Personality Traits
and Family
Dynamics
Anyone can have eating and weight issues. For some clients, these problems are situational—postpregnancy, seeing a loved one through a terminal illness, or starting a stressful job—while others will tell you they cannot remember a time when they were not struggling with food or the scale. As discussed earlier, because of cultural stereotypes of fatness and thinness, it may be difficult not to think in terms of character traits for both of these groups. It is in our clients’ interest, however, that we not only avoid pigeon-holing them because of their appearance or behaviors, but help them get out from under damaging stereotypes so that they may view themselves more clearly, objectively, wholly, and lovingly.
Although stereotypes remain largely untrue, there are certain aspects of personality that correlate with ongoing eating problems. Note, though, that this is an area in which we need to tread carefully to avoid blaming the victim. Because there is a substantial body of evidence that suggests that some 70% of our weight is genetically predetermined, we must make sure that we do not fault clients for something that is by and large out of their control (Kolata, 2007). The goal is to strike a balance between helping them recognize that no matter how hard they try, they will not be able to maintain a physiologically impossible weight, while encouraging them to do everything in their power to reach realistic eating and fitness goals (alas, no easy job!).
We also have to pay attention to cause and effect, that is, how having an eating or weight problem in childhood can shape or color a person’s personality—how being a fat 4- or 5-year-old entering kindergarten might foster shyness, fear of rejection and exclusion, or the desire to please; how being a string bean among chunky siblings in a body-conscious family might generate guilt or fear of fat; how adolescent weight gain due to medication may increase insecurities about popularity and awkwardness in dating. The best way for practitioners to approach personality in relation to eating and weight is with an open mind that entertains all possibilities, the same way we endeavor to understand other issues that pertain to character development.
To understand how being over-
or underweight affects the client, ask:
1. How has your weight affected your feelings about yourself during different times in your life?
2. How has being outside the norm influenced your attitude and behavior in terms of school, play, work, self-esteem, and socializing?
3. How has your body image shaped your personality and how have your personality traits impacted your body image?
Self-regulation
Patterns of over- and undereating (or alternating between the two) are often found in clients who have difficulty self-regulating in other areas of life as well. Whether the predominant cause of disregulation is biochemical or learned in the family (or, in all probability, a combination of the two) is yet to be learned. Most likely, appetite malfunction is a product of the intersection of nature and nurture, as heredity in the form of a neurotransmitter imbalance predisposes clients to disregulation and family interactions cement unhealthy behavioral responses. For instance, a child who is genetically inclined to put on weight will be reinforced by parents who cannot say not to food or by a food-centered extended family that celebrates cooking and feasting. This same child, raised by parents who attempt to eat healthily and stay fit or by a family that is not food-centered, may have less of a struggle managing appetite.
Self-regulation issues abound in our caseloads—clients are either too emotionally shut down or their lability and impulsivity make it difficult for them to control emotional outbursts. They race through life as if the world will end tomorrow or stay in bed all day, are chronically late or compulsively on time, are shopaholics or mindlessly wear the same few outfits over and over. The list could go on and on chronicling addictions, phobias, and compulsions that drive clients to either over- or underdo. Practically speaking, most of us have regulatory difficulties in one area or another because that is the nature of being human. However, many clients have problems that make healthy functioning nearly impossible because they are riddled with chronic questions about what is enough.
Over time, treating clients with eating and weight issues, I have come to the conclusion that we should have a diagnostic classification called an Enough Disorder. Time and again, the same pattern emerges. A client cannot do enough to succeed at work or to help her friends and family, yet does little to take care of herself—perhaps other than eat. Or, a client cannot refrain from shopping because buying new things gives him a high and saying no makes him feel deprived and depressed. More than any other, an Enough Disorder is a product of our times, when our historic Puritan ethic of self-denial collides with 21st-century materialism and overindulgence. We can ascribe some client difficulties in this area to cultural excess, but family and biology also play a large part in being unable to function within reasonable boundaries of “yes” and “no.”
Knowing what is enough is described by Reindl (2001) as a felt sense, which is attributed to the realm of feeling because it registers as a ping of recognition, a thud of awareness. However, that does not mean that this felt sense emerges solely through sensation. Cognition plays a role, often unconscious, in this process as well, such as when we wonder if we are done with a task, tired and need to sleep, too busy to take a phone call, or crave time off or a vacation.
Recognizing what is enough is an idiosyncratic and fluid function. What is just right for one client is too much or too little for the next. Moreover, “enough” is not a static condition and what works to keep an individual in balance is strongly affected by external circumstances and changes over a life span. Self-regulation, therefore, involves not only knowing what is enough in any given moment, but being able to fluidly respond to the question correctly over and over, from moment to moment.
Many clients who have difficulty with states of hunger and satiation also struggle with other body issues. They do not know when it is time to rest or sleep, resisting bedtime (often staying up by eating) or using excessive sleep to reduce loneliness or boredom. They try repeatedly to fall asleep and rise at a sensible hour, only to slip out of the habit for no discernible reason and are unable to easily reestablish it. It seems as if their body has its own internal clock that is both arbitrary and capricious, sabotaging their best efforts to regulate sleep times and amounts.
Some clients run their bodies ragged until they are weak, sick, and exhausted, or cannot motivate themselves to do anything—chores, family commitments, socializing—for long periods of time. Or they begin a regimen of vitamin- or supplement-taking in an attempt to better care for their physical selves. Charging full speed ahead, they make detailed schedules of when to take what pill only to forget for a day, and leave the remainder of their supply forgotten in the refrigerator or medicine cabinet.
Such clients may also deal poorly with being unwell or in physical discomfort. They may either rush to the doctor at a hangnail or put off going with the oft-heard refrain of “I hate going to the doctor (or the hospital),” as if most people clamor at the chance. For the avoidant, forgotten are regular checkups and preventive care. These clients wait for their backs to be against the wall before seeking medical attention. Alternately, there are clients who spend their lives in doctors’ waiting rooms, panicked at the smallest physical twinge, too anxious to ride out ailments, and fearful that something terrible will befall them if they do not nip conditions and diseases in the bud.
A sense of what the body needs in terms of activity and exercise can also become disregulated. How many times have we heard how wonderful clients feel when they sign up for a gym membership and go at regular intervals for a matter of days, weeks, or months? They swear they will never again stop exercising because their bodies feel so alive, so energized, so joyful at being active. Then, just when we believe they are finally committed to staying on track, they tell us that they missed a day or two at the gym or walking because they were sick, had out-of-town guests, or had been asked to work overtime. We watch helplessly as they suddenly or gradually give up exercise and fall into the same physical lethargy or passivity they were in before they started.
These types of disregulation that do not directly relate to appetite are important because they often do have a subtle to significant influence (depending on the client) on eating. For example, when clients fail to get sufficient sleep, they may become irritable, which may lead them to turn to food to soothe themselves. Or they may get so run down that they become ill and comfort or energize themselves with food treats. They might end up eating in order to stay up at night or fortify themselves with sustenance when they awaken exhausted in the morning or are ready to succumb to mid-afternoon fatigue.
From Chapter 3, it should be clear that appetite regulation, although considered a felt sense, is engineered from more than cognition and emotional awareness. Satiation and satisfaction in relation to food are primarily generated from leptin, ghrelin, and other hormones that influence hunger and fullness. Although we cannot know, unless clients are tested, whether they have an actual deficiency, glut, or imbalance of hormones, it is safe to assume that many of them suffer from appetite disregulation because their “appestat” is malfunctioning. Once again, clinicians have to be careful not to jump to the conclusion that only family dynamics, lack of insight, or insufficient motivation is at the root of disordered eating. In fact, it is likely that we will discover down the road that an imbalance of chemicals is responsible for many (if not most) kinds of disregulation and that these inequities drive a good deal of yes and no responses.
To assess the client’s disregulation in
areas other than eating and weight, ask:
1. Do you have trouble overdoing or underdoing, or often feel uncertain if enough is enough?
2. How do you decide whether something is sufficient, complete, or done?
3. Do you have difficulty regulating sleep, exercise, shopping, cleaning, or other activities?
4. Do you generally say yes to others and no to yourself or the other way around?
Character traits
Many therapists already have an excellent sense of the character traits that accompany eating problems and disorders. Quite possibly, these qualities are precursors to eating issues rather than existing concurrently with them. Even when disordered eating is eliminated or, more realistically, decreased, clients continue to exhibit certain personality characteristics to greater or lesser extents. Fortunately, however, when inroads are made with food regulation, a client’s personality may also change. For example, a client who has always considered herself on or off the diet bandwagon may, when more comfortable with food and at a reasonable weight, start to soften her all-or-nothing stance toward life. She may be able to find middle ground in areas such as sleep, social versus alone time, and time dedicated to others or self. A client who has never known satisfaction with food may gradually recognize sufficiency in other areas of life as he takes pride in knowing and respecting his limits, that is, if he can say no to food, he can refuse other things—stressful situations, intrusions, overdoing it at the gym, or excessive sexual activity.
One of the most obvious personality traits that permeates disordered eating is black-and-white or all-or-nothing thinking. In fact, as with addictions, it is a hallmark of eating dysfunction. Disordered eaters view the world in two camps—those who are fat and those who are thin, those who eat “normally” and themselves. Ask them to identify people they know who are of average weight or who seem comfortable around food, and they often have difficulty because they fail to notice what is between either end of the eating or weight spectrum. They will spout off the names of all the thin and fat eaters in their world, but “normal” eaters? And they do not polarize only in the weight arena; much of life is viewed in extremes of good or bad, on or off, in or out, easy or impossible.
All-or-nothing thinking in relation to food and body size is most dangerous in terms of either dieting or exerting no control over food choice or amount, in struggling to be thin or letting the pounds pile up until no-longer-thin becomes obese. When clients are at their slimmest, it is hard for them to imagine putting on so much weight that they would ever be considered fat. The same is true when they are at their highest weight and cannot entertain the possibility that they could ever lose enough weight to be happy and feel normal. Vaulting from one extreme to the other, they miss the middle ground, the center where they might be an average weight that does not preclude enjoyment of food but does involve ongoing self-monitoring.
Clients who are prone to black-and-white thinking may easily become addicted to dieting. No matter that they have lost and gained 100 pounds or more several times over, they are only able to conceive of their body in two ways: fat or slim. Therefore, when they are fat, the only answer is to diet and become thin. And if they cannot become as skinny as they desperately desire, why not simply shrug off all restraint and let themselves stay fat? They act as if they hear only two musical notes or see only two colors. It therefore falls to us to painstakingly point out every note on the scale and all the colors of the rainbow.
A good number of clients with eating problems suffer from a victim mentality. They are mired in the unfairness of and angry at the fact that they must struggle with food and the scale. Some believe they are powerless to reach their eating or weight goals and resent having to try so hard. They will tell you all the reasons they cannot stop overeating or start eating healthily—over-the-top job or family stress, co-workers or relatives who tempt them with goodies, friends who insist on socializing over food, a love of cooking, no time to shop for healthy foods—and all the situations that prevent them from exercising. They will insist that everyone in their family is fat, that they cannot fight genetics, so what’s the point? They will try to convince you that it is too late to start getting healthy at 30 or 42 or 65 because the damage is already done. They will remind you of how many diets they have tried and failed at and how nothing has worked because they are simply too weak-willed or love food too much.
A victim mentality almost certainly dooms clients to failure, especially in tandem with all-or-nothing thinking. A client might lose some weight, but not all she wants or not as quickly as she would like—proof to herself that she really cannot have the body she wants—and give up. When success shoots holes in learned helplessness and challenges clients’ self-view, they can become extremely uncomfortable. If they can learn to eat “normally” or reach a healthy weight, they will have to recognize that they have based their entire existence on a faulty premise, that is, they have wrongly believed they are victims of circumstance or have a black cloud hanging over their heads.
Another characteristic that is prevalent in clients who have eating and weight problems is denial and avoidance, or magical thinking. These ways of processing information are the same as those underlying addictive behaviors—change will happen without effort, no harm will come from self-destructive habits, the discomfort involved in changing patterns is unbearable and intolerable, and one can avoid having bad things happen if one refuses to think about them.
Anyone who has treated even a handful of clients knows the power of denial. Moreover, every therapist recognizes that this defense is universal and part of being human. Denial can be adaptive—think of the child who turns docile and quiet around a verbally abusive parent or the parent who maintains hope that a terminally ill child will recover—but it is a case of too much of a good thing. As we well know, clients who use denial habitually cannot help but cause themselves trouble and lead unhappy lives.
Nowhere is this truer than in dealing with eating and weight issues. Clients who have difficulty sitting with emotional discomfort or pain often use obsessing about food, preoccupation with thinness, or compulsive eating to ward off distress. They may truly believe that avoiding emotional discomfort is possible and in their best interest or that they are unable to bear painful affect. No matter what they believe; we know that they will end up trading unfamiliar emotional upset for the self-hate and contempt that will surely come after overeating. For example, a client who is fired from his job might find it too upsetting to contemplate his work history or future. Instead, he eats. What he refuses to acknowledge is that his denial will inevitably lead to more pain—when his clothes are too tight or, still jobless, when he is evicted for not paying his rent.
Magical thinking plays such an overwhelming part in eating and weight problems that it needs to be thought of as a special kind of denial, functioning on many levels. It is there when a client eats mostly junk food and does not think about her health, when she says she will start her diet tomorrow or the next day or after the wedding or on New Year’s Day, when she cannot fit into her clothes and blames the problem on dryer shrinkage, when she has downed a box of cookies but fools herself into believing that it is okay because they are low fat. Magical thinking operates on so many levels in weight and eating disorders—from the physical aspect of eating to considering its consequences—that we can almost say that a client who ceases magical thinking might cease to struggle with eating.
To help the client understand how
specific personality traits influence eating
and weight problems, ask:
1. Do you tend to view the world in black-and-white or all-or-nothing terms?
2. What role does denial or magical thinking play in your food and weight problems?
3. Does difficulty experiencing uncomfortable emotions play a part in your food abuse?
4. Are you a pessimist or an optimist and how does your outlook on life affect your eating difficulties?
Another characterological issue that underlies eating problems involves internal conflict about dependence. For clients who have difficulty being independent and autonomous, food is the perfect crutch. It is always there and never demands a thing in return. Rather than working on increasing ego strength, clients instead fall into the trap of depending on food to lift them over life’s rough spots. Rather than learning to speak up and assert their needs, set goals and persevere, or find meaning through work or creativity, they rely on a narrow dependence on food. They eat to quash feelings, to soothe themselves, for something to do, to arouse passion, and to give meaning to life (that is, they live to eat).
Other clients, a substantial number with food problems, are counterdependent. In childhood, they learned that they could not readily depend on people or their own internal resources to meet their emotional needs, and they eventually buried or spurned these authentic desires. These clients insist that they value independence over dependence, yet what they yearn for more deeply than anything—more than ice cream and chocolate, even—are understanding, connection, support, companionship, comfort, and validation, things only another human can provide.
One of the problems with attempting to be completely autonomous and not rely on people emotionally is that it is highly stressful, causing more of a need to depend and exacerbating a vicious cycle. The more strongly counterdependent clients feel a need for other people, the greater their denial or suppression of this unwanted yearning, and the more likely they are to turn to food. When clients equate mental health and emotional well-being with total self-sufficiency, they are cutting off half their emotional selves. The more pronounced this personality feature, the more difficulty clients have regulating their eating and, ultimately, their weight.
More often than not, a harsh superego and a tendency toward perfectionism are characteristics of people who have eating or weight problems. This is especially true of chronic undereaters and those who are underweight. They want desperately to be perfect (it may be their unspoken supreme and only goal) and that means having the ideal body. No matter that they come from a line of short, heavyset ancestors or have a terrible sweet tooth and hate vegetables or have been chubby since childhood. This desire for body perfection overwhelms reality and objectivity and can drive clients into relentlessly endangering their health.
However, people who are overweight and overeaters also may have a proclivity toward perfection. Ironically, it is often the case that the only place they allow themselves to be imperfect is around food. We know that everyone must be able to tolerate creating a mess, making mistakes, and failing. Clients who are overachievers and who try to live up to unrealistically high standards often find that the only place they can “let it all hang out” and not hold themselves on such a tight leash is with food. The more they try to achieve, succeed, and be faultless and flawless in other areas of life, the more out of control their eating becomes.
Clients who are perfectionists are really afraid of failure, making mistakes, and feeling ashamed. They are driven to do well so that they do not have to feel the shame that lurks close to the surface. Shame of this kind is due to growing up in shame-based families that could not teach them how to bear feelings of inadequacy and incompetence. However, because emotions will do their darndest to get us to attend to them, shame cannot help but emerge—for these clients, in the realm of eating and weight. When a client struggles with shame, there will always be some behavior in her life, some tell, that leads her back to that emotion.
A sister characteristic to perfectionism is when clients are exceedingly hard on themselves and possess only a minimum of self-compassion. More often than not, these clients are overly compassionate with others, but not always; sometimes they are, indeed, hard task masters and their standards are unreasonably lofty all around. Failing to recognize that the carrot often works better than the stick, their fear is that unleashing self-understanding will lead to having no standards at all. Perfectionism and a harsh superego are a powerful duo, and keep the disordered eater in a rat race of trying harder and harder to succeed. Because they interpret every failure at curbing appetite or losing weight as as a result of their ineffectiveness, they redouble their efforts in order to keep shame at bay.
Clients who regularly sabotage their best efforts to eat well and lose weight also tend to harbor underlying, unconscious mixed feelings about being thin and fat. Again, this is not true of all overweight clients, due to the fact that some may be trying to dip below their set point. But those who have internal conflicts about weight often play them out through self-sabotage. For some, the conflict revolves around deservedness. As they approach their target weight, they unconsciously recoil in doubt about whether they are worthy of being happy and healthy. Another inner tug-of-war is what it means to be thin: Will they be hit on more romantically or sexually? What if life still is not perfect? What if they feel too good about themselves? Clients often fear that once they are thin they will have to give up enjoying food forever, and most have valid misgivings about doing so.
Additionally, sabotage might occur if clients are conflicted about an unhappy relationship or situation—if they feel better about themselves, might they leave an unlovable or mismatched spouse or a partner? Will looking better move them closer to quitting a job they hate and throw them out into a tight employment market? If they feel fit and in control, will they move away from parents or siblings who have an unhealthy investment in their sticking around? We cannot help clients when they sabotage themselves over and over if we are unable to help them decode what this start-and-stop behavior means, if we are unable to untangle competing fears and desires that, unresolved, will always bring clients back to the status quo.
Another area that presents difficulties for overeaters and undereaters relates closely to self-regulation: setting and keeping boundaries. Clients with eating issues are inclined to be what might be termed porous, that is, they empathize strongly and overidentify to the point of taking on others’ pain. They are therefore often the kinds of people who will give you the shirt off their back. All well and good, we might say as therapists, if you have other shirts. But, often, these clients metaphorically do not. What they have is an enormous difficulty setting tight, safe, secure boundaries around themselves so that they will not be hurt or taken advantage of. Their boundaries are, instead, loose and wide open, which generally lets in trouble.
To help the client understand
how specific personality traits influence
eating and weight problems, ask:
1. Is it easier to depend on food for comfort or excitement than people? Why?
2. How does your ability or inability to set and keep boundaries affect your eating?
3. Do you strive to be perfect? What happens when you are not?
4. What do you fear about failure and making mistakes?
5. Do you often feel shame about your thoughts or actions?
6. Do you sabotage your best efforts at eating and losing weight? Why?
There is a final set of traits, which Freud labeled emotional defenses, that are employed frequently by clients with eating and weight problems. Denial, avoidance, and magical thinking have already been discussed, but other less prominent defenses also plague this population. One is rationalizing, which occurs when clients, in the moment, entertain the belief that overeating is not going to make a big difference in their weight—just a honey-glazed doughnut here, an extra Snickers bar there. Clients may also minimize strengths and accomplishments, shrinking them to almost nonexistent in comparison to their mistakes and failures. They focus on the weight they have yet to lose rather than what already has come off, ignore their amazing achievements, and zero in on being out of control around food or the plus-size dress they are wearing.
Projection is another defense that is often part of the overeaters’ arsenal. They tend to ascribe their own intensely negative feelings about fatness and positive feelings about thinness to other people. This is not to say that we do not live in a fat-phobic culture. We most assuredly do, and as therapists we must acknowledge that overweight clients go out every day of their lives and have to work and play in a thin-is-in world.
However, it is not true that everyone a fat person comes in contact with will think badly of or feel contempt for them. People may harbor unkind thoughts, but few will express them. In fact, for the most part, clients have no idea what folks think of their size. Perhaps, because they do not know or cannot imagine anyone accepting or feeling compassion for being oversized, they assume something negative. That way, of course, they are at least prepared if someone judges them harshly. However, this kind of thinking also sets them up to expect and assume the worst, which works against building self-confidence and self-esteem.
To help the client evaluate use of unhealthy
emotional defenses that may work against
achieving eating and weight goals, ask:
1. Do you minimize your strengths and often focus on your weaknesses or challenges?
2. How does rationalizing get you into trouble with abusing food?
3. Do you feel so negative about your body that you assume other people will as well?
4. Are you always expecting and girding yourself for the worst?
Although eating disorders and problems can be found across every Axis II diagnosis, they are more prevalent in some than others. A detailed discussion of food problems and Axis I diagnoses such as anxiety, dissociative disorders, and depressive disorders may be found in Chapter 7, “Clinical Disorders.”
Because three of the key criteria for borderline personality disorder (BPD) are affective instability, impulsivity, and chronic feelings of emptiness, it is often linked to eating problems. Although many people with disordered eating cannot tolerate intense affect, are impulsive, and eat to fill up an internal emptiness, not every disordered eater has BPD. However, especially in cases of intractable bulimia and anorexia, this diagnosis should be seriously considered.
Affective instability, often called lability, occurs when clients rapidly move from one mood or state of mind to another. They describe feeling ruled by shifting moods and unable to regulate intensity. This difficulty is likely due to an imbalance in neurotransmitters that modulate affect, but may also be rooted in a history of trauma and in a family situation in which parents were unable to soothe themselves or the client. The client with BPD, therefore, often feels at the mercy of her emotions and is at a complete loss of what to do with them. Unfortunately, abusing food (overeating or obsessing about weight and calories) often acts as a soothing agent and becomes a learned way for these clients to contain their feelings.
Because they are impulsive, clients with BPD are at high risk in many areas for acting first and thinking later. They often understand that they act rashly but feel powerless to stop themselves. It is unclear whether they have learned to bypass using good judgment or whether their impulses are so powerful that their frontal lobes cannot kick into gear quickly enough to control behavior. Clients who eat impulsively often feel terrible regret and fear (of gaining weight) after a food abuse incident. The goal is to help them move this fear ahead of their behavior so that they can predict its consequence.
Feelings of chronic emptiness seduce clients with BPD into trying to fill themselves up with material things, substances, achievement, or busyness. Again, studies suggest that there is a biological component to “the hole” described by these clients that is based on imbalanced neurotransmitters. It is likely, again, that at least some of these clients have a genetic tendency toward feeling empty and that, in childhood, they did not learn effective ways to feel filled up. Food is so accessible that we can see how it becomes easy pickings for someone who cannot tolerate an inner void.
Another Axis II diagnosis that is often found in people with eating problems is avoidant personality disorder (APD). Key criteria include fear of engaging in relationships and discomfort in social situations. Lacking companionship and deep emotional attachments, clients with APD may view food as a best friend who will never reject or ridicule them. We might not realize that clients have APD until we fully understand how they function in intimate relationships and social situations. A tip-off is a client who has few, if any, close friends. When we ask about friendships, we might find our client indifferent to intimacy. Sometimes a client with APD is far more comfortable with animals than people, and may have several or a string of pets. She may appear a loner by choice, and it may take a long time to understand the depth and breadth of rejection and/or abandonment that makes her feel so uncomfortable in relationships with people.
This kind of client goes out of her way to not place herself in settings in which there are a great many people. She might say she is too busy to attend an after-work party or that she cannot possibly make her cousin’s wedding because it is too far to travel. What she is not saying is how awkward and frightened she feels at gatherings and how heightened internal distress keeps her away from them. Fear of intimacy and of social situations is a setup for clients with APD who have eating problems. Because they have no, or few, close friends to share upset with, they may turn to food for comfort. And because they avoid social activities, they are often alone with too much time on their hands; eating becomes a low-anxiety activity that is always within reach.
Clients who have dependent personality disorder (DPD), characterized by discomfort at being alone and exaggerated fears of being unable to care for themselves, are also at risk for food-related problems. For them, food is a way to nurture, comfort, and soothe themselves and make them feel less alone. In a way, they have the opposite set of issues from the client with APD, because their anxiety derives from being alone. They therefore seek out other people 24/7 and when they are alone, their anxiety is so high that the turn to food to for self-soothing.
These clients do not believe that they can take care of themselves, whether they appear to have the skills or not (and generally they do not). Because they do not know many non-food ways to nurture themselves, food becomes the universal panacea. Regularly turning to food for self-care in turn precludes them from developing more effective and appropriate strategies and reinforces their belief that they are unable to adequately take care of themselves.
To assess whether the client may have
an underlying character disorder that
contributes to eating and weight problems, ask:
1. Do you have problems controlling your impulses, feel empty inside a lot, or have shifting moods that seem to come out of nowhere?
2. How do you feel about being close with people and about engaging in social situations? Does your anxiety go up or down around people?
3. What do you think of your ability to take care of yourself compared to other people’s ability to care for you? Are you more comfortable around people or alone?
Family dynamics can also be a major contributor to eating and weight problems. Obviously, for a young child or adolescent, how her parents regulate her food consumption and the eating behavior they model will be the largest factors, other than genetics, affecting her relationship with food and her body. Parents who are “normal” eaters and have a healthy attitude toward weight will likely produce children who are comfortable in their bodies and around food.
On the other hand, parents who are uptight around food—obsessed with calorie- and fat-gram counting, constantly dieting or monitoring their food intake, or who eschew anything but “health foods”—pass along to their children distorted, negative messages about the positive role food should play in life. Moms and dads who regularly struggle with their children around food issues, especially if they try to rigidly control what gets eaten (or not eaten), are setting the stage for future eating dysfunction. At the other end of the spectrum, parents who pay no attention to nutrition and make a habit of emotional or compulsive eating are also programming their children to neither feed their bodies nor manage their feelings effectively.
The act of feeding is not the only behavior that leaves an imprint on children’s attitudes toward food and weight. Parents who are preoccupied with their own, their partner’s, or their children’s weights are modeling a mind-set that says there is not a range of acceptable weights, only one ideal number for each person, which implies that there is something wrong if a body does not achieve it. Clients who grow up with parents who overtly or covertly express extreme dissatisfaction with their own or each other’s bodies pick up the attitude that bodies cannot be loved unconditionally, but must be whipped into acceptability. Children also suffer enormously when their young, growing bodies are criticized and when parents overfocus on weight, whether it is above or below normal. Moreover, parents who are always talking about eating, exercise, and weight loss make it seem as if this is natural and normal, and overemphasize the importance of food and fitness to being happy and successful.
Comments do not have to be directed at the client to leave their mark. Family members who make frequent pronouncements about fat or thin people in public or in the family or who make a habit of criticizing or praising each other’s weight give children the impression that it is natural and acceptable to be judgmental about body size and shape. Most damaging is hearing one parent constantly chastise or demean the other for what she weighs or eats. Even if the child is not the target of remarks, he learns that it is the norm to make harsh judgments about what a person eats or weighs.
Criticism can be especially devastating when children reach puberty and have to deal with a host of physical changes. If parents are relaxed about these changes and explain them as natural, children become comfortable with their bodies. When parents ignore these transformations or are frightened by them, teenagers may believe that their shifting shapes are abnormal and scary. Additionally, parents who make no effort to be fit and maintain a healthy weight are setting the stage for their children to let themselves go and not take care of their bodies.
Family dynamics do not stop affecting clients’ views about food and their bodies when clients reach adulthood, especially under two conditions. The first is when clients have not adequately separated emotionally from parents and are unable to think for themselves about (and stand up for) their size and how they wish to eat. The second is when parents—or other family relatives—violate boundaries and comment on clients’ eating and weight. Family remarks are frequently triggers for acting out with food, whether what is said is positive or negative or intended as helpful or hurtful.
To assess how upbringing might
affect the client’s attitude toward
food and their body, ask:
1. How would you describe your parents’ attitude toward food and eating when you were growing up?
2. How would you describe their attitude about weight?
3. What family messages make it especially hard to have a positive relationship with food?
4. What family messages make it difficult to feel good about your body at any weight?
5. What family relationships today influence how you feel about food and your body?
6. How can I help you improve those relationships?
Although some disordered eaters might be substantially free of character disorder, most were raised in families in which messages about food and body size were unhealthy, and these are the messages clients are carrying around today. By helping clients evaluate how their personality impacts their eating and weight problems, we give them a chance to change their attitudes and beliefs. By helping them understand how family dynamics shaped their mind-set about food and body, we give them a chance to overcome learned dysfunction and move toward healing.