Although the recognition that eating disorders are related to self-concept was a huge breakthrough for the field, the truth is, low self-esteem doesn’t cause eating disorders. Let me explain.
Before I had ever seen someone with an eating disorder in my outpatient practice, I had been taught that eating disorders were a problem with self-esteem. So I rolled up my sleeves, put my “build em’ up” hat on, and set myself to meet someone with low self-esteem. Boy was I in for a surprise.
17-year old Ashlee follows me to the office. She is dressed impeccably, in the conservatively-trendy way that someone featured in “Teen Magazine” would look. She walks with confidence, she makes eye contact with me, small talk with the receptionist and is discreetly polite to other people in the waiting area. She shakes my hand with soft firmness, asks me about the picture of my boys on my desk. She sits upright and if I didn’t know better, I would say she was the clinician and I was the client with low self-esteem.
Me: “So, what can you tell me about your strengths?”
Ashlee: (deeeep breath) “Well, I am the president of my class, I get straight A’s in advanced courses, this is because I want to be a neurosurgeon when I grow up and cure Parkinson’s disease. I am a cheerleader. I used to be the captain but I gave over the position to my best friend because she really wanted it. Although my mom was disappointed she was proud of me for being so kind. I run track but not all year, just when I am not playing soccer. I love to practice the piano and I volunteer to read to the blind on Saturdays. Sorry, should I talk slower so you can write all this down?”
Me, after picking myself up off the floor: “You know, when I was your age my main hobby was going to raves and smoking pot with my boyfriend. He looked just like Kirk Cobain. He was so dreamy…”
Needless to say, (so why say it?) I was thoroughly shocked. This client was NOT someone with low self-esteem. I know because I had worked for 9 years with people who have low self esteem. In community mental health, we would spend months or even years trying to get our clients to create a list of strengths, mobilize those strengths, and start doing esteem-building things. Through the months, it dawned on me that self-concept problems of people with eating disorders was an entirely different animal than lack of self-esteem. But clearly there was a crisis of self happening–how else could the emaciation and self-punishment of these clients be explained? Could it be that there was more than one dimension of self-concept, and that eating disorders simply lived on a level that didn’t involve one’s perceived strengths and abilities?
So the task at hand was to identify the other level of self: one for people who didn’t know their strengths and another for people who didn’t know their worth. I call the first level “self-esteem”, and work on this dimension involves building lists that describe someone’s talents, goals, abilities, and encouraging clients to embark upon esteeming experiences. This aids the person’s sense that they are valuable because of what they do.
The next level of self-concept is what I call “self-worth”. It encapsulates one’s sense of intrinsic, inborn worthiness, lovability, their sense of being deserving of attention and care just for who they are as a person. In other words, it is the degree to which someone can say “I would be a valuable and lovable person even if I didn’t have all these skills and talents, even if I didn’t reach all these goals all the time. I am worthy just for who I am.”
Eating disorders are caused by deficits in self-worth. Does this mean people with eating disorders all have high self-esteem? Certainly and sadly, no. However, as I quickly learned in my first session, high self-esteem is neither a necessary nor sufficient condition for recovery from an eating disorder. Eating disorders are a crisis of self-worth, and building self-worth in our clients is the only way to lead them through recovery. Since I had the audacity to contradict traditional psychological treatment of self-concept more complicated and bifrucate it, I had better also propose how we can differentially work with the two levels. So keep reading, as I will describe how that is done throughout this blog.