At the heart of relationships lies the understanding that separation and loss will occur within all relationships. Eating disorder patients bring a litany of wounding experiences and events into therapy, which signals the presence of pathological loss and increases the difficulty faced when it comes to bonding (attachment issues) and separation.
Pathological separation and loss can be understood in symbolic terms, i.e., emotional disconnection from another. These losses can occur as a result of interpersonal interaction in which a person feels let down, disappointed, hurt, criticized, shamed, misunderstood or misrepresented by those she most wishes to trust. It is the type of loss that typically occurs in the absence of a familial holding environment – where safety, trust, and empathy are weak or nonexistent. These types of losses are experienced quite often by eating disorder patients, who remain highly sensitized to perceiving them – whether real or projections – in most interpersonal situations. Hence, patients with eating disorders are often identified as the one in the family or social group who is “too sensitive,” “too serious” or who lets nothing “roll off her back.”
Bowlby uses the terms “separation” and “loss” to describe normal and inevitable processes, i.e., the child’s attachment figure (parent) becoming inaccessible, either temporarily (through separation) or permanently (loss). Among Bowlby’s most significant themes are the “centrality of loss as a determinant of disturbance, the importance of the [primary caregiver(s)] in neutralizing and defusing the destructive effects of rage in response to loss, and the use of affective withdrawal as a defense against the pain of unmet longing or anger faced alone.” How fitting is the use of eating disorder symptomatology as a response to and metaphoric representation of Bowlby’s themes, i.e., the eating disorder is a replacement for symbolic losses, serving to reduce highly charged negative affect (anger) through control by not eating, or expressed via the physically aggressive act of purging. The symptoms serve also as means to distract, numb, and soothe emotional distress so that the affect is withdrawn, projected onto, and soothed by the very use of the symptom.
Loss of the eating disorder that comes with recovery
Experience has shown that, by the time patients are recovered, they have made peace with their disorder (made possible through the process of grieving) and with the person they were who needed it. Sometimes patients experience regret and remorse over the number of years spent obsessing over calories or hours spent alone eating and throwing up. Many, however, do not look back with regret, but in fact develop and retain compassion toward their disorder and life before recovery. Some recovered sufferers report that, were it not for their eating disorder, they may not have come to view their lives and the lives of others with empathy or understand what it means to respect the frailty and vulnerability in all human beings.
The use of the symptom as a voice of competing needs – attachment versus separation
Eating disorders are powerful symptoms and representations of the clash within the child who simultaneously utilizes her eating disorder as a statement of her will over others and her need for vigilant care from others. Such a contradiction creates a bind that keeps a person ill, sometimes for a long time. The struggle over her voice of independence and the need to rely upon others is confusing, as both voices jockey for a position of dominance. Since most eating disorder sufferers view life in “all or nothing” terms (self-disgust versus perfectionism or reproach versus idealization of the object), the notions that one can have simultaneous and competing feelings, a variety of positive outcomes, or conceive the possibility that relationships are often ambivalent are foreign concepts. So it is understandable why many patients think that, in order to be independent (separation issue), they must renounce any and all aspects of themselves that need to depend on others. And if dependency implies being controlled, criticized, or manipulated, or the longing for others feels too intense or anxiety-provoking, it is understandable why dependency would be cast in a negative light. Total loss of a relationship is the preferable outcome to maintaining a relationship that feels unsafe or ambivalent – most vividly apparent with eating disorder patients who have co-morbid personality disorders. The use of symptoms is a powerful tool to create and maintain separation from interpersonal issues – and as the means for a person to dissociate from intra-psychic conflicts.
Separation and loss that occur symbolically are often experienced by eating disorder patients in profound and debilitating ways. The attempt to protect from these kinds of symbolic losses is equally powerful; the eating disorder symptom is a primary means to deny and avoid losses, while simultaneously being the metaphoric voice to express them.
Many of the issues regarding separation and loss are highlighted when treating adolescents and their families. Family therapy is a dynamic, often highly charged and poignant way for families to become aware of how symbolic representations of separation and loss occur. Shame, criticism, control, absence of emotional availability and understanding by parents toward their children, and lack of empathy all create an absence of emotional safety and trust; eating disorders develop and flourish in these environments. Symbolic issues of separation and loss are ripe in these families. Helping these families heal often includes creating an environment in therapy where an emotional language can emerge. The separation from the symptom occurs with the creation of a holding environment in which feelings of anger, grief, sadness, and loss can be experienced and expressed. Autonomous family function can then have an opportunity to emerge
Originally Published in The Meadows