What Makes Anorexia a "Harder Case"?

Earlier this week, I was chatting with Martha Peace, who is working closely with me on my book and discussing revisions with me as we go. I very much consider her a mentor, and the depth of her experience in the biblical counseling field helps me to learn about how to best minister to young Christian ladies. (Not to mention, as a bestselling author, her writing suggestions are much appreciated)!

During the course of conversation, she mentioned a book she and several other recognized biblical counselors, including the brilliant Stuart Scott, are compiling on hard counseling cases. The topic on which Martha will write, for her contribution to the anthology, is anorexia nervosa. (Needless to say, I am looking forward to the book's release - I want to be as well-prepared as possible when I am a fully-certified NANC counselor).

Now, bulimia is quite a bit more common than anorexia, but this project is to zero in on the toughest cases of all.

This got me to thinking: why is it, exactly, that anorexics are more difficult counseling cases than bulimics? This was not a subject I got into in my own book - I did not focus on the differences too much between the two disorders, but rather dealt primarily with the root sins contributing to both behaviors. Moreover, most anorexics end up becoming bulimic at some point, anyway...it is much harder to continue to starve than it is to give in to the urge to eat, and then purge as an "escape hatch".

However, there are women who maintain anorexia long-term without ever giving in to bulimia. I have known of women to go well over a decade as anorexics, while their body tissues slowly disintegrate, still pursuing that elusive "thinness". This scenario is much rarer than the more common one: a low-to-average weight woman who binges and purges in secret, or an overweight lady who habitually overeats and cannot seem to moderate her eating habits.

What is it about anorexia that makes it harder to counsel? Here is my theory (and it is just that; my somewhat-educated opinion): the level of self-delusion in anorexia is deeper.

A bulimic knows that what she is doing is wrong. She feels shame constantly, even when she has been purging for so long her conscience is desensitized. Even before she seeks counseling, inwardly, she knows it is sinful to gorge and vomit up food. She knows the risks of laxative abuse, and is filled with disgust and self-loathing. She wants to stop the binge/purge cycle, but on the other hand is conflicted: 1) the frenzied act of eating/purging retains some sort of "reward" to her that she is reluctant to give up; B) she is deathly afraid of gaining weight. As with her anorexic sister, the bulimic has made weight her idol. Nevertheless, she rarely has any delusions that bingeing and purging is anything less than sinfully self-destructive.

The anorexic Christian, on the other hand, is less likely to really see her self-starvation as wrong. Anorexia seems the more "noble, stoic" of the two eating disorders -- after all, it takes enormous willpower to consistently refuse food. The anorexic is typically very proud of "overcoming" her baser human instinct - the need to eat for survival - and sees herself as of stronger, more self-controlled stock than other women. She has never eaten food only to "get rid of it"; what's the problem? she may reason.

Add to this the grossly distorted body image more common to anorexics, and you would have a hard time convinvcing them that they need to gain weight. I remember when I was anorexic in 11th grade, looking in the mirror (at 5'5" and 90 lbs.) and seeing a normal-weight girl. Interestingly, in photographs of myself I saw how emaciated I was; but anorexics do not see themselves realistically in "real time". For this reason, I highly recommend meeting with a nutritionist as well as a biblical counselor during the re-feeding process. A nutritionist provides an objective, science-based eating plan according to biological, nutritional needs. In my experience, this was helpful in giving me the confidence to eat nutritionally-balanced, if small, meals and to gain weight without freaking out.

A third reason anorexics may present tougher counseling cases than bulimics is the connection between asceticism and "religion". I use " " around the term 'religion' to distinguish this way of thinking from true, biblical Christianity. The ascetics were an ancient group that believed in subjugating the body (believing all matter to be evil, like the Gnostics) in an attempt to reach a higher level of 'spirituality'. This way of thinking was also rampant in Medieval Catholicism (see my post on 'holy anorexia' and the contemplative nuns of the Middle Ages) where flagellants and penitents would beat, starve, and sleep-deprive their bodies mercilessly as "penance".

The notion of "penance" is antithecal to the Gospel, which teaches repentance. Repentance is godly sorrow over sin; trusting in Christ's finished work on the Cross as atonement; and dependance on Him to turn away from the sin. Penance, on the other hand, is self-inflicted punishment or man's attempt to "make it up to God" by performing some act. This is the height of pride (thinking that we can add something to our redemption, on top of Christ's sacrifice); it is also a gross perversion of the true motivation for the spiritual disciplines (including fasting).

A Christian anorexic could easily justify her habit as "holy", by calling it a "fasted lifestyle". The secular media certianly reinforces this mindset, by glorifying women who successfully lose weight through "willpower" (the secular term for "self-control"). Self control is certainly a fruit of the Spirit, and fasting is something Christians are expected to do in seasons of intense prayer, but the anorexic mindset perverts them both. Although she is called, as a believer, to "put on the new self", she is in fact giving reign to vanity and self-absorbtion. Paul writes:

"Therefore if you have been raised up with Christ, keep seeking the things above, where Christ is, seated at the right hand of God. Set your mind on the things above, not on the things that are on earth. For you have died and your life is hidden with Christ in God." (Colossians 3:1-3)

The anorexic's mind is most definitely not set on "the things above", nor is she walking in the Spirit. Her mind is set on the carnal desire for unnatural thinness and audulation; she ruminates about food day and night. Her lifestyle and habits "sow to the flesh" (Galations 6:8). However, it is much more difficult for her to see her true spiritual condition through the eyes of faith than it is for a bulimic, whose purgeing habit is more obviously sinful (gluttony; waste; destruction of the temple - 1 Corinthinas 6:19). Anorexia is just as grievous a sin against the body as bulimia is, but for these reasons I believe it can be harder to convince an anorexic that this is, indeed, the case.

What are your thoughts on this? I am especially interested in feedback from some of you ladies who are (or have been) struggling with anorexia. Do you see this as a life-dominating sin, or something that makes you "purer" (even if only in your own eyes)? Do you consider jeopardizing your health by self-starvation as wrong as overeating; or do you see it as "virtuous" (even if only secretly)?

More Commentary on "Holy Anorexia"

From The London Review of Books, an excerpt from Hillary Mantel's "Some Girls Want Out", an analysis of several Italian "starving saints'" biographies. To read the whole article, go here.

Why is starvation/purging/self-inflicted punishment ever chosen, and how could anyone have ever thought it would make them more holy? Is it not possible, that without an accurate view of God (revealed to us through His Word, the Bible), the deception of one's mind can rationalize anything?

Gemma Galgani's deathbed




"....Anorexia nervosa is said to be a modern epidemic. If you skimmed the press in any one week it would be hard to see what is perceived as more threatening to society: the flabby, rolling mass of couch-potato kids, or their teenage sisters with thighs like gnawed chicken-bones, sunken cheeks and putrid breath. Are we threatened by flesh or its opposite? Though the temporarily thin find it easy to preach against the fat, we are much more interested by anorexia than by obesity. We all understand self-indulgence but are afraid that self-denial might be beyond us. We are fascinated by anyone who will embrace it – especially if there’s no money in it for them.

Bell emphasises in his introduction that what Gemma experienced was ‘holy anorexia’ and that it is different from anorexia nervosa. But what may strike the reader of a secular orientation is how similar they are. Starvation, as Bell shows in Holy Anorexia, was not an extension of convent practice, but a defiance of it. A fast is a controlled penitential practice. Most nuns fasted to keep the rule: the anorexics fasted to break it. Most nuns fasted to conform to their community: the starvation artists aimed to be extraordinary, exemplary. The secular slimming diet is also conformist and self-limiting. Dieting is culturally approved, associative behaviour, almost ritualistic. Restaurants adapt their menus to the Dr Atkins faddists; in a thousand church halls every week, less fashionable dieters discuss their ‘points’ and ‘sins’, their little liberties and their permitted lapses. Diets are prescriptive, like convent fasts – so much of this, so little of that. The anorexic, holy or otherwise, makes her own laws. Every normal diet ends when the dieter’s will fails, or the ‘target weight’ is reached, at which point the dieter will celebrate, the deprived body will take its revenge, and the whole cycle will begin again – next Monday, or next Lent. Diets are meant to fail, fasts to end in a feast day. Anorexia succeeds, and ends in death more frequently than any other psychiatric disorder.

Should we be comfortable in regarding it as a psychiatric disorder? Is it not a social construct? If the fashion industry were responsible for modern anorexia, it would be true that we are dealing with a very different condition from holy anorexia. But the phenomenon of starving girls predates any kind of fashion industry. In The Disease of Virgins: Green Sickness, Chlorosis and the Problems of Puberty, Helen King has amassed a huge number of references to a disease entity that was recognised from classical times to the 1920s. Greensick virgins went about looking moony, and didn’t menstruate, possibly because they didn’t weigh enough; in all eras, food refusal was part of the condition. The cure was a good seeing to – within marriage, of course. The snag was that men weren’t keen to marry women of unproven fertility. They must show, by bleeding, how worthy they were. If green-sickness was a protest against fate, it was a horribly conflicted and fraught protest. The cloister is the logical destination for those who protest too much. But in or out of the nunnery, how much should a good girl bleed? Should she settle for the natural orifice, or bleed from novelty ones – palms, eyes?

Sometimes the starving saints broke their fasts, were found at midnight raiding the convent larder. How did their communities accommodate this embarrassment? They simply said that, while Sister X snoozed celestially in her cell, the devil assumed her form and shape, tucked his tail under a habit, crept downstairs and ate all the pies. Starvation can be, must be, sustained by pride. (Emphasis mine). Sîan Busby’s book ‘A Wonderful Little Girl’ introduces us to this pride in a secular context. In 1869, a 12-year-old called Sarah Jacob starved to death in a Welsh farmhouse, under the eye of doctors and nurses who were watching her around the clock. Sarah had been a sickly little girl whose parents didn’t want to force food on her. She became a local phenomenon; visitors came to look at her not eating, and left useful donations. It is likely she was fed, minimally and secretly, by her siblings. But when the medical vigil began, this source of supply was cut off, and Sarah was too polite to say she needed anything – even water. Politely, proudly and quietly, she slipped away while the doctors and nurses watched.

It is a grim story of social hypocrisy, deprivation and bone-headed stupidity, but it is also a shadowy story with a meaning that is difficult to penetrate. This is true of the whole phenomenon of anorexia. The anorexics are always, you feel, politely losing the game. When the fashionable and enviable shape was stick-thin, a sly duplicity was at work. One girl, considered photogenic, could earn a living from thinness; another girl, with the same famine proportions but less poster-appeal, would be a suitable case for treatment. The deciding factor seemed to be economic: could she earn a living by anorexia? If so, make her a cover girl; if not, hospitalise her. The case is now altered. The ideal body is attainable only by plastic surgery. The ideal woman has the earning powers of a CEO, breasts like an inflatable doll, no hips at all and the tidy, hairless labia of an unviolated six-year-old. The world gets harder and harder. There’s no pleasing it. No wonder some girls want out.

The young women who survive anorexia do not like themselves. Their memoirs burn with self-hatred, expressed in terms which often seem anachronistic. In My Hungry Hell, Kate Chisholm says: ‘Pride is the besetting sin of the anorexic: pride in her self-denial, in her thin body, in her superiority.’[*] (emphasis mine). Survivors are reluctant to admit that anorexia, which in the end leads to invalidity and death, is along the way a path of pleasure and power: it is the power that confers pleasure, however freakish and fragile the gratification may seem. When you are isolated, back to the social wall, control over your own ingestion and excretion is all you have left; this is why professional torturers make sure to remove it. Why would women feel so hounded, when feminism is a done deal? Think about it. What are the choices on offer? First, the promise of equality was extended to educated professional women. You can be like men, occupy the same positions, earn the same salary. Then equal opportunities were extended to uneducated girls; you, too, can get drunk, and fight in the streets on pay-night. You’ll fit in childcare somehow, around the practice of constant self-assertion – a practice now as obligatory as self-abasement used to be. Self-assertion means acting; it means denying your nature; it means embracing superficiality and coarseness. Girls may not be girls; they may be gross and sexually primed, like adolescent boys.

Not every young woman wants to take the world up on this offer. It is possible that there is a certain personality structure which has always been problematical for women, and which is as difficult to live with today as it ever was – a type which is withdrawn, thoughtful, reserved, self-contained and judgmental, naturally more cerebral than emotional. Adolescence is difficult for such people; peer-pressure and hormonal disruption whips them into forced emotion, sends them spinning like that Victorian toy called a whipping-top. Suddenly self-containment becomes difficult. Emotions become labile. Why do some children cut themselves, stud themselves and arrange for bodily modifications that turn passers-by sick in the streets, while others merely dwindle quietly? Is it a class issue? Is it to do with educational level? The subject is complex and intractable. The cutters have chosen a form of display that even the great secular hysterics of the 19th century would have found unsubtle, while the starvers defy all the ingenuities of modern medicine; the bulimics borrow the tricks of both, and are perhaps the true heirs of those spider-swallowers. Anorexia itself seems like mad behaviour, but I don’t think it is madness. It is a way of shrinking back, of reserving, preserving the self, fighting free of sexual and emotional entanglements. It says, like Christ, ‘noli me tangere.’ Touch me not and take yourself off. For a year or two, it may be a valid strategy; to be greensick, to be out of the game; to die just a little; to nourish the inner being while starving the outer being; to buy time. Most anorexics do recover, after all: somehow, and despite the violence visited on them in the name of therapy, the physical and psychological invasion, they recover, fatten, compromise. Anorexia can be an accommodation, a strategy for survival. In Holy Anorexia, Bell remarks how often, once recovered, notorious starvers became leaders of their communities, serene young mothers superior who were noticeably wise and moderate in setting the rules for their own convents. Such career opportunities are not available these days. I don’t think holy anorexia is very different from secular anorexia. I wish it were. It ought to be possible to live and thrive, without conforming, complying, giving in, but also without imitating a man, even Christ: it should be possible to live without constant falsification. It should be possible for a woman to live – without feeling that she is starving on the doorstep of plenty – as light, remarkable, strong and free. As an evolved fish: in her element, and without scales."