Substance Use and Eating Disorders: Case Analysis
A. David Wall, PhD
Remuda Ranch Programs for Eating Disorders
Nursing staff brings Tiffany to my office wrapped in a blanket. She has unkempt hair and a tired face. Tiffany is 19. She is a college student. She was sent to treatment by her parents, who threatened to pull her out of college if she doesn’t change. Tiffany is not happy about being an inpatient, but is surprisingly pleasant given the circumstances. In spite of her tired appearance and messy hair, it is easy to see that she is an attractive young lady who typically pays attention to her appearance.
She comes from a successful family of high academic achievement and socio-economic status. Dad is a former college athlete, who owns a medium sized company. Mom has a college degree and taught grade school before Tiffany’s older brother was born. Since then, mom has stayed at home to care for the children.
As Tiffany continues to discuss her background it becomes clear that she has strong social skills and a likeable personality. While she presents as very nice, appearing open and motivated during the interview, she subtly suggests that she does not believe she needs treatment. She discusses her high school history in a non-boastful manner, but reveals that she was extremely popular and well-liked by most everyone in school regardless of their particular clique.
She appears open and honest about her family, mentioning serious problems and discussing positive points as well. Her father is heavily involved in his business. He is also an avid fitness buff who spends a lot of time exercising. He is very involved in her brother’s sports. He himself was a three-sport all-star in high school. Her mother is extremely involved in social activities. Much like Tiffany, mom had been homecoming queen and a cheerleader in high school and college. Tiffany belongs to the same sorority as her mother. It becomes clear that her family is focused on success and achievement. Neither parent had ever said anything openly, but As on report cards are an unspoken expectation as is social and athletic leadership in school. Tiffany’s parents are Christians and involved in a church. Tiffany had been involved as well, but school activities and a demanding social life had pulled her away by her sophomore year in high school.
Tiffany’s paternal grandfather and grandmother had severe alcohol problems. Her father had a period of time in college and a short time before her brother was born when he used alcohol excessively. In college he had used alcohol for social reasons, and as an adult to handle the stress of a new business. Her mother drinks occasionally but has never abused alcohol.
Tiffany’s openness during the interview suddenly shifts when we begin to talk about her alcohol use. She states that she is “not an alcoholic” and does “not have any problems with alcohol.” Her alcohol use is “no different than any other college student.”
I ask Tiffany when she first began to use alcohol, and she indicates that she began “drinking socially” with her ex-boyfriend, Sean, and their group of friends during her sophomore year of high school. Sean was one class ahead of her and every bit as popular and accomplished in academics and sports. Sean and his friends often went out after games and on the weekend to “party”; alcohol was part of those events. She admits that she “got buzzed and had a couple of blackouts”, but believes that she never had any problems because of her drinking.
Sean broke off their relationship after his senior year as he thought it best if both of them were free to date in college. Tiffany was devastated. She continued drinking during her senior year and dated several guys. Until that time, she had only been sexually active with Sean, but during her senior year she had sex with four different guys. She also began to purge sporadically through self-induced vomiting early in her senior year, but this had become a weekly occurrence by the end of the year.
She joined a prestigious sorority at a large southern college. Alcohol was a central component of her social world. Her alcohol use increased, but she states that she does not drink any more than her friends and that “this is just the way it is in college; it’s part of being a college student.” She did well academically her first quarter, but then her grades began to slide. She denies that alcohol and her social life have had anything to do with this. She has a new boyfriend who, like Sean, is very popular and older than she. He drinks regularly and occasionally uses marijuana. Although she had purged in high school, she began to binge in college. Now she is extremely fearful of “getting fat” due to her binges. She still becomes intoxicated at least once a week, usually on Friday and/or Saturday nights. She normalizes this because, in her perception, just about all of her friends from the sorority and the fraternity guys do exactly the same. Her father also drank too much in college and “he’s fine now.”
Assessment and Treatment
Tiffany may have a genetic predisposition to substance abuse from her father. She recognizes some genetic risk, but also minimizes since she has not experienced substance abuse firsthand in her family of origin. Her father’s misuse of alcohol occurred before she was born.
Although Tiffany is popular, she is likely insecure. Her connections with her parents are not as strong as they might appear. Her father is gone much of the time and, on weekends, is busy with his own activities and her brother’s sports. Time to deepen connection with her father is lacking, and he may be more interested in her brother than in her. Tiffany bonding and intimacy with her mother may not be very strong because Tiffany has received praise from her mother conditional on appearance and accomplishments. Tiffany’s family has therefore taught her that she needs achievement, physical attractiveness, and social status as evidence of self-worth. This leaves her vulnerable and insecure, because such a scenario bases her self-worth on external events that are difficult to control. Tiffany cannot allow herself or others to see her vulnerability and insecurity, because such inner experiences are not consistent with the persona she is expected to portray.
Tiffany’s social group is high achieving and popular in spite of its alcohol use. Alcohol use has become ego syntonic largely because it has been an accepted and even expected behavior in her social reference group. Neither do her parents have strong objections to alcohol use, so conflicts with family or peer group values would be minimal. Drinking has increased her status in her social reference group and has not, in her view, cost her status in terms of academic achievement or school activities such as cheerleading. Her eating disorder behaviors are also accepted within her sorority peer group.
Tiffany grew up with the influence of a church community and values. Although she has distanced herself from both at present, she continues to identify herself as a Christian. There may be a latent conflict between this identity and her current alcohol use and eating disorder behavior. Tiffany may be minimizing the extent and significance of these behaviors in an effort to harmonize her behavior with early internalized values.
I conceptualize eating disorders and substance use according to the following model, presented in the companion article in this issue of The Remuda Review:
Need Symptom Target Behavioral Strategy Outcome
Tiffany’s needs are to feel special, loved, and accepted unconditionally. The symptoms of her needs are painful feelings surfacing when she is alone, such as when her boyfriend abandoned her. Life has taught Tiffany that the fulfillment of her needs comes from external attributes that are superficial and difficult to control, such as appearance and achievement. To fulfill her needs, she therefore targets achievement, physical attractiveness, and social acceptance. Her chosen behavioral strategy is to fit in with the popular group by doing whatever that group requires for acceptance and approval. A major criterion for acceptance by her peer group is physical attractiveness. Alcohol use is central to this peer group’s social gatherings and is expected of group members. The outcome of Tiffany’s behavioral strategy is a high status boyfriend and external affirmation by the high status peer group that resembles her high status family.
Tiffany is in the Contemplation stage regarding her eating disorder, since it has become a burden leading to extreme fears of weight gain; hence, she is considering changing this behavior but has not yet committed to do so. Tiffany is in the Pre-Contemplation stage regarding her alcohol use: she does not see a need to change and is not interested in doing so. Pre-Contemplation is ripe for power struggles. The more one directly attacks the alcohol issue, the more resistant Tiffany is likely to become. Although Tiffany is in the Contemplation stage regarding her eating disorder, this resistance will likely generalize to eating disorder treatment as well.
Therefore, interventions need to be directed at moving Tiffany from Pre-Contemplation to Contemplation, where she is considering changing her alcohol use but has not yet committed to do so. Specific strategies to accomplish this movement from Pre-Contemplation to Contemplation are readily available and should be utilized. Tiffany may experience cognitive dissonance if she is helped to explore her substance use behavior in light of her Christian identity. This may open the door for her to consider the possibility of changing her behavior. As Tiffany progresses through the stages, interventions should shift to reflect her progressive level of motivation to change. As she enters the Preparation/Action stage, for example, more traditional treatment strategies can assist Tiffany with insight into her true needs and acquisition of the skills required to actually change her eating disorder and substance use behaviors and rely instead on healthier behaviors to meet her needs. Ultimately, relapse prevention strategies will assist her to maintain recovery.
Likely obstacles include her awareness that sobriety may result in social rejection or may require her to separate from her social reference group. Changing her substance use behavior will likely end her relationship with her boyfriend. If these possible losses are not dealt with openly and directly, and viable alternatives developed to meet her needs, she will be vulnerable to relapse.
Because Tiffany has a history of faith, this strength may offer a new social reference group and enable her to explore more internal views of personal value and worth.
