Anorexia and Friendship: Can Friends Galvanize Recovery?

Part four of a four-part series, on the role friendship plays in recovery.

Posted Oct 04, 2019

In the previous parts of this post, I explored the ways in which anorexia can change friendships and vice versa. I also looked at the scientific research about this relationship. Here I turn my focus to recovery.

As ever in anorexia research, the pickings are slim when it comes to recovery. Most of the studies conducted on friendship and anorexia (which I surveyed in the previous post) are focused on illness or its precursors rather than on what comes next. There are a few exceptions, with which I'll begin, but in this post, I’ll be relying largely on anecdotal evidence: from my own recovery and from the recoveries I have witnessed in other people.

Ways friendship can affect recovery

The first and most obvious scenario when it comes to the effects of friendship on anorexia is the one I ended the previous post on: the times when friendships create an impetus for change. In a study reviewing former patients’ opinions of what constitutes recovery from an eating disorder, social relations (specifically, the ability to establish social contacts and make friends, to partake in social activities, to feel comfortable in contact with others, and not to feel socially isolated) was one of the 11 factors identified as crucial (Noordenbos, 2011). So friendship is an important element of what many people are aiming for when they resolve to begin recovery.

Conversely, social isolation is one of the main reasons (along with loss of control of behavior and thoughts, mental exhaustion, inner struggle, and fear of recovery) why people seek out hospital treatment for anorexia (Gorse et al., 2013). (This can have an unfortunate secondary effect when the hospital environment provides a readymade social network, discouraging the recovery that would lead to loss of it [Treasure et al., 2011]. I will touch on these risks again in a moment.)

Outside the clinic, the capacity of friendships to contribute to recovery is perhaps most likely to take the form of a new step in a longstanding friendship—often when insight accumulates in the non-anorexic friend(s) to the point where something, at last, has to be said and done. This may happen because your illness worsens, or because something makes your friend(s) see it differently, or because their instinct to bite their tongue finally expires. Or you may begin the change, by taking steps independently to get recovery started, which gives your friend(s) a clearer role to fill when it comes to sustaining your conviction and providing practical help.

Friendships may also play a positive role in clinical settings. One study (Malmendier-Muehlschlegel et al., 2016) has found links between perceived support from ward friends, readiness to change, and friendship quality, in particular on the dimensions of intimacy and self-validation (listening, agreeing, encouraging, helping meet needs or goals), though the direction of cause and effect wasn’t investigated. Improving motivation might improve friendships as much as vice versa.

Other ways in which friends are invaluable supports in recovery are less tangible than buying you food or coming with you to doctors' appointments or eating with you, but they can be just as precious. One of the simplest contributors to recovery someone else can make is just being there, being your friend despite your illness (Tozzi et al., 2002). Friends who lead (on balance) happy and interesting lives can also be inspirations for keeping going: They can be weekly reminders of why it’s worth it to keep going.

This inspiration is all the more meaningful for coming, by definition, from people you’re drawn to and admire. Examples of rich, fulfilling lives led by people you don’t know are one thing; examples of rich, fulfilling lives led by people you know well and like and care about are quite another. Having a more close-up view of the reality of these other lives is important too: They aren’t just cut-outs from magazines or self-help books; you see their three-dimensionality.

And here too (as I mentioned in the illness context in the first post), other people can help you see yourself and them more clearly through contrast—in recovery, through a contrast which grows less stark and more nuanced the longer and more steadfastly you persist. 

Friendships can also help in the process of self-discovery that recovery involves. Especially in the later phases, starting to make new friends can give you exhilarating tastes of who you are and could be as a social being without anorexia. New friends are easier candidates for this because you don’t have the accumulated patterns of anorexia-shaped interaction to dislodge and replace.

But old, estranged friendships can be lovely for it, too, since you can come back into contact with each other as a new person, but also like someone with some traits of the younger you who was a friend before anorexia. You may have a strangely beautiful sense of picking up where you left off, even if the intervening darkness is of a decade or more. This is an effect on friendship, but also an effect on recovery, for it helps you trace the lines of continuity there have always been between the parts of you that were submerged but not destroyed by anorexia.

When both friends have anorexia or another eating disorder, the risks are greater. Specialist treatment programs have been found to pose risks to recovery if pro-anorexic dynamics are allowed to develop unchecked, and they can be hard to prevent, though it may help to place careful limits on the amount of discussion of eating-disorder problems and to match patients for commitment to recovery (Allison et al., 2014).

The dangers exist beyond clinical communities too. In the examples I’ve encountered of two friends trying to support each other in recovery, there has been damage done to at least one, often both, alongside the good done. This is true even if one is significantly further along in recovery than the other. Until recovery is over in a quite solid sense, an eating disorder is a terribly easy thing to get dragged back into. (For more on this, see my post on how and why not to stop halfway in recovery, here.)

And the trouble is that helping a friend can seem like a cause worth taking that risk for. But it isn’t. Because the most real help you can be is to get better yourself and then help your friend. Anything else is just putting you both at risk, by ignoring the future and downplaying the risks. Think of the old airplane analogy: Secure your own mask before helping your child. If you don’t, you’re compromising your chances of being there, fully functioning rather than brain-damaged through oxygen loss, to help your child down the evacuation slide and beyond. You’re also implicitly saying: this pressure drop thing is clearly an exaggeration; those pilots and medics and people don’t know what they’re talking about; I’ve stowed my tray table, so I’m fine. 

The importance of looking after oneself actually applies to everyone involved in supporting someone's recovery, whether they have an eating disorder themselves or not. Any illness and recovery place demands on more than the individual directly affected, and (as I emphasize in this post about how to help someone who is ill) anyone who wants to meet those demands effectively needs to be strong and able to care for themselves while helping. Martyrs are useless. Worse than useless, they crash and burn, and in so doing set an awful example and create masses of guilt.

So, if you have a friend who has an eating disorder, and you do too, I’d strongly recommend you not use each other as your primary support system in recovery. Until you can say, I’m fully recovered, be a friend (if you can be), but don’t try to be a carer or a guide. It almost certainly won’t work and will jeopardize both recoveries as well as the friendship.

The ways recovery can affect friendship

I mentioned above the beauty there is in improving or resuscitating old friendships that got lost in anorexia. I mentioned also the loveliness of making new friendships with people for whom anorexia is not a primary part of your identity—although you’ll tell them about it, one day, it will always feel more abstract for them than for people who knew you ill. 

As your willingness and ability to do ordinary enjoyable social things increases, your life begins to both intertwine with and resemble those of friends whose lives might at first have seemed unattainable kinds of inspiration. In one study on social engagement in anorexia (Tchanturia et al., 2013), the most significant impairment was found on the social leisure (as opposed to private leisure) dimension ("Because of my disorder, my social leisure activities with other people, such as parties, bars, clubs, outings, visits, dating, and home entertainment are impaired"). As that stops being the case, your recovery is furthered, and so are the friendships that can thrive only if such elements are part of them.

These are the delightful upsides of recovery for friendship. There are downsides too. Sometimes a friendship, however profound and longlasting, turns out not to be compatible either with the recovery process or with the person you become as a result. I’ll deal with these two scenarios separately.

Recovery from anorexia is weird. It requires you to be weird about lots of things: to try to gain weight, lots of weight, when the rest of the world seems to be fixated on losing it; to stop doing all exercise when every other website has a helpful tip for fitting in more; to reject, in general terms, a lot of the false wisdom of our age, in the knowledge that it will keep you ill if you don’t.

This can put a strain on relationships where the other parties are not practicing such rejection. Most obviously, where your friend(s) are dieting or exerting more subtle kinds of dietary restraint or have an aesthetics-centric or obsessive way of exercising or make lots of critical comments about their own body.

Or maybe they just don’t understand why you’re doing what you’re doing, and why you have to. This is to be expected. People don’t get anorexia. They often see it as one of two things: either a simple bodyweight thing, which should be sorted once you no longer look like a skin-clad skeleton, or a mental thing, which must be sorted once you’re eating three meals a day and generally not being so weird. It’s very hard for people—actually even people with anorexia, let alone those without—to appreciate the full extent of the mind-body interconnections, and the profundity of the revolution needed to switch those connections from unhealthy to healthy.

The depth of the associations between over-exercising or not-eating and "good," for example, and the need to contravene those personal (and social) laws not for weeks or months but for years to really destroy them, those kinds of fact about recovery are simply not accessible to everyone, especially if, as is almost inevitable, you doubt them and lose sight of them yourself fairly often. And especially, as is almost inevitable, they are prey to some version of them themselves. Some friendships, then, may not allow you the freedom to perform the revolution you need to. When this becomes clear, the right decision is to put the friendship, not the recovery, on hold. It can be a hard decision to make, but not making it can make health inaccessible.

The other scenario is related but distinct. In this one, the incompatibility is less with the process itself and more with the person the process lets you become. In the most basic sense, you are a different person once you’re recovered from the person you are when ill. (See my discussion of personality change in and after anorexia here.)

You may now bear more resemblance to the person you were before your illness (though if (s)he was only a child that will mean less). In most respects, you’ll probably be a much nicer person. But you will also simply have more character overall. You won’t have all your personality traits swamped in a grey blanket of malnutrition. You will be more forceful. You will have learned a lot of difficult things about yourself and the world, and this wisdom may make people uncomfortable.

You will not be to everyone’s taste. Nor was soggy-blanket you, of course, but (s)he was subdued enough that people could ignore the parts they didn’t like. When you have energy and conviction and real, proven knowledge about difficult personal things and a determination to act in line with it, the filtering-out will be harder for people.

And it cuts the other way too: You will have real preferences again, not just anorexia-driven habits. So you may realize you don’t like some of your friends as much as you used to, or used to think you did. This may be more likely if you made those friendships whilst ill rather than beforehand. Or you may realize that some of your friendships had dysfunctional or otherwise unsustainable dynamics that are only now visible to you. This is especially painful to acknowledge when the dynamic was precisely a caring one: when the friendship that no longer works was one shaped by helping you get better.

Maybe even the helping was part of what made it unsustainable. Maybe the toll was too great, or maybe the expectations for what the helping would lead to were misaligned. Maybe you will never know quite what the problem was, but simply know that the two of you can see no way through it, only the way out of it.

And so, in various ways, some of your friendships may not survive your recovery. And that is as it should be. You have changed, in the intervening months and years. Your friends have changed, too, if less dramatically. The point is not that any of this lasts forever. And the ending is not failing.

One of the great skills to learn with any relationship is how to say goodbye to it with gladness for what it gave us—with sadness too, for its ending, but with the knowledge that in its ending, it was not diminished. And that its ending is both a contributor to and evidence of your new ability to create new friendships for your future.

Conclusions

So, I’ve traced some of the many paths that friendships can take as illness and recovery proceed, and you may recognize some of them in experiences you have had or are having now or anticipate for your future. Do I have any advice to offer? 

A few things:

  • Resist the feedback! Don’t shut everyone out. Don’t let it get to the point where you have no one. 
  • If you do get to that point, recognize it as part of the kick you need to get you back out of it, and out of anorexia.
  • Don’t believe you need lots of friends to be happy. 
  • Don’t believe you can be happy with none.
  • Remember that people like being helpful in simple ways they can understand.
  • Remember that looking after someone is not the same as being a friend to them.
  • Know that the friends worth having will accept all of you. If they cannot, they are not worth having. 

"...after what seemed long weeks she crawled back out into the light, and marveled at the strangeness of sitting in the evening sun with a drink, talking to a friend." (2 June 2004)

References

Allison, S., Warin, M., & Bastiampillai, T. (2014). Anorexia nervosa and social contagion: Clinical implications. Australian & New Zealand Journal of Psychiatry48(2), 116-120. Paywall-protected journal record here.

Gorse, P., Nordon, C., Rouillon, F., Pham-Scottez, A., & Revah-Levy, A. (2013). Subjective motives for requesting in-patient treatment in females with anorexia nervosa: A qualitative study. PloS One8(10), e77757. Open-access full text here.

Malmendier-Muehlschlegel, A., Rosewall, J. K., Smith, J. G., Hugo, P., & Lask, B. (2016). Quality of friendships and motivation to change in adolescents with anorexia nervosa. Eating Behaviors22, 170-174. Paywall-protected journal record here. Direct PDF download here.

Noordenbos, G. (2011). Which criteria for recovery are relevant according to eating disorder patients and therapists?. Eating Disorders19(5), 441-451. Paywall-protected journal record here.

Tchanturia, K., Hambrook, D., Curtis, H., Jones, T., Lounes, N., Fenn, K., ... & Davies, H. (2013). Work and social adjustment in patients with anorexia nervosa. Comprehensive Psychiatry54(1), 41-45. Paywall-protected journal record here.

Tozzi, F., Sullivan, P. F., Fear, J. L., McKenzie, J., & Bulik, C. M. (2003). Causes and recovery in anorexia nervosa: The patient's perspective. International Journal of Eating Disorders33(2), 143-154. Paywall-protected journal record here. Direct PDF download here.

Treasure, J., Crane, A., McKnight, R., Buchanan, E., & Wolfe, M. (2011). First do no harm: Iatrogenic maintaining factors in anorexia nervosa. European Eating Disorders Review19(4), 296-302. Paywall-protected journal record here.