During a session with a client who has long suffered with an eating disorder I was discussing what it would be like if she could feel positive about herself. I was shocked with the response she gave me. Instead of reporting a desire to feel better about herself, this client laughed at me and retorted, “Self-esteem is laughable to me. I hope to be rid of the disturbing behaviors of the eating disorder, but I know it’s asking too much to like myself.” This encounter has been as intriguing as it has been disturbing. In this interaction I believe I came to understand, in small measure, what many women who suffer from eating disorders must feel about themselves. And, I better understand that when therapists, dietitians, and other helpers meet these women, survival is often the goal rather than happiness or feelings of self-worth. This interaction has come to symbolize for me the lie of the eating disorder in that it so efficiently creates such hopelessness, self-hate, and shame in women.
RELATIONSHIP BETWEEN SELF-ESTEEM AND EATING DISORDERS
Anyone working with women with disordered eating recognizes that self-esteem is intricately connected, however just how the two are related is not entirely well-defined. Inevitably, any discussion of eating disorders and self-esteem leads to the question of the chicken and the egg-which came first: poor self-esteem which made an individual more susceptible to disordered eating or an eating disorder which wreaked havoc on an individual’s self-esteem? While there is no simple answer to this question, there is substantial research that has investigated the relationship between self-esteem and eating disorders, and provides interesting insights.
In a review of the literature, Ghaderi (2001) concluded that low self-esteem, along with other factors, not only puts women at greater risk for the development of disordered eating but also serves to maintain an eating disorder. Numerous reports support the contention that low self-esteem is often present before the development of disordered eating, and that low self-esteem is a significant risk factor for both bulimia and anorexia even in young, school-age girls (Ghaderi, 2001).
According to Robson (1989, as in Ghaderi, 2001), self-esteem is “a sense of contentment and self-acceptance that results from a person’s appraisal of their own worth, attractiveness, competence and ability to satisfy their aspirations.” Given this definition, it is clear to see that self-esteem is multifaceted. Similarly, the development and maintenance of eating disorders is complex, including such factors as family environment, cultural environment, history of dieting, genetic predisposition, history of abuse, age and developmental concerns, length of time in eating disorder, immediate factors such as support system, emotional factors, and spiritual factors, of which self-esteem is only one factor of many (Berrett, 2002). However, self-esteem appears to be a primary risk factor that may contribute to the development of other risk factors for eating disorders. For example, three separate research studies found that development of bulimia is predicted by perfectionistic tendencies and body dissatisfaction only among low self-esteem women, whereas women with higher self-esteem did not have these risk factors and accordingly did not develop bulimia (Vohs, Voelz, Pettit, Bardone, Katz, Abramson, Heatherton, & Joiner, 2001; Vohs, Bardone, Joiner, Abramson, & Heatherton, 1999; Joiner, Heatherton, Rudd, & Schmidt, 1997).
Identity formation is an area of focus when discussing eating disorders and self-esteem. Attention has been given to the parent-child relationship and how parents’ perfectionistic expectations work to limit the child’s development of autonomy, consequently creating an environment where the child is reliant on parental expectations rather than on individual needs and desires (Stein, 1996). Bruch (1982) posited that as children attempt to meet unrealistic parental demands, they often develop a sense of being “nothing.” As these children grow into adolescence they may turn to an eating disorder as a way of defining self and establishing a sense of self-control (Stein, 1996).
While self-esteem is a significant risk factor for eating disorders, one research team found body dissatisfaction to be the single strongest predictor of eating disorder symptoms (Button, Sonug Barke, Davies, & Thompson, 1996). Therefore, in targeting body dissatisfaction, therapists do well to attend to improving self-esteem, a major determinant of one’s body image. For instance, one study found that assisting adolescents in recognizing what is positive about their bodies and physical appearances while at the same time increasing their sense of personal competence leads to less internalization of sociocultural norms idealizing thinness (Phelps, Dempsey, Sapia, & Nelson, 1999). This resulted in significantly less body dissatisfaction, which in turn meant less eating disorder behavior among the adolescents (Phelps et al., 1999). Improving self-esteem is a challenging task for women with disordered eating. Often, their negative thoughts and beliefs are deeply entrenched and consequently difficult to give up. Once negative thoughts are established they serve to maintain low self-esteem and an eating disorder.
A critical intervention for women with anorexia, bulimia, or compulsive eating is to begin challenging the deeply held negative beliefs. For example, most women with disordered eating equate their worth with their weight, dress size, or shape. The sooner a woman can let go of these negative self-evaluations and replace them with more meaningful alternatives, the sooner she can be on the road to recovery. This may include exploring questions such as, “What do you want for your life, your future, your loved ones?” Answering these questions may be difficult and could result in significant shifts in an individual’s vocational roles, leisure activities, and relationships (Ghaderi, 2001). Therapists can assist women in identifying and building upon positive sources of self-definition. The eating disorder functions to limit an individual’s resources, yet through therapy women can be challenged to try on new roles and pursue activities where they can gain confidence.
Too often, individuals with eating disorders make themselves the exception in life. They believe that others deserve happiness, love, and joy, but that they themselves deserve sorrow, disappointment, and punishment. One of the first challenges therapists can give to the eating disorder is to begin disputing these false beliefs. Therapists can begin pointing out how the client has made herself the exception, and can then begin exploring where these false beliefs come from, whether they be from past abuse, negative family interactions, childhood teasing, or other difficult experiences. Teaching the client that she is worthy of love and acceptance, and that there are no conditions to her worth can prove essential to improving self-esteem.
It is important to keep in mind that, at least initially, these types of interventions, along with the therapist, will likely be rejected by women struggling with anorexia, bulimia, or compulsive eating. Challenges to the negative mind-set do not fit with what many of these women believe is true of themselves. However, with persistence, patience, and continuing acceptance, therapists can help clients to recognize their value and may help to create hope – one of the most critical components of overcoming anorexia, bulimia, or compulsive eating.
Addressing perfectionistic tendencies is also essential to addressing self-esteem among women with disordered eating. Typically, these women make their worth conditional upon their accomplishments, whether it be through grades, vocational achievements, or other activities. However, inevitably as these women achieve goals their standards become more unattainable, creating a cycle in which they can never reach the point of acceptance or value. One of the tasks of therapy is to separate the individual’s worth from perfectionistic strivings.
For most women with anorexia, bulimia, or compulsive eating, the eating disorder becomes their identity. Considering perfectionistic tendencies, these women often desire to become perfect – striving to exercise longer, eat less, and do more than is healthy. Many women claim that the eating disorder is what they are “good at” and it becomes all-consuming. A woman’s identity based in the disordered eating prevents her from trying new activities, especially because there is the risk that she may not do them “perfectly.” From the perspective of these women, it is safer to do the disorder perfectly than to risk failure in other arenas.
Therapists do well to make this pattern explicit in therapy. By addressing the underlying fear of failure and unmasking the disorder for what it is, these women can begin facing their fears by taking small steps, while receiving support from therapists and other helpers. Such small steps may initially be associated with disorder behavior. For instance, these individuals may be challenged to begin replacing disordered eating behaviors with healthier alternatives, such as calling a friend or taking a walk when the urge to self-harm surfaces. As these women find success in choosing healthier alternatives to the disorder, their self-esteem is strengthened and they can be challenged to take even bigger risks, such as interacting with friends, strengthening relationships, or trying new activities.
Along with perfectionism, most women with disordered eating compare themselves with others, especially other women. When these women compare themselves to others, they never seem to measure up-in their minds someone else is always more capable, thinner, or more attractive. These comparisons serve to further destroy self-esteem, thus perpetuating the deleterious cycle of compensating for negative feelings through a disorder. In addition to harming self-esteem, comparisons strain relationships and contribute to further isolation from others. Therefore, therapy must focus, in part, on the comparisons these women make and how these comparisons serve to damage self and relationships. Therapists can encourage women to choose a new way of being in relation to self and others – a way that is based on kindness and respect rather than on hurtful comparisons. As these women recognize that there are no gradations to self-worth, hopefully they can begin letting go of needless comparisons.
Therapists must be especially aware of comparisons when leading an eating disorder therapy group. Unfortunately, group therapy can be a breeding ground for comparisons between group members. Aside from the effects to one’s self-esteem, group members may direct hostility towards those members whom they feel they don’t measure up to. Group leaders do well to point out tendencies to compare in the group, and members may desire to establish a norm of not comparing within the group. Identifying and labeling comparisons in the group can assist these women in recognizing hurtful behavior, and then, the women as a group have the freedom to choose new paths.
Control has long been recognized as a core issue of individuals with eating disorders. As hypothesized, individuals seek a sense of control when their lives seem chaotic or controlled by others.
For many women seeking a sense of control in their lives, this is gained in the form of control over the body. While perhaps initially women do feel more control in their lives, this is fleeting and inevitably leads to feeling out of control. Often, women with eating disorders use control as a substitute for self-esteem, holding the belief that “If I control myself and my circumstances then I’ll be acceptable.” Of course, this security is false and fails to offer genuine feelings of self-worth and value. Therapists must teach their clients that the control offered by an eating disorder is false and does not serve as a substitute for self-esteem.
As women with eating disorders seek control, they necessarily employ avoidance as a way of hiding from their pain. Avoidance of truth undermines their ability to live congruently, resulting in a cycle that serves to maintain low self-esteem and an eating disorder. By avoiding what they know is best for them, these women perpetuate feelings of inadequacy and self-loathing. Eating disorders thrive on avoidance, therefore therapists must make honesty a core issue of therapy. A therapeutic relationship that is grounded in honesty allows the client to begin being honest about behaviors, fears, and past experiences. By being completely honest in session, clients begin to break the cycle that maintains low self-esteem. Further, by honestly identifying fears, clients can begin to understand and conquer them, and can begin having success in the very areas that were once most frightening. These types of triumphs instill hope, strengthen self-esteem, and encourage individuals to choose healthier alternatives to an eating disorder.
In addition to specific interventions addressing self-esteem, prevention programs for eating disorders do well to encourage critical evaluation of current sociocultural norms, assist in clarification of personal values, and raise resilience through group discussions, problem-solving activities, and cooperative learning (Phelps et al., 1999). One such participant-oriented program has proven helpful in strengthening self-esteem and improving body image among participants (Ghaderi, 2001).
While eating disorders and low self-esteem are difficult to separate, research, along with clinical knowledge, have established the need to address self-esteem concerns in treatment. Further, interventions targeting self-esteem, particularly how it affects body image, have been shown to be beneficial and should be part of comprehensive treatment of women with eating disorders. As a therapist, the prospect of assisting clients in improving self-esteem can be daunting. However, the recognition that each intervention that challenges false beliefs and negative thoughts, each expression of caring and concern, each exploration of alternatives to perfectionism and comparisons, each authentic interaction grounded in honesty can assist women with eating disorders in finding the courage to believe something new for themselves, and can take them, like the client described above, from desiring to simply survive to a place of hope and healing.
Berrett, M. E. (2002). Factors contributing to development and maintenance of an eating disorder: A clinician’s view. Handout from Treating Teens: from Self-esteem to Eating Disorders. Center for Change, Orem, UT.
Bruch, H. (1982). Anorexia Nervosa: Therapy and Theory. American Journal of Psychiatry, 139, 1531-1538.
Button, E. J., Sonug Barke, E. J., Davies, J., & Thompson, M. (1996). A Prospective Study of Self-esteem in the Prediction of Eating Problems in Adolescent Schoolgirls: Questionnaire Findings. British Journal of Clinical Psychology, 35, 193-203.
Ghaderi, A. (2001). Review of Risk Factors for Eating Disorders: Implications for Primary Prevention and Cognitive Behavioural Therapy. Scandinavian Journal of Behaviour Therapy, 30 (2), 57-74.
Gross, J. & Rosen, J. C. (1988). Bulimia in Adolescents: Prevalence and Psychosocial Correlates. International Journal of Eating Disorders, 7 (1), 51-61.
Joiner, T. E., Jr., Heatherton, T. F., Rudd, M. D., & Schmidt, N. (1997). Perfectionism, Perceived Weight Status, and Bulimic Symptoms: Two Studies Testing a Diathesis-stress Model. Journal of Abnormal Psychology, 106, 145-153.
Phelps, L., Dempsey, M., Sapia, J., & Nelson, L. (1999). The Efficacy of a School-based Eating Disorder Prevention Program: Building Physical Self-esteem and Personal Competencies. In N. Piran, M. P. Levine, & C. Steiner-Adair (Eds.), Preventing Eating Disorders: A Handbook of Interventions and Special Challenges. MI: Brunner/Mazel.
Stein, K. F. (1996). The Self-schema Model: a Theoretical Approach to the Self-concept in Eating Disorders. Archives of Psychiatric Nursing, 10 (2), 96-109.
Vohs, K. D., Voelz, Z. R., Pettit, J. W., Bardone, A. M