Chapter 7

What Should I Do?

Guidelines for Friends, Roommates, and Relatives of People with Eating Disorders

1. When we care about someone with an eating disorder, our natural tendency is to see the eating disorder as a problem and to try to help the person get rid of that problem.

But it is worth remembering that an eating disorder is not only a problem but also an attempted solution to a problem.

That is, the disorder serves some purpose. Like many other symptoms and apparently maladaptive behaviors, an eating disorder, for all of the problems it creates, is an effort to cope and to communicate. Starving may be in part an attempt to establish a sense of self, an effort to experience some sense of one's own power, agency, worth and specialness. Bingeing may be in part an attempt to comfort or numb oneself. Purging may serve as a physiological and psychological release, a reliable means of achieving relief from pain, anxiety or numbness. An eating disorder is an expression of that which the person has found no other way of expressing - typically, feelings of shame, doubt, rage, grief, inadequacy; the experience of not being recognized as a separate being with a right to live her own life; the sense of being unseen, unknown, unaccepted for who she is.

There is no simple cause of eating disorders, and certainly no simple solution or cure. Many people find some combination of medical care, individual psychotherapy, group therapy, and self-help groups helpful in their process of recovery. Change is often slow, and recovery typically includes lapses and setbacks. Both the person with the eating disorder and those who care about her can feel frustrated and impatient with the pace of the process. Groups for people with eating disorders and groups and workshops for family members and friends can be sources of hope and support.

2. It is important in life not to take responsibility for things over which we have no power and to recognize those over which we do.

Ultimately, we don't have power over whether someone gets well, wants to get well, seeks help, stays with help, doesn't binge tonight, stops purging, or treats herself with care or respect. We might wish all of those things for someone. We might wish them from the bottom of our heart. We might make ourselves available to talk. We might recommend counselors and books and other resources. We might make an appointment for the person and offer to accompany her to that appointment. But ultimately, we have no power over another person's choice of how - or whether - to live. (Note: We are referring to people who are of a certain age. Parents appropriately have more power and responsibility in the lives of children. And yet parents will recognize even in the exuberance of a toddler's emphatic "No!" the self's determination to be included and respected in the making of choices.)

What we do have power over - and what we can take responsibility for - is the choice to express our concern and our authentic response to someone. Although we cannot know whether or how another person will receive our concern, we can still take responsibility for expressing it.

3. When we express our concern, we are wise to speak of our own experiences rather than to assume that we know what is true or best for the other person. That is, we are wise to use "I" statements rather than "you" statements. When we speak in "I" statements, we take responsibility for our response. When we speak in "you" statements, we tend to make judgments about the person which leave her feeling that she has to take a defensive position. We end up locked in a battle of wills that leads nowhere.

Examples of "You" statements:

"You're too thin." "You need help." "You aren't eating enough."

Examples of "You" statements disguised as "I" statements:

"I think you are out of control." "I think you are just trying to get attention."

Note: "You" statements can be appropriate and useful when they express basic right (e.g., "You deserve better;" "You deserve to eat;" "You have a right to your own life;") or specifically reference statements of fact (e.g., "Actually, you are thinner than that woman whom you say is too thin") rather than judgments.

Examples of "I" statements:

"I've heard you throwing up in the bathroom. I'm concerned. Let's get some help."

"I feel afraid that you're hurting yourself. I'm concerned that your health could be in danger or that you could die. Let's get some help."

"Look, I think we're both at risk for getting caught up on some sort of denial here. I know I've been avoiding talking to you about how concerned I am. I don't like it when we act as if nothing is wrong, because my sense is that something is very wrong. It's too much for us to handle alone. Let's get some help."

"I look at you and I see the light going out of your eyes and I feel like I'm losing you. I miss you. I'm afraid I really will lose you. And I'm scared for you."

"I want more for you than this life of obsession and guilt and self-control and self-contempt. There's so much more to life - and to you for that matter."

"I want to say, `Stop, don't do it!' But I know it's not that simple."

"I'm sorry, but I'm not going to work out with you anymore because I feel like I'm helping you abuse yourself."

"I know you say that I shouldn't be concerned and that I should mind my own business. In fact, to help me deal with that concern, I've consulted with a doctor and a therapist."

Concern isn't expressed only in direct verbal statements. A hug, loving teasing, a hand on the shoulder-such spontaneous gestures are powerfully healing. Being genuinely curious to know how the person experiences things; wondering with her about the things she wonders about; letting her know that you notice what makes her upset and what makes her laugh; wanting to spend time with her; letting her know the ways in which you are tickled or touched by her spirit; asking her opinion or asking her to join you in something; these, too, are expressions of care and concern.

It is important to remember - and help her remember - that she is more than her eating disorder.

4. We need to remain true to ourselves, authentic.

We sometimes feel that we should not be angry with someone who is sick. But the truth is, we feel angry. In families and rooming groups and other relationships, people get very worried about what they should and shouldn't do: they get caught up in trying to anticipate other people's responses and feel responsible for those responses. They start tip-toeing around as if walking on eggshells.

The effect is deadly. If we abandon ourselves by not being authentic, we don't do anyone any good. In fact, we aggravate the situation. If we feel angry and also concerned and scared, then why not acknowledge that-in all of its fullness and true-to-life complexity - is what we feel. The truth is, that is what we feel, whether we acknowledge it or not. If we disregard that truth, we can get caught in a web of denial. In dysfunctional relationships, everyone is at risk for denying the truth; not trusting their perceptions; acting as if things are fine when in some part of themselves they know things are not at all fine; acting as if they do not know what in fact they know; pretending they do not feel what in fact they feel.

It's okay - in fact, essential - to set limits for yourself.

The truth is, you do have limits, so what point would there be in acting as if you didn't? You don't have all the time in the world to listen; you can let someone know how much time you can offer, and when, and then really be there for that time, even if it is a very limited time. You can set limits on things like whether and to what extent you will keep the house free of food she doesn't want around. You can make it clear that you cannot accommodate all of her preferences and that you will not take responsibility for her eating. You can also set limits on specific behaviors that affect you. For instance, you can make it clear that if she throws up, she must clean up the bathroom afterwards. You can make it clear that stealing your food is unacceptable behavior.

5. Don't focus on eating and weight.

Friends and family members who are trying to be of help often end up focusing their concern on whether someone is eating enough, weighing too much, bingeing too much, purging, exercising too much, etc. These are valid concerns; eating disorders can result in serious health problems, and death.

Anyone with an eating disorder needs to be under medical care: it's simply a matter of her safety. But it is important to remember that the person with an eating disorder needs people in her world to respond to more about her than her weight and her eating.

She may feel profoundly misunderstood and feel that her deeper pain and her fuller self are unrecognized when family and friends attend only or mainly to her eating and her weight. What is more, focusing on eating and weight can be counter productive.

When a person with anorexia nervosa hears someone say that she is too thin, she is apt to pleased. Being too thin is precisely what she is trying to be: that defies her as special. When a person who is overweight hears someone say that she is too heavy or that she is eating too much, she can feel insulted, ashamed, and demoralized. It's not as if she doesn't already know those things. Such judgments and assessments can leave her feeling even worse about herself and result in her wanting to binge as a way of numbing herself to her feelings of self-contempt.

To say that one should not focus eating and weight is not to say one should never speak about someone's eating and weight.

It is important to acknowledge that given her purging/diet/low weight, you are concerned for safety. Even if she is not concerned, you can own that you are and that you need to know that she is not in danger of serious health consequences, including cardiac arrest due to electrolyte imbalances. You can say, "I need to know that you're medically safe. Let's make an appointment for you to see a doctor or nurse practitioner."

It is also important to let the person know how you see her.

"I know that you feel `disgustingly fat,' as you put it, but I want you to know that I see you as painfully thin - literally as if you are in pain."

"I know that when people tell you look healthier, you say they really mean you look fat, but that's not at all what I mean. I mean that you look radiant - your eyes are brighter, your smile is brighter, you seem more relaxed. It's like you're more here."

6. We sometimes work with the mistaken belief that there is a right thing to do with someone who has an eating disorder and that if we did that right thing, then the person would be helped and we would not feel enough. It is a fact that we are ultimately helpless over making another person feel some other way or be some other way.

Our helplessness is not necessarily a sign that we should be doing something else; it is a sign that there is a real limit to what we can do to make another person be or feel something else.

She may feel that she has no real effect on people, that she is known and appreciated more for her achievements and her appearance than for herself. Her eating disorder may be, in part, her attempt to communicate just how ineffectual and worthless she feels. Our feelings of inadequacy and ineffectualness is in part a result of our resonating with hers.

We may resonate with other feelings as well. When we feel frustrated, angry, scared, or even disgusted in response to someone with an eating disorder, we feel those things in part because we are empathizing with picking up on the person's own feelings of frustration, anger, fear, and self-contempt or disgust.

Our feelings are not necessarily a sign that we are doing something wrong or not doing enough; they are information for us about what the other person's experience may be. Although we can never be certain that we know what someone's experience is, our feelings as we listen to her are our guides in trying to know, or sense, her experience.

7. Human company and empathy matter.

Hurt and pain are often more bearable in the company of another human being. It is healing and comforting to share one's perspectives without being judged. To have another human being sense what one is experiencing and convey that he or she "gets it" - that is, understands and appreciates one's experience - is a precious gift.

The willingness to join someone so that we can see the world through her eyes requires that we not be invested in changing her or in getting her to change her perspective. Ultimately, we do not have the power to change another person. We therefore must learn to bear our own helplessness, that is, to accept that there is a real limit to what one human being can do to relieve another's pain. If we can bear our sense of helplessness, we won't try to make someone feel better so that we will feel better. We are then free to imagine what it is like to feel what she feels. "Imagine" not in the sense of "concoct" or "dream up" but in the sense of "get the picture" she is painting of her experience. We can then convey our image, or sense of her experience:

* "It's as though you could never do enough...."

* "It's as if you believe you are nothing more than your achievements. "

* "And you're so weary of it all ....?"

* "If only someone could see that there's so much more to you....?"

* "And sometimes you just ache for someone to hold you, to comfort you....?"

* It's as if you couldn't let yourself know the depth of that yearning.... ?"

With such responses, we say, in essence, "I sense that this is how things feel to you - is that what's like?" We are then open to her revisions of our understanding: "No, actually, it's more like...."

To empathize, we need not necessarily agree with the person's feeling or stance.

We might think that there is a more useful perspective she could take, a wiser or healthier place she could stand. But if we try to talk her into shifting perspective, we are likely to leave her feeling unheard, misunderstood, and frustrated - and to feel unheard, misunderstood, and frustrated ourselves as a result. Before she can take other perspective, she needs to know that someone recognizes the legitimacy and importance of hers.

But we cannot take someone's perspective instrumentally so that she will take ours. That would be manipulative and disrespectful. We must join her - stand beside her at her window on the world, so to speak - simply because we are curious to know how she experiences things from where she stands. Empathy is an effort to understand someone's experience as she experiences it and to convey that understanding in a way that both lets her know that we "get it" and indicates that we are open to her revisions and refinements of our understanding.

Empathy presumes our desire to know what she yearns for, what she needs, where she hurts, and what she fears. She may not know the answers, but our asking and our listening are still important.

It may seem as if empathy isn't very helpful....that is, just leave the person stuck in her own misery, and that what the person really needs is to be cheered up, or reassured, or distracted, or given the right advice, or put in touch with the right expert or the right book, or told in no uncertain terms that she has got to change.

But if you think about a time when you truly felt helpless or discouraged or frustrated. . .what kind of response did you want? A pep talk? A challenge to your point-of-view? Advice? Information? Reassurance? Jokes and distractions? Confrontation? Or acknowledgment of what you were feeling and going through? And trust from others in your own being, your own soul, your own sense of timing?

Despite the good intentions of pep talks and despite the wisdom of advice, such "helpful" responses often don't feel so helpful. The person we're trying to help often feels that we are simplifying the complexity of her experience, that we just don't understand.

There is a place for challenge, advice, information, experts, recommendations, pep talks, reassurance, distraction, jokes, and confrontation.

But that place is generally after a person first feels that her experience is understood and accepted for what it is.

John Birtchnell explains how this counterintuitive effort at empathy helps:

Motorists will know the correct way to bring a skidding car under control is turn the steering wheel in the direction in which the car is skidding. By turning into the skid, one is bringing the steering apparatus into alignment with the movement of the car. This action is counter to the natural inclination to turn the car sharply in the opposite direction. The maneuver is analogous to what is, to my mind, the correct way to respond to people who are suffering. Instead of trying to alleviate or divert attention from the pain, I believe one should focus down on it, encourage its emergence, and be accepting of it. . . [If you accept a person's pain,] you have turned into the skid and brought the sufferer into alignment with his suffering.

(From Birtchell, J. Turning into the skid. The Samartan. 1977 Autumn issue. Slough, England: The Samaritans.)

We often resort to advice, reassurance, and other means of trying to talk someone out of her perspective and into some other one because we cannot bear to stay with her in her pain. It simply feels too painful. Empathy requires that we trust her being and timing in a very fundamental sense. We must believe in her capacity to heal and grow. Empathy helps create an environment that supports healing and growth. When we try to understand a person's experience as she experiences it—not as we would like her to experience it or think she should experience it—something powerfully healing happens.

People often say about their struggles in life, "All the help in the world won't do me any good. I need to do this on my own." That's true.

It's also true that even though each of us needs to climb the mountains of life on our own, under our own steam and on our own two feet, we do not need to make the climb alone.

It helps, when climbing, to have company. As people recover, they come to know that they do not need to bear their difficulties and hurt alone or engage in compulsive behavior to escape from their pain period. They come to know that human company helps even if there are real limits to what one human being can do to relieve another's pain.

8. People who have recovered acknowledge the importance of being loved and being believed in.

When we ask people who have recovered from an eating disorder what helped them to recover or what led them to seek help, many say that they had heard from people for years that they needed to take their pain seriously, to get help, and to treat themselves with care and respect. And for years, it seemed as if none of those loving voices got through. In fact, those voices may have been met with contempt and drowned out by the harsh and judgmental inner voices with which the person spoke to herself. Many women with eating disorders feel a deep and abiding sense of guilt and shame. They feel "rotten at the core," so deeply undeserving that they do not feel they can accord themselves compassion or accept compassion from others.

But then one day one of those loving voices takes hold somewhere inside the person. And even one benevolent voice inside makes a big difference. People who have recovered say that it was important that friends and family members kept trying to reach through to them and kept delivering the same messages over and over, because one day they could hear and act on what they could not hear or act on before. They needed to keep hearing voices of love and respect, even when those voices seemed to have no effect. Hearing such voices repeatedly was part of the process by which they came to internalize more compassionate and generous self-regard.

People who have recovered also say that it was important that someone believed in them, continued to see and respond to the health and heartiness in them, and remembered that there was more to them than the eating disorder. They talk about how someone's trusting in their being, or soul, and how this helped them trust in themselves.

9. People with eating disorders often experience great shame about their eating behavior and great shame about their imperfections as human beings. They fear that if anyone really knew them, really saw who they were, that people would reject them.

They yearn to know that someone could both know the worst about them and love them and care about them anyway.

If we think about this, it means that if we say to someone, "No, I am not angry. I know you can't help it and I love you" we are saying that we cannot both be angry with her and love her anyway. How much more honest— and ultimately healing—it is to say, "Yes, I am angry. Yes, I am frustrated. I'm angry because I love you, and I see you treating yourself with such contempt. You deserve better and I wish you believed that."

10. Get support for yourself.

It can be frustrating and confusing to care about someone with an eating disorder. You may feel helpless, enraged, and hopeless. You may also feel vulnerable to becoming preoccupied with your own eating and weight. Don't try to go it alone. Find a friend, counselor or support group, some place where you can talk openly and receive support from others.

You might find the frustration and helplessness somewhat easier to bear if you have information about eating disorders, in particular about why people develop them and about the psychological purposes these disorders serve in their lives. Readings are one source of information; this book includes a brief list of books. You could also speak with a doctor or therapist about your questions and concerns. Consider letting the person with the eating disorder know that you are seeking the information to help you understand her experiences. But don't let your information search diminish your curiosity about her particular experience of things.

It can be especially frustrating when someone who is hurting refuses to seek or engage in any sort of help. Many women with eating disorders regard their needs and desires with disdain and contempt. They feel ashamed not only of their disordered eating but even having needs and desires—much less attempting to respond to them. This shame makes it hard for someone to seek help or to engage in any help she does manage to seek. Consider letting her know that you are so concerned that you consultation. Letting her know that you take her pain seriously may, in time, help her to take her pain seriously, too.

Source: American Anorexia Bulima Association, Inc.

Continue to the next chapter.