Fire & Smoke: I Had No Idea

This year’s eating disorder awareness catch phrase put forth by the National Eating Disorder Association (NEDA) is “I Had No Idea.” The list of I Had No Idea moments I have experienced as an eating disorder professional is long. From my first client struggling with Anorexia, the inadequacy of my standard formal education as a Registered Dietitian, even with a Master of Science degree in Foods & Nutrition, was obvious. I immediately began reading, studying, and consulting with more experienced colleagues about eating disorders. I attended a workshop specific to CBT (Cognitive Behavioral Therapy) for eating disorders led by Christopher Fairburn and a national conference featuring several high profile experts in the eating disorder field back in 2008, and still I had much to learn. As most eating disorder professionals will admit (in candid moments at least), we learn the most from our clients and patients.

Eating disorders work is about more than learning for me – I am truly inspired by my clients. Their perseverance in the throes of incredibly difficult challenges humbles me. One of the best I Had No Idea professional moments for me was learning that eating disorder clients can fully recover. While not all clients do for a variety of reasons, knowing that full recovery is a possibility and believing each of my clients has this potential is an idea I am grateful to know now.

In addition to the important work I do with clients, one of the incredible aspects of being part of the eating disorder treatment community is just that – a sense of community. We work in an area of nutrition, mental health and medicine that requires us to incorporate what we have learned over the past few decades about good practice, and perhaps more importantly, to stay open to new developments. I feel honored to work among so many dedicated, intelligent, and passionate professionals doing this work.

I plan to write this week about some of the topics the National Eating Disorder Association (NEDA) has made a part of this year’s awareness campaign. [See the list and more info here.] Beyond busting myths and stereotypes, encouraging more people to recognize disordered eating and related issues (like problematic exercise), and advocating for people struggling with eating disorders everywhere, I also want to be open about some of what I have learned on my professional journey working with eating disorders.

Fire and Smoke

I begin with an analogy I learned from a colleague at the intensive outpatient clinic for eating disorders where I worked for two years in the Seattle area. Jeanne Wiccomb, Director of the Intensive Outpatient Program, described the outward behaviors we see in eating disorders as the smoke. Beneath the smoke is the fire, with a variety

of “fuels” that can start the fire or keep it going.

Those of you who have attended one of my eating disorder presentations here in Jackson over the past year and half have probably seen the poster I made depicting this Fire and Smoke analogy for eating disorders. For those who have not I include pictures here of the newest rendition of my Fire & Smoke poster.

As you can see the smoke consists of the various behaviors we often use to define an eating disorder. Food restriction, binge eating, various forms of purgeing (including dysfunctional exercise), and the “other” category with additional forms of self-harm such as cutting that we see commonly with eating disorders.

Many people, including health and medical professionals, have no idea that these behaviors (the smoke) are not the eating disorder itself. This smoke is how the eating disorder presents itself but is only part of the whole picture.

The fire that produces the smoke can be caused by a number of “fuel” sources. Sometimes the fuel that starts the fire differs from fuel that keeps the fire going. Potential eating disorder fuel sources include:

Depression

Anxiety

Stress

Chemical dependency

Addictions (drugs, smoking, shopping, sex, exercise, gambling)

History of Trauma or other abuse (physical, sexual, emotional, psychological)

Poor body image

Low self-esteem

Personality characteristics & temperament (perfectionist, rigid, compulsive traits, obsessional, harm avoidant, sensitivity to rejection, reward dependent, anxious)

Feeling of Powerlessness

Life Transitions – life cycle, lifestyle changes, loss (death, divorce, move)

Troubled Personal Relationships

Sensitivity to rejection

Peer pressure

History of Bullying or Teasing Related to Weight/Size

Media Messages and Images (Unrealistic Thin or Muscular “Ideals”)

Cultural Ideals of Beauty – emphasis on outward appearance

Prejudice Against Obesity – Body Shaming

Inability to express emotion in healthy or appropriate way (emotional dysregulation)

Genetics?

Brain chemical imbalance?

 

There are many things I love about this analogy (in addition to the opportunity to do a really fun art project making this poster!). The treatment process and recovery journey is often long and complicated. Conceptualizing the eating disorder as a fire with many possible fuel sources helps us “see” why it can take so long to recover, why simply getting rid of the outward behaviors (or clearing smoke) is not enough, and why relapse is common or considered part of the process.

I have worked with eating disorder clients for nearly 15 years and I have yet to meet a client with only a single fuel source. When I show this poster to clients and their families they often immediately identify several possible contributors. This helps families, especially parents to feel less guilt, and clients to feel validated in the difficulty of their struggles. This also helps all of us see that socio-cultural factors such as the media portrayal of the “Thin Ideal” for females and the “Muscular Ideal” for males or problematic relationships may not cause eating disorders, though these can be significant contributors.

If you know someone who has no idea what eating disorders really “look like” I invite you to share this analogy and graphic with them.