In this episode, Ilene Fishman, LCSW, uses her over 30 years of experience as a clinician in the field to discuss what people need to do to get well from eating disorders. She specifically talks about getting well and wellness, and tells us how this is different from “recovery”.
Full episode –
Kathy: Hello and welcome to ED Matters. This is Kathy Cortese, your host and I am welcoming today Ilene Fishman. Hi, Ilene. How are you doing?
Ilene: Hi, Kathy.
Kathy: Ilene Fishman is a licensed clinical social worker and has specialized in the treatment of eating disorders for over 30 years and is in private practice in Northern New Jersey and New York City. After graduating from the NYU School of Social Work, Ilene trained and was on staff at the Center for the Study of Anorexia and Bulimia and is currently supervisor there. Ilene served on the National Board of the American Anorexia Bulimia Association when she helped found NEDA, the National Eating Disorder Association. She has remained very active over the years at NEDA as a clinical adviser for the NEDA Navigator program, the Law Support Network, and National ED helpline and is currently serving on their board of directors. Ilene taught that first masters level eating disorder elective class in New York City at the Wurzweiler, excuse me if I said that wrong, School of Social Work at Yeshiva University where she is an adjunct professor. She is currently working on her first book for publication with a working title of “Silencing: The Internal Tyrant. You can get healthy” which is such a great lead in for our topic today well chosen by Ilene and what we’ve decided to talk about is what do people need to get well from eating disorders? I noticed that you chose the words to get well versus the word recover and I think our listeners will be very curious about this choice. Can you please comment on this?
Ilene: Absolutely. I’m so happy to be doing this with you so thanks so much for having me, Kathy.
Kathy: Thank you.
Ilene: The reason that I talk about getting well and not just recovery is because moving beyond an eating disorder people focus a lot on the concept of recovery, the word recovery and in fact one needs to recover from all the symptoms and unhealthy behaviors of an eating disorder. Getting well goes beyond just recovery in terms of symptoms. Many people can get – can seemingly recover from their eating disorders yet still have a lot of aspects of their personality that in fact are I think sort of pretty eating disorder and we will talk more about that as we go.
Kathy: So what would you say some of the key components are for getting well so that one can go beyond the eating disorder?
Ilene: Relationship with self I think is really key. There’s a problem in relationship with self for people who develop eating disorders. How someone with an eating disorder treats him or herself about self-care, about self soothing, relationship with self is usually pretty painful and a lot of the traits that go along with having an eating disorder perfectionism driven, very successful, very detail oriented, all of those things are really, really positive traits but for somebody with an eating disorder they go really out of balance and they become way too extreme and problematic and even self-destructive. So someone’s eating can get better or purging can get better or over exercising get better but in fact, those aspects of their personality can still be sort of alive and well. So fully getting well I think includes that level of treatment as well as dealing with the symptoms. The more overt symptoms.
Kathy: And I think what you point out is probably something that rings really loudly for anybody who’s gone through the steps of recovery and by that I mean many people have said, well, now that I’m out of the hospital everybody thinks I’m well, everybody thinks I’m better, everybody thinks I’m recovered and what you’re saying is behind the scenes, what’s covert, what nobody gets to see, what nobody gets to hear. Maybe you can point out some of those internal experiences that people who are in recovery and moving to get well actually are encountering on the inside.
Ilene: Part of the relationship with self that is so problematic is tied in with low self-esteem. So people who have eating disorders have usually very low self-esteem, painful relationships with themselves, people don’t feel good about themselves. They don’t like themselves. They don’t feel confident. They’re very, very self-critical and sometimes those painful aspects of one’s personality and one’s relationship with self can prevail so that they still drive themselves too hard, they still, following an event or going over in their minds but what did I say? But didn’t I say? But what should I have done? Did I do this well enough? Did I do that well enough? Always trying to look for what could have been better, what they should have done better. So there’s really still no sense of peace. There’s that nagging drive.
Kathy: And now let’s have that connect to the eating disorder experience and maybe the words that accompany an eating disorder. Maybe you can, –
Ilene: Well, the eating disorder is really an attempt to feel better about one’s self. When people ask me what’s underlying eating disorder? I always say low self-esteem and eating disorder is an attempt to feel better about one’s self and in our society certainly we are all taught that being thinner we feel better about ourselves. Being more fit, we feel better ourselves. Being able to fit into this size, we’re going to feel better about ourselves and if we fit into that size. So we’re fed that everywhere in society and that those concepts and definitions of self-esteem are supported that way but in fact, it doesn’t work because and people who have eating disorders will tell you. People with anorexia, for example, will say, I got thinner and thinner and thinner. I kept thinking that if I got to this weight, I’d feel good about myself and it doesn’t work. So eating disorders are an attempt to feel better about one’s self but in fact, it goes awry because it really becomes a very self-destructive activity that never or not just activity but the relationship with self and group of behaviors and activities that it never gets the person to where they’re really trying to get to.
Kathy: So this, let’s just say pursuit, in terms of the self-protective defense actually morphs into a destructive mechanism.
Ilene: That’s true.
Kathy: And many of the people out there “see” what those behaviors are but again you’re talking about this internal destruction that’s going on as well.
Kathy: And what does happen to the self under those circumstances? Because many of the people that you’ve seen, that I’ve worked with they’re younger, you know, doesn’t mean that we don’t have the same thing happening at age 40, age 50, age 60.
Kathy: But there isn’t a whole lot of self to start with if you’re 12 if you’re 14. That’s sort of our developmental task at that time to develop the self, to develop the identity so then we throw in eating disorder.
Ilene: Well, when all is going well, life is hard, development is hard, adolescence is certainly hard but if all goes well in an ideal world, people are starting to have some sense of who they are, of how they look, a certain confidence, people are, you know, kids are more resilient so a question is why would some kids fall prey to an eating disorder and others don’t? Well, there’s something about those kids that are more resilient and I would say that maybe half have a better sense of self. Again, there are many, many factors and the whole question of nature versus nurture and biological traits and inheritability, there’s a lot of questions about how eating disorders come to be but I think that kids who do better actually do have a sense of themselves where they’re not feeling bad about themselves. If you talk to people who have eating disorders, who develop eating disorders, they will often tell you that from an early age they remember not feeling about themselves. Maybe even long before the eating disorder came to be.
Ilene: I always say the roots of eating disorders really go way back the seeds are sown much earlier than the eating disorder emerges.
Kathy: So many people in terms of the experience of healing discuss the challenge of what we say is the internal critic and we’ve heard that term over and over again. Based on your experience and expertise with eating disorders, I understand that you’ve coined a term, the internal tyrant which is really rather a descriptive term. You believe, if you will, that the internal tyrant is the bread and butter of an eating disorder and the undoing of wellness.
Kathy: Can you help us understand your concept as you present it off the internal tyrant.
Ilene: So the internal tyrant is the part of the person that is always trying to feel good about we’ll say herself. It’s easier to say herself than himself or herself so we will say herself and along the line developmentally she learned to feel bad about herself and she didn’t only learn to feel bad about herself but she felt ashamed and embarrassed that she didn’t realize that she should be feeling bad about herself. For example, she goes to a party and wears a pretty dress and feels very good about herself. Finds out later that her slip was showing so she not only realizes that, “Oh no, I didn’t look as good as I thought I looked” but “My slip was showing and why didn’t I realize that my slip was showing?” So the lesson becomes not, again, not only to feel bad about one’s self but to become hyper-vigilant about always being one step ahead of what might be wrong with me, what will I be doing wrong, what should I be doing better? So it becomes sort of instilled or something clicks where it’s not just about every time I wear a dress I’m going to now make sure that my slip isn’t showing. It becomes about everything.
Kathy: So it almost sounds like there’s this internal witness with a set of eyes that doesn’t look very well, doesn’t look at let’s say the composite but is looking for that next flaw.
Ilene: Yes. Because itself protective. Because if I could be one step ahead of every possible flaw then I won’t have that devastating experience of not only feeling ashamed of myself but how could I be so stupid and careless and imperfect that I didn’t know it. I could not have let my slip show but I missed it. I didn’t realize it. So I want to make sure that doesn’t happen again.
Kathy: So fertile territory for this internal tyrant. What happens next?
Ilene: And I also call this a lot and my patients really, the people that I work with really like this one I say, I’ll get me before you get me because what ends up happening is a self-protective I’ll get me first. So anything that you might see that’s wrong with me I’ll be first to figure out everything that’s wrong with me so that I can protect myself from failing to be perfect or opening myself up to criticism so I’ll be first to criticize myself. I’ll leave the party and think of all the things I said wrong and did wrong and all the ways that I could have done better. Now, all of this could be seen as a normal self-improvement, right? We all try to improve ourselves. We all try to learn from our mistakes and we all want to be better so that’s all normal and healthy but for the person, with the eating disorder it goes beyond that. It becomes a really painful, obsessive compulsive kind of self-destructive experience and for people with eating disorders very often it is constant. It’s not just after a party, it’s every time they go out in the world, every time they get dressed so it’s not just done I look fat? Is it have I run enough? Have I,- does my home look nice enough? Is my car clean enough? What could somebody possibly criticize me for? Is that e-mail good enough? Is that picture that went out on Instagram good enough? Is my Facebook page looking right? It’s every aspect of someone’s life. They’re trying desperately to feel perfect, to feel again the higher self-esteem but also to protect themselves from potential criticism that for them is devastating.
Kathy: Now, I’m listening to and I’m hopeful that our audience is hearing the type of pain an individual would experience walking around carrying all that. Maybe you can talk about what that’s like in terms of just the level of pain, there’s sort of the matter of fact stuff, of making sure that, you know, the handwriting is good or whatever but it’s this other internal pain and –
Ilene: That’s right. There is no peace for people with eating disorders that have this aspect and again I do think that I would even risk saying that I think everybody who develops an eating disorder has this more or less but this peace. That’s why I think in good therapy for an eating disorder it’s critical to get to this peace, to work this piece out but it is – I said peace and peace but there is no peace. There is no – it is unrelenting. People can’t relax because there’s always more to do. I always could have been doing better. I always could look better. I always could do better. I always should be doing more. So that’s the really, really painful experience that there’s no quiet and peace internally. And someone’s symptoms could be better but still that internal thing is running their lives.
Kathy: And there’s accompanying sense of shame so how readily are people – how ready are they to talk about how difficult it is on the inside?
Ilene: Well, I think that’s one of the tasks of psychotherapy to try to get to that and again, we’re all – we have our psychological defenses. That’s how our psyche comes to be and those defenses are important. So trying to get to all these issues that are part of why psychotherapy for an eating disorder is arduous. It takes time. People will not recover from eating disorders as long as they need their eating disorder. So as long as they need that defensive structure, they’re not going to be able to let go of it, really let go of it. Not sort of let go of it enough to seem better and family and everybody thinks okay you’re better now. I’ve spent all this money on your treatment, you’ve had all this treatment. People expect themselves to be better. Families and loved ones expect them to be better. In fact, it takes the time to get to these deep places, these painful places. It’s hard. It’s very, very challenging. It’s possible, though. Full recovery is possible. I’m a very strong believer in good therapy and the right therapy and that people can and I know from people sometimes are really hopeless because they can’t imagine feeling good about themselves but this stuff can absolutely be reversed and people can absolutely get healthy. I know it. I see it. I’ve been doing it for 32 years. People can get well from eating disorders.
Kathy: I absolutely agree with you on that. I’d like you to talk a little bit more about what life is like when someone has gotten well because I think you were sort of putting this nice stream of sunshine on the inside of somebody when you say, you know, that’s where we want to get so what would that person feel like? How would they go about their day?
Ilene: Look, they’re always going to people who have had eating disorders and I tell people this too it’s like been there, done that. This is part of your life long resume. So some people feel like they’re leaving that, you know, a special club of not having their eating disorder anymore but you know what, you have achieved that. Been there, done that. You did that. You know how to do that. So you may, again, not be actively eating disorder but and even when you’re well my definition of getting well and getting healthy you’re still going to have a tendency to be a perfectionist. You’re going to still be detail oriented. You’re going to notice things that maybe other people don’t but you’re more able to calm that voice down. Your self-esteem is less on the line. You feel generally more confident. You’re able to relax. You’re able to have internal peace. You know how to take care of yourself. You know how to soothe yourself. You know how to be gentle with yourself. You don’t feel like it’s a failure or a weakness or a flaw to be gentle with yourself. You know in fact to be able to find that balance. Balance is really key and people with eating disorders are generally very unbalanced because they’re so extreme and so perfect and in every way, how they’re eating, how they’re exercising, how they’re living so being able to find that healthy balance should be a normal sort of birthright. We’re all supposed to be able to have that. People with eating disorders have to learn to have that and develop that.
Kathy: You know, maybe some ownership, the individual maybe takes ownership of their tendencies to perhaps look at life via the internal tyrant but they also know how to silence or at least quiet down.
Ilene: And they don’t need the internal tyrant because they really believe that they’re safe without having that hyper vigilant I’ll get me before you get me. They come to believe that they don’t have to be that careful, that they’re good enough, and you know what, if your slip is showing, it’s okay because that sense of self is really more solid and well developed. So again, more resilient and you can tolerate all the imperfection that being human includes.
Kathy: The word safe, so relevant when it comes to just being human. I think that oddly but although people with eating disorders will understand what I’m saying having the eating disorder gives them that protective sense of safety.
Kathy: Having the tyrant gives them that self-protective sense of safety and what you’re establishing and what good therapy and good progress and the hope and belief in recovery establishes you’re safe, you’re safe as you. You don’t need these destructive aspects.
Ilene: And people are afraid that they will say to me, I don’t want to give that up because that makes me successful.
Ilene: And I want to say to people you can be successful without that internal tyrant. You’ll still be successful. That’s your potential. You have your strengths. You can still be successful without your eating disorder and without your internal tyrant.
Kathy: And age wise, you see people of all ages who have had an eating disorder for two months or 20 years and you’re a firm believer wellness, health recovery is possible regardless of their age or the length of time they’ve had the eating disorder.
Ilene: I really believe that. I know that it takes times, more time than I would like more time than again people who are suffering and families would like. It takes time but finding the right treatment, the right relationship, you can get fully well. I don’t care how long you’ve had your eating disorder. Sometimes it depends on what else is going on along with your eating disorder, right? That’s another podcast but eating disorder, pure eating disorder absolutely people can get well.
Kathy: And so I think as we end I’m curious what you would like our listeners to walk away with. What’s their take away?
Ilene: Well, I think understanding this concept which sounds simple at first like even you said inner critic, inner tyrant, it sounds like well, we all know about that but understanding specifically what an eating disorder, how it works and really realizing that that is significant and will be enormously helpful in your treatment if you can work with your treatment professional to locate and find that and to work on that aspect of your relationship with yourself is really key to getting healthy and recovery.
Kathy: I want to thank you so, so much, Ilene. You’ve been wonderful I would say educator today based on your practice wisdom and your many years of experience working with eating disorders. So thank you so, so much. Our guest today has been Ilene Fishman. Thank you.
Ilene: Thank you so much, Kathy. It’s been such a pleasure to do this with you. Thank you.