eating disorders

EATING DISORDERS SPRING 2006

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VOL. 4, NO. 2

A NEWSLETTER FOR RECOVERING INDIVIDUALS AND THEIR LOVED -ONES

EATING DISORDERS 101

The Looking Glass Self

The Hunger for Unconditional Love

Martha Peaslee Levine, MD, & Richard Levine, MD

Rita Freedman, PhD Imagine a world without mirrors. Now think how your life would change. “A day without those damn things would be heavenly,” declares Karen, who vowed to give them up for a week. She lasted only two days before giving in to a deep urge “to make sure I was still there.”

Reflection Obsession Just how often do you look at your own reflection? In one study, women turned to the mirror an average of 17 times a day, which comes out to once every waking hour. Why so often? To see how well they were doing inside and out, they explained. Mirrors are to self-image what scales are to weight: a gauge of reality and adequacy. Self-reflection often stirs up mixed feelings that swing between acceptance and rejection. While facing her image, Karen wonders, “How can I be fit, but still look so fat? Seem attractive one day, atrocious the next?” She describes seeing different selves in the mirror at different times, depending on her mood and where she focuses her attention. When depressed, “I zero in on my huge butt or big belly and feel basically gross.” She longs continued on page 11

“I feel empty inside,” a teenager de- worse. If a girl believes thinness will bring scribes from behind her curtain of hair. love and she ends up still empty and fragA poised mother of three voices these ile, the disappointment is intense. What can parents, other family, and same words. A skilled teacher, a graceful gymnast, and a vibrant singer—they friends offer to fill this emptiness? Unconditional Love and Acceptance. all share this experience. This feeling of It sounds simple, but is not easy. Howemptiness. ever, it is one Is it such a bad of the most imsensation? Yes. If all of your traits, beliefs, Empty means and dreams are shoved to the portant things that we can ofhollow. These womback, what’s left? That big fer our children en feel fragile, brithole of emptiness. and other famtle—ready to break. ily members. They feel as though a piece is missing inside of themselves. Researchers have studied the need for Longing to fill this empty space, bulimics social support, but it doesn’t require binge and then purge—pushing out these science to understand the fact that painful feelings. Anorexics embrace the people need each other. People seek out feeling of emptiness, turn it into a sought family and friends to share good news after goal. When this doesn’t make them and to celebrate. They share pains and feel better or causes their emptiness to disappointments because sometimes become even more intense, what can the most important thing is knowing you are not alone. Even more important they do? Their perfectionism pushes them to then not feeling alone is the sense that try harder, restrict more. If they are you are loved and accepted—completely thinner, they believe there will be more loved, warts, worries, dramas and dreams love in their lives. Isn’t that what society included. promises? Ad after ad shows excitement, popularity, and praise coupled with Abandonment of Self leanness. Magazines and music videos When growing up, children often promise that slimness equals love. craft their personalities and passions But without the power of self-love, to please important people in their external answers cannot fill this inner void. If anything, it makes the emptiness continued on page 14

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PAGE 6 Published by Gürze Books, specializing in eating disorders publications and education since 1980.

H I G H L I G H T S

Healthy Eating Rituals

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Denial: An Obstacle to Recovery

EATING DISORDERS Publisher Leigh Cohn, MAT Editor-in-Chief Joel Yager, MD

University of New Mexico, Albuquerque

Managing Editor Lindsay Woolman, BA Gürze Books Carlsbad, California

Editorial Board Arnold E. Andersen, MD University of Iowa Iowa City, Iowa

Carolyn Costin, MFFC, MA

Eating Disorder Center of California Malibu, California

Lindsey Hall, BA

Gürze Books Carlsbad, California

Craig Johnson, PhD

Laureate Psychiatric Clinic and Hospital Tulsa, Oklahoma

Divya Kakaiya, PhD, CEDS Healthy Within San Diego, California

Diane Keddy, MS, RD

Private practice Newport Beach, California

Russell David Marx, MD

University Medical Center at Princeton, New Jersey

Diane Mickley, MD

The Wilkins Center Greenwich, Connecticut

Rebecca Ruggles Radcliffe

EASE Publications and Resources Minneapolis, Minnesota Copyright ©2006 by Gürze Books. ISSN 1544-0303 All rights reserved. Reproduction, photocopying, storage or transmission by electronic means without permission from Gürze Books is strictly prohibited by law. Violation of copyright will result in legal action, including civil and/or criminal penalites, and suspension of service. Eating Disorders Today is published quarterly by Gürze Books, PO Box 2238, Carlsbad CA 92018, 760/434-7533, fax 760/434-5476, www.bulimia.com, [email protected]. Editorial questions should be addressed to Joel Yager, MD, or Lindsay Woolman c/o Gürze Books; [email protected]. Subscriptions and Online Archives questions should be addressed to [email protected] • See rates on page 16.

Nutrition Hotline Diane Keddy, MS, RD Q. Why do nutritionists recommend food journals for recovery? A. Many dietitians ask their clients to keep food, hunger, and emotions journals. They may provide a form to use, or they may ask you to keep a record in a notebook or on the computer. This journal includes a section to write down foods and the time they were consumed, a scale to rate hunger before and fullness after each meal and snack, and a section to write down mood, thoughts, and feelings while you were eating. Some clients find the hunger and emotions part to be overwhelming and may elect to start with just the food record. Keeping a food journal can be anxiety producing for many people. If a person was judged or criticized as a child or teen, writing down what he or she eats may bring back bad memories. Most dietitians are aware of this and will be sensitive to this issue. I frequently start with having my clients keep a food record for their use only, so that they may gradually get used to recording their meals and having it be a neutral or positive experience. Keeping these records helps to increase awareness of eating and to identify disconnected eating triggers. Disconnected eating happens when your eating is not based on hunger or fullness signals, or when you are not paying attention to eating. Examples of disconnected eating include eating in front of the television, eating while driving, or eating when sad or angry. Many people with eating disorders habitually disconnect while eating, and food journals can be a useful tool in recovery. Also studies have found that writing down what you eat is an effective tool in achieving a healthy weight. Q. I’ve heard that it’s healthy to eat protein at every meal. Is this true? A. Yes, eating protein at each meal is a good idea for many reasons. All of the cells in the body, including organs like the brain and heart, and muscles, require adequate protein intake to function at an optimal level. All hormones in the

body (such as estrogen, testosterone, and insulin) as well as digestive enzymes are made from amino acids, the building blocks of protein molecules. The immune system is dependent on protein to make white blood cells, other immune cells, and large molecules such as C3 Complement, which is frequently depleted in people with eating disorders. The blood proteins albumin and globulin maintain normal fluid balance and prevent edema in the extremities. Bones require sufficient protein to prevent osteoporosis. Your skin, hair, and fingernails are made from protein and become lackluster when deficient. Finally, protein can be used to make glucose for your brain and energy in the body. Including protein at each meal will stabilize blood sugars and increase satiety, allowing you to go longer before becoming hungry again. Healthy protein foods include yogurt, low-fat cottage cheese, eggs, tofu products, legumes, soy beans (edamame), fish, shellfish, chicken, turkey, milk, soy milk, lean meats, low fat cheeses, nuts and nut butters, soy yogurt, and soy cheeses. Q. How much protein should I eat in a day? A. The Recommended Dietary Allowance is 0.8 grams of protein per kilogram (kg) body weight. For the average person, this works out to about 62 grams per day for men and 47 grams per day for women. These values apply to people in good health with average activity levels. Athletes, adults with above average activity, and people who need to gain weight need 1.0–2.0 grams per kilogram body weight per day. Pregnant woman are generally advised to eat about 10 additional grams of protein. However eating too much protein is not good either, so it is best to check with your physician or dietitian to determine your actual needs. Diane Keddy, MS, RD, is a registered dietitian with a private practice in Newport Beach, CA. Eating Disorders Today

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CAN YOU HELP? I Have a Question… Fun? What’s That?

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Last week my therapist asked me what I do for fun. I sat there speechless. I know I’d be better off doing fun things, but all I do is fuss about food and my appearance. Can you give me some ideas on how to get started? A: All of us need fun and recreation to relieve the stress of daily life. Without laughter and relaxation we become increasingly driven and uptight until something snaps. Then our depleted bodies and minds force us to take a time out to recover from collapse. Unfortunately, many of us think having fun is bad. We are so controlled by the work ethic that we believe only schoolwork, career efforts, and housework are meaningful. Nevertheless, total health is impossible without recreation and fun. Recreation produces feelings of peacefulness, wellbeing, mastery, joy, discovery, concentration, belonging, support, and delight. Ideally, recreation provides balance and tension relief so you can return to work, school, and family duties with renewed zest and enthusiasm. Therefore, you will want to look for leisure activities that are different from your daily routine. If you have little control over much of your life, choose a leisure activity that gives you a chance to be in command and make the rules. How about hiking, photography, birdwatching, or collecting anything at all that appeals to you? If you produce no tangible results at work, relax by making something from scratch. Maybe you will like sewing, weaving, or jewelry making. If your daily routine is boring and repetitive, pick a hobby that lets you express your creativity—something like painting, working with clay, or writing poetry. If you spend a lot of time caring for others, relax by being selfish with NO apologies to anyone. Take a class, read an entire book, or learn to play a musical instrument. If your life does not challenge you, find a recreation activity that does. Learn to climb mountains or ride horses. If you feel like a failure, find some activity that gives you instant success. Learn to speak a foreign language, solve puzzles, learn a computer program, or play chess. If you feel isolated, volunteer or join a club. If your life is filled with deadlines, find something to do in your leisure time that lets you thumb your nose at the clock. Walk through interesting neighborhoods and look at the houses and gardens, go to a museum, rent slapstick movies, select a project and allow yourself to finish it. Remember, recreation is supposed to be FUN! Don’t turn fun into drudgery by thinking of it in terms of “should” and “have to.” Acknowledge and plan your recreation progress by listing potential activities on a calendar in different colors. Source material taken from the ANRED Alert. Find more ANRED information at www.anred.com

Eating Disorders Today

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Putting Emotions to Work to Overcome Your Eating Disorder Karen R. Koenig, LICSW, M.Ed

Whether you’re just beginning to address your under- or overeating problems, or have been making steady progress for years or decades, to achieve full recovery there’s one area you’ll have to address. To attain a satisfying, nourishing, happy, and successful life without food problems, you must learn how to put your emotions to work. This means not dancing around uncomfortable feelings by eating or calorie counting, obsessing about what you can/can’t/ should/shouldn’t eat, or focusing on the numbers on the scale. For many disordered eaters, identifying and sitting with feelings is the last hurdle to becoming a “normal” eater. Most are willing and often eager to practice new food- and weight-related behaviors, such as making satisfying food choices, eating mindfully, trying larger or smaller bites, throwing out the scale, eating without

distractions, taking deep breaths after each mouthful, and staying connected to the body’s pleasure center during the eating process. But most people with eating problems—actually, most people, period—have difficulty getting comfortable with feelings. Disordered eaters are far from the only ones who struggle with handling emotions.

Treasures, Not Trash Unfortunately, every time you use food (bingeing, purging, avoiding, etc.) instead of feeling an authentic emotion, you miss an opportunity to discover something about what’s happening in your internal world. Think of emotions as equivalent to your five senses. The latter alert us to our reaction to the environment—thumbs up or thumbs down—through touch, smell, sight, hearing, and taste. Our feelings have a

similar function: to provide information about our reaction to people and situations. The function of all our senses and emotions is to move us toward pleasure and away from pain. Emotions help us decide what is self-threatening—spotting flames across the room and smelling smoke—and what is self-enhancing— sensory delight derived from gazing out over the ocean as gulls soar overhead and the sun dips into the sea. Most people don’t realize the value and purpose of emotions and assume they’re unimportant, or worse, that uncomfortable feelings should be avoided at all cost. But you’d never think of shutting off your senses and wandering through the world without them. Yet, that’s exactly what happens every time you ignore or minimize a feeling. What if emotions aren’t demons after all? What if emotions are your teachers and caretakers? What if they’re not trash but treasures? One of the reasons that emotions get a bad rap is that they can feel truly awful. We may believe that if something doesn’t feel good, it can’t be good, but this is far from the truth. We tolerate painful cures—injections, dental fillings and implants, physical therapy,


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and surgery because we know they are necessary and promote ultimate health and well-being. No one says, “Gee, terrific! I’m going to have my body sliced open today and then I’ll be in pain for weeks on end recovering.” However, even though it’s often a nasty business, people schedule surgery because they know they’ll feel better in the long run. The same is true of emotions. Just because they hurt or make you feel badly does not mean they are bad. Like musical notes and colors (and foods too!), there are no good or bad emotions. They’re what’s called value neutral. Think of emotions as messengers, giving you vital information about what’s happening within your internal landscape—you’re disappointed, ashamed, overwhelmed, overjoyed, furious, grief-stricken, content, shocked, revolted, elated, confused, lonely, excited, helpless. True, some of these feelings are excruciating and hard to bear, but they do pass and people survive them every day and have since the beginning of human existence. Half the battle is allowing yourself to be with your feelings without making judgments. It’s a great deal easier to acknowledge, identify, experience, explore, and deal with feelings without all the associated criticisms.

You Can Handle All Your Emotions Recovery means blossoming into a full, emotionally mature person. For that to happen you must (yes, must) learn to experience all of your feelings; you can’t pick and choose. Becoming emotionally healthy is an all or nothing proposition, but one you can achieve over time. If you believe you can’t bear your feelings alone, find a therapist who can guide you through them. Share your feelings with friends, start a journal, hug yourself, cry, holler till you’re hoarse, beat your pillow, sob till you’re exhausted. At some point, you have to choose between food and feeling. You already know where a food obsession will lead you, so why not give feelings a try? m

Karen R. Koenig, LICSW, M.Ed, is a psychotherapist and educator who lives and practices in Sarasota, FL. She is the author of The Rules of “Normal” Eating, and the upcoming Food and Feelings Workbook (January 2007, Gürze Books). Eating Disorders Today

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Redo Your Body Image “A Reflection in the Rearview Mirror” Tammy Beasley, RD, LD, CEDSN

Picture this: You are standing in the check-out line at the grocery story and notice the magazines staring back. Model faces with model bodies are smiling at you, and you begin to feel self-conscious. The next thing you know, you are looking down, feeling shame about your body and hoping that no one else is noticing and comparing it with the magazine images.

What Happened? Your body image has entered the picture, and it’s not a reflection you like. How you see your body and how you think others see your body greatly affects how you feel about yourself. And how you feel about your body cannot be separated from how you treat that very same body…the fuel you give it and the activity you ask it to do. A positive body image does not necessarily mean that you love everything about your body and have no need or desire to make any changes. It DOES mean that you have a healthy self-identity, can appreciate the positive things that your body can do, and can enjoy life for the moment, instead of waiting until you are a certain weight. So what can you do? Where do you start to make a change from a negative to a positive body image? When you look in the mirror, does it reflect the REAL YOU or is the image distorted? It may be time to clean your mirror to improve your reflection.

The Rearview Mirror Analogy When you drive your car, you depend on the rearview mirror to see behind you, in order to drive safely and with purpose. You also need that mirror to be clean, not cloudy or broken. Only a mirror free of dirt or broken glass can give the driver a true reflection of the situation.

And regardless of the condition of the mirror, you cannot look in your mirror constantly and continue to move forward. You must look away from the mirror to concentrate on the road ahead. In fact, most of your driving requires a steady look ahead with just an occasional glimpse in the mirror’s reflection. Likewise, body image is the reflection you see in the mirror. The mirror often reflects what is in your past, behind you, and includes images that have been developed throughout your life. These images are influenced by things you have heard, read, and seen. Over time, dirt may have accumulated and that affects how clearly you can see reality. Or your body image might even be broken from years of abuse or neglect. Do you spend more time looking back in the mirror’s reflection, unaware that it’s broken or dirty? To move forward, work on cleaning and repairing your mirror, or body image. Try to stay focused on the road before you instead of the path behind. This can take a lot of time and patience, but the rewards of a clear reflection help guarantee more security and confidence as you keep your eyes on the road ahead.

Where Do You Start? First, believe that your body is capable of change. Remind yourself about all the things you have already accomplished on your road towards recovery. Next, believe that change occurs one small step at a time. No need to feel that change must happen overnight to be successful. It’s a process that takes time. Finally, believe that your body image does not have to be limited to body weight changes continued on page 15

Healthy Eating Rituals for You and Your Family Dawn Copeland, MFA, & Joanna Lindenbaum, MA

Whether we’re aware of it or not, we all have personal rituals regarding food and eating. Some of these behaviors support us, and some do not. At their best, eating rituals hold the power to connect us to the present moment and our inner selves. By beginning to look at these rituals, we start to see how mealtimes—and indeed how food itself—either connects or disconnects us from our families, our emotions, the present moment, and ourselves. Eating rituals take many forms: Some of us, perhaps, always have salad before eating protein for dinner; others always finish what we like least on the plate first, saving the best for last. Some of us have our midday snack routine—we leave at a certain time, go to the same vendor, and purchase a particular snack. Or we may have unhealthy behaviors like purging what we’ve eaten, or a steady practice after dinner of devouring sweet after sweet until bedtime. Take a moment and identify your current eating rituals. 1. How long have you had these rituals? 2. Do they serve to connect or disconnect you from yourself and your life? 3. What particular meaning do they hold?

Consciously Create Sacred Meals Intentional rituals encourage you to get touch with your inner wisdom by preparing the way for change and manifestation. Rituals align your mind and body to a greater purpose by allowing you to symbolically enact what you want in life. We see this, of course, in the many communal and religious rituals regarding food—from Christmas dinner to Passover Seder to fasting for Ramadan. These are rituals about food, but they are also so much more. Take, for example, the Passover Seder; bitter herbs are eaten, not just to remember the painful plight of the Israelites in Egypt millennia ago, but also to reflect on the bitterness and hardships that we’ve endured, particularly in the preceding year. Food becomes the symbol through which we become more present to our lives.

Creating new rituals has the potential to establish food as enjoyable and sacred. Food and the act of eating becomes our way of taking time to appreciate all that we are and all that we have. We learn to give thanks, release stress, and mindfully nourish our bodies. Below are several ritual ideas that may be used together or integrated individually into daily meals.

Preparing the Meal • Before preparing food, take a moment to mindfully wash your hands. As you do this, imagine or say out loud that you are washing away the stress of your day. Release any anxiety that you may have about the upcoming meal. Let this cleansing be a time to become present to yourself and how you are feeling. • Create a sacred or special environment to cook in. You might want to play music that makes you want to dance, sing, and have fun; or choose music that makes you feel grounded and connected to yourself. Or you might need silence and time to be with your own thoughts.

to radically changing the environment where you eat. This could include eating in another room, trying out a different seat at the table, or changing the dishes. Consider ways to make the table beautiful. From linens to centerpieces, choose items that make you feel comfortable, sacred, and nourished. The idea is to signal to yourself and your subconscious that you are ready and willing to have a different experience at mealtime. • Before eating, create an intention for your meal and light a candle as a symbol. If you’re dining with family or friends, share your intention out loud. This can be a beautiful ritual that allows each person to be heard and honored for exactly where they are today. A caregiver’s intention might be, "I will keep the focus on myself and enjoy each bite of food." For someone in recovery it might be, "I am willing to nourish my body with this

• As you prepare each part of your meal, give thanks to the food itself and its ability to nourish your body. Give thanks to the earth that provided this food, and all the people who grew it and who made it available to buy.

Eating the Meal • If meal times have been especially stressful, commit Eating Disorders Today

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food,” or “I am committed to stop eating when I feel full.” Then take some time to be together in gratitude for yourself, each other, and the food that you are about to eat. • Identify some quality you want in your life that day. Perhaps it is wisdom or courage or joy. Let the food become symbolic of that quality and imagine that with each bite you take, you are actually feeding and filling yourself with that quality.

Closing the Meal • When finished, close your meal by saying another prayer of gratitude for the nourishment of your body and blow out your candle. • Acknowledge the ways you have just taken care of yourself by saying out loud or writing down what has been accomplished. It could be as simple as "I acknowledge myself for eating dinner at the table" or "I acknowledge myself for really tasting the food in my mouth." Identify at least 3 ways that you took care of yourself. Over time, this is a powerful tool for seeing the gradual change that is taking place in your relationship with food. m

D aw n Co p e l a n d, M FA , & J o a n n a L i n d e n b a u m , MA , a re Co-Directors of WomanVision, an organization that creates rejuvenating and spirited experiences for women of all ages and backgrounds. Through women’s circles, personalized rituals, and life coaching, Copeland and Lindenbaum empower women to expand their visions of themselves and their lives. Please visit www.womanvis.com


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The Soul of Food The potential of your eating experiences is vast—it is an untapped source of your soul waiting to be uncovered many times throughout each day of your life. The following story marvelously illustrates this: While vacationing in Italy, a couple was involved in a minor car accident. Although relieved that no one was hurt, they were tired, hungry, and upset because the day would be lost. The driver of the other car involved in the accident was a 60-year-old, English-speaking, native Italian man. He confirmed the couple’s fears that the police would probably not arrive for hours and proposed they have lunch together. Following his suggestion, they walked down the block to a quaint garden café. They were seated in the sun among colorful and aromatic flowers where Italian music, voices, and laughter filled the air. They had “the best pasta we’ve ever tasted,” fresh bread, some wine, and enjoyable conversation. The couple learned more about Italy in that afternoon than they had during the previous three days. Without saying a word, they knew they had shared an experience deep within their souls. —Excerpt taken from The Tao of Eating by Linda R. Harper, PhD

Intimacy and Anorexia Nervosa Mandi Newton, RN, PhD

This is part two of a series on romantic relationships and anorexia nervosa. In Western culture, intimacy is considered an essential indicator of healthy romantic relationships. Unfortunately, intimacy has been largely unexamined in the relationships of women with anorexia nervosa. Why is this oversight important? Anorexia is an eating disorder that goes beyond the classic symptoms of self-starvation and the attainment of an idealized thin physique to include afflicted women struggling with who they feel they are, who they feel they should be, and what others in their relationships expect of them. This internal conflict raises questions about the nature and quality of intimacy given that the achievement and sustainability of it is related to a number of elements including authenticity and acceptance. Research studies, how-

ever, have only begun to focus on how women with anorexia nervosa develop meanings of intimacy in their romantic partnerships and to describe the nature of these experiences.

What is intimacy? Although the term intimacy is used casually in everyday conversation, scholarly literature has explored how intimacy develops and is sustained in relationships. These include the degree of sharing (also called disclosure), acceptance, trust, understanding, physical and emotional closeness, as well as how much someone is able to be authentic or themselves in the relationship.1-3

How do women with anorexia view and experience intimacy? Several studies show that women with anorexia have relational dissatisfaction related to: poor marital adjustment and a lack of openness between partners during communication, as well as limited and unsatisfactory sexual experiences. Our recent research 4 addresses how women with anorexia nervosa develop meanings of intimacy. We asked women to describe their experiences of intimacy in relationships, how they would define what intimacy represented, and what they needed within their romantic relationships to be intimate. For many women in the study, their desired level of intimacy exceeded what was actually present in their relationship.

The elements of intimacy that emerged from the women’s descriptions reflected what was already known: emotional and physical closeness, as well as companionship. Emotional intimacy was described by the women as feeling that they were on the “same wavelength” or “connected” with their partner. That is, the women felt emotional closeness to be achieved predominantly through mutual disclosure; feelings of acceptance by their partner allowed them to be authentic and fostered their own disclosure in the relationship. Physical intimacy encompassed both sexual and non-sexual experiences. For many women in the study, nonsexual experiences were valued over sexual experiences with women citing lack of desire and low self-esteem as a main contributor. Companionship was the final element of intimacy, which was felt to be achieved through recreational activity and parenting activities with their partner.

Do women with anorexia nervosa experience intimacy differently than women without the disorder? The short answer is yes and no! Meanings of intimacy for women in our study had similarities to individuals without an eating disorder. However, the intimate experiences of these women as well as those in other studies were often comprised by their eating disorders. For example, a lack of responsiveness in their relationships included the women’s fears of judgment or rejection related to their eating disorder. In addition, decreased or a lack of interest in sexual relations is likely from diminished hormone levels as a result of weight loss.

Where do we go from here? As a whole, research suggests that while women with anorexia nervosa report dissatisfaction in their intimate relationships, they also have satisfactory experiences. This suggests that these continued on page 15 Eating Disorders Today

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On Loving Someone With an Eating Disorder: Questions and Answers Robyn L. Hunter

For this piece, I interviewed my husband, David Belchick, about his perspective on various aspects of my illness, treatment, and recovery. David and I met during our first year of undergrad, and we have been together for 13 years, married since 2004. We live in Boston where, a few months ago, we were blessed with our first child, a healthy, precocious and stunning daughter, Isabel Leighton. Q: How has your understanding of eating disorders (EDs) changed since I was sick? A: It has changed in many ways, the most important of which is that I now understand that an eating disorder is not the person’s fault. I get how complex an eating disorder can be to cure and how insidious it is in taking over all parts of the sufferer’s life. Q: What is your greatest regret in all of this? A: Not seeing that the woman I loved had a very serious problem so I could intervene and help early, before the illness became so ingrained. I also regret not finding resources for myself, so I would be able to be the best advocate for you and help you argue against the terrible things your head was telling you. Q: Of what are you most proud throughout my treatment of anorexia? A: I don’t know if “proud” is the word I would use, but I am most grateful for the fact that you are alive. I’m amazed that you were able to have a baby and that you’re able to get up out of bed every day and go through what, at times, has been utter hell (both with the illness and with your treatment!). And I guess I am even more impressed with how you have never stopped trying and how you still seek to help other people who suffer…you never run out of kindness. Q: What do you feel you have lost most to anorexia? A: Our time together. We lost so many Eating Disorders Today

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years, because we weren’t able to live life with real joy…because it was debilitating and took so much for you just to breathe. Time is something you can never get back. We’ve lost so much. Q: What do you think we’ve gained from my illness, treatment and recovery? A: Pounds! Sorry… I think the biggest thing is an appreciation for the capacity of the human body and spirit to be repaired. And I’ve gained a greater appreciation for people who treat ED sufferers. Q: What has been the most important piece of advice someone has given you about my illness? A: The best advice I have received was that the anorexia is not your fault and that you really want to get better—you just don’t feel you deserve to be well. And the most I can do to help you is to constantly remind you and show you that you deser ve to live, and to live abundantly.

better. Don’t let the frustration get to you. Be as involved as you can in treatment, and know that you are not alone in your role. Make sure you are informed about theory and practice. Don’t assume that the doctors or treatment providers are infallible and, therefore, the ultimate authority on your loved one’s illness. This is not to say that they don’t know what they’re doing, but I’ve seen providers and treatment centers that are just not the right fit for the patient. There are no quick solutions or magic pill for eating disorders. The sufferer wants to get better, but she just doesn’t know how. Don’t make comments about appearances or weight. Don’t make the mistake of being the food police. Always believe that she’s going to get better. It’s a very long journey from the depths of an ED to a point of wellness, but it can be done and you can help. Love her until you think you are getting through. And then love her some more. m

Robyn L. Hunter describes herself today as ED behavior free, healthy, and happy.

Q: Three words to describe this journey to recovery: A: Hell…and…back. Q: What words of wisdom would you give others who are so intimately supporting someone struggling with an eating disorder? A: Remember it’s the illness’ fault, not the sufferer’s. There are many times things can be really frustrating, but you have to remember that it can—and will—get

Denial: An Obstacle to Recovery Johanna Marie McShane, PhD

Denial. You’ve probably heard the word. Perhaps someone has even said it to you or somebody you care about. It’s a popular term that gets thrown around a lot. But what does denial really mean and why might it be a problem? What can be done about it? And why does it exist?

The Basics Webster’s dictionary defines denial as “the refusal to admit the truth or reality.” In the world of eating disorders, people use the term to mean that someone either cannot see they have an eating disorder, or they don’t recognize its seriousness. Denial is a dangerous phenomenon when it precludes someone from realizing he or she may be in medical danger. It is not uncommon for people who have an eating disorder to experience some level of denial. A hallmark of anorexia nervosa, for example, is the inability for an individual to comprehend the reality of her body size. But why might someone not be unable to understand she has an eating disorder or see how serious it is? There may be myriad factors, but perhaps the biggest is fear.

Denial says “Everything is okay,” even when it’s not The primary fear might not be obvious at first glance. Individuals with eating disorders may be afraid of treatment or of letting people help them. Loved ones may believe the eating disordered person is pretending to not see reality so she can put off trying to recover. Sometimes these examples may be true, but generally, the person is most afraid of the idea that she may have to change or give up the eating disorder. An eating disorder is a powerful coping mechanism. It helps someone deal with emotions and make sense of the world. It gives a feeling of structure,

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clarity, and therefore, safety. The fear of having the eating disorder disappear is often overwhelming, sometimes leading to a desperate need to protect the status quo. This is where denial comes in, creating a belief system that continually repeats the message “Everything is okay” and “Your life is working just fine the way it is.” If the eating disordered person sees no need to make any changes, the problem stays intact. Remember that denial is an unconscious process—not a conscious choice. Before getting help, a person may not even know she is in denial.

How to Help Someone in Denial Talk to him or her about fears Denial is not an attempt on the part of the eating disordered person to be stubborn, difficult to deal with, or manipulative. By remembering that denial is born out of fear, we may be able to take a more compassionate stance. In other words, it is helpful to view the person with the

eating disorder as struggling with fear of how to manage her life, as opposed to being entrenched in denial because she wants to be or simply is not willing to change. This stance allows us to align ourselves with her, instead of oppose her (which only tends to create power struggles, frustration, and fatigue for all involved). We can talk together about fear and help her to understand what her denial really means, instead of emphasizing that she is obstinate or does not care about health. Anticipate a shift over time Expect denial to be chipped away over time, as opposed to getting rid of it all at once. Suddenly seeing the world in a radically different way is overwhelming for the eating disordered person to imagine. Faced with this prospect she will often only cling more diligently to the denial, since it is familiar. From her perspective the significance of addressing denial might be compared to the enormity of discovering the

Phases of Denial A person with denial will often go through stages, sometimes repeatedly. Here are a few common phases: • Denial that she is in denial • Anger that nobody will believe her when she says she does not have a problem • Confusion about what people are talking about • Feeling out of control and frustrated that something might be happening to her that she is not understanding • Feeling out of control and afraid

• Embarrassment that she might not be comprehending something even though in general she does not think of herself as dumb • Loneliness that she is the only person who knows what is “real” but cannot seem to convince anyone else of the facts • Embarrassment that other people are seeing something that may be true but she cannot grasp it

–J.M.M


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world is round when the conventional wisdom had always held it was flat. This can be a monumental and initially jarring shift in perspective. Fully adjusting to and accepting the reality can take awhile. But gradually coming to terms in bits and pieces and at a pace where she can get used to each step may not seem quite so daunting. Of course, there must be a balance between proceeding carefully and gently enough so as to not overwhelm her into retreating and dealing with the reality of any significant medical issues. This can be tricky to achieve. Be aware that denial may return Denial may appear differently at different points in treatment and recovery. For example, in the early stages an individual may have significant denial about the fact that she even has an eating disorder. Further into recovery she may deny that she still needs help (though perhaps not the intensity of assistance that she once required), or deny that her behavior may remain a threat to her health (although less of a threat than it was at the beginning of her recovery). Expect that this may occur and be aware that it does not mean she has failed at recovery, only that she has progressed far enough to encounter new challenges.

Identify, Explore, and Examine Many aspects of recovery from an eating disorder necessitate an individual identifying, exploring, and examining her views of the world, and subsequently deciding which ones work well and which need to be re-evaluated. Denial is often one of the first of these aspects to be encountered. Maintaining compassion, patience and respect for the difficulty involved in facing denial can go a long way towards supporting someone in this crucial aspect of recovery. m

Johanna M arie M cShane, PhD, is in private practice in Lafeytte, CA. She is the coauthor of Because I Feel Fat, which will be republished next year (Gürze Books, 2007).


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from her purse and desk, while also covering some at home. Gradually she to escape from the critical glass eye that learned to pass a hall mirror without haunts and taunts her, yet compulsively turning her head, to wash her hands turns back to it in a love/hate bond with without checking her face, to look but the looking glass. not touch—no fiddling, fixing, repairing. Eventually she was able to resist the A Temporary “Fix” urge until it gradually subsided. Many people like Karen are driven Avoiding mirrors for a day has been by something called an “intense appear- compared to a cleansing fast that ance orientation.” They have a strong heals the image from inside. Mirrorurge to check themselves out and to con- less Monday is one of many activities trol their looks. promoted each This condition year in February A glance at the glass offers a can be assessed brief escape from the real world during National by asking such Eating Disorinto a virtual one. questions as: ders Awareness Week. On that • Do you beday, mirrors in schools and offices are lieve that “I am what I see, so I have to covered with blank paper. Passers-by are see who I am?” invited to write positive affirmations or • Do you compulsively monitor skin, thought provoking questions on them, clothing, hair? such as: “What makes you truly beau• Do you keep returning to the mirror tiful? Who are you under the skin?” again and again? Do you have frequent (www.nationaleatingdisorders.org) intrusive thoughts about appearance? MIRROR continued from page 1

Image cravers are drawn to the mirror for a temporary “fix” that can feel both satisfying and alienating at the same time. Many get trapped in a seductive habit of routinely turning to it as a comforting distraction. A glance at the glass offers a brief escape from the real world into a virtual one, a handy diversion from troubling thoughts about work or love or life in general. Of course it’s true that mirrors are essential in helping us enhance our looks. However, cosmetic routines, which start out as a conscious act to improve something, can become a compelling drive that consumes far too much time and psychological space.

A Day Without Mirrors In my work with clients who have intense body image concerns, I use a variety of techniques to help them deal less compulsively and more comfortably with their reflections. For instance, self-scrutiny becomes less intense when you discard magnifying mirrors, when you change the lighting or stand further back from the glass. I first asked Karen to monitor her mirror habits, recording when, where, and why she checks her image; then noting her thoughts before and after each encounter. Next she removed mirrors

Mirror Meditation

We’re each born with a strong need to know ourselves. So we turn to our reflected image and ask: who am I? In search of self, we peer at ourselves, hoping to see into ourselves. The following gentle mirror meditation may help you develop a more compassionate self-regard. While seated before a full-length mirror with your eyes closed, take some deep cleansing breaths and fully relax. Next focus directly on your image and try to send a kind message of compassion to some aspect of yourself, one that causes anxiety, frustration, or shame. For example: May I accept my sick, (large, weak, flawed) body with tenderness and empathy. May I find forgiveness for failing myself or others. May I make peace with my body and be free of sorrow. What you see in the mirror alters who you are, which in turn changes what you see. What you see depends on how you choose to look. And there are many ways of looking. Mirrors do matter. Without them we would not be quite the same. Rita Freedman, PhD, a clinical psychologist practicing in Harrison, NY, is a specialist in body image and eating disorders. Her books include Beauty Bound and Bodylove. Visit her website: http://ritafreedman.com

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Positive thoughts on the journey back to health and happiness

Redirecting Will Tom Shiltz, MSW, CADCIII In his writings, author M. Scott Peck talks about the difference between a weak-willed and a strong-willed person. A weak-willed person, he says, is like having a donkey in your backyard. It won’t do too much damage; it might eat a few tulips, but it won’t take you very far either. A strongwilled person, on the other hand, is like having a team of Clydesdales in your backyard. Given their tremendous size and strength, they have the potential to cause a great deal of damage. If they are allowed free reign, they are liable to knock down everything in sight, including you. But if they are properly harnessed and carefully guided, they are capable of taking you a long way as well. The eating disordered person is an extreme example of self-will run riot. A team of Clydesdales out of control, although she usually doesn’t see herself that way. Because of the demands of her illness she sees herself as a donkey. To other people she believes she must be weak and needy. In reality, however, she has more than enough stamina and will to go far in recovery. The problem is that most of her energy and tenacity is misdirected. She rarely exercises her will except when protecting the eating disorder. Like a mother bear protecting her cubs, she will bare her teeth and fight back fiercely if she perceives that anyone or anything is trying to come between her and the eating disorder. I sometimes tell my clients that they are some of the strongest and most faith-filled people on the planet. They have absolute faith in their disorder. They are willing to go to any length to obey its commands. They are willing to suffer tremendous physical, mental, emotional, and spiritual torture to follow daily dictates and rituals. It takes tremendous strength and resilience to withstand the terrific beating that the disorder dishes out. You cannot be weak-willed and have an eating disorder. Recovery is not so much a matter of “having faith” or “finding strength,” as it is learning how to redirect energy and focus away from the eating disorder toward reliance on recovery principles. Positive affirmation: Today I will align my faith with recovery principles and direct my energy toward reaching recovery goals. I will protect my recovery with the same fervor and tenacity that I protected my illness. m

Tom Shiltz, MSW, CADCIII, is a Rogers Memorial training specialist and therapist in private practice.

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Books,Tapes,Videos Personal Stories Reviewed by Cynthia R. Kalodner, PhD This Mean Disease: Growing Up in the Shadow of My Mother’s Anorexia Nervosa Daniel Becker ©2005 Gürze Books, 192 pages, $14.95 This Mean Disease begins and ends with Daniel telling about his mother’s death from anorexia nervosa. The book starts with Daniel and his siblings dispersing her ashes in the Pacific Ocean. In the pages that follow, Daniel shares how her slow death felt to him and his family. Since most books about anorexia are written by or about girls or young women, the experiences Daniel describes are quite unique. Daniel’s story lets the reader in on the pain he felt when his mother was away for several extended hospitalizations, the confusion that he faced as a child and even as an adult about her illness, and the sadness he felt as “anorexia robbed a part of her from me forever” (pg. 18). He describes how his own life was complicated: problems he had at school, difficulty in interpersonal relationships, substance abuse, and depression. He felt unable to get support from his parents. Throughout the book, Daniel experiences disconnection from both his mother, who was distracted by her illness, and his emotionally unavailable father. Through Daniel’s eyes we see how anorexia nervosa destroyed Carol Becker. Daniel’s own psychological problems brought on in part from his troubled relationship with his mother show the toll that an eating disorder can bring on family members. One wise therapist told Daniel part of his own “recovery” would require that he accept the possibility that his life might be better than his parents’ lives. And in the epilogue, we learn that Daniel’s life does appear to be happier. Eating Disorders Today

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Running on Empty: A Diary of Anorexia and Recovery Carrie Arnold ©2004 First Page Publications, 185 pages, $14.95 Carrie Arnold’s diary is the personal account of her struggle with anorexia nervosa, with a happier ending than Carol Becker’s from This Mean Disease. This memoir provides an inside view of Carrie’s experience with obsessive-compulsive disorder (OCD), depression, and anorexia nervosa. While there are many books that show readers an insider’s view of anorexia, what makes this one different is the struggle with OCD. At times, it seems as if that disorder was driving the eating disorder. In fact, Carrie believes that if she would have been diagnosed with OCD in high school and had started taking Prozac that “it is unlikely that the eating disorder would have ever developed” (pg. 34). It is hard to believe that statement, though, when Carrie describes her flirting with an eating disorder beginning in middle school. In many ways the story is a familiar one. Carrie is a “young, white, female, middle-class, over-achiever…from a close knit family” (pg. 12), missing nothing but a dog and a white picket fence. She is very clearly bright and determined to do

well. She tells the story of her eating disorder, her failures to recover, and her reluctance to give up anorexia. Through the epilogue, we learn that Carrie graduated from college and looked toward a future without an eating disorder. However, there is still a sense that she continues to struggle with her body image, food and her weight. Many similar books like this are out there—young women telling their eating disorder story. While it probably felt good for Carrie to write this book, like Wasted and others in this genre, I would worry that this kind of book gives readers permission to keep their anorexia. Readers should be cautious that this book may trigger eating disorder behaviors. m

Cynthia R. Kalodner, PhD, is the author of Too Fat or Too Thin: A Reference Guide to Eating Disorders. Dr. Kalodner teaches at Towson University and is a licensed psychologist in Maryland.

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HUNGER continued from page 1 lives—particularly their parents. The “abandonment of self” has been discussed by William Shaver, MD, and other researchers. Everyone has certain talents that make up his or her unique character. When traits are rewarded in childhood, those qualities develop more strength. When other traits are ignored, they are pushed away. A child can sense what the parent sees as important. In attempting to please the most important people in her life, she works to develop the part of her personality that is rewarded. She smothers the part that is not as well accepted. The problem? All of these traits, beliefs, and dreams are an integral part of the person. Individuals deny a huge part of themselves when those qualities are shoved away. And if those aspects are shoved to the back, what’s left? That big hole of emptiness. “I feel empty inside.” Does that mean “I feel that you don’t value whole parts of me?” Does that mean “I’m missing something because I haven’t let myself be me?”

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Does that mean “You don’t love this part of me, so I don’t love it, but I have nothing else to put in its place?” “I feel empty inside.”

better?” Unconditional love cannot have strings attached. Unconditional love cannot have an angry, bitter tone. Unconditional love cannot be directly tied to healing. Healing may follow if the love is conTwo Kinds of Hunger In the profound book, Eating In the stant, but the love cannot be a carrot: Light of the Moon, Anita Johnston de- “If you get better, I will love you.” The scribes, “There are really two different hunger is now. It is intense. This empty void needs love kinds of hungers, poured in with those that come Healing may follow if the love the message from the stomach is constant, but the love cannot “I love you no and those that be a carrot: “If you get better, I matter what. I come from the will love you.” love you even if heart.” your view of the The problem with eating disorders is that these two world is different than mine. I love you types of hunger have become fused. Indi- even if you want to pursue dreams that viduals are hungry for love, but unaware I don’t completely share. I love you no of the depth of that specific hunger, they matter how much you might want to focus on food—either filling themselves push me away.” Simply. I love you. Unconditionally. almost to a bursting point or rejecting it No strings attached. No expectations. for fear of their intense longing. Easy? No. Necessary? No question. Often families ask, “What can we do?” Unconditional Love and Acceptance. A Poignant Example In the book How Can You Say That? by Amy Lynch and Linda Ashford, one of No Strings Attached the most poignant examples in the first When offered the suggestion that parents need to show their child un- chapter is a father’s phone call with his conditional love, daughter who was just accused of shopthe responses can be lifting. Uncertain what to say, he finally surprising. Fathers found his response, “There is nothing in have taken out their this world that you can do that can make daily planners and me stop loving you.” Can you tell that to your children? written down—unThey need to hear it. conditional love. In an editorial, Sue Thomas Hegyvary But this emotion describes a comment by a psychiatric can’t be put on a list and then checked colleague, “If one entire generation of off as completed. It children were unconditionally loved, has to be lived every most psychiatrists (and presumably most psychiatric nurses) would be out day. Another father re- of work.” Shouldn’t we start with this generalated that when he and his family first tion? Shouldn’t we feed their hunger for came to the clinic, love? they had been told m that the most important thing he Martha Peaslee Levine, MD, & Richard could offer was unconditional love. Levine, MD, are located at Penn State Milton He turned to his S. Hershey Medical Center. Martha is Assistant daughter in a fam- Professor of Pediatrics and Psychiatry and ily session and an- Director of Partial Hospital and Intensive Outgrily swore at her, patient Eating Disorders Programs. Richard saying, “And that’s is Professor of Pediatrics and Psychiatry and what I’ve offered, Chief, Division of Adolescent Medicine and so why aren’t you Eating Disorders.


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10 Tips for Positive Body Image for Everyone 1. Appreciate everything your body does for you: running, dancing, breathing, laughing, dreaming, etc. 2. Be thankful for your body’s uniqueness, because everyone’s appearance is different and “true beauty” comes from liking yourself, feeling confident, and self-acceptance. 3. Body shape and size is primarily determined by heredity, which is why 95 percent of dieters fail to lose weight and keep it off. 4. You will be at your healthiest weight by eating nutritiously and getting regular, moderate exercise, regardless of how your weight compares to cultural standards. 5. Enjoy regular exercise by doing physical activities that are fun, like dancing, swimming, sports, walking the dog, and hiking. 6. Eat nutritiously from all the food grounds and generally avoid junk food. 7. Realize that advertisers use enhanced images of thin, “beautiful” people to see you the appeal of junk foods and weight-loss; be critical of media messages. 8. Celebrate diversity by eliminating all teasing, weight prejudice, and judgments about people’s bodies—including your own! 9. Wear comfortable clothes that fit. 10. Have family meals often, because families that eat together joyfully feel better about themselves and their bodies.


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BODY IMAGE continued from page 5

ANOREXIA continued from page 8

only. Body image changes include how we relate to other people, how much we allow our thoughts about our body to affect our moods, and how we interact socially.

women have similarities regarding intimacy to women without the disorder. In this sense, women with anorexia nervosa should be considered first as women who have intimate relationships comparable to other women, but in the context of having an eating disorder.

Clean That “Mirror” Make a list of positive statements about your body that emphasize the way you want to think about yourself. For example, “My body deserves and needs to be nurtured by food” or “I can enjoy a warm summer day wearing shorts regardless of my size.” Try to repeat this list to yourself at least once in the morning and once in the evening. You do not have to feel or believe any of these positive statements as you say them, but repeat them often. Just like hearing a song on the radio repetitively until you notice that one day you know every word without even trying…new words and positive statements that you repeat frequently can begin covering up the old reflections of your body and replacing it with a more nurturing one. True change cannot be rooted in external changes that function only as a temporary bandaid to cover up the problem, but must be rooted from the inside out. To be successful in body image change, it is important to stay focused on the positive benefits that a healthy body offers you and believe in your ability to change. Implementing and maintaining these changes is an on-going lifestyle, not without set backs, but hopefully always without judgment.

References 1. Dahms, A. (1972). Emotional Intimacy. Denver, CO: Pruett. 2. Hatfield, E. (1988). Passionate and companionate love. In R. Sternberg & M. Barnes (Eds.), The Psychology of Love. London, UK: Yale University Press. 3. Buhrmester, D. & Furman, W. (1987). The development of companionship and intimacy. Child Development, 58, 1101-1113. 4. Newton, M., Boblin, S., Brown, B. & Ciliska, D. (2006). Understanding intimacy for women with anorexia nervosa: A phenomenological approach. European Eating Disorders Review, 14(1), 43-53. m

Mandy Newton, RN, PhD, is a research fellow at the University of Alberta. She can be reached at: [email protected]

m

Tammy Beasley, RD, LD, CEDSN, is a certified eating disorder specialist currently practicing in Huntsville, AL.

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Parents Suing After Daughter Dies

Uniform Change

A case involving insurance coverage for an anorexic patient is going on trial. Brian and Mary Smith are suing Magellan Insurance, who pulled the plug on their daughter, Janell, who was being treated in a hospital for anorexia nervosa. When Janell was forced to leave treatment over the objections of her doctors, she killed herself three days later. Janell, a special education teacher, had an insurance policy offering unlimited coverage for serious mental illnesses, including anorexia and bulimia. While the Smiths say they were denied coverage, Magellan says it paid all it was asked to pay and could have given more if it had been requested.

Australian cheerleadYours is one of them.” ers have been banned from baring midriffs by Kaz Cooke, Real Gorgeous officials of the sport who fear displays of skin may encourage eating disorders. Gymnastics taken aback by the rejection, hatred and Australia has ordered cheerleading troupes violence she provoked when they asked the to find new uniforms by the end of the children about their feelings for the doll. year. The decision, which follows similar Violence and torture against Barbie were moves in the U.S. and elsewhere, was due repeatedly reported across age, school and to girls feeling pressured to lose weight gender. Instances of torture and mutilation and because cheerleaders often perform included scalping, decapitation, burning, in front of family groups. and even microwaving. No other toy or

“There are millions of gorgeous body shapes.

brand name provoked such a negative response.

m

A Bad Day for Barbie

m

Professors at England’s University of Bath, studying adolescents’ reactions to brand names, found an astonishing level of hatred and violence toward Barbie Dolls. The findings were revealed as part of an in-depth look at the role of brands among 7 to 11-year-old schoolchildren. The researchers had not intended to focus on Bar“They’re selling an iPod that comes with an iScale.” bie, but they were

Nibbles, by Hunter

Dennis Quaid Admits to Eating Disorder Actor Dennis Quaid is dispelling the view that eating disorders are mostly a female problem. In Best Life magazine, Quaid says he battled anorexia during the 1990s after losing weight for his role as Doc Holliday, a man dying of tuberculosis in the film Wyatt Earp. Other actors, including Billy Bob Thornton and Matt Damon have also previously struggled with eating disorders. Their admissions may help remove the stigma that many men battle when told they have “women’s illnesses.” Quaid said he is coming forward and talking about the problem so that other men will get help.

© 2005 by Eating Disorders Today

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