Why won’t she just eat?
Why does he spend hours at the gym instead of with his friends?
Doesn’t she realize that she’s already too skinny?
These are examples of some of the comments I hear from family members and friends who have a loved one that’s struggling with an eating disorder. Treatment from these disorders is typically a long process and to those on the outside it can often appear as though the patient is not improving at all. However, this misunderstanding often is due to the flawed, yet all too common assumption held by many when it comes to these illnesses:
They are NOT just about food and weight.
In order to help parents better understand what their child is going through when faced with frustration towards the recovery process, I often draw for them the following picture:
In order for them to adopt a more empathetic attitude towards their son or daughter’s recovery it’s essential for them to understand that not eating, eating too much, exercising in secret, taking laxatives and other behaviors seen in patients with eating disorders, are just the tip of the iceberg and are ways for their child to cope with the larger issues that are looming under the surface and which they are hopefully working with a therapist to address.
This vision of eating disorders isn’t always readily accepted by parents, and rightfully so as it involves a paradigm shift, as well as acceptance that the problem is larger than they may have initially imagined. However, in the long run it’s a metaphor that allows them to have more patience in the recovery process, knowing that the problem is more than what meets the eye. And it also provides them with a way to relate to what their child is going through. While they themselves may not have problems with food or their weight, they most likely have struggled with at least one of the issues that is lurking below the surface, such as a desire to belong or a need to feel in control.
It’s true that restoring patients to a healthy weight, minimizing binge-purge cycles and ensuring adequate nutrition are all priorities in the treatment of eating disorders, given that these aspects of the disorder can lead to serious health consequences and interfere with the success of other aspects of treatment, such as those offered by psychological and pharmaceutical interventions. However, any treatment that fails to address aspects beyond weight and shape will ultimately fall short.
I’ve had numerous patients come to see me for issues that at first hand appear completely unrelated to an eating disorder. Yet, when they mention having struggled with bulimia or anorexia in the past, I often wind up drawing the same iceberg image for them as well.
While they’ve been able to get back to a more normal weight, are no longer throwing up, go to the gym less, don’t obsess over weighing themselves and no longer count calories, I explain to them that they’ve really only chipped away at the tip of the iceberg. They may no longer warrant a diagnosis of an eating disorder, but many of the factors that led them to develop an eating disorder, and served as maintenance factors, are still there, lurking under the water, waiting to be worked through. These may be difficulties with regulating their emotions, their perfectionism, low self esteem, unaddressed history of past abuse, unmanaged anxiety, etc. And more often than not, a new tip of the iceberg has developed, which is usually what brings them to therapy at that moment. These could be problems ranging from procrastination to addiction, panic attacks, insomnia, & depression.
If someone close to you is struggling with an eating disorder, I encourage you to keep in mind this iceberg metaphor to better understand the complexity of the struggle they’re currently facing, one that all too often gets summed up as a mere problem with food and weight.