Christy Henrich, a world class gymnast was told that she would have to lose weight to make the 1988 Olympic team. She was 4'10" and weighed 90 pounds. She died of multiple organ failure due to anorexia in 1994. Lea Thompson (Caroline in the City) was rejected by a ballet company because she was too 'stocky' at 5'5" and 96 lbs. "According to an article by Judith Newman in Redbook, young girls today are more afraid of becoming fat than are of nuclear war, cancer, or losing their parents." ¹

Society's pressure to be beautiful has an immense effect on a young person. Girls are aware of what "pretty" means before they enter kindergarten and quickly discover where they stand in relation to the other girls. As a girl moves through elementary grades she will discover, if she is deemed "pretty," that boys pay more attention to her, she is more easily accepted, thought to be smarter, and her teachers are nicer to her. As she moves into teenage years, she may find that thinness is a requirement for acceptance and especially so for some activities, especially sports.

"Eighty-five percent of American women are not satisfied with their body size and either have dieted, are dieting, or believe that they should be dieting...between 10 and 20 percent of all women will engage in bulimia at sometime during their lives, and 1 to 2 percent will experience anorexia nervosa."²

Eating disorders may begin during stressful times such as: puberty, a change of schools, divorce, a breakup of a relationship, or family problems. Often it starts as a diet that goes out of control. The disorder serves a purpose, it is an effort to cope and communicate. It is a problem and an attempted solution at the same time.

Perfectionism leads to unrealistic expectations and is the major root cause of eating disorders. The extreme definitions by which they measure themselves assures failure leading to feelings of worthlessness and inadequacy. Each unrealistic expectation is a false believe and in counseling can be corrected by demonstrating its irrational and illogical aspects. One false believe is that "I must be perfect to be loved." Scripture is overflowing with accounts of God working through imperfect humans. God's love is not based on performance or goodness rather in spite of our sins and imperfections (Eph. 2:9; Isa. 64:6).

Eating disorders are addictive disorders and the behavior is driven by the addictive cycle: need for love; pain of low self-esteem; addictive agent to anesthetize the pain of unmet needs; consequences; guilt and shame; self-hate which then starts the cycle over again. The longer the cycle continues, the more damage is done and the more firmly the illness is entrenched.

Eating disorders manifest physically as a "preoccupation with one's body, weight and eating; profound dread of obesity; distorted body image; malnutrition; little interest in or aversion to sex; cessation of menses; irritability, depression, and inability to concentrate; dehydration; faintness; and slow heart beat"³ Eating disorders manifest emotionally in perfectionism, low self-esteem, sexual identity confusion, depression, deception, power struggle, and interdependency.

Anorexia is an emotional illness. It alters the thinking of the victim in many ways. Anorexics believe that being thin is the most important thing in their lives. It become the biggest part of their existence and they fear that without it they will be nothing. "Approximately one percent of adolescent girls develop anorexia nervosa, a dangerous condition in which they can literally starve themselves to death. One in ten cases of anorexia nervosa leads to death from starvation, cardiac arrest, other medical complications, or suicide." ⁴

Anorexics belief that in order to be loved they must be thin. However, they lose sight of what "thin" is. They will look in the mirror and see themselves as "fat" when others see their appearance as appallingly and sickly thin. They chase the ideal but the ideal keeps dropping. There are always just a few more pounds that must be lost.

"The typical anorexic is a white female, approximately 15 to 25 percent below her ideal weight, and between the ages of twelve and eighteen. Both anorexia and bulimia mainly manifest in middle and upper middle-class families. The parents are usually educated, high achievers with at least one being health and diet conscious. One or both parents may also tend toward perfectionism and be intolerant of failure in themselves and others. Anorexia rarely starts after age twenty-five." The illness can also strike men and older women and other racial ethnic groups.

"People with anorexia tend to be 'to good to be true.' They rarely disobey, keep their feelings to themselves, and tend to be perfectionists, good students, and excellent athletes....Having followed the wishes of others for the most part, they have not learned how to cope with the problems typical of adolescence, growing up, and becoming independent. Controlling their weight appears to offer two advantages, at least initially: they can take control of their lives and gain approval from others."⁶

"Anorexia is characterized by preoccupation with body weight, behaviors directed toward losing weight, and intense fear of gaining weight, coupled with unusual preoccupation with food including bizarre behaviors in handling it. There is often refusal to eat, except for small portions, and a denial of hunger...There may be exaggerated interest in food and food planning. Often there is a high energy level coupled with excessive, compulsive exercise with diminished signs of fatigue. Menstrual periods will stop, sometimes as weight loss begins. As weight loss becomes severe, there is an intolerance to cold, especially notable are cold hands and feet. Loss of head hair coupled with a growth of fine body and facial hair may also occur. Pulse rate slows and blood pressure will fall...Sooner or later depression will occur, frequently coupled with thoughts of suicide. Social withdrawal usually occurs early as the victim becomes alienated from family and friends alike."⁷

Bulimia is identified by alternating eating and purging. The bulimic feels out of control and unable to stop eating. She stops only when she is physically unable to eat more, she runs out of food, or guilt and self-loathing become so great she must purge. Purging usually means vomiting by forcing her fingers down her throat but others use medicines intended to induce vomiting. Some also use laxatives and excessive exercise in order to keep from gaining weight. At times they may deny themselves food much like the anorexic.

"While they (bulimics) fear food they consume large quantities of it---sometimes up to 20,000 calories at a time. The foods on which they binge tend to be 'comfort foods'-- sweet foods, high in calories, or smooth, soft foods like ice cream, cake, and pastry. An individual may binge anywhere from twice a day to several times daily. In many instances, after the binge comes the purge. A bulimic may use as many as twenty--or more--laxatives a day." ⁸

Bulimia normally starts later in adolescence at ages 18-20, but may start earlier. Unlike anorexia, bulimics know of their problem, it is all too obvious. This disorder may not be noticed by those around them. It may appear that they have a weight problem although some binge eaters are able to maintain a normal weight. "The bulimic looks forward to the binge. Purging is merely the act of atonement for the indulgence of bingeing. To the bulimic, food is a friend, assuaging her loneliness because she won't let people get close to her. Food is a tranquilizer, providing escape from pressures and stress. Food is a reward, gobbled down with the attitude, 'I've had a hard day. I deserve these goodies.'" ⁹

Bulimics are hard on themselves due to their perceived failures. They have a hard time accepting God's forgiveness and grace even when they intellectually understand the theology. Their purging is a self-destructive atonement.

While anorexics may appear inflexible and overcontrolled, bulimics tend to be impulsive and undercontrolled. Anorexics have amazing control over their appetites; bulimics have little or no control. Both develop rituals regarding food, exercise, and other aspects of their lives. To the bulimic food is a friend, to anorexics it is the enemy. Anorexics starve themselves to a perceived ideal weight, while bulimics stay within 5-10 pounds of their ideal weight. Bulimics need peer approval and seek out relationships in contrast to anorexics who withdraw and are very private. Both, however, feel isolated and alone with their secret.

The neuroendocrine system, which regulates sexual function, physical growth and development, appetite and digestion, sleep, heart and kidney function, emotions, thinking, and memory are seriously effected by eating disorders. In bulimics, if purging is excessive, confusion, disorientation, rupturing of the esophagitis, intractable constipation, erosion of the teeth, seizures, and cardiac arrest may occur. Bulimics lose salt, water, and potassium all of which can create physical problems. If Ipecac is abused, death may result as Ipecac is toxic to the heart.

Seventy percent of all individuals with bulimia recover. Five to eighteen percent of all people with anorexia die within ten years. Seventy percent who receive treatment make a full recovery. The rest may have a life long problem even when the condition is not active.

Upon diagnosis, it must be determined if long-term treatment and/or hospitalization are required. Hospitalization would be warranted if there is excessive and rapid weight loss, metabolic disturbances, depression or risk of suicide. Treatment should include an internist, nutritionist and therapist. "The challenge of treating eating disorders is made more difficult by the metabolic changes associated with them. Just to maintain a stable weight, individuals with anorexia may actually have to consume more calories than someone of similar weight and age without an eating disorder. In contrast, some normal weight people with bulimia may gain excess weight if they consume the number of calories required to maintain normal weight in others of similar size and age." ¹⁰ Biochemical connections between depression, obsessive-compulsive disorder, and eating disorders have been found. Those with eating disorders may respond favorably to medication for depression or OCD. Also, medications for depression have been shown to be beneficial in some cases.

Regaining weight must be a very slow process. There is an impairment of digestion in starvation and the body needs time to rebuild the enzymes of the liver and pancreas. Rapidly ingesting food after starvation may result in bloating, nausea, vomiting, and even congestive heart failure due to the strain on the weakened heart from the large metabolic rebound.

Group therapy is more effective with bulimics than anorexics. This is because the bulimic is aware that s/he has a problem. "In a recent study of bulimia, researches found that both intensive group therapy and antidepressant medications, combined or alone, benefited patients. In another study of bulimia, the combined use of cognitive-behavioral therapy and antidepressant medications was most beneficial."

In treatment, the patient rather than the illness is often seen as the "problem." The patient is blamed and guilt becomes the treatment of choice. This approach actually exacerbates the problem. The perfectionism of the patient is a major factor in the feelings of being "bad" and deserving of punishment. Counselor's need to consider their own thoughts, feelings and actions with their clients. The client needs more than food to regain health, they need acceptance, hope, concern, respect, care, and love. Christ calls us to love our neighbor as ourselves in Matthew 19:19. This type of love, love that considers the well-being and needs of another equally important as our own, models for the client their importance and value.

Eating disorders are a result of complex behavior made up of many reasons. Counseling needs to be individualized. Conditional love, criticism, black and white thinking, perfectionism, low self-esteem, all can play a part in founding the disease in the patient to varying degrees. Those with eating disorders have underlying false beliefs. These false beliefs need to be exposed, argued against, and replaced with truth. While doing this the counselor can show themselves to be real people with real struggles that have real solutions.

"As most clients with eating disorders are bright and active, they are usually quite well-read and will soon detect gaps of knowledge in a counselor. If the gaps are too large and glaring, therapy will end as trust and respect are lost...Counselors, as well as parents, sometimes pretend they know all the answers to all the questions so that their respective clients and children will respect them for their great knowledge. This unhealthy approach is an example of a false belief that will certainly erode respect and have devastating consequences for the client."¹¹ Clients need a relationship with their counselors that is based on trust and that is based in truth.

They also need understanding. A sense of empathy will help ease the feelings of loneliness in their disease. We mustn't assume we know how the client feels but allow thoughts and feelings to be expressed in an atmosphere of acceptance and trust. This acceptance and trust will facilitate an environment in which the client can accept and assimilate truth.

An atmosphere in which the illness can be openly discussed is critical to recovery. The eating disorder has been a behavior that the client has tried to keep secret. They fear that lack of understanding will lead to rejection and punishment. They fear that who they are will be rejected and this is all they have. The counselor and client will cooperate in the healing process when their is an emotional bonding that cause the feelings of isolation in the patient to be lessened. Knowing and accepting each other will lead to being able to discuss thoughts and feelings. The task is to tell the truth in love as Christ did.

"Self-esteem problems may arise from seeing oneself in the mirror of distorted relationships. It suggests that resolution requires someone caring enough to notice the struggle, and offer the love, acceptance, and encouragement needed to risk removing the defenses so that the person can begin to see herself as she really is. We all need somebody who loves us enough to tell us the truth."¹² Counselors have the opportunity to be accurate mirrors.

"The largest obstacle to treating anorexia is that those who suffer from the disorder do not want to be treated." ¹³ Therefore, people with eating disorders may not receive medical treatment and therapy until they are dangerously thin and malnourished. People with bulimia are often at their normal weight and able to hide their illness. Eating disorders in males may be overlooked as they are rare.

Those with eating disorders feel that they must be punished for their "sins." The counselor and the patient are both "sinners saved by grace." In Romans 3:23-24, we see that God justifies and makes righteous freely and by His grace through redemption in Christ. Therefore, our pride and boasting (our striving for perfection) are worthless. God did not send Jesus to condemn us but that we might find salvation in Him (John 3:17). The solution for error is not punishment but forgiveness.

Resistance to recovery can best be interpreted as fear of change rather than rebellion. Clients may need to be helped to see that they have permission to change and then protected during the process of change. Knowing the principles of cause and effect that are specifically related to the illness, and presenting them in a caring manner place the power struggle between the individual and the unchanging reality of the consequences of the disorder. The person with eating disorder cannot gain health, joy and acceptance when starving to death. What we reap we sow (Gal. 6:7-9).

A refocusing of the family's energy will be necessary to reduce the power struggle at home. The family can be released from the responsibility of the eating behavior and be asked to be responsible only for the unhealthy self-esteem, perfectionism, and depression in their child. The patient is not the problem; the illness is the problem. If the child had cancer, the family would support and encourage the child and allow the physician to deal with the illness. The physician and family work together to fight cancer, it is the same with the counselor and family working together to fight this illness.

Those with eating disorders are afraid to grow up fearing that they will handle the increased responsibilities as poorly as they have their health. Counselors need to assist the client in making clear, attainable goals and then teach how to obtain them. As she sets more realistic goals, and sees small successes, she can feel that entering into adulthood in freedom and as a responsible individual may actually be possible.

Signs of recovery include: acceptance of self and others; love of self and others; appropriate self-worth in their sexual identity; joy; open honesty; independence; and collaboration. "When these thoughts, feelings, and behaviors are present to a reasonable degree and when they have become a very part of the individual's personality, one can be reasonably sure that the eating disorder has been resolved." ¹⁴

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1) Debbie Stanley, Understanding Anorexia Nervosa, (New York, NY, Rosen Publishing Group, Inc., 1999), p41
2) Raymond E. Vath, M.D., Counseling Those with Eating Disorders, vol 4 of Resources for Christian Counseling, edited by Gary R. Collins, Ph.D., (Waco, Texas: Word Books, 1986), p 58
3) Discovery Health Media, Inc., Eating Disorders. John Hopkins University, 1999
4) Lee Hoffman, "Eating Disorders," Your Mental Health National Institutes of Mental Health, No. 94-3477 (1994)
5) Debbie Stanley, Understanding Anorexia Nervosa, (New York, NY, Rosen Publishing Group, Inc., 1999), p29
6) Lee Hoffman, "Eating Disorders"
7) Raymond E. Vath, M.D., Counseling Those with Eating Disorders, vol 4 of Resources for Christian Counseling, edited by Gary R. Collins, Ph.D., (Waco, Texas: Word Books, 1986), p 37
8) Discovery Health Media, Bulimia Nervosa, John Hopkins Health, (Internet site, 6/1/98)
9) Frank Minirth, M.D., Paul Meier, M.D., Stephen Artenburn, M.Ed. The Complete Life Encyclopedia, (Thomas Nelson Publishers, 1995; Nashville), 78
10) Lee Hoffman, "Eating Disorders"
11) Raymond E. Vath, M.D., Counseling Those with Eating Disorders, p72
12) Raymond E. Vath, M.D., Counseling Those with Eating Disorders, p112
13) Discovery Health Media, Inc. Anorexia Nervosa, (John Hopkins University,1999)
14) Raymond E. Vath, M.D., Counseling Those with Eating Disorders, p112