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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