One central theme is the patient’s relationship to food and the significance of eating in her life. Strangely, some professionals carry on therapy for months without once attacking the patient’s problem with food. They seem to think that just by exploring underlying issues-problems with parents, for example-her eating will improve.

Nonsense! That’s like treating a broken leg with aspirin: It might help the pain a little, but it ignores the bigger problem.

Therapy has to address the symptoms themselves, as well as the feelings of guilt and shame that may result from the cycle of bingeing and purging or self-starvation. It must also look at the reasons food has become the patient’s means of defense, a kind of “anesthetic” against emotional pain.

Another important theme is autonomy, by which I mean two things: self-government and independence.

Self-government means having control over impulses and desires, and not being prey to emotional whims. Ironically, people with eating disorders, especially anorexics, feel they are totally in control of themselves. The truth is that their disorder controls them. Bulimics, in contrast, usually realize they are caught in a cycle they can no longer control.

Independence means not relying completely on other people to satisfy one’s emotional and physical needs. Many of these patients have tried to please other people all their lives-their parents, their teachers, their friends and lovers. They devote themselves to others’ desires and ignore their own. They base their identity on the reactions they stir up in other people.

In therapy, the patient learns to trust her own instincts. She recognizes her feelings and accepts them as valid. Through acceptance comes control and self-mastery.

Another recurring theme in therapy is learning how to tolerate moods. Sure, we all have “down times,” when depression or feelings of failure creep in. An eating-disordered person seeks relief from these feelings by resorting to her symptoms-bingeing and purging, for example.

As Marti, a twenty-nine-year-old woman, put it: “Some days I just can’t drag myself out of bed. I feel so hopeless-nothing is worth doing. I don’t care how I look. I don’t want to go anywhere or see anyone. Nothing cheers me up. Not the TV, not music, not even the comics in the newspaper. It all just seems so … so sad. The only thing I have energy for is eating. Once I start I just keep going. Cookies and leftover Halloween candy and stuff that’s been in the freezer probably since the Civil War. Anything. Then I puke. When I was a baby I comforted myself by sucking on my thumb. Now I do it by sucking food off a fork. Throwing up gives me the illusion that I’m in control. It’s pretty pathetic.”

Marti is describing feelings of depression, a mood she tries to lift by turning to food. For some people, food acts as a kind of substitute for the emotion itself. Others use food to calm themselves down after exploding in anger, or to soothe their guilt for feeling a “shameful” emotion, such as jealousy.

During therapy we explore these moods. We look at what causes them and how they disrupt the patient’s life. I try to help patients see that such moods are part of living. Expressing emotions is normal and nothing to be ashamed of. It’s what makes us human! However, in therapy we look for ways to avoid the things that trigger moods in the first place, and look for alternative ways to act when they do occur.

Coping with maturity is another topic that crops up often. As we have seen, anorexia causes the patient to regress to a preadolescent state. Her starving body loses its womanly shape and functions. In therapy I encourage the patient to examine her feelings about growing up, to find out what it is that frightens her so. Does she fear being abandoned by her parents? Is she scared of the responsibilities of adulthood? Is starving a way to avoid dealing with other people and the risk of being rejected? What is going on inside?

For the bulimic, too, food and eating substitute for mature relationships. As Enid, a twenty-six-year-old patient, told me, “Friends can say mean things. They’re not always around when you need them for support. You can sleep with a man and in the morning the bastard is gone and you never see him again. That’s not true with food. Food is always there. And if it isn’t, you can just go buy some.”

In a way, individual therapy provides a model relationship that the patient can use to explore these issues of maturity. If handled properly, the patient develops trust in her therapist. She learns she can reveal secrets or make mistakes without betrayal or rejection. In the process, she sees how to handle feelings without falling back on the symptoms of her disorder.

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While a newspaper reporter in Kansas City, Missouri, Barb grew fond of the local cuisine—especially the huge cuts of beef served in )and the barbecued chicken and ribs. Because she was fairly active, playing tennis and jogging on occasion, her waistline didn’t suffer as much as it could have. Still, she eventually carried 130 pounds on her 5-foot-5-inch frame, and she was used to being a lot leaner.

Then, cued by her social conscience, Barb signed on as a volunteer abroad with a nonprofit organization. Her assignment took her to Kuala Lumpur, where she was to help local women start their own businesses. Once she arrived, she couldn’t help but notice the vast differences between Malaysia and the United States, especially in terms of diet and lifestyle.

In Malaysia, for example, beef isn’t an everyday food. It’s used only sparingly in special-occasion dishes. Eggs and processed foods are also rarities. Instead, Malaysians eat meals of rice or noodles topped with small helpings of stir-fry or curry. They also enjoy a rich array of native fruits, including bananas, starfruit, and bright red, spiny rambutans.

Barb embraced the traditional Malaysian diet. She found that she could eat as much as she wanted without widening her waistline. And she walked almost everywhere. By the time she came home a year later, she discovered that she had dropped 20 pounds without even trying.

“It was easy to lose weight in Malaysia because of the normal lifestyle,” Barb says. “It made me realize how excessive we are in America. We regularly eat huge portions of foods that are considered luxuries in other parts of the world. And we drive everywhere. In Malaysia, people walk a lot more.”

Upon returning to the United States in 1988, Barb resolved not to gain back the weight that she had lost. So she incorporated much of what she had learned in Malaysia into her American lifestyle. To this day, she eats lots of grains but very few meats, eggs, or dairy products. She tries to buy fresh, organically grown produce when-

ever possible and has cut down on processed foods. She even planted a backyard garden so she could raise some of her food on her own. For exercise, she resumed jogging, and she plays tennis and basketball with her 7-year-old son.

Since adopting a simpler, healthier lifestyle, Barb has had no trouble keeping off those 20 pounds. At age 43, she maintains her weight at 110 pounds. “I have a lot more energy, too,” she says.

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