Boundaries

I think most people would agree that, in many ways, rules are entirely unhelpful in recovering from Anorexia, the wider canon of eating disorders and many mental health conditions. It seems somewhat counter-intuitive to replace one set of ill-advised, damaging rules with any others. For someone who has spent years, or even decades, living inside their own strict edict, it would seem natural that the answer were to break down those walls and free that person from their chains of constraint. Likewise, for someone trying to break away from the apothegm of Obsessive Compulsive Disorder, replacing one strict set of guidelines with another, equally strict, set of guidelines would appear to be the last thing that should be advised.

I’m not so sure how wise ridding oneself of rules completely proves to be, however. Someone who has lived within a very strict set of rules is used to that way of being – they have internalised their rules until following them is no longer a conscious process. Surely it makes little sense, therefore, to tell that person that their rules are ‘wrong’, or ‘unhealthy’ but neglect to re-educate, or give rules that are ‘right’ or ‘healthy’ to follow?

Actually, what I want to talk about here is boundaries rather than rules. There is a subtle difference: the former I imagine as being a tight hug, protecting from the outside world, and the latter being a sharp slap, punishing for misdeed. Boundaries, as far as I am concerned, are hugely helpful in recovering from eating disorders: they provide a safe space in which to experiment and to learn.

Think about it this way: if someone is sad, we want to hug them. If we really love them, we want to hug them so tight that they become part of us, perhaps so that we can take their pain. Someone else holding boundaries, for me, is like handing them some of my pain. Someone else holding boundaries for me is like them holding me tight; letting me know that it will all be OK.

For example, one of my boundaries is that I finish everything I eat. This boundary, at first, was held by nurses and doctors, consultants and the people I love. Now, I love myself enough (usually) to hold this boundary for myself. This means that I don’t have to overthink portion sizes: if I buy a sandwich, then I eat that whole sandwich; if I am given a plate of food, I finish what is on that plate. For me, this prevents obsessive calorie counting, and restricting what I eat by stopping when I become anxious. Obviously, this didn’t happen overnight and I had to make progress and learn to cope with my emotions before I was able to move within the boundary, but it is immensely helpful in social settings and also when I am eating alone.

However, where this differs from being a rule is that I don’t punish myself if I do not ‘comply’. There is no point beating myself up for the odd slip-up. I didn’t like the chicken in my sandwich today and so I removed it, but that doesn’t mean that I then have to perform a set of rituals to reset the balance, or punish myself by doing something I don’t enjoy. Conversely, it is helpful: although I didn’t finish my chicken sandwich today, the boundary still stands tomorrow, and I am still expected to finish my food. I am still protected by the boundary, even though I might be anxious about finishing tomorrow’s sandwich because I didn’t finish my sandwich today.

I am thinking about this after watching The Doctor Who Gave Up Drugs with Dr. Chris van Tulleken. Tonight’s episode (well worth watching, although potentially rather triggering, so be careful) focused on – among other things – the treatment of teenage depression with antidepressants. The focus was placed on a girl who was suffering from depression and self-harm. She had been out of lessons at school for ten months, although was still going to school.

This made me think about whether removing adolescents from lessons were helpful in the case of depression. One of the boundaries in place at a typical school is that students are expected to go to lessons and to remain in lessons. This is what makes a school function. This is what prevents chaos.

Yet, for the children who need the tight hug of boundaries most, they are removed. If you do not expect a young person to go to a lesson and stay in that lesson, there is no reason for them to do so. If they are allowed to walk out, they will do so. If they are not supported to go into situations they find challenging, yet are freely allowed to avoid them, their anxiety is going to increase, whilst attendance in lessons decreases. When attendance in lessons decreases surely, therefore, so does a sense of belonging? What is it, other than a sense of belonging which gives a person a reason to keep going somewhere; to keep joining in?

We know that when someone is living with acute depression, socialisation is very important in restoring their ability to function and stabilising their mood. Why, then, remove them from the place that would allow them to spend time with their friends? If a child is worried about harming themselves during the lesson, remove the means of harming themselves; support them within the lesson, do not simply allow them to miss the lesson, thus reinforcing their belief that the classroom is not a safe place to be, and the teacher’s belief that that student is not manageable in a classroom.

What I am not saying here is that teenagers with depression should be punished for walking out of a lesson, or missing a day of school due to their illness. That would be wrong. What I am saying (albeit probably awfully badly) is that, creating boundaries and supporting young people (and adults, and anyone) in the right way to live as normal a life as possible can only be conducive to recovery. And, for those who are well on the journey, setting their own boundaries which are aligned with ‘normal’ life, social norms and healthy behaviours can provide a loose guidance of what is expected and when.

Perhaps the most important part of my inpatient recovery was when my consultant made it very clear that I was to finish all of my meals and snacks. She did not set up punishments for failure, so it was not a rule, but she did make it clear where the boundaries lay. Had this not happened, there would have been no chance whatsoever of me being able to adopt this boundary and apply it myself when it was appropriate. It was a commonly understood boundary within the inpatient unit that food was to be finished; mealtimes were to be attended; group therapy was to be taken seriously. This made the place safe and effective. Similarly, if we don’t train teachers to understand how to set boundaries for teenagers and young people who need them the most, we will not be fulfilling the rights to have an education for adolescents with mental health conditions.

For me, what stands out as important in all this is that we learn that what people who are struggling with their mental health need – what will help them to recover and make progress – is the firm hug of boundaries. If it is you who is struggling, identify someone to hold those boundaries, explain what those boundaries need to be (don’t worry: you know already). If you are a teacher, or a friend or a family member of someone who is struggling with any form of mental illness, gently guide within boundaries; reassure and contain.

To make a baby feel safe, we swaddle them. Young people and adults, as far as I believe, need containing in the same way.