A symptom of choice

Worried young woman being accused

“I feel so guilty. I purged last night and I have been restricting all this week. I don’t want to tell my parents because I know they will be so disappointed in me.”

“Honey, if you are having moments of weakness, just tell us and we can help you be strong.”

“I just don’t want to let go of the eating disorder. I probably shouldn’t be in counseling at all because I am not ready to change.”

“You know, I had a friend who died of Anorexia. Do you want that to happen to you? Don’t you know what this is doing to your body?”

One of the most unfortunate things about eating disorders is that they are seen as a choice, a lifestyle, a diet, or a stubborn play for control. Eating disorders are real illnesses, and yet they so often evoke guilt and shaming. Would you feel guilty if you had cancer or the measels? Why do people with eating disorders blame themselves for having symptoms? Worse, why do people who don’t have eating disorders blame the affected individual for ‘choosing’ to be sick? Guilt implies choice, and the symptoms you experience while sick with an eating disorder are not a choice. The whole phenomenon of wanting to have the illness? Also not a choice–it’s a symptom of the illness itself.

You don’t have to be ‘ready to change’ to recover. Not being ready to change is a symptom of the illness itself, therefore waiting to be ready to recover requires that recovery has already started. So often, counselors set a prerequisite that their clients have to be ‘ready to change’ in order to benefit from treatment. This is wrong. When you are sick with an eating disorder, you will most likely “want” the eating disorder in a large part. Instead of using that as a criteria for determining potential responsiveness to therapy, we should look at it as a sign that the person needs treatment. My clients tell me they are ‘not ready to let go of the eating disorder’, as if I am going to be disappointed and wag my finger at them. I tell them the desire to let go of the eating disorder comes when the eating disorder lets go of you. This doesn’t make them resistant to therapy and it doesn’t mean they are not doing the work they need to do. It means they are sick. They are with me because they are sick, and as they get better the desire to be healthy will grow.

If you have an eating disorder, remember your symptoms are not choices. You are not a bad, irresponsible, stubborn, resistant person because you have symptoms. If you know someone with an eating disorder, don’t approach them with a lecture, don’t pretend to know better than they do what the experience is like. Don’t give them oversimplified advice like “you just need to come over and eat with us” or “you are so beautiful, you just need to gain some weight.” These illnesses are not forms of dieting, they are not a manifestation of lack of logic or common sense. Guilt and shaming make eating disorders worse. Almost everyone I come into contact with knows very little about eating disorders, and yet people hardly ever shy away from condescendingly presenting themselves as experts on the topic.

Re-conceptualizing the concept of self-concept


businesswoman looking in the mirror and reflecting

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.

Case #2

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.

Anorexia and the spawning rituals of North Atlantic sea bass

Male chef with seabass fish

What does Anorexia and the spawning rituals of the North Atlantic sea bass have in common? Well, most people have about as much understanding of one as they do the other. Even people who claim to understand eating disorders, specialize in their treatment, even leaders of the field, fall frighteningly short in their ability to explain why eating disorders happen and what to do about them. I say this not to be condescending, and perhaps I don’t really understand these illnesses myself. In fact, up until about 3 years ago I was as confused as anyone about this topic, which is embarrassing considering I had an eating disorder for 20 years, I have an M.S. in counseling psychology, I did my master’s thesis on eating disorders, and I was endeavoring to specialize in eating disorders for a private practice. Despite all that, I didn’t start to gain any footing with eating disorders until I became discouraged enough with the traditional treatment approaches to seek out a more enlightened perspective on the illnesses. After going through a period of frustration and despair, I started looking at things that we don’t usually look at when treating someone with an eating disorder; which is pretty much anything not directly related to weight, shape, eating, eating, or weight or body image, or shape, or…you get the picture. I started listening to the person underneath all that, only to discover that this was a voice heard seldom and with little volume–heard least of all by the client herself. Turn up the volume on that voice, and you will turn down the volume on the eating disorder.

Case example #1: The first client I saw with an eating disorder was dying. She came to me to show a gesture of effort to her parents–they sought me out because doing nothing was unimaginable, as unimaginable at that point as the idea of her actually getting better. Nevertheless, I gave it my best shot. During the first session, I did therapy ‘business as usual style’. I got out my manual and talked to her about food and weight and eating habits, gave her some homework to chart food and thoughts and blah blah blah. The second session, I left the manual untouched as I realized the more I followed it, the more I felt like I wasn’t talking to Sierra so much as I was talking to her eating disorder. I imagined the eating disorder embodied, taking over her like a ventriloquist. It was creepy. It was unproductive. The homework assignment for the second session was for her to buy a plant and start taking care of it, because she mentioned she liked plants. Then I asked her to buy some Barbie dolls and play in her Barbie beach house from when she was a kid–something she could say would be fun to her. Then she cut her hair in spite of being terrified of disappointing the people who adored her waist-length locks. She died it purple.

At the core of her eating disorder though, was exhaustion, as it is with every eating disorder I encounter. The real cure came when we discovered the source of her exhaustion (no, not the eating disorder itself, as that is an OUTCOME of the exhaustion, not the cause). Her relational exchange with her father was causing her to hemorrhage energy. We worked on challenging the beliefs she had about her role as a ‘good daughter’, restructuring what she took on as her responsibility with him. This restructuring caused her to no longer take inappropriate duty to protect him from himself, (a never ending source of entropy). Restoring her relational energy allowed her to meet her own unmet needs, eliminate the constant state of ‘failure’ that comes from trying to do impossible things for other people, (which by the way makes you feel fat). Sierra gained 40lb in 5 months, and she was discharged from therapy in another 4 months. She had a baby the next year, something her physicians said she would never do. Of course no one expected her to live, let alone recover either, but she did that too. And we both celebrated by eating a delicious North Atlantic sea bass.

Eating disorders and the data we dismiss


There sure are a lot of different perspectives about eating disorders, some of which make partial sense (Hilda Bruch came the closest in my opinion–she had the “what” more or less right, the “why” half right, and the “how” half right). And some of the eating disorders perspectives I read are just plain creative.Here is a way I think we can discriminate between a good theory/therapy and one that is not useful. I suggest we make use of data that we hardly ever look at–the reaction that patients with eating disorders have to what we tell them and how we treat them. I believe a good theory will more or less immediately make sense to the patient. It will cause them to enthusiastically engage in therapy, they will build insight and  a sense agency toward recovery. They will want to be treated, they will like being in treatment, they will lose the alexithymia. Their resistance will quickly turn into resolve, and they will quickly start to eat on their own without being forced to.One of the ways I can see that our theories are falling short is the way that clients tend to react to extant therapies. In many cases, we have to threaten and coerce (or arrest!) them to get them into treatment. They so often don’t comply, they don’t invest, they don’t engage and they don’t seem to feel positive about treatment. I think this is a huge, flashing neon sign that what we are telling patients about why they are sick and how they can recover is falling short or is downright false.

And it is a sign that we seem to not want to look at. I see that we generally discount these negative patient reactions as the result of advanced starvation creating an inability to engage, a resistance to giving up the eating disorder symptoms, a fear of gaining weight, a manifestation of ego-syntonia (yes that is for sure a word), or that the person is unwilling to give up the ‘control’ that comes from holding onto their illness. I believe these perspectives are both shielding and preventing us from having to actually look at the fact that PERHAPS these theories and therapies are unsophisticated and not well thought through.

I do have an alternative theory called Relational Exchange Therapy, you can read about it on my website, thedragonflyretreat.com under the ‘philosophy’ tab. I am not saying I have THE ANSWER, but I am saying we need to keep looking for better answers.

Like Bob Dylan says “You don’t need a weather man to know which way the wind blows.”