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Social Dimension of Eating Disorders Pt. 3


Summer 2004, Volume 3, Issue 3

Peers, Schools, and Eating Disorder Development

The Demise and Restoration of Intimacy: Eating Disorders and Recovery

The Summer 2004 issue of The Remuda Review continues exploring the social aspects of eating disorders following Remuda’s bio-psycho-social-spiritual model. In the previous issue, we discussed family contributions to eating disorders, since the family is the primary socializing influence for children. In the current issue, we discuss the social influences that occur as children grow—peers, school, intimacy, dating, and marriage—and their role in the development of eating disorders. In our upcoming issue, we will round out our discussion of social aspects by offering articles on eating disorders in relation to culture, media, and body image.

Editorial Staff

Peers, Schools, and Eating Disorder Development

Noëlle Kerr-Price, PsyD, Staff Psychologist
Department of Psychological Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

Become wise by walking with the wise; hang out with fools and watch your life fall to pieces (Proverbs 13: 20; The Message).

In a shopping mall I noticed a group of 12 year-old girls. Each wore an identical tube top reading, “Dare to be Different!” This ironic image captures the epitome of adolescence: the need to belong coupled with the need to be unique.

Erik Erikson (1980) characterized the essential developmental issue of adolescence as a conflict between identity and role confusion. As children move beyond the primary social influence of the family, they develop individual identities separate from their identities as members of their family. To do so, children look to peers for mes¬sages about who they are. Successful maneuvering of this stage leads to fidelity to one’s own values and an integrated sense of self. But successful adolescent development can be hampered by social and academic forces that may lead to a variety of problems, including eating disorders.


It is common knowledge that peer group influences are profoundly important for teenagers because belonging is of such high priority for them. Fitting in allows teenagers to feel acceptable. Being different, however, can come with a high price—becoming outcast. Yet because each teenager is an individual, they experience within themselves and observe in others differences that they often devalue rather than prize. Puberty especially has the ability to render one utterly self-conscious. Physical changes become painfully apparent, particularly for girls, who experience breast development, emerging curves, and necessary weight gain. Girls who experience pubertal onset earlier than average are at greater risk for adjustment problems and often feel negatively toward their bodies, perhaps because they tend to weigh more than average (Brooks-Gunn & Reiter, 1993). Dating and sexual experimentation are further domains of teen life that spotlight teens’ physical attributes and often promote the angst of self-consciousness.

Trusted friends may offer teens the acceptance they desperately crave and need. Less kind peer groups/cliques may be downright cruel and ostracizing. “Kind words heal and help; cutting words wound and maim” (Proverbs 15:4; The Message). Recent television reports suggest that 2/3 of violent school crimes committed by students are carried out by those who have been bullied, mocked, or tormented by their peers. School violence is obviously an externalized expression of complex emotions including rage toward peers and self-hatred born of ridicule. For some, an eating disorder may be an internalized expression of similar emotions.

I have worked with many eating disorder adolescents who have the cruel remarks of peers ringing in their ears—the result of peer maltreatment due to childhood obesity. For some, an extreme fear of humiliation by peers results in avoidant personality disorder or features thereof. The response of these wounded children can sometimes be an “I’ll show you”—communicated non-verbally but resoundingly through an emaciated body. Often, too, there is a second response: the depths of depression and a lacking will to live.

On the other hand, some adolescents with eating disorders have never struggled with weight. Some have done well in school and didn’t cause trouble. Their vulnerability consists of a lack of social skills needed to be effective in relating to peers. By default, these children are often discounted by their peers as “weird” and relegated to the fringe. In more extreme cases, some develop social phobia; others have schizotypal or even schizoid personal¬ity disorders/features. Lonely and often confused about what they ever did to alienate their peers, such students may develop eating disorder behaviors unconsciously to achieve a variety of potential goals.

Some are looking for a consistent companion and release from the loneliness of having no friends. Patients often refer to their eating disorder as their best friend. The eating disorder sets rules about good and bad behavior, offers rewards and punishments, occupies the mind with food and caloric obsessions, and distracts from emotional pain.

For some, eating disorder behaviors may supply an outlet for unidentified and ill-managed feelings—a form of emotion regulation. The core symptoms of eating disorders—bingeing, purging, restricting, compulsive exercise—can release endorphins, create temporary euphoria, and/or lead to emotional numbness. The negative feelings with which these teens need to cope include loneliness, despair, self-hatred, and anger related to their frustrated experiences with peers, as well as fears of sexuality.

Other teens have felt demoralized and hopeless that their social circumstances will change. For them, eating disorders may indeed be experienced as “something I can control.” Counting and re-counting calories, fat grams, and carbohy¬drates; finding novel ways to reduce food intake or eliminate consumed calories; keeping track of weights and body measurements—all these endeavors have structure, rules, logic, and direction that can offer an arena of control when the rest of life feels beyond their control.

For some, eating disorders are an attempt to become like admired or envied peers based on the perception that thinness equals beauty and popularity. Some are literally copying an admired peer or public figure who has an eating disorder; others are seeking to attain a similar look or body by way of eating disorder behaviors. The underlying rationale is often: “If I look like her/him, I will also be accepted by other people just like she/he is.” Other avenues also exist connecting problematic peer relations with the onset of eating disorders.

In contrast, some adolescent girls with eat¬ing disorders seem to have everything in place socially: an appearance that mirrors America’s cultural ideals of beauty, boy¬friends, teachers’ favor, popularity, and many friends. But adolescence, even for successful teens, poses many challenges, such as dating, athletics, academic success, and possible com¬petition to maintain popularity and status. Some teenagers with a high measure of status also feel pressured to be everything to every¬one. Some have narcissistic personality disor¬der or features. These pressures may intensify adolescents’ focus on external appearance and drive for perfection, gradually leading to more and more eating disorder behavior.

If she is in a peer group that is highly weight conscious, compares body sizes, or even exhibits eating disorder behaviors, a teen¬age girl may seek ever-increasing thinness and engage in extreme dieting, compulsive exercise, and a variety of eating disorder behaviors. Without realizing it, she may find herself caught in the quagmire of an eating disorder.


In addition to social and peer experiences, attendance at school challenges children with academic pursuits. For those with perfec¬tionistic tendencies, the demands of the high school workload may appear to mount, some¬times joined by performance pressures from well-meaning teachers, coaches, and parents. The performance expectations and perhaps coaching/training styles associated with cer¬tain sports that require a lean physique, such as gymnastics or figure skating, also place students at higher risk for dieting behavior and possible eating disorder development (Zerbe, 1995). Although perfectionism is not a requirement for an eating disorder, studies—beginning with Hilda Bruch’s classic work on anorexia (Bruch, 1973)—have consistently demonstrated that perfectionism is a hallmark personality trait of those with eating disor¬ders. In fact, one recent study concluded that in high school girls, stress intensifies the association between perfectionism and desires/plans to lose weight (Ruggiero, Levi, Ciuna, & Sassaroli, 2003).

For teens, the future may appear to be on the line with college admissions or the pursuit of meaningful post-high school employment. A perfectionist may conceptualize this experience in an equation such as: “failure to get an A in 9th grade geometry = a lost future.” Part and parcel of perfectionism is a frequent if not persistent experience of personal ineffectiveness and helplessness in spite of success in other people’s eyes. This can lead to eating disorder behavior for two interconnected reasons: 1) eating disor¬ders narrow one’s focus to food and body issues over which some sense of control/efficacy can be achieved; and 2) eating disorders offer a subjective experience of success as measured by eating disorder standards—e.g., weight lost, caloric restriction achieved.

The private school setting adds another dimension to the typical school pressures. A study by Lesar, Arnow, Stice, and Agras (2001) indicates that both girls and boys in private schools dem¬onstrate a higher level of eating pathology and are at higher risk for developing bulimia than their public school counterparts. While the authors posit that one explanation for this difference may be family driven or modeled, they do not discount the atmosphere within private school life itself as a likely contrib¬uting factor. Private schools may offer a different subculture than public schools, with more pronounced peer pressure and demands for students to achieve cultural ideals, including body weight and shape.

Many private schools have a Christian foundation. Sometimes—as is also seen in church environments—Christianity can be expressed legalistically or with expectations of perfect behavior. Groups of Christian students and teachers together may hold one another to impossibly high standards—standards, like body ideals, that may derive from a broken, misguided culture. This additional pressure may readily promote eating disorder behaviors.

In Christian school settings, it is important for teachers and administrators to reflect on and promote a culture that mirrors an essential Christian teaching. “For we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal” (2 Corinthians 4:18). “You were taught, with regard to your former way of life, to put off your old self… to be made new in the attitude of your minds; and to put on the new self, created to be like God in true righteousness and holiness; so from now on, we regard no one from a worldly point of view” (Ephesians 4:22-24; 2 Corinthians 5:16). There should be no distinction between “Greek or Jew” (Galatians 3:28), fat or thin, “for all are one in Christ Jesus” and all have value as unique creations of God.

Implications for Eating Disorder Prevention and Treatment

Recognizing the complexities of the modern teenagers’ social and academic world assists our understanding of how eating disorders may emerge. This has implications for eating disorder prevention and treatment efforts.

Research is indicating that peer-based primary prevention strate¬gies in the school setting can be effective in reducing the inci¬dence of eating disorders. McVey et al. (2003) found that middle school girls experienced increases in weight-related esteem and decreases in dieting behaviors after completing a 10-session inter¬vention group program. This study suggests that, with guidance and education, peer influence on teens’ body image and eating behaviors can be favorable rather than pathogenic. In fact, an additional study shows that merely asking questions of teens about risky weight control behavior and attitudes can discourage such behavior (Celio, Bryson, Killen, & Taylor, 2003).

For those teenagers with eating disorders, it is important to rec¬ognize the power of positive peer culture in the recovery process. Group therapy and education, peer recovery support groups, and other healthy peer affiliation groups such as church groups or certain team sports, can greatly assist eating disorder teenag¬ers to develop positive self-esteem and body image and to adopt healthful eating behaviors and attitudes.


Brooks-Gunn, J. & Reiter, E. O. (1993). The role of pubertal processes. In S. S. Feldman & G. R. Elliott (Eds.), At the threshold: The developing adolescent (pp. 16-53). Cambridge, MA: Harvard University Press.

Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa, and the person within. New York: Basic Books, Inc.

Celio, A. A., Bryson, S., Killen, J. D., & Taylor, C. B. (2003). Are adolescents harmed when asked risky weight control behavior and attitude questions? Implications for consent procedures. International Journal of Eating Disorders, 34, 251-254.

Erikson, E. H. (1980). Identity and the life cycle. New York: W.W. Norton & Company.

Lesar, M. D., Arnow, B., Stice, E., Agras, W. S. (2001). Private high school students are at risk for bulimic pathology. Eating Disorders: The Journal of Treatment & Prevention, 9, 125-139.

McVey, G. L., Lieberman, M., Voorberg, N., Wardrope, D., & Blackmore, E. (2003). School-based peer support groups: A new approach to the prevention of disordered eating. Eating Disorders: The Journal of Treatment & Prevention, 11, 169-185.

Peterson, E.H. (2002). The message: The Bible in contemporary lan¬guage. Colorado Springs: Navpress.

Ruggiero, G. M., Levi, D., Ciuna, A., & Sassaroli, S. (2003). Stress situation reveals an association between perfectionism and drive for thinness. International Journal of Eating disorders, 34, 220-226.

Zerbe, K. J. (1995). The body betrayed: A deeper understanding of women, eating disorders, and treatment. Carlsbad, CA: Gürze Books.

The Demise and Restoration of Intimacy: Eating Disorders and Recovery

David J. Rogers, MA, LPC, Assistant Program Director
Division of Patient Care Services
Remuda Ranch at The Meadows Programs for Anorexia and Bulimia

Intimacy: Theological and Spiritual Considerations

The Merriam-Webster dictionary (2003) defines intimacy as: “close, familiar, and affectionate personal relationship; close association with, or deep understanding of; sexually familiar.” Intimate is defined as: “showing a close union or combination… inmost, personal; of, pertaining to, or characteristic of the inmost or essential nature; intrinsic”. In short—intimacy means “to know and be known.”

From a Christian theological perspective, the Trinity is the basis of intimacy: three distinct personalities in perfect union (1 John 5:7; King James Version). When human beings, as distinct indi¬viduals, live in union with one another, we reflect God himself and his nature: unity in diversity (cf. 1 John 5:7; 1 Corinthians 12:4-27). Moreover, we then live according to God’s design for humanity. As Jesus said: “I pray … that all of them may be one, Father, just as you are in me and I am in you” (John 17:20-21; emphasis added).

Even more foundational to intimacy among ourselves, Christians believe that human beings were created to live in intimate relationship with God as the core of their existence: “From one ancestor he made all nations…he allotted the times of their exis¬tence and the boundaries of the places where they should live, so that they would search for God and perhaps grope for him and find him, though he is not far from each one of us. For in him we live and move and have our being” (Acts 17:26-28; New Revised Standard Version. See also Genesis 1:27; 2:7; Psalms 139:1-18; 145:13b-19; 1 Corinthians 13:12). Theologians have long spoken of the “I-Thou” relationship. For adolescents and adults, this personal interface between God and self is the experiential foundation of all intimacy.

Awareness of the contrast between, yet union of, myself and God–divine and mortal, infinite and finite, Creator and created, Savior and redeemed, Holy and broken, Father and child, Lover and beloved—is the birthplace of intimacy. The understanding that God has full comprehension of all my thoughts, feelings, motives, intentions, desires, and past, present, and future failings, yet loves me with inseparable love is the basis on which I can be fully disclosing, fully honest with myself and another (Romans 8:39-39).

In short, intimacy is about self revelation combined with the experience of being accepted. God has initiated this entire process by revealing himself to us in the person of Jesus Christ (John 1:14; 14:9), by searching and knowing us deeply, and by accepting us just as we are:

O LORD, you have searched me and you know me. You know when I sit and when I rise; you perceive my thoughts from afar. You discern my going out and my lying down; you are familiar with all my ways. Before a word is on my tongue you know it completely, O LORD (Psalm 139:1-4)… Accept one another, then, just as Christ accepted you… (Romans 15:7).

Trust and Identity: Psychological Foundations of Intimacy

The interplays between trust and fear, identity and shame, are critical to both the demise and restoration of intimacy in eating disorders. Trust. Erikson (1980) identified trust as the first and primary task in psychosocial development. He posited that trust is so foundational that if it is not attained, further development derails. In worst-case scenarios involving abuse, abandonment, and neglect, individuals’ capacity to trust is so damaged that permanent impairment can occur, preventing significant attach¬ment or bonding to others throughout the lifespan. Simply put: no trust, no intimacy. For women, research suggests that eating disorders often begin during the onset of adolescence, ages 12 to 14, or at its end, ages 17 to 19. Children face multiple developmental challenges during these ages—puberty, relinquishing childhood, embracing adolescence, increasing responsibility, separation/individua¬tion, acceptance/rejection by peers, identity formation, com¬petence, sexuality, and early adulthood. Teens need intimate relationship support during this time. In fact, the capacity for intimacy is one of the most critical resources needed for young people to successfully navigate adolescence. Individuals’ ability to develop intimacy during adolescence is directly related to the trust achieved earlier in life.

Without trust and intimate support during these transitional mile¬stones, young people are vulnerable to arrested development and reliance on unhealthy coping strategies. Eating disorders are part and parcel of these two difficulties. Anorexia virtually maintains or restores physiological childhood by eliminating menses and secondary sexual characteristics, by stopping physi¬cal growth, and by rendering the person physically diminutive. The primary features of eating disorders—bingeing, purging, restricting, and compulsive exercise—increase endorphin levels and promote temporary euphoria or emotional numbing, func¬tioning as a form of emotion regulation or unhealthy coping. Both anorexia and bulimia can represent attempts to meet other legitimate developmental needs through maladaptive methods. For example, self-starvation leads to thinness and the subjective perception of acceptance in lieu of actual peer relationships; purging prevents weight gain and can be experienced as the solution to anticipated peer rejection; eating disorders can become companions to the lonely; eating disorder behaviors can be forms of rebellion against family expectations and, as such, a method of separation/individuation. Other variants exist.

Identity. Erikson (1980) considered identity formation as the stage of psychosocial development occurring at the time of puberty. Identity formation specifically means learning to be oneself and to share oneself.

At this stage, adolescents start to more formally separate from family. They seek peer group belonging to find out who they are as unique and distinct from their family of origin. Identity is therefore shaped in the context of relationships.

Identity formation can be likened to growing up in a house of mir¬rors. Early in development children look to their families for input and affirmation about who they are and their value as people. If the early mirrors are healthy and accurate, the likelihood of inter¬nalizing/believing reality-based and affirming input about oneself is higher. If the early mirrors are shaming or distorted—akin to a circus mirror—the likelihood of incorporating inaccurate inputs into the self-concept rises proportionally. Of course, we know from psychological research that some people are prone to hear the most negative messages about themselves and to screen out the positive. Nevertheless, the nature of the mirroring we receive—the quality and tone of the messages about ourselves that others communicate to us—has a definitive impact on the development of our identity.

Once negative or shaming messages have been internalized as core to someone’s identity—a condition sometimes called “the shame base”—intimacy becomes frightening. The person’s inner dialogue will resemble this: “I know how bad and unacceptable I am; therefore, I cannot risk letting someone truly know me. If I do, they will find me out, reject me, and I will not be able to bear it”. Herein lies the linkage between shame-based identity and fear of rejection. This fear can become virtually paralyzing for young women with significant internalized shame about who they are and their lack of value as people.

From a Christian perspective, even the healthiest mirroring by other people cannot provide us with a complete and accurate identity. For Christians, God and the Bible are the ultimate, accu¬rate, and most penetrating mirrors. It has been said that we will never truly know who we are until we know who God is. “Anyone who listens to the word but does not do what it says is like a man who looks at his face in a mirror and, after looking at himself, goes away and immediately forgets what he looks like. But the man who looks intently into the perfect law that gives freedom, and continues to do this, not forgetting what he has heard, but doing it—he will be blessed in what he does” (James1:23-25). In short, true identity is lost when we are provided only man-made mirrors—when we “go away” from the ultimate mirror, God.

Sociologists inform us that culture is also a powerful mirror. The mirrors in US culture are heavily shaped by materialism and economic concerns. Alexis De Tocqueville (2000), who intensely studied emerging American culture in the 1800s, concluded that “materialism breeds violence”. Consider, for example, the mir¬rors our culture holds up for young women to look into during the vulnerable time of adolescence. On any night, American television offers messages, images, and mirrors about what women are, should and need to be, look like, and weigh in our culture in order to fit in. Often absent are spiritual virtues such as faith, hope, love, grace, mercy, justice, truth, wisdom, self-restraint, character, and integrity (Kilbourne, 1999; Knapp, 2003). Materialism cheapens humanity and personhood by low¬ering people to objects of utility—to be assessed as useful or not, visually pleasing or not, acceptable or not.

Such messages militate against the intrinsic worth given us by God himself, since we are created in his image. Such messages ignore that we are the intended recipients of Christ’s redemptive suffering and resurrection: “For God so loved the world…” (John 3:16; emphasis added). If a young woman’s identity and worth are built upon visual, material foundations, her true femininity and personhood will be lost because, at their core, true femininity and personhood are immaterial, spiritual, and unseen.

Your beauty should not come from outward adornment, such as braided hair and the wearing of gold jewelry and fine clothes. Instead, it should be that of your inner self, the unfading beauty of a gentle and quiet spirit, which is of great worth in God’s sight. For this is the way the holy women of the past who put their hope in God used to make themselves beautiful. (1 Peter 3:3-5)

The unseen virtues (above) are the very things which keep the seen (material aspects) in their proper place—safe and adequately anchored. Moreover, young women who are starv¬ing for self-respect and seeking this through visual acceptability wind up doing violence to themselves and their relationships through diets, extreme measures to change the body and looks, and even eating disorders. These efforts are perceived by the women so affected as more proof that they really are flawed and not worth knowing. The internal dialogue runs thus: “I must try harder and be perfect, or just give up and isolate to stay safe from being known”.

In Alcoholics Anonymous (AA) there is an interesting play on words regarding intimacy; AA calls it “in-to-me-I-see”. This expresses the notion that before we can be intimate, we must first understand and accept ourselves. How can a young woman share with another what she is unclear about herself? The bar¬rier here is that a young woman, affected as described above, is petrified to look inside of herself for fear of what she will find: shame and unacceptability. In our materialistic culture, it may seem easier to focus on changing something she knows how to change–such as her body–than on something she does not know how to change—i.e., the intangible aspects of her soul, character, identity, and virtues. Eating disorders readily arise from such desperate efforts to change the outer appearance, or to become symbolically invisible, as in anorexia, so that the fear of intimacy can be avoided.

Sexual and Marital Intimacy

The capacity for sexual and marital intimacy arises similarly to intimacy in general, but with additional features. For sexual and marital intimacy, critical foundations are established especially in the father-daughter relationship. This is commonly the first and most formative experience a girl has with the opposite sex. In essence, the father or father figure is the girl’s prototype for the entire male gender. He is the girl’s first exposure to, and model of, committed love from the opposite sex, and forms the template of her future interactions with men.

In this father-daughter relationship develop the girl’s identity and sense of personal value in opposite-sex relationships. This can occur through the interface and contrast of the father’s masculine characteristics with the girl’s feminine characteristics, as well as the extent to which the girl is affirmed as cherished and worthy of protection, provision, and sacrificial love by her father. Because the deepest levels of intimacy are spiritual—soul to soul and heart to heart—it is the father’s responsibility to not only teach the girl in words, but also to provide her with actual experiences of what such connection and tenderness look like in the absence of romantic contact. When this is handled well, the girl has a clear, healthy reference against which to measure future interactions with the opposite sex.

From a Christian perspective, relationships that are solely physi¬cally/sexually-based inevitably cheapen and devalue people. We are told that “the Spirit gives life; the flesh counts for nothing” (John 6:62-63). And we are exhorted to “love one another deep¬ly, from the heart” (1 Peter 1:22-23; emphasis added). Sexually-based relationships eventually destroy true intimacy because they derive from and focus on the material and sensual aspects of humanity only, and exclude the emotional and spiritual aspects of who we are. There is no wholeness in such relationships, and thus the whole person cannot be affirmed by such forms of inti¬macy. In fact, the excluded dimensions of the human person may be indirectly or even directly dismissed, devalued, and damaged by relationships that focus solely on sex. In addition, sexually-based relationships may neglect the interpersonal respect and trust which are critical for true intimacy and its soul-nurturing benefits. A father or father-figure can give a girl a priceless gift by showing her such respect and trust in his relationship with her throughout her developmental years, and by valuing her far beyond her body or appearance, so that she will seek and expect these essential components in her future relationships with men.

Yet the physical aspects of the human person do matter as well. They are not separate from the person, but integral to the whole bio-psycho-social-spiritual person. Author John Eldredge (2001) writes that a question which women carry within themselves is: “Am I lovely?” Although this question may sound a bit stilted to modern ears, it captures something important about body image–a woman’s need to feel accepted and comfortable with her physical presence in the world. God has answered this question with a resounding “yes!” “How beautiful you are, my darling! Oh, how beautiful!” (Song of Solomon 1:15). If a father has faithfully modeled Christ’s love to his daughter, the question about body image will have been largely settled for her, leaving her far less vulnerable to seeking the answer from poten¬tially inadequate or disruptive sources, such as other males or cultural influences. However, if this question has not been settled by puberty, a young woman may be dangerously vulnerable regarding her body image and who, or what, she will look to for affirmation of her identity. A woman may look solely to her part¬ner/husband to answer this question, but this will place excessive pressure on him, even though his acceptance may partially heal such a void. Her search will conclude successfully only when the answer resides within her and derives from her Creator, who made her beautiful in his all-meaningful eyes.

For some women, eating disorders are clearly an effort to answer Eldredge’s question, “Am I lovely?”, in the absence of a healthy, self-validating answer from within. But an emaciated body, or one contorted into artificial thinness by purging and compulsive exercise, can never satisfy a question so deep and intrinsic to the human soul. Such women may also evidence relational instability and promiscuity–companion efforts to answer this fundamental question about their sexual identity.

Restoring Intimacy in the Recovery Process

To begin, trust must be firmly established between the patient and therapist in order for the patient to feel safe enough to examine the pain, shame, and fear inside without feeling judged. Then, the specific relationship between the patient’s core under¬lying issues—e.g., identity, shame, fear of rejection—and eating disorder behaviors must be clearly identified and understood by both patient and clinician. You cannot address what you do not understand. Patients are typically relieved to discover that their behaviors are actually methods/attempts to meet legitimate underlying needs, such as the desire to be intimately accepted by self and others and the need to know truly who they are.

Shame causes people to hide in darkness—to not be known, to be rejected. Therefore, once a strong therapeutic alliance/bond has been established, the patient must take a risk to bring the hidden into the light. Healing occurs when shame-laden content is disclosed by the patient and accepted (though not necessar¬ily endorsed) by the therapist. Most importantly, regardless of the content disclosed, the patient herself must experience that she is fully accepted verbally and relationally by the therapist. In this moment the patient actually experiences the opposite of the rejection/abandonment that the shame convinced her she would receive if she ever opened up. This experience reinforces her initial risk/impetus toward intimacy and also provides the mechanism for restoring intimacy to her relationships: trust–dis¬closure–acceptance–to know and be known.

Many of us have responses and reactions to intimate encoun¬ters, some of which we are unaware of, that block intimacy or repel others from pursuing further intimacy with us. The patient may therefore need the therapist’s assistance in how to receive acceptance and experience emotional intimacy. Maintaining and cultivating intimacy will also inevitably entail points of conflict. The ability to tell another the truth in love is often difficult and requires training and practice, involving such skills as conflict resolution/management, forgiveness, reconciliation, and the dis¬tinctions between the latter two. Joint sessions with those closest to patients may be helpful in assisting patients further to develop their new-found relationship skills and generalize them from the therapy context to real life situations. But patients’ trust-dis¬closure-acceptance experiences occurring in therapy serve as a starting point from which patients can build intimacy with others and the skills needed to invite and maintain intimacy in their everyday lives.


Eldredge, J. (2001). Wild at heart: Discovering the secret of a man’s soul. Nashville: Thomas Nelson.

Erikson, E. (1980). Identity and the life cycle. New York: W. W. Norton & Company, Inc.

The Holy Bible (King James Version). (1996). New York: Alfred A. Knopf.

The Holy Bible (New Revised Standard Version). (1977). New York: Oxford University Press.

Kilbourne, J. (1999). Deadly persuasion: Why women and girls must fight the addictive power of advertising. New York: The Free Press.

Knapp, C. (2003). Appetites: Why women want. New York: Counterpoint.

Merriam-Webster, et al. (2003). Merriam-Webster’s collegiate dictionary (11th ed.). Springfield, MA: Merriam-Webster, Inc.

De Tocqueville, A. (2000). Democracy in America. Chicago: University of Chicago Press.

Next Issue: Social Dimension of Eating Disorders Continued

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