Monday, August 20, 2007
I must apologize for being off-line this past month. After a long and active life my 95-year-old father died two weeks ago, and I was back in Connecticut to be with him at the time and to help my mother afterwards. To watch cancer whittle a strong and capable man down to anorexic proportions is a sobering experience, especially for someone who has intentionally starved herself to those proportions. Such wasting serves as a grave reminder of how eating disorders, too, waste life.
These were challenging questions! Some of them pressed for insight that goes beyond my expertise. Rather than attempting to answer them “perfectly” on my own, I decided to admit my limitations and call for professional advice. (In other words, I used this occasion to practice what I preach in Gaining: when you need help, don’t be ashamed to seek it!) I turned to Judith Banker, president-elect of the Academy for Eating Disorders, who generously gave these questions her full attention. (For information about the AED, go to www.aedweb.org .) Because Judith’s responses are so full of important information, I didn’t want to paraphrase her, but included her answers uncut (marked by JB) alongside my own (marked AL). Bear in mind that Judith is the professional – she founded and directs the Center for Eating Disorders in Ann Arbor, Michigan(www.center4ed.org). My own answers reflect only what I have learned as a survivor and student of eating disorders, and from the feedback I’ve received from readers of Gaining.
I wish you health and peace and love.
Q&A WITH AIMEE LIU & JUDITH BANKER
1. Based on your knowledge, what does the medical community know now about the effective treatment of eating disorders that they didn't know at the time of your turning point?
AL: The entire scientific profile of eating disorders has been transformed by the research findings of the past twenty years. When I was in the grip of anorexia in the 1960s and early ‘70s, treatment was reserved for those who were in imminent mortal danger, and that treatment consisted almost exclusively of hospitalization and forced refeeding. Bulimia wasn’t even named yet! Doctors, families, and counselors alike mostly assumed that people with eating disorders were just very stubborn, and that if they chose to cooperate and stopped being “difficult” they could get well on their own. Recovery was defined almost exclusively in terms of weight gain and nutrition. Unfortunately, most of the general public still maintains these outdated notions. They do not understand that eating disorders represent serious psychological illnesses and that fasting, bingeing, and purging behavior are expressions of some combination of depression, anxiety, trauma, genetics, and biochemistry. The medical community is beginning to understand this, however, and changes in treatment have resulted as Judith details below.
JB: There is a greater appreciation now for the physiological influences and the psychological traits that serve as risk factors for the development of eating disorders. New areas of eating disorder research, such as genetics and neurobiology, have led to breakthroughs in our understanding of these illnesses. Genetic research shows that personality traits, such as the tendency to be anxious and depressed, predispose an individual to developing anorexia and that the role of heritabililty is quite strong (at least 50%) in anorexia nervosa. Neuroimaging research provides a window in to the brain processes involved in body image disorders.
2. At the beginning of Gaining, you encourage anyone suffering from an ED to seek professional help. What would you suggest that someone do if he or she can't afford treatment? Even with health insurance, programs I've found still cost more than what I can possibly pay. I want help, but don't think I can get it.
AL: This is a difficult question, as many treatment programs are intimidatingly expensive. But I have found professionals in this field to be generous and caring, and I would urge you to contact those that seem right for you, regardless of cost, and see what provisions they have for aid or referral. You can begin your research on the web at The Eating Disorder Referral and Information Center(www.edreferral.com). I have listed additional sites and resources on my new website www.gainingthetruth.com. Below, Judith offers more extensive and specific advice.
***Editors note: www.gurze.com now features a therapist directory.
***Editors note: www.gurze.com now features a therapist directory.
JB: Inadequate health insurance coverage for the treatment of eating disorders is frequently an obstacle for many individuals and their families to getting the help they need. There is an active health care advocacy movement within the eating disorder community that seeks to bring eating disorders the same health care coverage as other major medical illnesses.
3. My roommate has an eating disorder. I think she's bulimic, but I'm not sure. She also makes negative comments about herself and her body constantly, to the point that I just want to stay away from her sometimes because I can feel it wearing me down. I don't know what to do to help her and don't want to make my living situation any more uncomfortable. What should I do?
JB: This is a difficult situation but, unfortunately, not uncommon. Negative body image and disordered eating behaviors and attitudes can be contagious, particularly in schools, sororities, dormitories, and other environments where girls and women spend extended periods of time in close contact. These environments literally become toxic. Your roommate’s negative comments about herself and her body are damaging to both of you so I understand and support your desire to do something about the situation.
4. You say that the first step to recovery is to admit that you have a problem. This is in line with recovery programs such as Alcoholics Anonymous and Over eaters Anonymous. I've read recently that people with bulimia can benefit from following the OA program. Do you think there is any merit to this?
JB: Substance use disorders (SUD) are more strongly associated with bulimia nervosa than anorexia nervosa but the complex nature of the neurobiological factors underlying bulimia nervosa and substance use is not known. Therefore, the question as to whether or not bulimia is an addiction process has not been answered. That being said, programs that treat eating disorders and accompanying SUDs commonly incorporate Alcoholics Anonymous meetings. For someone in recovery from bulimia who has an accompanying SUD, the familiarity of the 12-step model and the ready availability of OA groups in most communities can provide an important source of ongoing support.
5. I have a history of eating disorders, and even when I'm healthy, am still- to a degree- afraid and anxious about food. I think I can handle my health, but am concerned that I might pass eating issues along to my children one day. What things can I do or keep in mind regarding a future family? Also, you write that eating disorders have a genetic componant. Does that mean that my future children are destined for an uphill battle?
AL: Recognizing this possibility and caring enough to stop the cycle before it affects your children is the first key to prevention, so good for you for asking this question! For yourself and for your children’s sake, I urge you to shift your focus consciously from fear to love. Ask not what you’re afraid to eat but what you love to eat – and what you love to do and try and explore in life generally. Focus on sharing these passions with your children, and take the stress off your fear of passing on your fears. Be mindful of all the pleasures that accompany mealtimes, food, shopping, and cooking, and consciously make MORE of those pleasures. Have fun with food yourself, and over time, your pleasure will overtake your anxieties around food, and you will naturally teach your children that healthy eating is a joy and a privilege as well as a vital necessity.
*It was a struggle not to pull back into the safety of my obsession with food and weight, where no one could see how I felt. It was frightening and humiliating to give up my established identity as a fragile waif when I
had no idea what identity would take its place. But I sensed I needed to
*"I think these girls are quite delayed," Harvard psychiatrist David Herzog agreed when I asked him about the emotional immaturity that so often is part of anorexia. "They've never been given the opportunity to experiment." *
AL: Patience and compassion are key. Hope, rather than urgency, is what drives recovery, and hope is all around us if we just pay attention, but it may come at first in mere glimmers – a friend’s caring smile, the love of a pet, the thrill of music sung by a chorus, or the beauty of sunshine on water. Emotional maturity is the result of countless daily encounters and appreciations such as these. The best way to hasten this process is to pay attention and cultivate mindfulness so that you notice what gives you hope, what engages you, what makes you feel as if you care and, through caring, that you matter.
I believe that a sense of purpose is essential to the formation of a healthy identity. By this I mean the sense of purpose that is gained by creating, giving, or working for the benefit of other living things. Eating disorders isolate and starve us of this sense of purpose, so it’s unrealistic to think that someone struggling with anorexia will, overnight, recover and save the world. But we don’t have to save the whole world to feel that we have purpose! Nor do we have to “recover” overnight. Showing kindness and compassion to one person, or dog, or plant is the first step in creating a larger, more mature identity. With each new demonstration of compassion to others, our ability to treat ourselves with kindness also grows and so does our sense of healthy purpose in the world.
JB: What an excellent question! It opens up a very complex aspect of recovery.
When you are recovering from an eating disorder the maturation process will occur at its own natural pace. Learning to trust that pace, not hurrying or pressuring yourself to grow up quickly, is part of becoming who you really are. However it is critical to have the guidance of a trusted therapist to help facilitate the process as it is easy to get stuck or discouraged. People often are afraid they will never catch up to their peers, however, many aspects of your self continue to grow despite the stunting influence of the eating disorder. Recovery is not about catching up to your peers---it is about opening up to and integrating the undeveloped aspects of your self with the parts of your self that are higher functioning and mature.
AL: Below, Judith explains how low self worth develops and offers some excellent strategies for reversing this conditioned pattern. I’d like to add that the reversal begins by training yourself to challenge all judgmental language. What do words like bad, fat, stupid, ugly, or for that matter, perfect, really mean, anyway? These are not objective or true assessments but labels used to compare and criticize that get branded into our psyches. We may not be able completely to erase them or the damage they do to us, but with practice we can teach ourselves to notice when and how we use them – and how often they are uncalled for. Then we can practice replacing these terms with others that are more accurate and constructive. Instead of berating ourselves for feeling “fat,” for example, we can look deeper at what we’re really feeling, which may be angry or hurt or lonely (fat, after all, is not a feeling) and take concrete action to deal with the true source of distress. Seeking out supportive friends, confronting the real source of unhappiness, cultivating activities that reduce stress and combat depression are all ways we can actively boost self-esteem.
You can start to cultivate a sense of self-worth by learning to recognize what a genuine expression of your real self feels like. Practice listening to your own needs, thoughts, and feelings without judgment or self-criticism. Sometimes when you first start to do this, these expressions of your self will come through very quietly or subtly. You have to listen very closely. Writing these “self expressions” in a journal can be helpful. The next step is to gradually learn to identify ways to respond in attunement to your needs and feelings. By developing a responsive relationship with your self, by taking your own needs, experience, thoughts, and feelings seriously your sense of self-confidence, self-worth, and deservedness will grow.
8. What advice would you offer someone who seems to succeed in residential programs but does not know how to transfer those skills over to regular life, with its stresses and busyness… and emotional undulations that the eating disordered individual feels ill-equipped to engage in a healthy manner?
AL: This is an area that is beginning to receive long overdue attention. Cindy Bitter, one of the women I interviewed for Gaining, works as a life coach in Rochester, NY, mentoring women through this phase. Many treatment programs, as Judith mentions below, offer after-care programs to help patients transition back into daily life. I believe there will be more of these services as therapists and patients alike recognize that recovery really is a gradual process.
My advice is to allow for imperfection, occasional backslides, especially at first, and not catastrophize these slips. Instead, remember that the same skills that worked in treatment really will work out in the world, but they require ongoing practice and patience. There’s a good phrase I heard recently: practice does not make perfect, but eventually it does make permanent. What seems impossible today will, with practice, seem feasible next month and routine in a year or two. Speaking for myself, I will never be happy-go-lucky or completely free of those “emotional undulations” you mention, but by developing an arsenal of calming, soothing, gratifying practices I have learned to effectively manage these swings without resorting to self-destruction. Progress, not perfection, is the measure of success.
JB: The period of transition from the 24/7 support, camaraderie, and safety of a residential treatment program must be planned very carefully to avoid significant backsliding or complete relapse. It is common for people to underestimate the role the support of the residential community plays in their recovery. In these communities communication is honest and open, and support is easily available. In “regular life” these systems are not as reliable.
Whenever possible, take advantage of “step down” opportunities following residential treatment. There are day-treatment programs or intensive outpatient programs (IOPs) that provide graduated levels of support, allowing people to make a more gradual transition in to their everyday lives. If these formal services are not available, it is important to intensify your own outpatient services following discharge from residential treatment. Plan to meet more frequently with your individual therapist, physician, and nutritionist, attend a support group in your area, involve your family and friends in providing increased support for you during these critical weeks. This extra support will help you maintain the progress you made in residential treatment while you learn to cope more easily with the inevitable stresses and demands of your life.
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