Billions of dollars are spent by millions of Americans each year in an unending quest for one thing: slimness. There is a national obsession with dieting, calorie counting, and beautiful thin models in books and magazines and on television and billboards. The message bombarding us from every direction seems to be: if you are thin you will be happy, you will have wonderful relationships, be admired, and have a fine career, and all your problems will be solved. Nearly everyone has been on a weight loss diet at one time or another, and millions of people go from one diet to the next, always hoping for the magic wand that will produce a beautiful, lean body without too much effort. Even though we see a great emphasis upon exercising and proper nutrition today, the most important thing seems to be getting slim rather than maintaining good health. A person's weight, measurements, and appearance have become too much a measure of a person's worth.

        Most people can go on a diet, go off a diet, overeat one day, and cut down the next day, managing to stay somewhere within their normal weight range. They become rather philosophical about never being really thin. With certain people, however, the desire for thinness eventually takes first place in their lives. These people suffer from an eating disorder, either anorexia nervosa or bulimia. They have the distorted belief that the thinner they are, the happier they will be. In their efforts to achieve happiness and thinness they become involved in the dangerous behaviors of an eating disorder. These behaviors become a way of coping with the demands of life. Kim Lampson, one of the most experienced therapists in the field, states that "the behaviors are like a life preserver, simultaneously a means of survival and a signal of distress."

1. An intense fear of becoming obese that does not diminish as weight loss progresses. Severe weight loss is the obvious symptom of anorexia nervosa. The person often suffers from dangerous physical and psychological symptoms, yet she is terrified of gaining weight and would seemingly rather die than get fat. Typically, the victim of anorexia nervosa rigidly controls her food intake to the point of self-starvation.

2. Distortion of body image the person claims to "feel fat," even when emaciated. On a recent television talk show an anorexic girl was being interviewed. She wore a bikini, and, standing about 5 feet 8 inches tall and weighing around 85 pounds, was almost skeletal in appearance. The show's host looked at her and said, "Surely you cannot think of yourself as fat." She picked at a tiny fold of skin on her abdomen and replied, "Oh, yes, I am. Look at this!" She was totally unable to see her emaciated body for what it was.

3. Weight loss of at least 25 percent of normal body weight for age and height. Anorexic weight loss is generally achieved by self-starvation, but the anorexic may also use self-induced vomiting, drastic curtailing of fat and carbohydrate intake, incessant exercise, laxatives and diuretics, diet pills, or a combination of any of these.

4. Refusal to maintain body weight over a minimal normal weight for age and height. No amount of coaxing by family and friends can get the anorexic to eat normally. Even during hospitalization medical personnel often find it difficult to get an anorexic person to gain weight. During hospitalization one anorexic would cover herself completely with her stuffed animals at night, hoping to perspire enough to lose weight.

5. No known physical illness would account for the weight loss. Amazingly, the anorexic maybe highly resistant to physical illness and exhibit a high energy level in an exercise program. For example, one anorexic girl regularly ran fifteen miles a day while consuming around 300 calories.

        Most people with this disorder steadfastly deny their illness and resist getting help. They like the feeling of losing weight and resent any interference from family, friends, or professionals. People who do not know of the problem will often compliment the person on her weight loss, thus reinforcing the anorexic behavior, since the motivation behind the refusal of food is the obsessive fear of weight gain and the accompanying pleasure of weight loss. The thinner she becomes, the more "special" she feels. Anorexics appear to be frightened of the demands of adulthood, preferring to remain in their childhood with an undeveloped body. They show little if any interest in dating and boyfriends.

        Typically, one who develops anorexia will be characterized as a "model child," one who never gave her family any problems. The girls tend to be "people pleasers," perfectionistics, overachievers, compulsive, and self-disciplined. As weight loss continues, a girl's thinking tends to become more irrational and distorted, caused in great measure by the starvation state and the malnourishment of the brain.

        Fluid and electrolyte imbalance causes dehydration and potassium deficiency and is the most serious symptom, resulting in muscle weakness, apathy, mental confusion, and irregular heartbeat. Death from kidney or heart failure may result.

        Families of the anorexic appear most often to be "enmeshed." They value "rightness" and not being different. They have a high degree of concern and involvement with each other. They want everyone to think and act in the same way, and, to avoid conflict, they do not discuss personal needs and feelings openly. The anorexic child is often involved in parental conflict in some way and may feel responsible for such conflict because she is not a perfect daughter. She will often feel guilty and unworthy and attempt to find acceptance through her achievements and being attractive.

        Families of children with eating disorders are not bad families; they are most often simply families doing the best they know how. They feel great pain over a daughter's problem. One mother wrote to me as follows:

        Where communication had been pleasant, it now becomes loud and tense on both sides, if it occurs at all. Then there are the tears. Gallons of tears. In front of her, in the privacy of your room, in response to a query from a friend about your daughter. You read all you can find about this illness that previously had been an unknown word to you. But what you read is of little comfort. In fact, it can easily have the opposite effect.

        You start to feel a real strain in your relationship with your husband as you invariably disagree on how to relate to your daughter or on what direction to go to help her get professional help. You turn to what seems to be one of the few sources of reassurance, friends who have already been through this hell and know just what you are feeling and just what to say. Through it all, you are scared to death! And you pray a lot.

        Rapid recovery is not to be expected, and, in severe cases, hospitalization is necessary to prevent death by starvation or one of the other severe symptoms. The victims cling tenaciously to their distorted beliefs, and I strongly suggest professional help for the sufferer and her family. Those professionals involved should be a medical doctor for a thorough physical evaluation, a nutritionist for help with healthy food intake and eating patterns, and a counselor or psychotherapist to help with emotional needs. These professionals should be chosen from those who thoroughly understand eating disorders and can offer continuing assistance. The victim is not helped by the admonition "Now you just go home and put on some weight, my dear."

        Some few anorexics are not starvers but bingers. This group appears to have several characteristics more like the eating disorder of bulimia than the anorexic who controls her weight in ways other than purging.

        A bulimic is usually similar in many ways to an anorexic in her behavior and attitudes, but she may differ in the following ways:

1. Food becomes an obsession and an addiction.

2. She wants to be attractive to men and to please them, and she is interested in having boyfriends.

3. She may have spent her life trying to please her father through her accomplishments and her beauty.

4. She is more socially skilled.

5. She will not lose a great deal of weight.

6. She may or may not lose her menstrual periods, but she may have irregularities.

7. Her body image is probably not distorted.

8. She recognizes that her eating behavior is abnormal.

9. Her eating is more impulsive, and thus less controlled

10. She may use drugs and alcohol more often.

11. She eats huge amounts of food and then purges the food through self-induced vomiting or taking large amounts of laxatives or diuretics.

12. She may feel guilty and depressed when she falls short of expectations.

        Many bulimics report that as their binge-purge behavior becomes a compulsion, they spend almost every waking hour thinking about food—how to get it, how to eat it without being detected, and how to get rid of it once it is consumed. Some bulimics binge and vomit many times a day, some once or twice a week. The practice becomes bulimic when it can no longer be controlled. Although generally bulimics have high moral principles, they sometimes lie, hide, and even steal to support their food habits. Expenditures of $100 a week are fairly common, with one bulimic telling of a habit amounting to $100 a day. One young woman reported that she spent every noon hour driving from one fast-food place to another, gorging as she drove, and then using up to seventy-five laxative tablets to purge. A person would die from this dosage if her tolerance had not been built up over time. Ironically, it has been estimated that only about 12 percent of the calories consumed are purged by the use of laxatives. It is also clear that no method of purging rids the body of all the calories taken in binges, since bulimics seldom achieve thinness with their purging methods. The binge-purge behaviors themselves are reinforcing, however, because they relieve the anxiety suffered by the victim.

        A bulimic has difficulty expressing her true feelings, which become so distorted that she does not recognize them for what they are but feels them as hunger. Her attention and energy are taken up with the binge-purge activities.

        As with anorexia nervosa, there is no quick fix for curing bulimia. The bulimic, being caught up in her "all or nothing at all" thinking, may declare, "I am going to recover quickly and completely. Fast is best." But eating disorders are among the most difficult problems to deal with for the individual, for the family, for school and church leaders, and for professional counselors.

        In order to recover, the person suffering from anorexia nervosa or bulimia needs the following:

1. Education about nutritional requirements of the body and the adverse physical effects of starving, hinging, vomiting, and the use of laxatives and diuretics.

2. Knowledge about her disorder. She needs to be able to discuss her fears and anxieties without fear of rejection or ridicule. If there are therapy groups nearby it may be beneficial for her to join one. This is true particularly of bulimics. Anorexics often do better in individual therapy.

3. To be able to recognize her distorted thinking. She may use all-or-nothing thinking: "If I can't do it perfectly, I'm a total failure." She may keep up a constant stream of negative self-talk: "I am stupid." "I always blow it." "I'm worthless." Perhaps she believes that she knows what other people are thinking about her: "They think I'm a loser." She may live by her feelings, acting according to her feelings without thinking things out. Or she may fill her life with "shoulds" and "oughts," expecting perfect compliance with her unrealistic ideals and then feeling guilty because she can't measure up.

4. Unconditional love with no pressure to change immediately. She must be convinced that she has worth; then she can listen to the truth about herself and her relationships with other people and with food. She needs help from people who understand her disorder. Also, she may feel so guilty and unworthy that she won't look to God for help. Care and acceptance from those around her will help her pray again.

5. To deal with her perfectionism. She wants to recover quickly and perfectly. But she must learn to accept two steps forward and one step back. Part of recovery is to realize she can't do things perfectly. She must give herself permission to fail and be imperfect. Kim Lampson puts it this way: "Anything worth doing is worth doing poorly, and with practice it gets better!"

        Patience is essential. She can practice saying, "It is okay to fail. It is an opportunity to learn rather than an opportunity to punish myself." A setback then becomes a learning experience, not a disaster.

6. To learn and use assertiveness and communication skills. She can practice the honest expression of her feelings. She should be encouraged to tell others her needs and feelings directly in a loving way. Most victims of eating disorders are afraid to do this because they believe they will say the wrong thing, cause conflict, and lose approval and love. One recovered bulimic said, "I could never express myself. Everything was all closed up inside of me. If I stood up for my rights, I thought others would be unhappy with me, and I couldn't stand anyone being displeased with what I said or did. Obsession with food helped me survive. It was a way to escape from the world. By focusing on eating and purging I didn't have to think about my poor relationships or anything else."

        The sufferer must understand her right to be treated with respect, to have and express personal feelings and opinions, to be listened to and taken seriously, to say no without feeling guilty, to ask for what she wants, to make mistakes, and to make choices based on rational thinking.

        She must realize that she is not responsible for the feelings of others. They have their own rights and the power to make choices just as she does. She can be direct and honest and behave appropriately. She can show a genuine concern for the rights of others and their feelings as well as her own. Her assertiveness will not drive people away but will enrich her relationships with others. She can express her love and care for others without fear. She can disagree with someone and be close at the same time. This knowledge is crucial. There is no cure, according to Lampson, until a person can honestly express feelings in ways that bring about closeness rather than distance.

7. A feeling of self-worth. A feeling of self-worth is enhanced by people around the sufferer who give her unconditional love without expecting perfection or superior achievement or anything more than allowing her to be herself. She has intrinsic worth as a human being, regardless of her accomplishments. What she is is more important than what she does or how she looks. Is it more important to be remembered for clothes, grade-point average, thin body, musical or sports ability, and a pretty face, or for listening ability, compassion, cheerfulness, kindness, and a love for others? She can practice identifying qualities that make her special. She might ask someone, "What do you really appreciate about me?" She can also realize that qualities not so desirable are also lovable. She does not have to be perfect for people to love her; often a person's weaknesses and mistakes make them easier to relate to and thus more lovable. As she shifts from a worldly to a godly perspective, she will look at the heart instead of the appearance. She can learn to encourage herself in all her righteous endeavors and to take pride in her character.

8. To give others permission to be imperfect. She should practice loving others unconditionally in spite of their weaknesses and mistakes. She needs to listen to their feelings and try to understand them. Especially, she can give her family permission to be imperfect. They have made mistakes in the past, and they will again, but they need acceptance too. She can forgive others for their trespasses against her.

9. The ability to make wise decisions. She can practice developing solutions for herself. She can be confronted with choices, alternatives, options, and the consequences of her decisions. Knowledge and practice of problem-solving skills will help her feel "in charger in her life.

10. To learn effective strategies for dealing with stress and anxiety. Ways to reduce stress and anxiety include practicing relaxation techniques, talking out frustrations with a close friend or family member, participating in hobbies and in sports, helping others, refusing to criticize others or herself, and trying to be a good friend.

11. To develop normal eating patterns. The person needs to establish eating habits that are flexible, meet nutritional needs, and maintain a healthy body weight. She should do away with her list of "forbidden foods." She should force herself to eat a little of everything without guilt in the presence of others.

12. To choose her own goals separate from expectations of family and friends. It's okay if these are different, and it's also okay if they are the same.

13. Accept her body and stop criticizing her own body and the bodies of others.

14. To think of her struggles as change taking place. She should learn from the pain and use it to motivate herself rather than trying to avoid it.

        Fortunately, most anorexics and bulimics do recover, in time. While there are no "pat answers" in treatment and recovery, skilled counselors are available and research is going forward. There is hope.

Suggested Readings and Resources

Anorexia Nervosa and Related Eating Disorders, Inc. P.O. Box 5102, Eugene, Oregon 97405, phone (503) 344-1144.

Bruch, Hilde. The Golden Cage: The Enigma of Anorexia Nervosa. Harvard: Harvard University Press, 1978.

Chemin, Kim. The Obsession: Reflections on the Tyranny of Slenderness. New York: Harper and Row, 1982.

Lampson, K. Kim, M.Ed. Lecture given at Brigham Young University, November 1983.

For additional information write to: K. Kim Lampson, M.Ed., Providence Professional Building, Suite 301, 550 16th Avenue, Seattle, Washington 98122.

National Anorexic Aid Society, Inc. P.O. Box 29461, Columbus, Ohio 43229.

Neuman, Patricia A., Ed.S., and Patricia A. Halvorsen, Ph.D. Anorexia Nervosa and Bulimia: A Handbook for Counselors and Therapists. New York: Van Nostrand Reinhold Company, 1983.

Vincent, L.M. Competing with the Sylph: The Pursuit of the Ideal Body Form. New York: Berkeley Books, 1979.

About the Author

Dr. Della Mae Rasmussen, a counselor at BYU Counseling and Personal Services for almost two decades, received her bachelor's degree from the University of Utah and her doctorate in counseling psychology from BYU. She has published in professional journals as well as in children's literature.

In the Church she has served on the Primary General Board, on the Church Teacher Development Committee, on a Church writing committee for parent education, and in many ward and stake callings.

She and her husband, Paul, are the parents of six children.