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Eating Disorders Support.com ( located on Mercer Island, just outside of Seattle, Washington )
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excerpts from the book Creating a Recipe for Recovery Eating Disorders: Nutrition Therapy in the Recovery Process is a long book!! 550 pages to be exact! We want you to have a feeling for what this book is like, so have included brief excerpts from each chapter for you to read. There is no such thing as a manual that can tell you exactly what to do to recover from an eating disorder because everyone is so unique. The process cannot be scripted; it has to unfold as a person moves through life and therapy. However, this book contains the vast majority of the ingredients necessary to get better. The amounts of each and how they are mixed create a different recipe for recovery for each person. In other words, what works for one person may not work for another. The issues needed to be addressed by one person may be totally different from those needed to be addressed by someone else. We believe that you have to know what it is from which you are trying to get better or you will not get better at all.
Chapter 1 - The Conceptual Framework (brief exerpt) This process, which entails figuring out what preceded the development of a person's eating disorder and what that person needs in order to recover, is much like putting together a jigsaw puzzle. Kim's grandfather was a master at completing difficult jigsaw puzzles. Because he was so good, people would cover the picture on the cover of the puzzle whenever they gave him a puzzle for a present. In turn, he agreed to not look at the picture until the puzzle was completed. All he know when he started working on the puzzle was that the pieces would fit together in a defined shape, usually a rectangle or square, sometimes a circle, to form some type of pattern or picture. He would begin by dumping the pieces out on a table, then turning over all those that were cardboard-side-up. The next step was finding, then putting together, the edges and the corners (if there were corners), because these pieces were the easiest to recognize and the edge provided a structure to guide him as he pieced together the remaining pieces. He would then put small clusters of pieces together that had similar coloring or patterns on them. Eventually, more and more pieces were added to the clusters and edges until the whole puzzle was finished. The puzzles that were easiest to do were those that had recognizable scenes or figures. Of medium difficulty were those of random designs or patterns. The most difficult puzzles to assemble were those that ere all one color because there was not tree or sky or figure to use as a guideline when putting together the pieces. Although he completed many puzzles on his own, they were finished faster when other family members helped put them together or joined in the search for a missing piece. When a therapist or nutrition therapist first meets a person with an eating disorder, it is like receiving a gift of a jigsaw puzzle with the picture on the box hidden. During the first session, the pieces are dumped on the table. Some are picture-side up and some-cardboard-side up, but none of them are put together yet. In other words. the person reveals some things about herself very quickly; other things she is more reticent to share. In future session, as the person continues to talk and tell her story, it is as though she is slowly turning over one piece of the puzzle of her life at a time. Just like jigsaw puzzles, some people's lives are easier to piece together than others. The easiest lives to piece together are those with one or more severe childhood traumas such as sexual abuse or death of a parent or sibling. These events have predictable emotional consequences and a defined treatment plan, although these people may have the most difficulty of any in trusting enough to share their pain. Lives of medium difficulty are those in which there is a series of random events, none in and of itself enough to precipitate the eating disorder, that when put together add up to a significant amount of emotional pain. For example, a person may have had someone make a derogatory comment about her weight, may have been rejected by a boyfriend, may have been fired from a job, and may have been teased mercilessly by siblings while growing up. The most difficult are like the puzzles that are all one color. These are the lives of people who develop eating disorders, most frequently anorexia nervosa, which lack anything that can be readily identified as a possible explanation for why they developed an eating disorder. Frequently victims of neglect or lack of validation of feelings, these people's childhoods on the surface appear problem-free. As noted by Bruch, "It is very easy to reconstruct an unhappy childhood with a father a drunkard and mother this and that, and a broken home and so on. It is very hard... to understand the unhappiness from the subtle misunderstandings." (1) Thus it may take longer for the therapist to identify the issues to address in treatment with some people than with others. However, as long as there is a basic conceptual framework into which to fit the pieces, an understanding of the process of recovery, and the ability to build a strong therapeutic relationship, the opportunity for recovery will be there. As the two grow to know each other, more pieces are turned over, and in time, the therapist or nutrition therapist is able to begin to put together some of those pieces such that they form patterns or a picture of that person's life. Because most people are afraid to share parts of themselves that they feel are unacceptable or unlovable, they often withhold information. The professional knows that there are some pieces of the puzzle missing, some bits of information that would help her to make better sense of why the person is doing what she is doing and what she needs in order to get better. As trust increases in the relationship, more and more of these missing pieces will be revealed. Sometimes a person will consciously withhold pieces for several years out of fear of the therapist's reaction. Other times she will unconsciously withhold them in that she is not yet consciously aware of the issues herself. Eventually, the person with the eating disorder and the therapist or nutrition therapist will be able to put together the whole puzzle, which will show them the major factors contributing to the development of the eating disorder and the issues that the person needs to resolve in order to be recovered. In this chapter, several ways of conceptualizing an eating disorder are presented. Although there may be some overlap between the conceptualizations, we have chosen to present all of them because we have found that some professionals find one conceptualization more consistent with their approach to treatment or way of thinking about psychological issues and others prefer another. We encourage our readers to take those things they find helpful and leave the remainder behind.
(1) Hilde Bruch, Conversations with Anorexics (New York: Basic Books, 1988), p. 196.
Chapter 2 - The Recovery Process (brief exerpt) The approaches to treatment advocated in this book build on the assumption that it is possible to completely recover from an eating disorder. This means that a person can return to healthy (or normal) eating patterns and reach a point emotionally and psychologically equivalent to others of her same age, level of maturity, and stage of development... The essence of the Recovery Model is that he measure of recovery is much more than behavioral change; it involves personal growth and development of life management skills. This means that it is possible for someone to stop using food-related behaviors out of sheer determination or in response to behavior modification, without being recovered...the person who gains weight without resolving the underlying issues is vulnerable to a recurrence of symptoms. According to Garfinkel and Garner, "Usually the recurrence has been associated with a stressful change in the person' life such as a marriage, pregnancy, or move to a new city."(1) In bulimia nervosa, behavior change can also be deceptive. However, in this model, what results in relapse in not ingestion of a particular substance but either the presence of psychological stressors with which the person does not know how to dope in a healthy way, a period of food restriction, or intense body dissatisfaction. Similarly, in obesity, weight loss alone is not considered to be the only indicator of recovery... Bruch does not see becoming "thin" as a sign of recovery but rather the absence of wild weight fluctuations and an acceptance of one's body as it is (progress being evaluated by clarification of underlying issues and achieving a high level of functioning). (2)
(1) Garfinkel and Garner, Anorexia Nervosa: A Multidimensional Perspective, (New York, Brunner Mazel, 1982) p.336 (2) Bruch, Eating Disorders: Obesity, Anorexia Nervosa and the Person Within (New York, Basic Books, 1973). Chapter 3 - Assessment and Diagnosis (brief exerpt) Just as each person with an eating disorder needs to understand from what it is that she is recovering, so do the professionals working with her. People with eating disorders are not a homogeneous group. Researchers and clinicians have made numerous attempts to further subdivide the DSM -Iii-R [now DSM-IV] diagnostic categories of anorexia nervosa and bulimia nervosa and upon differences in weight- or food-related behaviors, family patterns, and/or degree of psychopathology. Although obesity is not recognized in the DSM-III-R [now DSM-IV] as an eating disorder, professionals have attempted to subdivide people with obesity based upon differences in origin of obesity - physiological versus psychological factors, physiological factors alone, and a combination of factors. Regardless of the subgroup into which the person is placed, there remain within the groupings significant individual differences, especially in food- and weight-related behaviors and attitudes. The professionals who treat people with eating disorders are not a homogeneous group either. The increasing numbers of theories of etiology and approaches to treatment in the literature attest to this. Individual differences also affect approach to assessment. Some professionals prefer to use clinical tools to collect large amounts of information throughout the treatment process. Others prefer to collect information without using any tools, relying instead upon conversations with the person with the eating disorder and clinical intuition. The remaining clinicians fall somewhere in between these two extremes.
In this book, we have presented several clinical tools we have found to be helpful when doing psychotherapy or nutrition therapy with someone with an eating disorder. These include: the Eating Disorders Intake Form, the "Are You Dying to be Thin?" questionnaire, the Longitudinal Weight and Life Event History, the Belief Challenge Chart, the Relationship between Frequency of behaviors and Life Events form, the Emotions Record form, the Typical Hunger and Food Intake Pattern record, the Set Point Estimation Chart, the Typical Food Intake Pattern form, the Indicators of Recovery, and the Food Record form, and the Flower of Self-Worth.
Chapter 4 - The Multidisciplinary Team (brief exerpt)
Eating disorders are unique in that they involve potentially fatal medical complications, irreversible dental problems, and severe disruption of eating patterns, nutritional status, and body weight regulation mechanisms in addition to the dysfunctional cognitive processes and family interactional patterns inherent in other psychiatric disorders. In order for food-related behavior change to be permanent, medical, nutritional, psychiatric, and psychological issues need to be addressed concurrently. A multidisciplinary treatment team is the vehicle through which this type of treatment can best be accomplished. Although psychotherapy is the primary mode of treatment for people with eating disorders, abnormal food behaviors do not magically disappear following resolution of psychotherapeutic issues...
Chapter 5 - The Role of the Nutrition Therapist (brief exerpt)
One of the key functions of the nutrition therapist and the therapist it to help the person with the eating disorder to identify and accept her unique characteristics, psychological as well as physiological. This means both supporting her in not succumbing to societal pressure or expectations to "look" or be a certain way and accepting her how she should be. Learning about herself as an individual and being fully accepted by professionals who are treating her results in increased self-awareness and self-esteem.
Chapter 6 - Benefits of Behaviors, Resistance to Change (brief exerpt)
By the time anorexia nervosa or bulimia nervosa is diagnosed, the person's relationship with food has already become an adversarial one. The person is terrified of certain foods; feels safe when eating other foods; believes things about food, weight, and exercise that are not true; has developed rigid rituals with food; and, if challenged, may directly or indirectly defend her beliefs and behaviors vehemently. Something happens to the thought processes of the person with the eating disorder during the development of the disorder. It is of interest to note that the changes in thinking are remarkably consistent from person to person.
Chapter 8 - Weight - Related Issues (brief exerpt)
Unlike most people who seek treatment for anorexia nervosa or bulimia nervosa, the majority of people who make an appointment with a health care professional for treatment of compulsive eating or obesity do not expect psychotherapy to be an integral part of their weight loss program....We believe that a psychonutritional approach in which both psychological and nutritional factors are addressed is most likely to result in long-term success; however, success may not necessarily mean substantial weight loss. Success, as we define it, means that the person no longer eats compulsively as a way to avoid dealing with issues, feelings, or relationships and that she accepts her body at the weight she has chosen to maintain even thought it may be higher than the weight she finds desirable.
Chapter 9 - Hydration Shifts (brief exerpt)
A hydration shift is the result of a change in the total volume of body fluids, with a corresponding increase or decrease in body weight. People with eating disorders tend to confuse weight shifts due to changes in fat or muscle mass with weight shifts due to fluctuations in amount of body fluid. Learning to differentiate the two facilitates the recovery process.
Chapter 10 - Hunger (brief exerpt)
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