Key 3

IT’S NOT ABOUT THE FOOD

Just getting in control of my food and weight was not enough. I had been to programs and worked with professionals who got me to stop my behaviors but since I never dealt with any of the underlying issues, the behaviors kept coming back. Until I dealt with why I starved, or why I purged when I did eat, my behaviors continued to provide me with comfort and distraction. Until I learned to replace what my eating disorder gave me with healthier ways of getting the same thing, I stayed sick. Now I know that any desire I have to restrict or purge my food is related to some other issue and I need to stop and take a look inside.

—CR

A commonly held assumption about eating disorders is, “It‘s not about the food.” What does this mean? If it’s an eating disorder, how can it not be about the food? People started using the phrase, “It’s not about the food,” to help explain the complexity of an eating disorder, and to help debunk the notion that it is all just about dieting and weight. What the statement means is that, even though your relationship with food has taken over your life, and normalizing your eating is essential for recovery, food itself is not the problem. Simply creating a meal plan or gaining weight won’t cure an eating disorder. Treatment programs that provide consistent monitoring and control of your behaviors can help you gain weight or stop the binge-and-purge cycle, and some may find recovery this way, but for most this is not enough to guarantee lasting results. There are many factors that can contribute to the development of an eating disorder. In this key we will explore how you can go about addressing those that are relevant to you.

Whether or not your eating disorder began as a way to get healthier or lose weight, it quickly becomes much more. Chances are, your eating disorder has become a way you cope with other problems. Like many of our clients you might find yourself resistant to looking, or unable to see beyond issues of food and weight:

“When I was completely caught up in my bulimic cycle, you could not have convinced me that it was not about the food. I had heard about concepts like ‘managing your emotions with food’ and ‘numbing your feelings with food,’ but I really believed that those things did not apply to me. My eating disorder worked so well at managing my emotions and numbing my feelings that I was incapable of understanding what was happening. I thought all I needed was someone to help me get in control so I could lose weight. When I got some distance from my behaviors, it started to become clear how much they had helped me cope with a variety of underlying issues.”

—SW

You may need help figuring out what else, besides your relationship with food, is wrong, or you may already know what is wrong, but are unable to change it.

“When there’s fear or behaviors about or around food, that’s a huge sign that there’s something else going on…something I haven’t looked at, dealt with, or cried about in a while, because when I am using my eating disorder behaviors I don’t have to look at, deal with, or cry about much of anything because I’m focused on one thing: how to avoid calories or get rid of them.”

—KL

Why Eating Disorders Are Not “About the Food”

There are four main, overarching reasons for why we say that your eating disorder is not about the food. We will list them here first and then describe each category in detail:

•  An eating disorder is not about any particular food and is not an addiction to food.

•  An eating disorder is fueled by a cultural climate, which causes negative feelings about your body, your image of it, and your relationship with it.

•  Although many people diet to control or lose weight, those with an eating disorder usually have some other underlying issues that push them harder and further.

•  It’s not about the biological makeup of food, but rather the biological makeup of you, that contributes to the development of an eating disorder.

An Eating Disorder is Not About Any Particular Food and is Not An Addiction to Food.

There is no proof that binge-eating disorder, bulimia, or anorexia, which is essentially food refusal, are illnesses caused by any certain foods or food addiction. The 12-step addiction model was originally applied to eating disorders when it was used to help compulsive overeaters—now referred to as binge eaters—abstain from their “binge” foods. Later, this 12-step approach was adapted for bulimia and anorexia. The 12-step approach has helped many people with eating disorders, particularly those who binge, but not because any certain food or type of food is addicting, or abstinence from the food the cure. 12-step programs provide a variety of services that can be very helpful. They offer free support from others who have been there; they provide a sense of community, and have sponsors who are available to help outside of the group meetings. We particularly like the idea of people in recovery helping others along the way. In giving back you not only help others, but you strengthen recovery in yourself as well. We also appreciate that 12-step groups are available in most cities and sponsors can be called in the middle of the night. However, there are some aspects of the 12-step philosophy that can hinder or impede recovery from an eating disorder or can even be detrimental to recovery if they are not adjusted or adapted.

Adapting the 12-Step Model For Those With An Eating Disorder

1.  We suggest that you use the model to work on your specific behaviors such as bingeing, restricting your food, or taking laxatives, rather than trying to abstain from certain foods. If you binge or binge and purge, abstaining from certain foods, such as sugar and white four, can elevate their status in your mind and make you want them even more, contributing to a later binge. If you already restrict your food, write out something that clearly defines what would constitute restricting, for example, anything less than a certain amount of calories or less than three meals and three snacks.

2.  In 12-Step meetings, there is a customary introduction: “Hi, I’m (name) and I am an anorexic.” We believe that using the term “anorexic,” “bulimic,” or “compulsive overeater” reinforces the notion that the eating disorder is part of one’s identity. We prefer our clients to perceive themselves as “suffering from anorexia,” rather than as being an anorexic. We prefer that the person say, “Hi, I am (name) and I suffer from ‘compulsive overeating’ or ‘bulimia’ or ‘anorexia’ or even better, ‘I suffer from an eating disorder.’”

3.  The 12-step abstinence model involves “black and white,” “all or nothing” modes of thinking. Such dichotomous thinking is problematic for eating disorder clients and can interfere with honesty and recovery. Furthermore eating is different than drinking. In AA there is no acceptable amount of drinking but obviously one has to eat and deciding what amount is enough and what is too much lands in the area of gray rather than black and white. Recovery involves slipping up, making mistakes, and learning from your symptoms and behaviors. There is too much perfectionism and obsessive thinking in the temperaments and personalities of many with eating disorders, and one of our tasks is helping people to learn to live more in the gray areas of life.

4.  It is important to know that you can be fully “recovered” where the eating disorder is gone, a thing of the past. The 12-step philosophy uses the term “recovering.” In the 12-step model, people don’t ever get over the eating disorder. If you are not engaging in behaviors, you are abstinent or in remission like a non-drinking alcoholic, but you still have the illness and have to deal with it one day at a time. We don’t agree with this. There is no evidence indicating that once you have an eating disorder you have it for the rest of your life. We are recovered and know countless recovered people. Research also supports that you can be fully recovered. One final point: the word “recovery” or “recovering” is useful during the process of getting well, but can be misleading and confusing, because these terms can refer to someone who is still symptomatic or someone who has been without symptoms for 5 months, 5 years, or even 15 years.

An Eating Disorder is Fueled by a Cultural Climate, which Causes Negative Feelings about Your Body, Your Image of it, and Your Relationship With it.

We have never treated anyone with an eating disorder who did not have some problem with his or her body. Most clients are dissatisfied and many are also distorted regarding their appearance. Body image disturbance is part of the diagnostic criteria for anorexia, which is defined by the American Psychiatric Association (2000) as “Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self evaluation” (pg. 589) and the criteria for bulimia includes: “Self evaluation unduly influenced by body shape and weight” (pg. 594). Body image disturbance is one of the hardest things to treat and is the last thing to go in the recovery process.

Living in this current cultural climate, where women are bombarded with the thin ideal, it’s hard to imagine a female whose self-evaluation isn’t unduly influenced by her shape and weight. If you have an eating disorder you have taken this to an extreme. You are most likely obsessed with losing weight or controlling your weight, and some of you do not see, or do not admit the seriousness of your already low body weight. Your relationship with food is based on your relationship with your body, how you perceive it, how you feel about it, and your acceptance of it. If you instantly found out that there was a pill that allowed you to eat whatever you wanted and not gain weight, how would this change your eating behavior? If you knew you could eat whatever you wanted when you were hungry and stop when you were full, and be the weight you wanted to be, how would this change your eating? If you have an eating disorder, what you weigh, what you eat, and how you look have become more important to you than who you are.

Body image disturbance is brought on and perpetuated by living in a cultural climate where being fat is abhorred and where achieving an impossibly extreme version of thinness is considered desirable and attractive. In the pursuit to reach the acceptable or desired level of thinness, many people begin with a diet. According to Keel (2006), those who go on a diet are seven to eight times more likely to develop an eating disorder than those who do not diet!

We are all inundated daily with hundreds or more messages with an emphasis on weight and shape. These messages make us all feel inadequate in terms of our appearance. We live in a culture that bombards us with these messages through magazines, billboards, ads, television shows, and commercials, and thus resisting those messages is extremely hard. We find that most females and all of our clients say they feel objectified, judged, scrutinized, measured, evaluated, and “in need of improvement.” The use of extremely thin women, digitally enhanced and Photoshopped to perfection, fuels dissatisfaction and unhappiness and the need to improve ourselves to look more like they do, when in reality they don’t really look that way, either. We tend to blame our “faws” and ourselves for our unhappiness instead of the pervasive and constant messages that tell us we are not OK the way we are.

Every person in this culture is affected by these messages in one way or another, but people with eating disorders seem to be especially vulnerable, as we will continue to explore in this key. Since you cannot eliminate these messages, you need to find antidotes to combat them. Over the years, we have shared with our clients things that helped us not get trapped in body scrutiny or dissatisfaction. We suggest you avoid buying popular magazines that show only thin bodies, push diet tips or how to lose weight or get-in-shape-quick fads, which means most magazines. Don’t watch television shows that feature and promote women with unhealthy bodies. Go even further and write the television station about it. Avoid, interrupt, or walk away from conversations about dieting or comparing bodies or saying negative things about your own, or anyone else’s body. Write to advertisers, television producers, or networks who shamelessly use “anorexic-looking” models or actresses or make absurd advertising statements like, “You can never be too rich or too thin.” Buy clothes paying no attention to the size and buy food without reading calorie labels. We both used all of these antidotes when recovering and we teach our clients to do the same. Like many women suffragettes who fought for the right to vote, we may not see great changes in the cultural messages happen anytime soon, but we can begin now in the hope of changing the world for our daughters and granddaughters. In the meantime, practicing the antidotes helps you to feel better and protect you from body image bombardment now.

Writing Assignment: Exploring Your Body Image

In order to get a better understanding of your body image, use your journal to answer the following questions.

1.  Do you remember a time when you did not have a body image problem?

2.  What do you think are the characteristics of a person who is OK with his or her body?

3.  What family issues or personal challenges may have caused you to develop body dissatisfaction?

4.  Has anyone ever helped you with your body image? If so, how?

5.  Other than changing your weight, what would help you with your body image?

6.  What things do you keep yourself from doing because of your body?

7.  How would you help a young girl of 14 improve her body image or accept her body?

8.  What steps can you take to protect yourself from harmful cultural messages?

9.  What things can you begin to do to practice acceptance of where you are right now, even if you want to change?

10.  What are some positive things you can say about your body?

It will be helpful for you to look at the various questions you answered and reflect on how you might like things to change. Chances are that what you have been doing has not helped you, not just in terms of your body image, although that is important, but also in terms of how happy and loving or lovable you are. Most women in this culture have body image issues at least to some extent. However, for most people body image issues surface and are worked through without the person resorting to behaviors that are physically and mentally destructive in order to “fix” the problem. Most healthy people have a line that they will not cross in order to change their body, no matter how badly they feel about it. For various reasons explored in this key, that line, or limit, is something that people with eating disorders seem to be missing. Part of your recovery will be developing your own line or limits where you are no longer willing to betray yourself to “fix” or change your body. Throughout the keys we will provide information to help you with your body image.

Although Many People Diet to Control or Lose Weight, Those with an Eating Disorder Usually Have Some Other Underlying Issues that Push Them Harder and Further.

Not everyone exposed to popular culture hates their body or goes on a diet, and not everybody who diets takes it to the extreme and develops an eating disorder. Clearly, then, there are other contributing factors. Although the exact cause of eating disorders is unknown, there are a variety of risk factors that increase your vulnerability to developing one. Certain circumstances or experiences that have been identified as risk factors by researchers include but are not limited to: being overweight as a child; dieting as a child; having a mother who diets or has an eating disorder; early menstruation; being bullied or teased; engaging in certain sports with a focus on appearance or weight, like ballet, cheerleading, wrestling, and gymnastics; certain careers like modeling or acting; and a history of childhood abuse (Brewerton, 2004; Rorty & Yager, 1993). It is possible that many of these risk factors propel someone to a more serious or intense degree of body dissatisfaction, and push that individual into dieting and other behaviors as they try to “fix” themselves. There are many things that can contribute to the development of an eating disorder. The list gives an indication of what might make someone vulnerable to getting caught up in an unhealthy spiral of dieting or weight loss. But, none of these factors necessarily explain your personal situation. You have to look at your life and see what might have contributed to your eating disorder. To facilitate your understanding we will share some of our own stories.

Personal Reflections:

Carolyn: When I went on a diet with a few of my friends, why did I take it so seriously? Why was I was the only one who developed anorexia? Part of the answer involves going back to a time in my life before I ever started to diet. My dad always dieted, and as I entered my teens he began to make comments about my weight. I knew he loved me but his comments like “you’d be so much prettier if you lost a little weight,” undermined my confidence and self-esteem. When I was a teenager my dad divorced my mom and married a very thin, beautiful fashion model, and I had to move to a new house and start a new school. I was enamored with my stepmother’s beauty and her modeling career. There was a specific, telling incident that happened which I forgot about until years later in a therapy session. One day when alone, I secretly tried on one of my stepmother’s dresses and it was too small! I was only 14 and she was smaller than me! I remember saying to myself, “Someday I will ft into this dress.” I wanted to be like my stepmother. I wanted my dad to like me and not leave me. It was some time after this in the 9th grade that I tried out to be a cheerleader and lost to the thinner more attractive girls, and I subsequently began my first diet. All these events in my life—my dad choosing a model over my mother, moving to a new house, and attending a new school—left me feeling insecure. So when all my friends and I went on a diet, my feelings about my stepmother made me especially want to succeed. Sure enough, losing weight brought the approval and attention that I craved. I became proud of how little I could eat in a day and became obsessed with my weight and weight loss. I loved the praise I got for losing weight and “having such good willpower.” I loved showing my friends, who also were dieting, that I had the “control” to stick to my diet and succeed. I started restricting desserts and snacks in between meals, then fats, then starches, then protein. Eventually nearly all foods seemed too high in calories except a few fruits and vegetables. The weight kept coming off and I felt good about it. However, the time came where I didn’t want to lose any more weight but my fear of gaining weight and the taboo I had created in my head about eating so many foods had such a grip on me that the weight kept coming off and I couldn’t stop it. I did not understand what had caused things to go awry, how I had gotten so out of control. You don’t have to understand why you are where you are now either. I recovered from my eating disorder before I ever figured out all the things that had caused it. The important thing is to start turning it around.

Gwen: My mother was obsessed with her own weight, constantly talked about dieting, and was always on a diet. I was a very thin child, but as I entered puberty and started gaining some weight, she became very worried and determined to spare me the shame she felt about her body and the anxiety of weight problems. She rushed me off to Weight Watchers and signed me up at the local gym to get ahead of “the problem,” but instead of helping me, which I know was her intention, she planted the seeds of body shame, diet mentality, and low self-worth. She taught me that if I wasn’t thin, I would not be happy, or feel confident. It didn’t matter what else I accomplished in life; being thin was what I needed to feel valuable and lovable. Eating soon became a source of guilt and shame, and something that made me feel like a complete failure. My self-esteem and body image continued to decline throughout high school. I withdrew from sports and other things I enjoyed because of self-consciousness and fear of judgment. When I arrived at college I was lonely, depressed, and hopeless. I called home in a desperate moment and my mom responded in the only way she knew how. She suggested I increase my confidence by finally losing that extra few pounds and she sent me the diet that she and my dad were on. My erroneous belief that weight loss would fix my self-esteem and end my depression created the perfect storm of factors to allow for my diet to become my disorder.

Abuse as a Risk Factor

We are often asked about, and there is a lot of misinformation about, abuse as a risk factor, so we want to say a few things about it. Being abused does not necessarily lead to an eating disorder, but research shows that if you were sexually, physically, or emotionally abused and you developed post-traumatic stress symptoms, you are at a higher risk for developing an eating disorder (Brewerton, 2004, 2007). We have treated many people who have been abused, sexually or otherwise, and use eating disorder symptoms as well as other self-destructive behaviors to manage their feelings and feel in control of their life. The behaviors often express something about the way those who were abused feel about themselves as a result of what happened to them. Often behaviors such as bingeing and purging become ways to try to numb out and forget and dull feelings and memories, and control the body. Clients also describe these self-destructive behaviors as ways to punish themselves or ways to create physical pain to match the pain they feel on the inside. The behaviors can provide a sense of relief, but only temporarily. An eating disorder never heals anything and only makes matters worse. If you have an eating disorder and have experienced sexual abuse or other trauma, it is important for you to seek help from a professional or program with expertise in both areas. We have listed further reading on this topic in the resource section.

It’s Not the Biological Makeup of Food, but Rather the Biological Makeup of You, that Contributes to the Development of An Eating Disorder.

There are still other factors we have not yet discussed that contribute to why, given the same or similar circumstances, one person develops an eating disorder while another person does not. Why does one person who was teased as a child for being fat develop an eating disorder while another does not?

Carolyn: “After beginning a diet in high school, I developed an eating disorder, while my friends who also dieted did not. My sister, who grew up in relatively the same environment as I did, did not even diet.”

Why are there such differences even with similar circumstances?

One emerging answer has to do with biology and genetics. Research has shown that there are certain genetic factors that raise your risk of developing an eating disorder. If you have a family member or relative who has an eating disorder it raises your risk of developing one. Of course this could be learned behavior—like mother like daughter, as in the case of Gwen and her mom. Some of it can be learned, but twin studies reveal the influence of genetics. If an identical twin has an eating disorder, the chances that the other identical twin will also develop an eating disorder are significantly higher than is the case with fraternal twins (Bulik, 2010; Wade, Bulik, Neale, & Kendler, 2000). This points to a genetic component to the disorder, in addition to environmental influences, but we have yet to fully understand the nature of this genetic predisposition. Ongoing research will continue to help our understanding. What is known is that having certain genetic temperament traits such as anxiety, perfectionism, obsessive-compulsive tendencies, harm or risk avoidance, sensitivity to rejection, or lack of impulse control, all seem to make people more susceptible to developing an eating disorder and can be considered risk factors of a biological or temperament nature (Strober & Peris, in press). The twin and trait studies point to a genetic contribution to the development of an eating disorder. Combine a genetic predisposition with other factors, such as a culture that reveres thinness and pushes dieting, a negative body image, a psychological stressor such as parental divorce, and you can see “the perfect storm” coming together. The current understanding of the development of an eating disorder is that “Genes load the gun and environment pulls the trigger.” The term “environment” includes the culture you live in, the family you grew up with, and all the events and developments you experience in your life.

We listed several environmental risk factors earlier. We are not saying that if you have any of those risk factors, if you have the above temperament traits, or if you have a family member with an eating disorder, you will certainly develop an eating disorder. What we are saying is that these are all traits and tendencies that will make you more vulnerable to developing one. Also, it is important to note that absence of the risk factors doesn’t guarantee that you won’t get an eating disorder.

To help with your understanding we will discuss how our own temperaments contributed to our eating disorders.

Personal Reflections:

Carolyn: When looking at my own history, genetics might explain why I persevered in dieting when others did not, and why I developed an eating disorder and my sister did not. My sister and I both experienced the same difficult events described earlier (my dad leaving my mother for a fashion model and the transfer to a new school), and although she was younger than me, which makes a difference in our respective experience of the situation, we also have very different temperaments. My genetic makeup has given me a temperament that leans toward perfectionism, anxiety, and compulsive behavior. My temperament helps explain why, when I went on a diet with all of my friends, I took it very seriously, continued to lose more and more weight, and could not stop. I was the only one who wouldn’t “cheat” on my diet. I was the only one who consistently attained my weight goals. I was the only one who developed anorexia. So, did “my genes make me do it?” Not solely, but they helped. My eating disorder was a combination of my genetic predisposition, the prevailing cultural climate of “Thin is In,” and many environmental stressors in my life. The way I see it, my genes by themselves are not a problem. For example, my perfectionism can be an asset or a liability depending on how I channel it. It was important for me and will be important for you to understand how your traits can work for or against you.

I have the genetic predisposition classically described by researchers as typical of individuals with anorexia nervosa. I was a perfectionist, obsessive, anxious, harm avoidant, and a control junkie. If I was told to do something, I did it. I was too worried (anxious) about what might happen if I did not do my best at everything all the time. I followed the rules, did my homework, and pushed myself, even at a very young age. I was literal, a rule follower, and very controlling. In kindergarten, I was mad on Halloween because I was in a witch costume and all the other little girls were dressed up as fairies, princesses, or characters like Alice in Wonderland. I remember thinking they all just didn’t get it! Halloween was supposed to be about monsters, goblins, and witches!

My temperament and genetic traits helped me earn straight A’s, skip the sixth grade, graduate high school when I was 16, and earn two master’s degrees by the time I was 21. However, when I applied these same traits to losing weight, I pursued dieting with the same vigor and tenacity I pursued everything and ended up with an eating disorder. Had I lived in a different culture where all body sizes were admired, where there was no emphasis on thinness or special status for those who are thin, and where all my friends were not on diets, I would not have dieted or developed anorexia, though I might have had other problems. If I had dieted but had a different temperament, I probably would not have developed anorexia. But take my genes, add in the cultural climate, and combine all this with my psychological stressors at the time and not only was dieting a reasonable endeavor on my part, but the tenacity with which I pursued it, and the eventual development of an eating disorder, were understandable outcomes.

I have been recovered from my eating disorder for over three decades, but I still have the kind of hard-wiring my genetics dictate. The good news is that I understand myself better and have learned tools that help me focus and direct my behavior in appropriate ways. I calm my anxious temperament through meditation, walking in nature, music, or yoga. I turn my drive and perfectionist tendencies toward things like my writing, lecturing, taking care of my clients, and running the best treatment center I can.

Gwen: My temperament is marked by the features of perfectionism, worry, obsessive-compulsive tendencies, people-pleasing urges, and occasional impulse control issues. I usually felt like a failed perfectionist, never quite measuring up to what I thought I should be or what I thought others expected of me. With my obsessive tendencies, I often could not stop, sleep, or think of anything until I completed or fixed something I was working on, and I worried constantly about what people thought about me. The most difficult times came when my temperamental tendencies all came to the surface at once. An example of the way my traits worked in service of my eating disorder was my split-second decision to join the United States Army. I wanted to “Be all I could be,” get whipped into shape, become perfectly lean and disciplined, and be kept “in line.” I thought I was becoming lazy and wasn’t sure how I was going to keep up my rigid diet and exercise routine, which my mom had instilled in me from an early age. The army would provide me with a strict drill sergeant who would keep me from slacking. It seemed like the perfect solution. I didn’t take the time to talk to anyone about this decision, or think about it for a day, or even ask any questions. The minute I saw the sign outside the recruiter’s office, a light went on in my head, and I suddenly knew that this was answer to all of my worries. An hour later, I had signed on the dotted line and I was on my way home to make arrangements for boot camp. Four days later, I was on a plane to Fort Knox, Kentucky. As you can imagine, once I got there, things started to quickly unravel and fall apart. My “strict” drill sergeant seemed to feel sorry for me rather than try to keep me in line. I cried a lot, which isn’t very army-like, and when asked about why I had joined, I did not possess the ability to explain my reasons. After several distressing incidents, the army decided I was “emotionally unstable” and after four weeks I was honorably discharged. For a long time, however, my traits continued to propel me deeper into eating disorder behaviors. My perfectionism and obsessive nature led me to calorie counting, food scrutiny, and compulsive weighing. Finding a way to understand my traits and myself in a more balanced way was essential for me. My perfectionist and obsessive tendencies help me stay organized, make me work hard, prevent me from procrastinating, and help me run a successful household and therapy practice. Even my impulsiveness, when controlled and channeled in the right direction, keeps my kids entertained and my marriage from being dull (that is what I tell my husband, anyway!).

Traits as Liability or Asset

Consider the following traits and see how they can be either an asset or liability. We tell our clients that they can take any trait of theirs (whether it is caused by genetics or not) to what we call the darkness (liability) or the light (asset). This concept will help you understand that you are not doomed by any genetic predisposition you came into the world with, or for that matter, by any personality trait you may have developed along the way.

Liability	Asset
Perfectionistic	Precise
Obsessive	Thorough
Anxious	High energy
Impulsive	Spontaneous
Critical	Discerning
Manipulative	Strategic
Stubborn	Determined
Controlling	Directive
Compulsive	Driven
Avoidant	Careful

It is helpful to see how traits that on the one hand can be negative can also be positive when you work on developing awareness of them, and learn skills to channel them in the right way.

Writing Assignment: Your Traits—Assets or Liabilities?

See if you can think of any traits you have that you feel get in your way or are a problem for you. Think about things other people have said about you that were hurtful or critical. It might help to think of things about you that drive your eating disorder or interfere with your ability to get better. Make a list of your traits and then figure out how they can be an asset. Knowing your traits and how you can turn them into assets, rather than liabilities, can help you better understand yourself as well as others. You will find that your traits play out in various arenas; for example, if you are controlling about your food, chances are you are controlling in your relationships as well. If you are impulsive in your dealings with food, you are probably impulsive with money and relationships.

Writing Assignment: How is Your Relationship to Food Like Your Relationship to People?

Your approaches to both food and relationships will have similarities because of your temperament and who you are. Think for a minute about how you are with food. Are you cautious? Are you bold? Do you try to be in control? Do you fear you will never get enough? Now ask yourself if this is similar to your relationship with food. When we asked one of our clients with bulimia this question, she said, “Oh, I binge and purge men!” A client with anorexia said, “I scrutinize everything I eat and everyone I meet.” Since our traits play themselves out with people, food, and in other areas, it can be useful to explore this. Write out everything that you can think of regarding how this might be true for you. You will begin to see how your temperament guides your behavior in a variety of situations. The good news is you can work on changing your relationship with people, and your relationship with food will change as well, and vice versa. We suggest you come back to this assignment and do it again during the course of your recovery. This will help you see how your relationships with both food and people are changing.

From Risk Factor to Pieces of your Puzzle

Knowing about cultural pressures, environmental risk factors, genetics, and temperament is useful in terms of understanding and perhaps even preventing eating disorders, but it falls short in explaining why you in particular developed your eating disorder, and how to successfully treat it. People who develop eating disorders may have things in common, but each person has his or her own unique factors that contribute to their disorder. Think of your eating disorder as a jigsaw puzzle with many different pieces making it up. Your jigsaw puzzle is unique to you. In trying to understand your eating disorder, it is useful to explore the various pieces that together make up the whole picture. Some pieces of your puzzle may be more important or critical than others in terms of getting better. You don’t have to know all the pieces of the puzzle in order to get better, but knowing some of the pieces can help you understand, and even target, specific issues to work on.

Looking Further Into What Contributed to and Perpetuates Your Eating Disorder

Even with reading all the information so far, it may be hard to discern why you have an eating disorder and what it could be doing for you. In order to help you identify and work on your particular issues, we provide a list called “The Real Issues” adapted from the book Your Dieting Daughter (Costin, 1997). This list covers the most common issues that clients with eating disorders have identified as contributing to their illness. Read through this list and see if it helps you identify parts of your eating disorder puzzle.

Real Issues

1.  Poor Self-Esteem:

•  I’m afraid of myself and of being out of control.

•  I’m not worthy.

•  People don’t like me.

•  I can’t trust my own judgments or make decisions.

2.  Need for Distraction:

•  When I’m bingeing or throwing up, I don’t think about anything else.

•  I need something that distracts me from my thoughts and feelings.

•  Worrying about my weight keeps me from worrying about other things.

3.  Fill Up Emptiness:

•  Something is missing in my life and I try to fill it with my eating disorder.

•  I feel empty inside and bingeing takes me away from that temporarily.

•  Eating fills up my emptiness.

•  All my eating disorder rituals help me fill up a void in my life.

4.  Belief in a Myth:

•  I will be happy and successful if I am thin.

•  Thinner people are happier.

•  I have to be thin to be attractive and desirable.

•  Losing weight will solve my problems.

5.  Drive for Perfection:

•  I have to be the best at everything, whether it is taking a test or dieting.

•  I have the willpower to do things others can’t do.

•  I’m either fat or thin.

•  I’m either perfect or a failure.

•  If I can’t win or be the best, I won’t try.

6.  High-Achievement Oriented:

•  I feel constant internal pressure to work hard and achieve.

•  I can only achieve a good body through my eating disorder.

•  I am driven everywhere else and use my bulimia as a release.

•  Restricting is a real achievement, mind over matter, literally.

7.  Desire to be Special/Unique:

•  I get a lot of attention for my willpower over food.

•  I don’t know who I would be without my eating disorder.

•  My eating disorder causes others to worry about me and take care of me.

•  My eating disorder makes me stand out and be different.

•  My low weight is the only special thing I have.

8.  Need to be in Control:

•  I have to be in control of my body, and what goes in and out of it.

•  My eating disorder helps me feel in control of my “out of control-ness.”

•  My eating disorder behaviors keep my feelings under control.

•  My eating disorder is the one thing no one has control over but me.

9.  Wants Power over Self, Others, Family, Life:

•  My eating disorder gives me power over my body.

•  I feel powerless most of the time, except when it comes to my eating disorder.

•  My eating disorder gives me power over others.

•  It’s powerful to be able to resist food, like a saint or monk.

10.  Wants Respect and Admiration:

•  I finally got respect from my peers when I lost weight.

•  I wanted to be admired and tried restricting to lose weight, but I couldn’t do it, so I had to throw up.

•  When I binge I am rebelling because I know I will never get the respect and admiration that people get for being thin.

•  People respect my ability to resist food.

11.  Has a Hard Time Expressing Feelings:

•  I don’t know how to express my anger, so I binge and purge.

•  I feel like I swallow my feelings when I binge.

•  I can’t deal with conflict or confrontation so I resort to my eating disorder.

•  Restricting helps me shut down and deny my feelings.

12.  “Safe Place to Go”/Doesn’t Have Coping Skills:

•  My eating disorder is a “special world” created to keep all the “bad” out.

•  If I follow my own imposed rules, it helps me feel safe.

•  My eating disorder helps me get taken care of without asking for help.

•  My eating disorder has helped me avoid taking on adult responsibilities.

13.  Lack of Trust in Self and Others:

•  I don’t trust people so I isolate from them with my eating disorder.

•  I don’t trust anybody; I use my eating disorder as my best friend.

•  I can never make a decision; bineging and purging provides procrastination.

•  It’s easier just to follow my eating disorder rules than to trust myself or anyone else.

14.  Terrified of Not Measuring Up:

•  I know I can’t compete, so I let my eating disorder takes me out of the running.

•  I won’t have anything if I don’t have my eating disorder.

•  I’m constantly comparing myself to everyone.

•  I am terrified of being fat.

•  I am terrified of being deprived.

•  I am terrified of being deprived and of being fat.

Writing Assignment: Identifying Your Real Issues

Go back through the Real Issues List and decide which of the 14 issues apply to you. Write those down along with the examples that ft. Add any other issues of your own that you can think of and give specific examples. Take some time to journal about each issue, giving examples of your thoughts, feelings, and behaviors related to the issue and how your eating disorder symptoms are involved. Once you have identified which issues you know are present in your life and how you use your eating disorder to help you deal with them, you can begin working on resolving them or finding healthier alternatives to cope. Once again, we suggest sharing this assignment in therapy or with significant others who can help you come up with ideas.

Personal Reflections:

Carolyn: I already described myself as a perfectionistic, driven kid (Real Issue #5). I felt compelled to achieve and be the best at everything (Real Issue #6). When I went on a diet and lost weight I got compliments from others who found it hard to do so and my need for admiration was reinforced. (Real Issue #10). I got praise and increased attention from both males and females at my high school for my weight loss but also for my strong willpower, that is, for my ability to resist eating. All of this made me feel unique and special (Real Issue #7), and drove me to diet even more. I ultimately had to learn to deal with my need to be the best, to achieve, and to be special. I had to learn to love myself for who I was and accept that I was worthy even if I was not “the best” or accomplishing something.

Gwen: Until I got treatment, if never even crossed my mind that there were underlying issues contributing to my obsession with my body and weight loss. I needed to be thin. I knew that from an early age. It was just the way it was supposed to be.

Carolyn: When Gwen came in for treatment, she had not explored the possible underlying issues that could be contributing to her self-starvation, her body dissatisfaction, and her inability to satisfy her body’s real needs without guilt. Gwen was stuck in a familiar cycle: she wanted to be thin, feared being fat, and was unable to see what else was beyond the struggle being played out with food and her body. I decided to have a session with Gwen and her husband, Albert, and present the Real Issues List for both of them to look at and see what, if any, issues rang true.

Gwen: When Carolyn gave me the Real Issues List, it was my first introduction to what could be causing or contributing to my eating disorder. My husband, Albert, and I looked through the list and picked out which ones applied to me. All of the issues he and I selected that day surfaced throughout my treatment, and were worked on as part of my recovery over the next several years. These underlying issues take a lot of awareness, intention, and practice to change, because they are usually ingrained and connected to fundamental beliefs and fears. Going through the Real Issues List was the first time I could identify my underlying issues but I still could not understand how those issues were connected to my eating disorder. It may take time to see how certain underlying issues are related to your eating.

Carolyn: Gwen and her husband were able to identify several issues from the list. This made them both hopeful that there were things Gwen could work on to help her get better. What was interesting is that Albert picked out issues from the list that Gwen initially didn’t think applied to her. After discussing it together, she came to realize that in fact they did.

Gwen: I remember when Albert first pointed out that I was a perfectionist and tried to reassure me that I didn’t have to be perfect, I felt misunderstood. I kept saying, “Yes I do, you don’t understand me.” Even though at first I didn’t think I was a perfectionist I came to realize how true it was. I started to explore the idea of lowering my expectations of myself in some areas, or as my good friend, Sam, liked to tell me, “Go for the silver.” I had to learn that not being perfect did not mean failure and that no one expected me to be perfect. An important turning point for me was when I started to see that I was honest about my feelings without being critical or judgmental of others; I was less worried about being perfect, others experienced me as “real” and that made them feel more comfortable with me which meant they could be more authentic and real with me.

Carolyn: It turned out that using the Real Issues List as a starting point helped Gwen to see a myriad of issues that related to her eating disorder. Gwen continued to work on the issues throughout treatment and came to see how some of the issues were part of her personality and she would have to figure out how to best deal with them throughout her life.

Gwen: “Terrified of Not Measuring Up” seemed to be the deepest of all of the underlying issues for me. Feeling terrified of not measuring up is the one underlying issue which still continues to show up for me now and then. What used to be the eating disorder voice has become a critical voice I still hear from time to time. Fears of failure, judgment, criticism, or competition are very hard feelings for me to tolerate even today, but I no longer use any eating disorder behaviors to deal with those feelings; that is long gone. I now know that these feelings are my alert signal that something is wrong or needs to be looked into. I explore what might be going on and figure out the best way to deal with it.

From Eating Disorder Voice to Critical Voice

Even after the eating disorder symptoms are gone, you might hear what we often refer to as a “critical” voice inside your head in regards to areas where you have some insecurity. A strategy for dealing with this voice is being able to recognize that your own inner critic sounds strangely similar to your eating disorder voice (Key 2), except that it chimes in about all kinds of things, not just about what to eat and not to eat. You can use the same technique you learned in Key 2 and dialogue with your inner critic and your healthy self.

Gwen: I had to learn how to consciously ignore my critical voice. Contrary to my thinking, Carolyn taught me that the critical voice was not my conscience helping me do the “right” thing. The voice was left over from old wounds and old messages I had internalized about myself. It was not useful, and it was not coming from any wise place, or higher place, inside me. It was an inner critic keeping me afraid. I ultimately learned the difference between this critical voice and my core self or healthy self, but in the beginning I just had to try the good old “fake it till you make it” strategy. In other words, I had to act my way into a new way of thinking, instead of waiting for my thinking to change my behavior. It was a paradigm shift for me, but possibly one of the most important ones. I realized that if I waited until I was less afraid of something before trying it, it might never happen, but if I tried something even if I was afraid, I would always become less afraid of it over time. Learning to talk to myself less judgmentally was also very difficult, but not impossible. Even now if I notice that I am stuck in my head agonizing over something I did or said and I can feel myself getting more angry and critical, I stop myself. I now know that this type of self-deprecation will not help me at all. I try to use the concept of acceptance of the truth without any judgment, which you will learn about in Key 8. Basically, I accept the situation without judging myself. I might say something like, “I am disappointed in myself and I wish I had handled that differently, or better, but I will learn from this.” This way of thinking keeps me focused on the situation and how I might be able to repair it, or at least do it differently the next time. In the past, I would have thought something more like, “I am so stupid. I ruined everything and I can’t do anything right so I’m done trying.” This way of thinking was more about judging myself than the situation I had handled poorly, and over time it chipped away at my self-esteem. Changing my way of talking to myself has helped me immensely and I don’t think I could have recovered, or gotten very far in my life, if I hadn’t learned how to do it. It is a skill and can be learned by anyone, but it takes dedicated thought, effort, and practice.

It is important to learn the difference between having an inner critic and healthy self-reflection. An inner critic is nasty and mean. An inner critic will cause you to doubt yourself and keep you unhappy, insecure, and stuck. Self-reflection can help keep you humble and help you continue to improve yourself and grow. When writing this book we realized that both of us still have a critical voice that chimes in with things like, “Who do you think you are?” “Don’t get too full of yourself,” and “What will people think and say?” These kinds of messages used to drive us to eating disorder behaviors, but now we realize there is something we need to look at and figure out what is causing our self-doubt.

There are many real issues and other factors that have to come together in just the right way to make up your eating disorder puzzle. To our clients we say, “We are experts in eating disorders but novices in regards to you.” When you are trying to get better it is important to look at your own unique situation and all of the underlying issues that perhaps made it easier for eating disorder behaviors to take hold of your life.

Some Final Thoughts

We hope this key has helped you understand how various issues, aside from your desire to control your weight or shape, have contributed to the development of your eating disorder. You have begun to explore the many ways in which you have used your eating disorder to cope with various situations and the feelings associated with them. The next key, “Feel Your Feelings,” is dedicated to helping you begin to develop new tools so that you can recognize your feelings, learn to tolerate them without resorting to eating disorder behaviors, and finally use them as a guide for living a more healthy and happy life, complete with the full range of emotions that come along with it.

Additional Assignment

Writing Assignment: Exploring Your ED Puzzle

We end this key with asking you to get your journal and write about what you have learned. Spend some time summarizing your thoughts and feelings about the information in this key. The following questions are designed to help you think further about the development of your eating disorder and how your behaviors might be helping you deal with some underlying issues.

•  Write about when you developed your eating disorder, or when you first started dieting.

•  What else was going on in your life either before or around that time?

•  What are some of the things that you felt/feel that dieting or your eating disorder behaviors or even having an eating disorder gave/gives you?

•  What problems or feelings did/does your eating disorder help you deal with or distract you from?

•  How well does the eating disorder work to help you deal with or cope with underlying issues?

•  Even if the eating disorder behaviors “work,” what price do you have to pay, in other words what negative consequences are there?

•  What are you afraid will happen if you stop your eating disorder behaviors? (Although it is OK to list weight issues, be sure to include things other than gaining weight or getting fat).