Dr. Lissak's Treatment Plan

The Dangers of “Healthy Eating,” Part V

2012-01-27T13:09:00.000-05:00

It's worth spending a little more time on this exclusive club, those who purport to have willpower and self-control in spades. This group has the current ideal relationship with food, one largely innate, that many people will do almost anything to replicate. Examining them more closely yields knowledge about what is considered the goal of the compulsive dieting and weight loss and what is valued by a society with unlimited food.

People capable of a mostly rational approach to food, and devoid of the base urges to eat, also tend to fit a general personality type. In other words, the ability to resist the cornucopia of food in the modern world appears to come with a set of inborn traits, ones for the moment considered enviable, not an iron will. The traits in question include perfectionism, inflexibility, rigidity and, at times, a tendency towards self-punishment. Not only does this kind of person thrive on delayed gratification but often has limited capacity to enjoy the food, once finally allowed, much at all. Typically, food is a repetitive even monotonous daily chore performed with limited pleasure but instead dependent on mundane ritual. This way of eating most resembles the food as a utility model. Even when offered every possible delight, no food is a treat. Instead, the abstemious eater, completely uninterested in anything the food industry has to offer, exists outside this basic pleasure of human life. At its worst, the rigidity can lead to disordered eating or even anorexia, but the desperate overeater, after years of unsuccessful dieting, often sees this lifestyle very differently. To them, it's impossible to see abstemious eating as the door to a joyless world or an eating disorder as the horrendous and wrenching prison it is. In fact, many lifelong dieters wish all necessary food intake could come in a daily pill and want to totally eliminate meals from our existence. If the endless diet and concomitant weight loss are sacrosanct, then a life devoid of the pleasures of food isn't miserable. It's the newest ideal, perhaps the current American dream.

To learn more about the abstemious eater, it behooves the curious to ask the obvious: what do they eat? The answer isn't so obvious at all because it's a trick question. No one is going to follow a member of the club around and log their daily food intake. In fact, no one even asks what they eat. It turns out that what they eat is irrelevant; the perception of what they eat is what matters. What stops the actual inquiry is fear either of being shamed in comparison or of becoming hopeless after seeing the impossible, depressing meal plan in it's entirety. Left without any real information, the curious happen upon an answer based largely on perception: what would an extremely knowledgeable--from years of reading diet and nutrition books--dieter presume a pleasure-free eater to eat. Thus, there is no need for the idealized group to flaunt its superiority (or even mention anything about how to eat), for it's accepted without question by society as a whole. No one wonders or even cares about how unpleasant and joyless an abstemious eater's food life might be. No one cares what they actually eat. As is typically the case for an idealized group, perception trumps reality.

The fundamental perception of an abstemious eater's daily food isn't hard to figure out. A few years into chronic dieting and nutrition education, even the most optimistic dieter realizes that there is no magic solution. On reading assorted nutrition guides, from the extreme diets to the practical to the solely educational, the same information surfaces again and again: more vegetables, varied diet, fewer processed foods, whole ingredients, home-made food. The sage advice turns out to be obvious; there is nothing complicated about choosing a nutritious diet. The problem lies in the application of basic knowledge. The deeper drive to eat, especially the tasty morsels produced by the food industry, easily supplants the best intentions, thus the birth of the myth of willpower. Because nutrition education is so ineffective, most newfangled ideas simply tweak the facts enough to create a new, sure-fire, and hopefully best-selling diet. The public's insatiable appetite for an easy fix opens a market for meal plans that either subtly alter the specific amounts of the nutrition building blocks--protein, fat, carbohydrates, minerals, vitamins, etc--as the core of success or boldly find a new culprit for failed diets and eliminate it, the dreaded carbs being the current food villain. Even if purely unsubstantiated, any new fad can become popular when nothing works. The only thing the diets have in common is food restriction, necessary for any weight loss.

Even the most hard working, diligent dieter will forgo the diet fad and failure cycle after a time. The process is so demoralizing that the next step is usually a period of total hopelessness followed by a resurgent desire to truly understand why each diet fails. All signs first point to a lack of willpower, a myth that saves the diet industry from facing its own shortcomings by placing responsibility on the individual. It is much too easy to sidestep the fact that upwards of 95% of diets fail. The next logical step is to return to the perception of an abstemious eater's diet. After a life of education, it's clear that the answer, of course, is "healthy eating."

Ask anyone what healthy eating is and see the looks you'll get. The gist of any response is how can you not know? Isn't it a given for anyone, especially a parent, to know how and what to eat? It's one of the most basic things in life, like sleeping and walking. Like breathing! Hold on, is this a test? Are you asking if I know what healthy eating is? Really you must know what healthy eating means?

Yes, the reactions range from dumbfounded to incredulous to insulted. But what happens if you probe deeper? It turns out that although the most basic, general rules may be close to universal, once you get to specifics, the answers run the gamut. Anyone can list off the basic rules from nutrition guidelines, but they are of little help day-to-day in the real world. Tackling the real questions is simply overwhelming. Can you eat processed sugar? When and how much? Are snacks ok for adults? For children? What kind of snacks? How much does food really need to be organic? What do you think about all of the "healthy" food labels? Do you look at or tally the nutritional information labels on food? How much carbohydrates or fat or protein is too much, or even too little? Is it necessary to monitor daily salt intake? What to do about dessert? Is having dessert every day ok? What kinds of dessert? Should dessert always lead to guilt? Is dessert always a "bad" food? Are there even good and bad foods? The questions abound and quickly exhaust even the most patient and thoughtful person. If the abstemious eater follows "healthy eating" and the food rules are endless and unanswerable and the so-called experts often support misleading or flat-out erroneous information, then can anyone actually define what healthy eating is? Or is it possible that nobody really knows how to manage the world of plentiful food? Are we all left to fend for ourselves?

Part VI next

The Dangers of "Healthy Eating," Part IV

2012-01-18T15:37:00.002-05:00

It wasn't long ago that modern medicine purported that 90% of the brain was unused, a spectacular assertion to conceal our almost complete ignorance of brain function. The rapid rate of research in the past two decades has since shown how much there is to learn but also left us in awe of our own internal computing capacity.

Without a more complex understanding of brain function, computers, ironically, serve as the layperson's most apt and comprehensible analogy for how the brain works. Many people still see computers as more powerful, valuing the brute force of swift computation over the sophistication of the brain's learning, memory and recognition prowess. What is most appealing about a computer is that what you see is what you get. Ask a question and you can easily get an answer. Use an app and the function is clear. By comparison, the vagaries of what actually occurs in our brain remains very hazy.

In truth, incorporating the knowledge of brain function into modern life is a challenge. The unique element of being human is our self-awareness: a topic addressed by philosophers for centuries. It is our blessing and our curse. Forced to face the reality of human limitations, a uniquely human experience, people have endlessly searched for comfort through religion, power or substances, to name a few of the largely ineffective solutions. In our current world, much of the comfort stems from a sense of direction and purpose, or more succinctly self-determination.

It's a modern-day myth that hard work and confidence can lead to success. Underlying this goal is anyone's ability to harness their mind for a single purpose; ultimately, we are in control. The most confusing and perhaps most disconcerting realization is the concept that the majority of our brain functions unconsciously. It is preprogrammed to push onwards and, much like the heart, function completely out of awareness. That's fine when we are discussing the gastrointestinal system or neurological reflexes, but it's disturbing to many when it concerns problem solving or personal relationships. To think of our brains more like computers means the triumph of self-control and willpower over the unconscious, automatic brain systems that keep us alive and well. Many people feel lost without self-control as the ultimate tool. But that makes the true implication of brain science tough to process. If 90% of our brain power has been in use the whole time, just not within our awareness, then who are we?

The general consensus that individual motivation and conscious decisions should dictate daily life has clear implications in addressing weight and food. In this scenario, willpower is everyone's default excuse for diet failures or eating lapses. In fact, the general credo is that willpower, along with some common-sense knowledge about food, is the only way to manage eating when surrounded by excess. And this commonly held belief is the central building block for all of the marketed schemes to manage eating. Gladly, industry will capitalize on our willingness to accept that diet failures are our own fault! It's too easy to vilify the companies making a profit and not recognize the larger need to believe that the perfect diet or ideal weight management solution is just within our grasp. That's not to say we should blame ourselves, but that the alternative explanation, one that incorporates innate responses to food and the limitations of sheer willpower, remains too much to handle. A more reasonable food plan with moderate results that still demands substantial effort has little appeal. The goal is a quick fix with miraculous results, short-term effort followed by a return to life as we know it. This construct, created by individual desire as much as industry, ensures the repeated failures of any new eating scheme and the continuation of society's obsession with how to eat. We all unwittingly believe in the newest, wholly unproven diet and accept that its failure is always our own fault.

Questioning the willpower hypothesis can infuriate those who have spent their adult life bouncing from diet to diet. After years of obsessing about weight loss and dieting, no one wants to believe that the way we eat and what we weigh is largely predetermined. Who wants to think the endless dieting has all been for nought? These naysayers point to the segment of the population that seems to be able to eat when hungry and stop when full, despite access to plentiful food, and say these people have it all figured out. If they can do it, then anyone can. It's just a matter of self-control.

It's not hard to find a member of this group, especially one who is smug enough to think they have all the answers, that their own relationship with food is the solution to the scourge of obesity. The lack of interest in, at least to most everyone else, typically irresistible foods may very well be a coveted trait today but sure isn't any sign of superior willpower. It's just one of the ways humans are born relating to food. Ask a member of this group what their trick is. Not one person can describe a conscious series of thoughts or actions to explain their formidable restraint. It is apparent that willpower is instead the other end of the spectrum of human reaction to food, a variation of the innate way people eat. The emergence of unlimited foods designed to appeal to our base desires reveals the range of human response, from insatiable appetite to a total lack of interest. There are evolutionary explanations for both: overeating in times of plenty triggers fat storage and protects against famine; and delayed gratification leaves excess food for external food storage for the future. Both biological reactions to times of plenty are beneficial. The fundamental challenge is to recognize how we are all hard-wired to respond to the current food environment. Accepting the fact that we are preprogrammed to eat in a certain way is a very bitter pill to swallow. It's anathema to self-determination, that our brains function independently to dictate how and what we eat; or that the availability and quantity of food sets up many, if not the majority of people, to struggle with food; or that no diet or food elimination is the cure for eating in the modern world. So instead we live in the communal delusion that willpower is the final salvation, self-control is just a state of mind.

Part V soon to follow.

The Dangers of "Healthy Eating," Part III

2012-01-06T16:01:00.002-05:00

What is a person faced with an endless supply of food to do? The varied answers to this question have become increasingly important as first world countries buckle under the medical and social problems the world of plenty has produced. It seems so obvious that, with food shortage practically a relic, regular meals and snacks could be such a routine part of our day that food might become taken for granted as a utility, paid and consumed monthly like the electric bill. Some people even dream of a pill taken once in the morning that would provide all the nutrition for an entire day. But our minds and deepest desire to eat just won't comply. No matter the collective belief that overeating has become a public health hazard, for some akin to smoking a few decades ago, even the most clever ad campaign, junk food tax or industry regulation can't override our innate response to all this food. And as obesity, eating disorders and disordered eating wreak havoc with people's lives, society works on an intellectual fix to a deeply embedded, old brain, instinctual problem.

So, in a world overrun by media and overly reliant on the power of our intellect, the average person just can't find a way around the deep desire to eat. In fact, while the messages, whether subtle or overt, around us imply that a solution to eating is always within our grasp, modern life regularly sabotages any real chance of doing so. Alongside the photoshopped magazine covers of impossibly tall, unblemished, emaciated models lie the tantalizing tidbits thrown to all the normal looking people: lose ten pounds in a week!, the best way to avoid those carbs, three tips to the abs of your dreams. But what happens when the reader flooded with the ideal of skinny and easy weight loss looks up from the magazine? The world around them is all food all the time, be it at the office, at home or walking in the mall. Modern life pits the intellectual desire for thinness with the enormous supply of delectable goodies. And it is absolutely clear which drive wins out.

The hard truth is that the game is rigged. Yes, the medical community and public health system both know how personal struggle with food is the first health problem shortening average life span in several generations, but several large, powerful industries rely on both over consumption and chronic dieters to thrive, and they continue to dominate the discussion. The end result is that it's hard to find the motivation of society at large to alter how we eat. The diet industry, self-help books, reality TV and fashion magazines all profit from the unfulfilled desire to lose weight. Although the promise of weight loss abounds, scratch under the surface and it's clear no diet has ever shown any meaningful, large-scale success.

Tackling the impossible task of corralling our impulse to eat has preoccupied many of the brightest minds today. The diet industry floods the market with new options regularly. Despite the reputable data that diets fail over 95% of the time, the weight-obsessed, desperate to seize upon the newest hope, jump on the latest weight-loss bandwagon, lose weight and then promptly gain it back, and more. Many diets now include food products or even food delivery options in order to boost profits. The explosion of books which, with no scientific or medical basis, purport to have discovered the solution to managing hunger and weight, either through altering food choices, elimination of certain food groups or an often fabricated understanding of human nutrition or metabolism, has no end in sight. Not only does a successful theory capture the attention of a public starved for an approach to the world of plenty, but even the medical establishment will accept a popular new theory as one of its own. Similarly, a growing branch of medicine, from internal medicine to mental health to surgery, takes on obesity and weight loss. Not only are the masses of overweight people willing to trust their doctor to solve the diet dilemma quickly and easily, but doctors are more than willing to promise the short-term fix, through temporary, potentially harmful medications or surgery with dubious long-term results.

A public health campaign to educate the public about the reality of a weight loss program--challenging lifestyle modification that provides moderate but long-lasting success--is, at the moment, in no one's interest, and in fact could damage several industries whose profits rely on the general public never learning that the advertised weight loss schemes don't work. Some programs are small enough to escape the powerful lobbying organizations in Washington. The worthy government-sponsored programs--such as the Move Your Body campaign by Michelle Obama and the FDA changes in diet recommendations--and growing Farmer's Market movement are just sideshows to each person's futile struggle to monitor food intake and weight.

After years of frustration, people tend to give up on the great hope of a speedy solution and settle for the daily internal struggle. The growing sense of failure and hopelessness becomes a way of life. They seem to be holding out hope for the missing ingredient the diet industry, self-help books and doctors all say will lead to success: willpower.

Nestled comfortably between pop psychology and the latest weight loss guru manifesto, willpower is everyone's default excuse for diet failures or eating lapses. In fact, the general credo is that willpower, along with some common-sense knowledge about food, is the only way to manage eating when surrounded by excess. And this commonly held belief is the central building block of all of the marketed schemes to manage one's eating. Capitalizing on our society's desire to ascribe the regulation of basic human function, like food and weight, to a purely intellectual and cognitive mechanism ensures the repeated failure of any food management suggestion. We all unwittingly follow by accepting the premise that the failure of a wholly unproven method to work is always a lack of willpower.

Part IV will address willpower.

The Danger of “Healthy Eating,” Part II

2011-12-28T14:58:00.002-05:00

The flexibility of human metabolism is an evolutionary adaptation, one that conferred longevity to individuals to withstand food shortages and thereby helped ensure the species' continued existence. In a relatively stable environment, survival of the individual depended on a combination of luck and beneficial genetic traits, but survival of a people relied on the traits alone. Only a catastrophic event could throw a species into instant turmoil. Natural disaster, a new, lethal disease or a more global phenomenon like an ice age might upend the order of daily existence. In those moments, a random genetic advantage, rather than a long-tested one, determined an individual's and even a species' fate. These monumental events were, in the past, always acts of nature. Never before have people been able to drastically change the environment enough to create our own cataclysm that directly challenges our built-in survival mechanisms. The unimaginable changes in food production and supply in recent decades has done exactly that. The world of feast and famine, deluge and drought no longer exists in the first world. Now, as if by a miracle of fate, we all live in a perpetual world of plenty. But our current good fortune is no stroke of luck at all; it's simply an advancement of civilization.

Since the start of the industrial revolution, human capacity and ingenuity have tackled one impossible dream after another: electricity, transportation, even space travel. One less celebrated triumph is in the agriculture and food industry. The impossible challenge was to feed an ever-increasing number of people. The explosion of the human population--recently surpassing seven billion and with no indication of slowing down--especially in the growing urban centers necessitated a grand revision of food production and distribution, at least in the prosperous first world countries. Agribusiness, large food conglomerates and national supermarket chains made feeding the growing population possible, and then some. America produces almost twice the needed per capita amount of food, measured in calories, the country needs. The application of efficient farming techniques, food manufacturing--largely from creative uses of corn--and innovation in food transport is a marvel of the past half-century. These industries, currently vilified for their complete disregard of the public health effects of their products, began with a more progressive motive, to supply affordable food to the masses, and have succeeded beyond anyone's wildest dreams. What is now commonplace in a supermarket--Chilean grapes, choice of any baked good and canned food that could feed a small army--was as unlikely as the fantasy world of 1984 only a few generations ago. Although the national debate over obesity has taken center stage, that's not a reason to ignore another achievement of industrialization.

Depressingly, the people enduring regular starvation--from sub-Saharan Africa to North Korea to those suffering from anorexia nervosa--have evolution on their side, not those who live in the land of plenty. The body has built-in mechanisms to survive long stretches with little food. Much as the electrical conduction system of the heart, the neural "wires" that produce each heartbeat, has several backup systems when the front line breaks down, digestion, metabolism and energy production can run on emergency as well. The eternally well-fed, if not overstuffed, have no such internal regulatory system to rely on. That's how a man-made life-changing event--limitless food supply--has overtaken our adaptive ability to cope. The premise that humans can override our instinctive reaction to food has proven largely to be false, as the sharp increase in childhood obesity and eating disorders can attest. Our internal food and weight regulatory system is thoroughly confused by the interminable excess food intake and availability. The physical effects in just a few decades, to both young and old, act like our own self-inflicted catastrophic event. A system that once ensured human survival now threatens our health and well-being. The easiest way to understand how the system has gone awry is through the adaptive, and maladaptive, ways our body reacts insulin.

Insulin is a hormone that regulates the transfer of energy from the blood supply to the rest of the human body. Food first needs to be digested in the stomach and then absorbed from the stomach and small intestines into the blood supply. After that, it's up to the endocrine system, primarily insulin, to distribute the energy to different parts of the body, to short-term storage--an easily accessible carbohydrate called glycogen--or to long-term storage, fat. In the normal ebb and flow of feast and famine, this regulatory system worked beautifully. The body monitored both energy needs and food intake, and the endocrine system released insulin to maximize the health and longevity of the body through lean and plentiful periods. Weight and metabolism, variables modulated by the endocrine system to maintain health, shifted accordingly. Most importantly, they are not end points but flexible components that fluctuate with the body's needs, not at one's will.

With the advent of limitless food supply, the well-honed system has gone awry, and the rise of childhood diabetes is a case in point. A generation ago, childhood diabetes, caused only by the inability to produce insulin, was to be differentiated from adult-onset diabetes, caused by insulin resistance-- slowed or limited reaction to the release of insulin--an effect of age, or more often weight gain. The public health problem of overweight children has made this nomenclature obsolete. Diabetes is now separated into type I, no insulin production, and type II, insulin resistance, and the unfathomable diagnosis of type II diabetes in children, with the same treatment and long term medical outcomes as in adults, including amputation and kidney failure, is now run of the mill.

What has condemned so many children to the early fate of an adult, debilitating disease is the world of plenty. Left to fend for themselves among the fast food chains, ever-present snacks and vending machines at school, children take in much more food than their bodies need. A child's metabolism no longer faces times of famine or drought, so, exposed to the inability of human metabolism to compensate for persistent, increased food intake, the inevitable cycle of weight gain and overeating continues. As in older adults, obesity, in those susceptible, triggers the onset of type II diabetes. Metabolism could rise, fullness could be triggered more quickly, hunger could wane, but the endocrine system doesn't work that way, for coping with a land of plenty never happened before. Nothing stops the overweight, diabetic child from continuing to eat. No such evolutionary adaptation exists.

The rise of eating disorders--as a general phenomenon, rather than the suffering of one individual--is a different but equally maladaptive response to a world of plenty. Although the ideal female form has, in previous times, been very thin, never before has the entirety of a population encountered this desired body shape and the world of plenty simultaneously. The push-pull of willful food restriction and limitless supply of any food imaginable has tested the human food regulatory mechanism and exposed its weaknesses. The response to starvation, namely slowed metabolism followed by obsessive hunger, is a powerful evolutionary adaptation and almost always wins. The end result, for the majority of dieters and people with eating disorders, is periods of overeating or binging. Repeated attempts to starve only strengthens these internal responses. Surprisingly, years of restricting food intake, even when interrupted by bouts of overrating, affects the body similarly to the overweight who have type II diabetes: their bodies become resistant to insulin. In this case, the body refuses to increase metabolism after years of starvation and instead puts extra food intake into deep storage. Metabolism, and therefore insulin effectiveness, rises only after an extended period of regular food intake. Becoming immune to insulin and storing extra food as fat seems to be the only default reaction to eating patterns outside the norm. In today's world of plenty, it is highly ineffective.

The Dangers of "Healthy Eating," Part I

2011-12-15T09:18:00.002-05:00

Just walk through any main street, from the small country town to the big city, and it is evident that we have much, much more food than we could ever consume. The number of fast food outlets, convenience stores and supermarkets seems unlimited. The edible food waste of the First world could feed most, if not all, of the world's starving people.

But the larger realities don't change how each individual, still charged with feeding oneself, thinks about food. The now mundane choice, and for some the burden, of what to have for lunch among the wide options would have been a dream come true for humans through the ages. It is as if we have all become the wealthiest aristocrat with more food than we could ever consume, with every possible treat at our disposal. Yet this purported boondoggle turned out to be much more problematic than anyone could have guessed. Rather than creating a utopia, the world of plentiful food has left millions of people reeling without the ability to handle a seemingly basic fact of life, how to eat.

We are a species designed to live in a land with the natural ebb and flow of feast and famine, not in food heaven. A basic fact of human life for almost our entire existence, the worry of going hungry isn't relevant for an astounding number of people in modern life. The preponderance of food tempting our palate at every turn has completely perplexed our internal ability to regulate hunger and meals. Humans have been engineered to outlast famine and drought but have no clue what to do with an endless surplus. The newfangled coping mechanisms--ranging from arbitrary food rules to diets and, in more extreme cases, from eating disorders to Bariatric surgery--only highlight the futility of trying to outwit our fundamental instinct to eat to survive. But it is the least controversial and most widely accepted solution that confuses us the most. The next series of posts will address the effects of this insidious cultural innovation: the concept of "healthy eating."

In order to understand what's so ineffective about the concept of healthy eating, it helps to start with the current fascination with the human brain. The increasing knowledge about human's higher order functioning, such as consciousness and planning, mental constructs unique to people, has seeped into the mainstream. The unfortunate result is the expectation that people can think and reason their way out of any situation. When it comes to food, it is necessary to remember we have evolved from the same genetic line as apes and other mammals so the basest instincts apply.

Humans, like all animals, value survival of the species above all else. Enduring times of famine and drought was and still remains essential. Just as bears hibernate or squirrels store acorns for the winter months, people developed evolutionary adaptations, mainly an adjustable human metabolism and hunger drive, to weather more challenging circumstances. And that ability to survive, despite the creation of a world of plenty, trumps any intellectual means to manage food. Put simply, when it comes to food, basic drives override rational strategies. It is instructive to take a look at the basic biological reaction to times of need and times of plenty. An often used but misunderstood concept, metabolism, the utilization and dispensation of energy throughout the body, is the central tool to adjust to an ever-changing food supply.

A withering food supply triggers a cascade of physical changes: slowed non-essential body function, more efficient use of energy, steady breakdown of the body's energy stores and any extra food intake going directly to temporary storage. The swift transition in metabolism when times became lean is a key component to our longevity, otherwise humans would have become extinct many ages ago. The ability to survive famine is a trait deeply embedded in our genetic make-up. In other words, our bodies are built to survive starvation.

The same cannot be said about times of plentiful food. Those periods were, from an evolutionary perspective, mere blips in the calendar. The boom of a large food supply would never threaten humans with extinction so any adaptations are short-lived and limited in scope. In fact, these brief periods of plenty were, if anything, used to protect against the inevitable hungry times in the near future. Consequently, these were times of brief gorges while those more prone to restraint encouraged the tribe to consider external food storage, say for the upcoming winter, rather than rely solely on humans' internal ability to store energy.

After an extended period of overeating, the body will work hard to overcome the excess. Although the metabolic changes are the opposite of the starvation response, sped up metabolism and increased energy usage, the process is much less robust, and the body is willing to give up quickly and just store the energy as fat, fully expecting to need the backup shortly.

Stay tuned for part II.

Psychiatry and the Pharmaceutical Companies

2011-11-28T14:09:00.002-05:00

A patient of mine recently asked if all doctors are as gullible to the pharmaceutical companies’ marketing tricks as it appears. I was immediately transported to my days working in an academic hospital. At the time, the "drug reps," as they are called, used to have much more leeway to befriend and bribe exhausted and overstressed trainees eager for free food and a friendly smile. The companies knew better than we that our future prescribing practices were at stake. Falsely armed with a lethal combination of arrogance and naïveté, we medical residents assumed that we could toe the line as excellent clinicians while exploiting big pharma largesse. Even our respected mentors encouraged us to at least listen to the pharmaceutical information--advertisements disguised as clinical trials--while eating our free lunch. According to the hospital's motto, we were the "Best of the West" and that meant being fully capable of prescribing all of the newest medications, even if the only supporting data were generated by the drug company itself.

In the ten years that have passed, I have worked primarily in private practice. One of my first decisions was to eliminate all pharmaceutical company influence. I rebuff phone calls from reps every week, occasionally escort the brazen marketer, who appears unsolicited in the waiting room, to the door and regularly ignore invitations to dinners at some of New York's posh restaurants. In the meanwhile, I have also disregarded the bulk of clinical trials studying the newest drugs, even in the prestigious journals, since most of the funding for this research continues to come from the pharmaceutical companies themselves.

During my training, I believed I was simply acting according to my beliefs. Unlike many of my colleagues, I never believed I was immune to these sophisticated marketing techniques, and I wanted to practice apart from from these influences. What has surprised me through this past decade is the transformation of my prescribing practices. First, I have raised my threshold as to whether or not to prescribe medication at all. In an age when medication is supposed to cure all our ills, the default decision of a psychiatrist is to medicate and always medicate. It is liberating to know that prescribing is a clinical decision, not an automatic action. I also take into account variables never mentioned by a pharmaceutical rep: long-term safety data, years of efficacy with substantial independent research, and, finally, price.

Accordingly, I face the challenges of practicing psychiatry in a very different way. I have gravitated to routinely using medications that came on the market over 20 years ago because the safety record is proven and therefore puts patients and me at ease. I avoid new medication combinations and instead choose older, more thoroughly studied options, such as thyroid medication for depression--a treatment which has safety and efficacy data starting from the 1950s. I also weigh price into the equation both for my patient's pocketbook and to measure my small footprint on the explosion of health care costs.

The uneasy marriage between academic medicine and big business has had significant costs to medicine as well as to society at large. Physicians, by nature, are not business people. In recent years, several highly-esteemed physicians have been caught lining their pockets with pharmaceutical payouts while using their reputations to successfully sway doctors' prescribing practices. Clearly, no one is immune to such cutthroat and well-practiced marketing schemes. Left to their own devices, insulated from sales pitches cynically disguised as education, doctors might find alternate ways to differentiate between the true goals of a healing profession and the hidden influences of the marketplace. Protecting young doctors from powerful marketing influences early in their careers could have long-term safety benefits and help rescue the medical profession from the aura of skepticism and distrust that has come to surround it.

The Recovered Treating the Ill: Why so many Clinicians had Eating Disorders Themselves

2011-11-18T13:35:00.000-05:00

The clinicians who treat people with eating disorders have often themselves suffered from anorexia or bulimia. Little has been written about having the recovered treat the ill, but informal conversations quickly reveal strong reactions from patients and clinicians alike. In fact, many programs and individuals fall in one of two camps: those who think only someone who had an eating disorder can be an effective therapist and those who think that this creates a community of people who never get well.

Although everyone's goal is successful treatment, there is something about eating disorders that generates emotional and even political factions. The confusion only grows deeper as these illnesses burrow further into the modern ethos. The multiple possible causes, limited therapeutic options and endless debate of disease vs. lifestyle choice opens the door for multiple, unsubstantiated and fractious theories.

The movement for the recovered to treat the ill has a clear precedent. Addiction treatment has been notoriously challenging and largely unsuccessful. Alcoholics Anonymous, a peer sponsored, ongoing support network with a clear program and 24 hour system provides what no treatment option can. The components include a group of people like-minded in the desire for recovery with similar experiences and a formula for success. Most important, when an addict feels the craving, there are many people only a phone call away.

Similar to addiction, it remains very difficult for people without eating disorders to understand and have compassion for the incessant mental torture of these diseases. Trying to live in the world while struggling to eat at every meal creates a very isolating existence. The deep sense of loneliness and separateness of the recovery process experience remains a barrier to getting well. The psychological and emotional pain often makes the potential relief of the eating disorder symptoms irresistible.

Understanding why eating disorder recovery is such a lonely experience is very hard. However, everyone can identify with the actual feeling of being alone. One irony of the human condition is that the feeling of being alone in the world is universal. How can we all share together the reality of being so alone? Although feeling part of a group always alleviates this ill, the relief is always fleeting.

In the eating disorder community, the banding together of the recovered and the ill creates just such solidarity. A group of people whose experience runs the gamut from very sick to fully healed can embody the entire scope of the process in one room and generate hope in a way that is at the core of any successful treatment. Seeing a therapist who communicates hope just by being there and saying "I am well" can change the tenor of recovery. In the throes of the daily struggle to eat and get well, a daily reminder of hope is invaluable.

There is one critical, potential pitfall. In any group with people still quite sick with an eating disorder, the internal drive back to starving or binging remains strong. In the face of powerful forces that everyone in this group has experienced, there has to be a constant, overt undercurrent that recovery is the goal. This may seem obvious but many well-intentioned groups have succumbed to the power of relapse. The fundamental notion, borne out of AA, is to respect the disease. As long as even the members with the longest recovery acknowledge the risk of relapse, the group as a whole will remain on track.

What clinicians without an eating disorder provide is perspective. Treatment acts as a bridge from sick to well and from isolation to connectivity. To exist in a therapeutic environment simultaneously without judgment and with the luxury to be fully honest liberates a patient from the prison of an eating disorder. Nestled solely in the arms of the recovered, a patient will remain scared to be in the world. A clinician from the outside can help that person learn how, even with the history of an eating disorder, to be in the wider world.

The community of practitioners--the recovered and the outsiders--need to stay together. The treatment of eating disorders need not be a political battleground between the afflicted and the perpetrators. It need not foster the endless debates of illness or imposed prison. Yes, the social forces behind the steep rise in eating disorders in recent decades are polarizing, but it is the clinician's job to heal. Let's put aside the disparate motives and agree that there are many, many sick people in need of help to get well.

Talking Fat and Thin with your Kids, Part II

2011-11-09T14:18:00.002-05:00

It's a parent's job to translate a child's words and behaviors and then figure out how best to respond. Without the benefit of clear language and emotional regulation, children make basic comprehension of their actions difficult. In this day and age, a child's statement of "I feel fat" is just such a challenge.

Parents tend to interpret children largely based on the prevailing life philosophy. Following the most popular parenting books through successive generations is a great way to learn about the evolution of kids' expected roles in society. Parents, more often than not, will gladly accept any advice offered, so parenting guide books tend to be popular. Raising children is too daunting a task to leave parents with much energy to argue with the supposed experts. As the philosophy seeps into a generation, kids are gradually assimilated into their culture.

The current mode of healing in any day and age strongly influences the approach parents use to comprehend a child's baffling reactions to daily life. Often the most trusted member of the community is the designated healer.

The concept of therapist as healer--an ignominious status passed down from shaman to minister to psychoanalyst and now to therapist--has had a profound effect on how we live our lives today and, in communities focused on youth, how parents treat children.

Therapy, taken as a whole, presents many theories that can be used to understand children. There is a vast therapy literature that explores a child's use of play and transitional objects and another that focuses on the conflicts that arise in each stage of maturation, but the lay person's current takeaway message from a world of therapy is very different.

The current parenting book is now an adult-centered self-help paperback. A quick and easy read with a few throwaway lines you forget within an hour or two. Rather than interpreting a child's behavior as a clue to their current needs, the premise of these books is to wonder what might be going on in their little minds, as if they are just small adults.

Children no longer have the free pass of just being kids. The endless stream of self-help mantras and boiled-down therapy nuggets has led parents to apply adult advice to a growing child. Kids are now mistakenly seen as little grown-ups with mature motivations and emotions and are regularly misunderstood.

The over-analyzing and rationalizing of a child's behavior leads parents to ascribe sophisticated motives to the haphazard flailing of an animal that is all id. The bygone world less preoccupied with a child's inner workings left kids to their own devices to sort through personal development and hoped for the best. Now, watched at every turn, kids have each moment scripted practically from birth.

The end result is little freedom to engage in play and experiential learning and little time for a key part of childhood, self-exploration. At activity after activity, kids perform a task and search an adult's knowing gaze for approval. Kids don't flounder in the feeling of insecurity and confusion; there is no time or reason for that. They have been trained to look to the adults in their lives for signs not only of how they're doing, but of who they ought to be.

Treated as mini-adults and left little space for development of an identity, kids have resorted to adult language--such as "I feel fat"-- to try to express any sense of unhappiness. Because kids are seen as little people, parents and clinicians alike are apt to treat a child's comment about feeling fat at face value. The two possible interpretations undoubtedly magnify and sometimes even create a problem that was never there.

One option is to actually believe the child and put her on a diet. This step, meant, in therapist lingo, to validate the child's worry, only confirms that she is fat and encourages the descent into an eating disorder.

The second is to be the proactive parent and treat this comment as if the child already has an eating disorder. Unbeknownst to the worried adult, children have little ability to distinguish between looking for a problem and having one. Thus, the child will now believe that, magically, one statement itself is enough to constitute an eating disorder.

Just as the eating disorder treatment adage "It's not about the food" explains, this isolated comment is not about feeling fat. One of the biggest challenges with children is that they don't have the ability to express what's going on inside them. It is the privilege of adolescence and young adulthood to learn how to meld our emotional and rational worlds. And the truth is that doing it well is a life's work.

Often, in children, emotions come out in physical ways, like a headache or stomach ache, tantrums or, as in this case, copying the expressions of adults around them. So a parent, spooked by this comment, has to table the initial fear. Any emotional reaction by an adult will spark the child's interest, the opposite of the desired response. Just asking the child what's wrong will get you nowhere. Saying "I feel fat" was all the child knew how to say. This is a situation for the parent to do a bit of sleuthing to understand what's going on.

The first thing to look at is the child's behavior. Kids really at risk will be restricting food, secretly binging or obsessively checking their bodies, even as young as age five or six. If the only red flag is "I feel fat," without any eating disorder behaviors, then this comment is very unlikely to represent the start of an illness.

After dismissing the worst case scenario, however, this isn't the moment to ignore the comment. Any child aware of the adults and media around them knows that feeling fat is a way to express that something is wrong. Without another way to say it, this child is using sophisticated adult shorthand to get someone to understand. This is an opportunity to poke around at school about academics or friendships, to talk to teachers or other parents and suss out what might be going on. That way, the child will see that you know there is a problem, even if feeling fat has nothing to do with it.

Talking Fat and Thin with your Kids, Part I

2011-10-28T10:13:00.002-04:00

Although body shape and weight have long been a human preoccupation, things have changed since today's current parents were children. Yes, kids back then knew about thin and fat, but only when they saw it right in front of their eyes: a bullied peer or a body image-obsessed parent. These days, the abundance of processed food, the adoration of thinness and the explosion of eating disorders have created a world in which kids are aware of the many meanings of thin and fat at much younger ages.

The chasm between parents' memories of blissful ignorance and a child's premature exposure to the idea of weight creates a confusing scenario for families with young kids. Scared and perplexed parents seek out my advice when their young daughter starts to talk about feeling fat. Although children routinely mimic the adults in their lives, and the result is often amusing, this example stirs fear in any parent.

Sadly, there is nowhere to turn for reliable guidance. Most reassurance from friends or a pediatrician blends platitudes with unfounded opinion. Often, the advice given to parents is to put the kid on a diet, or at least restrict certain foods. I can't count the number of patients I've seen who say that it was the first diet that started their eating disorder.

In order to guide these parents, I have found that the best approach is to place their worries within the wider public health problem of eating disorders. This step acknowledges the fears are real while pointing out that one comment doesn't constitute an eating disorder.

Their child is just playing with the adult concept of weight, something innocuous on its own, when taken out of context. And a child won't really understand the context. Once familiar with the scope of eating disorders, parents can return to their own child's behavior with some perspective and, consequentially, develop concrete, practical ideas to steer their child clear of a worrisome illness.

When I describe my practice, to clinicians and laypeople alike, the choice to treat adults with eating disorders, but not adolescents, perplexes even the most knowledgeable and open-minded. The first eating disorder image that comes to everyone's mind is the emaciated teenager, lost and alone. Surely, that's who I must be treating. The existence of a practice treating exclusively adults with these illnesses implies a much larger problem than most people could imagine.

Binging, restricting and purging remain a by product of adolescence to most adults, symptoms of a bygone age of inner turmoil and impulsivity, quickly outgrown with the maturity of early adulthood. The few who aware of an eating disorder's wider reach have generally been touched by the illnesses directly. The rest, without cause to understand further, just see the chronically ill as a group of misguided women without the will or desire to eat.

A new subspecialty, which has emerged only in the past decade, further reveals how widespread the problem has become. The incidence of children ten and younger diagnosed with eating disorders has skyrocketed, now at about ten percent of all cases. Hospital units designed for eating disorder treatment report rising numbers of young children as patients, and the clinical community is scrambling to provide adequate services.

This phenomenon generates sympathy and horror, but, from a clinical vantage point, these are new illnesses which clinicians are only starting to learn how to treat.

As I have written, the longer the course of the illness, the more difficult the recovery. The behavioral eating symptoms, the most obvious and most disturbing, are the mainstay of diagnosis and priority of treatment. All children must start the road to recovery with weight restoration and normal eating.

But the path after that is unclear. What precipitates a young child to develop an eating disorder? How is relapse prevented? These are the obvious first questions to ask and the ones critical to parents wondering what to do about the young child who feels fat.

Any clinician would agree that protecting these children vulnerable to an early diagnosis of an eating disorder is a priority. Exposure to our culture's weight obsession is unavoidable. Objectification of even a young child's body begins with idle adult comments or a first wearing of Gap skinny jeans, even for pre-pubescent kids. This is the world we live in.

Every child will grapple to make sense of the miasma of information and feedback that comes their way, but where is the line between normal psychological development and a problem? Keeping the broader context of eating disorders in mind, I'll try to answer that question in the next post, part two of talking fat and thin with your kids.

Dessert and Children: The Final Frontier of Food

2011-10-14T12:27:00.002-04:00

Few issues generate more confusion and disagreement among parents than dessert. That extra little piece of chocolate or candy is the bane of many a parent's existence, and the true moment of success for a child.

These kids know how to get what they want. Adept at reading their parents' cues, they will home in on any ambivalence about dessert to cash in on the reward. In that moment ripe for exploitation, kids will pounce on the adult who, unaware of the ambush, soon relents and allows the desired treat. And why not? The pestering inevitably gets kids more sweets and they love it.

So it's no coincidence that nothing elicits more whining and crying than being denied dessert. Every meal, snack or even moment of downtime is a child's opportunity to scavenge for ice cream or a lollipop. A day with children can often feel like fending off one sweet entreaty after another until you've been worn down to a nub of fury. The final capitulation is all too familiar: "Fine! Do what you want! Eat every piece of candy in the house!" To a purely literal child, this is a simple, if angry, invitation.

An adult, after enduring this argument countless times, will sit down, rationally, and hammer out a dessert treaty. The results are predictable: a certain number of desserts is allowed per day or per week; perhaps one type of dessert is favored over others; and often the treat is linked to finishing a meal or completing a particularly onerous chore.

If only logic had a chance! Children can dismantle the best-laid dessert plan in minutes. Their relentless attack and single-minded goal undo a parent's good intentions almost instantaneously.

Just as with choosing a healthy family diet, a logical plan is only half the battle. Reaching an acceptable approach to dessert in the household may look like the solution, but, as children are well aware, every sweet rule is made to be broken.

The conflict between a child's developmental drive for autonomy and the equally strong need for security runs rampant in the daily dessert fight. It's the older kid's version of push me-pull me growing up.

The mind of a child hellbent on the prize represents nothing more than burgeoning independence. Something clearly deemed a treat, which also elicits an array of powerful feelings in an adult, is an irresistible hot button to a child testing the limits of parental patience. The wistful apology that follows the gorge is the requisite search for reassurance, saying, in essence: "Do you still love me Mommy?"

So the second half of the battle has to address the emotional conflict children see both in their parents' struggle with dessert and in their own developmental challenges. There are two critical steps to defuse the timeless family argument, which, although simple, are not particularly obvious to the frustrated parent.

The first step for parents is to tame their own dessert demons. Dessert is not evil or bad. It isn't something to be avoided like the plague. It need not trigger a level of guilt and shame that demands a weeklong diet or even a juice cleanse.

It is best to remember that the varied, healthful diet of an omnivore includes dessert. Like everything in this meal plan, dessert comes in moderation. No one thinks a nutritious meal is comprised of solely chocolate cake. Dessert, broadly defined, is a reasonably sized sweet after a meal or perhaps an afternoon snack.

The most powerful way for children to understand this concept is through action. What a parent does communicates much more to a child than what a parent says. In this case, that means sitting down to enjoy dessert with the children.

When a child sees you happily eat a piece of cake too, dessert starts to transform from daily family squabble to part of the routine. That undoubtedly takes away much of a child's ammunition. Without a parent's weakness to attack, the heightened emotions dissipate and the child loses interest. In today's world of food, one true gift from parent to child is to wrest dessert from its powerful perch as the ultimate sin and make it just another food.

However, children still do need dessert rules, even though they will immediately try to break them. As any law-abiding society can attest, rule enforcement is infinitely more challenging than rule creation. That leads to the second step to defuse the dessert battle: once parents create the rules, stick by the rules, most of the time.

Dessert has been the reward for childhood successes and the go to punishment for bad behavior for time immemorial. Kids live and breathe ice cream, candy and cake as the barometer of a good or bad day, and not only because dessert tastes good. The joy of pushing a parent to the breaking point and reveling in the extra treat is the real goal. Children get enormous gratification from pushing the rules until the parent breaks them.

In futile retaliation, the parent will then modify the rules to cover for their abject failure. In that moment of panic, dessert can magically be linked to any parental demand just so the adult can blindly reassert some power. Once the rules have changed, all children know the game is over. They have won.

Parents don't need to change the rules. They need to change the game. The answer is to approach dessert rules as a wise and thoughtful judge, not a hardened cop.

If the family dessert is laden with guilt and shame, thoughtless cop parenting is the only way out, but children know blind rule following when they see it. When dessert has become just another type of food, separate from punishment, reward or conflict, shifting the rules means something very different.

In the adult world, kids know that dessert can be a pastry for breakfast, something after lunch, midday or after dinner. The actual rules are arbitrary. They are guidelines to give children a way to learn how to eat.

The cop parent will follow the hard line: these are the rules and don't break them. A child finds that approach irresistible and will inevitably find a way to flout the rules. The wise judge parent will, unemotionally, follow the rules but can offer moments when the unexpected dessert becomes a regular part of life. That may involve stopping for dessert on a whim one afternoon or a special family dessert one evening. If these treats are emotion-free, the rules transform into guidelines, and the occasional deviation becomes a way to share something fun together.

An image that brings joy and a burst of nostalgia to many adults is the gleeful child, drenched in melting chocolate, licking an ice cream cone in summer. It is the rare adult who is able to replicate the same experience. Finding a place of sanity with dessert in the family can preserve these moments every child deserves.

The next and last post in this series will address how to discuss weight with children.

Healthy Food/Healthy Family?

2011-09-30T15:15:00.002-04:00

Anyone who has attempted to define healthy food knows how difficult a task it is. It's obviously better to choose vegetables over potato chips or grilled chicken over a Big Mac. But what about organic vs. conventional? How much meat is the right amount? What about fish, eggs, chicken? Is pasta a healthy choice?

Even after considering the endless questions, the prospect of planning a healthy diet (not to be confused with a weight-loss diet) is much more challenging when faced with the obstacles of daily life. Convenience outweighs healthfulness at every corner. It takes a surprising amount of attention and diligence to sustain a healthy meal plan.

Then, applying the healthy diet to a child or family vastly increases the level of complexity and the number of variables. As I discussed in the previous post, add in the child apt to reject food on a regular basis, and healthy food choice becomes, at best, secondary.

The underlying truth is that a healthy food plan is more a philosophy than anything else, and it has to be simple, convenient and easy if it's going to work every day. The best way to start is with a definition followed by a dose of practicality.

As the new FDA food plate suggests, a healthy diet starts with variety. Humans are omnivores which implies certain basic facts about our biological needs. There are many essential nutrients we must ingest since our bodies cannot synthesize them. We need certain building blocks such as the components of protein (amino acids) and fats (fatty acids) to maintain body function. We also need minerals and vitamins in small but finite quantities. In order to satisfy these requirements, a diet needs to be nutritious and varied. Filling your body with less valuable sources of energy such as candy, fast food or snacks neglects our basic biological needs.

Practically, this means that a healthy diet is one that fits our needs both in terms of calories and the building blocks of good health. It is too easy to get caught up in the maelstrom of assessing every morsel of food we eat. The daily chore of weighing the pros and cons of each item of food quickly becomes onerous. Either this approach becomes an obsession or is discarded. Instead, the healthy diet can't hinge on every food choice every day but comprises the entirety of what we eat over weeks and months.

These suggestions stray from the central theme of any popular diet advice: avoid a certain food group combined with calorie restriction. The goal of this type of diet is short-term weight loss. The goal of a healthy meal plan is a balanced, sane approach to food.

Similarly, parents encounter completely impractical ideas such as only organic food or wildly adventurous meals few kids will even tolerate on their plate. Any parent is aware of how impossible these suggestions are, but that doesn't stop the idealistic ones from trying. Even the most ambitious and best intentioned will falter regularly when faced with a hungry, demanding child and an evening schedule gone awry. The end result is a parent making the best choices in the moment but wracked with guilt.

The often ignored but essential piece of a family’s diet is the parent's sanity. The satisfaction of a day of organic, healthy, well-balanced meals is usually commensurate with a day of endless battles about food. But a day with more realistic food choices is generally a copacetic one. This is a perfect moment to use the wise adage, "pick your battles."

The most important concept to remember is that there is no perfect meal plan. Children will eat pizza, chicken fingers and fish sticks for dinner. They will eat chips and french fries and dessert. It isn't ideal to eat these foods constantly, but it's equally problematic to ban them from the family diet. Even if buying organic food is important, no child can possibly eat only organic food in this world. Each food decision is not critical. It is the overall meal plan that adds up to a healthy diet.

And parents have to remember that our own food choices reflect the world we live in, whether we like it or not. This means supermarkets selling products of large food companies, agribusiness and false marketing of food with dubious nutritional value to children. Not only do kids need a healthy diet, but they need to learn how to live in our current world of food.

Armed with the general concepts of variety and practicality, a parent faced with the daily chore of feeding children can keep in mind the bigger picture. A balanced approach to food choice in this cultural climate will both keep children healthy and teach them what they need to know.

The next post will discuss perhaps the question I'm asked most frequently: what do you think about dessert?

The Timeless Struggle with Picky Eaters

2011-09-19T14:16:00.002-04:00

Most parents would, ideally, say that one goal of raising a family is to know your child in the deepest and most profound of ways. It seems both cliche in an age of obsessive parenting and patently obvious that there is no other choice.

Yet many parents would also accede that, for years, nuance and complexity of the child are summarily ignored. Instead, the database about said child grows from endless comparison with other children. So a parent accumulates information in binary form: good sleeper/bad sleeper, obedient/oppositional, engaging/shy. That paradigm extends to food: good eater/picky eater.

As the data grows, any curious adult wonders what it all means. It's easy to accept and revel in the positive checkmark, but what about the less desirable chits? Should a parent accept these as a child's traits, work hard to eradicate impending faults, or assume personal responsibility for faulty parenting?

The recent trend in the psychological literature takes parents off the hook. The increasing weight on the nature component of the nature/nurture debate means adults aren't responsible for everything anymore. What a relief? Perhaps, except that this shift doesn't seem to apply to food.

Parents do have to teach kids how to eat and the role of food in our lives, but kids aren't a blank slate when it comes to eating either. Even though nature plays a role here too, that's not yet common knowledge. We still live in a world where a picky eater is undoubtedly the parent's fault. It's a lot easier to attribute delayed milestones like walking or talking to a pre-programmed developmental clock than to avoid self-reproach for a child only willing to eat cheerios, plain pasta and white bread.

In addition, there is nothing to dissuade lucky parents from taking full ownership over a child's accomplishments. And there is little more discouraging that the parent endlessly bragging about a child's accomplishments.

It's one thing if this is a nine month old who walks or the three year old reader. The the "each in his own time" theory can assuage the creeping worry.

But what about the three year old who eats sushi? Parents of picky eaters are going to have a much harder time absolving themselves of responsibility. Maybe the child needed exposure to whole grains earlier? Maybe the parent was too lenient about giving the same dinner every night, for a year? Precocious eating is practically a new developmental milestone, and picky eating a harbinger of that dreaded codeword: delay.

But, as I wrote in the last post, refusing food is a child's prerogative. It's how kids express themselves and fight to get heard. Obedience and a varied palate in a child says a lot about personality, preference and the adult-child relationship, but is certainly no sign of brilliance. One way to repackage the information is that all children are picky about something, and food, for many reasons, is an obvious and powerful option.

There are a few ways to approach picky eating. First, resist the daily fight! Nothing will entrench parent and child more than the expected duel at each meal. The child has the ultimate power to allow the food in or not. Any parent will be extremely frustrated by the regular food refusal and has to work hard to avoid forcing food or regular punishment. While repeating the mantra "no child will starve," the parent can place the plate in front of the child and just observe what happens. Yes, easier said than done but still the most effective strategy.

Some children may lose interest when denied the satisfaction of adult anger and just abandon the picky eater track. One possible result, though, of a more passive approach is a child pegged for many years as a picky eater. Considering that even limited diets in the Western world are more than sufficient to have a healthy child, family peace and normal development are much more likely if the child is allowed to assume that identity. Given some freedom to assert independence and exert choice on a regular basis gives many children peace of mind and allows family life to run more smoothly. Even these children gradually incorporate more food into their diet.

The most difficult picky eater emails I receive from families concern a child above age ten who eats perhaps three or four foods. The underlying fear is that these behaviors are the start of an eating disorder. There is no clear correlation between picky eating and eating disorders such as anorexia and bulimia. Any early warning of an eating disorder always comes with other psychological and emotional signs of distress that drive the eating behaviors.

The very rare case of a chronic, adult picky eater appears to stem from a physiological cause. Some variant of taste and preference leads these children to only be able to tolerate very limited foods. Although those foods may expand some into adulthood, a few of these children may maintain a fairly limited diet into adulthood.

For a child at risk, it's important for a pediatrician to be sure the child is healthy and rule out any underlying medical cause. Judicious use of vitamin and dietary supplements in addition to the limited but sufficient diet can keep the child healthy in the long run. Rather than creating a family crisis, parents are better off working within the limitations. As long as parents continue to gently offer new options and provide adequate food at mealtime, the child will be healthy, the ultimate goal.

As mentioned, the next post will address the tricky subject of healthy foods.

The Daily Feeding Ritual: Meal Time between Parent and Child

2011-09-09T09:24:00.002-04:00

I started this blog almost two years ago after receiving a series of emails from worried parents and grandparents about difficulties feeding their children. Those emails continue to trickle into my inbox, and I respond with some clinical advice and recommendations. The common theme of these entreaties remains consistent: how can you distinguish between the typical family power struggle and a nascent medical issue.

Even for an experienced clinician, these two things can be very hard to differentiate. Despite the fact that children are born completely dependent, the innate drive to assert independence starts, albeit unconsciously, in infancy. Refusing food may be the most effective way for a child to have an impact on the hovering adults. So the most common fear I hear about from parents is also completely normal childhood behavior.

Some changes in the modern world have exacerbated this dynamic. The family unit has become more and more isolated, and one result is that very few adults ever feed a child. It doesn't take a village to raise a child anymore, just a few tired grown-ups. With fewer adults bearing this load, the intensity of the parent-child bond has escalated accordingly.

The daily feeding ritual is the moment when the child gets an adult's undivided attention. This time consequently becomes a microcosm of the parent-child relationship as a whole, an opportunity for the child to try out a host of feelings and behaviors and see what happens. It's easy to see how this time can quickly escalate into a pitched battle between a recalcitrant child and frustrated adult.

The parent is charged with the responsibility to feed this child. Balancing the confusing and often contradictory information about nutrition and healthfulness with the task of getting food into a child's tummy is no easy feat. What is easily ignored is that the child's individual participation in the food ritual is a form of communication. The parent's inherent fear is unfounded: the child won't starve. Unless there is a clear and very rare medical cause, children are programmed to eat enough to survive. But that doesn't mean the child will eat when the parent wants them to.

Instead, the daily routine offers a child the chance to "talk" to the parent. When the parent really listens, the child's physical and emotional reactions can say much more than the child's ability with words. Even a verbally precocious child won't be able to translate abstract emotions into conversation for many years.

A parent needs to try to listen to what the child is trying to say and respond in kind. That doesn't mean pseudo-psychological babble, but it does mean, for instance, that a tired, cranky child might have trouble sitting through dinner that night and might need a new strategy not to melt down. To the adult, the goal of meal time is to feed the child. To the child, this is time to talk, learn, vent and play.

There is nothing easy about this process, and the rewards happen not over days but over months and years. However, the message sent from not listening to that child is loud and clear: no one is really paying attention.

For a focused, harried parent, the goal of feeding is just to complete the task and perhaps to educate about healthful foods and eating. Whether the obedient child complies or the oppositional one rails against the meals and rules, that child is learning many things through meal time, only one being what foods to eat and what constitutes a meal. The adult reaction to varied behaviors, moods, pickiness and food choices also represents how that child learns to see herself. These experiments aren't just games. They allow a child to figure out who she really is in this world. Parents' actions and reactions end up saying just as much, if not more than, their words.

There are many ways to react to the child who refuses dinner night after night or swallows the meal in three massive gulps or plays with food or turns the meal into a sibling fight. Over time, the family reactions become an expected social paradigm the child knows all too well. Food and meals begin to correlate not only with certain emotions and experiences but also with a reflection of that child's burgeoning identity. From this vantage point, it is artificial to separate food and healthfulness from family dynamics and emotion. The daily ritual of meal time melds quickly with the complicated task of managing the relationship with your child. Remembering this perspective can take away the urgency of of each meal and put the routine of meal time into the context of raising a child.

The fruits of this labor end with really knowing your child. Understanding that feeding a child is a process of communication can be an enormous relief for many parents, but it still begs the following question: how do you still teach your kids about food? We live in a world of complicated food choices, the pressure for thinness and the specter of disordered eating and eating disorders. Any parent would be remiss to ignore these warnings and assume that the norm for a child is an uncomplicated relationship with food. But if the child at meal time isn't really focused on food, when does a parent teach these critical lessons?

I'm going answer these questions by addressing the most common concerns parents express. And I'll take these one at a time over the next several posts: picky eaters, healthy foods, dessert and thin and fat talk.

The Parent Trap of "Healthy" Eating

2011-08-14T21:01:00.003-04:00

A generation of parents raised on an unhealthy dose of dieting, weight obsession and eating disorders are ill-equipped to figure out how to feed their kids. The deluge of parenting tips is overwhelming, and the often contradictory food-related suggestions subtly undermine even the most attentive parent. How does a parent choose when faced with organic everything from produce to cheesy snacks? What does a parent do when one misstep feels like it can cause a lifelong eating disorder? And how can any parent tackle the impossible balance of "healthy" eating? Indeed, there is nowhere to turn. This is the case for the kids from well-off families while the poorer ones have limited access to "healthy" food, let alone supermarkets, and are becoming increasingly obese. The irony is that the only children who may get off scot-free are the ones left to their own devices. It may come as a shock to many, especially from a doctor focused on eating-related disorders, but food and meals are not meant to be perfected and obsessed over but simply to be eaten.

One of the almost magical abilities of our brains is to absorb skills and make them automatic. For instance, the acts of, say, walking or driving are relatively complex endeavors. They each entail a series of coordinated movements adjusting constantly to changing sensory input to be completed successfully. Yet, after a surprisingly short amount of practice, each becomes automatic. Both walking and driving can be accomplished with limited attention while our conscious minds are free. The same can be said of eating. Even if we focus our attention on the food we're eating, a few minutes into the meal the conversation, and our minds, have shifted elsewhere. Eating is an automatic behavior meant to be shared and social with the added benefit to enable us to survive. With the growing concerns around parenting and food, automatic eating is not the norm for the current generation of parents. Instead, when it comes to food, they have become obsessed with two things: starvation and fear.

Starvation is sadly the ideal state for many parents today. The pressure to remain thin is paramount. In a parental miasma of endless days filled with various organic snacks and the requisite birthday party pizza and cake, not eating looks like the only lifeline. Inevitably, the cycle of under and overeating takes root and numbs the parent into a cycle of hope and despair. The flip side of the typical starvation trap is the obvious need for secrecy: the children need to believe everything is fine. The fear of raising children similarly stuck in the disordered eating loop consumes many of today's parents. The current possible solutions, however well-intentioned, are unlikely to have the desired effect. Parents model undereating and overexercising behaviors, spend way too much time discussing “healthy” food choice and are often oblivious to their kids' inculcation into the cultural obsession with thinness. In other words, raising "healthy" eaters in today's environment inevitably means welcoming the newest group of disordered eaters to the world.

The easiest way to understand the difference between automatic and obsessive eaters is to compare the two in real life. Children are clearly born automatic eaters. Given a plate of food, it is mesmerizing (as an innocent bystander rather than a worried parent) to watch them work by eating, playing, experimenting and socializing. By the end of the meal, the child will have eaten his fair share and fully tested the texture of each food while also testing the limits of his parents' patience. In case it seems like I am describing an infant, this behavior lasts, in age-appropriate form, for years. What is truly educational is that these children don't starve. They eat what they need and play with or discard the rest. And this is automatic and intuitive. We are born with the knowledge of how, unconsciously, to eat.

The most obsessive eaters struggle with anorexia. Food, rather than embodying its social and nutritional value, becomes the source of endless psychological and emotional torture. The person has to consider every morsel of food in light of the internal drive to starve and become emaciated. No bite is ever automatic but instead induces fear and dread. Even in the face of medical illnesses from longstanding starvation, eating any meal is so wrenching that conscious attention can never be distracted from the food at hand. A person with anorexia has unlearned the ability to eat automatically. The concept feels completely impossible and foreign.

Armed with this information, the job ahead is apparent. A child is born with the innate ability to eat enough and not starve. Before the advent of endless child advice books to balance the current of thinness and dieting, parents just fed their kids. Until very recently, food choice was much more limited, and meals were just meals. Children sat at the table in front of a plate of food and ate what they ate. They all survived and grew into adults focused on life, not food. Perhaps today's parent will consider the more healthful options in a supermarket influenced by the powerful food industry, but to the children, food is just food. If the parents sit down and eat their plate of food, just as the children do, without obsessing about portions and calories and dieting and carbs, those kids may keep eating automatically and never learn there is another way to eat. The goal of talking to your kids about food is not to talk too much.

The next post will focus on some of the pitfalls that can still happen when faced with children dealing with eating issues at young ages. I am often asked either socially or by people who find me online similar questions about children and eating. I'll try to address some of them in the next post.

Chronic Dieting: the Third Pillar of the Obesity Crisis

2011-08-07T08:42:00.003-04:00

The most striking result of a population obsessed with thinness and weight loss is how unsuccessful most people are at achieving the goal. The more energy used for exercise and dieting, the fatter the country becomes. Miracle diets blanket airwaves, papers and websites. Exercise routines and gym memberships move through one community after another. And yet we just get fatter and fatter. When 99% of people who diet end up gaining all the weight back and more, when exercise programs seem to have no impact on a sedentary population, it is time to go back to the drawing board. The new food political writers vilify the food industry, itself incredibly lucrative and grossly under-regulated, but there is no proof that eliminating McDonald's and Coke will solve rampant obesity either. In fact, the evidence shows that the health-conscious, disordered eating sub-population can still gain as much weight on Pirate's Booty as they can on Doritos because overeating and a sedentary lifestyle are only two of the three pillars the obesity crisis has been built on. The last, paradoxical and ignored issue is dieting.

It's abundantly clear how overeating and lack of exercise can lead to weight gain, but the link between chronic undereating and weight gain is not obvious to the majority of the population. The newest diet plan stationed alongside the tried and true, established programs constitute a bevy of healthful and hopeful alternatives to the frustrated masses longing to reach their goal weight. The proponents for various diets rarely experience public questioning and are instead viewed as saviors for a population lacking willpower. Our national obsession with thinness blinds us to the dangers of chronic dieting. Just look at the parade of celebrities that the diet industry uses to lure us into their web. As one television star loses weight, her success is charted by the company to prove the plan's effectiveness and induce people to follow its success. But, inevitably, as the person begins to gain weight, she is succeeded by the next star as spokesperson. Of course, the company quietly blames the person’s inability to follow the plan. No one questions the plan itself.

To understand how dieting fuels the obesity crisis, it will help to return to the set point theory. As a reminder, the body has a set range of weight, about 15% from top to bottom, within which it moves freely. Homeostasis, the mechanism the body uses to maintain stability in a variety of functions necessary for life, applies to weight as well. The central tool to maintain weight is metabolism, which represents a host of changes in the body to use energy, namely food, either more or less efficiently. At first glance, the set point theory seems contradictory. Overeating when a person is at the top of the weight range leads to a metabolism increase, decreased hunger and burning off energy. In fact, a significant spike in eating over a period of weeks can increase metabolism sharply and curtail any further weight gain above the top of the range. Why, then, if there is a built-in cap on weight gain do so many people become obese? On the other hand, chronic undereating leads to a conservation of energy: metabolism slows down, hunger increases significantly and the body, when given any surplus, voraciously stores food as fat. In addition, studies of evolutionary adaptation have shown that the tendency to survive lean times, such as the winter, is much stronger than the need to override times of plenty. Practically, this means that periods of chronic starvation will trigger a strong, protective mechanism to expect coming famines and store food for the future even when the times of plenty follow.

It will come as no surprise that even the most overweight portion of the population spends a fair amount of time dieting. The more overweight, the more drastic the diet. In fact, many diets suggest intake of 50-75% of the food needed for a given day. A few weeks with such low food intake will trigger a powerful homeostatic response from the body, which means initial swift weight loss, followed by a sharp metabolism slowing and voracious appetite. After reviewing the set point theory, the overall effect of periods of chronic dieting are clear. These periods of undereating bring about the adaptive response to famine and that undoubtedly means weight gain. In fact, the most overweight who follow the most severe diets can then continue to gain weight past their set point because of their extreme dieting.

To understand this confusing link between undereating and weight gain better, it can be helpful to look at chronic anorexia. One of the most confusing aspects of anorexia is the patient, ten or more years into her illness, who, despite continued food restriction, no longer is underweight. The psychological toll on the patient is overwhelming: how can years of decreased food intake, which consistently produced a very low weight, suddenly stop working? For the more rare patients who maintain very low weight, severe illness and death around age 30 is almost certain. For those whose weight returns to the normal, or at least not emaciated, range, the answer lies again in the set point theory. Built into their genetic make-up is the ability to severely curtail metabolism. The drive to slow down energy use, increase hunger and store fat easily overpowers the drive of the eating disorder and causes enormous frustration and despair in the patient, even though it also enables them to survive. The most confusing aspect for the general population to understand is that an anorexic patient of normal weight can still be as severely ill as the emaciated one. The medical complications and psychological torment from years of restriction, even if the body maintains a more normal weight, are severe and lead to disability, illness and premature death.

The set point theory is old, established medical knowledge. Why has this information been summarily ignored through the obesity crisis? How has the medical community spent so much public capital on new, ineffective weight loss techniques? Can't an obese population desperate for successful measures to stop the trend look at the basic scientific data for simple answers? With effective measures like weight maintenance plans and with a critical examination of the diet industry, these changes seem well within our grasp. Instead, there has been an explosion in weight loss television shows while the nation tolerates a large number of children attending fat camp. The public forum ignores this third pillar in the obesity epidemic while searching for the enemy to explain away our problems. Yes, the food and diet industries are largely responsible, but we refuse to acknowledge the truth. We have to stop dieting and praying for a miracle cure and instead need to find our own maintenance meal plan.

In adults, this transition is complicated by years of chronic dieting. Finding a maintenance plan also entails the process of normalizing metabolism, which can be challenging for someone searching for a quick fix. But nowhere is this more important than in children. As promised in the last post, I will address how to apply the idea of a weight maintenance meal plan for kids and their parents.

The Dangers of Thinness and Dieting

2011-07-23T09:45:00.000-04:00

It isn't hard to find article after article expounding upon the scourge of obesity in our society today. The most popular magazines know a little teaser on the front page about weight loss will always sell more. Slower moving academic medicine has cottoned on to the trend with scholarly writing on various, unsuccessful weight loss measures. Bands of young women cannot help but jealously ogle the newest pop star or actress singled out for her recent weight loss or demonize one who has recently ballooned. Not to ignore the supposed even-handed media like the New York Times, any number of weight loss tips (written by an exercise-fanatic who herself does not look well) can be found regularly in the Science Times section.

The fetish of "fatism" and the concomitant obsession with thinness is so pervasive as to have surpassed the current mode and become an accepted fact of life today. Everyone wants to be thin: it is considered healthy, attractive and necessary for survival and success. No one wants to be fat, which equals lack of willpower, sloth and undesirability. It has become much too easy to forget of course that this is a cultural preference. There are many, usually poorer, countries for which the opposite is true. In fact, the flip-flop of thin-fat preference is all but new, a few decades old. How has it not only become the norm but unassailable? Now even the most sober, rational parts of society cling fiercely to this notion, as if it were handed down from on high.

The most insidious means that leads skinny to prevail over fat is the medical establishment. Although it is clear that the mass media preference follows the current mode, that is to be expected. Fashion and trends are meant to be fickle. As much as the general population blindly follows the movements of the famous, what is fresh and new is meant to be upended regularly, and the masses will follow. However, the medical establishment, and often confusing medical journalism, moves much more slowly. The growing medical treatment for obesity now dominates many of the brightest minds of medicine and comprises a vast array of new preventative, medical and surgical treatments. It has become impossible to ignore how mainstream the public health problem of obesity has become and how no one can question its veracity.

What goes unnoticed is that acceptance of a general issue by the establishment reinforces a prejudice by the masses. When government and law supported slavery, the general public felt vindicated in the belief in such an abhorrent practice. When psychiatry included homosexuality as a mental illness, the hatred of gays was accepted. That doesn't mean that being overweight can be compared with bias against innate parts of who we are. However, it does highlight the power of the establishment to sanction accepted bias. The rational justification of the dangers of obesity shouldn't condone blatant prejudice.

The way people sneer at an overweight person walking down the street, avoid him on the subway or scoff at him on a TV show now feels accepted, a part of daily life. The irony is that although a fuller figure could become a la mode in a moment, the medical prejudice against obesity will take much longer to overcome. Although the rationale of the medical risks of obesity are clear-cut, the overarching risks of promoting thin over fat are great. Where are the articles on the scourge of thinness? The underfed, underweight population risks osteoporosis, various vitamin deficiencies and anemia. The chronically underweight also are always at a cognitive loss, struggling to think clearly and to maintain a normal memory. Moreover, it isn't just the underweight who suffer. The number of overweight and even normal weight people who diet comprises a larger and larger percentage of our population. One effect of "fatism" is a general sense that everyone could stand to lose some weight. The pervasive and unchallenged diet industry has the freedom to tout one crash diet after another and guilt people, fat and thin, into severely restricting their food intake. These normal weight people starving on the newest diet are not able to function at a normal level. Even more troubling is the assumption based on the set point theory of weight explained in a recent post. The long-term effect of chronic diet restriction is overeating to compensate for recurrent starvation. The overeating and body's instinctive fear of famine triggers the body to slow metabolism, store fat and paradoxically gain weight. In fact, the drive for thinness in the general population may actually be worsening the obesity problem. We all need food to survive, yet this basic fact is summarily ignored for the supposed common good of facing obesity or perhaps facing our own misguided prejudice.

Medicine itself needs to own up to the risks of chronic starvation and an underweight population. This goes beyond those with eating disorders and instead highlights the general population risking their health by following the unsubstantiated advice of the powerful diet industry. Education is not just about a new government-sponsored food plate but a goal of weight normalcy. The population needs to be aware of the risks of chronic food restriction, and the diet industry needs clear guidelines as to what is medically acceptable. A strong voice against thinness and dieting might at least open the door to a backlash against this dangerous fashion and simultaneously ease the bias against the overweight.

The next post will apply these thoughts about diet and the drive to thinness to children and the risk not just of developing an eating disorder but of a culture of youth that prizes thinness over everything else.

"Pathological" Obesity

2011-07-16T10:52:00.001-04:00

A New York Times blog post this week started a discussion about "fatism." It is widely accepted that obese people endure professional and social bias in America. The data point to slower advancement in the workplace, decreased appeal as a mate and social isolation. The shame of being fat in this day and age feels like a scarlet "F" emblazoned on your forehead. Obese people frequently describe feeling invisible in their daily life, any attention quickly turning into scorn.

Although this is a sad commentary on the current trend to emphasize thinness above all else, the blog post aligns the bias against obesity with the gay rights, civil rights and women's rights movements. Being born a homosexual, African American or woman is an inescapable fact. Prejudice against people based on basic elements of their personhood is a strike against human rights. Not to minimize the impact of the bias against overweight people, obesity is a not a similar genetic trait. Although people may be born with a genetic predisposition to being overweight, that is a very different story. Unfortunately, jumping on the political process that has been highly effective recently in the gay rights movement oversimplifies the growing bias against the obese and obscures the real, underlying problem for this population.

It is critical to remember that obesity has been rising precipitously for the last 40 years. The significant advances in the food industry has created a land of plenty with more than enough food to feed our entire population, a remarkable feat of production and engineering. The drive behind providing the country with adequate nutrition is the profit-seeking, under-regulated food production business. Accordingly, the food widely available is what will appeal most to our sensibility and thus sell best: highly processed food laden with fat, sugar and salt and, based on increasing amount of hard data, deleterious to human health. There is no reason a profit-driven company should factor public health into its business plan unless a regulatory agency insists on it to protect the population's health. Although the exact medical reasons behind the rise in obesity remain unclear, the increasing availability of highly caloric, unhealthy foods is one obvious cause.

The clash between government just starting to recognize its collusion in this vast public health problem and industry hellbent on profit above all else has just begun. In the meanwhile, the social problem of millions of citizens lugging around dozens of extra pounds continues to grow. The empty promises of the diet and weight loss industries just cement the overall frustration. The medical establishment tries vainly to keep up with the increasing medical problems associated with a vastly overweight population. But, as the Times blog post suggests, individuals need to learn how to live with the reality of being overweight.

The eating disorder community has coined the term pathological obesity to describe this phenomenon. In addition to the practical component of both weight loss and weight maintenance meal plans, the most important psychological step in obesity therapy is to separate the physical and psychological effects of being overweight. The physical symptoms range from metabolic illness to orthopedic problems to long-term cardiac effects. Psychologically, the overwhelming shame of obesity combined with the prevalent social bias creates a mental state of absolute obsession with food restriction and weight loss. Repeated severe dieting triggers an overwhelming sense of starvation, as explained in the last post, which only exacerbates the ruminative state of pathological obesity. The result is that a functional, driven and psychologically healthy person puts life on hold until the weight comes off. Years can elapse while someone spends more and more energy focusing on the latest diet or exercise plan, holding off all goals for the future, only to be devastated when one magic cure after another fails to deliver. The wasted years and energy of this process is so demoralizing as to render life truly hopeless.

The treatment of pathological obesity is twofold. First, establishing realistic goals of weight loss and, more importantly, weight maintenance creates an environment of success and a promising direction for the future. The hopelessness is replaced by an advocate clearly able to put the obesity and powerlessness around food and weight into perspective. Second, the weight maintenance phase focuses not on change but on stability, a state of mind and body never experienced by an obese person obsessed with weight loss. The relative calm of just eating to maintain weight enables the therapy to re-establish life goals, separate from food and weight and remind obese people of their true passions and goals. The therapy can reconnect the person with true self-worth and label the weight issue as a solely medical issue. Although this process cannot eliminate the fatism rampant in today's society, treating pathological obesity gives an overweight person the personal freedom and power to overcome this bias day by day. Freeing the patient's mind from food and weight obsession opens up the possibility of seeing options in life and goals for the present and future once again.

The perceived powerlessness of the obese reinforces society to continue to overvalue thinness, but the resurgent voice of the obese population can allow those struggling with weight to feel empowered again. While obesity therapy helps an individual separate self-image from weight and then re-engage fully in life, the steps towards generalizing the experience are less clear. The next post will address how to broaden the message about pathological obesity and help society share the responsibility for the clash between thinness and obesity in our culture today.

Weight Maintenance: the Crux of Obesity Therapy

2011-07-09T11:08:00.003-04:00

Psychotherapy to treat obesity cannot be another weight loss program. The most popular medical treatments for obesity focus only on weight loss and are no better than the latest fad diet. The clearest message from any unbiased data assessing the weight loss industry is that diets just don't work. Calorie restriction, in whatever proportion of nutrients deemed successful by the latest guru, inevitably leads to a powerful feeling of starvation. Surprisingly, the psychological effects of starvation--obsession with food, strong urges to overeat and slowed metabolism--are a universal reaction from the anorexic to the obese. Although an anorexic patient may have the genetic predisposition to withstand starvation without eating, everyone else will be compelled to eat when ravenous, an evolutionary response clearly geared towards the survival of our species. So the obese person starved for months on a diet can only resist eating for so long and inevitably will eat enough to compensate for the long-term starvation and gain back the lost weight.

A universal reaction to starvation, even in the obese, makes little sense. Shouldn't the body be aware that extra weight has medical consequences? The medical explanation for this conundrum is called the set point theory which postulates that everyone's body has a relatively fluid weight range of about 15% of body weight but will strongly resist moving outside that range. Any pressure to go above or below this range triggers a powerful metabolic response aimed at maintaining the set range. At higher weight, the metabolism increases to burn off extra calories and hunger eases. The opposite occurs at lower weights. The human body has a powerful, innate drive to maintain the status quo.

Based on this theory, the eating disorder treatment community has focused on weight maintenance rather than weight loss. Most anyone who is overweight can lose weight but, once the protective mechanism of set point theory kicks in, no one can keep it off. Built into obesity therapy from the start is a focus on slow, gradual weight loss for a period of a few months followed by a similar period of weight maintenance. In fact, weight maintenance is not only meant to be a critical component of treatment but is necessary for consistent, long-term weight loss. At the end of a weight loss phase, the person will be at or near the bottom of the current set point range. Weight maintenance will allow the set point range to slowly decrease and enable another weight loss phase in the future. It is usually a shock to an adult devoted to the study of dieting to realize that weight loss is only half the battle. All diets promise short-term, rapid weight loss with long-term effects, but all the promises are false. The lure of a diet is rooted in the hope for salvation, for the perfect fix to a lifelong problem. The therapy for obesity immediately grounds the relationship in much slower but realistic prospects of success.

Practically, the treatment involves establishing the calorie and meal goals likely to maintain the patient's weight. For the first 6-12 weeks, the initial weight loss phase, eating 10-15% below the maintenance level should lead to gradual weight loss of 10-15% of body weight. As the patient's weight nears the low end of the range, weight loss slows and then stops, hunger escalates rapidly and metabolism begins to slow and conserve energy. Further dieting invariably triggers excessive hunger, overeating and a profound sense of food deprivation quickly followed by overeating and weight gain. These physiological responses, in a society that idealizes restraint and thinness, become signs of psychological weakness, not the body's adaptation to extreme hunger. Instead, the therapist can identify any sign of increased hunger or deprivation as a sign that the therapy needs to enter the maintenance phase. The addition of the extra food will curtail the excessive hunger quickly and help the body adjust to a new phase of adequate nutrition. After a period of months, the therapy will be ready for a new weight loss phase. At the start of treatment, most patients, after a recent period of overeating, are usually at the top of the set point range, but after a period of weight maintenance, the weight is more towards the middle of the range. Thus, subsequent weight loss phases lead to 5-7% weight loss. Perhaps the hardest aspect of obesity therapy to accept is the length of treatment. The behavior modifications are meant to be lifelong, but the weight loss associated with true weight maintenance takes years, something unheard of in a dieting culture. It typically takes years of overeating to lead to excessive weight gain and it similarly takes time for the body to adjust to weight loss.

From a medical standpoint, this therapy often has long-term success. Several practical issues can disrupt slow and steady progress such as a sedentary lifestyle, diabetes and a chronically slow metabolism from years of excessive dieting. These issues can be addressed with education about the process of obesity treatment and the help of a knowledgeable primary care doctor. However, psychological obstacles also impede the treatment and serve as the most powerful reasons an obese patient gives up. The next few posts will address the pitfalls in obesity therapy and how to overcome them.

The Treatment of Obesity: Overview

2011-06-16T14:10:00.002-04:00

Obesity is the most pressing public health problem of the moment. The average weight of Americans, adults and children, has skyrocketed over the past few decades. The medical complications secondary to obesity have risen precipitously as well. With infectious disease and food-borne contamination largely in the past, the medical establishment has hoped that longstanding health followed age-related illness would predominate routine care. Instead, diabetes, high cholesterol and hypertension are the bread and butter of the primary doctor bent on helping an obese population survive. Meanwhile, the current efforts of government and industry, the parties primarily accountable for this crisis, may reluctantly raise awareness but accomplish little else to find a solution.

The reasons for the obesity epidemic are clear although their relative importance is hotly debated. The transformation of the food industry and available choices in the local market has changed the way we eat. Fast food, sugary drinks and junk food comprise a significant percentage of our diets and explain why literally twice as many calories are produced in our country than what we need to survive. On top of that, the average American leads a much more sedentary life than a few decades ago. And our attitude towards food and weight has changed drastically. The most salient theory of the cause of the obesity crisis combines all three social forces--food options, sedentary lifestyle and preoccupation with food and weight. However, without a fully accepted theory, industry can blame lack of exercise, food pundits can blame industry and government can avoid needed regulations. The overall effect is to dilute the message and splinter the drive for a solution.

The government has finally signed on at least to acknowledge this issue. Despite the lobbying power of the food industry, Michelle Obama has devoted much of her energy to food choice and exercise, especially in children. There is no doubt that placing her powerful spotlight on an issue the corporate food world can easily evade was necessary to have any impact. In addition, government-sponsored nutrition education has taken a big step forward. The new food plate replaced the confusing food pyramid to make much clearer the basics of meals and nutrition. None of this changes the reality that fast food and junk food remain a much tastier and affordable way to feed yourself and your family. Although new initiatives can spearhead debate and, subsequently, awareness, more regulation of the food industry along with incentives to provide healthful food at reasonable costs will be necessary to stem the tide of obesity.

Faced with the deterioration of the health of the population, the medical profession has to tackle the myriad consequences of an obese population and, more to the point, try to devise strategies to fix the problem. Preventive medicine has a history of success with vaccines and vitamin fortification, but those were public health initiatives to combat preventable diseases, the wheelhouse of medical success. The conflicting forces at play in the rise of obesity, both within and outside health care, largely overshadow the good will of the medical community. While many physicians toil away to ensure the health of obese patients, our profit-driven cohorts endorse new, exploitative measures that purport to offer a quick fix for an intractable problem, such as medical weight loss programs and surgical intervention. But these band aids only mask the problem.

As of now, no doctor or specialty has the answer. Primary care doctors, with almost no formal training in weight management or nutrition, advise patients with their own personal and often distorted views of food and weight. Nutritionists recommend modified versions of weight loss diets with short-term benefit but almost guaranteed long-term failure. Studies show that about 95% of people who lose weight dieting gain it back and more within 6-12 months. After years of futility, patients seek a consultation from a Bariatric surgeon. The FDA recently lowered the BMI needed to consider this option, and many more people, some not even considered obese, are now eligible. While surgery has faster and longer-lasting effectiveness, it's already clear this is no panacea. Complications, subsequent health risks and unclear long-term safety and effectiveness are apt to plague the post-surgical population. Plus, how can we as a society abide lives of overeating followed by surgical remediation? This is no real solution.

As in past decades, frustration within the medical community at large leads to the general consensus that the underlying pathology is psychological. Increasingly, the road to obesity treatment goes through the mental health community and, more specifically, eating disorder specialists. Clinicians who treat eating disorders have two things going for them: a non-judgmental stance on food and weight and a willingness to tackle a challenging public health concern. Initial attempts at treatment combine behavior changes around food with a mandate to not let the weight impede on daily living. Losing weight becomes an obstacle to overcome through gradual lifestyle change rather than an actual disease. The crux of the therapy is a collaboration to change one's relationship with food, an approach fundamentally no different from treating an eating disorder, while simultaneously reinforcing the need to be engaged with the world. It's unclear how successful that philosophy will be, but the increasing number of obese patients referred for therapy will test this treatment quickly. The next post will explain obesity therapy in more detail.

Meaning vs. Materialism: How to Make Food Just Food Again

2011-06-08T11:31:00.002-04:00

In all earnestness, a friend of mine once said, "Isn't all technology intended to make our lives better?" After my initial shock at such undiluted naïveté, it was hard not to berate myself for being so cynical. I consider myself a technophile. I can lament the loss of personal time and space and still covet the latest streamlined, expertly-hyped, mesmerizing Apple product. What I can't abide is the loss of process and patience in our lives.

We were always forced to wait for answers. Life took its own sweet time to reach a conclusion. Things happened when they happened and our ability to speed them along was fairly limited. Now we can immediately satisfy our urgency with a text message, email or web search. I embrace the change. I know the unbridled pleasure of googling the answer to a heated personal dispute or the quick fix for a household emergency. But it is the process, the debate, the creative thinking, even the aftermath of doubt, that no longer exists. That internal world, such an essential part of being human, feels as if it's being phased out and, like the iPod classic, discarded into the dustbin of expired technology.

However, the loss feels much greater here. The new adage may say that we have gone from creators to aggregators, the transition utilizing the plasticity of our minds in a new reality. And content, the new term for the creative process, although necessary, is beside the point, relegated to the least adaptable minds stuck in the 20th century. But as our inner lives continue to erode from a steady stream of media and entertainment, packaged and repackaged into new products of sameness branded as content, so goes life's meaning. And as I have stated time and again in this blog, the loss of meaning is intricately connected with the rise of disordered eating.

Our collective minds more and more resemble a linked computer network than an amalgam of individuals. What passes for individual thought turns out to be a formulaic gimmick, advice just reworked from old-wives' tales or self-help mumbo-jumbo. The savvy self-promoter can transform into a modern guru able, perhaps, to unlock life's deepest mysteries, or at least powerful enough to leapfrog a new book to the top of the bestseller's list. Our minds gobble up the endless stream of content, and we each pledge our allegiance to the network by parroting back the information to our colleagues and friends, duly doing our part in the mass marketing machine. What used to pass as individual thought now just marks our acceptance of the vetted data, content, meant to fill our brains.

Each community, class and region has its own information niche, but the self-worth download to our own workstation in the collective server is fully nationalized. Everyone knows the drill: diet, exercise and thinness are the only road to inner peace. Yes, the sidekicks of yoga, self-help and meditation may reflect new paths to nirvana. But come on! Those people are skinny first before they ever set foot in a yoga studio, or at least so goes the completely misguided, but common knowledge. In the download, you see yourself first in the ideal body gliding comfortably and confidently through life. Only that iteration, body 2.0, will incorporate yoga into a daily routine or check off the list of self-help items in the hippest, new advice book. Body 1.15, the reality version, fails the newest diet, glumly re-ups the membership at the gym and impatiently waits for life to finally start.

The personal loss of mental space, process and patience has created a new universal dilemma. We all may be searching for meaning but have settled for materialism instead. Surprisingly, the transition from meaning to materialism, both in physical possessions and in physical appearance, runs the socioeconomic gamut. The occasional existential crisis may feel as antiquated as a record player, aerobics or Levi's jeans but is as prescient as ever, just in a new form. Some part of our society needs to care before the gluttony of materialism reduces us to a national eating disorder.

Yet there is one fundamental fact I have learned from working with people with eating disorders. Only in a world devoid of meaning can so many bright, driven women become focused on something as mundane as food. The fundamental misunderstanding starts with the self-worth download. Take a driven, talented but confused teenage girl and give her basic rules about food and weight to live by, and it's not hard to see how a few simple mantras become an eating disorder. It is one thing to follow the strict guidelines set by family, school and society, but the adolescent drive for autonomy needs an outlet too. What better alternative exists than to be skinny? Before long, skinny becomes the only way to view life's meaning.

A patient in recovery suffers from the reverse of the dilemma. Faced with the search for life's meaning outside of an eating disorder, a patient quickly grasps that few models exist in the modern world. Is a choice between the eating disorder and a new existential crisis placed in a cultural void really a choice? Obviously, I would say yes. The therapy for people with eating disorders is a tutorial in how to apply age-old philosophical questions to modern life. The time in therapy focused on process and patience brings a disoriented soul to a calmer place long enough to find the meaning food and weight will never really provide.

This is really the underlying lesson. The food business, diet industry and self-help marketing machine have become the parallel educational system of our time. Yes we all learn reading, writing and arithmetic, but we also know about junk food, dieting and how to look skinny for the summer. What we don't learn is how to create a life of meaning. When the matter and substance of our existence are topics of discussion, when a life is considered for its value to society, when a parent's priority is to teach a child how to love and live, food can go back to being plain old food. Social contagion can spread quickly. A people bent on tearing down the old foundation can do so in a moment of time. Harnessing the creativity and desire, deftly deleted from the current self-worth download, would steer the debate from the latest fad diet back to the value of a human life.

The next series of posts will shift to the problem of obesity. A growing health problem, obesity has tested various medical specialties from primary care to pediatrics to general surgery. Increasingly, patients are being referred to eating disorder clinicians for treatment. The next posts will summarize the current therapy and treatment for obesity.

The Social Contagion of Eating Disorders

2011-05-25T11:05:00.002-04:00

The canon of Western philosophy can be summed up in one sentence: in the end we are all alone. From that first self-aware moment, the first realization we all are going to die, this truism seeps into the zeitgeist of our humanity to become the one balm to ease our panic. But how true is it really now? With the unlimited ways of staying in touch, can anyone feel alone in this day and age? The existential crisis of modern life pits the alone hypothesis against our growing interconnectivity. It all leaves me hopelessly confused. What I do know is that the study of human social systems and group dynamics makes the isolated philosopher a dated creature. The age-old academic stance on the human condition needs an update.

I'm aware that this is clearly a big leap for a psychiatrist. But when it comes to understanding how eating disorders have spread like wildfire, the logic of this post will become clear.

The first point of business is to reconcile the isolated individual with the breadth of humanity. Until recently, any one person's world remained fixed and small. No one could easily travel or keep in touch with the world around them. A life was led in a small geographical area amongst family, friends and neighbors. The larger scope of humankind was a heady concept, an abstraction in need of a theoretical framework. Instead, the nature of pre-industrialized civilization led inward. Living a relatively isolated life, the intellectual focus was on our individual existence and the inherent loneliness of experiencing the world behind the filter of the mind. The juxtaposition between the unique human gift of self-awareness and the universal prison of our own minds occupied the best and brightest minds for centuries. The result is a compendium of philosophical transcendental and religious treatises that solve nothing and ignore a basic, equally important fact of being human.

We have conquered the world through sheer mass and numbers. Our consciousness and self-awareness distinguish us from other animals, but let's not fool ourselves. The sophistication of our individual minds is only as powerful as the community, society or nation we belong to. The lone peacock may spread its plume to attract a mate, but no one cares unless the peacock clan survives. The brain development and capability of humans matter only because the complex social forces--no different from the lion or elephant herds--shaped history as it did. The philosophical truism, enlightening as it is, missed the forest for the trees. To ignore the magnitude of social forces in our own daily lives is akin to the blind spot in anorexia: you can't survive without food.

The social forces behind the eating disorder epidemic are incontrovertible. No one in this country can ignore the mass media pressure for thinness and weight loss. For each eating disorder recovery forum, there is a website schooling the budding anorexic in how to lose weight faster, or the bulimic in purging tips. Even mainstream eating disorder programs, clearly intent on promoting recovery, have to clamp down on underground education for the new generation of anorexics and bulimics. An ambivalent group of patients without clear guidance is as likely to egg each other into illness as into recovery. And the conflicting, powerful forces proceed unabated.

But recognizing the social forces at work in the proliferation of eating disorders only scratches the surface. It is the precious few who still read and follow any guidance from philosophers. We may be trapped in the human condition but are too distracted by the interconnected world to care anymore. In the modern era, it's hard to find a spare minute to reflect on our individual fate. Each moment is steeped in the enormity of the broad scope of humanity and reinforces our small place in that vibrant mass of life. The overarching mantra of the modern era has left behind internal reflection and instead revolves around the philosophy of food and weight. The combination of willpower with the right number on the scale equals salvation. The burden is off the lone philosopher charged with explicating our suffering. Now philosophy 101 is taught in the mass media and celebrated in pop culture. The slow, inevitable reach of distorted food thoughts can feel like our modern-day consumption. Just instead of the image of the philosopher coughing incessantly and wasting away, we all starve, and suffer the consequences.

The obvious examples of the disordered eating contagion abound, but one less obvious choice is the severe calorie restriction movement. I remember vividly the blinding media coverage of the starving rats in the mid-1980's. In a quick summary, rats fed half the normal rodent diet lived significantly longer than their unstarved brethren. In an interesting turn of events, starvation as an elixir of youth and longevity was too tempting an offer for an already deprived society to refuse. No one seemed to feel sorry for the poor, listless creatures. Instead, everyone marveled at the extraordinary discovery. The lure of a guaranteed century of life, no matter how miserable, hungry and food-obsessed it might be, was like a carrot to a bunny. And carrots, along with other vegetables and fruit, are the mainstay of a calorie restrictor's diet. How else to survive on such a paltry sustenance? The steps from lab discovery to philosophical movement to an eating disorder aren't hard to follow. We have all seen it before from Weight Watchers and Atkins to Bariatric surgery.

The real concern is that antibiotics might have eliminated consumption but it's much less obvious what will make us eat again. Stay tuned for the next post.

Let Freedom Ring

2011-05-13T13:37:00.002-04:00

Life, liberty and happiness are three fundamental rights borne out of the creation of this country. The meanings of liberty to a society over almost three hundred years fluctuate wildly. Initially as an escape for the oppressed and the pioneers, America stamped its reputation as the land of the free. In later years, immigration and the lure of the American dream bespoke the reality that all classes could aspire to success and wealth. The hypocrisy of a long history of slavery and oppression of women finally amounted to the civil rights and feminist movements and culminated recently in a hotly contested primary between an African American man and a woman. In one sense, freedom clearly still reigns.

But to the individual, the fundamental American right is much less clear. Class distinction, based largely on socioeconomic and racial differences, is growing. The disparity between the rich and the poor has widened exponentially. Educational opportunities for the lower classes have all but disappeared. Perhaps for the first time, this country is divided into the haves and the have-nots. We all may be grateful for the individual freedom to speak our minds and for our human rights, neither to be taken for granted, but too many people are trapped, their freedom not even an afterthought. Either the fortunate buckle under the pressure to be in the haves or the less fortunate wallow in the despair of never having. One pressure is usually applied by knowing, desperate parents hoping to push their children towards success, the second by hopeless, desperate parents who know of no escape. The freedom of the individual, one pillar of American life, is more a relic of the past.

Children can sense the futility of a predetermined life. Even the wealthy, a class known to produce children with eating disorders, suffer this fate. A child with means, who knows she will always get what she wants, has nothing to drive her, nothing to prove. The unusual child with preternatural internal motivation might find her way, but the bulk of these children of means live the lives set by their parents and find identity through other means, a scenario that can easily produce an eating disorder. The message is clear. Your life is set by your place in birth and the freedom to move within society largely relegated to distant memory.

There is a glimmer of hope: the philanthropy aimed at improving a broken education system; the technology opening new avenues in staid industries; the growing backlash against the food industry; and a president who represents hope and change. These all foreshadow a piece of society interested in bringing freedom back in future generations but with little sense of how to do so.

What is so often overlooked is that personal freedom doesn't exist in a vacuum. American idealism grew out of a loosely structured but firm Constitution open to interpretation but upheld as the truth. Different legal schools of thought vary widely, some may be controversial, but all point to this document as the American bible. It is a miracle that an entire nation can accept a political compromise as a guide to good living almost 250 years later. And that bible makes clear that freedom is a high priority.

But freedom in and of itself is not what works; freedom within a clear-cut structure is the lesson to be learned. The American dream grew not only in a land of endless opportunity but in a land of endless rules. Granted, those rules largely proclaimed individual freedoms, but a national proclamation of freedom is much more than good intentions. Instead, the message reads like good parenting advice: follow the basic rules, then you can do whatever you like.

Backed by American history, this philosophy works. The freedom of the individual, the wild successes of the high-minded entrepreneur, the social-minded activist and the idealistic politician have in turn molded the innovation, individuality and liberty grounding this country. As the rules break down so goes individual freedom. Class and money now open unlimited opportunity while the growing masses see no way out except the mind-numbing path of materialism and commercialism. The nascent but obdurate class system may just cut off individual freedom at its knees. The new generation is getting the hint. Good grades, extracurricular passions and an entree into elite education don't replace the wide open American life. Individual liberty trumps the class system, even if you're on top. The young deeply feel a sense that they are missing something. The momentary high of an eating disordered identity is like a new generation getting stoned together. It's an adolescent solution to an insoluble problem. But on an individual level, letting freedom ring can open the door back to opportunity. With generations of experience with individual liberty, the land of the free, it isn't like this society needs to remake the world. Going back to basics will suffice, and hopefully make it easier for everyone to eat again.

Just the other day, I was asking a colleague a question about my child, just to surmise what the future might bring. She sensed my trepidation, even anxiety, and quickly interpreted it in her own way: what might happen to my child? Could this snowball into a life of failure? But her way of assuaging my fear was all too telling. She said, "I have known children like your daughter who have gone to Brown, some even to Princeton and Harvard." And then life is set, all worries forgotten? The path is clear? Life's satisfaction as simple as an Ivy league degree? All I could think was that we have surely lost our way. There is nothing sacred to grasp onto when the future is unclear. That philosophy will be the ruin of this country. Contrary to current popular belief, peace of mind comes in a moment when all is not lost, when opportunity lies ahead and when, above all, freedom to aspire, to dream and to live fully remains within our grasp.

The next post will switch to a new topic: the role of social contagion in the spread eating disorders and disordered eating.

Beware of our Good Fortune

2011-05-04T11:31:00.002-04:00

Many people in this country are fortunate enough to spend their days searching for happiness, rather than eking out survival. History points to aristocracies with such luxury but never the better part of an entire society. Not until the advent of clean water, abundant food and antibiotics have the lower classes been able to take daily survival for granted. Although we can agree that hunger and poverty still ravage many, at least here that is no longer the norm.

While the comfortable aristocrats focused on education, breeding and power, with a few directed to ascertain the meaning of life, the bulging middle class now has ample security, and practically a national obligation, to pursue happiness as a birthright. As a national phenomenon, happiness can mean many things: professional success, financial security, family, but many if not most people are still perplexed by this newfound freedom. In addition, outside forces can manipulate the extra leisure time and lack of direction to turn happiness into entertainment or materialism and precipitate a descent into a deeply felt meaninglessness, something easily mistaken as depression. The residual memory of a parent or even grandparent who struggled to survive can temper the fall into complacency, but at some point, in some generation, a child far removed from these fears will think we all do have it easy. Who can ignore how available everything is in this country? With that safety net in place, any child taking in the surroundings will know life is good. In fact, any child will believe we can control anything we want. Living well is most clear at the mundane miracle of your local supermarket: everything is available all the time. Just pick what you'd like.

It just feels like we haven't wrapped our minds around the idea that we all have it so good. There are countries in the world with illness and lifespan data unchanged from a century ago. To think that we all now expect to live twice as long as our forbears, and with good health to boot, is an astounding shift in a moment in time. Entertainment, capitalism and the food industry may fill our time and minds. Many smart people devise ways for us to while away our luxurious lives comfortably, if mindlessly. But I'm not sure who is truly thinking about our well-being. What in the world should we be doing with ourselves?

The answer seems to lie in future generations. It is unnerving to see small children, barely out of diapers, nonchalantly using a computer (more adeptly than their grandparents no doubt), turning on the TV or unlocking screen after screen on Angry Birds. It's just as disconcerting to see these same children shamelessly manipulate their parents in public, and succeed. Without the pressure or instinct that comes with the struggle to survive, young children can live with their enthusiasm and drive to pursue pleasure unbound. With only parents' willpower between them and the proverbial candy, children are overwhelmingly successful in their endeavors. Honestly, when do these kids not get what they want?

However, the freedom to get anything you want isn't equal to the freedom to be whoever you want to be. Parents raised in a world of security have since learned that adulthood doesn't come with guarantees and place the onus of vicarious success onto the next generation. Increasingly desperate parents, now egged on by sanctioned professional opinions, think they have found the answer: flood children with endless encouragement. What happens when the comments like "good job" and "you're so smart" are a dime a dozen to a growing child? Success, accomplishment and praise become the only way to understand the world; pleasing parents the sole purpose. Although survival may be a birthright, academic, professional and personal success are not. Just because the middle class can take food (even organic, pesticide-free), shelter (one room per kid) and clothes (the latest fashion, of course) for granted doesn't mean success comes along with it. Some people work hard their whole lives and don't get far. Others just get lucky.

So children are very much expected to fill the void. They live as scheduled a life as their parents. Their future goals are lined up long before they can even tell time: the right schools, the right people, the family expectations. What's so scary about letting those children run free? What's going to happen if they fritter away some time in the afternoon after school? The obvious answer is that they will fall behind. In the endless rat race, each kid always has to be caught up or even ahead. If you're left behind, you'll be lost forever. But in the lost freedom to think and explore, to wonder and question, lies true answers. Who can better figure out what to do with all the extra time? Imagination is the essence of childhood. The answer may lie in creative play.

I don't mean to say one generation of children left to run free will magically solve the pointlessness of our miraculous longevity. Parents clamping down on childhood to absorb their own doubts, failures and excess healthy years isn't helping either. The rampant disordered eating and eating disorders certainly can attest to that. The complacency, if anything, heralds the slow descent of a nation from its most glorious moments. If parents attend to their own failures and frustrations, children can be left to focus on their struggles and be free to learn both how to succeed and how to fail. And hopefully to learn to have compassion for the uncertainty of life ahead, no matter how long and healthy it might be. The general idea is that a more realistic, freer experience of childhood allows the child to gradually see the human condition for what it is and not become trapped in an artificial world they are supposed to save. Undoubtedly, placing the weight of the world on young shoulders collapses the true order of the world. The young need to contribute but also need to be free to forge new, uncharted paths ahead. They are much more likely to find ways to constructively fill all this extra time. The undue, poorly timed pressure leads instead to childlike solutions, like eating disorders.

There is no question that a laissez-faire approach to rearing children can feel anachronistic, like a proto-hippie backlash. Freedom needs to mean something else. Children crave structure and order, in large part to have rules to break. So if the rise in disordered eating stems from a desire for order, why would freedom lower this need? Look for the next post.

How Do You Say Goodbye to an Eating Disorder?

2011-04-22T21:33:00.000-04:00

A chronic eating disorder with a prolonged course well into adulthood invariably becomes intertwined with one's identity. A girl who learns how to master food and experiences the praise and envy of those around her will find solace in the eating disorder. The typically adolescent, intermittent and painful growth of self-awareness and self-worth will pale in comparison. Before long, the eating disorder will become her sole identity. Once the brief window of triumph subsides, and the eating disorder lingers and festers, praise turns into hushed whispers and horrified stares and finally into nothing. People stop noticing. All that remains is the misery of chronic illness: a bottomless pit of guilt and regret fed by profound hopelessness. And all for the empty promise and glory of being thin.

Returning to life again means, first and foremost, reclaiming identity from the illness. The gradual process of teasing the eating disorder apart from the long buried sense of oneself is arduous and painstaking. It can be both liberating to disarm the punishing thoughts and horrifying to recognize the destruction left in the eating disorder's wake. Every patient in recovery who comes to understand how completely an eating disorder can hijack the mind and turn an entire person into a shell of oneself spends weeks if not months in shock at the discovery. The realization leads to two important thoughts. First, the psychological torment, which feels self-inflicted, really is the core of illness even more than the eating behaviors. Second, recognizing an identity separate from the eating disorder is a profound step towards wellness.

Not long after, perhaps the most curious and painful step in treatment comes to the fore. The more one's identity sharpens into focus, the more clear it becomes that saying goodbye to the eating disorder is no easy feat. While recovery has been a desperate wish for years, the actual parting doesn't feel like the anticipated relief and joy. Surprisingly, it feels more like the end of a tortured relationship with a dear friend.

In the abstract, equating the eating disorder with personality traits or even a person seems absurd. Surely, it's an illness or a choice or the twisted joke of a society turned on its head. But truly understanding the meaning of an eating disorder means getting this point through and through. The rules, behaviors, punishment and reliability of an eating disorder ironically provides as much comfort as it does pain. In a confusing, pressured and unforgiving world, an eating disorder makes things as plain as day. The calm of knowing what you should or shouldn't eat, of knowing what is right and what is wrong is irreplaceable. Anyone living in the modern world knows that believing in right and wrong or good and evil is a luxury of childhood. Adults grapple with endless uncertainty and strive, day in and day out, to muddle through and hope for the best. The dreary, endless gray of life is a bitter pill to swallow for an adult accustomed to the satisfyingly black-and-white world of an eating disorder.

The two points from the last posts--that children are expected to make up for parents' disappointments and the subsequent lack of freedom of childhood--both trap children in a very adult conundrum. Combining the open and curious mind of a child with this kind of inflexibility is a setup. Children may be physically adaptable and even eager for new experiences but do not have the psychological sophistication to sort through complex, covert family expectations. In other words, they just won't get it. Stuck in the morass of mixed messages, kids will think their parents' wishes are their own. They will just get lost and yearn for a simple system with easy answers, like those provided by an eating disorder. Without any coping skills, the world will look like a scary place, one much safer with satisfying rules about eating and food.

So, take this adult in recovery searching for her old identity. If the eating disorder saved her from all of this fear and confusion in the past, what can she expect after saying goodbye? Part of the experience is something everyone can identify with. In this moment, a person with a fully developed, adult mind is thrown into the disorientation and intensity of one aspect of adolescence: finding oneself. Certain formative memories make an indelible mark on self-image. The pangs of regret, embarrassment and ultimately nostalgia create lines we won't cross in the world. It is a universal experience to wish to relive youth with the knowledge of an adult. In many ways, that is the experience of someone with an eating disorder who reclaims her identity. But the old adage doesn't ring true in the slightest. Every step of the way is painful.

The next post will extend this last idea to a different philosophy of parenting. Saying goodbye to the eating disorder leads to a deep exploration of identity separate from adolescent strife and family pressures. The growth of self-image in the cocoon of recovery occurs in a setting with flexibility and freedom, both clearly lacking for today's children. So I'll begin with a question: what might kids raised in this new world be like?

The Dos and Don'ts of Parenting a Child in an Eating Disordered World--Part II

2011-04-08T13:30:00.002-04:00

In an increasingly homogeneous and anonymous world, we all seem to be interchangeable pieces on a chess board, shifting back and forth according to abstruse rules, awaiting the inevitable endgame. In the end, a rook is just a rook, a bishop just a bishop. The qualities that might have made someone unique years ago in a small village are a dime a dozen in the wide, interconnected world. The hope of being special or extraordinary--the unspoken dream if not expectation of modern-day parents--is just a mirage, completely out of reach. Reasonable goals of comfort, companionship and even personal satisfaction are too humdrum to mention. They are the bare minimum, what's to be expected.

The building urgency to be special and recognized above all else has taken over a large swath of childhood. One stark result has been to complicate relationships, for parents and children alike, from the barest acquaintance to the most dear family member. Cooperation and even altruism have been critical to the evolutionary success of humans. The growth and complexity of our social system along with the sophistication of our minds distinguished us from all other species and led to the astounding development of civilization, a continuing process we witness every day. Within this framework, the value of the individual needed to be acknowledged to provide incentive to work for the greater good. Only in recent generations has the scale of the world become so large to essentially eliminate any sense of the individual and leave a growing set of driven, albeit privileged, people competing in a race to nowhere. Yet the larger changes in human society cannot extinguish the personal desire for purpose, identity and recognition. With no outlet for these basic urges, the frustration, especially among the young, has acceded to a blunt disregard for others' well-being. Taking responsibility for one's actions seems to be a thing of the past. Intention is now the bellwether for responsibility: if you didn't mean to do it, then it doesn't really matter. The experience of being an indistinguishable player on a chess board has relegated cooperation a thing of the past.

Nowhere is this change more clear than in families, especially those of privilege. With unrelenting pressure on children to accomplish, excel and succeed, competition is drilled into a child's development almost instantly. The societal pressure to expose infants to stimulating classical music videos, track early educational milestones like a stock trader glued to the latest market report and craft extracurricular activities to ensure a child is gifted in something valuable drowns out the freedom and creativity that embodies this stage of life. As panicked parents watch the acceptance rates at elite universities gradually diminish, effectively approaching zero for all intents and purposes, the mantra goes that a child has to achieve something valuable, something extraordinary, something miraculous in order to gain admission, and thus an entree into any semblance of success. And so the disappointed parent turns a child into the family pawn, the most mundane of all chess pieces, to achieve something noteworthy, redeem the family name and, of course, experience nothing but personal satisfaction. And the parent will be sure to make this happen with no regard for others along the way.

Looking back to the end of the last post, the question of how not to micromanage as a parent becomes absurd. How can a child come close to achieving these results unsupervised? Who will watch how this child works, plays, sleeps and eats? Each minute is precious to reach the family goals.

There are two points to take from the undoing of a child's freedom. Several times in the last few posts, I have referred to personal responsibility, namely that the personal drive for recognition and the family urgency to rectify past failures means that personal gain trumps all. As the privileged youth largely ignore the growing inequality of our society, unless volunteerism as a graduation requirement makes a difference, the group most likely to shed light on our failures instead slaves away at the mundane tasks that lead to personal success. A parent, aware of the luxury privilege brings, would do well to reflect on the responsibility that comes with such good fortune and realize that a child needs to be taught to look outward at the world around them. Inculcating civic duty, a deep sense of fairness and an ingrained sense of personal responsibility may not follow the current doctrine for parenting success but can shift the focus from the cult of family and recognition to the molding of a good person.

Second, there is hubris in believing that everything a child needs to learn and do can be mapped out by devoted parents. The freedom to be a child, to be allowed to think and create and grow and learn also has value in society. Undoubtedly, each generation adds a new perspective to the current state of society and helps us all see and understand things a little differently. The value of a new and agile mind piecing together the facts of the world opens up unseen paths and helps the world become a better place. The expectation that good parents will force children into a scripted world, with every moment and activity accounted for, devalues the voice and legitimacy of new ideas and thoughts. A parent would do well to squeeze freedom, exploration and creative thought into the daily lives of children and encourage them to develop and trust their budding point of view.

If the parents breeding children mired in disordered eating instead focused on raising responsible, thoughtful, reactive minds, would this really lower the in incidence of kids with eating disorders? Any answer to this question is likely a blind prediction and at best an educated guess. Nevertheless, the next few posts will explore the possible results of a shift in parenting in the context of another question: why is it so hard to give up an eating disorder?

The Dos and Don'ts of Parenting a Child in an Eating Disordered World

2011-03-30T11:25:00.003-04:00

It is a telling sign of privilege when family life revolves around what's best for the children. In the stereotypical household, adults organize their time, night and day, around entertaining and enriching children's activities. The underlying sacrifice is unacknowledged, even expected, because who would dare not follow this parenting model. Brushing aside any remaining adult desires is a given, although the most pressing, if subconscious, ones become incorporated into the often unspoken family philosophy, thereby creating the myth of unity, as if the disparate personalities and needs of the family members can come together as one. Unity of purpose may have been an evolutionary benefit, but unity of mind--a cult of family--certainly was not. It is a dangerous precedent to equate psychological well-being with toeing the family line but that is exactly what the cult of family dictates. The ultimate conceit of the privileged family--the socioeconomic class most at risk for producing an eating disordered child--is not just the goal but the inalienable right to raise a happy and, using community-based measures, successful child. And that somehow, inexplicably, this must be what the child wants too.

Not particularly long ago, but long before the disordered eating epidemic, children were expected to fit into adult life. This was a time when there was living memory of a brood of children raised primarily to improve family survival. The pressure to make it far outweighed the luxury of nurturing a child's identity. Providing for children--maybe just surviving to adulthood--was enough; moderating feelings, massaging egos and micromanaging personal growth were not even on the table. They became who they were to become and, hopefully, followed the path laid out before them. Children were psychologically free since no one was terribly interested in what went on in their minds, unlike the current norm when nothing is private or sacred. These days children, burdened by the expectations meant to overcome their parents' personal disappointments, have their identity crafted like a shell made to order by their parents' exact specifications. Sadly, this happens long before developing any self-awareness, let alone a fledgling sense of identity, themselves.

This default view of involved parents has been seen as a sign of the evolution of the privileged family. No one questions the benefit of parent as de facto child psychologist, subtly questioning the kid like a little adult and unconsciously teasing the impressionable mind to tell the parent what he wants to hear. Parents used to know, instinctively, that kids simply played and learned for many years; the struggle for self-awareness, internal stability and personal direction, thankfully, came later. Now the false premise of making mini-adults co-opts the freedom of childhood for the personal satisfaction of needy parents. The inevitable pressure that builds between the desire to please with the innate drive for independence and identity has clear consequences, one of which is the temptation of food restriction and thinness.

It is humbling to see the well-intended parent guide children into the chaos of an eating disorder. It is daunting for the child not to see a way out. But the anti-tropes of the privileged family are never spoken: not every child is a prodigy; some kids get C's; different children have different strengths and weaknesses; achievement is not guaranteed from hard work; any difficulty in school is not by definition a learning disorder. Most importantly, a child's life is his to lead, not a second chance for parents to correct their mistakes or move past their regrets.

The path from prolonged, encouraged dependence on family to a focus on thinness and weight is a theme of this blog. The reward and praise for weight loss both satisfies proud parents and opens a new but false direction of independence and identity. The underlying message of a burgeoning eating disorder is clear to any adult who will listen: "No one can tell ME what to eat." This tidy package satisfies the cultural norm, especially during adolescence, while providing the simple solution any child craves. There is no gray area around disordered eating and weight, just a simple right and wrong. Encased in the pre-fab shell of identity and expectation, draped in the mantle of hope and unlimited potential, this child desperately seeks an escape. An eating disorder can be just that way out.

The attitude towards food and weight taught at home is a critical part of helping a child avoid the risk of an eating disorder, but the family message about identity and expectation is perhaps less obvious but equally important. The rise in the incidence of eating disorders has coincided with the transformation of family. Ironically, fostering the growth of a child's identity takes away from the freedom to explore and learn. The creation of the hovering, over-involved parent has stifled the experiences of childhood that lead to a sense of identity, with both accurate and flawed parts, that grows with time. But this ever changing sense of who we are is a freedom of being human, a right akin to the basic self-awareness and consciousness we take for granted every day. Recreating a world where we just pay a little less attention to the inner workings of a child's mind, where we grant kids a little privacy, may go a long way to stem the tide of eating disorders.

This post addresses the freedom for children to be allowed to become their own person. Part of the prescriptive approach to raising children stems from unhappy parents looking for salvation in future generations. That salvation is no longer something attainable, like the antiquated belief in the American dream. The family expectation is to become something great, something beyond one's imagination: the bar has been set much too high. Under this pressure, the suggestion for a parent not to do something falls on deaf ears, especially in a culture which insists that something can always be done, someone can always be blamed--society, media, government, big business or parents. Then is it not just the moral but legal obligation of a parent to guide children through the maze of the modern world? The next post will address this vacuum: if a parent doesn't micromanage, then what should a parent do?

The Tangled Web of Identity and Eating Disorders

2011-03-11T10:49:00.000-05:00

In a recent meeting, a colleague, speaking about her work with children over many decades, recounted the story of a patient she has treated for thirty years, starting at age six, for "the most profound anxiety disorder I have ever seen." Just the other day, the patient, deliriously happy but exhausted, called to recount the story of the birth of her first child. "Imagine me," she said, "dealing with needles and so many doctors examining me! But I just explained to them my longstanding anxiety and fear of doctors, then they helped me through it." My colleague paused for emphasis, clearly proud, and then presented the moral of her story: if you know yourself and are clear with others about your limitations, anything is possible.

As she went on to expand her thesis into play therapy for children and even parenting advice, I found myself thinking about identity. This patient's sense of accomplishment was momentous and her ability to recognize her achievement moving, but I felt something nagging at me nonetheless. Although self-acceptance is no doubt a critical part of maturity, an identity--the reflection we see both in the mirror and through our family and friends--cloaked in symptoms and limitation seems like a misguided message for kids. Isn't childhood a time for hope and promise? Won't the humbling lessons of adulthood only limit a child in need of perseverance and confidence? All of this left me stuck on the larger question: what are the implications of an identity based largely on the extent of our deficiencies?

The individual accomplishments of my colleague's patient were something to celebrate, of that I was clear. The intended message, though, explored one way of addressing kids' struggle to find identity in today's world: find oneself through difference or limitation and fashion a life from the options remaining. But the implicit advice was cautious if not undermining: avoid challenge and even confrontation to do what you're capable of. Satisfaction comes not from hard work but from the most manageable path in front of you. This reeked of a self-help approach to the world, or the opening salvo of a daytime talk show special, not a potential solution to helping kids build a sense of who they are and certainly not a philosophy of expectation or hope for change. But when the pursuit of happiness becomes the prevailing life philosophy--an unfortunate consequence of the banal advice-giving media spawned from its roots in psychotherapy--progress, hard work and challenge all seem to go by the wayside.

The infiltration of psychiatric symptoms and diagnoses into our self-image is a given in many pockets of society. It used to be that only medical students during their psychiatry rotation nervously thumbed through the latest DSM--the bible of psychiatric diagnoses--terrified to find their deepest secret staring back at them from the criteria of a mental disorder. Now, the DSM is widely available through a mere search of the web, and identifying with mental illness a rite of passage for adults and youth alike. The trying, social process of overcoming shameful secrets has been supplanted by the now commonplace but brazen announcement "That's just my OCD." Your own personal psychiatric symptom is almost a part of the social resume: hometown, religion, race, socioeconomic background ... current mental illness. Or perhaps it's a permanent crutch, a built-in limitation for what one can achieve.

Of all the psychiatric symptoms, manipulation of food and weight create purpose, attainable goals and success out of thin air while simultaneously obliging those looking for children to just be happy. In the cloud of psychiatric symptoms, weight loss and the subsequent positive attention--including the hushed whispers of "is she anorexic?"--is almost a badge of honor, not a crutch in the least. It feels like the sky is the limit as the pounds come off. The demoralizing expectations of a life hampered by a series of psychiatric symptoms evaporates. The world figuratively and literally feels a little bit lighter. The growing epidemic of disordered eating and pursuit of thinness is a simple solution for the directionless child compelled to find meaning in the world. At least for a little while.

Caught between the adolescent drive for purpose and the lure of losing weight, many girls find solace in identifying as eating disordered. The formative years from middle school through college, if nothing stops the onslaught of the disease, can leave one's identity intertwined with the disorder itself. A bright, quick mind, when consumed with the fear and intensity of an eating disorder, will create a vast and complex array of rules to follow in this hidden world. While being controlled by the details of calorie-counting, avoidance of terrifying foods or the search for culinary perfection, the consummation of identity and the disorder is complete. In the end, "you ARE anorexic" is the accepted statement, not "you have anorexia." The grammatical difference may be subtle, but the meaning is crystal clear. Treating an illness is one thing; treating an identity is another.

This post brings up as many questions as it does answers. How do adults help children form identity? What avenues for self-exploration and achievement don't exist for kids? Without other available options, weight loss and food manipulation are powerful tools easily at a child's disposal. Whose responsibility is it to open new doors so at least there is competition for a child's attention and drive? I'll start with these ideas in the next post.

A True Moment of Reflection

2011-03-02T11:16:00.002-05:00

Looking in a mirror is a trivial moment in most people's day. Whether to survey an outfit, observe a blemish or simply take stock, few things are more routine. Yet this nonchalance is symbolic of a life blindly led. It is common to mistake emotionally-charged moments, such as languishing in disappointment and self-criticism or relishing successes, for moments of true introspection. Deeper reflection means not just living in the moment but looking at what we hide even from ourselves: jealousy, greed, explosive anger and shame but also the most vulnerable love, dependency and tenderness. A person living without reflection is still driven by these internal, emotional forces but acts as if reasoned decisions and illusory control pave the way.

In its entirety, the community of people with eating disorders share the burden of empathy, as I described in the last post, and the concomitant role of society's emotional mirror, a thankless role for a world unwilling to take a good look at itself. With a quick glance, perhaps for something as mundane as checking its hair, the larger community may acknowledge what's in the mirror but has no interest in true reflection. Just as a family can heap responsibility onto an empathic family member, society can choose to blame the faulty reflection.

Many of the truths, even those too obvious to ignore, can be readily explained away. Obesity and diabetes in children: lazy, uninformed, uncaring parents. Homogeneous, unhealthful fast food: uneducated poor food choices of the masses. Epidemic of disordered eating: children making immature decisions. Explosion of eating disorders: ah what these crazy women will do to look thin. And the quick fixes are like patching a roof about to collapse from a deluge: misleading nutritional information on food items, Bariatric surgery, spa retreats to cure eating disorders.

The facile mind can always find a new explanation for the unusual or even the absurd. History is rife with tales of societies caught up in sheer folly on the way to destruction and chaos. The path lined solely with reason lands, sooner or later, in the muck. After crawling out of that mess, finally, one will have to really look in the mirror to see what happened. In that moment, the empathic women, silenced by eating disorders and filled with a different understanding of the manipulation and degradation of food and weight, might have their moment.

If empathy is the glue that binds humans into a complex, interdependent and ultimately fair society, then is a world without empathy worth living in? Modern living is about shared experience lived in isolation. We all live in our little bubbles, know a smattering of like-minded people and misuse our unfulfilled desire for connectedness to obsess about our own daily minutiae. The care and concern for others is routinely quashed: war looks suspiciously like the latest video game; natural disaster like the most recent apocalyptic movie. And if the empathizers, lost and ignored, have been wooed by calorie counting and the number on the scale, who cares about what's happening to people in need? Where is the mirror to steer us back to our collective responsibility to care for each other?

The most curious and disturbing aspect of our current food culture is that the well-off now starve while the poor are fattened up on food akin to garbage. This discrepancy is most notable in children. It's the right of passage for a suburban girl to start her first diet while the inner city kid only finds McDonald's in the neighborhood. The implicit government support--through lax regulation of the food industry--of this travesty and the blatantly unethical corporations which capitalize on the social forces (both the weight loss and various food industries) work hard to silence the reflection of empathy. Nothing can tamper with the bottom line. Instead, we all just continue to blame the reflection.

I fear that the silenced voice of empathy hides the ugly underbelly of our isolated world. The shameless celebration of the culture of plenty obscures the inequality, need and pain all around us. Surrounded by such abundance, the acceptance both of starvation and obesity-related illness--paradoxically in the well-off and poor, respectively--is unconscionable yet sadly has become routine. Meanwhile, the group of people most aware of the absence of social justice and most able to spearhead a revolution--an apt analogy during this time of upheaval in the world--suffer needlessly at home alone except for their food and scale.

The next series of posts will shift to food, children and identity. I will start by discussing how our relationship to food helps create identity in children and is closely intertwined with the development of an eating disorder.

Empathy: From the Individual to Society

2011-02-18T10:47:00.000-05:00

During the transition from the psychoanalytic to self-help era, empathy is one of those words that has seeped into the general lexicon. For many, empathy and sympathy are false synonyms with the new vocabulary word intended to impress others rather than convey new information. In other circles, using the word, still not necessarily correctly, in casual conversation serves as a hidden signal to search out like-minded emotional souls. If received by one in the cohort, the missive opens the door to commiserate about the burden of carrying others' emotional pain--an unappreciated service to society. Otherwise, the message easily slips by those not afflicted.

In short, empathy means identifying with and feeling the pain of others. A complete lack of empathy, a rare and terrifying aberration in emotional development, is a crucial element to become a sociopath. People with a low empathy quotient tend to be self-absorbed and, although not particularly harmful to society, devastating to any intimates. In some ways, the single-mindedness of the self-involved can propel them to high achievement while limiting the ability for any close relationships. An overwhelming majority experience empathy for others in pain but can emotionally protect themselves from being overwhelmed by these feelings. Without this unique social construct, humans would not have developed the complex, social civilizations we have today.

For a few, empathy feels like a sixth sense, at times a gift and others a gaping wound. Feeling other people's pain is not a choice but a part of how one experiences the world. Deep personal connections, friends in need and even sad films or documentaries are all entrées into a powerful emotional abyss that allows for a vivid, invigorating world experience but, with no way to turn off the intensity, can at times turn into its own prison.

Many women with eating disorders have this level of empathy and describe the relentless feelings as unbearable. The illness numbs all emotion and pushes away any closeness in relationships, thereby significantly diminishing the intensity of any empathic response but simultaneously leaving innately interconnected women painfully alone. As a consequence, reconnecting emotions during recovery--a raw, exposing process--means not only re-engaging with the world but re-living empathy for others. This can leave people gasping for air at the overwhelming emotional intensity. Others' feelings come crashing down on them in a burst of psychological and emotional torment that can be hard for a person in recovery to identify, let alone tolerate.

The process of recovery can no more cure the hyper-empathic person than therapy changes one's personality. The goal is to learn to live with this ability and find a way to manage and cope with the vulnerability of daily life. What was a confusing and overwhelming realization as an adolescent can in time become a facet of life as an adult. Our success and maturity depends as much on the ability to accept and hopefully harness our personality and interactive style as it does on the sheer luck of our life station. Empathic people can use their ability to identify and clearly express the collective emotions of those around us. But my optimism can hide the immediate reality in recovery. After a protracted illness, the road through treatment to acceptance is a long and arduous one.

Based on the last post, silencing people with eating disorders has significant meaning for our society. It's a short step to intuit the hidden meaning: people who harness their own empathy can be very powerful indeed. Individuals with a facile empathic response tend, on an individual basis, to harbor and reflect the emotions of those around them. For instance, in a relatively inexpressive family, the empathic member is usually seen as the "sensitive" one. On the surface, this moniker implies the person most emotionally connected but effectively means the ridiculed one attacked for not repressing her feelings sufficiently. Particularly unemotional families often accuse the empathic member of being fully responsible for everyone's feelings. When no one accepts their own emotions, it's convenient to blame the one incapable of repression for all of the emotions in the family. As absurd as this dynamic looks from the outside, scapegoating is an age-old method of maintaining stability in chaos.

However, by definition, the empathic family member actually reflects the emotions around her. She is a mirror for the family to see what's truly inside them. And if the reflection is too painful, why not blame the mirror itself. On a larger scale, a group of empathic people can reflect and even amplify the emotions of the society around them. Silencing those emotions dampens the impact of certain social forces. In a society ripe for change, the empathic set can galvanize a group to open new avenues for communal growth. The non-violence of the civil rights movement reflected the pain and patent prejudice to rally effective support and long-lasting effects.

What would the group of suppressed, empathic women--many trapped in the internal hell of eating disorders--reflect to society today? What social forces can be ignored by covering the mirrors around us? Injustice? Intolerance? Callousness? A stagnant, polarized world? I think the answers lie in what these silenced people might finally say when given the podium. Look out for the next post.

The Meaning of Silence

2011-02-09T11:35:00.000-05:00

The emergence of eating disorders as a new group of psychiatric illnesses in only a generation opens the door to a host of inquiries. The changes in food supply, the homogeneity of modern life and the cultural focus on weight and thinness are the explicit pressures encouraging disordered eating and, for those susceptible, eating disorders. But the more profound questions remain unanswered as to why the public remains so uneducated about eating disorders and why those afflicted are never heard.

From a sociological perspective, the increased incidence of eating disorders coincided with the impact of the feminist movement. Protesting the oppression and limits of women's lives brought about substantive change and opportunity. Today's girls feel confident that their goals and dreams need not be different from the boys. Simultaneously, the pressure to look thin, to harshly critique their bodies and to become a sexual object encroach on younger and younger girls. Disturbingly, the current ideal woman's body is that of a fifteen year old, not a grown woman. The academic, intellectual and professional achievements possible because of Betty Friedan and many others seem to have come at a steep cost. Why has this external equality among the sexes forced women and girls collectively to feel enslaved to an internal source of inequality?

Much of what I have written explores the hidden side of these diseases as opposed to the DSM-IV-TR--the psychiatric Bible--which lists a series of relatively concrete symptoms that comprise an eating disorder. Although an accepted diagnosis is necessary to create consensus among clinicians, the absence of an emotional and psychological guideline only propagates the deeply rooted misunderstanding. It is too easy for the public to equate Anorexia Nervosa solely with starvation, for example, without any awareness of the psychological torment at the root of the illness.

Perhaps the most suffering is caused by the feeling that someone is at fault for their entire illness, that they are solely to blame. One goal of therapy is to see the self-blame as part of the illness--how can you blame yourself for something you never could control? Relinquishing the personal responsibility makes room for healing and subsequently the painful, personal growth necessary for recovery. However, misunderstood by family, the media and even ignorant clinicians, patients remain alone and often spend years sure that blaming themselves is completely accurate. It is curious to me that the general public response to these horrific diseases is to corner the patient into feeling fully responsible. Why is the needed compassion replaced by ridicule or contempt? How did eating disorders turn into a media spectacle? It is hard not to interpret these circumstances as a covert societal force intended to silence this subset of women.

Interestingly, this is one similarity between eating disorders and disordered eating. The self-reproach of disordered eating can be a modified version of the self-blame of eating disorders. Both serve to tamp down any burgeoning confidence fostered by the equality among the sexes today. Just as girls might be finding their rhythm in school, their attention shifts to body and self-image. Often, pressures to be attractive, including sexually appealing, entraps younger and younger girls. Considering the personality traits that increase the risk of eating disorders--motivation, perfectionism, drive and powerful empathy--it is hard not to connect the dots: many of the most successful girls are lost to the preoccupation with food and weight. The full implication of this statement is profound. Equality exists in this country no matter one's sex, but the covert societal forces now seem to generate enough internal turmoil in girls to severely limit their potential. By hiding the truth about eating disorders, society ignores and silences voices no one wants to hear. Now the inequality exists but can't be seen.

The next post will focus on the experience of empathy in people with eating disorders and the concomitant emotional pain of outpatient recovery, both on an individual basis and on the contribution to what remains concealed behind the public ignorance of eating disorders.

A Public Education on Eating Disorders

2011-01-28T12:37:00.000-05:00

It is one thing to consider the bias against people with eating disorders and the misunderstanding, judgment and fear driving the power of false beliefs. Standing up for the rights of the oppressed is a natural, if not always heeded, instinct. It is another thing entirely to imagine a world where the true suffering caused by eating disorders is widely understood and accepted.

However, the changes that occur in a generation can be astounding. There was no known diagnosis in the sixties and early seventies, limited treatment options a few decades later and a plethora of choices now. Children today are raised hyper-aware of eating disorders--diseases their parents at a minimum accept and their grandparents still question--and have usually been touched by their effects. Perhaps there is some hope on a communal level for greater understanding.

The obsessive desire to be thin--and all of the dieting and self-criticism that comes along with it--feels like a cultural fixture. Even though our passion for starvation has directly led to the increased incidence of eating disorders, the pressure to adhere to this norm is here to stay. And the seemingly natural extension that personally worrying about food and weight equates with a breadth of knowledge about eating disorders appears to have become the de facto logic of the uneducated masses. It is a short step to feeling entitled to express, with great certainty, completely false opinions. But without any public entity correcting the prejudice and revealing the reality of eating disorders, the cultural bias goes unchallenged. It is hard to change a belief without starting with education: a diet is not an illness. The first step is differentiating between disordered eating--the practically universal experience--and eating disorders.

Disordered eating is a choice to eat in order to lose weight instead of following the internal cues of hunger and fullness. And the options, fully condoned by society, to eat this way are endless: diets, food restriction (low sugar, low carbs, low protein, no refined foods, etc.), skipping meals and the list goes on. The underlying belief is that choosing what and how much to eat is always within our control. Because this premise is so deeply untrue, the result of disordered eating is chronic dissatisfaction with one's body, disgust with one's inability to manage such a "simple" task and a series of futile attempts to find a satisfactory result. Even if someone lands at an acceptable weight, there is no end to the disordered eating because of the fear that any lapse will mean immediate failure. This is a state of mind as much as a state of eating.

To an uneducated mind, some of these concerns may sound like an eating disorder, but the fundamental difference between the two lies in one word: choice. Disordered eating is a choice to manage dissatisfaction with oneself by manipulating food. An eating disorder is not a choice at all. It is an illness. The driving force behind an eating disorder is the psychological torment that compels someone to continue all of the symptoms. The person is powerless to stop the cycle and attempts to function within the very limited confines the disease allows.

People with eating disorders are silenced by their illness so no one who really understands is ever heard. The clinical treatises, scientific papers, self-help books, documentaries and exposés all promote awareness of these illnesses without changing the misunderstanding and prejudice. Amidst the recent P.R. hype for Portia de Rossi's memoir about eating disorder recovery, a patient pointed out something critical: people who have these diseases are only heard AFTER they have recovered. Per usual, the media blitz around her successful recovery papered over the behind-the-scenes ridicule. And the private flogging is led by those with eating disorders. It is too easy to see through an apparently vulnerable attempt to show others the road to recovery. Instead, she becomes a symbol: the poor, weak TV star who had to learn to eat all over again. Why doesn't she say what having an eating disorder is really like? Because, more to the point, no one really wants to hear about that.

There is one place you can really learn about having an eating disorder. Pro-Ana sites are a provocative way of exposing the truth behind anorexia. While people are horrified by the glorification of extremely emaciated women, there is no attempt to understand what these sites mean. The takeaway message for the uninformed is that this is a subversive way to spread destructive tips to get sicker. The truth is there are many, many ways for people to learn eating disorder tricks. In fact, many patients say their first trip to an eating disorder hospital unit was really a crash course in how to really have an eating disorder.

The pro-Ana sites are one of the few ways the sickest people can feel less alone. The photos of emaciated women are meant to express how painful an eating disorder can be, how distorted and destructive the thoughts are. How can one's life goal turn into getting terribly sick and underweight? Yet it is telling that this one forum of honesty has been summarily banned. Something is clearly askew when the places of healing can be as counterproductive as a website created to propagate the illness. But in one instance the sick are locked away, and in the other they are out in public. The completely illusory danger of these sites is the fear that eating disorders are contagious. Disordered eating is most certainly spread through the masses, but eating disorders are not like the flu. Based on fear and misinformation, the message is clear that eating disorders are a menace better seen than heard.

In wondering how to spread real knowledge about eating disorders, I come back to the continuous stream of emails and calls I receive from those who find me online. The questions revolve around seeking hope and finding someone who truly understands. From the patient sick of years of inadequate treatment to scared parents of a young child, they are all shocked when the truisms of disordered eating don't compare with the reality of an eating disorder. To find someone who understands the difference and is willing to acknowledge how much pain an eating disorder causes is half the battle. Without being presumptuous, I hope this blog contributes a little to spread the word. But nothing will change until the people who are sick are finally heard.

The next post will posit some thoughts as to why the community at large wants to keep the real, painful experience of having an eating disorder silenced.

The Prejudice Against Eating Disorders

2011-01-19T11:09:00.002-05:00

The bias against mental illness has eroded over the past generation. There are still plenty of people who view depression as a lack of will power, psychiatric medication as a sign of weakness or psychotherapy as a salve for people who have no friends, but several changes in our society and the field of psychiatry have eliminated much of this prejudice. The advent of a diagnostic classification system for mental illness gave people a clear, accessible resource to understand the meaning of different diagnoses. The representation of mental illness in the media has exposed the public to the suffering of and healing process from diseases such as depression and schizophrenia. The explosion in direct-to consumer medication advertising--despite all of the deleterious effects I have described in several posts--has improved the public perception of psychotropic drugs. Finally, the recently enacted federal law mandating parity in insurance coverage for "biologically-based" psychiatric diagnoses with medical illness only reinforces our society's gradual acceptance that these are real diseases.

But where do eating disorders fit into the changes in attitude toward the mentally ill? Anorexia and Bulimia are two of the psychiatric diagnoses covered under the parity law. There are no medications advertised to treat eating disorders. And, as I wrote about in the series of posts on the media, eating disorders are everywhere in our national mind. On the surface, it seems like the pervasive view of eating disorders should be changing like it is for other mental illnesses. But, unlike other psychiatric problems, it is a fine line to the community at large between disordered eating--practically an accepted norm about food--and a full-fledged eating disorder. Not everyone has a theory about the cause of Bipolar Disorder or Schizophrenia, but who doesn't feel like they have a right to express their opinion about eating disorders? Even conscientious doctors often believe it is ok to discuss nutrition advice or personal opinions about thinness to patients known to have an eating disorder! The prejudice remains hidden behind a screen of seeming good intentions and judgment laced with complete ignorance of the reality of these illnesses.

The rationale of our preoccupation with food and weight--from any weight loss scheme to daily meal choices--is that we are in control of our destiny. Calories in equals calories out, right? Aren't we all little machines? These tropes drive the multi-billion dollar diet industry but vastly oversimplify the balance of diet and weight. Nevertheless, it is a small step in logic for most people to erroneously apply this line of reasoning to an eating disorder: staying sick is merely a lack of will power. One fundamental message of this blog is to dispel this myth.

Eating, even for those who struggle with it, is an automatic, natural process. It is impossible to understand, let alone imagine how powerless someone with an eating disorder is when confronted with food. Will power has nothing to do with it. But the endless discussion about food in our culture mistakenly gives the impression that there is little difference between worrying about weight and a mental illness. In this mindset, calling someone anorexic--a label of severe mental illness--can morph into an envious taunt. And nothing more clearly shows the extent of our communal bias.

I have written before how our society essentially exposes all adolescents to the risk factors of developing an eating disorder. The idealization of being thin, the rite of passage of dieting and the acceptability of weight loss and food restriction pressure almost all teenagers to expose themselves to a prolonged semi-starvation state. At that point, other factors including biological predisposition and family and social dynamics--which are clearly out of the child's control--determine the final outcome.

Just as an adolescent girl may be praised for losing weight, despite the inherent risk of getting sick, her inability to recover will be seen as a sign of weakness. In fact, families and friends, after extended periods of support, sadly express their frustration by writing the person off. That doesn't mean eliminating the person from their lives but a more subtle expression of bias. If developing an eating disorder is a sign of weakness, then remaining sick well into adulthood is not an intractable illness but a permanent character flaw. The person with a chronic eating disorder becomes almost less than a person: she no longer deserves to be seen or heard.

The results of this prejudice are subtle. Often the person has a job, friends and even a relationship. But those closest to her dismiss her thoughts or feelings. No one really is around to listen anymore. Under these circumstances, someone with an eating disorder has no one to turn to but the eating disorder itself. The prejudice serves to isolate those suffering even more.

The public message--from industry to the media to government--promoting the understanding of mental illness needs to expand into eating disorders as well. Instead, society continues to reinforce the prejudice. One recent example is the reality television craze depicting severe weight loss in the morbidly obese. This is a symbol of the bias that eating disorders aren't really mental illnesses but instead constitute an evening's entertainment. With the current knowledge in the diagnosis and treatment of eating disorders, what can be done? How can knowledge about the real suffering caused by eating disorders replace the public notion of weak, unmotivated women? I'll talk more about this in the next post.

Can Families Heal from an Eating Disorder?

2011-01-07T10:15:00.002-05:00

There is a long history of blaming psychiatric illness on dysfunctional families. The most storied example is the "schizophrenogenic" mother. Schizophrenia, a disease classified largely by psychosis or the misperception of things that do not exist, has since been shown to be caused primarily by inheritable, genetic traits in association with developmental brain abnormalities. During the period when psychiatry was grounded in psychoanalysis, the schizophrenogenic mother theory was based on the only means of psychiatric healing at the time. In a field with only psychotherapy at its disposal, putting the blame on an overbearing, emotionally overwrought mother for a primarily biological illness seemed only logical.

Since eating disorder research is still in its nascent period, the temptation to rely on family dynamics--in this case "enmeshed" mothers and daughters--as the primary cause of eating disorders is extremely strong. The extent that biological, hereditary and social factors play a role in the sharp rise in the incidence of eating disorders is unclear, but no one doubts the complexity of these illnesses. Although family dynamics surely play a role for many, the overarching mother-driven theory feels like a frustrated group of clinicians grasping at straws. But that is not meant to dismiss the role of family dynamics either. The effectiveness of the Maudsley treatment, as discussed in the last post, makes it hard to ignore the family as a powerful force that shapes the course of an eating disorder. Acknowledging the toll an eating disorder takes on families--and attempting to help the family heal--is an often neglected part of recovery.

For many patients, the guilt of putting their families through the trials of eating disorder treatment--financially, emotionally and psychologically--for the second, third (or umpteenth) time serves as a huge barrier to progress. For people consumed with caring for others, the realization that getting better causes their family to suffer can be enough for a patient to forgo treatment altogether. It seems easier to function as best as possible and hide the disorder by pretending to be well. The internal suffering feels more bearable than the overwhelming guilt of revealing her persistent, shameful inability to recover.

This pattern usually occurs after someone has been sick for some years and been living independently. The missing piece in this obstacle to recovery is working on healing the long-term effect of an eating disorder on families. There is a wide range of responses from families early in the course of treatment. For some, an eating disorder is a willful act of disobedience from the beginning. A patient in this family often feels as if she caused the eating disorder and in some ways deserves her fate. But other families spend years researching the disease, seeking the best help and participating in the treatment process. After a time with limited improvement, even the most supportive family gets frustrated and eventually can't help but voice their feelings to the patient. It is exceedingly rare to find a family that, in one way or another, doesn't blame the child for her illness after a certain number of years. The simmering, silent anger and sense of loss can cause a seemingly unfixable rift between the patient and her family.

A necessary part of regaining both hope for recovery and healing in the family is to enable someone with an eating disorder to re-engage with her family. As an adult, the patient doesn't need her family to guide treatment anymore. Conveying a sense of purpose and progress can be enough to include families in the process while opening the door for new lines of communication. The entire family almost always remains aware that the eating disorder still dominates the patient's life but is bound to a false secrecy. The burden of maintaining this secret grows into a mountain of frustration and misunderstanding. When a family learns the patient is working hard in treatment on her own, those families which were initially supportive can often address longstanding grievances and try to establish a new joint effort of love and support. The relief of not having to be the driving force behind treatment also allows families to reconnect without the pressure of having to find an immediate cure. In families which blamed the child at the outset, the treatment needs to persevere alone, very separate from the family's influence, and the sense of loss that follows is a key element of recovery.

A patient's rightful place in her family, even after recovering from a protracted illness, is precarious. Families often act like the child with an eating disorder abdicates her ability to be a full member. She can be treated as fragile, irresponsible or even incompetent. On a general level, it is commonplace to view people with eating disorders as incapable in all facets of life. How can someone who can't feed herself be able to function in the world at all? This naive, prejudiced question exposes the fear and complete lack of comprehension of eating disorders in our society today. This will be the topic of the next post.

What the Maudsley Treatment Might Mean for Adults

2010-12-30T10:25:00.002-05:00

The Maudsley Therapy is a relatively new treatment for adolescents with Anorexia Nervosa. In a nutshell, the parents are responsible for feeding the child and finding any acceptable way to be sure she eats. The treatment team aids the parents and empowers them to leave no wiggle room for the child to continue to restrict. The parents are full members of the treatment process and an integral part of recovery.

There is nothing novel about the concept behind the Maudsley treatment. Behavioral problems in children more often than not stem from ongoing issues in family dynamics. Accordingly, treating adolescents almost always includes family therapy, and that therapy also must support the parents' authority. Although teenagers are continually working on--and pushing acceptable limits of--their independence, parents ultimately have the responsibility and ability to set rules and enforce them.

What does make the Maudsley method unique is that, unlike so much of the treatment for Anorexia Nervosa, it seems to work. This approach focuses on children early in the course of the illness, and, as I have written many times, the chance for a relatively fast and full recovery is greatest before the eating disorder has fully taken hold. Using Maudsley either after inpatient treatment or right after initial diagnosis can enable a child and family to overcome the eating disorder and its psychological and emotional causes in the initial stages of the illness. The treatment tackles the triggers in daily life and helps heal the family dynamics that may be at the core of the disorder. With the eating disorder so exposed, the child can no longer hide her feelings or her symptoms and is instantly brought back into her life and into the relationships around her. The process does not allow the eating disorder to transform from starvation into a way of life.

Any ray of hope within the professional community quickly makes its way into clinical practice. Effectively, this means that therapists will try to incorporate new, promising treatment alternatives into the process of recovery. The Maudsley method is no exception.

But there are several obstacles to adapting the treatment to adults with a chronic eating disorder. First, the patient is an adult. As I wrote in the last post, it is critical that this adult have the autonomy to make decisions about her treatment. Imposing any steadfast rules--and the fear and uncertainty that is sure to follow--only strengthens the hold of the eating disorder: the patient has no other tools to cope with high levels of stress. Second, what does relinquishing some control over food look like for an adult? Third, who is the person (or are the people) in charge of supervising the eating? And exactly what role does this person have in treatment?

The first step is one simple fundamental adaptation to the Maudsley concept. A child often has little awareness of the scope of the eating disorder, how much the illness consumes her and the long term risk to her life. Most adults with a chronic eating disorder--those without the delusional component I discussed in an early post--are much more aware of these realities. Because of this difference, a patient will often be willing to accept that, despite her resolve and motivation to get better, she cannot do so on her own. The eating disorder thoughts remain too powerful. And that means she will need help throughout the day to eat. If more structured programs have had limited long term benefit, using the relationships in her life to help her eat can not only be effective but can be appealing to the patient herself. It can offer a new alternative rather than returning to the limited and largely ineffective options she has tried in the past.

The other difference is that the patient cannot be forced to eat the way a child can. Instead, she needs first to establish the proposed changes to the meal plan on a regular basis--preferably daily to weekly--with her nutritionist. She then needs to share these changes with the designated person or people in her life who are going to help her face the eating disorder thoughts. And third, she needs to empower her helpers and herself to make these changes happen. The patient needs to acknowledge that the changes in her eating will only take place when people in her personal life are allowed to support her against the eating disorder. This person is usually a parent or friend, significant other or spouse. Under certain circumstances, the therapist can also offer this kind of support and be effective. The difference between this situation and a parent helping an adolescent is that this helper does not have the same kind of authority a parent does. Accordingly, the power to make changes comes only from the collaboration between this person and the patient herself. So the crucial component to success is the patient's ability to let people into her life. That is how the Maudsley approach is most similar for adults: it insists the patient no longer is so alone.

After the last two posts indirectly referred to the possible role families play both in the inception of an eating disorder and in the healing process, I think the next post should focus more specifically on the family as a whole and how disordered eating and an eating disorder disrupts its function.

The Residential Treatment Option

2010-12-17T22:10:00.000-05:00

The decision to go into residential treatment for an eating disorder is a challenging one. First and foremost, the purpose is to restore health to someone who has become too ill to function in the world. In a controlled setting, the eating disorder thoughts cannot reign unabated. The program enables restorative nutrition so that the person's body and mind can heal.

The most pressing concern is how to be sure an inpatient stay fits into the recovery plan. Eating solely to improve short-term health is of little consequence to real recovery. Although the decision to seek a residential program can be harrowing for a patient and her family, it is often followed by a sense of relief on all parts. Just the act of doing something concrete gives the illusion that full recovery is near.

Certainly for many patients, this respite can act as a springboard for more effective treatment after discharge, but a significant minority relapse and return to their pre-inpatient physical state before long. For these patients, restoration of health is not sufficient to overcome the relentless thoughts and compulsions of the eating disorder. And there are times that this sequence of events is more demoralizing than just staying the course.

For the patient with her first, second or even third episode, the professional consensus is that residential treatment is a necessary step. As I have discussed prior, resuming eating and normalizing body function can be enough to stem the onslaught of an eating disorder--especially early in the course of the illness--and to lead to full recovery. However, the patient and family need to understand the purpose and limitations of an inpatient stay, most importantly that the end result is not that the eating disorder just disappears.

Inpatient recovery exists in a bubble without any of the pressures and stresses of daily life that lead someone back to the eating disorder symptoms. On the most basic level, the patient needs to learn new ways to cope with the world and her feelings once she has returned back to her life. A clear, directed treatment plan needs to be in place long before discharge. Everyone must be aware that the inpatient program is a stepping stone towards recovery and not a magical cure.

For patients considering hospitalization after a protracted illness, the decision process looks very different. The severity of the physical symptoms takes precedence. The person's medical status needs to be the top priority because a lengthy but effective treatment does no good if the patient's health completely deteriorates during the process. Inpatient treatment becomes necessary when the person is at high risk to maintain her health and well-being, no matter the other gains in recovery.

However, people who have been struggling with an eating disorder for many years have become accustomed to feeling very ill most of the time. Because of their unusually high pain tolerance combined with the shame of being ill so long, patients find it very hard to admit to their fragile physical state. Even families begin to get used to the patient being sick. The therapist and doctor need to regularly assess the patient's medical condition and reinforce how dire her suffering is and the necessity of trying to be open about her physical state.

At the same time, after a series of hospitalizations, patients and families are aware of the limitations of an inpatient program. The history of disappointment added to growing hopelessness makes it hard to commit to such a disruptive and costly decision in recovery. Medical stability and breaking the eating disorder cycle become the only clear gains of hospitalization. But even when treatment is moving forward, a residential program can be a critical step because it may very well afford the patient more time in a stable medical state to get well. Another round of inpatient treatment often appears to the patient and family to be a futile merry-go-round rather than a part of a larger recovery, but a frank discussion about the purpose of this step often is extremely helpful. The result is to ensure that the patient's physical well-being remain a crucial part of the larger picture of recovery.

The other roadblock to making a clear and useful decision is the patient's role in the process. Someone with a chronic illness needs to reclaim some autonomy when inpatient treatment seems likely or at least a serious consideration. She can't feel like she is being shipped off to the hospital again like a child. These patients are full-fledged adults and, accordingly, can make their own decision about treatment. I have encountered too many patients well into adulthood still submitting to the will of families or paternalistic therapists who imply that having an eating disorder renders a person incompetent. There is no doubt that the eating disorder thoughts, at their most powerful, can affect someone's judgment, but almost all patients can weigh the options with a therapist and make a reasonable decision. The result is a patient who feels empowered by her own role in treatment decisions and feels much more willing to try to take an active part in making this commitment worthwhile.

The second way a patient with chronic illness takes hold of her treatment is a bit paradoxical. As I have stated before, an eating disorder effectively isolates someone from the world around them. There is no room for people and especially intimate relationships when the thoughts and behaviors of an eating disorder consume all of the time and energy a person has. One relatively new treatment program called the Maudsley method is aimed at treating adolescents with anorexia. The protocol entails the patient relinquishing all decisions about food to her parents who supervise every meal and snack and are an integral part of the treatment process at each step and each appointment.

It is a new concept to apply this approach to patients with chronic eating disorders. An adult cannot have her independence taken away, but she is also acutely aware that she cannot eat normally on her own: the eating disorder thoughts remain too powerful. The general idea is to formulate an individual plan to include an important person in her life in the daily process of eating. This is another powerful way to let someone in. I will elaborate on this idea in the next post.

Love Thyself?

2010-12-10T13:39:00.000-05:00

"Love thyself" has become the mantra of the modern woman. According to the current gospel, i.e. women's magazines, the path to a healthy relationship is blocked until you love yourself first. But it's hard to figure out exactly what that means, although there is no shortage of people who think they've figured it out. The answer, for women who are looking for a simple fix, comes in assortment of self-help checklists meant to impart romantic enlightenment. After sifting through the blather, the only consistent message is a covert one: your personal responsibility in society is to make a relationship work and if it's not working, it's your fault. It has been all too easy for women to feel trapped in this double bind.

What has made this message so powerful and also left it relatively uncontested is the isolation of modern day life. Left alone to find their way, women are ripe for any sage advice. The media happily obliges with many--often uneducated--forays into pop psychology. The common wisdom of the day emphasizes that not just self-acceptance but self-love is essential for happiness. But a thread throughout this entire blog is that there is only one reason in our society that a woman can truly love herself: if she stays thin. So the fundamental message equates thinness with suitability as a mate, and the media's attempts to rescue women's self-image actually leads women, obsessively, back to the scale, desperate to shed the pounds that will magically land them in a happy relationship.

What's so backwards in this philosophy is that our own self-image is grounded in relationships., not in loving oneself. Historically and psychologically, that is the cornerstone of how people, and especially women, see themselves. To arbitrarily separate oneself from one's relationships is akin to tearing away the essence of our humanity.

Fundamentally, we have always had a social nature. The successes and downfalls of the human race rest largely on our sense of community, and much of our intellectual pursuit has focused on the dichotomy between our sense of individuality and our social existence. We have attempted to understand our innate need to relate to others through philosophy in the distant past, but in the last century the mode of inquiry has been scientific, namely psychological and biological.

Some of the most basic understanding of human relationships has come from studies of the mother-child bond. Our identity originally forms in a symbiotic way with the mother. A trove of psychoanalytic research explores every nuance of a baby's transition from literally being one with its mother in utero to learning to differentiate between itself and other objects, also initially its mother. But it's startling to recognize that when a baby first looks at its mother, the baby identifies her as part of itself! And seeing oneself as an individual comes not days but a few years into life. Our sense of being independent is an outgrowth of living in the world and not at all an innate part of our psychological make-up. If that's the case, then "love thyself" as a mantra to adopt in our little bubble ignores the basic facts of our dependence on others. No wonder such an artificial way of living ends up being translated into something so concrete and meaningless as "stay thin."

Further research into child development places increasing importance on parent and peer relationships as the central mechanism a child uses to learn who he or she is. The child studies these reflections from others to learn how to become a fully independent person, also one of the goals of parenting. But if the most powerful tool to foster independence is the relationship with a child, then perhaps the goal is not complete autonomy at all. In a social society, a fully functioning adult learns to hold up her end of the relationships in her life. So the idea is to exist in a web of people and know one's place in one's own network. Maybe that's how to become a mature adult.

The difference between these two philosophies--love thyself or live in a network of relationships--can help direct a confused, at risk adolescent either towards an eating disorder or a healthy self-image. At this stage of life, a child is struggling to form an identity and, as I discussed in a previous post, is routinely trying on different hats to see if they fit. Outside of appearance and weight--things children this age universally criticize--a teenager will see little else in the mirror, so advocating the impossible edict to "love thyself" will only stoke the flame of the self-hatred.

Adolescents use all of the relationships around them to shape their sense of themselves and are susceptible to be quickly influenced by the people around them. For further proof, anyone can remember poor decisions of that time of life, and these powerfully emotional memories are always tinged with shame and the shock of being so painfully vulnerable. But these events remain defined markers of when we learned about ourselves. The positive and negative consequences of those relationships signify the process of coming to know who we are.

The critical importance of relationships to personal development in adolescence leads to an obvious step for parents. The key is to use the personal relationship with children to reflect who they are and what they mean in the world. It's a mistake to think children will acknowledge the information as an adult would. In fact, a child will look in that mirror again and again to be sure of what they saw and often challenge it for years before accepting this reflection. But if adults help the child learn who she is, then she won't end up relying on food and weight as the only barometer. We can only love ourselves as well as we have been loved. Ironically, we best see ourselves in reflections of others than in the mirror.

I want to switch gears for next time. In an early post, I discussed the pros and cons for residential treatment for eating disorders. I'm going to revisit that topic and speak about some alternate treatment ideas.

Expectations

2010-12-02T09:26:00.002-05:00

At the end of the last post, the ideas of specialness, hope, living through the future and secretiveness--all discussed here previously--began to seem as relevant to adolescence as they do to eating disorder recovery. The question that came to mind is that perhaps the narrative of an eating disorder tends to remain stuck in the limited scope of adolescent expectations. That doesn't mean that someone with an eating disorder IS an adolescent at all but that having an eating disorder stops the personal development of how one views life's course. And then understanding the difference between the expectations of an adolescent and those of someone with an eating disorder might be a clue to help protect children from getting sick.

The state of becoming--the central theme of adolescence described in the last post--is a precious moment in life when everything seems possible for an instant. But this developmental stage has instead become the Holy Grail, so revered that people try to extend it well past its expiration date. The sense of becoming is valuable for society at large because, by definition, it remains a brief moment in life. Teenagers embody the hope of a community for a new and improved future, but there is nothing pretty about someone in middle age working too hard to look or seem ten or twenty years younger. At some point, to have value for oneself and one's community, we all have to become something, namely ourselves.

In the world of an eating disorder, one is always becoming: becoming thinner, becoming sicker or imagining a future life when one has become well. In the end, the therapy for an eating disorder must lead to one significant transformation: from becoming to having become. A patient is so used to focusing on a future of being well and the fantasies of what life will be like that she has generally lost the ability to think and feel today, now. The end result is to completely eliminate any expectations for today and to ignore the real process of how life changes. The goal, dictated by the rules of an eating disorder, is predetermined. Each day is the same. Someone with an eating disorder continues to mature but her sense of how to become doesn't. And so expectations become almost contradictory: the aimless musings of a teenager explained by an intelligent, sophisticated adult.

But these free-floating expectations are the essence of adolescence. Suspended between an unrealistic yet somehow universal sense of promise and a tumultuous, emotional present, teenagers seem incomprehensible to any adult. They resemble wild, irrational beasts with the potential brainpower of a Nobel Laureate, the libido of a dog in heat and the emotional intelligence of an infant. The challenge of having a rational conversation can feel like learning Mandarin in one sitting. And even any linear sense of narrative is constantly being interrupted by fantasy and wild expectations. The precarious mental state and instability of a self that dominates adolescence seem to act like bait for disordered eating. As I have written in several posts, focusing on food and weight can provide order and identity to the utter confusion facing these kids. How then does a well-meaning parent talk to them in a language that will make sense? How does a parent be sure that the process of becoming lands a child squarely in the world of having become?

This is where the difference between eating disorder recovery and adolescent angst is useful. In treatment, the relationship in therapy acts like a mirror, and the patient consistently learns about herself by looking at her reflection each session. The disorder makes that image look like a monster: fat, slothful, disgusting and unlovable. Session after session, it becomes harder to believe the disorder when therapy reveals a very different self-image. The role of the therapist is to remember to state the obvious. Consistent positive feedback is something a patient has never received and needs to hear over and over again. Patients with eating disorders have pretended to be okay while hiding the constant internal suffering. By letting their guard down and still getting regular praise--something most people take for granted--an entirely new reflection comes into focus. The subsequent confusion, emotions and dependence, previously inundated by eating disorder thoughts, represents the patient's introduction to life without the disorder. Living no longer needs to be synonymous with isolation. Being real no longer needs to mean being a burden on others but getting help and support.

The opportunity of involving all of oneself--thoughts, feelings and apprehensions--in the moment is an enormous relief for a patient unable to allow her expectations of life to mature since first becoming ill. For an adolescent, especially one at risk of perpetually becoming, the role of adults in her life is to act like that mirror. The adult doesn't need to tell or retell the child's story. The kid needs to figure that out on her own. But an adult needs to try to translate the Adolescent language (Mandarin perhaps) into something the world can understand. Although it certainly will take a few tries--and likely be very trying--a caring adult needs to show the child her reflection--with a combination of practical advice and regular positive feedback--and attempt to really understand the confusion of identity, emotion and expectations. Just as in therapy, this can create a stabilizing force. Think of it as harnessing all of this energy so it really can become ... something.

The risk of an adolescent slipping into an eating disorder, according to the above argument, hinges not just on self-esteem but on the reflection adolescents get from adults in their lives. I want to speak more about reflections and relationships in the next post.

The Process of Becoming

2010-11-21T09:53:00.002-05:00

A few months ago, I wrote about the difficulty a parent faces in raising a child in a world preoccupied with food and weight. The message that thinness and food restriction is a panacea for all the ills of childhood and adolescence is ubiquitous. A diligent parent is hard pressed to compete for airtime with the less appealing alternatives of family meals and traditional recipes. The age-appropriate drive for identity and individuality has become its own market-driven brand, and various forms of media have leapt on the bandwagon by adjoining the disordered eating and body image chic into a boondoggle for their bottom line.

Exposure is the first-line risk factor today's children face for developing disordered eating and perhaps an eating disorder. Offering the alternative story of food as shared time in the present and connection with a venerable past may not eliminate the risk--a veritable impossibility at this moment--but does give our children another point of view. Even if this proposed sanctuary from the relentless pressure to conform is soundly rejected, children won't quickly forget--they know all too well the norms they are railing against. In fact, rejection in and of itself can be the highest form of flattery from a child.

The last few posts add a different, and less obvious, dimension to a child's risk of becoming lost in the morass of food and weight. This has to do with personal story. In childhood and adolescence, one's story is tied to the family story with the child's occasional sidebar noted and retold (and, to the child's chagrin, often re-imagined) by the parent. A teenager will strive to find new storylines, hide them from meddling parents and keep and preserve them like secret treasure. These forays into personal narrative are baby steps to developing a sense of themselves and, within reason, need not just to be tolerated but cherished by parents. To prize the process of transformation of the child into an adult sends a clear and different message: I won't interfere with your becoming.

That remains the ubiquitous role for a child in the family: a sense of promise. The story of a child is about what is to be more than what is. Parents and children alike gloss over the daily routine to create the fantasy and hope of what this child might one day become. How many times does a child hear, "What do you want to be when you grow up?" The dreams and hopes only reinforce the urgency of a teenager to become, but in hindsight the trumped up (and often embarrassing) storylines of an adolescent dissolve not behind what that child has become but behind the internal process of becoming. The true gift a parent or adult can give--the exigencies of being with an adolescent notwithstanding--is to allow this process to unfold.

The world of thinness and food restriction is especially appealing to the child who combines the process of becoming with the urgency to become someone else. This child feels deeply the sense that she will not be satisfied with any of the choices around her because she herself is not and cannot be enough. She needs not just a new storyline but a new identity to hide behind, with new goals to attain. The problem, of course, is that many, if not most, teenagers fall into this category for a time, and many subsequently fall under the sway of dieting and weight loss.

But most adolescents avoid the fall into the abyss of an eating disorder. The need to become someone else and the burning self-loathing abate enough so they can return to the process of becoming again. The tipping point appears to relate to expectations. In the eyes of parents, the media and the world around them, teenagers know that the process of becoming no longer ends with reasonable goals. It's the rare throwback of a child who is searching for stability and comfort and whose success means education and a steady paycheck. The urgency to become famous, notable or otherwise special has become the de facto goal for all children. The covert message is that becoming the next music star, movie icon, writer or athlete is within everyone's grasp. And how much of these outlandish expectations is supported by parents' unfettered hope for vicarious stardom? As the dreams dissolve into fantasy, the true test is whether the child can return to her fledgling story. If it is intolerable to become mediocre--as I described in a previous post--dieting and weight are ready to represent both the pinnacle and the end of becoming.

The next post will talk about what parents can do specifically for children who combine internal drive with a world of unrealistic expectations. How does a parent cope when that child does not meet her own expectations?

Personal Story

2010-11-11T09:38:00.000-05:00

We all need a narrative of our lives, something that creates a picture of who we are and where we have come from. It keeps us in the present moment and connects us with our place in the world.

For people with an eating disorder, their own story was abruptly halted when they first got sick. One step towards health is to circle back to that time and resume the narrative with a simple question: what caused the disorder in the first place? Since patients so often feel robbed of the time taken from them, piecing together the story is of the utmost importance. It is a way of reclaiming that lost time. The immersion in the isolating world of the eating disorder erases both identity and personal narrative. Picking up the pieces and retelling that story over and over again until it is right are a means to recover.

Practically, this means a significant portion of therapy involves looking back. The girls who first started to get sick seem so different from the women escaping the disorder years later. Those girls were in the throes of adolescence. They were inundated with the physical and emotional shifts in their lives. They battled the cravings for independence while clinging onto the lack of responsibility and freedom of being a girl. Whether they stumbled upon the high of a diet or the release of a purge or whether someone introduced them to it, these girls were much too young, confused and desperate to know what was happening. It can be hard for an adult struggling to recover not to get angry at that girl and at herself. Shouldn't she have known what was coming?

In hindsight, the answer is clearly no. However, after years of being sick, it is a big hurdle for the person in treatment to accept the utter confusion and helplessness of the girl who got sick. But that acceptance is a crucial step towards restarting one's story. It is much easier to avoid these painful memories altogether and instead stay focused on the search for a straightforward, simple cause of the eating disorder. In fact, the burning desire to answer that question can take on symbolic meaning. People often think the answer will cure the eating disorder in the magical way an adolescent mind works. I wish that were the case. Realistically, the answer will help someone stop blaming themselves and try to see how this painful experience was both an abyss she never saw coming and a trap she did not know how to escape. More to the point, she needs to see that the disorder has become part of her story.

Needless to say, a patient in recovery wants to eliminate the disorder and never look back. The idea that it actually needs to be incorporated into the story is never welcome news. Answering the question is supposed to put the experience to rest once and for all. Instead, the treatment begins to review the painful memories of the transition from adolescence into the disorder--the time when the narrative stopped--and from that point formulate the rest of the story up to the present moment.

But from the perspective of treating and also preventing eating disorders, I find myself circling back to a related but different question: why are more and more women derailing their own life story and curtailing their own personal momentum by turning to food? For these girls who first got sick, there are places in which threads of each individual story blend into a larger theme. I have tried to address some of the societal changes that preceded the increase of eating disorders and disordered eating such as the change in food supply, loss of a food community, increased freedom and opportunity for girls and the media's influence on weight and self-worth. In upcoming posts, I want to use the knowledge, perspective and experience of those stories to address the girls at risk now. What can be done to help those girls susceptible to falling into an eating disorder? How can their narrative withstand the bumps and continue without a long detour into food? Why do girls turn to food to create their own story? What other options do children and parents have?

I want to start the next post addressing the role personal story and narrative have in children's lives and what purpose an eating disorder psychologically and emotionally serves in that regard.

The "Real" Relationship in Therapy

2010-11-03T12:43:00.000-04:00

One difference between normal relationships and therapy is the clinical scrim that blocks the patient from knowing the therapist as one would an acquaintance, friend or family member. Starting with the almost silent, omniscient analyst in classical Freudian psychoanalysis, the theoretical foundation of therapy began with the patient's responses and reactions to a relatively blank slate. The trove of adaptations to the initial psychoanalytic model either justify a small amount of visibility through the screen or enable the therapist to hide behind a systematized (the current code word is evidence-based) technique. No matter the newfangled, popular approach, there is one question that lingers in any patient's mind: is this relationship real?

There are two general ways to answer this question. In traditional treatment, the therapist will ask the patient what triggers the question and what are the underlying motivations and feelings behind it. In evidence-based treatment, the answer is that the question is moot: the stated objective is solely to minimize or eliminate distressing symptoms.

Most clinical literature about eating disorder treatment recommends a completely paradoxical approach. The emphasis from the outset is that the relationship in therapy needs to be real and that self-disclosure--a nifty bit of psychological jargon ripe for (mis)interpretation--is not just advisable but necessary for treatment to be helpful. Necessary! How can something considered strictly forbidden since the inception of psychotherapy suddenly be essential for psychological disorders only first categorized a few decades ago?

I remember reading articles about being "real" in eating disorder treatment for the first time without fully taking in the subversive context. To the therapy universe, this is heresy. But it certainly explains a few things. If the experts agree that eating disorder treatment must flout the most basic tenets of traditional therapy, no wonder most therapists have so much trouble treating people with eating disorders. If these experts really have tapped into the well of recovery, no wonder eating disordered patients in treatment focus on the question whether the relationship is real. Nothing has ever been real for them except for the disorder itself.

I have written about most of the reasons why therapy in this context needs to be different, but they bear repeating. Patients with eating disorders have trusted no one but the disorder so the therapy relationship has to be meaningful, powerful and real to break through that barrier and open the door to even contemplating recovery. With a keen ability to read others and to be excellent caretakers, patients will almost instantly recognize a lack of genuine interest or a therapist hiding behind a professional wall and respond in kind by retreating behind the eating disorder. A patient, embarking on true recovery, needs to believe in something previously impossible: a real connection with someone--in this case the therapist--and that can't happen behind the therapeutic screen. Moreover, one of patients' common complaints about previous therapists is that they just weren't real, they just didn't care. And that's where the clinical literature has it right. Patients with eating disorders have withered under the assault of worthlessness and self-criticism unless they constantly engage in the symptoms, but somehow they feel cared for by the disorder itself. And a patient needs to know she can find that elsewhere. As a therapist, being real means more than following some guideline in a book. You really have to care.

An ethical therapist with no experience with eating disorder treatment will no doubt shudder after reading this post so far. The exhortation to dive in headfirst, arms open wide, feels like a recipe for disaster. The clinical, personal, theoretical and legal reasons to stay firmly, safely behind the scrim look very good on paper and moreover won't jeopardize a bustling practice. The psychological term--written and vehemently argued about through generations of therapists--is the boundary crossing. In the most general terms, this means neglecting the therapeutic frame I mentioned in the last post. Practically speaking, the result is the transformation of the professional relationship into a personal one. The steps that lead towards crossing that line always seem innocuous at first: extending a session a little longer or spending some time discussing the therapist's personal problems. (Just watch the first season of the TV show In Treatment for a textbook case.) The worst scenarios involve the transition to a fully personal relationship or even a romantic one. No matter the transgression, what links these examples is that the therapist's needs and desires come first. The ultimate responsibility of the therapist is to remember that she has her personal life outside the office. Really caring for the patient as a therapist means NOT letting the patient take care of you.

Without the natural give and take of relationships, without the potential to care for each other, with clear boundaries in place, the most basic question still looms: how can this relationship be real? Yet, when the therapy works and the patient does truly feel cared for and starts to get well, it is impossible to see it as anything but real. Effective, meaningful therapy is, in many ways, a re-experiencing of past relationships in the context of something both cathartic and brand new. In eating disorder therapy, this concept helps a patient remember and relive distant relationships in which she was allowed to be herself. So the artificial boundaries actually enable a patient to return to a time before the eating disorder took over, a time when she really could be herself.

When two contradictory experiences in therapy--creating artificial boundaries along with a "real" relationship--feel simultaneously possible, I try to think outside the box of therapy to all the types of relationship we experience in our lives. The idea is to draw on the concept of therapy as a re-experiencing of prior relationships and use those experiences to better understand the moment. The only other relationship that combines the deeply felt caring with strict boundaries is that of a parent and child. When this relationship works well, the parent cares deeply and powerfully for the child but needs to draw strength and support from elsewhere. Relying on the child like an adult stunts psychological and emotional development immeasurably. In no way does therapy compare or replace the parent-child dynamic, but the powerful healing that takes place in eating disorder treatment does tap into a similar experience. Freed from caring for the other person, freed from the tyranny of the disorder and free from self-punishment as the only source of solace, the patient can restart the emotional and psychological process of knowing herself. In an environment where she can be real and true and honest, she gets the chance to continue her own personal development which was stopped by the presence of the disorder in her life.

Of course, the relationship is real. But real not just for now because this isn't meant to be a blip in the course of a lifelong tragedy. This is meant to help her feel real for good.

In recent posts, I have written more about how a chronic eating disorder leads to the derailing of one's psychological and emotional development. Several older posts have referred to the risk factors for developing an eating disorder. I want to switch gears in the next post and start a series of posts about children’s susceptibility to disordered eating and eating disorders and ways to avoid this fate.

Boundaries

2010-10-22T21:27:00.002-04:00

Doctors and therapists are often slow to adopt new technology, so it comes as no surprise that the explosion in modes of communication has thrown medicine and therapy into turmoil. For some doctors, the refusal to use even email at all stems from the medicolegal exposure of such an accessible paper trail. Others have embraced email, Skype and texting to offer easier access for patients in need.

The reluctance of a therapist to use electronic communication has a philosophical basis. One axiom of therapy is absolute adherence to the frame: the practical structure of the relationship is critical for its success. The agreement includes the time and length of the session, the amount of the fee and mode of payment and how the session transpires. In therapy jargon, the code word for these decisions is boundaries. This used to mean limited contact outside of the therapy except for emergencies and, of course, phone was the only option. With the current, ever growing smorgasbord of modes of communication, boundaries have become much, much murkier.

Interestingly, as I discussed in the last post, the eating disorder treatment community has embraced the ease of keeping in touch with patients but not without controversy. Let me start with some positive results supported by the professional community at large. A prominent psychiatrist in North Dakota ran a study testing Cognitive Behavioral Therapy for Bulimia Nervosa via Skype and found the success rate was equivalent to face-to-face therapy. There are also pilot programs which involve sending text messages to patients with eating disorders to support them through the day. Because these studies were standardized, the texts were generic and impersonal, but the concept was very progressive. Under the guise of research standardization and academic support, these pilot studies pushed the boundaries of therapy within an acceptable framework but implied the need for further testing of these limits in typical eating disorder therapy.

In addition, I have spoken to colleagues who treat eating disordered patients, and many have significant contact with their patients by phone, email or text. However, most therapists conceal this information until they know you're a like-minded soul, and I can understand why. To begin with, the general fear of new forms of communication has plagued every step forward in technology: the telephone, television, computer and cell phone have all been branded evil in their time. That fear invades the therapy community at large. I have been questioned at length as to how text messaging a patient can be professional. I have been chastised by an inpatient psychiatrist for emailing with a patient. And this was a psychiatrist, mind you, who was all too eager to read confidential emails made available by a third party without the patient's consent! But, in my mind, the risk of exposure is far outweighed by the unquestioned benefit and progress that comes both from extra time and especially from communication that is not in person. And that is why, as complicated as the process can be, reassessing the boundaries of eating disorder treatment is so important.

I explained in the last post how a patient with an eating disorder is bombarded all day with thoughts and internal pressure to rely on her symptoms in order to live in the world. No matter how effectively and consistently the time is spent in therapy, patients will need more help to learn how to resist the urges to use eating disorder symptoms and how to use other coping mechanisms. Faster, easier and more accessible communication can aid in this process.

But another benefit to electronic communication is the obvious: it is a disembodied act. The shame of being seen and of feeling one’s body while with another person--especially in the exposed reality of therapy--inhibits more honest communication. Often the anxiety of physically being with the therapist simply shuts down the patient's ability to think clearly at all. Despite these challenges, the consistency of regular office sessions can lay the groundwork for therapeutic breakthroughs in between sessions. In a private place where the patient is not seen, the intensity of the shame diminishes, and she is able to think more clearly and express her feelings more honestly. As the therapy helps the patient separate the eating disorder from her self-worth and identity, she needs to use any opportunity to speak for herself and needs to have someone there to hear her, to mark the moment of success. These steps forward undoubtedly move recovery along faster and help the patient find new ways to counter the eating disorder on her own.

But loosening the boundaries of communication has a profound effect on the nature of treatment and the therapeutic relationship. The continuity of contact means that sessions mark the dedicated but not exclusive time of the treatment. The relationship is more natural and fluid, unlike the limited weekly allotment of most therapy relationships. The clear message to the patient is that therapy must follow her, both literally and figuratively, through the week to have any success in treatment. The expectations of the patient and therapist are significant and the commitment to the therapy and to each other must be strong because the stakes are high and the process of recovery arduous. The nature of this relationship forces the patient to reconsider her reluctance to have hope, to engage in personal relationships and to imagine a life free of the disorder. Perhaps most importantly, the loosening boundaries highlight the paradoxical (to the eating disorder) belief that the patient is a valuable, meaningful person. How else can she reconcile her vicious internal self-hatred with the reality of her treatment?

The next post will continue to discuss boundaries in the context of a question often posed by patients that I briefly discussed a few posts ago: is the therapeutic relationship real?

Trust in Eating Disorder Treatment

2010-10-14T09:43:00.002-04:00

Relationships are the fundamental but unreliable cornerstones of daily life. We need people to chat with about the weather, people who will care about our problems, people who we just can't stand, people we nod hello to in the corner store, and above all people we love. Unexpectedly, trust is at the heart of not just the most intimate but all of these relationships.

Trust implies reliability. In any relationship, it is comforting to know what to expect, whether it is the daily chat about small things, the almost imperceptible nod of recognition or the hug that confirms you're not alone. In our increasingly isolated world, more and more common wisdom points to loving yourself first, yet so much of our self-image stems from the relationships we take for granted in our lives from the deepest to the most superficial. That foundation acts as confirmation that our own self-image is accurate and as a springboard for challenges we face each day: successes, failures and the critical feeling that we belong.

Learning to rely on an eating disorder means losing faith in human relationships. The eating disorder symptoms are always reliable. The immediate benefits are very predictable. Life, painful as it is, moves forward in a highly structured fashion. The experience of living with an eating disorder is a bold rejection of personal relationships and even the concept of trust entirely. Some people completely isolate themselves and others just keep their friends or even boyfriends at bay because the disorder remains paramount.

In addition to reliability, the second and more hidden benefit of the eating disorder is its availability. Unlike any human relationship, the disorder and symptoms never let you down. Any disturbing event, feelings or even thoughts can be eliminated by listening to the eating disorder and doing what it says. Unlimited access to such a powerful way of life is hard to replicate. No single person can be so available and so reliable. Existing alone in the world demands that the person handle the discomfort of feeling emotions and find the patience to let these experiences pass, both daunting tasks.

For any patient to embark on the process of recovery, she needs to reconsider her belief in trust and relationships again. I have written at length about the importance of the relationship between the patient and therapist in eating disorder treatment, specifically how that relationship can provide hope, direction and motivation to move a patient away from the security of the disorder towards a fuller life. The intimacy combined with self-reflection in therapy can help a patient question the truths that the eating disorder stands by: the certainty of her negative self-image and the fact that she must live life on her own and trust no one. But just the step of questioning these beliefs--which have been written in stone for years--begins the process of trusting in the therapy. And that means considering the unthinkable: learning how rely on others for a different view of herself and a new way to live.

Once a patient begins this shift in her mindset, the treatment becomes a trial run for building relationships in life. That means learning what availability and reliability mean in personal relationships. The eating disorder literature postulates that the relationship in therapy needs to be nurturing but also gently authoritative. I have always understood these traits to represent those of a kind mentor who gives caring, firm advice. But these traits have also felt limited, as if the treatment were a revolving door, as if the therapist shouldn't really care too much. In order to compete with the eating disorder, the therapy--even better, the treatment team as a whole--needs to understand what it's up against. The team needs to work hard to provide reliable and available care to have any chance of competing. Although consistent, effective work in treatment can establish both of these in the session, that leaves many, many hours in the week when the person is still very alone.

In all of those free hours, a patient can start to drown in the eating disorder again. The thoughts of doubt turn back to shame and finally to an overwhelming surge of emotion. These experiences, many patients have told me, just don't usually happen to someone with an eating disorder. Before long, even the most motivated patient will cede to the inexorable pull back to the symptoms. For patients who start to believe in recovery and the therapeutic relationship, the goal is to learn how to hold onto the idea of recovery and the relationship as a buffer--at times even a buoy--to survive the onslaught of the disorder. Then the therapy can begin to provide comfort even outside the sessions. More often than not, contact outside the therapy is critical, by phone, email or even texting. Almost always, when the patient begins to think treatment can be reliable and available in a different but meaningful way, the patient is overwhelmed with the fear that the therapist doesn't really understand or care and even that the relationship isn't real.

What does a therapist say to that? When the therapy is bounded by a financial agreement and (hopefully) clear limitations, what defines real? Moreover, this line of reasoning is the last resort of an eating disorder, backed into a corner, saying, "I don't trust you and I don't trust anyone!" Although the therapeutic relationship is unique, this belief--so strong and dominant in the mind of an eating disorder--repudiates how we all function in this world. How can a relationship not be real? But there is a quieter voice behind this absolute saying something very different. This voice, the thoughts and feelings of the person behind the disorder, wants desperately to be seen and heard and cared for, but it also believes the relationship will ultimately be disappointing and eventually just vanish. After the internal torture by the disorder, the patient is terrified to trust anyone again. Each small step strengthens her belief in the therapy and in her ability to lead her life without the buffer of the disorder but also intensifies the terror of believing in trust and relationships again. The fragility of human relationships seems to pale in comparison to the certainty of the disorder yet also makes the patient feel real and human again. The ultimate goal is to reopen the visceral power of personal connection for the patient, and, hopefully, to make her feel alive again.

The next post will reflect more concretely on how therapy can even begin to replace the availability of the eating disorder. This topic, not often discussed among therapists, is contact outside of therapy, and, more generally, the complicated nature of boundaries in eating disorder treatment.

Mediocrity and Specialness

2010-10-04T10:34:00.002-04:00

I didn't think Mandarin classes for a five year old was that outlandish--why wouldn't a parent want her child to speak the family native language--until I learned the family wasn't Chinese. But then I hesitated a moment. Isn't it a parent's prerogative to want to do everything for their child? What's wrong with learning a second language? It will help in the long run with ... then I caught myself. It's just too easy to get swept up with the tide.

There is a singularly American concept that success is measured only by being the best, extraordinary, unique. But I think the ultimate goal of this undue pressure is to be special. Our culture celebrates the accomplishments of the rich and famous and exalts these chosen ones to a class of their own. The communal desperation to be special has even transformed the American dream--originally known as hope and opportunity for everyone--into an all-out pursuit of wealth and fame. Taking this line of reasoning another fateful step, life is worthless without publicly admired success. Quality of life and meaningful experiences have been squeezed out by resume-building activities starting with children too young to understand. The underlying truth too painful for children and parents alike is that very, very few people find that kind of success in life. There is a fine line between the drive to achieve realistic goals and the absolute necessity of specialness at all costs. But for many, a moderately successful life has become simply mediocre. From what I can tell, many people believe mediocrity is a sad fate for us all.

There are few spots to fill in the elite world, and that reality starts to become clear to the adolescent. The weeding out of the undeserving begins in high school and college--a stage of life marked by the need for a concrete identifier, something that screams to the world who you are. The fear of just being you overwhelms any sensible judgment. The internal belief of immortality means no option is off limits. At a time of exploration and experimentation, the memories and experiences at this time of development often leave an indelible mark on a life but can also lead someone astray in the name of individuality and specialness. One surefire way out of the world of mediocrity is mastery of food and thinness. Nothing attracts the envious glares of other girls and the lustful stares of the boys as well. The attention is immediate and powerful and the message is clear: you truly are special. An eating disorder can catapult a teenager out of mediocrity into the promised land.

The real danger of associating an eating disorder with specialness is the effective merger of identity and illness. An adolescent grapples with a chameleon-like sense of herself. Being a teenager means putting on one costume after another, picking up bits of an identity along the way and hoping to find coherence in the end. These sudden internal shifts and endless string of poor decisions are laughable from a distance, perfectly reasonable to the child and terrifying to the adult trying to contain her. An eating disorder soaks up all the adolescent angst instantly by providing identity, specialness and coping mechanisms in a neat little package.

Many people can live in this bubble for years. The limited satisfaction and opportunities are routinely trumped by a powerful identity and point of reference. For years you really feel special by staying thin and by following your disorder. There are many pro-Ana sites that prove the power of that sisterhood. For some people the combination of a strong identity and sense of immortality sends them to the grave. Clarity never comes in time.

A moment of doubt in the eating disorder is a small step back into the terror of mediocrity. Teenagers who never experienced the liberating step into an eating disorder had to come to grips with their own mediocrity over a stretch of years. The recognition of strengths and weaknesses, successes and failures, realistic goals and outrageous expectations all aid to create a solid foundation in adulthood. Specialness and mediocrity blend into a more nuanced view of the human condition. To the person trapped in an eating disorder, mediocrity and the subsequent loss of identity feel catastrophic. She has never had to struggle with the feelings of isolation and hopelessness. She has never had to manage the intensity of emotions and fear associated with both the process of life and its defined end.

The transition from mediocrity to a realistic view of one's life often originates in the therapeutic relationship itself. The relief of fully exposing the eating disorder and all its beliefs and flaws has two important consequences. First, the patient feels as if she can stand alone separate from her disorder. Perhaps, there is more to her than the number on a scale. Second, the desire to feel special shifts from the disorder to the therapy. This is the first time the patient actually looks outside herself for guidance and restarts the process halted years ago when the eating disorder solved all of her adolescent fears. Since her peers no longer face the same identity crisis she ignored for years, she could just feel so alone that she retreats back to the disorder. But therapy can provide the mirror and feedback to start this arduous but potentially fulfilling journey back to feeling whole--and, in a different way, even special--again.

These last three posts have addressed some emotional sticking points in recovery, reasons the eating disorder just won't let go. The last post in this series will cover the topic of trust both in treatment and in life.

What Does Forgiveness Mean (in eating disorder recovery)?

2010-09-24T14:29:00.002-04:00

This topic runs the risk of devolving into a self-help diatribe but also touches upon something fundamentally necessary for full recovery. People commonly mistake the motivation for having an eating disorder as vanity and competition. I have tried to describe how someone with a chronic eating disorder actually exists in a very different internal world. The reality of feeling trapped by shame, self-criticism and suffering lacks any of the perceived mastery of food and glamour of being thin. For a patient to embrace the concept of a world without interminable mental torture, she needs to consider two steps towards forgiveness: choice and regret. The inability to accept either one inevitably limits the possibility of full recovery.

When someone gets sick, the initial human but often futile response is to find blame. Who caused this to happen and why? There are a few controversial exceptions: lung cancer, drug abuse, obesity-induced diabetes--illnesses seemingly caused by personal choice. And that includes eating disorders. A group of students in the lunch line or colleagues at the water cooler all too often gossip about the girl who's too thin. The implication is that she can choose to start eating and she would be fine. And if that girl dips her toe in the water of the illness and then proceeds to dive in head first, to everyone around her she chose to develop an eating disorder. Granted, she could have been a confused and scared 14 year old girl with no one to turn to, but, in the eyes of her family, friends, treatment team, in the eyes of the world, she is surely responsible. She wasn't stricken with an illness; she chose her own affliction.

What is similar about illnesses that blame the patient is that society has a role in the initial exposure. Although someone chooses to smoke and smoking causes cancer, that person--usually a young person with poor judgment--does not believe it will lead to a lifelong addiction. Moreover, how can it be legal for a lethal substance to be legally sold and marketed, especially to those most vulnerable? If our society promotes thinness and weight loss as a necessary part of being a successful woman, a percentage of girls who do go on a diet or throw up their food will end up with an eating disorder. The values of an era define the social illnesses of the time and are inherent in the disorder itself. So that even with these issues clearly laid out, even if the patient brings them up herself in treatment, escaping blame for the eating disorder remains a challenging leap in recovery. Indeed, the cause and effect appear to be one and the same.

The experience of having an eating disorder is centrally a mental exercise. Since emotion and personal connection is stripped from her life, the patient exists largely through her painful, harsh, punishing thoughts. In a world where every negative emotion or thought can be diagnosed and medicated away, the societal norm is that thoughts can and should be contained and eliminated. Any unwanted thought that lingers and, heaven forbid, leads to action, is a sign of weakness. Even the central mechanism of the disorder--not just the cause and effect--reinforces the idea that having an eating disorder is a personal choice.

Forgiveness starts with true recognition of how powerless the patient has been to the whims of the eating disorder. The driving force to remain stuck and spinning in the world of disordered thoughts and behaviors has been impossible to escape. I have discussed in previous posts why someone who experiments with disordered eating might become sick and why an acute eating disorder becomes chronic. These factors remain out of the patient's control. Our society has created a world to lure young people into an eating disorder and provided few means of escape. The seemingly controllable thoughts are actually the critical symptom of the disorder. The burden of personal responsibility for the eating disorder is the communal tactic to fob off our own responsibility of sacrificing so many young women. And the myth that all of these girls chose this disorder is debunked by the fact that society paints them into a corner. What other choice do they have?

When a patient begins to concede she is powerless and may not control the illness, she unleashes a torrent of regret. A glimpse of recovery makes the years trapped in the disorder even more painful to remember. To imagine there was a way out all that time makes the cycle of the illness even more pointless. How does one reconcile those lost years and begin the struggle to find a new path in life? Having been grounded in an excruciating present, the past looks like a tunnel of loss too deep to even contemplate, let alone mourn.

Unfortunately, although therapy can often make headway in reducing the sense of blame, I have found that directly facing a mountain of regret can backfire. For women who are smart and motivated and who have allowed themselves lofty but attainable goals, fully reconsidering the past is a sobering task. Instead of having years to reevaluate their future, the sudden revelation they are not to blame opens up the immediacy of the state of their lives today. There is no easy way to handle such a shift in self-perception and personal direction. I think people who do find full recovery tend to use a moderate amount of denial of the enormity of the change in order to function each day. They try to stick with the transition in the moment and work to lessen the punishing thoughts and incorporate a new self-identity. By staying present, they don't dwell on the past. The regret still lies under the surface and frequently is discussed in therapy but rarely takes over. In this way, the mourning is protracted but tolerable and doesn't impede movement forward.

The recognition of being powerless and of the sense of loss is a bitter pill to swallow after riding the high of food mastery for so long. These changes highlight the slow descent into mediocrity--a word frequently used by patients in recovery and uniformly despised. The eating disorder makes people feel special, even as its appeal diminishes over the years. The next post will address the importance of mediocrity and specialness in recovery.

Shame and eating disorders

2010-09-15T14:11:00.000-04:00

The experience of shame is a part of the human condition: we all eat the apple from the garden of Eden at a very young age. Children experience shame of their bodies or their behavior without the perspective to comprehend what it means. This shame--in its primal form--is deeply buried within an eating disorder. The obvious shame of being sick is one facet, but at the center is something truly existential. People with eating disorders feel like there is something really wrong or even, in the most simplistic term, bad at the core. The irrefutable existence of this badness makes the eating disorder feel like a just punishment. The problem in treatment is that the source of shame is both fully accepted by the patient but also completely elusive. There is nothing to point to or home in on because--and this is where the logic of the eating disorder becomes a house of cards--there is nothing there. The shame and the central badness are one and the same. Rather than searching for a source for the shame, the therapy needs to find out why and how the shame took over in the first place and then expose it to the patient. If the shame was planted there first, then the patient unknowingly created a world to justify her false reality. Recovery can feel like a complex knot to untangle.

In treatment, shame creates a barrier which stops the patient from being able to talk freely and to be herself. Everyone knows what it's like to feel inhibited. Imagine having a secret so large, so abhorrent that revealing anything about oneself will lead to catastrophe. Imagine not knowing exactly what that secret is except that letting one's guard down will without a doubt reveal everything to the world. Imagine knowing that one is an absolutely awful person but pretending to be someone else will keep the charade of life going. Imagine always feeling like you're one step from losing everything. Living in such a precarious world can--too most people--seem surreal: constantly putting on an act, being terrified of being found out, never being yourself and never-ending shame. But this is the world that traps someone with an eating disorder. Under these circumstances, the punishing eating disorder completes the circle and feels like just retribution for just being allowed to live.

The first step towards addressing the shame is to break the almost delusional cycle. Even though the logic of the eating is precarious, the shame and punishment feel completely deserved. The therapist can start to question these deeply-held beliefs. What makes you so bad? What are you being punished for? What makes you different from everyone else? By gently probing the thought process, the therapist pokes holes in the eating disorder mantle. Patients have never spoken about the shame with anyone so it can be a revelation to actually question the eating disorder in any way. Often the effect is surprisingly brisk and empowering.

But the shame cannot instantly wash away and leave good self-esteem and well-being in its wake. Once the logic breaks down, patients are confused that the shame lingers and are furious that the requisite punishment continues. Eating the forbidden fruit may have shattered eternal bliss, but the process doesn't happen in reverse. The work in therapy involves looking for a new reflection of oneself. With no other way to process thoughts and feelings in the world, we all revert to the default self-image. The long-term goal is to build a structure that explains how to live in a world not dominated by shame.

The bigger revelation is that the shame was never warranted, and years were spent enduring an illusory punishment. Many people, faced with this shock of reality, find themselves quickly hidden behind the shame and the eating disorder again. The process of nurturing a new self-image necessitates intense feelings of vulnerability and discomfort--experiences that until now were avoided at all costs. Trust in oneself and in the treatment is crucial to take the first steps away from shame and from this badness. This post highlighted several important issues in eating disorder ecovery related to shame--namely feeling special and trust--and these will be further discussed in upcoming posts. But for a new way of seeing oneself in the world to fully take, the next step is forgiveness. That will be the topic of the next post.

Reflections on Media and Eating Disorders

2010-08-27T20:16:00.000-04:00

Using therapy as a model for good parenting is a dangerous line of reasoning and altogether inaccurate. Although effective therapy can reveal what was missing in a parent-child relationship, inflicting therapy on your children never helps. The therapeutic relationship has many boundaries and rules that render it awkward and distant yet incredibly intimate--very unlike the parent-child bond. However, those limits also make therapy safe for the patient to explore experiences and feelings that otherwise feel taboo in the outside world. The therapist--in addition to fully engaging with the patient--uses these explorations first to understand how a patient lives, feels and relates in the rest of her life and then to reflect back what it might mean about the past, present and future. This process creates a mirror for the patient to look at herself and her life in a new way, and that perspective can lead to therapeutic change. I think that the collective therapies of women with eating disorders similarly generalizes to explain why disordered eating has become an accepted way of life. Perhaps the powerful ambivalence of these women in treatment reflects a society that has trapped them within an epidemic of eating disorders and disordered eating. And perhaps the aspects of therapy that help patients find the way to moments of arrival also explain what is missing in the media-centered environment women live in--and kids grow up in--today.

Attention, compassion, listening, limits and patience. These attributes of eating disorder therapy are sufficient for successful treatment. They are also essential for parenting but on their own represent the ineffective therapy-influenced ideal: treating kids like mini-adults. What is missing is the eternal frustration and anger that bubbles over--from parents and kids alike--when children come up against rules and limits. Kids seem hardwired to creatively challenge any boundary set in their way until the child and/or responsible adult finally gets angry. In therapy for eating disorders, personal expression of anger is almost exclusively self-inflicted since any sense of individuality, identity and self worth emanates from the success of controlling food and weight. Even experiencing anger is taboo and a sign of weakness--how can you stand up to others when it is impossible to stand up to the thoughts in your head--and leads directly to an escalation in the harsh, punishment of the eating disorder. Thus, the therapist needs to focus on compassion and kindness to counter the horror of the disordered thoughts and behaviors. The moments of arrival expose how harmful and unnecessary this punishment is and open up a world of hope, promise and emotion. There is no need for the therapist to reinforce the rules and limits children might need because the eating disorder has turned them into a prison.

The contradictory expectations of young girls--boundless opportunity combined with extreme limitations--explain how the developmental anger of childhood transforms into the punishing disorder. Girls need to strive academically, socially and athletically to achieve as much as, or even more than, boys just to prove themselves. Yet the insidious, fully accepted message of thinness and control over food is the necessary foundation to any measure of success. Fat women who are financial scions, CEOs, lawyers or doctors are still fat first. This message is a societal leash that reins in any excess confidence women may feel by demanding they strive for an unattainable goal. In addition, girls are expected to be grateful for what they have since women have never been lucky enough to have so much opportunity. Last, girls see the lives their role models lead: a frantic rush to have it all while doing nothing very well. Despite the seeming excess of opportunity, girls are fully aware of life's limitations. The promise of a wide world of options does not match the lives of women around them. With the burden of generations past, the demand for thinness and no clear path ahead, there is no room to push up against the boundaries the way boys do. Instead, an inward focus on food and weight is encouraged at an early age to channel any frustration. If striving for thinness and disordered eating provides children a solution to an insoluble reality, then it is up to parents as a whole to devise a more effective alternative.

It is all too easy for me to write a series of prescriptions for parents: support girls' self-esteem, raise sensitive, self-aware boys, make sure girls know they are loved and be sure girls know their value in the world. I certainly believe that and more, just as I know those messages--when a patient really starts to believe them--contribute greatly to eating disorder recovery. But these truisms don't address the real goal: prevention.

Life often feels like an endless series of choices. Each fork in the road closes off certain opportunities forever while opening up otherwise hidden options for the future. But progress comes from making those decisions. Trapped by unreasonable expectations and inwardly-focused anger, girls are supposed to leave all of their options open yet not make any decisions, all of which guarantees that they have none. Towards the end of successful treatment, long after the moments of arrival, the sessions are tinged with a sense of peacefulness intertwined with loss. Patients often are waiting for the next storm of recovery to weather, but it never comes. Gradually, we start to talk about acceptance of themselves and their lives. Perhaps this is who they are and their life has taken a certain path through the eating disorder in a new direction. The calm doesn't mean life will lack ups and downs, successes and disappointments, new adventures and painful losses. But those changes are now external, not reflections of the internal chaos and punishment within the eating disorder. These patients are free to foist the anger elsewhere and not suffer for it. Parents may not be able to change the conflicting pressures girls face but can work together to find new rules to play by. Feminist thought has left girls holding the imperative not to accept the world as it is, a motto distorted by the media--and condoned by society in general--into a personal attack against girls' self-acceptance. But perhaps parents can reflect a new model of life to which girls can aspire: a balance between the continued need to buck the inherent paternalism (because girls can get angry too), with a renewed focus on self-acceptance--mind, spirit and especially body.

The next post will move away from the topic of media to explore the role of shame in eating disorders.

Children, Media and Eating Disorders, Part II

2010-08-17T14:29:00.000-04:00

Most people can describe the gist of where their eating disorder came from, what they're missing in their life and what the eating disorder does for them, but it is an intellectual exercise and often only camouflage. Fundamentally, they don't really know what will help them get better. Focused and effective treatment of people with eating disorders needs to address the painful reality that their lives are run by the disorder without disrupting the core therapeutic relationship. This demands a few critical things: consistent but not judgmental attention to eating behaviors, unwavering compassion for the trials of enduring the illness, the capacity and desire to really listen, clear limits as to what therapy can do and what it can't and, most important, patience. When one of these ingredients is lacking, the patient will quickly recognize the deficiency and react, usually by getting angry or leaving the treatment. In a larger context, the therapist's job is to figure out which of these essential components means the most to the patient. In other words, what aspect of the relationship really helps slow down or even stop the symptoms.

For people whose symptoms do get better, there is a moment--or more likely a series of moments--when they finally see and feel what it is like to let someone, initially the therapist, into their lives. In that moment, a patient, who has only let herself exist in a small world hemmed in by a ruthless disorder, can finally see the freedom that exists for everyone else. What has felt like the calm sanctuary of the disorder transforms into the lonely prison she has occupied all these years. This is the opportunity for a patient to truly see what recovery looks and feels like, to finally arrive in treatment. It can be simultaneously terrifying to acknowledge how much time has been lost and miraculous to see the symptoms as relentless but for the first time not invulnerable. And this all happens with another person, the therapist. Allowing this real connection helps the patient realize what has happened to her, what is happening and how painful it all has been. The hidden suffering, even from the patient herself, becomes a moment of shared compassion for her struggle to try to survive the illness. At that point, when the intellectual exercise becomes grounded in the reality of living with an eating disorder and in the possibility of recovery, going back no longer feels like an option.

Patients often experience these moments as an immediate reliving of the entire course of the eating disorder but from a completely different point of view. This necessitates a rethinking of what the disorder has meant all these years. Most eating disorders begin between the ages of twelve and twenty, but the time of onset has more to do with luck and opportunity--such as enough privacy to use symptoms or exposure to really learn how to do them--than anything else. The vulnerability to the illness begins much earlier, as I explained in the last post. For many people, by the time they have ridden the course from initial exposure through the powerful, painful high of the first years of the illness, they are trapped. What felt like a choice, although it never was, starts to feel like a life sentence. The main delusion of an eating disorder, and what makes it so enticing, is that the person has mastered the world of food and weight and therefore is special, but the reality is quite the opposite: she is ill and unable to truly live. By allowing the therapist in and facing this reality, the patient irreversibly shatters that delusion. Re-evaluating every moment of the entire eating disorder opens up a host of emotions. It is a rude awakening from the blinding calmness the eating disorder creates and a personal challenge to find the resiliency to face a wholesale shift in identity and self-worth.

These moments of arrival perplex me more and more. As I explained in a recent post, it has been eye-opening to realize that women with eating disorders often seem less stricken by an illness then chosen by a set of core personality traits--ones well-suited to success--combined with the conflicting expectations of society. The near universality of these powerful moments in successful therapy has the same jarring effect on my understanding of eating disorders. The moments feel remarkably similar no matter how different the person or relationship. I feel like I have witnessed the shattering of the shared delusion so many times, but how can they all feel the same? The essence of psychotherapy reinforces that all people and therapies are different, and so the sameness of these moments becomes all the more striking and has brought me to consider that the derailed development of identity and self-worth, especially in children, may be the missing link. The realizations occur when success within the eating disorder stops being synonymous with self-worth. But this means that the patient's identity must have been intertwined with food and weight long ago, well before the eating disorder started. Similarly, perhaps no true self-understanding ever started to develop, and these moments in therapy may be the first ones--no matter the age of the patient--of recognition of her own identity and value in the world.

With this foundation, these moments of arrival appear to be the formative experiences of learning to know oneself--something the influence of media has largely replaced in a child's process of growing up. If the messages and influence of the media are inescapable, then the goal is not to fight back as much as to offer viable alternatives: a way out for the young girls who see no other solution than to build an identity around food and weight. It also explains why these moments in therapy are so similar. Each moment represents a collective experience of helplessness and frustration: if living through an eating disorder--the preferred lifestyle of the times--does not work, what else is there? Living through food and weight seemed like the only way to make sense of it all.

These women have practically become the casualties of a lost art of parenting: creating hope and opportunity and individuality in kids in lieu of the current message of striving and conforming to a meaningless norm. What other value do women have in our society? Where can kids, especially girls, find role models who believe in a different kind of self-worth? What is there to strive for when the media influences our every thought and feeling? This brings the post full circle. When I wrote above about what a therapist needs to do to create an environment to promote successful therapy, I also described what children need to avoid this exact pitfall. When I suggested the therapist needs to search for what aspect of the relationship alleviates the eating disorder symptoms, I also described what children need from parents, friends and the world around them to find their own identity and their own voice and not succumb to the reductive appeal of the world of the media.

Next post, I will try to expand on how to apply the critical aspects of successful therapy to parenting about food, weight and the media.

Children, Media and Eating Disorders, Part I

2010-08-04T08:34:00.002-04:00

The media's message has invaded the home and family as much as every other facet of our society, and there are many obvious reasons why. As a business opportunity, children represent a valuable advertising target if only because of their potential lifetime brand loyalty and penchant for browbeating parents into spending money. Millions of young souls are the tabula rasa of a media culture--a social movement masquerading as entertainment--primed to usurp parents' rightful authority and shape a directionless generation all too prepared to feel inadequate and fat, fat, fat. And why not? Kids have no idea where to look for guidance and identity, and the media can't do enough satisfy its own hunger for power and influence in the marketplace and for growth at any cost. And who's going to protect them anyway? Regulatory agencies or big business? Several previous posts make it clear that the answer is no. Parents? Themselves?

For parents raised on the splendor of icons like Tony the Tiger and "Trix are for Kids," media, advertising and TV used to mean something very different. It felt like sitting on the edge of your seat as a whole new world of promise came into view. As MTV and Star Wars dominated an ever-growing portion of the national psyche, kids placed their aspirations for a better world into media and entertainment. No one thought the media would renege on its unspoken promise and betray the national trust. Back then, the afternoon special starring a bulimic teenager seemed like a public service message about the rise of eating disorders, not the harbinger of a national identity crisis on the horizon. This was a time when the media knew its social responsibility to culture and society, when media celebrity meant being a role model to a new generation and MTV really did think it was changing the world. It's not that the media is less powerful--although that influence is no longer the purview of a handful of venerable institutions--but that the onus of building a better world has morphed into the need for immediate impact. When the goal is numbers and influence, nobody cares anymore what happens to the individuals who consume the media. Far from the heady but seemingly innocuous years of media forging a new frontier, now everyone is a consumer charged with protecting themselves. And with parents still awash in the old media ethic, that leaves children even more vulnerable to this brave, unforgiving, new world.

With no one protecting kids from media influence, it might be worth reviewing some child psychology to understand what the media uses to exploit children’s vulnerabilities. The development of self-worth and identity goes through several stages, but one thing remains fairly constant: an absolute belief that they are the center of the world. Perhaps becoming an adult means fully realizing how false this is. For children this is not a character flaw--as many overwrought parents are wont to believe--but an interesting psychological reality of modern life. It doesn't mean children think they are all powerful or that the narcissism makes them king of the world. Instead, it is a temporary solution to understand confusing events around them. Children understand the facts of the world long before they have emotional comprehension or a sense of personal identity. When kids don't have the tools to take something in, they almost magically believe they caused the events around them to happen and confuse their emotions with personal responsibility. Think of a child witnessing parents arguing. All kids think that they did something to cause the fight to happen: the emotions and context are too confusing. An adult would react emotionally but see that confusing feelings cannot cause something to happen. But that's much too sophisticated for a children, even for adolescents. And there is no amount of reasoning that would help a child to believe otherwise: call it the shared delusion of childhood. This means that, for a critical period of their lives, children determine their place in the world, i.e. their identity and self-worth, exclusively from the world around them. If that world is predominantly peaceful and pleasant, the child has little to worry about. The more a child's life is complicated, confusing or worse, the development of that self-worth is marred by, for lack of a better term, "badness." Parenting manuals have distorted this fact of development into a backlash against discipline. Children still need rules and consequences and lots of them, but they also need consistency and praise. They need to hear through words and action regular reinforcement of their value and place in the world. By action, I mean the way parents, family and friends live their lives. Emotional maturity will follow.

With this background, it's easier to see why many children are at risk. Some kids will have the support system of family, friends and school that insulates them enough from the media to develop identity and self-worth influenced but not dominated by the culture of thinness. But what about the kids who have instability at home or live in a community consumed with thinness or take in too much "badness" in their lives or even just have parents who are unaware of the power of the media? For the vulnerable kids--not a small minority--this social movement becomes not just a culture but a cult that reels a large group of children into its fold. The appeal of a set of rules to define identity, a definitive moral code of food and weight to separate good from bad and an obsessive mantra that blocks out the confusing emotions of childhood and adolescence is just too satisfying to pass up. Add in parents themselves focused on media and thinness as a way of life and peers already drinking the Kool Aid and it's easy to see why the society as a whole has a tough time seeing the way to create a healthy, positive self-image in kids these days. An epidemic of eating disorders is hard enough to imagine, but what about the media culture as a rite of passage, or worse a method of raising the next generation? A discussion of some options to counter these real possibilities will be the topic of the next post.

The Media, Eating Disorders and Self-Worth

2010-07-23T15:22:00.001-04:00

It's not enough to create the life you want unless you have the body to match. That's the adage most people live by in our society. Starvation, dieting and weight loss dominate a large swath of the mental time and energy of our daily lives. Even the most productive and successful people usually have a running food loop in their mind. To explore why maladaptive eating is so highly valued, it makes the most sense to understand what other values have slowly become worthless in recent decades. The daily pleasure of eating and the community of food has declined in importance, unless the food industry is your career. Youth and perceived immortality routinely trump the value of experience and knowledge. Any worthwhile political or social movement buckles under the weight of the media's choice of the news du jour. The substance and dialogue of our collective narrative are largely devoid of meaningful content in favor of celebrity gossip or diet tips. Even the more serious news reporting often emphasizes the need for lighter matters to shield us from the real concerns in the world. There is little focus on the meaning of our lives as an individual or as a whole. It is unclear whether there is inherent value in having an opinion, a voice or a community anymore or if they are just a means to an end. So the mastery of food and weight represents the apogee of personal identity almost by default. It's either a place holder while we wait for something of true significance to shape our self-image or a prolonged drug of the masses that lulls us into perpetual slumber.

If this were only the newest communal vice, maybe we could all just chuckle and move on, but there seems to be something insidious and more deeply disturbing underneath. The history of psychiatry reveals a series of psychosomatic illnesses which have primarily affected women--fainting spells and hysteria as the two most notable examples. These diagnoses were social constructs to pathologize, contain and, presumably, treat overwrought women who had no alternate emotional outlet in that era. How is it now that eating disorders often pick out extremely bright, driven and talented women and render them impotent? The media suggests that these illnesses are just a luxury of the well-off--just watch an episode of "Gossip Girl"--with nothing better to do than obsess about their weight and manipulate their food. Yet, across socioeconomic and ethnic groups, the personality traits that self-select for eating disorders suggest otherwise. Perfectionistic, diligent, hard-working. Self-sacrificing, empathic, engaging. Funny, self-deprecating, quick-witted. And always remarkably unaware of their strengths and talents. Working with these women often feels like going to the hall of mirrors at an amusement park. No matter how much I reflect back the person that I see and know, all they can see is a distorted self-image. In the post-feminist world of supposed opportunity, these women seem primed to thrive and take advantage of what life has to offer. Yet, in the forty years since the feminist movement opened those doors, the incidence of eating disorders has skyrocketed. It feels too pat to imagine this is a coincidence. Has the influence of the media helped an entire society find a new way to contain and manage capable women in the useless pursuit of dieting and thinness? Eating disorders do seem like the current iteration of silencing women with psychopathology.

This is another instance where social phenomena and clinical acumen overlap. Effective treatment needs to undo the pervasive influence of media as much as the emotional and psychological cause of the disorder. That doesn't mean discussing the pros and cons of Us magazine. It does mean reassessing what gives value to a smart, capable woman in our society. Or what are the realistic goals a driven woman can aspire to. Or what it means to engage in the world without the constant fear and anticipation of personal judgment or sexual leering. Addressing these issues means directly questioning the world the media has shaped. Although that's a start, it's naive to think it's enough since we don't live in a bubble. Coming to terms with one's own place and value in the world will also mean questioning family, colleagues and peers: the immediate world around each of us. Patients who fully recover don't just stop their behaviors. Many people may eat relatively normally but still view food and weight as the most important part of their identity. Treatment that works has to help the patient recover her identity both personally and within her community. She needs to see herself outside of the hall of mirrors but also know that her value may still be seen through the prism of the media by many around her. It takes motivation and strength to persist in real recovery while the world still swirls around thinness. Recovery demands that one always pushes back against the tide of the media and strives to show one's true value. While everyone else just wants to lose weight.

If recovery involves taking a moral and philosophical stand against the perceived norm, it follows that the media, pursuit of thinness and eating disorders may be the closest thing we have to a social movement right now. With all of the current press about an anti-obesity campaign that largely ignores the complicity of big business and lax regulatory agencies, how can our national starvation escape without a mention? Michelle Obama placed her spotlight on childhood obesity but put her pre-teen daughter on a diet? The message cannot be more clear. The inherent danger of a widespread social belief that thinness is best leaves children with no other way to see themselves. The media has invaded the home and parents have made it acceptable to inculcuate children in this world view. And everyone just looks the other way. This will be the topic of the next post.

Media, Food and Weight-Overview

2010-07-12T18:21:00.001-04:00

The media is meant to seem like benign, light entertainment to fill our days. But the magnitude of its influence on our lives is as unavoidable as it is insidious, especially when it comes to food, dieting and body image. It's not just that all actresses and models are thin so we want to be thin too. The media assumes we all know that being thin is the key to fame, popularity and success. In fact, it is the only way. The media does not act as if it dictates the social norms but rather lulls us into a state of mindlessness. How could Lindsay Lohan's last arrest not be supremely important? And, of course, she's wildly successful anyway. Because she is thin. You'd be completely out of touch--or worse, hopelessly lost--to believe otherwise. But then the media is much more than fashion, TV and movies. It's a philosophy and a social movement, a world view and a political ideology, and even a ubiquitous educational tool that shapes the way we see the world. Denying the existence of the media is like being an atheist. It's a personal choice but that doesn't eliminate the media from the world any more than denying god eliminates religion.

The media, perhaps more than anything else, taps into our true wishes and desires through expertly crafted images and messages that fill a huge void in modern life. Deep down, we all know the media did get it right. That's why it's so hard to resist. And, like any entity wielding such enormous power, the exeuction of its influence is solely a matter of exploitation. Just think of it. At any moment, people are reading the same magazines and watching the same movies and therefore striving for the same goals and to be like the same people. The role models--once limited to family, friends and perhaps a neighbor or teacher--now are universal. As the arbiter of cultural norms and ideals, especially for those affected most, adolescents and young adults, the media tells us exactly what really matters. And an industry has followed to monetize every aspect of our infatuation and continue to spread the word.

On an individual level, the road to social acceptance and personal success is lined with diet tips, new food fads and one central message: lose weight! By providing an inherently irrelevant yet alluring solution to the fear and isolation bred into our society, this industry has discovered infinite ways to distract us from the aimlessness and lack of personal identity that--literally--embodies our youth. Each airbrushed picture of an actress or model offers up the culturally sanctioned ideal, which each subculture and community attempts to slavishly recreate by searching for its own Lindsay Lohan or Lady Gaga. It's not only that these icons are unattainable but that following their every move serves as a kind of acceptable addiction that fills the void while providing an ethical and moral standard to guide us through life. It may seem banal to equate dieting with a reason to live, but that's truly what has come to pass. In no way does the media have a conscience for our social welfare. No, it's looking for what gets the most airtime and what sells. Thinner is better; starving is right; no weight is ever low enough; no diet is ever too radical; lose ten pounds and life will be perfect.

The current and growing backlash against the media campaigns to normalize food and weight. But we can't all go back to a time when weight and food choice didn't dictate your place in the social hierarchy. A public health initiative to promote healthful eating only shows these young men and women how the establishment is hopelessly out of touch. People that age feel invincible and immortal. They are not cowed by long-term health consequences. Their fears are deeply rooted in finding an identity, somewhere they belong. The media taps into this longing with a quick, simple and supposedly easy solution. The old ads educating about the effects of smoking or drugs--and now about healthful eating--make sense to the middle-aged person in charge but don't touch an adolescent. "Lose ten pounds in a week. Look great for the summer!" or "Eat right. Get your fruits and vegetables every day. Healthy eating for a healthy life!" The only people who hear the latter message turn healthy eating into an identity of its own: orthorexia. For young women especially, the post-feminist era leaves too many choices, few realistic life paths and a paucity of successful and happy role models. But to control food, appetite and weight opens hidden doors in every part of life. Other women are impressed or envious. Men pay much more attention. People are willing to offer new opportunities, both professional and personal. Sadly, being thin, often at any cost, is transformative.

So eating less and losing weight do solve the problem, at least in the moment. A day spent not eating is a day lived well. Accomplishment for the day: 1000 calories, check. Your actions and your body do represent who you are. Your thoughts and feelings are extraneous--expendable items of daily life to be ignored or, when they break through, medicated away. Like it or not, this has become the norm for a generation raised on technology, quick and easy communication and domination of media in culture. Having some version of an eating disorder is a lifestyle, for many a choice, an identity and maybe even a career. It is a stamp of approval, the entrance into a coveted world of control inspiring envy in your peers. In many social circles, the misfit is the one who hasn't been on a diet, intentionally thrown up or taken diet pills. The young woman who orders chocolate cake for dessert when out with her friends inspires a world of gossip. Unless the whole group decided to have a sanctioned binge together. Because there is no viable alternative, an entire generation has turned to the media to answer many questions about life. And this is the result.

As adolescence stretches past college to age 23, 25 or even 30, the media extends its scope even to young adults having children of their own. One generation passes this misguided sense of self on to the next like the secret family recipe or grandma's heirloom necklace or an inherited predisposition for diabetes. As the older generation fights the food industry and agribusiness, does anyone really think twenty-somethings are clamoring for organic produce and humanely-raised chickens? No, they're too busy throwing up the apple pie, Luna bar or handful of grapes. Something--an idea, social movement, national crisis--would have to replace the coveted role the media now plays in society. How else could the younger generation navigate the growing complexities of the interconnected, homogeneous world of the masses? How else to avoid the fate of just becoming a number? Where else can one find identity other than hitting the goal on the scale?

This introduction is meant to lay out the reality of food and weight in a media-centered world. I want to break this discussion down more specifically into a few components that focus more on the implications for the future. First, what does this mean for the value of eating disorders and disordered eating in our society? Second, how does the media politicize a world of thinness as a life goal? Third, has the media found a way to embed weight and food as something passed on to the next generation? Stay tuned.

Hope

2010-06-16T20:14:00.002-04:00

By the time most people with eating disorders seek treatment, they have little hope their lives can really change. The symptoms and disordered thoughts are relentless and, without any perspective, it feels impossible to imagine seeing the world any other way. The impetus to seek help comes instead from either external pressure or internal desperation. So much of what I have written about recovery boils down to maintaining hope. The daily battle of questioning the eating disordered thoughts, trying to eat and engaging with the world is exhausting. Without a sense of purpose or direction, the emotional pain feels pointless. All too often, the hope dies and the treatment along with it. Dropout rates are notoriously high, so much so that just continuing therapy is a predictor of improved outcome. Circling back to hope as a touchstone--a benchmark of progress--is one of the therapist's primary responsibilities, at least until the patient feels ready to share this duty too.

Living with an eating disorder means being grounded solely in the present. The past and future are irrelevant: the thoughts about food and weight in the moment are all that matter. Any decision either follows or breaks the rules of the eating disorder. It is a success or a failure. By definition, this sense of immediacy cannot coexist with perspective--an ability to step out of the moment and see the bigger picture. And perspective is a necessary component of hope. Without that psychological and emotional distance, any progress or change gets buried under an ever-present sense of inadequacy and shame. But the immediacy that makes the eating disorder powerful is also what makes it safe. Lack of perspective means lack of an identity separate from the eating disorder and that feels special, as if the person has life figured out, as if she a free pass from the daily struggles everyone else has to deal with. Perspective means starting to disentangle the patient's own identity from the eating disorder. Even acknowledging this is a possibility has far-reaching consequences. It implies that a different path may lie on the horizon. I have mentioned several ways to gain perspective in previous posts: food journals, medical effects of eating disorders, regular review of progress and developing a meaningful therapeutic relationship. Each of these steps will cause fear and apprehension but also cultivate hope in a future of recovery.

With perspective comes a very different emotional understanding of the eating disorder. The thoughts that are so harsh, demeaning and critical remain powerful only when the patient is consumed by the urgency of the present moment. People with eating disorders are, by and large, compassionate when contemplating other people's struggles. Some distance from the eating disorder stirs up that same sense of compassion for their own plight. The conflict between these two internal reflections is a pivotal part of maintaining hope. Once the therapy touches upon compassion for oneself, distinct from pity or self-recrimination, progress becomes palpable. The therapist can regularly remind the patient of her own sense of compassion for others and the possibility of feeling that way for herself too. Hope springs from the gradual process of learning to see oneself with understanding instead of reproach.

The other important result of having perspective is how it shatters the idealization of recovery. Many patients view their own potential recovery through the black-and-white prism of the eating disorder: perfection or utter catastrophe. The fear of prolonged misery, even after starting to eat normally again, girds the patient from any sense of hope, compassion or change. With some distance from this narrow scope of the world, the prospect of recovery changes too. Life, with all of its messiness and complexity, becomes clearer and lets the patient off the hook from needing to attain perfection. As terrifying as things look from this vantage point, the therapist can help the patient learn to be grounded in this new reality and feel as if she can survive, mainly by emphasizing hope. The ability to even acknowledge a world of confusion and complexity is a phenomenal step forward. The latent desire to move away from the security of the eating disorder is the patient's own way of seeing hope for a different life.

Occasionally, a patient who has been a stalwart believer in the immediacy and identity of her eating disorder glimpses how the other half lives. After months of hearing me go on and on about perspective, hope and compassion, she will let slip a word or phrase that suggests she has been listening. It could be a side comment about the eating disorder as separate from her; or an acknowledgement that the treatment has affected her eating disorder; or a hint at the progress in recovery; or even a session with limited discussion of food and weight. At that moment, it is clear that something has shifted. Any one of these comments or omissions implies that the patient has begun to have some perspective from the eating disorder. More importantly, it shows she is ready to share the mantle of hope for recovery. Perhaps what appeared at first to be complete fantasy may indeed start to feel very real.

The next few posts will shift in a new direction. I will address the impact of media on the culture of thinness and strategies to cope with its broad influence on our lives.

Medical Complications of Bulimia

2010-06-07T11:19:00.001-04:00

Unlike starving, the symptoms of bulimia--primarily binging, purging and laxative use--cause immediate harm to the body. No patient can deny the physical toll these symptoms take. For many, the pain and weariness is a welcome relief from the emotional misery of the eating disorder. Although most patients are terribly afraid of the potential long-term damage, they are just as likely to ignore the risks of their behaviors and signs of deteriorating health. Patients often confuse the immediate physical effects of bulimia with the chronic medical complications and thereby underestimate the serious long term risks. Like with starvation, the body has to adapt to malnutrition and nutrient deficiencies, in this instance from lack of digestion and malabsorption. Unlike anorexia, which the body has an evolutionary inclination to weather, bulimic symptoms are a trauma to endure with a cascade of increasingly toxic effects.

The gastrointestinal system--the part of the body most immediately affected--functions through peristalsis, the muscle contraction initiated by swallowing that pushes food through the system's entire length. Binging, purging and laxatives all disrupt this muscle contraction in quite similar ways. Binging expands the stomach and slows or even stops the muscle contractions temporarily, an effect even more pronounced after purging. Laxatives actively stimulate the colon leading to forceful and often painful diarrhea. These tramuatic shocks to the GI system lead to a period of slowed peristalsis with limited digestion and constipation. After recovery, peristalsis gradually resumes; however, prolonged symptoms can impair the body's ability to return to normal function. For instance, laxatives are addictive and chronic use makes it extremely difficult to have a bowel movement without them. Persistent binging may permanently slow digestion as the stomach is regularly overwhelmed with too much food or expects the contents to be purged. Consistent purging can lead to GI reflux (the food goes backwards into the esophagus) which is experienced as esophageal pain and bleeding.

One lingering effect of bulimic symptoms is electrolyte abnormalities, most notably a low blood potassium level. Purging, laxatives and diuretics all lead to excretion of this essential mineral and a gradual decline in the blood level. Life is considered untenable as the potassium level nears 3.0, but to many doctors' shock and dismay, bulimic patients have been known to walk around with levels under 2.0. For some people, the body adapts to the low level and manages to survive, for a time, but this is the most sudden and lethal complication of bulimia. Low potassium affects the heart rhythm and can precipitate cardiac arrest. Chronic low potassium also leads to kidney damage, and patients with bulimia even end up needing kidney transplants.

These complications are the most destructive, but the list of medical complications is long and equally mind-numbing as that for anorexia: hormonal abnormalities including infertility, slowed cognitive function, breakdown of dental enamel, persistent fluid retention and swelling. Most patients sit quietly waiting for the medical lecture to be over and are too afraid to see the full impact on their bodies. Two factors can help break through the powerful denial and help patients begin to process the risks of their behaviors: fear and timing.

The most common binge trigger is fear: fear of emotions, fear of new situations, fear of people and, ironically, fear of really being hurt by the eating disorder. The last fear is pervasive but hidden deeply beneath the need to binge to survive daily life. Using this fear to chastise the patient drives a wedge into the treatment: no one recovers when being consistently hammered with clinical facts. The therapist needs to broach any discussion of medical complications from a place of genuine compassion and caring. Too often families, friends and, sadly, clinicians place the blame on the patient and undo much of the progress. By trying to understand--and perhaps imagine experiencing--these fears, the therapist can make it safe for the patient to let down her guard. Feeling understood for the first time will allow her to express these feelings and acknowledge her desire to be well and to live fully.

A therapist needs to choose the right time to discuss the medical issues. Even with a sense of safety, a mistimed discussion often becomes an ignored lecture. If a patient is feeling vulnerable and confused but also safe and understood, the medical information can get through and help her face the reality of the eating disorder. This component of therapy relies heavily on the therapeutic relationship and on the therapist's ability to surmise that the patient is ready to trust the treatment enough to face her reality.

These two posts highlight how damaging and even lethal eating disorders are. Patients and therapists are often afraid to discuss these consequences and risk overwhelming the treatment. At the same time, any therapist who avoids this discussion is remiss. Engaging in this part of eating disorder treatment successfully sidesteps the patient's most valued protector, denial, and opens the door for another deeper question. How do you maintain hope during treatment for an eating disorder? Look for the next post.