Understanding Anorexia in Males: An Integrative Approach Book Interview

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!

The Little Girl with the Hummus Lunch

By Malak Saddy, RDN, LD

***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.

Finding Nourishment In Life As Well As In Food

by Karen R. Koenig, LCSW, M.Ed.

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.

1. Pleasure/play

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.

2. Challenge

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?

3. Wonder/awe

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.

4. 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.

5. 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.

6. 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.