Last night’s BBC1 documentary Desperately Hungry Housewives exploded the media-created myth that eating disorders are only about teenage girls aspiring to become fashion models. By concentrating on the stories of four housewives, and by allowing them to tell their own stories without comment from ‘experts’ this documentary managed to be revealing and poignant.
The narrator spent a month with the four women, concluding (32:50):
It’s become increasingly clear to me that for these women eating disorders are nothing to do with skinny celebrities or size zero. They’re all telling me that their bizarre relationships with food are about control. Trying to control the chaos of their lives, or the pain of their past.
The programme, made for the BBC by Betty TV Ltd., is available online for six more days. No broadcast repeat is currently scheduled.
The programme is revealing of the causes of these disorders. All four women mention events in their past that any competent therapist would be able to use as the starting point for effective treatment.
However, the notion that there is a single issue of ‘control’ in cases like these, or that these women’s lives are in ‘chaos’ is journalistic fancy. You can see for yourself that there is no chaos and that the issues of control are different in each case.
Equally, you can see for yourself that none of these women speaks of the past with more than usual pain. All of us have some pain in our pasts. The causes of mental illness are more subtle than simply that painful things once happened. They are that painful things happened and the way the person coped at that time has had unintended emotional consequences.
Effective therapy should be about understanding the past and fixing the specific things that went wrong. After successful therapy, the past remains painful — just as painful as it is for all the rest of us, but after successful therapy the past no longer has a devastating hold on the present and the future.
Jane, now in her fifties, has had alternating anorexia and bulimia for thirty years, originally triggered by traumatic events.
Her GP sees Jane’s problem as a weight problem, apparently ignoring the emotional side of it.
Tracey is bulimic. She had no eating issues unil four years ago when her mum died and her marriage broke down, but there’s more to Tracey’s past that those events (10:45):
I think the underlying problems were already there from way back. I’d been abused as a child, never dealt with that, wasn’t talked about in those days, just ignore it, move on. My parents had a…not a very good marriage. They split up. Had a couple of miscarriages which I never relally addressed. So I think that’s how it started. I think that…it became a warped sense of control. It never really had anything to do with how I looked. It’s entirely to do with how I felt about myself, how I still feel about myself.
Zoe’s anorexia developed five years ago, according to the voiceover, but she herself hints at a much longer history (14:25):
For most of my life I’ve felt happy when my weight’s gone down.
Georgia is again losing weight after having her third child. She has a long history of anorexia, which was so severe that when she was eighteen she was sectioned under the Mental Health Act. Her eating disorder began when her parents split up and her mum moved in with a new partner (30:05):
I felt like, because my mum was making the decisions about where we lived and who we lived with, I felt like I didn’t have any say in anything. And so that’s probably why I resorted to this. Why I chose food, I don’t know, but…my weight and food were things that I could control. I could control what I put in my mouth and I could control what happened to my weight.
Jane Finds that hypnotherapy helps. She has a CD to listen to at home, and her problematic thoughts around eating seem to have gone away.
Tracey is on a waiting list for counselling. Meanwhile she is trying to help herself with positive thinking. On a cupboard door, she lists the things she aspires to, as if making a list and concentrating hard can magically make things different:
14) I take ownership of my difficulties/issues and actively aim to improve them.
15) I refuse to give in to my problems
16) I am determined that I will become a much happier, healthier person.
Zoe had NHS “CBT” for two years four years ago, and is now said to be ‘in recovery’. However, she is still underweight and gradually losing weight, and her continuing struggles with her thoughts suggest that the “CBT” she had was unsuccessful, fake, or more likely both (18:50):
I’m often struggling with thought of fullness equals fatness in my head still quite a lot. Before I can reason over it, that’s my automatic reaction…I feel full therefore I feel fat. So I have to use these cognitive behavioural therapy techniques to tell myself: “Well actually I know I’m not fat. This is just a feeling of fullness, and it will pass.”
Georgia does not seem to be having any treatment.
The three treatments (hypnosis, positive thinking, and thought control) have in common that they try to fix the patient’s current state of mind and behaviour without addressing the cause. The experience of CBT therapists is that this doesn’t work.
At best, it dooms patients to a lifelong struggle with their own thoughts, a struggle that Zoe describes well. At worst, it convinces patients that there is no alternative to these half-baked remedies by using the term “CBT” fraudulently. Real CBT does address causes, and it does release patients from that lifelong struggle.
There are various types of therapist out there who will attempt to treat eating disorders.
First there are the untrained. Very often they are nurses, psychologists, counsellors or even psychiatrists — people who are well-qualified in their own fields but who have little understanding of CBT. They are the likely culprits in Zoe’s treatment. Two years without being able to release Zoe from her struggle.
Then there are the apparently trained but uncomprehending. The BABCP’s accreditation scheme does not distinguish between CBT therapists and behavioural therapists. The behavioural ones employ a variety of tactics to evade addressing root causes of mental illness.
Then there are the inexperienced. Eating disorders are typically complex and severe, potentially life-threatening. They are not a good subject for a beginner in therapy, even a beginner who has a good understanding of CBT and good skills in applying it.
Finally there are real CBT therapists who are accredited and experienced. Hard to find, but worth finding.
Ironically, in the NHS the existence of an eating disorders unit in your area, staffed by well-meaning phonies, will actually prevent you from being referred to a CBT specialist who could provide effective treatment.
In the private sector it’s a little easier. The CBT Register identifies accredited therapists, and reading over a therapist’s website or a doing little questioning weeds out most of the ones who only work with behaviours or who are inexperienced.
Collaboration between private therapists and the NHS is also possible, with a short course of private CBT to address the fundamental issues being followed up by NHS treatment and support to mop up residual behaviours.
Overall, though, the picture for such women as these in the programme is pretty bleak. The widely-available treatments are weak, although certainly better than nothing, and only the very lucky or very well-informed few are able to find real CBT.