School, Eating Disorders, and Academic Achievement: A Formula for Failure

Most parents don’t like to watch their children suffer. When parents encounter a suffering son or daughter they become solution-oriented, looking for the quickest means of alleviating the problem. Parents who have a child with an eating disorder are the same. Unfortunately, the problem in using this tactic with a child who suffers with an eating disorder is that the sufferer develops complicated and often distorted thought processes. As a result, what appears to be the logical and quick solution to a problem may produce the opposite effect in an individual with an eating disorder. In fact, an individual with an eating disorder can twist perfectly normal and loving statements into negative affirmations of self that trigger greater entrenchment into the eating disorder. Thought distortion in an eating disorder sufferer affects every aspect of their life, especially behavior and achievement in the socially intensive environment of school. One of the ways parents unknowingly promote increased entrenchment in their child’s eating disorder is to encourage their continued and even enhanced involvement in school with hopes that it will eliminate the problem when, at the same time, the child is actively distorting the messages they receive because of the eating disorder.

THE PROFILE OF A TYPICAL EATING DISORDER SUFFERER

An eating disorder sufferer is a contradiction in behaviors. An individual who is deeply entrenched in a disorder displays a set of characteristics diametrically opposed to their behavior when not suffering with the disorder. They become listless, withdrawn, emotionally numb, unexpressive, disinterested in activities, anti-social, and incapable of concentrating. Once they work through their distorted thinking they revert back to their real selves – sensitive, intelligent, outgoing, involved in many activities that reveal their many talents, able to focus on multiple projects, and very giving and loving.

Amy is a beautiful and gifted senior in high school. She is a cheerleader, the English Sterling Scholar from her school, writes beautiful poetry and stories, and is very active in school affairs. Amy has rebounded from an eating disorder that completely disrupted her life. She writes,

“Eating disorders are born, raised, and sustained by negativity; it is the bitterness I experienced with my eating disorder that allows me to appreciate and savor sweetness much more than I did before… Like any addict or substance abuser…I refused to think I had a problem. Not until I had been hospitalized for nearly three months…did I realize the horrific consequences brought about by my eating disorder. It had made me into the person I strived NEVER to become: I fought with my parents, I said things I will forever regret, I lied, I stole, I slipped in my studies, I isolated myself, twice I was tempted with suicide….ultimately, everything I had worked for and wanted was either gone or going as a result of my eating disorder. I lived in a grey haze which never cleared and allowed the little light left in my life to wane systematically.”

The contrast between ED behaviors and healthy behaviors are drastic and frightening. Parents who witness this transformation in their child’s behavior, from a bright, energetic, and out going person to the opposite, react with a swift desire to alter the trend. Unfortunately, very often the tried and tested methods of eliminating suffering and changing undesirable behaviors are the very things that make the disorder worse. Telling a daughter, “You are beautiful and don’t worry!” usually is interpreted as, “She feels she needs to say that because I am so ugly,” and the command, “Eat all the food on your plate!” may be interpreted as, “My parents want me to be fat and unpopular at school.”

THE SCHOOL ENVIRONMENT

One of the most obvious evidences of something going wrong in the sufferer’s life is the impact the disorder has on school achievement. The sufferer’s normally very good grades start to slip. They begin to withdraw from activities and become more antisocial. They lose interest in school subjects and extracurricular activities. They lose their ability to focus on important projects, papers, and tests. They become much more sensitive to what is going on around them and what others may be thinking about them.

“I could not stay focused on my school studies. My concentration level was terrible and I could never read book assignments without my thoughts wandering. I was always too tired to stay awake, and more often than not my head was on the desk top sleeping. All of my energy went towards my eating disorder. It was first priority.” – 19-year old woman

“My concentration level decreased, I skipped classes, isolated myself from friends, and didn’t care about grades. I went from A’s and B’s to D’s and F’s.” – High School Junior

School is a quick-paced, unrelenting, socially competitive, and demanding environment. When you combine this with the changes that are taking place in the lives and bodies of young men and women, it becomes a potentially threatening and frightening place. If an individual starts to wonder and worry about their social and intellectual status, the school environment can become a very intimidating place. For an individual suffering from an ED the school environment is filled with messages that can be twisted and confused. The whole experience can become too overwhelming to bear.

“My anorexia destroyed my concentration, my drive, my love of school, and my performance in classes. Education no longer played a vital role in my life. My anorexia preoccupied and consumed all of my time, leaving little time for school and studies. Anxiety-producing stress only exacerbated my anorexia, which, in turn hindered my performance.” – College Freshman

Parents looking for the quickest and most logical means to alleviate the disruption of anorexia or bulimia causes in the family encourage their eating disordered child to become more involved and to work harder to display their natural talents and abilities in their school settings – Talents they know their children have because they have observed them for years. The child unable to cope with the negativity they sense all around them in school, reacts in the opposite manner and starts to withdraw and shut down even more. They know what they feel and are confused about their inability to cope with the seemingly simple solutions their parents offer. They very naturally start to believe that something is wrong with them, i.e., that they are a social outcast, unable to fit in, and undeserving of good things.

“My eating disorder destroyed school for me. I hate school and I sleep through anything. My focus isn’t on anything but my eating disorder and so school is a waste of time.” – 21-year-old woman

UTAH STATISTICS

Over the last year approximately 4000 junior and senior high school students in Utah County and Las Vegas Nevada have filled out an eating survey designed to assess ED behaviors. The results of the survey suggest that approximately 6% to 13% have already developed a diagnosable eating disorder; 30% to 35% have attitudes and beliefs about food and weight that fall into the abnormal ranges and that put them at risk for eventually developing an eating disorder. These findings document that there is a great need for effective education and prevention programs.

A TEACHER’S DILEMMA

It is important for teachers to understand the impact of anorexia and bulimia so they can pick up on the signs and consequences among their students. Since most students with anorexia and bulimia are very bright and talented it can be difficult for teachers to pick up student’s subtle changes in feelings and attitudes before their academic performance suffers. Consequently, knowing that 2 out of 10 girls in their classes are at risk for developing an ED presents a dilemma about when to raise concerns about anorexia and bulimia. Thus, it is helpful to raise the subject matter at different times throughout the year in general fashion. Doing this will encourage students struggling silently with the pressures and stresses of life and school to talk to you or a school counselor in private before they develop eating disorder behaviors that disrupt academic performance. The fact that a teacher is willing to broach this subject in an open and general fashion can be perceived as a safe invitation for students afraid of negative consequences of an eating disorder to do something for themselves.

Another dilemma for teachers is often in how to approach a student about a suspected eating disorder that is disrupting personal and academic performance. Most girls with a disorder will deny, minimize, or lie about the problem when confronted directly. They often feel ashamed of who they are and their behaviors. It is important to not make direct accusations about concerns, but rather, gently talk about what you are seeing as a teacher and encourage them to talk to you, or someone else, when they feel more ready to do so. Raising the concern in their presence and then giving them room to come back to you, whether they are struggling with an eating disorder, depression or some other personal problem, will let them know that you have noticed, cared, and have offered a kind invitation to do something about it.

For the student more entrenched in the ED, another dilemma for a teacher is whether to tell other school personnel or the parents about their concerns. Sometimes parents are the last to see the eating disorder because they want to believe their daughter’s responses to their questions. It is important to first talk to the student in private. Explain that you need to do something to help them rather than ignore or avoid the problem. Then give them some time to get back with you about who they are willing to let you talk to about the problem. For many girls with eating disorders it was the persistence and honesty of a significant other that led to their decision to seek treatment. For those girls who are too afraid or angry to admit to or address the eating disorder, it is very important to make more people aware of their problem including the parents so that teachers do not become silent collaborators of the disorder. The student may not be ready to change but they will know the secret is out.

POSITIVE STRATEGIES FOR TEACHERS

There are a number of things teachers can do to help their students:

Encourage counselors in schools to start support groups for those who struggle with eating problems and body image concerns. Develop working relationships with counselors who can do one-on-one work with students and who can refer to outside professionals. Encourage the school to have assemblies or combined classes where outside professionals and recovered eating disorder sufferers can do presentations for the students. Provide materials and information that students could review on their own. Conduct a school-wide awareness program during national eating disorder awareness week in February. Be sensitive to the reality that eating disorders are about psychological and emotional pain and conflict and not about food and weight. Actively give invitations and encouragement to students to get help to overcome their eating fears or disorders. Talk to other teachers informally to develop a network who can identify at-risk students and offer support to those identified students.

POSITIVE STRATEGIES FOR PARENTS

Parents can help their daughters by doing the following: Do not treat this problem as just an academic issue, but rather recognize the emotional roots of anorexia and bulimia. Be open to feedback from teachers, counselors and others who can help. Educate yourself on the causes, impacts, and treatments of eating disorders through literature, books, seminars, and the Internet. Talk to your daughter about what’s underneath the disordered eating behavior, don’t just focus on the eating patterns. Recognize the need for proper assessment, dietary counseling, medical consultation and outpatient and inpatient therapy treatment. Get involved in a parent support group. Talk about the issues and possible solutions to eating disorders with the whole family. Don’t be fooled by a daughter’s attempts to minimize and ignore the real problem, be firm about the need for recovery while being sensitive to not forcing the issues. Be a good role model around food, take care of yourself, don’t blame yourself, and be patient. Recognize that recovery takes time and don’t place unrealistic demands for a quick fix for your daughter’s eating disorder.

THE EDUCATIONAL PHILOSOPHY AT CENTER FOR CHANGE

A fundamental belief at Center for Change is that education is a basic right and opportunity for all human beings. Eating disorder sufferers are inhibited in their ability to take advantage of academic education opportunities. An individual with an eating disorder can forfeit their right to an education because of a basic belief in their inability to do what is necessary to meet educational goals and cope with the educational environment. At Center For Change we recognize that fundamental to the gaining of an education is the ability to: (1) take advantage of educational opportunities (i.e., have appropriate social, coping and learning skills), (2) maintain personal motivation for educational activities (i.e., learn to love education), and (3) believe in one’s personal ability to achieve educational goals (i.e., believe in one’s ability to cope with the environment in addition to meeting class requirements).

Center for Change incorporates an educational philosophy and program designed to help participants become able, motivated, and self-efficacious learners and continue their academic educational development. The goals of the educational program are designed to augment the intensive care the Center utilizes to overcome an eating disorder, thus providing a powerful and synergistic therapeutic and academic experience.

The Effects of Media on the Skinny Side of Eating Disorders

What is the most deadly psychological disorder today? If you guessed an eating disorder, then you are right. According to WebMD, eating disorders are illnesses that cause a person to adopt harmful eating habits. So, does this make WebMD just a great resource, or is this really true, and is an eating disorder really a dangerous illness? Most sufferers of an eating disorder are often mocked about their problem, and they are not taken seriously. People should not misinterpret or disbelieve sufferers of an eating disorder because it is, in fact, a very serious illness. There are, however, minor cases of eating disorders but there are far too many deaths related to them, thus we must take this issue very seriously and approach it with care.

Why are eating disorders the greatest killers among the many different psychological disorders? This is because of the media, as well as the disorder’s dramatic and deadly affects on the body. Today, media is in our lives no matter where we go. From television, radio, and the news, to magazines, newspapers, and the internet, media plays a big role in the spreading ideas, norms, and styles to people. Media spreads information really quickly to millions of people. Media is around people no matter where they turn, and they face it on a daily basis in some form. So, how is media related to eating disorders? This question, and many other questions, will be answered after we get a better understanding of what an eating disorder is, its characteristics, statistics, and ways to prevent and treat it. I will, however, focus only on anorexia and bulimia because they are more affected by the media than overeating disorders are.

People with eating disorders obsess about their intake of food, and they spend a lot of time thinking about their weight and body image. Their body is badly affected both emotionally and physically. People with an eating disorder may suffer from a number of different symptoms, and not everyone gets the same symptoms as they vary from individual to individual. According to the Help Guide-Mental Health Issues, even though anorexia is the most revealed eating disorder in the media, bulimia is the most prevalent eating disorder.

A person suffering from anorexia sees themselves as fat when they are, in fact, skinny and underweight. Their weight does not match their height, activity level or age. They get bad memory, feel depressed, have a fear of gaining weight, feel light headed, and often faint. Women with anorexia may have problems with their menstrual cycle such as missed or late periods, as well as trouble getting pregnant. Woman who are pregnant have a higher risk of a miscarriage and a higher risk to need to deliver their baby through C-section. People suffering from anorexia can also have muscle and joint problems, kidney stones, kidney failure, anemia, bloating, constipation, low levels of potassium, magnesium, and sodium in their bodies, low blood pressure, slow heart rate, and heart failure. Some physical signs that can be seen on a person suffering from anorexia are dry or yellow skin, brittle nails, more hair growth on their body, and thin and brittle hair. A person with anorexia may also get cold easily, bruise easily, and feel down a lot.

A person suffering from bulimia can get the same effects as a person suffering from anorexia since both disorders involve the loss of major and rapid weight, which leads to very unhealthy changes in the body. Symptoms between anorexia and bulimia sufferers differ in the way that sufferers of bulimia would eat a lot of food in a short amount of time and then force themselves to throw up, when people with anorexia just don’t want to eat altogether. People with bulimia also misuse laxatives and go on strict diets of fasting and rigorous exercising. Sufferers from eating disorders in general are affected emotionally, psychologically, behaviorally, and socially. Emotional and psychological changes include increased anxiety, depression, suicidal thoughts, guilt, and low self esteem. Some changes in behavior of a person suffering from an eating disorder include dieting, frequent visits to the bathroom after eating, a change in fashion, and constantly checking their weight. Some social changes of a person suffering from an eating disorder may include isolation, being anti-social, avoiding social gatherings where food is involved, and a loss of interest for hobbies. Other physical signs of eating disorders in general include edema, a reduction in metabolism, sore throats, stomach problems, heartburn, and hypoglycemia; which leads to irrational thinking, shaking, confusion, irritability, and comas.

Eating disorders have a big impact on society on a small and on a large scale; meaning both individuals and society as a whole dedicate significant parts of their lives to the struggles of dealing with eating disorders. A lot of money and time go into the troubles of dealing with an eating disorder, as well as into the measures taken in order to treat and prevent them. Eating disorders are very common amongst celebrities, mainly because their profession puts pressure on them to be skinny. The majority of celebrities that we see in the media are all skinny, and most of them are anorexic or bulimic. The fans of these celebrities look at the bodies of their idols and they want to be like them. The problem with this is that anorexic and skinny celebrities do not make good role models for their fans because their skinny figures are not a healthy look to follow. Famous people believe that in order to be successful they must be skinny. This is not true. Celebrities expose their looks and body image to the media where fans can see them and get the wrong idea that their idol’s looks are acceptable when their idols are only trying to lose weight for their own “success”. In a weight article, Monica Seles stated that “Women in society have much tougher pressure to be thin.” It is like a cycle; celebrities are skinny in order to impress their fans and companies. They send their fans the wrong idea, thus making their fans lose weight. In the end, everyone has the idea that they must be thin and they must lose weight, thus, being skinny becomes the norm.

According to the article “Eating Disorders and Body Image in the Media” by Heather Mudgett, media can be very hypocritical because while the media shares news about celebrities dying from eating disorders, it also contains images of underweight celebrities modeled as if everyone should look like them. We might also see an article about a person dying from an eating disorder in a magazine, and on the next page we might see an underweight model, modeling a popular product. The underweight images of people in the media give consumers the wrong idea that being skinny is OK and that there is nothing wrong with it, when, in fact, being that skinny can lead to a person’s own death. Consumers spend so much money on products and services that will help them lose weight, such as weight loss drinks, nutrition bars, pills, laxatives, weight loss videos, and they even take weight loss classes. People also misuse drugs and liquids in order to force themselves to lose weight, and this can be very stressing to the body. Any time that we do something against our body’s natural functions, we hurt our body and put ourselves at great risk to further health problems in the future.

So many celebrities suffer and have died from eating disorders. Singer Karen Carpenter was struggling with anorexia and bulimia and after she went to treatment for years, everyone thought that she had recovered and was doing better. After that, she was found dead on the bathroom floor in her parent’s house. She had a heart attack and it was said that the result of it was because she had abused the drug Ipecac for years. Ipecac is a liquid that is used to induce vomiting, and it is often abused by anorexics and bulimics.

According to the South Carolina Department of Health, about seven million American women and one million American men have an eating disorder. About one in every two hundred women in America has anorexia, and about two or three out of one hundred women have bulimia. About half of Americans know at least one person who has an eating disorder. According to the National Association of Anorexia Nervosa and Associated Disorders, about 5% to 10% of people diagnosed with anorexia will die within 10 years of having the disease, about 18% to 20% of people will be dead after having the disease for 20 years and only 30% to 40% of people will recover from it. It is very scary fact that the rate of mortality for people with anorexia is twelve times higher than the rate of death of all of the causes of death for females from 15 to 24 years old. (South Carolina Department of Health). Nearly 20% of the people who have anorexia will die prematurely from health problems and heart problems due to their eating disorder. About 95% of people with an eating disorder are between the ages of 12 and 25, about 50% of females between the ages of 11 and 13 see themselves as overweight, and around 80% of 13 year old’s have, at some point, tried to lose weight. It is a very sad fact that over 80% of females who have made an effort to go get treatment for their eating disorder, have not received the full treatment that they need in order to fully recover. This often leads to the disorder reoccurring and to the patients hurting their health even more. Obviously, eating disorders are really serious and they should be treated as soon as possible.

Since eating disorders are such important problems facing society today, researchers have used psychological theories to try to solve these problems including group therapy, medical treatment, and nutritional counseling. Eating disorders are treatable, and a person who has an eating disorder does have a chance of getting better, however, if the media continues to idolize skinny celebrities and condone their extremely thin size, it will continue to aid people in trying to lose weight. Having an eating disorder is like a really bad habit that needs to be stopped. A lot of people do not have the ability to stop this bad habit on their own, thus they need help from professional doctors and even family. There are several different methods used to treat an eating disorder. Since an eating disorder affects individuals both physically and psychologically, the treatment for an eating disorder has to satisfy both the physical and psychological aspect of the disorder. Medicine alone wont help a patient get better. In order to get positive long term effects from the treatment, a patient has to receive a mix of medical and psychological help for their disorder. Some therapies that psychologists use to determine the problem and treatment of an eating disorder are cognitive behavioral therapy, interpersonal therapy, rational emotive therapy, and psychoanalytic psychotherapy.

Cognitive behavioral therapy allows psychologists to see the patient’s thought process, interpersonal therapy involves dealing with difficult relationships with others, rational emotive therapy involves studying a patient’s unhelpful beliefs, and psychoanalytic psychotherapy involves looking at a person’s past experiences. All of this information can help a psychologist find the problem, and come up with the solution to the problem. Group therapy is a helpful part of treatment that allows sufferers of the similar eating disorders get together to discuss their problem. Groups are able to discuss coping strategies, ask and answer questions, and talk about ways to change their behavior. Medical treatment is necessary in order to make sure that the patient receives full treatment. Drugs such as anti-depressants can be prescribed by an experienced doctor who knows your condition in order to help treat your illness. Nutritional counseling is another effective and good way to help treat eating disorders. Dieticians and nutritionists can help patients understand what a well-balanced diet is and what foods they should eat on a daily basis. Nutritional counseling can also help patients face their fears about food and get over their fears of being afraid to eat.

A lot of people are confused about what “normal eating” is so they need nutritional counseling to help them get back on track. Not that many people who suffer from an eating disorder go to get treated for it. According to the South Carolina Department of Health , only 1 out of 10 people who suffer from an eating disorder go to get treatment. The cost of treatment for an outpatient is very expensive. Costs for outpatient treatment can be over $100,000. In the US, the cost of treatment for an eating disorder per day is anywhere from $500 to $2,000. On average, a person in inpatient treatment has to pay $30,000 a month. People with eating disorders need approximately 3-6 months of inpatient care in order to recover. The cost of treatment for an eating disorder is ridiculously high, and the high costs might be a reason that people do not go to get treated. It is very hard for most families to pay for the treatment of their illness, especially when insurance companies don’t usually cover eating disorder costs. Another way to help reduce the number of people with eating disorders is to educate people about the dangers of eating disorders through media. The media is a good tool to help educate people on the dangers of eating disorders, but it is also a tool that hurts people by condoning the appearances of skinny people who suffer from such disorders. Another way that eating disorders can be treated and minimizes is through the “Doll Experiment”. People were shown that if a human being had the same attributes as a Barbie doll, the body would not be able to hold itself because of its awkward shape and structure. This is a good way to show people that a Barbie doll isn’t necessarily what women today should aim towards looking like. In the same way, the celebrities we see on TV are not people who we should try to look like either.

I believe that as long as the media continues to idolize thin celebrities, the effects of education about the dangers of eating disorders through the media will not be effective. For each step that they take forward to solve the problem, they take two steps back by continuing to idolize thin celebrities. It is not a question of what effects have a greater likelihood of causing an eating disorder, but it is a fact that media does contribute to people developing and maintaining eating disorders. There are other causes of eating disorders, such as interpersonal or biological factors, but if the problem of media influencing eating disorders can be changed, there will be fewer cases of eating disorders. We have to take one step at a time in order to solve this very serious problem of eating disorders, and a great place to start is to change the fact that media influences eating disorders. There is not one cause of eating disorders, but media is a big influence to them since media reaches so many people. Personally, I think that group therapy very helpful in the treatment process of an eating disorder. Victims of an eating disorder are able to ask questions and receive answers in order to better understand their situation.

This is very helpful and it might make the victims of eating disorders feel more comfortable knowing that there are other people out there who are going through the same thing. Unfortunately, people are put under so much pressure to be thin by watching skinny celebrities all over the media be idolized. If they are being idolized does that means that they are good role models and their behaviors should be followed? No, most of the time, celebrities are not good role models. I believe that early childhood education is very important because I think that eating disorders start at an early age when children are naive and susceptible to being changed by others. Educating young kids about the media and how to criticize media is a very important step to reducing the number of people with eating disorders. Since media has such a big influence on eating disorders, children should be able to effectively criticize it and not fall victim to its schemes.

Personally, I don’t think that the media will ever be an effective resource for people to learn the truth and to learn about eating disorders. The media spreads a lot of false information and people tend to misinterpret the messages they hear on TV. Companies try to sell us products that will reduce our weight and make ourselves look “beautiful” by spending millions of dollars on advertisements. Consumers spend a lot of money and time trying to lose weight and buying these products that are not what the body needs. I believe that our bodies know what they need and ever one’s body is different. Everyone has a different metabolism and shape, and we have to learn how to love ourselves for who we are. We need to teach children at a young age that what they say on TV is not what it is cracked up to be and that they need to have self confidence, because if they don’t create an image for themselves, the media will do it for them.

Towards an Understanding of Self-Esteem and Eating Disorders

During a session with a client who has long suffered with an eating disorder I was discussing what it would be like if she could feel positive about herself. I was shocked with the response she gave me. Instead of reporting a desire to feel better about herself, this client laughed at me and retorted, “Self-esteem is laughable to me. I hope to be rid of the disturbing behaviors of the eating disorder, but I know it’s asking too much to like myself.” This encounter has been as intriguing as it has been disturbing. In this interaction I believe I came to understand, in small measure, what many women who suffer from eating disorders must feel about themselves. And, I better understand that when therapists, dietitians, and other helpers meet these women, survival is often the goal rather than happiness or feelings of self-worth. This interaction has come to symbolize for me the lie of the eating disorder in that it so efficiently creates such hopelessness, self-hate, and shame in women.

RELATIONSHIP BETWEEN SELF-ESTEEM AND EATING DISORDERS

Anyone working with women with disordered eating recognizes that self-esteem is intricately connected, however just how the two are related is not entirely well-defined. Inevitably, any discussion of eating disorders and self-esteem leads to the question of the chicken and the egg-which came first: poor self-esteem which made an individual more susceptible to disordered eating or an eating disorder which wreaked havoc on an individual’s self-esteem? While there is no simple answer to this question, there is substantial research that has investigated the relationship between self-esteem and eating disorders, and provides interesting insights.

In a review of the literature, Ghaderi (2001) concluded that low self-esteem, along with other factors, not only puts women at greater risk for the development of disordered eating but also serves to maintain an eating disorder. Numerous reports support the contention that low self-esteem is often present before the development of disordered eating, and that low self-esteem is a significant risk factor for both bulimia and anorexia even in young, school-age girls (Ghaderi, 2001).

According to Robson (1989, as in Ghaderi, 2001), self-esteem is “a sense of contentment and self-acceptance that results from a person’s appraisal of their own worth, attractiveness, competence and ability to satisfy their aspirations.” Given this definition, it is clear to see that self-esteem is multifaceted. Similarly, the development and maintenance of eating disorders is complex, including such factors as family environment, cultural environment, history of dieting, genetic predisposition, history of abuse, age and developmental concerns, length of time in eating disorder, immediate factors such as support system, emotional factors, and spiritual factors, of which self-esteem is only one factor of many (Berrett, 2002). However, self-esteem appears to be a primary risk factor that may contribute to the development of other risk factors for eating disorders. For example, three separate research studies found that development of bulimia is predicted by perfectionistic tendencies and body dissatisfaction only among low self-esteem women, whereas women with higher self-esteem did not have these risk factors and accordingly did not develop bulimia (Vohs, Voelz, Pettit, Bardone, Katz, Abramson, Heatherton, & Joiner, 2001; Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999; Joiner, Heatherton, Rudd, & Schmidt, 1997).

Identity formation is an area of focus when discussing eating disorders and self-esteem. Attention has been given to the parent-child relationship and how parents’ perfectionistic expectations work to limit the child’s development of autonomy, consequently creating an environment where the child is reliant on parental expectations rather than on individual needs and desires (Stein, 1996). Bruch (1982) posited that as children attempt to meet unrealistic parental demands, they often develop a sense of being “nothing.” As these children grow into adolescence they may turn to an eating disorder as a way of defining self and establishing a sense of self-control (Stein, 1996).

SELF-ESTEEM INTERVENTIONS

While self-esteem is a significant risk factor for eating disorders, one research team found body dissatisfaction to be the single strongest predictor of eating disorder symptoms (Button, Sonug Barke, Davies, & Thompson, 1996). Therefore, in targeting body dissatisfaction, therapists do well to attend to improving self-esteem, a major determinant of one’s body image. For instance, one study found that assisting adolescents in recognizing what is positive about their bodies and physical appearances while at the same time increasing their sense of personal competence leads to less internalization of sociocultural norms idealizing thinness (Phelps, Dempsey, Sapia, & Nelson, 1999). This resulted in significantly less body dissatisfaction, which in turn meant less eating disorder behavior among the adolescents (Phelps et al., 1999). Improving self-esteem is a challenging task for women with disordered eating. Often, their negative thoughts and beliefs are deeply entrenched and consequently difficult to give up. Once negative thoughts are established they serve to maintain low self-esteem and an eating disorder.

A critical intervention for women with anorexia, bulimia, or compulsive eating is to begin challenging the deeply held negative beliefs. For example, most women with disordered eating equate their worth with their weight, dress size, or shape. The sooner a woman can let go of these negative self-evaluations and replace them with more meaningful alternatives, the sooner she can be on the road to recovery. This may include exploring questions such as, “What do you want for your life, your future, your loved ones?” Answering these questions may be difficult and could result in significant shifts in an individual’s vocational roles, leisure activities, and relationships (Ghaderi, 2001). Therapists can assist women in identifying and building upon positive sources of self-definition. The eating disorder functions to limit an individual’s resources, yet through therapy women can be challenged to try on new roles and pursue activities where they can gain confidence.

Too often, individuals with eating disorders make themselves the exception in life. They believe that others deserve happiness, love, and joy, but that they themselves deserve sorrow, disappointment, and punishment. One of the first challenges therapists can give to the eating disorder is to begin disputing these false beliefs. Therapists can begin pointing out how the client has made herself the exception, and can then begin exploring where these false beliefs come from, whether they be from past abuse, negative family interactions, childhood teasing, or other difficult experiences. Teaching the client that she is worthy of love and acceptance, and that there are no conditions to her worth can prove essential to improving self-esteem.

It is important to keep in mind that, at least initially, these types of interventions, along with the therapist, will likely be rejected by women struggling with anorexia, bulimia, or compulsive eating. Challenges to the negative mind-set do not fit with what many of these women believe is true of themselves. However, with persistence, patience, and continuing acceptance, therapists can help clients to recognize their value and may help to create hope – one of the most critical components of overcoming anorexia, bulimia, or compulsive eating.

Addressing perfectionistic tendencies is also essential to addressing self-esteem among women with disordered eating. Typically, these women make their worth conditional upon their accomplishments, whether it be through grades, vocational achievements, or other activities. However, inevitably as these women achieve goals their standards become more unattainable, creating a cycle in which they can never reach the point of acceptance or value. One of the tasks of therapy is to separate the individual’s worth from perfectionistic strivings.

For most women with anorexia, bulimia, or compulsive eating, the eating disorder becomes their identity. Considering perfectionistic tendencies, these women often desire to become perfect – striving to exercise longer, eat less, and do more than is healthy. Many women claim that the eating disorder is what they are “good at” and it becomes all-consuming. A woman’s identity based in the disordered eating prevents her from trying new activities, especially because there is the risk that she may not do them “perfectly.” From the perspective of these women, it is safer to do the disorder perfectly than to risk failure in other arenas.

Therapists do well to make this pattern explicit in therapy. By addressing the underlying fear of failure and unmasking the disorder for what it is, these women can begin facing their fears by taking small steps, while receiving support from therapists and other helpers. Such small steps may initially be associated with disorder behavior. For instance, these individuals may be challenged to begin replacing disordered eating behaviors with healthier alternatives, such as calling a friend or taking a walk when the urge to self-harm surfaces. As these women find success in choosing healthier alternatives to the disorder, their self-esteem is strengthened and they can be challenged to take even bigger risks, such as interacting with friends, strengthening relationships, or trying new activities.

Along with perfectionism, most women with disordered eating compare themselves with others, especially other women. When these women compare themselves to others, they never seem to measure up-in their minds someone else is always more capable, thinner, or more attractive. These comparisons serve to further destroy self-esteem, thus perpetuating the deleterious cycle of compensating for negative feelings through a disorder. In addition to harming self-esteem, comparisons strain relationships and contribute to further isolation from others. Therefore, therapy must focus, in part, on the comparisons these women make and how these comparisons serve to damage self and relationships. Therapists can encourage women to choose a new way of being in relation to self and others – a way that is based on kindness and respect rather than on hurtful comparisons. As these women recognize that there are no gradations to self-worth, hopefully they can begin letting go of needless comparisons.

Therapists must be especially aware of comparisons when leading an eating disorder therapy group. Unfortunately, group therapy can be a breeding ground for comparisons between group members. Aside from the effects to one’s self-esteem, group members may direct hostility towards those members whom they feel they don’t measure up to. Group leaders do well to point out tendencies to compare in the group, and members may desire to establish a norm of not comparing within the group. Identifying and labeling comparisons in the group can assist these women in recognizing hurtful behavior, and then, the women as a group have the freedom to choose new paths.

Control has long been recognized as a core issue of individuals with eating disorders. As hypothesized, individuals seek a sense of control when their lives seem chaotic or controlled by others.

For many women seeking a sense of control in their lives, this is gained in the form of control over the body. While perhaps initially women do feel more control in their lives, this is fleeting and inevitably leads to feeling out of control. Often, women with eating disorders use control as a substitute for self-esteem, holding the belief that “If I control myself and my circumstances then I’ll be acceptable.” Of course, this security is false and fails to offer genuine feelings of self-worth and value. Therapists must teach their clients that the control offered by an eating disorder is false and does not serve as a substitute for self-esteem.

As women with eating disorders seek control, they necessarily employ avoidance as a way of hiding from their pain. Avoidance of truth undermines their ability to live congruently, resulting in a cycle that serves to maintain low self-esteem and an eating disorder. By avoiding what they know is best for them, these women perpetuate feelings of inadequacy and self-loathing. Eating disorders thrive on avoidance, therefore therapists must make honesty a core issue of therapy. A therapeutic relationship that is grounded in honesty allows the client to begin being honest about behaviors, fears, and past experiences. By being completely honest in session, clients begin to break the cycle that maintains low self-esteem. Further, by honestly identifying fears, clients can begin to understand and conquer them, and can begin having success in the very areas that were once most frightening. These types of triumphs instill hope, strengthen self-esteem, and encourage individuals to choose healthier alternatives to an eating disorder.

In addition to specific interventions addressing self-esteem, prevention programs for eating disorders do well to encourage critical evaluation of current sociocultural norms, assist in clarification of personal values, and raise resilience through group discussions, problem-solving activities, and cooperative learning (Phelps et al., 1999). One such participant-oriented program has proven helpful in strengthening self-esteem and improving body image among participants (Ghaderi, 2001).

While eating disorders and low self-esteem are difficult to separate, research, along with clinical knowledge, have established the need to address self-esteem concerns in treatment. Further, interventions targeting self-esteem, particularly how it affects body image, have been shown to be beneficial and should be part of comprehensive treatment of women with eating disorders. As a therapist, the prospect of assisting clients in improving self-esteem can be daunting. However, the recognition that each intervention that challenges false beliefs and negative thoughts, each expression of caring and concern, each exploration of alternatives to perfectionism and comparisons, each authentic interaction grounded in honesty can assist women with eating disorders in finding the courage to believe something new for themselves, and can take them, like the client described above, from desiring to simply survive to a place of hope and healing.

REFERENCES

Berrett, M. E. (2002). Factors contributing to development and maintenance of an eating disorder: A clinician’s view. Handout from Treating Teens: from Self-esteem to Eating Disorders. Center for Change, Orem, UT.

Bruch, H. (1982). Anorexia Nervosa: Therapy and Theory. American Journal of Psychiatry, 139, 1531-1538.

Button, E. J., Sonug Barke, E. J., Davies, J., & Thompson, M. (1996). A Prospective Study of Self-esteem in the Prediction of Eating Problems in Adolescent Schoolgirls: Questionnaire Findings. British Journal of Clinical Psychology, 35, 193-203.

Ghaderi, A. (2001). Review of Risk Factors for Eating Disorders: Implications for Primary Prevention and Cognitive Behavioural Therapy. Scandinavian Journal of Behaviour Therapy, 30 (2), 57-74.

Gross, J. & Rosen, J. C. (1988). Bulimia in Adolescents: Prevalence and Psychosocial Correlates. International Journal of Eating Disorders, 7 (1), 51-61.

Joiner, T. E., Jr., Heatherton, T. F., Rudd, M. D., & Schmidt, N. (1997). Perfectionism, Perceived Weight Status, and Bulimic Symptoms: Two Studies Testing a Diathesis-stress Model. Journal of Abnormal Psychology, 106, 145-153.

Phelps, L., Dempsey, M., Sapia, J., & Nelson, L. (1999). The Efficacy of a School-based Eating Disorder Prevention Program: Building Physical Self-esteem and Personal Competencies. In N. Piran, M. P. Levine, & C. Steiner-Adair (Eds.), Preventing Eating Disorders: A Handbook of Interventions and Special Challenges. MI: Brunner/Mazel.

Stein, K. F. (1996). The Self-schema Model: a Theoretical Approach to the Self-concept in Eating Disorders. Archives of Psychiatric Nursing, 10 (2), 96-109.

Vohs, K. D., Voelz, Z. R., Pettit, J. W., Bardone, A. M., Katz, J., Abramson, L. Y., Heatherton, T. F., & Joiner, Jr., T. E. (2001). Perfectionism, Body Dissatisfaction, and Self-esteem: an Interactive Model of Bulimic Symptom Development. Journal of Social and Clinical Psychology, 20 (4), 476-497.

Hope for the Hopeless – Depression and Eating Disorders

Approximately 80% of all severe cases involving anorexia or bulimia have a coexisting major depression diagnosis. Depression is a very painful and all consuming disorder in and of itself. However, in combination with an eating disorder, depression is beyond devastating and is often masked within the eating disorder itself. Depression in eating disorder clients looks different than it does in clients who have mood disorder alone. One way to describe how depression looks in someone who is suffering with an eating disorder is: hidden misery. For eating disorder clients, depression takes on a heightened quality of hopelessness and self-hatred, and becomes an expression of their identity, not a list of unpleasant symptoms. The depression becomes intertwined with the manifestations of the eating disorder, and because of this interwoven quality, the depressive symptoms are often not clearly distinguishable from the eating disorder. One purpose of this article is to highlight some of the distinctions and differences in how depression manifests itself in someone suffering with anorexia or bulimia. Another purpose is to provide suggestions that will begin to foster hope for these hopeless clients within the therapy setting.

When dealing with eating disorder cases, it is important to understand that if major depression is present, it is most likely present at two levels. First, it will be evident in a history of chronic, low level, dysthymic depression, and secondly, there will be symptoms consistent with one or more prolonged episodes of acute major depressive disorder. The intensity and acuteness of the depression is not always immediately recognizable in how the client is manifesting their eating disorder. Clinical history taking will reveal chronic discouragement, feelings of inadequacy, low self-esteem, appetite disturbance, sleep disturbance, low energy, fatigue, concentration troubles, difficulty making decisions, and a general feeling of unhappiness and vague hopelessness. Since most eating disorder clients do not seek treatment for many years, it is not uncommon for this kind of chronic dysthymic depression to have been in their lives anywhere from two to eight years. Clinical history will also reveal that as the eating disorder escalated or became more severe in its intensity, there is a concurrent history of intense symptoms of major depression. Oftentimes, recurrent episodes of major depression are seen in those with longstanding eating disorders. In simple words, eating disorder clients have been discouraged for a long time, they have not felt good about themselves for a long time, they have felt hopeless for a long time, and they have felt acute periods of depression in which life became much worse and more difficult for them.

Unique Characteristics
One of the most unique characteristics of depression in someone who is suffering with an eating disorder is an intense and high level of self-hatred and self-contempt. This may be because those who have these major depressive episodes in conjunction with an eating disorder have a much more personally negative and identity-based meaning attached to the depressive symptoms. The depressive symptoms say something about who the person is at a core level as a human being. They are much more than simply descriptive of what the individual is experiencing or suffering from at that time in their life. For many women with eating disorders, the depression is broad evidence of their unacceptability and shame, and a daily proof of the deep level of “flawed-ness” that they believe about themselves. The intensity of the depression is magnified or amplified by this extreme perceptual twist of the cognitive distortion of personalization and all-or-nothing thinking. A second symptom of major depression shown to be different in those who suffer with severe eating disorders is that their sense of hopelessness and despair goes way beyond “depressed mood most of the day, nearly every day.” The sense of hopelessness is often an expression of how void and empty they feel about who they are, about their lives, and about their futures. Up until the eating disorder has been stabilized, all of that hopelessness has been converted into an addictive attempt to feel in control or to avoid pain through the obsessive acting out of the anorexia or bulimia.

Thirdly, this hopelessness can be played out in recurrent thoughts of death, pervasive suicidal ideation, and suicidal gesturing which many clients with severe anorexia and bulimia can have in a more entrenched and ever-present fashion than clients who have the mood disorder alone. The quality of this wanting to die or dying is tied to a much more personal sense of self-disdain and identity rejection (get rid of me) than just wanting to escape life difficulties. Fourth, the feelings of worthlessness or inadequacy are unique with eating disorders because it goes beyond these feelings. It is an identity issue accompanied by feelings of uselessness, futility, and nothingness that occur without the distraction and obsession of the eating disorder.

A fifth, distinct factor in the depression of those with eating disorders is that their excessive and inappropriate guilt is tied more to emotional caretaking issues and a sense of powerlessness or helplessness than what may typically be seen in those who are suffering with major depression. Their painful self-preoccupation is often in response to their inability to make things different or better in their relationships with significant others.

A sixth factor that masks depression in an eating disorder client is the all consuming nature of anorexia and bulimia. There is often a display of high energy associated with the obsessive ruminations, compulsivity, acting out, and the highs and lows in the cycle of an eating disorder. When the eating disorder is taken away and the individual is no longer in a place or position to act it out, then the depression comes flooding in, in painful and evident ways.

Compassion for the Hopelessness
The reality of working with people who are suffering in the throws of depression and an eating disorder is that it is difficult not to feel hopeless for their hopelessness. Their hopelessness is extremely painful. It is an inner torture and misery, and it is encompassed by intense feelings of self-hatred and self contempt. For many, their emotional salvation was going to be the eating disorder. It was going to be thinness, physical beauty, or social acceptability. Many come to feel that they have even failed at the eating disorder and have lost the identity they had in the eating disorder. Hence, the hopelessness goes beyond hopeless, because not only is there nothing good in their lives, there is nothing good in them. Not only is there no hope for the future, there is nothing hopeful at the moment but breathing in and out the despair they feel. It feels to them like the suffering will last forever. Therapists who work with eating disorders need to be prepared for the flood of depression that pours out once the eating disorder symptoms and patterns have been stabilized or limited to some degree.

It is my personal observation that clinicians need to change what they emphasize in treating depression in those engaging in recovery from eating disorders compared with those for whom depression is the primary and most significant disorder. Therapists need to find ways to foster hope for the hopeless, much more so for someone with an eating disorder because oftentimes these clients refuse comfort. They refuse solace. They refuse support. They refuse love. They refuse encouragement. They refuse to do the things that would be most helpful in lifting them out of the depression because of their intense inner self-hatred.

For the therapist, the pain that fills the room is tangible. Clients are often full of sorrow and anger for who they are, which takes the symptoms of depression to a deeper level of despair. In working with eating-disordered clients with this level of depression, it is important for the therapist to show a deep sense of respect, appreciation, and love for those who feel so badly about themselves and who are suffering so keenly in all aspects of their lives. In spite of all the suffering, these people are still able to reach out to others with love and kindness and function at high levels of academic and work performance. They are still able to be wonderful employers, employees, and students, but they are not able to find any joy in themselves, or in their lives. These clients tend to carry on in life with hidden misery, and a therapist’s compassion and respect for this level of determination and perseverance provides a context for hope. As therapists it is important that a sense of love and compassion grows and is evident in these times when the client feels nothing but hopeless and stuck.

Separating Depression from Self-hatred
One of the key components of working with the depression aspects of an eating disorder is to begin to separate the depression from the self-hatred. It is important to help the client understand the difference between shame and self-hatred. Shame is the false sense of self which leads someone to believe and feel that they are unacceptable, flawed, defective, and bad, an inner sense that something is wrong with their “being.” They feel unacceptable to the world and to themselves, and feel that somehow they are lacking whatever it is they need to “be enough.” Self-hatred is the acting out of that shame within and outside of the person. The self-hatred can be acted out in the negative mind of the eating disorder, that relentless circle of selfcriticism, self-contempt, and negativity that is a common factor in all who suffer with eating disorders. The shame can be acted out through self-punishment, self-abandonment, emotional denial, avoidance, minimization, self-harm, self-mutilation, and through impulsive and addictive behaviors both within and outside of the eating disorder. Self-hatred is the ongoing gathering of evidence within the client’s own mind that they are broken, and unacceptable. In time, the eating disorder becomes their main evidence that there is something wrong with them and that they are unacceptable. And so, in a sense, the eating disorder is their friend and their enemy. It is a source of comfort and it is the reason they will not be comforted, and until they can achieve perfection in the mind-set of an eating disorder, they have great cause to hate themselves for who they are and who they are not.

All of these examples of self-hatred become intertwined with the symptoms and the expression of the depression, and so it becomes important in therapy to help the client to separate what depression is and what self-hatred is for them. It has been my experience that focusing on the aspects of shame and self-hatred has been more helpful to those who have eating disorders than focusing only on the depression itself. The self-hatred amplifies the intensity and the quality of the depressive symptoms. By focusing on the self-hatred aspects we begin turning the volume down on how the depressive symptoms manifest themselves with the client.

I have found that emphasizing the separation of self-hatred from the depression and its symptoms, and then beginning to change and soften the expressions of self-hatred fosters hope and generates hopefulness. Clients begin to see and sense that maybe the problem is not entirely who they are. Some hope comes from knowing that the feelings and the sense of self they have may not be accurate and true. They may recognize that some of what they have done forever and what has felt very much a part of their identity is really a chosen and acted out pattern of self-hatred. Somewhere in this separation of self hatred and depression they begin to feel hope in themselves, hope in letting go of pain, and hope in having their life feel, look, and be different.

Another reason for the emphasis on self-hatred is to help clients begin to recognize and challenge the unique quality of the all-ornothing thinking that leads them to filter everything about their lives in this most negative, personal, and self-contemptuous way. Hope is generated by learning that everything does not say something bad about who they are, that normal life experiences are not evidence that there is something wrong with them, and that negative feelings do not prove as true, what they have always felt about themselves. The unique perfectionism inherent in this all-or-nothing thinking allows no room for anything but perfection in any area of thought, feeling, or behavior. To be able to let go of the self-hatred filter and begin to see many of these thoughts, feelings, and behaviors they experience every day as typical, usual, and acceptable begins to foster hope, more importantly the kind of hope that is not tied to the false hopes of the eating disorder itself. Part of what has made the eating disorder so powerful is that clients put all of their hope in the eating disorder itself. Eating disorders are hopeless because after clients have done everything in their power to live them perfectly, they have only brought misery, despair, dysfunction, and more hopelessness. The attempt to generate hope through anorexia and bulimia has failed. By focusing on the self-hatred, they begin to separate their eating disorder from themselves. They also begin to separate the eating disorder from their source of hope. They begin to recognize that hope is within themselves and hope is within reach if they will soften how they view themselves and if they will change how they treat themselves internally and externally. Separating the depression from the self-hatred can help clients see the eating disorder for what it really is, with all its lies and consequences, and can help them begin to see who they are in a more honest and accurate way.

Renaming the Depression
I have also found it helpful in working with this clientele to rename or re-frame the depression and its symptoms within some kind of specific pain they are experiencing. I emphasize the pain aspects because part of what makes the depression so painful for those with eating disorders is the internalization of hopelessness. We can remove the global, ambiguous, and future sense of the depression, and break it into smaller pieces, more specific, immediate, and emotionally connected to their experiences rather than to their identity. We talk a lot about their feelings of hurt and sadness, and explore and deepen their understanding about their sense of feeling unloved, or their sense of inadequacy, or their feelings of rejection and disapproval, etc. I try to underpin the depression in very specific and emotionally-connected understandings and expressions. Rarely do I talk to them about their depression explicitly while we are trying to understand, validate, and generate hope in specific areas of their pain. I have found it more helpful to spend sessions talking about how to generate hope for themselves over a sense of loss, a sense of powerlessness, a sense of disappointment, etc., rather than to keep talking about depression and what to do to help lessen it. The realization is that in the process of fostering hope by focusing on and discussing the different kinds of pain, we are also de-amplifying and de-escalating the depression. It is impossible to get to the bottom of depression and avoid the specific pain, since avoiding the pain is what clients have been trying to do through the eating disorder.

It is important to note here that there certainly can be, and usually is, biochemistry involved in the quality, intensity, and type of depression they are experiencing, and that careful evaluation and utilization of antidepressant medications is strongly encouraged as an active part of the treatment. It is also important to remember that clients with severe eating disorders often resist the notion of medication or sabotage use of the medication as an attempt to control their body and weight, and to foster a sense of control. It is important to be very attentive and regularly follow up on taking medication and continue to help them in the positive interpretation of the use of medication. Too often, medicine represents weakness and becomes evidence to again engage in self-hatred rather than being viewed as one more piece of the puzzle that will help generate hope in their recovery. It is my experience that clients often respond to and benefit from medication if we can reframe the medicine as a hopeful part of their healing and their recovery from both the depression and the eating disorder.

When dealing with eating disorders it is also important to continue to evaluate and recognize the impact of malnourishment on clients’ ability to process and/or modify the way they process information about themselves and about their lives. It is important to stabilize the eating disorder as a primary intervention and to emphasize renourishment before there will be a lot of success in treating the depression. Renourishing the brain and body is an important early framework for fostering hope.

Reducing Isolation
Another important component in treating depression among eating disorder clients is moving them out of isolation. It is often a very powerful intervention for clients to re-engage and reconnect with other people. Moving out of isolation and reconnecting with others in their lives generates hope. Pursuing a re-connection with others emphasizes opening themselves up to feel connected, to feel the love, compassion, and interest from others towards them and in expressing their own compassion and love toward family members, friends, other clients or patients, etc. Involving families in family therapy, partners in couple therapy, and friends in the treatment are often very powerful ways to lessen the depression and increase hope for clients because they feel comforted and supported by those who love them and care for them. Helping clients to communicate again with people in their lives brings hope and renewed ability to feel something different than self-hatred. To receive expressions of someone else’s love, concern, and genuine caring is hopeful and becomes a very important part of treatment for the depression.

Letting go of False Guilt
Another aspect of the treatment of depression relates to the intense and unrealistic levels of guilt. Again, the reason the guilt becomes unique for those with eating disorders is because of the self-hatred. The guilt tells them to feel bad and terrible about themselves because they are not perfect, or not in complete control, or not accomplished, or not accepted or liked by everyone, or because there are people in their lives who are unhappy. A pain that will not heal is the false guilt associated with untrue or inaccurate realities. It is helpful in working with eating disorder clients to help them clarify the difference between real guilt and false guilt. We can help them recognize that real guilt is associated with having literally done something wrong. Their recognition of that fact can lead them to correct it. False guilt tells them to feel bad and terrible about themselves, and whatever has happened becomes the evidence against them which supports the feeling of guiltiness. Oftentimes I try to help clients understand specific ways that false guilt enters the picture and feeds the self-hatred. It is frequently tied to areas of their lives where they feel or have felt powerless but have made themselves emotionally responsible. An example of this might be feeling bad about themselves because they feel responsible for a specific relationship outcome they do not really have the power to create on their own. They may feel badly about themselves because they cannot fix a situation or problem someone they love or care about is experiencing, or because they could not prevent a tragedy. False guilt is a sense of shame, feeling like they “should have known better” or had it “figured out” beforehand. False guilt is often an expression of what they are not, rather than who they are or what they are capable of doing. Sometimes the false guilt is just an active expression of the intense pattern of negative comparison between themselves and others that is so common with eating disorders. Eating disorder clients are constantly comparing themselves to someone else, both physically and behaviorally, and end up feeling a great deal of guilt about who they are because they do not match up in their comparison with someone else. Sometimes false guilt is an expression of self-hatred for some wrong done in the past, something they will not let go of or forgive themselves for. They continue to actively punish themselves for what happened or what they felt bad about doing, sometimes a very long time ago. They hold it against themselves mentally as support for their self-rejection.

Often the false guilt and feeling bad about themselves is tied directly to how important people in their lives are behaving or acting. They tend to somehow feel responsible or accountable for someone else’s negative choices or behaviors. False guilt gives them a sense of hopelessness because their ability to change it or re-frame it differently is impeded by their all-ornothing filter of self-contempt. They may compare themselves to unreasonable self-standards that no one could live up to, and therefore they become the exception to all the rules of normalcy. Somehow they have to live above acceptable, and the sense of guilt is evidence that they are not living at that expected, higher level of performance. Oftentimes when they hear feedback from other people about their behaviors, in particular their eating disorder, it becomes another encouragement to feel false guilt. The problem with self-guilt is that it produces intense feelings of fault, blame, guiltiness, shame, anxiety, and sadness, but instead of moving them to correction and change, it moves them to selfhatred, self-criticalness, self-doubting, and self-punishment. False guilt always leads to more hopelessness. Releasing false guilt fosters hope because it leads to an increased sense of freedom and choices through the setting of clear emotional boundaries.

In conclusion, it is important to emphasize that in order to truly intervene in the area of depression with those who have an eating disorder, we need to first stabilize and lessen the intensity and the acting out of the eating disorder. Until we do that, we are probably not going to truly see the depth and the extent of the depression and the very personal nature of how the depression manifests itself in eating disorder clients. It is also important to increase our awareness and understanding of how depression is uniquely different in those who suffer with eating disorders because it gives us therapeutic options and a framework to intervene in a more compassionate and hopeful way with those who have these coexisting disorders. The most helpful thing we can do in every session with these clients is to generate hope. Nurturing hope is not always a clear-cut and obvious list of techniques or interventions, but rather a willingness by both client and therapist to face the hopelessness in a kind and loving context. I hope that these therapeutic distinctions and suggestions will begin to foster some hopefulness for clients suffering with a coexisting depression and eating disorder. In facing the hopelessness, pain, selfhatred, guilt, and isolation, we can, little by little, foster and generate hope and decrease the depression. New hope will lead to answers. Genuine hope will lead to something better. Honest hope will lead to change.

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