Thanks so much for your reply.
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Okay...this is going to be super long. I woke up early and read this and I've been thinking about a lot of it ever since. A lot of it really made me think. I think I've come to some kind of rough conclusions, but I needed to get there eventually. I just don't think I want to admit some things that are probably painfully obvious to everyone else.
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What are some things that you do you not want to admit?
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My lists: 1) Pros of no treatment: I'll be around for friends and family events in near future, I can focus now on moving forward with my life in other areas (theoretically), along the same lines, I can focus right now (theoretically) on future planning regarding career, relationships etc, I don't have to worry about admitting to family/friends (who don't already know) or work that I'm "sick", will hopefully boost my self-esteem by giving me a chance to prove to myself that I'm capable of "saving" myself, will allow me to deal with the ED in the real world in real life situations as it's likely going to be a life-long battle and IP treatment just isn't the real world, won't miss any more work and it'll be easier financially, will allow me more time in the immediate future to focus on preparing to return to medicine
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I don't have a good handle on how much working you can realistically do in the current state of your health. How realistic is it to hold a job steadily now and otherwise move forward as described here?
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4) Cons of treatment: It's a locked unit - due to past trauma issues, I have big time issues with this idea, I honestly don't know if I can handle even the idea of it, I'm not sure I'm ready to deal with past issues that I'm guessing from past experiences the team will want to discuss, I'm kind of scared who I am without my ED - it's been more than half my life, I'm terrified of gaining weight, my family and most of my friends will assume I'm 100% better the second I leave treatment and will expect me to act and function as such, I'm also afraid I'll lose what little support I do have from them once I look like there's no longer an issue, I'm afraid I'm going to fail at everything - ED tx, my career, life, I almost don't even want to try, I almost feel like I'd rather not try than try and fail, and practical issues - I'll have to miss even more time off of work, which may endanger my job, and I've already missed a lot of friend/family stuff. I don't want to miss even more.
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Some of these issues it would seem could be addressed proactively. But then I don't know what happened at previous ED units, maybe people have already tried these things.
To what extent can your support people be taught that you are not 100% cured when you leave? Or is this something you just have to deal with?
The locked unit: can this be specifically looked at promptly with cognitive therapy? It sounds like a panic-type disorder, has/could a therapist help you with this?
In general I am puzzled about the past issues: here you say that staff at a unit will want you to look at them and you won't want to...but below you say that your T wants you to look at them and you trust her clinical judgment.
It sounds like ED is something of a refuge from an overwhelming fear of failure. What do you think? As long as you are sick you don't have to take your chances in any of the areas of life that you mentioned.
You mentioned your residency, and it sounds like a wonderful time: what happened to the fear of failure then? Somehow you functioned well despite it, you overcame it. How? And what happened after that in your life/career?
So the fear of failure brings up two big issues in my mind: 1. I speculate/assume that this overwhelming fear is rooted in whatever happened in the past, which it seems from what you are saying included a less-than-fully-supportive family who perhaps expected virtual if not actual perfection and did a lot to make failure so feared today, and 2. what bad things do you think will happen if you "fail"?
Thanks! 
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so I'm going to have to really watch that and keep an eye on how long and how hard I'm exercising so I don't backslide too much.
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Good.
I of course read everything you said about your health now, your attending, and about going home. All I can say is: I worry. I worry about whether you can keep yourself safe with what is, admittedly, support well below that which you might need right now.
Thus: I worry.
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It's likely I'll end up in the hospital again fairly soon, not that I want to, I really, really don't, but things are just that unstable.
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Then maybe it is safer not to leave?
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Some of the time staying alive is a goal. Sometimes, I just don't care what happens one way or the other. I could live, I could die, it's all kind of the same to me. I agree that it may be very difficult right now to address past issues, but my therapist is really pushing for it and I do trust her and her clinical judgment and I think that may be part of what's holding me back and why previous IP treatments didn't work for long because I need to find a place of acceptance for some things and in the past, I've left treatment, done well for 6 months or so and then started obsessing about past mistakes, hurts, things done etc. And that's usually what's begun my downfall. So I think I do need to suck it up and face things. Maybe not in the very beginning, but shortly after.
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I completely agree that it was unwise to be allowed to be discharged from ED treatment, multiple times it seems, without addressing underlying issues from the past. Still, that level of wellness is not where you are now. Now you are unwell. What sort of schedule/plan would your T have for working on past issues? How readily could she accept that being done at JHU?
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And I really do like "helping others", as cliché as it sounds. Thanks for saying that. I've always been told I've had a good bedside manner and I like to think I do I try to. Everything I say, I do say because I honestly care and want to help.
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All that kind of stuff is a large part of what keeps me going, I became a doctor because in part I was fascinated by medicine, but also because I honestly really enjoy trying to help others. It does help to feel like I'm at least doing some small thing that may help someone else and that maybe, if recovered and healthy, I'll be able to go back to medicine and do what I really want to do. That's probably my single greatest incentive for everything - staying alive, trying to recover, getting treatment etc right now.
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You said above that being scared doesn't motivate you. What about being "scared", if that is the right word, for your patients? You care about them, a lot, when you are at their bedside. What if you bring them to mind when you are deciding, let's say, whether or not to purge?
I mention this to help you see your greatest motivating factor--your greatest incentive--every day, in every moment. Could that happen? Could you see them when you are tired--sick and tired--to help you move forward when every ED impulse is telling you not to?
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I get ambivalence is common, but it still makes it really hard to seek out treatment. I wonder what is different between myself and the pts in the study and why they wanted IP treatment while I'm so stuck on the ambivalence piece that the other factors aren't playing quite as big of a role?
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We could look at the other factors: where are you when it comes to control (behavioural and thoughts); how exhausted and isolated are you?; how intensely do you fear recovery?
Maybe it is the last one? Maybe you have an intense fear of recovery, as discussed above. What do you think?
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I do get that my time with family, friends isn't great quality right now and I'm probably using wanting more time with them/not wanting to miss anything else as an excuse. I really just need to admit some things to myself. And accept them as true whether I "believe" them or not. The idea that I'll have better and more fulfilling relationships once in recovery is one of them.
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I would put it slightly differently. I'd say act as if those beliefs are true, even if you don't right now believe them.
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I did spend some time texting a friend and also spent a couple hours speaking with a high school girl I'm mentoring, so not quite a family/friend, but it was good, a good distraction nonetheless. She's going to come to the hospital on Sat and I'm doing her hair and make-up for prom, so that'll be fun.
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This is great!
And while it is a distraction, I don't see it as mainly a distraction. I see this as beginning to rebuild yourself, block by block. Getting back to caring about others in action, in person, getting back to what made you a doctor, getting back to what makes you you. I see this not just as distraction, but as recovery. How did this relationship get established?
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And I did spend some time journaling. Not quite 30 min, but I will today. I've already started. I think you're right, I think it'll be a good outlet.
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Excellent!
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I'm not sure how or if it'll provide a reason for living, but I definitely think it'll help me cope with everything so I can see past the negative and hold on to other reasons for living.
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That sounds really good. You do know that you are allowed to write about the negatives? It is okay, it is most desirable, to expressin the journal whatever is on your heart at that moment in the journal.
Have you ever done the raisin mindfulness exercise? You examine the raisin in great detail, from all perspectives, turn it over, listen to it, smell it, and eventually eat it slowly and with full attention. You can do that same thing with negative thoughts, feelings: examine them, look at them with great interest and curiosity, rather than try to bury them.
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The time in my life when things were going the best they've ever gone is when I was in residency. I had a built in support structure - fellow residents, great attendings and med ed director and I was doing what I loved and learning a lot. And I was busy. I didn't have time to obsess over things like my weight or food when there were more important things to worry about. There was meaning in my life, what I did every day made a difference, it mattered if I got up and did my job and how I did my job everyday. I felt like I mattered for maybe the first time in my life. I felt like what I did or didn't do mattered so it became much more important for me to make healthy decisions and lead a healthy life.
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This is still true. Just not so obvious. Your healthy decisions today help tomorrow's patients--and they help your mentoree today.
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You asked what are my reasons to live? I think the single greatest reason is just to give myself a chance. A chance to be who and what I want to be, to do what I want to do and what I have the potential and capability to do. If I die, I'll never have that chance, I'll never know what might have been or what could have been. And I don't think I want that...I don't think so. Not at this moment anyway, but who knows how I'll feel tomorrow or 5 hours from now. It really is exhausting being stuck in this cycle.
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Really it sounds like you have two greatest reasons: to give yourself a chance, and to use your self to help your patients (as above).
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Thanks for this. This really made me think. It was hard, but in a good way
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I am glad to try to help you start to find you again.
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