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Psychotherapy

Volume 37/Summer 2000/Number 2

HIDDEN GRANDIOSITY IN BULIMICS LINDA RIEBEL

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Saybrook Graduate School

A hidden grandiosity in bulimics, with supporting case material and a theoretical framework, is described. The author describes its relation to social pressures, its masked manifestations, how it functions in the bulimic's psychic economy, how it emerges in therapy, and treatment strategies. The trait is described as relevant to well-known features of bulimia, such as black-andwhite thinking, perfectionism, different rules for self and others, and specialness. Of particular relevance are the connections to borderline personality disorder, narcissistic injury, and ego deficits. Introduction The serious eating disorder bulimia (recurrent binge eating accompanied by inappropriate compensatory behavior such as purging and by overconcern with body shape and weight) is usually accompanied by such traits as low self-esteem, insecurity, poor body image, and self-criticism. However, beneath this layer of negativity, some bulimics have a hidden streak of inflation or selfimportance, sometimes amounting to grandiosity. This article describes the manifestations and variants of this hidden grandiosity, relates them to known eating-disorder traits and to theories of bulimia, and finally suggests the implications for treatment. The hints of inflation can be striking. For instance, one bulimic said, "I was the Miss America

Correspondence regarding this article should be addressed to Linda Riebel, Ph.D., 927 Contra Costa Drive, El Cerrito, CA 94530.

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of purging. I was the best. Friends of mine got exhausted after two times. I could do it nine or ten. I could always make the food come up. . . . It was amazing what I could do" (Sands, 1989, p. 80). Sands (1990) also described a patient who was outraged that after screening she wasn't admitted to a research program. "I felt special being in a research project. Because of me science would advance! It elevated my status" (p. 82). One of my clients, a 32-year-old nurse, was beautiful and knew it. Sometimes when she was depressed, she would put on a bathing suit and sunbathe in the park so people would look at her. She talked once about being "Cinderella, a princess, I get admiration. I'm special, desirable. I can do anything." Another nurse with a history of erratic relationships said, "I'm so complex, only a brilliant therapist could understand me ... I act superficial, but I'm not." A 25-year-old graduate student who won the state championship in her sport as an undergraduate was asked how she felt about that. She shrugged and said, "It's a small state." She devalued her achievement by immediately thinking of national rankings and added, "If I had known my parents' problems I could have prevented their separation." She wished they would stop feeling so guilty about her bulimia. "I can handle it better than they can, so I'll take the blame," she said. Another young woman felt "powerless, defeated" because of bulimia, but had a secret consolation with her tactic of going without food. "I'm better than you, and I don't have to do that [eat]. . . . I need to be better than other people. I can't tell who's good and who's bad, but the separating factor is, I'm not going to rely on eating." These statements hint at one central hidden trait: an inflation of one's uniqueness, importance, endurance, entitlements, or the rules and expectations by which one lives. Grandiosity inflates the good part of the self, detaches it from reality, and keeps it safe from both actualization and scrutiny.

Grandiosity

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Hidden grandiosity may be manifested in the following ways: • devaluation of one's own adequate or good performances (the feature most easily observed) since one is supposed to be world-class; • unrealistic, ambitious goals and relentless perfectionism with respect to almost any activity; • dread of being (or seeming to be) a beginner; • a sense of being special, set apart from others; the rules are harsher but the drama is more important; • disrespect of others (the most hidden feature). As most bulimics are female, in this article the pronouns "she" and "her" will be used. Examples and Variants of Grandiosity Behind the visible manifestations just mentioned, there are variants of grandiosity, described here with illustrations taken from the author's clinical experience. Lacy A college senior with a 4-year history of bulimia described her hopes and goals: "to write novels that satisfy my aesthetic standards and to find my soul mate." Her greatest fear was of "not fulfilling what I believe to be my destiny—to be one of the greatest writers who ever wrote, immortal." She knew she was ambitious, saying, "I have a big ego and good ideas. People should hear them. If I'm wrong, my whole life is a big, pathetic mistake." Lacy was a bright and articulate person whose curiosity and creativity gave her actual potential, which she inflated to this "immortal" plane. She acknowledged the relentlessness of her drive, because even if she made her mark in the world, "I could only be happy for one minute, because you have to always be hungry." Her grandiosity was artistic, romantic, and ambitious. The message seemed to be, "I have special things to say, and I want the world to know it."

Marcine The first nurse mentioned earlier had been bingeing and purging for 12 years. Why did she, a skilled health professional who worked diligently in therapy, overlook the biological risks posed by her purging habit? This loving wife also had a series of extramarital affairs. Then one day she was arrested for driving while intoxicated. In her next session she mentioned, almost in passing, that she had had a warning—she almost did not take the last short drive that got her in trouble. Her "warning voice," as she called it, was familiar to her. "It's intellectual. I look around and see what I'm doing, and tell myself not to do it. Then I override it, and go ahead. Sometimes I get in trouble; other times I don't." When asked why she overrode the warning, she said, "It seems as if the rules don't apply to me. I take the easier path. If I can get away with it, I can deal with things—no remedy is needed, it's easy to solve. I don't have to admit error; I'm above being inconvenienced. Special me, special rules. I get

away with things others can't. It's based on breaking rules." These disclosures explain a lot. The purging she knew was unhealthy, extramarital flings, and flirting with danger, which I thought represented rebellion, were really a superior attitude. She did not rebel against people—she was above them. Her grandiosity was spacey, overriding common sense. The message seemed to be: "I can get away with it, because I am above the rules."

Gail A third nurse (there may be an occupational factor here, in that nursing is a poorly rewarded but virtuous career) felt she was supposed to emulate Jesus, and repressed all in herself that was incompatible with Christian ideals. As the daughter of an alcoholic father, she was angry that her mother did not leave him and take the children to safety. Yet she disowned this anger, saying to herself, "I can stand to do without. I've been given the calling to rise above needs." Her grandiosity was quiet and virtuous. The message seemed to be: "I can and should be superhuman. The world needs it."

Other variants of grandiosity include indifference to other people's realities ("I don't have to worry about them. They don't count"); relentless self-punishment when failing to meet goals ("I'm supposed to be the best at everything"); and splitting in relationship to others ("They're not good enough, and their needs don't matter"). Relevance to Known Eating Disorder Traits Grandiosity seems connected to many of the familiar traits of bulimia, though it is unclear which precedes which. Perfectionism and Self-Criticism High standards and perfectionism are familiar traits in bulimia (Davis, 1997; Moulton, Moulton, & Roach, 1998) and generate endless selfcriticism. To the grandiose bulimic, the selfcriticism is logical: a 3.9 grade point average is horrible, or a rank of third out of SO disappointing, because she is aiming for the top. I suspect the grandiose bulimic holds out her performance as a substitute for the despised self, urgently needing approval of the performance, including a performance as a top dieter. The bulimic does not appreciate praise for a moderate or good performance, thinking the praise-giver may be trying to pull her down to mediocrity or not know what excellence is. Relentless self-criticism and deflecting praise while absorbing criticism are also common in bulimia (Dennis & Sansone, 1997). Furthermore, the bulimic fears being scrutinized or judged by others and usually works hard to obey social rules and fulfill obligations, in what Hewitt, Flett, and Ediger (1995) call "socially prescribed perfec-

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Linda Riebel tionism," in order to shine and excel. By contrast, my overweight compulsive-eater clients try to keep a low social profile. When I ask them about any disadvantages to solving their weight problem (to elicit secondary gain), they invariably say one or both of the following: "What will I do about men?" and "People will expect more of me." Attention from men and high expectations are seen by females who are compulsive eaters as negatives. Bulimics expect to do well and have it seen, and to be attractive and have it noticed. The secret fantasy of being Jesus or the princess rarely peeks out, but it is the patient's most precious gem of identity.

are turned inward. But underneath you find the scorn of others; She may say that so-and-so is a "tramp" or the parents are "pathetic." This sense of superiority is usually hidden. As a socially savvy individual, the bulimic knows that haughtiness loses friends, and to a person who needs constant reassurance (Friedman & Whisman, 1998; Moulton et al., 1998), that cost is too high. Ultimately, then, despite an apparent tolerance, there is no genuine acceptance of others. Behind the terror of their judgments, if you get close enough, you'll find the bulimic's judgments of them. No wonder she sees disrespect and rejection everywhere—it is a massive projection.

Black-and-White Thinking Seeing the world in polarities is a fundamental trait of the disorder (Polivy & Herman, 1993; Wilson, Fairbum, & Agras, 1997). Many bulimics live with wild feasting or rigid dieting, shopping sprees or penny-pinching, study binges or procrastination. One client even coined the oxymoron "diet binges" to explain her periodic fasts. The grandiose bulimic has a script with the princess and the toad. If she is not one, she must be the other. Thus her sense of badness when the grades are average. Once this splitting of experience becomes established, it is not long until her sense of self is equally subject to wild extremes: the princess or the scum of the earth—but the best scum, the most interesting and complete failure, the fallen Lucifer. Anything but mediocre! This leads to the next point.

Different Rules for Herself Some bulimics I have known cannot imagine what ordinary would mean for anyone. Others, when questioned, readily admit that it is acceptable for other people to make a mistake, ask for help, or turn in a merely competent performance, but the rules for the bulimics themselves are stricter. Friends and relatives often comment on these high standards. They say, "Don't be so hard on yourself," but this friendly exhortation never works. In therapy, the bulimic may say, "I shouldn't have to use crutches" (such as behavioral techniques), or "I shouldn't want to receive." When questioned, the patient might say, "It's all right for others to receive." The discussion does not go much further, for the bulimic cannot explain why the rules are so much stricter for herself. The sheer intensity of the disparity between rules for self and rules for other can be amazing, until we realize that the attitudes "I'm the worst in the world" and "More is expected of me" are reverse pride. For the bulimic person, mediocity is even more unbearable. The beginner stage of any activity (learning a foreign language, dancing, learning to use computers) is intolerable because it can be mistaken for mediocrity. The harsh self-rule serves an important function as the badge of specialness, the organizing principle that justifies one more swallowing of anger, one more act of caretaking. The meaning could be, "I'm strong, I'll survive" (quells fear), "They'll never understand me" (explains loneliness), or "I'm special" (solves worthlessness).

Comparing In a black-and-white world, it is vital to know which you are. Thus the grandiose bulimic is always aware of rank. Who is the prettiest, the thinnest, the smartest person in the room? Attaining the coveted number one spot is expected to assuage the worst fears. A comparing lifestyle (Riebel, 1985) means constant vigilance (one could lose one's precarious foothold) and negative emotions toward other people (resentment and envy toward the "higher," contempt for those "lower"). Comparing may originate from fear of being rejected, but as a lifestyle, it ultimately involves rejecting others, a trait more fully described below. Hidden Judgment of Others The bulimic is superficially tolerant and nice, possibly even everyone's confidante. Judgments

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Specialness and Being Above Others Average isn't good enough—in fact, it is awful, undermining the secret specialness that may be the bulimic's only source of identity. Specialness

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Grandiosity makes the harsh rules bearable (although the reverse is also true; specialness may generate harsh rules). Moreover, it can be a post hoc rationalization for avoiding conflict and swallowing negative feedback. The bulimic person may think, "I'm superior so it's okay that I not complain about this mistreatment" or "These poor people don't even know what they're doing." Then, specialness takes on a life of its own and accumulates meanings and uses. The secrecy of the bingepurge habit is consistent with the secret sense of specialness; there is a separate reality, a way to break the biological rule that overeating can lead to overweight. Thus grandiosity may include the symptom. The bodily havoc wrought by bulimia, feared by some, is blithely ignored by others in a kind of belle indifference. The assumption seems to be, "I'm special so I can get away with it: eat without getting fat, purge without getting ill." Specialness and the Body The purpose of a bulimic's compensatory behaviors (purging, fasting, excessive exercising) is to undo the weight consequences of bingeing so she can regain or retain fashionable slimness. The bulimic lives in fear of fat, frequently seeing herself as fat even when she is not. This springs largely from the exaggeratedly thin media image of women, which research has shown (Garner, 1997) represents only the thinnest 5% of American women. Perfectionism and black-and-white thinking intensify the dilemma with the attitude that if one is not exactly as thin as the models, one is fat. No middle ground exists. The grandiose bulimic does not even notice average-sized, plump, or overweight women except as cautionary tales about the horrible fate that awaits if she is not careful. The possibility that they could be happy, successful, or loved is unthinkable and anyway irrelevant, since they are not special. Thus to the bulimic, and especially to the grandiose bulimic, the body is just one more battleground. Specialness and Breaking the Rules Some bulimics break common rules of honesty and civility, in a kind of rebellious selfishness. Of all my clients, it is the bulimics who park in the reserved spots, put their shoes on the sofa, come to group screening sessions without a checkbook saying they did not know there would be a fee, or do not return calls after missed ses-

sions. The message seems to be, "That rule doesn't apply to me." Stealing and other problems of impulse control have consistently been reported as characteristic of bulimics (Fahy & Eisler, 1993; Holderness, Brooks-Gunn, & Warren, 1994; Kaye, Bastiani, & Moss, 1995; Rowston & Lacey, 1992; Wiederman & Pryor, 1996). In the present context, stealing is a way of saying, "What I want now is more important than what the other person wants or owns." A Macho Trait Friends and family who urge, "Don't be so hard on yourself," or, "Don't be such a perfectionist" do not realize that behind an apparent modesty the grandiose bulimic has an enormous, almost macho appetite for the difficult, the impossible, the heroic, or the artistic. The message seems to be, "If it can be done, I should be doing it." However, this charge is not accompanied by the corollary, ". . . and I can do it." For the female the formula often is, "I should, but I can't." The "should" is there, but the means to achieve it are not, and the ambition is driven underground—or into the symptom. According to Wooley and Wooley, bulimia, for all its horrible effects, is all that stands between them and an anticipated loss of all self-worth. They accept the pain of purging rituals gladly, as the only remaining test of endurance they know they can pass. (1985, p. 400)

Theory Several psychodynamic interpretations can account for grandiosity. Borderline Traits Borderline traits have long been studied in bulimia (Dennis & Sansone, 1997; Johnson, 1991; Steiger, Goldstein, Mongrain, & Van der Feen, 1990; Tobin, 1993). Splitting, a major feature of the borderline style, involves dividing self and world into distinct categories of extremely good and bad. Splitting projects the small quantity of good from being overwhelmed. Most of the time the self is bad and the other must be placated, but grandiosity is the hidden opposite, promoting the attitude, "I'm the best and the others are shallow or pitiful." Narcissistic Injury In this society, despite significant movement toward gender equality, girls' exhibitionistic strivings may be squelched, and they are discour-

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Linda Riebel aged from showing "pride, expansiveness, efficacy, and pleasurable excitement . . . The little girl is also learning certain excitement boundaries: she is learning that she is only allowed to build up a certain level of stimulation, then she must hold herself back" (Sands, 1989, p. 77). It is probably no accident that most bulimics are female. But exhibitionistic strivings are permitted for females in being good caretakers of others or in attaining a desirable physical appearance. Steiger, Jabalpurwala, Champagne, and Slotland (1997) found narcissism in both anorexics and bulimics in self-report instruments, and describe the trait in terms that capture many of the points made in this article: Pathological narcissism is characterized by apparently opposing tendencies: over-weening ambition and entitlement, inflated selfimportance, and dysempathy for others—juxtaposed with hypersensitivity to criticism and proneness to deflation of selfesteem . . . The narcissist's compensations, aimed at protecting a vulnerable ego, often create a deceptive allure of self-assurance, self-sufficiency, or grandiosity, (p. 173)

Tobin (1993), adds, Eating-disordered clients often report feeling the most empowered when they are losing weight. They often attain an illusory-grandiose feeling of power through controlling their bodies and being thinner than others. This illusory sense of power is a protection against a terrifying awareness of the fragility or helplessness that goes with a poorly defined identity. Therapists must challenge female clients to develop a new kind of power—intrinsic power, (p. 300)

Ego Deficits and Defense Mechanisms Flaws in ego development and functioning among those with eating disorders have been well studied (Goodsitt, 1997; Steiger et al., 1990; Steiner, 1990). It seems that grandiosity is a solution to the ego's task of compromising the ideals: and the grandiose attitude says, do not compromise them! If one's performance does not match tire ideals, taking a secretly superior attitude stores the ideals and protects them from examination. Gender Issues and Socialization Bulimia is overwhelmingly a women's issue, condensing into one sign the body as object, the acting-in process of exerting power over self instead of over the world, and dual sets of cultural expectations. Springing largely from the culture's obsession with slimness (Gamer, 1997; Polivy & Herman, 1993), they form a cap on development, diverting intelligence, determination, and ambition into the relatively trivial enterprise of body shape. Where do excellence and ambition go? For

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many women, I propose, they go underground to a hidden well of grandiosity. Grandiosity is usually hidden from the self, buried beneath a layer of self-criticism. It is hidden from others because the cost of revealing it is too high, involving potential conflict or rejection. There are risks to being an assertive female, to expressing opinions, saying no, and having lofty ideals. So grandiosity, like its saner cousin assertiveness, is driven underground. The unhealthy national secret is that liberation is only half achieved. The glass ceiling, the second shift, the third shift (Wolf, 1991), the feminization of poverty—all are vulgar realities that the bulimic does not protest overtly. She wants approval too much (Friedman & Whisman, 1998; Moulton et al., 1998). Other Factors Grandiosity may be related to depression (Breaux & Moreno, 1994; Kitron, 1994; Steiner, 1990), which is an important part of many eating disorders. Grandiosity is also a defense against normal belonging, keeping the bulimic separate from others—above them, in welcome relief to her more usual low self-esteem. Grandiosity lets the bulimic avoid learning to communicate (Riebel, 1989), confront, compromise, and practice the day-to-day routine of sustaining a relationship. Grandiosity helps explain why therapy with bulimics takes so long. Trying to soften the patient's harsh universe, we question the strict rules and the perfectionism, reassure the client, normalize feelings, and challenge self-punishment. Yet it is famously difficult to accomplish this goal. Kindness does not erase the script, which is based on the assumption that "someone is better than someone else." Whenever a bulimic dodges a cruel critic, the script also includes her being the critic. The grandiose bulimic wants not to abolish monarchy, but to usurp the throne. Therapy The goal of this article is to describe grandiosity, deferring a detailed discussion of treatment. Nevertheless, a few suggestions may be offered. Insofar as grandiosity is a substitute for realistically grounded self-esteem and for healthy pleasure in mastery, therapy involves some or all of the following elements. Making the Client Aware of the Grandiosity When working with a bulimic client, a therapist must repeatedly note the phenomenological themes:

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Grandiosity perfectionism, rejecting praise, fearing others' judgments, specialness, cringing from projected judgments, ignoring or repudiating goodwill from others, ignoring sensory cues, and retroflection of anger. Get the details. Why is getting a grade of B so bad? Why is an error so bad? Why should one be judged and rejected? How does the client think her body handles all the vomiting? Eatingdisorder specialist Jane Kaplan (personal communication, 1999) suggests that a tactful entry point is to ask about the grandiose fantasies of childhood or the teenage years. Later in treatment, the client can be asked about how she indulges or denies the grandiosity in the present. A college-age athlete presented at court mandate, having been caught stealing binge food. Lengthy treatment including hospitalization curtailed her purging, but other aspects of eating disorders (restricted and monotonous diet, amenorrhea, excessive exercise) remained. When she confessed to a recurring tendency to shoplift, I told her that shopowners (and even the stockholders of big grocery chains) are real people, who are hurt by theft. She was surprised. She had put them out of her mind; to her, her need for a thrill today or a free snack now outweighed anything another person might need. Encouraging Acceptance of the Whole Self Sands said that empathy, an early holding environment, mirroring, and idealization are key. It is the therapist's empathic stance that allows the needs and feelings hidden beneath the bulimic symptoms to be articulated, welcomed into the total self-structure, and experienced at last as part of 'me.' If the bulimic self is not empathized with, it will continue to clamor for attention, or it will go underground for a while, only to sprout up in unpredictable and often self-destructive manifestations . . . This ability to hold all of the patient at one time is particularly important. (1990, p. 42)

This includes eliciting and processing rage and judgments of others. Working with the Client on Relationships Fairburn (1997) found this so important that he made it the centerpiece of treatment. Interpersonal difficulties are common in bulimia nervosa although many patients have limited awareness of them because of the distracting influence of their preoccupation with thoughts about eating, shape, and weight. The interpersonal difficulties play an important role in maintaining the eating disorder through a number of mechanisms, (p. 281)

Attention to relationships can be given in individual therapy, in family therapy (Johnson, Mad-

deaux, & Blouin, 1998), or in group therapy, which is a well accepted modality for eating disorders (Polivy & Federoff, 1997). It has even been suggested that interpersonal therapy for bulimia can be effective with little or no attention given to the symptom (Apple, 1999). One of my failures illustrates the importance of work on relationships. A severely bulimic borderline computer professional hinged and purged multiple times a day and lived a reclusive life centered around her habit. A month of inpatient hospitalization followed by a month of all-day outpatient treatment produced a remission, but gradually the symptom crept back as she used it to stifle difficult feelings. In therapy she did not hide her sense of superiority. She could tell me about her judgments of other people: so-and-so was a tramp, a coworker was a moron, and so on. Her splitting was extreme, and her grandiose style was hostile and acted out. I should have known to prepare the ground carefully and to examine all possible meanings when it came time to raise my fee. She was outraged, though the new fee was well within her budget and partly paid by insurance, and left therapy owing for two last-minute cancellations, telephoning to terminate and complaining that it was not "nice" for the therapist to expect payment. This client needed extensive work on object relations and communication with others in order to handle an imagined affront. Building the Client's Genuine Self-Esteem Genuine self-esteem is based on (among other things) body awareness, taking in others' goodwill and love, and realistic evaluation of strengths and limits. The therapist can reassure the client, normalizing her feelings—including feelings of happy mastery. "Investment in others occurs only insofar as this satisfies egocentric needs for recognition or adoration. Such a constellation [intropunitiveness] would logically be present in disorders in which pathological fixations upon the self and the body stabilize a fragmented self-image and compensate for the felt failure to obtain others' recognition" (Steiger et al., 1990, p. 137). Building the Middle Ground Using procedures familiar in treating borderline cases, the therapist builds bridges between extremes, emphasizing the reality of attainable achievements, questioning the habit of idealizing the unattainable pinnacle as the only source of

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Linda Riebel worth, and challenging the prejudice against being a beginner. A 27-year-old woman, who was highly educated yet worked as an exotic dancer, was plagued with intense self-punishing tendencies, including occasional cutting. She did not try new activities, even though she was intrigued by foreign languages and winter sports, because "I don't want to be bad at anything . . . I don't want to look incompetent and foolish." Several months later she repeated this theme: "I don't give myself a normal human's chance to fail. I can't stand to be a beginner—I have to be an expert the first time." She felt that any onlookers would surely be angry or laughing at her imperfection. She called herself "lazy, stupid, a failure" because she did not know what she wanted to do with her life—she should have known by age 22, even though she realized that not everyone has a life path chosen at that age. She acknowledged her grandiosity. One of my goals with her was to show how these self-condemnations borne of grand goals actually brought about the catastrophe she feared: failure to perform in her chosen fields. Addressing the Client's Self-Critic However, one must tread carefully when dealing with self-condemnation. Driscoll (1989) found that it can take very different forms, such as: An appraisal, to understand real limitations; Renunciation of failings, to maintain high standards; Low expectation, to allay the shock of possible failure; A show of modesty or weakness, to prevent accusation from others; A pitiful self-portrayal, to elicit sympathy and attention; and Acceptance of one's place, to be loyal and prevent conflict. Thus, self-criticism may represent very different goals, and it would be an error to simply attack self-criticism without knowing which variant is in play. For the grandiose person, the second form listed above is perhaps the most relevant. The therapist can elicit the specific purpose of selfcriticism and teach other ways to get to the same goal. Sands (1990) wrote, "If the needs hidden in the bulimia are not analyzed before the bulimic symptoms are given up, the needs will remain split

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off and will eventually demand discharge" (p. 47). If high goals exist to protect an otherwise attenuated self-esteem, they serve an important function. Teaching the Client Life lessons can be taught directly, such as the notion that one can actually produce more if one's talents are not paralyzed by an inner punisher. The therapist who deals with grandiose bulimics may wish to have a stock of anecdotes about people who excelled without being neurotic perfectionists. Other life lessons and perspectives may also be valuable. It is helpful to teach practical communication and decision-making skills, as these bridge gaps between the bulimic and other people and help limit the potential for secondguessing and self-flagellation. More recently, I have added an awareness of nature to my perspective on life and therapy. Ecopsychologists view separation from the natural world as the source of many psychological disorders (Kanner, 2000; Kanner & Gomes, 1995; Metzner, 1995,1999), including eating disorders (Riebel, in press). Getting out in a natural setting, tending a few plants, or caring for a pet can help correct the imbalance between the bulimic's grandiose and self-condemning images, and they represent a modest start at healing the painful split between person and planet. Summary Grandiosity is the source of self-judgment, a sense of failure and isolation. It is also the storehouse of talents, ambition, and energy. It needs to be acknowledged, accepted, integrated with reality testing, and empowered with assertion and communication skills. Bulimics fear they will be diminished—which is why they are reluctant to give up self-criticism. Paradoxically, the self-criticism that is part of the grandiosity just paralyzes actual talents. We need to show them that there can be more to their lives if their inner voice is supportive, rather than unrealistically perfectionistic. Like the symptom itself, grandiosity serves many functions. It rationalizes that the symptom is safe, rationalizes avoidances, preserves a sliver of self-esteem, binds anger, and explains the discrepancy between the rules for self and others. As with so much else in eating disorders, therapy involves building the middle ground between extremes, eliciting and expressing anger and judg-

Grandiosity ments, acknowledging social inequities, and building self-esteem grounded in genuine strengths.

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