Welcome to all my visitors

Thank you for visiting my thoughts and ideas site. If you want to speak directly or have my thoughts on something that is important to you email me at admin@ncfed.com

Monday, 8 August 2011

Amy Winehouse: New Poster Girl For Anorexia?

I did wonder if Amy had an eating disorder and while everyone made a fuss about her drug abuse, she really may have succumbed as a result of eating disorders rather than drugs. Yesterday, writing in the Times, Caitlin Moran described how little Amy ate (just Haribos, it seems) and how much exercise she did (treadmill for hours apparently). Moran writes “with an eating disorder like that, you’d have all the tolerance for drink and drugs of a newborn baby”.

Winehouse’s eating disorder was as clear as the nose on your face, it hardly matters whether it was anorexia or bulimia, the damage can be just as bad. Drugs are nirvana for people with eating disorders because you just don’t get hungry. When you go into rehab, you just feel fat when the drugs wear off, or you get very hungry as their effect starts to wane. This makes recovery feel very unsafe, so having eating problems gets in the way of being on the wagon.

Why do I feel cross; Winehouse was the queen of cool for some people, the girl on the edge, who wasn’t supposed to care what people thought. But all the time, behind that bravado, her real pain was the pain of everyone else who has an eating problem, the wish for absolute conformity by being as thin as all the other poster girls like… Cheryl Cole. I wish she had the courage to come clean about it, to help those she has left behind.

Wednesday, 3 August 2011

Children With Anorexia

There is a new little girl in our family and like many people I hope that she will not start worrying about her weight by the time she is only 5 years old.
Children as young as 4 or 5 can notice the weight of other children and silhouette studies dating back for at least 30 years show that fatter children receive fewer nominations to be a chosen playmate. I have asked why this is so and haven't had any good insights from my colleagues. After all, size zero pop stars are a recent phenomenon, aren't they?  So let's just assume some atavistic reason why even young children stigmatise the overweight.
I have been aware for many years that nursery school age children can complain about their simply caused by the wish to be thin, and it generally shows its ugly face in children who are deeply anxious and burdened with a wish to be perfect in all things. Having parents who are open about their food and weight issues or dietary quirks doesn't help.
Tanya Byron writing about children and body image troubles in the Times pointed out that obesity is a major health risk to children and this should not be forgotten in the current panic about anorexia. Our children are getting more obesity and more anorexia it seems, how on earth will we get the balance right?
The BBC want to find some families with children who have had, or have anorexia. If you know someone who would be prepared to take part in a documentary, contact The National Centre for Eating Disorders on 0845 838 2040 or email admin@ncfed.com

Wednesday, 27 July 2011

The Death of Amy Winehouse

There is a great deal written about Amy Winehouse this week and I like many others have been drawn to listening to her music. We have had the typical musings about the waste and costs of drug addiction and the importance of rehab and other forms of treatment.

But did anyone ever consider that she may have suffered as a consequence of low weight.  I was struck by her early photos and she was clearly a very different size and shape in her teenage years - chubby even.

There is a very strong link between bulimia and addictions, in particular alcohol in both sexes. A lesser link, but one none the less, between anorexia and addiction. The presence of body image problems makes it harder for someone to recover from an addiction. When you stop using, you may gain weight or start feeling fat. This is partly because you start experiencing emotions in your body where emotions must be felt.

If you are bulimic or anorexic, the health risks of addiction are magnified. With poor nutrition, the heart can simply stop beating.

We have yet to discover more about her untimely death. But why haven't I seen any mention of an eating disorder yet? Perhaps?

Friday, 15 July 2011

Body Image, How Do You Feel About Your Body, Continued.

I have been writing about the media and bodies. How do we get the balance right between encouraging people to take responsibility for their eating in this food filled society, versus promoting eating disorders?

This quite topical, today an article in the Daily Mail proposed to have fat children put into care. One obesity expert,  Kelly Brownell said that some parents are lazy and some are thwarted and some are ignorant. So there we are.  It's a very contentious solution.

I have listened to many proposals for managing media images to prevent body dissatisfaction. They seem like small solutions to big problems, such as putting health warnings on airbrushed pictures. Or being absolutely frank about the amount of airbrushing that has been done. I do not think this will be popular with celebrities.

Some schools offer media awarness training for adolescent pupils, but these are few and far between. So, we are what we are, a culture saturated with images with bodies that can never stay slim enough, perfect enough or slim enough to measure up for long. Not all of us are suffering because of this but some people are. If you think that your thoughts about your body are driving you mad, call us 0845 838 2040 or read about body image in our time on our information page. http://www.eating-disorders.org.uk/     We can help.

Wednesday, 13 July 2011

Body Image And The Media: Getting The Balance Right

In a previous life I  worked as a marketing executive for a major magazine publisher. Magazines sell to niche markets by providing content that the market wants to read. This content doesn’t always make people feel happier. Psychologists try to make people happier. There is an uneasy marriage between these two roles. Magazines have been slated for their portrayal of very thin, emaciated women. And they are now being condemned for their obsession with celebrity weights and body shapes.

There is no point in trying to categorise the media as good or bad, its purpose is to mediate between the individual and his culture, provide targeted information and forge invisible connections with like-minded people, at the very least. Magazines appeal to our dreams and possibly bring to the surface our greatest anxieties so that they can help us to do something about them.

So it has to be their purpose to create insecurity about our size and shape then provide solutions like yet another weight loss plan. This leads to some contradictory features like a recipe for chocolate cake alongside an article on how to lose weight fast. Magazines have been like this since I was young, but there are some recent, more worrying trends. The one that most comes to mind is a growth in the number of publications aimed at men's fitness and health. They are remarkable for their front pages showing  muscled torsos with the well defined 6-pack. Undoubtedly many of these photos have been digitally adjusted. But men are increasingly senstitive about their bodies too and many are taking steroids to try and build up muscle and lose fat. That can't be good at all.

Women's magazines have deflected the argument that they are responsible for "an epidemic of anorexia". They argue that anorexia is not a slimming illness and to some extent they are correct. Notwithstanding,  a social conscience is creeping in with respect to correcting harms. In 2009, Alexandra Schulman, Editor of Vogue wrote to to designers urging them to provide samples in reasonable sizes – size four rather than size zero; well it is a start.

The media is also giving us good quality information via documentaries, dramas and helplines to address potential harms. Yet this can also lead to some confusion. With conflicting concerns about the obesity epidemic and the eating disorder epidemic, some of the information we get is muddled. People say to me, I don't want my child to get fat but I don't want to risk her getting an eating disorder either. How do we get the balance right?

To be continued........

If you have concerns about body image, body dysmorphic disorder and eating concerns visit http://www.eating-disorder.org.uk/. We could save your life.

Monday, 11 July 2011

Obesity Surgery: North Staffs NHS Trust & Mr Condliffe. Barking Up The Wrong Tree?


This gentleman has been refused obesity surgery and is appealing the decision of the North Staffordshire NHS Trust. He claims that he will die if he doesnt have it. The Trust says that he isn't fat enough yet. Many people overeat to gain weight so that they can qualify for the surgery. Then they have to undereat to prove to the Trust that they are capable of managing their diet.


Mr Condliffe who wants the surgery needs to understand that the surgery isn't a panacea. If he has a bypass or the gastric sleeve his diabetes will go away and he will lose a lot of weight for a while. He will have to eat a very modified diet and he won't be able to turn to the jam butties very easily if he is stressed. If he doesn't sort out his relationship with food, he could get in  trouble down the line.

On the other hand if he has a gastric band, it may be a total waste of money.

North Staffordshire NHS Trust could have saved itself a great deal of time and money if it had paid The National Centre for Eating Disorders for Mr Condliffe to have an eating disorder assessment. This would have cost them about £55. If Mr Condliffe is eating for comfort a great deal, a course of eating disorder treatment would have gone a long way toward dealing with his weight problems and also his diabetes. His family would also benefit from the knock on effects of his counselling - in terms of their overall lifestyle and his ability to exercise.

Who is to blame here when someone gets into such a fix? Is it the GP who treats the diabetes but doesn't provide the help for the underlying problems with food? Is it the Trust who doesn't see that a course of counselling costing, say, £500 - is far cheaper than everything else? Why is everyone barking up the wrong tree?

Would someone please find a way to get this Blog to North Staffordshire NHS Trust and to Mr Condliffe and I will offer this gentleman an eating disorder assessment free of charge. Call 0845 838 2040 or email admin@ncfed.com

Tuesday, 28 June 2011

Body Image: How Do You Feel About Your Body? Continued..

In 1982, a psychiatrist called Peter Slade wanted to rename the eating disorders as body image disorders. Most of you are familiar with the terms anorexia, bulimia and compulsive eating disorders. But while eating disturbance is what you get on the surface; Slade argued that the term "eating disorders" is akin to calling pneumonia a coughing disorder or measles a spots disorder. His view – which is shared by modern thinkers, is that starving, sometimes to death; purging, compulsive exercise, yo-yo dieting, obsessive weighing, taking slimming pills or steroids if you are male, and adopting strange eating plans like avoiding all meats and dairy foods; - all this is just a reflection of your altered perception of bigness, fatness and too much-ness from which you may be continually trying to escape in order to feel better about yourself.

But even those of us who don’t have eating disorders are somewhat unforgiving about the way we look. So how does it all go wrong?

Body image is subjective and open to change by social influences and personal social experiences. Most people on the planet have a reference group that furnishes information about the ideal appearance. In this country it is arguably a tall thin coat hanger and in Burma it is a very long neck. In all cultures, beautiful is the same as good . We are surprised to find a loving heart inside Beauty’s beast and its only lovely Cinderella or wafer thin Kate who gets a Prince.

For most of us, our  first reference group is in the home: with parents who might feed you instead of giving you a hug, or diet and rebuke themselves and name-call other people for their fatness. I bet you have heard them say "she's put on weight" a hundred times. You may have a bother or sister who teases you for being fat. If your best friend happens to be thinner (or stronger if you are a male) your body evaluation may shift. If you are taller or shorter than other people, if you have experienced abuse or violence at the hands of another person, you may turn your anger and sadness against your body which was the subject of their harms.

But what we see in the home is only a reflection of what is in our wider social world. Nowadays, it is the norms and aspirations of our society that we find reflected and, to some extent guided by a pervasive media which reaches deep into our lives. This media gives us clear messages that what is valued is youth and slimness that most of us will never reach. That’s OK, ideals were never meant to be attainable – that’s what makes them ideal!

But we are led to believe that our failure to get our appearance right means that we are weak, lazy, or unwilling to take of ourselves properly.

And where that takes us is,.... to be continued.

Friday, 24 June 2011

Body Image: How Do You Feel About Your Body?

I consider that my body shape is....?
When I think about my body I feel....?

The most real thing about us from the beginning is our embodiness - we sense our body even before we are born and have a natural knowledge of what is going on inside and outside of us. After we are born, we know if we are falling or comfortable, fed or empty. Something in our guts grips us when we are afraid and we put things in from outside which give us alternatively a sense of wonder or disgust. As we grow and mature, all of our experiences of bliss and dejection are felt - not in our head - but in the way the body works. Bliss is interpreted when our heart turns over warmth cascades up from our centre, and our pulses race, dejection will be felt as a pain in the heart, the hunch of your shoulders or a gripping in the throat.

Freud said that our first ego state is a body one; thus it is in the body that we first have our sense of self and how it is different from not-self.

Because we are embodied beings, we all develop opinions about our bodies which are both ABSOLUTE in terms of experiences like pain and comfort; and RELATIVE in terms of how we look. We may think of ourselves as tall or small, old or young, ugly or beautiful. But, in relation to what? Small in relation to what? beautiful in relation to what? How we behave, dress and relate to others has much to do with our body opinions and what those opinions mean to us. If we feel ugly, and if it is matters, we may hide away from other people, stay at home rather than go to a party and take holidays in an igloo. If we feel attractive we will dance on the table and walk tall in our clothes.

The natural sense of our body is basic to our survival. Pain alerts us to the fact that something is wrong. The adrenaline rush when you see a tiger enables you to freeze so that it won't see you or alternatively propels you to run away.

But, sometimes, our natural experience of the body goes wrong. If anyone reading this has broken even their finger for a while,  you become your finger, it seems to be bigger and more troublesome than it is. So our sense of the body is more than just feedback about what is going on in it. Our body sense becomes a big part of our sense of self. Sometimes, nothing is wrong with the body at all, but it comes to feel wrong and our natural wisdom goes astray. We are separated from our natural sense of self. It is in this type of ground that eating disorders can set in.

to be continued......

Wednesday, 22 June 2011

Obesity Treatment: Enthusiasm and Desperation

Last week I led a 3 day course on managing weight problems. It was really interesting and the delegates, some with long standing weight problems themselves brought many good ideas into the room. The issue of helping people to be motivated was raised. It’s one thing trying to persuade someone to lose weight, and it’s quite something else to help someone to be fully committed to the hard work that weight loss involves. Goodness ! it would be hard for me to lose half a stone, how much harder to lose even more.

It’s easy and hard to lose weight. You can lose a few pounds without even touching your fat stores. A few days of eating very little will remove a great deal of water and stored sugars from your body. People think they have lost weight and congratulate themselves but nothing has really changed at all. Losing fat is something else entirely and floaty-light- fat is so energy-dense that you use up very little to meet your daily energy needs. Your motivation must be realistic and stand up over time in the face of the stresses and strains of life.

We mustn’t confuse motivation with enthusiasm or desperation. Wanting to lose weight is not the same as wanting to stop eating your favourite foods. It’s now clear that obesity is a long term medical condition which is self perpetuating and which needs lifelong management. Some people might be better off not trying at all. If people engage in dietary oscillations, like eating little all week and feasting at weekends, they will regain their weight. If people do not move around a great deal, they will regain all their weight. If people return to baseline behaviours, like keeping crisps at home for the children, they will regain all their weight. Unless healthy behaviour becomes intrinsically gratifying, people will regain all their weight.

Susie Orbach said that fat was a feminist issue. I think we have moved on. It’s a commitment issue, with enthusiasm and desperation playing very little part in changing behaviour at the end of the day.

Binge Eating and Food Addiction

I have done a short presentation at a medical conference "Addiction and the Liver" in London. My topic was to discuss the link between food addiction and binge eating; a big subject for a short presentation. The weblink for the presentations is: www.mahealthcareevents.co.uk/addliver/0611/presentations. No login is required. Scroll down to find my name and the presentation is there. I prefer the view that binge eating is more complex than an addiction and a great deal of what we believe to be emotional eating is in fact driven by thoughts and the feelings that arise from those thoughts. But people think that its only about feelings. I feel a mega blog coming on, so perhaps another time.You can read all about binge eating on the information page of our website http://eating-disorders.org.uk/

Friday, 10 June 2011

Children and Body Image: How to Help

Here is another useful opinion piece. Food for thought. Pass it on, the wiser we are the more we can share out wisdom with others. What was it like in your own home. If you have a parent who does a lot of fat talk, time to get it to stop, dont you think?


Getting there is another thing entirely. If you have a parent or your child has a grandparent who parades their own unhelpful opinions about weight and eating, get in touch. Visit http://www.eating-disorders.org.uk/ or email admin@ncfed.com for advice.

Children, Body Image, Eating Disorders & Sexualisation

Sexing up our children is in the news this week. One mother is reported to be buying her 7 year old "breast surgery" (to implant ping pong balls?).

In girls particularly, there is a link between early growing up, sexualisation, low self worth and eating disorders. So there you have it, there is no way to twist away from that one. Buy your child the wrong clothes or send her out to play in make up and you get what you get down the line.

My little grandgirl loves to wear my necklaces and I think it is wired into children to mimic their parents, they cuddle their teddy bears and put them to bed. This kind of play practising  is what helps them to grow up. But how do we get the balance right?  It is OK to play with our children in the park or take them out for bike rides. But when we show them that mummy "has" to go to the gym, or when we show them that "mummy isn't eating carbs today" we cross over the line. Children are like sponges, they soak in our own insecurities and our own self doubts and embody these as their own body hatred.

I have had many young people with eating disorders who find their parents' obsessions with running, workouts and exercise toxic, although they dont know it. They resent this behaviour in their parents - it sends out the wrong messages about what it is to be a relaxed human being. Because they can't admit to their resentment, they simply feel ashamed, not knowing why.

Please let your kids be kids, and, get a life. Say no to things which aren't suitable for 8 year old girls. Don't be drawn into competition with parents. Read a good book, take a walk in the rain, eat good food without dietary quirks and read the article below which says it all.


Worried about your child, email admin@ncfed.com or visit http://www.eating-disorders.org.uk/

Wednesday, 8 June 2011

Binge Eating Treatment

Let food by thy medicine and let medicine be thy food,  said Hippocrates more than 2000 years ago. How right he was. Its an important part of treatment for binge eating and I've been saying this myself for years.

Tomorrow I give a lecture on the treatment of binge eating and food addictions. I will be making a case against regarding binge eating and even compulsions to eat food like chocolate as an addiction.

There is a lot to say in half an hour. Its not helpful to view people as carbohydrate addicts or anything similar. Our eating is driven more by what we believe about food, what we say to ourselves when we start to eat it. Ive blown it now.... this will make me fat.... I shouldn't be having this.... I can't control this. These thoughts do more damage than any property inside the food. If we treat compulsive eating with abstinence programmes, we only make desirable food seem even more desirable and forbidden.

Treating binge eating is complex. We will use food as medicine - thanks, Hippocrates! We work with emotions, help you manage relationships, we will correct poor body image and transform unhelpful thoughts so that they dont propel our eating. We know what to look for and what to work on. Everyone is different, so if you purge we may need to add some therapy and if you have very low self worth we would have to do something about that too. If you accept yourself better you feel more in control.

Need help? Eating can be fun and rewarding. Food is life.  Visit http://www.eating-disorders.org.uk/binge-compulsive-recovery.html   If you binge eat and it is ruling your life, we can help.

Thursday, 28 April 2011

Visit To BOSPA- British Obesity Surgery Association

Yesterday I did a talk at a self help group for bariatric (obesity surgery) patients in Chsiwick. My talk was called "What is normal eating anyway?" I guess I should be blogging about this sooner or later.

There were some pre-ops there wating for surgery or just getting some information and some post-ops talking about their experiences. The common theme from the post-ops was that the surgery had changed their lives; they were walking miles and wearing clothes that had been in the attics for years. The gastric banders were certainly less successful and the gastric sleevers and the gastric bypassers were equally happy.

Now for many of them it is early days and as time goes by they have to confront some obstacles. I was so sad that there aren't many people with the wisdom and training to help them emotionally speaking. One soul was angry with me for being there talking to them in my slim body, she felt that I would have no idea at all what she was going through. She is a deeply compulsive eater who ate 20 easter eggs over the last weekend and she has been refused surgery until she has "dealt with her eating disorder" but how is she supposed to do that?

Everyone is talking about "getting CBT" or she has "had CBT" and it didn't work. But CBT does not work for everyone, if that is all the therapist is doing - there is only 50% success rate with CBT alone. So, we need to take each person, one at a time and bring a whole range of skills to the table which can be built around a package of treatment that will focus on the eating disorder mindset at its heart but can also provide help with feelings, trauma, lifestyle and empowerment.

Don't you think? Email me if you have a view on this - see above and remember to visit our website www.eating-disorders.org.uk to see what is going on.

Thursday, 21 April 2011

Top Tips For Working With Eating Disorders: Counsellors Must Get Anxious Too

I wrote a few days ago that clients must be a little and sometimes a lot anxious for therapy to work. We therapists must be able to tolerate our own anxiety too.

My own experience mentoring therapists is that can get very anxious. Someone may be losing a lot of weight and nothing the therapist does seems to stop this from happening. Someone with bulimia may be reporting very frequent purging. Someone with anorexia is gaining a little weight and then there is a setback; weight goes down, someone seems to “stop trying”.
Or a person with a weight problem is doing very well. The therapist is anxious, can she keep it up? The client seems to be a little less motivated; is she heading for a relapse?

Carers’helplessness can make a therapist very anxious too. The carer come to us saying “This therapy isn’t working! My son/daughter won’t talk to me! Why aren’t you able to stop her or him from losing weight now!”

Or maybe our client tells us that their parents seem to be at war with each other. Why has a parent bought their anorexic child a gym club membership for Xmas? What on earth is going on?

Therapists can get very anxious because they simply do not know what to do next with someone who seems to be very stuck; we start off by considering ourselves as the client’s white knight and then we start thinking of ourselves as a bad therapist. None of this anxiety is going to help the client in the end.

One way of preventing anxiety is to suspend any emotional interest in recovery, weight loss - or even weight gain if it comes to that. This surprises people. Surely is it natural for us to praise the anorexic who gains weight and to praise the obese person who loses it? The whole slimming industry is based around rewarding people for weight loss - with gold stars, medals and badges of honour. We pat anorexics on the back for weight gain, which they hate - and only confirms to them that they might be getting fat.

And surely it is useful for us to want our people to recover? Yes, but we must have personal investment in this. Our clients must want it – not us! So we must simply be willing to stay beside them on this journey. While praise and criticism may work a little in the short term, it hardly helps in the long term. By rewarding weight, for example, we are rewarding the wrong thing – people are not always happy if you reward weight change because you are not rewarding what really counts, their efforts, or their willingness to learn new things. You are simply teaching them to look to you for praise and to be scared of your disapproval if they fail. This is hardly good practice and it does not teach people how to motivate themselves when the going gets tough.

This kind of struggle for position with a therapist was well described in a recent conversation with a therapist who had this to say about her anorexic client:

“The Client made me feel like I wanted to rescue her and not be yet another person who let her down. This level of anxiety required containment as was achieved through the establishment of a relationship that was one of listener yet provider of education, settler of tasks and presenter of hope.”

The therapist needs to deal with the fear of letting the client down because sometimes our clients come with impossible expectations of therapy and a therapist that can never be met. It is clear that therapists can be neither to be the white knight nor the abuser. If we focus too much on being good enough for our clients we may miss what the disorder is communicating about our client and their motivations.

By the same token it isn’t really helpful to get anxious if weight falls during recovery from anorexia. It could just be a blip and we need to wait and see before getting in to a panic. Weight does not always follow a straight line and it is better to wait and see what is really going on. If I am working with someone whose weight is truly falling week by week, I tend to stay calm as a cucumber. I would say “the Voice seems to be shouting at you at the moment. What do you feel you would like to say to it?”If weight is going really low, I might say something like this “It seems to me that one way of taking care of yourself is to get so weak that you will have to go to hospital. Another way of taking care of yourself could be to eat a little more. I wonder which of those feels best for you.”

So we therapists need to be able to tolerate uncertainty (Waller 2010 CBT Today) without panicking. If we are worried about the weight of a client we are not able to focus on what the undesired change is telling us. It is much harder to be half way recovered from anorexia than it is to be in denial about how unwell you are. You may have gained weight, but you will have lost everything that the disorder did for you without feeling any of the benefits - yet.

If someone seems to be stuck, there are many reasons why this is so. Taking supervision is a very good idea of course and sometimes you may have to consider putting therapy on hold. You can say “We have come as far as we can – for now”.

And if someone fails with yet another weight loss plan you are coaching them in - it could be that you are not in touch with everything they believe is bad about weight loss. One obese person confessed to me that he felt that people who don’t let themselves overeat at holiday times “are boring”. Why would he want to be like that? The therapist panics and misses the opportunity to listen to what the client has to say.

An anxious therapist is one who gets easily angry and into blaming mode: they aren’t trying; they aren’t ready: they are rebellious and naughty. This therapist is not resourced and will not serve their client well. If I am mentoring an anxious therapist I will turn my attention to the therapist’s anxiety rather than the client’s apparently difficult behaviour. What does this anxiety remind you of? What are your beliefs about uncertainty?

Calm down and let the bad ideas go, and maybe something inspirational will come to you both. From ”sufferers” out there in the community, some with long standing problems and some just newly captured by an eating disorder, I hear a lot of bad things about therapists who get angry and abusive, who give people clearly inappropriate treatment, or unwelcome labels without thinking what they are saying or what that will mean, who haven’t listened, or who simply do not speak the unique language of an eating disorder. How can any eating disorder therapist fail to understand the Voice? Most of this boils down to anxiety. We all need to be able to tolerate anxiety without panicking.

Tuesday, 12 April 2011

Having An Eating Disorder: What Does It Mean About You?

Melanie Reid who writes about her spinal injury in The Times says; … the world is split into people who moan and people who don’t. I have heard enough moaning in the past 12 months to last me a lifetime. In this regard, I refuse, ever again, to spend time with anyone who complains continually about the weather, their job, their relationship or their appearance. These people are death to the soul; they suck the oxygen out of the air; they need to be avoided at all costs. …….. avoid people too stupid to appreciate what they’ve got. Like loud and aggressive persons, they are vexations to the spirit.

So, are people with anorexia or bulimia stupid?
Or, vexations to the spirit?

On television recently I said words to this effect. People with anorexia are sensitive, even before the illness they find it hard to cope with the slings and arrows of life. And this brought forth a sort of rant from someone, let’s call her Jane. She said to me, you are saying that anorexics are weak, you are undoing all the good I am trying to do trying to get people to understand this illness! I work as an Ambassador for B-eat and you are undoing all my good work!!! My reply to her was lengthy.

So, are people with anorexia or bulimia weak?

And, in OK magazine this week, there is a story of a footballer’s wife who is fading away and refusing to eat, having got rid of some baby weight plus a great deal more. She admits to having anorexia and who knows what else she is doing to herself. She threatens, if anyone comments about my weight loss I will stop eating even more. Now here’s the thing; mature people do not punish people who reach out to show their love, do they? If someone says to me “You look tired, are you working too hard” I say to them “Thank you for caring”. Her anxious friends are damned if they show their concern and they are damned if they don’t.

So, are people with eating disorders infantile or immature?

One person who wrote to me recently said her therapist views her as having a “mental health problem”. Another therapist suggests that she suffers from “Body Dysmorphic Disorder. Because of the shame she feels about these unwelcome labels she is unable to continue with treatment. She chooses to wake up every day trapped in the prison of her eating disorder and her preoccupations with food and weight, rather than be labelled as a mental case.

So, are people with eating disorders mentally ill?

An eating disorder charity says “it’s not about food, it is about feelings”. I heard myself say this on ITV as well. We talk of using food or starving to medicate pain or block feelings that cannot be expressed. I have found that some of my people seem to have “too many feelings” and use binge eating or purging just to calm themselves down. Purging can be the only way you know to get those feelings out.

So, are people with eating disorders “in pain”?

Experts who write textbooks for each other say all kinds of things about people with eating disorders and call it “research findings”. They associate eating disorders with many different pathological presentations. If we are to believe this research, we would view people with anorexia, bulimia and compulsive eating as being either:



Personality disordered?

Narcissistic – desperate for attention and desperate when they don’t have it in the way they want?

Dependent- always needing approval from other people?


Insecurely attached; meaning not very good with relating to other people?

Having autonomy fears - which means that they aren’t able to grow up, separate from their families and live “normal lives”?

Experts, even those with eating disorders themselves, pre suppose that there is something very wrong with eating disorder sufferers and bend over backwards to be kind and do everything they can to help the person with self esteem. Even in the field of obesity work, there are experts who designate all emotional eaters as food addicts with poor attachment skills.

And experts do not generally view the person with an eating disorder as very strong, no matter how much they can manage hunger pangs. We call this perfectionism, which is always couched in derogatory terms. We may secretly wish that someone could simply lighten up.

And, that feels to me like a slap in the face with a wet kipper too.

Or are people with eating disorders amazing, strong, creative, intelligent people who have been captured by an evil spirit? It sometimes feels like that to people looking on. If that were so we would have to accept that someone with an eating disorder is enslaved.

When I see someone with an eating disorder, whether it is anorexia, bulimia or binge eating disorder, I try not to make assumptions about what is wrong or right about them. Yet it is hard not to see predictable patterns in each disorder. Our sufferers are generally misinformed about food, dieting and weight. They know a lot about calories but very little about the science behind appetite and weight control. As to the rest, there is a great deal of fear, panic and anxiety. Closely followed by shame, misery and guilt. There is a huge amount of self talk about food, weight and diets. There may be a great deal of purpose in managing food but very little self confidence, something which we all aspire to in life.

There is a trail of people in the wake of the sufferer who are confused, angry or worried. Eating, it seems, is a relational issue. So the collateral damage of an eating disorder is very far and wide.

So what does it mean about you if you have an eating disorder? I say this. Stop worrying about the labels for a start, because these labels do not capture what it means to be human and imperfect. I am not sure that we can quest for recovery, or even desire it, until we have looked inside ourselves to find out “what my eating disorder is saying about me, personally”.

Perhaps we all need to accept our shadow side, name the bad as well as the good, the weak with the strong, the evil and the angelic, so that we can become the master of our fate.

Friday, 8 April 2011

Denial in Bulimia Nervosa

It’s normal to want to be in control over our eating habits. It’s normal for some people to want to let go of that control some of the time like at Christmas time or when you are having a picnic with friends. It’s very normal for some people to eat a horribly bad diet full of junk food, because they like the taste. Perhaps they think that people who eat healthy food are boring? I often wonder if they are in denial about how dangerous their eating habits really are, when they tuck into their ready processed trans-fatty laden foods. But who am I to judge? If we all ate what is best for us, the economy would collapse. Who would be left to buy chocolate flavoured coco pops or one kilo chocolate bars?

On the other hand, since I have just written a blog about Orthorexia which invited some dissention, I wonder how many healthy eaters out there are in denial about the emotional issues that are behind their dietary rules. When it comes to food, we do the best we can with the resources we have at the time.

So, there is lots of denial around and so what, anyway. Experts say that where bulimia is concerned, denial isn’t really an issue because sufferers are already fully aware that their control over eating has been undermined. They know that they have a problem, and they know that normal people don’t do what they are doing -which is why they take such trouble to hide their rituals. I guess that last sentence doesn’t apply to Jockeys – where purging is normal, or models who teach each other all the tricks for staying thin so that they won’t be accused of looking fat.

People in the early stages of bulimia may be in denial about their behaviour. They don’t yet know it has a name. They almost certainly don’t know that what starts as a way of controlling weight gain quickly becomes an addiction. In the beginning, it is something they control and it ends up controlling them. They never know when they will think they have eaten one bite too many and will have to get rid of it as soon as they can. They certainly don’t know that what begins as a way of controlling food turns into a way of managing feelings. They are denial about their ability to stop.

They also deny to other people that they are doing anything unusual and go to a great deal of trouble to cover things up. Spraying perfume in the bathroom or playing the radio to mask the sounds of purging are common tactics. Pretending to your boss that you have a stomach upset is better than saying you have taken too many laxatives. This makes sense; few of us would want to admit to doing things that would cause us shame.

Denial has a lot of different meanings. People can think that what they are doing is okay because they lack the information which would help them to think differently. Many people who vomit or take laxatives think that this is a really good way to control their weight and they are therefore terrified to stop. Purging is a wonderful weight gain strategy in the long run and many bulimics gain a great deal of weight. This is because purging affects the appetite chemistry of the brain and purging interferes with the body’s ability to burn off calories.

The word “denial” implies, however, that even with the right information people say “this doesn’t apply to me” or “I don’t believe it” or “what I am doing now is better than any alternative that comes to mind” or “I don’t have a problem and can stop whenever I like”.

Perhaps the most interesting form of denial is to say “I know I have a problem but I am not sure I want to do something about it”. Therapists call this “ambivalence” and they are anxious to turn this into a real desire to change. We can understand ambivalence by turning our attention to the benefits of having an eating disorder. For one thing, purging allows us to have what we like without having to pay for it, to have our cake and eat it, so to speak. Taking laxatives helps get rid of everything that feels bad and dangerous and that mustn’t stay inside.

Bingeing and purging isn’t just a way of getting rid of food, it gets rid of feelings as well, and it helps us to get on with our day. I have often thought that purging is a kind of communication. It says what someone is unable to say, such as “I hurt, I am angry, I feel confused, I can’t cope with this, I hate you because you are more popular than me”.

And people can also be very ambivalent about change because they aren’t convinced that their problem is all that serious. One person put it like this:
“I found that - the part about me having a very serious eating disorder - hard to listen to ..because I physically look totally fine so I have been saying if it were that serious then I would surely look as if I have one when I don't and ….eating disorders are mental health conditions so if they are right and I do have a serious case of bulimia then I actually have a mental health condition and I feel really uncomfortable about that…”

So here we have two aspects of denial, one about whether the problem is serious enough and one about being willing to accept what the bulimia might mean about you.

Regarding seriousness, let’s make no mistake. Bulimia is not just about getting rid of food. Everything is affected, your brain, your fertility, the cells in the throat and mouth, the damage to the gut. Blood tests tell us very little about what is changing in our cells so it may be years before the damage shows up. It’s much the same as smoking. You can live a long life with bulimia – of course, but I doubt it will make you very happy. I don’t call to health risks to persuade people to change. On the other hand, bulimia makes you gain weight very easily and that does make people with bulimia very uneasy.

If you want to deny the seriousness of bulimia in case it means you have a mental health disorder, take heart that some bulimics DON'T have serious mental health problems. And some normal eaters DO have mental health problems so why bother to get into a strop about labels. I will have to another blog about that!

An eating disorder - whether you think it serious or not - is something that stops us from having to pay attention to what isn’t working underneath. It’s easier to think that you have an eating problem which isn’t really going to do you much harm, than it is to grapple with a problem that is really painful. Many bulimics have had a history of serious invalidations, unhappy childhoods, struggles coping with an alcoholic parent or abuse from other people which they were powerless to prevent.

For these reasons, I do not fight against denial nor do I assume that my enthusiasm for recovery will be taken up by my clients. Some people have been upset with me for so-called labelling people as bulimics, anorexics or orthorexics. At the end of the day it is about people, not about labels and it's about figuring out how to help someone to be happier. I know that purging, starving and binge eating helps someone feel safe but isn’t a recipe for a happy life; it is happiness and a meaningful life that is always in my focus.

Thursday, 7 April 2011

Criteria For Recovery From Eating Disorders A Reader Request

Someone has asked me if there is a definition for recovery. What do you think recovery means? What does it mean to you? Recovery to me meant that eating did not rule my life. Many people think that recovery is about gaining weight if you are anorexic or stopping symptoms like vomiting or taking laxatives. The good therapist knows that recovery is much more about the person than their weight or their eating disorder symptoms. Recovery is helping a person to reclaim what has been surrendered to the illness. This means finding their potential, their trust, their sense of safety, their ambition or purpose and their ability to manage their feelings and connect properly with other people. But the following can do for a start.

Does not take laxatives
Is able to express their emotions (verbally)
Does not feel too fat
Self esteem is no longer dependent on weight
Does not punish herself after a meal
Has a realistic image of herself
Can eat three meals a day
Has no binges
Does not vomit after dinner
Does not use diuretics
Is not obsessed by food and weight
Is able to express emotions (non-verbal)
Is able to handle negative emotions
Is not isolated
Feels no need to slim excessively
Does not exercise excessively
Does not use slimming pills
Accepts appearance
Is in touch with their own feelings
Has a positive experience of their body
Has adequate self-esteem
Is able to handle positive emotions
Is not depressed
Amount of calories is normal
Heartbeat is normal
Is able to handle conflicts
Sleeps normally
Is able to make contact with others
Has some friends
Is not extremely perfectionistic
Dares to express a different opinion

Finally, recovery is when the person can accept his or her natural body size and shape and no longer has a self destructive or unnatural relationship with food or exercise. When you are recovered, you do not use eating disorder behaviours to deal with, distract from, or cope with other problems. When recovered, you will not compromise your health or betray your soul to look a certain way, wear a certain size or reach a certain number on the scales.

Wednesday, 30 March 2011

Top Tips For Eating Disorders: The Client Must Be Anxious for Therapy To Work

People with eating disorders present with dietary chaos. There is starving, dieting, stuffing, purging, feasting and fasting, lots of coffee and diet drinks. This changes the body, assaults the brain, including appetite systems, fosters weight instability and leads to many of the emotional symptoms like depression which people bring to treatment.

Part of our work is nutritional rehab. This will help the body to burn energy rather than store it as fat. It will help with feelings and appetite control. For binge eating-purging clients we have to bring structure into the diet. We have to deal with strange beliefs about food such as “I am addicted to chocolate” and beliefs about good and bad foods. People with anorexia will believe “If I eat a piece of toast I will gain 5 lbs”. They believe “If I start eating again I will never stop”. People who binge think “If I eat a normal diet my weight will shoot up”.

Changing eating and other habits, like constantly weighing yourself, or constantly checking yourself in the mirror is a very scary thing to do. But how can you learn that your worst beliefs will not happen unless you are prepared to test them out? You may well be right about your convictions. However, If you can let a good therapist be your guide and agree to experiment with change slowly and purposefully, you may find that your fears were just imaginings.

They key for a therapist is to explain to their people that recovery depends on doing some things that will make them anxious. We must always remember how hard it is to change any habit, even the smallest ones in our own lives. We can negotiate with people what level of anxiety is manageable so that they can test our some new behaviours one week at a time. For example, next week you will eat regularly even if you binge. Or, next week delay for 5 minutes before you agree to purge. Or, next week how about having a glass of milk first if you feel the need to binge.

The changes have to be enough to make the person anxious about the outcome but not so great that they are too scared to try it.

Acknowledgement, Prof. Glenn Waller CBT Today Dec 2010

Thursday, 24 March 2011

Getting to Grips With Orthorexia: A Media Frenzy

I was asked to do an interview for the BBC on the subject of Orthorexia and since then, all hell has broken loose. There have been attacks from members of the public and health professionals about purportedly describing the quest to eat healthy food or even vegetarian food as a mental health disorder. I have even been accused to trying to promote the obesity epidemic by demonizing healthy eating.


The term “orthorexia”(correct appetite) was first coined by Stephen Bratman who observed some typical ways of thinking about food among people who had worries about the properties of food and its ability to do them harm. I didn’t need Bratman to teach me something I had noticed anyway among people who I met in my work with eating disorders. Orthorexia isn’t just about weight, it can be just an obsession with healthy eating as well as worries about weight in disguise. So, I agree that it is helpful to have a name for something with which I was familiar, because of my experience with people of all weights struggling with control of food.

In the course of my work I have met overweight clients who wouldn’t eat more protein because “I am vegetarian” and “I am also allergic to dairy foods” and “wheat makes me bloated.” I treat people who were binge eating and who had spent years “food combining” and going from one healthy diet plan to another; like the Stone Age Diet or the Fit For Life Diet. I noticed that some people bury the need to control their weight by a conviction that they are just trying to be “healthy”. Most diet books these days are published as healthy eating plans like the Metabolic Typing Diet.

I have seen orthorexic patterns expressed among vulnerable young girls who convince themselves that animal products would make them gain weight. This is often the start of a slippery slope. Although convincing themselves that this was “healthier” they went on to develop anorexia or bulimia.

I then saw it really taking hold as a result of celebrities and the media promoting the message that you are a good person if you go on a detox after holidays; and it is so easy for detoxing to become a way of life. Something you feel you cannot do without.

I have tried to point out many times that this thing "orthorexia" is not a medical condition. Mental issues defy attempts at categorisation because people come in many different packages. Anyway we must make a distinction between people who like to eat healthy food like me, without extreme ideas and rules, compared with people who have very rigid patterns of eating because of religion, weight control issues, ethical values, health issues and real or perceived health fears. Orthorexia is not just a description of behaviour, it is really about underlying motivations and the need for some people to escape from underlying fears by turning to the control of food in some predictable ways.

The need to eliminate certain food types, such as meat or wheat, or food groups such as all carbohydrates or all fats, resonates with anxiety disorder, obsessive compulsive disorder and even delusional disorder in some people. Delusional disorder is where people have extreme ideas about contamination or badness of certain foods. It is simply grist for the mill of anxious people that there are genuine health concerns about the foods we eat, to which attention might be paid.

I am often asked how many people there are with orthorexia. I have no idea, since not being an official “condition” no-one has developed a test for it with clinical validity. However, I see aspects of orthorexic thinking in a great many of my friends and colleagues who are adapting their diet, who have just happened to become uncomfortable with eating certain foods or who are convinced that certain foods will do them harm.

Experts have called “orthorexia” an “escape from anorexia” by helping people who “cannot starve” to find alternative ways of controlling food. The underlying common features, shared by both conditions, and which have nothing at all to do with food, are about finding ways to deal with things that lie beneath. Individuals with either condition are likely to have unmanageable feelings and negative core beliefs which are managed by control of food and weight.

How do we know that these are similar conditions? People with anorexia and orthorexia – even those who are not underweight – have similar characters. Both tend to be highly perfectionist, anxious, rigid, fearful of mess, have ascetic (purity) beliefs and even underlying fears of maturity. They also have a narcissistic need for status which can be acquired by having an unusual diet. People with orthorexic thinking often wear their eating choices as a “badge of pride.” It is no accident that the majority of people with anorexia are also vegetarian, with a suicide rate 57 times higher than we would otherwise expect.

Regarding the discomfort about vegetarianism: well, please don’t misinterpret what I am saying about its links to orthorexia. In a recent reply to an indignant writer, I proposed that while omnivorous eating is wired into our physiology, I accept that as humans we overlay moral and also emotional choices to our instinctive appetites. But where food and other choices are concerned, I believe that none of us is truly aware of the reasons why we do what we do. The research literature on the psychology of vegetarianism is interesting and begs to be read, especially by psychotherapists who work with the general public and who may be orthorexic themselves. I worry that conventional psychotherapy training does not require students to disclose and reflect on their own relationship with food. I am even more worried about eating disorder specialists who may be orthorexic, because these experts need to help sufferers feel comfortable with eating a wide variety of foods.

Spectacularly hidden

So orthorexia is hard to capture in single sound bites or short paragraphs written in the press. It’s one of these things which is widespread and yet spectacularly hidden because it comes in many guises. It only becomes a problem when it affects physical health due to nutrition deficiencies or it affects your social life to such an extent that you lose your friends, your social life, or become so obsessive that you know you have a problem. Most people do not want to change.

When looking for the cause of orthorexic faddism, (as opposed to food choices which are motivated by other things), we can see it everywhere in the society we live in. If you are not emotionally resilient, if you have body and weight issues and low self confidence, you will be vulnerable to all the messages about toxic qualities of food, foods that will make you gain weight or foods which are dangerous to eat side by side.

There are too many experts diagnosing food allergies or food intolerances which may not exist and who blame food allergies for making you fat. There are too many people telling you that eating meat will affect your health. Food faddism, disguised as nutritional misinformation has crept into the sports and fitness field, causing people to rely on supplements and on strange diets to make you fit, boost your endurance and build your muscles while making you lean. Even the food industry is getting in on the act. Not everyone is captured by this whirlpool of advice but it has a bad effect on some. Orthorexia can even start at home, when a boy or a girl sees a parent taking on strange eating plans.

I have chosen to be interviewed about orthorexic thinking because we need to legitimise- with a name if necessary - some patterns of eating that cause physical harm or which affect a person’s life. Some people become so obsessed with food that they can’t function properly anymore. These are people who cannot eat out unless they take their own box of food. These are people who are scared of eating carbs. Extreme cases get the headlines but there are many milder ones.

We do not need a genuine mental health concern to be clouded by people writing indignantly that they are not orthorexic just because they choose to eat organic food. The following questions might help you know if you or a loved one has the condition.

• Do you spend a great deal of time studying facts about food or food and health?
• Do you read a lot of books or visit websites about diets or healthy eating plans?
• Have you eliminated certain foods or food groups from your diet. If so, which?
• Is your diet solely organic?
• Would you describe yourself as interested, or obsessed about eating healthy food?
• Do you eat flexibly or do you have to plan your eating?
• If you were stuck somewhere and only unhealthy food was available, would you be able to eat it just once?
• Would you feel extremely guilty or anxious about eating foods on your forbidden list?
• Do you feel superior because of your eating choices or restraint?
• Does eating differently from others enable you to feel special?
• Do you have bad feelings about eating out, at social occasions where you cannot control the food?
• Do you refuse social invitations because you do not wish to eat the food?
• Do you feel that avoiding certain food groups (like carbohydrate) will help you control your weight?
• Are there foods that you think are bad to your health or bad for you – other than foods generally acknowledged as unhealthy or fattening such as “chips?”

There is no foolproof test for orthorexia, but answering yes to most of these questions suggests that someone has signs of it. There is little chance that people will go to a therapist and ask to be “cured” because there is a heavy investment in keeping the status quo. Eating habits are resistant to change, and, why start eating food that is going to make you feel afraid?

Eating disorders are not just about food of course. But if I have a client with an eating disorder who is also orthorexic, I may find them difficult to treat unless they are able to let go of some of their beliefs so that they can have a balanced, relaxed relationship with food.

Wednesday, 16 March 2011

Getting Better – Wanting Versus Doing And Denial In Recovery

I’ve just written about denial in eating disorders and something has led me to a great deal of thinking about the difference between treatment and recovery in eating disorders and anorexia in particular.

Focusing on anorexia for the moment; Professor Chris Fairburn has described 3 phases of treatment, the first being getting the person to accept there is a problem and weight restoration; the second being psychological support and the third is prevention of relapse– with overlaps between these processes.

This is all very well if you are working in a treatment setting and wanting quick results or any results at all. But this doesn’t quite meet the needs of someone with a long standing problem who decides to get better on their own.

I meet many people who have had an eating disorder for a very long time. They may have been in treatment for a very long time as well. It seems to me as if this “treatment” has largely been focused on helping the person to WANT to get well. In other words, all the re-feeding, trips backwards and forwards to hospital, conversations, explorations of the past and meetings with the family, swapping of psychotherapists and encouragement from dieticians are just stepping stones in a process whose end point is helping the person to want to do things which are impossible with anorexia – such as eat with other people, or, have a child.

I am known for not caring whether someone is fat or thin and I don’t pat people on the back for eating more. At the end of the day, whether someone is able to eat more is their choice and their fate. Some people can function well, sleep well and lead a normal life at any weight.
But, if you have had anorexia it is ONLY weight restoration to a BMI above 20 that will even start to reduce some of the symptoms of anorexia (obsessions, excess hunger, feeling fat, sleeplessness, low mood and infertility). And it is only staying at a higher BMI for quite a long time that will make these symptoms go away. The bottom line for this awful illness which is not about food is, “stay thin, stay ill, no matter how much psychotherapy you do”.

While anorexia is not about food and weight “underneath” it takes a sustained period of eating to start the process of recovery.
So once a person has reached the turning point of wanting to get well, recovery is much, much harder than staying in the golden cage of the illness. For example; weight seems to go on first on the tummy and then will go to where it looks best after a while. Eating will be very scary. How on earth can someone do this on their own?

Recovery isn’t just about eating more calories, whether someone gets better depends on how that nutrition is delivered. This must be done really caringly, to ensure that the right balance of carbs proteins and omega fats are eaten. Depression is more likely to set in if the balances aren’t correct.

I have also found that people want to recover while continuing to avoid meat, eggs or fish. For people with eating disorders, vegetarianism is usually a symptom of anorexic thinking which can make it very hard to get all the right nutrition and “food for the brain”. Recovery thus also means targeting orthorexic thinking which is possibly the hardest thing of all and most fiercely resisted by the person who is trying to get well. This is denying the need to confront the orthorexia, which is the anorexia in another guise.

So how can we help people who have decided to do it on their own? Time and time again I find that people start strong and slip back when the going gets tough or when they confront the predictable effects of eating more for a while. Without the right support, they may go back to wanting to recover instead of doing the hard work which recovery entails. Denial sets in, like going on holiday without planning how to keep an eating plan on track.

What then is the right kind of support? I suppose I would have to ask the person what kind of support they really need. How do we get the balance right with giving the right kind of empathy, time and guidance together with some hard talk - such as “beware of pretending to yourself that this or that (like orthorexia or planning to run a marathon for charity) is not a problem.

Recovery from anorexia and fighting the anorexic voice is the bravest thing one can do. It’s like asking a mouse to fight a lion. Why aren’t there more websites giving active 24/7 support for people who have engaged with that fight instead of all those other awful sites.

Wednesday, 9 March 2011

How To Form A Habit

In the eating disorders training I put great emphasis on the simple need to change habits in order to help enable change in the relationship with food. This is because this relationship, which contains many subsidiary habits ( like how to binge, purge, buy food, where we eat and how we eat) is only part of a greater hierarchy of “being” habits which defines how you function in your personal life and your life with other peole.

Health psychologists are interested in habit change for obvious reasons: to assist people in breaking unhealthy habits while helping them adopt new ones. They call on a great number of theories about habit formation but no-one appears to have studied habits systematically as they are formed. NLP suggests that 20 repetitions of a behaviour are likely to make it stick. (Where did this come from?)

What all people seem to acknowledge is how hard it is to change habits. This is partly due to brain architecture, habits are laid down in neural pathways to fire automatically, giving rise to preferred ways of thinking, feeling and behaving in response to circumstances. The automatic firing of these neural networks frees up the brain to respond to more pressing and unexpected matters.

Habits are also hard to change because of the values associated with the performance of certain behaviours. If you are trying to get someone to refuse that extra piece of cake, it might conflict with that person's belief that restrained eaters are boring.

Habits have a great many components which must be taken into account. For example, giving up an unhelpful habit like nail-biting is not quite the same substituting one habit for a different one. I might add a habit rather than change one, for example if I decided to start eating apples for tea but continue to eat a bar of chocolate as well.

A researcher asked a group of 86 undergraduates to do a health related behaviour once a day for 84 days (like eat a piece of fruit with lunch or do 50 sit ups after morning coffee). She studied the patterns of habit formation. The findings were as follows:

• Early repetitions make it more likely that the behaviour becomes automatic.
• There comes a point where more repetitions don’t increase the chance this will become a habit. The best automaticity takes about 66 days but there are huge individual variations.
• More complex behaviours take much longer to form a habit.
• Missed days don’t seem to affect the chance of developing a new habit but “too many” missed days do have an effect.

What can we infer about making and breaking habits?

I don’t think we have learned very much. For one thing, the habit change was randomly suggested by the researcher and tells us nothing about the effect of each person's indivdual beliefs about the new habit or what is the mediating effect of self efficacy beliefs relating to the adapted behaviour.

So it’s back to basics. We have to help people become more flexible to promote health behaviour change. We still don’t know what it takes to make a difference.

With acknowledgement to ThePsychologist & the October issue of the European Journal of Social Psychology.

Monday, 7 March 2011

How To Manage Diet Talk If You Have An Eating Disorder

Talking about diets is part of everyday life. It’s in the press, on TV with the Biggest Loser series and it’s in fitness magazines, largely disguised as the quest for better health. On one of my trainings, a delegate told me that she had spent a 5 hour train journey listening to a group of girls talking about nothing else but dieting and ways of losing weight. Talk about diets starts in primary school and women can talk about diets for the rest of their lives. Even 90 year olds talk about diets, those that worked, those that didn’t work, those that are in today’s paper. The new weight loss wonder of the day.

It seems like talking about diets makes you part of a club. Membership of this club is admitting that you don’t feel you look right and you are trying to do something about it. There is companionship in this kind of club; we are all in it together. People who are not in the club can feel like outsiders. If diets don’t interest you, you are in the minority. If you are slim, people will say “well, you don’t have to worry”. If you are fat, they will imagine that you are not looking after yourself.

The more we talk about diets, the fatter we are getting, so talking about diets is a waste of time unless you are stuck for something more interesting to say.

People with eating disorders have a hard time listening to talk about diets. It’s bad enough thinking about ways of controlling your weight all the time without having to hear about yet another miracle diet that is helping your best friend of colleague “lose loads of weight”. Perhaps you will panic and think “maybe I should be doing this”. Well hold that thought, because the chances are that the diet won’t work. Nearly 99% of all diets don’t work in the long run. And I mean ALL diets, including those which happen after Christmas or those which come stamped with a seal of medical approval.

If you are recovering from an eating disorder, the chances are that you have been helped to give up dieting and work on your relationship with food, and with yourself. This can feel very scary. People with anorexia who are trying to recover say “why am I being told to give up restricting food, look at all those people out there all obsessed with diets and all trying as hard as they can to lose some weight. Why, if they see me eating they will suppose I’m greedy. ” It’s enough to make you want to go right back to where you were.

If you have had bulimia, or binge eating problems, you will surely be helped to use food to re-nourish yourself. You will have to re-learn how to eat all the danger foods without going out of control. How difficult it is to hear people say that this or that food is fattening and forbidden. Perhaps your friends are boasting that they aren’t eating carbs, or that you should only eat protein after 4 o clock in the afternoon. Perhaps they are telling you that their latest diet is only organic food or that wheat will make you fat. You may think of yourself as a bad person if you don’t do what everyone else is doing. But what they are doing is usually crazy.

So, dieting talk is very hard to hear when someone is trying to recover from an eating problem. What then can we do about it? I suggest that we need to develop a different way of listening to this talk without reacting to the feelings about what we are hearing. Here are some solutions and doing them gets better with practice.

When you hear talk about diets

1 Say to yourself “diet talk is boring and a waste of time and energy.”
2 Tell yourself “I’m Ok and I am learning to do things differently now.”
3 Remind yourself “A life on diets is a life badly lived.”
4 Remind yourself “Diet books only make money for the author.”
5 Remember that people who lose weight on any diet usually put it all back on again.

When you feel anxious around diet talk and dieting friends

1 Give yourself a mental hug and repeat “I approve of myself” (even if you don’t).
2 Tell your friends (in your head if necessary) that it’s better to work on your relationship with food rather than go on another diet which will only make your relationship with food even worse.
3 Take a very deep breath and wait for the feelings to pass, they will pass.
4 Remind yourself of all the reasons why you are giving up the dieting hoax.
5 Seek out someone you trust to talk about your feelings before doing anything else.

If anything else has worked for you, email Deanne on admin@ncfed.com and we will add this to our blog.

Sunday, 6 March 2011

Binge Eating – Now, There’s A Mouthful.

In today’s image obsessed world, we’ve all at some time wished for a svelte body or defined torso. Size zero is the new size eight and the photos in magazine are flawlessly perfect. It’s therefore little wonder that cases of anorexia and bulimia nervosa are tragically on the rise as people feel compelled to achieve the beautiful but impossible. As familiar as these conditions are, however, another, even bigger, darker problem, is far less recognised and understood: Compulsive Overeating.

It's estimated that around 1 in 4 adults suffer from binge eating problems at some time in their lives. I call it the Cinderella problems because it isn’t as sexy to the media as anorexia or bulimia. These problems are considered illnesses while binge eating is thought of as just being greedy and out of control. But I would guess that it kills more people than anorexia and bulimia combined, yet it still remains widely unacknowledged. Many sufferers do not seek help, either because they feel too embarrassed and ashamed, or because they don’t realise support is available.

I would even go so far as to say that it’s the emperor of eating disorders. It’s a double problem in terms of mental health and weight and, furthermore, it has serious health implications."

Compulsive eating goes under various names, such as “food addiction, binge eating disorder or Ednos (eating disorders not otherwise specified). Now, there’s a mouthful.

Whatever name we give it, there is an uncontrollable urge to eat, in some cases very large quantities of food, usually in a mindless state and in a short space of time. Milder forms of compulsive eating can involve smaller quantities such as going backwards and forwards to the fridge, or picking or nibbling. There are usually cravings for food seen to be forbidden, like chocolate or cereals. Most people say that they aren’t hungry, they just need to eat. Some people just nibble all the time. Night eating is a problem for some people. Many sufferers binge to suppress or distract themselves from difficult feelings such as stress, depression, anxiety, low self-esteem and self-loathing.

Indulging on on high fat, high sugar foods has a number of benefits. It can feel like a treat as well as a punishment. These foods at the same time offer comfort as the sugar provides a rush and foods such as chocolate trigger the release of endorphins that lifts mood. When compulsive eaters do not purge after a binge, many are overweight or obese despite the fact that they usually try to control their weight with one slimming diet after another. One person recently expressed her issues with me thus: I am only in control if I am on a diet, but I can’t seem to stick to a diet for long. Every diet, you name it I’ve tried it, but I am fatter than ever.

So – what is compulsive eating? I see it as a skewed relationship with food in which overeating occurs as an unhealthy coping strategy to deal with difficult emotions – TOGETHER WITH a mindset characterised by unhelpful beliefs and attitudes about food, weight, dieting and the self. The last point is important. To say that binge eating is JUST about feelings is not correct.

For one thing, binge eating can be induced by extreme weight-loss plans. Research shows clearly that dieting gives rise to cravings and binge eating in anyone, even if they are emotionally healthy.

Spotting the signs
One of the reasons it has taken so long to recognise binge eating disorders is because it is difficult to define what is a binge. After all, “One man’s binge is another man’s meal.”
What constitutes a ‘binge’ and defines Binge Eating Disorder varies greatly from one person to the next. While some people will be or become overweight, others might not. For many people it stems from an emotional trigger, but again, not always. Jade says, “BED is a troubled relationship with food, but you don’t always have to define it.”
To spot the signs of compulsive eating, ask yourself the following questions, but keep in mind everyone is different:
• Do I eat much faster than normal at times?
• Do I eat until feeling uncomfortably full?
• Do I eat a large amount of food when I’m not hungry?
• Do I eat alone or secretly due to embarrassment about the amount of food I consume?
• Do I feel guilty, shamed or disgusted after overeating?
• Do I feel I eat more than I need?
• Do I feel abnormal?
• Do I feel ‘taken over’ as if by another presence in respect of eating?
• Do I try to compensate for overeating by dieting or restraining food?
• Do I feel in control when surrounded by my favourite food?
• Do I feel insecure if I can’t eat my favourite foods?
• Do I eat mindlessly, in a rush as if I don’t taste it, or erratically
• Does eating interfere with and/or control my life?

It’s really not that difficult to treat. We concentrate on building up the person so they feel in control and strengthened. This can be achieved through some mental flexibility training, nutritional rehab, communication skills and stress training.

But we must have some focus on food. To change a relationship with food we first must look at it closely. We monitor patterns in binging to see what causes them. The binging patterns begin to inform the sufferer about their eating behaviour and help them to understand the emotional and other triggers.

If the triggers are emotional, or about buried emotions which are not being expressed, we must identify these feelings and help someone to deal with them more appropriately. If the triggers are about beliefs, such as feeling as if you have “blown it” if you eat a biscuit, people need to learn how to manage their thoughts. So keeping a log of your thoughts and your feelings is as important as keeping a log about food.

It’s also important to do some nutritional rehab. to beat compulsive eating, and this does not involve staying away from all sugar and white flour as suggested by some addiction programmes. Regular eating small snacks is helpful at first and we can use some new exciting methods for appetite sensitivity training and teaching mindful eating skills which can help people to feel in control surprisingly fast.

Eating control is also a family issue. We all feel that we should crack our problems on our own, but the support of family members can work a treat. It’s helpful not to have temptation in the house like crisps for the children or cake for your partner. Seeing these foods is too much temptation for everyone, not just binge eaters and your family would prefer you to be happy more than they need these treats.

When it comes to weight loss, there is no quick fix. If you don’t treat the eating disorder, you will be less likely to stick to a healthy-eating plan. Or, if you do lose weight, you won’t EVER keep it off. In other words, if left untreated, binge eating will leave a person’s chances at weight loss almost zero. And if they do succeed, in two years it’s almost 100% likely they will have regained.

If you think you might be suffering from compulsive eating, consult an eating disorder specialist. General counselling wont sort you out. Always check they have the relevant qualifications and experience. You can contact me, Deanne Jade on 0845 838 2040 or at www.eating-disorders.org.uk

Tuesday, 22 February 2011

Denial- Friend or Foe In Eating Disorders

I’ve been asked to blog about denial so here we go.
Denial is what happens when someone insists that they do not have a problem with food, usually in response to the concern of carers or friends who may notice that weight is low or that someone isn’t eating very well.
Some writers suggest that “denial is something that exists in the counselling room”. In other words the person who has a problem may know that there is a problem but doesn’t really want to be helped right now.

Let’s take some possible scenarios;
They do not trust that therapist.
They are afraid of getting fat or losing control.
They get benefits from their eating control such as feeling special and powerful , or getting some attention from loved ones – who would want to stop feeling these things?
They feel ashamed of their eating behaviour, especially if they are binge eating or purging.
Or, the anorexic voice drowns out the voices of concern from other people. This voice tells them that they will feel a little better if they lose a bit more weight.

Denial- any of the above - is more likely to be present in a person who is thin. Bulimics for sure know they have a problem although they may not want to admit to it. At the same time, denial can be real – not knowing that you have an eating problem and not knowing that you are very ill. Some people who are in recovery say that, looking back, when they were in the grip of their eating disorder they were so compulsive and obsessive with food, exercise and eating rituals that they had convinced themselves that they were fine. It was as if they had been taken over by an alien being, and only if they collapse might they begin to accept that they are weak and ill.

Even then, a few days of rest convinces them that they were just overtired and can continue doing what they were doing before. We use things like muscle weakness tests to help convince some people that they are weak and that they might need to get some long term help.

I see denial around me in a great many forms. I see it in people who choose unbalanced eating patterns and who are convinced that they are allergic to certain foods, or that they can’t eat meat because they “really love animals”. I see denial in people whose gym or running patterns are a front for an addiction to exercise and perhaps the only way that they give themselves permission to eat. I also see denial in people who say that they are “working on their problem”, by going to therapy and talking, but they may refuse to turn talking into action; probably because they are terrified of change.

I also see horrible and selfish denial in parents who insist that their child doesn’t have an eating disorder. The child is just doing a lot of sport and is getting along very well at school thank you very much. God forbid that this family has a problem. Let’s not rock the boat. On the other hand, about half of all the calls I get are from worried carers, saying “how can I get my daughter/son, wife and even parent to accept that they need some help”.

Us therapists have a hard time with denial; we either call it “unconscious incompetence” or we say that someone is really “in denial” when what we mean is that we haven’t the sensitivity, the skills, the patience, the pacing and the ability to bring ambivalence, fear and resistance to the surface and deal with it safely.

So how do we sum up all the above; perhaps to say that we are all in denial to some extent about the motives for doing what we do. We might be in denial about our eating habits, our use of alcohol, or the effects of too many late nights. There isn’t a one-size-fits-all solution to the problem of “denial” but if anyone out there has some stories or some perspectives to add, please email me on admin@ncfed.com. Please!

Tuesday, 15 February 2011

Top Tips For Treatment : Focus On The Core ”Cognitive Problem”?

“The core.... problem here is the over-evaluation of food, shape and weight as threats. This manifests as beliefs such as ‘If I eat normally my weight will rocket out of control and I will never be able to stop it".”
The eating disorder mindset is very much more complex of course. There are many other beliefs which affect our behaviour with food, such as beliefs about good foods and bad foods, binge foods and safe foods and making a tragedy out of eating an extra piece of toast. Even a fat person who thinks “I will die if I do not get my treats” suffers from a distorted mindset.
It might be useful to create a whole library out of all the beliefs we encounter in someone with an eating disorder. Some of these beliefs are really just the reflection of the “real issue” underneath, which is feeling out of control. Poor self regard, feelings of ineffectiveness, mistrust of others and worthlessness are the real source of the “cognitive problem.”
We must be careful not to dismiss some of these ideas. People do have differences in their “normal appetites” and there is a place for primary disturbances of appetite in how we think about eating disorders. This means that many people have to live in a continual state of mild restraint in order to control their weight. Is that “normal eating?” I may eat “normally” and I hardly think about food and weight. But I am pretty convinced that if I were to eat exactly what I wanted, I would be heavier than I am and possibly mildly overweight, which carries health risks. Saying “no” to an extra piece of cake is par for the course and part of the way we must respond to the world we live in if we are to avoid gaining a great deal of weight over time.
So, all psychotherapists must reflect on what normal eating really is before leaping to change mindsets, and that is a whole new essay. We need to discuss the idea of normal eating with our clients before we help them to amend their ideas. Many people with anorexia do not value “normal eating” because of other values associated with normal eating such as “people who eat what they like are greedy and disgusting”.
Or, conversely, some people with weight problems may not wish to eat normally if they believe that “people who eat what they like are fun loving and sociable”.

Professor Waller (CBT Today Dec 2010) states that if what we are doing does not explicitly target these beliefs it is not “CBT for eating disorders”.

The eating disorder practitioner needs to know more than CBT if treatment is to work. CBT while crucial does not work on its own for all people, especially for anorexia. It seems to me that framing up a therapy as belonging to a specific treatment model is safe for therapists, so when we have a new tool such as “mindfulness” we call it “Mindfulness based CBT” or, if we add emotional tools to our treatment we can call it “Cognitive –Emotional Behaviour Therapy”.

It really scares me however, to think of how many therapists don’t know or understand the principles of mindset change or how to do it. Empathy, giving our clients unconditional positive regard and even working on self esteem or early trauma isn’t enough. We owe it to sufferers to understand every aspect of how they think, how they process information (such as through the filters of all-or-nothing thinking) and how this affects their behaviour, before we should consider working with them.

Monday, 7 February 2011

Top Tips for Working with Eating Disorders: It Helps to Know Some Physiology

Its crucial, not helpful, to know some physiology. Glenn Waller writes in CBT Today Dec 2010 that we need to be able to give people "key information" about their eating disorder, the effects of starving and laxative abuse. Do you really get rid of everything when you purge? Are all calories the same? Is all fat wicked? Are carbs as dangerous as we are led to believe? What is the connection between your emotions and your eating habits? What are the secrets of what diet drinks do to your body? What does normal eating "look like?"

And what does dietary chaos do to your ability to control your weight? Can you turn your body into a fat-making machine just by drinking a lot of coffee? What is the role of the thyroid and does it matter? What is the chemistry of appetite? Does fullness predict weight gain? How can you manage a diabetic with an eating disorder?

How complex do you need to get to be sure that you know enough to be useful?

The eating disorder practitioner who practices constant CPD about the physiology of food, weight and appetite is the only practitioner doing their patient justice. You need to know a great deal across a wide range of rapidly changing fields, where even specialists have difficiulty keeping up with latest thinking.

Knowing the information is one thing. Knowing when and how to communicate relevant facts is something else. Using the information to help transform behaviour, some experimentation, some risk taking on the part of your clients, is the final must-do. Knowledge ONLY becomes power when it is felt in the muscle.

I have put up some useful information online to help your clients, such as on how much do you really need to eat and the effects of undereating. Visit http://www.eating-disorders.org.uk/information.html

Sunday, 6 February 2011

What Do You Want Me To Write About?

Please followers let me know if you would like me to write about something YOU are interested in for a change. You can email me at deanne@ncfed.com

Friday, 4 February 2011

Top Tips for Working with Eating Disorders: Are You A Coach or Therapist?

This point was raised in CBT Today Dec 2010 by Prof Waller. I introduce all my eating disorder trainings by asking this question. Eating disorders are usually treated by people who describe themselves as therapists because, after all, therapy is about healing the sick, or making ill people well. And therapists do therapy, which is what they are trained to do.
I don't like regarding all people with eating disorders as fundamentally sick. Much of their behaviour makes sense. The person with anorexia sees most women trying to lose weight. Fat people get such a bad break in our society that it almost makes sense to purge if you have eaten too much so that you can stay in control of your weight. It is quite normal for a binge eater to have cravings because dietary chaos makes their blood sugar very unstable.
Prof. Waller suggests that we should coach people to be "her (or his) own CBT therapist" so that the client can make good use of the hours they are on their own, over and above the hour or so they have in the room with their counsellor. I agree and yet feel that this means a great deal more than being a coach.
Do we concur with the view that CBT in its many guises is the best we can do so far for working with eating disorders? Yes, since we are working to change behaviour, and to change the eating disorder mindset and the emotions which inform behaviour, whether this refers to starving or binge eating on chocolate.
Changing the eating disorder mindset requires us to be a guide, to help our clients cope with their lifestyle, and a teacher to provide useful information to deal with myths about nutrition and calories.
But information on its own is only useful when a person has the skills to use it appropriately - so we may need to teach some basic skills such as relaxation or problem solving skills and communication skills to help people become more effective and able to use the information which we have given to them.
When we work on the eating disorder mindset, we also confront some important barriers to change such as how much you feel you need to weigh in order to accept yourself. To do this, we have to help a person to know and realise their deeper aspirations in life rather than simply attend to the eating disorder aspirations of being in control of food and weight. This subtle task is more about being a mentor for change by opening out possibilities which were not there before.

So, coach or therapist? Definitely both and more, and even being a bit of a magician wouldnt come amiss, although the evidence base for conjouring is not yet there.

Monday, 17 January 2011

Remember The Carers (And Try Not To Blame Them)

Carers can be a valuable resource in helping the patient to change. He adds that educating them in the treatment model can help them to assist the patient.There are now a great many books written specifically to help the parent help their loved one to fight the eating problem.
Therapists are taught not to attribute blame to families and to consider them a useful treatment resource. I can still remember, however, when family therapists such as Minuchin and Selvin Palazzoli claimed great success in treating anorexia by targeting unhelpful patterns in family behaviour such as detouring (avoiding issues) enmeshment (not giving the patient "space") and putting a nice face on no matter how you feel.
Families factors are also known to increase the risk of someone getting an eating disorder. There may be weight specific pressures such as mothers who go on diets and who are always groaning about their size, fathers who reward their daughters for losing weight, brothers or sisters who tease each other for being too fat, or even mothers who are overweight and their daughter says to herself "I surely do NOT want to look like you when I grow up!"
And there are pressures associated with eating disorders that come from families, like pressure to succeed, parents who teach their children to behave like adults all the time, and parents who put out messages that it is not acceptable for the child to have any feelings.
Personally, I have read hundreds of life stories from sufferers and from counsellors who want to specialise in treating eating disorders, many of them have had their own experience of anorexia, bulimia or binge eating. Sometimes I say to myself no wonder this person had an eating disorder when I read what has gone on in a family, the lack of caring, the abuse, the cruelty, the awful examples of weight control behaviour that has passed from mother to child.
Then I meet parents who bring their child for help and I ask myself, why is it the father who more often than not brings their daughter, while the mother is "busy" and the mother who usually brings their son because father is "busy" and do these patterns mean anything where the eating problem is concerned?
Many carers call us up at NCFED and beg us to give them some advice about how to help a loved one who is clearly suffering but will not admit to it. We have discovered, by experience, that even the most reluctant sufferer will come to accept some help if the parents come together to get some support for themselves in coping with the eating problem. This will often lead to an extended period of counselling for either the carers or for the sufferer. And how many eating disorder counsellors know what is going to be helpful?
So we rise to meet this need in the following way. We have some information on our website which can be useful for carers. There is a carers page and some information on our information page about how eating disorders are to be treated. http://www.eating-disorders.org.uk/helping_carers.html
We are also offering a 1 day Masterclass in Counselling Carers in April 2011 and hopefully also in 2012. Check out http://www.eating-disorders.org.uk/information.html and please come and join us on what should be a really helpful and inspiring day.
Acknowledgement to Professor Glenn Waller writing in CBT Today December 2010

Tuesday, 4 January 2011

More Top Tips For Eating Disorders: How Important Is The Working Alliance?

Professor Glenn Waller writing in CBT Today, December 2010 says that a good working alliance is necessary but not sufficient to bring about change in eating disorder symptoms. He says that despite the commonly held belief that this relationship is a key agent of change, the benefit attributed to the working alliance is "relatively small".
I agree. I have met hundreds if not thousands of sufferers who have not recovered despite getting along really well with their therapist. I have met people who are so good at doing therapy that they can deflect the therapist from the real work of change with all kinds of diversion tactics. If we tell a sad enough story we might even find therein reasons why we have an eating disorder but it may not really be the truth.
As a trainer I have suggested that being a good listener while being important, may sometimes deflect from the work that must be done to elicit and change the eating disorder mindset. Everyone needs to tell their story and the story must be heard - but sometimes listening must give way to questioning, guidance and teaching new skills including skills for thinking , or thinking about thinking as well. Some of the techniques of eating disorder treatment are not very person centered at all  (though they can be delivered with respect for the person who can "become").
I hope that therapists can suspend the need to be liked by their clients. The eating disorder client knows how to manipulate and sometimes wants to take a diversion from the issues that need to be faced. It is better to know the skills that eating disorders really respond to - so that respect for the therapist's competency can grow into the client's own self respect and self regard.
As Prof Waller says, there is evidence that when clients do change as a result of proper clinical practice the working alliance is enhanced, not the other way round. If you want to be liked, get a puppy. If you want to be trusted, be congruent.. If you want to help people change, know your stuff. Know nutrition, cognitive therapy, emotional resilience training, body image work, lapse prevention, when to stop listening and interrupt.The rest will follow.