Common Terms, Questions and Explanations for the Eating Disorder Experience
The conversation of “recovery” starts almost as soon as an Eating Disorder has been identified and diagnosed. Whether the person is a child or an adult, family and friends view the person as having “the issue” which must be fixed, cured or removed. Almost always the person also is surprised to find themselves in a diagnosis and unaware of how to reverse the situation. The whole family now has to become acquainted with certain facts and ways of thinking to understand the situation and find the way out. Here , I will try to address some of the common terms and questions that arise in treatment.
Eating Disorders rarely start later in life. The underpinning anxiety almost always starts in early teenage where the young person associates the internal feeling of emotional discomfort with the changes happening in their changing physical body. There are common jovial and flippant comments made about “teenagers” being ‘out of control’ or difficult to understand. The truth is that teenage is the most significant metamorphosis we will ever experience in our livesin a very conscious way. Such a profound change cannot but come with anxiety. I often talk about the caterpillar changing into a butterfly. However, the caterpillar has the comfort of his homespun cocoon to hide his messy business. Teenagers are on display in their awkward , gawky bodies. Some lucky teenagers happen to have found their groove and manage to feel supported and successful as they change, whether it be in athletics or academics or just the chess club. But others struggle. Add on to all this a sensitive temperament and the social pressure of a 1000 pictures of perfect symmetrical bodies and we have the makings for an eating disorder. It is good to know that an ED is not a teenager “acting out” , it is rather a deeply internalized expression of distress that is oozing out despite the teenager’s best efforts to not rock the boat.
Teenage is also the period of “differentiation”. We start out in a highly enmeshed state, completely dependent on our parents. As the years go by, we move through numerous little separations towards adulthood where one is expected to make decisions, move out and care for oneself. Teenage is a period where the expectations go up exponentially while we are making peace with our emerging sexuality, differences and defining the self. This does not go smoothly very often. Anxiety accompanies every separation and every transition. Some anxieties might have been invisible while others not as much. When the anxiety of transitions overshadow the excitement and the process becomes scary, the young adult might retreat back into the last safe place they experienced. In a way, the ED becomes the cocoon that the teenager finds comfort in.
Why an ED?
The anxiety, discomfort or awkwardness connected to puberty always existed. The language of diet culture that suggests you can change your body into what you want it to be exists louder than it ever did before. Coaches and dance teachers use body- focused language to achieve goals without considering the mental state of their students. Parents are simply people who are also trying to live in their bodies and adjusting and experimenting. We live in the times of diets, botox, plastic surgery and Ozempic - quick fixes that imply magical solutions that take us far away from finding peace with the body we inherited. The body is talked about as a separate entity without loving ownership. Control is misunderstood as “care”. A young person , desperate to dispel the ordinary anxiety of growing up, grasps around for a solution and quickly realizes that they can count calories, keep track of numbers and over-exercise or vomit. In the beginning it feels like a magical solution till the person realizes the battle with a hungry, growing body is a conundrum that will not go away.
The anxiety of puberty requires co-regulation with a regulated, patient, caring adult who understands that this anxiety is a normal part of this evolution and does not feel challenged by it. Simple solutions like “ getting over it, focusing on the positive, moving on or pulling up your bootstraps” do not work and makes the individual feel there is something wrong with them that they cannot dismiss their feelings successfully. The absence of this attuned co-regulation results in a teenager who is ashamed of expressing their struggle and starts believing there is something fundamentally flawed in them. Co-regulation requires a parent to slow down, listen carefully and be able to find the careful words that allow the teenager to breathe easy and feel understood. The goal-oriented busy-ness that many families have fallen into , albeit for the wellness of the children, leaves little room for this. A child might not express their distress if they feel a parent has too much on their plate or a parent cannot tolerate distress or to “not rock the boat”. Many children cannot actually keep pace with all the activities they are enrolled in along with the weight of growing up and an ED interrupts the fast moving train. If therapy works as it should, the ED brings attention to what the teenager needs and when the train starts again, we will move at a pace where everyone can breathe easy.
There are three outstanding themes in an ED - Elimination, Substitution and Compensation.
Elimination of food groups - I will start by saying that in the normalized diet culture we live in , it is common practice to hear people talking about eliminating one thing or the other, talking about their bodies in a criticizing tone, talking about eating a dessert in punitive terms and generally implying that food must be restricted for a “healthy” life. Food is spoken about not as “stews, steak or bread” but as “carbs, proteins and sugars”. Caolries are counted with certainty whereas the real truth is that we are just following numbers on a box. Sometimes a client confesses to me that they are just making up numbers as they go. Since the advent of TV and other electronics, the practice of gathering at the table has also fallen away and parents are often not aware if children have breakfasts or lunches. In my practice, I commonly hear that - “ Oh, she doesn’t like breakfast”. “Like” is an interesting word. It is a word that one cannot really argue with - a person is allowed not to ‘like’ something. This is true. However, breakfast is so named because it breaks the long fast of the night. It is a fact that bodies are hungry in the morning. But when we are in the practice of over-riding hunger in our desire to restrict, it becomes easier and easier to not really stop to notice hunger in the rush of the morning. Breakfast is perhaps the most skipped meal in families , at this point. The order of elimination in the early stages of an eating disorder would be carbohydrates, fats, sugars and red meat - loosely in that order. Elimination is often not noticed if others in the home are also dieting or eliminating.
It is helpful to know that anxiety creates physical feelings of discomfort in the chest and stomach. However as we do not think about or notice anxiety for what it is, stomach issues are often first treated with elimination - of gluten and dairy and meat. In the world of eating disorders, becoming “vegan” also falls in line with elimination under an ideology. I do not believe that everybody must eat meat. I myself grew up in a vegetarian home in India. But the food on our table was plentiful and the delight in my mother’s cooking was palpable. Elimination was not an accepted go-to methodology.
Compensation - In the simplified thinking of the anxious ED mind, every calorie that is consumed has to be compensated / accounted for. Every calorie is accounted for by the body burning these calories for the energy to think, to walk , to read , to carry, to breathe, to stay alive. However, in the current simplified “calories in , calories out” culture, people have come to think that they have to put in focused, specially planned ‘work’ to compensate for any calories consumed. Dr. Oz has a piece of cheesecake on a plate and quizzes women about how much they have to walk to “work off” the piece of cheesecake as though that piece has a special compartment in the stomach where nothing else happens till you walk. This kind of thinking is absurd and common-place. Older women commonly comment that it “is all going straight to my thighs!”. The fear and absence of complexity in these comments are stunning if we pause to think of how complex a body is. What lies beneath is an anxious feeling that clients start calling ‘guilt’ associated with any delightful feeling associated with food. In a starved mind, just eating is equated with delight and at this point, when all delight is associated with ‘guilt’ or ‘deserving’ , all eating becomes difficult. The only way , then , that a person can eat without ‘guilt’ would be to eat minimally and “work it off” which often ends up in vomiting, compulsive exercise or other more dangerous methods like using diuretics and laxatives to achieve that feeling of emptiness that comforts a person that all the calories are “out”. It is good to understand that this becomes such a tight circle that it completely preoccupies the person’s mind thus leaving no room for the real life anxieties that set the ED into motion in the first place.
Substitution - The desperate search for less calories ( because a person cannot live without eating) leads to the phenomenon of frantic substitution. I first became acquainted with quinoa, oat milk, rice milk, soy milk and edamame beans once I started working in the field of eating disorders. What starts out as an attempt to reduce calories gradually melds into the alternate universe of dieting substitution that has already existed over the last few decades. What I have learned over the years is that substitution does not actually work. It sure works to lose weight temporarily but it creates unrequited longings and deep cravings in its wake. The fight against hunger and delight is a losing battle. Choosing to eat brown bread while allowing oneself to eat cake and pizza is a distinctly different situation than the rigid cage of an eating disorder where one has no permission to eat outside the lines. Choosing to eat brown bread because it is the only bread I am “allowed” to eat is a completely different scenario. In my experience, desire for a piece of chocolate cake will only be satisfied with a piece of chocolate cake. For a while it will feel that one has conquered the piece of chocolate cake but over a period of time , it will lead to a binge , in the case of Bulimia or Binge Eating disorder or a very grumpy life, in the case of Anorexia. Something will give.
Healthy - In the upside-down world of eating disorders, “healthy” is a word that ends up in the very opposite of what it means for the body in the real world. And in the disordered world of diets and controlled eating, “Healthy” is the new spaceholder. The spoken language of eating disorders is a code. And these often-used words have different meanings.
To the eating disordered mind, “healthy” stands for being good, feeling good, feeling safe, feeling light, feeling empty. It would be a mistake to assume that “healthy” means what it would mean to a physician. However, healthy is used to mean successful restriction by many non- eating disordered people in the dieting world too, who might fall under the classification of having “disordered eating” - poor eating that is not organized enough to be diagnosed as an Eating Disorder. The person with the eating disorder - a collection of behaviours to manage their overwhelming anxiety- is simply borrowing words and language from what they hear in their everyday life for want of more accurate words. It is helpful to know that much of normalized language comes to us from diet culture that is a response to weight reduction in the obesity world. Obesity that is the result of over-eating to self-soothe is the opposite counterpart of Anorexia. Both are disordered food responses to emotional difficulties. However, the conversation about the behaviours in the Obesity world are borrowed and normalized by my Anorexia clients as it aligns very well with their restrictive thoughts. Obesity has long been addressed with quickfixes like bariatric surgery and weight-loss medications without any patience for a deeper understanding and it is only getting worse. The impatience that medical professionals, families and clients alike have for emotional work is monumental and unfortunately fueled by our marketing industry. And our limits for thin-ness are defined by the fashion industry where Anorexia is normalized and rampant. Being healthy is rarely understood as living with the body I have in an accepting, kind, compassionate way that is sustainable into old age. Rather it is understood in a conquering , controlling way that can only be sustained with tight vigilance and criticism.
Delight and Hunger - There are two parts to our relationship with food - the delight of feeling the texture and taste of food in our mouth and the empty / full feeling in our stomach. Ideally , we cultivate a comfortable connection with all these feelings to co-exist with the need to eat at least 3 main meals a day with snacks as needed , in between, without mental interruptions. Our relationship with these experiences start as soon as we are born with our mother as the facilitator , in the very early years. As you can imagine, the early pre-verbal relationship with food is heavily influenced by our mother’s impressions and relationship with food and body. Anxiety is a companion as well, in this relationship. A mother who struggles to breast-feed feels like a bad mother. A mother who was not prepared for a baby might struggle with post-partum depression and feel no interest in attending to the 1000 needs of a new baby. A very welcoming mother might still feel waves of anxiety about the new responsibilities of a new baby. A mother with a lot of support and many extra hands might have a wonderful experience of joy because she can eat and sleep when she needs to. One family might be afraid of a baby gaining weight while another family might rejoice that they have a plump baby. Added to all of this is another unspoken complication - babies can be plump , teens and adults cannot.
Delight in food is not much spoken about other than in cooking shows. Since “you are fat” or “fat cow/pig” is an unbearable insult, it is quite common to have a fear-based relationship with food and body. The limits of “fat” of course, vary in every person’s mind. Every family has a language around food since every member has to eat and food has to be prepped, cooked and served throughout the day, every day. It is informative to check whether a family’s conversation is “fear-based or delight-based”. The kitchen table is where the family gathers and all the family dynamics come alive. Do I look forward to the kitchen table or not? Is it possible to delight in food and have a body that is not overweight? My dietitian friend tells clients that the “idealized body is different from the real body” and herein lies the struggle. This is an important point. The struggle for the air-brushed, adjusted or perhaps disordered body of another person ( who we might believe, in our simplicity , is a “happy” person ) to compensate for our inner unhappiness. We compare our insides to other people’s perceived outsides and start the quest to find “happiness” in a life-long habit of counting numbers. Delight and my connection to my body have to be sacrificed. How can one ever hope to find happiness without delighting in the very thing that is synonymous with Life?
The Scale and “The Number” - The scale has become Snow White’s step-mother’s mirror in many homes. The scale tells us if we are good or bad, if we are “safe” or not and ultimately whether we are going to have a bad or good day. The trouble with the scale is that it contributes to the experience of seeking reassurance outside myself and not realizing that one has much more freedom in carrying that reassurance inside oneself. Finding reassurance inside oneself takes work for many of us but in the end , is well worth the effort. The scale is a much shorter route but does not always comply with what we are seeking. For the scale to work, the body has to be a fixed entity. However, the truth of the body is that it reflects life - it exists within a range and is fluid by nature. For the game of numbers to work, the body has to stand still, without breathing, without moving. And at some point, when anxiety is at its peak, the number has to go down and loses all context of its connection with the wellness of the self.
It is good for every professional and parent to know about “the number”. The number is the line where any progress comes to a sticky stop, in the mind of the anxious person in recovery. The number can signify many things - the number a doctor once randomly mentioned, the weight a person was when they got married and fit into a certain dress, the weight a person was when they took a certain picture and liked how they looked, the number that the person remembers feeling happy in general, the weight of my mother or sister or the weight a person was to fit in a favourite pair of jeans when they were at their lowest weight. I always ask about this number and I always get an answer. This is not a casual number, there is much invested in not crossing the line into what the person believes is scary territory. Progress becomes possible when the number and its significance is acknowledged and addressed in a broader context.
Craving - Cravings are a natural outcome of severe restriction and starvation. A craving is an accumulation of small desires that have been suppressed and ignored. When people follow diets they quickly realize that there is no instruction for what one can do with a craving. Diet gurus conveniently forget to address this very natural phenomenon and the naive dieter criticizes themselves when they find themselves dreaming of foods that the body needs to fulfill the tasks being asked of it. This leads to a cycle of restriction and self-blame and shame for desiring the forbidden foods. In Anorexia, where a person actually finds the stoicism to restrict to an incredible degree, we see people beginning to look at recipe books, watch cooking shows and cook and bake for others. Some clients have told me that they start dreaming of food. The brain is frantically asking the person to “go find food” and in response , the individual does everything to be in contact with food without eating it. People also come to believe that if they allow themselves access to the forbidden foods they will never stop eating them. Ironically, treating all foods the same and allowing oneself access to all foods eliminates any desire from building into a craving. Excessive reliance on carbohydrates and sugar to soothe emotional feelings can also build into a visceral craving that has a life of its own. This is the other end of the continuum and in a way , also requires a meal plan that includes all foods along with therapy to separate the reliance on food to resolve emotional distress.
Perfectionism - Perfectionism is not actually the search for perfection as the word may imply. Perfection is a frantic effort fueled by an intolerance of disappointment. Learning to have tolerance for mistakes is important to a peaceful life. Parents of very anxious perfectionistic children might not remember telling their children in so many words that mistakes are not allowed. Sometimes parents do. An anxious child might want to avoid rocking the boat, avoid upsetting a busy parent who already looks flustered or learn from watching a parent be perfectionistic themselves. Perfectionism might attract praise before it starts becoming an impediment as life becomes more and more complex. In any case, the solution continues to be finding the capacity and tolerance to take mistakes and disappointments in our stride and include them as a part of any endeavour. The solution - pause, breathe and do the next best thing.
Non- negotiables - Non-negotiables are exactly what the word implies, things that are imperative for a full sustainable recovery. Things that are not up for negotiation. It is a simple non-negotiable of life that we have to eat to survive, flourish and grow. In treatment, it is a non-negotiable to follow a mechanical meal plan overseen by a knowledgeable dietitian. Avoiding looking at numbers of any kind, including all foods in the meal plan and not following restrictive trends on social media are all non-negotiables. It is also a non-negotiable to work on the emotional reasons that keep an ED in place. Other helpful actions might be getting rid of clothes with a particular significance and ending toxic relationships that contribute to the maintenance of an ED. It is a coomon mistake to think that “I will do recovery my way” or to desperately look for yet another formula. It is attributed to Einstein, the saying that one cannot resolve a problem in the same way that it was created. It is a non-neotiable that all ED related behaviours have to go. Keeping a tiny part of the ED will invite it back when the going gets tough.
“Just eat”- It is common for families to be baffled by the person/ child not eating and in their frustration to say - “Just eat !” In the early days of an ED, this is simply impossible and does not feel like a choice. While the ED is driven by emotional reasons, these are predominantly unconscious and are inextricably tied to food and body feelings. The feeling of fullness in the stomach is often a trigger and experienced as unbearable and unsafe. Effective treatment separates and gives voice to the feelings and the person is slowly able to speak to their food rules in a conscious way. Therapy is successful when the unconscious workings of the mind and body are brought up to consciousness. The person now realizes and feels they have choices. Of course, the process has to be accompanied by taking action with an evolving meal plan. Towards the tail end of recovery, the person is able to realize that they do have to “just eat” till the body and mind are able to reconnect with the delightful connection with food is re-established. This is a non-negotiable. Recovery is not really sustainable recovery as long as the relationship with food is based in fear and the secret disagreements in the mind are not addressed and articulated.
And finally, what is Control?
Control is simply the flip side of anxiety. Anxiety can be soothed either externally or internally. Self-soothing internally has to be experientially learned with a co-regulating adult till it can penetrate, be internalized and become second nature. In the absence of this time-sensitive experience, a person learns to regulate by controlling things outside of themselves. One can control other people in one’s life or one’s environment or one’s own body - or, all of the above. The “A type” personality is admired , till something goes wrong. Learning how to self-soothe later in life can absolutely be done - wth patience and practice and intention and support.
Living with the Body in Peace -
I eat in accordance with hunger and fullness without constant mental interruptions about what is "healthy".
I can actually live my life without weighing myself or calculating when I am going to weigh myself next.
Not being caught up in reading labels and calculating.
Not freaking out if I change a dress size.
Not hanging onto clothes of a certain size to keep check.
Knowing that all the "calories" that I eat will balance out over a month or year and not hour by hour.
Without a compulsive relationship with exercise.
A more complex understanding of the body and food than "good" and "bad" and "healthy".
Freedom to eat a meal and go on your way. ( The body does not need day by day or hour by hour monitoring).
Being able to look in the mirror and meet myself as I am, without comparison and criticism.
Recovery is not about eating the random muffin, recovery is actually about acknowledging the secret agreements and disagreements in one’s mind.
