ONE

The Toxic Triangle

For Jill, a thirty-year-old account executive at a large bank, there were two distinct parts to each week. When she was “on-duty,” from Monday morning to Thursday night, she tightly controlled everything she ate and drank. Breakfast, if she ate it at all, was just a piece of toast with a bit of jam (no butter) and lots of black coffee. Lunch was always a small, pristine salad with no-cal dressing. Dinner was as sparse and low-fat as she could make it and still call it dinner—usually just a frozen diet entree. And alcohol never passed her lips while on-duty, no matter how much she wanted it. Even if she went out with clients to a nice restaurant, she ordered sparkling water, adopting an air of casual self-righteousness about her abstinence from alcohol.

By Thursday night, however, Jill’s cravings for food and drink were powerful. The sense of control and superiority that she gained from avoiding food and alcohol all week were overcome by feelings of frustration, longing, and defeat. Why wasn’t she more fulfilled in her job? Could she really handle the stresses of her position? When was she ever going to find a man she could really fall in love with? And why did she have to deprive herself all the time just to stay skinny and put in long hours at work?

The second phase of Jill’s week, when she was “off-duty,” usually began slowly, on Thursday night. She’d come home from work, feeling tired but agitated, desperately wanting a drink. “Just one drink,” she told herself, “I deserve it the way this week has gone.” She’d pour herself a glass of sauvignon blanc and sip it slowly while she sorted through mail and microwaved her dinner. “Oh damn,” she’d say, when the first glass was drained. “I’m not ready to eat yet.” Then she’d pour another glass, vowing that two was going to be her max, for sure. By the time dinner was ready and the second glass was empty, Jill was ravenous. And a diet entree out of the microwave was not what she wanted. She put the entree in the fridge and brought out the chips. “I need some starch to soak up this wine,” she’d tell herself. Jill then took her chips, and another glass of wine, and flopped down on the couch to watch TV. It felt so good, such a relief, to let go and do what her mind and her body seemed to want to do—eat and drink. Jill spent the rest of Thursday night snacking on junk food and leftovers and drinking more wine, until she collapsed into bed around midnight.

Of course, she felt terrible the next morning. But Fridays were usually absent of meetings, so she could hole up in her office, popping Advil while kicking herself for her indulgences the night before.

By Friday night, however, she was ready to party. It was the weekend, she was off-duty, and she wasn’t going to waste a minute of it. From Friday’s happy hour with workmates through a party on Saturday night, into Sunday’s get-together with friends to watch football, Jill raged. She ate anything she wanted to—hamburgers and fries, fettuccine Alfredo, everything that she forbade herself while she was on-duty during the week. And she drank. Hard liquor, beer, wine, whatever was being served.

Come Monday morning, Jill was back “on-duty,” wracked with self-loathing and shame. Why did she do this to her body? She had to stop, she had to be better about controlling her eating and drinking. She felt dirty, defective, diseased.

JILL ISN’T DISEASED but she has entered a perilous zone where millions of women every year find themselves trapped. This toxic triangle is the intersection of three troubles that affect women at alarming rates: yo-yo eating, heavy drinking, and self-criticism and despair. Each of these afflictions does damage on its own. Binge eating and self-starvation ravage a woman’s body, increasing her risk of a number of serious diseases. Heavy drinking can wreck a woman’s relationships, her career, and her vital organs. Low self-esteem, sadness, and lethargy can stop us in our tracks, preventing us from claiming all that life can provide.

Millions of women play at the edges of depression, eating disorders, and alcohol abuse. They’ll take a few steps into the realm of eating disorders, calling their self-deprivation a diet or throwing up a meal every now and then because it “didn’t settle right” with them. They’ll experiment with how much they can drink before they begin to slur their words. They’ll allow themselves a day or two in bed, wallowing in angry thoughts about themselves and others, or just shutting down and not thinking about anything.

These little forays can be insidious. At first, we step over the line just a bit, and pull back relatively quickly. But we are lured to return. The symptoms can feel good—it’s such a relief to let go and binge or give up and curl into a little ball. After a while, we find ourselves inside the danger zone for eating disorders, or alcohol abuse, or depression, only this time more often, and for longer. Our symptoms, which were once mild and occasional, have become moderate and more frequent.

More dangerous than either of these discrete realms, however, is their intersection—the toxic triangle. Depressive symptoms, crazy eating habits, and heavy drinking rarely happen independently. As many as 80 percent of women who are drawn into one of these afflictions find themselves crossing the line into at least one of the others. The vortex where all three intersect is a whirling mass of confusing and self-damaging actions and feelings. A woman stuck in the toxic triangle can shift from immobilizing sadness to strength gained from controlling her eating, to shame and frustration from losing that control, and then to the relief of anesthetizing herself through alcohol or binge eating. Her family members and friends may try to help, though the target for their interventions keeps shifting. One day she won’t get out of bed, can’t get to work, and her voice is pure misery. The next day she seems happier, but she might be drinking heavily. Later, she swears she’s stopped drinking, but she’s losing (or gaining) weight rapidly.

Why Don’t We Recognize the Toxic Triangle?

Although the toxic triangle is both poisonous and prevalent in women’s lives, it has been largely ignored both by the lay public and by mental health professionals. One reason is the expectation that mild or moderate symptoms of depression, eating disorders, or alcohol abuse are “typical” for women today, and not terribly dangerous.

We comfort ourselves by saying things like, “Sure I drink, but I’m not a heavy drinker,” or “Every woman I know goes on and off diets all the time—I’m no different from them,” or “I’m not happy with how my life is going, but I’m not depressed—depression is an illness that you have to take Prozac to get over.”

A critically important finding in my own research and other recent studies is that moderate, or subclinical, forms of eating disorders, alcohol abuse, and depression are each in themselves highly toxic and dangerous. These subclinical symptoms chip away at a woman’s physical and mental health, harm her ability to function in everyday life, and set her up for more serious symptoms down the road.

Another reason that the toxic triangle has gotten too little attention is that it’s just easier to focus on one problem at a time. Scientists tend to study depression or eating disorders or alcoholism, but rarely do they study two or more disorders at a time. We also like to think linearly—that one thing causes another, and then another, and so on. So if a person is suffering from two or more problems, we tend to think that one must have caused the other. In particular, mental health professionals and laypeople often assume that if a woman is both depressed and binge eating or binge drinking, then the depression must be causing her to binge. This is sometimes the case, but not always. Often the binge eating or binge drinking comes before the depression. And relieving a woman’s depression through treatment doesn’t automatically stop her from bingeing on food or alcohol.

The toxic triangle is not as simple as one thing causing another. It is a place where symptoms of depression, eating disorders, and alcohol abuse play off one another and enhance one another. There are many pathways into the toxic triangle. Some women enter through the path of depression; others through binge eating and self-deprivation; still others through alcohol. Once they are in the toxic triangle, women can find it very difficult to escape.

Taking It upon Ourselves: Women’s Tendency toward Self-Focused Coping

At the root of women’s vulnerability to the toxic triangle is their tendency to respond to stress with what I call self-focused coping. When women are faced with a difficult situation, they turn inward to control or change themselves rather than focusing outward on the environment and individuals that need to change. Whereas men tend to externalize stress—blaming other people for their negative feelings and difficult circumstances—women tend to internalize it, holding it in their bodies and minds. When something bad happens to women, they analyze everything about the problem—how they feel about it, why it came about, and all its meanings and ramifications for themselves and their loved ones. Women are acutely aware of how their body feels in reaction to a problem—tension, agitation, lethargy, and a sense of being out of control in reaction to a problem. As a result, they are especially likely to do something to change how their body feels.

Many women do self-destructive and damaging things to overcome their feelings. They may binge eat to escape their feelings in the fleeting pleasures of excess or their favorite “forbidden foods.” They may refuse to eat, welcoming the feelings of power and control that come with self-denial. They may drink alcohol or take sedatives in an attempt to anesthetize their feelings. Or they may simply remain glued to their feelings and thoughts, rehashing things that have happened in the past, worrying about what will happen in the future, immobilized by a crushing sense of being overwhelmed.

Self-focused coping takes many forms, but each involves managing your internal self in a misguided attempt to manage external situations. Feeling that you can’t do anything about your problems at the moment, you turn inward and focus on how you feel or think about the problems themselves. Not all forms of self-focused coping are self-destructive. Employing strategies to quell your anxiety—such as deep-breathing exercises—can help you think more clearly and is a highly adaptive form of self-focused coping.

But when self-focused coping involves hurting your body in some way, or gets in the way of doing something productive to overcome your problems, it becomes dangerous and maladaptive. Indeed, it can help transport you into the toxic triangle—depression, yo-yo eating habits, and heavy drinking. Self-focused coping can lead to depression by amplifying feelings of despair and preventing you from taking action to overcome the true sources of your problems. Self-focused coping can lead to symptoms of eating disorders by causing you to focus on your control (or lack of control) over your body rather than on the ways you can change your life situation. And self-focused coping can lead to abuse of alcohol and other drugs as a way of escaping those troubling thoughts and feelings that it inspires.

Unfortunately, once a woman enters the toxic triangle, the symptoms of depression, disordered eating, and heavy drinking work in lockstep, creating a self-perpetuating syndrome that grows in intensity. Depression leads to attempts at escape, and many women achieve this through drinking or binge eating. But binge eating and drinking lead to more depression. In fact, the cycling of bingeing and drinking changes the way the body metabolizes food and alcohol. Once the cycling starts, it fuels itself, making it hard to stop.

Women can break out of the toxic triangle. This book will help you understand how the toxic triangle emerges in women’s lives and will help you use this knowledge to break free from the power it exerts over your life. Women’s self-focusing tendencies develop in part because we are attuned to our own emotional lives and the emotions and needs of others. These sensitivities can be used to acknowledge and understand the sources of our stress, and develop more effective ways of dealing with stressors. Stress need not be internalized or taken out on our bodies and minds; instead, we can learn how to use self-focusing skills to develop the kinds of solutions that strike a balance between our own values and the best interests and needs of those we care about.

The Three Pathways into the Toxic Triangle

Each of the three pathways that lead to the toxic triangle has unique characteristics that draw in its victims. To give you a sense of how each pathway looks and feels, and how each converges into an overpowering trap, I will describe them for you here.

“I JUST DON’T CARE ANYMORE”

Depression has been called “the common cold of modern times.”1 Indeed, rates of depression appear to have increased in recent generations. Researchers Myrna Weissman and the late Gerald Klerman of Columbia University examined data from several studies and determined that people born in the latter part of the twentieth century are much more likely to experience depression than those born in the early part of the century.2 Lots of different explanations for this generational effect have been offered: older people simply may not remember their periods of depression and so don’t report having experienced it, or something about our contemporary life—lack of strong family and social ties, a vacuum of common values, materialism—may be making people, particularly young people, more vulnerable to depression.

Just what is meant by depression? It’s a word that is used so casually these days, like stress, that it’s understood to mean any general feeling of malaise and psychic discomfort. But psychologists and psychiatrists have a specific set of symptoms that they place under the label of depression.

Sadness is the cardinal emotional symptom of depression. You’re blue, feel as if you’ve lost something, as if there’s a huge weight on your psychological shoulders. Some people who are depressed don’t so much feel sad but it’s more like their emotions have been sucked dry and they can’t feel anything anymore. What used to give them pleasure now just lands like a dull thud on their consciousness. They watch a favorite movie—one that used to make them smile every time they saw it—and they can’t see or hear what used to make them feel so good. They talk with a trusted friend, and instead of feeling relieved or uplifted, they feel dull and drab and lifeless. They go shopping, or go out to eat, and nothing can pique their interest. They really couldn’t care less about anything.

The physical symptoms of depression are often confusing because they can swing from one extreme to the other. When you are depressed, you may want to sleep all the time, or you may not sleep at all. You may feel tired, slowed down, heavy, and lethargic, or agitated and unable to sit still.

When you are depressed, your thoughts may be filled with themes of self-blame, guilt, and pessimism. You may feel as though you can’t think at all—your powers of concentration and attention have disappeared, along with your ability to make decisions. Writer and researcher Kay Redfield Jamison has described these feelings this way: “It seemed as though my mind has slowed down and burned out to the point of being virtually useless.”3

One in four women, at some time in her life, will experience symptoms of depression severe enough for a diagnosis of major depression, one of the most severe forms of depression.4 Milder symptoms of depression, short of such a psychiatric diagnosis, but still painful, plague most women at least occasionally. In one of my own studies, I assessed depressive symptoms in approximately 1,300 adults, half of them women, half men. These people had not sought help for depression or any other psychological problem—they were a random sample of people from all walks of life. Over a third of the women reported experiencing five or more symptoms of depression at the time of the study. Although this may seem like an astonishingly high rate of depressive symptoms, it is well in line with other studies of the general population in the United States, Europe, Australia, and New Zealand.

Women’s vulnerability to depressive symptoms seems to skyrocket in early adolescence, as psychologist Jean Twenge of San Diego State University and I showed in another recent study. Employing what is called a meta-analysis, we combined data from over 300 studies of depressive symptoms in children and adolescence to examine the emergence of depressive symptoms in girls and boys over time. We found that before about age 13, girls and boys are equally likely to have symptoms of depression, but around age 13 to 15, girls’ levels of symptoms escalate sharply, while boys’ levels remain relatively flat and even seem to peter out a bit.

While depression is the most familiar pathway into the toxic triangle, there are other ways of getting there. In women, depression rarely occurs by itself; most often, it’s accompanied by behaviors that allow a woman to escape depression for a short time, only to ultimately feed and expand the depression further.

“I SHOULDN’T HAVE EATEN THAT”

Do the following statements sound terribly familiar?

I think my stomach is too big.

I eat when I am upset.

I stuff myself with food.

I think about dieting.

I think that my hips are too big.

I feel extremely guilty after overeating.

I am terrified of gaining weight.

If I gain a pound, I worry that I will keep gaining.

I eat or drink in secrecy.

I feel fat even when others say I look thin.

I am very conscious of even small changes in my weight.

I have gone on eating binges when I felt that I could not stop.

Psychologist Peter Lewinsohn of the Oregon Research Institute and his colleagues asked a sample of 1,056 young adults to say how often they had these thoughts about food and their body.5 It probably won’t surprise you to learn that women entertained thoughts of this kind much more often than men did. Many women, perhaps even a majority, spend an inordinate amount of their lives concerned about their weight, what they have and have not eaten, and what they can or cannot eat. Binge eating and excessive dieting are rampant, with 32 percent of college-age women saying they binge at least twice a month and 45 percent of women saying they are chronically on a diet.

Emotional turmoil is especially likely to lead women to eat, binge, and be preoccupied with their bodies. In one of my own studies, I asked young women (25 to 35 years old) and middle-aged women (45 to 55 years old) how they cope when they are sad, blue, anxious, or generally distressed. One of the most common responses of the young and middle-aged women in the study was “I eat.” One in four young adult women and one in three middle-aged women say that eating—chocolate and other sweets, chips, anything they can get their hands on—is what they often or always do when they are upset. A smaller but still significant fraction of these women (14 percent of the young adult women and 16 percent of the middle-aged women) say they binge eat when they are upset.6

Just as in depression, obsessions about weight, body shape, and dieting begin early in life. Over 70 percent of girls have been on a diet by age 10.7 Once puberty hits, girls are especially unhappy with their bodies, particularly if they enter puberty a year or so before their girlfriends.8 They say they feel fat and don’t look like the girls in the fashion magazines. Because girls’ self-esteem is often closely tied to their figure and weight, their feelings about themselves can take an abrupt turn toward the negative at this age. As a result, they may rely on excessive dieting to try to control their weight.

For some women, concerns about eating and weight become so overwhelming and patterns of eating, or avoiding eating, so out of control that they are said to have eating disorders. This is where a student of mine, whom I’ll call Hillary, found herself.

Hillary was always an overachiever. A straight-A student in high school, she was also an extraordinary violinist, playing recitals and concerts to large crowds since she was ten. She began college when she was just seventeen.

The thing Hillary was best at, however, was dieting. At 5 feet 11 inches, she weighed 102 pounds. She began dieting when, in fifth grade, her height soared above her classmates’ and she began to feel “big.” During her junior year in high school, she decided she had to take drastic measures to lose more weight. She began by cutting her calorie intake by half. She lost several pounds, but not fast enough for her liking, so she cut her intake to 500 calories per day. She also began a vigorous exercise program of cross-country running. Each day, Hillary would not let herself eat until she had run at least ten miles. Then she would have just a few vegetables and a handful of Cheerios. Later in the day, she might have some vegetables and some fruit, but she would wait until she was so hungry that she was faint. Hillary dropped to 110 pounds and she stopped menstruating. Her mother expressed some concern about how little Hillary was eating, but since her mother tended to be overweight, she didn’t discourage Hillary from dieting.

When it came time to go to college, Hillary was excited but also frightened, because she wasn’t sure she could maintain her straight A’s. In the first examination period at college, Hillary got mostly A’s but one B. She felt very vulnerable, like a failure who was losing control. She was also unhappy with her social life, which, by the middle of the first semester, was going nowhere. Hillary decided that things might be better if she lost more weight, so she cut her food intake to two apples and a handful of Cheerios each day. She also ran at least fifteen miles each day. By the end of the fall semester, she was down to 102 pounds. She was also chronically tired, had trouble concentrating, and occasionally fainted. Still, when Hillary looked in the mirror, she saw a fat, homely young woman who needed to lose more weight.9

Hillary’s self-starvation was severe enough that she was diagnosed with anorexia nervosa, one of the three types of eating disorders recognized by psychologists and psychiatrists (the other two are bulimia nervosa and binge-eating disorder). Women with anorexia nervosa starve themselves until they are 15 percent or more below a normal body weight for their height, and still they feel fat. Their entire self-worth rests on being extremely thin.

In both bulimia nervosa and binge-eating disorder, women (again, the disorder afflicts mostly women) binge eat. In addition, in bulimia nervosa (but not in binge-eating disorder), women engage in purging behaviors to get rid of the food they just ate, or the weight they fear gaining. Purging is not pretty—vomiting is a favored method, along with laxative abuse. Some women also engage in extreme exercising in an attempt to purge their weight.

What constitutes a binge? A binge is technically defined as eating an amount of food that is larger than what most people would eat in a relatively short period of time, such as an hour or two.10 The size of a binge can vary from woman to woman. The average binge is about 1,500 calories, but about a third of binges are only 600 calories and another third are over 2,000 calories. Some women consider eating just one piece of cake a binge. What binges have in common is the sense that control over eating has been lost, and that you feel compelled to eat even though you aren’t hungry.

While most girls and women don’t cross the line into an eating disorder, they do spend days and nights closely monitoring how much they eat, how much their friends are eating, and evaluating their self-worth based on the ability to control what goes into their mouth. In the study I mentioned earlier, I asked women to rate how important it was for them to look good to others versus how important it was for their body to be healthy and well. Forty percent of young adult women and 31 percent of the middle-aged women rated their looks as more important than their body’s functioning.

You might think that women who care more about how their body looks than how healthy it is would be especially careful to watch what they eat. Ironically, women who scored higher on concern about their looks were more likely to binge eat when they were upset than women who were less concerned. It seems that women’s tendency to cope with their emotions by doing something with their body, in this case binge eating, is so strong that even those who are excessively concerned with how they look turn to body-focused coping strategies when they are upset.

“I DON’T DRINK THAT MUCH”

Drinking-related problems in women have largely been ignored, in part at least, because we have been taught to expect men rather than women to suffer from them. True, men tend to drink more than women and are more likely to be diagnosed with alcoholism. But nationwide studies suggest that about 60 percent of women drink, and even more astounding, every month over 13 percent of women in America engage in heavy binge drinking (five or more drinks in a couple of hours). Statistics show, too, that 20 percent of women display some signs of alcohol abuse and 10 percent have drinking patterns so severe that they could be diagnosed with alcoholism at some point in their lives.

The image of an alcoholic in the popular mind is that of a binge drinker who goes on tears lasting days or weeks, consuming quarts of vodka, cases of beer, and magnums of wine all in a single evening. As troubling as these stories are, they are also comforting because they make our own drinking seem totally tame in comparison. “Whew! I’m clearly not an alcoholic—I’ve never come close to drinking that much!”

You may be shocked to learn that the latest dietary guidelines from the government suggest that a woman should never have more than one drink per day. “Oh well,” you may say, “I don’t drink every day so I can have more than one glass of wine when I do drink.” But recent studies suggest that “heavy episodic drinking”—having three to four drinks a couple of nights per week—is more damaging to women’s health than having a glass or two of wine each night.

How much can a woman drink before she is diagnosed as an “alcoholic”? In truth, the diagnosis of alcoholism has nothing to do with the quantity you drink. Instead, it depends on the consequences of alcohol use, at work, in social relationships, and to your physical health. Signs of alcohol-related disorders include frequently missing work or having trouble completing a project, friends and family expressing concern or harassing you about your drinking, and finally, drinking even after a physician suggests you should stop. Because the diagnostic criteria for alcoholism are subjective, it can be difficult to know when a person has crossed the line into a disorder, especially as girls and women may mask, or fail to share, just how troubled their lives have become. Consider, for example, fifty-seven-year-old Vicki, a full-time homemaker and mother of three.

Vicki’s children, all of whom share her blond Nordic looks, are grown, in college or in jobs, with families and lives of their own. As a result, Vicki doesn’t see them nearly as often as she’d like. Since her youngest child left home, she has felt lost and abandoned, unsure whether she has accomplished as much as she should have by this point in her life. Without motivation to go to work or try something new, Vicki just feels as if there is a tremendous weight on her that rarely lifts for more than an hour or two at a time.

Alcohol has always been part of Vicki’s adult life—drinks before dinner, wine with dinner, and cocktail parties on the weekends at the country club. In the last few years, she’s noticed that she gets intoxicated on much less alcohol than it used to take in her younger days. Vicki keeps telling herself she should cut back on her drinking. But when she and her husband, Tom, settle down for before-dinner drinks, she feels a little less lonely and depressed than she did earlier in the day, and so she continues to have a couple of drinks before dinner. Then Tom usually opens a bottle of wine to have with the meal. Now that they have enough money to buy good wine, Vicki hates to deprive herself, and typically drinks her half of the bottle. By bedtime, she is tipsy enough to often fall asleep on the couch, where she finds herself when she wakes up at 4 A.M. Many mornings she skips her exercise class at the club, feeling she couldn’t possibly drag her body through the aerobics routine.

Vicki’s sense of sadness, her lethargy, lack of motivation, and problems sleeping have increased in recent months to the point that she sometimes spends all day in bed. She thinks her drinking may feed her symptoms of depression. But the little bit of relief she gets each night when she drinks with Tom makes it really hard for her to forgo alcohol altogether.

Vicki may not seem like a classic alcoholic—she doesn’t drink vast amounts of alcohol at one time, she restricts her drinking to dinner with her husband, and she isn’t out on the road careening around in a drunken stupor. But Vicki’s symptoms could qualify for a diagnosis of alcohol dependence—the technical label for alcoholism. She repeatedly drinks more than she thinks she ought to, and although she tells herself she should cut down, she doesn’t. Several mornings each week she has a hangover. Like many women, Vicki, as it turns out, has been following this pattern for many years, even though no one, including Vicki herself, has ever considered that she may be suffering from a serious psychiatric disorder.

The Tie That Binds

Although depression, unhealthy eating patterns, and heavy drinking can happen as individual problems, they more often happen in combination, because all three are tied to self-focused coping in women. These links first became evident in the community study I mentioned earlier in this chapter. We measured self-focused coping by asking if people coped with stressful events by “thinking about a recent situation, wishing it had gone better,” “thinking about how upset I feel,” “boiling inside, without showing it,” and “keeping my feelings to myself.” Both women and men who scored high on this measure of self-focused coping were more depressed and more likely to binge eat or turn to alcohol when they were upset. Women, overall, were significantly more prone to lapse into self-focused coping than men.

The links between self-focused coping and the toxic triangle are evident as early as adolescence. In a recent study of adolescent girls, my collaborators and I found that those who engaged in self-focused coping developed more symptoms of depression, bulimia, and substance abuse over a three-year period than those who didn’t engage in self-focused coping.11

Just how does self-focused coping lead down the pathway to depression, unhealthy eating habits, and binge drinking? When you focus inward on all your concerns and how you feel about them, instead of taking action to overcome your problems, you start a chain reaction that can culminate in a disabling depression.12 As you think about one major concern or problem in your life, you analyze it, wonder what it means for you, think about how overwhelmed you are, and possibly think you should do something in response to the problem. The more you think, however, the bigger the problem becomes, just like a snowball rolling down a hill. Then this problem reminds you of another problem in your life, which you begin analyzing as well. Thoughts of more problems join in, and pretty soon you have an avalanche of problems burying you. Even if you have generated a solution to your first problem, you now feel so overwhelmed by those that have taken its place that you can’t take action. You just curl up in a little ball, crushed and suffocating under the weight of your concerns.

Some women try to eat their way out of this crush of negative feelings. Binge eating can serve as a temporary distraction from feelings of sadness and despair, or feelings of rage against others that you aren’t allowed to express.13 Psychologist Eric Stice of the University of Texas at Austin followed a group of adolescent girls for two years, looking for predictors of binge eating.14 He found that girls who engaged in emotional eating—eating when they felt distressed in an attempt to feel better—were significantly more likely to develop chronic binge eating over the two years.

One of the most famous binge eaters (and purgers) in history was Diana, Princess of Wales. The public had known for several years that Diana’s marriage to Prince Charles was in trouble. Diana shocked the royal family and the public when she openly discussed her bulimia nervosa in a 1995 BBC interview:

I had bulimia for a number of years. And that’s like a secret disease. You inflict it upon yourself.… You fill your stomach up four or five times a day—some do it more—and it gives you a feeling of comfort. It’s like having a pair of arms around you, but it’s temporary. Then you’re disgusted at the bloatedness of your stomach, and then you bring it all up again. And it’s a repetitive pattern which is very destructive to yourself.

Although Diana’s life was extraordinary by any standard, the development of her bulimia contains themes that are very common. She suffered symptoms of depression, but because she felt pressured never to show weakness, even to her immediate family, the bulimia became a release valve for her negative emotions, while further damaging her self-esteem and sense of control.

Binge eating to quell negative feelings is sometimes referred to as self-medicating. The eating temporarily takes your mind off your troubles and makes you feel good again. But, as with Diana, the consequences of bingeing—the bloated feeling, weight gain, and shame associated with loss of control—backfire to increase the negative feelings that began the binge. Later you’ll binge again to gain some relief from those feelings, which is how a self-perpetuating cycle of bingeing and self-loathing sets in.

Women also use alcohol to self-medicate against negative feelings. The alcohol temporarily drowns out their frustrations and concerns, and gives them a bit of release from their tight control over their emotions. Unfortunately, using alcohol to self-medicate can lead to a pattern of heavy drinking and abuse of alcohol, as we see with Brenda:

Brenda was a short, waiflike woman of twenty-seven who had had dreams of going to law school after college. Her college grades weren’t that good, however, and her parents couldn’t afford the tuition for law school. So, after college, Brenda began working in a government office, mostly doing boring paperwork. After work each night, she’d go home to her apartment and immediately pour herself a drink. She usually drank wine but sometimes she’d make herself a pitcher of margaritas. Brenda had learned in college that drinking made her feel happier and helped her forget the stresses of course work and exams. Her friends at college had all been heavy drinkers, and together they typically went to parties three or four nights per week. This was probably one reason why Brenda’s grades had not been that strong, but being with her friends and drinking felt energizing, whereas studying did not.

These days, Brenda found herself craving a drink by about three in the afternoon. It frightened her a bit when she realized how much she actually needed that drink as soon as she got home. But she didn’t see any real solution to her predicament, and she didn’t see any reason to sit around being miserable every night when a little bit of wine could so swiftly lift her spirits.

In my research I have found that alcohol use for women, much more so than for men, is part of a more general pattern in which they ruminate about their worries and concerns but do not take action to overcome them.15 Instead, women use alcohol to escape those worries and concerns for a while. Over time, these women are at higher risk of developing symptoms of alcohol abuse, such as losing a job due to drinking, or having conflicts with family members and friends because of their drinking.

Alcohol may be an especially attractive medicine for women who have spent their lives holding in their feelings, trying to conform to social pressures to be self-controlled and upbeat. Alcohol loosens your inhibitions. Words that you’ve wanted to say for years but felt you couldn’t just fly out of your mouth. You find courage you didn’t know you had to confront the people who make you feel bad.

Of course, you may say things you regret later. You may be punished by family and friends for your behavior, or for your loss of control, either of which will just make you feel worse. But the alcohol and the loss of control feel so good in the moment that you indulge them. Over time, a pattern of alcohol abuse and addiction can set in that is very hard to break.

Entering the Toxic Triangle

Many women first enter the toxic triangle in late childhood or adolescence when they begin to feel they don’t quite fit in or measure up. They’re not as good as the other girls—not as pretty, or smart, or athletic. They certainly don’t have the relationships with boys that they want. They live with these feelings for months, maybe even years, doing okay but not great in school, having some, but never enough, friends. Life just seems hard, and it lacks the spark that they see in the lives of other girls. They are sort of depressed, but not really, not enough for anyone to notice or do anything about it.

They don’t know what to do about these feelings and the concerns and dissatisfactions that are behind them. They don’t really feel there is anything they can do. But still they think about their feelings and disappointments all the time, mulling them over, wondering what they mean. They worry that these feelings will go on forever. They compare themselves with other girls and feel they are uniquely incapable of improving their lives.

Then they discover the pleasures of drinking, or eating too much or too little. They find that they can hold their alcohol and that it makes them feel really good. Or they find that they feel really superior and strong when they stick to a strict diet and get really skinny.

Around age fourteen, Teresa, a tall, thin, sandy blond-haired girl from the upper Midwest, began to question everything, especially her own self-worth. She would go for weeks at a time feeling little motivation or energy to do her schoolwork. If her mother, who also had bouts of depression, would let her get away with it, Teresa would skip school and stay home in bed all day. At school, her grades were dropping. She did have one friend, Amy, who Teresa described as a “rough” girl—Amy was prone to swearing in almost every sentence, liked to dress in punk-style clothes, and was known to race around town on a motorized dirt bike. Amy introduced Teresa to beer one night when they were supposed to be hanging out at the mall. Amy’s parents were working, so the girls went to Amy’s house and downed a six-pack of beer in the space of an hour. Teresa felt more free and lighthearted than she had in months. So the next time they were out together, Teresa asked Amy if she knew how to get some beer. “No problem!” said Amy, who led them to the apartment of an “older” friend of hers who, in turn, went down the block to purchase several six-packs of Budweiser for them.

Over the next year or so, Teresa’s drinking escalated until she was getting drunk most nights of the week. She felt terrible during the day, but the alcohol freed her inhibitions and drowned out her self-loathing thoughts, so she kept drinking. As she began to gain weight from the calories in the alcohol, this gave her even more to hate about herself.

Teresa decided she had to lose some weight, but because she didn’t want to give up the beer, she had to cut back on the amount of food she ate. Teresa would go all day long barely eating anything, then would drink heavily at night. She did lose some weight, but because she was drinking so many calories in beer, she didn’t lose very much. In addition, sometimes at night while she was drinking she got so hungry she would binge on junk food that Amy always seemed to have around. Teresa resolved that if she could just keep from gaining any more weight, everything would be okay. By the time she graduated high school, a regular pattern had developed: her days were spent avoiding food and feeling hungover and guilty, longing for a drink; at night she would consume as much beer as she could get her hands on, and if her willpower broke, binge on the junk food at a party or a friend’s house.

When a girl drinks too much in an attempt to quell feelings of unworthiness and dissatisfaction with life, as Teresa did, it is easy for others to get hung up on her heavy drinking instead of dealing with the root of the problem. Teresa’s family would be very frightened to discover how much she drinks, and with the best intentions might focus their concerns exclusively on getting her to stop. If she stops drinking without addressing her low self-esteem and general unhappiness, though, she’ll still find herself trapped. She may stop drinking but also begin to starve herself in an attempt to feel “totally in control.”

Doing Permanent Damage

It would be misleading to think that women’s heavy drinking or chaotic eating patterns always develop as a result of depression and feelings of unworthiness. For a substantial number of women, drinking or unhealthy eating comes first, and depression develops as a result of the effects of these behaviors on her body and life.16

Before she married Bruce, Nicole didn’t drink that much—she might have had a couple of beers or some wine when she was out to dinner at a nice restaurant with friends. But her job as an elementary schoolteacher demanded a lot of energy and concentration, so she usually avoided alcohol just to be able to keep up with the kids.

Bruce, on the other hand, usually had something to drink every night. He is a big man—6 foot 8 inches and 200 pounds—so he could hold a lot of alcohol. Bruce fancied himself a wine expert, and he often took clients out for dinner at nice restaurants, where the maître d’ would suggest an expensive bottle of wine to go with the meal. Because he was chief account manager for a brokerage firm, Bruce had a generous expense account and usually ordered at least two bottles of wine over the course of the evening for him and his guest.

Nicole was captivated by Bruce’s sophistication, and when they were dating she tried to match him, drink for drink. She usually paid a price in energy and general well-being the next day—she was tired, grumpy, and had trouble concentrating—but she was so in love with Bruce that she didn’t care and would drink just as much the next time they went out.

Once they were married, Nicole cut back somewhat on her drinking. But Bruce sometimes kidded her for being a prude and not being as fun a dinner partner as she had been when they were dating. Under pressure, Nicole would have “one more glass” (which usually led to two or three more glasses) of wine that evening. She did indeed feel that drinking helped smooth out conversations between her and Bruce, and this motivated her to put aside her concerns about how she would feel the next day. Then she’d toss and turn all night, her sleep disrupted by the alcohol, and wake up the next morning kicking herself for feeling terrible again on a school day.

By the time Nicole and Bruce had been married a year, Nicole was drinking nightly with Bruce, and they regularly polished off a couple of bottles of wine each night. She began falling behind in her work, unable to get any lesson plans or grading done in the evenings. She increasingly had to call in sick for work because of hangovers—at first only occasionally, and then more regularly, even weekly. The students began reporting to their parents that Nicole was irritable with them, and even fell asleep at her desk at times while they were quietly working on their own. The principal of her school called Nicole in to confront her about her behavior, warning that if it continued, he would not renew her contract at the end of the year. Nicole was ashamed and devastated that her promising career as a teacher seemed to be in jeopardy.

Heavy drinking or unhealthy eating patterns often develop in an attempt to manage a relationship with a man. We want to impress a guy by keeping up with him drink for drink. But our bodies are smaller and don’t metabolize alcohol as well as men’s so we can’t hold as much. Because we’re more focused on managing our relationships than taking care of ourselves, we often don’t notice how drunk we’re getting, or how often we’re getting drunk.

In the meantime, life gets more and more out of control. The toxic effects of alcohol on our brains make us tired, lethargic, and moody. Drinking can leave us to neglect other important aspects of our lives—our relationships with other women, moving forward in our career, our health—which can make us even more depressed, leading us to turn for solace wherever we can find it.

Even though Nicole’s problems didn’t begin with feelings of depression, they resulted from self-focused coping. Nicole tried to manage her relationship with Bruce by controlling her own body in an unhealthy way. She denied and ignored the signs her body was giving her that she was drinking too much, and tried to change how she reacted rather than changing her pattern of interaction with Bruce. Why was it so important to him that she continue to drink heavily with him? Why did they need alcohol to have “smooth” conversations together? These are questions Nicole avoided confronting, in favor of trying to cope by forcing her body to take in more alcohol than was healthy for her.

Escaping the Toxic Triangle

Effectively and permanently escaping the toxic triangle requires understanding how it affects women’s lives and how it evolves. We must confront the danger the toxic triangle poses to our own lives, and the lives of our daughters, sisters, and women friends. By first recognizing the social, psychological, and biological forces that pull women into the toxic triangle, we can design strategies that capitalize on women’s strengths to break free of these forces.