Let me start out by saying that I come from a family with eating disorders. What I have learned has been from both personal and professional experiences. There is a lot of technical information available about eating disorders, but what I want to discuss are the personal aspects. My purpose is to explain how I view these problems, why they occur and what parents can do to discourage their development in their children. I use the word “discourage” here and not “prevent” because to stop someone from developing an eating disorder is nearly impossible. Control lies at the heart of an eating disorder. Nobody, not even a loving parent, can prevent someone from developing an eating disorder if that person has a propensity for it. We are talking about compulsive over eating, anorexia and bulimia in all their forms.

Eating disorders are complex and there are many avenues to them. The contributing factors can be broken down into groups of personality, family dynamics, media and cultural influences, biology and family genetics, history of traumatic experiences, loss and abuse, especially in childhood.

Starting with personality, generally, these people are highly sensitive. They are like sponges that absorb the emotional environment around them. While they take it in, they have little ability to cope with it. They are high achievers, people-pleasers and hold high expectations for themselves. They frequently ask themselves, “Am I ok? Am I enough?” There is little room for error and little in the way of personal forgiveness for weaknesses. They try not to be a problem or burden their families and will often behave more as an adult than a child. They will swallow their own needs in order to get along. They find value in doing, being productive and have a difficult time relaxing. Success is valued over happiness. Success can have concrete goals and clear accomplishments while happiness is unclear and vague.

The family dynamics are surprisingly similar in clients with eating disorders. Fathers tend to be emotionally unavailable while mothers are over-involved. It’s a sticky area to talk about because no parent wishes this on their kids. We all do the best we can with what we have. Intentionally or not, fathers will often put distance between themselves and their daughters as their little girl begins to turn into a woman. Her focus changes, her moods are volatile and her friends become very important. He isn’t sure where he fits in. Although the love hasn’t changed, its expression has, and neither father nor daughter may understand what’s happened. Typically in these families, boundaries are not clear, and mothers have the tendency to become emotionally enmeshed with their daughters. Daughters may feel they can’t disagree or disappoint their moms. They may feel they cannot say no to favors or commitments. There is a lot of personal pressure to “be perfect,” smile and say yes.

Also, eating disorders develop in families where physical appearance is a high priority, where how pretty you are can mean more than how smart, kind or generous. Women who diet and talk about their own and other women’s bodies in disparaging ways are setting the stage for the next generation. If my mom is unhappy with her figure, and I take after my mom, does that mean I’ll have a flawed figure too? Will she and others see me in a bad light? A lot of fears about fitting in, being accepted and liking one self are at the root of these problems.

Wanting to be liked, striving to be loved is all part of the eating disorder mentality. If I’m only good enough, then I’ll be loved. What is “good” enough? Well, we look around us, absorb society’s messages and believe the media has the answers. Adolescents in particular are susceptible to the media’s message about how bodies are to look, what fashions are right to wear, what make-up, lotions and perfume to use. For anyone going through this stage of development, self-identity is at the core. It is about finding what’s right for us, who we are and how we fit in. Social pressure, friendships and heartbreak are also prominent features of adolescents. Hormones rage, emotions flare and many become depressed or anxious.

Looking at magazines, we are bombarded with images of super thin, possibly anorexic models. They are much taller and thinner than the average American female, and yet, we are supposed to believe that by buying a product we could be like them. As consumers, we really need to start asking ourselves what the advertisers are saying. More often than not the message, no matter how subtle, is that we are not okay the way we are. We have to lose pounds, wear a particular designer label, shop at particular stores, use this lotion or face make-up or else. It’s based on fear, insecurity and threat of exposure for being who you are-that not quite right or ok person who could be better if- when you don’t use their products. It’s all about wanting your money. You have what they want. They get it by convincing you that you are not good enough the way you are. More often than not, to get as good as they pretend to be, it will cost you a lot of money, effort and frustration. Notice the next time you watch a commercial or look through a magazine. Ask yourself these questions: What are they selling? What images do they use? What words do they use? Inevitably they use words and images to invoke an emotional response to convince you to buy their products.

When we come to biology and genetics, we find that people who develop eating disorders often have family histories of depression and alcoholism. They may be depressed themselves or suffer from an undiagnosed illness like dysthymia, which is a chronic low grade depression. People often describe it like, “being down in the dumps” most of the time. In childhood it often manifests as irritability. Many adults don’t realize their brain chemistry is robbing them of serotonin or other important neurotransmitters that help all of us get up and face the day. They have felt sort of blue most of their lives, it’s become normal. Brain chemistry, our ancestors and what we bring to the table all contribute to our abilities to manage our feelings, cope with stress, and feel loved and able to give love.

Childhood trauma, especially sexual abuse, is a major factor in the development of eating disorders. I’ve worked with men and women who have had this experience. The boundary violation, the threat and emotional nightmare that sexual abuse causes can overwhelm anyone, especially a vulnerable child. As a girl turns into a young woman, her body changes, develops curves and may draw attention from the opposite sex. However, drawing attention may also be something to be avoided if you are someone who has been raped, molested or otherwise traumatized. The body can become an enemy with its womanly hips and bust that so many males believe they have the right to comment on. Some women will starve themselves and exercise until their bodies resemble a teenage boy, narrow hips and flat chest. Others will gorge themselves until their female body is hidden beneath layers of fat.

In my opinion, eating disorders are not about food. They are about feelings. This is where so many people get lost, in the land of messy emotions. We’d rather avoid them; push them down and away from our awareness. Not knowing how to cope with feeling uncomfortable inside, we turn to the outside. Here there is some control. With the focus aimed at the physical body, seen to be inadequate and endlessly flawed, there is little focus on the inner life. I can control what I eat, what I weigh, what size pants I wear and how much I exercise. These are clear cut and easy to understand, unlike emotions.

If I’m like an emotional sponge that hasn’t been taught how to expel emotions, then I’ll be overwhelmed in no time. If I’m a conscientious teenager who can’t say no, doesn’t understand where my boundaries are, or even what they are, then I am set up for trouble. If I have experienced a loss, have been molested or raped and can’t access my pain then I will cover it up.

Feeling management becomes the driving force behind an eating disorder. I don’t want to feel the pain, sadness, anger, frustration and rage that is within. I want to numb it. I’ll eat or starve. I’ll obsess over thin women, read endless magazines, diet and exercise to exhaustion. I’ll learn about calories and keep reducing what I take in. By now my head is fuzzy a lot of the time. It’s hard to concentrate. I can’t think. My hands and feet are always cold. I may lose hair and grow a fine sheen of it over my body. My moods are all over the place. I’m jumpy one moment and gleeful the next. When I do eat, especially if I eat something that wasn’t planned for, I feel incredible guilt. I hate myself for my lack of self control. I envision the food turning to fat within seconds. I’ve lost control. I hate myself. I can no longer trust myself. I may exercise compulsively, starve for days, vomit whatever I ate, and take laxatives or diuretics as an ill conceived idea of flushing the calories out of my body. Meanwhile I have declared war on my body. Kidney damage, esophagus tears, electrolyte imbalances and heart failure are a few of the casualties.

There are many things parents can do to discourage the development of eating disorders. Start with the media. Talk about what you see on television, especially the commercials. Notice how often the message is that we are not ok the way we are. We, therefore, need their products. Look through magazines together and talk about the images portrayed. Teach your daughters that the average American woman is 5’4’’ and 140 pounds while the average model is 5’10” and 115 pounds. Perhaps some are genetically designed this way, but the search for models is world wide. Something like 2 percent of the world’s population is naturally this tall and thin. The rest of us are only buying into the idea that what we see is what we should be.

Look to your personal habits. Do you diet? Are you self critical? Do you strive to be different than how you were made? Do you comment on other women’s bodies? Do you routinely find yourself at fault? These are just a few of the things to take notice of and stop for all concerned.

Praise your kids for their inner qualities, not their appearances. Tell them you appreciate their love of animals, their kindness to others, and their sense of humor. Pay attention to their unique personality, and don’t compare them with others. The actress (Charlize Theron ) talks about this in almost every interview. The interviewer inevitably comments on her beauty and wants to know how she lives with it. Charlize’s response is that she grew up in S. Africa and they didn’t have the media emphasis on looks. Her upbringing was quite different than those of our youth. It’s given her a solid grounding that she can work in the movie industry and not get lost in what a “beautiful woman” is supposed to be.

Another way that parents can help is to be honest about emotional pain. As a therapist, I work with people all the time on naming the emotions. Some event occurs and feelings are hurt. We become upset, but do we know if it’s anger, sadness, grief, frustration or disappointment or a combination of them? How are they different? Where do we feel them in our bodies? How can we learn from them? What are they telling us? Somewhere along the way, the emotional needs of people who develop eating disorders have been overlooked.

Emotional awareness takes time and can be a life long process. Once we know what we feel we have to learn how to cope with the feelings without hurting ourselves or others. I tell my clients that anger has a message. It comes up when a boundary has been violated. Somewhere someone has crossed a line and the anger tells us about it. What we do with the message depends. Do we believe we have the right to protest? Are we in a position to stand our ground? Do we ignore it? Do we pretend it didn’t happen?

The popular newspaper columnist, Ann Landers, was known for her witticism. She used to say that people can’t take advantage of you unless you let them. This is where the anger and boundaries, fear and courage come in to play. If someone hurts my feelings by some rude comment, uses and breaks my things without apology or some other infraction, I have a choice. I’m going to be angry because a boundary has been broken. What I do with my anger is up to me. Women are notoriously bad at dealing with anger. In our society men have been given permission to get angry but not women. We’re socialized to be nice. We fear not being liked. We seek approval. We often go out of way to accommodate others, and yet we get taken advantage of and that makes us angry. If we swallow our anger, we hurt ourselves. We have to step up and speak our minds.

This can get messy and friendships may be lost. It’s an awkward dance at first. To begin, we must identify the feeling. What happened and what did I tell myself about it? Where do I feel it in my body? Are my hands balled up? Is my stomach tight? Do I feel nauseous? Is my jaw tight? Do I feel heat rising to my face? Am I scared? Once we can name what it is we are feeling and recognize the signs, we can make a choice about how to deal with it. How we talk to ourselves is crucial. Making a decision that validates you but doesn’t attack another is not always easy. Most of us will continue to work on this skill until our dying days. It isn’t easy, but emotional honesty is critical for someone with an eating disorder.

Treatment options vary. If we have physically damaged our internal organs, we’ll be admitted to the hospital until we’re stable. Hospitalization is not where recovery happens. It’s the beginning of a very difficult road. The work mostly takes place in the real world, with out-patient therapy, support and love from friends, family and self.

Learning to love one self, to be one’s own best friend, these are things that can happen in therapy. I encourage people to tell their stories. I may teach them breathing techniques for relaxing. I’ll show them how our inner dialog can be unmasked and made concrete by writing. I help them create a dialog with themselves, their eating disorders or anyone else they have in their heads at the time. So many messages we carry around about ourselves were given to us by others when we were too young to question it. In therapy, I want people to identify those messages, the voices they associate with them and question if this is something they will choose for themselves or let go of. We work on how to rid ourselves of harmful or unhealthy beliefs. It’s a process of reconnecting with the self that got lost along the way. We are ok just the way God made us. Maybe we need some anti-depressants to help with brain chemistry. Maybe we need to work with a nutritionist to get an idea of what a healthy meal looks like.

Everyone needs help at one time or another. The sooner someone with an eating disorder gets help the sooner they’ll get on the road to recovery. Recovery is often one step forward and two back. It is trial and error, missteps and forgiveness. The eating disorder has served a purpose. Part of recovery involves finding out what that is, and making the changes in your life so the eating disorder isn’t needed anymore. The average recovery time is 7 years.

Case Studies: Hospital Ward, 1996

Damaged and scared.

Jen was an attractive 26 year old woman who looked a bit older than her years. She worked as a flight attendant and became obsessed about her weight. She was one of three, a middle child from a conservative East Coast family. Her father ran a business and was rarely home when she was growing up. Her mother was active in social and church committees. Jen’s older sister was bright, independent and tall. She had inherited her father’s height and build. Jen was more like her mother. She was average height and weight, also attractive and very outgoing. Jen struggled in school and disappointed her family by not going to college. Instead, she joined her best friend in applying for the airlines. Although she flew miles away from home, she carried the values, beliefs and self-talk that she learned early on. She saw herself as not being very bright, too fat and could never compete with her older sister. She berated herself for any and all flaws, real or imagined. Her mother’s perky voice played over in her head, “Jen, if only you tried hard enough.” So, Jen became good at losing weight. She abused laxatives for years until she lost a kidney. When we met she was still abusing laxatives and was showing kidney damage to her remaining kidney. She left the hospital early and I never saw her again.

Cammy-Alaskan Native. Hurt and brave.

Cammy was a high school junior, bulimic and overweight. She was depressed and expressed a desire to die. After spending time with her alone in her room, she told me her story. She lived in a small village in Alaska where everyone knew everyone else. In her community, it was incest that bound everyone. She described hiding in a closet whenever there was a family function in order to hide from uncle. She told her mom what was happening, but her mom couldn’t do anything about it. She too had been molested by this same man. Working together in the evenings, we explored her feelings, expressed her anger and came up with a plan. Eventually, she quit purging, stopped punishing herself and returned home briefly. She refused to attend any family functions if she wasn’t going to be protected and applied to college in Seattle. I last saw her as a college student at SPU.

Marie-food allergies

Marie was 22 when she came to see me. She had developed anorexia as a result of food allergies. Her body felt so badly after eating just about anything, that she quit eating. She didn’t know what was safe to eat, and she wasn’t about to bother her overworked parents about meals. She got a lot of attention and praise for losing weight. Many of the high school girls were on diets but nobody lost weight like she did. After two years, Marie began to eat more. She felt so guilty and filled with shame that she immediately threw it up. This became her pattern. By the time we met, she was purging three to four times a day.

What helped Marie:

Meeting with a nutritionist to find out what she was allergic to.
Meeting with a psychiatrist, diagnosed with dysthymia and given anti-depressants.
Journaling.
Therapy 1 x week.

History of sexual abuse as a child. “No big deal.” Dialoged with child self.
Recorded self talk. Examined beliefs and consequences of those beliefs.
Gradually, found her own self.

Diagram of TA, Cognitive Behavioral Model, Developmental needs-age of molestation, not being able to go to parents. Weight of anger and mistrust for years.
Pretending everything was fine. Pretending became what she was best at.