GAINING:
The Truth About Life
After Eating Disorders

Essays, Articles, & Nonfiction Works
by Aimee Liu

RESOURCES
These treatment facilities offer specialized programs for eating disorders, including men and women over age 21.
Discover the many ways others are using their voices, talents, and passions to turn suffering into creativity and hope.
Links to websites and organizations that provide information and referrals.
References cited in GAINING
Books
How do anorexia and bulimia impact life AFTER recovery? GAINING is one of the first books about eating disorders to connect the latest scientific insights to the personal truth of life before, during, and especially after anorexia and bulimia.
"I've read countless books about eating disorders, but I've never seen one like this. Combining the professional wisdom of leading experts with personal experiences from women and men all over the globe, this book fills a gap on the recovery bookshelf. Anyone who has been touched by an eating disorder needs to read this."—Jenni Schaefer, author of Life without Ed
America's first memoir of anorexia, and one of the earliest books about eating disorders, originally published in 1979

Newsletter

Back to life with ChickSpeak!

August 20, 2007

Monday, August 20, 2007

Dear Friends,
I must apologize for being off-line this past month. After a long and active life my 95-year-old father died two weeks ago, and I was back in Connecticut to be with him at the time and to help my mother afterwards. To watch cancer whittle a strong and capable man down to anorexic proportions is a sobering experience, especially for someone who has intentionally starved herself to those proportions. Such wasting serves as a grave reminder of how eating disorders, too, waste life.

On a lighter note, I was recently contacted by the brilliant new website www.ChickSpeak.com to answer a set of interview questions posed by ChickSpeak readers. I’m pleased to be able to post the resulting interview for you below.

These were challenging questions! Some of them pressed for insight that goes beyond my expertise. Rather than attempting to answer them “perfectly” on my own, I decided to admit my limitations and call for professional advice. (In other words, I used this occasion to practice what I preach in Gaining: when you need help, don’t be ashamed to seek it!) I turned to Judith Banker, president-elect of the Academy for Eating Disorders, who generously gave these questions her full attention. (For information about the AED, go to www.aedweb.org .) Because Judith’s responses are so full of important information, I didn’t want to paraphrase her, but included her answers uncut (marked by JB) alongside my own (marked AL). Bear in mind that Judith is the professional – she founded and directs the Center for Eating Disorders in Ann Arbor, Michigan (www.center4ed.org ). My own answers reflect only what I have learned as a survivor and student of eating disorders, and from the feedback I’ve received from readers of Gaining.

I wish you health and peace and love.
Thrive!

--Aimee

CHICKSPEAK.COM
Q&A WITH AIMEE LIU & JUDITH BANKER

1. Based on your knowledge, what does the medical community know now about the effective treatment of eating disorders that they didn't know at the
time of your turning point?

AL: The entire scientific profile of eating disorders has been transformed by the research findings of the past twenty years. When I was in the grip of anorexia in the 1960s and early ‘70s, treatment was reserved for those who were in imminent mortal danger, and that treatment consisted almost exclusively of hospitalization and forced refeeding. Bulimia wasn’t even named yet! Doctors, families, and counselors alike mostly assumed that people with eating disorders were just very stubborn, and that if they chose to cooperate and stopped being “difficult” they could get well on their own. Recovery was defined almost exclusively in terms of weight gain and nutrition. Unfortunately, most of the general public still maintains these outdated notions. They do not understand that eating disorders represent serious psychological illnesses and that fasting, bingeing, and purging behavior are expressions of some combination of depression, anxiety, trauma, genetics, and biochemistry. The medical community is beginning to understand this, however, and changes in treatment have resulted as Judith details below.

JB: There is a greater appreciation now for the physiological influences and the psychological traits that serve as risk factors for the development of eating disorders. New areas of eating disorder research, such as genetics and neurobiology, have led to breakthroughs in our understanding of these illnesses. Genetic research shows that personality traits, such as the tendency to be anxious and depressed, predispose an individual to developing anorexia and that the role of heritabililty is quite strong (at least 50%) in anorexia nervosa. Neuroimaging research provides a window in to the brain processes involved in body image disorders.

Advances in psychopharmacological research have given the medical community a better understanding of how to use antidepressants and other medications in treating people with eating disorders. And the evolution of an integrated team treatment approach in the acute care of anorexia has helped to significantly reduce the mortality rate. Psychotherapy research has shown Cognitive Behavioral Therapy is effective in the treatment of bulimia and that manual-based family therapy (the Maudsley Method) is a promising new treatment for children and adolescents with eating disorders.

Research on all these fronts has provided important new information that has improved eating disorder treatment and prevention over the last 20 years.. But there is much more we need to learn about the causes and treatments of eating disorders. Unfortunately, the funding for eating disorder research is inadequate.
Advocacy groups throughout the U.S. are working hard to educate legislators and funding agencies about the seriousness of eating disorders so funding dollars can be directed to support further eating disorder research.


2. At the beginning of Gaining, you encourage anyone suffering from an ED to seek professional help. What would you suggest that someone do if he or she can't afford treatment? Even with health insurance, programs I've found still cost more than what I can possibly pay. I want help, but don't think
I can get it.

AL: This is a difficult question, as many treatment programs are intimidatingly expensive. But I have found professionals in this field to be generous and caring, and I would urge you to contact those that seem right for you, regardless of cost, and see what provisions they have for aid or referral. You can begin your research on the web at The Eating Disorder Referral and Information Center (www.edreferral.com). I have listed additional sites and resources on my new website www.gainingthetruth.com. Below, Judith offers more extensive and specific advice.

JB: Inadequate health insurance coverage for the treatment of eating disorders is frequently an obstacle for many individuals and their families to getting the help they need. There is an active health care advocacy movement within the eating disorder community that seeks to bring eating disorders the same health care coverage as other major medical illnesses.

Many individual practitioners and outpatient programs will offer sliding fee scales. Some university settings offer affordable treatment with graduate student interns or through student health services. Some university-based programs conduct research trials which provide free treatment in exchange for participation in a research project. The best advice I can offer is not to give up. The resource network for eating disorder treatment is vast. Keep searching and making contacts. Ask friends and family to search too. Affordable treatment is often available—but it can take an extensive hunt to find it.


3. My roommate has an eating disorder. I think she's bulimic, but I'm not
sure. She also makes negative comments about herself and her body
constantly, to the point that I just want to stay away from her sometimes
because I can feel it wearing me down. I don't know what to do to help her
and don't want to make my living situation any more uncomfortable. What
should I do?

AL: I’m asked similar questions all the time by concerned friends and family members. A close friend of mine recently arranged an intervention by the dean of students when her friend – a male – developed exercise anorexia. Another teamed up with her father to get her sister out of school and into treatment. I mention these examples in order to persuade you that you should not shoulder this problem alone. Do confront your roommate, but make sure you express your concerns for her rather than accusing her. Encourage her to consult your campus counselor, student health services, or dean’s office. If she denies the problem, consult them yourself. Enlist other mutual friends who care for her to show that they do care, not about how she looks but about how she feels and about the distress that underlies her self-punishment. Isolation fuels eating disorders, and social support is vital in fighting them. But make sure you have plenty of support for yourself, too. It won’t help you or her to “go it alone.” Read on for Judith’s astute advice…

JB: This is a difficult situation but, unfortunately, not uncommon. Negative body image and disordered eating behaviors and attitudes can be contagious, particularly in schools, sororities, dormitories, and other environments where girls and women spend extended periods of time in close contact. These environments literally become toxic. Your roommate’s negative comments about herself and her body are damaging to both of you so I understand and support your desire to do something about the situation.

It is important that you talk with your roommate about your concern for her and about how her comments and behavior are affecting you. There are some steps to take before you have this conversation however. First, decide what it is you hope to accomplish by talking with your roommate. For example: Do you want her to seek treatment? Do you want her to stop the self-critical remarks? Do you want her to agree to talk with a resident director with you to resolve the issues you are having? Next, be honest with her about your concern for her and about how you are affected by her actions. Be compassionate but clear about what you feel and what you would like to have happen.

This conversation may simply be a first step. Confronting a friend about such a serious subject can be difficult. Just remember a satisfactory resolution can take time. Don’t hesitate to seek support for yourself. Talk to your parents, or consult a counselor at your school or an eating disorder treatment specialist to help you navigate this situation.


4. You say that the first step to recovery is to admit that you have a problem. This is in line with recovery programs such as Alcoholics Anonymous and Over eaters Anonymous. I've read recently that people with bulimia can benefit from following the OA program. Do you think there is any merit to this?

AL: Twelve-step programs can provide positive support and do encourage self-transcendence, an important element of recovery. I’ve met many people who have benefited from OA while battling compulsive or binge eating or bulimia. However, many others have told me that these programs can do more harm than good, depending on the composition of the group and one’s own specific circumstances. If you are underweight, for instance, it can be extremely triggering to enter a group that is mostly overweight. Even when the group is all struggling with the same problem, such as bingeing and purging, the exchange of experiences and “methods” can be triggering. Some people report that they actually learn how to binge and purge “better” in 12-step groups! Except for those held within hospitals or organized treatment programs, these groups generally are unsupervised and so are only as helpful as the individuals who attend.

JB: Substance use disorders (SUD) are more strongly associated with bulimia nervosa than anorexia nervosa but the complex nature of the neurobiological factors underlying bulimia nervosa and substance use is not known. Therefore, the question as to whether or not bulimia is an addiction process has not been answered. That being said, programs that treat eating disorders and accompanying SUDs commonly incorporate Alcoholics Anonymous meetings. For someone in recovery from bulimia who has an accompanying SUD, the familiarity of the 12-step model and the ready availability of OA groups in most communities can provide an important source of ongoing support.


5. I have a history of eating disorders, and even when I'm healthy, am still- to a degree- afraid and anxious about food. I think I can handle my health, but am concerned that I might pass eating issues along to my children one day. What things can I do or keep in mind regarding a future family? Also, you write that eating disorders have a genetic componant. Does that mean that my future children are destined for an uphill battle?

AL: Recognizing this possibility and caring enough to stop the cycle before it affects your children is the first key to prevention, so good for you for asking this question! For yourself and for your children’s sake, I urge you to shift your focus consciously from fear to love. Ask not what you’re afraid to eat but what you love to eat – and what you love to do and try and explore in life generally. Focus on sharing these passions with your children, and take the stress off your fear of passing on your fears. Be mindful of all the pleasures that accompany mealtimes, food, shopping, and cooking, and consciously make MORE of those pleasures. Have fun with food yourself, and over time, your pleasure will overtake your anxieties around food, and you will naturally teach your children that healthy eating is a joy and a privilege as well as a vital necessity.

As for your children’s innate vulnerability, remember that genes are not destiny and that every child is different. If you notice that your child from an early age is finicky, needs rules and order, worries about making mistakes or not being “good enough,” then you’ll know this child has a heightened risk for eating disorders and needs your help to learn how to relax, have fun, make solid friends, and feel safe even when taking risks. But you also need to let your child make mistakes as she grows up and establishes her own identity apart from you. One of the best ways you can protect her is by encouraging her to think for herself, make her own well considered choices, and learn from her inevitable failures. Show compassionate support without passing judgment, and she’ll learn to treat her body and herself with similar compassion.

JB: Recent genetic research indicates that anorexia nervosa is moderately heritable and that the tendency to be anxious and depressed, an inherited personality trait, is a significant factor associated with the development of anorexia. What does this mean for you and your future children? Learning ways to manage worries, anxiety, and depressed mood will help to protect you against relapse and will also help you teach your future children how to effectively work with their emotions.

Remember that recovery is an ongoing process. Our culture continues to bombard us with messages that generate fear and anxiety about food and weight. We each must practice pro-active measures to protect ourselves from internalizing these messages. The ways to do this are myriad. Yoga and meditation, relaxation techniques, incorporating play and outside activities in to our daily lives, and building strong community and social supports are valuable ways to counteract general anxiety and depression.

Continue to gently challenge your ongoing food fears and anxieties. Don’t let yourself become complacent. Try new foods regularly. Experiment. You will see that many of your fears are simply superstitions that are leftover from your eating disorder.

Learning to work with your own anxious or depressive personality traits and your own food fears will help you parent your future children in ways that will protect them from developing eating disorders.


6. Aimee wrote in Gaining:
*It was a struggle not to pull back into the safety of my obsession with
food and weight, where no one could see how I felt. It was frightening and
humiliating to give up my established identity as a fragile waif when I
had no idea what identity would take its place. But I sensed I needed to
experiment.*

*"I think these girls are quite delayed," Harvard psychiatrist David
Herzog agreed when I asked him about the emotional immaturity that so often is part of anorexia. "They've never been given the opportunity to experiment." *

How does one create a sense of urgency about creating a new identity and a
need to experiment? How do you face the fear and begin to let go of the life that is really keeping you from living? And is there a way to hasten the onset of emotional maturity?

AL: Patience and compassion are key. Hope, rather than urgency, is what drives recovery, and hope is all around us if we just pay attention, but it may come at first in mere glimmers – a friend’s caring smile, the love of a pet, the thrill of music sung by a chorus, or the beauty of sunshine on water. Emotional maturity is the result of countless daily encounters and appreciations such as these. The best way to hasten this process is to pay attention and cultivate mindfulness so that you notice what gives you hope, what engages you, what makes you feel as if you care and, through caring, that you matter.
I believe that a sense of purpose is essential to the formation of a healthy identity. By this I mean the sense of purpose that is gained by creating, giving, or working for the benefit of other living things. Eating disorders isolate and starve us of this sense of purpose, so it’s unrealistic to think that someone struggling with anorexia will, overnight, recover and save the world. But we don’t have to save the whole world to feel that we have purpose! Nor do we have to “recover” overnight. Showing kindness and compassion to one person, or dog, or plant is the first step in creating a larger, more mature identity. With each new demonstration of compassion to others, our ability to treat ourselves with kindness also grows and so does our sense of healthy purpose in the world.

JB: What an excellent question! It opens up a very complex aspect of recovery.
When you are recovering from an eating disorder the maturation process will occur at its own natural pace. Learning to trust that pace, not hurrying or pressuring yourself to grow up quickly, is part of becoming who you really are. However it is critical to have the guidance of a trusted therapist to help facilitate the process as it is easy to get stuck or discouraged. People often are afraid they will never catch up to their peers, however, many aspects of your self continue to grow despite the stunting influence of the eating disorder. Recovery is not about catching up to your peers---it is about opening up to and integrating the undeveloped aspects of your self with the parts of your self that are higher functioning and mature.

The eating disorder thought system can confuse you along the way by triggering self-criticism, shame, guilt, or other negative emotions, when you touch on your genuine identity. The support and guidance of your therapist can help you avoid getting derailed by these reactions and experiences.

Each time you sit with your feelings, each time you allow yourself to recognize and identify your own thoughts, reactions, needs, expectations, and desires you are growing and strengthening your true identity. With enough support, this opening up to your self can become self-perpetuating---that is, each time you connect to your authentic self it sets you up to do it again. Learning to recognize when you are experiencing your real self, learning to trust your real self, and learning to let go of the ways you have learned to disconnect from your real self is a complicated, dynamic journey. If you have the safeguards of emotional support and expert guidance the pace of your growth will take care of itself.


7. It seems like one might describe some of those suffering from eating
disorders as experiencing a poverty of self-worth, a low sense of deservedness despite often high achievements that signal otherwise. How can a sense of deservedness be cultivated? Where does one start?

AL: Below, Judith explains how low self worth develops and offers some excellent strategies for reversing this conditioned pattern. I’d like to add that the reversal begins by training yourself to challenge all judgmental language. What do words like bad, fat, stupid, ugly, or for that matter, perfect, really mean, anyway? These are not objective or true assessments but labels used to compare and criticize that get branded into our psyches. We may not be able completely to erase them or the damage they do to us, but with practice we can teach ourselves to notice when and how we use them – and how often they are uncalled for. Then we can practice replacing these terms with others that are more accurate and constructive. Instead of berating ourselves for feeling “fat,” for example, we can look deeper at what we’re really feeling, which may be angry or hurt or lonely (fat, after all, is not a feeling) and take concrete action to deal with the true source of distress. Seeking out supportive friends, confronting the real source of unhappiness, cultivating activities that reduce stress and combat depression are all ways we can actively boost self-esteem.

JB: The answer to this question relates to your earlier question about developing a sense of identity. When we are infants there is no gap between our experience of need and the expression of that need. As infants we didn’t question whether or not we deserved to be held, fed, or have diapers changed. We didn’t judge ourselves as needing “too much.” Over time our self expression gets shaped by the response of our environment. If our caregivers respond haphazardly or punitively to our expression of need we learn that our needs are not important or, even worse, that they are bad or wrong.

You can start to cultivate a sense of self-worth by learning to recognize what a genuine expression of your real self feels like. Practice listening to your own needs, thoughts, and feelings without judgment or self-criticism. Sometimes when you first start to do this, these expressions of your self will come through very quietly or subtly. You have to listen very closely. Writing these “self expressions” in a journal can be helpful. The next step is to gradually learn to identify ways to respond in attunement to your needs and feelings. By developing a responsive relationship with your self, by taking your own needs, experience, thoughts, and feelings seriously your sense of self-confidence, self-worth, and deservedness will grow.


8. What advice would you offer someone who seems to succeed in residential programs but does not know how to transfer those skills over to regular life, with its stresses and busyness… and emotional undulations that the eating disordered individual feels ill-equipped to engage in a healthy manner?

AL: This is an area that is beginning to receive long overdue attention. Cindy Bitter, one of the women I interviewed for Gaining, works as a life coach in Rochester, NY, mentoring women through this phase. Many treatment programs, as Judith mentions below, offer after-care programs to help patients transition back into daily life. I believe there will be more of these services as therapists and patients alike recognize that recovery really is a gradual process.
My advice is to allow for imperfection, occasional backslides, especially at first, and not catastrophize these slips. Instead, remember that the same skills that worked in treatment really will work out in the world, but they require ongoing practice and patience. There’s a good phrase I heard recently: practice does not make perfect, but eventually it does make permanent. What seems impossible today will, with practice, seem feasible next month and routine in a year or two. Speaking for myself, I will never be happy-go-lucky or completely free of those “emotional undulations” you mention, but by developing an arsenal of calming, soothing, gratifying practices I have learned to effectively manage these swings without resorting to self-destruction. Progress, not perfection, is the measure of success.

JB: The period of transition from the 24/7 support, camaraderie, and safety of a residential treatment program must be planned very carefully to avoid significant backsliding or complete relapse. It is common for people to underestimate the role the support of the residential community plays in their recovery. In these communities communication is honest and open, and support is easily available. In “regular life” these systems are not as reliable.

Whenever possible, take advantage of “step down” opportunities following residential treatment. There are day-treatment programs or intensive outpatient programs (IOPs) that provide graduated levels of support, allowing people to make a more gradual transition in to their everyday lives. If these formal services are not available, it is important to intensify your own outpatient services following discharge from residential treatment. Plan to meet more frequently with your individual therapist, physician, and nutritionist, attend a support group in your area, involve your family and friends in providing increased support for you during these critical weeks. This extra support will help you maintain the progress you made in residential treatment while you learn to cope more easily with the inevitable stresses and demands of your life.

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Anorexia's Red Herring

Too-skinny models may be a factor in spawning eating disorders, but they're just one of many.
By Aimee Liu

Published in the Los
Angeles Times,
September 22, 2006

THIS WEEK in Madrid, heroin chic was prohibited. For the first time, the organizers of a major international fashion show recognized that by showcasing emaciated models, the fashion industry promotes eating disorders. Under pressure from the Madrid government, medical associations and women's advocacy groups, the Assn. of Fashion Designers of Spain finally rejected morbidly thin models.

When selecting models for this year's Madrid fashion week, which ends today, the designers set a minimum body mass ratio (calculated on the basis of height and weight). Their required ratio was 18 — meaning a minimum of 119 pounds for a 5-foot, 8-inch woman. The bar was by no means high. For ordinary mortals, a ratio of 18.5 qualifies as underweight. Even so, five of the 68 auditioning models flunked.

To understand why they flunked, we need to look beyond the fashion industry to the true causes of eating disorders. These include genetic predisposition, temperament, family dynamics and personal trauma. I know; modeling fueled but did not cause my own adolescent eating disorder nearly 40 years ago.

Twiggy was my generation's Kate Moss. I fixated on her at age 13, and by the time I started modeling one year later, I'd dropped 30 pounds. Being skinny became my identity. At 5 feet, 7 inches, I didn't weigh more than 100 pounds again until I was 21.

My anorexia ultimately destroyed my career.

Models were — and still are — paid to make fashions look good, and that meant fitting sample wardrobes. Reigning teen cover girls Shelley Hack and Colleen Corby understood this. In dressing room lunches between shoots, I'd watch them wolf down tuna salad sandwiches while I pretended not to be hungry. They were lucky, I told myself, they could get away with eating. I began to lose jobs when I became so thin that stylists couldn't even pin dresses on me to look right. Still, I felt I couldn't eat.

Like many anorexic models, I was drawn to the fashion world because it reinforced my anorexia. I would be willing to bet that most, if not all, of the runway models disqualified in Madrid fit the same pattern — as do many emaciated gymnasts and ice skaters.

Three years ago, I began interviewing medical researchers as well as middle-age women and men with histories of anorexia and bulimia. I wanted to find out what we know now that we didn't know in the 1970s, when I quit my self-imposed hunger strike. I learned that researchers now are discovering genetic links between eating disorders, depression and obsessive-compulsive disorder. Genes also shape the temperaments of people who are prone to anorexia and bulimia, although the mechanisms for this are still poorly understood.

A landmark 2003 British study found that certain innate childhood traits, such as perfectionism, inflexibility and cautiousness, each increase an individual's risk for anorexia by a factor of seven. Someone like me, possessing all five traits measured in the study, is 35 times more likely to develop an eating disorder than a daredevil who happily wears mismatched socks.

Further, eating disorders are triggered not by pictures of Kate Moss but by sudden or cumulative experiences of intolerable emotion, such as shame or fear. Puberty unleashes a natural tidal wave of these emotions. Adolescence also happens to be the age when rates of sexual abuse soar, academic and social pressures intensify and parents become a source of embarrassment rather than solace. It makes sense that this is prime time for eating disorders. Obsession with weight offers a distraction. Extreme weight loss signals distress.

It also makes sense that rates of anorexia and bulimia spike in middle age, when many women again face emotional turmoil. Women over 30 now make up a full third of residential patients at the Renfrew Center, a Philadelphia treatment facility specializing in eating disorders. Divorce, grief, the empty nest — all can trigger illness if the individual possesses a genetic predisposition.

The onset of eating disorders is like the firing of a gun. Genetics form the gun. Cultural influences such as the fashion industry and familial attitudes about weight then load it. And intense emotional distress pulls the trigger.

Healthier figures on international catwalks may help to disarm the gun. However, of the more than 40 women I interviewed, only a handful had ever paid any attention to fashion. When they started starving, they were asking for help, not admiration. Those models who failed the test in Madrid need treatment, not rebuke.



Copyright 2006 Los Angeles Times