Eating Disorders in Adult Women: A long term therapy group through the lens of Relational-Cultural Theory
Karen Samuels, PhD
Isolation is the glue that holds an eating disorder in place. (adapted from Laing, K. 1998). Seven women wait expectantly for everyone to settle in their seats to begin group therapy, focused on women at midlife. Ranging from 45 to 60, these women represent decades of secrecy and suffering alone. Collectively, they have lived hundreds of years with various aspects of their eating disorders. They have come together to heal and learn in connection.
We know that age does not immunize women across the life span from the challenges and symptoms of disordered eating (Maine, 2010; Bulik, 2013; Gagne, et.al. 2012; Samuels & Maine, 2012; Maine, Samuels & Tantillo, 2015). Growing evidence indicates that increasing numbers of adult women experiencing both clinical and subclinical eating disorders areseeking treatment (Zerbe, 2013). Treatment centers for eating disorders offer adult programs and report a rise in the numbers of women in their later 40’s, 50’s and 60’s seeking a higher level of care. While previously these adult programs targeted women “over 30”, women at and beyond mid-life report a need for treatment that takes into consideration issues such as: later life health concerns such as a pregnancy or symptoms of menopause, an aging body, divorce and remarriage, children entering and graduating college, career changes and retirement, and grand parenting (Maine, 2010, Maine & Kelly, 2005). Another distinctive characteristic described by women at mid-life: their eating disorder is a chronic illness, long past the acute disorder that emerged in their teens or early adult years.
Mid-life poses numerous challenges to treatment. The eating disorders continue to manifest in all ways: AN, BN, BED, and NEC, and sub-acute or partial variations. These bring the full gamut of physical complications including compounding physical deficits, advanced bone density disease, co-morbidities like depression, anxiety and substance abuse, and long term social isolation. Since a larger proportion of these women experience NEC and subclinical symptoms, seeking care is more of an obstacle (Maine, Samuels, & Tantillo, 2015). Many health care providers do not inquire and these adult women may be reluctant to identify their eating disorder as a contributing factor to other health conditions. Medical professionals, not aware that eating disorders continue or emerge later in life, may pursue a variety of tests to identify other physical diagnoses instead of eating disorder related complications.
Finances may be another obstacle to treatment. Savings are often earmarked for children’s education or retirement planning at this time. Demanding careers may compete with the need for intensive care. Care for children, significant others and elderly parents may also compete with necessary medical, dietary and psychological treatment. Adult women at and beyond midlife have spent much of their lives working. The job of caregiver has been consuming: family, peers, jobs, careers, service work, and balancing the needs of everyone else in their life. They appear to have a rich life while feeling internally empty, alone and unfulfilled, struggling in secret (Maine, Samuels & Tantillo, 2015).
This specific mid-life ED therapy group has been meeting for over four years. The seven women have a range of experiences; everyone describes challenges with disordered eating began in their teens. Onset of one woman’s eating disorder was age 12, not diagnosed or specifically treated until age 45; another woman went for residential treatment in her 20’s and considered her eating disorder in remission until her mid-50’s when life events triggered relapse along with associated significant medical concerns. Another woman reports a strong genetic predisposition: the third generation of women in her family to experience a clinical eating disorder. She returned to treatment as her daughters approached adolescence, determined that the cycle NOT continue yet another generation.
While rarely bitter or upset, each woman shared her understanding that her ongoing struggles with the symptoms and consequences of the eating disorder were “unmentionable”. They consider eating disorders a teenager’s problem; since they were now approaching or beyond menopause, they were “beyond help.” Most of the woman agree their adolescent years marked the onset of disordered eating, weight preoccupation and dangerous methods of restriction, binge-purge, excessive exercise, etc. Everyone reported prior psycho-therapeutic experiences. Most commented that their eating disorder had not been addressed, or minimized. As one woman stated: “I understood my problems were anxiety and major depression, and was assured the eating disorder would resolve when my mood disorder was better managed.” Another woman described her spouse’s decade’s long sobriety and continued involvement in 12 step meetings and fellowship. She “longed for something similar” for herself. These women were eager to meet and develop a “safe environment” to share their concerns, support one another and seek recovery.
Eating disorders in adult women may present in many levels of severity. Some may have previously experienced years of Anorexia and Bulimia, or Binge Eating Disorder, meeting full clinical diagnostic criteria. Today they may suffer with the manifestation of their disordered thoughts consuming the day, but are classified as Feeding and eating conditions not elsewhere classified, or NEC, BED or subclinical eating disorders, such as orthorexia. Some struggled since youth and have never escaped the grip of these obsessions. Others have struggled, recovered and relapsed over many decades. Some have been preoccupied with food and weight for a lifetime, but never at clinically significant levels until now (Maine & Samuels, 2014). These women ALL relate to one another’s disordered eating, changing and aging bodies, and the desire to live with more peace.
Relational-Cultural Group Process emphasizes the focus on teaching the importance of an intersubjective perspective within the group by encouraging group members to be empathetic, to listen, to inquire and to resonate with others. Group members learn, and hopefully appreciate, the other’s perspectives and feelings. Yet an effective relational group will also include a feedback model of “This is how I see you”. It is in integration of an Other-Centered working group that creates an “Us” rather than just a “You” or “Me” perspective. When group members fully listen to each other and think about how the other individual’s perceptions compare and contrast with their own, then a new experience emerges — an experience that is uniquely different from what each individual has previously known. New understandings emerge, old beliefs change, and new emotional experiences occur (Jordan & Dooley, 2000).
It is through shared affect and perceptions that old emotional experiences can be integrated with current relationships that are uniquely individual and simultaneously uniquely relational. In doing so, we create a place that belongs solely to no one in particular and yet it belongs to each and all – a creative place of relationship (Jordan, 2000). Relational-Cultural theory shifts the primary models of psychology from an emphasis on the “separate self” to an appreciation of the centrality of relationship in our lives. Shifting this paradigm from separation to connection transforms the group experience, both in the therapy room, and in the larger culture and society (Jordan, 2010). Empathy is understood as a cognitive-affective resonance, joining with the other person in a shared state of human connections. There is compassion, a lessening of the suffering of separation. Mutual empathy moves us toward one another, out of isolation (Jordan, 2000). This group seeks to demonstrate and learn to implement the experience of mutual empathy, both in the sessions and brought into their lives.
Four years later, these women have witnessed and welcomed the relational group support through the passages of life: menopause, major illness, challenges of relationships and divorce, deaths of close family members and friends, career changes, new business ventures, sending children to and graduating from college and birth of grandchildren. The rates and progress in managing disordered eating symptoms vary; but the resounding centerpiece of each meeting remains to prioritize self-care, self-empathy and practicing mutuality in connections. Isolation is the glue that “holds the eating disorder in place.” (K. Laing) This response, to no longer withdraw into preoccupation with harmful symptoms of the eating disorder, has frequently been replaced with motivation to connect, reminders of CBT and DBT strategies discussed in group, and self-soothing practices. The relational “we” is the chorus in these group therapy meetings. We do understand, we see and hear your struggles, we appreciate that “recovery” may appear different as menopause challenges the “loss of status” in a youth-obsessed world: at the core these women do not want their “sisters” in recovery to go through the healing process alone.
The group sessions begin with a round robin, borrowing from the work of Martin Seligman’s Positive psychology (Flourish, 2011). “What went well?” This question is posed to each woman as she reflects on her experiences with recovery since the last group session. The group is invited to inquire and support the threads of continuity from previous group meetings. Thus trends of positive outcomes are emphasized, following up on intentions and goals of treatment and the forward focus. The focus of the group’s opening activity is to accept positive emotional feedback, the sense of engagement with the group, the deepening of connections in these relationships and the sense of enlargement: serving something bigger than one’s self (Seligman, 2011). The women learn to advocate for themselves: stating their achievements, stepping forward amidst the challenges of very full, demanding lives, practicing self-empathy and receiving compassion and encouragement.
Many times these women have dedicated themselves to the service of others. To claim their strides forward, to receive the empathy and resonance of the group members, and share the sense that “we are no longer alone; in this together”, creates meaning and context (Seligman, 2011; Miller & Stiver, 1997). Next is the challenge: asking for time to discuss their personal difficulties and challenges. Adult women frequently are reluctant to ask for time and attention. The group encourages and invites one another to reveal their recovery roadblocks, impediments to self-efficacy, as well as success. The practice of mutuality in relationship, self and other-empathy, especially pertaining to their disordered eating, becomes another layer of relational learning and growth fostering connections (Miller and Stiver, 1997). Each session ends with a didactic handout. These may include exercises (CBT, DBT, EFT based), recommendations for recovery related to seasonal or holiday demands, recent articles especially related to adult women with eating disorders, and text that highlights recurring group discussion topics.
Further strategies of recovery support have been to challenge one another to practice exposure to feared stimuli: shared meals via phone, text and skype. Reaching out to a peer, driving carpool, or at the workplace, these women have learned to “share a meal”, and use technology to incorporate much needed encouragement amidst busy and demanding lives. The concept of “text support”— when faced with potential relapse “triggers”— has become the “language of recovery”. During the holiday season one year, each group member handcrafted gifts for one another. The theme was recovery and connection. The gifts included: hand sewn embroidered “Cope-ing bags” containing stones marked with body acceptance affirmations; beaded bracelets with an arrow pointing out the “road to recovery”; laminated book markers each with a recovery theme; crocheted scarves in favorite colors and targeted meditations that emerged from group themes. These shared “creations” aided the women to join together and maintain a sense of “connection” between group sessions.
Ella studied dance at a conservatory from age 12 to 18. Always slim, her eating disorder went undetected during these years of endless hours in the studio. Battling low weight, depression, anxiety and a myriad of injuries from dance studies, she never put the “face and name of anorexia” to her restrictive eating and battle against a maturing body. Prior psychotherapy addressed her mood disorder. At the age of 45, she returned to psychotherapy following the death of her father. The therapist concentrated on early trauma and the recurring patterns of depression since puberty. Steadily dropping weight again, she was confronted with “having an eating disorder” and directed to enter a 4 week residential program 5 hours from home. Her daughters were 9 and 12, and she couldn’t fathom leaving them in the care of her husband, 20 years her senior, now retired. In this eating disorder program, she expected to be informed she did not belong there and it was a big mistake. Quite the contrary, her team was dedicated to weight and meal restoration and addressing the 30 years of body hatred and despair. Upon her return home, her therapist resumed work on grief and childhood sexual trauma. Within months her weight plummeted again and she could not fathom spending another $35,000 of the family’s life savings to return to treatment. Terrified, she changed therapists to an eating disorders specialist and joined the adult women’s eating disorder recovery group.
Two years after her initial entrance into residential treatment for her eating disorder, her depression worsened, weight dropped and she was urged to return to a higher level of treatment. Again the decades of denial led her to believe that this was unfathomable. At her last meeting with the adult women’s group, she finally understood. Each woman in the group expressed their fears for her survival and admitted they were terrified she would not be alive by the next group’s meeting. The group encouraged and supported her residential care, sending dozens of cards and messages. Upon her return from intensive treatment, she was welcomed and supported by her group, treatment team, family and peers. Some three years later, she attributes the strength of these connections, working with a specialized treatment team and acquiring relational skills as key to her stabilization and recovery. Coming back from treatment the second time to a strong network of women offering relational engagement contributed to Ella’s health and healing. She now describes the value and benefit of finding trust and safety receiving care and support, confidentiality and “acceptance without judgement”.
“Knowing that as an adult, I am no longer alone and silent, with no one in my life or family who got my eating disorder: this has made a great difference, and been a relief to find understanding and acceptance from our group. There is also wisdom shared about the nature of recovery and life’s challenges, such as relationships, loss and menopause.”
Jean Baker Miller (1976) describes the “Five Good Things” of growth fostering relationships: zest, sense of worth, clarity, productivity, and a desire for more connection. The women who gather in Relational Cultural group describe these five and more. A recent discussion about the nuanced nature of “eating disorder recovery” for women post-menopause brought a collective sigh of relief. I am deeply moved and inspired by the shared wisdom and determination these women bring both individually, and in “sisterhood”. Recently, when the group was asked about adding new members, the resounding response was: “YES! We have suffered alone for too many years.”
No one else needs to.
These women demonstrate the healing connections possible in treating long term eating disorders in group therapy. More research and practice will further understanding and sharpen clinical understanding of the unique treatment needs and benefits of working with women at and beyond mid-life.
ABOUT THE AUTHOR
Karen Samuels, PhD, is a licensed clinical psychologist, consultant to the Family Medicine Residency Program and on medical staff at Halifax Medical, Daytona Beach, FL. Working in the field of eating disorders for 30+ years, she identifies primarily as a community activist. In 2001, she co-founded COPE (Community Outreach to Prevent Eating Disorders) a nonprofit seeking to educate the local medical, education and lay communities. She presents nationally raising awareness about the needs of adult women with disordered eating across the lifespan. Related areas of interest include primary prevention in public education, training family physicians in multi-disciplinary outpatient treatment, and treatment groups for adult women. She has been a long time affiliate at the Jean Baker Miller Training Institute (JBMTI), Wellesley Centers for Women, and, with Margo Maine, Ph.D., co-wrote a working paper on midlife women with eating disorders. She contributes to the JBMTI eConnections and delivers workshops informed by Relational Cultural Theory. Dr. Samuels received the 2014 NEDA Westin Family Award for Activism and Advocacy.
REFERENCES
Bulik, C.M. (2013). Midlife eating disorders: Your journey to recovery. New York: Walker Publishing Company.
Gagne, D. A., Von Holle, A., Brownley, K. A., Runfola, C.D., Hofmeier ,S., Branch, K. E., & Bulik, C. M. (2012).Eating disorder symptoms and weight and shape concerns in a large web-based convenience sample of women ages 50 and above: Results of the gender and body image (GABI) study. International Journal of Eating Disorders, 45(7), 832-44.
Jordan, J.V. & Dooley, C. (2000). Relational Practice in Action: A Group Manual. No. 6. Jean Baker Miller Training Institute at Wellesley Centers for Women.
Laing, K. (1998). Katalyst leadership workshop presented at In Pursuit of Parity: Teachers as Liberators, Boston, MA.
Maine, M. (2010). The weight- bearing years: Eating disorders and body image despair in adult women. In M. Maine, B. McGilley & D. Bunnell (Eds.), Treatment of eating disorders: Bridging the research – practice gap (pp. 285-300). London, UK: Elsevier.
Maine, M., & Kelly, J. (2005). The body myth: Adult women and the pressure to be perfect. New York: John Wiley.
Maine, M., Samuels, K., & Tantillo, M. (2015). Eating Disorders in adult women: biopsychosocial, developmental and clinical considerations. Advances in Eating Disorders: Research and Practice, DOI: 10.1080/21662630.2014.999103.
Miller, J.B. (1976) Towards a New Psychology of Women. Boston: Beacon Press.
Miller, J.B. & Stiver, I. (1997). The Healing Connection: How Women Form Relationships in Therapy and in Life. New York: Guilford Press.
Samuels, K. & Maine, M. (2012). Treating eating disorders at midlife and beyond: Help, hope, and the Relational Cultural Theory. Work in Progress: No. 110. Jean Baker Miller Training Institute at Wellesley Centers for Women.
Seligman, M. (2011). Flourish: A Visionary New Understanding of Happiness and Well-being. New York: Free Press.
Zerbe , K. J. (2013). Late life eating disorders. Eating Disorders Review, 24 (6) pp.3-5.
