About the Author
Acknowledgements
Introduction

Chapter 1: Everything You Need to Know about Anorexia Nervosa: An Overview

Chapter 2: A Feminist Sociocultural Explanation of Anorexia Nervosa

Chapter 3: Psychotherapeutic Models

Chapter 4: A Multidimensional Model for the Treatment of Anorexia Nervosa

Chapter 5: Case Studies

Conclusion
References
Additional Resources
Index

Women are rarely satisfied with the way they look. There is always something wrong or something they don’t like about their appearance. Why is it that women are known to walk into a room and do a "once over" to assess themselves in comparison with the other women in the room and subsequently adjust how they "feel" on the basis of how they measure up in terms of looks? And depending how we feel or who we compare ourselves to, we can feel either "thin" or "fat," having nothing to do with body size or weight. Women know what I mean. Why is it that women seldom eat what they really want? There are always self-imposed limits to what and how much they eat in order to look "good" and fit into something trendy. And something trendy is always small. We are never okay just the way we are. We have "bad hair days," we have "nothing to wear," our shoes hurt and we "feel fat." We are constantly surrounded by something or some way to improve ourselves – something we can buy, a product with a promise, or something we can do, be it a diet, a procedure, or surgery. The quest for beauty is endless.

Our cultural preoccupation with thinness is unavoidable. We are surrounded by images of skinny women – magazines, billboards, television – questionably airbrushed images. For women, self-esteem and appearance are intertwined and based on a culturally predetermined ideal body – hardly realistic when each person’s body is different. It certainly makes logical sense that women engage in disordered eating as a means of achieving a thin, culturally idealized body. Anorexia nervosa is a psychiatric disorder characterized by a willful determination to control the intake of food to the point of starvation, one that is precipitated by a myriad of causative factors. All too often, anorexia is an ultimate, overwhelming obsession with the ideal of an unequivocally skinny body – and a life-threatening means of achieving it.

Some of us remember where we were the day man first set foot on the moon. I remember what I was eating. For someone who grew up in an Italian family, it’s certainly not unusual to remember a meal. What I know to be true is that food is love and celebration and comfort and sustenance; food is everywhere and everything. So I guess it makes perfect antithetical sense for me, as a psychotherapist, to have taken an exceptional interest in anorexia nervosa.

My personal interest in self-imposed starvation began when I was about 12 years old. I had a cousin who visited from time to time who was very skinny and simply refused to eat. But she looked good in the latest fashions, and she didn’t have to hold her breath to zip up a skirt. The family was always in an uproar when she visited because she did the unthinkable: She rejected food – really great food. My grandmother would cook for hours; her house had the most heavenly aroma of marinara sauce, detectable three houses away. To me, this made it altogether impossible to even consider not eating, hungry or not. I was fascinated by my cousin’s ability to unaffectedly dismiss food. The adults were beyond aggravated and forever worried, always coaxing her to eat, but to no avail. They would say, "Why can’t you eat like . . .?" – and they would point to me, and I was confused as to whether it was a compliment or an insult. I remember my aunt’s unrelenting warning that if you didn’t eat, you would die. She said this hoping that her daughter would take heed. After my cousin left, my family would talk about her for weeks, in dismay and utter disbelief. I wanted to understand.

I grew up in the 1960s and remember when, once a year, you were weighed in front of your entire class. I still cringe when I recall my fifth-grade teacher choosing the cutest boy in the class to call out everyone’s weight so that she could write it down. I really don’t know why they needed to record everyone’s weight, but, one by one, we were called to step on a scale, and our weight was announced for the entire world to hear. As if that wasn’t bad enough, a few would have to go the nurse’s office. We all knew what that meant, and I always held my breath for a few seconds and prayed not to be sent to the nurse for eating too many of my grandmother’s meatballs. Being sent to the nurse meant that you were either underweight or overweight, either of which warranted a note home to your parents. That was worse than a bad report card. And to make matters worse still, those were the infamous days when Twiggy, an emaciated British model who appeared to never have eaten a dish of lasagna, had lowered the bar for weight and thinness in the fashion world and set a standard for body size that few could attain.

It was the beginning of an era in our culture marked by weight obsession and the emergence of the diet industry. Women were burning bras and fighting for equal rights. It was during those years that I became keenly aware of the juxtaposition between the pressure for women to be skinny and the pressure for women to be equal to and competitive with men. There were moments when it seemed as if women really could compete with men and enjoy equal opportunities for career directives. Yet, at the very same time, the fashion industry began to present women with a new ideal body image that was far thinner than ever before. "Skinny," as an ideal, was all over the place, and women’s bodies and clothing sizes were shrinking. Women have always been known to read magazines, and these were filled with repetitive and unavoidable images of skinny women. Those were the days when the door opened for the diet industry to flourish and invent bizarre regimens, all aimed at helping women achieve the Twiggy look. As an adolescent girl, I remember feeling the pressure of having to become skinny to fit into a mini skirt like Twiggy and having to diet to do so. But it was confusing – was skinny good or bad?

When man set foot on the moon, I was on an "ice cream diet," eating a bowl of peppermint stick ice cream while on vacation with my family. I had been eating only ice cream for breakfast, lunch, and dinner. My brothers thought it was stupid. My parents didn’t try to convince me to abandon it because they knew it wouldn’t last. I ate ice cream all over New England, and by the time we returned home, I was hungry and never wanted to eat ice cream again. I eventually made peace with the fact that I was not going to look like Twiggy, no matter how, or how much, I rationed my food. And I was not sure if that was bad or good.

Nevertheless, I was motivated to understand the cultural forces that caused otherwise reasonable women to diet unnecessarily, starving themselves to achieve a certain look. I took issue with the pervasive cultural pressure for women to undermine their bodies’ natural, comfortable setpoint weight. I wondered why women complained of "feeling fat" and obsessed over being thin – a standard that did not seem to apply to men the way it did to women. Perhaps the current epidemic of obesity in the United States is a swing of the pendulum in the entirely opposite direction – a reaction formation of sorts. Perhaps Americans are giving up and overdoing it because the cultural ideal of "skinny" is so far out of reach for many. Perhaps our current anti-obesity climate is an ultimate pronouncement that "skinny" still rules.

This book contains an overview of anorexia nervosa from a feminist sociobehavioral perspective and a treatment model for clinicians. Although the book is intended for clinicians, those close to an anorexic may also benefit by familiarizing themselves with the strategies used in psychotherapeutic treatment – which may, in turn, provide some insight and direction for guiding an anorexic back to health. Through a better understanding of the disorder, those close to an anorexic may approach the patient with a more tolerant and informed attitude, thus supporting and facilitating treatment interventions.

My work is based on 28 years of clinical practice and many successful treatments of anorexic patients. I present a treatment model that has evolved from my deep concern for the phenomenon of women feeling pressured to be "skinny" and starving their bodies to do so. My treatment approach has demonstrated the ability to overcome the willfulness and marked resistance to therapeutic intervention that usually occurs in attempts to treat anorexia. I have managed to address the biggest problem in treating anorexia, which is the marked resistance to any kind of intervention. I have also found a way to give the anorexic patient control over her food intake, control aimed in the direction of healthy weight and recovery.

This book also provides an overview of anorexia nervosa itself, using both theoretical and practice-based perspectives. I present theoretical approaches that are consistent with my work and have informed and influenced my treatment approach. I provide a definition of anorexia nervosa as a composite of the literature and describe symptoms as they are reflected in research. I also provide a narrative description of how anorexia is a feminist issue and how the culture at large has largely contributed to its existence. As part of an overview of the disorder, I explain, from a sociobehavioral perspective, the manifestation of anorexia in a postfeminist era. To support my premise, I include clinical case studies and explain the treatment of anorexia nervosa in theory and from my own clinical perspective.

One day, while in the midst of researching anorexia, I entered a college bookstore, where I found – prominently displayed for young women to see – a book titled Skinny Bitch: A No-Nonsense, Tough Love Guide for Savvy Girls Who Want to Stop Eating Crap and Start Looking Fabulous! (Freedman & Barnouvin, 2005). It was upsetting to me that a book promoting the ideology that "looking fabulous" requires being "skinny" was in a university bookstore – especially considering how prevalent eating disorders are among young women! Horrified by the title, I picked up the book and began reading, and what I read validated my contention that women continue to be unnecessarily pressured to value "skinny" and strive for thinness, no matter how aware of the dangers they are. Skinny Bitch was published in 2005, when political correctness seemed to have somehow become separated from the subject of women and their relationships with their bodies, evidenced by the book’s bearing the "#1 New York Times Bestseller" seal on its cover. Women have always had tenuous relationships with their bodies and have always been pressured to meet impossible cultural standards for beauty; the extreme of that pressure is manifest in the prevalence of anorexia nervosa.

Impressionable young women have read and will be reading books that encourage dissatisfaction with their bodies – dissatisfaction that, in turn, feeds into and reinforces a dysfunctional cultural climate that breeds eating disorders. Even worse, and more dangerous, are pro-anorexia (or "pro-ana") Web sites that promote anorexia and encourage disordered eating as what the site creators deem "a lifestyle choice." Anorexia can lead to death and numerous serious health complications, such as compromised fertility and pregnancy, muscle and bone loss, and heart damage (which notably caused the death of Karen Carpenter), to name just a few (Shaw, 2005). Viewed through a sociological lens, there appears to have been a strong cultural influence, historic in nature, encouraging women to prove their worthiness through self-imposed starvation, and that notion has carried through to the present. There is something terribly wrong with this picture.

According to feminist author Susie Orbach, our culture at large has been the cause of "body hatred" among women of all ages. Orbach (2008) contended that 90 percent of all women want to change one aspect of their appearance, only 2 percent of women are able to refer to themselves as "beautiful," and 70 to 80 percent of women manipulate their eating. In her research, Orbach found that 72 percent of girls and 68 percent of women avoided ordinary activities because they felt "awful" about their looks, and that dieting has a 97 percent failure rate. In the course of a week, women are exposed to about 3,000 images of skinny women – "lollipop" women with extremely skinny bodies and large, disproportionate heads, images of whom appear constantly in advertisements and magazines. Women form relationships with their own bodies on the basis of these images in the media.

Yet women were not always expected to be "skinny." In the American Movie Classics television series Mad Men, we are given an opportunity to observe things as they were in the early 1960s, before the Twiggy era. Watching Mad Men, we see children playing happily with plastic dry cleaners’ bags over their heads, we marvel at widespread smoking, and we can’t help but notice that the women of those pre-feminist years were curvy – very curvy. But shortly after, as the feminist movement became the voice that challenged women’s second-class citizenship, the cultural norm for women’s bodies seemed to shrink. Curvy seemed to be replaced with skinny, angular, and boy-like. In The Beauty Myth, Naomi Wolf (1991) made the connection between the importance of beauty for women and their attainment of power. There were cultural influences that determined those body ideals – a conspiracy of sorts, aimed at keeping women and their perennial fight for equality with men at bay. Wolf contended that the "beauty myth" was about men’s institutions and institutional power waging a counteroffensive against women, aiming to defeat women’s strength with the expectation of thinness. At the point in history when women were gaining equality with men, the "skinny" archetype – lank, underfed, and weakened – emerged into cultural prominence. A similar effect occurred during the 1920s’ "flapper days," when women finally got the right to vote. Women earned rights, and "skinny" emerged as the new norm. And eating disorders became prevalent.

Anorexia Observed in My Clinical Practice

Early in my practice as a psychotherapist, I began working with anorexics and understood that treating anorexia was a "holy grail" of sorts in the treatment world. It was widely known that those suffering from anorexia nervosa were very difficult, if not impossible, to treat. Yet our universal need to survive as a species makes it imperative that we find a way to lead anorexics back to healthy eating. What later evolved into my treatment approach was originally a careful and respectful challenge of the anorexic’s relationship with food through language. Outwardly, anorexics appear to reject food, starving themselves, yet inwardly they are hungry, literally hungry – how could they not be? Because there is comorbidity between anorexia and obsessive-compulsive disorder, I found that anorexic patients were amenable to allowing me to obsess about food with them. In fact, if you talk about food enough, you will get hungry. The anorexic’s willful refusal to eat is a defense against the longing to eat. My premise was to challenge the willful defense of starvation by appealing to the obsessional nature of the disorder, using logic, and thus replacing unhealthy obsessional eating with obsessing about healthy eating. This is an ideal use of a cognitive-behavioral intervention.

Joan Brumberg (2000) began her book about anorexia, Fasting Girls: The History of Anorexia Nervosa, with this statement: "I am not a recovered anorexic nor am I the mother of an anorexic daughter" (p. 3). It is important for me, also, to state that I, too, am neither a recovered anorexic nor the mother of an anorexic daughter. I began my psychotherapy practice in the early l980s, and as a family psychotherapist, I began to see more than a few Italian American patients worried about daughters who were "too skinny" and refused to eat. And so I began to treat anorexics as an offshoot of my work as a family therapist who treated numerous members of a family from a family systems theoretical approach. For Italians, the "refusal to eat" was a crisis and a cause for concern that prompted the seeking of professional intervention, even though Italians as a cultural group were chronically in denial and self-reliant when it came to mental illness, seldom seeking professional help.

My early work began with treatment of the daughters of my original patients, who had been treated for unrelated psychiatric conditions and had experienced successful treatment outcomes. Some time later, I would be asked to treat the anorexic daughter. "My daughter won’t eat, and she’s too skinny – that’s not normal, and you need to see her" was the phrase with which several of my first anorexic patients were referred. One of my first anorexic patients was the daughter of a patient I was treating for depression; she had initially attended family sessions as part of her mother’s treatment. The daughter’s bizarre eating rituals slowly began to surface and were discussed in the context of the family sessions. As it became apparent that the daughter was possibly anorexic, I began the assessment and engagement phase of the treatment process.

The first intervention involved tentatively and cautiously interviewing the patient individually to determine if there was a viable treatment situation. I then met with the parents together with the patient and proceeded to meet with the patient individually, including her in family sessions when needed. Consistently, the patient would engage in treatment with marked resistance and refuse all other psychotherapeutic intervention and referrals. Initially, my concern for the patient’s self-reported refusal to eat and visibly emaciated state necessitated referral to an eating disorder hospital unit to address the medical crisis and stabilize her weight. After having spent some time in the hospital as an inpatient, however, the patient returned to me still skinny – at the referral of the treating physician, who, at the time, stated to me on the telephone, "She’s all yours; she actually wants to see you, and that’s better than how she’s doing here." There was a willfulness and marked resistance to therapeutic intervention that, for some reason, I was able to overcome. And so began my work with anorexics.

The more I have researched anorexia, the more I have come to realize that there is not one definitive explanation for this terrible phenomenon. My clinical experience has demonstrated, however, that it can be treated successfully and that the process of healing is quite possible. Taking into account the complexities of the disorder, the subsequent chapters define anorexia, explain it, and delineate how to treat it.

Despite the fact that anorexia nervosa is not a condition that affects women and girls only, it is one that affects women and girls primarily, and the account of its etiology and treatment provided in this book is concerned with its specific presentation in the female population. Thus, when I speak of the anorexic patient throughout, I refer to that patient as "she." No exclusivity or contention that anorexia does not affect men and boys is meant by, or should be inferred from, this usage choice.

Maria Baratta, PhD, LCSW, ACSW, BCD, is a clinical social worker in private practice in New York City. Dr. Baratta has taught social work courses in the Department of Sociology and Anthropology, St. John’s University, and published several articles. She has treated patients with eating disorders for over 25 years.