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Alternative Group is deeply committed to public education and health promotion. We embrace the principal that the benefits and assumptions underlying any treatment program should be clearly and publicly stated. Accordingly, these newsletters are part of an ongoing effort to promote understanding of our philosophy of treatment and to promote discussion of treatment issues.
IN THIS ISSUE
Not all eating disorder treatment programs employ the same philosophy. In fact, there are widely ranging treatment approaches that seem to have little in common. Some programs focus on controlling a “food addiction.” Other programs view food issues as merely surface distractions covering more serious, deeper issues. Some programs aim for full recovery. Other programs do not believe recovery is possible and maintain that the “disease” can only be arrested. The following is a discussion of the Alternative Group philosophy pertaining to these matters.
TEACHING ANOREXIC THINKING:
Wrong Approaches to treating food and weight problems
William C. Shearer, Ph.D., M.P.H., M.B.A.
Robin L. Shearer, M.F.T., M.A., M.P.H., R.N.
Sound like a strange title? Is there really a need to teach food and weight troubled people to think and behave like anorexics? Strange as it seems, many well-meaning but uninformed treatment programs, health professionals, and self-help groups are doing just that--and often with fanatical zeal. Some cite health or a spiritual basis while others promote a cult-like acceptance of flawed basic assumptions. One does not question some beliefs without being labeled a heretic and ostracized accordingly. Fifty years of relevant research is often ignored or discounted, mass denial not to be influenced by facts.
Confused? Let us travel back through the tangled history of eating disorders treatment. You will see how differing basic assumptions have led to radically different ideas about recovery. You will understand how some well-intentioned approaches have perpetuated food and weight mythology and left millions stranded in a morass of dietary chaos. False beliefs have blocked change. Rigid behaviors have resulted, leading only to deepening misery. Overly simplistic advice has encouraged all-or-none thinking and excessive guilt. The belief of countless people that there is something fundamentally wrong with them for not meeting current cultural weight preferences has been strengthened. The only cure is openness to new thinking--but new thinking is often staunchly resisted.
Ready for our trip? Let us travel back five decades to the founding of Alcoholics Anonymous.
Since 1935, A.A. has been an organization that is difficult to describe without superlatives like “incredible, awesome, and monumental.” Millions have benefited. No doubt, multitudes have been rescued from a certain downhill slide into oblivion. You may be thinking, “Yes, I know all that. What does it have to do with eating disorders?”
When people were at last able to perceive what had always been there--the problem of eating disorders--a crescendo of voices called for help. Poorly understood, eating disorders appeared to be yet another addiction, with many features reminding people of alcoholism. At a time when these problems seemed mysterious and inexplicable, the recovery model of A.A. was readily perceived as the most hopeful. It was such a natural and obvious development. Many professionals were helplessly ineffectual or simply blind to the problem. Victims, beginning to come out of the closet, felt hopeless. It was much the same as 1935. The philosophical transfer was made--but with a serious and unforeseen flaw. The word “food” was substituted for “alcohol” in the twelve steps of A.A.--with food being seen as another addictive substance taking control of its victims’ lives.
The A.A. model is brilliant. The structure and organization has been successfully applied to a wide variety of human difficulties, such as those experienced by adult children of alcoholics, codependents, gamblers, and many others. The potential application to eating disorders is clearly there--but with some change needed.
Today there are a wide variety of food focused programs and support groups for “food addicts.” Transplantation of the A.A. model has meant that powerlessness over alcohol has been translated as powerlessness over food. Legions have embraced the idea of their food and weight problem as food addiction and a “disease for life.” Support groups have struggled to help one another suppress their urges for between meal snacks and binge foods. Many people have concluded that they are “sugarholics” and that sugar makes them crazy. Othes call in their food lists daily to their “food sponsor” or turn to their “Higher Power” in order to bestow upon them greater control over food.
Just as alcoholics struggle for abstinence from alcohol, millions struggle for abstinence from snacking, sugar, carbohydrates, and overeating--and become more deeply mired in their eating DIS-EASE. The more they heroically suppress now, the more they will obsess later—over-control leading to out of control. Adding insult to injury, they are taught that character defects underlie their lack of control. Keep in mind that eating disordered women are different than hardened, predominately male alcoholics of 1939. There is no shortage of humility, guilt, or and eagerness to see themselves as totally defective.
Can an understanding of alcoholism provide insights into eating disorders? Can that same understanding engender a therapeutic wild goose chase? I will have to answer each question with an emphatic “YES!” Great successes as well as dismal failures have flowed from the same alcoholism treatment truths. How is that possible?
The last thing anorexics, bulimics, and compulsive eaters need are more rules about food. They already have those. In fact, rigid food rules and the resulting stress and guilt are essential for developing an eating disorder. Food is not the problem. Abstinence from food is simply the wrong treatment for the wrong problem.
Alcoholics are physically, mentally, and chemically addicted to alcohol. Their “disease” is progressive and lifelong. Forever recovering, never recovered, their disease can be arrested--never cured. Alcoholics Anonymous is based on these principles. It has had unquestionable success. In a well meant attempt to help those afflicted by eating disorders, the same philosophy has been religiously employed, almost without change, by groups such as Overeaters Anonymous, founded in 1960. Therein lies the problem, a problem based upon a fundamental difference. Food and alcohol are very different.
If alcoholics are addicted to alcohol, what then are those with eating disorders addicted to? Is it sugar? Refined carbohydrates? If so, must one maintain strict abstinence from these substances? Can one be a “foodaholic?” Is it a lifelong problem? Is recovery possible? Many have misread valuable lessons from alcoholism treatment to conclude that he answer is "yes" to the above questions.
These beliefs are crucial. If these beliefs are tenaciously held, one must act as if they are so. They become an all-pervasive self-fulfilling prophecy. Phobic avoidance of sugar and guilt over eating “bad” foods becomes an overwhelming obsession that precludes real solutions to real problems. A belief that one has a disease for life heaps despair on those who already feel hopeless. New food rules elevate anxiety to panic for those already inundated by countless rules and oceans of guilt. A belief in one’s “failure” with food reinforces low self-worth and engenders further loss of control.
The O.A. premise that bulimics are “sick people” suffering from a “progressive illness which cannot be cured but . . . can be arrested” is anything but encouraging (O.A., 1979). We know clearly that anorexics, bulimics, and compulsive eaters can be treated successfully. Our files are full of success stories. Our staff members will readily talk of their own successes. To tell people they are incurable without any concern for research-based reality is a terrible thing. To teach despair as part of a treatment approach is reprehensible.
Then there is denial. Denial for an alcoholic takes the form of, “I do not have a problem with alcohol. I drink because I have problems.” Eating disordered people are overly focused on their food problem. Denial for one with an eating disorder takes the form of, “My only problem is that I cannot control my food and weight. Everything would be fine if I had more control.” With all the similarities, there are vitally important differences.
To a nonscientific observer, an eating disorder only seems like an addiction to food. Food can serve as an all purpose emotional pain killer. It can fill a void, seem as nurturing as mother-love, provide distraction from loneliness, as well as foster a sense of security. Food can be used to stuff down anger. It can reduce an awareness of unmet needs and distract from issues that seem overwhelming and irresolvable. As with other addictions, temporary gratification is followed by greater pain. For clients with eating disorders, fear of weight gain and rejection from others leads to added stress, food obsessions, purging behavior, and renewed bingeing. An addiction? Yes, but not to food.
A focus on abstinence from certain foods totally misses the point. Food and weight issues are smokescreen concerns. The real underlying issues have more to do with powerlessness, identity, self-esteem, rage, lack of assertiveness, and the stress of unmet needs.
This obsession provides the illusion of control. “If I can just lose ten pounds, everything will be okay” is the rationalization of an individual with an eating disorder. A list of foods to avoid serves only to enable the eating disordered person in her need for a counterfeit problem. Her belief that certain foods are wrong and that she is wrong for eating them is basic to her disorder. If food is her only way of coping and nurturing herself, telling her that she must give up certain foods generates enormous stress and an explosive condition. Restraint is a setup for a binge. Restraint plus pent-up needs operate like Mt. St. Helens. Regular breakdown of control and a desperate consumption of forbidden foods is inevitable.
How about a fresh perspective? Far from being a food addiction, many eating disordered people are hooked on control and food restriction --with binge eating as a periodic breakdown of their dependency on severely limited food intake as a way of feeling okay.
“Anorexic” hours or days are experienced as "highs," while bulimic attacks are viewed as disintegration of will power and marked by depression and self-hatred. If bulimics, anorexics, and compulsive eaters are like addicts, their addiction is for extreme self-control of weight and appearance. Changing the shape of their bodies is a desperate attempt to change the shape of their lives. Their greatest terror is losing that control. A focus on abstinence from binge eating directly feeds into and supports eating disordered thinking. Teaching controlled eating is analogous to teaching an alcoholic controlled drinking--a contradiction that usually escapes attention.
An alcoholic must learn to live WITHOUT alcohol. An eating disordered person must learn to live WITH food while tackling real problems. Paradox: her best defense against bingeing is learning to eat without guilt, learning to eat mindfully while thoroughly enjoying what she eats.
Food is not the problem. Food nourishes the body and should be enjoyed. It is guilt and fear over food that is crippling. It is a smokescreen for real problems--often a case of needing the problem more than the solution. Food has become symbolic for needs and feelings not seen as legitimate. Food, in turn, has become something to which people are not entitled. They feel wrong for eating in much the same way they feel wrong for being. To break out of this trap, they need to strongly and honestly believe two things: 1). They may eat whatever they choose to eat and enjoy it without ever having to feel fearful or guilty. 2). They can learn to act directly on their needs and feelings without ever having to feel wrong or unentitled.
The first point is paradoxical. If a person no longer has to restrain herself from eating, it becomes much less important to have “forbidden foods.” Getting rid of guilt over food means the stress of eating “wrong” foods ceases to be a trigger for compulsive eating -- and an obsessional focus on "bad" foods goes away.
This is extremely difficult. If an individual believes her only problem is addiction to certain foods, it becomes a self-fulfilling prophecy. A person who believes sugar makes her crazy, must act as if it is so. The more an individual restrains, the more she will obsess and feel out of control and guilty. The more freedom from guilt and self-condemnation is experienced, the less important food becomes. This is especially the case when a person is able to meet needs in a wide variety of nonfood ways without guilt and fear.
Abstinence is an important concept. Abstaining from food, however, leads nowhere except to an intensification of distress and reinforcement of beliefs in a mythical problem. From what then should an individual abstain?
For the millions of eating disordered (mostly women), relevant abstinence might be abstaining from the following:
2. Missing meals, fasting, starvation, dieting
4. Guilt and self-punishment
6. Denial of needs and feelings
7. Refusal to take responsibility for recovery
8. All forms of extreme self-control and refusal to accept “human qualities”
Overeaters Anonymous seems to be moving beyond food abstinence. O.A. literature now proclaims that “O.A. is not a diet club”--a big step beyond the “Graysheet” days of rigid food rules and dogmatic instruction on how members were to eat. Still, there is much variation between meetings. Some clearly have a spirit of recovery with solid guidance. Other meetings seem infused by a diet, weight, and food emphasis. Such a focus may leave members practicing their “disease” to perfection. Sponsorship can be either co-addiction (food focused) or open, accepting, and facilitating growth. It remains to be seen how fast the organization will resolve internal controversy and achieve a uniform direction. Caring is curative. Caring along with good information works wonders.
Abstinence from compulsive restraint, phobic and guilt ridden avoidance of taboo foods, and all forms or purging behavior is the key to overcoming “powerlessness” over food. Such abstinence can only be achieved gradually, as one is empowered to deal with life from a position of confidence, strength, and optimism. Thus, the compulsion is weakened and finally broken. Food ceases to be a source of preoccupation, shame, and fear.
We suffer not from our vices or our weaknesses, but from our illusions. We are haunted, not by reality, but by those images we have out in place of reality.
-Daniel J. Boorstin
Insights from alcoholism recovery can be invaluable. Breaking through denial, recognizing the problem, and making the commitment to recover are necessary first steps. Group support is essential. Recovery takes place best with people who are similarly involved with recovery. “One day at a time” and “Easy does it” along with the Serenity Prayer convey a highly evolved philosophy. Such thinking is as useful with eating disorders as with alcoholism treatment.
Teaching alcoholism treatment professionals about eating disorders has been highly rewarding. There is great transfer of learning and rapid skill development. A clear understanding of the different as well as similar needs of the eating disordered client is imperative. Understanding similarities and disparities between eating disorders and other addictions is the difference between “enabling” and providing the tools for recovery.
To be nobody but myself, in a world which is doing its best night and day to make me everyone else, means to fight the hardest battle which any human being can fight and never stop fighting.