Remuda Ranch

Cognitive-Behavioral Therapy with Eating Disorders: A Christian Perspective

A. David Wall, PhD
Department of Psychological Services
Remuda Ranch Programs for Anorexia and Bulimia

Cognitive-Behavioral Therapy (CBT) is commonly considered the most scientifically-valid psychotherapeutic approach to eating disorders (American Psychiatric Association, 2000). But some Christians have concerns about CBT. They associate it with humanistic psychology in general, and specifically with controversial figures such as Albert Ellis, whose writings–e.g., The Justification of Sex Without Love (Ellis, 1966)–raise red flags for Christians.

Remuda believes that CBT can be extraordinarily consistent with, and expressive of, Scriptural truth. Indeed, Remuda bases its therapeutic interventions on CBT. We therefore examine: 1) what CBT is, 2) how CBT applies to eating disorders, and 3) why CBT can serve as a primary modality in Biblically-based eating disorder treatment. The next issue of The Remuda Review will focus in more detail on specific CBT strategies and tools.

1. What is CBT?

CBT begins with a behavioral view of human beings. It recognizes that human behavior depends on how our previous behavioral responses to the environment have been reinforced and punished. However, behaviorism asserts that this learning history alone explains human behavior. It denies free choice. But CBT affirms human freedom. According to CBT, when individuals experience stimuli they have only learned tendencies to respond in a particular manner. They also have the ability to contemplate and choose a response. In short, CBT asserts that individuals process stimuli cognitively and respond according to their cognitions or thoughts. Hence, CBT is not just behavioral, but cognitive-behavioral.

Process and Content

Process. Cognitive processing is simply the mechanism by which human beings handle incoming information to respond to complex stimuli. Cognitive processing itself is neutral–neither healthy nor pathological. It is a fact of brain functioning.

Content. Cognitive processing is guided by well-developed, learned belief systems, known as schemas. These belief systems or schemas influence how we perceive reality. For example, a person who comes from a loving family and believes in basic human goodness may perceive an approaching stranger as an innocent tourist needing directions. A person who comes from an abusive family and believes that human beings are dangerous may perceive the approaching stranger as a mugger, a rapist, or a threat of some other kind. By processing the same information from the environment, two different conclusions would be reached because each person is guided by a different schema.

Pathology arises from the content of schemas. Schemas filled with irrational beliefs result in defective and maladaptive behavioral choices. False/irrational assumptions yield false/irrational conclusions. The degree of psychopathology is related to how irrational belief systems are, that is, how inconsistent beliefs and cognitions are with reality and logic. Here is an example.

Rattlesnakes are dangerous. This is a logical and rational conclusion, because in reality people bitten by rattlesnakes suffer deleterious consequences. However, concluding that a caterpillar is dangerous is irrational, because caterpillars do not harm people.

Fear is the emotional response engendered by the belief that something is dangerous. With the rattlesnake, fear is rational emoting, consistent with reality. With the caterpillar, fear is irrational emoting, inconsistent with reality.

Rational emotions are necessary to help us make wise choices, such as avoiding a rattlesnake. Emotions are rational when they flow out of rational, reality-based beliefs and “...when they help you achieve [life] goals” (Ellis & Harper, 1975, p. 23). Irrational emotions flow out of irrational beliefs, cause unnecessary psychic pain, and typically lead to behaviors that make things worse. E.g., someone cannot sleep for fear that a caterpillar may crawl into bed. This situation would constitute psychopathology.

CBT’s core therapeutic principle is to help individuals distinguish beliefs, perceptions, cognitions, and behaviors that are rational and appropriate from those that are irrational and inappropriate–to change the content of schemas. A variety of methods have been developed to effect these changes. When schemas become more rational, so do emotions. If I no longer believe that caterpillars are dangerous, I will not experience fear around caterpillars. My psychopathology, my phobia, will be alleviated.

CBT is not defined by specific interventions, such as adherence to a therapy manual or the format of thought journals. Nor is CBT defined by what various authors may opine to be rational versus irrational beliefs. Instead, CBT is defined by the scientific understanding of cognitive processing and by the application of a variety of methods that share the common features of examining schemas, determining how beliefs impact current emotional and behavioral functioning, and helping patients to modify schemas to reflect more rational beliefs. CBT’s methods may include any intervention that expresses this core therapeutic principle.

Many therapeutic issues arise from situations more complex than fear of a caterpillar. Is it rational or irrational for a female rape victim to conclude that men are dangerous? Such a belief may indeed protect her from a repetition of her trauma. Such a person may need assistance in developing a more complex and sophisticated schema–e.g., the recognition that only some men are dangerous under certain circumstances–and testing this revised schema safely against reality through controlled practice. In some cases, discerning rational from irrational beliefs is less a matter of observable fact and more a matter of moral judgment. For example, is it rational or irrational to have negative cognitions about engaging in premarital sex? Is guilt, in this case, rational or irrational emoting? This depends on the patient’s sociocultural and religious experience. Psychotherapists using CBT must be sensitive to the complexities and socio-cultural context of each case.

Formation and Function of Schemas

How are schemas formed? Children encounter a multitude of learning experiences. Their brains look for patterns, structures, and cues that make situations predictable. Predictability allows for anticipation. Accurate anticipation permits adaptive responses, enhancing survival and thriving.

The patterns, structures, and cues perceived by the brain are formed into distinct belief systems or schemas. Schemas are mental maps that help individuals interpret situations and choose appropriate responses. Ellis states that schemas help us fulfill life goals (Ellis & Harper, 1975, p.23). Others suggest that we are born with certain needs and that schemas provide blueprints to meet these needs with minimal risk. Although there is disagreement about what these needs are, they likely include air, water, food, sleep, connections with others, a sense of significance and purpose, a sense of power and autonomy, and love (e.g., Maslow, 1970).

After a schema has been reinforced for a period of time it becomes ingrained and self-perpetuating. A tendency arises to perceive events in such a way that they are consistent with and can be readily assimilated into existing schemas, rather than to change or accommodate schemas to fit events. Information that is consistent with a schema is noticed and even sought after, while inconsistent information is filtered out. Schemas that involve strong emotion, like most eating disorder schemas, are the most difficult to change.

In summary:

• 1. Schemas are belief systems.
• 2. Schemas develop through learning as we encounter life situations.
• 3. Schemas guide how we interpret events.
• 4. Schemas include beliefs about how to meet our needs.
• 5. Schemas filter out or interpret as consistent contradictory information–they are self-perpetuating.
• 6. Schemas most resist change when they are highly emotionally charged.

2. CBT and Eating Disorders

Recently, I looked at a blueberry muffin and wondered: What has to happen to transform this muffin into a big problem? A muffin can be the stimulus for major power struggles in families. It can make intelligent teenagers cry uncontrollably– irrational emoting. How does this happen?

Self and Eating Disorder Schemas

A central schema, the self-schema, organizes and incorporates what each person has come to believe about him/herself based upon life experiences. Beliefs about intelligence, likeability, beauty, shyness, talents, shame, and other areas are included in this schema.

As children grow and experience more of life, the self-schema changes. Pre- and early teens are constantly searching for information from the environment to define themselves and develop self-schemas that will guide and protect them and meet their needs. The self–schema tends to crystallize as teens get older. New information is assimilated/interpreted to fit the self-schema, rather than the self-schema changing to fit the information. The self-schema–an emotionally charged view of oneself–becomes resistant to change.

Early on, food is simply food. Emotion-generating aspects of food arise from whether or not the food tastes good, features of the caregiver-child relationship, and the context in which the food is given, such as fun at a birthday party. A food schema is developed from these experiences. At some point, especially for girls, a connection is made between food and body image. The food and self-schemas intertwine. Conflicts arise as good-pleasurable food, an approach tendency, collides with the possibility of becoming fat, an avoidance tendency. As girls reach puberty, strong connections are made between body image/physical attractiveness and worth/approval/love. Girls may see what happens to those perceived as thin and attractive versus those perceived as fat. These perceptions are not distortions of reality, but are, unfortunately, rational in light of anti-weight biases in American culture.

Now, when a young woman looks at a blueberry muffin, she no longer sees just a muffin. She sees through a belief system that associates muffins with fat, rejection, and loneliness. So she may avoid the muffin, as well as other foods associated with negative expectations. In some cases, she develops anorexia. In other cases, she eats but learns to purge, developing bulimia.

Illustrative Example

Case History. Lucy is 19 years-old. She grew up with a “workaholic” dad. She cannot recall the words “I love you” from her father. Dad was also unaffectionate with her mother. However, he provided well and was interested in Lucy’s achievements. Lucy watched the joking and affectionate relationships her friends had with their dads, and she longed for this.

Mom had “weight issues” when Lucy was younger. When Lucy was a teenager, mom became very strict in dieting, a “health-nut.” Mom is currently slender and very body focused. Dad has increased his attention to mom since she lost weight.

Lucy is very attractive. She began attracting male attention as early as 7th grade. As a sophomore, she began dating a popular senior, Jared. As a Christian, Lucy had determined not to have sex until marriage. But a year into her relationship with Jared, she was regularly sleeping with him.

Lucy had flirted with an eating disorder for much of her teens. She had experimented with self-induced vomiting, but ultimately found that by exercising two hours a day and more on weekends, she could keep her weight down without vomiting.

Lucy was certain that Jared was the man she should marry. He visited from the state university regularly; they always slept together when he was in town. Then Lucy heard from a friend that Jared was cheating on her. She refused to believe it until Jared confessed when she confronted him on the phone. After he hung up on her, she immediately went into the bathroom and threw up due to the emotional shock. She felt slightly better. Before long she was causing herself to vomit. Soon she was bingeing as well.

Case Conceptualization. Let’s look at Lucy’s life from a CBT perspective. What needs did she have? What had she learned from her experiences? What was her self-schema?

Lucy’s need for love and attention from males was primary. Unfulfilled over the years, it had grown strong.

Due to her father’s lack of affection, she had not learned that she was worthy of love and approval simply because of who she is. In contrast, from her mother’s focus on appearance, her father’s positive reaction to her mother’s weight loss, and her experiences at school she had learned that attention comes primarily from appearance.

Lucy may have concluded: “There is nothing about me that is worth loving, except my body.” “I can use my attractiveness to gain love.” “If I stop being attractive, I will be rejected.”

We interpret events to fit our schemas. Lucy might have seen Jared’s rejection of her as his inability to be faithful, but instead she interpreted it according to her schema–as evidence that she is unworthy of love from a man.

When we are insecure, we retreat to areas where we feel most competent. For Lucy, this meant appearance. The more hurt and insecure, the more body focused she became. To her, that was the solution.

Treatment Considerations. Eating disorder behaviors often become the primary tool that individuals use to meet needs. Although eating disorders’ outward behaviors may look similar across patients, the needs being fulfilled–the function(s) of the eating disorder–usually differ across patients. It is necessary to understand the function(s) in order to effect therapeutic change.

Eating disorders are irrational, unhealthy ways of pursuing rational, healthy goals. In Lucy’s case, she wants to be loved by a man–a rational and healthy goal. She believes that she will receive love primarily for physical attractiveness– a logical conclusion given her experiences. And so she pursues love through compulsive exercise and purging–logical behaviors given her beliefs. These behaviors may even work in the short-term. When patients believe that their needs can only be met through an eating disorder, they resist treatment. It is therefore essential to help patients separate the legitimate function(s) of the eating disorder from the eating disorder itself. To accomplish this, rapport and validation are critical. CBT confirms for Lucy that there are rational reasons why she has an eating disorder–a validation of her need for love and the legitimacy of this goal.

In addition to validation, CBT confronts Lucy with the ability to change, and thus the choice to change. The ability to change lies in changing her belief systems or schemas. Change-oriented interventions with Lucy might begin by teaching her the basics about how schemas are formed, to connect her past experiences to her current belief system, and to help her see how she interprets events. As she recognizes the logical connection between her experiences and the development of her eating disorder, she will experience a reduction in shame. In the absence of this information, she will explain her eating disorder using her negative self-schema: “I must be a really sick person,” “I am hopelessly sinful,” “I am a worthless loser.”

Parodies of CBT suggest that people can change beliefs simply by looking in the mirror and repeating self-affirmations. Nothing could be further from the truth. Our most significant and often troubling schemas are formed primarily in the context of relationships (Beck & Freeman, 1990)–as Lucy’s were formed in relation to her father, mother, and boys at school. Thus, schemas can best be transformed in the context of relationships. To focus strictly on changing distorted cognitions apart from a relational context is likely to be ineffective. Furthermore, patients’ existing relationships usually reinforce or exacerbate existing schemas. But a directive therapeutic relationship can help transform schemas.

The importance of relationships cannot be overemphasized. It is essential to recognize that the function of eating disorders–the rational goal–is almost always relational. These relational needs are experienced and/or expressed by patients in various ways, such as: I want to connect with others. I don’t want to be rejected or attacked. I want to have autonomy and control over my life. I want to be heard. I want attention, to be significant. I want my family to get along. I don’t want to be a sexual object. I don’t want to be afraid. I want to be loved. For Lucy, the relational goal was the desire to be loved by a man.

CBT helps the patient to see the legitimate relational goal(s) of the eating disorder. It proceeds to assist the person in seeing the cost of using the eating disorder to meet this goal, as well as the eating disorder’s ultimate ineffectiveness in achieving the relational goal. CBT then introduces and assists the person to develop new ways of meeting legitimate relational needs, such as skills training and wise mind (Linehan, 1993)–i.e., learning not to have emotions be the primary determinant of reality. Patients cannot give up an eating disorder if they have nothing to replace it with. New skills are essential. Through new skills, CBT helps the person to develop healthier relationships. Healthy relationships better meet the person’s relational needs, making the eating disorder obsolete.

In Lucy’s case, cognitive restructuring may focus on her self-schema, assisting Lucy to develop an intrinsic sense of worth as a human being and self-esteem based on her many positive qualities apart from her appearance. The therapist can create cognitive dissonance by reflecting how Lucy’s values, such as not judging people based on their appearance, conflict with the beliefs she imposes on herself. Cognitive dissonance disrupts homeostasis and motivates the person to resolve the dissonance. Assertion skills training may be needed to help Lucy recognize and appropriately ask for her emotional needs to be met in relationships with men and express her feelings to her family. Lucy may benefit from emotion identification and regulation skills, so that she need not rely on eating disorder behaviors to handle difficult feelings. Other tools will likely be incorporated into treatment.

3. CBT as a Biblically-Based Treatment Modality

More than many psychological approaches, CBT arose from scientific research. As demonstrated in the first issue of The Remuda Review, because the methods of science study God’s creation objectively they are capable of revealing truths that were built into the creation by the Creator. So with CBT.

To begin, scientific research has recognized that the human brain readily packages experiences and information into organized belief systems/schemas and that such schemas allow human beings to manage a wealth of information and respond to the environment in ways that meet basic needs. This inherent schema-building process of the human brain is an intelligent, adaptive function, which Christians would attribute to God’s design.

But CBT is consistent with Scripture not merely in describing how the brain was designed by God to function, but also–and more importantly–in recognizing that thoughts and belief systems matter greatly in healthy mental functioning. This truth has long been understood by Christians, and has in a sense been reaffirmed by CBT’s scientific research.

The Bible, like CBT, acknowledges the centrality of thought. Scripture indicates that when our thoughts dwell on evil, we are harmed. “Their thoughts are evil thoughts; ruin and destruction mark their ways” (Isaiah 59:7). The Bible accordingly exhorts us to “... take captive every thought to make it obedient to Christ” (2 Corinthians 10:5), and instructs that “...whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable–if anything is excellent or praiseworthy–think about such things” (Philippians 4:8-9). This latter verse resembles a CBT assignment: change your thoughts to focus on the positive rather than the negative. Strikingly, the Bible teaches that our thoughts define who we are: “For as he thinks in his heart, so is he” (Proverbs 23:7; New King James Version).

Perhaps the Biblical counsel that most concisely expresses the core therapeutic principle of CBT is this: “Do not conform any longer to the pattern of this world, but be transformed by the renewing of your mind” (Romans 12:2). We see clearly in this verse the Biblical perspective: changing how we perceive reality–renewing the mind–is central to achieving psychological and spiritual health. This is likewise the primary tenet of CBT.

In this Bible verse, two words stand out–conform and transform.

Conform means to follow the same pattern. We have seen how cognitive processing searches for patterns in the world to form beliefs/schemas about how things work. But the Bible teaches that we live in a broken world. We therefore develop schemas that reflect the limitations of a sin-endowed environment and fallen socio-cultural order. We learn that life’s primary goals are to gain pleasure and avoid pain, climb and succeed, achieve power and wealth, be physically attractive and sexually active. We are taught that, rather than being created by a loving God, we evolved and are subject to the law of survival of the fittest. All people, including Christians, accept this “world schema” to one extent or another. Girls and women, in particular, absorb distorted beliefs about their bodies and self-worth that can lead them to eating disorders.

According to Scripture, the solution involves a mental transformation, a renewing of the mind. To transform means to change form. The New Testament Greek word is metamorphous, as in a caterpillar changing form to become a butterfly. The transformation to which the Bible refers involves changing from a schema derived from the fallen world to God’s schema or God’s way of seeing things. God’s schema involves no distortions, misperceptions, denial, or lies. It is truth. It involves natural and easily observable facts as well as deeper spiritual and moral truths revealed in Scripture. “‘For my thoughts are not your thoughts, neither are your ways my ways,’ declares the LORD” (Isaiah 55:8).

In Christian CBT with eating disorder patients, mental renewal occurs when patients are offered and build a self-schema from Gospel truths. Key truths include:

1) You were created by a loving God with intrinsic value apart from your appearance, gifts, talents, or willingness to do for others. “And even the very hairs of your head are all numbered. So don’t be afraid; you are worth more than many sparrows” (Matthew 10:30-31). “...I am fearfully and wonderfully made” (Psalm 139:14). “God is love...” (1 John 4:16).

2) Nothing you have done in the past can change your great worth and value today. “Because of the LORD’s great love we are not consumed, for his compassions never fail. They are new every morning; great is your faithfulness” (Lamentations 3:22-23). “There is now no condemnation for those who are in Christ Jesus” (Romans 8:1). “If we confess our sins he is faithful and just to forgive us...” (1 John 1:9).

3) Your life has meaning, value, and purpose. “‘For I know the plans I have for you,’ declares the LORD, ‘plans to prosper you and not to harm you, plans to give you hope and a future’” ( Jeremiah 29:11).

4) What you are attempting to achieve through the eating disorder is a legitimate and appropriate need. It is not necessary for you to let go of this need; in fact, God intends to fulfill this need in a life-giving way. “...God will meet all your needs according to his glorious riches in Christ Jesus” (Philippians 4:19). “I have come that they may have life, and have it to the full” (John 10:10).

5) The eating disorder may have worked to some extent in meeting your legitimate needs, but it is costing you much and is killing you. “There is a way that seems right to a man, but in the end it leads to death” (Proverbs 16:25).

6) You are not a powerless victim over the eating disorder or difficult experiences from your past. There is a way out. “...in all these things we are more than conquerors through him who loved us” (Romans 8:37). “For God did not give us a spirit of timidity, but a spirit of power....” (2 Timothy 1:7). “...when you are tempted, he will also provide a way out so that you can stand up under it” (1 Corinthians 10:13).

7) The way out includes an examination and transformation of your beliefs and usual ways of perceiving the world, a new schema. “...be transformed by the renewing of your mind” (Romans 12:2). “... take captive every thought to make it obedient to Christ” (2 Corinthians 10:5).

Summary

By assisting patients to renew the mind, Christian CBT promotes a therapeutic transformation: from irrational to rational schemas, emoting, and behaviors that are consistent with God's plan for each person whom he has lovingly made.

References

American Psychiatric Association (2000). Practice guideline for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, Suppl., 157, 1-39.

Beck, A. & Freeman, A. (1990). Cognitive therapy of personality disorders. New York: The Guilford Press. [N.B. The notion that schemas are primarily formed in the context of relationships is woven throughout this book.]

Ellis, A. (1966). Sex without guilt. Fort Lee, NJ: Lyle Stuart.

Ellis, A. & Harper, R.A. (1975). A new guide to rational living. Hollywood, CA: Wilshire Book Co.

Linehan, M.M. (1993) Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.

Maslow, A.H. (1970). Motivation and personality (2nd ed.). New York: Harper & Row.

Reclaiming The Self Through Art Therapy

Brenda J. Fox, MS, ATR
Division of Patient Care Services
Remuda Ranch Programs for Anorexia and Bulimia

Art therapy is based on a simple, yet powerful principle: By entering into the creative process, patients experience improved self-awareness, hope and vision for the future, and self-esteem (Dokter, 1994). Through art therapy, patients may renew a spiritual journey. Because artwork can be a metaphor for difficult feelings and issues, the art therapy process helps patients to discover and find a voice for emotions. This is especially important for eating disorder patients who are often alexithymic, confused about their feelings, and unable to label or articulate feelings verbally (Garner & Bemis, 1985). Eating disorders routinely serve as dysfunctional methods of emotion regulation, relied on because patients are unable to identify or express their emotional turmoil so that it can be approached therapeutically through cognitive-behavioral and other techniques (McCabe & Marcus, 2002).

Art therapy also has deep Scriptural roots relating to the core identity of human beings. In Genesis 1:27, we read that “...God created man in his own image...” What is God’s image? The Bible begins with these words, “In the beginning God created...” (Genesis 1:1), and recounts God’s many acts of creation. Thus, the first thing we learn about God is that He is a Creator.

Looking at Scripture’s opening verse, we see that God expressed creativity in all that He made. The earth, sea and sky, birds and animals, and men and women are all part of God’s creative design. God is the ultimate artist. Not even Van Gogh’s or Monet’s paintings, or Michelangelo’s sculpture of David, can match the awesomeness of God’s creativity. From a flaming Arizona sunset to the deep blue hues of the Mediterranean Sea; from the ice-covered pines sparkling in the Alaskan sun to the nighttime winter sky and the aurora borealis–God’s artistic mastery is matchless.

God is the Creator, and we are made in His image. We, then, are little artists, inherently creative beings. As Ephesians 2:10 says: “You are God’s craftsmanship, his work of art, created to do good works.” As an art therapist, I often hear people say that they are not creative. Yet because we are made in God’s image, we are indeed creative, each in his or her distinctive way. This truth helps eating disorder patients to discover the “hidden or sleeping artist” within them. And through the expression of their creativity in art, they reclaim their identity as artists, discovering emotional truths within their souls and reconnecting their spirits with God’s creative nature.

At first, patients will often say that they are “not good at art”. To soften their fears and create a safe environment, I gently reinforce the following guidelines:

(1) There are no mistakes in art.

(2) There is no right or wrong in art.

(3) It doesn’t have to be perfect.

There is usually relief when hearing these guidelines, and patients give themselves permission to not have to be perfect or perform. Patients embark on various projects guided by therapeutic themes. Examples appear below.

1. Anger Sculpture. Instructions: Use newspaper and masking tape to create an image of your anger. This patient has anorexia. She labels her sculpture, The Ever-Ready Bunny, expressing the magnitude of her obsessive thoughts to “keep going and going and going.” The bunny represents her and holds a can of Ensure. This enables her to talk about anger at herself, at her eating disorder, and at her dietician for “making me drink it”. The patient uses a lot of tape in creating her sculpture, and recognizes that this symbolizes her tendency to “stuff my anger and keep it hidden.” Through this anger sculpture, the patient identified anger-related issues needing to be addressed in treatment.

2. Anger Sculpture. Same instructions as #1 above. This patient describes her anger as a monster with a sharp red tongue and beady black and red eyes. She states that she struggles with admitting that she has anger and a lack of knowing how to express it. She indicates that the sculpture also represents what it feels like when someone gets angry at her—“it hurts.” This anger sculpture assisted the patient in recognizing her extreme discomfort with angry feelings, both her own and those of other people, opening the door for treatment to focus on these issues.

3. Mask. Instructions: Create a mask that explores your feelings and/or the face of the eating disorder. The patient paints the face pink to symbolize how the eating disorder “seduced me into believing that it was good, soft, and pretty, and promised happiness.” Horns and black eyes represent its true evil nature. Out of the mouth come its lies and deceit, painted in red and black. The tic-tac-toe on the forehead symbolizes “the mind games which the eating disorder plays with me.” When the patient reflects on how much time she spent creating this mask, she is able to identify how much time was wasted by practicing her eating disorder and how angry she is at the eating disorder for stealing her life. The patient also recognizes that she is beginning to see light and goodness in her future, represented in the yellow pupils. This mask served as an excellent summary for the patient of the truth about her eating disorder that she was discovering through treatment.

4. Canvas Collage. Instructions: Choose three pictures from magazines; create a collage painting to explore connections of the images to your issues. Through this artwork, the patient describes her desire to be loved and to see herself as beautiful. The rose symbolizes purity and fragility, and the love she experiences from her husband. The Barbie Doll represents beauty and reclaiming her lost childhood. The green garden represents meeting God with peace and serenity; the verse from the Song of Songs describes her renewed relationship with God. The patient states that she is beginning to capture God’s love for her and is finding her true identity in Him. This collage clearly expressed themes of hope and renewal; it helped the patient to recognize and verbally affirm the healing that was taking place in her and her emerging healthy identity.

Note: Written authorizations were secured from patients whose artwork is reproduced here.

References

Dokter, D. (1994). Art therapies and clients with eating disorders. London: Jessica Kingsley Publishers Ltd.

Garner, D.M. & Bemis, K.M. (1985). Cognitive therapy for anorexia nervosa. In D.M. Garner & P.E. Garfinkel (Eds.), Handbook of psychotherapy for anorexia nervosa and bulimia (pp. 107-146). New York: Guilford Press.

McCabe, E.B. & Marcus, M.D. (2002). Is dialectical behavior therapy useful in the management of anorexia nervosa? Eating Disorders, 10, 335-337.

Three Common Eating Disorder Myths

A. David Wall, PhD
Department of Psychological Services
Remuda Ranch Programs for Anorexia and Bulimia

“Any story sounds true until someone...sets the record straight” (Proverbs 18:17; The Living Bible)

Myth 1

“Bulimia is caused by sexual abuse”

When asked, “Has anyone ever touched you sexually, in a way that made you feel uncomfortable?”, a patient with bulimia responded, “I didn’t think so, but something must have happened ‘cause my therapist told me that bulimia is caused by sexual abuse.”

This myth can be destructive. The potential to promote false memories, the hunt for perpetrators, and the belief that one has been sexually abused can all be iatrogenic. Treatment can be misguided, missing real issues while chasing a phantom.

Approximately 35% of patients with bulimia have been sexually abused. In these cases, sexual abuse will likely be a significant etiologic and maintenance factor needing clinical attention. But clinicians must remember that most patients with bulimia, about 65%, have not been sexually abused. Etiologic and maintenance factors for their disorder must be sought elsewhere.

Myth 2

“Anorexia is a disorder of vanity”

This myth is true in a small percentage of cases. Some with anorexia are seeking to look like supermodels and be admired for thinness and beauty. But for most patients with anorexia nothing could be further from the truth. Far from flaunting their bodies for social accolade, they hide—certain that others are disgusted by their bodies. Most of the time, eating disorders have little to do with vanity but arise from an interaction among biological, psychological, social/family, and spiritual factors.

Myth 3

“All eating disorders have a common cause”

This myth is expressed in common statements, such as: “It’s all about control.” “It’s about perfectionistic, unemotional, overachieving families.” “It’s just rebelliousness.” “It’s a spiritual issue.” “It’s an addiction.”

Eating disorders are about control, maladaptive family systems, power struggles in the separation/individuation process, and spiritual issues, and they resemble addictions in some respects. However, there are dozens and perhaps hundreds of other core issues that can blend in varying degrees like primary colors mixed to form a new and unique hue. In a single individual certain issues will be very important, some moderately important, and others not important at all. Assuming standard etiologic factors, and providing the same treatment to all patients, is ineffective. There are common themes in eating disorders, but individuals with eating disorders are unique. Careful multidisciplinary assessment is therefore imperative, with individualized interventions driven by the assessment.