Nina Savelle-Rocklin, Psy.D. joined us for an interview on her book, Food for Thought: Perspectives on Eating Disorders. What follows are our questions in italics, and Dr. Savelle-Rocklin’s thoughtful responses.
You apply a psychoanalytic approach with eating disorders, viewing eating disorders as “an unconscious solution to problems or conflicts.” Can you please provide more of your thoughts that guided you to this perspective?
My perspective developed as a result of my personal history with eating disorders, as well as my professional experience. When I was five years old I developed an obsession with my thighs. I thought that if my legs were thinner, I’d be perfect. I was a normal weight child but I was convinced that skinnier legs would somehow make me better.
My obsession got worse as I grew older. Throughout adolescence and into college, my last thought at night was, “What did I eat today?” I fell asleep counting calories and fat grams. I calculated every bite and sip, wondering if I’d lose weight by the next morning or gain it. The scale was my most welcome friend and my biggest enemy. If that scale registered an added pound, my day was ruined. A lost pound made me feel euphoric. When I hiked with friends, I focused on how many calories I was burning instead of how much fun I was having. I alternated restriction with bingeing and purging.
Eventually I began therapy. I shared my boyfriend problems, my goals, my dreams and my fears. I was open with my therapist about every aspect of my life – except one.
I never told her what was going on with food.
I went to therapy once a week for three years and never talked about what was going on with food. My therapist had no clue whatsoever what was going on. At first I did not want to give up my disordered eating. Starving gave me a sense of strength and superiority. I felt secretly better than other people because I had the will to deny myself. Eventually my willpower failed and I would binge, and usually use laxatives, or vomit to get rid of the food I had consumed. My struggle was too shameful to admit to anyone, including my therapist, so I waged my war with food in private.
Several months into therapy I noticed changes. Restricting no longer made me feel superior; it made me feel deprived. I became aware of feelings that I had denied and began processing those emotions, rather than denying them. I began to be more curious and less critical. By the time I left treatment, without ever talking about food, I no longer engaged in any eating disorder behavior.
How was this possible? How did I recover from a cycle of disordered eating without once talking about food?
My eating disorder behavior was never the problem. It was actually a temporary solution to the real problem, which was my harsh relationship with myself. In therapy, I learned to identify what was bothering me, which was difficult because I’d used focusing on food and body image as a way of pushing emotions and conflicts out of my awareness. I coped with difficult situations instead of distracting from them by counting calories. I soothed myself with words instead of using ice cream or cookies for comfort.
It was not until my analytic training that I figured out why I had suddenly developed the idea, at age five, that my thighs were too big. My parents were academics, and I experienced them as intellectually curious and brilliant, but emotionally detached. I was constantly being told that I was too loud, too sensitive, too dramatic and too emotional. The message was that I was “too much” to handle. My five year old mind translated this as being literally too much, too big.
My experience in treatment illuminated the importance of unconscious motivations in the formation of eating disorders, and created an interest in helping others. My personal and professional experience has also shown me that true and complete recovery is possible.
What are some of the similarities you note are shared by Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder?
Psychoanalysis views self-defeating behaviors such Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder as “symptoms” of deeply rooted conflicts and emotions rather than looking at them as “the” problem. As every gardener knows, removing a weed is not a permanent solution; you have to dig out the root to get rid of it for good. The problem is not the weed, but the root that grows it. Similarly the “weed” as the symptom is that which brings a person into treatment, and can only be alleviated by what I like to call emotional gardening, which means getting rid of the proverbial underground roots.
Those roots represent an underground part of the mind that is unconscious, meaning out of awareness but not out of operation. These unconscious forces have a significant impact on our beliefs, behaviors, and expectations. The ultimate goal of analysis is to identify and process the unconscious dynamics that lead to the behavior, no matter what form it takes.
From my perspective, the symptoms of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder, as well as subclinical diagnoses such as Orthorexia, Chewing and Spitting, and other forms of disordered eating, are all different ways of expressing internal conflicts and responding to painful or upsetting emotions. In my experience treating eating disorder patients of all genders, ages, ethnicities, histories, and personalities, I consistently find several commonalities:
- Difficulty self-soothing
- Difficulty identifying and expressing emotions
- A primary relationship with their bodies rather than other people
- A high degree of somatization, meaning that the conversion of psychological conflicts into physical symptoms
- A history of trauma
Whether someone is suffering from Anorexia, Bulimia, or Binge Eating Disorder, the behavior serves him or her in some way, and this secondary gain needs to be understood in the service of change. One patient called her Bulimia a “frenemy” because it was both a friend and an enemy. As a friend, it served to help her calm down and numb out. As an enemy, it caused emotional and physical pain. Once the symbolism of her behavior was decoded and she learned a new way of relating to herself, she gave up her eating disorder. When patients learn to soothe themselves, express themselves, and process the trauma of the past, they no longer need the eating disorder to cope, express, or distract from their pain.
One caveat is that psychoanalysis is not the treatment of choice for many anorexic patients. People cannot think clearly or process when their minds are starved, and anorexia can lead to delusions or even psychosis. Therefore, for patients with anorexia, they can only be treated psychoanalytically once they are healthy enough (both in terms of weight restoration and cognitively) to do the work.
Through your psychoanalytic lens, you examine eating disorders via the influence of caregivers on an individual’s development. Can you please give us a case example?
As a psychology graduate student in 2000, my curriculum included one seminar on the history of psychology, including a brief overview of psychoanalysis. The instructor declared, “Nobody does this kind of thing anymore. Psychoanalysis is a relic of the last century.”
The class nodded in agreement. Our instructors and supervisors taught us that evidenced-based therapies were the treatments of choice. Symptom relief was the goal, and the sooner the better.
Had I not encountered a client early in my training who caused me to challenge these ideas, I would never have discovered the richness, diversity, and effectiveness of psychoanalysis. Her story illustrates the influence of caregivers on development.
Lottie was in her late 20s, morbidly obese, over 200 pounds overweight. She came to therapy to “learn how to say no” to her mother and co-workers. Her previous therapist tried to convince her to have weight loss surgery, which caused friction between them. She was not interested in weight loss as a goal. Would I still see her?
I agreed to her terms.
Lottie never discussed her weight but she had a lot to say about food. She ate to soothe any discomfort. She stuffed herself until she was so full that she could barely move, and was in physical pain. Despite the physical toll of this behavior, and the emotional burden of being a large woman in a society that values thinness, Lottie was terrified at the idea of limiting her food consumption. Food was her sole means of comfort, the only constant in her life.
I kept my promise and never mentioned her weight.
My superiors expressed concern. One supervisor suggested I was colluding with Lottie’s self-destructiveness and advised me to refuse treatment until Lottie agreed to explore her obesity in session. Another suggested a dietician as a requisite for treatment, along with Overeaters Anonymous.
Nobody asked “why” Lottie was eating so much or why she turned to food instead of people. They cautioned that if there was a fire in a building, it was unhelpful to spend time wondering how the fire started. The fire must be extinguished as quickly as possible. In other words, forget delving into the past; just deal with the here-and-now.
Yet wasn’t the present an outcome of the past? If the source of this metaphorical fire were not identified, it would surely spark again and again.
Lottie was the oldest of three girls, all of whom were less than two years apart. Her father traveled for work and was often absent, and her mother relied on Lottie to be her “little helper.” Lottie felt obligated to care for her mother but was deprived of the experience of taking in maternal comfort and love. She essentially functioned as the mother to her own mother. She began getting in touch with her feelings about being a parentified child, a girl who had to give up her own needs to meet the needs of a parent.
She worked as a nurse for a geriatric physician, continuing to care for older people (parental figures) and not thinking about her own needs. Lottie used food as a substitute for relationships. Food was the only thing she could take in, literally, as she gave everything she had to others, leaving her depleted and empty.
Food had become a de facto mother, and eating was a way of expressing her emptiness, anger, and pain, all of which was enacted and expressed through her behavior with food. By eating until her stomach hurt, Lottie converted emotional pain into physical pain. As she expressed her yearning and disappointment, Lottie gradually started giving up her intense relationship to food. She stopped bingeing and she lost weight.
My experience with Lottie illuminated the importance of understanding what the eating disorder behavior reveals about a person’s inner world, and shows how his or her past informs the present difficulties. Again, once those underlying reasons are recognized and processed, change comes naturally and permanently.
You develop the experience of “I feel fat.” Can you provide us with a brief explanation?
Eating disorder patients often reference their bodies as a way of indirectly expressing what’s going on in their minds and hearts. The phrase, “I feel fat,” can be a way of symbolizing thoughts, wishes, emotions, and conflicts that may be too disturbing or upsetting to consciously recognize.
People develop eating disorders for reasons that are as unique as they are, so there are many reasons why people assert that they “feel fat.” When they do so, I invite them to explore the fears, disgust, and shame embedded in their description of their bodies as fat.
Conceptualizing a patient’s relationship to his or her own body is a crucial part of therapeutic exploration. Those who define themselves by their appearance alone believe that they will be good enough only when their bodies are good enough. They think they can get other people to like them, hire them, accept them, and appreciate them by changing their appearance. They unconsciously imagine that by ridding themselves of excess weight they are getting rid of the aspects of themselves they despise.
These patients use their bodies to express what their minds cannot. Their bodies are often a source of shame, and humiliation, rather than pleasure. They turn their bodies into objects rather than experiencing their bodies as subjects, part of the totality of their self-representation. They abuse their bodies, starving, stuffing, hating, despising, and loathing their physical selves. Therefore, one goal of treatment is to decode the language of their bodies, to bring the hidden communication into consciousness awareness, so we can work it through together.
The term “fat” usually functions as an umbrella expression covering a range of thoughts, emotions, conflicts, and fears. Feeling “fat” may express that someone feels as if he or she is too much for others to handle. It may reference a sense of taking up too much space, or that their wants, needs, and emotions are overwhelming and too big.
I find that many people have no language for their internal states, and experience great difficulty identifying what’s going on in their internal worlds. They use “fat” to describe anything that is too much or too uncomfortable, and often lack the ability to describe any emotion. When the hidden language of eating disorders is deciphered, such as what is conveyed by the term “I feel fat,” then the true underlying meanings can be explored and processed, leading to change.
What is the “wish-fear dilemma” in the context of eating disorders?
Many people wish for connection, safety and trust, yet have a concurrent terror of loss, disconnection, abandonment, and rejection. Those with eating disorders have often learned that hungering for love, attention, and kindness is futile. I call this the “wish-fear dilemma” because to me that most accurately describes the quandary of simultaneous hope and dread.
This often goes back to some experience of the past. When the environment covertly or overtly enforces the idea that basic needs for warmth, compassion, safety and love will not be met, or are somehow wrong or even weak, children become hostile to their needs, or embarrassed by them. They grow into adults who struggle with their longing for love, and for life, and unconsciously use food to enact their conflicts over such longings. One form that the wish-fear dilemma takes is the struggle between dependency and independence. Many people hope to lean on another person, yet fear losing themselves.
One patient, Michelle, believed dependency would invariably lead to pain, loss, or withdrawal, and only by being fiercely independent could she protect herself from pain and disappointment. She chose men who were married, since they were safe and could not leave her, nor could they be available and potentially too close. As a result, she was lonely, and binged to fill her symbolic emptiness. When Michelle understood and resolved her fears about connection, she was able to develop fulfilling relationships instead of symbolically filling up on food.
Like Michelle, many eating disorder patients face painful choices, torn between staying true to themselves at the expense of their connections to other people or sacrificing their authentic selves in order to maintain some form of connection. Their solution is to use food to express inner turmoil. Some withdraw from relationships and restrict food as a way of expressing indifference to their needs. Others eat out of loneliness, anger, or pain. They binge until they are filled up with food, instead of being fulfilled by relationships. They eat until they are stuffed to the point of pain, converting emotional pain to physical discomfort. Others binge and then purge, symbolically ridding themselves of their needs and wants.
I find that this wish-fear dilemma also plays out in the therapeutic relationship, when patients hope that I will understand and approve of them, even love them, but simultaneously they fear discovering a critical or judgmental part of me. Typically, if a patient feels that way about me, he or she is feeling that way about other people in the world outside therapy. By resolving it in the therapeutic relationship, we change it in the outside world, too.
Although focused on the relationship between psychoanalysis and eating disorders, your book can also serve as a way to understand the nature of psychoanalysis. Did you have this in mind?
Absolutely. I wanted people to know that the stereotype of a cold, silent (and usually male) analyst has little to do with the reality of contemporary psychoanalysis. I can’t tell you how many people have responded in surprise when they learn I am a psychoanalyst. They often say, “You mean, like Freud?”
“Yes,” I tell them … “And no.”
Comparing modern psychoanalysis to Freud is like expecting a 21st century electric Ford Focus to be identical to a turn-of-the-century Model T. Ford, and furthermore, expecting that the only cars on the road are Fords. There is no single mode of psychoanalysis, since psychoanalysis encompasses a range of theories, philosophies, and techniques.
The experience of psychoanalysis is actually deeply personal, an intimate relationship in a formal setting. It is a journey embarked on by and between two people, an investigation into the past that transforms the present. My work with patients is collaborative; we are detectives of the psyche, working together to solve the mystery of what has caused current difficulties, and in doing so, forming a new paradigm for being and relating.
What are some of the rewards of engaging in psychoanalytic treatment for an eating disorder?
The great artist Michelangelo once said, “Every block of stone has a statue inside it, and it is the task of the sculptor to discover it.” From this perspective, he did not turn marble into statues; he freed those statues from the stone.
I love this because it a perfect way to describe the process of therapeutic change. Patients often think that there is something flawed and wrong with them, and they need to change. Instead, our challenge is to chip away at what keeps them stuck, and free them, so that they can be their most authentic selves, the true selves that have been there the whole time.
Psychoanalysis helps people come to a deeper understanding of themselves in the service of making lasting change. To use another metaphor, I often tell patients that they cannot fight an invisible army. They feel emotionally battered and beaten by what they cannot identify. Only by making this internal army of un-thought thoughts and conflicts visible or conscious, can patients see what they’re actually battling. Then, and only then, can they challenge those ideas and beliefs about themselves. The treatment is thus reparative on the deepest level.
For me, this way of understanding and treating people with eating disorders is incredibly profound. Having the opportunity to help them discover why they do what they do, and then working together to create lasting change is deeply gratifying and rewarding. Patients often tell me that the work can be challenging at times, and intense, yet liberating and ultimately transformative.
About the author:
Dr. Nina Savelle-Rocklin is a psychoanalyst, author, radio host and internationally-recognized expert in the psychology of eating. She has been featured in Psychology Today, The Los Angeles Times, Prevention, Real Simple, Redbook, Huffington Post, Eating Disorder Hope and many other publications, as well as numerous radio shows, summits and events. She has presented at the prestigious National Meeting of the American Psychoanalytic Association and contributed chapters to two books on psychoanalysis. Dr. Nina also writes an award-winning blog, Make Peace With Food, has a video series, and hosts a call-in radio program, The Dr. Nina Show, which airs Wednesdays at 10am PST on LA Talk Radio. Her book, Food For Thought, explores the psychoanalytic underpinnings of eating disorders. For more information please visit: http://winthedietwar.com