In eating disorder treatment and recovery, people often talk about the eating disorder’s “voice.” Sometimes patients and family members are initially wary of this language, wondering if they are “hearing voices,” and whether that means they are “crazy.” However, that’s not the case at all!

When we refer to the E.D.’s voice, we are actually referring to the set of thoughts and beliefs that support the eating disorder (E.D.) – the rationale or arguments by which people are convinced to use E.D. behavior. The authors of Biting the Hand that Starves You: Inspiring Resistance to Anorexia/Bulimia, describe it this way: “Its seduction, imprisonment, torture, and murder of women

[and men] is accomplished through its voice and the rhetorical strategies it uses to influence how they view themselves, their bodies, and the world around them.”

Talking about the E.D.’s voice, as if the E.D. were a separate entity, is a way of beginning to distinguish E.D. thoughts from the person’s own thoughts and beliefs. Doing so brings what the E.D. is “saying” into greater awareness, allowing us to challenge the “truth” of its claims, and examine these claims in light of the person’s beliefs, values, hopes, and dreams. It also lessens the self-blame people may feel because it puts the blame on the problem rather than on the person. In contrast, if the E.D. is seen as part of the person, then fighting the E.D. is like fighting oneself.

Referring to it as a “voice” not only separates the E.D., it also personifies it. Sometimes people will even name the voice. Some people call it “Ed” (for example, see this recent post by Cheryl Kerrigan), but many other names have been used, both male and female. Some have chosen to reclaim Ana or Mia from the “pro-ed” camp for pro-recovery purposes, and others have come up with their own names (such as Eddie, Edith, Fred, Anastasia, and Lucifer).

Viewing the E.D. as a person allows us to examine its tactics and motives. In fact, E.D.s seem to draw from a limited repertoire of tactics, that are quite similar from person to person. Most fall into one of two categories: an abusive significant other, or a stereotypical “mean girl.”

An abusive significant other may be male or female (depending on the person’s gender and sexual orientation), but tends to draw on predictable tactics. It is initially seductive, seeming to understand the person as no one else can, offering reassurance and promising to help them fulfill their hopes and dreams. At the same time, it starts to erode the person’s self-worth, replacing it with feelings of guilt and inadequacy by painting any imperfection as a failure, and claiming that anything that might not work out for the person is their own fault – the result of being unlovable, selfish, stupid, lazy, etc. Then, it promises to correct these flaws, if only the person follows all of its rules by using whatever E.D. behaviors it prescribes. If the person begins to recognize the criticism as abusive rather than constructive, the E.D. switches back to reassurance, and offers to soothe the person’s distress, all while suggesting that they would be all alone without it, that they couldn’t live without it.

As a “mean girl,” the E.D. takes a slightly different approach. It is more openly critical, remarking on the person’s every imperfection, with a clear implication that they could never compete with the “popular crowd.” Then, the E.D. offers to rehabilitate the person – to give them a complete makeover. It tells them that achieving thinness through self-control, self-discipline, and self-sacrifice is the only way they can be good enough. Then, it promises, the person’s pain and suffering will end and they will finally be happy, because they will be successful, accepted, loved, and respected…they will be perfect. If the person begins to doubt the E.D. because it does not seem to keep its promises, the E.D. claims that the person has simply not followed its rules well enough, and encourages them to try harder.

Both of these personas also try to separate the person from other people who care about them, who may question or challenge the E.D.’s claims. As an abusive significant other, it is jealous of any other relationship the person has, and tells the person that no one else truly understands them, and no one else can be trusted. As a “mean girl,” it questions the motives of anyone who tries to help. At best, it says that other relationships are a distraction from following the important work the person should be doing to become more “perfect;” at worst, it says that others are actually jealous of what the person has managed to achieve.

These tactics can make it hard for someone to engage in treatment, because the E.D. voice is loudly calling into question treatment providers’ motives, accusing providers of lying, and arguing that treatment is invalid for the person because their body is different from everyone else’s. It is only fitting that we turn the tables on the E.D., by calling its motives into question, unmasking its own lies, and helping individuals recognize and connect around their similarities.

When people are able to join with others moving toward recovery, they begin to overcome the sense of isolation the E.D. has cultivated. They begin to recognize that others understand and support them, and learn that the E.D. has used similar tactics with other people, making it easier to recognize and resist the tricks it tries to play. As they come to recognize the E.D. voice more easily, it becomes more separate, and they are ultimately able to hear and listen to their own voice first and foremost. And that is when recovery becomes a reality.

Reference:

Maisel, R., Epson, D., & Borden, A. (2004). Biting the Hand that Starves You: Inspiring Resistance to Anorexia/Bulimia. New York: W.W. Norton & Co.

About the author:

Natalie Hill, LICSW, is lead clinician of the Adult Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) at the Braintree Clinic, where she provides group, individual, and family therapy.  She also facilitates a training program for masters-level interns, and plays a supportive role in clinic operations. Ms. Hill’s professional interests include Narrative Therapy, upon which this post is based, and innovations in Eating Disorder treatment. She is the author of the blog Practice Wisdom.