Eating disorders represent a emotional and cognitive struggle of some kind, be it trauma, low self-esteem, poor body image, bullying….clients present with many different root causes of their disorder. A client’s spirit is suffering and a person tends to have a breakdown in their spirituality. The one underlying theme is the difficulty in managing the most uncomfortable feelings. The eating disorder and one’s spirituality are often at competing ends. The eating disorder serves as a coping method that presents as a friend, a confidant, a powerful secret, or a god that needs to be obeyed and the eating disorder appears at the time the client needs it most. In a storm of chaos and fear and inconsistency, the eating disorder swoops in and appears to give the feeling of rescue that the client feels temporarily from the distress.
Michelle Lelwica (2010) shares that while the client is focused on creating a “good” body or engaging in eating disorder behaviors like restricting or purging, the inner life is being ignored. No matter how thin the client gets, no matter how filling the binge, there is an eternal sense of emptiness and hunger that is never satisfied. All of the crises that pile up in life, all of the hurts and trauma, drive a wedge through the true self. Big questions like “What is important in my life” and “How do I understand my life’s purpose” cannot be answered when the soul is entrenched in an eating disorder. There is simply no energy left for living. Recovery becomes a spiritual journey as clients attempt to access their pain and face it with the help of a higher power.
Randy Hardman and Michael Berrett (2015) explain that many people with an eating disorder have had some degree of personal spirituality in their lives. Some have participated in religious observations and others may have felt connected to yoga or nature or a meditation practice. Despite this, during the course of the eating disorder these connections were lost. Feelings of unworthiness creep in as the eating disorder, which at one point served a purpose, becomes harder and harder to sustain. Indeed, eating disorders cause sufferers to chase false pursuits that ultimately replace spiritual connection. Hardman and Berrett list these false pursuits:
- False sense of control
- False form of communication about pain and suffering
- False sense of being the exception or exceptional
- False crusade for evidence against self
- False pursuit of perfection
- False form of comfort and safety
- False identity
- False compensation for the past
- False attempt to avoid personal responsibility
- False pursuit of approval
Eating disorders may represent some or all of these falsehoods for clients. Richards et al (1997) state that eating disorder clients often have difficulty letting go and having faith, despite their spiritual background, leading to a worship of these falsehoods in pursuit of a sense of control and well-being. Along the way the eating disorder gains control of every aspect of their lives, rendering clients powerless when all they were seeking all along was a powerful sense of being good enough.
Not all clinicians work with spirituality in treatment with their clients, but it is a significant aspect of recovery that should not be avoided. Clients who wish to regain their spiritual connections, or foster connections for the very first time, can do so in the safety of the therapeutic alliance. Eating disorders are very hard to give up because it is difficult to remember what life was like beforehand and next to impossible to consider what life might be like in recovery. There is so much unknown and that is often one of the biggest barriers to recovery. Spiritual exploration during treatment can help clients resolve any negative impacts their spiritual pursuits had in the past and move forward with new resolve to take care of their physical, emotional, and spiritual selves.
Lelwica, M. (2010). The Spiritual Dimensions of Recovering from an Eating Disorder. Psychology Today, www.psychologytoday.com
Hardman, R. and Berrett, M. (2015). Eating Disorder Recovery: A Spiritual Perspective. BYU Idaho Counseling Center, www.byui.edu
Richards, P., Hardman, R., Frost, H., Berrett, M., Clark-Sly, J., and Anderson, D.
Spiritual issues and interventions in the treatment of patients with eating disorders. Eating Disorders: Journal of Treatment and Prevention, 5(4), pp. 261-279
When an eating disorder strikes an individual, his or her entire family is affected. According to an article by Abigail Natenshon, MA, LCSW, GCFP, 87% of eating disorder patients are children and adolescents under the age of 20. As many in this age group still live at home, the eating disorder develops and plays out within the family dynamic. It often takes on a life of its own and can be the cause of many battles at meal times, family gatherings, holiday events, and can even affect extended family and school environments. Family therapy is an essential part of eating disorder treatment and is necessary to ensure everyone who is a part of the family system is cared for.
The Family System Theory
Developed by Dr. Murray Bowen, family systems theory posits that the family is a unit and the emotional connections fostered by thoughts, feelings, and actions create an interdependent environment. This interconnectedness helps the family to become cohesive and supportive of its members. If there is unrest and tension, emotional connections can become more stressful. If there is a member of the family who tends to take on the emotions of the other members and may take on an accommodating role, leading to overwhelm and isolation. This is the family member who may become more susceptible to addictions, depression, anxiety, eating disorders, and illness.
There are eight concepts to the family systems theory:
- Triangles: A three-person relationship system
- Differentiation of self: Variation in how people are susceptible to pressures to conform to the group
- Nuclear family emotional system: Four basic relationship patterns (marital conflict, dysfunction in one spouse, impairment of children, emotional distance)
- Family projection process: The way parents transmit their emotional issues to children
- Multigenerational transmission: Differences in differentiation across generations
- Emotional cutoff: Managing emotional issues by cutting off family members
- Sibling position: Impact of sibling position on behavior and development
- Societal emotional process: Emotional systems govern behavior on the societal level
Family systems theory can be used to help clinicians understand the dynamics of the family presenting to work through one member’s eating disorder.
Family Involvement in Eating Disorder Treatment
Comprehensive treatment plans at all levels of care will involve family therapy. Center for Discovery residential programs involve the family weekly in a therapeutic way, not only in family therapy but also at meal times by facilitating therapeutic family meals. The purpose of these activities is to observe family dynamics at meal times and in social situations in order to best prepare the family for realignment and a return to balanced interconnectedness.
Some clients benefit from a type of family therapy called Family Based Therapy (FBT, also known as Maudsley). This outpatient approach, which places the refeeding process in the hands of the parents and moves the family through phases of treatment as recovery develops, has proven to be very successful for adolescents with anorexia.
In outpatient settings, family therapy is usually recommended in conjunction with individual therapy, nutrition services, and group work. As the eating disordered member reintegrates back to the system after being away at treatment, therapy is needed to help the family adjust once again. An eating disorder has the potential to isolate family members from one another, create discord in the system, and indeed can be either sustained or eliminated depending on the dynamics of the family system. It is important for clinicians and parents to know that parents do not cause eating disorders. The entire system needs attention and support to thrive again.
Natenshon, A. Family Treatment is Cornerstone of Effective Care for Eating Disordered Children. Treating Eating Disorders, www.abigailnatenshon.com
The Bowen Center for the Study of the Family. www.thebowencenter.org
Recovery from an eating disorder requires an incredibly courageous step into the unknown. It requires relinquishing control and moving through the stages of change to reach acceptance and health. This is easier said than done and takes time. One of the first steps is identifying what purpose the eating disorder serves and therefore what emotional needs it is meeting. Only then can the person begin to find healthy ways to meet those needs and heal.
What is the Function?
Very often, people with eating disorders find themselves in life circumstances that leave them feeling like they’ve lost control. Maybe there’s been trauma or a loss, or maybe bullying at school or a lack of identity. The eating disorder swoops in at these vulnerable times, offering a lifeline in the form of a sense of power and control, a numbing of painful emotions, something to feel accomplished about….a savior that ends up creating devastation and life-threatening complications.
Stages of Change
Moving beyond resistance and denial to contemplation and action feels impossible when the eating disorder is in full swing. Many people arrive at treatment at the urging of family and friends without the slightest idea themselves of why they are there. The stages of change put a timeline to this process, and it is possible to envision when one might arrive at identifying and challenging the purpose the eating disorder serves.
Precontemplation: People in this stage tend to be resistant to change. They are in treatment for others. They feel hopeless.
Contemplation: Recognizes there’s a problem (and perhaps now is aware of the purpose the eating disorder serves) and begins to anticipate an imminent change.
Preparation: People sometimes experience ambivalence in this stage as they prepare for change but still aren’t 100% convinced it’s a good idea.
Action: Time and energy are committed. Behaviors begin to change.
Maintenance: Continued action is required to maintain recovery. It is a fluid process with frequent adjustments.
A person in the throes of an eating disorder truly believes that the illness brings value to their life. It likely has shown merit at some point, in the form of the purpose it serves in the person’s life. For example, someone who has experienced life in an alcoholic home may now feel in control for once….amid all that chaos, the eating disorder created a way for the person to feel competent, in control, and superior. In this case, the eating disorder creates control where there was chaos and a false sense of self-esteem where there was self-hate and uncertainty. It becomes difficult to build a case against the eating disorder when it has brought some semblance of order to the person’s life. Recovery begins when the person recognizes the purpose served and can accept that what once felt like control has now become out of control and not sustainable. An article by Emily Troscianko (2010) poignantly states: “Somewhere along this road….You may come to see that exerting control is simply no longer what’s required of you.” Letting go catalyzes action, and action leads to recovery.
Troscianko, E. (2010). Why Control Won’t Bring You Happiness. Psychology Today, www.psychologytoday.com
I have seen so many of my own patients with Eating Disorders (ED) struggle with how to move beyond the Stage of Change in recovery : “I know I have a problem but not willing to do anything about it ” and get to the Stage of Change: ” I know I have a problem and I am willing to do everything I can to get better”.
With my patients who tell me that they can’t get better, they won’t get better or they don’t even really have a problem, I have noticed a few things:
- GREY MATTERS: The majority of people that have the disease of an eating disorder think in absolutes. Black and White. I am either fat or thin. I have no control or I am in total control. I have to do everything perfectly or not at all.
- They feel they can not survive life without their Eating Disorder. They believe that if they choose to start recovery they will lose all control, their voice, their protection, their identity and their purpose in life.
- They believe that if they do not have their ED they will no longer be successful, fulfilled, special and worthwhile.
So to be able to get to the next stage in recovery, one must believe:
- That they are capable of anything they put their mind to. Someone with an eating disorder is a very determined and capable person. Perseverance is key.
- Their ED has begun out of some form of unmet need. They need to learn to be able to fulfill their wants and needs out of assertiveness, determination, perseverance and creativity.
- They are capable of change. They are not made of stone, but of soft clay that they can continue to mold, sculpt and make into their best selves.
As a therapist, my role is to never give up on finding a way to communicate these truths, to motivate them to take risks and to take one baby step at a time.
I think of the “little engine” who despite it’s limitations, never gave up, believed in it itself and always had someone cheering him on.
Heather Baker, LCSW, CEDS