Recovery from Eating Disorders

A Guide for Clinicians and Their Clients

Greta Noordenbos

• Publisher: Wiley-Blackwell
• Year: 2013
• Print ISBN:
  9781118469194
  9781118469200
• Edition: 1
• eBook ISBN:
  9781118469187
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

With a uniquely perspective on the key factors in recovery from eating disorders, this practical guide for patients and clinicians draws from relevant, real-life case studies.

• Focuses on real-life recovery strategies that involve motivational factors, physical and psychological health, and issues such as self-esteem, body attitude, emotion regulation and social relationships.
• Draws on extensive qualitative research with more than 80 former sufferers
• Offers experience-based guidance for professionals assisting clients in their recovery process

1

Problems in the Period before the Eating Disorder

Introduction

To understand why recovery from an eating disorder is so difficult and takes so much time, it is important to understand how and why the eating disorder developed in the first place.

Eating disorders never come out of the blue; they are preceded by many problems and risk factors (Fairburn et al., 1997; Jacobi, de Zwaan, Hayward, Kraemer, & Agras, 2004; Stice, 2002; Striegel-Moore & Bulik, 2007). The risk factors can be divided into genetic and biological, psychological and socio­cultural factors. These factors make patients vulnerable to starting a diet and developing a disturbed eating pattern which can result in an eating disorder.

Many eating disorder patients have family members who have or have had an affective disorder such as depression, alcohol problems, drug ­addiction or an eating disorder (Keel, 2005). Although these genetic factors never predict the development of an eating disorder, they make the person more vulnerable than people without these risk factors.

The psychological risk factors mentioned most often by eating disorder patients are low self-esteem and negative self- and body-evaluation (Cervera et al., 2003; Noordenbos, 2007). Perfectionism and fear of failing in the eyes of others are also important risk factors for developing an eating disorder (Jacobi et al., 2004). Eating disorder patients set high standards for themselves and feel that they have failed when they do not achieve their goals. A major risk factor is having a negative body attitude and the fear of becoming overweight or fat. Negative comments about their body or being teased about their weight and appearance are important factors in the development of a negative body attitude. Sociocultural factors, such as the slimming ideal and dieting behaviour of mothers, sisters and friends or strict weight ­standards in ballet schools and in sports such as skating and athletics in which weight plays an important role (Levine & Smolak, 1998; Pinhas, Toner, Garfinkel, & Stuckless, 1999), can also contribute to these negative feelings.

Risk factors, however, are never predictors for eating disorders, but only increase vulnerability. Moreover, no single risk factor is in itself enough to develop an eating disorder; the more the risk factors, the greater the ­possibility of starting to diet in a culture where being slim is the ideal for the female body. What were the most important risk factors which preceded former patients’ eating disorder?

Lack of Self-Esteem and Negative Self-Evaluation

The psychological problems mentioned most often by eating disorder patients are lack of self-esteem and negative self-evaluation (Noordenbos, 2007). Because of their low self-esteem, they feel insecure about themselves and need support from others. In order to receive approval and support, they do their best to comply with the expectations of others. However, they are very insecure about their own opinions and find it difficult to express their own thoughts and feelings, as they want to avoid any criticism. They do their best not to be criticized by others, because they experience censure as rejection. This is clearly described in the following quote:

ANGELIQUE: ‘I was strongly dependent on the approval of others and tried to avoid any criticism or negative comments, because I was very afraid of not being accepted. When I got critical remarks from others I had the feeling that I was being completely rejected. In order to prevent other persons from having a negative opinion about me or criticizing me I always did my best to comply with their expectations.’

Compliant and Pleasing Behaviour

In the period before the development of an eating disorder, many patients are kind and obedient children who do their best at school and at home. However, at the root of this compliant behaviour is the fear of not being able to cope with the expectations of their parents and teachers. According to Bruch (1978), they do not feel that they may be who they are, and hence they try to comply with the image they think others have of them. When they try to comply, they receive approval and affirmation and feel accepted.

Pleasing behaviour is very often found in anorectic patients. The famous author Jane Fonda therefore labels anorexia nervosa as ‘the disease to please.’

Patients spend most of their time trying to discover what other persons expect from them because of their low self-esteem and need for support and acceptance. However, this prevents them from exploring their own feelings and opinions and expressing these to others. The following ­quotation from one of Bruch’s patients clearly shows how much she ­conformed to others:

I was sitting with these three people but I felt a terrible fragmentation of myself. There wasn’t a person inside at all. I tried with whoever I was with to reflect the image they had of me, to do what they expected me to do. There were three different people, I had to be a different person to each, and I had to balance that. It was the same when I was a child and had friends. It was always in response to what they wanted (Bruch, 1978, p. 49).

In the period before the eating disorder, patients often struggle with the ­following questions: What do other people think of me? Do they like me? How do I have to behave in order to be accepted? How can I prevent people from criticizing or rejecting me? In order to be accepted, they always try to adjust to the expectations of others, hiding their own feelings and opinions (Miller, 1981).

Hiding Real Thoughts and Opinions from others

Children who suffer from lack of self-esteem, insecurity and fear of failure often try to adapt to the expectations of their parents and teachers in order to be accepted. They are afraid to express their real feelings and opinions and hide them from others when they feel these views might be different from what others feel or think. They adjust to others as much as possible and feel valued for their pleasing behaviour. Much before the development of their eating disorder, they learn that their outward behaviour and appearance is important to gain approval from others, and they hide their inner insecurity and negative feelings as much as possible.

ANN: ‘When I was a teenager I always tried to hide my real inner feelings from others. By adjusting to the expectations of my parents and teachers I hoped to be accepted and valued. I always did my best at school and tried to be the perfect daughter. Unfortunately I did not realize that my pleasing behaviour did not bring me what I really longed for: attention and acceptance of my real self.’

Sensitivity to the Needs of others

Many patients told me that in the period before the development of their eating disorder, they were very sensitive to the needs and feelings of others. They were able to register subtle signals from their parents, especially ­signals of sorrow, disappointment, anger, depression, fear or stress.

This is clearly described by Hilde Bruch (1978): ‘They try to fulfil the needs of others as best they can and do their best to give no problems. This psychological worrying about their parents and especially their mothers makes that they feel obliged to help their mothers as much as possible and to be the sunshine in their home.’

However, being so sensitive to the expectations and needs of others often has a price: patients learn to neglect their own needs and feelings. They become experts in caring about others, but do not learn to express their own needs, hiding their problems from their parents. When one of their parents is unable to fulfil the emotional needs of the other parent, they try to ­compensate; but behind this adjusting and pleasing behaviour is a deep lack of self-esteem.

LINDA: ‘I remember clearly that during my puberty I worried much about my mother, who was very ill and finally died of cancer. I felt so much sorrow for her ongoing decline and her disappointment when the ­treatment was not ­successful. I also saw how my father suffered because of my mother’s cancer. I tried to fulfil their needs as much as possible and suppressed my own troubles and need for attention. I could not blame them for not spending enough ­attention on me. But I became more and more depressed and felt very lonely and empty with all my sad feelings, knowing that my mother would die of her cancer. For that reason I never dared to ask ­attention for my own emotions and show my feelings of ­disappointment, sorrow, or anger. I felt very alone, but I could not blame my parents because they had so many serious problems and were completely absorbed by their own feelings of sorrow.’

Patients with bulimia nervosa often say that they felt emotionally empty, because their parents never asked how they felt. In order to comfort themselves and to suppress their negative and sad feelings, they developed binges.

MARY: ‘As soon as I got feelings of distress I started to eat in order to avoid and suppress them. But even after a huge binge my feeling of hunger never went away and I never felt really satisfied. It felt as if there was a huge hole around my hearth and stomach. I was really longing for emotional comfort, and the only way I could comfort myself was by eating plenty of food.’

Perfectionism and Fear of Failure

In the period before the eating disorder, anorectic patients are often extreme perfectionists. They set very high standards for themselves and are never satisfied with their performances. They feel they are not good enough and always think they need to be better. At school, they try to please their ­parents and teachers by doing their best and aiming for the highest grades.

SUZAN: ‘at home I always wanted to be the most loved child, and in school I wanted to be the best student. I really needed to hear from my parents that I did my best and to be ^­valued for that, because I felt so insecure about myself. I was often afraid that I did something wrong and my parents would no longer love me. When I received a high grade in school I felt reassured for a short time, but always was afraid I would fail the next time, and my ­parents would be disappointed with my performances.’

Even when they always have high grades, patients often feel that this is not good enough.

NATASCHA: ‘When I made even the smallest mistake, there was always a ­critical voice in my head that said: “you did not do your best, ­everybody can see that you made mistakes and that you failed”.’

Inner Criticism and Negative Self-Evaluation

Eating disorder patients are often very critical about themselves. This ­self-criticism already starts in the period before they start to diet, but increases when they have developed an eating disorder. This inner criticism is described by several therapists, such as Bruch (1978), as an ‘inner dictator’; Claude-Pierre (1997) refers to this as an ‘inner negativist’ and Kortink (2008) labels it as an ‘inner saboteur.’

It is especially children who are very insecure about themselves who run the risk of developing this inner criticism and negative self-evaluation. They have a very strict superego and high standards and blame themselves for every mistake.

Some patients had parents who were very critical of them and expected high grades and excellent performances from their children. When they internalized this attitude of their parents, they learnt to look at themselves in a very critical way. They began to have unreasonable expectations from themselves and were never satisfied with their performances.

CAROL: ‘For my examinations I always did my best, because I knew that my grades were very important for my father. He pushed me to have an 8 or 9. I still can remember those times that I had a 7.5 for a very difficult examination. When I went home I felt very bad about myself: I already saw the disappointed face of my father and heard his voice: “Why a 7.5? Didn’t you study hard enough? You might have worked harder! You can get an 8 or even a 9”. After this kind of rebuke he would open his newspaper, leaving me alone with all my negative feelings. Even years later, when I lived on campus, I still heard my father’s voice ­criticizing me for not having done my best.’

Most eating disorder patients experience their inner critical thoughts as a result of their own high standards. In the severe stage of their eating disorder, however, they sometimes hear an inner negative voice in their head which has got out of their control (Bruch, 1978; Noordenbos, Boesenach, Moerman, & Trommelen, 2012; Tierney & Fox, 2010).

BEA: ‘In the period when I had severe anorexia nervosa I continually heard that critical voice in my head, always censuring me. It was as if I had the voice of an inner dictator in my head and after each small bit of food I heard the voice saying: “that was too much, you were not allowed to eat that, now you have to be punished, and you cannot have dinner, because you already ate too much today”. It was terrible to hear that voice all day long and it was utterly impossible to resist it. This inner critical voice made me very unhappy and depressed.’

How can we explain eating disor...

Table of contents

• Cover
• Title page
• Copyright page
• About the Author
• Foreword
• Acknowledgements
• Introduction
• 1 Problems in the Period before the Eating Disorder
• 2 First Stage: Extreme Dieting
• 3 Negative Consequences of Eating Disorders
• 4 Turning Point and Motivation for Recovery
• 5 Normalizing Eating Habits
• 6 A Positive Body Attitude
• 7 Physical Recovery
• 8 Developing More Self-Esteem
• 9 Expressing Emotions
• 10 Improving Social Relations
• 11 The Most Important Questions and Answers about Recovery
• 12 Checklist for Full Recovery
• References
• Index