Greg Wright:
Welcome to Social Work Talks. I'm Greg Wright. More than 30 millions live with eating disorders. Today, we are talking with NASW member, and eating disorder expert, Mary Anne Cohen, about how social workers can help people living with eating disorders. Cohen is author of the NASW press book, "Treating the Eating Disorder Self: A Comprehensive Model for the Social Work Therapist." She is also director of the New York Center of Eating Disorders. Welcome to Social Work Talks, Mary Anne. How are you doing today?
Mary Anne Cohen:
I'm doing very well.
Greg Wright:
How long have you worked with people who are living with an eating disorder?
Mary Anne Cohen:
I began working with eating disorder patients in 1982 and I became director of the New York Center for Eating Disorders. I became very intrigued when I started to realize that the underlying theme that many people with eating disorders have in common is this. That for them trusting food is safer than trusting people and that loving food is safer than loving people. Food never leaves you. It never abuses you. It never rejects you. It never dies. It's really the only relationship where we get to say where, when, and how much. Really no other relationship complies with our needs so absolutely.
So, this realization helped me see how compelling the urge to turn to food can be for people to help themselves feel better and quote unquote "solve their emotional problems." By the way, I say quote unquote "solve their emotional problems" because no amount of binging, purging, or starving does really resolve emotional problems. It may make you feel better in the moment, but it's not a long-term solution. And by the way, Greg, I tell all my patients that trying to help themselves feel better is a healthy intention. But, using or abusing food as a mood altering drug cannot be the only game in town. So, we have to expand, and I talk a lot at this in my book, our patients' repertoire of what will soothe them and what will comfort them.
I also want to say one other thing about why I became interested in this field. Because I realized that eating disorders, on one hand, are clearly about food. Binging, starving, purging, dieting. But, they're also not about food, but a way to, as I said, comfort and soothe oneself, a way to self-medicate depression and anxiety, and a way to numb pain. So, this makes treatment really complex because the therapist needs to address both the hurtful behaviors about food and eating, but also the emotional roots that make binging and purging, or starving, seem like the solution for emotional pain. So, it's a two-prong treatment.
Greg Wright:
There are different types of eating disorders. There's bulimia, anorexia, binge eating. So, it's manifested in different ways and I was wondering if you could explain to our listeners the different types.
Mary Anne Cohen:
Great question. Well, first let me say that the correct diagnostic terms are bulimia nervosa and anorexia nervosa. The nervosa, as in nerves, the same root, indicates that these are emotional disorders. That these are mental health disorders. Now, binge eating disorder was included in the DSM, the "Diagnostic Statistical Manual of Psychiatric Disorders," in 2013 as a bonafide psychiatric disorder.
Greg Wright:
That's very, very recent.
Mary Anne Cohen:
It's very, very recent. But, it's done something very important. By making binge eating disorder a bonafide psychiatric disorder, it has been extremely validating for the millions of people with binge eating disorder, as well as their families, who assumed that their struggles with food was just about a lack of willpower. So, when we add this as a psychiatric diagnosis we realize this is not about willpower. This is not about eating too many potato chips. This is a bonafide emotional disorder that requires treatment, and that is not about willpower at all. So, this was extremely validating.
Now, let's move on to bulimia. Bulimia is defined as binging on food, and then making yourself get rid of it through vomiting, through laxative abuse, or even through excess exercise. And there are people called exercise bulimics who's main thrust in life is to burn off calories through exercise. It's not about pleasure in exercising. It's about the anxiety about food, fat, calories. So, those with bulimia who are trying to get rid of the food that they've taken in generally have a higher incidence of drug and alcohol abuse. They generally have a higher incidence of sexual abuse and many family members may also have addictions to drugs, alcohol, or food. This points to a possible underlying biological connection between the eating disorder and other addictions. So, many bulimics have post-traumatic stress disorder, and as I said, many families also have addiction problems, depression struggles, drug struggles. So again, this points to an underlying biological underpinning with this disorder.
Greg Wright:
Would you even go as far as saying that it's a genetic thing so that might also be a factor here?
Mary Anne Cohen:
Absolutely. Primary biological relatives, by which I mean siblings, and parents, or grandparents, have a higher incidence of drug and alcohol and food disorders than let's say, the anorexic, or maybe even the binge eater. So, yes. Very much so a genetic predisposition.
Now, anorexia refers to self-starvation where the person develops an almost paranoid relationship with food and eating. So, food is considered the enemy, being fat. And let me just say real or imagined fat because the anorexic is generally often emaciated. So, real or imagined fat is considered to be the enemy. It's almost a paranoid relationship with one's body. And the wish for the anorexic is to be in control, as much as possible, to eat as little as possible. But, the anorexic never feels thin enough. I have worked with emaciated anorexics. They do not see what they look like because there's a reality distortion and because there's an emotional connection with the wish to be thinner, and thinner, and thinner. So, even when you point out, or family members point out, "Look how much you weigh. You weigh 75 pounds." For the anorexic, they cannot see it because their distortion and their need to be thin and thinner is what drives their inner life.
Let's remember that the binge eater, it refers to a person's over eating not because of physical hunger, but because of a compulsive need to stuff down feelings, to stuff down food, and quell anxiety. And by the way, one of the thrusts of treatment is to help people reclaim eating according to hunger, physical hunger. Because we can say that all of the emotional eaters, the anorexic, the bulimic, the binge eater, really are working on feelings of being hungry from the heart and not from the stomach.
Greg Wright:
Mm-hmm [affirmative].
Mary Anne Cohen:
Although each of these people, misuses food in different ways, they're all concerned about being fat and losing weight. And we'll talk more about that when we get to the outer world.
In 1982, I originated the term "emotional eating," to describe the varied and conflicted, fluctuating and frustrating, relationship that many people have with food to deal with anger, boredom, fear, loneliness, anxiety, guilt, grief, shame, fear of crying, sexual conflicts, trauma, such as posttraumatic stress disorder. So really, any strong emotion that a person cannot face directly, they can look for refuge in food, eating, and preoccupation about weight loss, dieting, and body image. So, there are so many triggers, which is why I call emotional eating the umbrella term for binging, purging, and starvation because the root is the emotional struggle that people cannot face directly. If you can digest your strong emotions, you don't need to recruit food or an eating disorder to deal with them. But, the person with emotional eating is using the food to distract, to detour, or to deny their inner feelings.
And Greg, let's also remember, food is the cheapest, most legal, most available, socially sanctioned, mood altering drug on the market. And there's no doubt that food is a mood altering drug. So, because food is legal, it's cheap, it's available, it makes it very easy to turn to in moments of stress and comfort.
Greg Wright:
Is family a factor as well? I remember when I was growing up... I come from an African American family from the South. If you visit a family member, they'll have out a lot of food. You are expected to eat it. If you don't eat it, you are insulting people. I had a cousin, she would burst out crying if you did not eat a big plate of her food. Is it also how we are brought up to look at food?
Mary Anne Cohen:
Of course. Food is love. I come from a Jewish family. Food is love. My husband comes from an Irish family. Food is love. Go to Italy. Food is love.
Greg Wright:
Yeah, it's a common thing.
Mary Anne Cohen:
It's a common thing. But you know, the difference is that in the story you relate, food is about providing love, and it's providing sustenance, and it's providing connection and generosity. But, that's not about an eating disorder. An eating disorder comes from a very deep inner need to take care of emotional issues that have been diverted, rather than deal with them directly.
For instance, one of the things that I do a lot of writing and thinking about is how much people who cannot go through their grief and their mourning directly, either because it's been an abuse experience, or because they are terrified of strong emotions, or because they were taught, "big girls, big boys don't cry." Very often, grief becomes frozen in an eating disorder and it's only when you go through the process of mourning, very often in therapy, that people can begin to resume an appropriate grief reaction.
I just want to give you an example from my practice. I work with a woman, I'll call her "Joan." And she came to me... she was a compulsive overeater and told me that her father had died when she was three years old. And I said to her, "What do you remember? Let's talk about him." And she said, "Nah. I don't remember anything." And then, she started to cry. And she began in every session to cry about his loss, about the fact that she never grieved him, about the fact that her childhood was hijacked because of his death. And at one point, she said to me, "I think that my tears are becoming liquid grief and the fat that I've carried around in my body has been frozen grief." I will never forget that because it was such a beautiful image of how people can be frozen in their feelings, their eating, their fat, their bodies. And she talked about her crying, and being able to break through with the crying as turning her grief into something liquid that could be expressed to the light of day.
Greg Wright:
Wow.
Mary Anne Cohen:
Yeah. Powerful right?
Greg Wright:
Yes, yes. Absolutely. Absolutely. Our culture prizes thinness. It's in our advertising. It's in our music. It's everywhere. Is that a driving factor a lot in making a person either be bulimic or anorexic?
Mary Anne Cohen:
This is a really great point because we know... and this is where in my book I talk about the impact of the outer world on eating disorders, and you are defining that outer world as the media and the advertising that we are all subject to. Once upon a time, Marilyn Monroe, who is curvy, was considered the beauty standard. Then, it moved on to someone like Twiggy who was thin and she was the beauty standard. So, advertising is very fickle and what is considered in a woman changes... particularly women, but also men... changes according to the decade. But, what we know about the media and advertising is that they constantly hold up a mirror of what an ideal woman should look like. Now, I'm going to talk about men in a minute too, but let's just talk about the ideal woman.
The ideal woman is young, thin, White, and heterosexual. And so, although the media is expanding into larger women, and women of color, and this is very heartening, the "ideal" quote unquote image that has been foisted on us is this ideal White, young, thin, heterosexual. So of course, here's the point, not all of us take in this harmful message that there's only one way to look beautiful and turn it into an eating disorder. You have to have a predisposition to turn these harmful advertising and media messages into a destructive assault on your own body with an eating disorder. So, there are those who are vulnerable to taking in these messages in self-destructive ways and they will turn to dieting and weight loss to achieve, or hope to achieve, better self-esteem. But, here's the point. It rarely works.
First of all, diets do not work. And because changing and altering your outer appearance rarely improves lasting internal self-esteem. Self-esteem really is an internal job, an inside job. So, although media is hoping that we jump on the bandwagon for the latest and greatest imagery, and clothes, and diet aids, the truth is you really need to work on self-esteem from the inside out.
What was really powerful to me when I was writing this book is to learn about how many women of color, and I'm talking about African women and Asian women, especially Asian women, turn to skin lightening products even though many of those skin lightening products contain mercury and very harmful chemicals. But, here is a population of women who want to look lighter while we White Americans are always rushing off to our tanning salon to look darker. So, the irony is that we can never get it right. The media and advertising breeds within us perpetual dissatisfaction. So, being able to educate, particularly young women, into how these messages are manipulative, and how these messages are trying to get you to buy new products, can be enlightening so that they are inoculated. They become inoculated against taking in these very harmful messages.
Greg Wright:
Eating disorders, I've heard, are very hard to treat. Have you found it a hard slough to actually bring folks up out of this?
Mary Anne Cohen:
Everyone is different. One of the things that I stress is that every person's eating disorder is unique as a fingerprint. So, there is no one size fits all. There are many healing ingredients that can make treatment successful. Let me tell you about some of them.
First of all, if a client is working with a therapist who is empathic, and attuned, nonjudgmental, and curious, this can really help someone because eating disordered people are so judgemental about themselves. And to work with someone, a therapist, who's trying to generate curiosity... let's try to understand what makes you tick with food. Let's try to understand what triggers you to turn to food, or purging, or starving when you're under emotional stress. So, that's really the foundation of a good treatment. When someone can relate to a therapist, who feels like they understand them, that they've been there with other clients, that they know what it's like to feel stuck in one's body.
So, I believe, and I talk about this in my book, that there are four causes of an eating disorder. The first cause is lack of knowledge. And what I mean by that is people often turn to diets as a way to try to get control of their eating. But, diets do not work because they set you up for feeling deprived, restricted. If someone said, "Here's a diet, and you can eat anything you want except bagels and cream cheese," what are you going to want more than life itself? Bagels and cream cheese. Because forbidden fruit is the sweetest. So, diets are always on the verge of failing you because there will always be a binge waiting on the horizon when you can no longer tolerate the restrictions of the diet. So, this is the first cause of an eating disorder. Lack of awareness and the belief that diets are the solution to eating problems. And a psychoeducational approach where people are taught that diets don't work in the way that I just expressed to you, and how they really set you up for a vicious cycle, is really the first step of what causes eating disorders.
Now, the second cause of an eating disorder is habits. Hurtful habits that cause someone to be ingrained in destructive eating. So, that means coming home from work and breaking open the container of ice cream. That means coming home from a date and purging on the dinner that you had. So, there are certain habits that, through behavioral and cognitive treatment, people can put a wedge between their automatic reflex of binging, purging, or starving after they've indulged or engaged in emotional eating. So, that's the second cause of an eating disorder. And the behavioral cognitive treatment is the second level of intervention.
So, the third reason... and by the way, I'm expressing these reasons in order of severity. The least severe being a psychoeducational awareness that diets don't work. Then, the next level of severity being ingrained habits and obsessive or compulsive thinking. Then, the third layer is that of psychological issues. And as i mentioned before, issues of grief, even issues around the fear of success. I've had a lot of people in my practice and have been doing this work since 1982, so I've had a lot of people in my practice. And by the way, let me just add that my book, Treating the Eating Disorders Self, has 200 case examples from my practice. So, I have culled some really, if I may say, rich examples of what makes people turn to food and what makes people find recovery.
So, in these two examples I talk a lot about the psychological dimension of eating problems and one of the issues I was going to mention to you, Greg, is the fear of success. That even though people say, "I want to get rid of my binge eating disorder," or, "I no longer want to be bulimic," the truth of the matter is so much of their lives has often been about what I'm going to eat, what I shouldn't have eaten, how many calories I'm going to take in, and this becomes a way of life.
And I say to people, "Well, if we cured your eating disorder and you were no longer thinking about food, and weight, and calories 24/7, 365, what would give your life meaning?" And it's so surprising that people don't know. The preoccupation with food, and dieting, and weight loss has become such an integral part of one's personality, that people often don't know what would give their life meaning. But, as a therapist, I remain quiet. And then, someone will say, "I guess I'd have to divorce my husband if I weren't thinking about how much weight I'd have to lose." And it's kind of funny when you ask, "Well, what's the next issue which would come up for you?" and generally, you're going to hear a deeper psychological cause. And so, you can understand why people would want to stay entrenched in an eating problem. Because it protects them from going deeper and having, perhaps, to make other changes in their life.
Greg Wright:
Got it.
Mary Anne Cohen:
You got it. Right. This happened very recently that I said to somebody, who has spent a great deal of her session telling me about her blue jeans, and how many she has in her closet, and which ones fit, and she's really obsessing about it. And I said to her, "So, if we cured you of your eating disorder, what's left next?" And she said to me, "I really don't have much meaning in my life. I'm a mother, but I got married very, very young. I really never developed my own sense of personality. I guess this is a detour from figuring out who I am and what I need to give meaning to my life." This was so heartening to hear someone come to this realization because it meant that the eating disorder was not going to be the only definition that she could come up with for herself.
Number four, and this is the most severe level, is really when food becomes an addiction. While most people eat to live, the addict lives to eat. Their whole life has become subsumed in eating, isolation, and retreating from the world in order to take care of their needs for food, and needs for, perhaps, drugs and alcohol.
So, the treatment of choice for people here might be a 12 step program, like Alcoholics Anonymous, or Overeaters Anonymous. It might include an inpatient hospitalization. It might include an intensive outpatient treatment where they can really be helped to find other ways of connecting. Because I always say that people need to connect with others in order to heal their eating disorder. Food can be a very, very self-contained universe and people need the comfort, and the help, and the support of others who have been going through the same journey. And groups, and hospitalization, and intensive outpatient programs, or a 12 step program can be very helpful.
And also, let me add that often medication can be helpful as well. And I talk... I have a chapter in my book on the use of medication for eating disorder patients. Because if someone is using food, or purging, as a form of medicating depression or anxiety, they may have, as we've talked before, a biological issue that medication can really be helpful for. And so, many people are helped to dial down their depression or their anxiety, and then food does not have to be the only way to help themselves feel better.
So, those are the four causes and treatments for eating disorders. And, I did want to mention that in my first book... because the book we're talking about today, Treating the Eating Disorder Self, is my third book. But, in my first book, French Toast for Breakfast: Declaring Peace with Emotional Eating, I offer an extensive questionnaire to help both clients and therapists determine what level of care is needed in order to create a comprehensive individualized treatment for themselves, or for each unique client. Because as I said, I believe that everybody's eating problem is unique as a fingerprint. So, we need to create, as therapists, a comprehensive and individualized treatment for each of our clients.
Greg Wright:
Now, there are several shows out there that either focus on weight loss, for instance, The Biggest Loser, or My 600-Pound Life. I was wondering, are you watching these? Are they doing more harm, than say, good here?
Mary Anne Cohen:
If someone is enabled to eat more consciously, and with more awareness, and to separate out their food from their feelings, their emotions from their eating, then these programs may, and I say that, may have a beneficial aspect. But, often the thrust is on weight loss without getting to the root cause that this person did not become 600 pounds overnight. And there's a lot of work that needs to be done to help someone detangle their relationship with food.
Cohen:
I think that the programs may do more harm than good because most of these people have tried everything before coming on this program, and there's a lot of humiliation that goes on in these programs, and a lot of competition. When you go back to your real life, your regular life, you're not going to be pushing bricks in a wheelbarrow up and down your block for the rest of your life. So, I would have to ultimately say that these are very dubious programs because they don't help someone get to their inner life, which is basically... in addition to genetics, as we talked about before. But, the inner life is so much a part of what needs to be unraveled and needs to be teased out as to what's going on that's triggered someone to turn to food.
Greg Wright:
Now, we are living in a pandemic. A lot of folks are at home. One of the few things now that a lot of folks are doing is they're actually cooking a lot at home. I'm finding, personally, that I'm eating a lot of comfort foods that I ate as a child. Meatloaf, sloppy Joe's. Things that I haven't eaten in years I'm making it at home. A few neighbors are making bread and they bring the loaves over. It's just food, food, food. Is this pandemic making people more likely to have a disorder?
Mary Anne Cohen:
Well, of course. By the way, Greg, I'm coming over to your house for dinner. I like the way those Sloppy Joe's sounds. But, of course eating problems are more rampant during this time of lockdown and uncertainty because people are more depressed, they're bored, they're cut off from socializing, they're isolated from seeing people they care about. And here's the thing. The fact that we do not know when this pandemic is going to end ramps up our anxiety tremendously. And this is where food comes in.As we said, food is the most legal, cheapest, socially sanctioned mood altering drug on the market. And by the way, drinking has also increased during the pandemic. People are turning to alcohol, and cocktails, and booze a lot more because it's kind of a recreational activity.
So, yes. Stress eating is a thing that needs to be acknowledged. What can be helpful for people is to put back some of the structure that has been missing in their lives during the pandemic, such as eating regular meals, eating regular snacks, that have a beginning, a middle, and an end. And, staying in touch, as much as possible, with family, friends, or a therapist, to process what you are going through. And, this will help a person be emotionally nourished, not just food-nourished. But, just because people are overeating during the pandemic doesn't mean that they actually have an eating disorder. Time will tell when the pandemic lifts and we can resume our normal lives whether people stay stuck in their food, in their eating habits, or whether they can go back to life as normal.
And, let me just add that my book also covers why social workers need to be culturally competent in dealing with eating disorders. Because eating disorders do not discriminate on the basis of race, or gender, or sexual identity, and there are an increasing number of African American, Hispanic, Asian, Muslim, and gay, lesbian, and trans people presenting for eating disorder treatment. And psychotherapists need to be aware of the unique and special issues relating to isolation and alienation.
My practice is in Brooklyn, of course now I'm in virtual reality, and so I have Hispanics, I have Muslims, I have orthodox Jews. Brooklyn is a microcosm of the world. And each person has their own triggers, microaggressions, and issues that have fueled their eating problems. So, becoming culturally competent, both of gender issues, and racial issues, and ethnic issues, is also an important part of treatment, which I deal with pretty extensively in my book.
Greg Wright:
Mary Anne, I was wondering if you could let us know how social media plays into the arena of eating disorders. Does it really influence people who are dealing with these disorders?
Mary Anne Cohen:
Well, this is a great question because social media has become a double-edged sword for those with eating problems. On one hand, online communities can be part of the solution. And on the other hand, they can be part of the problem. You know, Greg, it has been said that comparison is the thief of happiness. Comparison is the thief of happiness. And young girls, especially, are caught up in comparing themselves to other girls' posts on Facebook, Twitter, Instagram, Snapchat, to see how they're measuring up. Unfortunately, there are also pro-anorexia and pro-bulimia websites proliferating on the Internet encouraging people how to be better anorexics and better bulimics.
But, when you measure yourself to some friend or actress who has posted their most ideal, polished image, you will feel inadequate and deficient. And then, the girl's conclusion may be that she has to lose weight in order to measure up, in order to look better, in order to fit in better, and a vicious cycle then begins with her eating struggles. However, on the other hand, social media has provided many, many recovery sites for people to get help. Podcasts, referral information, articles. We have the National Association for Eating Disorders. We have [inaudible 00:39:49] Value Core, who's website is EDCatalog.com. And then there's EDReferral.com, which is an eating disorder referral and information center. And my website is emotionaleating.org.
Greg Wright:
Well, I want to thank you for being our guest. I've learned a lot.
Mary Anne Cohen:
And thank you very much for having me.
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