Eating Disorders Resources and Support

Chronic Eating Disorders in Midlife

The development of anorexia, bulimia, or a related disorder in midlife is relatively rare, although it is becoming more common. Usually, an individual develops an eating disorder during adolescence and it continues in some form into adulthood. This might be because the illness went undiagnosed, the person was unable to find or stay in treatment, or the disorder appeared to be fully resolved early on, but resurfaced sometime later. This article addresses chronic eating disorders in midlife and how to approach them.

Resolving the Eating Disorder at Different Stages Eating disorders can be complicated and challenging to treat no matter when they begin. Generally, the longer someone has the illness the more difficult it is to change or resolve. An eating disorder that has been a part of someone’s life for 10, 15, or 20 years is different than one that has existed for a few months. Over time, the person with a chronic eating disorder feels she has fewer and fewer other options to cope with emotions and other facets of daily life. She also becomes less connected to other people as a consequence of the illness establishing itself as her strongest, if not, primary, relationship.

Often, a recent disorder will not have become as embedded in someone’s life, and in such cases a goal of treatment may be to entirely eliminate the problem. With a chronic condition, a more reasonable objective may be to develop additional coping strategies and ways the person can have a gratifying life, despite the presence, to some degree, of the illness.

Seeking Recovery After 30 Years A 43-year-old woman came to see me a few years ago. She had anorexia and bulimia for about 30 years and had been in a variety of treatment settings over the past decades. She was frustrated by her seeming “inability to recover,” and demoralized that every time she made progress in terms of food, weight, or being more involved in her life, she significantly relapsed, with enough weight loss to leave her medically unstable. She was sure she wanted to recover, but every time she relapsed she felt more like a failure.

Over the first few months in therapy we explored her idea of recovery—what about it appealed to her and what about it frightened her. She realized that after living with the eating disorder for so long she couldn’t imagine life without it. She began to understand the dynamics of her relapses: Each time she made a change in her eating or gained weight (for example, letting herself eat a new, previously “bad” or “unsafe” food), or when she participated more in truly living, she felt it meant she was moving toward totally losing the disorder, which terrified her, precipitating a relapse.

Since the approaches she had so far employed to work on her disorder had turned out to be largely counterproductive, we tried something else. We began to conceptualize a life where she could “keep” the disorder, as opposed to continually (and futilely) attempting to get rid of it. She was amazed at the idea that she might not have to “kill it off” and that she could stop expending so much energy in the service of an end result that she, in truth, felt was neither possible nor in her best interest. Giving herself this permission allowed her to explore other options, such as “How to begin to have more of a life I want, even though I might always have some part of this disorder.” It also freed her from her belief that she was “bad” and a failure since she hadn’t been able to fully recover after so many years of trying.

Managing the Symptoms In shorter-term eating disorders, the focus may be “How to fully resolve the disorder so the person can resume life,” the conceptualization being more akin to an acute medical condition. For example, imagine a course of action one might take in the case of a severe and suddenly occurring bacterial infection. All available resources would be devoted immediately and intensely toward eradicating the disease and returning the individual to health, ideally with little or no remaining effects from the infection.

In a chronic eating disorder, we’d do better to primarily work within the framework of “How can I live the best life possible?” as opposed to “How can I get rid of the eating disorder forever?” The difference in viewpoint can be illustrated by an approach likely taken with a chronic, as opposed to an acute, medical condition. One might hope for major gains in resolving the disorder, but the focus would more realistically be on managing the symptoms and additionally doing whatever one could do to assist the individual in having the fullest, most gratifying life possible. While this approach is not recommended for most cases, in chronic disorders it can be helpful.

No Relapses in Two Years The aim of acknowledging and accepting differences in treating and overcoming a chronic disorder is not to be pessimistic, but to be realistic, and in fact, as a result, hopeful. Working on one’s relationship the disorder is always a worthy endeavor. Remaining cognizant of the length of time the illness has been a part of someone’s life and consequently the nature of her relationship with the disorder, affords a structure within which to focus the therapeutic work.

The woman who came to see me a few years ago continues to work on her relationship with her eating disorder. The difference now is that she feels empowered and excited by what lies ahead, not ineffective and immobilized in her life. As a by-product, she has suffered no relapses in the past two years. Ironically, it has been “giving up the idea of recovering fully” that has allowed her to truly progress in recovery.

Johanna Marie McShane, PhD, has a private practice in Lafayette, CA. She is co-author of Because I Feel Fat. The second edition will be published by Gürze Books in early 2008.

Reprinted From: Eating Disorders Today

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Brothers and Sisters: How They Can Help You Recover By Walter Vandereycken, MD, PhD, and Ellie Van Vreckem, MA

They may be irritating and impossible at times, but your brothers and sisters may actually help speed your recovery from an eating disorder.

Over the many years that we have worked with families of anorexia nervosa and bulimia nervosa patients, we have learned how helpful brothers and sisters can be and the importance of their relationships with the patient and parents. Whenever possible, we try to involve siblings in therapy, regardless of their age or the fact that they are no longer living at home. All of the siblings are invited to participate, even those who other family members say are “certainly not coming” or “not important.” Most brothers and sisters react enthusiastically when asked to participate.

“Younger siblings may feel unfairly excluded if not informed about, or involved in, treatment; and not telling younger children might give the impression that they are part of the problem.” —Bulimia: A Guide for Family & Friends by Sherman & Thompson

Why should brothers and sisters be included in treatment? Siblings help clarify family interactions. First, siblings can help therapists understand and clarify past and present family interactions. They often have surprising and refreshing ideas about how the family functions. In this way, they can act as “consultants” to therapists, especially when issues between family members remain unresolved.

Siblings may act as “nurturers.” Brothers and sisters often lean upon each other for support, particularly in families that have poor parenting. One surprise is that real and genuine help is often provided by those siblings from whom one would expect the least help—for example, the “silent” sister who is having problems herself.

We try to understand each sibling’s position within the family and ask for everyone’s second opinions. If for some practical reason they can’t come to the treatment sessions in person, we interview them on the phone or ask them to write us a letter. We explain our treatment principles and goals in separate sessions. Usually siblings understand the significance of the eating disorder and its social effects very well. By understanding what is going on in treatment, siblings can also act as “co-therapists” at home, getting the family involved in discussions or more freely expressing their opinions about daily life.

Siblings can act as role models. Finally, siblings who have independent lives while keeping a positive contact with the parents can act as “models” to help patients make the often-difficult transition from child to independent adult.

Setting boundaries Siblings can be a tremendous force for good, but can also be part of the problem. For example, a sibling, usually an older brother or sister, can be over-involved or may try to act like a parent. Or there may be sibling rivalry or incest. Each of these problem areas is handled individually, with special sessions.

Although we have only touched on a few aspects of including siblings in treatment, our conclusion is clear: we can learn a lot from brothers and sisters. They help us deepen our understanding of eating disorders and enlarge the scope and potential of treatment.

The Authors Walter Vandereycken, MD, PhD, is Professor of Psychiatry at the Catholic University of Leuven, Belgium. Ellie Van Vreckem, MA, is Clinical Psychologist and Psychotherapist at the Eating Disorders Unit of the University Center St. Joseph in Kortenberg, Belgium.

Sisters with Anorexia Nervosa Question: Two of our three daughters have symptoms of anorexia nervosa. Is this common, and, if so, why don’t all sisters develop it?

Answer: The fact is, sisters of girls with anorexia nervosa (AN) do have an increased risk of developing this disorder because it does run in families. The good news is that only a few sisters of girls with AN also develop it. Eating disorders do appear to run in families, but we still don’t know why some sisters are affected while others are not. A recent study of 45 pairs of sisters gives us a few clues. In that study, those with AN differed from their healthy sisters in several ways. First, they were more perfectionistic and/or more likely to comply with their parents’ wishes. Next, they had feeding problems when they were infants. Daughters who developed AN also reported that their parents had higher expectations of them, and that they were highly competitive with their sisters. They thought their sister was their parents’ favorite and that she was more attractive than they were. The sisters with AN were also more likely to report sexual abuse. There were no marked genetic differences among the sisters (Psychological Medicine, volume 31, page 317, 2001).

Reprinted From: Eating Disorders Today

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Eating Disorders: Risk Varies By Age And Gender

Binge eating and purging can occur in boys and girls at a variety of ages, but the risk factors for these behaviors largely vary by age group and gender, according to an article released on June 02, 2008 in the Archives of Pediatrics and Adolescent Medicine, one of the JAMA/Archives journals.

Eating disorders, such as anorexia nervosa and bulimia nervosa, are syndromes that involve compulsive eating or compulsive undereating, and they generally are detrimental both mentally and physically for the sufferers. One habit common in these disorders is binge eating, when the patient eats uncontrollably for short bursts of time; another such habit is purging, in which the patient vomits or uses laxatives to limit the digestion of the food and thus control his/her weight. Body image and control issues have been attributed as causes for many documented cases of eating disorders but there has been very little research in teens who are not actively in treatment regarding the early development of these habits.

To help elucidate early causes of behaviors such as binge eating and purging, Alison E. Field, Sc.D., of the Children’s Hospital Boston and Harvard Medical School, Boston, and colleagues analyzed data from the ongoing Growing Up Today study taken between 1996 and 2003. In total 6,916 girls and 5,618 boys, aged 9 to 15 at the start of the study, were questioned regarding various habits and influences. The study examined various risk factors, including frequent dieting, attempts to mimic persons in the media, negative weight comments from fathers or from peers, and any maternal history of an eating disorder. It then correlated these risk factors to the development of frequent binge eating, purging, or both.

In the seven years of follow up, 10.3% of the girls and 3.0% of the boys began binge eating or purging at least once a week. For girls, purging was slightly more common, with 5.3% of the total population, while binge eating was less common with 4.3%. In males, the opposite was true, with 2.1% binge eating and 0.8% purging. A very small proportion of boys and girls engaged in both behaviors.

For girls under 14 years old, a mother with a history of an eating disorder was associated with a tripled risk to begin purging. However, this association was not true when patients were older. “Maternal history of an eating disorder was unrelated to risk of starting to binge eat or purge in older adolescent females,” the authors say. “Frequent dieting and trying to look like persons in the media were independent predictors of binge eating in females of all ages. In males, negative comments about weight by fathers was predictive of starting to binge at least weekly.”

The authors conclude that different risk factors are important for different groups of children. “Our results suggest that prevention of disordered eating and eating disorders may need to be age- and sex-specific. Efforts aimed at females should contain media literacy and other approaches to make young persons less susceptible to the media images they see,” the authors conclude. “In addition, programs for females should focus more on becoming more resilient to teasing from males, whereas programs for males should focus on approaches to becoming more resilient to negative comments about weight by fathers.”

Family, Peer, and Media Predictors of Becoming Eating Disordered Alison E. Field; Kristin M. Javaras; Parul Aneja; Nicole Kitos; Carlos A. Camargo Jr; C. Barr Taylor; Nan M. Laird Arch Pediatr Adolesc Med. 2008;162(6):574-579.

Written by Anna Sophia McKenney Copyright: Medical News Today

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Male eating disorders: how much do we really understand?

Last weekend’s transmission of BBC2’s Revealed…Manorexia highlighted the subject of male eating disorders. It’s a subject that’s not raised often enough, say some experts. After all it’s not unusual to read about women who have eating problems, but we seldom hear about how disorders such as anorexia and bulimia affect men.

‘Eating disorders are still rare among men,’ explains Dr Peter Rowan, consultant psychiatrist at Cygnet Hospital Ealing’s Eating Disorders Unit. ‘The incidence in males over the age of puberty who suffer with anorexia, for instance, is around 10 percent or so.

‘But the longer we study all eating disorders, the more we discover variations of disorder that don’t quite fit the classical diagnoses For instance, among women there are not only bulimics but there are also those who suffer with binge eating disorder, and, of course EDNOS (eating disorders not otherwise specified).’

According to Dr Rowan, there are also many men who have an unhealthy relationship with food who don’t fit the diagnostic criteria - which are, of course, designed for women. For instance some men are obsessed with fitness, but not necessarily because they are trying to change their body shape. Some may, for example, become addicted to exercise in an attempt to live longer and avoid coronary heart disease.

‘As a result, these men avoid certain types of food - for instance, fats - and some may develop a very unhealthy relationship to food and eat restrictively. And by doing so, they maintain a low weight,’ explains Dr Rowan.

‘It’s likely that there are more men than we recognise who have some form of abnormality of eating and attitude to food and weight - though most are probably not truly anorexic or bulimic.

‘However, it’s not clear whether or not these men should be described as ill, whether they have an eating disorder and indeed whether we should attempt to do anything about them unless they seek help. Many don’t seek help and although perhaps they should, they often lead pretty normal lives and don’t want to change.

‘On the other hand, those who do seek help are likely to have more severe symptoms and are more likely to fulfil the diagnostic criteria of anorexia nervosa or bulimia nervosa.’

How to get help

For men or women who are worried about an eating problem - whatever type of problem that is - help is available at the Eating Disorders Unit at Cygnet Hospital Ealing. The unit offers outpatient and inpatient treatment for a full range of eating disorders such as anorexia nervosa and bulimia for all patients aged 16 and over with a diagnosis of eating disorders.

The Cygnet Ealing’s EDU offers one of the largest and most experienced multi-disciplinary team of staff, including specialist consultant psychiatrists and medical team, experienced consistent nursing team, psychodynamic family, occupational, art and complementary therapists, dieticians and psychologists.

New patients are seen within 24 hours of the initial contact, some even at weekends. Treatment packages include full medical monitoring and therapeutic group sessions alongside individual work as well as family therapy. Patients also receive help with body image and achieving a normal approach to food, including planning, shopping, preparation and eating meals.

Cygnet Health Care

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At dinner time, parents will often tell their child to clean their plate. However, that old maxim might lead kids to eat more than they need, especially when portions are adult-sized or supersized.

In findings presented at The Obesity Society’s Annual Meeting on Oct. 7, children took more food when larger portions were made available to them.

Jennifer Fisher, Ph.D., associate professor of public health and researcher at the Center for Obesity Research and Education at Temple University, and her research team observed 61 children between five and six years old to determine their eating habits when normal entrée portions (275 g) and “super-sized” entrée portions (550g) were offered. The children used either teaspoons or tablespoons to serve themselves.

They found that while children served themselves larger portions when the super-sized meal was available, portion sizes varied by gender, ethnicity, and parents’ reports of child feeding practices - all environmental influences on children’s eating behavior.

Fisher theorizes that having large amounts of food available conveys a social expectation about portion size that condones larger self-served portions.

“Seeing a large amount of food in front of you can lead you to believe that someone decided this portion was the right amount to eat,” she said. “These results suggest that children take cues from their eating environments when deciding how much is enough.”

There currently is very little research on what factors affect children’s eating habits, but Fisher’s team hopes to pinpoint some of these factors to determine how children’s eating patterns develop, which could help stave off unhealthy relationships with food later on in life.

“We are interested in the cues that children take from their eating environments when serving themselves,” said Fisher. “Many questions about children’s eating habits are as yet unanswered, such as whether large quantities of food and large utensils prompt children to eat more or if the size of children’s self-served portions influences their caloric intake.”

Fisher and her team are currently exploring a number of different avenues to determine the association between the amount of food children are served and the amount they’re actually eating.

“Our goal is to try to identify ways to promote healthful choices from an early age,” she said. “We want children to grow up with good eating habits, and without having to struggle with food issues into adulthood.”

————- Article adapted by Medical News Today from original press release. ————-

Other authors on this study include Michael A. Grusak, Ph.D, and Sheryl O. Hughes, Ph.D, of the Children’s Nutrition Research Center at Baylor College of Medicine, and Leann L. Birch of the Center for Childhood Obesity Research at Penn State University. Funding for this research was provided by the United States Department of Agriculture.

Source: Renee Cree Temple University

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Many people equate the holidays with food big meals equals big times. Americans, especially, attach a lot of social and personal value to what, and how, we eat, often through family rituals or attitudes. For many, family gatherings are positive events, but for the 9 million men, women or young people who have an eating disorder, the holidays, without proper planning, can feel like nightmares.

Three out of four American women have “disordered eating” behavior, and 10 percent have an eating disorder such as anorexia or bulimia nervosa or binge eating disorder, says Cynthia Bulik, Ph.D., the William and Jeanne Jordan Distinguished Professor of Eating Disorders in the UNC School of Medicine’s department of psychiatry and director of the UNC Eating Disorders Program. Her latest book, “Crave: Why you binge eat and how to stop,” is due out in early 2009.

If you have an eating disorder, plan ahead. Bulik and the UNC Eating Disorders team offer the following suggestions to navigate the food minefields of the holidays:

– Have a “wing man” someone you trust to help run interference at family get-togethers or office parties. This should be someone who knows your triggers and can help distract you from temptations (or someone pushing your buttons), change the subject or assist you while you handle the stress.

– Make up a code signal or phrase with the wingman before going to the holiday party. If you start to feel overwhelmed give your friend the signal so that you can both step out of the room and they can offer you some support.

– Keep your support team on speed dial and call them at any time during or after a party. Talking relieves the pressure. You’re not overburdening them. They will undoubtedly have stories to share, too.

– Potlucks are your friends. Don’t hesitate to take a food you prepared that feels safe enough to you so that you will have at least one manageable entrée.

– Lavish holiday spreads don’t have to be the enemy. If faced with one, channel your inner Boy Scout or Girl Scout skills and be prepared! Before stepping in line, and before getting a plate, evaluate the options. Mindfully consider which foods you’ll sample, portion sizes and whether you feel comfortable trying a “feared food.” Make a decision and stick with it!

– If your treatment team has given you a meal plan stay on track so you aren’t starving when you get there.

– Listen with your heart, not your head. Hear the happiness and caring in a person’s tone when they tell you that you look “so much better.” They are saying they care about you. Don’t let the eating disorder lead you to misinterpret those words in a way that deprives you of hearing that people really care about you.

– Get Real! People too often have a fantasy about how “perfect” the holidays are going to be. When family members fail to live up to unrealistic expectations, it might be tempting to restrict or overeat in an effort to feel better temporarily. Try to anticipate some of the possible emotional traps in advance so you can cope (and maybe even laugh) when you encounter them.

– The well-known HALT slogan works for any type of recovery. Don’t let yourself get too hungry, angry, lonely or tired. This is especially important over the holidays.

– ‘Tis the Season to Forgive, so forgive yourself if you have an eating slip.

– Try your best not to skip appointments with your treatment team. It’s an important time to stay in touch with people who can help.

University of North Carolina at Chapel Hill School of Medicine 101 Manning Dr., 6002 East Wing Chapel Hill NC 27514 United States http://www.med.unc.edu

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What is Anorexia Nervosa?

Anorexia nervosa, in the most simple terms, is self-starvation. Anorexics (anorectic is also correct usage) are typically described as “walking skeletons”, a graphic image that depicts the pallor and frailty of these struggling individuals. Anorexics are also often characterized as stubborn, vain, appearance-obsessed people who simply do not know when to stop dieting. But anorexia nervosa is much more than just a diet gone awry, and the sufferer more than an obstinate, skinny person refusing to eat. It is a complex problem with intricate roots that often begins as a creative and reasonable solution to difficult circumstances, and is thus a way to cope.

Anorexia is Greek word meaning “loss of appetite,” which is misleading because only in the late stages of starvation do people in fact lose their appetites. Instead, an intense fear of weight gain leads anorexics to routinely and vehemently deny their hunger. In order to formally diagnose an individual with anorexia nervosa, clinicians turn to the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, 1994). The DSM-IV lists four criteria that an individual must meet in order to be diagnosed as anorexic, generalized as follows:

A. The individual maintains a body weight that is about 15% below normal for age, height, and body type.

B. The individual has an intense fear of gaining weight or becoming fat, even though they are underweight. Paradoxically, losing weight can make the fear of gaining even worse.

C. The individual has a distorted body image. Some may feel fat all over, others recognize that they are generally thin but see specific body parts (particularly the stomach and thighs) as being too fat. Their self-worth is based on their body size and shape. They deny that their low body weight is serious cause for concern.

D. In women, there is an absence of at least three consecutive menstrual cycles. A woman also meets this criteria if her period occurs only while she is taking a hormone pill (including, but not limited to, oral contraceptives).

The DSM-IV also differentiates between two specific types of anorexia nervosa. “Restricting Type” denotes individuals who lose weight primarily by reducing their overall food intake through dieting, fasting and/or exercising excessively. “Binge-Eating/Purging Type” describes those who regularly binge (consume large amounts of food in short periods of time), and purge through self-induced vomiting, excessive exercise, fasting, the abuse of diuretics, laxatives, and enemas, or any combination of these measures.

Reprinted From: Anorexia Nervosa: A Guide to Recovery

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Changing something that’s familiar to you, even if that “something” is harmful, can be difficult to do. When that “something” is an eating disorder, the motivation to change can be further complicated by your history, especially if you’ve previously tried and failed to overcome your problem or have spent a lot of time denying that the problem even existed. You may have little hope that you’ll succeed this time and assume that you’ll always be “stuck” in your current patterns. You might be skeptical about therapy and therapists. It’s only logical, then, that you’d hesitate to ask for, much less accept, assistance. Instead, if you’ve been through this before, try to “reframe” your present situation in positive, proactive terms. Whether you’re having a temporary lapse in recovery or a more severe, prolonged relapse, think of the flare-up as a wake-up call that you need additional help to renew your commitment to life without an eating disorder. If you’re starting this process of recovery for the first time, your initial challenge may be to admit that your problem won’t go away by denying it exists.

In fact, the opposite usually happens: the added strains of secrecy and lying make the situation worse. What will make it go away is your willingness to face up to reality and to work hard on your recovery. In either case, it takes a lot of courage to decide to face up to an adversary as tough as an eating disorder and then let a group of virtual strangers help you redirect your efforts and energies toward recovery. But you can do it. How to Find the Help You Need and Want Once you decide you’re willing to try therapy, the next step is to find the right kind of help. If you’re a teenager or young adult, your parents or guardians will help you do this. They’ve probably made most decisions about your health care, to date, and it’s possible you’ve never before had a voice in this process. But this is one time where your input is both desirable and important. How do you begin? What are your options?

1. Find a qualified therapist who has special training in working with anorexics and bulimics. The Academy for Eating Disorders (AED) (703/556-9222; www.aedweb.org) and the International Association for Eating Disorder Professionals (IAEDP) (877/540-5691; www.iaedp.com) maintain memberships lists of qualified therapists. Both of these organizations have stringent requirements for professional training before they will allow health care professionals to become members. (This doesn’t mean the therapists who aren’t members of either group are untrained or unprofessional. It may just mean that they have not applied for membership or haven’t yet fulfilled all the continuing education and training requirements for membership.) The AED also publishes an annual directory of health care professionals with information about each member’s practice (the geographic location of the office, if they work with children and adolescents or adults, if they do individual, family, or group therapy, how to make contact by phone, fax, or email).
2. Shop around. Since finding the right therapist is such an important part of recovery, call and/or interview as many people or places as you need or want to before making your decision. This is a common practice which is expected by most therapists. A family member might help you do the ground-work, but the more you’re involved in this process, the greater will be your commitment to therapy. In a way, this is similar to beginning a class in school that you’re initially hesitant about. Maybe you’re afraid you’ll be bored or worried it will be too hard. If you sit in the back of the room, never answer questions, rarely participate in discussions, then those negative expectations will probably come true. But if you sit up front, raise your hand a lot, and get involved in activities, you might like the class so much that you want to come back to the next session.
3. Make a “shopping list” of the qualities of the professional “helper” or “helpers” with whom you see yourself succeeding. Answer the following questions:

*Does the gender of the doctor or therapist matter to you? Why? If you are a girl, would you prefer a female practitioner? If you are a boy, would you prefer a male doctor or therapist? What are the reasons for your preference? Have you had a particularly good or bad experience with a same-sex or opposite-sex health care provider in the past that has caused you to feel this way?

*Would the age of the doctor or therapist alter your willingness to work with this person? Why? For instance, could you discuss your problems more openly with a young therapist because you’d feel more in sync? Do you think you’d have more confidence in someone older who had more professional experience? Is your reasoning based on actual past experiences with older versus younger teachers or doctors? Is your reasoning based on gut feeling?

*Does the therapist’s style of working with patients matter to you? Do you feel so overwhelmed at this moment that you think you’d prefer a directive, authoritative therapist with a clear-cut approach? Or would you like someone with a more flexible approach? Are you looking for someone who is willing to give you all the time you need to tell your story and explore your problems? Or do you want to work with someone who will dive right in and try to get things resolved quickly?

*Would you be willing to be seen by a health care provider who had worked with and was recommended by one of your friends or relatives, or would you prefer going to someone unknown by anyone else in your network of relationships? Why? Some people find that knowing about a therapist’s personality and reputation from the firsthand experience of a friend or relative eases the tension of initial visits and makes the thought of therapy a bit less unnerving. What qualities match the items on your own “therapist shopping list”? On the other hand, you might be concerned about privacy and confidentiality, and feel threatened by the thought that someone else who knows you also knows your therapist. Perhaps you’re concerned that you won’t be able to speak openly and honestly with a therapist who has a connection to your family or peers.

*Is there a chance that the location of the office might affect your willingness to work with the doctor or therapist? As odd as this question might seem, many people are put off by the location of some offices. This is often the case when appointments take place in hospital-based offices, because some people find hospitals to be intimidating. Perhaps the location is hard to get to: maybe it isn’t within walking distance from home, school, a bus or subway stop, or is so far from home that driving there and back takes a long time. Lots of people get sloppy about keeping appointments if getting to them is such an effort that the payoffs don’t seem to outweigh the inconvenience involved. Think about this ahead of time so that the office’s location won’t turn into your excuse to avoid or stop therapy after you’ve begun.

4.Make a list of anything you would want to ask a therapist.

• Here are some questions I’m frequently asked by prospective clients.
• * What is your educational background?
• * How long have you been a therapist?
• * How and why did you become an eating disorder therapist?
• * Do you or did you have an eating disorder?
• * Are you a licensed professional?
• * What is your preferred treatment approach?
• * How much does a session cost?
• * Do you accept insurance?
• * Do you have a sliding fee scale if I don’t have insurance that will cover your services?
• * Do you prescribe medications? How do you decide what medications to prescribe?
• * Will you work with me alone and have my family work with another therapist, or will we all work with the same therapist or therapy team?
• * Do you offer group therapy?
• * How often would we meet? How do you decide how many times we will meet?
• * Can I contact you between our scheduled sessions if I need to? Will those interactions be confidential?
• * Can I communicate with you by email? Will those emails be confidential?
• * What will you do if I disagree with your suggestions during therapy?
• * How long will it take me to know you’re the right therapist for me?
• * What if you and I don’t click? Can you refer me to someone else? Will you be angry with me?
• * Can I be forced into treatment against my will?Any concern you have is valid; it’s better to ask too many questions than too few.

When Negotiation Isn’t an Option The last question in the above list, “Can I be forced into treatment against my will?” is a very common fear of people who struggle with eating disorders. The answer to it is “Yes,” if your eating disorder is so far advanced that your life is currently in danger. In such a case, your preferences may have to be overridden by the choices that others must make, on your behalf and in your best interest, to save your life. You won’t have a chance, then, to negotiate and choose a particular style of therapist or treatment situation. You may find yourself in an emergency room at a hospital, or on one of the inpatient facilities discussed in Chapter 8. Until your health has stabilized to a point at which life or death is not the overwhelming and overriding concern, don’t expect to negotiate about anything, much less your ideal therapy situation. How to Improve the Odds for Success Once you’ve thought about the therapy environment in which you see yourself succeeding, and the style of therapist you’d like to spend such intense moments with, you may be more ready to talk about this with your parents, guardian, or any other appropriate person. Comparing your preferences with those of your family members should result in a win-win situation for everybody, even if it involves some compromise between what you want and what your family thinks you need. Whatever therapy situation you eventually end up in, give yourself credit for being actively involved in the selection process, approaching things logically, stating your needs and wants, and accepting the challenges of recovery. Whomever you choose to work with, you must be honest and accurately represent your problem. It’s especially crucial that you tell them about any and all physical problems along with the emotional issues that are bothering you. No therapist is a mind reader. If you don’t speak candidly, he/she might not ask you about the issues or situations that you feel are problematic and important to discuss. Worse, the therapist may diagnose and want to treat you first for something other than an eating disorder because you’ve been dishonest about your signs, symptoms, concerns, etc. A New Base of Competence By doing all this thinking and pre-planning, you’ve effectively changed the focus of your life from problems to solutions, from negatives to positives. You’ve made a commitment to therapy and taken the first steps. You’re now at a potential transition point in your relationship with family and friends; you’ve confronted yourself and your eating disorder; you’ve admitted the need for help and taken the steps to find it; you’ve shown your strength and guts, and your willingness to grow. You’ve proven that you can be assertive and self-aware; your words and actions show that you can be capable, rational, and assume appropriate control of some aspects of your life. You are building a foundation of competence-success breeds success, and confidence comes with competence. Competence is a powerful word that implies readiness, skill, ability, fitness, and proficiency. From this stage of recovery on, others will continue to believe in and respect your competence as long as you remain well-informed and honest about the changes that are happening in your life. Familiarizing yourself with the clinical definitions of anorexia and bulimia that you will find in the Appendix of this book might make it easier for you to discuss your symptoms with your therapist. Take your responses to the EAT-26 (in Chapter 4 on anorexia) or your answers to the statements about bulimic behaviors (in Chapter 5 on bulimia) with you to your initial therapy sessions. Also, bring your written responses to any of the exercises throughout this book. The more concrete, current data you share about yourself, the more raw material your therapist will have to work with.Ten Things to Remember About Finding a Therapist

1. Your input in finding a therapist is a desirable and important element in the selection process.

2. If possible, find a therapist who has special training in eating disorders.

3. List what you think would make your therapy experience successful, including characteristics of the type of place and kind of person you imagine helping you.

4. Take the time to compare and contrast your preferences with those of your parents or guardian, and see what kinds of compromises can be reached so you all feel confident.

5. Write out a list of questions you want a therapist to answer to help you and your parents decide.

6. It’s okay to talk with several therapists before making the final decision about whom you will hire to work with you.

7. If your health is in grave danger, your choices and preferences may have to be overridden by immediate choices others must make to save your life.

8. No therapist is a mind reader. Once you make the commitment to therapy, it’s crucial that you’re honest and describe your physical and emotional issues with as much accuracy as possible.

9. Choosing a therapist is an unmistakable signal to family and friends that you have the courage, strength, and willingness to challenge and change your eating-disordered ways.

10. Your willingness to learn and share about your self and your disorder with your therapist will greatly increase your feelings of competence and confidence.

From: The Beginner’s Guide to Eating Disorder Recovery By Nancy Kolodny, MSW, LCSW

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Nourish yourself physically, emotionally and spiritually. Accept that everyone has needs, legitimate needs, and you don’t need to be ashamed of yours. Learn how to meet your needs in healthy, responsible ways. If you make yourself feel needy, you will be tempted to look for comfort in diet books or the refrigerator. Especially make sure that every day you spend time with friends. In person is best, but phone calls and e-mail are better than nothing.

Also every day spend time doing things you are good at, things you can take pride in, things that demonstrate your competency and abilities. Allow yourself to enjoy your accomplishments and refuse to listen to the nagging inner voice that insists you could do better if only you tried harder.

Schedule something to look forward to every day, something that’s fun and pleasurable. Watch comedy videos and laugh out loud at outrageous jokes. Play something — a board game, a computer game, a musical instrument, tapes or CDs. Go outside and enjoy the birds, trees, flowers, and fresh air. If you live in the middle of a big city, go to a park. Make something with your own hands. Figure out how to give yourself a fun break from the daily routine, and then do it.

Keep tabs on your feelings. Several times during the day, especially in the first stages of recovery, take time out and ask yourself how you feel. If you notice rising stress, anger, anxiety, fear, sadness — and even strong joy — be alert to the possibility that you may try to dull these strong emotions by turning to, or away from, food. Find a better way of dealing with your feelings such as talking them over with a trusted friend.

Do someting meaningful every day, something that gives you a sense of having made the world a better place, if only in some small way. If you do this consistently, you will build a sense of your dignity, value and ability to make a difference in your world.

The 12-step folks have a useful formula. When they feel on the verge of falling into old behaviors, they say HALT! Then they ask, “Am I too Hungry, too Angry, too Lonely, or too Tired?” All of those states are strong ***** triggers. Additional triggers for people with eating disorders seem to be Boredom and Unstructured time. If you find yourself stressed by any of these feelings, figure out a healthier and more effective way of dealing with them than ***** eating or starving.

If you feel yourself slipping back into unhealthy habits, call your therapist and schedule an appointment. Returning to counseling in no way means you have failed. It means only that it’s time to reevaluate and fine tune your recovery plan.

ANRED Anorexia Nervosa and Related Eating Disorders, Inc.

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