Off the Couch

Thoughts about the therapeutic process, and the dynamics of client-therapist interactions.

Starving to Death

Guess what! Dieting can be bad for you.

Stephanie* is a 28-year-old professional woman. She has a boyfriend, a good job, and lots of friends. She is smart and personable. And she is also starving to death.

Throughout her adolescence and early adulthood, Stephanie has struggled with anorexia. For months at a time she has kept herself on a starvation level diet while exercising three to four hours a day, sometimes even waking up in the middle of the night to get in another workout because she was afraid of gaining weight in her sleep.  She had interrupted this pattern for short periods of time over the years. Once, she fainted on the street and was hospitalized. Twice her doctor, who was monitoring her heart, kidney and liver function, which were all seriously compromised, insisted that she enter a treatment facility where she would be forced to eat more healthily, stop obsessively exercising, and gain weight.

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Stephanie is tall, slim and extremely fit. She looks like a model. When she has a little fat on her body, she can be funny and charming. When she loses that weight, she becomes brittle, irritable and sometimes even irrational.

I began working with clients like Stephanie in the early 1980’s, when the behaviors were still relatively rare, although occurring in increasing numbers of young women. I quickly learned that the wish to be thin was driven by a combination of low self-esteem, difficulty managing feelings, and beliefs about what other people find attractive – a lot of it driven by the media.

Today, counseling staff at some of the colleges where I give workshops tell me that even students with clear signs of severely disordered eating are seldom referred for help. The symptoms are so common that they seem to be a normal part of adolescence.  Sometimes they are outgrown with the end of adolescence. But today the external pressure to be thin is often overpowering.      

For example, in a story reported in the New York Times this past week, Julie Bosman writes,

   "Amy Chua may have to hand off the title of Tiger Mother to Dara-Lynn Weiss, whose article in       the April issue of Vogue painfully detailed her effort to get her 7-year-old daughter, Bea, to lose   weight.

  "Alarmed that Bea, at 4 feet 4 inches tall and 93 pounds, had developed habits like scarfing down   'adult-size plates of food' and failing to 'self-regulate' at the preschool snack table, Ms. Weiss placed her on a strict diet, cutting the size of her dinners in half and banning almost all desserts.

  "'I once reproachfully deprived Bea of her dinner after learning that her observation of French Heritage Day at school involved nearly 800 calories of Brie, filet mignon, baguette and chocolate,' she wrote. 'I stopped letting her enjoy Pizza Fridays when she admitted to adding a corn salad as a side dish one week.'"

I won’t go into all of the reasons this behavior is problematic. Both this mother and Random House Ballantine Imprint, which has bought rights to her new book (of course) have been raked over the coals in the media. Jezebel labeled the piece in Vogue  “the worst Vogue article ever.” Salon’s Mary Elizabeth Williams writes, “while I am greatly concerned about rising rates of childhood obesity and the health toll they will take on an entire generation, I am convinced that the way to promote healthy eating and activity isn’t by berating or shaming 7-year-olds.” It is, she adds, however, a great way to sell books.

But we don’t need this book or these articles to convince us that in today’s world it is hard to know how best to feed our children.  The abundance of so-called “bad” foods and the equally overwhelming number of so-called “healthy” diets take us far away from the fact that learning to eat well is also about learning to pay attention to what our bodies have to say to our minds. It is about learning to listen to ourselves and to respect our own needs. And it is about sorting out psychological and emotional needs from physiological ones – something that is not simple.

Stephanie controls her weight for a number of reasons. The oldest of four children* she has a younger sibling with a physical disability that took up much of their parents’ time, energy and financial resources. She loves her sibling and was always happy to help out at home in any ways that she could. She became responsible for making dinner for the family and for getting herself and her younger siblings ready for school in the morning.  In therapy, she has uncovered feelings of guilt about her own good health and anger at her parents for neglecting her and the other two siblings. But she is ashamed of her resentment towards her parents, since she knows that they are good people who did the best they could with the hand that fate dealt them.

She also began to recognize an underlying sense of anxiety that the world she grew up in was not safe. Not only can it end up with children being born with severe disabilities and parents being overwhelmed, but if, as she once put it, “one little girl is in charge, it can’t be a good place to be.”

Understanding these personal psychological factors was only part of the struggle for Stephanie to get back to good health. She had to also come to grips with the messages being sent to her from the world in which she lives now.  According to all of the media reports, it is better to be thin than heavy. Thinness is healthy, we are told. Exercise and diet are good, our doctors tell us.

But according to the National Association of Anorexia and Associated Eating Disorders, Inc, about the same number of people die each year from anorexia, bulimia and other “unspecified eating disorders” (which one would assume to also include compulsive overeating leading to obesity)  In my own practice over nearly thirty years, I have had more clients near death from starvation than from all other forms of eating disorders combined.

As Williams says, book ideas are bought by publishers because they will bring in money, not because they are thoughtful or good for the reading public. What is crucial and oh so hard to remember is that thinness does not equal health, either psychological or physical. Eating disorders are attempts to manage feelings. Most of us use food to make us feel better. Starving to feel better can have serious consequences. No matter what anyone says.   

*names and identifying information have been changed to protect privacy and confidentiality

F. Diane Barth, L.C.S.W., is a psychotherapist, teacher, and author in private practice in New York City.

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