A POTENTIAL SAFETY NET
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.
THE FRUSTRATION OF EATING DISORDERS
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.
PUTTING EATING DISORDERS IN THEIR SOCIAL CONTEXT
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.
DENIAL AND RESISTANCE
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.
TYPICAL CAUSES OF EATING DISORDERS
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.
FAMILY DYNAMICS AND GENETICS
There are several factors known to increase the risk of development of an eating disorder. These include:
- Family history for eating disorders
- Family history for drug or alcohol abuse
- Family history for depressive or anxiety disorders
- High BMI in early adolescent years
- Early onset of menarche for girls
- 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.
THE STAGES OF CHANGE IN TREATMENT
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:
- Awareness and acceptance
- Ownership and responsibility
- Commitment to change
- Self-correction and service to others.
TOOLS USED IN THE TREATMENT PROCESS
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)
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.
SUGGESTIONS FOR A SUCCESSFUL APPROACH TO TREATMENT
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.
TREATMENT FACILITY OPTIONS
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.
WHAT ARE THE NEXT STEPS?
- 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.
ABOUT CENTER FOR CHANGE
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 www.centerforchange.com.
Center for Change is accredited by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)Share