Eating disorders are a complex set of illnesses. They present in different forms including the more commonly known illnesses such as anorexia nervosa, bulimia nervosa, and binge eating disorder. Other forms of eating disorders that are less well known include orthorexia (a compulsion to eat only “health food”), night eating syndrome, and compulsive exercise.
Eating disorders involve a combination of physical symptoms, obsessive thoughts and behaviors, rituals related to food and exercise, and emotional and psychological issues. To fully recover from an eating disorder, all aspects of the disorder must be addressed and treated. If left untreated, some eating disorders can result in death, often from cardiac arrest or suicide.
Development of an Eating Disorder
Eating disorders are generally the result of mutiple factors which can vary from person to person, and usually there is no one root cause that can be blamed for the development of an eating disorder. Certain personality traits can make a person more susceptible to developing an eating disorder, but in and of themselves don’t cause them, for example, anxiety, perfectionism, obsessive compulsive inclinations, or people pleasing tendencies. Some of these may have a genetic or physiological basis that is seen in other family members.
Additionally, the culture we live in sends messages all the time through magazines, TV, movies, billboards, and advertisements in all forms, that are impossible to ignore, about how our self worth is measured by the appearance of our body. Specifically, bodies that are thin, lean, and muscular, are depicted as valuable and desireable, while all other shapes and sizes are seen as flawed. A pressure arises to fix or change one’s body, while in reality, the real problem lies in the messages from our culture. The conscious and unconscious influences produced by these messages can contribute to the onset of an eating disorder.
Circumstances in an individual’s life can also trigger an eating disorder, which initially develops as a way to cope with identifiable or even undetected feelings, and overwhelming situations. A traumatic event, sexual boundary violations, onset of puberty, or a big transition, such as starting college, are some examples of events that could elicit an eating disorder.
Additionally, explicit or implict messages from one’s family can also play a role in the development of an eating disorder. Families where there is an emphasis on looks and weight may unintentionally convey a message that a person won’t be loved or valued as much if their bodies aren’t attractive enough. These messages wind up becoming absorbed and internalized so that the individual eventually starts experiencing him/herself as not “good enough” and attempts to fix the problem through food and exercise behaviors. It is also worth noting that a significant number of people who develop eating disorders, were either forced to diet as a child or put themselves on a diet at some point.
My approach to treating eating disorders begins with two things simultaneously. One component is a thorough assessment of the person’s symptoms, eating disorder behaviors, physical health, and emotional health. If a person is not already under a physician’s care, a referral is made for a physical evaluation in many cases. Generally, collaborating with other professionals in a team approach works best. The team can include a physician, therapist, nutritionist, psychiatrist, and group therapist, but may not always involve all of these professionals. The other component, which is equally important at the beginning of treatment, is creating an environment of safety, warmth, understanding, and trust. Often, a person with an eating disorder has been experiencing feelings of shame, mistrust, misunderstanding, and judgement with those around them. A client needs to feel emotionally safe enough and understood, in order to begin disclosing the complex and sometimes shameful or embarrassing thoughts and feelings they are plagued by. Opening up to a trusted other (the therapist) is necessary to help lessen the burden of feeling so alone with the critical messages created by the eating disorder. It also makes it a little easier to consider, and then follow through with, the scary, but necessary behavioral changes that eating disorder clients must often make. Tracking a client’s experience of how he/she is feeling in the therapy, and how he/she is feeling about what is being discussed as the session unfolds, is a way to create trust and understanding. In addition, this close tracking creates an experience for the client of not feeling alone with their experience, which contributes to the development of a caring bond and connection between client and therapist.
If a client is exhibiting a lot of eating disorder behaviors, for example, restricting food, counting calories, food rituals, binging, purging, laxative use, compulsive exercise, etc., these behaviors must be identified, and goals set at an appropriate pace, to reduce or extinguish these behaviors. This is not necessarily simple or easy because while these behaviors are unhealthy and at times destructive, they also often serve as a means of self soothing and self reassurance that can be threatening to give up.
Meanwhile, the psychotherapy is addressing how the client is experiencing the modifications they are being asked to make. For example, what it feels like when they have eaten more food or less food than they are used to, or how it feels after exercising for less time than they are used to, or what is going on in their minds and bodies after eating a previously taboo food for the first time. This type of work will be onging as the client continues to modify their behaviors, until they reach their goals.
As some of the eating disorder behaviors become more stable and there is less need to focus as much on them, attention can be directed to exploring the underlying issues that triggered the development of the eating disorder. There may be issues around self worth, self confidence, anxiety about sexuality, fear of emotions, conflict about desires and needs, a deep sense of insecurity in the world, and many other possible issues that become masked by the eating disorder. Therapy then can become a process of discovering the deep places where vulnerable feelings are held, allowing them to be talked about, witnessed, “held”, and soothed by a caring “other” (the therapist). At times, old experiences may need to be grieved. Sometimes, a person has lived with an eating disorder for so long, that it becomes a dominant aspect of their identity and the individual doesn’t know who they are without it. This makes it scarier to give up, and exploration into finding out what else there is, is an essential part of therapy.
The goals of treatment are to help each individual develop an experience of themselves that is worthy and secure, based on who they are on the inside, at their core. This transformation occurs as a client begins to feel their worthiness, and a sense of mattering, reflected back to them through the therapist’s experience of them. Additionally, examination of how the client experiences this process with the therapist, helps to identify and overcome defenses that might be there, blocking these good feelings. When there is a sufficient experience of inner worth and security, the outer focus on the body as the means to reassuring one’s worthiness or “good enough-ness” is no longer necessary. An individual is then free to have a normal and healthy relationship with food, weight, exercise, and their body. Additionally, developing the confidence, trust, and adaptive skills to attend to difficult situations or troubling emotions, (which arise for everyone at one time or another) is incorporated into the work.