Beneath the will lies the ill

Weight Scale

During this time of year we are inundated with stories of weight-loss resolutions, dietary goals and exercise aspirations. Most of us want something approximating the media-dictated “perfect body” but, luckily, never get there because in the healthy person, normal appetite overrules the drive to be stick-thin. It is apparent that drive to be thin and a belief that one’s body is too large is not a recipe for weight loss. In extreme cases, people are literally told by their doctors “if you don’t lose weight, you will suffer dire health consequences, even death”. At that point, motivation to eat less would be probably as high as it could be, and yet still many in that position can’t lose the pounds needed to achieve even the most basic health.

This brings up an interesting question: if Anorexia is really about a desire to lose weight and a belief that one is ‘too fat’, then how is it that people without Anorexia who want nothing more than to lose weight, who believe their bodies to be severely overweight, can’t lose the weight they want? I propose that viewing your body as being too large and strongly desiring weight loss is not what causes Anorexia, otherwise we would see the Anorexic eating habits in everyone whose New Year’s resolution is to lose weight. I’ve even heard people say “I wish I could catch Anorexia for just a month or two to get this damned weight off!” Certainly there is more to this equation than is apparent at first glance.

Anorexia (and eating disorders generally) are not something one can turn off and turn on. It is not a function of wanting to lose weight, and recovery is not a function of wanting to gain weight. There is something much deeper going on with this illness that has nothing to do with feeling too big and wanting to be smaller. Yes, being distressed about one’s body, feeling it is too big and wanting to lose weight are associated with Anorexia, but they do not cause Anorexia. Otherwise, there would be an epidemic of “Anorexia” on January 1, and all the people who are on diets would instantly “catch it” as part of their diet plans.

No, Anorexia is much more complicated than that. It frustrates me how much research and clinical effort is spent on variables that, in my view, are the result of the Anorexia process but not the cause of the illness itself. The approach we have is similar to treating a patient for the flu, and believing that lowering the fever is going to resolve the illness. Yes, the fever is associated with the flu, but the fever didn’t cause the flu, the flu caused the fever. Similarly with Anorexia, wanting to lose weight and thinking you are too fat is a symptom of the illness, but didn’t cause the illness itself. The illness causes affected individuals to start feeling too large and wanting to take pounds off, but that is not how it starts and not how a meaningful resolution is achieved.

To provide people with Anorexia the recovery and understanding they truly deserve and desperately need, we must avoid confusing the outcomes with the causes of this illness. We must stop being so distracted by the idea that this illness is caused by wanting to lose weight. That viewpoint is simply shortsighted and erroneous, and all it takes is to look around at the tens of millions of people on diets to see that wanting to lose weight and hating your body does not cause Anorexia.

There’s a word for that


“I just can’t swallow normally anymore. My doctor has done months of tests but they can’t seem to find out what is wrong with me. Maybe if I get another MRI…?”

“Our daughter just has a really high metabolism. I was a skinny kid too. I watch her eat regularly, sometimes she really binges. It is confusing that she never seems to gain any weight.”

“I want to gain 20lb, but I just can’t no matter how hard I try. I know I am underweight and I don’t like how I look.”

“Fitness is just a way of life for him, besides he’s training for the wrestling team. He has to go to extremes to get ahead.”

“I’ve always been thin naturally even when I was a kid. I honestly don’t think about food that much.”

“These allergies are just terrible, I am allergic to so many different kinds of food that my diet has to be really specific.”

“I keep throwing up involuntarily and the doctor doesn’t know what is wrong. It’s not like I am doing it on purpose though.”

During my work specializing in eating disorders, I have heard all these comments from clients and their families. In all the excerpts above, the client was able to restore normal weight and start eating regularly after counseling intervention. Sometimes parents and doctors refer patients to me totally convinced that genes and metabolism are accounting for the low weight. In one instance, the 9-year old client was in the 5th percentile for her weight and everyone thought she would stay that way through biological determinism. We initiated therapy and the client doubled her weight in a year and sustained it. One of the things that makes Anorexia Nervosa and Bulimia Nervosa so dangerous and difficult to treat is that they are not properly diagnosed. People don’t seek treatment, don’t bring their sons and daughters to counseling because all these other variables obfuscate the clinical picture. Of course there are as many instances as not that the low weight and food-related difficulties are, in fact, purely couched in physical and medical origins. But sometimes they aren’t physically-caused at all. The need to be vigilant and attentive to the very real medical etiologies cannot be understated. However, I recommend that, in addition to the medical rigor, we be equally attuned to the very real possibility that the eating and weight-related problem in question may really be psychologically and socially caused. Investigating and intervening on both ends of the causal spectrum (psychological and medical) is the best way to quickly restore patients to health and functioning. Counselors and family members should never dismiss an eating disorder just because it doesn’t fit neatly into the categories outlined in diagnostic manuals. These illnesses are good at hiding, and sometimes they masquerade as anything BUT what they truly are. Our ability to read between the lines and spot eating disorders early on can mean the difference between life and death, health or illness, for those we serve and love.

Breaking through the shell

Russian Dolls Matryoshka Isolated on a white background

To understand why eating disorders get so much worse during adolescence, we must look to the social issues that characterize this period. As much as researchers invest time and resources into understanding the genetic and hormonal issues in teens, to me, eating disorders worsen mostly due to social variables in the family. In particular, when the person can no longer successfully please the self and the social system, it creates a strain that manifests in the form of eating problems. The emerging drive to individuate gets stronger and stronger, and with it, the family can sometimes push harder on the child as a means of resisting that change. I have encountered clients who are much more responsible than most adults, at age 17, never being allowed to have any unsupervised alone time with a boyfriend, even when folks are at home. I have heard children say how they want to go to community college just so they can live with mom forever. I have met sons who at age 17 were not allowed to go on a walk alone or use the stove when parents weren’t home. I have had married clients move home to be with their parents again because they felt that mom and dad needed them. Often the child who is not allowed to ‘grow up’ is really being stopped from achieving her own identity separate from what mom and dad want. The rigid rules that are ‘for her/his protection’ are really most about the needs of the parents, and not the needs of the child. These rules have the effect of reinforcing in that child that the preferences of the family are much more important than the preferences of the self. How the person views the needs of the family, her or his particular role obligations within that system becomes very rigid, almost unrealistic and unfulfillable. Then, during adolescence, the need to individuate and become an independent self emerges, threatening the role that the child has thus far played in the family. If this conflict between self and family cannot be resolved, certain susceptible individuals will feel that they have failed the family and this creates disturbance in body image and problems eating. Sometimes, the perceived needs of the family become so loud in the person’s mind, that he or she will start to sacrifice the needs of the self in order to continue fulfilling the needs of the social system. When this happens, the needs of the self don’t simply disappear, the manifest in other ways like mood problems, anxiety and eating issues. In order to help adolescents overcome the teen obstacles, we have to help them to challenge some of the internalized rules that are untenable. Therapists should help clients understand what they expect from themselves in terms of making others happy, compensating others for life circumstances, taking responsibility for other people’s relationships and other people’s choices. We must empower our clients to say ‘yes’ to the self more often and say ‘no’ to the unrealistic (perceived) demands of the family. Most of the time they will realize that pushing forward in achieving individuality will not cause the sky to fall on those we love. The families are most of the time much healthier after the unrealistic dynamics are corrected. Once this is resolved, the self is able to grow, the needs of individuation are met, and the eating disorder disappears.

In the dining room, the elephant gets all of the attention

elephant mask young handsome bearded hipster man

Nancy sits down with her son James, who is an adorable 12-year old boy. He constantly looks lovingly up at his mother in a way that reminds me of how my sons (occasionally!) look at me, melting my heart.

“Mealtimes are really hard for us all. I have been given a lot of suggestions on what to do but nothing seems to really resolve the problem. There’s just things that he won’t eat and the list of items on that menu is decreasing all the time. I feel a lot of stress already having to cook for a big family, but now I also have to make whatever James is able to eat and it is really a strain. Also, my husband gets irritated with me for catering to him so much because he’s kind of a traditional dad. We all, even the little kids, tend to center our whole conversation and activity around whether or not James is eating, and the dinnertime is then lost to the stress everyone feels. I’m always caught in the middle and I could really use your help.” Nancy implores.

While listening very attentively at his mom, James gets tense and fidgety, even seems to have some tears in his eyes.

“I bet this is also really stressful for you too isn’t it,¬† James?” I ask.

“Yeah I don’t like upsetting everyone and then dad gets mad at mom and mom is unhappy and the other kids are unhappy and I feel like it’s all my fault.” James says.

“Well, I’m hoping today I can help with that. A really important thing to remember here is that your family dinner time is usually the only time that everyone can get together and share their feelings, experiences, thoughts and moods with each other during the day. It’s a really essential time Nancy, I agree. Remember when we were talking earlier about how emotions tend to build up and kind of make a ball in your stomach, James, which causes you to not be able to eat?” I ask.

“I remember, and I think that is really true. Some days if there is stuff going on between me and my parents or if I have been fighting with them, I can’t eat, and other days if we are all getting along, I can eat just fine.” He comments.

“Ok, so building on that idea, if dinner time is when the family gets together and it is what allows us to express our emotions, understand and take care of each other’s feelings and thoughts, then that contact is probably pretty important. Sitting down and talking to your family is what prevents those emotional buildups from happening. What’s interesting is that you guys seem to be caught in a self-perpetuating cycle. Eating problems disrupt dinnertime and make everyone stressed talking about food and not about each other. Dinner is the most important time that the family has to connect, and that has been taken away by the eating problems. Take away the time that you guys connect, and the emotional build-up and family estrangement that creates the eating problem in the first place gets worse. As the symptoms get worse, dinnertime becomes harder and harder, thereby reducing the amount of focus you have for each other.” I take a deep breath.

“Oh. I think that makes a lot of sense. I never really heard it put that way before but it was right there the whole time.” remarks Nancy.

“You’ve got to get the elephant out of the room. The elephant is the eating problem and he is getting all the attention. The more we divert the attention and focus and effort toward the elephant, the less we devote it to James, the less he feels heard, the more he feels that he is causing everyone stress, and the harder it becomes for him to eat. Everyone in this scenario suffers.” I say.

The homework assignment for this family was for mom to cook dinner as usual and serve it as usual. No one is to talk about food or eating at the table, in particular whether or not James is eating. Mom keeps a stash of appropriate food that James can go get on his own and bring to the table if he wants to eat something other than what is prepared. This will all be done without comment, thereby enabling the family to give their attunement and care toward each other and toward James, which will strengthen the emotional foundation upon which James’s appetite actually sits. This will restore his appetite naturally and eventually food will be no big deal again.

I understand that this technique is rather antithetical to the Maudsley method, which has been clinically indicated as effective for restoring normal eating in children with eating disorders. However, the Maudsley method is not founded on any etiological theory–it’s approach never ties back to a thesis on how the eating problem with the child started in the first place. I believe good therapies should not only fix the symptoms, but their methodologies should tie back to the origins of the illness itself. Maudsley¬† takes the symptoms and controls them directly rather than addressing the underlying causes of those symptoms. I prefer to understand why the eating problem happens in the first place and help families redirect their energy toward the deficits that created the unmet need, which is what led to pathology. The family I write about here must do additional work which involves restoration of internal boundaries and implementing some critical adjustments on James’s behalf. Simply not talking about eating at the dinner table will not be sufficient to restore normal eating in James. However, getting the attention off of the elephant in the room will free up everyone to focus on the family relationships, and that is where the real work can and must begin.

The disappearing act: First the person, then the body


rough sketch of man on grungy paper

“light as a feather, floating on air, I want to be perfect, barely there.”

This is a quote from a Pro-Anorexia website. This is one of the best summaries of the experience of an eating disorder that I have ever heard. In particular, the comparison of being perfect with being ‘barely there.’ If you really look at the Anorexia the disease and not the manifestation of it (which is the weight loss part), what you might see is that this is an illness of disappearing first as a person, and then as a body. What does it mean to ‘take up space’ as a person? To me it means that your needs, wants, preferences, feelings, wellbeing and vulnerabilities are made known to those who matter to you in your world. In other words, you are not afraid to let others know how they can nurture you, what you feel, and what you need for your self. You can and do ask others to make room for your needs in the daily goings on of the family system or in the lives and agendas of those who love you. You don’t see your vulnerabilities and needs as a liability, you don’t resent yourself for being human. Unfortunately, most people with eating disorders do resent their needs, they feel their needs are a burden, are a liability or an endangerment to those they love. They are afraid to ask for accommodation of their self-needs because doing so shows lack of gratitude, makes the family worry or is a sign that one is ungrateful. The degree to which these needs can be hidden or minimized is the degree to which one achieves ‘perfection’ in their role obligations. The process of Anorexia is not just about being perfectly restricted physically–that is the last step in the process. Before any of that happens, one learns to restrict their needs psychologically and socially. The contempt one feels for needing food is an extension of the contempt one feels for needing anything at all. In this process, first the person disappears, and then the body starts to disappear. I don’t ever push someone with Anorexia to gain weight because doing so puts the cart before the horse (plus I would probably only be the 714th person to have told them this, so what on Earth would be the point?) What I do suggest (which elicits much less fear and more commitment) is rethinking some of the internalized role obligations that have caused the person themselves to disappear. The body part will only reappear once the person within is allowed to reappear.

Breathing between the waves



Most of us only drown some of the time…gasping for breath between life’s waves. Symptoms of anorexia and bulimia are what happen when you are drowning in overwhelm. Having to swim harder and harder to keep up with the strong current and waves crashing over your head. Sometimes you come up for air and sometimes you’re under water. The illness comes in waves.

If eating disorders are about an internalization of the thin ideal, a perfectionistic personality style and dispositional need for control, then why do the symptoms of Bulimia and Anorexia change depending on what is going on in one’s life and environment? Most people think if a person has an eating disorder, they always have it–the symptoms are the same across the timeline. However, that is hardly the case in my experience. Most of the clients I work with report symptoms change all the time. Some weeks it is better and some weeks it is worse. When I ask how this could be so, they usually give me a perplexed look and say they don’t know. But my intent isn’t to stump them, I want to make them think about their illness differently. Perhaps the eating disorder isn’t so much about wanting to be perfectly thin and in control all the time as it is about one’s footing in the social system.

When we graph the symptom severity, we can see that things usually worsen when there are social issues and interpersonal dynamics creating strain. Of course, most eating disorders theorists propose that the symptoms are a reaction to stress, so more stress would mean worse symptoms. I agree that stress worsens the symptoms, but I don’t believe the symptoms are one’s attempt to cope with stress so much as the stress one endures reduces his ability to care for himself in a healthy way. And not all stress is created equal. Some stress will worsen the eating disorder (fighting with mom because she feels you are choosing your new fiance over her) and some stress will not worsen the eating disorder (my car broke down and I had to pay a tow truck and wrangle with the dealer over my car’s warranty).

In other words, indiscriminate stress doesn’t worsen symptoms, what worsens symptoms is the strain and overwhelm one feels when the perceived needs/demands of the social system and one’s proscribed roles outweigh one’s ability to fulfill those roles. Eating disorders are not perfectionism and control or a stress reaction, they are a disease of exhaustion. The only cure is to navigate in one’s social world in a way that is less exhausting. The exhaustion comes in waves, and so do eating disorders.

Bullying and eating disorders–the REAL connection

Female student being bullied by other group of students

What is the connection between bullying and eating disorders? Some that jump to mind are: when someone experiences the stress and devaluation of a bullying encounter, they are more likely to escalate their symptoms as a coping mechanism. Loss of self-worth can make symptoms escalate. Kids who are bullied often feel lonely and unsupported, leaving them more vulnerable to having eating problems and body image issues. Particularly if the bullying involves weight and shape-related comments and teasing, this could make and eating disorder flare up.

However, this column is not to explore the already explored aspects of eating disorders and bullying. Instead I want to focus on some often unrecognized dynamics between being bullied and being afflicted with eating pathology. Too often, I see clients who are suffering from Bulimia or Anorexia, and they often describe being bullied in school. In my perspective, bullying worsens when the victim of the abuse acts in protection of the abuser, which is in alignment with how people with eating disorders often interact with their social worlds. There is a general tendency for someone with an eating disorder to be more likely to protect and accommodate others over themselves, and this is the interaction that reinforces bullying exchanges.

The other day I met with Alice, she was telling me about how the kids at school tease her. With tears in her eyes she relates this heartbreaking scene. “They call me a whale, they say I’m dumb and I should just go away. It really hurts my feelings.”

“No one should ever say those kinds of things to you. That is awful of them. What do you usually do when they say those things?”

“I laugh, I pretend it doesn’t matter, I just play it off like it’s no big deal.”

“So they won’t have to feel embarrassed or on the spot for being cruel to you?”

“Yeah, I figure if they see me cry or if I get mad at them or call them out on it, they will just do it more and have even more of a reason to target me.”

“So you kind of throw yourself under the bus so you can protect them and not make them look bad, in the hopes that they will ease up on you, but it seems to just make the bullying worse?”

“Yeah, and my eating disorder gets bad after that.”

As it would, and here’s why. We believe everything we do. So when you put your needs secondary to the protection of some aggressive and disrespectful jerk, you are sending yourself the message that your needs and feelings don’t matter as much as the other person’s convenience that you are not calling attention to their awful behavior. This lowers your self-worth, which makes the self-deprivation and self-punishment pattern of an eating disorder worse. The other bad news is, others believe everything you do as well. When you protect their honor and let them save face by acting like they didn’t say anything offensive, it sends them the message that their comfort matters more than your feelings, and they become even less likely to respect you or consider your feelings in the future. This sets off a self-perpetuating cycle that leads to increased symptom severity by means of reduced self-worth and triggering interactions.

Bullying involves some complex internal and social dynamics, and if we are to protect our kids with eating disorders from having triggering encounters, we must teach them to think critically and act with intentionality in every interaction. The more they can understand these dynamics, the more they can protect themselves and stop protecting those who would harm them.

What’s the hijab REALLY got to do with it? Another look at culture and body image

woman wearing head scarf

In reference to a very interesting NPR article called “Covering Up With The Hijab May Aid Women’s Body Image” by Michaeleen Doucleff September 15, 2014

“…across all parameters, the women who wore the hijab, at least some of the time, had more positive views of their bodies on average. They had less desire to be thin. They appreciated their bodies more. And they weren’t as influenced by media messages about beauty standards.”

Any research, no matter how diligently and expertly conducted, is only as valuable as the interpretations we make from our data. Statistical findings give us a sense of where reality lies, but it is only useful insofar as we interpret it correctly. I am certainly not suggesting that the author is wrong in the conclusions drawn here, but I would like to propose a contrasting analysis.

The findings here are viewed through the top-down lens of body image, the conclusion being that covering up the body takes the body image pressure off. If people don’t see your body, and if you don’t preoccupy yourself with being seen, you are less likely to have poor body image.

Let’s go deeper though, and look at the surrounding landscape of this phenomenon. In order to understand the role of the hijab, we have to look at the broader context of women who choose to wear this attire. Let’s assume that they wear the hijab as part of a lifestyle, one that endorses perhaps traditional roles for women, religious conviction and cultural norms that are more limited for women than they are for men. In other words, they come from a world where women are not expected or encouraged to adopt multiple role obligations. Women have their place in the home, these roles are clearly defined, their role in the community is limited and clearly defined, everyone around them knows and accepts this. So a woman from this kind of background, living this kind of lifestyle will be less likely to pursue lofty role obligations in multiple areas of her life. This is in contrast to a woman who does not wear a hijab, who is more likely to come from a culture or subculture where women are expected and encouraged to pursue the highest achievements, multiple role obligations, etc. So the real difference between the women wearing a hijab and women who don’t could be very profound, involving many aspects of family, culture, internalized self-expectations, etc. In other words, the hijab garment itself might be the least important variance between these two study groups.

Maybe the real question this article is answering is, ‘How do varying role obligations and societal expectations affect body image?

My theory is, the more a woman pours into doing and being everything for everybody, the more likely she is to of course be successful, earn money, change the world, etc., but she is also more likely to be bothered by feelings of failure and exhaustion. In every day, we must balance the energy, time and resources we allocate to self-care v. other-care v. accomplishments. The more roles a woman stacks onto her life, the more difficult it becomes to balance these demands on her energy. She is so busy giving to these obligations and accomplishments, that there isn’t anything left for her. Eating disorders are diseases of exhaustion, and what better way to exhaust yourself than to feel that you must conquer the world in every way humanly possible.

The reason women who take on multiple role obligations are more likely to have distorted body image has to do with the insula, which controls proprioceptive awareness and error detection. The more a woman spreads herself too thin, the more she is likely to feel that she has not done enough, should have done more, let someone down, failed, committed an error, etc. This lights up the insula’s error detection and disturbs the way she experiences her body. She literally starts to feel like she is bigger than she really is, and the more she feels she is failing, the bigger and more distorted she feels.

So back to the original research, my interpretation of these findings is that women who wear a hijab have less opportunity to feel they are insufficient in the pursuit of their role obligations. This makes them less likely to be exhausted in themselves and less likely to be having an insular hyperfiring, which is why they have better body image.

Women in modern, Westernized culture need to protect themselves from overextending into multiple (and often opposing) role obligations. It is not for anyone else to say what your roles should be or how you should define them, but we are bombarded by media messages whose sole aim is to make us feel that we should be doing more, more, more. Sometimes, less is more. Be mindful of when your self-expectations become a liability to your wellbeing and enjoyment of life.


Anorexia: A revealing history

Certosa di San Martino, Naples

Despite the widely-accepted notion that eating disorders are the result of a thin-idealizing media saturation, these diseases have actually existed for hundreds of years, long before being skinny was seen as anything other than a sign of poverty. The first cases of Anorexia were seen in people that were the least likely to pursue vanity or recognition for physical attributes. Anorexia emerged in nuns, saints, monks and other stations of life that promoted a sacrificing of self for the achievement of ‘higher good’ for others. What does this tell us about the nature of eating disorders? Perhaps it demonstrates that the thin ideal is more of a spurious variable rather than the actual cause of the pathology. Further, most patients with Anorexia before the 1960’s didn’t report a drive for thinness as being significantly related to their symptoms. Maybe exposure to skinny models is the most obvious variable that we latch onto when attempting to understand why people would emaciate themselves. Because it makes sense in the absence of a more enlightened perspective on the disease, we have run with this explanation and proceeded to ignore the more deep causes that we really need to examine. The more energy we invest in barking long and hard up the ‘thin is in’ tree, the less energy we devote to taking a more comprehensive look at the real dynamics involved. Is there a correlation between self-sacrifice as a personality feature/way of life, and the habits of self-deprivation that embody an eating disorder? I see that there is. We need to challenge ourselves to seek explanations that account for all of the facets of this disease and its history. When we find the true explanation for eating disorders, all of the unexplained pieces will fall into place and we won’t need to rely on tunnel vision to support our perspectives on this disease.

She’s leaving home


Having some trouble at school

There is a very interesting Beatles song called “She’s leaving home”, and I often ask my clients listen to it because it describes the way that some families react to a child going off to college. Many people with eating disorders hold unrealistic role obligations within their families, serving as the proverbial hub of the family wheel. They reassure mom, mediate fights in the family, hang out with dad when mom doesn’t share his interests, help younger brother with his school work, clean the house because no one else wants to, visit grandma when the rest of the family is busy, make the family look good by achieving more , they are mom’s ‘best friend’, they parent younger siblings, offer a therapeutic ear to adult problems, the list goes on and on. So when a child with these roles leaves home to go to college, the result is a very poignantly felt void in the family. Eating pathology and body image disturbance are worsened when one feels guilty, feels she/he has let others down, failed, harmed or deprived the family system in some way, and moving away from home can create these feelings. The eating disorder can really flare up when Atlas finally shrugs. Most often we think increased stress, independence and peer pressure at college make symptoms worse, but I always look to the ways that the family reacted to the client leaving. Most often we will discover the client’s underlying feeling of self-blame for no longer being there to hold the family together, coupled with a pushback (subtle or otherwise) from family members in response to their own sense of deprivation. To resolve the eating disorder, we must look at realistic v. unrealistic internalized roles and be more fair and accurate about what one person can shoulder in a family. I teach my clients internal boundaries so they can stop being responsible for everyone else’s issues and needs. When the burden of that heavy role is lifted, so often the burden of the eating disorder is lifted as well.