Several years ago I remember speaking to a therapist who specialised in eating disorders. They had decided on this specialty because they knew that when they got a client that they would be with them for several years. I felt angry then and I still feel angry today. As with any addiction, it will take years to get into recovery, a proper robust new way of living rather than the state of sobriety with occasional 'slips'. But I think our first job as therapists is to spoil a person’s using and turn their heads to the possibility of recovery, to inspire them, and that can happen quite quickly. We can get caught up in the argument as to whether an eating disorder is an addictive process or not, but my sense is that if something works we should apply it. I have worked for over 2 decades with people suffering from anorexia, bulimia and binge eating, or over-eating, and am privileged to be part of many peoples recovery journeys.
In each case, my priority is to consider what abstinence means to that person, and try to encourage them to establish their own bottom lines - rather than ones imposed by me, so that if, and when, they breach them it is a process of self-reflection that is required rather than a kind of confession associated with compliance and defiance. I insist it is their recovery not mine. I am just delighted to be allowed to work with that individual, whatever they decide to do. We look at what is possible in terms of eating and digesting an appropriate level of nutrition, or working towards that. And it must be planned in advance so that the food choices are not dictated by the mood in the moment. As a minor digression, this is what I consider compulsion to be: rather than literally feeling compelled to do something, I think about compulsion as when your feelings dictate your behaviour, which is almost the same thing, but which focuses more on the person and what's going on for them at any given time.
Second I always consider the job of the eating disorder - what purpose is it serving, or should I say trying to serve? Is it a best friend? If so, for those of you who are familiar with Shakespeare, it is the Iago to Othello, whispering in his ear to kill his sweet Desdemona. An eating disorder is no friend. Often it is a voice of protest, anger turned inwards (shame) or outwards (blame)? Of course it's also a form of control, usually because there was a time when is was extremely painful to have no control.
Alongside this I believe that all eating disorders have a connection with family, as the distortion relates directly to nutrition and so family work is strongly advisable wherever possible. I would also say, as with all addictions, that sobriety is about the substance, and recovery is about having the freedom to live comfortably in your skin, with dignity and respect - and that goes way way beyond healthy eating or achieving optimum weight.
For many years now I have treated the three main areas of eating disorder through a relational lens, in other words seeing them as behaviours that are deeply ingrained in the person rather than solely in relation to their attitude and experience of food. I believe that where there is an eating disorder there will always be a distortion to a person's relationship with money, and also in intimacy and attachment. All their relationships with nourishment either in a physical or a profound sense are affected, and I have seen over the years many examples of these parallel processes. Knowing this allows me an opportunity of intervention where otherwise I may have been blocked. For example if somebody is a dyed in the wool anorexic they will probably know more about food than I ever will, so in a way it's almost pointless to talk to them about food beyond establishing an abstinent outline. I prefer to talk to them about their relationship with money or in terms of their interpersonal relationships with others instead, as I find this can provide a key to release them around the anorexia too. I don't think if you're anorexic with food you are anorexic across the board either, rather that you might restrict with food, overeat in relationships by being needy, as if nothing is ever enough and with money perhaps it falls bulimically through your fingers. I have outlined some further thoughts about this as follows:
Of course I recognise that restricting is extremely dangerous, with the potential to cause the body to shut down, the brain to malfunction, followed by a lifetime of severe health consequences. I should add that with any eating disorder I usually collaborate with nutritional experts and often psychiatric care to treat the myriad dimensions of an eating disorder, recognising it as a sickness of mind, body, emotion and spirit. And I am not a one stop shop, the work I do is therapy, it is relational, and the way I see anorexia is as a coping mechanism related to controlling vulnerability: finding safety in not needing. For me this is critical to understand when treating an anorexic. If someone decides it's safer not to need, then their entire defence mechanism depends on them never needing and it may even feel reasonable to accept starvation as a consequence. It makes therapy counterintuitive to the anorexic who in my experience will either comply or defy, on the one hand forming a ‘special’ alliance with the therapist, commensurately somehow handicapping that very therapist from properly helping or flat out refusal. It's part of the relational sickness whereby the anorexic will control their need, talking themselves into believing that they know better in terms of the sustenance they can live on, in every way. By extension of course an anorexic will often attract overt caretaking, someone who feels compelled to protect and rescue them, micromanaging on their behalf, inadvertently enabling them to remain without responsibility. Ultimately the anorexic will seek to take up as little time, food or resources as possible as a way of controlling their vulnerability, deskilling the people they love who often describe walking on eggshells around them, which in turn can leave the anorexic feeling frustrated that their defence is so convincing – an important opportunity for intervention!
Similarly I see bulimia not just as (over) eating and being sick, using laxatives or exercise to offload calories and weight, but as a relational condition. Similar to anorexia, I would encourage the bulimic to eat little and often to avoid the purge trigger and to train themselves out of the need to feel physical pain when they eat. So many bulimic's talk about the fog or the food coma that they experience at the point of saturation just before the purge. As with all addictions it's important to avoid all or nothing behaviours, binge and purge or indulge and restrict patterns and sometimes it is more effective to approach these behaviours in other areas of the bulimic's life other than food, once that is planned and in place. Another dimension of bulimia in my experience is rage, a silent, violent rage that happens behind a closed bathroom door, veiled by the sound of the shower, and concealed behind the often smiling face of the people pleaser who simply can't digest. There we have it, an appetite to take but no appetite for permission to benefit. This can translate as a fear of commitment, and a shame about taking and often I have found that there is a distortion of the experience of need and reward in families where there is an eating disorder. By this I mean I find favouritism, and sometimes envy from parent or sibling that makes taking and being nourished from that resource a deeply conflicted experience.
I've noticed over the years that people who suffer from this form of eating disorder are also often bulimic in the way they talk and interact, often quite volatile, going from being super happy and smiley to overreacting like a spark on gunpowder, supersensitive to the opinion of others. It's as if they take something in, a compliment or a secret and then have to purge that out by converting the complement to a criticism or by gossiping. Hidden in plain view the bulimic will often be a good friend to somebody who is high maintenance, or selfish, as if somehow reinforcing their conflicted sense of wanting but not being allowed to receive.
A particularly painful form of an eating disorder in terms of shame, as the overeater wears the consequences of their using in body weight. I recently worked with a woman who was 28 stone and I grew to care deeply for her as a result of the extraordinary courage she had, and her determination to rid herself of this deeply destructive, negative coping mechanism, a determination I recognised as self-worth. Although she had more than once considered taking her own life, what she really wanted was to live freely without the weight of her history wrapped around her body. For her, as for anyone I have worked with who suffers from obesity and who has an overeating eating disorder, they feel other people's judgement as if it were disgust. This causes the overeater to venture less and less out into the world for fear of being stared at or laughed at, or at the terror of becoming stranded, running out of breath or feeling unable to catch a bus or a tube or walk another step. As a result the overeater will be inclined to do exactly what their eating disorder needs to do which is to isolate and take no exercise at all. The thing about overeating is that it seems there is no physical sensation of being full. Like the high the crack addict hopelessly and helplessly chases, the overeater never experiences satisfaction. Not in anything. The relational dimension being that the overeater really doesn't know what is enough, so detached are they from their own need, and with a critical voice installed where kindness should be in charge.
I have no doubt that trauma is held in the body, and for the over ater it is held in every kilo so that weight loss causes that trauma to become live again, and without the right support, the overeater will of course instinctively repress... by eating.
So often I have noticed the connection between overeating and codependency, illustrating that cliché that 'we teach best that which we most need to learn'. It is a common profile, the overweight caretaker giving their time, understanding and care to another when they are running on empty themselves, abandoning their own need and creating a great hunger of loneliness that then needs feeding.
For family members of anyone with an eating disorder, the answer seems obvious: eat, eat and digest, eat less! But it's not only about the food and until that is understood, each profile will trigger a reaction from those around them that reinforces the core belief that either it's not safe, they don't deserve it or that they are disgusting/greedy. Yes its complex work, but once the person realises it's about them and finds a safe place to process what's going on inside their head, they can start to create a small gap or definition between them and their old best friend. I always refer people and their families into the fellowships too as I think the most important word in those rooms is 'we': fracturing the isolation, showing the real potential of recovery and fellowship can help cement a new way of life, even as it is kickstarted in the privacy of the therapy room.
Founder and Clinical Director and Addiction, Parenting & Relationship Expert, Charter Harley Street
Mandy Saligari MSc MBACP (Reg) SMMGP NCAC (accred) is an addiction, parenting and relationship expert with a strong media platform. From her outpatient clinic, Charter Harley...