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Look Beyond Surface for Eating Issues

November 1, 2006
by Jeffrey D. Roth, MD
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Those of us who work with chemical dependence as the major form of addiction that we see in our group members may be thrown for a loop when confronted with a group member who has an eating disorder. We have very simple instructions for our alcoholics and drug addicts: “Don't use, and go to meetings.” Yet those in recovery from an eating disorder still must go into the lion's den three times a day.

Jeffrey D. Roth, MD

A discussion of issues arising in working with recovery from eating disorders should address three areas. First, it is essential for the therapist and the group to recognize that one or more group members may suffer from this form of addiction. Second, the frequency of moving from one addiction (chemical) to another (food) is higher than many of us imagine. Third, the first indication of a group working on its relationship with food may appear symbolically in the group process, as opposed to a member bringing up the relationship with food explicitly.

Hidden problems

The dramatic life-threatening quality of chemical addictions may obscure the slower, more insidious development or co-occurrence of eating disorders. One may assume that the cocaine or heroin addict who shows up emaciated is suffering from malnutrition. Many of these addicts do attain a normal weight after abstaining from substance use. However, we may find that some of them have used their chemical addiction, at least in part, to support anorexia. Indeed, even when nutrition is provided and weight gain occurs, these addicts may show signs of starving in other areas of their life, such as financially and emotionally.

In addition, the presence of compulsive overeating may be overlooked or even encouraged as a form of harm reduction. Recovering alcoholics may be advised that putting something sweet in their mouth is preferable to drinking, and many AA meetings provide cookies or doughnuts as part of their refreshments. These traditions, which may be carried into the residential treatment unit or outpatient therapy office, may play into the denial of persons with eating disorders.

Other symptoms of eating disorders also may be overlooked as they are assumed to be part of chemical dependence. Hearing about the alcoholic's history of vomiting when intoxicated, or the heroin addict's vomiting while in withdrawal, may not trigger further questions about the vomiting's possible function as part of a bulimic pattern. Vomiting may precede the history of alcohol or drug use, or may remain a pattern of controlling tensions about food well after the beginnings of sobriety.

One major source of denial that stands in the way of exploring eating disorders in our groups is the ubiquity of these addictions. (I tend to see parallels and similarities among the various eating disorders, and use these principles in my treatment.) Many therapists have their own complicated relationships with food. Given food's multiple meanings, including it being our most powerful symbol of nurturing and caring, we need hardly be surprised that those of us who enter the caring professions carry the impulse to feed our group members, whether literally or figuratively.

Once we begin to work with the group in examining the eating behavior of one of our members, a well-functioning group will begin to examine and question the eating behavior of other members. This examination may be experienced as violating explicit or implicit group norms about what the group may or may not work on. Indeed, training for addiction counselors does not take a uniform approach on the role that may be assumed when group members have conditions other than chemical dependence. One extreme position holds that eating disorders are not in the domain of addiction counseling. I would suggest that whether or not this is the case, we cannot avoid seeing group members who have these conditions, and they invariably affect our work with these groups.

How food issues present

Perhaps most interesting and relevant for our work in groups are the ways in which our relationships with food appear as part of the group process. Becoming aware of the various forms of anorexia helps us to be more empathic with social isolation, withdrawal, and deprivation. When we are confronted by a group member who sits session after session in silence, do we automatically attribute a hostile or passive-aggressive meaning to this withdrawal? Might this person be starving for attention, and avoid asking for any attention to avoid the resulting hunger and loneliness that would become apparent if the need for attachment were admitted? Recognizing that starving oneself for food, whether through full-blown anorexia or compulsive dieting, inevitably leads to intense hunger once eating is resumed may help us to weather the storm that may result from the isolated member's beginning to form an attachment to the group.

Another role that has been described in our therapy groups is the help-rejecting complainer. This group member constantly demands our attention, always complains about not getting enough, and then invariably rejects whatever support is offered as irrelevant, inadequate, or untimely. This pattern of ingesting huge quantities of attention and then vomiting up anything that is fed resembles bulimia so closely that I will often ask directly about purging behavior when I see the help-rejecting complainer in action. The form of the purging may not be vomiting; whether help is emptied out the other end (laxatives), chemically discharged up in smoke (most commonly via nicotine), or compulsively exercised away, the interpersonal pattern of complaining about not having one's needs met and then pushing away any help has a life of its own.