Clarity on anorexia nervosa: from childhood through motherhood
Jessica turned 38 years old on the day that her story was posted on The Diary Healer. After reading her insightful account and seeing the photo of her carefully cradling her newborn child, flanked by her two daughters, I asked myself, “Is this the same person you treated for restrictive anorexia nervosa a quarter-century ago? The scared little girl who did everything that she could to avoid gaining weight, while also doing everything to be The Best Little Girl in the World?” Because I have kept in touch with Jessica over the years, I know that this IS the same person…only better. MUCH better. OUTSTANDING!
Jessica noted, “My anorexic chapter didn’t happen overnight, it evolved along with me while I evolved.” A powerful statement in many ways. It was a chapter in her life—she did not allow it to define who she was to become as an adult. It took time to develop—and time to get better. It evolved as she evolved—from girl to woman. As is true for many girls who develop anorexia nervosa, by 10 years of age Jessica was “questioning” the size of her body referencing both what she saw in the mirror and how it felt to her. By 12 years old, she equated food and appearance. Those early experiences are called “embodiment”.
“Am I normal?”
As was true for Jessica, it is common, especially regarding pubertal changes in adolescents, to question, “Am I normal?” And, like Jessica, not mentioning this doubt to others is common because “someone may think I was crazy.” Since adolescents tend to compare themselves with their peers, I teach health care providers the value of reassuring both females and males about normal pubertal changes, although they may be earlier-or-later, faster-or-slower, more-or-less noticeable than their peers. I also note that for females, in contrast to males, evidence of puberty (breasts developing, hips widening, getting taller) occurs earlier and more visibly, and self-esteem tends to fall—often dramatically—in early teenage years. This may account, in part, for anorexia nervosa being more common among teenage females.
Jessica did not decide one day to get anorexia nervosa. It is neither a “choice” nor a “lifestyle” as proposed in the “pro-anorexia” book that she mentioned. Her story shows that it’s often a matter of “won’t power” as well as “will power”. For Jessica, early on, the anorexia helped her to cope with issues related to development between childhood and adulthood. For more than 90 per cent of affected people, symptoms of anorexia nervosa first emerge between age 12 and 20—adolescence and young adulthood. However, as symptoms persist, the more normal growth and development can be arrested and symptoms of anxiety, depression and obsessive-compulsive traits emerge and become ingrained, as occurred for Jessica.
Behind the fear of being misunderstood
Jessica eloquently discussed her “lack of voice” and self-imposed silence. Both her inner voice and internal emotions were “sacred”. She felt vulnerable sharing those because of possibly being misunderstood or judged to be “crazy”. Carol Gilligan wrote the book In A Different Voice: Psychological Theory and Women’s Development, in which she explored issues related to the “inner voice” for girls that gives insight into silencing oneself. Later, in Making Connections: The Relational World of Girls at Emma Willard School, she explored how adolescent girls need to connect with their true self, as well as with others, and how disconnections or misconnections or lack of connections can be serious problems.
Earlier theories of development of adolescent autonomy assumed that both males and females moved from childhood dependence to independence in adulthood. However, based on her research focused on adolescent girls, Gilligan proposed that becoming independent as an adult can be associated with feeling alone, isolated, cut-off. On the other hand, interdependencepromotes growth through validating and mutual relationships. In that context there is a huge difference between a girl looking forward to being interdependent, “on her own” vs fearing being independent, “all alone” as an adult.
Jessica detailed her “rules” related to eating and exercise: doing whatever she could to avoid weight gain while appearing to gain weight, even when in the hospital. If she broke any of the eating disorder rules, there were consequences, such as needing to run up-and-down the 120 steps from the cottage to the lake shore. Although Jessica did not describe her struggle as “political”, in 1986 Catherine Steiner Adair wrote The Body Politic: Normal Female Adolescent Development and the Development of Eating Disorders linking anorexia nervosa emerging with the physical changes of puberty. She proposed that demonstrating control over one’s body with anorexia nervosa as a “political” statement—regarding how a girl can “govern” her body. More recently, she wrote A New Body Politic: Learning to Like the Way We Look, recommending that adolescent girls avoid striving for some unrealistic media-generated body ideal, and demonstrate more healthy and authentic control by liking one’s appearance.
Dismantling the self-imposed rules
For both females and males with anorexia nervosa, self-imposed rules are often black-and-white, absolute, non-negotiable, and incredibly detailed. As explained by Jessica, they tend to be held “in private” and are rarely expressed openly. However, once expressed they can be the focus of treatment. I facilitated group discussions among hospitalized patients that were very helpful. Once individuals realized that their “private” thoughts and rules were also held by others and neither unique nor private, they were able to begin to consider other, non-eating disordered ways of thinking and behaving.
With respect to rules, once patients acknowledge that they have an eating disorder that governs their life, I have found Jenni Schaefer’s self-discovery books to be useful in helping them consider different ways of thinking and behaving. Central to her process of recovery was to assign her eating disorder a name—validating that she had an eating disorder. However, she wanted a life beyond it, and to emphasize that she did not want it to define her, she named it Eating Disorder, with the nickname ED. To clearly identify that to recover from an eating disorder, she needed to consider living without it, so her first book was Life without ED. This was followed by a book about replacing ED with something better, something authentic, detailed in Goodbye ED, Hello ME.
A common misconception that only females develop anorexia nervosa can make both diagnosis and treatment difficult for males. Our comprehensive eating disorder program in Rochester is grounded in relational-cultural theory that supports adolescent females and males both developing validating, mutual relationships. In her recent book Deep Secrets: Boys’ Friendships and the Crisis of Connection, developmental psychologist Niobe Way notes that boys also benefit from interdependent connections. Though not focused on eating disorders, her message is clear: adolescent boys striving for independence may miss out on potential growth-promoting mutuality found in interdependent relationships. Jessica is clearly invested in working on interdependence in her ongoing emotionally focused therapy (EFT).
Three essential facts for recovery
I agree with all 11 points that Jessica makes and conclude by highlighting three essential factors for recovery:
- a) Stop blaming yourself or anyone else (#1)—also stop trying to figure out what caused the eating disorder to develop. In the end, that also focuses on blame, fault, guilt. In 41-plus years of treating thousands of patients, I have never found it helpful to discuss blame, fault or guilt. LET IT GO!
- b) Listen(#3)—a founding member of our Rochester Eating Disorder Support Network was a father with five daughters, three of whom developed anorexia nervosa. His advice to every parent who participated in this group was, “When my third daughter was diagnosed with anorexia nervosa, I finally realized that God gave me two ears and one mouth, so I listen twice as much as I talk.” Listening is not merely being quiet, not talking. It requires actively giving your undivided attention to what and how a person is sharing information.
- c) Breathe (#5)—which is also a focus in mindfulness (#9), to stay in the present. When we start thinking about the past (which we cannot change) or the future (which we also cannot change) we often focus on bad things and may start to get anxious. When we get anxious, our breath becomes more rapid and shallow. Mindfulness is about staying in the present—the only time when we can change anything. And one of the central features of mindfulness is focusing on each breath, in-and-out….
Like many of my other patients who have made remarkable strides in recovery from having had anorexia nervosa as an adolescent, I am in awe of the amazing person, woman, wife and mother that Jessica has become. In many ways, I believe that having recovered from her eating disorder has made her stronger than if she had sailed through adolescence without engaging in the hard work of redefining herself. To anyone who is presently struggling with anorexia nervosa, I believe that Jessica’s story can be a source of hope and strength. Don’t give up. You are worth fighting for….
Carol Gilligan. In a Different Voice: Psychological Theory and Women’s Development. Harvard University Press. 1982
Carol Gilligan, Nona P. Lyons and Trudy J. Hanmer (Eds). Making Connections: The Relational Worlds of Adolescent Girls at Emma Willard School. Harvard University Press. 1990.
Jenni Schaefer, Thom Rutledge. Life Without Ed: How One Woman Declared Independence from Her Eating Disorder and How You Can Too. McGraw Hill. 2003. Goodbye Ed, Hello Me: Recover from Your Eating Disorder and Fall in Love with Life. McGraw Hill. 2009.
Niobe Way. Deep Secrets: Boys’ Friendships and the Crisis of Connection. Harvard University Press. 2013