om Wooldridge joined us to discuss his book, Understanding Anorexia in Males: An Integrative Approach. What follows are our questions in italics, and Tom’s thoughtful answers.
In Understanding Anorexia in Males: An Integrative Approach, you focus “on the male experience of anorexia nervosa.” What can you tell us about stigma and alienation for a male with anorexia nervosa (AN)?
The triad of stigma, shame, and alienation must be considered throughout all phases of the treatment, especially during treatment engagement and the early stages of building a working alliance. Men and boys encounter a different kind of stigma and shame than do women and girls. In addition to the stigma and shame that accompany having any psychiatric disorder, anorexia nervosa has been culturally labeled as a “women’s problem.” It’s common for me to hear patients express considerable shame about this. In addition, there is an adversarial relationship between traditional constructions of masculinity and help-seeking behavior. In other words, many men feel that it’s not masculine to seek help, to delve into their emotional lives, to shed tears. In the treatment process, this must be addressed with considerable empathy, exploration, and of course education about the fact that men are, indeed, sufferers of this disorder.
Alienation is likely inherent in having any psychiatric disorder; the degree of suffering that patients experience sets them apart from those around them who are “healthy.” When you add in stigma and shame, males with anorexia nervosa encounter a more complicated experience of alienation that needs to be explored throughout the treatment process.
You define an essential aspect of the therapeutic alliance – engaging in “taboo talk.” Please explain.
Taboo talk means straightforwardly acknowledging and exploring the part of the patient that is motivated to continue engaging in eating disordered behavior. When we as therapists, family members, or friends are confronted with a person who is depriving himself of nutrition (in addition to the other kinds of deprivation, which are emotional and relational), we naturally want to encourage him to change his behavior as quickly as possible. When we’re in the role of a treatment provider, though, it’s essential to first understand what motivates the patient, at the deepest level, and to allow him to give voice to that, with the hope that over time all aspects of the patient can be taken up more fully.
The essential idea here is that the parts that aren’t spoken inevitably return and undermine the recovery process. It’s not that we don’t want to influence the patient in moving toward recovery – of course we represent a possibility of health and healing – but we must also facilitate the patient’s developing authentic motivation that is rooted in himself, and that can never happen when parts of the self are silenced.
Can you please tell us more about the value of exploring the male client’s ambivalence about anorexia and recovery?
Any psychiatric disorder – and, in fact, with any aspect of our personality more generally – develops, at least in part, as a way of managing psychic pain. Put differently, in language that has more popular appeal, anorexia nervosa is a “coping mechanism.” When we encourage patients to engage in recovery and healing, we must recognize that we are asking them to give up ways of being – ways of managing painful emotions, difficult relationships, and other adversities that life inevitably brings to all of us. And patients who have relied on anorexia nervosa, with its characteristic rigidity and inflexibility, are confronted with a self that is depleted and empty as the disorder is increasingly relinquished. They intuit this and, so, are naturally ambivalent about moving toward recovery and the deeply painful experiences that the recovery process entails.
One aspect of the integrative approach presented in your book involves addressing “negative explanation” in males with AN. How do these explanations relate to the concept of “constraints”?
Negative explanation is an idea developed by Gregory Bateson, which casts intervention as a task of removing obstacles that prevent the patient’s healing process. Constraints are identified in the process of negative explanation. That is, constraints are statements of each particular obstacle that is identified in the treatment process. This way of thinking posits that the patient has a “true self” that, given the right environment, naturally moves toward health and healing. As an example, we would typically ask, “Why does Jay starve himself?” But with negative explanation, we frame the question slightly differently: “What keeps Jay from adopting a healthier and more balanced diet?”
In my way of thinking, this model has several advantages. First, I wanted to emphasize the patients’ innate resources. Second, it is notoriously difficult for treatment providers to work with patients with anorexia nervosa. It’s deeply upsetting to witness such a profound form of psychological and physical suffering, and this naturally elicits the provider’s desire to alleviate that suffering. Unfortunately, though, this patient population is notoriously sensitive to having their agency overridden. (Although this is certainly necessary at times, we must always recognize it for the trauma that it is.) By framing our case conceptualization using negative explanation, I am attempting to promote our recognition of the patient’s agency and how a facilitating environment can promote this.
What do you believe may contribute to an increased risk of eating disorders in the gay and bisexual male population?
That’s a very complicated question, and I don’t have a clear-cut answer. Gay men likely experience more cultural pressure around certain body ideals – for example, to be thin and “cut,” than their heterosexual counterparts. This is accompanied by more pressure to diet, for example. There also seems to be an increased incidence of childhood sexual abuse in this population. So these factors, along with the homophobia that is of course still rampant in our society, leave gay men facing more adversity than heterosexual counterparts. If we think of anorexia nervosa as a way of managing psychological pain, then it’s not surprising to me that we see an increased incidence in this population.
You note the paradox of pro-ana websites that “simultaneously encourage self-expression and provide a sense of belonging and understanding while simultaneously providing encouragement to pursue self-destructive practices.” What does the research tell us about pro-ana websites and their impact on males with AN?
As a researcher and a clinician, I think I can say unambiguously that pro-anorexia websites are profoundly disturbing. And yet we must ask – in the same way we ask about anorexia nervosa itself – what is the function of these forums for participants? And what I’ve suggested is that there are many different functions, ranging from the purely pathological (i.e., encouragement in the process of weight restriction) to the more nuanced (i.e., seeking social support around experiences of shame and alienation). We must also recognize that while it is sometimes possible to persuade patients to give up participation in pro-anorexia forums, in other cases it is not or, even worse, our attempts to exert influence lead to increased secrecy and even alienation between therapist and patient. This is why it’s so important to understand the function of these forums.
You’ve found a way to bring to light the remarkable complexities typically involved in the clinical treatment of AN and, specifically, males with AN. Any additional words you’d like to share with the professionals who read your book?
Thank you for reading the book! I wrote it with two purposes in mind. The first was to provide education about males with anorexia nervosa in an effort to address the shame, stigma, and misinformation that are so prevalent. At the National Association for Males with Eating Disorders (www.namedinc.org), colleagues and I have continued to work on this important task. The second was to highlight the complexity required in thinking about this complex form of suffering, and how that complexity necessitates a multifaceted approach to the treatment process. If you’ve taken away these two ideas from the book, then I think the writing process was well worth it to me!
***This is the first of a two-part series that addresses the significance of culture and ethnicity in eating disorders treatment.
Food, religion, culture, and traditions are part and parcel of humans’ daily lives. It is perhaps the most unifying aspect of humanity. Past our bodily needs for nourishment, and sustenance, what, where, how, and perhaps with whom we eat, identifies us. Throughout history religious holidays worldwide have been celebrated with different foods and traditions as part of the gatherings and festivities, with each holiday having its soul dish, or dishes, reflecting that culture’s resources and the ethnicity of its people. Yet, for me it took two decades to appreciate being that unique individual.
The scene at the elementary cafeteria table was always awkward, cautiously pulling out my piece of pita bread, and tub of hummus from my lunchbox, and explaining it to all the girls sitting around me. I winced at the smell of fresh garlic while they were eating their crust-less peanut butter and jelly sandwiches, and sipping on Hawaiian Punch. I was always trying to avoid their repulsion, and stares, finally swallowing it down as quickly as possible in a private moment of humiliation. I wanted so desperately just to have a simple white bread sandwich in my lunchbox, or at least a cool name for the creamy mush that I brought in, almost every day.
Socializing outside of school was similarly loaded. On the rare occasion my parents would let me go to a friend’s birthday party, I quickly learned that the cheese pizza would vanish first and I would almost never get enough. Chuckie Cheese’s pizzas were always layered with loads of pepperoni and ham and as a Muslim, I couldn’t eat it—there’s a dietary prohibition on pork in Islam. I learned later, after experience and a couple of misses, to always leave my game machine no matter how close to winning I was, and be one of the first ones at the table, so I could get first dibs on a slice of cheese pizza.
My childhood insecurities were my earliest cognizance of the implications food has in our culture and our lives. My childhood home’s food supply was ruled by an American-Lebanese health nut (my mother) who only gave us cookies from packages scrawled with the words “oatmeal” and “flaxseed,” and always made sure we had protein for breakfast before going to school, even if that protein came from a can of tuna at 7 a.m.! She took advantage of our Middle Eastern ethnicity (hence the hummus for lunch), using that cuisine’s traditional ingredients like olive oil, cracked wheat, and plain yogurt, and infusing them with some of the American recipes she would find in health magazines. The results, always beautiful homemade meals, and the aroma of freshly cooked ingredients, welcomed us every afternoon coming back home from a long day at school.
Her nutritional awareness, and cautiousness, stuck with me. Preventing my father’s organs from being ravaged by diabetes was dependent on the foods we ate as a family. As his children, we are also genetically predisposed to diabetes, so nutritional meals and good eating habits were of utmost importance.
The positive and negative of that food equation mattered, I realized. I used that realization, but not always in a productive way. My later relationship with food was altered by the culture and media around me. Regardless of the foundation my parents instilled in me as a child, the media was more powerful and had the upper hand. Magazines, television ads, and billboards always displayed the skinniest, most beautiful girls, even if the ad was for dog food! There was no escape. I didn’t know how I could channel my good and bad experiences about food until I decided I wanted to become a dietitian with a focus on eating disorders.
Upon agreeing to write this article, I decided to dig a little deeper past my own personal definition of culture. When you Google the word “culture,” multiple definitions come up: top stories on how MTV is gearing more towards the young culture; creating positive cultures in the work place; culture of cheese; and the biological culture of bacteria. The definition that held true throughout my research, and was pertinent to this article was “culture is a way of life of a group of people—the behaviors, beliefs, values, and symbols that they accept, generally without thinking about them, and that are passed along by communication and imitation from one generation to the next.”(https://www.tamu.edu/faculty/choudhury/culture.html)
Food consumption, restrictions, variety, and resources in a society, all affect that culture. As dietitians, therapists, or clinicians in this field, we must be thoroughly aware of our clients’ religious, and cultural backgrounds, to help build their trust in us, and be able to eventually help themselves through their personal recovery process. In my next part of this series, I will discuss the Hispanic and Asian ethnicities touching on cultural norms, dietary values, and common ingredients and foods used within each group. Religious sensitives of the Muslim, Jewish, Seventh Day Adventist, and Hindu population will also be broken down all in part to better prepare us before meeting with clients who identify to a specific faith or culture.
When we think of nourishment, what comes to mind is likely food—nutrition and eating healthfully to feed and sustain ourselves. We imagine furnishing our cells with nutrients to fuel our bodies and keep them in good repair. But what about how we fuel our minds and hearts? What do they require for sustenance?
If you consider our universal emotional and mental needs, then you know that doughnuts, chicken wings, carrots, fudge, or even the most nutritious, non-GMO, pesticide-free, organically grown foods won’t do the trick. To feel emotionally nourished, we must first recognize what our emotional needs are, then find ways to feed them. Here are six emotional/mental essential needs that, when met effectively, will help you eat more “normally”: pleasure/play, challenge, wonder/awe, authentic connection to ourselves, authentic connection to others, and creativity and passion or a reason for living.
Many dysregulated eaters act as if pleasure or play are dirty words. These people feel good about themselves only when they’re productive. If they want to relax or slow down, they believe they’re being bad or lazy and spur themselves on. They expect nothing less than perfection in all they do and beat themselves up if they don’t reach it. No wonder they turn to food for a good time.
We have a universal need for play, which is engaging in an activity merely for pleasure, not to meet any other goal. Play involves being in the moment, with no thought to how things turn out. It is all about tuning in to now. In play, there is no judgment, only absorption in each perfect, pleasurable moment.
Alternately, humans require appropriate, realistic challenges. Think Goldilocks: not too easy and not too hard. We enjoy learning new things at our own pace—tap dancing, crocheting, Chinese, skiing, chess, or origami. Learning both activates our brains and gives us a sense of satisfaction. It provides us with knowledge and teaches us new skills.
Too often we grind ourselves down by doing the same things in the same ways over and over. This pattern causes us to feel as if the lifeblood is being drained out of us or that we are robots, set on automatic as we march on through time. One reason we think we want to eat is because we’ve stopped taking a big, fat, juicy bite out of life. Starved for stimulation, we wrongly believe that drive-through, fast food is where we’re going to find it.
Dysregulated eaters may find it difficult to feel nourished by challenge because they so badly want to succeed and so hugely fear failure. They’re constantly judging themselves and fearing they’ll be judged by others. They want to know how to do everything correctly yesterday. But, by looking at challenge as a gradual process, one to engage in at our own pace, then learning new things becomes exciting and keeps us growing. And isn’t that what nourishment is for: to help us grow?
Another way we fail to nourish ourselves is that we don’t wonder enough because we want to play it safe. Both wondering and experimentation are ways of taking care of ourselves as much as sticking to a routine is. Wonder is how we bring awe into our lives—about the universe, how a snake undulates, the way no two snowflakes are exactly the same, how people who lived thousands of years ago are both similar and dissimilar to us, or what technology will be like at the dawn of the next century.
We are nourished by awe because it both takes us outside of ourselves, and also because it helps us feel deeply a part of the amazing world around us. Awe breaks down boundaries and takes our breath away. There’s nothing like this kind of mind- blowing feeling of oneness that nourishes us even after the fact, when we’re only remembering how we felt.
Authentic connection to ourselves
It is vital to be connected to ourselves physically and emotionally, but it is not enough if what we are hooking into is only the person we wish to be. We need to feel connected to who we really are—the good, the bad, and the ugly. It’s not sufficient to only attune to yourself when you are feeling strong or successful. It’s equally, or possibly more important, to feel okay about ourselves when we see ugliness in ourselves that upsets or disappoints us.
Dysregulated eaters often don’t feel nurtured by themselves because they are so busy being critical of what they see when they look inward—what they did or didn’t do, all their wrong actions and none of the right ones, their worst moments rather than their best. An authentic connection means accepting yourself as human, even when you wish to be better. It’s not enough to pick and choose only those qualities in yourself to which you like to connect —your talents, strengths, and special gifts. The richest type of nourishment is offering yourself kindness and compassion when you’re at a low point. That’s what raises you up in your own eyes and makes you feel whole.
Authentic connection to others
Many dysregulated eaters are unhappy with themselves and, therefore, are
uncomfortable with others. They are anxious about being judged and feel afraid to reveal their real selves. But think about the moments when you are your authentic self and make a connection to someone. Those moments are almost electric. When we bond with others, we feel warm and shiny inside and out. We are not meant to be alone. If we were, would there really be so many of us in the world?
Having authentic connections with others validates us and helps us see ourselves through new eyes. We get to see our strengths that we normally don’t recognize because we’re too busy zeroing in on our weaknesses. We get to see that we can laugh or cry, question or confront, or do a mediocre job or fail outright, and no one thinks the worst of us. Too often, dysregulated eaters go it alone and turn to food for comfort. This leaves them malnourished emotionally and generates craving for attachment that no amount of food will fill.
Creativity, passion, or a reason for living
Not everyone can be wildly creative like John Lennon or Pablo Picasso. Some people
feel fulfilled by going to their same job every day and doing a service. Maybe they are bus drivers, are EMTs, or are long distance truck drivers, teachers, or bank tellers. They know that what they do is of service to others and that this nourishes their sense of being valuable and valued. Others find their reason for living in dance, poetry, sculpture, films, or floral design. By making the world a better place through our creativity, we end up nourishing ourselves.
So many dysregulated eaters only feel excited by food—planning their next meal, hitting the snack machine mid-afternoon, zoning out on food at night when they’re lonely or bored. For others, their reason for living is to be 5 or 15 or 90 pounds thinner. Nothing matters but the number on the scale. Nothing makes them feel filled up like emptying themselves out violently or slowly slipping away pound by precious pound.
They could be putting their focus and energy into devoting themselves to a craft or doing good works. Instead of measuring life in terms of quality, life is all about quantity. Sometimes it’s acquisition and consumption of material goods. Sadly, because they’re never putting themselves out into the world in a meaningful way, they feel starved and empty inside.
Take time to consider what nourishes you emotionally. When you read over the above list, which are your strong suits and which are your weak ones? When you reach for food, which kind of nourishment are you really seeking? If you’re not hungry, it’s not food you want and you will need to figure out what will truly satisfy you. When you are fulfilled and know how to refuel and find fulfillment, you will no longer look to food or weight to enhance your life. You will know that there is more than one kind of way to feed yourself.
Harriet Brown joined us to discuss her book, Body of Truth: How Science, History, and Culture Drive Our Obsession with Weight – and What We Can Do About It. What follows are our questions in italics, and Harriet’s thoughtful answers.
In your introduction to Body of Truth: How Science, History, and Culture Drive Our Obsession with Weight – and What We Can Do About It, you comment that “Obsessing about weight …” has “become social currency not just for women but for teens and even children.” We’d like to hear more from you on this.
What I mean by that is that it’s become de rigueur for nearly everyone to be self-deprecating about their weight, to bemoan how “fat” they are, and to publicly aspire to a different, thinner body. If you don’t participate in this ritual of self-flagellation you are automatically outside the social circle (or most of them); you can be thought stuck-up, conceited, arrogant if you don’t hate on your body.
Can you please discuss some of the ways professionals use fear to motivate adults and children to lose weight?
They do it through health scare-mongering: “You’ll die early if you don’t lose weight!” or “You’ll develop diabetes if you don’t lose weight!” Fill in the blank for pretty much any illness you can imagine.
What would you like people to know about “the 5 per centers”?
They’re a group that prioritizes weight loss above just about everything else in their lives. Almost without exception they say they maintain their weight loss by devoting a LOT of time and energy to it. They also tend to devote a certain amount of mental real estate to counting calories and tracking calories burned, and keeping up a certain level of hyperawareness about food and eating. They tend to weigh and measure their food. They also tend to eat relatively few calories, which makes sense because every major weight loss resets the metabolism so it requires fewer calories.
In your opinion, what are some of the problems that can develop from a “good food/bad food” belief system?
Demonizing certain foods makes them more attractive in a sense. Highlighting “good” foods also sends a message that these are unattractive but necessary. Setting up this kind of dichotomy tends to send people boomeranging from restricting to disinhibited eating, neither of which is useful for supporting good health (mental or physical).
Medical professionals seem to span a range of beliefs on weight, weight gain, weight loss, and BMI. What questions would you suggest a potential patient ask when looking for a health care provider who is without weight bias?
For starters there’s a website where someone has compiled a list of “fat-friendly” doctors, and it’s at http://fatfriendlydocs.com/. Beyond that I think it’s more than fair to set up a time to talk to a doctor about her/his philosophy on any number of things, including weight and health. One good question if you’re talking to a doctor about a specific health issue is, “How would you treat someone who was thin and presented with this same problem?”
What were some of the critical pieces that came together for you to appreciate your self and move on from years of body loathing?
I think I’d reached a real low point in my relationship with my own body, and a sense that I just couldn’t keep doing what I’d been doing, i.e., hating my body and myself. I felt I was setting a terrible example for my daughters. So I think I was ready. And then I was lucky enough to have a therapist who really knew her stuff on this issue—Ellyn Satter, who I consulted by happy coincidence.
“Maintain” seems like a relatively calm verb. Merriam Webster defines maintain as, “to cause (something) to exist or continue without changing. : to keep (something) in good condition by making repairs, correcting problems, etc. : to continue having or doing (something)” Of the definitions the second one best describes it best. To have a healthy body image, people have to actively do something and remain vigilant to repair and correct. Body image is like a wood fence that is constantly weathered by the environment of thin and perfectionistic ideal images. It becomes necessary to teach clients how to “maintain.”
From the earliest studies of eating disorders 40 years ago, researchers have noted the influence of cultural standards of beauty and thinness. Consider the classic study by Garner and colleagues that demonstrated that the thinning of magazine models’ sizes coincided with increases in eating disorders during the 20th century ( Garner, Garfinkel, Schwartz & Thompson, 1980). It has been observed that as cultures become industrialized/westernized the rate of body dissatisfaction and eating disorders increases (Nasser, Katzman & Gordon, 2003). These authors presented data showing eating disorders are most impactful in emerging and second world economies. The majority of young women in the U.S. are dissatisfied with their bodies and idealize a size that few obtain. Increasingly, young men are also experiencing these pressures to change their bodies (Bucchianeri, Arikian, Hannan, Eisenberg, & Neumark-Sztainer, 2013). Those with positive body image are people who reject the cultural ideal. Put more simply to develop or assist a client in developing a positive body image is to work to become abnormal.
A number of approaches work on a cognitive basis and these have been explored for several decades. For example, Cash’s (1997) Body Image Workbook for clients is based on research into cognitive research to change body image beliefs. (See also Cash & Lavellee, 1997, for research). Key goals are: helping people become aware of how unrealistic the cultural body image ideal is and raising awareness of automatic negative thoughts and working to create positive self-talk.
It may help at times to focus on non-appearance or non-weight related aspects of the self. One of the newer approaches that incorporates that view is ACT (acceptance and commitment therapy). In ACT there is acceptance of the negative thinking but clients are encouraged to step outside of that thinking to follow goals and values that are meaningful. Positive feelings come from acting in accordance with personal goals. Pearson, Heffner and Follette (2010) review the theory, research and techniques of this approach.
Another variation of the cognitive approach is the use of cognitive dissonance in improving body image. Stice and colleagues have extensively demonstrated in prevention programs that these techniques are effective, long-lasting and boost body image (Stice, Shaw, Burton & Wade, 2006; Stice, Marti, Spoor, Presnell & Shaw, 2008 and Stice, Durant, Rohde & Shaw, 2014). The key idea is that by asking participants to encourage positive body image in others, a cognitive dissonance is created with their own negative views. This dissonance drives an internal shift in attitude to align self-related cognition to the expressed behavior. On the surface it may seem backwards, but these techniques have been empirically validated multiple times by the research group as well as others (e.g. Becker, Smith & Ciao, 2006). In my own work with teen groups these methods are very engaging and create lots of active dialog.
Those of us who work with eating disorder clients know that many treatment centers also employ expressive/movement therapy and yoga to improve body image. There have been few studies of these experiential methods. Much more research is needed. Koch, Kunz, Lyko, and Cruz (2014) were able to support the efficacy of dance therapy across studies in their meta-analysis. Both body image and overall well-being improved. Researchers have also begun to look at the impact of yoga and body image with some positive findings such as Dittman & Freedman’s (2009) study. Other studies present a cautionary note such as in Neumark-Sztainer, Eisenberg, Wall, and Loth (2011). These authors observed in a study of over 2000 individuals that many who participated in yoga or pilates had higher rates of body image and eating pathology. Perhaps these individuals are recognizing the need for change. However it is useful to know what is in the community when therapists recommend different activities for maintaining positive body image.
Taken together there are many strategies for maintaining good body image and research has helped us along the way. We can challenge cognition, strengthen our values and intentions, express counter-culture body image messages, and finally engage in physical strategies through dance and yoga. We seem to have enough strategies to appeal to everyone in our quest to overcome stormy cultural seas and maintain positive body image.
When I ask my patients who struggle with binge eating to identify triggers for their episodes, they frequently point to words and actions of family members and loved ones. Often the report sounds something like this, “I know he/she was trying to help me lose weight, but when he/she asked me ‘should I really be eating that piece of cake’, it just made me want to devour the whole cake and then see what else was in the pantry.”
Family members (including parents, spouses and siblings) and friends of people who binge eat are in a tough spot. Even when their intentions are good, the comments they make about the binge eater’s food choices or body size can trigger emotions in the binge eater that trigger urges to eat.
Shame is one such emotion that is commonly triggered. Anger, resentment, and fear are others. Even when the family member is not being overtly critical or shaming, someone who feels ashamed about their eating or body is easily triggered when these topics are commented upon. Sometimes an intended compliment from a family member observing that the binge eater “ate less than usual” or “made a healthy choice” or “seems to be getting thinner” can trigger shame for past behavior that was less optimal. Binge eaters are typically sensitive to attempts by others to control their eating and body, and a resistant part of the binge eater may respond with a desire to eat fast and furiously as an act of rebellion.
Loved ones who want to be helpful can usually find the best guidance by talking with the person struggling with eating. Start by expressing your desire to help and simply ask “what, if anything, could I say that would help you if I see you starting to eat inappropriately?” Many of my patients will ask family members and friends to offer to do something together that soothes and distracts without calling attention to the eating. For example, one may offer to take a walk together, go out somewhere, or engage in a mutually enjoyed activity that is not compatible with eating, such as a game. Each patient is different in what they need but many agree that a genuinely compassionate desire on the part of the family member or friend to be helpful along with the absence of judgment or frustration with the binge eater are most important.
Sometimes, the impact of loved ones is through the environment rather than words. Parents or spouses might bring food into the house that tempts the binge eater. Sometimes the family member doesn’t realize the food will be too tempting for the binge eater but feels justified because they or other people in the family want that food to be available. Here, too, a family member faces a challenge to find the right balance between trying to help the binge eater and meeting other needs. There is no single solution to the problem of what foods to keep in the home, and this is best discussed openly and honestly so fair compromises can be reached. For example, there could be a certain time frame when some foods are avoided, and then, at a later time when skills for resisting binge urges are better developed, those edibles can be reintroduced. Or perhaps some types of “fun foods” can be identified that are less tempting for the binge eater and can be substituted. Almost always, one thing that can be done is to keep typical binge foods out of sight (e.g., in the back of cabinets, fridge or freezer, or in the basement or in someone’s car trunk) and therefore, hopefully, out of mind. Though binge urges are often triggered by thoughts, emotions, and body sensations, the sight of tempting food can sometimes become the difference between a patient giving in to a binge or not.
The environment created by a binge eater’s loved ones is not only through food and direct comments, but also through the way that bodies are discussed. For example, a friend that frequently comments on people’s appearance and weight sends a message. Making statements about a movie star who gained or lost weight, or a family friend or acquaintance who is “looking good,” whether the judgments are positive or negative, conveys the idea that people are being primarily judged based on appearance. This type of communication sticks with many binge eaters and adds to self-disgust and self-judgment. Binge eaters, whether they are obese, overweight, or normal weight, are acutely aware of the impact that their eating patterns could potentially have on their weight. A family environment that keeps the focus on weight is a shaming environment, regardless of how much love for the binge eater is expressed in other ways.
Family members will often ask me how they can help their child or spouse reduce binge eating. Often, the answer is to hold an attitude of genuine compassion for the binge eater’s struggle with their habits and urges and a genuine acceptance of the binge eater as a lovable person, even if their body size causes the parent or spouse anxiety or disgust. Binge eaters by definition feel self-disgust. Often asking the binge eater what types of comments or actions would be supportive and what types of comments or actions are triggering will give the family member important information. For example, being a good listener when the binge eater wants to talk about something bothering him or her, or spending family time in ways that don’t revolve around food are often identified by my clients as ways their family members have been helpful to them.
As a therapist for people who binge eat, I usually assume that there will be no significant change in family dynamics, at least in the early phases of treatment. I, therefore, don’t send the message that symptom improvement depends on a family member changing. Rather, my job is to teach the binge eater skills to resist urges to binge and these include skills for managing emotions triggered by family dynamics. This is where skill-based therapies such as Dialectical Behavior Therapy and other Mindfulness-based therapies have so much usefulness. These therapeutic approaches for binge eating center around the skill of observing emotions, thoughts, and body sensations that arise in one’s self moment to moment. Noticing urges-to-eat that arise in response to a loved one’s comment can then allow a choice to be made about whether to act on the urge by eating or whether to take a different path. Taking a different path requires strategies for soothing oneself without escaping into a trance of eating and for mindfully absorbing oneself in activities and sensations that will reduce one’s urge to eat. Also, interpersonal skills, such as assertiveness in asking for what one wants or does not want without threatening the relationship can often reduce the impact that family and other relationships have on the binge eating illness. It is helpful to view binge eating as an illness that can be improved by skills, perspectives, and strategies, rather than a flaw in the character of the binge eater.
Before ending this article is it important to point out that binge eating is complex and often very stubborn to change, like other addictive behavior patterns, and is certainly not caused by family dynamics. If someone is binge eating, it does not mean that his or her family or friends are doing something wrong. Many of my patients describe their loved ones’ compassion and support as the one thing they are lucky to have, otherwise their problem would be significantly worse.
By Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS
This is the first of a 2 Part series on Recovered Therapists and the Treatment of Eating Disorders.
Whether or not a therapist with a personal history of an eating disorder should treat patients with eating disorders and disclose that history has long been a subject of debate. The discussion continues—without resolve—between proponents in favor and those who oppose such self-disclosure. It is important to note at the outset of this article that both authors are therapists who have recovered from an eating disorder and support appropriate self-disclosure in the therapeutic relationship. We believe that being recovered from an eating disorder can be a significant asset when working with eating disorder patients.
Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. Early reports suggested about one out of three or four (Barbarich, 2002; Bloomgarden, Gerstein & Moss 2003; Johnston, Smethurst, & Gowers, 2005; Shisslak, Gray, & Crago, 1989; Warren, Crowley, Olivardia, & Schoen, 2008). More recent reports indicate perhaps even higher percentages. De Vos and colleagues (2015) noted that eating disorder clinicians with personal eating disorder histories ranged from 24% to 47%. The 2013 Academy for Eating Disorders online survey (unpublished) spearheaded by Dooley-Hash, de Vos, and the Professionals and Recovery Special Interest Group, revealed that out of 482 respondents from the Academy for Eating Disorders, International Association of Eating Disorders Professionals, Binge Eating Disorder Association, and Sports, Cardiovascular, and Wellness Nutrition, 262 (55%) reported a personal history of an eating disorder. Of the 262 professionals with personal histories of eating disorders, 182 (51%) reported working directly with eating disorder patients. Since many eating disorder therapists have had eating disorder histories, and according to Bloomgarden and colleagues (2003), 67% of therapists surveyed used self-disclosure in their treatment approach and “all recovered clinicians used it in their therapy in some way” (p. 165), it seems important to explore this topic further and assist clinicians in this area.
Over the years, some have suggested that clinicians with eating disorder histories should not disclose this to clients, while others have suggested they should not even work with eating disorder clients. As reported by Johnston and colleagues (2005), Clothier, MacDonald, and Shaw (1994) suggested that individuals with an eating disorder history be banned from the nursing profession, while Bullock (1997) recommended they be banned from all healthcare professions in the United Kingdom. Many have expressed concerns, listed potential disadvantages, and devised parameters to follow if a clinician with a personal history of an eating disorder wants to work in the field. In 2003, the issue was debated by the European Council on Eating Disorders, however, an agreement on whether clinicians with a history of an eating disorder are at a disadvantage when working with eating disorder clients could not be reached. What are the factors keeping us from some kind of consensus on this issue?
This article briefly looks at the history and literature on the topic of clinicians with an eating disorder past, explores values and pitfalls of these clinicians disclosing or not disclosing their history, the need to clarify terms in the field, and defining “recovered.”
The Value of Recovered Clinicians
Carolyn: “I saw my first eating disorder client in 1979 and told her I was recovered from an eating disorder. I also said, ‘If I recovered, so can you.’ She recovered and I’ve been saying the same thing to all clients ever since. Sharing my eating disorder history and serving as a role model and guide for others has been a huge aspect of my success as a therapist in the eating disorder field.”
Alli: “As a developing eating disorders therapist, I sought a place to train where I didn’t have to hide that I once had an eating disorder and could allow that personal experience to be a part of the work—not a dominant part, as the clinical aspects need to be, but not a hidden part, either. So my first day as a trainee therapist was with Carolyn Costin at Monte Nido. Almost 10-years later, I can wholeheartedly say that both having learned appropriate parameters about, and having had permission to disclose my status of being recovered has helped many of my clients to believe that freedom from an eating disorder is possible—AKA ‘hope.’”
Carolyn: “I learned early on that a recovered clinician has the unique value of having lived with a brain that was once hijacked by an eating disorder and then having successfully gotten their real brain back. Having been through it, these clinicians can explain to clients, as well as to other clinicians, from a personal perspective, the mind set of someone with an eating disorder. Recovered clinicians can confront and challenge clients while empathizing in a deeply connected and personal way with the client’s fear of giving up the disorder. A recovered clinician is unlikely to encounter resistance that comes in the form of common refrains such as, ‘You just don’t get it’ or ‘Unless you’ve been there, you can’t understand.’ Over the last three decades I have hired and trained countless recovered clinicians to work with me at various levels of care, all the while receiving consistent reports from clients and families that working with a recovered therapist was a significant factor in their treatment success.”
Though there is little research on the topic, informal surveys and interviews pointed out that eating disorder patients felt that exposure to people with recovery, those who understood the illness or have recovered, was or would have been beneficial (Eivors, Button, Warner, & Turner, 2003; Redenbach & Lawler, 2003). In “Been There, Done That,” Costin and Johnson (2002) delineated advantages and disadvantages of clinicians with personal recovery and concluded that advantages outweigh the disadvantages thus “organizations need to acknowledge the useful contributions these clinicians can make to the field” (p. 303). Eleven years later, using qualitative and quantitative methods, Warren, Schafer, Crowley, and Olivardia (2013) revealed many similar benefits of utilizing therapists with eating disorder histories such as increased relational understanding, empathy, and knowledge of the disorder.
A recent and significant contribution by de Vos, Netten, and Noordenbos (2015) came from a survey at their clinic, Human Concern, where they examined both patients’ and clinicians’ experiences of treatment when the therapist was a self-disclosing, eating disorder-recovered clinician. Of the 205 patients who responded (out of 357), 97% indicated that the experiential knowledge of recovered therapists was beneficial in the therapy. Advantages included: the patient feels attunement (recognized, understood, and heard), therapy safety (equitable relationship with high levels of acceptance), the therapist seems available (authentic, open, honest), the therapist has enhanced awareness (knowledge and insight) into the eating disorder, and the patient feels increased hopefulness regarding healing and recovery. Overall, 93% of the patients indicated that the therapy provided by a recovered therapist positively influenced their recovery. Of the 32 recovered therapists who worked at Human Concern during the study and who received a mailed questionnaire, 24 (75%) completed the questionnaire. Of these therapists, 100% endorsed the same advantages as those reported by patients’ and additionally listed the following benefits: quickly bolstering therapeutic trust and cooperation in the working alliance, reducing fear and feelings of shame (the clients knew the therapist had been there or some place similar), providing a positive example (role model), having high empathy, and motivating positive change.
Potential Pitfalls of Clinicians with an Eating Disorder History
Along with potential benefits, Costin and Johnson (2002), de Vos and colleagues (2015), and Warren and colleagues (2013) presented very similar potential risks, limitations, and pitfalls that might arise when therapists who have a personal eating disorder history work with eating disorder patients. Costin and Johnson pointed out the risk of relapse and various kinds of countertransference including having narrow views of how recovery takes place and a high sense of personal mission that could lead to over-involvement. De Vos and colleagues reported potential concerns from both patients and therapists. Patients cited the possibility of making comparisons and becoming overfamiliar with the therapist as a potential negative of therapist self-disclosure, and clinicians noted potential disadvantages as increased projection, over-identification (based on personal versus client experience), and risk for over-involvement or closeness with the patient. Warren and colleagues cited clinician-related potential risks as: over-identification or biases from personal history, countertransference, and experiencing feeling triggered, which can result in setbacks or relapses for some.
Relapse concerns were highlighted by Barbarich (2002), where 27 out of 97 (28%) of eating disorder professionals with a history of an eating disorder reported relapse after entering the field as a professional. However, there are important questions to ask about this study: 1) Were these therapists “recovered,” did they describe themselves as recovered? 2) Did the therapists have at least two years of being recovered before working in the field? 3) How many of these therapists kept their personal histories concealed from colleagues and/or patients? 4) How many of these clinicians received guidance or supervision in how to appropriately use their history in their work? Of note here is that Carolyn has worked with recovered clinicians in various treatment settings for 30 years. Adhering to hiring clinicians who consider themselves recovered for at least two years and providing consistent guidance and supervision has resulted in only one known case to date where a recovered staff member relapsed.
Clarification of Terms
Many people think that the terms “recovery,” “recovering” and “recovered” are just semantic and do not make much difference. We respectfully disagree. When related to how people might view clinicians with eating disorder histories, these terms can be confusing.
Early on in the eating disorder field, professionals and patients started applying the 12 Step program, disease model of addiction, and corresponding language to the treatment of eating disorders. Though Bill Wilson included the term recovered in the Big Book of Alcoholics Anonymous, substance abuse and chemical dependency circles rarely use it and more widely utilize two other terms, recovery and recovering. However, these terms become vague and ambiguous when applied to eating disorders. To say, “I’m a recovering alcoholic” or “I’m in recovery from alcoholism,” typically means the person is notdrinking and acknowledges a lifelong disease/addiction. When a person with an eating disorder says, “I’m a recovering anorexic” or “I’m in recovery from anorexia,” what does the person actually mean? The truth is, someone who says this can mean any number of things such as, the person is in residential treatment, has just discharged from a treatment program, or has been well and normal weight for 10 years.
We respect that the terms recovery and recovering connect, inspire, and work for many. Our hope is for the eating disorder field to come up with a clear and accepted definition of recovered that denotes a person who is no longer engaging in symptoms or suffering from the illness. If clearly defined, the term recovered could be unifying and helpful to clients, practitioners, researchers, and carers alike.
Though there is no consensus, most people would likely agree that to be “recovered” from an eating disorder, there must be an absence of clinically diagnostic behaviors. However, many would also likely agree that this alone is insufficient. What if someone’s only symptom is purging once or twice every other week? Even though the person’s behaviors would not meet diagnostic criteria, most could agree that calling such a person recovered would be incorrect. Likewise a person who is abstaining from overt symptoms while restricting calories, fighting the urge to purge, weighing and body checking multiple times a day, and/or unable to eat with others or in restaurants should not be considered recovered.
Carolyn, who has been self-disclosing and using the term recovered for over three decades, knew it was important for her to define what she meant by the term. Her definition can be found in her books, 100 Questions and Answers About Eating Disorders and the 8 Keys To Recovery From an Eating Disorder:
“Being recovered is when the person can accept his or her natural body size and shape and no longer has a self-destructive relationship with food or exercise. When recovered, food and weight take a proper perspective in your life and what you weigh is not more important than who you are; in fact, actual numbers are of little or no importance at all. When recovered, you will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on the scale. When you are recovered, you do not use eating disorder behaviors to deal with, distract from, or cope with other problems.”
Both authors have repeatedly experienced clients who come to us after years of struggling with an eating disorder. These clients often report finding both motivation and a sense of hope in knowing that we were once seriously ill but are now recovered. Exposure to those who are recovered, whether clinicians, friends, celebrities, speakers, etc., is important for anyone who has an illness as it provides real proof that being recovered is possible.
Though we firmly believe that clinicians who are recovered from an eating disorder can be in a unique position, we acknowledge complexities that can come from how self or others determine when a clinician is “recovered enough” (Bloomgarden et al., 2003) to safely work with clients who have eating disorders.
How can we know when a person is really recovered? In “Eating Disorder Counsellors With Eating Disorder Histories: A Story of Being ‘Normal,’” Rance, Moller, and Douglas (2010) commented on and critiqued information gleaned from interviews held with therapists who had personal eating disorder histories. The theme of an “emphasis on normality” (p. 382) emerged, meaning that the therapists repeatedly stressed the message that “I am normal” (p. 385) in regard to food, weight, and body attitudes and that their work with eating disorder clients didn’t affect these attitudes. Examples included being free of their eating disorders (“When I got better”), eating normally (e.g., “I’m comfortable about eating”), and body acceptance (e.g., “I’m really ok with my body . . . I don’t mind its changes”) (p. 384-385). The authors added that the clinicians’ expressions generally contradicted research (Shisslak et al., 1989; Warren et al., 2009) indicating that it could actually be more normal to have their attitudes on food, body and weight impacted when working with clients with an eating disorder. Statements made that emphasized normality were originally explained as “adamant assertions” that involve “denial” (p. 389). Fortunately the authors considered an alternative interpretation—that recovered clinicians likely have worked through body, weight, and food issues and have thus “developed a far healthier relationship with these issues” than much of the population (p. 389).
Alli ; “I remember when I first began as a Mental Health Worker at Monte Nido; a miscommunication happened that led to a meeting with Carolyn to discuss and assess my recovered enough status. Not knowing what to express that would ameliorate or clarify the concern, I said, ‘I think this is like the situation where a sane person is accidentally admitted into a psychiatric ward, and anything that person says is not going to be helpful. If it’s OK with you, just watch me.’ I knew that time and observation, not words, would reveal whether I was recovered. And yes, I admit that having self-disclosed my recovered status at work added a layer of stress in that I felt ‘watched,’ but the benefits of being able to train at Monte Nido and harness how to use my past eating disorder experience in helpful ways far outweighed the time limited period of anxiety.”
Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or “using.” There is no similar test to determine if a person is “using” his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & O’Toole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?
Other suggestions have ranged from ongoing assessments of the recovered clinicians’ relapse potential, how they conduct therapy, and a myriad of other “indicators.” Some have recommended that for clinicians with an eating disorder history the following should be regularly assessed: absence from work, inability to make decisions or cope in emergencies, seeking therapeutic relationships with colleagues, potential risks to patients, and potential to collude with the patients and their illness. After almost thirty years as clinical director of eating disorder day treatment, residential, and hospital programs, it is noteworthy that Carolyn has not seen higher incidences of problems in any of these areas with her recovered staff verses her staff with no eating disorder history. It seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post traumatic stress disorder, or another diagnosis in their past. We leave readers to ponder that question.
The Downside of Not Telling
There is another important consideration here that is seldom discussed. Clients often directly ask their eating disorder therapist whether he or she ever had an eating disorder. Is not disclosing an eating disorder history a risk-free option?
Bloomgarden (2000) noted that when she was treating eating disorder patients and actively withholding her own eating disorder recovery, a barrier was created that negatively affected her working alliance with patients. Others have acknowledged the same was true for them. For example, over the last few years eating disorder physician, Dr. Mark Warren, has been speaking to audiences about clinicians and recovery after finally revealing his own eating disorder history on a panel with Carolyn at a national conference. Dr. Warren told the audience that not disclosing his eating disorder history to patients and their families became so distressing that it undermined his sense of integrity and finally caused him to disclose his eating disorder past.
What Else to Consider
The implications surrounding therapists’ personal disclosure are far reaching and involvea myriad of considerations that cannot possibly be covered in this article. Considerations include: clinical issues; ethical concerns; legal ramifications; human resource management; hiring policies; training and supervision; countertransference problems; self-disclosure guidelines; potential and actual relapse red-flags and concerns; and necessity for research on the pros and cons for both client and clinician, including outcome studies.
Clinicians with a personal history of an eating disorder should be able to make their own decision about whether or not to work with eating disorder patients and whether or not to disclose their personal history. Some colleagues practice a “tell only when asked” policy, meaning they share only if asked by patients or colleagues. Some choose not to share at all, and some share as a routine part of their work. Our ultimate goal is to explore how clinicians with a personal history—who want to use it in their work—can best do so while also recognizing the many related complexities.
Without the existence of widely accepted guidelines that can help eating disorder clinicians to effectively use self-disclosure and personal eating disorder experience, the only guiding ethical cornerstones that exist are to do what is in the best interest of the client and do no harm; however, determining what these mean is up to each individual. For now, any clinician considering self-disclosure, will have to rely on introspection, colleagues, training, professional ethics, consultation, tenets of their dominant theoretical orientation, client feedback, and supervision or employment policies.
In the hopes of generating further discussion and assisting clinicians with an eating disorder past, a second article will be devoted to guidelines for self-disclosure and how to use one’s eating disorder history when working with patients.