No one doubts that many people with eating disorders often feel shame for their symptoms and behavior, particularly those suffering with bulimia. Admitting to yourself and others that you spend a portion or much of your day secretly eating copious quantities of food and then throwing up is often ripe with feelings of self-disgust, self-reproach and low self worth, all emotional states that fuel shame.
To cover shame, patients with bulimia often lie and deceive others to protect their vulnerability and their secrets. Sometimes entire new personas are made up in order to conceal. Some sufferers overcompensate by appearing overly self-confident and gregarious. They may act as if they have little or no concern for how others feel about them and appear to have very high self-esteem. However, they often feel oppositely and are deeply worried about how others perceive them and acknowledge having very low self-esteem. They are painfully aware of the charade they play every day. Usually, the persona they have developed to conceal who they really are is not part of who they wish to be or how they wish to behave in life and relationships; lies are used in order to protect themselves.
This type of persona is difficult to dismantle for sufferers who have spent so much time appearing healthy, put together or even envied by others for their apparent strength of character. However, they usually accept that how they appear is not who they really are and so it is of great concern to them; lying is not easy or comfortable. As the belief that they are imposters occupies much of their daily thoughts, negative self-worth is further reinforced. They often want to recover and seeking treatment for their eating disorder is likely.
The upside is that recovery is absolutely possible for those whose duplicity serves to primarily cover their shame and the symptoms of their eating disorder. They want to be better and feel better about themselves; their integrity has suffered. They long for authenticity and want to abandon the lies and manipulations and ultimately the eating disorder. Primary goals in therapy, in addition to medical and nutritional stabilization, are to "convince" them that if they are open and willing to trust in the therapeutic relationship that their authentic self will be revealed, that loved ones and friends will likely support the real them and that they can lead a life without symptoms.
This type of duplicity and deceit that a sufferer may adopt to protect them from having their vulnerabilities exposed is not characterlogical in nature…not part of their personality, but rather is an adaption and response to cover up the eating disorder.
There is another type of persona that may develop for other eating disorder sufferers who rely on manipulation, lies and deceiving others.
Sometimes their eating disorder is one issue in a longer line of personality issues that predate the eating disorder and are deeply seated in psychological unrest and conflict. For these individuals, behaving in deceitful and duplicitous ways is more comfortable for them and integrated in to their personality. Usually, the characterlogical issues for these individuals have been in the making long before the eating disorder developed. As a result, the eating disorder is usually more difficult to treat.
The persona they develop is unfortunately more ingrained and relied upon, often without conflict for them, i.e., they feel little guilt. They consciously do not believe they are compromising themselves or others. Many times these individuals seek medical treatment because a medical or physical consequence of their disorder, like vomiting blood, heart palpitations or chronic and severe gas and bloating, scares them. It is often the medical practitioner who diagnoses the eating disorder and is then placed in the position of speaking candidly and hopefully with warmth and support to the patient about getting comprehensive (medical, psychotherapeutic and nutritional) help.
Sometimes when these patients enter treatment, they often terminate quickly or pre-maturely. Let’s face it: Recovery isn’t for the faint of heart. It takes a lot of stamina, truth, trust, commitment and determination. The risk of exposure and emotional vulnerability is greater for these patients who rely on the persona they have created and developed over time. It works for them; nothing speaks to giving it up.
Patients who are “career” liars, deceivers or manipulators are not so inclined to recognize how these personality issues are affecting them and their relationships. Often, they cannot imagine living life with honesty. There is often a great deal of fear in giving up the personality. They are often the eating disorder types that many have heard so much about…angry, entitled, manipulative, grandiose, self-centered and immature. These are the sufferers who often hold their loved ones hostage to their rage and emotional tirades.
Underlying these patients’ personalities are individuals who are often extremely psychologically vulnerable. They cannot imagine trusting anyone, as they know that they are not trust worthy themselves. They do not recognize that their rage, self-centeredness and entitlement is rarely, if ever, useful in relationships. They do not recognize that others’ needs are as important as their own.
These are individuals for whom the eating disorder is so embedded in their make-up that they rationalize and minimize its significance (i.e., throwing up is to prevent weight gain)
Recovery, therefore, is way more challenging. Helping them recognize in therapy that their self-abusive behavior may indeed be a direct result of their own fear, insecurity, and deep-seated shame, takes time. They do not recognize consciously that their own behavior is self-abusive and that this self-abuse is the price they may have unconsciously self imposed because they deceive, lie, manipulate and rage at others. It is a vicious cycle.
How do you help these patients who have an eating disorder for whom deceit and manipulation is a way of life?
As a practitioner, all patients deserve compassion, support and understanding. It is their vulnerability that ultimately enables recovery. So, judging from whence comes the duplicity is helpful to the extent that it aids the practitioner in understanding the likely or potential obstacles that may interfere with a patient’s ability to recover.
Diagnosing a patient is important so that the practitioner can know which theoretical models and treatment approaches may be most helpful and a good fit for the patient. Having realistic goals with all patients is important. Supporting medical and nutritional care for all or most patients is imperative. However, teasing out the differences in the patients need for the symptom, use of the symptoms and use of the need to lie and manipulate is important for both patient and practitioner in establishing rapport, minimizing and maximizing expectations, setting realistic goals, maintaining compassion, and in helping the patient and practitioner confront feelings. It is easy for practitioners to become more easily frustrated by patients who the therapist believes is regularly lying or manipulating. It is imperative for therapists to confront their own reactions in order to maintain compassion and support; remember, the patient came to you for help.
Here are a couple of questions for sufferers who may identify with some aspect of this blog post to consider when assessing and addressing whether or not they are ready for treatment:
Bottom line, recovery is possible no matter who the patient is or from where they came.
Judy Scheel, Ph.D., LCSW