Using Summer for Recovery: How to Help Someone Struggling with an Eating Disorder During The Summer Months

By Center for Change

Summer Solstice marks the day when the sun will appear at its highest point in the sky and there is more daylight than any other day in the year. This year, solstice will begin on June 21st for those of us in the Northern half of the world. This day ushers in the beginning of summer and bears a special recognition for the wondrousness of the sun and all it does to sustain our life. Our sun, the fiery ball in the sky, is an incredible life force for us on earth as it marks the beginning and ending of each day, provides us with natural Vitamin D, life giving heat, light, and ultimately holds the solar system together.

image001In many ancient cultures summer solstice was celebrated with festivals, holidays, and rituals. For those of us in the West, we are often having a different kind of celebration: a break from school or a vacation from work. Quite fitting as the word solstice is derived from the Latin words sol (sun) and sistere (to stand still or stop). Summer is a time to break from the rigors and stress of school or work and engage in relaxation and play. For many people it is associated with freedom and positive emotions. Words like vacation, friendship, joy, warmth, and exploration come to mind. Summer often symbolizes freedom, growth, and love.

For individuals struggling with an eating disorder or body image issues, summer vacation may be a very different experience. It can be an extraordinarily stressful time. Instead of freedom, rest, and play they feel increased pressure and distress. The consistent schedule of school and work is no longer available in the same ways and the less structured days of summer and the standing still metaphor of the solstice creates anxiety and fear about food and body.

Messages about getting in shape for summer, exercises for the perfect swimsuit body, and diet fads are splashed across the covers of both men’s and women’s magazines. What is historically meant to be a season of freedom and adventure is often an avenue for cultural messages about value as a person linked to one’s physical shape and a way for a 60 billion dollar diet industry to increase their profit margins. Indeed, it seems there is a need in the summer for increased tending to mental health issues such as anxiety, depression, and disturbances with one’s relationship with food and body image. While summer may bring freedom for some, it can certainly also function as a catalyst for an increase in eating disordered symptoms and isolative behaviors.

As treating clinicians our role is not only to support, but also to help our clients challenge the part of the disorder that is keeping them from fully engaging in life. In thinking about the summer season specifically, the eating disorder often keeps our clients from experiencing the joys of feeling the warmth of the sun on their face, their toes in the sand, the taste of a backyard BBQ with friends and family, or immersing their body in the cool water of a pool or the ocean.

Part of the work we do is to provide our clients with alternative options and coping strategies for the challenging seasons of life. We want to share some ideas with you about how our clients can take on summer as a golden opportunity for making meaning in their lives and perhaps even having a joyful healing experience despite the anxiety and self-worth issues.


Some Explorations for Summer

  • Exploring the Meaning of Summer: This can be used as a journaling tool for clients to explore some of the positive memories they may have of summer as a child and the symbolic ways they can connect with the themes of the season.
    • What is a favorite memory of summer as a child? What are the different senses connected to that memory? Taste? Smell? Sounds? What did it look like or feel like?
    • What brings sunlight to your life? More symbolically, what are the things or people that light up your heart?
    • What kinds of activities bring a feeling of warmth and goodness?
    • What images come to mind when you think about freedom?
  • Exploring Nature: Summer provides ample opportunities to nurture oneself in the expansive beauty of nature.
    • Honoring your one precious body through engaging in mindful non-weight loss focused movement that brings joy such as strolling through the woods, throwing a Frisbee with a friend, walking in a sun-drenched field, playing in the water, or miniature golf
    • Walk barefoot through the grass or in the sand, feeling the earth under your feet
    • Planting a garden, getting your hands in the dirt, establishing roots for fresh herbs or flowers can be a wonderful way to connect with nature
    • Get up early and watch the sunrise
    • Fly a kite and pay mindful attention to the assistance of the wind


  • Exploring the Deepening of Relationships: Relationships are the foundation of support for recovery and there are so many possibilities for intentionally engaging with people over the summer season.
    • Embrace the unexpected and perhaps do something spontaneous with a friend such as drive to the lake or have a picnic in the park
    • Plan a road trip with a friend or family member
    • Bring joy into social gatherings with a favorite playlist or game
    • Ask for support – eat lunch with a friend or seek help from a trusted loved one at an event that might be particularly challenging around food


These ideas are just a start. Hopefully they will help get your own creativity moving and generate conversations with your clients about the meaning of summer and how we can introduce healing elements into something that often brings anxiety and fear. We truly believe that full recovery is possible and summer, with both its challenges and great joys, provides an ideal opportunity to recommit to or perhaps for some, begin the journey for the first time. In the words of the great poet Mary Oliver, from her poem The Summer Day, “Tell me, what is it you plan to do with your one wild and precious life?” Hope and recovery can start anew or be strengthened by taking positive steps this summer.


Self Compassion…the New Self Esteem?

By Nikki Rollo, Ph.D., LMFT

There is a lot of interesting research that has developed over the past several years about self-compassion and how it stacks up against self-esteem. The self-esteem movement in Western culture in the 70’s and 80’s was based on the idea that the root problem for individuals, the very issue at the core of anxiety, depression, and fractured relationships and other psychological issues, was found in low self-esteem of the individual. At the most basic level, self-esteem is about an evaluation of oneself as a good or bad person in the world.

Self Compassion

People struggling with low self-esteem may have high levels of self-criticism, chronic indecision, and struggle with perfectionism, pessimism, hostility, and guilt. Self-criticism found in low self-esteem has been linked to depression and difficulty with seeing oneself as loveable or of value as a human being.

People with high levels of self-esteem are known to fully trust in their capacity to solve problems, succeed in their life endeavors, deem themselves worthy of love, and do not spend precious time worrying excessively about what happened in the past or what will happen in the future.

Having high levels of self-esteem sounds great right?


Well, in our modern world, in order to feel good about ourselves, there seems to be an unfortunate cultural message of competition that has become intertwined with self-esteem. So, it is no longer enough to feel good about oneself solely based on yourself, rather self-esteem is now linked to being better than other people or consistently performing above the perceived average. And of course, no matter how hard you work someone else will always be smarter, richer, or what we perceive as more successful in various areas of life. We can feel fantastic about ourselves one minute and as soon as we see someone who looks like they are doing better than we are, our self-esteem can plummet and negative messages can start swirling around in our minds.

Researcher Kristen Neff suggests that this competitive culture leads to building ourselves up and tearing others down, in an effort to feel good about our own human condition. It is as if we are now on a rollercoaster ride of self-esteem. It goes up and down not only depending on what is happening in our own life, but now also depending on how we measure what is happening in our life against the life of another person or perhaps many different people.

It seems positive affirmations are not quite enough to help us feel good about ourselves in a culture of competition and getting ahead in a sustainable way.

So what is the alternative?

Kristen Neff’s research on self-compassion may be the answer. It certainly seems to be changing the way we think about achieving a state of emotional well-being and the possibilities available to us to live in the world with contentment and acceptance for our own humanity with both its challenges and delights. Self-compassion is linked to less depression, greater happiness, and more life satisfaction.

She suggests that if we stop labeling ourselves as good or bad and accept ourselves with an open heart, kindness, care, and compassion- the kind we would show to a friend- this is a way to help us avoid destructive patterns and increase the joy in our lives.

So what is self-compassion?

It is quite simply defined as a way of relating to oneself that involves treating yourself kindly regardless of what is happening in life. It is showing yourself the same care and concern for suffering that you would for a loved one.

Diving in a little deeper to the definition, Neff has identified three core components of self-compassion:

  1. Self-kindness: this asks that we offer gentleness in language and understanding toward ourselves instead of harsh judgment and criticism, actively stopping to soothe oneself when we are in pain
  2. Common humanity: this is recognition of our connection with others in the experience of life, rather than sinking into the isolation that comes from competition and suffering. It is about recognizing that suffering and imperfection is a shared human experience.
  3. Mindfulness: this is about holding a balanced awareness of our experiences in life- not ignoring pain or amplifying it, but being fully in the present moment.

This can feel quite foreign if you are used to beating yourself up and the ups and downs of the roller coaster ride of self-esteem. Self-compassion gives us the opportunity to see ourselves clearly. A stable sense of self-worth developing from this kind of compassion means that when we make a mistake we can give ourselves a sense of care.

What about taking responsibility? How do we react when life is falling apart?

So this idea of self-compassion might sound like a lack of taking ownership when something goes wrong for which we bear responsibility. In reality, when we are in a cycle of up and down with our self-esteem, that is when it is actually easier to blame the other person. Why? Because when we are constantly criticizing ourselves and feeling depressed, taking on ownership for one more thing is simply too painful. We are already down and feeling horrible.

On the contrary, self-compassion gives us emotional courage to take responsibility for our actions because it is in that state that we have the emotional capacity to fully accept who we are as humans with both the pain and the joy of life.

How do we do this?

As with most things, practice is needed to cultivate a new response. Here are a few ideas about the how of self-compassion.

  • Ask for Help: One of the most important points is learning that it is safe to be kind to yourself and acknowledge where you might need help. Self-compassion is about acceptance of the shared human experience of imperfection and suffering. There is no expectation that one has it all together or won’t make a mistake. It is a normal human experience to need help in the midst of struggle.
  • Ask Questions and Listen for the Answers: Meditation teacher Jack Kornfield poses the following questions as a meditation guide and suggests we listen for deep answers from our body, heart, and spirit:
    • How have I treated this difficulty so far?
    • How have I suffered by my own response and reaction to it?
    • What great lesson might my suffering teach me?
    • What does this problem ask me to let go of?
  • Try a New Approach: The next time you make a mistake and move toward self-ctriticism, see if you can notice it and try something different. For example, instead of that first thought that might come into your mind of, “I messed up…I am an awful worthless person” we might instead try to say,“I messed up…I am human and made a mistake- how will I use this opportunity to show self-compassion?” In the latter there is no judgment about whether one is fundamentally a good or bad person- just acceptance or responsibility and acknowledgment of our humanity. This has now become a unique opportunity about how to respond to our own suffering by turning toward it and offering it gentleness as you would toward a friend.

Jack Kornfield said, “If your compassion does not include yourself, it is incomplete”.


If you are interested in knowing more about Self-Compassion, check out these books below:

Germer, C. (2009). The Mindful Path to Self-Compassion: Freeing yourself from destructive thoughts and emotions

Kornfield, J. (1993). A Path with Heart: A Guide Through The Perils and Promises of Spiritual Life

Neff, K. (2011). Self-Compassion: The Proven Power of Being Kind to Yourself


Yoga at Center for Change

Have you ever wondered yoga is like at Center for Change?  Check out these questions and answers:

1.  Why do we have our patients do yoga?  Yoga Asana has been proven to be a primary movement strategy which connects individuals to emotions held within the physical structure.  For this reason, patients may feel emotionally engaged while doing yoga.  This is not a reason for avoidance – this is a reason for participation.  Often, yoga will help patients break through emotional barriers and will help other areas of therapy begin to flow.  As well as the emotional benefits, yoga is specifically designed to benefit the movement, vitality, and function of internal organs.  Breathing techniques in yoga help overcome shallow and restrictive breathing habits which often lead to dizziness and nausea when moving.  Digestive health is especially improved through the practice of yoga.

2.  Why do the instructors talk so much during yoga?  Many yoga classes outside of the Center have very minimal talking throughout the practice.  These are usually mid-level to advanced yoga classes in “Power Yoga”, where the students are very familiar with the postures and the class format is the same every time.  This is also very prevalent in “gym” yoga classes, where the instructor may not be familiar with the full practice of yoga – which includes physiology and philosophy to explain why we do what we do.  Also, most classes outside of the Center are designated as “beginning”, “mid-level”, or “advanced”.  Here, we have patients of all levels and ability, so explanation of the practice is offered throughout class.  In the practice of “trauma sensitive yoga”, speaking throughout class is an important technique to keep students feeling grounded, give students reasons to be moderate in their movement, and to ensure that all students feel safe in the environment.  This style of yoga is called “Kripalu” yoga. 
yoga class3.  Why don’t the instructors do hands-on adjustments in yoga?  In the practice of “trauma sensitive yoga”, it is important to be aware that hands-on adjustments may be detrimental to a patient’s feelings of well-being and may not be appropriate to the environment.  Especially in a class setting with many students, hands-on adjustments are difficult to facilitate for the entire class and it may be difficult to determine who would benefit from hands-on adjustments and who would be adversely affected.  For this reason, it is doubly important to be able to verbally articulate the entire practice, which requires extensive “talking” throughout class.  This is the implementation of “Kripalu” yoga. 
4.  Do the instructors allow patients to modify when needed?  Yes!  Because we have patients of all levels of ability in the same group, we offer a wide variety of modifications and alternatives for participation.  If someone has a particular issue, I try to speak with them before group and give them some personal modifications to use during group.  While I offer modifications and ask the care techs to help monitor the patients for appropriateness, many patients try to “keep up” with the most advanced patient.  This, in turn, can lead to feelings of inadequacy and unwillingness to participate in the future. While I can’t get into their head and force them to let go of performance anxiety, I can offer an environment that encourages patients to listen to what is possible for them right now and let that be enough for today.



How You Can Feel More Beautiful Right Now

By Center for Change

A person’s overall appearance is more than outfits, hair, and make up. The secret to being beautiful is made up of several different factors, which all contribute to a person’s overall appearance or true beauty. These characteristics make up inner beauty, and they are confidence, kindness, and being positive. The best part is that you can access this inner beauty right now without spending a dime.

image001Be Confident

Everyone has something that they are good at doing. The best way to figure out what talents you have is to look at your hobbies. Do you enjoy singing or playing a certain sport? Maybe you spend your time reading and have a large vocabulary or creative imagination. Most of the time, people are good at doing the things they enjoy, so start your evaluation there. You have multiple talents, so start making a list and refer to it when you need it.

Another method to build confidence is to try new things. This gives you a chance to find more activities you are good at and more hobbies. New activities can also help you stretch your comfort zone a little. New experiences can boost endorphin levels and help you realize how strong and capable you are in different situations. Take the extra time to figure out what you are good at and feel confident in yourself.

Choose to Help Others

One of the most ironic situations is when a person goes to help someone else, it seems they receive more in return. When you help others, you feel good inside because you know that you are making a difference. Take your strengths and talents and put them to good use. Tutor, teach, or become a mentor in an area where you are comfortable.

Helping others doesn’t have to take a lot of time. Even small acts, like saying hello to someone you pass on the sidewalk, giving a compliment, dropping a quarter in a performer’s guitar case, or returning an item someone has dropped all contribute to this feeling. When you feel great on the inside, it shows on your outward appearance, bringing light to your entire countenance.

Keep a Positive Attitude

A smile can change the entire appearance of someone’s face. When happiness radiates from a person, they draw other positive people and things into their life. Find a way to start your day off right and focus on the positive things in your life. Post a quote on the bathroom mirror, smile at yourself in the mirror for twenty seconds, or find time to meditate before starting your day. At the very least, think of all the great things in your life. Think of these things through the day and remember to smile. Positive, happy people are the most beautiful.

An extension to a positive attitude is to talk positive about yourself. The things you say about yourself matters more than you think. Tell yourself you are beautiful, smart, and have value. Say these things out loud to stimulate the auditory portion of your brain. When you do this, you literally hear these things about yourself and they make a bigger impression. You are already beautiful and sometimes you just need to hear it.

Be Your Biggest Fan

While it’s nice to have a fan club, what matters most is that you are the president. You are a wonderful, beautiful person and treating yourself as such helps reinforce all of the positive building you do. All of these suggestions are like a scaffolding to inner beauty. Once you start doing all of these things, they become second nature and you become stronger and more confident. Together, these all add to your inner beauty and will help you feel more beautiful, starting right now.


Open Heart, Loving Boundaries

By Nikki Rollo, PhD, LMFTimage001

Your task is not to seek for love, but merely to seek and find all the barriers within yourself that you have built against it.- Rumi

The idea of love and boundaries has been on my mind lately. As I have been diving deeper into my own practice of yoga and meditation, my understanding of Love has become much more expansive. One of the things that often is generated from the practice of yoga is the creation of space. Space is opened up in the tight muscles of the physical body through the various poses and the organs have more room to function effectively at their maximum capacity; however internal space is also opened up through the quieting of the mind. This is the space I want to focus on here. This space is about increased capacity to feel, breathe, and ultimately space to love.

When I use the word Love here, I am not just referring to romantic love for a significant other, but also to loving kindness for oneself, for the earth, for animals, for other souls who are suffering throughout the world, for family and friends. I invite you to explore with me this concept of love at a deeper level than we often think of it.

At the core of our humanity is a desire to love and be loved…to find belonging and connection. For most of us, somewhere along the way we have experienced pain as a result of attempts to meet this need and built up barriers against the longing for love. It seems a bit absurd when you really think about it–we have this deep desire at the innermost center of our being and yet we build barriers that keep us from accessing and fulfilling it. Of course, the reality is these barriers often make a lot of sense. Somewhere along the way we have experienced hurt, pain, rejection, betrayal of love, and broken hearts that have initiated these barriers as a much-needed protective response.

Eventually these barriers can close us in so tightly that we can become quite lonely. There isn’t space for engagement with others or even ourselves with these barriers up around us. As we engage in healing efforts such as psychotherapeutic work or mindfulness practices, what often results is more openness: to ourselves, our therapist or teacher, to our loved ones and to the earth. Healing from our emotional wounds starts to bring down the barriers to love for self and others and create openness to receive love from self and others.

Now this is a wonderful thing! We absolutely can experience healing and love; however I have become curious about this following question: How do we maintain an emotional openness to a deeper exploration of love for ourselves and others, yet simultaneously maintain emotional safety?

I believe that the answer to this is found in the difference between Barriers and Boundaries.

Let’s look at how these two things are defined to help us understand the difference.

A barrier is defined as an obstacle that prevents movement or access.

A boundary is defined as a line that marks where one area ends and another begins.


So, how do we really love others? And really experience internal capacity to love ourselves deeply? Begin with yourself- here are some ideas for a little exploration into boundaries, barriers, and loving big.

  1. Get Curious: Look internally and ask what kind of barriers to love have been built up inside of you? Honor them….take the time to thank them for what they protected you from, recognize their value and how at one time they were needed.
  2. Be Honest: Be honest and upfront with yourself. Visualize yourself looking through eyes of love at yourself as you ask: Are these barriers still needed? Or is it fear that is keeping them in their place?
  3. Identify Your Needs: There is no right or wrong answer here. Make a list of your desires in the relationships that mean the most to you. Respect your feelings, desires, and needs by spending time with the statement, “I want to strengthen my boundaries in __________”.
  4. Communicate Clearly: Setting boundaries is about telling people how they can treat us, what we will allow or accept relationally. This is actually an act of love, for yourself and the person with whom you are in relationships. Try journaling what you will say, visualize it, or practice with a trusted friend.

In this kind of relational connecting, the kind with boundaries instead of barriers, people can still reach you and very importantly you can still move and are free to be the fullest expression of yourself in the relationship. So, love big, love deep, but do so with healthy boundaries, taking care of yourself and then others.


How to Start FEELING Beautiful

By Center for Change

How we perceive our outward appearance is very closely linked to how we feel about ourselves on the inside. Self-esteem, positive thinking, and the way we treat ourselves and others can directly impact our self image and help us to start really feeling beautiful.

Beauty is, and always has been, a very subjective perception, but one way or another it’s tied to the things that are inside us as much as it is our physical appearance. So how do you change how you feel? Is it really possible?

In fact, there are a lot of very simple, everyday things that anyone can do to start feeling beautiful.

Do those things you’re good at  – Focus more on the things that make you you. Is it drawing? Singing? Helping others in difficult positions? Explore the things you can do and see how you feel when you share those abilities with others.

Find an energy release – Dancing, running, walking – we’re not talking about burning calories with these activities. We’re talking about doing activities that you enjoy and that help your body release tension and stress. It’s about releasing those wonderful endorphins into your system.

fSoak up some rays – Sunshine can be a really mood booster. Get outside and feel the warmth of the sun on your skin. Just be sure that you take the steps to protect your skin at the same time.

Get some fresh air – Take a nice walk, breathe the morning air, open your lungs, and give your mind a chance to focus on the beauty that’s around you.

Brighten up – Studies have shown that the colors you wear can impact how you feel. Bright colors invite happiness, excitement, and energy to your day. It doesn’t have to be a lot of color. A couple accents may be enough.

Reinvent your look – You don’t have be engulfed in the most recent fashion trends, but you also don’t have to hold onto a look because that’s what you’ve always done. Be flexible. Find the things that are fun to you. Find a wardrobe that is stylish, elegant and comfortable. It will broaden your self-image a bit more, and you may find something new to like about yourself.

Smile – But not a fake smile. Find the things that make you grin or laugh. A smiling face lifts the muscles around the eyes and lips and tells your brain that it’s time to be happy.

Get your sleep – Proper amount of sleep makes it much easier to be positive. A good night’s rest has an impact on how you feel about yourself and, for that matter, the world around you.

Stand up straight – Your brain, body, and emotions are all tied to each other. Your brain reads the body to determine how you’re feeling, and when you stand up straight, you’re making a statement to your brain – and others – that you feel good about yourself.

Self affirmation – Find something you love about yourself and focus on that. We have a tendency to immediately let our eyes track to our least favorite places when we look in a mirror. We perceive them as flaws, and can’t seem to look away. Instead, make a conscious effort to dwell on the good.

Positive reinforcement – Surround yourself with people who will support you without criticism. At the same time, be sure you offer the same thing in return. It is easy to be positive when you surround yourself with people who are uplifting and who invite happiness.

Be grateful to others –When someone compliments you take the time to be grateful, and to give thanks to those around you. When someone says your artwork is inspiring or your eyes sparkle, just say thanks and be honestly grateful.

Comparisons are futile and competition is useless – There will always – always – be someone who has the characteristics you wish you had. It’s hard to imagine them looking at you and thinking the same thing, but the truth is they have their own “wish list.” Embrace and celebrate what makes you unique.

Meditate – Breathing deep helps you feel more relaxed, while quick shallow breaths make you feel more tense and bunched up. Get centered and clear your thoughts. This is also a chance to spend some alone time to gather your positive thoughts and reassuring attitude.

Try out a few of these simple activities at first, just to see how you start to feel. You might be pleasantly surprised at the positive, beautiful feelings that you have towards yourself and the world around you.


Nurtured by Nature

By Nikki Rollo, LMFT

“Nature does not hurry, yet everything is accomplished.” ~Lao Tzu


Advancements in technology such as computers, phones, and the Internet have massively changed how we live our lives and relate to people and the world around us. We now fully live in the digital age. In so many ways, this has benefited our society and our growth as a culture. We have immediate access to information and connection with people across the globe, as two wonderful examples. In other ways, it brings us great challenges and loss. What comes to mind for me is the way in which we increasingly grow up in buildings with less green space around us and engage in indoor technology based activities over those that open up pathways to connect with nature. In fact, a study from the University of Illinois, Chicago found that Americans spend 25% less time outside now than in the late 1980’s. I would like this article to serve as a reminder of the ways in which nature is our classroom and how we can not only learn life lessons from the world around us, but also experience deep support in our unique healing journeys.


While we have known anecdotally or in our clinical wisdom as therapists that nature has inherent healing properties, with its peaceful landscapes and ability to make us feel a part of something bigger than ourselves, studies have been conducted that indicate this is more than just a subjective experience, but that we can be both grounded in and nurtured by nature. Two in particular I want to call attention to are:


  1. Shinrin-yoku: A researcher in Japan Yoshifumi Miyazaki has been studying forest medicine and a concept called Shinrin-yoku or “forest bathing”. This involves spending a short, but leisurely time in a forest setting, taking in or really absorbing the forest’s healing properties. In a recent study on this activity, researchers found that a walk in the woods greatly improved stress levels, blood pressure, and heart rate in comparison to those who spent time in an urban setting. “Forest Bathing” or making contact and taking in the atmosphere of the forest is a simple practice. It involves either walking at a relaxed pace or sitting and gazing at the trees, inhaling the aroma of the bark and needles, and listening to the movement of the leaves from the effects of the wind. One need not make effort to try and relax or meditate….the thought behind this meditative practice is that the forest will do that work for us, linking us to itself through our five senses. One of the key elements is deep relaxation- resting deeply with the trees.
  1. Garden Gazing: A study published in 1984 by Roger Ulrich demonstrated that gazing at a garden can help speed healing from surgery and is beneficial to patients who are in a hospital setting. Stress affects healing and this study showed the restorative power of nature and therapeutic landscapes as well as a discussion on the possible benefit of lively landscapes. Gardens, trees, alcoves of greenery can encourage healing, reduce anger, anxiety, and pain as well as induce relaxation…just 3-5 minutes a day spent looking at that landscape can induce a contemplative calm. This can be done with being in the actual garden or if this is not easily accessible to you, even looking at pictures can bring tranquility to a busy life.


Interacting with Nature

Clinebell, who wrote about ecotherapy, says that this kind of therapeutic approach refers to both the “healing and the growth that is nurtured by healthy interactions with the earth”.

Let’s explore some possibilities for these interactions:

  • Use Your Five Senses by intentionally interacting with nature through sight, smell, taste, touch, and hearing. Feel the breeze blowing your hair in the wind, wiggle your toes in the grass, let the snow melt on your tongue, hear the crunch of the leaves under your boots, observe the tree branches moving in the breeze, smell the aromas of the flowers, or look at the intricacies of a leaf.
  • Bring the Outside Inside through things like bringing a plant in your house or office or if this isn’t possible, perhaps a nature landscape screensaver on your computer or framing a picture of a place in nature that you feel a connection to and place it by your bedside. Another idea would be to draw or paint what you saw or experienced in nature and hang it on your wall as a reminder.
  • Create Nature Within by visualizing a comforting landscape and meditating for a few moments each day on something in nature that feels sacred to you and opens up possibility for a transcendent experience, beyond the limitations of only that which we can touch in service of expanding our sense of self and interconnectedness with nature. Perhaps you even consider meditating or praying at the river, ocean, or another sacred space. If you can’t go outside, envision the clouds, stars, planets, trees or flowers to promote relaxation and rest in your body.
  • Tend to Nature by participating in restorative experiences of caring for plants, trees, and flowers. Something like gardening can foster resiliency and sense of purpose in caring for something growing and getting your hands in the soil of the earth…and perhaps even growing and eating fruits and vegetables that you nurtured and allowing them to nurture you in return.
  • Spend time with Animals in honor of your interconnectedness with all living beings and to take advantage of the therapeutic affects of animals such as emotional balance, decreased anxiety, increased social interaction, and decreased loneliness.

Disconnection from the natural world can further feelings of anxiety, depression, or stress. Reconnecting with nature through things like forest bathing, garden gazing, playing with an animal, or bringing a plant into your indoor space can positively affect these symptoms, decreasing alienation and isolation often present in this digital age and increase our capacity and openness for the joy of connection. Tending to our relationship to nature is interconnected to our well-being and tending to the relationship with our own souls, allowing ourselves to be nurtured by nature.


Clinebell, H. (1996). Ecotherapy: Healing ourselves, healing the eatth. Minneapolis: MN: Fortress Press.

Greenleaf, A. T., Bryant, R. M., & Pollock, J. B. (2014). Nature-based counseling: Integrating the healing benefits of nature into practice. International Journal For The Advancement Of Counselling, 36(2)

Juyoung, L., Bum-Jin, P., Tsunetsugu, Y., Kagawa, T., & Miyazaki, Y. (2009). Restorative effects of viewing real forest landscapes, based on a comparison with urban landscapes. Scandinavian Journal Of Forest Research, 24(3), 227-234.

Pergams, O. W., & Zaradic, P. A. (2008). Evidence for a fundamental and pervasive shift away from nature-based recreation. PNAS Proceedings Of The National Academy Of Sciences Of The United States Of America, 105(7), 2295-2300

Richter, W. (2011). Forest bathing: Good for the spirit–and the body. Alive: Canada’s Natural Health & Wellness Magazine, (348), 46-51.

Todesco, T. (2003). Healing Through Wilderness. Trumpeter: Journal Of Ecosophy, 19(3), 90-104.


Wall of Awesome February 2015

This past month’s “Wall of Awesome: Who’s Your Helping Hand?” was 100% imagined, designed, and created by the adolescent unit!  Here are some of the patient’s helping hands:

Processed with Moldiv

(The name “Wall of Awesome” was chosen by patients who were inspired by Kid President, an inspiring YouTube star who believes that “the world needs more awesome!”.  The “Wall of Awesome” is a positive community art space upon which anyone at Center for Change can contribute their ideas.  Each month a new wall is created by a group of patients).


Courageous Breath

By Nikki Rollo, LMFT

BreatheI listened to a Ted Talk this week called Breathing into Life by Brad Lichtenstein, ND. He asked a question of the audience that drives his medical practice and his work with people seeking healing from physical ailments: How do you want to live?

That question struck me as one we could all benefit from asking ourselves, especially as we are warming up into 2015. As is tradition, we set resolutions for the New Year that rarely last and quickly fall by the wayside- and of course, most of the time these resolutions are about unhealthy and unrealistic expectations about our relationship with our body, diet, and exercise. I wonder what might happen if instead of resolutions we spent some time pondering or contemplating these questions: How do we want to live? Is the way in which we are living a reflection of our deepest values as human beings? How do we discover our gifts and talents? What we can give back to the world?

This can certainly be a collective question of a community of people; however for the purpose of this exploration, let’s make it a bit more personal.

Take a moment to ask yourself the questions: is the way I am living a reflection of my deepest values? What do I stand for? What do I want to do with my precious time on this planet? How am I breathing my breaths?

You might notice as you ask yourself these questions, some kind of fear or anxiety creeping in. Really living in a way that is congruent with our deepest values or what Dr. Lichtenstein calls, “Breathing into Life”, takes tremendous courage and vulnerability.

Shame and vulnerability researcher, Brené Brown tells us that courage is to tell the story of who you are with your whole heart and that vulnerability is the most accurate measure of courage. Wow, that sounds both beautiful and terrifying! Relational wounding is a universal human experience and for some of us, we retreat deeper and deeper into a shell of fear and protection. Courage and vulnerability are no easy endeavor -but necessary explorations for being truly alive and living well.

So….How do we live from our hearts, and breathe courageously into our lives?

The simple answer is Practice.

Practice Breathing

Breath is a universal thread of the lifespan- it is the bookends of life- the first thing we do outside the womb and the last when we reach the end of life. It is such a remarkable thing because although most of the time it is purely involuntary, we can also take it from its natural or more passive automatic state to a more intentional space of practice in order to cultivate or develop it as a skill to calm our bodies and connect to ourselves more deeply.

The cultivation and practice of breathing is a courageous way to bring our inner and outer life into alignment and help us in the endeavor of telling the story of who we are with our whole heart- really living out our values in the world. If we slow down and create a space that invites stillness and deep listening, even for a minute or two, our hearts begin to let us know how we are engaging in life and if we are in alignment with our values.

Practicing the actual act of breathing, (which you will get a chance to do if you keep reading!), helps us get in touch with and deepen our connection with what is in our hearts. We will discover much about whether we are on a path of love and living well or if something in our path needs to be adjusted in order to have inner and outer alignment.

Practice Acts of Courage

Following the path of our hearts even when we feel fear and anxiety is key to breathing into our lives courageously. Learning to stay connected to our values even in the face of discomfort and unpleasant feelings develops and hones the skill of courageous breath. Start with something small, but expose yourself to the fear. Practicing and exposing oneself to that which we are afraid of lowers the psychological fear response and allows us to become more comfortable living life along side fear (which is a normal human reaction), rather than trying to cut it off or hide from it. Make it personal- what would this be for you? Perhaps this would be sharing a dream or hope for your future with a trusted friend of family member. Maybe for you an act of courage would be seeking help for something you are struggling with, or trying out something new, like a painting class, writing a short story, or volunteering at an animal shelter. Think of something that connects you to a deep value you have and start small, but start somewhere.

Practice an Attitude of Compassion (for yourself)

When we practice acts of courage and standing up for core values, things might not always turn out as planned…but they might! Either way, having an attitude of compassion for oneself allows an acknowledgement of the beauty the courage with less attachment to the outcome. The willingness to stand up for what matters in service of breathing into and engaging wholeheartedly in your precious life on this planet is worthy of honoring. Notice how you talk to yourself – a compassionate heart has the potential to transform suffering.

Practice with Courageous People

Think about those people that you admire, those that live a life of inner and outer alignment. Learning from others about acts of courage are invaluable lessons. Become curious and engage these people in conversation. Most likely what they will tell you is that courage is not the absence of fear. It is not even about a conquering of fear. Living a life that is a reflection of our deepest values requires vulnerability and a willingness to stand alongside fear, exposing oneself to it, moving through it, surviving, and growing.


Even with all of these ideas, we cannot breathe into life if we are physically holding our breath! I invite you to take the next minute as an opportunity to explore your own breath in service of cultivating an awareness of your inner life.


Breathing Practice

Sit comfortably and invite your body to relax. This can be in a cross-legged position, or in a chair with your back supported and your feet on the ground. Your eyes can be open with a soft gaze or closed- whatever feels safe and comfortable for you.

Begin to notice your breathing. What are your breaths like? Perhaps they are long and maybe they are short. They may be shallow breaths in your chest or they might be deeper in your diaphragm. Notice your breathing without judgment of what it is- it just is. Notice what is happening in your mind- is there a lot of noise or is it quiet? Bring your compassionate attention to your heart. Does it feel contracted or soft? Neutral? Open or closed?

Does your heart have something to tell you? Continue breathing softly- allowing your breath to deepen and expand your lungs, honoring whatever emotions may arise with a compassionate attention, without judgment or criticism. Perhaps ask the question of your heart: What might lead me to a greater connection with my values?

After a few more rounds of contemplative breath, begin to bring your awareness back into the physical space you are in. I encourage you to take a minute to write about what you discovered in that moment of stillness and courageous breath. What was your heart telling you about breathing into your life with courage and vulnerability?

Courageously breathing into your life helps make not only your life, but also the world a more accepting loving place. The world needs what you have to offer it, your unique values and the unique expression of them.


How to Maintain Self-Confidence in a World Filled with Artificial Beauty

by Center for Change

Women anywhere from their teens, up to their 40’s have likely opened up a favorite magazine to find a “scandal” of a celebrity’s before and after photo-shopped picture. Whether these are a popularity stunt, or actual leaked photos, there is one reality, nearly all models and celebrities shown on magazines and television are either photo-shopped or altered in some way.

PhotoshopEating Disorder Treatment is a photo editing program that can brush out extra weight, wrinkles, skin flaws, even the color of someone’s eyes can be changed. On-screen, camera lenses can be adjusted, people are wearing various forms of body cinchers and tighteners, and makeup contouring can fool any lens into making someone appear thinner, their nose appears smaller, and their muscles to look more defined.

It’s important that women of today are aware that what they see is not reality. We are comparing ourselves to an unrealistic ideal of beauty that is highly toxic and for some, incredibly dangerous. Teens are not the only group affected. An article by titled “Dying to be Barbie,” highlights that four out of five 10-year-olds are afraid of being fat and 42% of girls in the first through third grades wish that they were thinner.

Possible reasons for this are that the dolls and images young children are being exposed to are highly unrealistic. Some of the first image ideals we have in life only sets us up for the exposure to thousands of unrealistic photo-shopped images and contoured bodies we’ll see in the media for years to come. What we see in the media affects us throughout our entire lives. We are constantly trying to attain something that cannot be attained.Anorexia Treatment

The great news is that now we know what we are up against. Now we know that what we are seeing isn’t reality. Many celebrities who have been photo-shopped so severely have even spoken out against it. In reality, there is so much to love about who we are and what we really look like.

Fstoppers wrote an article featuring a video that was created by Buzzfeed showing four women who were given the opportunity to have a makeover, have their photos taken, then were photo-shopped just like in the magazines. They were expected to love the results, but in the end, they actually liked the way they really looked better. Their natural beauty and their inner beauty were enough.

These women, who may or may not have had some self-confidence to begin with, were shown a new reality. The fact is, most of us are not going to be photo-shopped into thinking how much better we look in real life, so we can find other ways to discover how beautiful we really are.

  1. Be grateful – We can all start on the path to feeling beautiful by being grateful. Wake up each morning and remind yourself of what you are grateful for. Be grateful for your great freckles that make you so unique. Be thankful for the stretch marks that came from having that beautiful child. And then, go deeper. Be grateful for another day to be alive. Appreciate the sound of the rain against the window or the gorgeous blue sky. Find something and write it down as a reminder for the day that you have something to be grateful for.
  2. Find things to love in others – It’s just a simple fact that when we are focused on the good in others, we focus less on what we may dislike about ourselves. Look beyond the physical though, and see the true good. Notice the young boy opening the door for his classmates, or the girl buying coffee for the person behind her in line. Notice the joy someone emits when they smile or their contagious laugh. Look for the good all around you, and you will instantly feel happiness.
  3. Love yourself – The fact is, you are you, and there are so many things to love. Others see it, and you deserve to as well. When you are going about your day, think of at least one thing you love about yourself. It can be your smile, your awesomely painted toes, the color of your eyes, or your funny personality. You can love that you are shy and quiet, because some people find that endearing, and you can even love how hard you worked to pass your last test. The things you can love about yourself are endless. Keep a list and look at it to remind yourself how incredible you are.
  4. Let your inner beauty shine – When there is so much to love about the world and about yourself, you can’t help but have something to appreciate. Use that for good and show the people around you how beautiful you are, from the inside. Give someone a smile who looks like they need one, compliment someone you don’t normally talk to, and simply be you.

Bulimia TreatmentThe truth is, you are amazing just the way you are. Follow these steps each day to get the boost that you need and get on the path to being confident in who you are in a world that is so full of false ideals of beauty. The beauty that really matters comes from within.

For more information on Center for Change and body image therapy please visit us online at  .



Understanding One’s Worth: A Cornerstone of Recovery from Eating Disorders and Other Mental and Emotional Illness

By Michael E. Berrett, PhD

There are few things more painful than feeling worthless or “not good enough,” minute by minute, day by day, and year by year. I know because I have felt that way myself, much of the time during the first half of my 60 years. Additionally, I have provided counsel and treatment to many hundreds of individuals who have felt similar feelings over the past 30 years as a clinician. To those individuals, their beliefs went well beyond emotion. In fact, many of them felt that they knew “beyond any doubt” that they were as worthless as they felt. How painful it is to live in that place, and yet how wonderful it is that there is hope for every one of us – that we can improve our sense of self, even to the absolute knowledge that we are wonderful beyond anything that words can express. It is this gradual but growing understanding that can increase motivation to change. You, and I are worth the effort it takes to transcend illness and create a recovered life.

Why is it that we medical and mental health professionals dedicate our lives to helping those suffering from illness? There are many reasons, but key among them is the understanding that each individual we serve is worth everything we can do and so very much more. As Mother Theresa said, “I serve not because an individual is in need, but because they are holy.”

It is my belief that our clients – those suffering – reach out for help for many reasons including these two primary ones: 1) They are feeling an intense and utter desperation that has brought them to their knees, and 2) Because deep down inside, beyond all self -doubt and self- contempt, and well beyond their negative and false perceptions of self- they too have a small sliver of a glimpse of their worth – that maybe they also are worth the efforts of themselves and others to make change, transcend illness, and receive the blessing of healing. That little sliver – that glimpse- is a small seed that can grow.

GAs individuals begin to take steps towards recovery, they find reasons to recover, and any reason is to be honored and remembered to strengthen the resolve towards recovery. Desperation, fear, love for others, passion, life’s purpose, deep desires, and dreams are among common reasons to recover and to live. Eventually, on the pathway to recovery, individuals learn that in addition to all other worthy reasons – the truth that “I also am worth it,” is a powerful force which helps move individuals towards better choices, more self- care, and hard work towards recovery.

Gaining a sense, an understanding, and even a sure knowledge of one’s self worth is a process which is very gradual. As we are patient and consistently taking steps over time, it helps us not only to attain recovery, but also to maintain and retain it in the long haul. It wards against relapse, and protects and solidifies recovery in our lives.

The word recovery means “to bring back that which was lost.” In that sense, when we are in recovery, we bring back our lost perceptions, perspectives, thoughts, feelings, relationships, and sense of self – both who we are, and who we can be. Similarly, when we recover our true sense of self and self- worth,

We also recover that which was lost. I sincerely believe that each of us once, at an age very young, had some understanding of our worth. This can be seen in a young child racing around the house naked, escaping his or her parents for a few moments after a bath, or in the unguarded words of a child, who says simply everything she feels to say, without hesitation. These are examples of the state of a child before they begin to lose sense of self, and sense of goodness. This is before we receive false messages from those around us which teach us that we are deficient, broken, not good enough, and not enough.

Luckily, while there are many losses in life, the “loss of a sense of self and worth” is one of those which can be recovered. The following are a few ideas and places to start in building again, a lofty, truthful, and positive sense of identity, and knowledge of one’s individual worth:

  1. Be willing to be wrong about how worthless you think you are
  2. Start with the openness that “maybe” I am not as bad or worthless as I think I am. “Realities can start with Maybes.”
  3. Seek to see some of your identity and worth in the mirror of the faces of those who you know love you, care about you, know you well, and have your best interest in their heart. Start with admitting at least, that they see the good in you, even if you don’t understand what or how.
  4. Seek to become your own mirror and witness of your beauty, your wonder, your magnificent worth, and your goodness
  5. Learn to look for and notice the good things about you. The things you feel good about, the things you are proud of. Find them, tell the truth about them, document them in your journal, and read these journal entries often.
  6. Treat yourself “as if” you are worth every-thing, until you know that you are worth everything. Treating yourself so will help those feelings and understandings grow.
  7. Learn to leave behind the damaging external criterion for self- worth as sold in our modern Western Culture Marketplace. Cease to use Appearance and Approval as markers or evidence of self- worth
  8. Learn to look for internal evidences of self- worth including: talents, gifts, hard work, effort, deepest desires, principles, character, love, engagement, and the intentions of one’s heart.
  9. Learn to listen, understand, and then follow your own heart, and understand that it is linked to self- identity and self- worth
  10. Set reasonable and modest goals, and then take small steps towards your goals. Keep your feet moving in the direction of the goal, not with lightning speed, but with consistency and persistence
  11. Strive to live a life of congruence and integrity so that you can say to yourself “Not all things went my way today, but at least I strived to live the way I believe I need and want to live” (remember : perfection is unnecessary, while striving is required).
  12. Learn to self- correct when you make a mistake, rather that becoming a harsh judge and jury. Learn to learn from mistakes, stand up, brush off, get clear on learnings, and try it again with your newly gained understanding.
  13. Ponder the truth that we are the artistry of the Creator, “who hath made no junk,” but rather, a person of great beauty both inside and out
  14. Remember that a sense of self- worth is both psychological and spiritual. Embrace your spirituality, honor your spiritual beliefs, and live with good will towards all including yourself.
  15. Remember that love of self and of others is the most powerful healing force available. Take steps to ask for help, and to receive love in your life. Express your love for others without “holding back.”

Friends – Improving self- worth, self- esteem, self- image, body image, sense of self, sense of identity, self- understanding, and self- love – are lofty goals, but goals which are within the reach of us all. These states of true understanding come over time, as the result of processes of being willing to see, doing the hard work of treating oneself well, giving what we have to give to others, and receiving the love and support others have for us as well. Let us all press forward on this pathway to being, knowing, and becoming – never to stop!


Michael E. Berrett, PhD

Psychologist, CEO, Co-founder

Center for Change, Orem, Utah

November 2014


Athletes & Eating Concerns

Sport Related Risk Factors

Many in sport believe that weight or body fat reduction enhances sport performance, and so there can often be pressure to lose weight.  Unfortunately, sometimes unhealthy and risky eating behaviors may be encouraged for weight loss.  These behaviors more typically damage performance rather than enhance it.  Due to the focus on leanness in many sports, athletes may develop competitive thinness with peers, and may feel added pressure to lose weight.  This is known as the contagion effect and may include subcultural expectations to look a certain way, known as the “sport body ideal.”  Another concern, especially common among female athletes, is the revealing nature of sport uniforms, which in turn increases body image concerns.  Individuals who participate in the Aesthetic/Lean/Judged sports, such as gymnastics, diving, and figure skating, are at the highest risk for unhealthy body image and eating difficulties.  Further, there seems to be a parallel between “good athlete” traits and eating disorder characteristics, so that coachable, perfectionist, and compliant athletes may be at greater risk for the development of eating concerns.  Finally, identification of eating concerns in sport is more challenging and may delay early intervention and treatment.

iStock_000015504497SmallDetermining Unbalanced Exercise

There are many indicators that “unbalanced”, “unhealthy”, “compulsive” or “damaging” exercise is occurring.  Excessiveness can show up in frequency, duration, or intensity of exercise.  Exercise should be considered unbalanced if:

•  Exercise continues despite illness or injury

•  Exercise interferes with balanced activities and relationships

•  Exercise is rigid: must exercise in a narrowly defined way or at a certain time

•  Exercise is a rigid obligation: must happen regardless of any life circumstance of higher importance

•  Exercise is the primary and only means of coping with stress

• Exercise reduction leads to withdrawal symptoms such as: agitation, anxiety, anger, insomnia, appetite changes, feelings  of guilt, etc.

Unbalanced exercise can be observed in patterns of activity and in patterns of exercise versus appropriate nourishment to sustain the activity level.  Asking specific questions about exercise can reveal patterns and asking specific questions about the physical, social, mental, and emotional consequences of exercise or not exercising can also shed light on unbalanced exercise.  It is not only external or behavioral patterns which indicate “unbalanced” exercise, but also “internal” responses and motives which illuminate the depth of potential problems with exercise.

How Does One Know if an Athlete is Struggling With an Eating Disorder?

When someone is struggling with an eating disorder, the signs and symptoms will show up in all areas of life: physical, social, mental, emotional, and spiritual.  The symptoms are straightforward and many of them are observable, yet those suffering with eating disorders are most often experts at hiding their struggles and minimizing their symptoms.  They have many reasons to keep their struggle secret.  Athletes have additional motives in keeping the illness hidden, as they don’t want their participation restricted.  Some eating disorder signs and symptoms in an athlete are as follows:

• Actions suggesting need for perfection

• Low self-esteem, which motivates need for achievement & perfection

• Extreme sensitivity

• Obsessive & compulsive behaviors

• Over-achievement

• Lack of self-confidence

• Drastic weight changes

• Changes in eating habits

• Excessive exercising or over-training

• Frequent trips to the bathroom

• Refusal to share feelings

• Frequent excuses

• Lying

• Chewing a lot of gum

• Excessive drinking of liquids, especially diet drinks

• Avoiding food or serious restriction

• Guilt feelings after eating

• Social isolation

• Watching what others eat

• Loss of interest in enjoyable activities

• Binge-eating with no weight gain

• Comments about purging food or calories

• Weakness, fainting, etc.

• Red eyes

• Calluses & blisters on knuckles

• Comparison of body, beauty, etc.

•  Comments of body dissatisfaction or body hatred

• Depression

• Tendency to order food in small and insufficient amounts

• Solving other’s problems, but ignoring one’s own

• Avoiding any contention at all

• Self-harm or suicidal thoughts

• Wearing baggy clothes to hide body

• Avoiding responsibility

• Preoccupation with food

• Defensiveness about food, weight, etc.

• Obsession with dieting, calorie-counting, low-fat foods, diet pills, laxatives, etc.


How Do I Know if I am an Unbalanced Exerciser?

• Do I exercise at inappropriate times or settings?

• Does exercise negatively impact my relationships?

• Do I exercise despite illness or injury?

• Does exercise negatively impact my psychological or physical health?

• Does exercise interfere with everyday activities, such as work or school?

• Do  I exercise in order to create an energy deficit despite normal or low weight?

•  Do I feel significant anxiety or guilt if I don’t exercise?


Consequences of Unbalanced Exercise

The consequences of unbalanced exercise can be serious.  Consequences include development of compulsive exercise disorder, impaired balance in life and consequent reduction in general quality of life, premature loss of career as an elite athlete, physical, skeletal, and internal organ damage, including cardiac arrest and death.  These potential consequences outweigh the temporary consequence of potential and illusive fear of loss of “peak performance.”  Some of the many consequences of unbalanced exercise include the following:

• Decreased bone density (Osteopenia or Osteoporosis, depending on severity)

• Stress Fractures:  Overuse injury that occurs when muscles are fatigued & unable to absorb added shock, which then transfer overloaded stress to the bone, resulting in a fracture

• Hormonal Changes:  Loss of menstrual period for females, low testosterone level for males

• Recurrent injuries (Soft tissue strains)

• Decreased immunity (Intense exercise for extended periods of time decreases the strength of the auto-immune system)

• Overtraining Syndrome or Staleness (failure to make expected training gains)

• Female Athlete Triad:  Low energy availability, menstrual irregularities, & bone loss

• Dehydration, Heat Stroke, Hyponatremia• Potentially lethal cardiac events (Sudden Arrhythmia Death Syndrome, Prolonged QT Interval)

• Added stress when responsibilities & relationships are sacrificed for exercise

• Depression, anxiety, irritability when exercise is sole coping behavior

• Rationalize exercise for “health” when actually putting health at greater risk

• Isolation or withdrawal due to exercise compulsion• Depression due to Overtraining Syndrome

• Exercise to compensate for or legitimize eating

• Exercise to maintain negative energy balance (despite hunger, intentionally eat less if unable to exercise)

•  Increased risk of development of eating difficulties or eating disorders


Tips for Coaches in Protecting the Athlete From the Damage of Unbalanced Exercise

Coaches play a critical role in not only the performance of the athletes they coach, but in the general health and development of those under their tutelage and example.  Their impact is on the “person,” not just the “performance.”  The importance of development of character as an individual transcends the importance of performance as an athlete.  With this great opportunity and power comes responsibility to watch out for the health and welfare of the athlete far beyond performance.  That balance between “pushing the performance now” versus “longer term performace” and overall health is a fine line. To aid in this difficult yet rewarding responsibility, coaches may consider the following:

• Do pre-athletic screening exams for eating disorders

• Focus on the whole athlete, not just athletic performance

• Know that weight loss does not equal performance enhancement

• Loss of menstruation is a sign of physical dysfunction, not a sign of effective training

• Avoid comments and comparisons on weight, body image, and appearance

• Focus on health, not weight

• Know that quick weight loss results in loss of lean muscle which equals decreased performance

• Don’t be afraid to talk to an athlete about your concerns

• Enlist support within the community (athletic trainers, sports psychologist, ED specialists, dietitians, physicians)

• Assure the struggling athlete gets professional help

• Allow time for athletes to eat and hydrate

• Don’t encourage extra or excessive training or workout sessions

• Don’t allow sick or injured athletes to train or compete

• Provide sound nutrition education

• Don’t encourage crash or fad diets in preparation for competition

• Don’t do body composition tests or group weigh-ins.  These shame individuals!

• Provide ongoing education; the coach’s perspective has a critical impact on athletes’ perceptions

• Use common sense education; convey the seriousness of eating disorders without highlighting war stories

• Don’t glamorize eating disorders or place them on a pedestal

• Address emotional, social, & physical aspects of eating disorders

• Focus on sport-specific information (nutrition, sports performance, & body composition)

•  Use your positive influence to nurture the athlete towards healthy living in addition to athletic performance


Approaching an Athlete:  What Not To Do

• Don’t confront the athlete in a group of people or in the presence of others

• Don’t be judgmental; don’t tell the athlete that what he or she is doing is “sick” or “crazy”

• Don’t follow the athlete in an effort to “catch” them in eating disorder behavior

• Don’t give advice about weight loss, exercising, or appearance beyond your own expertise in sport training

• Don’t label someone with an eating  disorder because there are some signs.  Leave that to diagnostic experts.

• Don’t get into an argument or battle of wills

• Don’t promise to keep secrets

• Don’t try to police the athlete’s eating or force the athlete to either eat or not eat

• Don’t let the athlete monopolize your time & energy

• Don’t try to fix the athlete’s problems and don’t attempt to help them by yourself.  Expand the circle of support.


How to Approach the Athlete

Who:  Who should approach the athlete when a potential eating or “over exercising” concern is identified?  An individual in a position of authority as part of the Sport Management Team is best equipped to approach the athlete.  The individual who has the best rapport and closest relationship with the athlete is ideally positioned to address concerns.   A fellow teammate should NOT be the one to approach an athlete as there is no power behind the intervention, it may create a dependent relationship, and it could exacerbate an already competitive relationship or contribute to the development of a competitive relationship.  Be prepared for a negative response, including denial, when first approaching an athlete with concerns.

When:  As soon as an individual close to the athlete identifies a potential problem, based on the presence of a number of signs and symptoms.  Early identification results in fewer and less severe complications, less resistance to treatment, and faster, easier, and more positive treatment outcome.

How:  In approaching an athlete, express concern and ask how the athlete feels, both physically and psychologically.  The athlete needs to know that people care and that others will not criticize or embarrass them.  Focus on the athlete’s well-being, and approach the athlete gently, with no accusations.  Ask, rather than tell.  Assess, rather than judge.  One goal of intervention includes maximal sensitivity and minimal invasiveness.

Speak to the athlete privately and allow time to talk.  Express your concern to the athlete and calmly share the specific observations that arouse your concern.  Allow the athlete time to respond, and listen in a non-judgmental manner.  Keep your focus on the concerns you have observed.  If the information you receive suggests an eating disorder and/or excessive exercise, share with the athlete that a) you think the athlete may have a problem, and b) you are concerned about the athlete’s health and well-being.

Be prepared to offer resources, including counseling, dietary, physician, and community referrals.  Assist the athlete in making parents and other support systems aware of the concern.


Refusal of Treatment

It is imperative that the athlete be encouraged to accept treatment as soon as reasonably possible.  However, sometimes despite best efforts, athletes may refuse treatment.  If the athlete initially refuses treatment, don’t push too hard unless you suspect the athlete is at risk medically.  Make continued sport involvement contingent on the athlete seeking and complying with treatment and physical health.  Allow the athlete to remain a part of the team by attending practices and competitions. Don’t “kick the athlete off the team.”

Suspension from the team is the last resort as the athlete may continue to train on their own, which may be more dangerous as there is no monitoring.  Suspension may deprive the athlete of their primary source of positive feelings and self-esteem.  The athlete may view suspension as an attempt by others to control, and thereby respond with frustration and increased resistance.  If all attempts to persuade an athlete to evaluation and treatment fail, there is no alternative but suspension.

Enlisting a Support Network

The Sport Management Team has a responsibility to inform parents of concerns, ensure the athlete is seeking treatment, and use athletic participation as appropriate leverage for seeking treatment. Comprehensive Release of Information forms for the full treatment team (therapist, dietitian, physician, athletic trainer, coach) should be in place to ensure coordination of care.

Ongoing communication between team members is essential as the support network becomes a united front against the eating disorder illness — not the athlete.  A treatment plan devised through ongoing communication should include criteria for athletic participation.  Ongoing communication also ensures appropriate boundaries are maintained throughout treatment.  Each team member supports and encourages the treatment approach and clear communication ensures that various treatment team members are not undermined.  Abiding appropriate boundaries also prevents the athlete from receiving mixed messages.  When there is a concern or question, support network members defer to the treatment team for consultation.


The Exercise Balance by P. Powers & R. Thompson (2008), Gurze Books.  

Eating Disorders in Sport by R. A. Thompson & R. T. Sherman (2010), Routledge.

Eating Disorders:  Physical, Social & Emotional Consequences.  Secondary education lesson plans about eating disorders, Foundation for Change (2001).  

Helping Athletes with Eating Disorders by R. A. Thompson, & R. T. Sherman (1993), Human Kinetics Publishers.  

Eating Disorders and Athletes:  A Handbook for Coaches edited by S. C. Holliman (1991), Kendall/Hunt Publishing Co.


Battling Our Bodies: Understanding and Overcoming Negative Body Images

Author:  Nicole Hawkins, PhD

How often do you look in the mirror and say “If I could just lose ten pounds, then I would be happy”? Unfortunately, the majority of American women and girls are dissatisfied with their bodies, and many take extreme measures in an attempt to change their bodies. For example, one study found that 63% of female participants identified weight as the key factor in determining how they felt about themselves – more important than family, school, or career. Other research suggests that 86% of all women are dissatisfied with their bodies and want to lose weight. Women and adolescent girls regard size, much like weight, as a definitive element of their identity. Some girls assume there is something wrong with their bodies when they cannot fit consistently into some “standard” size; others will reject a pair of jeans simply because they won’t wear a particular size. The majority of girls step on the scale to determine their self-worth; if they have lost weight, then it is a good day and they can briefly feel “okay” about themselves. If the number on the scale has increased ever so slightly, then the day is ruined and they feel worthless. Body image has now become intertwined with one’s weight, and therefore, if women are not happy with their weight, they can not possibly be satisfied with their bodies. Unfortunately, girls and women take this a step farther and rationalize that negative body image is directly equated to self-image. We are now living in a society where young girls believe the one way to definitely improve their self-image and to feel more confident is to lose weight and become thinner.

woman looking into a broken mirrorWomen and young girls are now living in a society where their bodies define who they are. Girls are terrified to gain weight and are continually reminded by the media about various new diet products on the market, and the value in weight loss. They are also bombarded by countless television shows on plastic surgery and the number of cosmetic surgeries in this country are increasing every year. Women today face impossible images of beauty on a daily basis when they watch television, see a movie, or view a magazine. It is estimated that young girls are exposed to 400 to 600 media images per day. Young girls and women inescapably feel insecure about their bodies and physical appearance and often believe they must change their bodies to gain self-esteem. A recent survey found that only 2% of women in the world would describe themselves as “beautiful.” The vast majority of girls want to change various aspects of their appearance. In today’s society, self-esteem and body-esteem have become one and the same. Unfortunately this is having an emotional toll on young girls, and they are feeling inadequate and often turn to severe behaviors in an attempt to manipulate their bodies to “fit into” an unrealistic standard of beauty. Eating disorders have flourished in this beauty-driven society. Young girls and women are trapped in a negative cycle of body hatred. Women with eating disorders are particularly vulnerable to this negative body image cycle.

Although a large majority of women are displeased with their bodies, many women and girls experience extreme body image difficulties that can be part of more complicated problems. These extreme body image disturbances include body dysmorphic disorder, eating disorders and severe depression.

Body Dysmorphic Disorder: This is a disorder of “imagined ugliness.” What individuals with this disorder see in the mirror is a grossly distorted view of what they actually look like. Often, these individuals will spend hours examining, attempting to conceal, or obsessing over their perceived flaws. Some people actually spend thousands of dollars on plastic surgery in an attempt to improve their bodies.

Anorexia Nervosa: This disorder is characterized by an extreme fear of gaining weight and these individuals actually perceive their bodies as larger or “fat” even though they are grossly underweight.

Bulimia Nervosa: Individuals with this disorder are also very dissatisfied with their bodies and have extreme concern with body weight and shape.

Depression: In many instances, individuals with depression often have a distorted view of themselves and believe they are less attractive than they really are.

Since negative body image is a prevalent problem for many women and girls and can also be a component of many serious disorders, it is critical that women learn to change their body image towards a healthy and positive view of self.


1. Fight “Fatism”

Work on accepting people of all sizes and shapes. This will help you appreciate your own body. It may be useful to create a list of people you admire that do not have “perfect” bodies. Does their appearance affect how you feel about them? It is also important to remember that society’s standards have changed significantly over the last 50 years. The women that were considered the “ideal beauties” in the 1940’s and 1950’s, like Marilyn Monroe (size 14) and Mae West, were full-bodied and truly beautiful women, but they would be considered “overweight” by today’s standards.

2. Fight the Diet Downfall

Ninety percent of all women have dieted at some point in their life, and at any one point in time, 50% of women are dieting. A recent survey found that 14% of five-yearold girls report that they “go on diets” in an attempt to lose weight. By the time girls are ten years old, 80% report going on a diet. Women are two times more likely to diet than men. To dieters’ dismay, 98% of all dieters gain the weight back in five years. Studies also show that 20-25% of dieters progress to a partial or full-blown eating disorder. Research has found that when restrained eaters are exposed to commercials related to diet, weight loss, or fitness, they experience negative emotions and are more likely to then overeat. Women are foolish if they believe that dieting will make them feel better about themselves. Dieting only helps you lose your self-esteem and energy. Dieting also creates mood swings and feelings of hopelessness. To fight the diet downfall, an intuitive eating approach can be extremely helpful. This approach focuses on moderation of all types of foods and not counting calories or label reading. Food is “just food” and not labeled as “good” or “bad.” Clients learn to monitor their hunger/fullness and enjoy a healthy relationship with food. If you feel pressure to lose weight, talk to a friend or loved one, or seek professional help. There are many helpful books that focus on intuitive eating that may be a good resource.

3. Accept Genetics

It is critical to remember that many aspects of your body cannot be changed. Genetics play a role in your body and at least 25% to 70% of your body is determined by your genes. While there are many aspects of your body we cannot change, you can change or modify your beliefs and attitudes which influence the way you feel about yourself. Change starts with you – it is internal, and it starts with self-respect and a positive attitude. It is important to focus on health and not size. It is important to not compare your body with your friends, family members, or media images. We are all unique, and no two bodies are the same. We can’t be truly happy or healthy if we “diet into” a new body.

4. Understand that Emotions are Skin Deep

It is important to discover the emotions and feelings that underlie your negative body image. The statement “I feel fat” is never really about fat, even if you are overweight. Each time a women looks at herself in the mirror and says “Gross, I’m fat and disgusting,” she is really saying “There is something wrong with me or with what I’m feeling.” When we do not know how to deal with our feelings we turn to our bodies and blame our bodies for our feelings. Every time you say “I’m fat” you are betraying your body, and you are betraying and ignoring your underlying feelings. Remember that “fat” is never a feeling; it’s avoidance of feelings. Learn to discover your emotions and feelings, and realize that focusing on your body is only distracting you from what is “really” bothering you.

5. Question Messages Portrayed in the Media

The media sends powerful messages to girls and women about the acceptability (or unacceptability) of their bodies. Young girls are taught to compare themselves to women portrayed as successful in the media, assessing how closely they match up to the “ideal” body form. Unfortunately, the majority of girls and women (96%) do not match up to the models and actresses presented in the media. The average model is 5’11” and weighs 117 pounds, whereas the average women is 5’3/8” and weighs 166.2 pounds. This is the largest discrepancy that has ever existed between women and the cultural ideal. This discrepancy leads many women and girls to feel inadequate and negative about their bodies. It is important to realize that only 1.8% of women genetically have the “ideal” body currently presented in the media. The other 98.2% of women feel they must go to extreme measures to attempt to reach this unobtainable image. Many of the images presented in the media have been computer enhanced and airbrushed. The models’ hips and waists have often been slimmed and their breasts enlarged through computer photo manipulation. Many of the women presented in the media suffer from an eating disorder or have adopted disordered eating behaviors to maintain such low body weights. It is important to start to question images in the media and question why women should feel compelled to “live up” to these unrealistic standards of beauty and thinness. One interesting side note: Glamour magazine tried to use more “average size” models in their magazine and found that sales went down. It is interesting that research demonstrates that women report feeling positive about their bodies after seeing normal images of women in the media, but this did not improve readership for Glamour magazine.

6. Recognize the Influence of Body Misperception

Women are prone to more negative feelings about their bodies than men. In general, women are more psychologically invested in their physical appearance. Your body image is central to how you feel about yourself. Research reveals that as much as 1/4 of your self-esteem is the result of how positive or negative your body image is. Unfortunately, many women with eating disorders have a larger percentage of their esteem invested in their bodies. Women with eating disorders often exhibit unequivocal body image misperception, in which they misperceive the size of part, or the entire body. Hence they are “blind” to their own figures. This distortion is real and it is not due to “fat,” but to the eating disorder illness. It is important to recognize this misperception and attribute it to the eating disorder. When you feel fat, remind yourself that you misperceive your shape. Judge your size according to the opinions of trusted others until you can trust your new and more accurate self-perceptions.

7. Befriend Your Body

It is important to combat negative body image because it can lead to depression, shyness, social anxiety and selfconsciousness in intimate relationships. Negative body image may also lead to an eating disorder. It is time that women stop judging their bodies harshly and learn to appreciate their inner being, soul, and spirit. A women’s body is a biological masterpiece; women can menstruate, ovulate and create life. Start to recognize you do not have to compare yourself to other women or women in the media. Begin to challenge images presented in the media, and realize that your worth does not depend on how closely you fit these unrealistic images.

In Margo Maine’s book “Body Wars,” she teaches women to reclaim their bodies and offers ways to help women love their bodies. Here are examples of 10 ways you can love your body:

  1. Affirm that your body is perfect just the way it is.
  2. Think of your body as a tool. Create an inventory of all the things you can do with it.
  3. Walk with your head high with pride and confidence in yourself as a person, not a size.
  4. Create a list of people you admire who have contributed to your life, your community, or the world. Was their appearance important to their success and accomplishments?
  5. Don’t let your size keep you from doing things you enjoy.
  6. Replace the time you spend criticizing your appearance with more positive, satisfying pursuits.
  7. Let your inner beauty and individuality shine.
  8. Think back to a time in your life when you liked and enjoyed your body. Get in touch with those feelings now.
  9. Be your body’s ally and advocate, not its enemy.
  10. Beauty is not just skin-deep. It is a reflection of your whole self. Love and enjoy the person inside.

In conclusion, negative body image is a serious problem and has damaging affects on women’s self-esteem. It can lead to depression, as well as an eating disorder. Changing our world starts with you. Self-love and respect, and the end of prejudice start with one person at a time. The external pursuit of changing your body can often damage spirituality by taking you away from the internal-self – the spirit, the soul, and the whole genuine self. If you or someone you care about suffers with negative body image, please seek professional help and stop the cycle of body hatred.


Body image is particularly difficult to treat in women with eating disorders. There are several concepts that can assist professionals in their treatment of women with body image issues. It is helpful to first assess the degree of negative body image present. One example of how this can be done is by having women draw a front and side profile of their body and then identify the areas of love, like, dislike, and hate with different colors. Process each area with the client and have her describe why she feels that way about each particular area. Often negative body image issues have stemmed from past teasing experiences, and young girls and women focus on negative comments family and peers have said to them. For example, I had a 17 year-old client that was repeatedly teased from having “chubby cheeks.” When she was anorexic her cheeks were sunken in, and she believed her family would finally accept her and stop teasing her. Therapy had to focus on her childhood teasing before she could accept having her cheeks.

Another helpful step is to determine how much negative body image impacts their everyday lives. Many women avoid wearing a variety of clothing and also use clothing to conceal their bodies. For example, many clients will wear big baggy sweatshirts all year long to avoid showing their stomach. Women also avoid activities to protect themselves from negative body image. Many clients have not gone to a swimming pool for over a decade. Having clients begin to face their fears and “avoid avoiding” will slowly help them embrace their body. Encourage clients to try new things and find and express their real self.

It is also helpful to have women practice appropriate self care. This means that they need to get adequate sleep, food, and exercise. Often women with eating disorders feel so negative about their bodies they avoid caring for themselves, and this self neglect continues to create a negative downward spiral. Encourage clients to re-engage in activities that they have been neglecting due to their bodies.


What Do You See When You Look in the Mirror?, Thomas F. Cash, Ph.D., Bantam Books, New York, 1995.

When Women Stop Hating Their Bodies, Jane R. Hirschmann & Carol H. Munter, Fawcett Columbine, New York, 1995.

Body Wars: Making Peace with Women’s Bodies, Margo Maine, Ph.D., Gurze Books, Calsbad, 2000

Reviving Ophelia: Saving the Selves of Adolescent Girls, Mary Pipher Ph.D., Random House, Ballantine Books, New York, 1994.

Intuitive Eating: A Recovery Book for the Chronic Dieter, Evelyn Tribole M.S., R.D. & Elyse Resch M.S., R.D., New York 1995

© Copyright Center for Change, Incorporated
November 2009, Revised August 2014


For the Loved Ones of Those Suffering with an Eating Disorder

Author:  Michael E. Berrett, PhD


One of the most difficult tasks any of us face is watching the struggle and suffering of those we love.

It is especially difficult and heart wrenching to watch a loved one suffer with an eating disorder. What makes it so difficult are its far reaching effects: physical, mental, emotional, social, and spiritual damage, confusion, and chaos. With anorexia that chaos and confusion can be hidden under rigid perfectionism and an illusion of control. With bulimia and binge eating disorder, the confusion and chaos may be more obvious to us on the outside.

It is hard to watch suffering which seems initially deceptively “avoidable” or “fixable”. It doesn’t take long, however, to see the complexity.

In helping a loved one suffering with anorexia, bulimia, or binge eating disorder, I offer a few ideas to consider:

1.) Remember — eating disorders are complex and most often require many kinds of help. Don’t try to deal with this problem alone. Reach out to other professionals and other loved ones while searching for answers.

2.) What’s not said can be as damaging, or more so, than what is said. Don’t pretend, deny, or avoid the issue — that won’t help at all. Don’t “walk on eggshells.” Do address your observations and concerns to your loved one in a direct manner with kindness and respect.

3.) Ask your loved one for specifics about what they would like you to do and say and what not to do or say to best support their recovery from an eating disorder.

4.) Ask questions about “the person” rather than questions about their “eating disorder”. Have a relationship with them — not their eating disorder. Even if they act as if 90% of their life is their eating disorder, treat them as a person — not a behavior or an illness.

5.) Provide hope. Discouragement, fear and at times feelings of hopelessness are common to those suffering from eating disorders. These feelings don’t need fuel — but correction. There is hope, there is something worth encouraging. Find it and do some coaching. After listening, acknowledging, empathizing, and validating feelings, move on to ideas, hopes, and positive possibilities.

6.) Don’t blame yourself. It’s not your fault. Whatever your mistakes or weaknesses as a parent, spouse, or loved one, you did not create this eating disorder. Take ownership for your weaknesses and frailties, take stock of your talents, gifts, and resources, and get to work providing love, support, and open invitations for them to come into a safe relationship with you as they are ready.

As you implement these and your own ideas to help your loved one, put yourself in their shoes, try to see the world from their model, listen to your heart and follow those impressions. Don’t give up. Since the fruits of your influence and efforts may not be fully recognized and seen for a while, patience and hope need to become friends of yours. Recovery can be a reality!

Written July 2008, Revised July 2014


What is ‘Better': Chocolate Milk and More

Author: Jenni Schaefer

My motto these days seems to be, “It gets better.” Even though my struggle with food and weight actually got worse before it got better, it did get better. Recovery is very difficult and oftentimes excruciatingly painful, but it does get better. I am definitely starting to sound like a broken record about this point, and people are now beginning to ask me, “What is ‘better’?”

Some of us in recovery from an eating disorder have been told that ‘better’ is the point where we will merely be able to manage the disease. In other words, we have been informed that we will never experience any real freedom from food and weight obsessions. We have been warned that while our eating disordered behaviors might not totally consume us in our normal day-to-day lives, the disease will frequently take over during stressful times. Ultimately, this form of ‘better’ does not really seem better at all.

When I say that it gets better, I mean really better. I can honestly say that I experience true freedom from my eating disorder. To explain this feeling to the fullest, I need to introduce my eating disorder appropriately. His name is ‘Ed,’ which is an acronym for ‘eating disorder.’ I was taught by psychotherapist and author Thom Rutledge to treat my eating disorder as a relationship — rather than an illness or a condition. Today Ed does not control my mind or my body like he did in the past. Years ago, if Ed said run, I ran. If Ed said eat, I ate. Whatever Ed said, I did.

My relationship with Ed is absolutely, in no uncertain terms, changed for the better. There is that word again. For most of my life, Ed was the decision maker. Today, Jenni makes the decisions. I decide when to eat and what to eat, what to say, what to do, and so on. All decisions are my responsibility. The other day I had the opportunity to eat in a school for the first time since I had actually been a student myself. It was great to walk through the noise-filled cafeteria and make food choices in the lunch line without Ed whispering in my ear. So when making my milk selection — for the first time in all my years of schooling — I was able to choose the little brown box labeled ‘chocolate’! I was so thrilled that I called a woman also in recovery to let her know how wonderful it felt to have the freedom to choose.

After reading a brochure discussing normal-eating the other day, I can honestly say that I eat like a normal person. (I am not saying that I am normal, just that I eat normally!) Normal eating, among many other things, is about trusting your body, having flexibility at mealtimes, and choosing foods that you really like to eat. I am still very grateful today when I realize that I am just eating like a normal person, including drinking chocolate milk out of a box. Because I had such a complicated, love-hate relationship with food for so long, each and every bite I put into my mouth today is done with a sense of awareness and deep gratitude for where I have been and where I am now. Surprising to even myself, I actually have moments of thankfulness for imperfections with my body. Surprising to even myself, I actually have moments of thankfulness for imperfections with my body. (That is not a typo — I wrote that sentence a second time because it felt so good the first time.) As corny as it may sound, I have experienced so much gratitude that I have actually become grateful for my gratitude. Now that is better. Better does not mean that Ed has been magically exorcised from my body. Not yet anyway. I still sometimes hear his voice creeping in to make wisecracks about my body. The good news is that his remarks get further and further apart as time goes by. While it is possible that one day I will not hear him anymore, the even better news is that does not have to happen. Thom always taught me that the goal of eating disorder recovery is not to get rid of Ed but instead to change my relationship with Ed, to not be controlled by Ed. Whether or not Ed eventually goes away does not matter. My relationship with Ed is absolutely changed today. Agreeing with Ed is not an option. Obeying Ed is not an option. Negotiating with Ed is not an option even during very stressful times. More often than not, I have actually found that I do not even think about turning to Ed during times of crisis. I am not managing my disorder. I am experiencing freedom.

Ed even provides some humor in my life today. His occasional comments can be quite funny. For instance, I laugh out loud these days when he sporadically tells me that I gained 20 pounds overnight, which is an absolutely unreasonable and irrational remark. Then I follow up these chuckles with an even louder, “Shut up, Ed!” I am not sure what my upstairs neighbors think, but I will do anything to keep myself better.

So what is ‘better’? It is deep understanding. It is drastic change. It is deep appreciation. And it is absolute freedom.

Jenni Schaefer is a singer/songwriter, speaker, and the author of Life Without Ed: How One Woman Declared Independence from Her Eating Disorder and How You Can Too (McGraw-Hill).  For more information, visit or email

Written in 2008


HOPE: Believing in Yourself and Letting Go

By: Jenni Schaefer

You gave me hope.

People like you who have confronted and overcome challenges in life gave me hope. Those who have battled addictions, triumphed over abuse, and survived broken hearts gave me hope.

My hope deepened when I met men and women who had found freedom from anorexia and bulimia. Maybe, just maybe, I could recover from my eating disorder.

True hope began when I connected with others. My friend in recovery from alcoholism found that hope only started for him when he realized he could not do it alone. I discovered this to be true in my recovery from anorexia and bulimia. When I attempted to make changes in my unhealthy behaviors alone within the walls of my silent apartment, I only grew worse. I felt hopeless.

As my passion for life faded, I became honest with myself. If there is even the slightest chance for me to change my behaviors with food, I am going to have to tell someone. I need to reach out for help.I did not recognize that I was also reaching for hope.

I filled my life with people who actually knew that the term “eating disorder” was a part of the English language and who would support me in my journey of recovery. Of course, among the bunch were my therapist, dietician, doctor, and psychiatrist. I wove into my life people who were in recovery from various types of eating disorders. I became close to women who had actually broken the chains from their eating disorders and who were pursuing their dreams. I gave my hand freely to all of these people, because I believed that they could help me. I wanted what they had out of life. As I held their hands, my hope that I could recover grew stronger. And my recovery grew stronger.

When I fell, I fell harder. In the middle of a relapse, I would often find myself deeply depressed and alone in my home ­— doors locked, curtains pulled. My former therapist, Thom Rutledge, says, “When it comes to eating disorders, isolation kills.”

I did not want to die, but I would have rather died than live the way I was living. I did not think anything could possibly change. Then the hands reached out to me. The phone rang relentlessly, emails quickly filled my inbox, and knocks sounded at the door. (I was always glad I had never given anyone a spare key.) Even when I ignored the voicemails, auto-responsed the emails, and avoided the knocks, I could not stop hope from infiltrating my home. The light of hope helped take away the darkness. I would pick myself up off the ground, stand back up again, and open my curtains to let the sunlight in. Letting light into my apartment was a symbol to me that there was always some hope — no matter what.

After kicking and screaming (and hitting my bed with a plastic baseball bat), I would let go of whatever part of my disease was holding onto me at that moment. I would eventually move on. Letting go. Everyone always talked about that concept. They said I would ultimately have to let go in order to make it to the other side of my eating disorder. I would have to let go and eat. Let go and accept my body. Let go of this and let go of that. I thought to myself that I would let go of this and this, but hold onto that. I will do it my way. They will see.

And then I realized that my way did not work very well. And I understood that they were not just talking about letting go. Most of them had already actually done this whole thing themselves. They were asking me to do something that they had already accomplished. They had let go. They were letting go. If they could do it, so could I. At least I hoped so. There’s that word again. More hope.

Today I know the true meaning of letting go. Throughout early recovery, I would let go of one thing only to find out that I was holding on really tightly to something else. So I kept opening my arms and letting go of that something else. This was excruciatingly painful and was only possible by keeping my eyes on hope and my hands in the grips of others who had gone before me. Throughout this powerful process, I found freedom from my eating disorder. I still practice letting go in my life today.

I will never let go of one thing: hope. I never know when I might need it. I never know when you might need it.

You gave me hope.

Jenni Schaefer is a singer/songwriter, speaker, and the author of Life Without Ed: How One Woman Declared Independence from Her Eating Disorder and How You Can Too (McGraw-Hill). She is a consultant and spokesperson with Center for Change in Orem, UT. For more information, visit or email


Coping With A Loved Ones’ Eating Disorder During the Holidays

Authors: Randy K. Hardman, PhD and Michael E. Berrett, PhD

For most people, the holiday season is a wonderful time of year. It is often a time of family reunion, socializing, and celebration – a time when families, friends, and coworkers come together to share good will and good food. The season is meant to be bright, happy, and full of the best of relationships. Yet, for many who suffer with eating disorders, this is often the worst time of the year. For those who are trapped in the private hell of anorexia, bulimia, or binge eating disorder, the Holidays often magnify their personal struggles, causing them great internal pain and turmoil.

At Center for Change, we have asked many patients over the years to share from their private experiences what the Holidays have been like during the years they suffered with an eating disorder. The women quoted in this article are of different ages, but all suffered with the illness for many years. As you read the following passages you will feel something of the agony of suffering with an eating disorder at this festive time of year.

Family having Christmas dinner eating turkey“Unlike any other normal teenager, I always hated it when the holiday season would roll around. It meant that I would have to face my two worst enemies – food and people, and a lot of them. I always felt completely out of place and such a wicked child in such a happy environment. I was the only person who didn’t love food, people, and celebrations. Rather, holidays for me were a celebration of fear and isolation. I would lock myself in my room. Maybe no one else gained weight over the holidays, but just the smell of food added weight to my body. My anorexia destroyed any happiness or relationships I could possibly have had.”  -Nineteen-year-old woman

“The holiday season is always the most difficult time of year in dealing with my eating disorder. Holidays, in my family, tend to center around food. The combination of dealing with the anxiety of being around family and the focus on food tends to be a huge trigger for me to easily fall into my eating disorder behaviors. I need to rely on outside support to best cope with the stresses of the holidays.”  -Twenty-one-year-old woman

“Over the past few years, during the Thanksgiving and Christmas holiday season I have felt horrible. I felt trapped and like the food was out to get me. I lied on endless occasions to avoid all of the parties and big dinners that go along with the holidays. I felt horrible about my body and did not want anyone to see me eat for fear they would make judgments about me.”  -Eighteen-year-old woman

These quotes from those suffering from anorexia, bulimia, and binge eating reveal the emotional intensity they feel during the holiday season. Their fear of gaining weight and becoming, in their minds, fat, gross, and disgusting, is the monster they deal with every time they partake of any of the foods that are so wonderful and common to the holidays.

Starving for the Holidays – A Tale of Anorexia

Those struggling with anorexia are terrified of the holidays because they have no idea what a normal amount of food is for themselves. Most of them feel that anything they eat will mean instantaneous weight gain. In fact, some of them have said that just the sight or smell of food is terrifying to them because their fear of being fat or becoming fat is so ever-present in their minds. For some, just thinking about food is enough to create intense turmoil, pain, and guilt. Anorexia creates tremendous guilt about any kind of indulgence involving food. The eating of food becomes evidence, in their mind, that they are weak, out of control, and undisciplined. Anorexic men and women are often terrified of being seen eating food or of having people look at them while they eat. One client felt that every eye was on her at holiday gatherings. Many suffering with anorexia have shared their feelings of being immobilized by their fears about food.

“My life with an eating disorder during the holidays is a living hell – constant hiding and fear, confused about life and hating every moment being surrounded by food. There was so much pressure, so many stares and glances, and days with endless comments. My whole life was a mess. There was so much pain and guilt inside of me and I didn’t know where to turn, except to my eating disorder. I hated the pressure of eating the food, the constant worrying of offending others.”  -Twenty-two-year-old woman

“It’s hard to be around all the food and festivities. When I’m hurting inside and struggling with what “normal” food portions even are, I need the help, emotional understanding, and support of family and other people. “Handle with care, but please handle.” Accept me the way I am. Let me back in the family”  -Twenty-three-year-old woman

The importance of these quotes from clients in treatment for anorexia is found in their honest expression of the tremendous pressure and conflict they feel inside in response to the normal food and social activities of the season. Their internal suffering and pain are sometimes revealed to others around them by their continual remarks about “being fat,” or their suffering may be hidden in their patterns of avoidance and withdrawal from social involvements.

The Hidden Beast of Holiday Feasts – Tales of Bulimia and Binge Eating

On the other end of the eating disorder spectrum, a person with severe bulimia or binge eating disorder often finds the holidays are a genuine nightmare because there is so much emphasis on food that they become preoccupied with it. Binge eating and subsequent purges become even more prevalent because many of the foods and sweets that are associated with holiday celebrations are very enticing to them. The holidays can be a time of convenient indulgence, but also a time of great shame and self-reproach because of their secret life. Some even use the binge eating and/or purging as a form of self-punishment throughout the holidays.

Those who suffer with binge eating or bulimia often live out this painful eating disorder hell in private and in secret, and often feel great self contempt. To many of their family and friends things may look positive and normal even while the sufferer feels significant despair and negativity about their loss of self-control. Those whose family members know about their eating disorder carry this awful feeling that they are the main attraction at the holiday dinner, where every trip to the food or to the bathroom is seen as a major defeat and disappointment to their family.

“Christmas is the hardest time with my bulimia. So much food, so much love, and so much joy, but I could not feel the love or joy, so I indulged in the food as a replacement. It was hard to see everyone so happy before I made the trek to the bathroom. I felt unworthy to be happy. I didn’t deserve the love and joy. I’ve discovered that if I can focus on the love and joy, everything else falls into place”  -Eighteen-year-old-woman

“The secrecy and lying make it very difficult for me during the holiday season. I have to decide whether to restrict my food or to binge and then sneak away to purge.”  -Twenty-two-year-old-woman

Some of the painful consequences of binge eating and bulimia are found in the time, planning, and dishonesty that is required to protect and cover up their eating disorder during the holidays. They often feel hatred for themselves for the ongoing deception to family and friends to excuse or explain their behaviors. In addition, they live in constant fear of being “found out” by their significant others, or in fear of continually letting others down because of their inability to stop their compulsive behaviors.

Family and Friends – Turning Potential Triggers into Gifts of Support

Holiday ideals epitomize what is good about family and other personal relationships. Activities during this time of year can involve family members and friends in intense and often emotional ways. Unfortunately, those with eating disorders can find it terrifying to be emotionally close with other people. In such situations they may feel vulnerable and unsafe, and then revert to their eating disorder to restore a sense of control and self-protection.

Some family dynamics, such as conflict, can be triggering to those with eating disorder difficulties. Struggles with perfectionism, feelings of rejection, disapproval, and fear of being controlled, are all cited frequently by women who suffer with the illness. Harboring strong feelings and beliefs that parents, family members, or friends find them unacceptable, inadequate, or disappointing is challenging for anyone, but is particularly devastating to someone with a painful eating disorder. Being immersed in a family setting during the holidays has the potential to dredge up old issues, fears, conflicts, and worries about family relationships. The resulting emotional disruption can feed the eating disorder and exacerbate the problem.

“Having an eating disorder during the holidays presents quite a contradiction in my mind. I anticipate all the food and get excited, while at the same time I dread the many family members around. I feel that the family is over to “watch”. I know that they simply want to reach out and help, but I feel that a big help would be to make a concerted effort to shift the holiday focus from the food to the underlying purpose. I wish the food could be a minor deal, just an accessory to the holiday, rather than the focus.”  -Twenty-year-old woman

“Holidays, with all the food and family commotion, are pure hell when you have an eating disorder. For me, when the focus isn’t on food and is on the real reason for the holiday, it’s a big help. My family helped me out with this one, but I had to do most of it internally. Remember, it’s just food, and we have more power than food.”  -Thirty-nine-year-old woman

The following suggestions resulted from a survey question we asked patients in treatment: “What three suggestions do you have for family and friends who want to help the holiday season go a little better for a loved one suffering with an eating disorder?” The women offering these suggestions ranged in age from fourteen to forty-four, and their suggestions offer some valuable insight and understanding that could be helpful to you as a friend or a family member. Being compassionate about the struggles in the eating disorder illness can help make the Holidays less of a battle for those you love. The suggestions are:

  • Do not make a big issue about what your loved one is eating. A little bit of encouragement is okay.
  • Do not focus too much on food, it may only fuel the eating disorder.
  • Ask her how she is doing and see if she needs any help.
  • Do not become angry about how the she feels, just do your best to support her.
  • Offer a lot of support and be aware of what may be creating anxiety and try and understand what she feels. Be understanding, kind, and supportive.
  • Spend quality time with your loved one.
  • Make sure that the primary focus of the holiday is not on the food but rather on the family and the valued time you will share together.
  • Allow for other activities that do not involve food, such as games, singing carols together, opening gifts, decorating, and spending time just talking together.
  • Allow her to make a dish that she would feel comfortable eating.
  • Before the Holiday itself, and before family gatherings, make agreements about how you can best help your loved one with food. Honor the agreements you make.
  • Do not give her loud and attention drawing praise when she does eat.
  • Do not talk about diets, weight loss, or weight gain. It causes great anxiety and may increase a felt need to engage in eating disorder behavior.
  • Do not stare.
  • Learn enough about the illness and the triggers to help your loved one develop skills as well as strategies to defy eating disorder thoughts and urges.
  • Know something about her struggles, triggers, and behaviors. Then, if you see those, you can approach her in private after a meal and suggest ways she might be helped in some of those behaviors and learn ways you can be helpful and supportive.
  • If you see her struggling, ask if she wants to talk, but ask this in private.
  • Focus on how she is feeling inside, what issues she is worrying about, what her fears are, what she needs, rather than just how much she is eating or not eating.
  • Try not to focus too much attention on the eating disordered behaviors.
  • Be patient and nurturing.
  • Treat her with love and respect no matter what is going on.
  • Let her know that she is loved.
  • Help her take her mind off of food by generating a conversation with her about general or important topics.
  • Don’t allow her to excessively isolate.
  • Be there for her emotionally with messages of love.

There are several themes that are evident in these suggestions for loved ones and friends by those suffering with eating disorders. One of the most important is to keep the primary focus and interest on the family member or friend – the individual beyond her eating behaviors or eating disorder. Consider well these suggestions, they are actually heartfelt requests.

How Family and Friends Can Help During the Holidays

Family members and friends need to know ways to help a loved one suffering from an eating disorder during the holidays. In addition to those suggestions offered above, the following suggestions from clinical professionals may also be helpful:

  1. If your loved one is a child or adolescent in treatment, and/or if you are involved in Maudsley/Family Based Treatment, then continue with your regular outlined treatment plan through the Holidays.
  2. If your loved ones is a child or adolescent with anorexia, then learn about the Maudsley/ Family Based Treatment approach. It is important to give this approach consideration.
  3. If your loved one is in acute medical or self harm risk then arrange for intensive medical/psychiatric care immediately.
  4. Get professional help for your loved one with those who have experience and expertise with eating disorder treatment.
  5. It is important for everyone to be honest and direct with each other. When going into a family or social event, especially if people are aware of the eating disorder problem, it is helpful that everyone talks honestly about what will help and what will not help during the event. Armed with this knowledge, family and friends can set up some structure around holiday activities that is agreeable to all parties involved. Give reassurance about your desire to “be supportive” of them without trying to control every problem. You can respond to their feedback about what may be helpful to them by making positive adjustments. It helps to express love, gratitude, respect, and acceptance for your loved one.
  6. It is important to emphasize the purpose for the celebration of the holiday and focus less on food or meals.If the focus is on the holiday itself and its true meaning and purpose rather than on the food or eating disorder, it will be easier for your loved one to focus less on it herself. Emphasize time together, activities, and traditions that transcend meals and eating. Let food become a support to the holiday rather than its central focus.
  7. It is important for family and friends not to feel responsible and guilty for the eating disorder.There is no need and there is no good time to feel guilty or at fault for your loved one’s eating disorder. The Holidays are especially not the time. Eating disorders are complex illnesses that are not caused by a person or a relationship. It is also important for the eating disordered person not to feel responsible for their family and friend’s emotional response to the eating disorder. One helpful agreement around the holiday season is, “We will spend time focusing on the need for nourishment as previously agreed upon, and primarily, we will spend time focusing on each other and the things that are available and that are meaningful in our family or social setting.” Let them know that you can look beyond the outward manifestations of the eating disorder because you are also concerned about the hurt, pain, fear, and guilt they are feeling inside. In acknowledging the pain inside, no one has to be at fault or to blame for the eating disorder, allowing positive family associations and caring to become the emphasis. There is no need to “walk on egg shells”, especially when everyone understands and acknowledges the underlying needs associated with the eating disorder. Compassion is a wonderful holiday gift for someone with an eating disorder.
  8. It can be helpful during the holiday season to break activities into smaller numbers of people, when possible.It is easier and less overwhelming to deal with five people than fifty people. Invite your friends or family members to participate in smaller, quieter, and less chaotic social activities and events. Simple talking and sharing as a small circle of family members or friends can do much to increase the sense of belonging and safety for someone with an eating disorder.
  9. Encourage your family member or friend to gather extra support around themselves during the holidays.Additional support can come from extended family, other friends, community, and even treatment team members. If you recognize the benefit of these additional support people during the holidays, you can encourage this extra involvement rather than be hurt and offended by it. Sometimes, a person with an eating disorder might not be ready yet to receive the full love and support family and friends offer, but support and love them anyway! You can send the message, “We’re here to support you and it’s okay if others support you as well. We want you to have all the help you need during this time.”
  10. It is important for family and friends to remove any unreasonable behavior expectations or pressures of performance.Sometimes you want so much for things to be better that you do not realize how your disappointed hopes and expectations actually play out as triggers for the eating disorder. Letting go of these specific expectations in your own mind frees you up to respond to and enjoy whatever your loved one is capable of during the holidays. It would be more helpful to express a lot of warmth, love, kindness, and acceptance toward the person – “There is no pressure to prove anything to us during the holidays. We just want to focus on being together the best we can.” Eliminating specific, overt, or implicit expectations will be more beneficial than almost anything else you can do.
  11. It is important to offer care “giving” and not care “taking.” Being a self declared nurse, dietitian, therapist, or detective takes you out of your most important role – “loved one”.  It is not your job to fix or solve the eating disorder. It is your job to assure nourishment of the body in young family members and encourage nourishment of the body in adult family members and provide nourishment to the soul. Working too hard to stop the eating disorder behaviors during the holidays can fuel dishonesty and defensiveness which actually feeds the problem. You are not responsible to say or do everything right. Nothing you do or not do will take away your friend or family member’s own responsibility to overcome and recover from their eating disorder. She/he is the only one who can do that job, but you can care, empathize, encourage, and share the process with them. The good intent you express is often more helpful than what is actually said or done. If your friend or family member knows that your heart is on their side, then you become a source of comfort, support, and safety to them.


These general holiday suggestions by patients and professionals are not a complete list, but they do emphasize some positive approaches to help and support someone suffering with an eating disorder. The specific ideas, strategies, and agreements that can come out of your interactions with your loved one before and during the holidays will allow these ideas to be personalized and unique for each situation. Remember also, that the person struggling with the eating disorder has her own list of positive things that she can do to help her through the holiday season as well. We hope this article is helpful in better understanding the significant and difficult ordeal those who suffer from eating disorders will face at this season of the year. We hope this awareness and understanding will help us identify the best gifts of the holidays for those we love and care so much about at this time of year.

Written October 2006, Revised and Re-edited July 2014


Dieting is Out; Listening to Our Bodies is In

Author:  Alice Covey, RD, CD and Kim Passmore, RD, CD

While dieting may not cause eating disorders, it is often a precursor. The National Eating Disorders Association reports that 35% of “normal dieters” progress to pathological dieting and that 20-25% of those individuals develop eating disorders. It is far too common that eating disorders start off as dieting. Dieting can be a way for individuals to exercise control – counting calories and fat grams, limiting types and amounts of food, and watching the numbers drop on the scale. Focusing on dieting and weight loss can become an escape from life stressors and difficult emotions.

Dieting as a Cultural Norm

Dieting has become common and normalized in our society. This is evident since children ages nine to eleven are dieting at alarming rates. A study published in the Journal of American Dietetic Association in 1992 found that 46% of nine to eleven year olds are “sometimes” or “very often” on diets and that 82% of their families are “sometimes” or “very often” on diets. It is not surprising that the rates have increased over the years, especially since that has been the trend of the dieting industry. In 1980 the dieting industry was a $10 billion dollar industry. In 2013 it was reported to be a $61 billion dollar industry in the US, and it just keeps growing. Sixty billion dollars is more than the Gross National Product (GNP) of over half of all the nations in the world.

This trend for dieting and the pursuit of thinness is a relatively new phenomenon in the course of history. Less than one hundred years ago Americans strived for “excess” body fat. They viewed fatness as a sign of success, health, and beauty. There were even articles in magazines like Harper’s Bazaar with advice on how to put on extra pounds. At this time physicians were even encouraging Americans to gain weight, and they believed that a “balanced personality” was obtained by having a large number of fat cells.

Diet Failure

Our culture has blatantly sold the false idea that being ultra-thin is equated with beauty. To obtain this image, Americans place an alarming amount of time, energy, and money into diets, and in the end the diets rarely work. The dieting failure rate helps to explain the industry’s rapid growth. When a diet fails, the search is on for a new one that “really works.” Ninety-five percent of dieters regain their lost weight. Plus, many of those who have “failed” put on additional weight within one to five years. The 5% of “successful dieters” are usually successful because they have actually adopted a new lifestyle, not because they have stuck to their rigid new way of eating.

Most people blame themselves and their “lack of willpower” for their diet failures. In reality, diet failure can be attributed to the body responding to hunger and the body’s state of semi-starvation or starvation. The body and mind react to a diet in the same way they would to starvation. In starvation, the body’s metabolism decreases, and cravings increase. This is the set up for diet failure. Metabolism naturally slowing down during starvation is the body’s attempt to conserve energy. A decrease in metabolism means the body is burning calories at a slower rate. Also while on a diet, the mind becomes preoccupied with thoughts of food and cravings intensify, especially for foods that will provide quick energy, like sweets. Eventually, it is too difficult to fight nature. People can’t remain on diets forever and when dieters terminate their diet efforts, it is common for overeating to ensue. Overeating and even “normal eating” with a suppressed metabolism will cause the weight that was lost to come back. The failure rate of dieting (95%) is so high, not because people aren’t good enough or strong enough but because our bodies were designed to fight weight loss.

The Downside of Rigid or Tightly Counted Meal Plans to Treat Eating Disorders

Many treatment facilities and dietitians use meal plans that count calories, carbohydrates, or that utilize measuring or weighing portions as a way to treat eating disorders. This approach has some pluses, but also has disadvantages. Meal plans such as these are similar to a diet. People following meal plans are allotted a certain amount of carbohydrate, protein, and fat servings, or they are allowed to choose from pre-planned food items. Just like a diet, there are strict rules and boundaries. Some individuals with eating disorders may really need and like this structure, however, for many the new set of rules and boundaries that the meal plan provides are just replacing the old set of rules the eating disorder provided. Sometimes dietitians will even encourage their clients with eating disorders to weigh and measure their food to get the “correct” amount. The act of weighing and measuring food allows for no flexibility. And on top of that, it gives the message that food must be controlled, regulated, and monitored, which is exactly how someone with an eating disorder already feels about food. If a meal plan is not followed precisely, often strong feelings of guilt and failure emerge. Meal planning which is done in a rigid manner, may give an individual with an eating disorder the impression that they need these guidelines because they have proven themselves untrustworthy with food. They can become very dependent on this external method of controlling food intake, instead of relearning to rely on themselves for the answers.

Intuitive Eating

Intuitive eating (also known as “Mindful Eating”) teaches individuals how to rely on themselves and listen to internal cues. It also provides guidance on how to form a healthy relationship with food. It is an anti-diet approach to eating. There are no rules to break and no temptations to resist. Intuitive eating is possible for most clients once they have allowed structure to help them re-nourish their bodies.

To get back to a healthy and natural experience with food, it is important to remember that infants and toddlers innately possess this ability. Infants easily know when they are hungry and full. Doctors guide new mothers to respect their infant’s inner wisdom. It is amazing that infants intuitively know that they need more food right before a growth spurt and will naturally crave increased feedings. Toddlers are the same. A study done by Leann Birch, Ph.D., showed that children ages two to five were eating, on average, the same amount of calories daily for a week, even though the calories from their individual meals varied greatly. This study shows that toddlers don’t need to count calories to get the appropriate amount of energy; they naturally know what they need.

The ability to use these internal cues (hunger and satiety sensations and cravings) to regulate food intake is present in everyone. This is true no matter how long the individual has been ignoring them. The challenge in becoming an intuitive eater is to reconnect with the already present internal cues and to learn to ignore the external ones. After years of poor eating habits and eating disorder behaviors, it may take months for normal hunger/fullness cues to return.

Dieting is a purely external way to regulate food intake. Other things that control food intake, which are external, are:

  1. Only choosing “good” or “healthy” foods,
  2. Automatically finishing everything on the plate, and
  3. Taking the portion that is listed on the food label.

Using external factors to determine what, how much, and when to eat is a starting place, with an eventual goal of learning to honor internal cues.

In the case of patients who are suffering with severe anorexia, external control and assistance will be necessary, at least in the initial stages of treatment, because they are not yet physically or emotionally capable of eating intuitively.

Fears Regarding Listening to Our Bodies

Most people initially believe that by using internal cues to guide food amounts and food choices, they will inevitably be “unhealthy,” make the wrong choices, and eat too much. This is a sign of a lack of self-trust, which is natural when external factors have been used for so long to make these choices for us. Regaining trust is a process. It takes time and practice, but it is well worth it. By using internal cues it is possible to never diet again! Trusting internal cues can work when clients learn to listen to their internal cues rather than the negative voice of the “eating disorder” mind, or emotion driven cues to over or under eat.

When people start eliminating all the old external rules and controls, it is normal to crave foods that were once restricted. For example, when individuals go on low-carbohydrate diets, usually that is the nutrient they start to think about and crave. After stopping the diet it is quite common to “over-indulge” in foods high in carbohydrates. This is because the body is craving them so intensely. It is the same with any food. The more and longer a food is restricted, the more intense the cravings will be. This can be especially scary for individuals with eating disorders. At first, it may make them feel out of control and like they cannot be trusted with food. But eventually the extreme cravings subside and return to “normal.” It is important for them to keep this in mind as they are going through the process of becoming an intuitive eater.

Just as the body and mind intensely crave foods that have been restricted, the reverse also holds true. An example of this is going on a road trip and only having limited options of fast food available. At first it may be fun, exciting and pleasurable to eat these foods, especially if they aren’t foods normally consumed. However, after a while, fast food will get old and boring, and cravings for other foods will arise. This is because your body and mind get tired of the same thing over and over. We crave variety, as typified in the old adage “variety is the spice of life.”

Listening to the Body and Weight

By listening to hunger and fullness cues and to what the body is craving, our body will naturally find a weight where it feels comfortable. This is known as the body’s set-point weight. An easy way to understand this concept is with an analogy. A thermostat is set at 70 degrees. When the room drops below that temperature, heat will blow out of the vent and warm the room. If the temperature in the room goes above 70 degrees the air conditioner will blow cool air. Metabolism and hunger operate in a very similar way.

Hunger and fullness cues and metabolism play a role in the regulation of our body’s weight, just as the heating and cooling of the room helps control the temperature where the thermostat is set. When weight drops below our set-point, hunger will increase and metabolism will lower to conserve energy. When our weight goes above our set-point, hunger decreases and metabolism increases to burn energy more easily.

It is true that the regulatory mechanisms do work harder to keep the body from going below the set-point than above it. This is most likely due to the fact that during the majority of human history food sources have been scarce, and it has been vital for the body to preserve energy as a means of survival. However, the more we are able to tune into the regulatory mechanisms, the more likely weight will remain stable.

A study was done to exhibit the phenomenon of set-point weight. Volunteers were made to either gain or lose weight. After the artificial control was removed from the experiment, their weight automatically returned to normal. Possibly, the individuals in this experiment were able to reconnect to their bodies by listening to their hunger and fullness cues, after the artificial, external controls were removed.

Being Mindful While Eating

In order to get back in touch with hunger/satiety cues and to figure out what the body is craving, it is important to be mindful while eating. Using our senses while eating is a great way to get back in touch with our bodies. In our modern-day lives, many of us are rushing around and eating food on the run. Eating in this manner, most individuals do not pay attention to hunger and fullness cues, let alone the taste, texture, sight, and smell of their food. Staying fully aware of these aspects of food will enhance the experience of eating, and more enjoyment and satisfaction will be derived.

Checking in during various times throughout the meal can also help us to be mindful while eating. We can ask questions like:

  1. Where is my hunger/satiety level?
  2. Am I enjoying this food?
  3. What would make my eating experience more pleasurable in this moment?
  4. Would I rather be eating something else?
  5. Am I staying present while I am eating, or is my mind wandering around?
  6. What external things influenced my food choices today?
  7. How can I reconnect to the internal signals my body is giving me?

Asking questions and being curious and mindful during mealtimes will be beneficial to someone working on becoming a more intuitive eater. Awareness is such an important component of change. Without this subtle awareness we may find it impossible to become an intuitive eater and difficult to move out of the diet mentality.

A loved one with anorexia or restrictive traits will initially need structure to help them eat enough food to be re-nourished. Those who are purging or otherwise “getting rid of” ingested calories are also at high risk for malnourishment – no matter what their body weight or size might be. Re-nourishment is the most critical immediate concern for someone suffering with an eating disorder. Meal planning, mealtime structure and supervision are important especially in initial stages of recovery and if weight restoration is imperative due to compromised medical health. The structure provided by a therapist specializing in Family Based Treatment (FBT) approaches can be helpful in many circumstances, and a well trained dietitian can aid in a consulting role to parents. It is important, however, to wisely manage that structure and supervision, especially for adult clients, to best reduce the resistance many clients have when parents take on a food management role. As clients begin to progress and stabilize medically, emotionally and mentally, they can work towards intuitive eating where structure comes from the inside-out and clients are listening again to their bodies.

Tips for Families

Get rid of scales

This doesn’t mean just hide them. Actually, throw them away. To someone with an eating disorder the number on the scale can become a way to determine how much to eat or how to feel (“good” or “bad” about themselves). Weighing can become an unhealthy obsession. The number on the scale is another way for individuals with eating disorders to look outside themselves (externally) for answers. Clients can weigh-in “back to scale” with professionals who monitor their weight to assure progression is being made.

Don’t comment on appearances

This is true even if you think it’s a compliment. Something like, “you look healthy,” or even “you’re so thin,” can be twisted around and distorted in the mind of someone with an eating disorder. Try to avoid these comments. It may be more helpful in relationships to talk to loved ones about those things “internal” rather than “external” and those things of greater importance.

Keep a wide variety of foods around the house

Being an intuitive eater means figuring out what is being craved during times of hunger. The more variety that is available, the better chance the craving can be identified and satisfied. Keep various grains like breads, pastas, rice, and cereals on hand. Also, try to keep fresh and frozen fruits and vegetables in the house. Meats, like deli cuts and ground beef and other protein sources like peanut butter and cheese are important for specific cravings. Snack foods are a necessity, as well. Try to keep chips, cookies, and nuts around. These are just some suggestions. It is important to consider taste preferences and meal options while shopping at the grocery store.

Don’t buy “diet foods”

These are very triggering and tempting to individuals with eating disorders. They feed into eating disorder thoughts and behaviors. Plus, they are generally unsatisfying.

Challenge traditional beliefs about food

Avoid labeling foods as “good” or “bad.” Food is food. It has no moral value. All foods have nutritional value because every food is made up of carbohydrates, protein, and/or fat. These are the main nutrients needed for bodies to function properly, a.k.a. macronutrients. By listening to and tuning into the body’s needs, these macronutrients will be consumed in an appropriate way.


Thank you to Alice Covey, RD, CD, Kim Passmore, RD, CD, and Michael E. Berrett, PhD who contributed to the writing of this article.


Facts and Figures on Body Image and Eating Disorders. Available at: Accessed October 10, 2005.

Know Dieting: Risks and Reasons to Stop. Available at: www. Accessed October 10, 2005.

Reiff DW, Reiff KKL. Eating Disorders: Nutrition therapy in the recovery process. Set-Point. 1998.

Robison, JI. Weight, Health, and Culture: Shifting the paradigm for alternative health care. Alternative Health Practitioner. Spring 1999; v 5; n 1.

Taylor, Mary. Tasting Mindfulness. Yoga Journal. Available at: Accessed August 10, 2005.

Tribole E, Resch E. Intuitive Eating: A Revolutionary Program That Works. 2nd ed. New York, NY: St. Martin’s Griffin; 2003.

© Copyright Center for Change, October 2006, November 2009 Revised: September 2014


The Importance Of Outpatient Follow-Up With A Registered Dietitian

By: Rachel Scott, RD, CD, CNSD

Inpatient treatment for individuals with eating disorders is an important time for receiving adequate therapy, working on underlying issues, changing relationships with food, and establishing healthy eating behaviors. It can be more cost-effective than intensive outpatient treatment alone1. However, 80% of women who receive treatment for their eating disorder do not get the intensity of treatment they need to sustain recovery2. Many patients leave inpatient treatment prematurely for financial or personal reasons. With this in mind, it is shocking to see that one study shows individuals with eating disorders average 79 months to achieve full recovery3. Outpatient follow-up after inpatient care is imperative for full recovery. A key to success of outpatient care is continuing to see a registered dietitian in order to help support the new eating behaviors in a less structured environment.

The transition from inpatient residential treatment to a home environment can be harder than most people expect it to be. Some eating disorder behaviors resurface with less structure. Many individuals are triggered by returning to the environment they were in before inpatient treatment. A dietitian can help the patient remember the changes the patient has made and what the patient is capable of accomplishing. A dietitian can also help the patient to see how to apply what they learned, as an inpatient, to their new home setting.

Individuals receiving follow-up care after inpatient treatment need continued nutrition education. While much education is provided in an inpatient setting, there is still more for the patient to learn. Also, the material taught in the inpatient setting needs to be consistently presented to the patient as repetition is key to replacing old eating disorder beliefs about food. These individuals may not have been as ready to receive accurate nutrition knowledge when it was presented in an inpatient setting but may be more willing to accept it as an outpatient when they are further along in their recovery.

Meeting with a dietitian can be an opportunity for continued improvement and support. Individuals leaving an inpatient setting still have some eating disorder behaviors and food beliefs that they need to continue to work on. Regular nutrition counseling sessions can offer the individual a chance to voice concerns about what they’re seeing in their eating behaviors and have an opportunity for objective feedback. In a world of misconceptions about food and body image, these individuals need to hear and be reminded of how to maintain a healthy relationship with food. A dietitian can be a voice of support and encouragement needed for the recovering individual to continue her newly established eating behaviors.

It is important for the registered dietitian to have a background working with eating disorder patients. Dietitians who are not experienced with eating disorders can unintentionally say things that trigger the negative mind and exacerbate harmful eating behaviors. Communication between the inpatient and outpatient dietitian is important for continuity of care for the patient. Some items to discuss include: eating disorder behaviors at the beginning and end of treatment, anthropometrical data, and current goals for the patient.

Continuing to visit with an outpatient dietitian can be beneficial in sustaining recovery. It can help to solidify behaviors that were learned in an inpatient setting as well as serve as a support in a less structured environment. Follow-up sessions with a dietitian can offer continued nutrition education and advice in changing eating-disordered behaviors. In general, the registered dietitian plays a key role in, but is only part of, the outpatient treatment team.


Deep-Soboslay A, Sebastiani LM, Kaye WH. Weight gain with Anorexia Nervosa. Am J Psychiatry 157:1526. accessed April 11, 2005

Strober M. Long-term outcome in Anorexia Nervosa: survival analysis of recovery, relapse, and outcome predictors in a 10-15 year prospective. Neuropsychiatric & Hospital, UCLA School of Medicine.



It Gets Better: Not Just For Everyone Else

By: Jenni Schaefer

Hello. I would like to introduce myself. I am the only person in the world who cannot recover from an eating disorder. No matter how hard I try or how desperately I want to let go of my eating disorder, I am doomed to failure. It will never get better.

That was years ago. It turns out that I was not so special after all, not the worst case scenario, and not the hopeless one. I am thrilled to say that I was not the lone ranger and that it did get better, in fact, much better. Many of us battling the illness believe that we are the sickest and that we will never recover. I am walking proof that recovery is possible. Countless others – who were also the sickest of the sick – have arrived at this point of amazing freedom as well.

These are people with all types of eating disorders, including anorexia, bulimia, and the most absentmindedly named category of all, eating disorder not otherwise specified (EDNOS). These are the people with subclinical eating disorders and all of those who think the aforementioned categories do not describe them appropriately. The people who have broken the bonds with food and weight are ones who developed eating disorders as teenagers, at younger ages, or much later in life. Some individuals struggled for a few years and others for over twenty. Those who battled for more years often heard from the experts that a successful recovery was less likely, because the disease was not ‘caught’ early. I heard this comment, too. I had strong tendencies toward eating disordered behaviors beginning at the young age of four but failed to reach out for help until almost twenty years later. Needless to say I caught nothing early except my unhealthy attitudes toward food and weight, but it got better. It got better through hard work, patience, and lots of pain.

Unfortunately, things actually get worse before getting better. In order to begin making true progress in my recovery from anorexia and bulimia, I had to begin tackling the difficult, gut wrenching parts of the process. For those of us in recovery from an eating disorder, we know that means finally letting go and taking on the food. Yes, we have to start following the food plan. If that means writing down what we eat on a little form to turn into our dietician like a homework assignment, we do it. Unlike our attempts in the past, now we actually write down the food legibly and accurately in the little blocks marked, ‘lunch’, ‘dinner’, ‘breakfast,’ and ‘snacks.’ We do our best to stop bingeing and purging. If we have lapses in old behaviors, we are honest. Rigorous honesty is a part of getting better.

Another part of getting better means we have to be willing to look our worst nightmare in the face. Even though we might not like what we ‘think’ we see in the mirror, we have to be willing to maintain a healthy weight. In the beginning, there is nothing fun or exciting about this concept. Challenging our negative body image is excruciatingly painful. We must be willing to do whatever it takes to recover, because we know that half measures have not been working. Our therapists, dieticians, and doctors will all pat us on the back and tell us that we are doing great. Despite the fact that we are doing well, we arefeeling bad. This is progress, and it means things are actually getting better. Slowly the horrible feeling begins to actually feel good. Eating feels good. Eating becomes natural and enjoyable. Even accepting our body’s natural size and shape feels powerful and strong. Moments not consumed by food and weight string into hours and days. This means we do not have to enter a panic about whether or not we are accidentally served a regular soda instead of diet at a restaurant. It means a day occurring over ten years after our high school graduation is not deemed as good or bad by whether or not we can still fit into our prom dress. But it means much, much more.

Eating disorders are not truly about the food and weight. Today I am able to engage in conversations with friends and become involved in relationships. I can pursue lifelong dreams and passions. Life exists in a full range of colors now, not just black and white. I am happy to be alive and am not just surviving day by day. Let me introduce myself again. I am just like anyone else out there in recovery from an eating disorder. I am no different. And I got better.


Tamagotchi and Eating Disorder Treatment

Author:  Elayne McArthur

Did you know that by playing an electronic game you could learn about life? One of the hottest holiday items this year is the Tamagotchi electronic pet. If you haven’t heard of a Tamagotchi, it is simply a hand held, LCD screen with attitude. It has real life demands such as needing to be fed, cleaned up after, played with, rested and to be socially connected to other Tamagotchi pets. In essence it is a pet without fur and requires batteries (not included). Why are these toys in such high demand? The answer is simple; in our high tech busy world we often need to feel valued and connected to something. We love our pets because they provide us with companionship and something to care about. The owners of Tamagotchi are responsible to provide all essential needs to sustain life. If their pet does not get fed, played with or properly rested, it will shut down to the dismay of the owner.

The students, who are adolescent patients at Center for Change and who are part of Cascade Mountain High School, have many resources to ensure their needs are taken care of and not forgotten. We want to make sure that all of their educational needs are fulfilled individually. Like the Tamagotchi, these girls will be able to enhance their own personal academic and social achievement by sharing with others in and out of eating disorder treatment. The electronic Tamagotchi pet needs to be played with in order to thrive. If the toy is not played with enough, it will self destruct. In our lives we need to have play and social interaction. These are key components to excelled learning and a healthy lifestyle. Just like the Tamagotchi toy needs to be played with in order to maintain a high quality of life, our students need to learn to personally express themselves appropriately to others. When the health of the Tamagotchi begins to deteriorate, the owners immediately recognize the need for play and begin interacting with their pet so it may regain its strength. Some girls with eating disorders have forgotten their unique passions in life. I have often questioned girls about their interests only to discover blank stares and “I don’t know” as their answers. It is our passions that make us who we are and give us our drive to live to the fullest. Cascade Mountain High School allows students to take a step outside of traditional studies by providing a variety of theme based activities in all areas of study, making real life connections, and allowing them to rediscover who they are as unique individuals.

Knowledge is vital to ones own progression. Without continually learning we become stagnant. The makers of Tamagotchi understood this and allow the pet owners to discover this truth by themselves because the health of the pet declines if it doesn’t learn new tricks. The faculty of Cascade Mountain High School care deeply about the academic needs of our students. CMHS provides educational experiences through an integrated curriculum. Our curriculum provides students with learning experiences that are important and applicable to student interests and lives. The curriculum is also applicable to adult patients at Center for Change. Teachers expect students to understand connections between different subjects and how they relate to the real world. In other words, students will be able to answer the age old question of “Why am I doing this?” Based upon the subjects they have studied in class, students will be able to make connections to their own lives both academically and personally.

One of Tamagotchi’s most popular features is that it can be connected to other Tamagotchis by using the Internet. This allows owners of Tamagotchi to make new friends by playing games and swapping training tools with other Tamagotchi pet owners. Even electronic pets need social experience to help them grow and develop. This social connection is often lost to girls and women with eating disorders. Many of our students are focused on only getting good grades at all costs. They lose the ability to make connections with other people and isolate themselves from the world. Unfortunately, their only “real” friends are their eating disorders. One of our goals at Cascade Mountain High School is to provide adolescent patients with a nurturing and safe social environment that allows them to reconnect to others. Our integrated curriculum includes many group projects that incorporate interactive social skills such as communication, collaboration, creativity and leadership. The benefits of working together are many. Our students learn how to give and receive productive feedback for progression. They take ownership of their learning by expressing opinions, resolving conflicts head on, and learning how to be flexible. Students will be better prepared for the transition home because they will have learned needed social skills to prevent themselves from slipping back into isolated situations and feeling unwanted. This term we have been learning about different patterns that exist both in each subject area while at the same time making connections with their own lives. Making a quilt required their own creativity while depicting a scene or picture demonstrating patterns in all the core subjects. While making a quilt they had to face their fear of failure, perfectionism, negative thoughts, and needed to learn patience and most importantly they learned how to share and express their ideas with others while turning their academic learning into real life situations.

Although there are many similarities between the Tamagotchi toy and Cascade Mountain High School there is one significant difference. The Tamagotchi is a toy and can easily be recharged with new batteries if one of the key pieces to sustaining life is missing. If our students are not taught to value each unique life sustaining factor their batteries will become weak and their quality of life will diminish. Cascade Mountain High School recognizes the importance of maintaining a balance between all the essential elements of life such as socialization, education, play, life skills, therapy and nutrition to make sure that our students stay connected and can stand on their own. If our students learn to balance these key principles they will be able to embark on creating their own life experiences and live their own dreams. They will no longer be like the Tamagotchi dependent upon someone to charge their batteries. Instead they will begin charging their own batteries, making them able to sustain themselves by recognizing their own unique needs and abilities.


Eating Disorder Treatment Questions and Answers With Several Center for Change Staff

The following three questions were asked of several professionals who were presenting at a recent Center for Change Training Conference on Eating Disorders. These presenters had no prior knowledge of these questions and each of them, at the time of their presentation, were asked to respond to these questions with whatever first came to their mind. We would like to share these valuable “on-the-spot” insights with you in this section.

Question no. 1: From your experience, what are three important things you tend to emphasize in your work with and treatment of eating disorders?

  1. We need first to re-nourish the brain with proper nutrition.
  2. The relationship with the client. It is the relationship with the client that creates healing. That relationship needs to be a welcoming environment.
  3. Help patients find better choices. Help them conceptualize the eating disorder from a variety of different perspectives.
  4. Develop a better relationship with food and accept that there are no bad or good foods.  Help them understand and resolve their body image concerns. Help them discern hunger and fullness. Develop more awareness of internal cues verses external cues of fullness.
  5. Monitor health and in particular cardiac health during their recovery. Be a part of the treatment team and work on medical needs.
  6. Be a cheerleader for the patients and supportive of the staff.
  7. Help them become better in touch with themselves. Restructure their thinking and beliefs. Develop long-term goals of real value in and outside of themselves.
  8. Help them come to know that an eating disorder is not about food, though they need to eat healthily.
  9. Spirituality, honesty, avoiding avoidance, and developing self-trust through self-correction rather than self-abandonment is important.

Question no. 2: From your experience, what are three of the toughest issues that women with eating disorders need to face and resolve in order to recover from their eating disorder?

  1. To understand that the eating disorder is not about food, fat, or bodies.
  2. To have understanding for the fact that their eating disorder is an illness and can become a coping mechanism to deal with pain and that it is not who they are.
  3. They need to heal from trauma, abuse, painful experiences of their life, self doubt, and self contempt in their life.
  4. To face the fears about being unacceptable and unloved and find other ways beyond perfectionism to deal with those fears.
  5. The development of self-love, self-kindness, and self-compassion.
  6. The need to resolve their issues with food, health, and nutrition so that they can live their lives.
  7. The need to resolve body image distortions and concerns.
  8. Giving themselves permission to feel and to eat.
  9. Establishing assertiveness and boundary setting in relationships.
  10. To stop using size and shape to determine their self-worth.
  11. To learn to trust themselves again.
  12. Learn to ask for help.

Question no. 3: What have you learned about the strengths and positive qualities of the women with whom you work?

  1. They are some of the brightest, most articulate, spiritual, and beautiful women I have ever met.
  2. They are really talented; the most beautiful women inside and out.
  3. They are delightful, decent, and good.
  4. They are loving, kind-hearted, and sensitive.
  5. Most are very determined and very brave. They fight an uphill battle.
  6. They are very strong women, smart, and capable.
  7. They have an incredible capacity for empathy for others.
  8. They are brilliant, talented, honest, loving, caring, tenderhearted, compassionate, spiritual, intelligent, honest, loving, and generous when they are not in the fears of their eating disorder.


Date Written:  Unknown

Reviewed & Edited: November 2014


Social Support: The Cradle for Growth and Recovery with Eating Disorders

Author:  Michael E. Berrett, PhD

It was 1970. I learned at a young adolescent age to appreciate the value of support. I remember well my teacher, Mr. Monson, and his tall lanky frame, his worn black flood pants, his shortsleeved white shirt and black tie. I remember most his gentle kindness to a longhaired, tuned-out, and lost soul – an unlikely recipient. He said clearly, “I’ll be waiting for you after school to help you with your math.” I learned more than basic arithmetic. I learned that there are those who really care. Somehow, I wanted to be like him.


Social support is the support we receive from those around us which uplifts, assists, and gives a sense of connection and belonging. Social support involves the sharing of good times, and the giving and receiving of help through the rough times.


Glenn and Nelsen (1989) teach us that our modern cultural trends have placed monumental stress on traditional support systems. These trends include: decreasing family interaction, fewer intergenerational associations, less family work, increasing divorce rates, increasing classroom size, and the replacement of creative family fun with chronic entertainment through television and other technologies.

Despite the external forces that decrease actual and real support and the feelings of being supported, most of us do too little to offset these trends. It will take active building and careful maintaining if we are to have support around ourselves and our loved ones.

The fast pace of our western society and the stressors of an everchanging world of technology, the economy, and the family brings with it stress and a host of stress-related problems. Basic to the ills and problems we face is the waning of family, neighborhood, community, and organizational ties and relationships. Ouchi and Jaeger (1978) refer to an increasing number of behavioral scientists who point to a “weakening of associational ties” as the basis for many of the social ills – mental illness, alcoholism, divorce, and crime. George Homans (1950) argues that without those relationships, people begin to have a variety of problems. He states:

“Now all the evidence of psychiatry . . . shows that membership in a group sustains a man, enables him to maintain his equilibrium under the ordinary shocks of life, and helps him bring up children who will in turn, be happy and resilient. If his group is shattered around him, if he leaves a group in which he was a valued member, and if, above all, he finds no new group to which he can relate himself, he will, under stress, develop disorders of thought, feelings, and behavior. . . The cycle is vicious; loss of group membership in one generation may make men less capable of group membership in the next. The civilization that, by its very process of growth, shatters small group life will leave men and women lonely and unhappy.” (pg. 457)

Social Support helps each of us to fulfill basic and critical needs. Everyone has a need to “feel a part of and to belong.” Each one of us has a basic need to feel important, wanted, needed and loved. Each of us needs the affiliation which comes from feelings of being valued and of being accepted.


Social support is important in our lives because it lessens the consequences of physical and psychological stress. Research studies give the following examples:

  • Heart attack victims who go home to even a pet are less likely to have another heart attack than those who go home to an empty house.
  • Pregnant women with high stress and high support experienced complications in 37 percent of their births, while women with high stress and low support experienced complications 91 percent of the time.
  • Men or women who are widowed, but have at least one confidant, are significantly less likely to die during the 24 months after the death of their spouse than those who lack such a confidant.

In the process of recovery from physical or emotional illness, addiction, and specifically eating disorders, social support is the very “cradle” in which recovery takes place. Support is equally necessary to ward against relapse, and it brings recovery into a shared experience in which love is exchanged and progress celebrated. Whatever the source – God, loved ones, friends, or self – support is a healing experience.


In a model of social support proposed by Berrett and Cox (1983), the following main kinds of support are delineated:

  1. Assistance – giving or receiving aid or material goods
  2. Belonging – feeling that one is “a part of,” and an important member of a common cause
  3. Emotional – encouragement, understanding, personal warmth, empathy, unconditional love
  4. Feedback – giving information of appraisal, comparison, validation, or constructive criticism
  5. Information – imparting specific knowledge, the gift of advice, suggestion, or direction
  6. Relief – providing fun, pleasure, distraction from the tasks of life, a “get away”


There are three primary dimensions of support. Each one is important in the process of recovery from eating disorders and related addictive or emotional illnesses. They are as follows:

  1. The support we receive from others
  2. The support we give to others
  3. The support we give to ourselves

While support has three dimensions, it can also be viewed as having “two sides.” It is a process of reciprocity. Billy Graham (1993) said, “God has given us two hands – one to receive with and the other to give with.”

It is important that we all learn to ask for, and receive, help from others. It has been said that there are no people without problems, while there are both healthy and unhealthy people. Healthy people are those who admit their problems, work hard to overcome them, and have learned to ask directly for and accept help in overcoming their weaknesses. Asking for help requires humility and a willingness to learn from others. To receive support and learn requires a decrease in pride, and an increase in facing fear. Eric Hoffer (1963) described well the consequence of an unwillingness to be a true learner: “In times of change learners inherit the earth while the learned find themselves beautifully equipped to deal with a world that no longer exists.” Learn to seek support, and to learn at the feet of another.

It is important that we all learn to give support to others, that is, to extend ourselves in the benefit and positive growth of another. It is important for each of us to recognize that we have talents to offer others, and that others count on us, want to be with us, and appreciate the presence that we are in their lives. Finally, it is important that we recognize that we can and do give support. Recognize that you have something great to give – and then give it! Giving support helps the giver as much as it helps those who receive. In a study by Berrett (1987), it was found that adolescents not only have a significant need to feel supported, but that they had an equally important need to know that they were indeed supportive to others, and that they thereby “make a difference” in the life of another. in the following story: Feinberg (2003) reminds us of the unknown yet significant impact of giving of oneself.

“In a suburb of Dallas known as Richardson, a small bright-eyed gentleman named Jim Hoyt manages his own bike store. The mom and pop shop, Richardson Bike Mart, is known throughout the community as a strong sponsor of bike racers, and Hoyt maintains a personal passion to help kids get started in the sport. Keeping an eye on the street front, Jim noticed a young woman who faithfully took her son to a nearby shop for fresh donuts each week. He began talking to the woman, discovered she was a single mom, and instinctively knew she was struggling to get by. Jim took an interest in the small family and decided to give the woman a discount on a bicycle: a Schwinn Mag Scrambler. The mom accepted the offer, and through the act of a stranger, seven-year-old Lance Armstrong was introduced to the world of biking. Describing the bike, Armstrong writes, ‘It was an ugly brown with yellow wheels, but I loved it. Why does any kid love a bike? It’s liberation and independence, your first set of wheels.’”

Armstrong would go on to set an unprecedented record of winning the gruesome Tour de France multiple times, and in 1996 he established the Lance Armstrong Foundation, a charity to aid the fight against cancer.

It’s important to give support to ourselves. What if we receive support from others, yet refuse to give support to ourselves? The support we receive from others has much less chance of making a difference in our lives unless we also learn the art of “self-support.” After all is said and done, it is ourselves on whom we must depend to be a generous gatekeeper, opening wide the door to both giving and receiving. If we ultimately do not learn to support and take care of ourselves, support from others may sadly become of little consequence.

In clinical practice, we are the lucky beneficiaries of seeing support in action on a regular basis. We have seen the best and the worst in the world of support. We hope the best for those we help, as typified in the words of Sheldon B. Kopp (1972):

“One pilgrim may help another as when a blind man carries one who is lame upon his back, so that together they may make a pilgrimage that neither could make alone.”

Preparing to be released from inpatient treatment at Center for Change, a young woman shared these thoughts and feelings with a group of women – her colleagues and companions in treatment. They were fellow pilgrims. She said:

“Each of you have touched me in such a way that cannot be expressed with words. For the first time in my life, I have experienced genuine love and compassion in true friendships. I did not think it was possible for me to be loved outside of the protection, even blinding shield of my family, but each of you have filled my soul with warmth. Every hug, every smile, and even every tear have allowed me to feel your love and the connection we have with each other. I thank you from the bottom of my heart for your acceptance and genuine friendship. . . . Your support, compassion, and inspiration have changed my life, and your willingness to let me in, to be a part of your lives, and support you along your journey have filled a deep hole within my heart that once left me in emptiness. The love and genuine inspiration from all of you will always remain within my heart even as we go our separate ways.” — Past client, 2003


Receiving support best involves self-assessment or appraisal of how one is doing in receiving support, building and nurturing a support system, and accepting and “letting it in.” I offer a few guidelines:

Assess your support system by drawing it on a piece of paper. Draw yourself in the middle of the page, and draw symbols or put the initials of those in your support system in placement on the paper which best represents their closeness, and/or relationship with you. (Keele and Hammond, 1988)

Carefully look at the drawing of your support system and then ask questions like: Is my support adequate? What is missing? Whom could I ask help from right now? With whom would I like to create a better and closer relationship?

  1. Decide what you need to do to encircle yourself with more support.
  2. Take one small step towards creating that support today
  3. Make sure you take successive steps every day.
  4. Find opportunities to ask for help, and then ask often.
  5. Avoid the seemingly safe, subtle, and ineffective indirect requests for help (such as hoping someone will notice your needs).
  6. Take a risk to ask others explicitly and directly for what you need.
  7. Remember, when you ask and allow others to help you, you give them the gift of knowing that what they have to offer is important, valued, and appreciated.
  8. Train and teach your loved ones on the specifics of the kind of support you need.
  9. Reach out and be a friend. That will bring friends into your life.
  10. Keep at it, and be patient, since it takes time and effort to nurture and develop good relationships.


Giving support and being a good support to others also requires self-appraisal, taking the risk of involvement and loving others, and developing a lifestyle of sharing and helping others along the path of life. I suggest a few ideas:

  1. Write down ten people who are most positively impacted by your support, friendship, helping hand, or love.
  2. Write down some of the talents, gifts, emotional support, and information which you share with others.
  3. Write down the names of three people you would like to give help or support to now or in the near future.
  4. Choose one person and take a supportive step today – a phone call, a letter sent, a kind act, a smile, an expression of gratitude or encouragement.
  5. Choose to take similar steps everyday.
  6. Choose someone with whom you would like to become closer or more emotionally intimate. Let them know of your hopes in that relationship, and begin to share with them and serve them.
  7. Remember, good friends accept you as you are, and great friends accept you as you are and then push you to become better. Have the courage to be a great friend.
  8. Spend your time giving love rather than trying to get it. As David Wilcox (1999) wrote, “The only love that lasts a lifetime is the love you give away.”


Finally, what about being one’s own best support? What would that look like? What would our lives be like if we truly became our own best friend, teacher, coach, mom and dad, and our own best advocate? Confidence and peace can replace that gnawing feeling of emptiness. I offer a few suggestions:

  1. Take responsibility for your own recovery. There are no magic wands. You must do the work.
  2. Quit worrying so much about who you can trust, and worry more about whether you can trust yourself to take good care of you. Then earn your own trust the hard way, by making and keeping promises to yourself.
  3. Dare to dream again, to have hope, to tell yourself and others the truth about what you want and hope for.
  4. Work hard on the most important priorities each day so that your dreams might come true over time.
  5. Have a voice, let it be expressed and heard, and respect and keep boundaries of self- respect in relationships.
  6. After mistakes, avoid self-judgment and punishment. Simply ponder the lessons, make corrections, and move on.
  7. Learn to recognize and acknowledge your goodness, the good intentions of your heart, and your gifts and talents. If you can’t see them – look harder.
  8. Don’t travel the path alone – invite others to come along with you.
  9. Be wise enough to make your spirituality the hub of the wheel in your life. Whether you believe in God, a higher power, nature, or the striving for a refined personal character – whatever it is, kneel often at that alter of belief as opposed to self-neglect.
  10. Treat yourself as if your importance, value, and worth are grand and immeasurable. That “as if,” IS true. If you persist, the thoughts and feelings will eventually follow in a very real and genuine way.


In conclusion, someone with much wisdom pointed out: “As you open your hand in order to ‘let go’– you are in that moment open for something new.” So it is with support. It can seem scary to become vulnerable enough to receive support, and scary to give your gift, fearing it will be rejected or believing that what you have to give is not good. It takes courage to let go of the old beliefs: “I should be able to do it myself.” “Asking for help is weak.” “I don’t deserve help anyway.” Even if that “letting go” is for but a moment, it gives way to something new.

That “something new” for each of us can be a new sense of commitment to let love in, to freely give, and to advocate for oneself. That cradle of support holds us up, lifts our spirits, and provides calm during rougher times. May we, each one, have the wisdom, the courage, and the blessing to seek and share support.


Berrett, M.E., Reciprocal Social Support of Adolescents: An Assessment Model and Measure, Doctoral Dissertation, Brigham Young University, Provo, Utah, (1985)

Berrett, M.E. & Cox, V. Social Support Assessment, Unpublished Manuscript, (1983)

Cochran, Michelle, Letter of Hope, (2003)

Feinberg, M. & Rockwell, N., Simple Acts of Faith, Harvest House Publishers, Eugene, OR, (2003)

Glenn, Stephen H. and Nelsen, Jane, Raising Self Reliant Children in a Self Indulgent World, Pri ma Publishing & Communications, Rocklin, C.A., (1989)

Graham, Billy, in Simple Acts of Faith, by Margaret Feinberg and Norman Rockwell, Harvest House Publishers, Eugene. OR, (2003)

Hoffer, Eric, The True Believer, Harper & Row Publishers, New York, N.Y. (1951)

Homans, G.C. The Human Group, Harcourt, Brace, and Company, New York, (1950)

Keele, Reba L., & Hammond, S, Support Systems: To Give and Receive, BYU Today, February, (1988)

Kopp, Sheldon, If You Meet The Buddha On The Hill, Kill Him: The Pilgrimage of Psychotherapy Patients, Science and Behavior Books, Palo Alto, CA ,(1972)

Ouchi, W. G., & Jaeger, F. M., Type Z Organization: Stability in the Midst of Mobility. Academy of Management Review, 3(2), 305-314.

Wicox, David., David Wilcox Underneath, Music CD, Vangaurd Records, Santa Monica, CA, (1999)


Eating Disorder Characteristics


Physiological Characteristics and Medical ComplicationsAnorexic and Bulimic clients are at risk of serious medical consequences. Consequences range from gastrointestinal distress to death. The mortality rate for anorexia is roughly 10 percent. Although most individuals with eating disorders endeavor to present a facade of good health, the severity and variety of their physical ailments tell an alarmingly different story. Bulimic sufferers with extreme purging by laxatives or vomiting may show obvious electrolyte imbalance in lab work. Those with anorexia may yield somewhat normal blood lab values, only to later have sudden failure of the heart or another organ of the body.
Anorexia NervosaBulimia Nervosa
Body Weight85% or less of normal body weightWeight fluctuations with body weight below, at, or above normal range due to alternative bingeing and fasting
Slowed Heart RateWeakening of the heart due to malnourishmentPotential heart arrhythmia and irregularities related to electrolyte imbalance
Body Fluid RegulationDehydration, possible impaired renal functionSwollen glands, puffiness around the face, and burst blood vessels in eyes. Edema (swelling due to retention of body fluids). Possible impaired renal function.
Blood PressureLow blood pressureNormal or fluctuating blood pressure
Body TemperatureSensitive to cold Cold hands and feetNo Change
Body HairGrowth of body hair (lanugo)
Immune systemLowered resistance to infection
Movement and FunctioningDizziness and muscular weaknessChemical imbalance caused by low potassium (and sodium) which can produce dehydration, muscular fatigue, cardiac rhythm irregularities, cardiac arrest.
ImbalancesEmaciation, dehydration altered brain function and sizeFluid and electrolyte imbalance.   Edema accompanying refeeding.
Heart ProblemsSlow heart rate
Low blood pressure
Reduced body temperature
Weakness of heart muscle
Possible heart arrhythmia and irregularities.
Muscular SymptomsLoss of muscle tissueOverall muscular weakness
Gastrointestinal disordersSluggish bowel, bloatingAbdominal pain, esophageal or gastric dilation or rupture, non-responsive bowel.
Menstrual PeriodMenstrual irregularities, including amenorrhea.Menstrual irregularities possible
Nutritional ProblemsNutritional imbalance, AnemiaVitamin deficiencies
Bone and DentalOsteoporosisTooth decay and gum erosion from regurgitated stomach acids.   Enlarged salivary glands
Other SymptomsFatigue, abdominal pain and constipation (stomach distress and hiatal hernia).Headaches, fatigue, and damage to esophagus: sore throat, hoarse voice, abdominal pain and constipation (stomach distress and hiatal hernia).
Behavioral CharacteristicsAnorexic clients often see their restricted caloric intake as brave and as a high achievement. They tend to prize challenges over comfort. By contrast, bulimic clients view their behaviors as shameful and disgusting. In order to recover, clients need help learning to understand the connection between their beliefs about themselves and their eating disorder behaviors. They often view themselves with such hatred they feel deserving of the painful eating disorder behavior. They need to see that their eating disordered behavior is not an achievement, but an illness. The individual suffering from destructive eating disorder behavior must begin to challenge a negative mindset and learn to create and allow positive feelings and thoughts about themselves.
Anorexia Nervosa (common patterns)*Bulimia Nervosa (common patterns)*
Bingeing and Food ControlExcessive dieting, food control, and fasting. Collects recipes and likes to cook/bake, but sometimes refuses to eat with family. Tension at mealtimes; Fear of food, avoidance of consumption.Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances. Fear of inability to stop eating voluntarily (bingeing), a feeling that one cannot stop eating or control what or how much one is eating.
PurgingFasting and / orCompulsive exercisingFasting and / or compulsive exercising alternating with bingeing
Eating BehaviorFood rituals: calorie counting, rigid rules, and schedules.Secretive food foraging and hoarding, especially at night. Shoplifting and/or petty stealing of money to buy binge food. Vomiting; laxative, diuretic, or diet pill abuse; or use of other emetics (syrup of ipecac).
Sleeping BehaviorInsomnia and early morning awakeningVarious sleep disturbances
Clothing and Dressing RitualsFrequent weighing, layering of clothesOften dresses to hide body shape.
Social BehaviorSocial withdrawal, physically and emotionally.
Focus on job and / or school work
Social irregularities, alternating withdrawal with erratic need for social contact and approval. Chaotic relationships and interaction possible
Abusive BehaviorSelf-hatred and feeling of unworthiness.Drug and / or alcohol abuse possible. Suicidal gestures or attempts. Self-hatred and self mutilation, feeling of self-disgust.
Emotional and Cognitive CharacteristicsIndividuals suffering from eating disorders have restricted emotions and often cannot identify their feelings. What they are aware of is extremely negative thoughts related to their body, which becomes an effective diversion from their emotional turmoil and pain. Their thoughts are obsessive and their feelings are often avoided and hidden, even from themselves.
Anorexia Nervosa (common patterns)*Bulimia Nervosa (common patterns)*
Body Image ProblemsIntense fear of becoming fat;
Distorted body image.
Preoccupation with appearance and “image”, overly concerned   about body weight and size.
Perfectionist BehaviorPerfectionist: thinnest, smartest, neatest. Dichotomous thinking: all or nothing, black or white.Perfectionist: high performance and achievement expectations. Perfectionist inside, but sometimes chaotic outside. Facade of normalcy, seemingly “got it together”.
Low sense of self-worth.
Low self-esteem: self-loathing, self-disgust, and depression.
Motivation for helpDenial, usually doesn’t want help, desire to solve problems alone.Usually wants help desperately, yet shame may prevent reaching   out.
SexualityDecreased interest in sex.May be promiscuous or confused about sexuality, a mask for a   desire to be accepted and respected.
Social BehaviorSelf-centered and non-social, isolation from others; IrritableConstant feeling of being out of control; vacillates between isolation and extreme need for external validation
Cognitive SymptomsDifficulty thinking clearly, potential severe cognitive deficits due to malnourishment.Inability to accurately identify and express feelings. Out of touch with one’s feelings, e.g., anger, affection, humor. Thoughts obsessive and focused on the eating disorder cycle.
*Patterns, systems and traits may vary from one person to another
Adapted in part from Mary Pabst, MSW, Maryland Association for Anorexia Nervosa and Bulimia (MAANA), from Panhellenic Task Force.

Intuitive Exercise

Author: Nancy Heiber, RD and Michael E. Berrett, PhD

Intuition is that inner sense which can guide our lives and what we do, not only towards external and sought after goals, but also towards inner peace and harmony. Living by intuition requires noticing, listening, understanding, and then following that inner sense and voice.

You have heard of intuitive living and intuitive eating. How about intuitive exercise?

Not only is intuitive exercise possible, but it is critical, especially for those recovering from compulsive exercising, eating disorders and related addictions. Without intuitive guidance, exercise can become a part of an addictive and destructive cycle. This cycle can and does lead to physical, emotional, and spiritual damage. Intuitive exercise, on the other hand, can improve life.

Exercise has been shown to increase energy, lower stress, increase restful sleep, improve bone strength, resistance to illness, and improve health generally. Proper exercise, done in moderation, and with intuition, is an important and healthy part of life, from the development of coordination in the toddler, to strengthening cardiac function in the elderly. Proper exercise can help ward off obesity, increase one’s ability to participate in and enjoy recreation, and can strengthen not only muscles, but the autoimmune system as well. Exercise can ward off the debilitating effects of daily life stress. It can lead to increased awareness and acceptance of one’s body and improve one’s physical and emotional self-confidence. There are positive benefits of exercise, while the decision to underexercise brings unwanted consequences.

Then there’s the problem of exercising too much!

A little exercise is good for you, so a lot must be even better, right? Well, not always. At a particular point the body says “enough is enough,” and the results of not listening can be devastating. There are also real and present dangers in overexercising. The most common risk in exercising is injury to muscles and joints. This usually happens from exercising too rigorously, or for too long. Overexercise can cause injuries to legs, feet, and joints of the body. Muscle fibers are fatigued and stressed during exercise, and are susceptible to damage when overexercised. Heart damage is also a real possibility in overexercise, especially when a person is not eating enough to sustain the workout.

The dangers of overexercise are very real, and are both physical and mental. Physical dangers include stress fractures, fatigue, exhaustion, tendinitis, damaged or torn muscles, ligaments and tendons, osteoporosis, malnutrition, dehydration, anemia, irregular menstruation, arthritis, and heart problems.

The emotional and mental dangers of overexercise can be just as debilitating. These include potential development of obsessive compulsive behaviors of differing kinds. Compulsive exercise is an addiction of significant proportion standing alone. Additionally, compulsive exercise can feed or fuel other related obsessive-compulsive disorders including anorexia, bulimia, and related disorders of eating and distorted body image. Overexercise can also lead to disorders on a continuum of addiction ranging from a life “out of balance” with narrow and inappropriate priorities, to a full-blown obsession with all the consequences of any progressive addiction. An obsession with exercise can also lead to an external versus internal orientation to life, wherein “looks” and performance are all important, and failure to reach or maintain goals becomes a trigger for depression, anxiety, and feelings of “not being good enough.”

How do I know if I, or a loved one is overexercising?

To know if you are overexercising, watch for signs and symptoms. The following are physical signs and symptoms of overtraining and overexercising:

  • Pain or pressure in the left or mid-chest area, left neck, shoulder, or arm during or just after exercise (Could indicate a heart problem – stop exercising and contact your doctor.)
  • Sudden lightheadedness, cold sweat, pallor or fainting (Could indicate a heart problem – stop exercising and contact your doctor.)
  • Decreased performance
  • Loss of coordination
  • Prolonged physical recovery from exercise period
  • Elevated morning heart rate
  • Headaches
  • Loss of appetite
  • Chronic muscle soreness
  • Gastrointestinal disturbances
  • Decreased ability to ward off infection
  • Leaving a workout more exhausted than rejuvenated

There are also important emotional, mental, and behavioral signs of overexercising. They include:

  • Exercising for the wrong motives or reasons
  • Depression and emotional sensitivity
  • Reduced self-esteem
  • Difficulty concentrating
  • Feeling that you “can’t get enough” of exercise
  • Exercising two hours or more in any one day
  • Time to exercise is stolen from work, school and relationships
  • Significant feelings of stress and anxiety build when unable to exercise or when routine is disrupted
  • The exercise challenge is focused on with grim determination while ignoring bodily symptoms and the intuitive sense that it is time to stop
  • Fanaticism or preoccupation with weight, diet, and body form
  • Little or no satisfaction gained from accomplishments. No savoring of victory or accomplishment, but instead only a rigid focus on the next new goal.
  • Working out even when physically injured
  • Thinking often about working out in the time between workouts
  • Ignoring that feeling of tiredness which indicates that it’s time to rest
  • Ignoring intuitive inner messages from the body, mind, and heart which say “enough”

So what is healthy exercise ?

As in all other areas of life, the core of a healthy exercise program requires some sense of consistency and self-discipline, yet without an obsessive-compulsive drive. The old saying, “moderation in all things,” applies well to exercise and its place in our lives, along with all other important life activities. The following basic guidelines give some structure to consider when implementing a healthy exercise program:

  • Exercise because you want to – not because you feel that you have to.
  • Do exercise activities that you enjoy – not exercises that you dislike.
  • Include a variety of exercise activities – don’t get in the rut of doing only one or two things.
  • Include leisure recreation activities such as bike riding or hiking in the canyon as part of your exercise.
  • Stop if it hurts! Do not exercise when your body is in pain, or when fatigued.
  • Never exercise with an injury.
  • When your body is telling you something – listen!
  • Get some physical activity every day, even if it is just walking around the block.
  • Drink plenty of water during exercise and afterwards.
  • Eat enough to properly fuel your body for the rigors of daily life and exercise.

Remember, exercise feels good and in proper doses can extend life and make life more enjoyable. On the other hand, overexercise can damage your physical ability to participate in some of life’s activities, and through addictive processes, can make you a slave to a compulsion which controls and decreases your true sense of freedom and peace of mind.

In intensive cardio-activity training, exercise 3-5 times per week for periods not longer than 40 minutes. In intensive weight training, exercise 3-5 times per week for periods not longer that 55 minutes. If you are doing both cardio exercise and weight training, make sure you do them for shorter periods of time and at separate times. Many professionals recommend that these activities should be done on separate days. Exercising at a moderate pace for 30 to 60 minutes, 4-5 days per week generally is healthy, while working out seven days per week at maximum intensity is pushing oneself too far and is selfdefeating. Since each of us has different risks and needs, it is best to consider the advice of your family physician or another medical professional who knows you well. Make sure you ask and follow your doctor’s advice if you have an eating disorder and desire to exercise! If you respect the true needs of your body, then your body will most likely take good care of you.

Now, back to “the Intuitive” in exercise.

The above guidelines provide minimal and basic structure. They can provide a “reality check” if we are significantly “off the healthy track.” Each person, however, has individual needs which are best met within a lifestyle of following one’s intuitive sense. An exercise routine should not be made up of arbitrary rules creatively made up in one’s mind. Anyone who says in their inner dialogue, “I must exercise this many days per week for this long,” is most likely not listening to their body nor their internal intuitive messages. Instead of arbitrary rules, a routine best consists of doing a variety of things you enjoy doing when your body feels up to doing them. Exercising for the right reasons will allow you to honor your intuitive sense and can lead to enjoyment, stress relief, and physical and emotional health.

For young children, being an intuitive exerciser is easy. It is their natural way. It is just as natural for them to move when they have an urge to be active, as it is for them to eat when they feel hungry. Children follow their intuitive sense in living until they are incidentally, accidentally, or purposefully taught to ignore their own intuitions. As adolescents and adults, it takes more effort. We have often been taught to live by external rules or to please others, rather than to listen to our internal messages. We can, however, learn to live, eat, and even exercise intuitively again. It will take effort, time, patience, and positive self-encouragement. We may need to start by following the structure provided by our treatment team as we prepare again to become intuitive in exercise.  As in intuitive eating, intuitive exercise always begins in a healthy structure given by an expert treatment team.  Work towards becoming an intuitive exerciser! It will require desire, commitment, and a willingness to start. The following are a few guidelines towards becoming an intuitive exerciser:

  • Spend some quiet and quality time listening to your mind, heart, and body.
  • Respond to that self-understanding and approach exercise accordingly.
  • Respect your inner needs and consequent internal messages.
  • Respect and respond to your body, especially those messages of pain and fatigue.
  • Examine your motives for exercise.
  • Adjust your exercise as needed and develop the healthiest motives.
  • Reserve and make sacred the time you need to take care of yourself.
  • Find exercise and physical activities which are enjoyable.
  • Remove concepts of fat, calories, and size from your exercise thoughts and language.
  • Feed your body what it needs to assure nourishment and adequate fuel to burn.

In summary, understanding always precedes a helpful course of action, and listening always precedes understanding. Learn to listen to your treatment team, and then listen to that quiet inner voice and then follow. This will lead to the development of an exercise plan and lifestyle that will work for you.

Written 2005, Revised July 2014


Experiencing Change

Author: Kara Ohlsen CTRS, TRS

All of us learn by discussing principles and by actually experiencing the impact of these principles. Understanding mentally and feeling are both vital in making the lasting changes necessary to overcome an eating disorder. Mark Twain put it well when he said, “The man walking down the street carrying a cat by the tail is gaining at least ten times as much experience as the man who is just standing there watching him.” Recreation therapy is therapy in motion. Through this active therapy, individuals with eating disorders experience healing patterns, engage socially, learn to relax, and successfully transition from inpatient care.

Ropes Courses and problem-solving activities simulate real-life challenges. The way we act in these types of activities parallels our real life patterns. Through ropes course experiential therapy women with eating disorders practice challenging self-doubt and overcoming fears. Trying to maneuver on a high ropes course naturally brings out feelings of fear and anxiety. When a person pushes through a frightening climb with shaking knees and pounding heart to finish the task, they experience conquering anxiety. Over time, they actually feel their anxiety lessen by facing these fears. Overcoming the anxiety of high course challenges relates to dealing with the anxiety of living and coping with life’s pressures without an eating disorder. When we know that uncomfortable emotions do not decide our actions and will not always be as strong as they are at the moment, the thought of recovering from an eating disorder feels less daunting.

Social challenges, including group problem solving and social outings, provide a structured setting to challenge self-destructive social patterns. In group problem solving, individuals experience working through difficult problems rather than avoiding the difficult issues. When facilitated properly, a problem-solving challenge provides an opportunity for people who tend to isolate themselves to experience social support. Oftentimes, individuals with eating disorders lose touch with much of their social support. There simply is not time for friends and family when the eating disorder consumes so much time. A structured social outing provides an atmosphere where a woman with an eating disorder can feel loved and accepted for her true self. Regaining confidence in one’s ability to become a part of social support is vital in a successful recovery.

Another important aspect of experiential therapy is service. Service projects bring to light the reality that our worth is so much more than the appearance of our bodies. Changing our focus and thoughts to what we can do rather than what we look like happens as we serve. A key concept to discuss after service projects is the difference between serving and seeking approval from others. Recognizing the state of mind, source of reward, and feelings associated with true service is a powerful part of recognizing inherent self-worth. Service sets in motion the practice of forgetting self-doubts and involving ourselves in a higher purpose.

Enjoying recreation is another key to a complete recovery from an eating disorder. Being able to relax is at the core of mental health. Many people suffering with anxiety are anxious about being anxious. Simply telling someone to relax is not necessarily the most effective method. Rather than fighting and forcing relaxation, it is important to find activities that allow a centering of attention. Doing something such as painting, mentally stimulating games, creative writing, reading, and other activities that require focus are often more relaxing than simply watching random television shows. However, it is important to include quiet time when making recreation plans. Take time to enjoy nature and center attention on gratitude. Recreation time is a great time to re-create thinking patterns and focus on personal affirmations.

Individual life-skills counseling is a unique opportunity to take concepts learned in therapy and put them to work in real life. Individual life-skills counseling at Center for Change includes experiential therapy with community integration support. Having a personal coach to assist in the transition from inpatient treatment to outpatient better assures that healthy coping mechanisms will actually be used. Getting “plugged in” socially, utilizing skills, being of service, and taking time out to enjoy are all ways people become confident in taking care of their own needs without the structure of inpatient treatment.

One experiential intervention I use in life-skills counseling is canoe training. Learning to steer the canoe is so similar to recovery. I start out with a verbal instruction of how to properly steer a canoe. Then we head out on a flat water river with me steering the canoe. Once I have demonstrated that steering the canoe is possible, I change positions and allow my client to demonstrate all that she has learned. Of course it is easy to talk about paddling but more difficult to actually steer the canoe. There are zigzags and crashes, yet we are still moving down river. Gradually there is less back and forth motion. She is in control of the boat more and more. Once in awhile she may lose focus and get off course, but by the end of the river trip she is maneuvering around fallen trees and rocks. The challenges of the canoe journey are so similar to the challenges of putting therapy into life action and sticking with recovery; the slipups do not take the canoe all the way back to start even though it feels rough.

All of us know that change is a life-long process. Yet so many of us forget this in the rush of daily living and ever increasing expectations. In our quest to improve ourselves and the world around us, it is essential that we take the time to experience emotions, connect with others, relax, and be patient in life transitions.

Seven Keys to Remember in Creating Your Own Healing Experiences

  • Simplify. You don’t have to do it all. Choose 2-3 leisure interests that provide you with the most enjoyment. It is hard to be intuitive when you are constantly busy.
  • Balance work, rest, and play. Periodically check your own balance and make adjustments as needed. A good recommendation I have heard before is 8 hours of work, 8 hours of sleep, and 8 hours of recreation each day.
  • Keep life interesting. Expand your skills within your areas of interest. Find or form a club to expand your knowledge base. Take a class with a friend just for fun.
  • Endorphin. Remember that physical exercise is not the only way to “burn off steam.” Talking with someone, building something, and creating artwork also helps the brain to increase the release of endorphin.
  • Put your heart into it. If excessive exercise has been a part of your eating disorder choose another recreation interest to help you to cope. Connect with other human beings. Do things that help you feel alive instead of numb. Look at free time as an opportunity to expand the size of your heart.
  • Lighten up. Give yourself permission to be young and human in your free time. Experience the sense of wonder and excitement you felt as a child. Spend time with children.
  • Get out there. Are you truly overworked and exhausted? Or is that tired feeling a symptom of depression? Recreation is not a way to run from feelings, but in conjunction with therapy it does elevate mood.

Defining Me

Author: Melanie Aldis

My name is Melanie Aldis and I have a message of hope for recovery. My message comes from personal experience, passion, and from the heart.

I had an eating disorder for ten years, from the age of thirteen to twenty-three. I am now in my thirties. Unfortunately, I don’t have much memory of those ten years, only bits and pieces. What I do remember is that I felt inadequate at a very young age. I never felt pretty, smart, popular, or accepted as me. I thought I was just plain old average or less than and that wasn’t good enough. I don’t remember how or when the eating disorder started, but I know that underneath it all I had intense self-hatred. Eventually the eating disorder became my entire identity and that is when my process of self-discovery came to a halt. I thought that the eating disorder would help me find thinness, beauty, and the answer to true happiness and success in life. As you all know, the excitement and glamour of the eating disorder does not last forever. My life was consumed with food, insecurities, and my outward appearance. While other kids were learning what their favorite sports or colors were, I had my head in a toilet.

After ten years of slow suicide, my esophagus was eroding; I had heart burn all the time, and my heart would randomly beat irregularly throughout the day. What kind of existence is that? I discovered that I wasn’t invincible and that if I didn’t do something I would be “the girl who had died of an eating disorder.” I wasn’t ready to leave this world with that kind of label. I didn’t know what my purpose in life was, but I knew there was a reason I had to keep holding on. I was finally ready to fully commit to recovering from the eating disorder.

After ten years in the illness, my relationships with my boyfriend, friends, and family had deteriorated. At this point I could not stop on my own, but I knew that didn’t make me a failure. What I needed was to be in an environment that could save me from myself. I needed to be surrounded by people who cared about my life because I didn’t. I checked myself into an inpatient facility. During that time, I was the “perfect” patient. I was an inspiration to all and the one who would reach out and become a role model for the other patients. At the same time, I was screaming and yelling at my mother in the middle of the night telling her that the clinicians in the facility were the enemy and that I was just trying to survive their evil plan to make me “fat.” Not surprisingly, I ended up signing myself out after 30 days. At the time, I thought that I was the expert about what I should weigh and that they were just out to turn me into a hideous beast. When I got out, I thought that those 30 days had reversed the 10 torturous years with an eating disorder. It hadn’t. I thought that my little time of freedom from the eating disorder gave me another identity, which I defined as “perfect recovery.” The thing is – perfection never lasts. I have now learned I am perfectly imperfect.

Does this story sound devastating? Well – this illness is devastating, yet I have been blessed in finding the way out. I have learned that I am a smart, funny, beautiful, successful woman who had an eating disorder but is not an eating disorder. I am now a representative of one of the most incredible treatment programs I have ever seen. I work for them not because I need this job, but because I choose my passion in life of helping others instead of choosing to die.

I am grateful for being a part of something so meaningful and fulfilling. I hope that people struggling with eating disorders have a reliable and caring person or people in their lives to hold on to their desire to live until they can do it themselves. I was lucky enough to have that, but I don’t believe that is the only way out. If you are currently struggling with an eating disorder, look within your heart to find out why you haven’t given up. There are reasons, important reasons. These reasons can help you walk the long and challenging path of healing. Hold on to those little daily miracles that keep you alive and use them as inspiration to reach out for help. You may feel alone and scared, but when you ask for help something beautiful can happen. I believe that you want to live, and I know that you deserve to live. Through my recovery process I had the opportunity to learn about me. My biggest lesson is that I can not be defined by one label. I am Melanie Aldis – and those two words alone have so many definitions.

With love from my heart and my soul,
Melanie Aldis


Therapeutic Insights in the Treatment of Binge Eating Disorder

Author:   Kimberly Crossley, LCSW and Wendy Jensen, LCSW

Center for Change is committed to ongoing research with eating disorders to enhance the awareness and treatment of this population and our clientele. Last year we became part of a research team on Binge Eating Disorder (BED). After reviewing the current literature and in conjunction with our case studies, it was discovered that those with BED have specific treatment needs. There are many commonalities with other eating disorders. However, BED differs from other eating disorders in many ways beyond the lack of compensatory behaviors. It elicits feelings and responses that vary greatly and warrant attention. Our research and gained understanding prompted us to develop several concepts to help us better understand and work with females struggling with BED. Our research of both written materials and case studies are the foundation of this article; we will begin with the following case study with treatment implications.

One patient dealing with abuse and trauma issues in therapy used binge eating to relieve the symptoms of depression and anxiety. As work in therapy continued, it was discovered that she began emotionally eating at the same time the abuse occurred. As a child certain foods were monitored by her parents, such as cereals with sugar. She was only allowed such cereals one day out of the week. Therefore, the intake of cereal was monitored. As this patient got older, she learned that much focus and attention was given to what kind of food she ate or did not eat.

When she was unable or unwilling to verbalize her emotions and feelings, she turned to binge-eating behaviors. It became a source of contention between she and her parents. In treatment it was discovered that food was being used as a source of getting attention, although negative in nature, from her parents. Her parents did not know she was being abused and, as a child, she was threatened by the perpetrator if she told anyone about what was happening. As she got older, when she and her parents did not agree about something, she turned to food as a retaliation against them.

Over time, as she was able to discover and express the hurt and anger to her parents because certain foods were being monitored, she gradually found other ways to get her needs met. No longer did she need to “rebel” or retaliate with food. Instead, she was able to verbalize the emotions and feelings, and as she did so, the binge eating behaviors subsided. Work was done with the parents to help them deal with their emotions about the abuse as well. They felt helpless and expressed failure for not doing something about the abuse. However, they did not know it was taking place.  All in the family have learned to share feelings and communicate more openly.

This case study shows the importance of addressing the psychological issues at the same time as teaching healthy nutritional philosophies and practices. If only body image and eating patterns were emphasized, the destructive cycle of binge eating may have continued to be perpetuated for years and years without resolution.

The characteristics and diagnostic criteria of BED are outlined by the DSM-V. Many patients struggling with BED are ashamed about what they are doing and fear others finding out. As a result, it is helpful to know some of the indicators of the disorder.

The warning signs of BED are many:

  • Frequently eating abnormal amounts of food in a short period of time, usually less than two hours
  • Not using any methods to purge foods
  • Eating rapidly, often swallowing without chewing
  • Eating episodes marked by feelings of lack of control
  • Often eating when not hungry
  • Feelings of guilt, embarrassment, or disgust
  • May binge eat alone to hide the behavior

Often, these “adaptive” behaviors are used to comfort and soothe the individual. They are not necessarily used as punishment. Accordingly, there are different rewards and struggles for the individual than the rewards and struggles of one struggling with anorexia nervosa or bulimia nervosa. The cycle of addiction is also somewhat different.

An outline derived from “The Obsessive Compulsive Addictive Cycle©” by Michael Berrett, Ph.D., will be used for the framework of explaining the emotional dialogue and compulsive behaviors clients utilize to avoid painful emotions.

  1. Primary Difficult Emotion ( i.e. anger, hurt, sadness, loneliness, etc.)
  2. Obsessive Thoughts (distracting thoughts or obsessing about the compulsive behaviors)
  3. Anxiety (builds from ruminating thoughts and anticipation)
  4. Compulsive Behaviors (acting out obsession – eating disorder behaviors, drugs/alcohol, sex, etc.)
  5. Relief (oft described as “high”, “euphoria” – temporary in nature due to cessation of anxiety)
  6. Secondary Difficult Emotions (guilt/shame/hopelessness)
  7. Withdrawal (isolation, secrets, disconnection from self and others)

For anorexia nervosa and bulimia nervosa the addictive cycle flows in the manner listed above. However, with binge eaters the “relief” stage of the cycle precedes/accompanies the compulsive behavior of binging. Then they move directly into the stage of “secondary difficult emotions” and experience what seems to be a more intensive self-loathing due to unhealthy cultural norms about over eating without compensatory behaviors.

The following is a journal excerpt from a client who suffered with Binge Eating Disorder. Watch for the placement of the “Relief” phase of the addictive cycle in both entries:

How I feel after I restrict:
“I feel like I’m beating the monster. I’m rebelling against it. But I feel the emptiness within me. Maybe I’m meant to feel the missing hole. But if this is what not getting what I want is, then what’s the point? I may be beating the monster, but yearning can grow to a great catastrophe later. This could be the “right” thing though. I don’t feel embarrassed, like a pig around others. But my mind is constantly thinking of new things I’m missing out on. I’ll feel lighter though, a spring in my step. No bloating or excess. Even better, I might like what my body will look like.”

How I feel after I binge:
“Initially I feel relief. I’ve come to my comfortable and safe place. I feel a numb high come over me. This familiar action of taking food and putting it in my mouth. This is what I know how to do, something I’m good at. I feel invisible. Nothing can come between the food and me. The world around me is on a pause for me. Reality falls on me and slams me on the stone floor. I feel a deep pain in the pit of my stomach or guilt, regret, hopelessness. I hate my body. I feel injected with poison, tainted. This body is not mine, I won’t accept that. This body is ugly, it belongs to a weak clumsy owner. What have I become and you know what, you’re even more meaningless because you don’t even purge. Too chicken. Everybody else assumes you do. Perhaps I can keep the food to learn my lesson. Let it grow like layers of gunk within me.”

The entry from the binge episode identifies the modified addictive cycle as previously explained, wherein “relief” accompanies the “compulsive behavior”. When a client struggles with binge eating they exhibit different types of emotions in both blatant and subtle ways. Oft times these patients, if they have a history of anorexia or bulimia they will acknowledge the DSM criteria for anorexia and bulimia while resisting disclosure about their binge eating behavior, which they feel so much shame about.

Feelings and responses of one struggling with BED are both similar and different from those of other eating disorders. Accordingly, the following interventions help individuals deal with their emotions in order to resolve BED symptoms and behaviors.

  • Appropriate assessment according to the DSM-5 criteria including specific items to account for the behaviors and feelings as listed in this article. This may heighten BED anxiety and shame momentarily yet reduces elements that enable the client to harbor shame.
  • Medical evaluation and without imminent danger focus on emotional issues while assuring healthy nourishment.
  • Dieting history, focusing on intense craving, out of control feelings with food and the rapid and unconscious eating that “dieting mentality” evokes. Often these are precursors for binging and associated feelings of shame.
  • Self-soothing skills to decrease the intensity of the first three stages of the addictive cycle.
  • Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and Acceptance and Commitment Therapy approaches provide skills to assist the client to manage the underlying psychological implications of BED.

We advocate that clinicians, dietitians, and direct-care staff who work with eating disorder patients become aware of the unique differences clients with BED experience so they can be better supported away from shame and into recovery.


Written: Date unknown

Reviewed and Edited: November 2014


Coping With An Eating Disorder During The Holidays (2004)

By: Randy K. Hardman, PhD

Five years ago, I researched and wrote an article on eating disorders and the holidays based upon my experiences working with women of different ages who were struggling with anorexia and bulimia. They provided me feedback concerning aspects of the holiday season that were difficult for them, from which I developed suggestions designed to help family members during the Thanksgiving and Christmas holidays. I recently asked women currently in treatment at Center for Change who are actively engaged in the recovery process to share their suggestions and ideas about how to help someone suffering with an eating disorder better approach the holiday season. It is important to note that although five years have passed since the original article, the painful feelings and struggles and the issues that complicate the eating disorder during the holiday season are very much the same. This article includes many new quotes related to these difficulties as well as ideas and suggestions to help families and friends help a loved one who is suffering with an eating disorder to get through the holiday season a little better.

For most people, the Thanksgiving and Christmas holiday season is a wonderful time of year. It is often a time of family reunion and celebration – a time when families, friends, and coworkers come together to share good will and good food. The season is to be bright, happy, and full of the best parts of relationships. Yet, for women who suffer with eating disorders, this is the worst time of the year. For these women, trapped in the private hell of anorexia or severe bulimia, Thanksgiving and Christmas magnify all of their personal demons, causing them great internal pain and turmoil.

I asked women who are currently in treatment for anorexia and bulimia at the Center to share from their private experiences what Thanksgiving and Christmas have been like in recent years.

Unlike any other normal teenager, I always hated it when the holiday season would roll around. It meant that I would have to face my two worst enemies – food and people, and a lot of them. I always felt completely out of place and such a wicked child in such a happy environment. I was the only person who didn’t love food, people, and celebrations. Rather, holidays for me were a celebration of fear and isolation. I would lock myself in my room, take lots of laxatives, and exercise compulsively. Maybe no one else gained weight over the holidays, but just the smell of food added weight to my body. My anorexia destroyed any happiness or relationships I could possibly have had. No matter how much I tried to deny it, I couldn’t get better on my own. My only wish is that I could have gotten treatment or help so much sooner, so I wouldn’t have wasted so much of this precious life I have found. – Nineteen-year-old woman

The holiday season is always the most difficult time of year in dealing with my eating disorder. Holidays, in my family, tend to center around food. The combination of dealing with the anxiety of being around family and the focus on food tends to be a huge trigger for me to easily fall into my eating disorder behaviors. I need to rely on outside support to best cope with the stresses of the holidays. – Twenty-oneyear- old woman

Over the past few years, during the Thanksgiving and Christmas holiday season I have felt horrible. I felt trapped and like the food was out to get me. I lied on endless occasions to avoid all of the parties and big dinners that go along with the holidays. I felt horrible about my body and did not want anyone to see me eat for fear they would make judgments about me. – Seventeen-year-old woman

Holidays have been one of the most difficult times for me while I’ve been in my eating disorder. Often the anxiety is overwhelming. I feel like running and hiding from everyone. It is so hard to be surrounded by food, family, and the pressures these two things create. One Christmas I was so worried about having to eat in front of my family that I purposely had my wisdom teeth taken out on December 20th, just so I would have an excuse not to eat. On other holidays I have waken up early just to run extra long so that I’d be able to eat what other people were eating and not be traumatized. – Twenty-two-year-old woman

These quotes from women suffering from anorexia and bulimia describe the emotional intensity they feel during the holiday season. Their fear of gaining weight and becoming, in their minds, fat, gross, and disgusting, is the monster they must deal with every time they partake of any of the foods that are so wonderful and common to the holidays.

These women are also terrified because they have no idea what a normal amount of food is for themselves. For most of them, and in particular for an anorexic, they feel that anything they eat will mean instantaneous weight gain. In fact, some of them have said that just the sight or smell of food is terrifying to them because their fear of being fat is so ever present. For some, just thinking about food is enough to create intense turmoil, pain, and guilt. An anorexic feels tremendous guilt about any kind of indulgence involving food. To them, that is evidence that they are weak, out of control, and undisciplined. Anorexic women are often terrified of being seen eating food or of having people look at them while they eat. I have had patients remark that they would rather jump off a cliff without a parachute than have someone watch them eat. These women feel that every eye is on them at holiday gatherings, and at the same time feel ashamed and immobilized by their fears about food.

My life with an eating disorder during the holidays is a living hell – constant hiding and fear, confused about life and hating every moment being surrounded by food. There was so much pressure, so many stares and glances, and days with endless comments. My whole life was a mess. There was so much pain and guilt inside of me and I didn’t know where to turn, except to my eating disorder. I hated the pressure of eating the food, the constant worrying of offending others, and what’s worse, my body was always freezing cold. I could never stay warm and I feared to say I was cold because of the response I would receive from others. – Twenty-two-year-old woman

Social pressures are hard. I feel like everyone is watching. It’s easy to avoid social situations to avoid the pressure of all the food and all the comments like, “I ate so much,” or “I’ve gained this much weight during the holidays,” or “My New Year’s resolution is to drop so many pounds”. It’s hard to know how much food is appropriate. What would help during the holidays is don’t watch and don’t push the food. – Twenty-eight-year-old woman

It’s hard to be around all the food and festivities. When I’m hurting inside and struggling with what “normal” food portions even are, I need the help, emotional understanding, and support of family and other people. “Handle with care, but please handle.” Accept me the way I am. Let me back in the family. – Twenty-three-year-old woman

I would fake being sick much of the time to get myself out of family and social gatherings. – Twenty-two-yearold woman

Trying to eat in large groups and experiencing anxiety being around a lot of people – I feel like I’m being watched and compared and I feel fat, ugly, and inferior. – Fifty-six-year-old woman

All I wanted to do was isolate myself and have nothing to do with my family. When I had to be with them, I felt paranoid that they might find out or judge me. – Twenty-one-year-old woman

It was and still is hard for me to interact even with my family. I’m very withdrawn and hesitant to make a wrong move or say a wrong thing, so I say nothing at all. It’s hard to communicate with someone when you speak an unknown language, a secret language. – Fourteen-year-old woman

Food and family, that’s what makes the holiday season miserable for those of us with eating disorders. This is a time where practically every activity is focused on the two things that are most difficult to deal with. It is especially hard to get along with family when they are constantly watching your every eating habit, which is so much worse during the holidays when the types and amounts of food are a nightmare for anyone with an eating disorder. – Twenty-two-year-old woman

All of the food, so much fattening food. Everyone expects you to eat but you will do anything to make them think you’ve eaten when you really haven’t. All of your relatives will notice how withdrawn, sad, and gaunt you are and how you don’t eat or talk to people. They may tell your parents or family who have not noticed because they have become accustomed to this behavior. – Fifteen-year-old woman

Because of the many dinners and parties, there are many lies told and it is very difficult to keep my eating disorder a secret. I am forced to eat dinner in front of people and could be judged about what I eat and what I don’t eat. – Seventeen-year-old woman

On the opposite end of the eating disorder spectrum, a severe bulimic finds the holidays are a genuine nightmare because there is so much emphasis on food that they become preoccupied with it all. Binge eating and subsequent purges become even more prevalent because many of the foods and sweets that are associated with holiday celebrations are very enticing to a bulimic. The holidays can be a time of convenient indulgence, but also a time of great shame and self-reproach because of the bulimic’s secret life. Some even use the binge eating/purging cycle as a form of self-punishment through the holidays.

Those who suffer with bulimia live out this painful eatingdisorder hell in private and in secret, and feel great selfcontempt. To many of their family and friends things may look normal even when the opposite is true. On the other hand, bulimics whose family members know of their disorder may have the feeling that they are the main attraction, where every trip to the bathroom is seen as a major defeat and disappointment to their family.

Christmas is the hardest time with my bulimia. So much food, so much love, and so much joy, but I could not feel the love or joy, so I indulged in the food as a replacement. It was hard to see everyone so happy before I made the trek to the bathroom. I felt unworthy to be happy. I didn’t deserve the love and joy. I’ve discovered that if I can focus on the love and joy, everything else falls into place. – Eighteen-year-old woman

The holiday season draws out awareness of the eating disorder. It is harder to be deceptive over the holidays because much more is expected of you by your family. – Twenty-one-year-old woman

The secrecy and lying make it very difficult for me during the holiday season. I have to decide whether to restrict my food or to binge and then sneak away to purge. – Twenty-two-year-old woman

Holiday ideals epitomize what is good about family relationships. Activities during this time can involve family members in intense, emotional ways. Unfortunately, women with eating disorders find it terrifying to be emotionally intimate with other people. In such situations they feel vulnerable and unsafe, and so they revert to their eating disorder to restore a sense of control and protection.

Family dynamics can be a major trigger and contributor to eating disorder difficulties in women. Struggles with perfectionism, feelings of rejection, disapproval, and fear of being over-controlled, are all cited frequently by women who suffer. Harboring strong feelings and beliefs that parents or other family members find them unacceptable, inadequate, or disappointing is challenging for any person but is particularly devastating to women with eating disorders. Being immersed in a family setting during the holidays can dredge up all of the old issues, fears, conflicts, and worries about family relationships. The resulting emotional disruption feeds the eating disorder and exacerbates the problem.

Having an eating disorder during the holidays presents quite a contradiction in my mind. I anticipate all the food and get excited, while at the same time I dread the many family members around. I feel that the family is over to “watch” the “freak” as I pig out. I know that they simply want to reach out and help, but it seems like the food police are out on patrol. I feel that a big help would be to make a concerted effort to shift the holiday focus from the food to the underlying cause and purpose. I know that it is not possible for people in our everyday lives to assume this role, but in our own families, I wish the food could be a minor deal, just an accessory to the holiday, rather than the focus. – Twenty-year-old woman

Holidays are pure hell when you have an eating disorder, with all the food and family commotion. For me, when the focus isn’t on food and it’s focused on the real reason for the holiday being there, it is a big help. My family helped me out with this one, but I had to do most of it internally. Remember, it’s just food, and we have more power than food. – Thirtynine- year-old woman

I always make myself really busy so I don’t have to eat. I just stay busy and keep helping the little kids and making sure that everything is filled and refilled to meet everyone’s needs, making myself scarce. Then when everyone is through, I just start to clean up things and stay busy in the kitchen. If I see stuff I like, I put it in individual Tupperware bowls and hide them so I can go on a binge later and then no one really notices me because everyone is in the other room talking and laughing. No one seems to notice I’m not anywhere around so I can clean up, feel resentment, and then just go do my own thing and no one even misses me.- Forty-five-year-old woman

After a while I began to isolate myself because I couldn’t handle all of the confusion. Even though it was a holiday, I fell into a deep depression and had a lot of anxiety. I slept a lot and exercised. I did anything by myself to give me a distraction. – Seventeen-year-old woman

Almost all holidays are hard for people suffering with eating disorders. My situation is made extra hard because I don’t get along well with my Dad so I usually take my anger out on my food. – Twenty-one-year-old woman

The following suggestions resulted from a survey question that patients were asked: What three suggestions do you have for family and friends who want to help the holiday season go a little better for a loved one suffering with an eating disorder? The women offering these suggestions range in age from fourteen to fifty-six, and I believe their suggestions offer some valuable insight and understanding that could be helpful to you and helpful to your family members.

  • Be a help with the preparation of food, decoration, shopping, etc.
  • Do not make an issue about what your loved one is eating.
    A little bit of encouragement is okay.
  • Offer a lot of support and be aware of what creates anxiety and try to understand what the person feels.
  • Do not focus too much on food, it will only fuel the eating disorder.
  • Ask the family member how she is doing and see if she needs any help.
  • Do not get angry about how the family member feels, just do your best to support them.
  • Be understanding and supportive.
  • Spend quality time with your loved one.
  • Get her help if she is ready for it.
  • Make sure that the focus of the holiday is not on the food but rather on the family and the valued time you will share together.
  • Allow for other activities that do not involve food such as games, singing carols together, opening gifts, decorating, etc.
  • Allow the one suffering to make a dish that she would feel comfortable eating.
  • Do not be the food police.
  • Do not judge or create shame and guilt about the eating disorder.
  • Be aware and notice behaviors and identify healthy from unhealthy behaviors.
  • Do not pressure someone to eat. This will make the eating disorder worse.
  • Do not give her tons of praise when she does eat. The last thing a person with an eating disorder wants is attention.
  • Do not talk about diets, weight loss, or weight gain. It causes great anxiety and makes the sufferer’s behavior even worse.
  • Talk with your family member about their fears and anxiousness and see how to ease the meal or day for them.
  • Do not stare at her.
  • Learn enough about the illness and the triggers to help them to develop skills as well as back-up plans.
  • Know something about the person’s struggles, triggers, and obsessions. Then, if you see those behaviors you can come up after a meal, pull them aside and tell them how they can be helped in some of those behaviors and discuss ways to be helpful and supportive.
  • If you see her struggling, ask if she wants to talk, but do not say something in front of everyone – just do it in private.
  • Just be supportive and kind.
  • Do not mention the eating habits in large groups but individually ask what you can do to help.
  • Focus on how the person is feeling inside, what issues they are worrying about, what their fears are, and what they need rather than how much they are eating.
  • Treat them with love and respect no matter what is going on.
  • Let the person know that she is loved.
    Try not to focus too much attention on the eatingdisordered behaviors.
  • Do not let yourself get in a fight with the one struggling with an eating disorder.
  • Try to be as patient and nurturing as you can to your loved one.
  • Encourage her and tell her she did a good job even when she eats a small amount.
  • Do not make her feel bad about not eating.
  • Do not comment on how much or how little they eat. They are more likely to do better if you let them be.
  • Be there for them emotionally and physically with hugs and expressions of love.
  • Take the person’s mind off of food by talking about something else: sports, gifts, movies, T.V. shows, etc.
  • Never leave the person alone.
  • Always care no matter what because these people feel alone in their lives, but if you are there at least they will have someone.

Family members of a woman suffering from an eating disorder need to know how to help their loved one during the holidays. The following suggestions may be helpful.

1) It is important for family members to be honest with each other. 
When going into a holiday or family event, especially if the family is aware of the eating disorder, it is helpful that family members talk honestly about what will help and what will not help. Armed with this knowledge, the family can set up some structure around holiday events that is agreeable to all parties involved. Give reassurance about your desire to “be there” for them without trying to control every problem, and respond to their feedback about what may be helpful to them by making positive adjustments. It helps to express love, gratitude, respect, and acceptance for your loved one.

2) It is important to emphasize the purpose for the celebration or the holiday and focus less on food or meals.
If the focus is on the holiday itself and its true meaning and purpose rather than on the food or eating disorder, it will be easier for your loved one to focus less on it herself. Emphasize time together, activities, and traditions that transcend meals and eating. Let food become a support to the holiday rather than its central focus.

3) It is important for the family not to feel responsible and guilty for their loved one’s eating disorder.
It is also important for the eating-disordered person not to feel responsible for the family and the family’s emotional response to the eating disorder. One of the agreements that needs to take place around the holiday season is, “We will not spend time focusing on the eating disorder or what you are eating or not eating, but we will spend time focusing on each other and the things that are available and that are good in our family setting.” Let them know that you can look past the outward manifestations of the eating disorder because you are more concerned about the hurt, pain, fear, and guilt they are feeling inside. By acknowledging the pain inside, no one has to be at fault for the eating disorder, allowing positive family associations and caring to become the emphasis. No family members will have to “walk on egg shells” if everyone first acknowledges the underlying emotions associated with the eating disorder. Compassion is a wonderful holiday gift for someone with an eating disorder.

4) It can be helpful during the holiday season to break activities into smaller numbers of people, when possible.
It is easier and less overwhelming to deal with five people than fifty people. Gently invite your loved one to participate in smaller, quieter, and less chaotic family activities and events. Simple talking and sharing as a small circle of family members can do much to increase the sense of belonging and safety for someone with an eating disorder.

5) Encourage your eating-disordered family member to gather additional support around themselves during the holidays. Additional support can come from extended family, friends, and even therapists.
If the family recognizes the benefit of these additional support people, they can then encourage their involvement rather than be hurt and offended by them. Sometimes, a woman with an eating disorder might not be ready yet to receive the love and support of her family, but at the same time she may be afraid of hurting her family. The message the family needs to send such a person is simply, “We’re here to support you and it’s okay if others support you as well.”

6) It is important for the family to remove any unreasonable behavior expectations or pressures of performance.
Sometimes you want so much for things to be better that you do not realize how your disappointed hopes and expectations actually play out as triggers for the eating disorder. Letting go of these specific expectations in your own mind frees you up to respond to and enjoy whatever your loved one is capable of during the holidays. For the family, it would be more helpful to express a lot of warmth, love, kindness, and acceptance toward the person, with a message saying, “There is no pressure to prove anything to us during the holidays. We just want to focus on being together the best we can.” Eliminating specific, overt or implicit expectations will be more beneficial for the woman suffering from an eating disorder than almost anything else you can do.

7) It is important to offer care “giving” and not care “taking.” Being a self-declared nurse, dietitian, therapist, or detective only puts you in a position you will later regret.
You are not responsible to say or do everything right. Nothing you do or do not do will take away your family member’s own responsibility to overcome and recover from their eating disorder. They are the only one who can do that job, but you can care, empathize, forgive, encourage, and share the process with them. The good intent you express is more helpful than what is actually said or done. If your eating-disordered family member knows that your heart is on their side, then you become a source of comfort, support, and safety to them.

These general holiday suggestions for family living are not a complete list, but they do emphasize some positive approaches to help your eating-disordered family member. The specific ideas, strategies, and agreements that can come out of your interactions with your loved one during the holidays will allow this plan to be personalized and unique for each family. Remember also that your loved one suffering with the eating disorder has her own list of positive things to do that can help her through the holiday season as well.


Eating Disorders, School, And Academic Achievement: A Formula For Failure

By: T. O. Paul Harper, PhD and Randy K. Hardman, PhD

When a parent, teacher, or school counselor is faced with the need to give advice on ways to help an adolescent with slacking academic performance, it is important to consider if that student has an eating disorder. An eating disorder is born out of intense distorted thoughts and beliefs, and an individual with an eating disorder can distort messages meant to inform, console, educate, and advise into twisted self-contempt messages that promote further reliance upon the eating disorder and increased withdrawal from activities and friends. This is a process both frustrating and confusing to those who work with students with eating disorders and to the students themselves, fostering low self-esteem and a belief in their inability to perform. In order to undo this negative cycle in one who suffers with an eating disorder, it is important to understand what is happening to them and to provide opportunities to confront and counteract these negative and twisted beliefs. Academic performance and school activities are almost completely curtailed in the advanced stages of an eating disorder and will lead to massive disruption in a student’s educational advancement unless addressed in the appropriate manner. Traditionally, educational advancement in many who have suffered with serious eating disorders has been checked with periods of inactivity, hospital stay, setbacks, and disappointments, and in falling further and further behind in academic requirements for college. This does not need to be the case when the student is placed in the proper educational environment designed to address both the severe eating disorder and to foster continued educational advancement.

An Educational Profile of a Typical Eating Disorder Sufferer

An eating disorder sufferer is a contradiction in behaviors. An individual who is deeply entrenched in an eating disorder displays a set of characteristics diametrically opposed to her behavior when not suffering with the disorder. She becomes listless, withdrawn, emotionally numb, unexpressive, disinterested in activities, anti-social, and incapable of concentrating. Once she works through the eating disorder, she reverts quickly back to her real selve – sensitive, intelligent, outgoing, involved in many activities that reveal many talents, able to focus on multiple projects, and very giving and loving. Amy is a beautiful and gifted senior in high school. She is a cheerleader, the English Sterling Scholar from her school, writes beautiful poetry and stories, and is very active in school affairs. Amy has recovered from an eating disorder that completely disrupted her life. She writes,

Eating disorders are born, raised, and sustained by negativity; it is the bitterness I experienced with my eating disorder that allows me to appreciate and savor sweetness much more than I did before… Like any addict or substance abuser…I refused to think I had a problem. Not until I had been hospitalized for nearly three months…did I realize the horrific consequences brought about by my eating disorder. It had made me into the person I strived NEVER to become: I fought with my parents, I said things I will forever regret, I lied, I stole, I slipped in my studies, I isolated myself, twice I was tempted with suicide….ultimately, everything I had worked for and wanted was either gone or going as a result of my eating disorder. I lived in a grey haze which never cleared and allowed the little light left in my life to wane systematically.

The contrast between eating disorder behaviors and healthy behaviors is drastic and frightening. Parents who witness this transformation in their child’s behavior, from a bright, energetic, and outgoing person to someone with the exact opposite characteristics, react with a swift desire to alter the trend. Unfortunately, very often the tried and tested methods of eliminating suffering and changing undesirable behaviors are the very things that can make the disorder worse. Telling a daughter, “You are beautiful and don’t worry!”, usually is interpreted as, “She feels she needs to say that because I am so ugly,” and the command, “Eat all the food on your plate!” may be interpreted by the daughter as, “My parents want me to be fat and unpopular at school,” etc.

The School Environment

One of the most obvious evidences of something going wrong in the sufferer’s life is the impact the eating disorder has on school achievement. The sufferer’s normally high grades start to slip. She begins to withdraw from activities and becomes more antisocial. She loses interest in school subjects and extracurricular activities. She loses her ability to focus on important projects, papers, and tests. She becomes much more emotionally hypersensitive to what is going on around her and what others may be thinking about her.

I could not stay focused on my school studies. My concentration level was terrible and I could never read book assignments without my thoughts wandering. I was always too tired to stay awake, and more often than not my head was on the desk top sleeping. All of my energy went towards my eating disorder. It was first priority. (19-year old woman.) My concentration level decreased, I skipped classes, isolated myself from friends, and didn’t care about grades. I went from A’s and B’s to D’s and F’s. (High School Junior)

School can be a quick-paced, unrelenting, socially competitive, and strenuous environment. When you combine this with the changes that are taking place in the lives of young women, it becomes a potentially threatening and frightening place. If an individual starts to wonder and worry about their social and intellectual status, the school environment can become a very intimidating place. For an individual suffering from an eating disorder the school environment is filled with messages that can be twisted and confused within their negative self-judgment and criticisms. The whole experience can become too overwhelming to bear.

My anorexia destroyed my concentration, my drive, my love of school, and my performance in classes. Education no longer played a vital role in my life. My anorexia preoccupied and consumed all of my time, leaving little time for school and studies. Anxiety-producing stress only exacerbated my anorexia, which, in turn hindered my performance. (College Freshman)

Parents looking for the quickest and most logical means to alleviate the disruption of an eating disorder often encourage their eating-disordered child to become more involved and to work harder in their school setting to display their natural talents and abilities. The child unable to cope with the negativity she senses inside herself and all around her in school, reacts in the opposite manner and starts to withdraw and shut down even more. She knows what she feels and is confused about her inability to cope with the seemingly simple solutions her parents offer. She very naturally starts to believe that something is wrong with her, e.g., she is a social outcast, unable to fit in, or undeserving of good things.

Positive Strategies for Parents

Parents can help their daughters by doing the following:

  1. Do not treat this problem as just an academic issue, but rather recognize the emotional roots of anorexia and bulimia.
  2. Be open to feedback from teachers, counselors and others who can help.
  3. Educate yourself on the causes, impacts, and treatments of eating disorders through literature, books, seminars, and the Internet.
  4. Talk to your daughter about what is underneath the disordered eating behavior, do not just focus on the eating patterns.
  5. Recognize the need for proper assessment, dietary counseling, medical consultation and therapy treatments and options.
  6. Get involved in a parent support group.
  7. Talk about the issues and possible solutions to eating disorders with the whole family.
  8. Don’t be fooled by a daughter’s attempts to minimize and ignore the real problem, be firm about the need for recovery while being sensitive to not forcing the issues.
  9. Be a good role model around food, take care of yourself, don’t blame yourself, and be patient.
  10. Recognize that recovery takes time and do not place unrealistic demands for a quick fix of your daughter’s eating disorder.

High School Eating Disorder Research

In the past, approximately 1500 high school students in Utah and Nevada have filled out an eating survey (Foundation for Change Study, 2000) designed to assess eating disorder thoughts and behaviors. The results of the survey suggest that approximately 6% to 13% have already developed a diagnosable eating disorder; 30% to 35% have attitudes and beliefs about food and weight that fall into the abnormal ranges and that put them at risk for eventually developing an eating disorder. These findings document that there is a growing need for effective education and awareness programs on eating disorders in high school settings.

A Teacher’s Dilemma

It becomes important for teachers to understand the impact of anorexia and bulimia so they can pick up on the signs and consequences of eating disorders among their students. Since most students with anorexia and bulimia are very bright and talented it can be difficult for teachers to pick up students’ subtle changes in feelings and attitudes before their academic performance suffers. Consequently, knowing that approximately 2 out of 10 girls in any school class are at risk for developing an eating disorder presents a dilemma about when to raise concerns about anorexia and bulimia. Thus, it is helpful to raise the subject matter at different times throughout the year in general fashion. Doing this will encourage students struggling silently with the pressures and stresses of life and school to talk to you or a counselor in private before the eating disorder behaviors begin to disrupt academic performance. The fact that a teacher is willing to broach this subject in an open and general fashion can be perceived as a safe invitation for students afraid of negative consequences of an eating disorder to do something for themselves.

Another dilemma for teachers is often how to approach a student about a suspected eating disorder that is disrupting personal and academic performance. Most girls with eating disorders will deny, minimize, or lie about the problem when confronted directly. They often feel ashamed of who they are and their behaviors. It is important to not make direct accusations about concerns, but rather, gently talk about what you are seeing as a teacher and encourage them to talk to you, or someone else, when they feel more ready to do so. Raising the concern in their presence and then giving them room to come back to you, whether they are struggling with an eating disorder, depression or some other personal problem, will let them know that you have noticed, cared, and have offered a kind invitation for them to do something about it.

For the student more entrenched in the eating disorder, another dilemma for a teacher is whether to tell other school personnel or the parents about their concerns. Sometimes parents are the last to see the eating disorder because they want to believe their daughter’s responses to their questions. It is important to first talk to the student in private. Explain that you need to do something to help them rather than ignore or avoid the problem. Then give them some time to get back with you about who they are willing to let you talk to about the problem. For many girls with eating disorders it was the persistence and honesty of a significant other that led to their decision to seek treatment. For those girls who are too afraid or angry to admit to or address the eating disorder, it is very important to make more people aware of their problem, including the parents, so that teachers do not become silent collaborators of the disorder. The student may not be ready to change but they will know the secret is out.

Positive Strategies for Teachers

There are a number of things teachers can do to help their students:

  1. Encourage counselors in schools to start support groups for those who struggle with eating problems and body image concerns.
  2. Develop working relationships with counselors who can do one-on-one work with students and who can refer to outside
  3. professionals.
  4. Encourage the school to have assemblies or combined classes where outside professionals and recovered eating disorder
  5. sufferers can do presentations for the students.
  6. Provide materials and information on eating disorders that students can review on their own.
  7. Conduct a school wide awareness program during National Eating Disorder Awareness Week in the spring of each year.
  8. Be sensitive to the reality that eating disorders are about psychological and emotional pain and conflict and not about food and weight.
  9. Actively give invitations and encouragement to students to get help to overcome their eating fears, concerns, or disorders.
  10. Talk to other teachers informally to develop a network which can identify at-risk students and offer support to those identified students.

High school students suffering with an eating disorder can create an unusual challenge for any teacher, but the awareness of this illness can give a teacher increased opportunities to help these students.

The Educational Philosophy at Center for Change

A fundamental belief at Center for Change is that education is a basic right and opportunity for all human beings. Eating disorder sufferers are inhibited in their ability to take full advantage of academic education opportunities. An individual with an eating disorder can forfeit their right to an education because of a negative belief in their ability to do what is necessary to meet educational goals and cope with the educational environment. At Center for Change we recognize that fundamental to the gaining of an education is the ability to: (1) take advantage of educational opportunities, e.g., have appropriate social, coping, and learning skills, (2) maintain personal motivation for educational activities, e.g., learn to love education, and (3) believe in one’s personal ability to achieve educational goals, e.g., believe in one’s ability to cope with the environment in addition to meeting class requirements. We recognize the full negative impact of anorexia and bulimia on a young woman’s life and on her ability to fully function in an academic setting.

Center for Change incorporates an educational philosophy and program designed to help participants become able, motivated, and self-efficacious learners who can continue their academic educational development. The goals of the educational program are designed to augment the intensive care the Center utilizes to overcome an eating disorder, thus providing a powerful and synergistic therapeutic and academic experience.

The school at Center for Change will offer a complete academic curriculum for the high school student, grades eight through twelve, designed to move participants toward graduation and competency in university studies. Each student is given a complete battery of psychological, educational, and intelligence assessments designed to determine the most appropriate placement of students in our academic program. We are able to offer a unique set of core and elective courses that address the special challenges faced by students who suffer with eating disorders. We are committed to quality education, offered by certified teachers in an accredited academic institution. We are doing all we can to meet the above goals and provide the finest education available to our students.


Managed Care

Author: APA

Editor’s Note: “From the Therapist’s Chair” is intended to be a forum for professionals in the field. We invite you to forward articles or papers to : ANAD, Newsletter Editor, Box 7, Highland Park, IL 60035.

Insurance companies, faced with the rising costs of health care and reduced profits over the past decade or so, developed new types of coverage – HMOs, PPOs, and related managed care vehicles. Many businesses and individuals, in purchasing insurance for their employees, bought the new types of coverage as an attempt to reduce the cost of premiums, deductibles, and co-insurance fees, thinking the quality of care would not be compromised, yet unaware of the sometimes-dangerous sacrifices consumers would be making with managed-care coverage.

The intention of the insurance companies has always been to reduce their payments to the health care providers, but that is not, of course, the pitch they make to potential customers. They applaud themselves for what they call excellent quality of care at reduced cost to the consumer and increased profit to them: the cherished “win-win” situation. Too good to be true? Of course! What the managed-care companies are deeming “excellent quality of care” is measured by their yardstick and is not an assessment of quality measured by the consumers or providers of care. What managed-care companies do not tell the consumer about are the restrictions to care that often dangerously hamper treatment availability, duration, and ultimately, quality. Obviously, the focus is not to manage care but to manage cost. They are not interested in the person, the nature of a patient’s illness or the way in which one person with depression may differ from another; or how one patient might be in need of inpatient treatment, while another with bulimia might appropriately be treated on an outpatient basis.

The process of attempting to hospitalize a patient with an eating disorder presents multiple obstacles for outpatient clinicians and serious potential emotional and further physical damage to bulimics and anorexics in need of inpatient care. To managed-care companies, the symptoms of an eating disorder per se are not sufficiently life-threatening to warrant hospitalization. Unless a patient is actively suicidal, the managed-care companies state that the person’s psychological symptoms are not sufficiently acute and that inpatient treatment “is not medically necessary.” The exception to this rigid, and often irrelevant, criteria occurs only if a patient’s physical examination or lab results indicate severe physical, metabolic or organ system complications from the eating disorder, enough to warrant inpatient medical treatment.

The psychological crisis is never of sufficient severity to warrant hospitalization unless the patient says she/he is suicidal. I was once told by a managed-care medical reviewer, when I was trying to hospitalize a bulimic who purged 15 times a day, was severely depressed and no longer left the house, “We don’t hospitalize attitude problems.” As many know who work with or have experienced an eating disorder, a patient can often be severely out of control with binge/purge or restricting behavior, yet their blood work and physical exam can appear normal. Managed-care companies, with their impersonal checklist of criteria for what comprises disorders, and their lists of criteria for when hospitalization is necessary, fail to understand the critical and life-threatening natures of eating disorders. They are ignorant of the insidious, all-consuming chronic behavioral symptoms of eating disorders and fail to recognize the connection between long-standing symptoms and the poor prognosis for recovery. The managed-care templates for treatment of eating disorders is too simplistic: globally assuming all bulimics are alike and all anorexics are alike and that all should be treated on an outpatient short-to-intermediate-term basis with antidepressants and cognitive-behavioral treatment. They fail to recognize that, in some, the self-destructive behavior may be beyond behavioral control in an outpatient setting, and may have to be treated in an inpatient setting in order to redirect the behavioral dyscontrol, reduce the chances of chronicity and enhance the prognosis for long-term success. Bulimics and anorexics may not be overtly suicidal, but eating disorders lead to death more often than any other psychiatric condition, even major depression.

What can you do to help change these insufficient and life-threatening policies? Write or call your insurance company administrators when any kind of care, inpatient or outpatient, is not authorized based on their indirect, impersonal, non-specific medical review. They do not know you or your patient. No matter how specific their checklist or their knowledge of the literature on disorders is, they do not work with the specific individual in need of the treatment requested by the professional. Don’t hesitate to contact legislators in your district and inform them of insurance controls over your health care that limit treatment inappropriately. Don’t take no for an answer when you know what you need!

Marla M. Sanzon, Ph.D., P.A. Annapolis, MD


Exercise…What Kind of Shape are You Getting Yourself In?

Author: Calene Van Noy, RD, CD

As the Olympics begin and we see the dedicated athletes run, jump, or swim across our television screens, it raises an interesting question related to eating disorders. When does “dedication” turn into an unhealthy obsession? When does exercise become part of an illness known as anorexia or bulimia?

Individuals may be diagnosed with anorexia or bulimia with compulsive exercise being a major component. The role that physical activity plays may vary a great deal. Exercise may serve to “purge” the body of unwanted food. It may help individuals to maintain control or feel success in their lives. And it may serve as a means of “avoiding” emotional pain or alleviating depression.

Are you concerned for yourself or for someone you know? The following is a list of possible signs and symptoms associated with compulsive exercise:


  • frequent injuries such as stress fractures
  • irregular menstrual cycles for females
  • fatigue and chronic muscle soreness
  • anemia
  • frequent dehydration
  • osteoporosis


  • exercising beyond the point of pain or injury
  • punishing self for missing a workout or eating too much
  • the exercise regime maintains priority over social life, work, and/or family
  • keeping detailed records of exercise and eating patterns
  • using exercise to compulsively control weight
  • turning to exercise to deal with emotional pain or difficulty
  • preoccupation with exercise, body, and “health” issues


  • compulsive behavior – repetition and perfection associated with exercise routine
  • depression
  • social isolation or abandoning relationships
  • damaged careers
  • drop in school performance
  • anxiety
  • obsessive thoughts and continual rumination about exercise or body

Ask yourself the following questions to see what your tendency towards compulsive exercise is:

  1. Do you feel you have to exercise 7 days a week for greater that 1 hour per session?
  2. Do family, friends, and/or coworkers comment that you are exercising all the time?
  3. Do you exercise despite injury or illness?
  4. While exercising do you think about burning calories and fat, or begin planning your next diet, or how much weight you’re going to lose, etc?
  5. Does your exercise take priority over your social life?
  6. Is your primary motive for exercise to lose weight or maintain a particular weight?
  7. Do you adjust your exercise according to how much you have eaten?
  8. If female, have your menstrual cycles become irregular or ceased?
  9. If you miss a workout do you punish yourself or try to “make-up” for it by restricting your food intake or increasing your exercise the next day?
  10. Are you terrified of gaining weight if you don’t exercise?

If you answer yes to any one of these questions please consider it a warning flag, and assess your priorities. If you answer yes to 2 or more questions please seek professional help.

So, you may be asking yourself, “What is a healthy amount of exercise?” We all know that there are many benefits to physical activity that cannot be denied. However, exercise in no way guarantees you the golden apple of health. Quality of life and balanced health are the true keys. It is important to spend time cultivating all aspects of your life – including mental, physical, social, and spiritual components.


Food For Thought – Ten New Year’s Resolutions

By: Unknown

10 New Year’s Resolutions You Will Want to Keep!

  1. Be Patient. You have to eat a lot of cereal before you find the free toy.
  2. Strategize. If you want a kitten, start out asking for a Jaguar.
  3. Be Flexible. That way you’ll never get bent out of shape.
  4. Embrace your greatness within. Objects in the mirror are greater than they appear.
  5. Steer your career. Your job is merely a tool to create a good life.
  6. Search for the Silver Lining. If you fall in a mud puddle, check your pockets for fish.
  7. Go ahead, make your day. If you can’t make your day, make someone else’s.
  8. Be a student of life. Pay attention, there are lessons all around you.
  9. Become a role model. Make choices that reflect the person you hope to be.
  10. See through eyes of love. Love casts a cheery glow that shines back on you.

Music Therapy: An Innovative Approach In The Treatment Of Clients With Eating Disorders

By: Lynette L. Taylor, MT-BC

Many of you probably use music therapeutically on a daily basis without even realizing it. How many of you listen to music that is more upbeat than usual when you need a little extra energy? Or, conversely, when you are feeling a little blue, pop in that perfect sad song? Music is covertly serving as a conduit for releasing or expressing emotion. Still, many people ask the question: “What exactly is music therapy?” The American Music Therapy Association (AMTA) defines music therapy as “the prescribed use of music by a qualified person to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems.” This article will explore a few facets of music therapy interventions and results for eating disorder clients in an intensive treatment setting.

Music therapy interventions allow clients to express their thoughts, opinions, and feelings, in a nonverbal, safe, and constructive manner. Music evokes a response that is immediate and genuine. In essence, one cannot falsify their initial response to music – it is the authentic emotion coming to the surface. One client, who had buried her feelings for years, described the powerful influence of music in resurrecting those feelings: Nothing seemed to get through the barriers I had erected in my mind and in my heart. In regular therapy they would try to get me to talk about my feelings. I just couldn’t seem to find the words, like words were such an inadequate way of describing what was going on in my mind. My first day in music therapy, I cried, really cried for the first time since I was told not to cry as a little girl. I’m not sure what happened, but the music seemed to pierce my stone heart and break down all of the defenses I had. It was hard because I felt vulnerable and defensive at first.but the girls were so supportive, and I felt safe. -Former Patient

As a newly admitted patient, an eating disorder client may experience several conflicting emotions including feeling overwhelmed, fear of rejection by other residents, vulnerability, and lack of conviction in their choice to seek treatment. In addition, many of these people have learned to please others and neglect themselves, resulting in unhealthy interpersonal skills. Due to the secrecy and shame of the disorder, they have not had much practice in being honest in relationships (Priestly, 1975).

By participating in a structured music therapy group, the eating disorder client is able to work through these issues by restructuring the way she views herself in relationship to the other residents. She gains an awareness of her unique attributes which enhance the group experience and provide her with the sense of being a necessary and integral part of the group.

Structured music therapy groups include, but are not limited to: group song writing, drumming, and karaoke.

Song Writing

Often, people who have failed to make desired progress in outpatient treatment have struggled because they either cannot use words, or use words extremely well as a defense (Justice, 1994). Some, who have been in treatment and have struggled for years, can talk circles around their therapists. Music can be used to move past these defenses to connect with deeper issues through symbol and metaphor (Kenny, 1982). These symbols can be solidified through graphic arts or writing. For example: clients were asked to write a song describing feelings associated with their eating disorder. The following verse demonstrates how powerful symbolism and metaphor can be used to accurately describe the acuity of pain and fear.

I dreamed a dark and narrow path
where I faced a dragon’s grasp,
He held me tight within his fist
and breathed a suffocating mist,
He choked me and stole my voice
believing there was no other choice,
Creating lies, I paved the way for a path that led astray.

Not only is a client able to express feelings associated with her disorder while engaging in song writing, but she is able to experience being a part of a cohesive group, where her input is valued. Original melodies and lyrics leave a lasting impression on those who had a hand in creating them – impressions which will stay with them long after treatment. About a year and a half after her treatment at Center for Change, a former client wrote: “I’ve often thought about the song ‘Shine Through Me’ that we all made up and it has brought me comfort so many times and helped me to get through the difficult moments.”


According to Carl Seashore in Psychology of Music (1967 pp. 140-145), there are eleven basic ways by which rhythm affects our perception. In effect, rhythm does the following:

  • Favors perception by grouping;
  • Adjusts the strain of attention;
  • Gives us a feeling of balance;
  • Gives us a feeling of freedom, luxury, and expanse;
  • Gives us a feeling of power;
  • Stimulates and lulls (contradictory as this may seem);
  • Is instinctive;
  • Finds resonance in the whole organism;
  • Rouses sustained and enriching association;
  • Reaches out in extraordinary detail and complexity with progressive mastery; and
  • Results in play, which is the free self-expression for the pleasure of expression

During a drumming activity, one client reported that she was able to imagine her eating disorder as a separate entity, not inside of her, but on the head of the drum. For the first time in years, she was able to feel a sense of empowerment over her eating disorder as she repeatedly hit the head of the drum and thought the words “F-You, Eating Disorder!” The sense of power she felt during the drum circle was the antithesis of the powerlessness often felt by eating disorder clients. Feeling such power can give clients a taste of their own strength and ability to forsake their eating disorders.

Prior to attending a music therapy drumming group, a client reported that she wanted to leave treatment early. She was unmotivated and showed little to no desire to overcome her eating disorder behaviors. After engaging in a drumming exercise, this client described feeling a profound change in her entire outlook on staying in treatment. She said, “Something just clicked inside me that night when I listened to the drums beating.the voices of the drums fit together and I felt a bond with the other girls that I hadn’t felt before.” Commenting on the client’s change, a care technician said “Her outlook on her time here has changed dramatically since that night. She is forming great relationships with the girls and said it was a beautiful experience for her.”


As aforementioned, clients have shown success in using symbolism and metaphor to express feelings associated with their eating disorders. Commonly used symbolic words, such as “suffocate,” “mute,” “blocked,” and “alone,” convey feelings of frustration due to deficits in the eating disorder client’s communication skills.

Whether due to lack of self-esteem or fear of rejection, communication is often strained with eating disorder clients. Karaoke, or singing a solo in front of a group, is a strong medium in the development of assertive communication skills. Fear of rejection, lack of perfection, vulnerability, etc., make most clients resistant to participating in karaoke exercises. When a client pushes herself to work through her fears, she learns that there is a well of personal power within her, and that she has the ability to overcome her issues related to performance anxiety. Following discharge from the Center, a former client wrote: Guess what?! I sing in a contemporary singing group at church. I love it and find it very fulfilling. To be honest, I don’t think I would have the courage if it weren’t for your “assertive communication” group. Karaoke made me be more assertive.

The interventions described in this article represent only a fraction of music therapy interventions implemented in the treatment of clients with eating disorders. Music therapists and music therapy can provide several levels of experiences that facilitate further goals and processes.


Justice, R. Music Therapy Interventions for People with Eating Disorders in an Inpatient Setting, MI: National Association of Music Therapy, Inc., 1994.

Kenny, C. The Mythic Artery . Atascadero, CA: Ridgeview Publishing, 1982.

Priestly, M. Music Therapy In Action . New York: St. Martin’s Press, 1975.

Seashore, Carl E. Psychology of Music , pp. 140-145, New York: Dover Publications, 1967.


Revised September 2014


Effects Of Self-Concept, Media, And Gender Differences On Eating And Exercise Disorders

By: Kristine Wright, Care Tech

Eating disorders have been on the rise and a center of study since the 1980’s. They have been a serious concern for patients suffering from these disorders, their families, friends, and health care professionals. According to the National Association of Anorexia Nervosa and Associated Disorders (ANAD)(2004), eating disorders affect seven million women and one million men in the U.S., and have one of the highest mortality rates of all psychological disorders (anorexia has the highest). Unfortunately, eating disorders are very harmful to the body and very difficult to overcome. Treatment is expensive and not always effective. Anorexia alone is the number one cause of death among young women (ANAD).

Many factors influence the onset and continuation of these disorders. This article will focus on three main factors. The first factor is self-concept, which also includes self-esteem, body image, body satisfaction, and identity formation. The second factor is the impact of the media, which includes TV, magazines, advertisements, movies, and the internet. And lastly, gender differences and their influence on eating and exercise disorders.


Research suggests that female problem eaters have low physical and personal self-esteem which includes a negative perception of their appearance, physical and personal competence, sexuality, and self-worth (Nelson & Hughes, 1999). It has been reported that the transition from high school to college can be a very emotionally draining and vulnerable time for young women in this area. It is speculated that because of women’s socialization, eating problems are very much connected to one’s self-concept. During this transition, self-concept tends to deteriorate and therefore the risk for disordered eating patterns increases (Hesse-Biber & Marino, 1991).

One research study conducted on patients with eating disorders has characterized them as lacking self-affirmation, having high levels of self-hate and self-blame, and as having an overall negative self-image and interpersonal style (Bjorck, Clinton, Sohlberg, Hallstrom, & Norring, 2003). This particular study found that patients with anorexia are more prone to have higher levels of self-control, self-blame, self-hate and less selfemancipation as compared to other categories of eating disordered patients. Other research suggests that patients with more severe eating disorder pathology lack interoceptive awareness (knowledge of inner life), are characterized with high levels of somatization, bulimic behaviors, muscle tension, anxiety, and low self-concept (Faldt & Johnsson, 2002). It was found that with more severe psycho pathology there was lower self-concept and poorer self-image.

How people strive to achieve self-worth differs from person to person. Each person bases their self-worth on different dimensions. For some, having love and support from their family makes them feel worthwhile, and for others it may be doing well academically or winning a competition. In a study of college students, it was found that when self-esteem was based on appearance, students experienced more symptoms of disordered eating and spent more time exercising than those who based their self-esteem on other domains (Crocker, 2002).

People with eating disorders have been widely labeled as “perfectionists.” In a study comparing female aerobic exercisers and college athletes it was found that athletes were characterized as having higher levels of perfectionism than exercisers, but that exercisers showed a positive relationship between perfectionism and drive for thinness that wasn’t shown with the athletes (Krane, Stiles-Shipley,Waldron, & Michalenok, 2001). In this particular study, most of the women did not seem to suffer from eating disorders or social physique anxiety, but some were categorized as excessive exercisers. It was noted that possibly body dissatisfaction may be combated through participation in physical activity.

Not all people who suffer from eating disorders fall into the categories of anorexia nervosa and bulimia nervosa. Many people – especially women – suffer from Eating Disorders Not Otherwise Specified (EDNOS) as outlined in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). These disorders vary widely and are basically defined as not meeting the specific criteria for the other eating disorders. In one particular study it was found that college women suffering from EDNOS experienced high levels of body dissatisfaction, attention to body image, and drive for thinness (Schwitzer, Rodriguez, Thomas, & Salimi, 2001). An overall theme of perfectionism was found and related to higher levels of stress, anxiety, decreased self-esteem, and episodes of depression. Other characteristics found were maturity fears, self-sufficiency concerns, and struggles with parents and family for young-adult autonomy. From the above research it seems there is a pattern of low self esteem and self concept, poor body image and high body dissatisfaction among those who suffer from eating disorders. There also appears to be high levels of perfectionism, self-hate, and self-blame which are all interrelated. There seems to be more similarities of individual characteristics between eating disorders than differentiating characteristics. An underlying theme of poor self-concept displayed through many diverse arenas, is a very powerful factor contributing to eating disorders.


Adolescence is a risky time for many young girls, and acts as the foundation for most eating disorders. Hoskins (2002) focuses on the relationship between identity development and cultural symbols and images, and how they influence an adolescent girl’s onset of an eating disorder. By the 1980’s the ideal body size for women had decreased 10 pounds since the 1960’s (Hoskins, 2002). Today’s media portrays women’s sexuality as very graphic and unrealistic. A young girl growing up in this type of atmosphere is prone to feelings of inadequacy and low self esteem when comparing herself to the unrealistic body sizes and standards of thinness. Hoskins states that many girls buffer these negative feelings towards themselves, by using their bodies as self improvement projects. This type of behavior is further reinforced by society’s beliefs which according to Furnham, Badmin, and Sneade (2002, p.587), “.encourage and reward the pursuit of the perfect body because it is an ideal that symbolizes the attainment of numerous personal virtues and achievements.”

It is important to note that eating disorders are a learned behavior (Hoskins, 2002). This is illustrated by a study done by Anne Becker (1999) in Fiji emphasizing the impact of television on eating behaviors and body dissatisfaction. She reported that once adolescent Fijian females were introduced to Western ideals through exposure to television, levels of dieting and body dissatisfaction increased.

Media can not be limited simply to exposure to television. In a study done on the relationship between media consumption and eating disorders in women, results showed that magazine reading had a positive, significant relationship to eating disorder symptoms (Harrison & Cantor, 1997). Magazine reading significantly predicted drive for thinness and behaviors of both anorexia and bulimia. Comparatively, television watching only significantly predicted body dissatisfaction. In this particular study, men were also studied. They found that magazine reading for men not only was significantly and positively related to dieting and endorsement of thinness for themselves, but also that the transition from high school to college can be a very emotionally draining and vulnerable time for young women in this area. It is speculated that because of women’s socialization, eating problems are very much connected to one’s self-concept. During this transition, self-concept tends to deteriorate and therefore the risk for disordered eating patterns increases (Hesse-Biber & Marino, 1991). One research study conducted on patients with eating disorders has characterized them as lacking self-affirmation, having high levels of self-hate and self-blame, and as having an overall negative self-image and interpersonal style (Bjorck, Clinton, Sohlberg, Hallstrom, & Norring, 2003). This particular study found that patients with anorexia are more prone to have higher levels of self-control, self-blame, self-hate and less self emancipation as compared to other categories of eating disordered patients. Other research suggests that patients with more severe eating disorder pathology lack interoceptive awareness (knowledge of inner life), are characterized with high levels of somatization, bulimic behaviors, muscle tension, anxiety, and low self-concept (Faldt & Johnsson, 2002). It was found that with more severe psycho pathology there was lower self-concept and poorer self-image. How people strive to achieve self-worth differs from person to person. Each person bases their self-worth on different dimensions. For some, having love and support from their family makes them feel worthwhile, and for others it may be doing well academically or winning a competition. In a study of college students, it was found that when self-esteem was based on appearance, students experienced more symptoms of disordered eating and spent more time exercising than those who based their self-esteem on other domains (Crocker, 2002). People with eating disorders have been widely labeled as “perfectionists.” In a study comparing female aerobic exercisers and college athletes it was found that athletes were characterized as having higher levels of perfectionism than exercisers, but that exercisers showed a positive relationship between perfectionism and drive for thinness that wasn’t shown with the athletes (Krane, Stiles-Shipley,Waldron, & Michalenok, 2001). In this particular study, most of the women did not seem to suffer from eating disorders or social physique anxiety, but some were categorized as excessive exercisers. It was noted that possibly body dissatisfaction may be combated through participation in physical activity. Not all people who suffer from eating disorders fall into the categories of anorexia nervosa and bulimia nervosa. Many people – especially women – suffer from Eating Disorders Not Otherwise Specified (EDNOS) as outlined in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV). These disorders vary widely and are basically defined as not meeting the specific criteria for the other eating disorders. In one particular study it was found that college women suffering from EDNOS experienced high levels of body dissatisfaction, attention to body image, and drive for thinness (Schwitzer, Rodriguez, Thomas, & Salimi, 2001). An overall theme of perfectionism was found and the endorsement of thinness and dieting for women. They also found that watching television with only thin people being portrayed, significantly predicted the importance of thinness and dieting for men once more.

A study of college women was conducted looking at internalization of the thin ideal transmitted primarily through media (Low, Charanasomboon, Brown, Hiltunen, Long, Reinhalter, & Jones, 2003). They found that awareness and high internalization of the thin ideal was correlated with fear of maturity (growing up), body dissatisfaction, greater drive for thinness, and an increase of weight and shape concerns. Additionally, women with a body further away from the sociocultural ideal (having a higher body mass index) experienced higher body dissatisfaction, drive for thinness, and increased risk for eating and body image concerns.

Not only do the media constantly portray an extremely thin body size; but it also portrays women as having a trivial role in society, as being objects of male dominance, and sends out contradictory messages to young girls. These messages promote independence and strength while promoting compliance and vulnerability simultaneously. These different cultural messages and images become very complex and confusing for an adolescent girl who is searching to find her identity (Hoskins, 2002).

Hoskins suggests that eating disorders begin as an attempt to relieve oneself from the complex and confusing demands of creating a self, or identity. For example, by taking on an “anorectic identity” the adolescent girl is relieved from this task, and now has rules and norms to guide her behavior. The catch is that once an eating disorder begins it is very difficult to reverse (Hoskins, 2002).

In addition to the challenges already discussed, the advertisement of and increasing popularity of plastic surgery has created a whole new realm of unattainable standards of body size and shape, and a narrowing of society’s beauty standards. Consequently, the more rigid the standards become the more drastic and harmful the attempts will be to reach them.

Gender Differences

In the past the majority of eating disorder patients have been women. Recent research has shown that the male population may have been overlooked (O’Dea & Abraham, 2002). It seems that problem eating attitudes and behaviors are not solely experienced by women, but a relatively large portion of men also experience such problems. In one particular study 20% of college men displayed problem eating attitudes and behaviors and 8% displayed and exercise disorder (O’Dea & Abraham, 2002). Of concern to health care professionals is that most men do not feel they have a problem or are hesitant to seek help even when they feel they do have a problem. The profile of a male problem eater tends to differ from a female in several ways. The strongest differential factor for men is current psychological distress, followed by high levels of patriarchal psychological control and dealing with single family relationships (Nelson & Hughes, 1999).

Men and women also differ in their quest for the ideal body. In a study conducted of adolescent’s ages 13 and 14, gender differences about body dissatisfaction were compared (Furnham, Badmin, & Sneade, 2002). It was revealed that 29.4% of boys and 10.2% of girls wanted to be heavier; compared to 35% of boys and 69% of girls wanting to be thinner. They also found that 73% of the boys wanted to increase the size of their upper body, whereas 63% of girls wanted to decrease the size of their lower body. It seems then that because there are different ideals for men and women, the sources of body weight and concern are also different. Men are more pressured to have a muscular and V-Shaped body figure which is achieved through exercise, weight training, and not necessarily through diet restrictions and weight loss. It was also found that body image dissatisfaction was only significantly correlated with girls’ self-esteem and not boys’. Therefore, in girls where body satisfaction is a central factor of their self-esteem, there tends to be more concern about weight and a higher chance of having negative attitudes toward eating.


Eating disorders are very complex and multidimensional with many causes and many outcomes. Researchers and healthcare professionals are now being faced with a broader range of disorders and patient profiles. Much of the research conducted in this area of study is focused on a small range of disorders, focuses mainly on young females, and is mostly corralational data.

Eating and exercise disorders are very difficult to study because the information gathered for most research is based on self reports, questionnaires, interviews, and case studies, which are easily biased and unreliable. Not much true experimental research has been done due to the unique and personal nature of these disorders. They can also be difficult to diagnose (especially in the early stages) and many sufferers don’t even recognize they have them.

From the studies that have been explored, it seems there is definitely a relationship between self-concept, media, and gender on eating disorders. The American culture is very media oriented and is largely influenced by its messages, images, and portrayals. This influence is further complicated by sex and gender issues, identity formation, and individual perceptions of the self.


Becker, A. (1999). Body, Self, and Society: The view from Fiji. Philadelphia: University of Pennsylvania Press

Bjorck, C., Clinton, D. Sohlberg, S., Hallstrom, T., & Norring, C. (2003). Interpersonal profiles in eating disorders: Ratings of SASB self-image. Page 22 Page 23 Psychology and Psychotherapy: Theory, Research, and Practice, 76, 342-344.

Crocker, J. (Fall, 2002). The cost of seeking self-esteem. Journal of Social Issues, 58 (3), 601-605.

Diagnostic and Statistical Manual of Mental Disorders: DSM-IV (1994). Washington D.C.: American Psychological Association.

Faldt, E. B., & Johnsson, P. (2001). Personality and Self Concept in Subgroups of Patients with Anorexia Nervosa and Bulimia Nervosa. Social, Behavior, and Personality, 30(4), 354-355.

Funrham, A., Badmin, N., Sneade I. (Nov, 2002). Body Image Dissatisfaction: Gender Differences in Eating Attitudes, Self- Esteem, and Reason for Exercise. Journal of Psychology, 136 (6), 581.

Harrison, K., & Cantor, J., (1997). The Relationship Between Media Consumption and Eating Disorders. Journal of Communication, 47(1), 60-63.

Hesse-Biber, S., & Marino, M. (Mar, 1991). From high school to college: Changes in women’s self-concept and its relationship to eating problems. Journal of Psychology, 125(2), 204. Hoskins, M. L. (2002). Girl’s Identity Dilemmas: Spaces defined by Definitions of Worth. Health Care for Women International, 23, 232-239.

Krane, V., Stiles-Shipley, J. A., Waldron, J., & Michalenok, J. (Sept, 2001). Relationship among body satisfaction, social physique anxiety, and eating behaviors in female athletes and exercisers. Journal of Sport Behavior, 24(3), 247-564.

Low, K. G., Charanasomboon, S., Brown, C., Hiltunen, G., Long, K., Reinhalter, K., & Jones, H. (2003). Internalization of the thin ideal, weight and body image concerns. Social Behavior & Personality, 31(1), 86-88.

National Association of Anorexia Nervosa and Associated Disorders: ANAD (2004). Facts about eating disorders. Retrieved March 3, 2004, from

Nelson, W. L., Hughes, H. M. (Fall, 1999) Anorexic Eating Attitudes and Behaviors of Male and Female College Students. Adolescence, 34(135), 625-626.

O’Dea, J., Abraham, S. (2002). Eating and Exercise Disorders in Young College Men. Journal of American College Health, 50(6), 274-277.

Schwitzer, A. M., Rodriguez, L. E., Thomas, C., Salimi, L. (Jan, 2001).The Eating Disorders NOS Diagnostic Profile Among College Women. Journal of American College Health, 49(4), 157- 167.

Straub, R. O. (2002). Health Psychology. New York: Worth Publishers.


Suggestions To Help Anyone With An Eating Disorder “Get Through” The Holiday Season A Little Better


These suggestions and ideas come from women at Center for Change who are currently engaged in treatment for an eating disorder and are at various stages in their own recovery:

  • Be honest about your feelings with your family.
  • Be open with your family about your struggles and allow them to help you.
  • Do not try to avoid situations that involve food.
  • Do not spend a lot of time by yourself.
  • Interact with other people.
  • Be honest and open about how you are feeling.
  • Do not avoid others.
  • Remember holidays are about friends, family, and fun – not food.
  • Get extra help in treatment.
  • Eat what your body wants.
  • Do not think about what is in the food.
  • Spend more of your focus on family instead of food. Your family is more important.
  • Try not to isolate yourself but surround yourself with people you love and care about.
  • Try to have fun and not think about what food will be involved. Just handle it as it comes.
  • If you feel yourself struggling, it may help to talk to someone about those issues before it gets too big.
  • Talk to your family before the holiday events or family gatherings and let them know how they can help you. Try to focus on the people you are with and the spirit of the season and what you can to do reach out to others rather than the food.
  • Talk to a therapist or a professional who can help you make it through the tough times.
  • Do not avoid family situations, it only makes things harder.
  • Try your best to be normal and not play into your negative mind.
  • Do not get mad at your family for wanting you to be around them.
  • Find things and activities other than food to focus on.
  • Take each day one at a time.
  • Do not look at the holiday season as a whole.
  • It is easiest to take it step by step.
  • Remember if you over eat one time, it will not make a difference in your weight.
  • Be kind to you in your thoughts.
  • Talk with your family about your fears, anxiousness, and how to ease the meal or day for you and them.
  • Stay with people. Always be with someone.
  • Be patient with those who do not understand the eating disorder struggles.
  • Never give up.
  • Never give in.
  • Better family communication skills and less stress between family members.
  • Use healthy coping skills.
  • Help others to help you. Talk to them about what they can do and what you can do to help.
  • Take time for yourself but do not isolate yourself the entire time. Just take a break.
  • Try to eat intuitively and listen to your body. You do not need to starve or binge. Find a medium place.
  • Relax. You do not need to use harmful coping skills to distract yourself from distress. There are better ways: walks, bubble baths, music, etc.
  • Simplify. Do not feel that you have to do more than is necessary or what you are up to. Let go of perfectionism and enjoy.
  • Eat what you are comfortable with but try to challenge yourself to enjoy holiday treats without guilt. It is a chance to get out of your comfort zone.
  • Take time for yourself. Do relaxation things such as a manicure, a haircut, massage, etc.

10 Tips To Help Deal With Images Of Women Presented In The Media

By: Nicole Hawkins, PhD

1. Avoid or decrease exposure to publications or television programs that promote unrealistic body images of women.

2. Remember that many of the images presented in the media have been computer enhanced and airbrushed. The models’ hips and waists have often been slimmed and their breasts enlarged.

3. Only 4% of women genetically have the ideal body image that is currently presented in the media, the other 96% of women must go to extreme measures to try to reach this unobtainable image.

4. Many of the women presented in the media suffer from an eating disorder or have disordered eating behaviors to maintain such low body weights.

5. Women encounter constant messages from advertising and the culture that stress dieting and obtaining the “ideal body.” Cultural standards cannot harm you unless you buy into them.

6. You don’t have to adopt these standards of thinness and beauty and pressure yourself to live up to them. When you have extreme standards, especially with your body, you will feel depressed, ashamed and guilty.

7. Start to question images presented in the media and question why women should feel compelled to “live up” to these unrealistic standards of beauty and thinness.

8. People don’t just wake up one day convinced they hate their body. It is important to determine how the messages from the media and the culture have affected your body image.

9. When your self-esteem is as negative as your body-esteem, working on improving your self-esteem can benefit your body image as well. Learning to improve body image is possible for everyone.

10. Numerous research investigations have concluded that other people do not judge you as harshly as you judge yourself. Learning to accept yourself for who you are is the best defense against cultural messages.


Eating-Disorder “Proofing” Your Home

By: The Staff at Center for Change

There is no sure way of ridding your home of everything that triggers an eating disorder. However, there are ways to help make your home a safer place. Whether you yourself or a family member are recovering from an eating disorder, here are a few suggestions to make your home a more friendly environment.

  • Throw away all scales – don’t hide them, throw them away. Hidden scales are too easily found.
  • Throw away all fashion and exercise magazines or catalogs. Looking through these magazines is sure to send a shaky self-esteem through the floor.
  • Lock up or dispose of all laxatives, diet pills, diuretics, or other potentially harmful medication.
  • Refrain from any comments about a person’s body or appearance. Even compliments may be twisted in the mind and become something negative.
  • Try to eliminate diet talk and lingo from your conversations. There are no such things as “Good” or “Bad” foods. A comment such as, “Don’t worry, it’s fat-free,” can create a mixture of negative emotions in a recovering person.
  • Have the individual’s favorite food around the house for snacking. It is important to enjoy food and not get too hungry.
  • Don’t buy “diet foods”.
  • Create an environment that is open to conversation. Ask what would be helpful for you to say or to avoid saying. Each individual recognizes the things that trigger them most.
  • Most of all, be a good listener.
  • When inviting those with eating disorders to talk, ask how they are doing or feeling in general and in life, rather that asking about the eating disorder behaviors.
  • Create a “buddy system”. Ask a loved one to be available to talk, go for a walk, or otherwise be with you at those times you feel the urge to act out your eating disorder.
  • Get rid of depressing videos or music and replace them with uplifting, meaningful, and positive books, music, and movies.
  • Ask a loved one to check in with you on a regular basis (e.g., once each week), to inquire about how you are doing with your eating disorder. You decide how often, what, and how to share. Teach your loved ones to accept and be satisfied with what you share.
  • Make a list of 10 things you can do to confront or calm yourself when struggling with eating-disordered thoughts and feelings. Commit to do 3 things on the list before you engage in any eating disorder behavior.

Special Thanks to Monica Toni, Michael, and Nancy.


Perfectionism and Eating Disorders: The Pedestal With A Cage – A Guide for Parents and Families

Author: Diane Starks, LCSW

I once heard it said that when you reach the top of the pedestal, you will find there, a cage. What brings one to the top of a pedestal is some form of excellence. The cage is created by the demands of self and the expectations of others to maintain or excel in this acquired accomplishment. It is a common occurrence for people to place others on a pedestal, in response to their accomplishments or seeming perfection. As a society, we do this to great leaders, heroes, and performers. The problem is that people in the public eye often find themselves imprisoned on the pedestal, and feel caged by expectations of repeat performance. This puts enormous pressure on them to fit the “image” that is expected of them by society, or themselves. There are times when a girl is placed on a pedestal by loved ones. Parents, desiring to help a child grow in self-confidence and esteem, often provide opportunities for the child to excel. Then, as an attempt to reinforce the child’s positive feelings about self, they often praise them and may even “brag” about them to others. Most have honest intentions, to help the child, however, some do it to glorify themselves, by showing others what “great kids” they have produced. Sometimes parents may seek to fulfill their own unfulfilled wishes or dreams through their children. Though well-intentioned, this pursuit has the potential of creating and producing an unwanted result, and perfectionism may become the child’s approach to self-esteem. Self-esteem is a critical aspect of growing into a normal, healthy and happy adult. It begins its development in childhood, and is influenced by a wide variety of factors. Glenn R. Schiraldi, PhD, in his Self-Esteem Workbook (2001), identifies the foundations of self-esteem as: 1) unconditional human worth, 2) love, and 3) growing. He states, “While all three factors are essential in building self-esteem, the sequence is crucial. Self-esteem is based first on unconditional worth, then love, and then growing.” In other words, our self-esteem is healthy when built upon a rock, rather than upon the sand. The order of this development is vital to each child. Many try to start with the “growing,” without the basis of sensing their worth and love. This “cages” them by basing their worth on the opinions of others. As they seek excellence, gaining some external validation, they soon find that the demand for excellence escalates to a tiring endeavor that never produces the desired result. Their accomplishments are never enough, and their selfesteem deflates, because it is damaged by being based solely on external validation.

Research indicates that “perfectionism” can present itself in several ways. The striving to be perfect can be self-imposed, other-imposed, or socially prescribed. A high standard or goal can serve as the driving force for one’s achievement. Healthy perfectionism consists of allowing for mistakes or falling short of the desired goal, and can lead to excellence or achievement without damaging the self-esteem. The unhealthy type of perfectionism leads to self-degradation and beratement if the goal is not reached as planned. This becomes a vicious cycle, and can demand professional intervention to help reverse the depression and negative thinking patterns that ensue.

Sometimes perfectionism may be value-based, or out of religious teachings to be “perfect.” This might be a mis-perception, as it has been shown that the Hebrew and Greek translations of the word “perfect” indicate “finished” or “complete,” not to mean “flawless.” Children need to perceive that they are valued and cherished, just because they “are,” not because of their accomplishments. It is this base upon which self-esteem is built. Then added accomplishment and recognition serves to build upon that core sense of worth.

As professionals working with eating disorder clients, we often see these girls develop problems from the belief that their body must be perfect, oftentimes produced by media and cultural expectations. Body shape and size can become a critical piece of their esteem, so they focus on excellence, and develop a strong need for praise or approval from others. They develop a perception of “fat” that has an extremely negative connotation. In this negative thinking mode about themselves, they must be thin to be “okay. But no matter how thin they become, it is never enough. This attitude is often generalized to all areas of their life, and they desire perfectionism to prove to themselves that they are a worthwhile person. In most cases, this effort is not an attempt to feel superior to others, rather to merely feel equal.

This is an effort to build a self-esteem without the core, and their efforts fall short. Besides perfectionistic tendencies towards body shape and size, it is not uncommon to see them push themselves to a 4.0 GPA, or to win many awards and trophies, and recognition from outside sources. A problem with this unhealthy perfectionism is that as these girls continue to strive for more excellence, they recognize their flaws, and don’t feel they have ever reached that place of perfection, creating feelings of guilt and shame, regardless of the outward praise and recognition. This obsessive cycle leads to a downward spiral to guilt and hopelessness.

Abuses of any kind also send a negative message to most young people who suffer them. Their perception of what the experience means about who they are is usually damaging to their self-worth. Many abused children believe that he or she caused the perpetrator to do the terrible action that was done. The victims often don’t see themselves as a victim, rather, a perpetrator who causes others to perpetrate. I believe that this comes from our societal tendency to blame victims for their experience, as a way to lessen our own feelings of vulnerability. That is why there is a high correlation between past child abuse and the subsequent development of an eating disorder, due to the devastating effect on the self-esteem of the child. Some eating disordered clients report a feeling of such low selfworth that they do not consider themselves even worthy of food. This came to light when I was working with a teenage girl who was a beautiful ballet dancer, with a bright smile, who finally admitted to me that she hated herself. She had very loving and supportive parents, and acknowledged their love and support. As I contemplated my own experiences with teachers and coaches as a youngster and as a parent, I remembered the negative feedback given about improving performance. I am sure that these people meant well, and wanted to help her to excel. However, some of the best and most compliant youngsters internalize this encouragement or criticism as a reflection of who they are as a person, and don’t attribute it just to their performance, as this young lady did. It is a common characteristic of eating disorder clients. Often, parents and other adults involved in a child’s life unknowingly promote this type of negative thinking in children. As parents, many feel that it is important for our children to find their talents and gifts, and so we try hard to help them develop them. This can give them a sense of accomplishment and confidence, and can enhance their self-esteem. It is common for coaches, directors, and teachers to focus on improvements that their young patrons need to make, rather than praising their successes. This becomes problematic when the youngster does not have an inner feeling that she is a worthwhile person, and so she perceives the feedback or criticism of their performance and internalizes and applies it to the “self,” developing the belief that she is not “good enough” as a person.

Sometimes a young woman does not perceive that she can achieve excellence in any area of her life, so she chooses to be the “thinnest” as an attempt to achieve a sense of personal power. Society usually rewards thinness with admiration, so she decides that she will excel in that way. This, she hopes, will bring validation. At first, the compliments and admiration do appear, and feed her need for validation. However, as previously explained, the void is not filled, and so she continues to lose more weight, until she is of the opinion that any fat whatsoever on her body means that she is not a good person. Thus begins the downward spiral as starvation symptoms set in, particularly damaging to the ability to reason and have insight, leading to being caged by her expectation that more of the same behavior will produce desired results. When it doesn’t, she perceives herself as a failure, and the already low self-esteem plummets into hopelessness and despair. This continued negative thinking pattern is devastating both to the victim as well as significant others, requiring professional help. What began as an effort to build a sense of esteem for oneself, ends up to be what robs them of any happiness in their life.

To prevent this unhealthy cycle of perfectionism, parents can help their children by making sure that they learn to value themselves and life itself. The following suggestions are some ways to help your children learn to value themselves:

1) Provide unconditional love and respect

Sit with your children, ask them about their feelings and thoughts about themselves and life. As you discipline, teach, rather than fuss at them. This can be difficult, but it works to create a close relationship. As much as possible and feasible, let the child make decisions and experience the consequences and show support and empathy as they learn difficult lessons.

2) Do activities with your child

Let them direct play with you. Compliment their successes, and encourage them to develop their talents. Let them explore their talents. Examine your own motives, and refrain from imposing your unfulfilled dreams for yourself on them.

3) Be aware of the type of people who work with your children

Pay attention to teachers, coaches, and instructors, and monitor whether they are making derogatory remarks that the child may internalize. If you find a great deal of criticism, beware of your child internalizing it. Try to involve your children with mentors who value the self-esteem of the children with whom they work.

4) Praise the child’s effort, not the grades they receive

As Edison stated, “I have not failed. I’ve just found 10,000 ways that won’t work.” Put successes and failures in the context of what works and doesn’t work, rather than right or wrong, or good vs. bad. Fred Astaire said, “The higher up you go, the more mistakes you are allowed. Right at the top, if you make enough of them, it’s considered to be your style”.

5) Remember, your child will most likely react to the world as you do

Your behavior is her most important teacher. If you react to the world in a loud and screaming manner, she most likely will also. If you are derogatory in remarks about yourself, and your body and looks, she will set her values based on her perception of yours.

6) Give children time to play and be playful as they grow up

Put a limit on how many lessons and structured activities you provide for them. Free play allows them to use their imagination and develops their personality, based on inner approval, rather than on outward reinforcements.

7) Be sure to send a message to the child of her intrinsic worth

Help her to develop her gifts and talents on that base of intrinsic worth. Help the child process any negative messages he or she may get from interactions with others, to prevent those messages from eroding the child’s sense of basic worth. Recently, as a therapist working with an eating disordered girl and her perfectionism, I have found that it is critical to slowly help her develop a deep sense of self-worth. This can be done by helping her to let go of the negative self-judgments that she is internalizing from her experiences and perceptions from the world outside of “self.” It is important to encourage her to develop her own set of personal values, from which she can develop integrity by strengthening them, and living congruent to them.

The key is that the core self-worth needs to be built on a rock, not on sand. She needs to learn to believe that she is acceptable just as she is, an imperfect person who makes mistakes, and able to gain the ability to learn from them. The unhealthy perfectionism is founded in a need for control, with the thought that the mastery or control will produce self-esteem. This is a false presumption, and does not give the wanted result. It is important that she learn to let go of the need for control, and to accept life and its challenges as a learning and growing field, whereby she can gain experience and wisdom. Striving for achievement and success can lead to great accomplishments, however, it can only be healthy if she only uses it for a drive to do things well, not connecting it to who she is. If its purpose is to give her a sense of worth, the efforts will fail, and put her in a cage, leading to the loss of esteem, and eventually hope.


Exploring the Relationship Between Eating Disorders and Academic Education

Author: T. O. Paul Harper, PhD, Former Education Director

An eating disorder victim’s body is not the only thing being wasted as a result of his or her food, eating, purging, and/or restriction obsessions. The mind and mental capabilities of the victim are also being impacted and impaired. As eating disorder obsessions increase, the mental capability of the victim gradually decreases until every aspect of their life is interfered with, especially their academic education.

The impact on academic education is all the more tragic as most eating disorder victims are very intelligent. Usually, eating disorder victims make excellent grades, often straight A’s while carrying very difficult class loads and taking honors and advanced placement classes. They are often recognized as gifted and talented and excel in academic life as well as many other areas in their lives. As the number of eating disorder victims increases while the ages of victims decrease, it is important to explore and address how the academic environment becomes a catalyst for an eating disorder and how to decrease the impact of an eating disorder on the victim’s academic education.


The North American school systems are complex organizations designed to increase the knowledge of students of various ages and to help them prepare for the challenges of life. To accomplish this massive and important task it usually requires that students be placed in specially designated social systems of peers. These social systems have only limited adult supervision. The school social systems develop elaborate sets of social norms, morals, and interactional rules between student populations and between students, teachers, and administrators. The social rules are often conflicting, confusing, and if broken, punishable with swift and cruel retribution.

An eating disorder victim is ill-prepared to meet the challenges faced in academic social systems. This is because of the unique mix of characteristics inherent in the eating disorder personality and the peculiar demands, inequities, and pressures inherent in student social systems. Although all students have similar characteristics, eating disorder victims’ beliefs converge in ways that accentuate social comparison, self-denigration, and compulsive compensatory coping rituals.

In order to understand the impact of the academic social system on eating disorder victims it is important to understand the characteristics of an eating disorder victim and how these characteristics evolve.


In general, an eating disorder victim is highly sensitive to what is going on around them, has strong perfectionistic tendencies, has low self-esteem, has a lost or ill-defined sense of self and social boundaries, and has obsessive compulsive tendencies. As their eating disorder gains intensity, victims display addictive tendencies and become trapped in powerful physical, social, and mental conflicts.


Many different things can result in an individual’s propensity toward hypersensitivity to what is going on around them. Some researchers suggest that certain individuals may have a genetic predisposition toward increased social sensitivity. Certainly, increased intelligence manifests itself initially as an increased interest in what is taking place in the immediate vicinity of the individual. Any traumatic event such as an illness, abuse, or being witness to a traumatic incident could increase one’s sensitivity to what is going on around them. Another major facilitator of social sensitivity is how one’s parents react to a child’s behavior and how safe they make the child’s world. This list, though incomplete, does illustrate how one could become hypersensitive to their surroundings. Depending upon the positive and/or negative feedback one receives as a result of their social empathy, the social sensitivity could be a blessing or a block to normal social development.


The belief that it is important to do and be one’s best at whatever one does is a persistent belief in western culture. This belief inherently promotes social comparison and competition. Many individuals discover their ability to achieve at an early age and recognize the positive rewards that come from achievement. If this belief is indiscriminately associated with strong social/family norms or religious convictions, an individual could easily assume that they have a heavy obligation and duty to be perfect, to be the best, at whatever they do. As one strives for this goal, the rewards come for excellent performance reinforcing the life style, but so also comes increased pressure to perform. If one does not learn to place perfectionistic beliefs in perspective then they can easily become mentally trapped into increasingly more complicated and demanding life styles which usually become impossible to maintain.

Low Self-Esteem

The harder one tries to be perfect the more they will be disappointed. Thus, for eating disorder victims even wonderful accomplishments are denigrated because of their inability to reach perfection. Consistent disappointment in one’s actions erodes self-esteem. One focuses on one’s failures and inability to be what they feel should be. One loses belief in their ability to be what they want to be, perfect. As they try harder and harder they become more and more disappointed. If one is in a social system that emphasizes the absence of perfection in achievement rather than abundance, then the victim becomes trapped in a difficult double bind of trying to be perfect for others and never being able to achieve it. An eating disorder victim can carry this process to extreme feelings of unworthiness and of self-hatred.

Loss of Sense of Self and Lack of Boundaries

As one is oriented more and more toward trying to be perfect for others, they increase the chances of being disappointed. It is virtually impossible to please everyone just as it is next to impossible to get everyone to agree on the same things. They try harder and harder to please and become more and more focused on determining what others want them to do. Over time, the concentration on what others want and the constant striving to achieve facilitates the loss of a sense of self and of clear boundaries. One’s inner desires and wants are ignored and replaced with what one believes others around them want. Eventually, this leads to an inability to recognize personal will and desires.

Obsessive Compulsive Behaviors Leading to Addiction and Double Binds

As one feels consistently frustrated in their attempts to please others and to achieve perfection, they become filled with the emotional pain of self-denigration. Just as one instinctively removes their hand from a hot surface, so too one naturally desires to remove emotional pain. This is usually accomplished by doing things that effectively distract from inner feelings. Eating, bingeing, and restriction of food bring about this distraction. In some cases the pain can be so great that the need to distract becomes obsessive and compulsive. As time goes on, some actions and behaviors, like eating disorders, become addictive in nature, further reinforced by strong physical and psychological needs. As a result of one’s dependencies on activities, situations, and substances which serve to temporally relieve the emotional pain of wanting to be accepted, loved, or perfect, negative feelings about self are enhanced. Individuals become trapped in a cycle of needing to perform, but never feel able to perform at acceptable levels. These types of double binds that throw eating disorder victims into vicious behavioral cycles and traps.


The educational social system negatively feeds an eating disorder victim’s: increased sensitivity to their surroundings, need to please those they interact with, inability to get satisfaction and support from all their peers, and desire to strive for perfection. For an individual with these desires and tendencies, the educational social system presents the perfect environment of frustration. The inherent challenge in the academic environment is that one cannot always be the best at everything, please everyone involved, and read, understand, and react to the millions of different positive and negative influences that surround them. In the absence of a relatively strong sense of self and self-worth, the educational social system is a world full of fear, disappointment, doubt, pain, and disillusionment. The double binds placed upon the eating disorder victim in this environment result in his or her engaging in behaviors that drastically reduce their ability to maintain normal academic activities. Their behaviors may result in the need to be treated in a comprehensive care facility designed to help break the negative cycles of behavior they utilize to cope with their environments.


When the negative pressures inherent in one’s normal social systems are relaxed and a safe environment is felt, it is easier to reduce destructive behaviors and be freed of negative double binds so one can again pursue educational goals. The distortions and momentum of a victim’s negative thinking remain, but the initial pressures and triggers which prompt addictive behaviors are reduced. This facilitates an introspective analysis of the old pressures and triggers and frees up intellectual capacities previously preoccupied with fear and control. Thus, educational studies can be resumed, (along with therapy) while in the comprehensive care center. Inherent in the treatment given at a care center will be methods and strategies designed to help the individual eventually return to old social systems with skills and tools that will help them successfully meet life’s challenges.


A fundamental belief at the Center for Change is that education is a basic right and opportunity for all human beings. Eating disorder victims are inhibited in their ability to take advantage of academic education opportunities. An eating disorder victim forfeits their right to an education because of a basic belief in their inability to do what is necessary to meet educational goals. The victim’s belief in their inability to meet goals stems from the mental and behavioral double binds they are unable to eliminate and control. Center For Change recognizes that fundamental to gaining an education is the ability to: (1) take advantage of educational opportunities, (2) maintain personal motivation for educational activities, and (3) believe in one’s personal ability to achieve educational goals.

As a result of our beliefs about the importance of education and the necessary personal prerequisites to gaining an education, the Center for Change incorporates an education philosophy and program designed to help participants become able, motivated, and self-effective learners. We have developed an integrated education programs designed to teach students how to maintain personal motivation toward their academic education goals, and to foster personal beliefs about their ability to successfully achieve education goals. In addition, the goals of the education program are designed to augment the intensive care approach utilized at the Center for Change, providing a powerful and synergistic educational experience.

While the purpose of this article is to explore the impact of eating disorders on academic education, it is also important to remember that with appropriate preventive education offered at appropriate times throughout a student’s life, the need to be treated for an eating disorder in a comprehensive treatment center could be avoided. This preventive education would require the proper types of psycho education regarding social comparison trends and personal belief development about self, others, beauty, weight, and food. Preventive education should also include the development of critical thinking skills about the explicit and implicit messages that are sent in our mass media and personal spheres of influence.

Caretakers should help those suffering with eating disorders to avoid the sense of helplessness and hopelessness which comes from being trapped in behaviors and thoughts that are seemingly uncontrollable. Eating disorder victims must be taught and eventually come to believe that help is available, and peace is attainable. They must be told that under proper care and the right circumstances they will be able to regain control of their lives, eliminate the mental traps, live normal lives, and pursue education. With the right kinds of emotional support victims can be free to live up to their abundant potential and be relieved of the torment of their mental prisons.


The Value of Recreation Therapy for Women Suffering with Eating Disorders

Author:  Kathleen Slade Hofer, MS, TRS and Alta Swarnes, CTRS

Quality of life is intimately associated with leisure experience and opportunities for self-development and self-expression. Play, recreation, and leisure experiences are an important aspect of the quality of human existence. If we are to affirm our humanness and enjoy genuine happiness, we must play. True quality of life is not found simply in improved functioning, but in the discovery of our humanity through experiences of joyful freedom that bring meaning and value to life. The purpose of recreation therapy is to facilitate the development, expression, and maintenance of a healthy leisure lifestyle.

Women and men who suffer with eating disorders have physical, mental, social, emotional, and spiritual limitations which prevent the quality of life inherent in a healthy leisure lifestyle. Upon admission to the inpatient program at Center for Change, an experiential and recreation therapies assessment is completed for each patient During the assessment, the patient describes how the disorder has affected her leisure lifestyle. She identifies active and creative leisure interests; perceptions of personal strengths, as well as areas that need improvement; career ideas; feelings about spirituality; and desires for treatment outcomes. It becomes apparent that the obsessive/compulsive cycle of the eating disorder becomes an obstacle to leisure, a desperate attempt at relieving stress, fear, anxiety, shame, guilt, anger, loneliness, insecurity, emptiness, and emotional pain. The eating disorder behavior gives a temporary false sense of euphoria and control — a counterfeit transcendence. This is followed by increased guilt, shame, disgust, discouragement, and spinning out of control. The eating disorder sufferer becomes hostage to the dark self-destructive power of the illness.

When asked in the assessment interview, “What do your active and creative leisure interests do for you?” patients have given the following responses:

Stress release, takes away frustrations; Gets me back to myself; Feel better about myself, sense of accomplishment; Express emotions; Have fun, get away from routine; Challenge, perspective; Relaxation, express my individuality; Adrenalin rush; I feel happy and calm; Capture nature and share the excitement of dance; Uplifting, motivating; It’s me, it’s my creative, happy self; Feel alive; Reminds me of my talents and abilities; Gets my mind off things; Peaceful; Freedom, communication, invigorating, outdoors; Time for myself; Confidence, forget painful emotions; Peace of mind.

When asked,”How does your eating disorder affect your leisure interests and lifestyle?” responses have included:

I don’t have fun anymore; Less energy; Lost desire and enjoyment; I gave up the things I like to do to have time to purge; It ruins my singing voice; I passed out, lost interest; When I binge, I don’t want to do anything else; I’m always fatigued; No more joy, stopped doing anything else; I cancelled dates and socializing; Lost concentration. Had to stop playing sports; It numbs me. No emotions; The eating disorder destroyed my life; I love water sports and I’m too scared to wear a swimsuit; Nothing is fun anymore, I’m grouchy, apathetic; I’m too cold. I isolate; It kills my creative energy.

Experiential recreation therapy interventions are designed to break the addictive cycle and facilitate self-awareness and self-expression. Experiential therapy differs from traditional psychotherapy in that an “experience” is planned which can provide a learning “body experience.” Concepts such as pushing past the fear, teamwork, communication, assertiveness, leadership, confidence, and self-compassion are in focus through activities which create an experience of these in the moment.  Experiential therapies help take the patient past “talking” and into “doing”.

Acceptance of self and others, relying on higher power, and trust can be experienced with the whole self (body, mind, and spirit). The Ropes Challenge Course provides an experience where residents and their family members can overcome physical challenges which then relate back to emotional challenges. A patient could spend weeks talking about the concept of trust and not really understand it until it becomes a personal body, mind, and spirit experience. Recreational and Experiential therapists are trained to help process planned experiences, facilitating an in-depth examination of beliefs, thought processes, emotions, and behavior patterns, helping patients experience how learning from experience can create positive changes. Patients move out of their “comfort” zone and into their “courage” zone.

The Center’s Leisure Education Services are based on the assumption that behavior can change and improve as the patient acquires new leisure abilities, knowledge, skills, and attitudes. Leisure activities are planned as a means of learning healthy coping skills. Active involvement in social outings and creative leisure skills can provide new resources and promote development of inherent talents. Service projects are planned as a means of reaching out to others and discovering the joy of helping others. Patients become more acquainted with what they have to offer as they give meaningful service to others. As patients become more focused on their strengths, gifts, and talents they become empowered. Perceptions shift toward perceived freedom, competency, problem-solving abilities, conflict resolution, successful experiences, and internal motivation. Life as an adult woman begins to be viewed as exciting rather than as terrifying. Eventually, patients can honestly believe “I can be a responsible adult who has choices and options; life is an adventure; it’s never too late for a happy childhood.”

Patients are encouraged to increasingly take responsibility for their leisure mental health and well being.  True leisure is only possible if a person is at peace with self. They may begin to realize what it means to be truly human, truly alive. As the recovering patient chooses life over death, chooses hope over despair, chooses health over illness, chooses light over darkness, she begins to be “re-created.” A healthy sense of self and a clear and accurate appreciation of who he or she is as a unique individual is critical to the experience of healing. Healing leisure experiences promote a sense of connectedness to a greater whole (environment and community). Recreation therapy addresses the total needs of the woman suffering with an eating disorder, and those needs can find fulfillment through leisure experiences. Recreation therapy can bring women a sense of joy, laughter, belonging, and a renewed sense of wholeness.

Revised September 2014


When the Road to Recovery is Full of Potholes

Author: Julie B. Clark, PhD

You seem to be sailing along with the wind in your hair and then bam! – you fall into a pothole. Finding yourself engaging in the same eating disorder behaviors you’ve been fighting so hard to be free from can be discouraging. Some refer to this pothole process as a lapse. This means using the old familiar but unwanted behaviors of the eating disorder to cope. It does not mean a complete return to the eating disorder. Recovery is a roller-coaster ride and it certainly has its ups and downs. The ride can be discouraging and feelings of fear and hopelessness often creep in for anyone trying to recover as well as for their friends and family members. Fortunately there are also those exhilarating moments of success. Hang on and learn how to enjoy the ride!! Don’t ever give up or quit!! The reality of recovery is that it takes time. Dr. Michael Stroeber did research on the long-term outcome in anorexia nervosa for recovery. He found that nearly 30% of patients had weight loss following hospital discharge, prior to achieving either partial or full recovery. For most patients the time to recovery was 57 months for partial recovery, to 79 months for full recovery. The relapse rate after partial recovery was 10%, but 0% after full recovery. He also found in his sample of 95 patients that 75% met criteria for full recovery with 86% of the sample achieving at partial or full recovery (recovery was defined in terms of partial or full remission, maintained for a period of no fewer than 8 consecutive weeks). Individuals suffering from bulimia typically have a larger percent in full recovery and it usually doesn’t take as long to achieve.

Let’s focus on lapses and what to expect. Lapses in recovery are a step in the process and provide opportunities to learn and utilize better coping strategies. Dr Craig Johnson, who is one of the leading researchers in the area of eating disorder treatment states:

Our program operates on the philosophy that patients who have long histories of eating disorders and other comorbid symptoms usually require long-term treatment. In our minds long-term treatment is measured in years, not days, weeks or months. In our opinion there is no shortcut to the process of undoing previously disappointing relationships and establishing new ones. In our experience, talk is cheap when working with these patients. Our more difficult patients have taught us that anorexia and bulimia are episodic disorders and that recovery is a process of taking two steps forward and one step backward. It is a process that requires a great deal of patience..

This may be comforting and overwhelming all at the same time. I have heard so many say “I just want it to go away–now!” Just remember that the eating disorder didn’t develop overnight and it will not go away overnight. It is a hard-fought battle but so possible. Dr. Paul Harper suggests that “recognizing the stages of the lapses can help you recognize the danger signals leading to relapse which can help you control and stop the negative trends.” Life is full of “opportunities” to encounter situations that test the fiber of your change. The situations that can be difficult include (I might add that this is true for any human being) painful emotional states, interpersonal conflict, social pressure, unhealthy dietary and health approaches, and failure experiences. Hello! welcome to life. Maybe the partial key to recovery is in normalizing the journey of life. Realizing that we all struggle and are doing the best we can in these roller-coaster situations. Unfortunately rigid expectations and perfectionism can be sabotaging to the process. Instead of learning to do it better and letting the lapses be a step to recovery many will see the lapses as failure. Often family members, friends, and therapists become discouraged and inadvertently or overtly support that notion. I like what Dr. Maria Root said in a recent article she wrote on relapse. She said:

The chance of a relapse exists for anyone who has had an eating disorder, even after being symptom-free for years. Humility, coupled with hope and a sincere willingness to carefully examine what happened during minor or even major slips, is what defines recovery.

Family members and friends can make a great difference in the process of recovery by providing encouragement and expressing confidence in your loved one’s ability to succeed. Avoid criticism. It is not a motivator to change. Keep up the expressions of love and acceptance. Whatever the emotional process to change is, it definitely takes repetition and constancy. Measure success on new dimensions and look for the change that is happening. Sometimes our expectations for ourselves and others can be too constricting and rigid and we label our efforts as not good enough. The fear of the destructive eating disorder behavior can also send us into a panic mode and create additional stressors. Using guilt or shame against the eating disorder won’t help. Remember that your loved one already has plenty of this. What they need most is love, acceptance, and a belief in their ability to overcome the eating disorder. In a similar way you must accept and value your abilities and efforts. The journey is a painful and joyful one for all involved. This challenge of recovery can provide the soil for the growth of incredible relationships and understanding hearts. With love, encouragement, and continuing effort the number of potholes will decrease as the road ahead becomes more smooth and predictable.


Written: Date Unknown

Reviewed: November 2014


Listen to Your Body

Author: Rebekah Mardis, RD, CD

Life is precious and fragile. Through the senses of your body, you have a unique experience of life. As a child you lived in the moment, you honored your body by doing what comes naturally. You ate when hungry, scratched when you had an itch, and yelled and laughed when you felt like it. As you aged you may have become more “civilized” by doing what is expected and by not making waves.

You may live without ever knowing what it is like to be alive. You may be constantly analyzing, reviewing, and planning — not paying attention to what is going on in your body at a given moment in time — as my mother says, “One foot in the future and the other foot in the past, while pissing on the present.”

Your senses provide you a tool to cue into the moment. As an example: You may be experiencing anger, have a twitch in your left eye lid, smell bread baking, hear a bird chirping, feel your lungs filling your body with life giving oxygen, taste the remnants of an onion eaten earlier, and see someone you love intensely, all in one second of your life.

If you are used to living without sensing being alive, you may only cue into anger and shut out the rest of the sensations. But if you were to die right after that experience what would have really mattered? I doubt it would be the anger.

When you begin to sense your body, life becomes very sensual. And what is important becomes clear — and that is being alive. Having a near death experience, a life threatening illness, and even recovering from an eating disorder can help bring perspective to life. Quoting the movie, Fight Club: “You are not your job, you are not the clothes you wear, you are not the money in your pocket.” If you are not all of these things, then who are you?

Focus on what it feels like to have a body, your senses, your movement, tastes, smells, etc., and who you are is apparent — you are alive. Listen to what your body is telling you: if you are tired, take a nap — and enjoy it; if you are hungry eat what you crave and savor every bite; if you are sad then cry and feel the joy of having the ability to do so.

If you are full on life, you do not need food or substances to fill the void, you don’t even need others to complete you, and you are someone even if you are not care-taking others. You are complete just being you. You are alive and that is wonderful.

With the recent world events it is clear that life is precious and uncertain. If this is your last second, your last hug, your last meal, your last dance, it should be sensual and wonderful. It should be savored. Give yourself the permission to be alive by listening to your body.


What Spring and Summer Bring

Author:  Julie B. Clark, PhD

Summer is coming. What does that mean to you? Is it the renewal of life, warmer and longer days, wonderful smells and beautiful colors, playing outdoors, coming out of hibernation? These sound like positive and pleasant things. Unfortunately, for most women spring is not a time of rejoicing, but a time of remorse. “Oh, I just look horrible”, “I shouldn’t have eaten that piece of pie last night”, “I hate the spring and summer—it means shorts and the unthinkable “s” word — swimsuit.”

Most women, and perhaps men, really find the thought of swimsuits to be unpleasant. Society has done a great job of indoctrinating us with its notion of what the “ideal body” should look like — to such a point of brainwashing that stepping in front of the mirror is frightening, and a journey of self-deprecation for most girls and women. “If we could only look like so-and-so.” We have become skilled in making a mental list of all our physical deficits in a relatively short period of time. It gives new meaning to the phrase, “Mirror, mirror on the wall, who is the fairest one of all?” Unfortunately, when we look at ourselves we often judge unfairly. Wouldn’t we be happier if we could be fair with ourselves? Robert Louis Stevenson said, “To know what you prefer instead of humbly saying Amen to what the world tells you you ought to prefer, is to have kept your soul alive.”

It is difficult to imagine what we might think “looks good” without the influence of the culture of “thin ideal”. Hey! Maybe this spring can be different. Instead of trying to live by the rules of the world, what if we really renew an appreciation for our bodies — not in a one-dimensional mirror image, but a multifaceted sense of who we are — keeping our souls alive. Then maybe aging would be an experience of growth and beauty. Maybe our eyes will see the beauty from the inside out, and really get in touch with what’s important and what we ultimately want to value. Will society ever accept us? Do we need society’s acceptance? It brings up images of a paper society all clipped out of magazines, walking around smiling and hoping no one rips us to shreds or blows us away. I wonder how differently we would deal with each other if we could really see the other person — or really be seen by others. It really doesn’t take much effort to think of all our faults. That negative barrage seems to flow so easily.

To change attitudes takes effort, work, and a determination to spit in the face of western culture’s touted expectations. Who gets to decide what looks good anyway? Do we? Could buying the magazines and paying for the weight-loss products be our way of saying “I agree” — “I should look this way”. We know that pictures of models are doctored up to look “better.” Why do we keep playing the game and paying for it emotionally, physically, financially, and spiritually? If we don’t fight the illusions of societal beauty, who will?

Could spring possibly mean more than a time of dread, worrying about how others will view our bodies? “We are not troubled by things, but by the opinions which we have of things.” (Eepictetus) All of us need to press for a new view — a new vision and acceptance of God’s creation — us, versus man’s creation or image. Truly, “beauty is in the eye of the beholder.”


Date Written: Unknown

Reviewed and Edited: November 2014


Managed Care

Author:  APA

Editor’s Note: “From the Therapist’s Chair” is intended to be a forum for professionals in the field. We invite you to forward articles or papers to : ANAD, Newsletter Editor, Box 7, Highland Park, IL 60035.

Insurance companies, faced with the rising costs of health care and reduced profits over the past decade or so, developed new types of coverage – HMOs, PPOs, and related managed care vehicles. Many businesses and individuals, in purchasing insurance for their employees, bought the new types of coverage as an attempt to reduce the cost of premiums, deductibles, and co-insurance fees, thinking the quality of care would not be compromised, yet unaware of the sometimes-dangerous sacrifices consumers would be making with managed-care coverage.

The intention of the insurance companies has always been to reduce their payments to the health care providers, but that is not, of course, the pitch they make to potential customers. They applaud themselves for what they call excellent quality of care at reduced cost to the consumer and increased profit to them: the cherished “win-win” situation. Too good to be true? Of course! What the managed-care companies are deeming “excellent quality of care” is measured by their yardstick and is not an assessment of quality measured by the consumers or providers of care. What managed-care companies do not tell the consumer about are the restrictions to care that often dangerously hamper treatment availability, duration, and ultimately, quality. Obviously, the focus is not to manage care but to manage cost. They are not interested in the person, the nature of a patient’s illness or the way in which one person with depression may differ from another; or how one patient might be in need of inpatient treatment, while another with bulimia might appropriately be treated on an outpatient basis.

The process of attempting to hospitalize a patient with an eating disorder presents multiple obstacles for outpatient clinicians and serious potential emotional and further physical damage to bulimics and anorexics in need of inpatient care. To managed-care companies, the symptoms of an eating disorder per se are not sufficiently life-threatening to warrant hospitalization. Unless a patient is actively suicidal, the managed-care companies state that the person’s psychological symptoms are not sufficiently acute and that inpatient treatment “is not medically necessary.” The exception to this rigid, and often irrelevant, criteria occurs only if a patient’s physical examination or lab results indicate severe physical, metabolic or organ system complications from the eating disorder, enough to warrant inpatient medical treatment.

The psychological crisis is never of sufficient severity to warrant hospitalization unless the patient says she/he is suicidal. I was once told by a managed-care medical reviewer, when I was trying to hospitalize a bulimic who purged 15 times a day, was severely depressed and no longer left the house, “We don’t hospitalize attitude problems.” As many know who work with or have experienced an eating disorder, a patient can often be severely out of control with binge/purge or restricting behavior, yet their blood work and physical exam can appear normal. Managed-care companies, with their impersonal checklist of criteria for what comprises disorders, and their lists of criteria for when hospitalization is necessary, fail to understand the critical and life-threatening natures of eating disorders. They are ignorant of the insidious, all-consuming chronic behavioral symptoms of eating disorders and fail to recognize the connection between long-standing symptoms and the poor prognosis for recovery. The managed-care templates for treatment of eating disorders is too simplistic: globally assuming all bulimics are alike and all anorexics are alike and that all should be treated on an outpatient short-to-intermediate-term basis with antidepressants and cognitive-behavioral treatment. They fail to recognize that, in some, the self-destructive behavior may be beyond behavioral control in an outpatient setting, and may have to be treated in an inpatient setting in order to redirect the behavioral dyscontrol, reduce the chances of chronicity and enhance the prognosis for long-term success. Bulimics and anorexics may not be overtly suicidal, but eating disorders lead to death more often than any other psychiatric condition, even major depression.

What can you do to help change these insufficient and life-threatening policies? Write or call your insurance company administrators when any kind of care, inpatient or outpatient, is not authorized based on their indirect, impersonal, non-specific medical review. They do not know you or your patient. No matter how specific their checklist or their knowledge of the literature on disorders is, they do not work with the specific individual in need of the treatment requested by the professional. Don’t hesitate to contact legislators in your district and inform them of insurance controls over your health care that limit treatment inappropriately. Don’t take no for an answer when you know what you need!

Marla M. Sanzon, Ph.D., P.A. Annapolis, MD


Listening to the Heart (With Artwork)

Author: Randy K. Hardman, PhD

Broken Hearts

image001This heart is covered by a dark cloud with empty space around the heart.


image003This is a heart of gold that is “always broken” and “Always feeling pain.”


image005Her heart is in a cage and bleeding green blood.  The green blood represents how she does not feel healthy and feels different from everyone else.


image007She feels a lot of pain in her heart and feels like it is locked.


image009Patient feels like part of her heart is a mystery to her.


image011This heart is broken with a tornado of acid reflux burning ulcers in her stomach.


image013There is a scared little girl who was abused still in her heart. The heart is fenced off with a “no trespassing” sign and danger” tape warns others to keep out.  There are also black tear drops throughout her heart.


image015The black spikes around the heart are painful and will keep people away.  Her heart is broken and burning inside.  The green eating disorder monster is lurking just below her heart.


image017There is a brick wall enclosing this gray heart.  At the bottom of the heart there is a gray cord leading to a remote control where other people and outside influences control her feelings.


image019This heart is seeking balance and growth.  However, the eating disorder and the negative mind, represented by the snake, are preventing her heart from being properly nourished.


image021This heart is torn.  One half is locked in a cage by the eating disorder.  The other half is desperately wanting to be loved.



Healing Hearts

image023This heart is starting to feel life and growth again.  Her heart is a flower with blue and red petals.  The blue is peace and the red is warmth.


image025     image027 She feels her heart has grown and shines more now that she is feeling some relief from her eating disorder.


image029The heart is feeling love and warmth.  It is warming up the rest of the body.  There is still a black tear drop of pain in the center of the heart.


image031The body is divided into sections.  The heart has its own section to radiate love.  It is not yet radiating throughout the body.


image033She compared her heart to the glass case in “The Beauty and the Beast” which kept the flower alive forever.  Despite everything that she has been through, she can feel the flame of life in her heart.  Client related that her gratitude has kept her alive through everything.


image035This heart still feels confusion but is beginning to break down the brick wall that has been surrounding it for so long.  She feels better able to give and receive love.  She feels more hopeful about her future growth.


image037In the beginning of treatment (left side) her heart was exploding from keeping her sexual abuse a secret since childhood.  She felt a lot of pain and anger in her heart. Towards the end of treatment (right side) her heart was a bright flame that could hvae a powerful influence on others.


image039In the beginning of treatment (right side) she was only feeling warmth in her heart.  The rest of her body felt numb.  As her heart became warmer (middle) the ice begain to melt causing a tidal wave of thoughts in her head.  By the end of her treatment (left side) she was feeling warmth and life from her heart throughout her body.


image041In the beginning of treatment (right side) her heart was smaller and more contained. Her heart was not expressing very much.  Further into treatment (left side) her heart begain to swell.  She began to express more of her brightness, the yellow beams radiating up, and more of her sadness, the tear drops falling from the heart.


image043     image045 In the beginning of therapy the client felt that her heart was a mystery.  She had a hard time knowing what was happening in her heart.  Further into therapy, the client recognized her heart as uniquely her own.  She reported that she is learning to trust her heart.


Eating Disorders: The Internalization of the Thin Body Ideal

Author:  Nicole Hawkins, Ph.D

Research over the last two decades has indicated that the incidence of eating disorders appears to be increasing. Health care professionals have reported what some consider to be epidemic rates of these disorders in recent years, particularly among adolescents. The rate of development of new cases of eating disorders has been increasing since 1950 (Wade et al., 2011)

Although most researchers concur that the number of new cases of eating disorders is increasing, there is less agreement about the factors that may be promoting this increase. Sociocultural factors are thought to play a central etiological role, and have received the most research attention in the last decade. Specifically, many theorists strongly believe that our culture’s ultraslender ideal-body image (or thin-ideal) portrayed in the media has been a critical contributor. The thin-ideal woman is actually a caricature; she is well below the average weight of typical women in our culture, and is portrayed as optimally successful, desirable, and happy. Sociocultural theorists and researchers also argue that the thin-ideal depicted in the media has become significantly thinner over the last several decades and, therefore, the discrepancy between the thin-ideal (i.e., 5’11”, 117lbs) and the average woman (i.e., 5’3/8″, 166.2lbs) has increased. This, combined with the intense focus on dieting in our culture, has reportedly helped promote the current epidemic rates of eating disorders.

According to the sociocultural model of eating disorders, young girls in our society quickly learn that thinness elicits many forms of social reinforcement, achievement, and rewards, whereas obesity is associated with various social punishments such as social isolation. Therefore, repeated exposure to the successful thin-ideal portrayed by the media leads some girls and women to overinternalize the stereotype. That is, women’s perception of the typically dramatic discrepancy between their body shape and size, relative to the cultural ideal, is thought to produce heightened body dissatisfaction and depressed moods, and prompts them to set unrealistic body-dimension goals for themselves. It is argued that as young girls are repeatedly exposed to thin-ideal images they will begin to internalize this thin-ideal. Theorists argue that with the thin-ideal becoming even thinner in recent years, many young women are finding it increasingly impossible to achieve an ultraslim body form. They begin to take more drastic measures to control their body weight (i.e., restricting, purging, excessive exercise) and develop negative feelings about themselves and their body. A vicious cycle is started, because growing body dissatisfaction is thought to lead to increased dieting and use of extreme measures to lose weight in some women.

Sociocultural researchers have compiled a plenitude of indirect evidence linking the decreasing size of the thin-ideal in the media and intense focus on dieting in our culture to increased rates of eating disorders. However, only a few research investigations have attempted to directly examine whether a relationship exists between the thin-ideal image portrayed in the media, and women’s satisfaction with their own bodies. Given the prevalence of eating disorders, more empirical evidence is needed to determine whether there is a relationship between the thin-ideal image depicted in the media, and women’s dissatisfaction with their bodies. To help further this area of research, I recently completed a study that experimentally examined the effects of exposure to the thin-ideal on women’s affect, self-esteem, body satisfaction, and level of internalization of the thin body image. My research also assessed how the thin-ideal image differentially impacted women with a diagnosed eating disorder. College women (N= 145) were randomly exposed to photographs from three popular women’s magazines (Cosmopolitan, Vogue, and Glamour) containing either thin-ideal images or neutral images (non-models). The subjects in each group viewed 40 images and were asked to answer a corresponding question on the Media Response Questionnaire. This questionnaire was developed specifically for this research to help maximize experimental conditions versus control effects and ensure that subjects adequately attended to all important features of the media materials for a set period of time. Subjects then completed several measures which included: subscales of the Eating Disorder Inventory, Second Edition (EDI-2), Profile of Mood States (POMS), Rosenberg Self-Esteem Scale (RSE), and the Sociocultural Attitudes Toward Appearance Questionnaire (SATAQ).

The results of this study indicated that brief exposure (30 minutes) to thin images produced heightened levels of body dissatisfaction among women, F (1, 143) = 44.76, p<.0001. The findings also indicated that after being exposed to the thin-ideal images, women in the experimental group reported increased negative mood states (i.e. depression, anger, anxiety, fatigue and confusion) compared to women who viewed neutral images, F (1,143) = 22.79, p<.0001. The findings suggest that women had lower scores on the self-esteem measure after exposure to thin images, F (1,143) = 17.42, p<.0001. It was also found that women in the clinical group exhibited lower self-esteem scores than women with eating disorders in the control condition F(1, 19) = 21.34, p<.0001. It was expected that exposure to the thin body image would result in higher levels of internalization of the thin-ideal; however, the results indicated that women exposed to these images had significantly lower levels of internalization compared to women in the neutral condition, P (1,143) = 4.10, P<.04. One explanation for this finding is that women in the experimental group were reluctant to endorse that they admired this thin-ideal body image given the majority felt dissatisfied with their bodies, exhibited negative mood states, and felt less self-worth after exposure to the images. Hence, women may be reluctant to willingly acknowledge wanting to aspire to look like a thin-ideal when it creates personal distress. One finding of particular interest was that women with eating disorders exhibited significantly more body dissatisfaction and depression after exposure to the thin-ideal relative to all other subgroups of women. This finding suggests that women with eating disorders experience pronounced changes in affect and self-approval compared with other women when viewing images of the thin-ideal.

It should not be surprising that media images have an influence upon their audience. However, the findings of this research suggest that the photographic representation of women in mass circulation fashion magazines can have a powerful influence on women’s self-appraisals. The broader social implications of this research become apparent when one considers the current debate over the appropriateness of ultrathin fashion models (e.g., Kate Moss). It is clear that these images send a dangerous message. Exposure to the media-portrayed thin-ideal was shown to be related to body dissatisfaction, negative affect, and low self-esteem and suggests that women may directly model disordered eating behavior presented in the media (e.g., fasting or purging). Additionally, the focus on dieting in the media may promote dietary restraint, which appears to increase the risks for binge eating.

Media presentation of “idealized” women cannot be the only factor responsible for women’s negative self-appraisals. However, this effect is substantial enough to suggest that media presentation of idealized women’s bodies may have practical relevance. In terms of a clinical application, it might be critical to advise female anorexics and bulimics to avoid publications or television programs that portray women as thin-ideal images. Second, women’s responsiveness to such images might be addressed through cognitive-behavioral therapy. Third, school-based prevention efforts could be aimed at reducing the internalization of the thin-ideal stereotype, as well as promoting body satisfaction. These programs should also emphasize the incongruence between biology and the thin-ideal body image. Negative psychological and physiological risks associated with the pursuit of this body type need to be underscored.

Today’s women can be helped by using media to their advantage, encouraging media representatives to adopt role models reflecting a broader spectrum of beauty than that which has traditionally been portrayed. Several campaigns (Dove Campaign for Real Beauty) suggest that some media representatives are trying to portray more realistic images.

Revised August 2014


Twelve Ideas to Help Women with Eating Disorders Negotiate Thanksgiving, Hanukkah, and Christmas

Author:  Center for Change Treatment Team

Eat regularly and in some kind of reasonable pattern. Avoid a pattern of “preparing for the last supper.” Don’t skip meals and starve in attempt to make up for what you recently ate or are about to eat. Keep a regular and moderate pattern or self nourishment.

Strive to worry more about the size of your heart than the size of your hips! It is the holiday season, a great time to reflect, enjoy relationships with loved ones, and most importantly a time to feel gratitude for blessings received and a time to give back through loving service to others.

Discuss your anticipations of the holidays with your therapist, doctor, dietitian, or other members of your treatment team so that they can help you predict, prepare for, and get through any potential uncomfortable interactions with family and friends without self destructive ways of coping

Have a well thought out game plan before you go home or invite others into your home. Know “where the exits are,” where your support persons are, and how you’ll know when it’s time to make a brief exit and get connected with needed support.

Talk with loved ones about important issues: decisions, victories, challenges, fears, concerns, dreams, goals, special moments, spirituality, relationships and your feelings about them. Allow important themes to be a part of focus and conversation, present and allow yourself to have fun rather than rigidly focusing on food or body concerns.

Choose, ahead of time, someone to call if you are struggling with addictive behaviors, or with negative thoughts, or difficult emotions. Call them ahead of time and let them know of your concerns, needs, and the possibility of them receiving a call from you.  Then if need arises, make that call.

If it would be a support or help to you, consider choosing one loved one to be your “reality check” with food, to either help plate up food for you, or to give you a reality check on the food portions which you dish up for yourself.

Write down your vision of where you would like your mind and heart to be during this holiday time with loved ones. Take time, several times per day, to find a quiet place to become in tune again with your vision, to remember, to nurture, and to center yourself into those thoughts, feelings, and actions which are congruent with your vision for yourself.

If you have personal goals for your time with loved ones during the holidays, focus the goals around what you would like to do. Make your goals about “doing something” rather than about “trying to prevent” something. If you have food goals, then make sure you also add personal emotional, spiritual, and relationship goals as well.

Work on being flexible in your thoughts. Learn to be flexible in guidelines for yourself, and in expectations of yourself and others. Strive to be flexible in what you can eat during the holidays. Take a holiday from self imposed criticism, rigidity, and perfectionism.

Stay active in your support group, or begin activity if you are currently not involved. Many support groups can be helpful. 12-step group, co-dependency group, eating disorder therapy group, neighborhood “Bunco” game group, book c;ub groups, and religious or spiritually oriented groups are examples of groups which may give real support. Isolation and withdrawal from positive support is not the right answer for getting through trying times.

Avoid “overstressing” and “overbooking” yourself and avoid the temptation and pattern of becoming “too busy.” A lower sense of stress can decrease a felt need to go to eating disorder behaviors or other unhelpful coping strategies. Cut down on unnecessary events and obligations and leave time for relaxation, contemplation, reflection, spiritual renewal, simple service, and enjoying the small yet most important things in life. This will help you experience and enjoy a sense of gratitude and peace.

Revised July 2014


Anorexia Nervosa and Bulimia Nervosa – Diagnosis & Treatment Guide for Professionals



Medical Doctor, Minister/Clergy, Psychologist, Psychiatrist, School Nurse, Dietitian, Dentist, Orthodontist, Social Worker, Teacher (junior high through college), School Administrator, Athletic Coach, School Counselor, Dance Teacher, Human Resources/Personnel Manager, Health Club Owner/Manager, Professional Counselor.

If you are a member of one of these professions, you regularly work with individuals who are at risk for, or suffering from anorexia nervosa, bulimia nervosa or other eating disorders. Those who suffer from these eating disorders are usually between 12 and 30 years of age and most often are women.

This overview will help you recognize and better understand those you see on a professional basis who may be suffering from anorexia or bulimia. It provides information that will help you interact with eating disorder sufferers and their families.

As a caring third-party observer, yours is a very important role. Your involvement can help lead women with eating disorders and their families to the specialized care needed for recovery. Ultimately, your ability to recognize, give care, and refer can help save lives from the terrible consequences of eating disorders.

Anorexia and Bulimia Defined
Anorexia: Deliberate self-starvation
Bulimia: Binge-eating followed by purging
Compulsive Eating: Emotional or binge eating not followed by purging or other compensatory behavior

Bulimia and anorexia are complex illnesses with many causes and variations. Individuals with these disorders sometimes begin with dieting and a desire to be thin and attractive, but find they cannot stop. For most people, the illness is an expression of unresolved psychological conflict. The conflict may be due to traumatic life experiences such as physical or sexual abuse, or an accumulation of other less traumatic experiences that result in feelings of being “out of control”, “defective”, or “not good enough”.

Because they feel flawed and defective, those with eating disorders experience negative behavioral spirals. They feel they are losing a sense of control in their lives. To relieve this emotional imbalance and psychological trauma, they will anxiously search for ways to regain control through anorexia and bulimia. Many do not recognize that these are actually selfdestructive, life-threatening behaviors.


First, it is important that you bring the proper mind-set in working with someone suffering from an eating disorder. As you understand these individuals better, you will be able to move past the roadblocks in treatment, and you will be able to develop the patience needed to be of help.

Unlike clients with other illnesses, eating disorder patients initially embrace and defend their symptoms. They see food restriction and excessive exercise as fully compatible with their goals of weight control and self-control, goals which are highly valued in our society.

It is important to remember that underneath the defensiveness and denial of an eating disorder is a frightened person who feels ashamed, out of control, and of little worth. Often, their greatest sense of identity and accomplishment is in losing weight.


Unrealistic Images

The “ideal” woman portrayed by fashion models, Miss America, Barbie Dolls, and screen actresses is 5’7”, weighs 100 lbs., and wears a size 2.

The Real World

  • The average American woman is 5’4″, weighs about 140 lbs., and wears a size 14 dress.
  • 75% of American women are dissatisfied with their appearance.
  • Many young girls are more afraid of becoming fat than they are of nuclear war, cancer, or losing their parents.
  • 50% of 9-year-old girls and 80% of 10-year-old girls have dieted.
  • 90% of high school junior and senior women diet regularly, even though only 10% to 15% are over the weight recommended by standard height-weight charts.

The Bottom Line

  • At least 4% of teenage girls and college-age women become anorexic or bulimic.
  • Anorexia has the highest mortality rate (up to 10%) of any psychiatric diagnosis.


Anorexia can be a very frustrating condition to treat. Very few disorders evoke such strong reactions from professionals, although substance abuse and psychosomatic disorders come close. Individuals in these disorders are seen as denying, deceiving, and rationalizing to protect the symptoms that they have brought on themselves.

Unless we understand that the denial and deception are an integral part of the illness, our ability to help individuals with these disorders will be diminished. Eating disorder sufferers often deny many things: They deny they are ill. They deny they are thin and even that they want to be thin. They deny they are afraid of weight gain, or that they are distressed and tired. They may deny specific behaviors such as vomiting and laxative abuse. They deny or are unaware of their feelings and the psychological issues impacting their eating disorder. They most often minimize physical symptoms.

Eating disorder clients are very good at diverting attention away from food and weight when professionals are concerned about their physical condition. They are also good at distracting from their real difficulties by focusing on food, body, and weight.

For example, a client might say:

  • For ethical reasons, I don’t eat meat.
  • I don’t eat butter because everyone knows that saturated fat is bad for your health.
  • I don’t eat sugar because I’m allergic to it.
  • I exercise three times a day because it relieves tension.

Very few eating disorder clients seek treatment with the intent to gain weight but rather to get help in dealing with side effects or with other issues that they do recognize as problematic.


Why Eating Disorder Victims Value Their Disorder – What They Gain

Those with eating disorders may view their illness as a guardian or protector, a security or even “a friend”. Their illness is seen as a means of being attractive, gaining confidence, avoiding emotion, showing difference and superiority, and a means of feeling self-disciplined, “in control” or powerful. It may become their identity. They receive praise and accolades of others in response to their initial weight loss.

What They May Lose Without Their Symptoms

For people with eating disorders, the illness is crucially important to a sense of self. Without the disorder, they fear they will lose the identity and the sense of accomplishment they feel when they are “successful” in their disordered behaviors.

Above all other fears, is the overriding terror that by giving up the disorder they will be eliminating the only effective coping mechanism they have for dealing with emotion, stress, and fears. Letting go of the illness seems terrifying and impossible. Their main awareness is the fear of being “fat” or “feeling fat” instead of emotional issues.

Inside the Minds of Those with Eating Disorders

Individuals with eating disorders often interpret self-deprivation and ritualistic behaviors as triumphs of willpower over weakness. In reality, for these individuals, ritualistic behaviors and restrictions seem the only way out of difficult situations. In the mind of someone with anorexia, the decision to skip a meal or run an extra mile has functional benefits and even moral meaning.


Women with bulimia see themselves as failures. They may not want any part of treatment when they see “it is working”. Some seek treatment hoping therapy can eliminate binge-eating so that they can become better dieters and continue to lose weight.

For those with anorexia, starvation makes it very difficult to appraise their condition rationally or to change their patterns of thought or behavior. Often their depression and demoralization causes hopelessness about the possibility of living differently and the possibility of recovery.

At first, individuals with either of these eating disorders embrace their symptoms. But after many years, the illness becomes debilitating and miserable. At this point, they continue not by choice, but because of their feelings of helplessness and fear of change.

Women with eating disorders are most often unaware of the underlying causes of their behavior. They become conditioned by their experiences to feel relief when they lose weight and to feel distress when they eat or gain weight–even when they no longer intend to keep restricting or losing weight.


No matter how the eating disorder develops and is triggered, over time it acquires a life of its own. Clients often refer to it as the “monster” inside, and dealing with the “monster” leads to engaging a variety of adaptive, yet unhealthy, behaviors.

To those with eating disorders, the illness may become a shield from issues such as maturity, sexuality, and independence. As they give themselves over to the illness, they see it as a positive influence in their lives. They derive a sense of competence and self-control, and with anorexia sometimes even a sense of moral purity.

For individuals who have difficulties coping with complexity and uncertainty, the illness has a clarifying function. The disorder helps them see their lives as more simplified. They handle life’s complexities and difficulties by focusing narrowly on goals about weight and food.


Extensive research shows that many different factors contribute to the development of an eating disorder. The underlying causes often accumulate over a period of time, gain critical mass, and eventually combine to manifest themselves as life-disrupting eating disorders.


There are several factors known to increase the risk of development of an eating disorder. These include:

  1. Family history for eating disorders
  2. Family history for drug or alcohol abuse
  3. Family history for depressive or anxiety disorders
  4. High BMI in early adolescent years
  5. Early onset of menarche for girls
  6. Personality temperaments or traits of perfectionism, excessive worry or impulsivity

It is believed additionally that genetic predisposition or genetic vulnerability plays a role in the development of an eating disorder. Future research will likely shed light on the extent of that role.

Obviously, environmental factors also have an impact, including societal pressures to be thin and achieve, stressors of various types and family factors as well. Extreme themes or pattern in the family of perfectionism, over protectiveness, abuse or chaos can also have a negative impact in some cases.


When eating disorders are viewed as a reaction to external or internal social forces, there are some widely recognized social influences on anorexia and bulimia:

  • Major life transitions, such as onset of puberty, entering high school or college, and major illness or death of a loved one, divorce of parents.
  • Societal expectations, especially body image expectations as reflected by super models in magazines, TV, and in advertisements where body size is seen as the means to achieve happiness in life.
  • Mother daughter connection, related to body image and dieting.
  • Prejudices against obese people, and anxiety caused by not wanting to be the object of these prejudices with the corresponding loss of respect and status.
  • Romantic and social problems, such as going through a difficult break-up, being teased or criticized by others, or believing that these experiences happen because one is fat.
  • Perceived failure at work, school, or competitive events, especially in individuals whose self-esteem is disproportionately tied to achievement and/or external validation. Women and men with eating disorders are often perfectionists who set nearly impossible standards for self-acceptance.
  • Traumatic events often set the stage for an eating disorder. An eating disorder can be an attempt to distract oneself from trauma. Some eating disorder symptoms can be an attempt to cope with sexual, physical, or emotional abuse. Certain foods may trigger flashbacks of abuse, resulting in food avoidance.


Mental health professionals recognize that clients need to move through several stages in treatment for full recovery from an eating disorder. Experienced specialists view treatment as a predictable process of change that takes the client through four basic phases towards recovery. We suggest four stages of change towards full recovery:

  1. Awareness and acceptance
  2. Ownership and responsibility
  3. Commitment to change
  4. Self-correction and service to others.



An assessment of current functioning and history is important in determining the most needed and effective treatment. It is important to gather information on: medical and nutritional history, cultural environment, family environment, history of dieting, potential genetic predisposition, history of abuse, age and developmental concerns, length of time in eating disorder and eating disorder history, immediate stressors, emotional factors, spiritual factors, emotional and mental functioning and status, level of motivation for change, and preparedness to engage in treatment.

The Addictive Process and Cycle

One helpful and practical model for viewing treatment of eating disorders is to view the client’s behaviors within the larger context of an addictive cycle. Understanding the client’s progression through the following cycle will help the professional understand the process of compulsive eating disorder behavior and thus, the times and ways to intervene towards recovery.

Steps in the Cycle:

  • Primary difficult beliefs and feelings (i.e., loneliness, shame, fear)
  • Obsessive thoughts used as a way to distract from emotional pain
  • Increased anxiety resulting from the obsessive ruminative thinking
  • Compulsive behavior used to release the escalating anxiety
  • Temporary relief and calmness from acting out compulsive behavior
  • Secondary emotional guilt, shame, self-contempt, and feelings of being out of control
  • Withdrawal from other people both physically and emotionally through hiding, deceit, avoidance, and isolation
  • Reaffirmation of primary, difficult, and negative feelings and beliefs

Intervening between any step in this cycle may begin to weaken the rigidity of the addictive process. (Addictive cycle adapted from Beck, 1990)


Spiritual Interventions

Religious and spiritual issues are frequently intertwined with the pathology of eating disorder clients. Unresolved spiritual or religious issues can continue to exacerbate, or help perpetuate eating disorders. However, religious and spiritual resources and interventions can also be instrumental in a client’s healing and recovery.

In clinical work, seven important religious and spiritual issues which eating disorder clients struggle with have been identified:

  • Negative images or perceptions of God
  • Feelings of spiritual unworthiness or shame.
  • Fear of abandonment by God
  • Guilt or lack of acceptance of sexuality
  • Reduced capacity to love and serve
  • Difficulty surrendering and acting on faith
  • Dishonesty and deception

Spiritual interventions have proven useful to help promote clients’ religious and spiritual growth and well-being, helping them to cope with and overcome their problems.


Individuals who use their spiritual beliefs as a foundation for change, will often see the following results:

  • They overcome feelings of shame and unworthiness.
  • They alter their negative body image.
  • They affirm their individual spiritual identity and worth.
  • They gain a clearer sense of life’s purpose and meaning.

Spiritual interventions should be used according to the desires and beliefs of the client and as part of an integrated, multi-dimensional approach to treatment that includes standard medical, dietary and psychological approaches and interventions.



Listen with Empathy

Developing a genuine empathy for the eating disordered experience is important. This begins first with listening to the client and attempting to view their world and “walk in their shoes.”


Individual therapy, while difficult, is essential in recovery. Caregivers need to appreciate the fully ego-syntonic nature of thinness and selfcontrol. It is often difficult for clinicians to come to terms with the notion that these victims are trying to keep and give up their illness all at the same time.

Eating disorder sufferers choose what they choose because they do not see any appealing alternative for themselves. Remember that the response of someone with an eating disorder is the response of a person who is deeply unhappy with themselves, and while they are in a compulsive cycle, choices made are not always directly under their conscious control. The treatment process increases awareness, control, and positive choices.

Understand the Resistance

Do not attach surplus meaning to resistance since most eating disorder sufferers are very conflicted about giving up their eating disorder.

It becomes a therapist’s job, at first, to convince clients that change is possible and desirable. In order to treat eating disorder clients, be prepared to cope comfortably with their resistance to change.

Respect the Risks They Must Take to Recover

Frequently acknowledge how difficult these changes needed for recovery are, and the clients’ great courage to try to do things differently. Be careful and respectful of what you are asking eating disorder clients to do, since they may risk changing their behaviors on the strength of your guidance as an expert.

Respect the client’s individuality. Get a feel for when to be the expert who can give a client security, and when to admit confusion and ask the client to help you understand. Above all, be honest–don’t tell clients things that you don’t believe or understand.


Medical Institutions

Some mainstream hospitals, medical centers, and psychiatric hospitals now offer in-house treatment programs for eating disorders. These hospitals sometimes create a “facility within a facility” specifically for the treatment of eating disorders. Other times, they treat eating disorder clients in a program together with general psychiatric clients.

Typically, medical facilities provide only shortterm treatment until the patient is out of medical danger rather than focusing on longterm recovery needs.

Intensive Specialty Treatment for Eating Disorders

This type of facility typically focuses on the underlying causes of eating disorders with multi-phase, multi-disciplined inpatient and residential care. The treatment is usually personal, and caregivers are experienced specialists in eating disorders.

Clients receive the medical and therapeutic help needed for recovery while in residence with others who have the same challenges.

There is 24-hour support. The long-term recovery rate for this type of facility is good when clients stay the recommended length of treatment, and when they follow-up with aftercare and follow through on discharge plans.


  • Talk with local professionals who specialize in eating disorders.
  • Gently confront your clients with your observations and concerns about eating disorder symptoms.
  • Maintain your relationship with them, as this is an important time to assure medical safety and give emotional support.
  • Call local professionals who specialize in treating eating disorders for consultation or referral.
  • Call Center for Change and ask to receive information about providers who treat individuals with eating disorders.


Center for Change specializes in the treatment of eating disorders. Its founding partners are recognized as specialists and leaders in this field. Center for Change in Orem, Utah is an inpatient, residential care, and outpatient facility.

Our staff includes physicians, psychologists, therapists, dietitians, nurses, and many other clinical specialists.

For more information, call 801-224-8255 or 1-888-224-8250 and visit our web site at

Center for Change is accredited by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)


Therapeutic Guidelines and Experiential Interventions in the Treatment of Eating Disorders

Author:  Randy K. Hardman, PhD and Michael E. Berrett, PhD

In this article we describe general guidelines as well as a few examples of the experiential and structured interventions that we use when facilitating individual, group, and family therapy with eating disorder patients. The purpose of these experiential and structural interventions is to help patients explore the emotional relationship and spiritual issues associated with their eating disorders. Within the context of therapeutic treatment, these specific experiential interventions are only one small component of our program, but they have proven to be invaluable in helping patients see, understand and choose something better in their pursuit of recovery.


The following general guidelines are the underlying foundations upon which our experiential and structural interventions are based.

• Involve the Family System
It is important, where possible, to involve families in treatment, unless the family is on the farthest extreme of dysfunction and unhealthiness. It is important to find resources within the family to help meet the patient’s needs. It is important to help the patient make emotional connections within the family, to increase empathy and compassion within the family, and to help the patient individuate from the family in a healthy way that allows family connections to remain intact.

• Be Directive and Specific
It is important for the therapist to take more responsibility to be active in treatment, to create energy in sessions, and direct the process in ways that help the patient, who has less experience to draw upon, and whose life style has been more externalized, approval and peer-acceptance based, rather than anchored in self-definition and internalized principles.

• Use Activity-Based Sessions
It is helpful to use more activity-based sessions and fewer “talking only” sessions when treating eating disorder patients. Activity based sessions give a chance for the therapist to join the patient in their world, since many eating disorder patients spend much time in externalization as their approach to life–a seemingly constant search for external approval. This activity-based approach is particularly important for adolescents who have difficulty learning from others’ experiences, and seem focused on creating and learning from their own experience only. Experiential interventions teach lessons which are more easily internalized, and set the stage for later learning from insight and from others’ experiences.

• Provide Structures for Therapy
Nebulous and unguided therapy can create additional confusion and insecurity for patients with eating disorders. It is helpful to give the patient information about the process of therapy and the process of change. It is helpful to predict struggles and to help them anticipate the ups and downs of recovery and to prepare for these times. Tell the patient what’s going to happen, the sequence of events, why you are doing what you are doing, what they can expect, and the changes they will go through. This increases their trust in your understanding of them and your ability to help them.

• Provide Immediate Encouragement and Support
Without hope to overcome these devastating illnesses, movement in recovery is minimal at best. It is the therapist’s job to attempt to provide, create, and nurture hope in the patient. Tell the patient about your vision of their future, because they often cannot see this for themselves. Remind them that their illness can be overcome and that their feelings creating hopelessness are temporary. Point out their progress and their successes. Help them find and label improvements as such, no matter how small they are. Help them set short-term, sometimes very short-term goals, and help them find evidence of progress. Teach the concept and value of the small steps of change, and help them see the progress in specific moments along the way. Help them see not only what they are doing differently, but the internal process taking place inside of them as well.

• Explore the Differences Between Love and Acceptance Versus Approval
Those with eating disorders have so often learned to deeply believe that “approval is everything and disapproval is the end of everything.” They often have minimized and compartmentalized themselves into one or two explicit parts of themselves–their bodies and their external performance. It is important to stress that what they do and who they are, are not the same. Acceptance of “all of the self,” taking the focus off what others think, and helping them turn to the inside to find value are important themes. Helping them find language and labels and helping them understand the difference between love, acceptance, and approval can help them notice these different experiences.

• Emphasize Having Feelings Without Self-Judgment
Helping patients feel, label, understand, accept, and express their own emotion without making emotional judgments about who they are and what kind of person they are is important in creating an environment of self-acceptance for themselves. Many with eating disorders are tender-hearted and sensitive people who have “shut down”, and become numb and avoidant, allowing their feelings to lead to secondary and consequent feelings of guilt, shame, selfishness, or “badness.” Helping patients enlarge their ability to notice and experience their feelings without self-judgment is critical throughout the therapy process.

• Make Honesty and Congruence an On-Going Theme
Helping patients become more honest and congruent without self-criticism is necessary for recovery. Stress the need to stop any pretending, hiding, or lying, and stress the need for being genuine and open with themselves and other people. Honesty and openness in the therapeutic relationship comes by building trust and creating safety in that relationship and by helping the patient understand the expectation of honesty. This honesty includes helping them reveal secrets so that they can process their beliefs and feelings out loud, begin to allow help from others in overcoming shame, and break the childlike cycle of “hiding under the blanket of shame.” Secrets to be told may include past trauma and abuse from long ag: it may include mistakes made, thoughts or feelings which seem to them unthinkable and unforgivable, as well as telling the whole truth about their eating disorder. Telling secrets helps in being “grown up” as opposed to feeling the fear of “being little”, and “sweeping out all the corners” in the private stash of misery can bring relief and peace.  The love and acceptance of individuals in the group can be healing.

• Teach Patients to Avoid Only One Thing-Avoidance
Eating disorders are disorders of avoidance. Help patients learn about avoidance, its many faces, its damaging consequences, its seductive yet short-lived rewards, and its relationship to eating disorders and other addictive patterns. Help the client understand their fears, their unhealthy responses to fear, and the need to “feel the fear and do it anyway”. Discuss with the patient their fears of failure and the all-too-common patterns of failing, to avoid failure. Give patients challenges and urge them to take risks and to face their pain. Teach and help them experience vulnerability as a healthy precursor to growth within oneself and emotional intimacy within relationships.

• Persistently Show Nurturance, Kindness, and Caring
Those suffering from eating disorders have most often had an absence of nurture and care, at least during the duration of their eating disorder, since they have withdrawn from it in their primary relationships, and since they most often feel unworthy of love and therefore have difficulty “letting it in”. Some have lacked nurturance throughout their lives and have actively resisted the caring given to them because they have deemed themselves undeserving of it. It can help to make this pattern explicit by pointing out the reality of care, love, concern, and acceptance within relationships and help them see that it is available to them in their lives-not only from the therapist’s point of view, but from many others who love them as well. As they learn to notice it, label it, and are encouraged to receive it, they prepare to again accept and nurture connections with others important to them in their social and family circle.

• Make Unhealthy Behavior and Relationship Patterns Explicit
As patterns of dishonesty, manipulation, pushing others away, justification for unhealthy choices, patterns of helplessness and powerlessness, and food and behavioral rituals show up in the therapeutic relationship by report or observation, make them an issue in therapy. This can be done by pointing it out, labeling it for what it really is, dismantling justification of the negative pattern, having them look at the negative effects of such, and helping them ponder and then risk in choosing “new ways” of living. The self-deception, justification, and rationalization of the eating disorder builds a strong wall which needs to be directly addressed and carefully dismantled.

• Help Patients Separate Themselves from Their Disorder
In the later stages of an eating disorder, it may become the patient’s identity. They begin to perceive and live congruent with that perception – that they are their eating disorder. This self-definition brings with it fear, disgust, self-contempt, helplessness, withdrawal and guilt. In the later stages of the illness, the patient truly loses some conscious control over their behavior and choices. They need help to understand that much of their behavior is due to the illness of the eating disorder, and that it is not the result of personal deficiency or flawed willpower. Again, a theme here is, “you are not your illness and you are not implied by your behaviors, thoughts or feelings.” As they begin to view their illness linked to well-intended yet self harmful coping strategies, and begin to have understanding and even compassion for their painful journey into the eating disorder, they then can feel a sense of hope and self empowerment in their lives. They can assume an increase in personal responsibility for their choices and have the power to change negative choices.

• Help Patients Actively Use Their Spirituality in Recovery
Helping patients use their own sense of spirituality or religiosity, or both, in recovery can be very beneficial for many clients. In the initial sessions of assessment and throughout treatment it is important to have the patient teach the therapist about their spiritual and religious beliefs. It is then beneficial for the therapist to help the client live congruently with those beliefs, and to help them actively use their beliefs in the healing process, including their belief in a higher power, God, or divine influences. There is nothing more powerful then faith, hope, love, service, sense of purpose, and other principles that are spiritual in nature. Research has shown the value of spiritually in recovery, and ignorance of such is a neglect of a powerful healing resource. Caution must be used to allow patients to guide this process and to help clients use their own value framework without imposing the therapist’s beliefs on the patient. Respect is crucial.


The following interventions will provide you with a few examples of how to incorporate experiential and structured process into the context of group, family, and individual therapy. These interventions can generate emotional energy, verbal process and feedback, and behavioral reenactments that can be very useful in a patient’s ongoing treatment and recovery.

Group Therapy

• Hiding Behind The Wall
This group activity can be done with a few members of the group inside the larger group circle or it can be done by having every group member participate throughout the room. The facilitator can bring in large pieces of 3’x4′ cardboard or large cushion pillows to be used as props–visual representation of the wall. Group members are asked to break up into dyads and sit facing their partner with one member of the dyad holding the cardboard or pillow in front of them in a protective and self hiding fashion. In turn, they are asked to honestly tell their partner why they’re hiding, what they are hiding, what they do not want other people to see, why they are afraid to show their real selves, what they are trying to protect themselves from, why they put the wall up in the first place, etc. Their partner can ask clarifying questions and give feedback about how it feels being on the outside of the wall. The facilitator can process the experiences, observations, and emotions that emerged during the activity as an entire group. At times, the facilitator can have individual group members create past relationship scenes with family members and friends in front of the group, where they interact while hiding behind the wall. Participants are then asked to return to dyads and explore ways to put down or keep the wall down while revealing themselves honestly to their partner. Specific questions can be asked again to facilitate the personal sharing without the wall.

• Enactment of the Negative Mind
In small groups of three people, each patient struggling with strong negative voices in their mind is invited into the middle of the triad. When cued, the other two members begin to talk into the opposite ears of the patient in focus. One voice is on the “negative side” or the negative mind, and the other voice the “positive side” or validating mind. The patient in focus is given opportunity to listen and experience the intense internal conflict that comes with the conflicted voices, and to express her feelings, explore her power and ability to quiet the negative mind, and to embrace the messages of the positive mind. The group can process the impact of messages, listening, and the power of choice in recovery.

• The Sculpture of the Group Around Commitment 
A person well on the road to recovery and with some leadership responsibilities and abilities in the group is asked to do a sculpture of the group around a central focal point in the room, and that client sculpts each member of the group in proximity to the central focal point based on their perception of each person’s commitment to “change” and commitment to giving up their eating disorder and related self-destructive behaviors and beliefs. It is a great structural and experiential way to give feedback and allow for self-exploration and “looking in the emotional mirror”. Each group member is invited to respond with sharing of feelings and reactions about where they were placed in the sculpture and is also given the opportunity to put themselves in the place they feel is more accurate for their commitment to change.

• Let’s See What Is Most Important to You
The group members are asked to bring to group several items from their homes or rooms which represent or symbolize what is most important in their lives. Each member places those items in front of them as all the group members sit in a circle on the floor. Each member, one by one, tells the group about the items, their symbolic meaning or what they represent, and shares feelings related to each object. Following this sharing, each participant is asked to turn their back on these precious things by turning around and facing the outside of the group and by facing away from the inner circle where these important things are placed. The group is asked to process their feelings of loss, hurt, anger, sadness, and fear related to the loss of these important things in their lives, and to talk about how their eating disorder is something which turns them away, or takes them away from that which is most important to them. The activity can also address issues of commitment and congruence or incongruence between their stated messages of “what’s important” and their incongruent behaviors. Therapy discussions can also address grieving losses and making hopeful plans for the future.

• What Does the Line Mean for You
The therapist uses masking tape to make a 10-foot line in the middle of the group room floor. Individually, each member of the group is asked to stand up to the line, one at a time, and they are asked what the line means to them. The line can have many different meanings and can open up discussions on emotional boundaries, taking risks, taking a stand, holding themselves back, taking a leap of faith, opening up to others, etc. Having the therapist and group members give feedback and reactions to individual members at the line can also open up therapeutic interactions that can lead to acting out positive movement in relation to the line.

Family Therapy

• Blind Walk Through the Mine Field
A large room is prepared with an obstacle course of books, chairs, and other obstacles strewn randomly yet rather tightly throughout the room. The patient is led into the room blindfolded, and the family is also brought into the room. The family is asked to take chosen positions around the outside edges of the room. The patient is placed on one end of the room with instructions to find her way to the other side of the room without touching any object on the floor with any part of her body. She is further instructed that any touch of an object will result in her starting over at the original spot, and that the activity will take as long as needed, up to four hours. The family is instructed to help her across with only words and they are instructed to stay in their places outside of the obstacle course. As the patient and family journey through this experience, issues arise including frustration, anger, helplessness, trust, control, coping styles, helping styles, leadership, and family roles. The patient can be guided to discuss what it’s like navigating through recovery, and the family can talk about their desires to help, their feelings of powerlessness, and their styles or approaches to support and whether they are helpful or non-helpful to the patient.

• Stacking the Books: Ownership, Responsibility, and Barriers
In family therapy issues of personal responsibility for the eating disorder as well as other issues and feelings, such as marital happiness, individual happiness, and choices about health and wellness may arise. In this intervention therapy is done around a table. A large stack of books over five feet tall is placed on the table. The therapist or family members can divide up books relative to responsibility for different things in the family and give a stack of related size to each family member. Stacks of books can also be used as symbols of barriers in relationships, where sometimes family members can’t see each other because of barriers. Feelings and reactions about barriers and responsibility, or barriers to each other in objective form and experiencing those things not only emotionally, but physically as well, arise.

Individual Therapy

• Carrying the Burden 
It can be helpful to help the patient experience what it physically feels like to carry a heavy burden to help them get in touch with deeper feelings about carrying inside burdens. The burden might be their eating disorder, guilt for some act in the past, shame, self-hatred, or responsibility for someone else’s life or happiness. The client can be given a rock, a box, or another heavy or awkward object, and be asked to carry it with her everywhere she goes for the next few days or weeks. Encouragement to notice the impact of the burden’s interference in her daily life and to talk honestly about what she is learning and feeling along the way is very important (the burden item cannot be so heavy that it might cause any physical damage from carrying it).

• Wearing a Sign: Making the Implicit Explicit
As themes emerge in therapy about core messages the patient may “send out” in her relationships with others, which either push others away or prevents her from allowing their love and support into her life, these and other messages can be put on a large card and worn by the patient on her front side in an obvious place (i.e, worn as a necklace). Processing in therapy sessions can be focused around the message, what she really wants to say, direct communication, other people’s responses to her explicit messages, new ways of meeting needs in a healthy way, and her desires to change. As she becomes acutely aware of the messages and “gets tired” of giving the same old messages, she can begin to replace it with new positive messages. An alternative use of the signs can then be done to help change inside messages to explicit positive or affirming messages that she wears on the outside for several days.


We utilize 40-50 different structured and experiential interventions to help eating disorder patients understand, experience, and reinterpret different contributing aspects of their illness. For the sake of brevity, we have only mentioned a few of these interventions in this article. We recognize and greatly appreciate the need for different therapeutic styles and approaches, as well as the need for a comprehensive and multidisciplinary program for the treatment of eating disorders. What we have also discovered as therapists over the many years of working with eating-disordered patients, is the power and impact of experiential and structured interventions as one aspect of their treatment. These interventions often by-pass the extreme analytical or emotional avoidance defense mechanisms of patients, giving them a “new look” or an “emotional perspective” on their problems, as well “a taste” of what new solutions might be available to them in recovery.  Specific interventions should be used according to groups and individual needs and adapted accordingly.  Therapists can create interventions in the moment as inspired or feel to do so.

Revised and Re-edited July 2014


Anorexia and Bulimia – How Friends and Family Can Help

Author:  Center for Change


When you realize that someone you love may be struggling with anorexia nervosa or bulimia nervosa, naturally you want to know more about it. And because you care, you also want to understand what they are experiencing so that you can be as supportive as you can throughout their recovery.

You may already know that anorexia and bulimia are complex and confusing illnesses. Now that you are past the initial shock of discovery, you may be experiencing feelings of anxiety, guilt, anger, fear, and frustration–all understandable reactions. Seeing a loved one suffer from an eating disorder is very frightening and difficult. We know it’s not easy.

What happens now? First, understand that the illness did not develop overnight, and that recovery will not happen overnight. Second, know that there is reason to have hope. With dedication to treatment, recovery is attainable.


When singer Karen Carpenter died of anorexia, it was at a time when many doctors lacked the awareness and education needed to diagnose and treat victims of eating disorders. Today we know much more about these illnesses–what causes them, how to recognize the symptoms earlier, and the steps required for recovery.

Even though you may find it difficult to understand, your loved one finds security in their eating disorder. To its victims, the illness is a powerful and misguided coping mechanism. But with treatment, enough time, and lots of love, you can look forward with hope to a day when your loved one will likely be able to break the stranglehold of this illness.

You can play a critically important role in the recovery process. Knowledge-based appropriate actions and support can be a tremendous source of strength and comfort to your loved one.


1. Learn about eating disorders

To begin, you can help your loved one by getting your own emotions under better control. Educate yourself about anorexia and bulimia and you will almost certainly feel less anxiety and fear. Sometimes the unknown frightens us the most.

Your local hospital, library, mental health organization, and eating disorder specialists are good sources of information. See also, Recommended Reading, at the end of this article.

2. Learn about treatment for eating disorders

Learn about different modalities of treatment: medical care, medication, therapy and counseling, and dietary counseling. Learn about levels of care and different programs: inpatient care, residential care, partial hospitalization, and outpatient care. Sometimes intensive or inpatient care becomes necessary.

Be a smart consumer. Identify those professionals who work with eating disorders. Ask pointed questions such as what are the credentials of those who will be working with your loved one? Whenever possible, visit facilities and treatment programs which are under consideration.

3. Seek professional help

Don’t try to deal with this problem alone. Consider this: Of all psychiatric disorders, anorexia and bulimia have the highest mortality rate. On the other hand, early intervention improves the chances of recovery.

When dealing with an adolescent or with someone who is in acute medical danger, be prepared to exercise responsibility and authority. Their life may depend on it. In such circumstances, you may not be able to convince them they need treatment, and therefore you may need to act for their safety and well being.

Find out what needs to be done, and discuss options with eating disorder specialists and family members. Do all you can to stabilize your loved one’s medical condition and prepare them for appropriate treatment options.

Even with full recovery, the longer the illness runs, the more serious its permanent effects are. Conditions caused by the eating disorder (such as osteoporosis, ovarian failure, brain damage, endocrine abnormalities, and a weakened heart) can diminish quality of life long after the eating disorder is under control. Seek help as quickly as possible.

Good therapeutic intervention will help them in understanding the problem and dealing with the reasons their eating disorder exists.

4. Help your loved one recognize the problem

Those suffering from an eating disorder cannot begin changing their beliefs and behaviors until they admit they are struggling. When you gently confront your loved one about your observations and concerns, be prepared for strong reactions. They will be embarrassed, will likely deny anything is wrong, and will be terrified of losing the perceived sense of control they believe the illness gives them. They may withdraw out of fear or lash out in anger.

Be compassionate yet firm in your resolve. Be prepared for resistance. Your loved one may question the need for treatment, claim they can do it on their own or try to instill guilt by claiming you don’t care about them. You will probably be rebuffed many times as you encourage your loved one to admit to and to take responsibility for their eating disorder and related difficulties.

The knowledge you have gained from reading and discussing the problem with professionals will help you persist in loving and appropriate ways.

5. Have meaningful communication

Since eating disorders are rooted in emotional struggles, solutions are found in emotional healing.

In your attempts to help, do not oversimplify by saying “just eat.” This will only alienate the person you are trying to help. Instead, try to see the world through their eyes. Listen to your heart and follow those impressions. In moments of frustration and anger, don’t let your emotion control what you say and do. Express your own thoughts and feelings — especially your loving concern, your desire to help, and your good intentions. Feel free to admit to some of your own frailties, weaknesses, and short-comings. This gives your loved one permission to do likewise.

Try your best not to shame your loved one into eating. One of the hardest things to do is not personalize your loved one’s eating disorder (i.e., “if she loved me she would eat”). If it were that simple, most sufferers would eat on their own again. They are out of control and don’t fully understand what’s happening to them. Nor do they know how to help themselves out of the self-defeating behaviors.

Try to be objective, calm, and caring. Avoid fixing blame or guilt. Be sensitive, but be firm. Share your observations and concerns in a direct manner with kindness and respect. And when you are at a loss for words, a hug can express many loving thoughts and feelings.

Those with eating disorders often feel ashamed, discouraged, fearful and hopeless. These feelings don’t need fuel, but correction through unconditional love and encouragement.

The reality of an eating disorder is that the underlying issues are about pain, emotional suffering, and selfconflict –- not food. Helping your loved one to discover these emotions or to begin to talk honestly about their pain is a very important step toward help and recovery.

There is hope for recovery – something worth encouraging. Find it and do some coaching. After listening, acknowledging, empathizing, and validating feelings, move on to encouragement, hope and positive possibilities.

Always remember to respect the privacy of those you are trying to help. Do not discuss their issues with others unless they have given you permission to do so or unless sharing is necessary in keeping a loved one safe from harm.

6. Interact in ways that do not center on the eating disorder

Express your love consistently, not just when they are doing well with food or with gaining weight. Identify other ways of expressing your approval and affection that have nothing to do with weight or with the foods being eaten or rejected.

Even if they act as if 90% of their life is the eating disorder, treat them as a person — not as a behavior or an illness.

Never refer to your loved one as “the anorexic” or “the bulimic.”

Try not to be drawn into arguments, threats, bribes, guilt, or blame concerning weight, eating, and food. Just give a consistent “broken record” response affirming your love, concern, and hope.

Unless there is endangerment to life, do not shield them from the natural consequences of their eating disorder. For example, don’t finance the binge episodes of a loved one. Sometimes the pain from the consequences of engaging in the eating disorder can become a cornerstone of the motivation to let go of it.

7. Develop a support network

Find people you can talk with openly about your feelings and experiences, your fears and frustrations, and your plan of action. Contact local mental health professionals to learn if there are support groups in your area for friends and family of people with eating disorders. Participation in such a group may be very helpful. Talking with people whose family members have recovered from an eating disorder can bring hope and encouragement to you during difficult or discouraging times.

8. Be a good role model

Be a good example with food and when discussing food or weight-related issues. This may call for changes in your attitudes, eating habits, and activities. Consulting with a dietitian and a therapist may help you determine necessary changes in your own attitudes and behaviors around food and weight.

First, remember you can set an example without lecturing or making a production of it. Start by eating a well-balanced diet with a variety of foods. Exercise moderately. Accept your own weight, shape, and your right to participate in activities such as swimming and dancing or any activity you might enjoy but have not allowed yourself to participate in due to body dissatisfaction. Do not make negative comments about your own or others’ bodies.

9. Don’t blame yourself

There is no single cause for an individual’s eating disorder. Eating disorders are complex illnesses. The eating disorder is not your fault. Whatever your mistakes or weaknesses as a parent, spouse, or friend, you did not create this eating disorder.

We all have weaknesses. We all have been less than perfect or ideal in our roles and relationships. Yet, most of us have made good efforts to do our best based on our abilities and knowledge.

Take ownership for your weaknesses and frailties and make genuine efforts to change and improve. More importantly, take stock of your talents, gifts, and resources, and get to work providing love, support, and open invitations for your loved one to come into a safe relationship with you as they are ready.

Don’t let your guilt, insecurity, or fear get in the way of being actively involved in your loved one’s life.

10. Take care of yourself and be patient

If you are exhausted emotionally or physically, you will not be able to provide the emotional support your loved one needs the way you would like to. Those with eating disorders often do not know how to get their needs met and often do not know how to take good care of themselves. If you take good care of yourself, you will have more energy in your efforts to help them, and you will be teaching by example something your loved one needs to learn. Set aside time to care for your own social and emotional needs.

There are no quick or easy cures for eating disorders, so pace yourself. Be patient with yourself and with your loved one as he or she recovers. Often it will seem they are taking five steps forward, then three backward. But there is hope and recovery is attainable. Don’t ever give up!



Surviving An Eating Disorder: Strategies for Families and Friends, Michelle Seigel Ph.D., Judith Brisman Ph.D., and Margot Weinshel Ph.D., Harper Row, New York, 1997.

The Secret Language of Eating Disorders, Peggy Claude-Pierre, Times Books/Random House, New York, 1997.

The Monster Within: Overcoming Bulimia, Cynthia Joye Rowland, Baker Books, Grand Rapids, Michigan, 1984.

Hunger Pains, Mary Pipher Ph.D., Random House, Ballantine Books, New York, 1997.

Reviving Ophelia: Saving the Selves of Adolescent Girls, Mary Pipher Ph.D., Random House, Ballantine Books, New York, 1994.

Breaking the Cycle of Compulsive Behavior, Martha Nibley Beck and John C. Beck, Deseret Book Co., Salt Lake City, 1990.

Shame and Grace: Healing the Shame We Don’t Deserve, Lewis B. Smedes, Harper/Collins, New York, 1993.

The Shelter of Each Other: Rebuilding Our Families, Mary Pipher, Ph.D., Ballantine Books, New York, 1996.

Raising Self-Reliant Children in a Self-Indulgent World, H. Stephen Glenn and Jane Nelsen, Ed.D., Prima Publishing and Communications, Rocklin, California, 1989.

Changing for Good, James O. Prochaka Ph.D., John C. Norcross Ph.D., Carlo C. Dielemente Ph.D., Avon Books, New York, 1994.

Feel the Fear and Do It Anyway, Susan Jeffers Ph.D., Faucett Columbia Books/Ballantine Books, New York, 1987.


Center for Change

Gurze Books

National Eating Disorder Association (NEDA)

National Institute of Mental Health

International Association of Eating Disorder Professionals

Academy for Eating Disorders

National Institutes of Health

American Dietetic Association

The National Eating Disorder Information Centre (Canada)

Center for Change is accredited by The Joint Commission.


The 12-Step Program At Center For Change

By: Bobbi Carter

A former patient stated: “I wanted to go to a treatment center that addressed all aspects of my eating disorder – my mind, body, emotions, and you know, my spirituality.” In their book, SQ Spiritual Intelligence; The Ultimate Intelligence ,Zohar and Marshall write, “Many of us are spiritually stunted to some extent – some degree of personal fragmentation is almost inevitable in our modern ego-dominated society. Yet the deep self is always there. Spiritual intelligence is an innate capacity of the human brain, and we don’t have to be spiritual heroes to hear its call. It may be evoked because the lifelong ego strategies with which we have coped cease to work – the psychic glue binding our fragmented selves together suddenly gives way. When we do hear its call, a spiritual crisis results.” (p.187)

The 12-Step Program at Center for Change offers the residents a non-threatening way to get in touch with their spirituality. In 12-Step, we incorporate AA’s five procedures, which are:

1.Giving to God
2.Listening to God’s direction
3.Checking guidance
5.Sharing, both confession and witness

The damaging effects of an eating disorder upon one’s relationship to their Higher Power can range from feelings of total unworthiness, to anger and distrust. Hence, women come to the 12-Step group with different views and in different places in regards to their spirituality. This works out well since our focus is on the personal relationship one has with their Higher Power. We talk about the difference between religion and spirituality. We use the term “Higher Power” and stress the importance of their own definition of their spirituality and how there are many paths to their own truth. “What does your personal relationship with your Higher Power look like?” adn “How would you like it to be?” are just two of the questions we encourage the women to ponder. These questions open the door to looking at spirituality not only as a personal issue, but interpersonal as well. The journey we begin is intended to allow each woman to develop spiritually, to learn tools to get them where they want to be spiritually, and to use these “spiritual tools” in their recovery process. Spiritual tools include such things as prayer, meditation, nature, church, anything that allows a person to feel they are in communion with their Higher Power. “Once I was able to define my spiritual tools I felt I had easy access to my Higher Power.” We encourage the women to use their spiritual tools and to work on their spirituality daily. “I came to realize that if I put as much energy into my spirituality as I did my eating disorder I got to know myself better on a heart level. I began to actualize what I really wanted in life. The sky’s the limit!”

We look for miracles. In treatment it is easy to get bogged down by everything that is “not right”. In journals, we record three miracles a day which may include insights gained in therapy to something coming to us at just the right time. Sharing miracles in group enables a readiness to accept the natural sacredness of everyday occurrences. “When I started to notice miracles I realized for the first time that I don’t have to do this alone…In fact I’m not alone.” A common example of a miracle is how a woman gets to the Center. The women talk about how they hit “rock bottom” and just as they felt there was no hope “things just fell into place” for admission to the Center.

We work the steps. Packets are handed out weekly from the workbook, The 12 Steps, a Way Out….A Spiritual Process for Healing. We work on the same step together and each week we work on a different step. Working a step is then followed by an experiential exercise which may include a trust walk, writing down your most shameful secret, or letters to our Higher Power. For example, after we work Step 4 and have completed a self inventory, we write all the character traits we want to let go of on balloons and turn them over to our Higher Power. We then write character traits we have that we feel are negative and turn them into a positive.

And finally we share our stories. Fellowship is one of the most important aspects of the 12-Step group. When the women start reaching out by sharing or extending empathy, real relationships develop, shame can diminish, and healing will begin.

By participating in the 12-Step Program residents begin to understand the spiritual aspects of their recovery. How they choose to use their spirituality in recovery is of course up to them. In 12-Step we look at the many different ways to gain strength from our spirituality, turning ourselves over to our Higher Power, to the feelings of unconditional love and never being alone – even on our worst days in the recovery process.

Zohar, and Marshall, SQ Spiritual Intelligence: The Ultimate Intelligence , Bloomsbury Publishing, New York & London, 2000.

The 12 Steps, A Way Out …A Spiritual Process for Healing , RPI Publishing, Inc., San Diego, 1995.


Dilemmas For Parenting Amid The Social Pressures Of Eating Disorders

By: Dr. Kip Rasmussen, PhD

The World of Those With Eating Disorders 
The first thing to understand about eating disorders is that they are extremely difficult to grasp and treat. But if there is a shortcut to this understanding, it is to remember this definition: Eating disorders are a desperate and ultimately self-destructive attempt to “cope” with intense feelings of inadequacy and worthlessness. This sense of worthlessness can come from a variety of sources. In this article, I will focus primarily on one of these sources: social pressures.

An acquaintance of mine recalled having had a crush on a school classmate for roughly two years. One day as she was walking down the hall at school, this boy walked by and said an incredibly insulting expression to her about her weight. This expression, though hurtful, was of the type heard commonly in ordinary daily life. Nearly all of us have heard comments similar to this on TV, popular films or in social circles – probably within the last week. The only unusual aspect of this incident is that both the boy and the girl involved in this incident were in second grade. As a result of this incident, my acquaintance vowed she would never again leave herself vulnerable to these expressions of contempt based on her weight. Over the years, she developed a severe eating disorder, one which has plagued her now for almost a decade.

It’s never been an easy world in which to grow up. It’s harder now than ever before. My experience with clients, youth of my acquaintance, and my own children has startled me at the severity of their challenge. Growing up is hard for both boys and girls, but I believe girls today face difficulties which would truly amaze their parents.

One of the most eye-opening books of recent years was Mary Pipher’s Reviving Ophelia, a book which galvanized the nation in its harrowing portrayal of the arduous path to adulthood experienced by many young women. Many readers, including this reader, were startled by the level of depression, peer infighting, sexual coercion/assault, and general trauma many of these young women had been through in their young lives. In fact, initially, I thought Pipher was relating the unusual experiences of a self-selected population, and that the majority of the population of young women were different than those she described. But upon inquiry among adult female acquaintances about trauma such as those Pipher recounted, I was dismayed to discover that the women who had escaped trauma were the exception, not the rule. I found very few women who had not experienced alarming levels of harrowing incidents while in their childhood.

My experience with clients suffering from eating disorders has only confirmed Pipher’s experience. In the last decade, we, those parents who have been given watch over development of children, have been made more starkly aware than ever before that children and youth cannot be expected to raise themselves without an increased level of watchful concern from us for their healthy growth.

• Social Pressures on Young Women
As far as the development of eating disorders is concerned, perhaps the most common experience for those women who are suffering is to have been judged regarding their appearance. The damage occurs for those women who experience both extremes of the judgment scale.

It is well known that girls criticize each other regarding virtually every element of their appearance, from clothing, to make-up and hair, to issues of weight and shape. It is rare to find a young woman with a serious eating disorder who has not been singled out for criticism regarding her appearance, (most often involving weight), even from other girls.

But this emphasis on appearance by girls pales in comparison to their being judged by young men. Boys, beginning from their years of puberty, engage in constant communication regarding the appearance of girls. While boys seldom intend for their comparisons and comments to hurt girls, the result is nonetheless often devastating. It only takes one or two incidents of hearing boys evaluate girls on issues of appearance for them to assume that the only way girls can get attention from boys is to look “hot”. One client found that when she lost weight, her phone began ringing off the hook. It was difficult to convince this wonderful individual, who had previously suffered so much loneliness, that this attraction to her physical appearance was extremely unlikely to make her truly happy in the long run.

While relatively few individuals of any gender reach adulthood without at least some rejection in romantic matters, many girls have faced much more than their share of it. Being rejected as objects of attraction by boys, often due to their weight, they are acutely aware of that relatively small percentage of girls who receive inordinate amounts of attention from boys, oftentimes based solely on their physical appearance. These girls, valued for their beauty alone, are often perceived to receive more offers for dates and invitations for parties than other girls, and because they are receiving more attention, they seem to be having more fun, and consequently leading better lives. It is not hard to believe that those who hold this view of their situation in life will lean toward taking extreme measures to lose the weight they see as preventing them from being accepted. I have worked with many young girls who would literally rather die than feel more rejection and worthlessness in their social encounters.

But the other end of the attraction continuum is fraught with the potential for even worse trauma. As, mentioned, many girls are under tremendous pressure from young men to engage in sexual contact they don’t want. These pressures range from the strategic use of alcohol to the old phrase, “If you love me…..” And many of these boys follow through on this threat to reject girls who won’t engage in sexual relations with them, leaving lost, confused girls in their wake. Sadly, girls often fail to consider that young men who want girls for this reason are shallow and do not yet possess insight into the fact that relationships based solely on physical attraction will never be truly fulfilling to either party. This fact is often lost on girls, who frequently fail to realize that this is not the kind of attention they really want from boys. What they invariably crave is for someone to really care about them as a whole person, not just for their physical appearance. This becomes a terrible dilemma for girls who don’t want to be rejected for being overweight, but don’t want to be sought after and used for their physical appearance either.

Even worse, many girls are victims to what amounts to various forms of sexual assault, falling prey to being groped and other forced physical contact. This can happen at parties, dance clubs, on dates and even in the halls at school. Many girls feel so violated that they go to the opposite extreme. In an effort to become unattractive to boys, they lose weight to the point of emaciation.

The Emotional “Benefits” of Eating Disorders
Faced with the tremendous pressures of growing up, girls will often turn to eating disorders for what they truly see as “relief”. Those with severe eating disorders are often asked why they do such terrible things to themselves. The answer is that it gives them an emotional and often physical “fix”, to something which can be as addictive as any drug. Girls often respond to trauma in “internalized” ways: self-loathing (a very descriptive word for depression), addiction to achievement, cutting on their skin, and eating disorders. Girls often turn to these “coping” mechanisms in order to sedate themselves from their feelings of trauma, self-hatred, insecurity and vulnerability. They want to “numb” themselves. Those suffering from severe emotional trauma feel a constant need to “not feel” since the feelings they have are overwhelmingly negative. And eating disorders provide a respite for these painful feelings at least at first.

Eating disorders also give them a form of quick weight loss, which often is very highly rewarded by those in their environment: “Wow, look at all the weight you’ve lost. You look great!” The eating disorder can also serve as a “friend” they can “rely” on, a form of control in the face of what they perceive to be an uncontrollable environment. In addition, when eating disorders worsen, and those who suffer start to look ill, the attention and sympathy they receive for being sick can become intensely addictive, since they often believe that they will not receive this attention in any other way.

How Parents Can Help if Their Daughter Already Has an Eating Disorder
Eating disorders lead to serious consequences for the physical and emotional health of those who suffe,r and parents naturally want to know how they can help. Here are some ideas of what you, as a parent, can do if you suspect your daughter has an eating disorder.

• No matter how frustrated you are, don’t approach her with anger.
You will most likely feel intense frustration, but you should show this frustration only with great caution. Approaching her with anger will almost inevitably push her even further away from what is reasonable and rational in her life. If she feels harshly judged, she will retreat even further into a shell of depression and further pursuit of eating-disordered behaviors. As mentioned, eating disorders involve intense feelings of worthlessness. What she needs more than anything is reassurance that you love her in spite of your fear and frustration.

• Give her the opportunity to accept your love.
Those with eating disorders often isolate themselves from the affection they crave from others. They do this for a variety of reasons, but usually because they don’t feel they deserve it. They will often push parents away, even when they secretly (and desperately) crave the affection parents can give. Let her know you love her and are willing to give her the physical affection she craves but will almost never ask for.

• Let her express herself.
Listen to her without trying to control the outcome of the conversation. Many of those with serious eating disorders have felt silenced by various sources of authority in their lives. But because of the universal need for self-expression, those with eating disorders resort to restricting or bingeing/purging as a very indirect and self-destructive way to express the pent-up feelings of worthlessness which are often, quite literally, killing them. Eating disorders have been called “the good girl’s rebellion” because rather than scream and yell at what is bothering or hurting them, they will turn to self-harm (including cutting and eating disorders) to “tell” those who can read the code that they disagree or are hurting.

• All parents make mistakes.
All parents make mistakes, even dedicated, caring parents. It is not a sign of weakness to admit that you inadvertently erred at times in the way you raised your kids. Be willing to take a look at the weaknesses in your own family and parenting. If you have made mistakes, admit it. Let your daughter know that you love her, that you never wanted to do or say anything to hurt her or impede her development and that you’re sorry for what you might have done that may have hurt her. Write these feelings in a Letter of Regret and give it to her without justifying your actions, without blaming her for anything she might have done (having her admit her part in the problem will come later). This letter will take some courage, but I have never encountered a therapeutic intervention as healing as sincere letters of regret sent from parents to their daughters.

• Get help from specialists.
The overwhelming complexity of the issues involved in treating eating disorders can make even experienced therapists look like rookies. Therapists unfamiliar with these issues can provide general levels of emotional support, but rather quickly run out of helpful ideas because of the lack of understanding of the relevant issues. Your daughter will also most likely need to visit a dietitian, one who can correct the numerous incorrect ideas regarding nutrition and physiology which girls with eating disorders hold. We also recommend that this dietitian understand an approach known as intuitive eating. We should also mention that this dietitian must never recommend an approach involving any kind of dieting or weight loss.

• Don’t be the food police.
Don’t give in to the urge to monitor her food intake unless she is physiologically collapsing. In this case, let qualified medical personnel engage their expertise. Eating disorders can be fatal, but let physicians help determine the course of treatment if she is suffering from this illness with severe symptoms. Explain to her how you see things in life, but remember that this is an uphill battle and she is unlikely to be convinced by logic if she is engaging deeply in her eating disorder.

• Allow imperfection.
Help her understand that it is not only OK to be imperfect but that it’s inevitable. Let her know that you will love her if she makes mistakes, and when it happens, prove it by showing her your regard and love for her.

How Parents Can Help to Prevent Eating Disorders
It seems critical when discussing issues of this severity to include a discussion about prevention. Here are some things to remember for parents who want to avoid the development of eating disorders in their children. Many of these will be similar to how parents should interact with their daughters who have serious eating disorders but there will be some critical differences:

• Love them.
Remember that love is an action. You may feel the intense emotions of love and protection parents have for their kids, but this is not enough. You have to show her in ways that she interprets as “love” for her to understand how you feel about her. Obviously, parents who give of their love freely serve to protect their children from a host of problems throughout their lives. This is particularly important in relation to young men. In fact, the more parents (particularly fathers) show appropriate physical affection to their daughters, the less likely they will be to desperately seek attention/contact/approval from boys later in their teens.

• Talk to them-Listen to them.
Establish a channel of communication so that when they need to talk to you about important matters, they will, by force of habit, come to you.

• Know their interests – Be a part of their lives.
If your interest is genuine, most kids won’t see your involvement as nosiness. Stay current on who their friends are, what they spend their time doing, what they want to do with their lives, and what their goals and objectives are in the present and the future. Make them aware of what you see as their talents and abilities. Become familiar enough with their lives that you will notice when they are not doing well emotionally. Again, you have to know how to decode them.

• Let them know that they are good enough.
Let them know that they are good enough even if they are not perfect; that perfection is not a pre-requisite for your love, approval, and acceptance.

• Allow them to speak their minds.
Allow them to disagree with you as long as they do it respectfully.

• Don’t value them for their appearance.
If they believe you value them for their beauty, they often become preoccupied with it, to the neglect of deeper, more enduring traits that have far greater capacity to help them succeed. Tell them you love them for reasons more important than outward beauty. Praise them for their personality and intelligence, their sense of humor, their integrity, reliability, talents, desires, spiritual strength, etc.

• Take notice of and emphasize their positive attributes and traits.
Spend more time recognizing and acknowledging their strengths, efforts, and successes. If they have weaknesses, help them work on them in a positive, encouraging manner.

• Teach them to respond effectively to pressures of physical affection they may not want.
As mentioned, girls with eating disorders often feel voiceless and powerless to change their lives or their situation. They can often submit to traumatic sexual experience because they feel they may deserve punishment, or haven’t learned to assert themselves over the course of their lives. Teach them to be able to set boundaries with people they encounter in their lives. Help them to develop direct and assertive communication patterns, to protect themselves in times of risk or threat.


The social influences that can contribute to the development of an eating disorder are intense, and, unfortunately, too evident in the world that surrounds these girls and young women. The awareness and influence of a loving parent is essential in combating and preventing these negative social influences or in helping to challenge and correct the flawed beliefs and experiences of a child suffering already with an eating disorder. Please remember to never give up on her. Remember also that recovery from eating disorders is a long and emotionally brutal journey. You will need your own support system through the ups and downs of recovery. You won’t fully understand many of the issues involved in the illness for many years-even if you were to study them intensively. The key is you don’t need to know everything. All you need to do is give her love and approval for the positive you see in her, while gently helping her to understand a more reasonable way of looking at the world than her errors in thinking and the mirages she truly believes in, which only lead her to even deeper levels of long-term emotional pain. Recovery is possible and women can heal from the hurts, rejections, untrue beliefs and the wounds of child or adolescent social pressures.


For the Loved Ones of Those with Eating Disorders

Author: Michael E. Berrett, PhD


One of the most difficult tasks any of us face is watching the struggle and suffering of those we love.

It is especially difficult and heart wrenching to watch a loved one suffer with an eating disorder. What makes it so difficult are its far reaching effects: social, emotional, and spiritual confusion and chaos. With anorexia that chaos and confusion can be hidden under rigid perfectionism and an illusion of control. With bulimia, the confusion and chaos may be more obvious to us on the outside.

It is hard to watch suffering which seems deceptively “avoidable” or “fixable”. It doesn’t take long, however, to see the complexity.

In helping a loved one suffering with anorexia, bulimia, or a compulsive eating disorder I offer a few ideas to consider:

1.) Remember — eating disorders are complex and most often require many kinds of help. Don’t try to deal with this problem alone. Reach out to other professionals or other loved ones while searching for answers.

2.) What’s not said can be as damaging, or more so, than what is said. Don’t pretend, deny, or avoid the issue — that won’t help at all. Don’t “walk on eggshells.” Do address your observations and concerns to your loved one in a direct manner with kindness and respect.

3.) Ask your loved one for specifics about what they would like you to do and say and what not to do or say to best support their recovery from an eating disorder.

4.) Ask questions about “the person” rather than questions about their eating disorder. Have a relationship with them — not their eating disorder. Even if they act as if 90% of their life is their eating disorder, treat them as a person — not a behavior.

5.) Provide hope. Discouragement, fear and at times feelings of hopelessness are common to those suffering from eating disorders. These feelings don’t need fuel — but correction. There is hope, there is something worth encouraging. Find it and do some coaching. After listening, acknowledging, empathizing, and validating feelings, move on to ideas, hopes, and positive possibilities.

6.) Don’t blame yourself. It’s not your fault. Whatever your mistakes or weaknesses as a parent, spouse, or loved one, you did not create this eating disorder. Take ownership for your weaknesses and frailties, take stock of your talents, gifts, and resources, and get to work providing love, support, and open invitations for them to come into a safe relationship with you as they are ready.

As you implement these and your own ideas to help your loved one, put yourself in their shoes, try to see the world from their model, listen to your heart and follow those impressions. Don’t give up. Since the fruits of your influence and efforts may not be fully recognized and seen for a while, patience and hope need to become friends of yours. Recovery can be a reality!