Off the Couch

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

When Someone You Care About Is Hiding an Eating Disorder

Understanding the underlying meanings can help you choose an appropriate action

Alice,* a tall, attractive and smart young woman, came to therapy for help with a severe depression. After she began to feel better, she stayed on to work on some of the issues that had caused the depression in the first place—in particular, her low self esteem and her relationships with men. Somewhere in the third year of our work together, she walked into my office with a spring in her step and a smile on her face and began telling me about a recent date with a man she had met some weeks earlier. She had talked about this date in our previous session with great anxiety. “What if he doesn’t like me?” she worried. “What if I make a fool of myself?”

“It went great!” she told me. “We got along really well.” She was silent for a moment, and then she looked at me and said, ‘‘I guess it’s time for me to talk to you about my bulimia.’’

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Because I have worked for many years with individuals with eating disorders, I was aware that Alice had some of the accompanying symptoms and behaviors, and I was not at all surprised to hear about her specific symptoms. In fact, I had from time to time asked her about her eating; but when she had denied any problems, I had taken her cue and backed off. We had plenty of other issues to work on, and I knew from experience that clients often need to work on other things before they can address their eating difficulties. When I worry that someone is in physical danger from the behaviors, I take a more aggressive position. Since I often request that clients get a complete checkup from a physician when they begin therapy, and since Alice had done so, I knew that she was healthy and that we could take some time working on some of the underlying issues before we addressed the eating head on.

But this is not always the case. When a loved one or dear friend is hiding or lying about self-destructive behavior, it often feels like we need to take action immediately. Even if it means destroying or disrupting a relationship.

Addressing an eating disorder with a loved one is not easy, but it can be done. Many articles, books and websites offer excellent suggestions about how to talk with someone about an eating disorder. I’ve listed a number of them at the end of this post.

How aggressively we address the problem depends both on the age and the condition of the person involved. But it always needs to be done with a combination of tact and genuine caring. And it is always important to remember that no matter how maladaptive an eating disorder may be, it is also serving some sort of adaptive purpose. It may be that it is the best solution to a variety of problems that the person can come up with. Part of the reason for setting limits and taking action is to help that individual find other, more adaptive ways of coping, of course. But even the best intentions can interfere with their sense of agency—that is, their sense that they have some power to control their own bodies, environment and lives. And in many cases, that is also the point, confusing, misguided and maladaptive as it may ultimately be, of the eating behaviors: they may be an attempt to control a body, a self or a life that feels otherwise out of control.   

This feeling of being out of control is actually one of the reasons that clients hide their symptoms from their therapists and their loved ones. I’ve written a lot about how the symptoms help someone soothe themselves and cope with painful and distressing emotions. (I’ve listed some of my articles at the bottom of this post as well.) Alice spelled out the fear of many of my clients: “If I start to tell you about it, you’ll try to get me to stop. And then where will I be? It’s embarrassing to admit, but I need to be able to binge from time to time.”

This need is the real conundrum. On the one hand, the eating behaviors may be a cry for help. For example, a woman with anorexia may deny the severity of her restricting food intake and become enraged when family members worry about her, yet also long for someone to put a stop to the behavior. A teenaged boy who purges in order to make a lightweight category in his sport may lie to his parents to protect the coach who is encouraging him to keep his weight down. At the same time he may secretly wish that his parents would forbid him to continue to participate in the activity and he may unconsciously find a way to ‘‘sabotage’’ himself, for example by failing to keep his grades high enough to allow him to remain on the team.

On the other hand, it may be a bid for independence. For Alice, for instance, the act of eating anything and everything she wanted, and then purging it, was a way of saying what every child says at some point or another: “You aren’t the boss of me! I can do what I want!” But Alice felt that she could not say that to her own parents, either literally or figuratively. Her parents both suffered from severe depression, which Alice had believed was the result of her separating from them. She therefore tried very hard to be a perfect daughter in order to make them happy.

I asked her to consider the possibility that she had not caused their depression but that they, and she, suffered from a biological or genetic predisposition to become depressed. As we also gradually worked on other tools to help her manage her own feelings, Alice began to need the bulimia less for both self-soothing and an unconscious declaration of independence. But her eating symptoms were also habits, and she had to learn ways to change those habits. Now that the eating disorder was out in the open, it was easier for me to offer some suggestions and easier for her to begin to put some of these ideas into practice. But it still wasn’t easy. Much to her surprise, it took a significant amount of time for Alice to change, and at times of stress the behaviors returned. But over time she had developed several new tools for coping with stress, anxiety and even happiness. She now had a sense that she could manage her feelings, even the ones that had once seemed unmanageable.

*names and identifying information changed to protect privacy

Teaser image source: stock-photo-23511153

Useful books, articles and websites:

Symptom-focused Dynamic Psychotherapy by Mary Connors, Ph.D. (published 2006)

Mindful Eating is Healthy Eating taught by Mary Connors, Ph.D. http://integrativehealthpartners.org/mindfuleating.shtml

Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy by Steven C. Hayes  and Spencer Smith

Suggestions for parents, siblings and loved ones:

http://www.medainc.org/resources/educational_information.asp

http://treatingeatingdisorders.com/

http://donnafish.com/?cat=5

Eating disorders and self-esteem: 

http://www.nedic.ca/knowthefacts/bodyimage.shtml

A number of useful web links can be found at: http://icpnyc.org/csab/resources/web-links/

A few of my own articles, chapters, books and online courses on this topic:

Hidden Eating Disorders: Attachment and Affect Regulation in the Therapeutic Relationship. In the Clinical Social Work Journal , vol 36, pp.355–365 http://www.dianebarth.net/hidden-eating-disorders.html

"Eat,Shop and Be Merry: Linking Eating and Shopping Disorders" in  I Shop, Therefore I Am: Compulsive Buying and the Search For Self, edited by A.Benson.

"The Treatment of Bulimia from a Self Psychological Perspective." Clinical Social Work  Journal, vol. 16, no.3, pp.270‑281. http://www.dianebarth.net/treating-bulimia.html

“Food For Thought:Thinking, Talking and Feeling in Psychoanalysis with Individuals with Eating Disorders,” chapter in Hungers and Compulsions, edited by J. Petrucelli and C. Stuart.

Chapter 9: Eating Problems. In the Handbook of Social Work Practice with Vulnerable and Resilient Populations, edited by Alex Gitterman. (to be published July, 2014).

Integrative Practice in Social Work by F. Diane Barth (to be published as a book and ebook March, 2014)

2008  Eating Disorders, Attachment Theory and Affect Regulation online course for PSYBC

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

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