Anorexia Nervosa and Bulimia : How to Help

by Duker, Marilyn

• ISBN13: 9780335212033
• ISBN10: 0335212034
• Edition: 2nd
• Format: Paperback
• Copyright: 2002-11-01
• Publisher: Open University Press

Summary

Praise for the first edition: "...this thoroughly researched and very detailed book provides the serious student of eating disorders with a great deal of useful and constructive information...it provides a complete picture of the individual sufferer's dilemma and notes the wide-ranging behavioural patterns that can occur in these conditions...The authors have made extensive use of their own experiences {of helping people recover} which help to illustrate their findings in a most straightforward and enlightening manner." - British Review of Bulimia and Anorexia Nervosa "This brilliant book helped me and my family to see that the illness is so much more than an effort to control weight. Sharing the book could also provide you with an excellent channel of communication." - The Guardian "...many therapists would benefit from reading this book. If more helpers treated their patients with the authors' degree of empathy and integrity, treatment of anorexia nervosa would take a huge step forward." - Society for the Advancement of Research into Anorexia "...a detailed and comprehensive guide to theories of causation, intervention and therapy. It discusses methods of treatment, help, and self-motivation in this demanding field of psychology, medicine and counselling." - Nursing Textbook Review This new edition continues the outstanding tradition of excellence for which Duker and Slade's Anorexia Nervosa and Bulimia: How to Help is internationally recognised. Updated to meet contemporary concerns, this book is a 'must' for anyone who wants to do something practical about anorexia nervosa/bulimia. Its unique contribution is the now widely acknowledged whirlpool theory which unifies the physiological and psychological aspects of the illness. This provides much needed alternatives for the helpers who are all too often drawn into coercing the sufferer to eat, which is psychologically destructive, or ignoring the physical aspects of the problem which can be dangerous. It also offers a basis for resolving continuing medical and legal dilemmas. To illustrate their approach, the authors draw extensively on their own research and many years of experience providing effective therapy. There is no other book that attends in such detail to the minute steps involved in leaving an anorexic/bulimic lifestyle behind. As incidence of all forms of the illness continues to increase, this new edition is more relevant than ever.

Author Biography

Marilyn Duker is a specialist in the process of recovery from anorexia nervosa/bulimia. Over three decades, and with a wealth of experience in working with sufferers at every stage of the illness, she has integrated theory and practice to establish a unique therapeutic approach. She has provided courses for relatives of sufferers and training for a variety of professional groups, including teachers, pastoral workers, nurses, dietitians and GPs.

Roger Slade obtained his doctorate from the University of Bristol for his work on anorexia nervosa/bulimia and is also author of The Anorexia Nervosa Reference Book. One of the first to apply modern psychological research methods early in the 1970s, his original thinking is distinctive for its clarity and cohesiveness and continues both to inform and to inspire.

Table of Contents

Acknowledgements	xiii
Introduction	1	(6)
Part I	7	(76)
Beginning to unravel the problem	9	(17)
Mysteriousness	10	(2)
The illness as a category problem	12	(2)
The physical illness category	14	(2)
The deliberate action category	16	(1)
Recognizing the condition that is anorexia nervosa	17	(2)
The importance of the 'anorexic attitude'	17	(2)
Distinguishing the food/body control that is characteristically anorexic	19	(3)
Informal observation	19	(2)
Formal measures	21	(1)
The similarities between anorexia nervosa and bulimia	22	(1)
Some medical and other objections to taking the two conditions as one problem	23	(3)
A path through the theories	26	(19)
Two types of theory	26	(1)
Theories and how they relate to what is seen as needing explanation	27	(2)
The practical significance of the theoretical divide	29	(1)
The psychological effects of starvation	29	(4)
Intellectual change	30	(1)
Sexuality	31	(1)
Moods and feelings	31	(2)
Theories that build on the psychological effects of starvation	33	(2)
Starvation as avoidance of sexuality	34	(1)
The starvation whirlpool	35	(3)
Decision making	35	(1)
Food preoccupation and the idea of self	36	(1)
The condition naturally intensifies	36	(2)
Positive ideas about food and body regulation	38	(4)
Fasting	38	(1)
Dieting, slimming and exercising	39	(3)
Professional objections to the idea of starvation effects	42	(1)
The idea of illness	43	(2)
Control by any other name	45	(17)
The dangers of authoritarian intervention	47	(3)
The anorexia nervosa/bulimia board game	50	(3)
Progression around the board	53	(1)
`Advantages' of a bulimic pattern of control	54	(2)
Completing the board game	56	(4)
The helper's dilemma	60	(2)
Bad medicine	62	(21)
False leads: appetite and mood	62	(2)
Treatment objectives	64	(1)
Additional medical interventions and their limitations	65	(2)
Insulin therapy	66	(1)
Electroconvulsive therapy	66	(1)
Surgery	66	(1)
Drug therapy	67	(1)
Taking control of the anorexic patient	67	(2)
Behaviourism: a theoretical rationale for taking control	69	(2)
Legitimating coercion	70	(1)
When black-and-white thinkers meet head on	71	(2)
The use of legal powers to detain and treat the anorexic	73	(1)
The anorexic's alienation from the medical profession	74	(1)
The doctor's point of view	75	(1)
How much weight gain?	76	(2)
The tyranny of assumptions	78	(5)
Sex roles	78	(1)
Thresholds	79	(1)
Overlooking male sufferers	80	(3)
Part II	83	(66)
The picture at low weight and foundations for help	85	(20)
The move to low weight	86	(1)
Different approaches and how weight gain is implicated	87	(2)
Weight gain as a prerequisite to psychotherapy	87	(1)
Gradual weight gain and psychotherapy in parallel	88	(1)
Different meanings of the same words	89	(2)
'Opposing food control'	89	(1)
'Weight' and 'weight gain'	90	(1)
Low weight and non-medical help	91	(2)
Monitoring physical safety	92	(1)
A stepladder for recovery	93	(2)
Mapping low weight	95	(7)
100--85 per cent, and viable weight	95	(1)
The 83--82 per cent AEBW band: alteration	96	(1)
The communication threshold: 81--78 per cent AEBW	97	(1)
Moving towards the classic picture: 75--69 per cent AEBW	98	(2)
Emaciation and danger: 68--50 per cent AEBW	100	(2)
The sufferer's response to the experience of starvation	102	(3)
Viable weight and the picture that is hidden	105	(14)
... but ever more came out by the same door as in I went	106	(1)
Being invisible	107	(1)
The key to the self-starvation whirlpool	108	(1)
Morality	108	(3)
Public rules and personal rules	109	(1)
Public rules from two sources	110	(1)
Worthlessness	111	(3)
Throwing self away	112	(1)
Humiliation in the guise of help	113	(1)
Sensitivity	114	(2)
Responding and responsibility	114	(1)
How sensitivity becomes a burden	115	(1)
External control	116	(1)
Hidden feelings	117	(2)
The culture of control	119	(15)
The female role: only part of the explanation	120	(1)
The Protestant or `work' ethic	120	(3)
The `therapy culture' in conflict with the sufferer's culture	123	(1)
Social standing	124	(1)
Circumstances that intensify commitment to the work ethic	124	(2)
Social mobility	125	(1)
'Missing' people	126	(1)
The transmission of values	126	(2)
Creating the symptoms	128	(3)
The moralization of body regulation	128	(1)
How moral imperatives fit extreme actions	129	(2)
Moving the spotlight away from women	131	(3)
Worst little boys -- or not	131	(3)
On becoming a person: through food control	134	(15)
Being ...	134	(1)
... and nothingness	135	(1)
How is an existential problem to be recognized?	136	(5)
Dither and indecisiveness	137	(1)
Lack of spontaneity	138	(1)
Controlling others ...	139	(1)
... or follow-my-leader	140	(1)
Food/body control: a solution to confusion	141	(1)
The difficulty there is in expressing nothingness	142	(2)
The significance of indecisiveness	144	(1)
Sources of confusion	145	(2)
Gender roles	145	(1)
Trying to make bricks without straw	146	(1)
The danger in resolving sufferers' conflict for them	147	(2)
Part III	149	(110)
Perspectives that maintain the ability to help	151	(15)
Food/body control and the use of alcohol compared ...	151	(1)
... and contrasted	152	(1)
Symptoms of excessive virtue	153	(1)
The preference for physical explanation	154	(1)
Seeing what is there	155	(2)
From praising control to imputing madness	156	(1)
Admiring the anorexic	157	(2)
Becoming drawn in and ineffective as help	159	(1)
Intervention: problems and strategies	160	(3)
Justifying intervention	162	(1)
Self-interpretation and virtue	163	(3)
Different languages and their implicit values	163	(3)
Getting through	166	(15)
Acknowledging the sufferer's style of thinking	167	(2)
Returning to the stepladder	169	(1)
Adjusting for the centrality of food control	170	(4)
Adjusting for altered thinking	174	(2)
Adjusting for low self-esteem	176	(2)
Adjusting for different physical experiences	178	(1)
Adjusting for different implicit values	179	(1)
Nurturing a sense of self	180	(1)
Good medicine	181	(19)
50-65 per cent AEBW: emaciation and medical help	182	(2)
How much time do we have?	182	(2)
50-65 per cent AEBW: communication	184	(1)
Refeeding the anorexic in hospital	185	(2)
Intravenous feeding	186	(1)
Nasogastric-tube feeding	186	(1)
Liquid diet	187	(1)
Ordinary food, with or without liquid supplements	187	(1)
Moderate aims for weight increase	187	(1)
Helping the sufferer feel safe	188	(3)
Refeeding and the need for predictability	191	(4)
Food as medicine	193	(1)
Avoid offering choices	194	(1)
Making hospital staff comfortable	195	(1)
The use of sedatives in hospital	196	(2)
Help: dividing the task: providing continuity	198	(2)
Turning around	200	(16)
How to begin working together?	201	(2)
Working with rather than against control	201	(1)
Offering an experiment	202	(1)
Discovering anorexia nervosa is in control	203	(1)
The inescapability of choice	204	(2)
Allowing the necessary time to choose	206	(3)
Calculating safety: recognizing danger	207	(1)
Anxiety in the helper	208	(1)
Choosing to change	209	(4)
Practical planning for experiment	210	(3)
Learning points	213	(3)
Transition	216	(20)
Catching the sufferer on the way down	218	(1)
Holding the sufferer on the way up	219	(2)
Getting better feels like getting worse	221	(1)
Giving sufferers the appreciation they need	222	(1)
The constructive use of crisis	223	(2)
Further learning points	225	(1)
Withdrawing from therapy too soon	225	(2)
Acting out the chaos	227	(1)
Help and care at viable weight	228	(1)
Patterns of food and body control	228	(1)
Stealing	228	(1)
Seeking oblivion	228	(1)
Self-harm	229	(1)
Using sexuality	229	(1)
Practical responses to the consequences of chaos	229	(7)
Mixed addictions	230	(1)
Giving control back to the sufferer	231	(1)
Overdosing and potential suicide	232	(1)
Stealing	233	(1)
Debt	234	(1)
Sexuality and 'relationships'	234	(2)
Moving towards a real sense of self	236	(23)
Choice, decision and selfhood	238	(1)
Constituent parts of choosing and deciding	239	(1)
Learning to live in the present	239	(1)
Discovering personal rules and core beliefs	240	(4)
Acknowledging the rest of the iceberg	242	(2)
Allowing feelings and emotions	244	(2)
Relating to the world	246	(2)
Integrating the experience of self	248	(3)
Signs and sounds of recovery	251	(2)
Further experiment, self-discovery and real development	253	(6)
Appendix	259	(6)
Index	265