Treating the Eating Disorder Self

Introduction

Part 1: The Inner World of the Emotional Eater

Chapter 1: When Trusting Food Is Safer than Trusting People

Chapter 2: Conducting an Eating Disorder Assessment: Who, What, When, Where, Why, How?

Chapter 3: Treatment Part 1: Awareness Is the First Step

Chapter 4: Treatment Part 2: Action Strategies

Chapter 5: Medications and the Eating Disorder Client

Chapter 6: The Therapeutic Relationship: Cultivating Hope and Connection

Part 2: Multicultural Perspectives, Gender Competency, and the Impact of Social Media in Eating Disorder Treatment

Chapter 7: A Multicultural Perspective on Eating Disorders

Chapter 8: Gender, Sexual Identity, and Eating Disorders: What’s the Connection?

Chapter 9: The World of Social Media, Eating Disorders, and “Selfie-Esteem”

Conclusion

Appendix A: The Diagnoses of Eating Disorders
Appendix B: Resources

References
Index
About the Author

Mary Anne Cohen, LCSW, BCD, is a social work therapist and has been a member of the National Association of Social Workers (NASW) since 1972. She has served as the director of the New York Center for Eating Disorders since founding the center in 1982. She has treated hundreds of people with a wide range of eating disorders, supervises social work therapists, and has written two internationally acclaimed books on this topic: French Toast for Breakfast: Declaring Peace with Emotional Eating and Lasagna for Lunch: Declaring Peace with Emotional Eating.

Cohen offers professional training workshops to social workers on eating disorders and body image at the NASW Addictions Institute, the New York State Society for Clinical Social Work (Metropolitan, Staten Island, and Rockland County chapters), and the New York University School of Social Work and provides trainings for social workers in hospitals, eating disorder treatment centers, and alcoholism facilities.

She has been the professional book reviewer for EDReferral.com (Eating Disorder Referral and Information Center) since 2014. She created a continuing education training webinar for social workers and mental health professionals, “Declaring Peace with Emotional Eating,” for Gurze.com, and both her books have been turned into continuing education courses for mental health professionals (see https://secure.ce-credit.com). Cohen also broadcast a weekly radio show for three years on the topic of eating disorders on AM and FM radio stations to New York City and the tristate area, interviewing experts in the field throughout the United States.

Earn 8.0 CEUs for reading this title! For more information, visit the Social Work Online CE Institute.

Click here to hear an interview with the book’s author, Mary Anne Cohen, on the NASW Social Work Talks podcast!

It may appear incongruous to describe a book so thorough, useful, and full of client stories as charming, but that descriptor is the one that kept coming back to me.

This book’s charm lies in the author’s ability to help us understand the dynamics of eating disorders and in her ability to, at the same time, give us a peek inside the lives, hopes, dreams, and horrors of the lives of her patients.

It’s also an exceedingly thorough volume, providing not only therapeutic techniques, but also much needed information regarding the multi-cultural aspects of eating disorders, a perspective on gender and sexual identity, and an examination of social media and the place it sometimes holds in this “skinny or die” culture. The detailed attention to so many elements of life makes this such a richly rewarding read.

Nancy Keeton, PhD, LCSW
Clinical Diplomate, Professor of Social Work
Brescia University, Owensboro, Kentucky

Read Dr. Keeton’s full review here.

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Mary Anne is a great resource to us all, both experienced clinicians and those entering the field. She brings a wealth of experience and knowledge, weaving clinical case examples and her own personal history. She brings “life” to the book and keeps readers engaged. What I appreciate most is Mary Anne’s emphasis on educating the reader on developing a rich understanding of their client, not just a focus on behavioral intervention.

Ann Biasetti, PhD, LCSWR, C-IAYT
Author and clinical psychotherapist, Saratoga Springs, NY

For many people, trusting food is safer than trusting people. For many, loving food is safer than loving people. Food never leaves you, never rejects you, never abuses you, never dies. It is the only relationship in which we get to say where, when, and how much. No other relationship complies with our needs so absolutely.

This book will explore the two worlds of the binge eater, bulimic, anorexic, and chronic dieter: the inner world of emotions and the outer world of cultural pressures. These two worlds collide together to cause the development of an eating disorder.

Every person’s eating problem is as unique as a fingerprint. This is not a book that advocates a “one size fits all” approach to heal an eating disorder. The goal for the social work therapist is to create an individualized and comprehensive treatment approach in collaboration with our clients that will help them break the chains of emotional eating and body image distress.

Finding the freedom to live a life unburdened by obsessive thoughts about weight and size and compulsive behaviors about food and eating is a tremendous relief, freeing the person to embrace life with more curiosity, zest, passion, imagination, and love. The role of the clinician is to help people sink their teeth into life, not into their relationship with food.

What the Social Work Clinician Needs to Know

Social work clinicians increasingly see clients with eating disorders in their agencies or their practices. Sometimes the client directly seeks help with binge eating, bulimia, anorexia, chronic dieting, or body image struggles. Other times, a client does not discuss their eating problems until therapy is well under way, and the person has come to trust the therapist with the shameful “confession” of having an eating disorder. And sometimes eating disorders are not full blown but “subclinical,” and a client has not fully realized the impact of their eating disorder behaviors on their self-esteem.

Given that at least 30 million people of all ages and genders in the United States are diagnosed with an eating disorder at some point in their lives and given that clinical social workers are one of the nation’s largest providers of mental health services, we need to be aware of the latest diagnostic and treatment information on eating disorders (National Association of Anorexia Nervosa and Associated Disorders [ANAD], n.d.-a).*

What We Know for Sure: The Perfect Storm

We know the perfect storm for the development of an eating disorder includes six interrelated factors. Identifying and understanding how these factors express themselves uniquely in each client will help us create effective interventions.

1. Media and Social Pressure

Our culture fosters the relentless pursuit of thinness. Through advertising and the media’s coverage of fashion models and celebrities, we get the message that young, skinny, and white is the ideal image. Many other cultures also define success according to weight and appearance. A poignant and heartbreaking documentary, The Illusionists, notes that women in Africa and Asia spend vast amounts of money on skin- lightening products with sometimes detrimental effects to their health (Rossini, 2015). In America and Western Europe, in contrast, white people are invested in tanning sprays and tanning salons that also can negatively affect their health. Some people even become obsessed with tanning, which has given rise to the label “tanorexia.” The media breeds within us perpetual dissatisfaction. If you are a woman of color, you want lighter skin. If you are a white woman, you want darker skin. We can never get it right. The poet William Butler Yeats writes,

To be born woman is to know
Although they do not talk of it at school
That we must labor to be beautiful.

And labor and angst we do. And men do, too.

2. Genetic Predisposition

Eating disorders are biological as well as psychological illnesses. To date, scientists have identified more than 400 different genes that are implicated in overweight or obesity, although only a handful appear to be major players. Genes contribute to weight by affecting appetite, satiety, metabolism, food cravings, body-fat distribution, and even the tendency to use eating as a way to cope with stress. Research suggests that for some people, genes account for just 25 percent of their predisposition to be overweight, whereas for others the genetic influence is as high as 70 percent to 80 percent (Harvard Health Publishing, 2019).

A family history of anxiety, depression, or addiction can predispose a person to eating disorders. Therapists in the field of addictions have applied the metaphor of a gun to describe the multifaceted reasons that people turn to drugs and alcohol. This is applicable as well to illustrate the development of eating disorders.

Sandra, a 19-year-old bulimic girl, came from a family where her father was a binge eater and alcoholic. This genetic background predisposed Sandra to an addictive relationship with food, and so the threatening “gun” got created. The gun got loaded when Sandra was 10 and her parents divorced, and her dad remarried and moved to another state. She started turning to overeating for comfort and companionship. But it was only after she left home to go to an out-of-town college that her sense of isolation, anxiety, and depression mounted. This emotional upheaval triggered the gun. Sandra began to binge and purge and developed a full-blown eating disorder.*

An empathic and nurturing relationship with a therapist can help soften and hopefully avert the impact of that bullet.

3. A Traumatic Life Event

Physical or sexual abuse, the early loss of a parent, or other traumatic events set the stage for people developing an eating disorder as a coping mechanism for pain and a way to dissociate from their anguish. When the boundaries of a child are violated through abuse, a child concludes that adults cannot be trusted. The child may learn that trusting food is safer than trusting people.

When Dave was nine, his beloved uncle sexually abused him and directed Dave not to tell anyone because he would not be believed. Dave began having insomnia and turned to overeating to quell his anxiety and confusion. Although he continued to be a good student, his insides were in turmoil, only relieved by the “sweet” comfort of food. This coping mechanism persisted through adulthood until his work in therapy helped him grieve the abuse he suffered and find other ways of soothing himself beyond the food.

4. An Obsessive–Compulsive Personality

People with obsessive–compulsive disorder (OCD) are driven to perfection. OCD is a biological illness, and we see this especially in anorexics, compulsive exercisers, and orthorexics who strive to eat only “clean” food. But no amount of exercise, weight loss, or “clean” eating is ever good enough to quell the anxiety of the person with OCD who can never get it perfect enough. Therapy, and sometimes medication, can help dial down the unrelenting quest for that elusive perfection.

Ashley came from a family devoted to sports where the children were pushed to choose a sport and devote their free time to practicing and staying as lean as possible. Ashley developed bulimia in college when she became drawn to creative writing and wanted to leave her life of sports behind. Her family’s disapproval locked her into a cycle of guilt, overeating, undereating, and purging until she came to therapy to sort out this conflict.

5. Weight Loss Diet

Diets have been called the gateway to eating disorders. When people experience emotional distress, they often turn to the “solution” of dieting to make themselves feel better and more in control. Although diets initially can lead to weight loss, they invariably set up cravings and rebellion and then breakout bingeing. The restriction of dieting willeventually lead to overeating, which may lead to purging and then even stricter dieting. A vicious cycle is created, and the person may become trapped in a lifetime struggle of chronic dieting and bingeing.

6. Family Attachment and Communication Problems

The seeds of eating disorders usually begin in childhood. From the very first moment of our lives, a connection exists between eating and deep emotions. The vital emotions of trust, dependency, security, generosity, and the acceptability of our needs begin at birth in the feeding experience with our parents. Love has its origins in the satisfying feeling of being well nourished. Family is where we learn to love and where we learn to be loved.

Learning Self-Care

How we feed ourselves, how we take care of ourselves, and how we tend to our own needs are based on these early patterns of how our parents cared or did not care for us as children. When we are taught that our needs and our hungers are acceptable and approved of, we, in turn, learn to care for our needs and our hungers in loving and self-protective ways. With that secure foundation, we do not need to resort to eating disorders to fortify ourselves. This capacity to soothe one’s self may be the key ingredient in preventing an eating disorder.

However, when we are shamed, neglected, or made to feel inadequate, we come to treat ourselves in a similar manner. Eating disorders are attachment disorders. When early attachments fail to nourish, addiction to food or substances becomes an attempt to repair the hurt self—to provide comfort, consolation, and to fill up the vacuum within. Emotional eating takes the edge off anxiety and is easier to control than the uncertainty of human connection.

Developing healthy attachments through friendships, love relationships, support groups, and psychotherapy provides good medicine for the body, heart, and soul.

Who Gets Eating Disorders?

Teenagers and young adults—both girls and boys—are vulnerable toself-consciousness and the messages that appearance is everything,weight is an accurate measure of one’s worth, and thinner is alwaysbetter. Adolescents’ vulnerability comes from the fact that they aredeveloping their identity and trying on for size the various cultural definitionsof what will make them popular and attractive.*

Adults—both men and women—also struggle with eating issues and body image dissatisfaction, and these may appear at different stages of their life. For adults, eating disorders can emerge in the following ways:

• A person may develop an eating disorder as a teenager and never resolve it, and it persists through their older years.
• An adult may develop an eating disorder as a teenager, succeed in resolving it for a period of time, but relapse as an older adult.
• People begin suffering from an eating disorder or body image dissatisfaction for the first time in adulthood usually when loss or grief rears its head—such as through a divorce, the death of a parent, the loss of a job or financial security, empty nest syndrome (when children move out), or illness.

What’s New in the Field of Eating Disorders?

Over the past 10 years, much has remained constant. Food is still the most commonly abused anxiety “pain killer” on the market. It is, after all, the cheapest, most available, socially sanctioned mood-altering drug. Bingeing, purging, starving, and dieting are behaviors clients can easily resort to as self-medication for anxiety, depression, anger, sexual fears, and a myriad of other emotions not related to hunger.

In recent years, significant strides have been made in research and clinical observation that have deepened our knowledge and treatment of eating disorders. In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for the first time included binge-eating disorder as a valid and bona fide diagnosis. This has helped reduce the shame and stigma about seeking help as more people are realizing that their inability to heal their eating disorder is not a matter of moral failing or insufficient willpower but due to a legitimate psychological disorder.

The latest scientific research has increasingly demonstrated the biological complexity of weight gain and weight loss. The simplistic equation is no longer valid that weight is solely dependent on calories consumed and the amount of exercise generated to burn them. Rather, more than 20 variables have been researched regarding weight:

• Fetal programming: Babies of mothers who smoked during pregnancy are more likely to become overweight.
• Sleep deprivation: Lack of sleep increases production of ghrelin, the hunger hormone, and decreases production of leptin, the satiation
• Neurotransmitters: Deficits in serotonin and other biochemicals underlying depression and anxiety may trigger cravings for high-sugar and high-fat food.
• Brown fat: Brown fat burns calories faster than white fat, and researchers are trying to harness this for weight loss.
• Microbiome: Differences in our gut’s bacterial mix may have an impact on what we weigh.
• Synthetic chemicals: Artificial chemicals found in toys, plastics, cookware, and cosmetics have been implicated in weight gain.

This information is reassuring to many of our clients who are always quite ready to blame themselves for their inability to lose weight. Knowing these factors may help clients reduce their self-blame and better appreciate that weight struggles are complicated and multifaceted (Gunnars, 2018; Koenig, 2019; Peeke, 2014).

The burgeoning of social media in the past decade has affected—for better and for worse—the lives of those with eating disorders. I will explore what social workers need to know about this double-edged sword.

Over the course of time, our society has also come to recognize that eating disorders are not just the domain of skinny white girls. In fact, more men, African Americans, Latinos, and gender-fluid clients are now seeking treatment. The good news is that there is more racial and size diversity in advertising, including plus-size models. I will explore what social workers need to know about multicultural and gender competency in eating disorders.

The body positivity movement is helping people focus more onhealth and self-acceptance than the number on the scale. People arepracticing conscious eating by listening and responding to their stomach’shunger, not to an external diet. This is a bold and courageous decisionin a world where restriction and anxiety about calories have ruledthe day. I will explore what social workers need to know about thevicious cycle of bingeing, purging, and starving that dieting promotesand how to teach our clients to get off this destructive roller coaster.

New medications to alleviate the depression, anxiety, and obsessivecompulsive and bipolar disorders that so often afflict emotional eaters have become more effective; this demonstrates how an eating disorder is as much a biological problem as an emotional one. This book presents information that social workers need to know about the latest medication updates.

From my perspective, the most heartening evolution over the past decade is that psychotherapists are less constricted by a posture of reserved detachment in which the therapist is the all-knowing expert and the patient is the passive recipient of the therapist’s wisdom. Psychotherapists have become more interactive and more “real” and not afraid to have a deeply human connection with their patients.

In my own psychotherapy practice and supervision of social work therapists, I encourage the collaborative partnership that clients and therapist create. When tears and laughter abound in sessions, eating disorder clients are enlivened to become more vibrant and genuine with their thoughts, feelings, and imaginations. Our authenticity helps undo the pain of early attachments that led many of our clients to learn that trusting food is safer than trusting people.

In Part 1 of this book, I will explore the inner world of the emotional eater: attachment theory, how to conduct an eating disorder evaluation, how to blend psychotherapy and behavioral–cognitive strategies, the role of medications, and the ingredients needed for a healing therapeutic relationship.

In Part 2, I will discuss how the clinician can develop multicultural, gender, and social media competence. Literacy in these three areas will bring us a deeper understanding of the impact that this outer world has on the eating disorder patient and how to intervene to modify the harmful effects.

This is a book about hope: hope that as we clinicians become more empathically attuned to our clients, they will come to trust the nourishment of human relationships as a way to blossom and heal their inner selves. May our clients come to appreciate and claim their hunger for connection and their hunger for life!

*All case examples in this book are true and based on hundreds of actual persons. All names and identifying details have been changed for confidentiality. These cases are presented in the hope of illustrating the heartbeat of what it means to connect with the inner, authentic core of eating disorder clients.

*That eating disorders are usually a shameful and solitary behavior complicates accurately calculating statistics on eating disorders. Men often consider this a female disease, which leads statisticians to conclude that the number of men with eating disorders is probably much higher than the statistics claim. And many sufferers may be on the spectrum of eating disorder behaviors without having a bona fide diagnosis from the fifth edition of the Diagnostic and Statistica Manual of Mental Disorders (American Psychiatric Association, 2013).

*The earlier in life that children become self-conscious about their eating and exercise, the more likely they will develop anxiety about their weight and develop restrictive eating habits. Childhood should be a sacred and carefree time to explore the enjoyment of moving one’s body for pure pleasure (Smolar, n.d.).