Brain Over Binge (18 page)

Once the habit was in motion and my brain and body were conditioned to binge, whatever comfort I may have received from binge eating only became fuel for the fire—more reasons my brain generated to get me to binge eat.
Eating will help you get to sleep,
I heard inside my head.
You've had a hard day and need to relax. Eating will bring you relief from your worries. You deserve some guilty pleasure. Eating will make you stop feeling lonely.
Those were automatic thoughts, disguised as "logical" reasons for binge eating, and those thoughts served as great excuses for my behavior.

Secondary benefits did become a major focus of my therapy. In therapy, I learned that, because binge eating brought me some measure of emotional comfort and pleasure, a deep-rooted inner need for emotional comfort and pleasure was therefore causing my binge eating. I learned that, because eating brought me temporary relief from problems, the problems themselves or my inability to handle them effectively was therefore causing my binge eating. So my therapists told me I needed to learn new ways to find comfort, pleasure, emotional fulfillment, and relief from my problems in order to stop binge eating. In other words, I needed to find substitutes for binge eating—other ways to get the secondary benefits of binge eating without actually binge eating.

The therapists' theory, although it seemed to make some sense when I was first introduced to it, was ineffective in practice. When an urge to binge hit, I found it extremely difficult to choose any substitute behavior. I came up with lists of things I could do to get the secondary benefits—take a relaxing bath, go for a long walk, watch a favorite TV show, listen to music, go for a drive—but I found that there were simply no substitutes for binge eating.

The problem was, I wasn't seeking the secondary benefits when I binged. I was seeking the food.
Nothing
could take the place of food,
nothing.
If I were seeking relief only from anxiety when I binged, then anti-anxiety medication, a relaxing bath, or some yoga would have done the trick. If I were seeking relief only from loneliness, a friend or boyfriend would have cured me. If I were seeking only mood improvement, then antidepressants, a long walk, or some uplifting music would have taken away my urges to binge. If I were seeking only tranquil sleep, then a sleeping pill or relaxation techniques could have easily taken the place of binge eating. If I were seeking only numbness from emotions, then zoning out in front of the TV or having a few drinks would have been enough. But none of these "substitutes" gave me what my brain truly wanted—food, and lots of it.

It is easy to illustrate why this was the case if I go back to the example of the baby. The baby cries at 3:00 a.m. because he has a conditioned need—not a real biological need—for a feeding. Along with that night feeding, the baby gets many secondary benefits, including closeness to his mother, comfort, security, and the pleasure of sucking. In other words, the feeding is not all about the food. However, food (in the form of formula or breast milk) is the
only
thing that will truly satisfy the baby, because food is his brain's top priority at 3:00 a.m.—the primary reason he woke up and cried. If the mother were to offer merely comfort and security by holding or rocking the baby, or perhaps giving him a pacifier, she would leave him unfulfilled and probably even more frustrated and upset. Sure, the secondary benefits that go along with the food are nice for the baby, but when the baby's brain is urging him to eat, the secondary benefits alone do nothing to satisfy.

So it was with my binge eating. It came with some secondary benefits, such as temporarily numbing me to emotions, helping me relax, and providing distraction. However, trying to get those secondary benefits without binge eating did nothing to quiet my urges, because binge eating was my brain's primary motivation. The secondary benefits weren't what I really wanted when I binged; I really wanted the food and the ensuing relief from my urge to binge.

Reward Sensitivity and Binge Eating Pleasure

A positive reward will reinforce behavior;
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and there is some evidence that the rewards or secondary benefits of binge eating may be more enticing for some people. As I discussed in Chapter 20, a personality trait known as "reward sensitivity" determines how driven we are toward rewarding experiences, such as eating pleasurable food. It's been shown that people sensitive to reward experience more intense and frequent food cravings.
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In those with higher reward sensitivity, the brain regions implicated in eating for reward are more active, even when those individuals simply
look
at pictures of food.
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The higher a person's sensitivity to reward, the more active these brain regions are when cues for appetizing food are present. This translates to a vulnerability to compulsive eating problems.
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A
vulnerability
to compulsive eating problems is not an
excuse
for binge eating. The reward network works to motivate food selection and intake— it doesn't pick up the dessert for you. My brain, and the brain of other binge eaters, may become more active around appetizing food than others' brains, lending attractiveness to the temporary pleasure of binge eating. This is simply a brain difference that could have made me more vulnerable to binge eating and enjoying it. But a higher reward drive is certainly not a signal of disease or lack of control. I find this reward sensitivity explanation of why I craved the pleasure of binge eating much more sensible than the idea that I craved the pleasure to fulfill some deep emotional needs.

REASON 5: THERAPY UNINTENTIONALLY ENCOURAGED ME TO FOLLOW URGES

Many things I learned in therapy only served to keep me following my urges to binge. When I believed, as therapy taught me, that I binged to cope with emotional and psychological problems, it only gave me excuses to binge. If one binge was about soothing an emotional upset, another binge was about seeking fulfillment, another binge was about dealing with pain from the past, and another binge was about escaping daily stress, then it was easy to find excuses to keep following those urges.

Below is a list of therapy concepts I learned, along with the harmful interpretations I placed on the concepts at the time.

Instead of empowering me to stop acting on my urges to binge, these concepts gave my brain ammunition, so to speak. Sometimes the logical reasons for binge eating that I learned in therapy were the tipping point that gave me the final push to give in to an urge to binge. I often fought the urges as much as I could but then reminded myself that I had a disease, that I binged to cope, that I would relapse often, or that I needed to become emotionally satisfied or happy to stop binge eating; and then I'd suddenly have the excuse I needed to stop fighting and go right to the refrigerator, with my brain rejoicing that it had gotten what it wanted.

I unquestionably agree with traditional therapy on one major issue: the first step in recovery is wanting to recover. No one—not a therapist, not a nutritionist, not any self-help book—can help until you are willing to stand up against what afflicts you. Others can educate you about the dangers of your behavior, they can help support you in your decision to quit; but they cannot make the decision for you. You have to make that decision for yourself. The problem with traditional therapy is, once a patient wants to quit, she is put through a long, complex, and unnecessarily difficult recovery process that does not usually lead to recovery, which is the subject of the next chapter.

22
: Why Didn't Therapy Work for Me?

W
ith my new understanding of my eating disorder, I am able to look back now and see clearly why therapy wasn't effective in helping me achieve recovery. Remember, I've defined
recovery
as the termination of all binge eating; and therapy didn't help me do that.

I've already given an account of my experience in therapy, explaining what I learned collectively from my therapists, nutritionists, psychiatrists, self-help books, and Internet resources. Some might say that I merely had a bad experience or that my therapists weren't the right match for me; however, the type of treatment I received was not the exception. I've found that the concepts and techniques I learned in therapy are in fact still in widespread use in bulimia treatment today. My treatment didn't fall much out of line with traditional approaches to treating bulimia, of which there are three.

The three main types of treatment currently used for binge eaters are: (1) psychodynamic therapy; (2) cognitive behavioral therapy; and (3) addiction treatment. I received a combination of these three approaches, as many patients do, during the course of my unsuccessful treatment. At the time I was in therapy—from the age of 18 to 22—I didn't know the names of these treatment approaches or the theories behind them; but looking back, I can see how my therapists drew from these three approaches and why these approaches failed me: because of the false assumptions they make about the nature of bulimia.

PSYCHODYNAMIC THERAPY

Psychodynamic therapy for bulimics is based on the psychodynamic theory of eating disorders. This theory holds that eating disorders are symptoms of underlying psychological problems that need to be uncovered and resolved before the patient can recover. The psychodynamic theory posits that eating disorders are "expressions of a struggling inner self that uses the disordered eating and weight control behaviors as a way of communicating or expressing underlying issues."
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The theory is that once the underlying issues are discovered, talked about, and resolved, the patient will no longer feel the need to binge eat.

The psychodynamic theory is the one I encountered at my first therapy appointment (after which I vowed never to go back), and it's also the theory I came to accept during therapy in college. My initial reluctance to accept psychodynamic philosophy was not uncommon. Many women who enter therapy see their eating disorders as habits they cannot break and are surprised when psychotherapy is the suggested treatment.
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It often takes the bulimic weeks to months of therapy to "realize that underlying conflicts and family issues are the true core of her illness."
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In the months that it took me to buy into this theory, I could have already solved my problem.

It seems that the psychodynamic view of eating disorders is the most prevalent philosophy today, not only among therapists and those with eating disorders, but throughout society. The problem is (as I mentioned in Chapter 6), it is all conjecture. There is no scientific proof that underlying psychological problems cause bulimia (or anorexia), and there is also no scientific proof that resolving those underlying problems leads to recovery.
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Yet the psychodynamic theory of eating disorders is often presented as fact in therapy, self-help books, and even academic and medical texts. Nevertheless, I believe it was extremely harmful for me to believe this theory.

The psychodynamic approach deems it necessary to understand two main components of the eating disorder: (1) the root cause or causes of the eating disorder; and (2) the current purpose the eating disorder serves in the patient's life—also called the "adaptive function" of the eating disorder.
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A psychodynamic therapist helps the patient uncover the root cause of her problem by exploring her past to see where the emotional damage may have occurred. Theoretically, root causes could be any of a multitude of life experiences or inner conflicts. Reported root causes often stem from childhood, such as the parental relationship, sexual or physical abuse, or a lack of affection; alternatively, the root cause could be a more recent trauma.

I never found a specific root cause for my bulimia; however, I hypothesized many life experiences as root causes. In reality, there was only one root cause of my eating disorder, and that was my decision to diet. Whatever factors may have put me at risk for problematic dieting would have meant nothing if I never would have started restricting my calorie intake.

While trying to uncover issues from the past, the psychodynamic therapist also helps the bulimic discover the adaptive function, or purpose, that the eating disorder plays in her life now. This requires constant detective work to decipher emotions, feelings, and the salient meaning of everyday interactions. Reported adaptive functions of bulimia are numerous; but most patients discover that the eating disorder helps them cope with problems, numb feelings of anxiety or depression, or avoid pain from the past or present. I reported all of the above adaptive functions and more during the course of my bulimia.

I never would have thought my eating disorder had served an adaptive function if my therapists had not suggested that to me. When I first began binge eating, I knew my binge eating only hurt me, even if part of me found it very rewarding. But once I bought into psychodynamic theory, I found all sorts of theoretical benefits of my eating disorder, most of which were just the secondary benefits of my behavior—the pleasurable physiological and emotional effects of ingesting large amounts of sugary and fattening foods. With the influence of psychodynamic therapy, I imagined there must have been some deep reasons I needed that pleasure.

Since, in psychodynamic theory, binge eating is viewed as useful for the patient, the therapist avoids trying to take the symptoms away. Instead, the goal of this type of therapy is for the patient to develop and learn new ways of meeting emotional needs and coping with problems so that the eating disorder no longer serves a purpose in her life. This includes helping the patient get in touch with feelings and teaching her to cope with emotions.

Since bulimia is not a way of coping with problems or meeting emotional needs, this simply makes no sense. Getting in touch with feelings and coping with emotions won't stop the survival instincts or end the habit of binge eating. It didn't matter how well I coped with emotions or how many feelings I "got in touch with," I still had those urges to binge and I still followed them. Additionally, while I was spending time working on feelings and underlying issues, my habit was only getting stronger in my brain. While my therapists were avoiding trying to take my adaptive function away, I was only further strengthening all those faulty neural connections by following my urges to binge.

Psychodynamic therapy is supposed to lead to "an individual's development of the personal feelings, opinions, values, beliefs, and desires that constitute who [he/she] is as a person. Another way to define this process is the development of one's identity."
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In the introduction to this book, I described a type of recovery I named the butterfly tale, wherein the woman undergoes a major transformation in order to stop her binge eating. Ideally, psychodynamic therapy should create these transformations. The binge eater enters psychodynamic therapy—the cocoon—as emotionally immature and ill-equipped for managing her own life; but she comes out of the recovery process fundamentally changed, with a new identity and a newfound ability to cope with feelings and problems.

This butterfly tale doesn't happen for everyone who goes through psychodynamic therapy, and it certainly didn't happen for me. It still angers me that my therapists led me to believe that those life goals—which could have taken me many years or even a lifetime to achieve—were necessary for recovery. I was 18 when I began therapy; life was confusing, and it would have been confusing even if I hadn't had an eating disorder. Psychodynamic therapy led me to believe I had to sort out all this confusion, develop a purpose for my life, reconcile everything in my past, and live with grace and peace—all at the age of 18 and all in order to stop binge eating. I still haven't done all of the things that psychodynamic theory requires for recovery, yet I am fully recovered.

Psychodynamic therapy made me think I was damaged goods, when in fact my brain and I were very healthy. It made me look back on my childhood and blame the development of my eating disorder on very trivial incidents, when the only cause of my eating disorder was my choice to diet. It made me blame my loving family for a problem that was in no way their fault, but my animal brain's. It made me look back at my young life and see all that was wrong with it, when my childhood was actually rather normal. It made me think I needed to sort out everything in my often confusing life, all in order to stop a behavior that was simply a natural function of my own brain. All of this caused me to lose focus on what I really needed to do to recover: stop binge eating.

I was not the only bulimic psychodynamic therapy failed. Psycho-dynamic therapy alone has not been shown to produce high recovery rates for bulimics.
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A common criticism of this approach is that "patients can spend years doing psychodynamic therapy gaining insight while still engaging in destructive symptomatic behaviors"
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—all the while feeding the habits in their brains.

COGNITIVE BEHAVIORAL THERAPY

Cognitive behavioral therapy (CBT) attempts to address destructive behaviors surrounding food and weight; and of the various psychotherapeutic approaches, CBT has been shown to be the "most consistently successful treatment of bulimia."
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CBT is often used in conjunction with psychodynamic therapy to focus on binge eating (plus the purging in bulimia) and harmful thoughts about food, weight, and body image. In my own therapy, as in most cases, the core of therapy was psychodynamic—searching for the deeper reason for the eating disorder—but in addition, I learned cognitive behavioral techniques to try to control the binge eating and purging.

CBT has many components, and the specific techniques used are too numerous and vary too widely among therapists to discuss all of them here; but I will summarize the main aspects of CBT as it is used to treat binge eating. The
cognitive
part of cognitive behavioral therapy addresses harmful thoughts—also called cognitions—that are suspected to contribute to binge eating; and the
behavioral
component of cognitive behavioral therapy attempts to directly address eating habits and reduce episodes of binge eating.

CBT is based on the assumption that binge eaters have "cognitive distortions"—incorrect thoughts or beliefs about food and weight. Examples of some of my cognitive distortions were thinking that eating a certain food would make me fat and thinking that eating one cookie would lead to a binge. Cognitive distortions are assumed to lead to negative feelings, which in turn are assumed to lead to the negative behavior of binge eating. In CBT, patients learn to identify and challenge their incorrect thoughts in "an educational and empathetic way,"
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as the therapist teaches the patient positive ways of thinking to replace the distorted thoughts.

For example, at one time in college, I believed I couldn't weigh more than 110 pounds, so that distorted thought often led to negative feelings as I gained weight. I felt bad about myself, and those negative feelings supposedly led to binge eating. So, in therapy, I learned the healthy weight range for my body type, which went well above 110. I bought bigger sizes as my weight kept going up and learned to let go of my desire to maintain that weight. The problem was, I had urges to binge even when I felt good about my weight. Learning to define a healthy weight and letting go of a desire to be super thin may have stopped me from dieting in the first place, but once my bulimia was in motion, correcting cognitive distortions was not all that helpful.

The cognitive component of CBT also addresses thought patterns that are not food-related. It is believed that many binge eaters harbor cognitive distortions about many aspects of their lives. For instance, I sometimes believed I was stupid just for receiving a less-than-perfect grade on a test; I sometimes believed that no one liked me; and I sometimes thought I was a failure if I didn't accomplish certain goals in school, sports, or work. In cognitive behavior theory, cognitive distortions like these, even though not explicitly related to food and weight, can potentially lead to binge eating—because any thought that leads to bad feelings could also lead to destructive behaviors.

Another example: I held the irrational belief that I had to please everyone; so when I got in an argument with a friend, I felt worthless and supposedly binged to "cope" with my negative feelings. Theoretically, if I had stopped thinking I needed to please everyone and become more assertive in relationships, I wouldn't have needed to binge to cope with relationship problems. So I spent much time in and out of therapy trying to correct cognitive distortions and replacing them with positive thoughts.