It seems timely, as we head into the holiday season, to reflect on one of the hallmarks of holiday gatherings: eating. Through much of the year, eating has a less ritualistic function (aside from birthday cakes and summer barbeques) than the gatherings at the end of the calendar year. Most people who celebrate this season include eating related functions in which disordered eating is the norm. I don't intend for this blog to be a how-to guide for surviving the holiday food excesses. If you wish to explore this there are many great ideas on the web. Rather, I want to point out the opportunity for those of us who work with eating disorders (not disordered eating) to encourage the rest of the world to understand better the unique and tragic challenges people with eating disorders face.
One of the most common and revealing statements of non-afflicted people (especially men, as 90% of those with eating disorders are women) is often "I don't get it, why doesn't the person with the eating disorder just eat?" This lack of knowledge and resulting lack of compassion is the result of several things: people often react to things they don't understand with bias based on their own experience, as they try to define and adjust to uncomfortable emotions.
Further, eating disorders have, for most of the history of professional diagnosis and treatment of eating disorders, been misdiagnosed, misinterpreted and maligned. As a nurse working in a major trauma center many years ago, I remember there was only one patient more capable of bringing out the GOMER (Get Out Of My Emergency Room) mentality in ER staff than a seriously medically ill eating disorder patient, and that was a drunk seriously medically ill eating disorder patient. Indeed, I myself have observed and partaken in these mistakes over the years: I read about and incorporated the proposals that eating disorders had been linked to the Electra dynamic, sexual abuse, addiction, personality disorders and willful adolescent oppositionalism.
And I remember studying closely the proposed dysfunctional family dynamics. Some of you may remember the 'Influence of the Family' article in an old ACA newsletter describing very eloquently the three stereotypical dysfunctional family dynamics to look for when treating eating disorders: The Chaotic Family, the Abusive Family and the Perfect Family. But as I studied them I realized that the writer had effectively described the vast majority of families in Western culture! Taking into account that the prevalence of the various eating disorders is somewhere around 8-15% of the general population, this analysis was overreaching, to say the least.
What are we to make of these errors, coming as they have from otherwise learned and experienced clinicians? Some of the answers might include the 'publish or perish' dynamic, but that is likely not the major culprit. Some might be attributed to a need to find explanations for a problem which is downright scary for those of us who see clients whose medical status is seriously compromised. And quite likely, some of the errors were sexist; as one of my professors once informed us, Freud was reported to say that he never intended psychoanalysis to bring about permanent change, he considered it as entertainment for bored housewives....I think sexism in our field has been a problem that is thankfully improving. And the traditional treatment community has been notorious for taking its time to change paradigms. It took 60 years for medical science to accept what "Limey" sailors knew: that fresh limes prevented scurvy. Doctors continued to use bloodletting as a primary treatment.
But in the past two decades, and especially the last decade, careful, replicated research has shown that eating disorders are a hereditary construct of a neuroendocrine dysfunction that is compelling, ne demanding. We even know which parts of which genes are implicated in anorexia and bulimia. We also know that the emergence of an eating disorder is now describable from a neuroscience perpspective, to the point that it may one day be described as a neuroendocrine disorder with psychiatric/behavioral symptoms.
Of course we all know that behavioral disorders are not diagnosable until the behavior is exhibited, and therein lies another part of the explanation for the misdeeds of our colleagues.
For many of those who currently suffer from E.D.'s, the trigger (not the gun) was the drive for thinness, usually predicated on fashion. One doesn't need to be Freud to understand why a provider might look askance at an otherwise (often) bright and capable person who is in mortal danger because of their eating behaviors. As one ER physician said to a client of mine who was in electrolyte crisis: "What, are you so vain that you would do this? Look at how you are making your parents suffer." (She attempted suicide that night.)
So what are we to do about this? First and foremost, we must stay abreast of recent research about etiology. We must follow the evidence based interventions and hear what these interventions imply about causation. (More about this in another blog.) And we must admit that just because we are intrigued by complex, intricate and elegant theories, that doesn't mean they are accurate.
One is reminded of former First Lady Barbara Bush. The media reported her increasingly irascible and pugnacious behaviors. During a medical exam she was diagnosed with Graves disease, was given appropriate medical interventions and her untoward behaviors stopped. But, to my knowledge, no one later said to her: "Now that we have fixed this endocrine problem, I would like to explore how your mother treated you during your formative years."
And we can do much to help both the sufferers of eating disorders and the general public perception with a comparison that everyone could relate to, especially during the holidays: imagine that you are newly married. This is your first time spending the holidays with your in-laws and you don't want to blow it. But both of your families live locally and your families' tradition is to have holiday dinner at 2:00 pm. You attend this festive occasion, eat all the favorite foods that your mother has painstakingly prepared-maybe even an extra piece of grandma's pie. All fine so far, but now you have to honor your spouse's family tradition: dinner is at 4:00 at their home. Even though you are not hungry at all, you may feel compelled to force yourself to be cordial and eat another full meal. So how do you suppose that third piece of pie goes down? That is the experience of a person with anorexia: they are not hungry because of a neuroendocrine messenger that says they are uncomfortably full, but others expect you to be naturally hungry and must politely eat.
I think we can all see the narrowness of this analogy, but following it through, how would the average, not psychologically sophisticated person respond? It could be difficult. We can all be agents of change in this paradigmatic shift. So let us share our loving acceptance of differentness. I truly believe that we can do no better than to function out of the attitude once voiced by William James. To paraphrase: the most important thing in the world is to be kind, the second is to be kind, and the third is to be kind. Happy Holidays to all of you-have a piece of pie for me.
Steve Bryson is a counselor in private practice in Whitefish, Montana and a registered nurse. He works with adolescents and adults, couples and families and has a special interest in eating disorders.