Sunday morning for me is coffee, The New York Times, the N&O, the Chapel Hill News. Unlike every other morning, on Sunday, I take my time and read deeply. This morning I was gifted with an unexpectedly heartfelt piece in the NYT Sunday Styles section. Cole Kazdin detailed how falling in love triggered a cascade of support from the man she was falling in love with, her family, and her friends that allowed her to embark on recovery from an eating disorder. Her piece made me think of our couple-based intervention for anorexia nervosa (UCAN: Uniting couples in the treatment of Anorexia Nervosa), and several comments she made triggered thoughts that I felt compelled to share in Exchanges. If you haven’t read her piece yet, read it now, then come back to this commentary. It’s called: Chubby, Skinny, Accepting and can be found here .

At 36, Ms. Kazdin was trapped in the vise of anorexia—aiming for ever lower numbers on the scale, achieving implausible 00 sizes, purging, doing incessant calorie math, and not recognizing, in fact rationalizing away, the impact that her obsession was having on her life. She acknowledged the perfectionism that plagued her “right out of the gate” as well as the belief that asking for help revealed weakness.

Ms. Kazdin was a grown, accomplished, and career-oriented woman who carried her secret with her every day. In fact, she even joked with her friends about purging after a meal, never revealing that she was actually doing it. Those early passages in her piece raised two important points. First, anorexia isn’t just for teenagers. Soon, a book that I have been working on—Midlife Eating Disorders: Your Journey to Recovery—will be released in which I recount many similar stories of women and men Ms. Kazdin’ age and older who suffer from all strains of eating disorders: anorexia nervosa, bulimia nervosa, purging disorder, binge eating disorder, night eating syndrome and more. Second, the image of her joking with her friends highlighted to me how lonely it is to have an eating disorder. There she was sitting with her friends joking about purging after a large meal, not one of them aware of the panic that sent her running home to do exactly what she had been joking about. Eating disorders thrive on secrets.

Then she met her man, and something changed. It was striking how natural eating seemed when she was with the man she was coming to love. She could eat and enjoy eating without experiencing that rebound sense of desperation and panic. Maybe it was the sense that unconditional acceptance might be around the corner; maybe it was being truly relaxed in her own skin; maybe it was oxytocin (the cuddle hormone); but, something about that budding relationship cut through the clamp of control that had been fueling her eating disorder. She came to realize that she had to be honest with him about the eating disorder, and to do so, she had to be honest to herself. She felt as if she were cheating on him with her eating disorder.

Over the past several years, it has become increasingly clear that family-based therapy is effective for anorexia nervosa in youth. Although the effects might not be immediate, positive therapeutic change tends to persist in young patients when family members are involved. While this body of knowledge about youth was developing, we continued to treat adults with eating disorders in isolation, as if their partners weren’t relevant to the recovery process. Confidentiality issues kept us from confiding treatment details, and we tended to only bring partners into the fold when there was a crisis or if the patient needed a ride! The partners were desperate. They wanted a blueprint for how to behave and how to help. They would tiptoe around as if in a minefield, fearful that anything they said would make things worse. We weren’t helping them, nor were we engaging them in helping the patients. So, Don Baucom, PhD, Jennifer Kirby, PhD, and I developed UCAN, and we are now testing two different approaches to the treatment of anorexia nervosa—each of which engages partners in different ways and to different degrees. We want to find out how best to engage the family in a developmentally appropriate way. We’ll be adapting UCAN for bulimia nervosa and binge eating disorder soon.

A study we did years ago planted the seed for our current work. We asked people who had recovered from anorexia what the most important factors in their recovery were. The most frequently cited factor was supportive nonfamilial relationships. Eating disorders occur in an interpersonal context. They affect relationships and relationships affect them. For Ms. Kazdin, the interpersonal support came from more avenues that just her relationship. The first thing she did was reach out to her Dad. I was fascinated by her concern that her father might be embarrassed by her eating disorder. In some ways, that line saddened me more than any in the piece. I can’t imagine someone saying they were afraid that having type I diabetes or allergies might embarrass their father. We have to continue to work hard to get past the stigmatization of mental illness and fight every headline that equates mental illness with dangerousness. In contrast to her fears, her dad wasn’t embarrassed. In fact, he was loving, didn’t judge, and helped her research the best treatment options. Her mother, her sister, and her friends all responded supportively. Her new love adopted her challenges as his own.

What she did was something I recommend in Midlife Eating Disorders, namely practicing radical honesty. Honesty does to eating disorders what water did to the Wicked Witch of the West. It melts them. Otherwise they terrorize you and hold you hostage.

I liked her twist on the old adage that you can’t love someone else until you love yourself. Her experience was the opposite and shows the power that relationships can have in personal healing. Our thanks to Cole Kazdin for sharing her story. I hope that it encourages more couples to become partners in recovery.

By: Cynthia Bulik, PhD, FAED

Director, UNC Center of Excellence for Eating Disorders