BED7787 - SECTION 6: ADDITIONAL ISSUES IN TREATMENT: FEAR OF FAT AND CULTURAL PRESSURE
Apart from the general treatment approaches used to address BED, there is also a need to address the pressures of weight and eating at the level of cultural pressures to be thin. While many messages about weight and eating are delivered within the early family system, as a person moves forward into the larger community of ideas and values, the early family values can either be challenged or confirmed.
Unfortunately, patients with BED often have their worst fears about their weight and eating confirmed and heightened in their interactions with the current larger culture. For this reason, part of the reconfiguring and re-education of the BED patient's perceptual landscape will involve some dialogue about the values and ideals that create pressures to be thin – and shame about being overweight.
There are many angles from which one can approach this dialogue. In this section, we are going to cover some of this material, including through the use of examples of how to address some of these issues with patients.
The terrain into which the clinician will wade is not going to be easy. The communications of the clinician will be like a solitary voice in the wilderness, competing against the food and dieting industries, the fashion industry and magazines, the star making machinery of Hollywood, and the invented horrors of the popular groups at school.
All of the competing messages will be advocating for thinness, achievement, perfection, and only shame will be found in resisting and refusing to conform. These are the voices that fuel anorexia and bulimia, and bring heartache and rejection to those who can't stop themselves from overeating. The clinician's goal is to build a moat of resistance to minimize their impact.
There are many points of entry to this dialogue. If there are indicators that the patient is not locked into inflexible modes of thinking or eating, the healthcare professional may try to slowly engage the patient in talking about the differences between ‘real bodies’ and ‘magazine bodies’, as well as conversations about different ways of eating. Some patients (even grown-up women) may not realize that magazine pictures are air-brushed, that some different ways of eating may be satisfying.
It may also be helpful to educate the patient concerning the use of make-up for magazine models, even when the models look natural. This is to dispel the sense of dismay a patient may have concerning her own appearance in relation to the "perfect" images presented on the magazine pages. A quick look at the long list at the bottom of the page - citing the many brands of make up – may be helpful in restoring a sense of reality to the unrealistic images that are used.
Used with skill and care, humor can sometimes be a successful way to initiate more flexible thinking styles on the part of the patient around these issues. “I guess we are now all expected to hire people to airbrush us before we go out the door,” or “Ten minutes to take the photo, ten hours to put on the make up so she looks like that.”
The task of engaging the patient in treatment will involve finding a way to lessen the admiration for these impossible ideals, and strengthen the sense of belief in oneself when one is less than perfect. It may never have occurred to the patient that one has a choice about whether one wishes to honor the ideals forwarded by the fashion magazines. Engaging the patient in treatment begins with creating some awareness of that choice.
That choice will also touch upon some aspects of a deeper concern. Talking about models and magazines can also spark a conversation about the reality of one’s body. BED and the treatment that these teenagers and even adults endure involve a kind of objectification of the body, turning one's body into an object devoid of life that needs endless changing and may never feel good enough.
The objectification that occurs in fashion magazines supports this idea of turning one’s body into a tableau, which is why there is likely a connection between the reading of fashion magazines and the diminishment of self-esteem. This is also why you will most likely not see such magazines in the waiting room of a clinician who specializes in BED.
The conversations must ultimately lead to some understanding a multitude of factors that involve genetics, family life, culture and lifestyle. It may be that they view the achievement of that ideal as the most attainable way to handle the complex task of fitting in and defining themselves. It may be that they do not trust their ability to handle the complex challenges of moving into adult life with the body they have. They may have endured ridicule and bullying.
As that information becomes available, it will allow the clinician to begin to formulate a viable response or alternative to the patient’s life. For instance, the healthcare professional may want to lead the discussion towards other activities that that do not center on body image and a preoccupation with appearance, e.g., reading, walking, taking care of pets, etc. A clinician can also help an overweight teenager feel better about herself helping her come up with ways in which she can feel beautiful and feel good about her body. Yoga classes, doing her nails, finding a special fabric to make the dress she wants. A clinician can recommend websites and books that are accepting of many body sizes.
This conversation may spark an alternative that makes sense: a life where one lives fully for the enjoyment of being a complete person – not as an object whose only purpose is to quiet the voices that demand conformity to a cultural ideal.
Concern with looks and with weight
During the second or third session with an eating disordered patient, BED specialists often explain to their patients what their work together may look like. A way to explain their task is to talk about the patient’s worries about flab, pounds and fat. Patients almost always welcome someone that will discuss with them fat, flab and weight. Talking about their concerns about fat and weight and shape may be the first way to let them know that they are taken seriously.
If this conversation comes up during the time when you are assessing the patient, there are some approaches that might be considered. The clinician may want to take the following position: although the patient will always be welcomed to talk about their concerns with weight, their talk will be a bit different than the talk they may have with others.
The primary point of difference will be the effort of the clinician to translate the language of calories of weight and food obsession into some understanding of the pain and suffering that the patient feels when he or she eats, or when he or she feels fat. In other words, the clinician’s work will consist of a bridge between the patient’s focus on weight control and food reduction, and the emotional landscape that is producing the eating disorder.
This refocusing will need to occur for the patient to engage in treatment. As long as the patient focuses on his or her weight as being the problem, the solution does not consist of psychotherapy. It consists of losing weight. A bridge must be made to the idea that the patient is in some kind of emotional pain, and the focus on his/her weight is an attempt to manage that pain.
In this bridging process, the clinician might want to say that talk about flab and fat is like a language, a language that needs some translation. He or she will need to understand how flab, pounds and fat translate into pain and ugliness, as well as met and unmet feelings and desires according to the patient’s experience.
There are specific ways that this bridging process can get started. The clinician might say: “In my experience as a clinician, so far, fat is never only, about just fat, even when a patient may be fat, by social standards”. The clinician might add: "Fat is a code word that means different things for different patients, and I would like - with your help - to find out what ‘fat’ may mean, if anything, to you".
With these words, the healthcare professional prepares a field of interpersonal relationship with the patient. In this field the relationship is between two people: the clinician and the patient. The work is for both of them - as a team – and it can only be done if the two cooperate with each other. Eating disorder clinicians need to tell their eating disorder patients that together within a treatment partnership they will develop a language, a new language.
The patient is given the power to talk about his/her fat and say what it means to her or him. The clinician also leaves an opening for the patient to disprove the ideas of the clinician. The clinician states things in terms of "her/his experience so far", which leaves room for another type of experience. In doing so, the clinician leaves room for the patient not to feel cornered.
Among clinicians, BED patients are notorious for erecting defenses against their feelings and desires via food, eating, weight and weight control. While the clinician leaves room for the patient to" save face", the clinician asks the patient for help in trying to figure out what fat and weight and inches might mean for her or him.
“I understand your pain and that you feel right now that your thighs are too big. Your feelings about your thighs are true because they are feelings. But, I have found out, and I‘d like to know what you think, that when people talk about pounds, kilos and inches it is like a code. A code like shorthand writing for hurts, for certain thoughts and for a lot of emotional ache. It is a code even when you might be larger that the cultural ideal. The reason why I know this is because no matter the weight overweight people feel good about themselves at times. Because they feel good about themselves at times, even when they weight the same, it stands to believe that even when one is large, obsessive thoughts are about feelings”
The job of the clinician is to help the patient understand his/her inner life, the self perceptions of his outer body and the way in which she/he eats or does not eat.
Because these elements – perception of physical self, ways of approaching food and, inner emotional life- are intertwined, the clinician cannot reassure the patient that he/she needs to change her or his weight; or that she/he is too heavy. In fact, doing so would only replicate what others in the patient’s life might have done, so far. This assurance, in general, turns the patient off.
Concern of pounds, shape and weight are psychological symptoms that point to deep inner suffering. Symptoms cannot be taken away by reassurances. Symptoms need to be understood in context.
Clinicians listening to patients complain about their looks or weight need to take these concerns seriously. They need to be and act interested because under the talk of weight and pounds there is the reality of fear and emotional pain. In this context, ‘fat’, ‘flab’ and ‘thin’ are concepts that mean more than weight and pounds.
The added problem with BED is that patients do live in larger bodies and living in these larger bodies bring an added doses of discrimination and hostility that a clinician cannot ignore either and that in fact, needs to acknowledge and validate. In fact the treatment session may be the only place where everyday insidious mistreatment may be acknowledged. ‘Fatism’ may be the last -ism that is accepted.
Clinicians may need to engage their eating disorder patients or patients who show problematic patterns of eating, slowly and patiently. Hearing their endless complaints is a way to show them their eagerness to understand them.
Most importantly, today’s talk about fat during a session may have a different meaning for the patient than yesterday’s talk about fat. Yesterday fat might have been ‘code talk’ for laziness “I am fat and so I am lazy” while today’s talk may stand for giving in to forbidden desires “I am fat because I ate all that chocolate!, I am this person that wants so much from life, even chocolate, a boyfriend, a career”. Clinicians need to listen to the weight complaints to read into them how desires are weaved in and intertwined with food and pounds.
Oftentimes, clinicians working with BED patients will discover serious deficits in the ability of the patient to understand their own feelings, and very poor skills in the expressing of feelings. As the treatment process unfolds, clinicians must explain and model the language of feelings, the connections between thoughts and feelings, and then create a bridge linking these transformed skill sets to the concepts of pounds and shape.
“It seems to me that you spent all those hours eating out of control, and that now you are feeling so fat.” It seems that you ate the ice cream and all of the pizza and the rest of the food as if you were applying a band aid to a hurt. But, your hurt, did not need the ice cream, it needed maybe some other kind of band aid. Do you have any idea what it could have been?"
“Your feeling fat, could it be that it is about the feelings you swallowed when you swallowed all that ice cream? Do you remember having any feelings then?”
Patients, under stress, may resort back to old ways of dealing with pain and disappointment. Patients may eat compulsively and binge non-stop for a long period oft time. Anytime during treatment there could be setbacks that need to be explored to see if they are a part of a transference reaction, part of outside stressors that the patient is dealing with, or part of the ending of a treatment.
If a regression in terms of food and eating and body image perception occurs, the clinician will - again and again - need to remind the patient that fat and flab and feeling and feeling and seeing fat when looking into the mirror are ‘short hand and code words’ that need to be decoded in psychological and emotional terms, even if the person is fat by social standards.
In cases where the clinician is making a first assessment of a patient who is suspected of an eating disorder, it is the clinician’s job to find out:
a) The severity of the case that is in his office and
b) What would be an appropriate referral to make, if the clinician is not prepared to take the case on.
The clinician’s job in practical terms is to have the patient:
a) Engage in the process of the assessment.
b) Acknowledge that there may be a problem with the way he/she is eating.
c) Understand that his/her binges have crossed a line into problematic behavior.
In the clinician’s attempt to engage the patient in treatment, there are methods of helping the patient see the connection between their emotions and feelings, and their problems with food and eating. One of the most straightforward of these is to look for areas in their life that they have more ready access to strong feelings, and then link these experiences to what is occurring with their use of food.
Clinicians might be able to begin these conversations with offering the patient an opportunity to talk about some of their social disappointments with friends or relationships in general…or, if the patient has acknowledged the presence of eating concerns, by linking them in the other direction.
-“I don’t know what happened I just found myself eating one slice of pizza and then, the whole thing and then, I reached for the cookies, then, the ice cream, and then I ended up eating the batter from the pancakes just like that, not even cooking it. Then, I felt awful I was so full. I said, I would never do it again, but I just did, this is hopeless. I am not sure why I am even coming here…it’s like a whole mess…
-“May be, we can make sense of what happened and then, may be it will not feel so hopeless, such a mess…let’s see…Let me ask you a few questions. Yes, feelings can feel messy, but that is until you organize them a bit. Did you know you were going to binge before you began eating the pizza or it just happened?
-Kind of…, like vaguely, now that you say so… it was just, not planned, but I was feeling edgy.
-I see, what was happening before the pizza…
-Well, Melanie and Lauren came over and Justin was there too. Remember I told you I thought Justin liked me? Well, he was like all over talking to Lauren and then when they left I was cleaning up and began to eat and you know the rest.
-You have a right have feelings about what happened, sounds that at the very least you were disappointed. Looking back do you know what feelings were you having at the time?
More specifically, clinicians may also want to be on the lookout for episodes of intense focusing on physical appearance, particularly as this relates to peer and romantic relationships. Many eating disordered patients immediately - and unconsciously - move any feelings they may experience into the arena of body-size and eating.
This self-protective maneuver creates a serious and self-propagating problem for the patient. It prevents the patient from working on and developing better skills in handling complex feelings. The deficits in this ability to handle more complex feelings then cause the patient to feel more overwhelmed when problems arise in social relationships. The feelings of being overwhelmed then turn into a stronger focus on concerns about weight and eating.
Part of engaging the patient in treatment resides in the ability to break this vicious cycle, and in giving the patient hope that skills in handling more complex feelings can be successfully acquired. The automatic looping to a focus on food and eating must ultimately be broken, and the patient made aware of his or her tendency to do this.
To help make this linkage, clinicians might want to ask the patient to ‘replay’ slowly in his mind the events prior to the binge. This can be followed by education and other techniques to improve the skill sets required to handle complex feelings.
This approach can help the patient connect feelings with food , but can also be used to make connections to other aspects of BED, such as with exercising, or even with the experience of being too fat.
-Can you tell me what you were feeling as you were bingeing?
-I am not sure.
-I know you are not. After, all, it is difficult to think backwards. Do you think you could just kind of give it a try, even like, make it up?
-Well, I was feeling shy. I wanted to talk to Jessica yesterday and I could not. I was embarrassed so I began talking to Laurie. And then, we left and I realized I had not talked to Jessica. And then, I just went to the gym and was so embarrassed. I was the fattest guy. I hate the gym but I went/ All the guys were pumping iron. I was the only fat , obese person. So out of place. Then I went home and binged.
-So you went to the gym after you could not talk to Jessica?
-You have gone to the gym other times in this last three weeks after you began this program. I know it is never comfortable. But it is not always so uncomfortable either, Do you think it is related to not being able to talk to the girl you wanted to talk to.
-Yes, I guess it is.
-Maybe we can talk about the many ways in which you already are powerful, or ways in which you may want to feel more secure in the body you have.
Patient –Clinician Interaction
Of course, many patients have a negative and avoidant relationship with exercising, too. These patients refuse to do the minimal amount of physical movement. This can be seen in binge eaters and obese patients who are or are not binge eaters.
In these cases the clinician may need to deconstruct with the patient the meaning of his/her hate towards physical movement.
Patient - I hate exercising, forget it. I was at the cardiologist and he told me I need to, must do some walking. I hate it. I will not do it.
Clinician -You hate it.
- I do! I will not do it.
- Ok, you don’t have to, it is your choice.
- But, I have to. I have to. It is a health thing, not even looks.
- I see. You have a dilemma. You have to do something you don’t want to. And even if you hate it, you should but you don’t want to.
- And you don’t seem to think that not wanting to, lets you off the hook. But at the same time you don’t want to.
- Right, right (the patient now looks less defensive and probably feels understood)
- So why instead of focusing on the fact of you hating to exercise, which you do. Or you having to exercise which is what you have been told to do why don’t we focus on why is it that you hate it so much.
- Well, when I was a kid during gym at school…
In the previous case the clinician helps the patient get out of a stand off with his medical doctor and the prescription of having to exercise and moves onto trying to figure out the reasons why this patient does not want to move. Probably in this patient’s past the clinician may find out about teasing or about rigorous schedules of exercising that left the patient feeling as if he cannot enjoy his body.
Because resistance is so high with many eating disordered patients, the assessing clinician needs to have enough skill and wisdom to avoid driving the patient away from treatment as these important signs and symptoms are being addressed.
While the assessing clinician does not need to have the full set of skills that an experienced clinician in the field would have, he or she does need to have enough of a background to know how to build motivation for change and commitment to treatment or at least to get things moving enough so that he can know that the patient needs help with an eating problem so he can refer her or him to the appropriate person.
In this case, the clinician was skilled enough as a general practitioner to help the patient get unstuck from a pattern of no moving-no exercising that was pernicious to his health.
If the clinician does not feel prepared to deal with the body image and food issues that the patient may bring she must tell the patient so. The wellbeing of the patient is always the clinician’s priority.
While the most common age of onset is between 14 and 25 years of age, eating disorders occur in a wide range of ages, and are increasingly seen in children as young as 10.
Source: National Eating Disorders Information Centre of Canada (citing Cavanaugh, Carolyn J. and Lemberg, Ray. What we know about eating disorders: facts and statistics. In Lemberg, Raymond and Cohn, Leigh (Eds) (1999). Eating Disorders: A reference sourcebook. Oryx. Press. Phoenix, AZ)
Tips for Clinicians from BED Specialists
There are a number of key principles understood by clinicians who specialize in BED. It may be helpful for the assessing and referring clinician to have some idea of these tips, since they will be useful as the clinician attempts to secure the patient's engagement in treatment.
-Do not be judgmental about your patient’s actions. He or she is in pain, not trying to manipulate you.
-A fat thought is always about more than fat.
-Try to tie in ‘food to feelings’.
-Try to find in your patient’s discourse what feeling state he or she is in “It sounds that the diet that you are in today makes you so happy that you forgot that the last three times you began dieting, it did not go that well. But, what do you think will be different today?”
-Use food and feeding metaphors such as “You fed the hungry child inside you with food instead of with a kind word”
-Acknowledge that the pain of weight and shape is real.
To work with eating disordered patients is a long term commitment. As a healthcare professional it is important to remember, just like we remind our patients, that there is no magic pill to make it all well, just, a hopeful road to be traveled together, your patient and you.
The two factors that increase the likelihood of bingeing are hunger and negative feelings. Both are reduced with structured eating.
Source: Apple RF, Agras, WS. Overcoming eating disorders. A cognitive-behavioral treatment for bulimia and binge-eating disorder. San Antonio: Harcourt Brace & Company, 1997