Thursday, 13 December 2007

How to interview an eating disorder!

As part of LifeLine*, I went to a training session the other night about eating disorders; anorexia and bulimia. Overeating was touched on too but wasn't the focus of the evening. It was fascinating. Some of the things that came out of it:

1. Early occurrences of anorexia, in the 13th century and earlier, were associated with religious purity and fasting. If you could resist the base urge to eat then you must be more godly.

2. Traditionally they have been female disorders but more and more men are being diagnosed with them.

3. A survey found 50% of primary school children wanted to weigh less and 25% have dieted.

4. 99% of women aged 18-35 years old are larger than the standard shop mannequin.

5. It is not physically possibly for a woman to match the measurement ratios of a Barbie Doll.

6. Nowadays young girls see more images of outstandingly beautiful women in a day than their mothers saw in their entire adolescence.

All interesting stuff. Unfortunately all these things conspire to keep women on an eternal treadmill, in search of the 'ideal' weight, along with the beauty, happiness and friends that it is supposed to bring with it. The sad part is that the treatment of anorexia and, to a lesser extent bulimia, is very difficult as the patient refuses to believe that they have a problem. So that brought up an interesting strategy.

The first step is something that applies to all conditions: don't label people as the problem. A person is not an 'anorexic', they are someone 'living with anorexia'. We were then taken through a process where we ask the patient if we could interview the problem.

"Could I have a conversation with just that part of you that is the Anorexia? This means you get the chance to just sit back and listen to us talk, is that okay with you?"

It sound bizarre but it can work really well. You can ask the problem when it came, how it helps the patient, how it hinders the patient, what it would like to change, when it will know that it is time to leave. It can be a revelation for the patient and yet they are answering the questions!

It does not have to be limited to eating disorders, of course. Any habit or condition can, theoretically, be interviewed the same way.

*Curious in some respects, as a characteristic of anorexia is denial that there is a problem so they would never call LifeLine.



  1. I'm glad you're educating yourself, curate's egg, but you should also be aware thta eating disorders are biological illnesses, NOT lifestyle choices. Culture can play a role in triggering but does not cause eating disorders. People with anorexia cannot choose to get sick or get well.

    For more information, I suggest you check out and Oh, and I'll be glad to help educate you. I'm a journalist and a mom whose daughter had anorexia and has recovered.

    --Harriet Brown

  2. Thanks for that. Just correcting a little dyslexia: the address is

  3. Thanks, Lee! That's what I get for thinking faster than I can type.

  4. Images like the one of the woman at the bottom are simply scary; I remember when my sister was 15 and her 14 year old friend and neighbor became anorexic; I was away at college when it happened and I refused to believe it until I came home for a break and saw her, emaciated and sickly, and was completely taken aback. It's difficult to know how to act around people struggling with an eating disorder or addiction. That's why the A&E show Intervention is so important. It shows all sides of addiction and all the people involved, and uses a highly qualified team of specialists to help people get on the road to recovery. I'm working with A&E because I think this show can really change lives. You can see more about it at New episodes air every Monday at 9pm/8c. Let me know what you think!

  5. I probably should put in a disclaimer here. I do not in anyway trivialize the seriousness of eating disorders. They are very real and can be very deadly.

    I had two perspectives in doing the post. Firstly, the rise of eating disorders and, secondly, the application of the interview technique.

    Like most brain disorders, medication may (but only may) play a part in treatment. Such disorders are usually a mixture of nature (predisposition) and nurture (triggers) and the increase in the numbers of cases, especially in men, suggests that there are more triggers about. It is possible that the levels of predisposition are rising but generally biological changes don't work that fast.

    How to treat any brain-based disorder is problematic but it can be a big help to dissociate the person from the problem. On her blog, Harriet talks of writing ransom notes. This is another way of saying that the person is living with the problem, not that they are the problem. That they are being 'held' by the problem. My only reservation with that technique is that it implies that the patient is not only captive but needs external rescue. But still it is a good way of visualizing the problem.

  6. Extremely interesting. I did "get it" that your post was mainly based on interview techniques. My Y7 daughter also fell in the category of "I'm fat I'm going on a diet" although it luckily only stayed with words, then she eats again. She's got a healthy body but I think they hear and see to much already at way to young ages.
    I need to loose a few kilo's and made a point to say (if I talk about it) that I want to slim down a bit to a HEALTHIER weight so she gets the messages it stops then, not going skinnier and skinnier. A weight that I will feel comfortable with in myself and clothes.
    Great post Lee.

  7. Lee,

    Everyone talks about the rise in eating disorders but I haven't actually seen any numbers that bear this out. It may be one of those situations where our awareness is rising. The n umbers are staying pretty steady as far as we know at this point.

    There is no medication that helps with eating disorders.

    And yes, I do believe a person with an eating disorder needs rescue. They cannot "choose" recovery any more than they have chosen the illness in the first place. They need the external compulsion of someone who is stronger than the e.d. Believe me, I've interviewed many people with e.d.s, and they pretty much all say this--if they can acknowledge that they have a problem in the first place. Anorexia in particular is anosognosic, meaning that people who have it often don't recognize it as a problem.

    So. Java, your daughter likely does not have the genetic predisposition for an e.d. Think about it: Given our current cultural norms, if culture caused e.d.s, we'd have 75% of young women with e.d.s rather than the (conservative) 5-8% we have now. Clearly there is something much more than environment going on.

    And if your daughter were predisposed to an e.d., your talk about needing to lose weight would definitely be a trigger. My daughter began restricting her food intake in an effort to, as her school had taught her, "eat healthy." Parents should not discuss dieting in front of children no matter what the "reason" (and if you've read my blog you know that I question the current conventional wisdom about weight on all fronts).

    Lee, I didn't mean to hijack your blog; you were speaking in part about interview techniques. Sorry about that. But there is so much misinformation out there about eating disorders--I'm trying to educate people in every venue possible.

  8. I'm horrified by the photo at the bottom of the post .... what a self-destructive illness this is.

    It makes me sad that so many people are stricken with this disease ... In the abundance that is the first world, what sorrow drives some people to lose sight of their basic needs for survival?

    I am aware that food really isn't the issue but I still cannot understand how any person could starve themselves to the extent that the woman in the photo seems to have done.

  9. Harriet: I have no qualms in the blog comments being used in this way, though my perspective was more from the psychological techniques, which can apply to almost any disorder (eg compulsive computer gaming), than eating disorders as such. I am happy to learn from others. In fact it is the main way I learn.

    I am a little concerned with your perspective on "external compulsion of someone who is stronger than the e.d.". Could you explain this a bit more? My worry is that some people, not all granted, find themselves with a eating disorder as a result of power struggles within a family. They find food intake something that they can control despite other superior forces in their life. From you experience, do you agree with this? How big is the risk that you are perpetuating the power struggle dynamic with "external compulsion"?

  10. Lee,
    The point of view you're voicing is the old one. It's the same perspective that used to tell us that "refrigerator mothers" caused autism and homosexuality and schizophrenia.

    The latest research on eating disorders disproves this loud and clear. Take a look at the University of California-San Diego's Eating Disorders site, for starters. You will see there the more recent pov on eating disorders. They are NOT caused by control issues, power struggles, wish to be thin, etc. They are biological illnesses. Either you're wired for an e.d. or you're not. if you are, many things can trigger you into one. if you're not, nothing can trigger you into one.

    So no, I absolutely do not agree with what you say. Neither does the latest research. Are you in England, Lee? The Maudsley Hospital in London has done much good work on this subject.

    And riseoutofme, please understand that no one sets out to starve themselves. It's not a question of losing sight of the basic needs for survival. It's a question of having a terrible, twisted disease.

    It actually *is* about the food.

    I think what happens for people who are chronically ill, who get sick in their teens, as is almost always the case, and stay sick for a decade or more, is that they ascribe meaning to their suffering. So an e.d. has to be "about" something. it's a very human tendency, to make up stories to explain our experiences, and I'm sure any one of us could look back at our families and say, My parents didn't meet my needs, or Life was shitty to me, and therefore I'm anorexia, or whatever.

    But I do not believe this is the truth. Ten years from now we will look back at that old way of thinking in horror.

  11. Harriet: "The point of view you're voicing is the old one. It's the same perspective that used to tell us that "refrigerator mothers" caused autism and homosexuality and schizophrenia." Rubbish. That is nothing more than a straw man argument and ignores my point entirely. Even you don't believe it to be true.

    The University of California site says: "Societal pressure isn’t irrelevant; it may be the environmental trigger that releases a person’s genetic risk". Basically exactly what I said.

    They also go on to say "Many treatments for anorexia nervosa (AN) and bulimia nervosa (BN) that are used today are based on hypotheses about what causes people to have an eating disorder (ED). It is not known whether or not these hypotheses are true." This is a scientific response. Scientists do not use absolutes in describing whether something is the cause or consequence of an action, they use probabilities and likelihoods. Certainties are for religion.

    The scientists are looking into it, they are investigating, they have ideas but they have no clear cut answers so, really, you have no strong ground to say what does or doesn't cause eating disorders. The case is still open and you cannot use "NOT" with any sort of scientific rigor when including or excluding causes.

  12. Not a straw man, Lee. It's kind of insulting that you would say so, actually.

    I've been talking to these scientists for 2 years now. I know what they *think.* It takes time for perceptions to change, but believe me, Walt kaye of UC-San Diego and dan Le Grange of U-Chicago do not think parents or environment causes eating disorders. Ask 'em. Go ahead.

    We used to think parents and/or environment caused autism, schizophrenia, homosexuality. Did we not? And now what do we think? Genes, genes, genes. It will be the same with eating disorders. Do some kids with the gene for autism not become autistic, because of environment? We don't know the answer to that. Same with e.d.s. Same with schizophrenia. (Homosexuality is a different story.)

    We're in agreement that environment can trigger an e.d. But not on cause.

    And the real point is that *it doesn't matter.* What matters is developing good evidence-based treatments rather than the standard fare, which includes therapy (which does not work well on people who are nalmourished), art therapy, equine therapy, etc. I'm all for science and evidence. But not for the blame game.


  13. I'm living with somebody who has bulimia and refuses to be helped. It drives me crazy when I think of the complications but it seems that the sufferer couldn't care less about it.

  14. Harriet: I do believe that the 'refrigerator mum' jibe was a straw man argument and I feel no remorse in picking you up on it. It was, in effect, saying "this is true therefore that is true". Not necessarily so. For the record my feelings on the three conditions are: Schizophrenia is perhaps closer to my understanding of eating disorders as it is considered to have a genetic predisposition element and to also be responsive to triggers to initiate onset. Autism and homosexuality are genetic and do not seem to have or need a trigger.

    This is obviously a subject that is dear to your heart and about which you are very passionate. You also exude a very strong sense of being right and knowing all the answers which perhaps come with the passion territory but is a little off-putting.

    I think this thing got off on the wrong foot when you offered to 'educate' me (inference: I am ignorant) based on a post of a few light facts about body image and an interesting psychological technique that has some application with eating disorder treatment. Should we be in a position to explore the subject more civilly, over a coffee, I guarantee you that you would find that I do know more about the subject than that. You may even find that we agree on most issues. And, yes, I do know that psychological techniques do not work with malnourished people. Their cognitive functions are seriously impaired and they need in-patient care. Once they have regained sufficient weight for some sort of cognitive balance to be restored (some sources say a BMI 18 or more) they are more receptive to therapy.

    Finally, you will have noticed that I rebel quite strongly to absolutes, be they from children (nobody loves me), scientists (this is the cause of that) or people who type 'not' in capitals. If only life was that certain.

    This has been an interesting discussion and I thank you for it and wish you well with your endeavours in what must be a quite challenging field.

    Melbourne, Australia.

  15. Nope, not a straw man argument at all. Parents are still being told these things, Lee, whether you like to believe it or not.

    Since I've clearly been dismissed now, we shall have to agree to disagree on parts of this debate.

  16. Yes they are but so what? It is an easy point to win and then imply that, because that point was won, the point on eating disorders was also won. Not so. Straw man.

    You may feel that you have been 'dismissed' but this is not my cause and we just doing the 'five men and an elephant' thing which is wasting both our energies.

    I wished you well. I meant it.

  17. mmm..i wish i have anorexia.


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