KEY 6:
CHANGING YOUR BEHAVIORS
I don’t think many people come into recovery thinking about how much they really have to change. I was overwhelmed by the uncertainty I felt, the challenge of trusting the unknown. I concluded that whatever I would find in the future would serve me better than what I had in the past or present. Letting go of a disordered life that compromised two-thirds of the time I have spent on earth was huge, but I just started changing my behaviors one at a time.
—KM
People with eating disorders engage in a wide variety of behaviors that interfere with well-being and recovery. There are the obvious behaviors directly related to the consumption and elimination of food that substantiate the diagnosis of an eating disorder. There are also many other behaviors that sabotage recovery but are less overtly recognized as eating disorder behaviors, because people without eating disorders also engage in them. We address both categories in this key.
Changing Your “Overt”
Eating Disorder Behaviors
Restricting, bingeing, and vomiting are what we refer to as “overt” behaviors because they are used in the diagnosis of an eating disorder. Without these behaviors, you would not have an eating disorder, so it may seem obvious to you that these are behaviors you need to stop. The truth is, many of our clients try to follow a meal plan or become conscious eaters without challenging or letting go of these behaviors, but without giving them up there is no way to become a conscious eater or recover. Other people want to stop their overt behaviors and have no idea how to do so. We realize that stopping these behaviors is very difficult and if you could just stop them you probably wouldn’t be reading this book. The information provided in this key will help. Take small steps and use the tools you have already learned in the other keys along with the information that follows.
Overt Food Related Behaviors:
Restricting
Usually when you first begin restricting your food intake, your body is still functioning properly with a regular metabolism, so losing weight can seem easy. When you take in fewer calories than you need, your body will begin to compensate by slowing down your metabolic rate. In response to restricting your intake (by not eating or getting rid of food), your body conserves energy by decreasing most bodily functions, such as digestion and heat production, and turns to storing as much energy as possible. People often tell us that learning about this on the Internet or in magazines makes them even more afraid to start eating again, thinking they have ruined their metabolism for life. The good news is you can restore your metabolism by starting to eat and taking in enough calories regularly throughout the day. This is one reason we encourage all our clients to eat three meals and three snacks, giving your metabolism continued boosts throughout the day. According to a study which researched the effects of starvation during World War II, all of the participants who, through a decreased caloric intake had lowered their metabolic rate by up to 40 percent, were totally recovered by one year, some sooner (Keys et al., 1950). Normalizing your eating behavior will help your body start to trust that you will be feeding it regularly. When your body is fed regularly it will return to its normal metabolic rate. You can’t talk your body into it, or exercise to force your metabolism to normalize. The only way to communicate to your body that it is OK to ramp your metabolism back up is through regular healthy eating behavior. If you continue to restrict your food and you do not work to reverse the natural conservation process, your body will become resistant to repairing your metabolism and over time, it will become harder and harder to maintain a healthy body weight. Furthermore, if you continue to restrict calories, your body will lose muscle mass, which is a huge aspect of a healthy metabolism. Instead, your body will try to store fat, which is the preferred mechanism to store energy when the body perceives it is starving. Therefore, restricting to control your weight will actually change your body composition to include more fat and decrease your metabolism, which means you will not be able to consume as many calories as before without gaining weight.
Over time chronic dieters and people with eating disorders who consume too few calories cannot lose weight or have a hard time maintaining weight. The bottom line is that regular and frequent eating is the best way to have a healthy, efficient metabolism. Fasting or restricting is the best way to slow it down. When you get up each morning and eat “breakfast” you are “breaking the fast” and revving up your metabolism. To keep your body efficiently burning calories you need to keep giving it fuel. Imagine a fire that has been left in the fireplace to burn down over night. In the morning there are just a few embers left, barely burning. When you throw some twigs and a log on the fire, the fames shoot up and the fire burns bigger and hotter. If you do not put any new wood on the fire it dies down even more and might even go out. Your metabolism works like that fire, in fact; that is why we call it “burning calories.” Putting food in your body is like throwing twigs or a log on the fire, increasing the rate of burn or your metabolism.
Writing Assignment:
Permission to Eat
How do you feel about giving yourself permission to eat the foods you want or the amount you need? What are your fears? See if you can think of a certain food you can begin to add back to your diet. What might you need to begin making changes? If you think restricting has led to a binge, write about that experience and what you might be able to do next time to prevent that from happening. Many people with anorexia also end up bingeing, some to the point of developing bulimia. Depriving your body of anything can create a compulsion for it. We tell our clients, “Imagine you are underwater depriving yourself of breathing. You are desperate for one thing, air, and when you come up, you gasp for it.”
Bingeing—Exploring the Causes
and Strategies for Change
Binge eating is something that many people say they do occasionally, like at Thanksgiving or on a special celebration. This kind of overeating is occasional and will not cause weight gain or an eating disorder. The bingeing behavior that we are referring to is when you consume large quantities of food in a short period of time, paying no attention to hunger and fullness and in such a manner that feels out of your control. The binge is followed by feelings of guilt, shame, and intense discomfort from being overly full.
Binge eating is involved, at least somewhat, or at some point, in the course of most eating disorders except those with restrictor anorexia. If you binge, you have to discontinue this behavior if you want to overcome your eating disorder. As with any behavior you want to change, gaining insight into what is causing the behavior can help. Binge eating is not due to laziness or a weakness in character, as is often supposed. The reasons you binge will become clearer as you work through the book, and you will find ways to change as you explore your lifestyle, belief system, and ability to listen and respond to your body and your emotional needs.
What Leads to Bingeing?
Exploring various categories might help when trying to understand what leads to your bingeing. The reasons people binge can be categorized into three main areas:
1. Bingeing due to deprivation or restriction of food.
When you are overly hungry, you will find it almost impossible to listen to body signals, pay attention to healthy choices, stop eating when you are satisfied, or care about how you will feel afterwards. The physical drive to eat is so strong it usually overrides everything else. The same is true when you avoid or hold yourself back from eating certain foods. For example, if you think of chips as a “bad food” and don’t allow yourself to eat them, when you do eat some, you may feel like you “opened the door” to chips and before closing that door again you find yourself eating way more than is normal or even satisfying. Many chronic dieters they tell us that sometimes even the thought of going on a diet or never being allowed to eat a certain type of food can trigger a binge. Planning to go on a diet on Monday, for example, often results in a weekend of bingeing. Incorporating “binge foods” back into your life will help to reduce the dieting mentality responsible for triggering the urge to binge. It is helpful to remind yourself that you can eat whatever you consider a binge food whenever you are hungry and you are not going to restrict or deprive yourself of this food later. Some people with eating disorders do not restrict calories, but hold rigid beliefs regarding what types and quantities of certain foods are acceptable. If the person then happens to eat those foods, it can flip a mental switch that triggers a binge. It may be hard to accept the fact that restricting food is a set-up for a binge, but we have seen this pattern play out over and over again with our clients. It might be helpful to think of the part of you that binges as rebelling against restriction, rigidity, and rules. In fact, review “Dialoging with Your Eating Disorder Self” in Key 2. This technique might work in this situation and help you figure out how to get past your drive to binge.
2. Bingeing as a result of emotions or strong feelings.
Emotional eating is common for everyone once in a while, but for some people, especially if they do not find other ways to deal with feelings, emotional eating can turn into binge eating disorder or bulimia. If you immediately go to food after a fight with a friend, loved one, or after other upsetting situations, that is emotional eating. Certain refined carbohydrates like candy, cookies, and chips are often chosen for emotional eating because they: 1) contain fat and sugar and are highly palatable and rewarding to your taste buds and your brain chemistry; and 2) are commonly considered forbidden foods when on a diet. Bingeing on highly palatable food changes the brain chemistry, so that it reinforces more bingeing. Having said all that, it is important to recognize that a binge can involve any food. Many individuals who binge will binge on anything and everything. Bingeing is a compulsive behavior that feels out of control. When people binge emotionally they are trying to eat as much as possible to distract from feelings or fill up emptiness, cover feelings of sadness, soothe loneliness, stuff down rage, or drown out fear. In other words, bingeing helps you distance from your feelings as quickly as possible. Hopefully you learned some healthier tools in Key 4 to help you tolerate and cope with your feelings.
3. Mindless, unconscious, avoidant, or habitual bingeing.
The third type of bingeing is often used as a way to escape, or numb out. It is very common when you are trying to avoid something like making a difficult phone call or some other unpleasant task. You might be completely unaware you are even eating, or you might be aware you are compulsively eating, but have no idea why. We call this mindless or unconscious eating because often you do not know what is causing you to eat or what feelings you may be suppressing with food. There are many ways you can begin to raise your awareness about your unconscious bingeing so you can learn to interrupt this behavior. One of the first steps you can take is to avoid places or situations that encourage mindless eating—for example, many people eat mindlessly while watching television. Try to not engage in other distracting activities when you eat. If you are bingeing as a way to procrastinate, learning to set small achievable tasks, rather than avoiding an overwhelming goal, can greatly help you reduce bingeing episodes. Bingeing to avoid something fearful does not make it go away. At the end of a binge, whatever you are trying to avoid will still be there, and you will likely feel worse as a result of the bingeing. Sometimes people habitually binge because they have been doing it so long it becomes automatic, and is not triggered by anything in particular.
Writing Assignment:
Exploring Your Feelings Before a Binge
The next time you have an urge to binge, try “surfing the urge” for five or ten minutes and journal. Ask yourself, “What am I feeling?” and “What happened right before I had the urge?” and “What might I be trying to avoid?” It could be a feeling or a task. You might also ask yourself, “What do I really need?” If you are not hungry, you don’t need food, but you might be able to identify something else you need. The answer might be simple; perhaps you need a break from the kids, from studying, or from worrying. Your need could also be more complex, like needing to have a difficult conversation or find a new job.
Use the following to help you resist the urge to binge. Refer to the assignments in Key 4 regarding dealing with difficult thoughts and feelings, and refer to Key 7 for how to reach out to others for help.
Many people binge and do not go to any extreme to compensate for bingeing. Others will resort to some kind of compensatory behavior. The most common compensatory behavior is “purging,” which we turn to now.
Purging
Most people think that purging means vomiting, however, in the clinical eating disorder world, purging is any method used to rid the body of unwanted calories or fluids. The four behaviors that are considered purging behaviors are vomiting, laxative abuse, use of diuretics, and use of enemas. All of these behaviors decrease your metabolism, and are harmful and potentially dangerous. All forms of purging eventually become ineffective, as the body learns to compensate. Let’s look at each one separately.
Vomiting
If you engage in self-induced vomiting, or have in the past, you know it is a very difficult behavior to stop. The behavior may begin as a way to compensate for overeating, but can become a coping mechanism for other things and easily turns into habitual behavior. Most clients who purge by vomiting want to stop, but it is difficult for them to accept that the behavior is usually part in a chain of problematic eating. Although this is not true for everyone, the chain often looks like this: restricting, bingeing, vomiting. It makes sense that a good way to stop vomiting is to stop bingeing, and a good way to stop bingeing is to stop restricting. Even though this is true and information on stopping those behaviors is provided earlier in this key, we often will try to focus on stopping the vomiting as the first intervention for many reasons.
If you focus on bingeing as the behavior to stop the chain, but then fail to stop a binge, you can find yourself saying, “I have to purge because I binged.” Of course it’s best not to binge but if you do, our response is, “Don’t allow yourself to purge.” In this way vomiting is the real target. No matter what, don’t vomit.
Another reason we start with targeting purging is that to target restricting or bingeing as the first step puts you in vague territory because both are a bit difficult to define. There is a wide range of what people consider an appropriate amount of food. Restricting for one person can feel like bingeing to another. Vomiting, on the other hand, is easy to define, and a very specific behavior to target. There is no appropriate amount of “vomiting.” It is a very specific and easy behavior to measure: you vomited or you did not.
Finally, not all vomiting happens as a result of bingeing. Sometimes a normal amount of food or eating a “forbidden” food, like dessert, will cause someone to vomit. Sometimes people vomit to “get rid of feelings.” Therefore, for all the reasons stated, we often encourage clients to work on reducing or stopping their vomiting behavior first.
Exploring some of the negative consequences of vomiting might also help you stop. Your body reacts to vomiting by lowering your metabolism because by purging your food, you are restricting the calories your body actually digests. Vomiting is also harmful on the rest of your body. The most common effects include: dehydration, tooth enamel decay, cavities, gum disease and eventual loss of teeth, swollen parotid glands resulting in swelling of the face, and negative changes to skin, hair, nails, and even your bones. More seriously, vomiting can cause rupture of the esophagus (Barrett’s esophagus), where the lining of the esophagus is damaged by stomach acid, and tears in the mucosal lining called Mallory Weiss Syndrome, all of which can be serious and even fatal. Other serious side effects are electrolyte and mineral disturbances, which can damage the heart and cause heart failure and death. If you are reading this and thinking these things won’t happen to you, you are very wrong. These serious side effects are real possibilities, and the longer you continue the behavior, the greater the risk. There is no way to predict when these symptoms will occur. In our experience, most people seem fine—until one day they aren’t. Doris and Tom Smeltzer’s daughter Andrea died in her bed only one year after she was diagnosed with bulimia. In their powerful book, Andrea’s Voice (2006) they share Andrea’s journals, and help bring home the message that you can be OK one day and then, with no warning, your eating disorder can take your life.
Laxative Abuse
Many people with eating disorders take laxatives as an alternative form of purging. Laxatives are hard on your bowels and your body and you can easily become physically dependent on them. If you are taking laxatives to “lose weight” or avoid weight gain, you are putting yourself at risk and doing something that will never work out for you in the long run. Once you know the facts, you will see that taking laxatives for weight control makes no sense. The food you eat enters your stomach where it is broken down, and then goes into the small intestine where carbohydrates, fat, protein, vitamins, and minerals are absorbed. Whatever is left, usually bulk fiber or other waste, then enters into the large intestine as fecal matter. The main purpose of the large intestine is to reabsorb the water from the waste to make it more solid. The purpose of taking a laxative is to stimulate the large intestine to empty, therefore since most of the calories have already been absorbed in the small intestine the “weight loss” you experience, after spending all day on the toilet, is mostly water, not real body mass weight loss. Therefore, taking laxatives will cause your body to lose fluid, but will be followed by periods of water retention and cause bloating, making you feel even worse, perhaps causing you to take more laxatives, and thus creating a vicious cycle.
Sometimes knowing the long-term ineffectiveness and dangerous consequences of laxative abuse is enough to help people stop. Here are the problems you will encounter if you use laxatives:
• Chronic constipation (due to dependency on laxatives)
• Severe abdominal pain: cramping, bloating, and gas
• Dehydration
• Nausea
• Loss of rectal function: losing control of bowels (unplanned and pretty awful)
• Electrolyte disturbance: causes heart arrhythmia and heart attack
• Complete loss of bowel function
• Partial or full colectomy
Many of our clients still have a hard time stopping laxative abuse even when they know the potential dangers and their ineffectiveness. Like them, you might still like feeling thinner after using laxatives. You may also be afraid of, or have previously experienced, constipation, rebound edema, and “weight gain” when trying to stop. These are temporary side effects but they can be managed and eventually will subside. It is important to note that medical risks associated with chronic laxative use get worse over time, so if you don’t stop soon enough some of the damage could be permanent. We have seen clients who lost all bowel function and would soil their clothes and their beds spontaneously, and others who had to get partial or total colostomies and live with a surgically attached bag to collect all bowel evacuation. All of this was due to laxative abuse.
If you have used laxatives regularly, expect to experience a “withdrawal” period that is very uncomfortable until your body relearns how to function on its own. Try to begin to taper off of laxatives, reducing the amount you take gradually. Our clients have found that it helps to put your feet up during the day to reduce edema. Taking a warm bath can also help with edema, and eating high-protein foods may be helpful as well. In some instances, supplementing with non-laxative stool softeners, mineral oil, or fiber can help, but expect an initial period of physical and psychological discomfort. We highly recommend you seek help from a physician if you are trying to wean off of laxatives. Costin (2007a) discusses laxative abuse in more detail in her chapter on “Medical Assessment and Management.”
Diuretics
Diuretics are another illogical and ineffective method of controlling weight. The purpose of diuretics is to reduce water retention in the body. Taking diuretics when your body does not need them causes dehydration and electrolyte imbalances, and can result in hospitalization and death. Persisting in the use of diuretics actually creates fluid retention, which can last even after the diuretics are discontinued.
Enemas
Occasionally we have had clients who have used enemas to lose weight. Let us be clear, the only use for an enema is to clean the colon of fecal matter. Any weight loss is due to getting rid of waste matter and you are better off getting rid of it the natural way! You might lose the ability to do so, if you use enemas. If you have severe constipation or a medical condition that you think might require an enema, see a doctor.
Recovery-sabotaging behaviors
There are several other behaviors that you may be engaging in that contribute to your eating disorder that are not as obvious or overt as the ones we just described. If you have an eating disorder, you need to look at all of your “recovery-sabotaging behaviors.” In this section we explore a few of the sabotaging behaviors that we see most often. Hopefully, this information will help you think differently about what you are doing, offer useful ideas from others who have changed these behaviors, or help you discover a new idea or two about how to make a change. A three-step guide for changing behaviors is provided, along with some examples, to help you see what it looks like to work on a behavior change. See if the following list includes some familiar behaviors:
• Compulsive exercise
• Counting calories, reading food labels, measuring or weighing your food
• Food rituals (cutting food into bits, chewing excessively, spitting out food, eating on small dishes, etc.)
• Comparing yourself to others either in real life or in magazines and on television
• Body checking and measuring
• Keeping clothes that fit only when you are underweight to inspire you to eat less
• Fasting, cleanses, detox diets, diet pills
There are many recovery-sabotaging behaviors that might be part of your eating disorder but aren’t on our list. It is important for you to identify, explore, and work on any behaviors that keep you in an eating disorder mindset or interfere with your progress. You might find yourself justifying some of your behaviors because people without eating disorders engage in them. Don’t fool yourself. If you have an eating disorder, all of the behaviors on our list, plus any others you have, need to be honestly evaluated. You will have to let go of or change these behaviors in order to truly get well and stay well.
Compulsive Exercise
One of the most commonly “justified” behaviors is compulsive exercise. It is easy to defend a behavior that we are all told is good for us and even critical for optimum health, but too much of a good thing is bad. Carolyn once coined the statement, “Give a person with an eating disorder anything and they figure out how to abuse themselves with it.” This statement is certainly true for those who compulsively exercise.
Many people think that compulsive exercising to get rid of calories is a form of purging, but technically, compulsive exercise is considered a non-purging “compensatory behavior.” In eating disorder terminology, a compensatory behavior is a behavior used to try to “compensate” for bingeing. Other than purging, the two main ways people with bulimia try to compensate for bingeing is fasting and compulsive exercise. Bulimia is not the only eating disorder where compulsive exercise shows up. Even those who do not binge may use excessive exercise to avoid weight gain or enhance weight loss. In fact some people develop an exercise addiction without having other eating disorder features. The question is when does this good thing go bad? If you are a compulsive exerciser, you are over-involved in exercise to the point where, instead of choosing to participate in an exercise activity, you feel obligated to do it and can’t stop. Essentially you have become “addicted” to exercise and continue your activity level even despite adverse consequences. Pinning down what is a healthy amount of exercise and what is compulsive or extreme isn’t always easy or agreed upon. Basically you are a compulsive exerciser if you engage in excessive and purposeless physical activity that goes beyond any usual training regimen and ends up being a detriment rather than an asset to your health and well-being. Maine (2000, pg. 253) provided a list of behaviors that can help you identify whether or not exercise is a problem for you:
Signs of Compulsive Exercise*
• You judge a day as “good” or “bad” based on how much you exercised.
• You base your self-worth on how much you exercise.
• You never take a break from exercise, no matter how you feel or how inconvenient it is.
• You exercise even though you are injured.
• You arrange work and social obligations around exercise.
• You cancel family or social engagements to exercise.
• You become angry, anxious, or agitated when something interferes with your exercise.
• You sometimes wish you could stop but are unable to.
• You know that others are worried about how much you exercise, but you don’t listen to them.
• You always have to do more (laps, miles, weights) and are rarely feel satisfied with what you have done.
• You exercise to compensate for overeating (or just eating).
Writing Assignment:
Assessing Your Exercise
Read through the list, “Signs of a Compulsive Exerciser,” and write down in your journal any item on the list that relates to you. If you experience any of the things on this list then exercise is a problem for you and will get in the way of your recovery. Do others tell you that you have a problem with exercise? Do you agree you have a problem with exercise? What, if anything, have you tried to do about this problem? Are you aware of any negative consequences of your exercise behavior?
Problems With Too Much Exercise
Over exercising is always bad for your body. Not giving your body enough rest and not giving it time to repair itself from exercise is damaging. Restricting your food and exercising too much is a very bad combination. If your body does not have energy to exercise based on food intake, it must create blood glucose for the brain and working muscles by breaking down protein from your muscles to use as energy. Less muscle means a lower metabolism. Spending all of your body’s energy (calories) for exercise when some of it needs to go to supporting other systems, like organ and brain function, or hair growth and healthy bone development, is dangerous. In a healthy person, bones are constantly being broken down and rebuilt as part of a dynamic process, but when there is not enough energy coming in, the bones will become weak and break down under the stress of impact, causing stress fractures, broken bones, and other injuries. Your hormone levels may also play an important part in the process. Low hormone levels are associated with bone density problems. Too much exercise and too little food results in low hormone levels. Many compulsive exercisers stop menstruating even if at a normal body weight. The body shuts down functions when it perceives it is not getting the amount of fuel necessary to sustain the amount of exercise being undertaken. If you are not menstruating, it is a clear sign your body is not in balance and is experiencing stress. It most likely means you are not taking in enough calories or do not have enough body fat, and if you are exercising this is contributing to the problem. It is important to note that even though hormone replacement has been shown to help postmenopausal females with bone density problems, taking hormones in order to menstruate and try to alleviate or prevent osteoporosis or bone loss has not been effective for people with eating disorders. Furthermore, clients mistake the artificial period caused by hormone replacement (birth control pills) as a sign they are healthy and menstruating normally when this is not the case. While you are taking birth control pills your hormone levels are kept up artificially and then drop when you switch to the “spacer” or sugar pills, causing your uterus to bleed. If you are taking hormones you have no way of knowing whether or not your body is capable of doing this on its own. We recommend our clients get a bone density test. Even if your eating and/or exercise problems have not been going on for very long, a baseline bone density test is important for comparison at a later date.
We are unable to predict who will become addicted to exercise to the point of being out of control, but studies have shown that if you are not eating enough, exercising can become quickly addictive. The combination of restricted eating and running is particularly problematic. Rats eating a normal diet will periodically exercise if running wheels are provided in their cage. Deprive these same rats of food and they will become addicted to running, and even run themselves to death! We also know that running is a common precursor to relapse. We advise our eating disorder clients who run to find an alternative exercise, at least in the beginning of recovery and for a period after weight restoration or other stabilization. Some compulsive exercisers may have to stop running forever and find a new exercise. Other clients may have to stop all exercising, at least for a period of time.
Helping You Normalize Your Exercise
If you are a compulsive exerciser, you may have some unknown biological predisposition that made you more prone to this, but you are also likely to have psychological reasons as well. If you examine yourself closely you will probably find that you use exercise to deal with feelings, to soothe yourself to feeling in control, and maintain your self-esteem. You are most likely a task-oriented, high-achieving individual with a tendency to be dissatisfied with yourself unless you are consistently setting and achieving new goals. You also probably pride yourself on being able to push yourself and use mind over matter. You most likely value self-discipline and self-sacrifice. You will need to learn that true willpower and self-discipline means cutting back on, or cutting out, exercise! Think about it, what is harder for you, to exercise or take a day of rest?
You will also find that your emotional investment in exercise becomes more intense and significant than work, family, and relationships. In fact, we have discovered that compulsive exercise seems to be associated with issues of intimacy. Do you turn to exercise when troubled or under stress, rather than seeking help from others? Do people who love you complain about your exercise interfering with the relationship? If you are a compulsive exerciser, look closely at the issue of intimacy and your relationships. Many of our clients who exercise compulsively use it as a defense against a fear of getting close to others. They have a hard time being vulnerable with or depending on people. What will help is to work on your relationships. The next key will discuss turning to others for support.
Just as it is important to develop a healthy and balanced food plan, it is also important to have a healthy, balanced and fun exercise plan. Think about exercise as a way to be active and enjoy yourself, instead of as a way to “burn calories.” Find things you love to do like dancing, hiking, or riding a bike. Find friends to be active with; together you can shoot hoops, play volleyball, rollerblade, or walk on the beach. Some people find they need to stop certain forms of exercise which seem to trigger eating disorder thoughts and compulsive behaviors (like running or spinning), but can healthfully continue with activities such as yoga, Pilates, or walking with friends. The process is just as important as the goal.
Carolyn: I went to my first yoga class during my recovery from anorexia and exercise addiction. I had sustained several stress fractures from compulsively running and was forced to look for a different form of exercise. I decided to try yoga and I cried during the first class. At that point my exercise addiction was very strong and I thought, “This is not exercise. This is too easy and will never keep me in shape.” I decided to keep going and give yoga a chance since I did not like to swim, I did not have a bike, and spinning just did not seem interesting to me. Yoga not only kept me and keeps me fit, it changed my life in other important ways, which will be discussed in Key 8.
There are things you can do to begin the process of letting go of your compulsion to exercise. The following list of possible exercise goals is adapted from a chapter in Costin (2007a).
• Decrease the length of time spent exercising (you may need to do this gradually, in increments of time).
• Instead of running, which has no official start and stop time, go to a class that lasts for a set amount of time.
• Change the type of exercise you do for example, if you run, substitute a day of yoga or weight training.
• Decrease the number of days you exercise.
• Set a weight goal that is necessary in order to continue exercise or increase exercise.
• Possibly stop exercise altogether for a period of time (sometimes this is necessary for health reasons or to break the addictive cycle). (pg. 57)**
Writing Assignment:
Fit or Fanatic?
Make a list of any possible signs that you might have a problem with exercise. Include things that other people have said about your exercise, and your moods and behavior when you can’t exercise. Ask someone close to you what they truly feel about your exercise behaviors, letting them know you will just listen to what they say without getting defensive. Refer to the list of possible new exercise goals. Come up with a goal for yourself that involves stopping, reducing, or changing an exercise habit. You will learn more about how to do this later.
If you compulsively exercise and cannot reduce your level of activity, or your health is already an issue, you might need to stop exercising altogether until you are healthier mentally and physically. Most people in this category have to be told by a physician to stop, be kicked off a sports team, or even admitted to a treatment program to get their exercise under control. It is advisable to seek the assistance of a professional in navigating this process. Please refer to the Resources section if you suspect or know compulsive exercise is a big issue for you, and you need more help and information than is provided here.
Counting Calories, Fat Grams, Carbohydrates, Etc.
Counting calories, fat grams, or anything else may start out making you feel safe or in control, but over time it becomes an obsession that you can’t stop. The behavior takes on a life of its own, with a habitual quality that overrides any rational intent that may have been present initially. When we present the idea of stopping the counting, most people admit that they wish they could, but they think it is impossible. How can you get information out of your head? How can you stop adding up the calories, when it seems to just happen automatically? We both remember having those same concerns, yet neither of us count calories or anything else today, automatically or otherwise. The first step is to stop looking at labels and stop looking up the calories or fat grams in the foods you are eating. And, do not write any numbers down! In the beginning this might not seem like much, because you may continue to add the numbers up in your head, but over time as you add new foods to your diet and don’t know the calories, you will not have enough information to add everything up. If you eat even one new food and don’t know how many calories are in it, you won’t know your total daily calories, and the system that is holding your brain hostage will start to break down. Of course there will be foods for which you already know the calorie count, but there are always new foods to try that give you the opportunity to free yourself from this mind trap. Trust us, this works. If you follow the conscious eating guidelines, you do not need to count calories.
Food Rituals
Food rituals differ from food rules, but they are just as resistant to change and will keep you stuck. Food rituals are behaviors you engage in routinely that make you “feel safer” about eating or while eating food. Examples of common food rituals include: eating the exact same food prepared the same way, eating at the same time every day, cutting up food into tiny bites, eating food only in a certain order, or always eating in the same or a certain size dish. You may not think these behaviors are a problem as long as you are eating your food, but the truth is that they keep you stuck in a life dependent on these rituals. Your brain will be resistant to changing, but as soon as you start to break the ritual, it will start to loosen up slightly, and each subsequent mealtime or snack will be easier. Imagine a big hill of dirt with a marble on the top. It could roll down the hill on any side, but if you push the marble down the same path many days in a row, a deep groove will develop, and soon the marble will easily go down that path. The brain works in a similar way; therefore, when you break a food ritual, it is like pushing the marble down the new path. Each time you do that, you will be making a different choice and giving yourself more freedom. While working on letting go of food rituals, make the commitment to not create new ones. It is very hard to break rituals once they have been established, so preventing any new ones from taking root is a great way to help yourself.
Comparing
Comparing yourself to others or people in magazines or on television is problematic, and a set-up for feeling bad about yourself. As with most sabotaging behaviors, clients tell us they compare to try to reassure themselves that they are OK—that is, thin enough—or to get inspired to “do better.” There are several reasons why this method of reassurance or inspiration will never work out well for you. Aside from the fact that you have a distorted body image (even if you think you are the one person who has an eating disorder who doesn’t), you also probably aren’t comparing yourself to all people you come across. Instead, you only compare yourself to people who seem thinner, prettier, or in better shape than you. When at the movies, do you compare yourself to everyone you see in the lobby or theater (the real people) or do you compare yourself to the stars in the movie? When at the gym, do you compare yourself to the personal trainers, or the other gym members? You will always be able to find someone who is thinner, prettier, richer, or smarter, and you will always be able to find someone who has less of everything than you do, too. It’s sad when we hear clients judging and ranking themselves and others as less than, or better than. Comparing body size with such a narrow range of what is considered attractive is a learned cultural behavior and you need to work hard to “unlearn” it. We guarantee you will be so much happier if you stop comparing yourself to others and learn to accept and value yourself for who you are inside. However, if you are going to compare yourself to others, at least be fair. Don’t compare yourself to Photoshopped models in a magazine, or your yoga teacher. Compare yourself to all the people at the grocery store, or every third person you see on the street. This little rhyme might help you: If you compare, you will despair, so at least be fair.
Writing Assignment:
your Recovery-sabotaging behaviors
Review the list of recovery-sabotaging behaviors. Write down any behaviors you engage in from the list and add anything else you can think of. The goal is to know exactly which sabotaging behaviors are keeping you focused on your weight or appearance, or otherwise keeping you stuck in your eating disorder.
Making Things Manageable
It can be overwhelming to even think about all the goals you have to set and things you have to accomplish to get better. It helps to break this process down into small manageable steps. You might find it helpful to use our “Weekly Contract” form (see the Appendix) where you set specific goals for each week under several categories. Using the form will guide you into setting short-term manageable goals in the area of nutrition, behaviors, exercise, and relationships. Clients have found that the weekly contract form helps them to get specific about what they will be working on each week in these different areas and it keeps tasks manageable. You may find it helps keep you accountable for following through on your goals for behavior change. If you are in therapy you can take this to your therapist and work on setting goals together.
Resistance to Change is Normal
Letting go of or changing your behaviors is difficult, because most likely you have convinced yourself that they are keeping you in line, sane, or safe. Don’t be surprised if you have an immediate and strong reaction to the very idea of letting go of your behaviors—many clients do. We often hear things like, “Oh, I have to do that,” “I’ve always been this way,” “That won’t work for me,” and “I’ll freak out if I stop.” These statements are built on false beliefs regarding what will happen if you change, or a belief that you do not have it in you to change. You may think that you do not have the qualities or skills that change will require, such as tolerance and patience. You might believe that people either have these qualities or they don’t—which is a classic example of “black and white” thinking. The truth is that nobody is born with these skills. Behavior change skills increase with practice. People who have these skills have developed them. You can develop them, too.
A Three-Step Guide for Changing a Behavior
Hopefully, by now you have a sense of what behaviors you need to work on and what distorted thoughts and perceptions might be in the way of your making a change. We provide a three-step process you can use to change any behaviors you decide to work on.
Step 1: Raising awareness by tracking the behavior
The first thing you need to do in order to change is to raise your awareness about the behavior. For a week, notice and keep track of the behavior and how often, when, where, how, and why you feel a certain way when you engage in the behavior. The following is an example of the process of modifying body checking behavior by a client whom we will call Gina. Gina uses body-checking behavior in an attempt to control and manage her feelings, and to make decisions about food. Gina was asked to keep a journal of all of her body checking behaviors in order to increase her awareness of how often she did this behavior and how she felt before and after. Sometimes just an increase in awareness is enough to facilitate change, but awareness is always the first step and a crucial one. The following is an excerpt from Gina’s journal.
| Monday | |
| 7:00 | body checked in full-length mirror, checked to see if I could see bones (relieved). |
| 8:00 | after getting dressed, made sure that belt fit on last hole (relieved). |
| 8:15 | body checked in mirror to see if clothes made me look fat; changed clothes three times (anxious, confused). |
| 8:45 | body checked in window near bus stop while waiting for bus. Didn’t like how I looked like in these pants (self-conscious, angry). |
| 9:15 | body checked in bathroom at work. Felt better about this mirror (relieved). |
| 12:00 | body checked in window to see if stomach is fat but it did not look fat (anxious), don’t want to eat lunch now that I saw that. Walked around instead and stomach feels fatter now (relieved). |
| 5:00 | body checked in the bank window after work (frustrated). |
| 6:00 | changed clothes at home and checked but everything made me look fat, put on jeans and tight belt to help me not eat too much (cried). |
| 7:00 | ate very little, noticed that last belt hole seems tighter than last time (anxious, distracted, irritable). |
| 8:00 | watching TV, I feel my hip bones and make sure my clavicle is sticking out (somewhat relieved). |
| 10:00 | body checked, especially stomach in mirror before going to bed. (sad, frustrated). It still was not fat so I decided to do better tomorrow. |
Notice how Gina’s feelings go from relieved and comforted to anxious, irritable, and angry based on perceived changes in her body. Logically, Gina’s body does not change that much in one day, but her “body image” obviously does. Initially Gina was very resistant to stopping her body checking. She thought her behaviors were helping her feel less anxious because they were meant to reassure her that her body is OK and she wasn’t changing. In reality, her body checking often made her feel bad. Even when she was momentarily comforted by the checking behavior, she was still driven to check again and again to be sure. If anxious and distressed by what she saw, she was driven to continue checking in hopes of finding something to relieve her anxiety; or she was driven to alter her food intake to ensure a better experience next time she checked. Gina’s behaviors around body checking will make it nearly impossible for her to make any changes in her relationship to food. Her body image is distorted and is taking up an enormous amount of time and energy and getting in the way of her recovery. Although Gina was at first convinced that her body checking was helping her, once she kept a log and gained awareness about the behavior, and her feelings around it she saw that it was problematic.
Step 2: Making a plan and taking small steps
When someone is willing to work on changing a behavior, we begin by setting some guidelines or parameters aimed at decreasing the situations that trigger or provoke the uncomfortable feelings and behaviors. In Gina’s case, she was asked to cover the full-length mirror in her bedroom, leaving only a small mirror available so she could see her face and neck. Instead of body checking anytime she has the urge, she made agreements regarding how many times she would body check in a day—for example, once in the morning after getting dressed, once around noon, and once again at night before going to bed. She also came up with alternative things she would do instead of body checking, such as call a friend or listen to a song. She maintained a log to keep track of, and gradually reduce, the amount of times she did body checks until she was able to stop the behavior. Gina was also asked to get rid of her belt she used for body checking. Gina agreed to consciously avoid looking into store windows as much as possible and find a way to reward herself for not looking. All of these suggestions helped Gina reduce and then eliminate body checking.
Behaviors like body checking become habits that are hard to break. Stopping any habitual behavior takes a lot of intention and conscious effort. It won’t be perfect. For a while Gina caught herself looking in store windows, and that was OK, because she began to build self-awareness and perspective to notice and analyze how the behavior was affecting her. Over time, she saw that on days when she resisted her body checking behaviors, she was less moody, and more present with people. She also found that nothing drastic happened with her body when she was not checking it. After the initial anxiety and distress that is part of changing these self-sabotaging behaviors, everyone feels relieved to be free from them. The following are some examples of steps others have taken to help them with body checking or body image:
• I will get rid of my “skinny” jeans.
• I will not buy magazines that contain pictures that I know are triggering to me.
• I will remove that huge mirror that makes me feel bad and makes it harder to eat.
• I will buy some loose clothes like yoga pants that don’t have a fixed size.
• I will no longer write down my calories.
• I will journal or call someone before carrying out any food rituals.
“I used to think body checking helped me stay thin. Although it took a while, once I stopped, I realized that it was the constant checking that actually made me so miserable—way more miserable than accepting my body.”
—CR
“Cleaning my closet was a more invasive task than just getting rid of clothing. My clothes represented a lifetime of armor used to create a perfect and beautiful exterior to cover a dark, empty, twisted interior of lies, torture, and sadness. Each piece of clothing held a story related to weight, an event where I had to please people in my life, a time when bulimia had wreaked havoc on my system. I knew I needed to get rid of these clothes to protect myself and to begin my new life. I boxed the items and dropped them off at the nearest Goodwill hoping they would serve someone else in need of a fresh start.”
—KM
Writing Assignment:
Taking a Small Step
What small steps can you take to cut down on or avoid a behavior that is interfering with your recovery? Try to list things that you can measure: for example, cover one mirror, or give away clothes that you use to check weight or shape, only cut your food into half of the pieces you do now. Choose at least one action to begin with, and make a commitment to taking that step.
Step 3: Noticing the difference
The final step is analyzing how things are different now that you have made a change. Many people are surprised that just a small difference in thought and behavior can produce a big change in feeling. Remember that at first, most change feels worse before it gets better. The following writing assignment will help you analyze any changes. Gina felt sure her behaviors were decreasing her anxiety, and when she first stopped them, her anxiety did increase. It was only after some time away from the behaviors that she could see that her anxiety actually decreased.
Writing Assignment: analyzing your experience
Write about how you feel when you are engaging in the behavior you are working on trying to stop, and how you feel when you are able to stop yourself. If you are able to stop your behavior for a few days, do your feelings change? Notice again in a week. You might even be able to write about what it feels like in your life to be letting go of the behavior altogether. Remember that at first you will feel very anxious not following through on your urges to do the behavior. If you give it time, you will start to see that the urges, and therefore the anxiety, both decrease, which make stopping the behavior easier.
Rewards and Consequences
Sometimes we ask clients to come up with incentives for making behavior changes. We often have clients make a list of the advantages and disadvantages of changing the behavior. Another technique is to come up with rewards or consequences that work for you. For example, if you don’t weigh yourself for a week, treat yourself to a pedicure, or something else that feels rewarding. Devising consequences can help too but also be risky if you aren’t creative about it, or if you are too punitive. Consider using this unusual consequences system some of our clients have found helpful. Think of something that you really do not want to do or that would go against your beliefs. Some good examples are: donating money to a cause you do NOT believe in, agreeing to wash your spouse’s car, or cleaning your parent’s house or garage. One favorite method came from a client who was a professional surfer who gave up her surfboards until she was abstinent from purging for three days in a row. This was the most motivation she had shown. Only you can decide what works best, but we have found that as long as you are the one coming up with them, rewards and consequences are useful in helping with behavioral change.
Progress, not Perfection
If you are like us and most of our clients, the process of change can seem quite slow, frustrating, or out of reach. You may think you are not getting anywhere, it’s not worth it, or you just can’t do it. Be careful not to criticize or berate yourself for lack of progress. Just imagine if you used this technique with someone else who was trying to change. Besides, if criticizing yourself worked, you would surely be well by now. One way to think about the process is to say that you are working toward something. You are learning to accept yourself where you are at this moment, are doing the best that you can, and will continue working toward change. This will involve having compassion for yourself.
Compassion and Change
In order to let go of your obsessive, destructive, or sabotaging behaviors, you will need to have compassion for yourself. The idea of having compassion may feel wrong and unacceptable. You might think compassion is self-indulgent, or believe that compassion for yourself or from others is permission not to change. What you might not be realizing is that nurturing behaviors—acceptance, compassion, forgiveness, and empathy—need to be in balance with rules, expectations, and limits. If either side is too dominant, unhappiness follows, and success remains out of reach. Learning the skills of self-compassion are just as important as learning how to set goal or limits and follow rules.
Compassion Involves Acceptance
Many people believe that they don’t deserve compassion, or that allowing self-compassion means they are powerless, indulgent, or pitiful. When we challenge our clients saying that this belief seems a bit harsh, most reply that it feels “realistic”—which shows they don’t understand the nature of compassion. This demonstrates how critical and negative their thinking has become. Self-compassion means accepting where you currently are and understanding how you came to this place in your life. Compassion is about learning to see the problems that you have in the context of your whole life. What we mean is taking into consideration where you came from, your understanding of the world, and the resources you had available, and accepting that you have done the best that you could. The best evidence for this way of thinking is simply that if you could have done better, you would have. You weren’t able to take care of yourself any better than you did, but that does not mean you can’t change now.
Some Final Thoughts
Changing the myriad of behaviors that contribute to your eating disorder or interfere with your recovery can feel insurmountable. In fact, you are most likely thinking, “If I could do that, I would be recovered.” That is exactly what we are talking about here. We did it, thousands of others have done it, and you can do it too! Leaving behind your eating disorder behaviors can feel unsettling and unsafe, but fear is never a good reason to stay with something harmful and oppressive. The change will feel uncomfortable at first—we always remind our clients that it gets worse before it gets better—but going through the discomfort is the only way it will become more comfortable eventually.
Letting go of habits that you worked hard to establish, such as counting calories or exercising, can feel like all of your hard work and sacrifice was a waste of time. It is hard to admit that many good years were wasted on things that didn’t really deliver what seemed promised. You might be tempted to hang on and just try a little harder or maybe a little longer to reach those old goals, but at some point you have to come to terms with the truth about what the behaviors are doing for you versus what they are taking from you. Your eating disorder will never really make you more lovable, a better person, or invulnerable to pain. As difficult as this realization is, it opens the door for creating a better life. Once you know the truth, you can never go back to denial or the belief that what you were doing was going to work. The great thing is that on the other side of letting go of your eating disorder is creating and holding onto that which can actually provide you with the love, self-worth, and connection you were seeking all along. We are talking about relationships and we turn our attention to that in our next key.
* Reprinted with permission.
** Reproduced with permission of the McGraw-Hill Companies.