A: You ask a really important question, Annie. There are some additional things I’d need to know to give you a good answer. Since I can’t ask you about them in person, I’ll ask them here in the hopes you’ll be able to think about them and sort this out for yourself.

The difference between exercise “addiction” — also called compulsive exercise — and just plain dedicated exercising has more to do with how you’re feeling about the exercise and about yourself than the actual behavior. For example:

• Do you feel you must exercise in order to make yourself acceptable?
• Do you exercise to “make up” for overeating? Or for eating, period?
• Do you feel guilty, worthless, depressed or anxious if you miss a workout?
• Do you feel you’ve “blown it” if you miss a workout?
• Do family or friends express concern or anger about the way your routine affects your relationship with them?
• Have you ever missed work (school) in order to work out?
• Do you feel weak or inadequate if you want to stop due to pain or fatigue?

If you’ve answered “yes” to any of these questions, certainly to several or more, you may wish to take a closer look at whether you’re using exercise for emotional or self-esteem issues in a way that’s not good for you or your recovery. Chances are, it has some of the same root system as your eating disorder. It would probably be useful to talk this over with whoever is helping you with your recovery.

Best of luck to you!

Susan

A: First of all, kudos for nearly a year in recovery, Rochelle. I’m glad you’re participating in a group to support your recovery and that you’re stopping to think about their advice.

There are going to be lots of voices supporting your impulse to diet. I’m going to give you two monster reasons to listen to your group instead:

• Dieting so frequently leads to eating disorders, it’s known as the “gateway” behavior. It’s equally potent as a trigger for relapse.

• Dieting doesn’t work. The overwhelming majority of people who lose weight through dieting regain the weight and then some.

If you have an eating disorder, dieting too frequently reinforces negative feelings about yourself; for example, that the most important thing about you is what you weigh. Keep your focus on recovery. You’ve done so well. Showing up at your sister’s wedding with seven more months of solid recovery under your belt is the best gift you can give to either one of you!

Best regrds,

Susan

Answer: Hi, Fran. First of all, congratulations on 6 months of recovery!

I’m glad you’re thinking carefully about what to share in a new relationship rather than just jumping in. I’m going to suggest you shift the focus of your question from what you owe your fella to what you owe yourself. If you two are just getting to know one another, you don’t owe him information, other than things that directly affect dating you: Are you seeing other people? Do you only date parrot–lovers? Are you about to move to Tanzania?

The important question now is what will feel best to you and support your recovery? You owe it to yourself to determine whether he’s a trustworthy person with whom you can entrust more vulnerable aspects of yourself, eating disorder–related or otherwise. How does he react to other people with challenges in their lives? Is he supportive? Non–judgmental? Caring? Getting to know you better is a privilege he needs to earn!

Good luck with your relationship and with your continued recovery!

Warmly,

Susan

A: You will be surprised at my answer, Lana. No, obesity is not an eating disorder. Or, as fat activists prefer to say it, being fat is not an eating disorder. This doesn’t mean people who are fat can’t have eating disorders. A number do. But you can’t tell from someone’s size what their psychological state is.

There are many determinants of body size. Genetics is an under–appreciated contributor. People may also gain weight for the more commonly–expected reasons: overeating and/or lack of exercise. But there are also many obese people who eat healthily and exercise regularly, the so–called fat but fit.

Your sister is lucky to have your concern, Lana. There are many good books and Web sites that will help you identify behaviors and thinking patterns indicative of eating disorders. For example, you might start with Something Fishy , a great all–purpose eating disorder Web site. You may also wish to check out Health at Every Size, a site representing the movement by the same name that emphasizes healthy lifestyle over a focus on weight.

Best of luck to both you and your sister!

Susan

A: Dear Brighton:

First of all, I can tell how hard you’re working on your recovery, despite lack of resources, and how determined you are. I really applaud you for it!

A lot of people, unfortunately, find themselves in your shoes: rich on resolve, short on support. Fortunately, advances in technology have increased the options for people who have to reach beyond their immediate environment for support.

One important example is the expanding supply of online support options, such as  support groups, chat rooms or forums. In an online support group, specific people purposely plan to come together  online at a particular time, just as a face–to–face support group would. In a chat room, you can communicate in real time, but you won’t know until you get there who else will be present. With a forum, anyone can leave their comments on a particular topic for others to read and respond to in no particular time frame. You’ll need to register for any of these activities and abide by site guidelines to remain a participant.

Though the Internet can be a jungle, many of these groups are monitored (the only kind I’d recommend) and endorsed by reliable organizations. If this interests you, you’ll want to be sure to visit the wonderful Internet resource for all things eating disorder, Something Fishy. The site maintains a list of moderated online support groups, chat rooms and bulletin boards (also known as message boards or forums). Just a few of the Internet options include Joanna Poppink’s Eating Disorder Recovery Discussion Forums, Pale Reflections, an online membership community, The Eating Disorders Recovery Resources & Recovery Support Network (with 24/7 moderation of their online communities), and the Message Board forum of the Joy Project.

Phone meetings and phone therapy are other options for bringing far–away support to your doorstep. More and more people rely on video calling with services such as Skype for a more in–person experience. Something Fishy’s Treatment Finder includes an international list of individuals and organizations that offer phone or video meetings for people with eating disorders. Some are for free; some are fee for service. Pale Reflections, listed above for online groups, also maintains a list of international phone numbers for ED support.

Twelve Step programs also supply local support. This can be in the form of the more familiar face–to–face meetings. But many also have telephone meetings and the kinds of online chat rooms and message boards discussed above. The following programs have international listings: Anorexics and Bulimics Anonymous (ABA),  Eating Disorders Anonymous (EDA), and  Overeaters Anonymous (OA) .

Please be extra alert about using services at a distance if any of the following apply to you: you have anorexia, your eating disorder symptoms are still severe, or you feel suicidal. In each of these instances, your symptoms may impair your judgment and you need the on–site availability of professionals who can help you ensure your own safety.

I hope you find the kind of supplemental support that’s just right for you and that you continue toward a successful recovery.

Warm regards,

Susan

A: Hi, back, Kelsey, and welcome to the Web site! I’m sure any number of people can relate to your question. It’s a huge shift to go from all the support and structure you get in residential or  day treatment to being back in your familiar setting without it.

First of all, I hope you’ve supplied yourself with an adequate support team at home. Depending on who you are and what your needs are, that might include an individual therapist, nutritionist, eating disorder group, trauma treatment,  alternative practices, for instance, yoga, massage, meditation, and/or experiential treatment such as art, music or dance/movement therapy. In a perfect world, you have at least one such person waiting for your return—someone you already know or someone you’ve contacted for an appointment before you leave your program. That person might help you identify other treatment needs and locate practitioners. That same person might also help you establish a “step–down” program to assist your transition, for instance, scheduling individual treatment twice a week at the beginning or participating in a 12 step program that includes people with eating disorders.

Second, let’s focus on your idea of bringing “Renfrew” back home with you. How about listing key phrases that capture important experiences or learnings from your stay?  These kinds of resources have a discouraging way of evaporating from our brains when we’re under stress. It can be very useful to have some kind of prompt at the ready to remind yourself of new ways of thinking or feeling about yourself. With practice, they’ll become part of you and then you really will have brought your treatment home!

Finally, some people find that just being home is so associated with being active in their disorder, home itself becomes a trigger. If this is true for you, you may wish to do some imaginal work, perhaps with your therapist, developing and rehearsing new, healthy images and experiences of being in your home. If you do this work, you’ll want to let your whole body in on the experience so you can start to associate relaxation or comfort with your home instead of tension.

I know you did lots of hard work during your residential stay. My best wishes to you as you experiment to find ways to make it an ongoing part of being you!

Best,

Susan

A: This is a wonderful question, Nancy! It’s very common for people with eating disorders to suffer from depression as well. For many people, traditional talking therapy, or talking therapy with medication, bring relief. But for a significant number of others, like you, more or different approaches are needed in order to rebound and become more emotionally resilient.

As I gathered my thoughts to respond to you, I found myself writing about the  underlying reasons many of the non–traditional depression treatments work. These  thoughts actually go beyond the scope of your question, but I think may be important in helping people understand why certain treatments are helpful when they are making treatment choices. So I’ve decided to offer a list of potential treatments here and save the why’s and wherefore’s for my upcoming blog post, “Re–regulating Your Mind and Body to Treat Depression in Eating Disorder Recovery” (Friday, 12/17/10).

Here are the kinds of non-traditional treatments I consider for treating depression:

• Physical interventions The medication you already tried, Nancy, was aiming at rebalancing the brain hormones involved in mood regulation.  Other physical treatments might include exercise, getting sufficient light via a light box (for people with seasonal affective disorder, “SAD”), supplementing with vitamin D and/or omega–3 fatty acids. In your post for the Visitors’ Forum, you list other supplements you and others have found helpful.

• Social connection—laughter, support, recognition—is crucial medicine for a depressed system. This can be the informal connection of family, friends, co–workers, organization membership, volunteering (in person, not money!), and the like. Individual and group therapy and/or self–help groups can be another important source of connection.

• Mindfulness practices, such as meditation, yoga, or tai chi, make a big difference to many depressed people.

• Body–based therapies represent an alternative it doesn’t sound like you’ve tried yet, Nancy.  These are not necessarily hands–on treatments (I do body–based treatment and never work hands–on). They involve engaging awareness of key body indicators of stress distress and learning how to modulate them.

• Trauma treatment is often important to clear historical contributors to depression (and eating disorders!) EMDR, Somatic Experiencing and Sensorimotor Psychotherapy are particularly good choices.

Thank you, Nancy, for starting such an important conversation. I hope you and others will check back in for my blog post on Friday.

Best regards,

Susan

A: You came to the right place, Alison! I’ve been using EMDR in my practice for many years and, along with others, have successfully adapted it for the treatment of eating disorders.

EMDR (Eye Movement Desensitization and Reprocessing) is a psychotherapy approach that addresses past experiences contributing to your eating disorder, current triggers for symptomatic thoughts, feelings and behavior, and future capacities you will need to sustain recovery.

We humans are thought to possess an innate information processing system that allows us to “digest” our experiences and file them as memories. EMDR therapists believe that problems like eating disorders occur when this system is disrupted, as it is in trauma or other highly negative events. The structured protocols of EMDR focus on such events with the aim of getting the stuck processing system working again. Your brain can then digest all aspects the experience and store the memory in a useful way that won’t keep causing you problems.

You don’t say whether you are already in some kind of individual therapy. If you are, your first stop is to talk with your therapist about how EMDR might fit in with the work you are already doing. EMDR can supplement ongoing therapy, or it can be a stand–alone approach to treatment. If you are using it to treat trauma, you will need to have developed skills for self–soothing and grounding before you undertake EMDR or any trauma treatment.

To learn more about EMDR or find an EMDR–trained therapist, you can check out http://www.emdria.org.

Good luck in your ongoing recovery, Alison!

A: Your daughter’s residential team is recommending a transitional program that involves more structure and frequency than out–patient therapy. Intensive out–patient programs (IOPs) typically meet for several hours several days or nights per week. They generally focus on group process facilitated by eating disorder professionals. It’s usual to include a meal as part of the program to help participants deal directly with eating anxieties. Transitioning through an IOP will provide your daughter with extra support for new behaviors and ways of thinking, thus reducing the risk of relapse.

By the way, people receiving individual out–patient treatment also may choose to participate in an IOP. This can be a good option if standard, unstructured care is proving insufficient to contain ED symptoms or a person is weathering a crisis that threatens recovery, but in neither case is in–patient treatment warranted.

I’m so glad your daughter is receiving treatment and has your support!

A:  Glad you asked! This terminology confuses lots of people. Here’s the lowdown. A number of people starve, binge or purge, but not exactly in a pattern that fits the formal definition of anorexia or bulimia. These people are lumped together in a diagnostic category called atypical eating disorders or eating disorders not otherwise specified (EDNOS). Examples include women with anorexia who still have their periods; people who binge and purge, but not as often as people who have official bulimia; or people who purge without bingeing. Binge Eating Disorder (BED) is actually still listed among the atypical disorders. So are chewing and spitting, which is exactly what it sounds like, and adult pica, in which a person eats non–food substances. Despite their name, atypical eating disorders are actually at least as common as anorexia and bulimia. They can also be just as serious, requiring the same level of treatment.