I asked, “How was he killed?”
Prudence bit her bottom lip. “He was out with friends after the state basketball tournament. I knew he would be drinking but I wasn’t worried. He explained to me that the group had a designated driver. But that night their designated driver was drunk. He hit a bridge outside of town. He wasn’t hurt, but Greg died instantly.”
She told me about the memorial service at the high school. More than 2,000 people came. The high school choir sang, and the captain of his basketball team gave the eulogy. She told me of the church service. “Everyone in the family put something in the casket for him to take along. Mom and Dad put in his fishing pole, basketball and his yearbooks. I put in my stuffed Russian bear, Misha.”
Prudence cried as she told me about their last serious talk. Greg had warned her about junior high and all the temptations she would face. He’d advised her to avoid sex and alcohol at least till high school. “I’ve followed his advice about sex,” she said. “I really don’t want to get involved anyway.”
She said, “After he died, we stopped talking about him. Mom shut his bedroom door, and we acted like he was away at camp or sleeping in late. I felt our family would fall apart if I brought it up.”
“The only person who could have helped us through this was Greg,” she said. “He knew the right things to say.”
I handed Prudence a Kleenex, and five minutes later she continued. “I was mad at God. Why couldn’t He have taken an old person with Alzheimer’s or a child murderer on death row? Why did he have to take the best person in the world?”
She cried more, but afterward she said, “It feels good to talk about it.”
“You have lots of catching up to do,” I said.
I felt pleased with that session. Prudence, like many bulimic young women, had learned to deal with feelings by bingeing and purging. I was hopeful that as she faced her biggest pain, she’d be able to face others and talk rather than binge when she was upset.
Over the next few months we talked about Greg. Prudence brought in other pictures of him and letters he had written her from basketball camps. She told me stories about their adventures together. She talked about Greg with her mother and Greg’s old girlfriend. She even tried to talk to her dad, but he said firmly, “Pru, I can’t do it.”
One day I suggested she find something in the natural world that reminded her of her brother, something that could help her feel connected to him whenever she saw it. I’d invented this strategy myself as a way to cope with loss. When I look at the Pleiades, for example, I think of a relative I lost who had many sisters. Next session Prudence came in with her connection. Her brother reminded her of cattails because he was tall, thin, brown-haired and loved the water. When she missed him, she walked to a nearby ditch with cattails and thought of him.
In addition to talking about her brother, we attacked the bulimia. Prudence found that she actually binged less on the days she talked about her brother. She learned to deal with other pain by facing it as well—by writing in her journal or talking to someone she trusted.
I encouraged her to take better care of herself. I told her the Overeaters Anonymous slogan: HALT—Don’t get too hungry, angry, lonely or tired. She learned to identify her feelings and not to label everything as hunger. She learned to rest when she was tired, tell people when she was angry, find something to do when she was bored.
Prudence liked the OA group very much. It was a relief to hear others talk so honestly about their eating disorders. She was heartened that some of the women were in recovery and doing well. She liked the support and conversations about feelings. She had a consciousness-raising notebook in which she kept track of lookist, sexist remarks. She brought in ads featuring thin women. She hated how women were portrayed as vacant-eyed sexual objects with no personality. Prudence prided herself on her independence and she grew even more outspoken in her resistance to being “bimboized.”
Then she decided to fight the incredible cravings to binge. This is a necessary and critical step in recovery, but it’s terribly difficult. From my clinical experience, I’ve learned that fighting the urge to binge is at least as hard as fighting the urge for drugs. It requires incredible self-discipline and pain tolerance. Prudence learned to call on her brother for help. She formed a picture of his face in her mind and talked to him, asking him for the strength to fight binges. When she succeeded, she thanked him.
Of course, Prudence wasn’t always successful. But gradually she was able to reduce her binges to once a day. After four months in therapy she had a binge-free day. Some of her energy was returning and her skin and hair looked healthier. She reported that there were days she didn’t even think about weight.
Prudence was a good talker, more sensitive to her own and others’ feelings than the average teenager. Slowly she battled her addiction. She made a commitment to live an examined life. Recently she said to me, “Greg would like who I am now.”
STARVATION IN THE LAND OF PLENTY
Anorexia is a problem of Western civilization, a problem for the prosperous. It is, to quote Peter Rowen, a question of “being thirsty in the rain.” Anorexia is both the result of and a protest against the cultural rule that young women must be beautiful. In the beginning, a young woman strives to be thin and beautiful, but after a time, anorexia takes on a life of its own. By her behavior an anorexic girl tells the world: “Look, see how thin I am, even thinner than you wanted me to be. You can’t make me eat more. I am in control of my fate, even if my fate is starving.” Once entrenched, anorexia is among the most difficult disorders to treat. Of all the psychiatric illnesses, it has the highest fatality rate.
Its victims are often the brightest and best young women. In my experience, it is the good girls, the dutiful daughters and high achievers who are at the greatest risk for anorexia. Anorexia often begins in early adolescence with ordinary teenage dieting. But instead of stopping the diet, perfectionist young women continue. They become progressively obsessed with weight and increasingly rigid in their thinking about food. They see themselves in a competition to be the thinnest girl around, the fairest of the fair.
The word “anorexia” implies an absence of hunger, but in fact anorexic girls are constantly hungry. They are as obsessed with food as any starving people. They have many of the physical symptoms of starvation—their bellies are distended, their hair dull and brittle, their periods stop and they are weak and vulnerable to infections. They also have the psychological characteristics of the starving. They are depressed, irritable, pessimistic, apathetic and preoccupied with food. They dream of feasts.
Anorexic girls are great at self-denial. They are obsessed with weight, which becomes their one important and all-defining attribute. They feel confident if they are losing weight and worthless and guilty if they are not.
By the time the anorexia is full-blown, family members are terrified. They try everything to make their daughters eat—pleading, threatening, reasoning and tricking. But they fail because the one thing in life that anorexic girls can control is their eating. No one can make them gain weight. Their thinness has become a source of pride, a badge of honor.
Anorexic young women tend to be popular with the opposite sex. They epitomize our cultural definitions of feminine: thin, passive, weak and eager to please. Oftentimes young women report that they are complimented on their appearance right up until they are admitted to hospitals for emergency feeding.
I think anorexia is a metaphor. It is a young woman’s statement that she will become what the culture asks of its women, which is that they be thin and nonthreatening. Anorexia signifies that a young woman is so delicate that, like the women of China with their tiny broken feet, she needs a man to shelter and protect her from a world she cannot handle. Anorexic women signal with their bodies “I will take up only a small amount of space. I won’t get in the way.” They signal “I won’t be intimidating or threatening.” (Who is afraid of a seventy-pound adult?)
SAMANTHA (16)
Against her will Samantha was brought to my office by her German-Lutheran mother. Wilma kept her coat on and her arms folded across her ample chest as she explained that her husband wanted to come but was in the fields. The corn needed to be brought in before the predicted snow fell this weekend. Wilma reported that the family doctor had said Samantha was anorexic. She hadn’t had a period in several months and her cholesterol level was 135, so low it could trigger a heart attack.
Wilma said that Samantha used to be a cheerful and peppy girl. Now she rarely smiled, and she was irritable and lethargic. Once she’d been a strong worker on the farm, now she could do only the lightest of chores. When she was home, she hardly spoke to the family and spent all her time exercising or studying in her room. Samantha was a straight A student, a cheerleader, and she was popular with her classmates, but Wilma said, “She doesn’t enjoy those things like she used to. She does everything like it’s one more job to complete.”
As her mother talked about her health problems and behavior changes, Samantha listened without emotion. She was 5 feet 6 inches tall and weighed ninety-nine pounds. Her head clearly showed the outline of her skull, and her eyes were watery and sunken. Her light brown hair, though attractively arranged, was dull and brittle. She dressed in a blouse and heavy sweater to disguise her thinness. She had the furry arms that often come with anorexia. It’s called lanugo—the soft, woolly body hair that grows to compensate for the loss of fat cells so the body can hold in heat.
I asked Samantha what she thought of her mother’s description of her. She said, “She’s exaggerating. I eat plenty. Just last night I had pizza and ice cream.”
Wilma looked doubtful and said, “Only a spoonful of ice cream and less than one piece of pizza. You took off all the cheese first.”
“I don’t like cheese,” Samantha said. “You know that.”
Wilma said, “She plays tricks on us with food. She pretends to eat but really just rearranges things on her plate. She says she ate at school, but we’ll find out from her friends that she didn’t.”
“Has your personality changed in the last year?” I asked.
“I am different now, I admit it. I don’t have as much fun, and I get stressed out. I have trouble sleeping.”
“When did you begin to lose weight?”
Samantha said, “I went on a diet.” She pointed at her mom. “You encouraged me.”
Wilma shook her head sorrowfully. “Yes, and I tried to lose weight with her. Only I stopped after a week of misery and Samantha never stopped.”
We spent the rest of the first session talking about treatment. I told Wilma to throw the scales away. Once a month Samantha could be weighed at her doctor’s office. Samantha was to keep track of her eating and exercising so that we could talk about patterns. I stressed that Samantha couldn’t get well unless she decided that anorexia was her enemy and made a conscious decision to fight back. Otherwise, she’d perceive me and her family as her enemies, trying to make her do something she didn’t want to do. She’d fight us and she could win.
Wilma agreed with me. “It is so painful to watch Samantha eat a dinner of lettuce and a few grapes when I know she’s starving. But we’ve learned that we can’t make her eat. We tried and it was awful. Samantha lost weight even quicker.”
Samantha said she was scared to lose the scales. “I can’t get fat. If I can’t weigh myself I’ll be too nervous to sleep.”
I gave her a list of books to read and scheduled an appointment for over the lunch hour. I wanted to see Samantha alone with a sack lunch.
Samantha arrived wearing a blue sweatshirt with white kittens on the front and blue jeans that looked ironed. I pulled out my cheese sandwich and apple and suggested we eat as we talked. Samantha showed me her lunch—two crackers, celery and carrot sticks and a small bunch of grapes. She explained that she had had a big breakfast and wasn’t hungry.
I asked what triggered her anorexia. “I broke up with Brad,” Samantha said. “We dated all through junior high. I thought I could trust him and that we’d be together forever.”
I put down my sandwich. “Why do you think he dated someone else?”
“He teased me about my thunder thighs. He wanted someone thinner.”
Samantha nibbled on a carrot stick. “I was much better at dieting than Mom or my friends. I lost five pounds the first week and then three the second. Twice I fainted at school.”
“How did others react to your diet?”
Samantha smiled in memory of the time. “I got lots of compliments. My friends were jealous, but I made new friends. Guys who wouldn’t have considered me before asked me out.”
Samantha was at risk for anorexia because of her perfectionism and enormous amount of self-discipline. She could will herself into starving, but soon anorexia was running the show. Samantha became obsessed with food and weight. The most important time was weigh-in time, first thing in the morning. If she lost weight, she felt great, but if she gained, she was distraught. Nothing else, not grades or social success, had much effect on her well-being.
She learned to love the “high” she experienced from fasting. She began running three miles a day, then five and then eight. Even though this running exhausted her and depleted her limited energy reserves, she wouldn’t cut back. She devised tests for herself to prove her control over food. For example, she invited her friends over for a party and, weak with hunger, watched as they devoured lasagna and ice-cream sundaes. She baked brownies for her family and would not even sample the ones fresh from the oven. She watched other people scarf down food with their animal appetites and felt superior. Samantha did what many girls with anorexia do: She reduced her complicated life to one simple issue—weight.
Samantha reminded me of a brainwashing victim. She had her own rigid ways of thinking about herself and the universe and was impervious to the influence of others. She thought people who wanted her to eat were jealous of her thinness. Like most anorexics, she didn’t want to fight her anorexia. She had brainwashed herself into thinking that anorexia was her friend. She was in my office because her parents and doctors wanted her to fight. We were her enemy, not the anorexia. She lied, distorted and hid her eating to protect herself from those who wanted to help her.