-emptively, pushing back people or help and support. The environment is rendered powerless, frustrated, and desperate. Simultaneously the individual is sinking deeper and deeper into isolation, and is therefore exposed even more to the unilateral influence and, consequently, brainwashing of the ED.
The ‘SELF’ has completely fallen under the spell of the ED regime now, being severely punished for any attempts to free itself. The ‘SELF’ has virtually vanished. It has been silenced. Its ability to feel, think, act (logically) has completely disappeared. And of course it quite literally can no longer see clearly.
Eventually the walls close in. In this stage it is not inconceivable that the individual has been irretrievably lost and the ED kills him or her directly, be it through malnutrition or exhaustion in anorexia, or heart failure from excessive purging in bulimia, or ‘simply’ through an ‘ordinary’ suicide attempt… All of these are direct consequences of the hostage’s severe, prolonged pain. Those suffering from an ED do not actually want to die, but they can no longer handle this life, the consequences of this dictatorial imprisonment for their environment, being in a constant state of terror and agony. Makes sense, doesn’t it?
Remarkably, particularly when the survival process is starting to become irreversible, the individual appears likely to make a final genuine attempt to survive the disease in its final stage. This is when they often find one last glimmer of hope or motivation for a final effort. Paradoxically the drive for said final showdown appears to be motivated by the quite literal onset of a death struggle. Once the individual ventures beyond the point of no return, intuitively sensing that the end is near, and that they’re at the end of their tether physically, only their extremely primitive survival mechanism appears able to take on the immeasurable force of the ED. Unfortunately by then it is too late.
This is just to indicate it is nearly impossible to fight the ED in its final stage. That is why many treatment facilities and hospitals resort to coercion.
Eating disorder enabling treatments
In this stage therapists are likely to label patients ‘beyond treatment’, ‘therapy resistant’, ‘unmotivated’, or even ‘aggressive’. Besides, in this stage comorbid disorders are often pulled from the DSM depository: BPD, ASD, PTSD, severe depression, or strong OCD. Clients are denied treatment, or placed into yet another compulsory treatment or emergency inpatient programme. Clients and their therapists have often tried anything and everything, but cannot manage to break through the ED wall. They are fighting along in the losing battle between the ED and the confined ‘SELF’. The ED regime has gained such strength that the ranks are slowly but surely closing.
It begs the question whether clients really are beyond treatment or have simply undergone the wrong treatment.
In my opinion said final stage, of either ‘desperate surrender’ or ‘desperate coercion’, is enabled by the contents and forms of preceding treatments. One may wonder about causality. Could it be, for instance, that multiple ‘failed’ or ‘temporarily successful’ treatments, aiming only at symptoms, followed by repeated relapse, have merely weakened the ‘SELF’ (rendering it more hopeless, negative, depressed) and strengthened the ED (rendering it more cunning, suspicious, aggressive)?
I am afraid so in some, if not many cases.
For every strike and threat (i.e. treatment) the ED doubles its troops and becomes better prepared for the next strike and threat (i.e. treatment). Certainly and especially in the case of (aggressive) coercive treatment. Such strikes are characterised by a temporary, coercive, at times aggressive take-over of false autonomy (ED autonomy). The ED will not allow its autonomy and authority to be taken away. When coerced, it may temporarily give in, but it will definitely not surrender. After inpatient treatment the cautioned ED acutely takes the helm again, triples its troops and defends itself against the next strike, determined to win the war. The stronger the strike, the stronger its counterattack, and the deeper the ED will take root in the individual. It will have branched throughout the entire being, nourished and empowered by external threats.
In my view, the abovementioned mechanism of ED enabling and empowering has not been sufficiently researched, it is understood too little, and is therefore not anticipated upon properly. Therapist and treatment allow themselves to be carried off into the wrong direction, trying to fight suspicion with suspicion, conflict with conflict, control with control, and violence with violence, resulting in increasing levels of force in which the ‘SELF’ disappears. At this point only the ED and its enemy, i.e. treatment or therapist, are taking part in the fight. The ‘SELF’ has vanished from the battlefield. And nobody has a clue.
Cooperating with the eating disorder
A different, more constructive approach would be not to be lured to a showdown, which would be a losing battle for an outsider anyway. Coercive treatment or forced intervention are often short-lived. It is impossible to permanently stifle the ED in a short period of time. It is merely put on hold. Besides, no work is done to simultaneously empower the ‘SELF’, enabling it to take on the ED and eventually take back control over its own life. On the contrary, the ED is empowered and grows stronger; the SELF withdraws and grows weaker.
The ‘SELF’ and any outsiders concerned (family, therapists) may still kindly cooperate with the ED in the first stages. Through understanding, respect, and recognition, by listening and learning. By designing different life strategies or coping skills. This may occur in relative harmony. There may be boundary disputes, but no war. There may be debates, but no deadlock. There may be negotiation, but no coercion. There will be boundaries, but no fight. In this stage, to prevent the stage of acute war, it is crucial to find a peaceful way to come into contact with the ED and to maintain said contact, together with the therapist. Mutual respect and understanding need to grow. The ED should not be provoked by coercion, violence, or demonisation. Stir it a little at times, followed by trust. The growing ‘SELF’ and diminishing ED will both be able to develop in relative harmony, as communicating vessels.
Different fundamental attitude and approach
If both treatment and therapist can guide and enable process this effectively, you will be on the right track together. In this stage and setting the eating disorder is not an enemy, but an ally, helping both client and therapist gain insight into solutions. Respect, listening, communication, and negotiation are key.
This does, however, require a fundamentally different attitude towards ED in both therapist and treatment. Separating ED from ‘SELF’ and giving specific attention to each is crucial. A frequently made ‘mistake’ is viewing ED and ‘SELF’ as a single identity. The ED is the individual, the client—an unreliable, stubborn, unruly, anxious, resistant, aggressive, manipulative one. These characteristics belong to the ED, however, a survival mechanism or strategy, going above and beyond to protect the individual’s autonomy by any means necessary. After all, if the ED surrenders without having formed a sense of identity and autonomy, the individual will crash. He or she will no longer BE, no longer able to exist—a life-threatening situation. No wonder the ED will protect its host tooth and nail.
In contrast to the characteristics displayed by the ED, the individual and their infantile identity behind the ED is actually usually gentle, cooperative, authentic, original, creative, willing, loving, reliable, loyal, honest, ready to fight.
The ability as a parent, friend, therapist, or researcher to continue to see these characteristics and separate them from the ED would greatly affect the manner in which a client is treated. It would naturally allow one to be more patient and to sympathise more, thus allowing parents or therapists to be supportive instead of being opponents or even enemies. This is because the individual’s or client’s behaviour is no longer taken personally.
From bad to less bad – The way out
So, if we are able to recognise, see, meet the individual or client behind the ED, ironically we find ourselves back on square one. That is, the lack of acknowledgement of the authentic, unique self. The self’s need for recognition. Why did this individual need their ED in the first place? To cope with their specific and unique makeup of personal characteristics.
It is not until we regard the actual individual behind the ED that we come to understand the reason, the cause, the underlying need, the pay-off, and the function. Only then can we figure out how to address the ED. That is, by recognising the underdeveloped authentic ‘SELF’, by acknowledging it and allowing it to exist. This angle immediately provides a different perspective on ED as a disorder, on the client as an individual, and on treatment as form and approach. This view would help ED to no longer need to attack the ‘SELF’.
If a different approach in treatment is opted for in earlier stages, the client is prevented from reaching a stage in which the ED has become integrated, the ‘SELF’ has grown even weaker, and the front has grown too strong for effective treatment in any way, shape, or form.
Source: Reader – HC therapist training (author and copyright: Carmen Netten)