GUIDE TO ED RECOVERY 2016

recovery
Marty Lerner PhD
Defining the Problem and Finding the Solution
eating disorder
A Guide To

Acknowledgments
No program, set of ideas, or distillation of knowledge is possible
without the collective energy and contributions of many. The
compilation of experiences and concepts incorporated within
this book is certainly no exception. Were it not for the generous
contributions and dedication of the people who have worked
at Milestones, as well as, those who remain here, this program,
book, and continuing legacy would not exist. It truly does take
the proverbial “village” to make it all happen.
I would be remiss if I did not give a special thanks to myfamily,
especially my wife, Michele. I suspect I could, and perhaps
should, fill the pages of another book about her patience,love,
support, and, did I mention patience, with me. Aside from being
an inspiration and the love of my life, Michele has taught me
more than anyone else about recovery and getting through the
good and bad times together.
Of course my daughters, Janelle and Danielle are not to be
excluded, they constantly teach me about the value of
tolerance, patience, and unconditional love. I suspect our
children are the legacy we leave behind when all is said and
done.

And, there’s Reggie – the official service dog of Milestones.
Without his bouncing around the halls and group room, Milestones
would not be the same. Actually, a unique thank you is due to all
of our dogs – since just about everyone on the Milestones staff has
a canine member of the family. Biscuits for everyone

FORWARD
Over the course of several years, probably more than I’d like to
admit, the professional community has become split as to how to
view, let alone treat, most eating disorders. If we distill the basic
essence of the division, it would come down to those who viewan
eating disorder as a mental illness and those who look at these
disorders as an addictive disease. What follows comes from the
latter camp. It is the intention of this book to provide both
anecdotal and empirical evidence to support the notion that most
eating disorders fit the accepted criteria common to an addictive
disease. Doing so has significant implications for successful
treatment.
The first section of this book addresses the addiction thesis. In
doing so, reference is made to the American Psychiatric
Association’s most recent description of addiction, as well as, the
criteria it utilizes to diagnose an addictive disorder. This allows the
reader to decide for her, or himself, whether the proverbial shoe
fits. I’ve also added a few articles to provoke additional thoughts
on the matter. As with most addictions, in the end the “addict”
must be able to make the diagnosis him/herself in order to begin
the process of recovery. Doing otherwise does little more than
provide an intellectual framework to further the symptom of
denial.

The second section begins to explore the commonality of eating
disorders and attempts to debunk the belief eating disorders
represent separate and different disease entities. The common
thread existing among the various flavors of eating disorders is
reviewed and the trap of focusing on weight, appearance, and
dieting is exposed. Setting the stage for treatment thus begins with
defining the problem.
The third section begins to look at the recovery process at
Milestones. By distilling the basic elements of long-term recovery,
participants in the program learn about, and most importantly
practice, a set of skills that virtually guarantees freedom from
addictive relationships with their eating disorder. In doing so, “one
day at a time” the physical, emotional, and spiritual symptoms
inherent with an addiction begin to change course and recovery
follows.
The fourth section focuses on maintaining your recovery and how
S.E.R.F (Spirituality, Exercise, Rest and Food Plan) can assistyou.
The fifth section of this book is devoted to continuing care and the
role of support groups such as OA [Overeaters Anonymous],
Anorexics and Bulimics Anonymous [ABA], Alcoholics Anonymous
[AA], Narcotics Anonymous [NA], etc. can help you maintain your
recovery.

The last section addresses insurance concerns with regard to
treatment and the types of questions you should ask any
treatment center before deciding to attend their program. I have
also included several “abstinent” recipes in this final section.
I hope you find this book helpful in your search forrecovery.
Marty Lerner, Ph.D.
Milestones in Recovery, Inc.
© Marty Lerner, Ph.D. May, 2015
All rights reserved. No part of this publication may be
Reproduced without the author’s permission.

Table of Contents
Chapter 1 – The Addiction Thesis for EatingDisorders
Eating Disorders – Addictive or Psychiatric Illness - 1
Table 1.0-Diagnostic Criteria for SubstanceDependency
APA Guideline - 3
Dopamine – the “Feel Good Brain Chemical “– 8
Dopamine, Brain Chemistry and Anorexia – 11
The Case for Commercial Food Addiction – Bloomberg –13
Closing Thoughts – Nature of the Beast- 24
Chapter 2 – Common Denominators in EatingDisorders
Defining the Problem – 29
“If it Walks Like a Duck” – 31
Table 2.1 Similarities among Eating Disorders- 35
Co-existing Addictions and Related Problems – 37
Table 4.1 – The Addiction Pyramid – 39
Table 4.2 – Dual Diagnoses Associated with
Eating Disorders – 42
Cross Addiction and Co-existing Issues – 43
Body Image and Body Dysmorphic Disorder – 43

Internal/External Cues: What makes us Different?- 47
My Friend Harry- 49
The Restricting Side of the ED Coin – 51
And the Good News – Long-term recovery is possible – 53
What Comes First – It’s the Egg – 54
Chapter 3 – Recovering from an EatingDisorder
The Roadmap –
When all Else Fails, Follow the Directions – 57
A Word about Therapy - 58
What Works and What Doesn’t Work - 58
Therapy or Therapeutic Setting- 61
The Secret to Recovery- 64
Living in the Solution: The Hard Work – 66
Principles of Constructive Living- 67
And for the Perfectionist-71
Triggers and the Paula Goldberg Theory- 72
So What, Now What – Move a Muscle, Change a Thought-77
Table 3.1 “Behavior First – 79
In Other Words – Easy does it, but do It! -79

Control Issues – 83
The Foundation of Recovery – S.E.R.F. – Page85
It’s All About the Food – Isn’t it? - 88
To Weigh or Not to Weigh, That is the Question-90
Measuring Recovery- How am I Doing?-92
Chapter 4: Maintaining your Recovery
SERF Lessons- 95
Spirituality – Give me an “S”- 95
An Exercise in Futility – Give me an “E” – 98
Rest, the Balance between work and play-
Give me an “R”- 100
Food Plans: Food for Thought – Give me an “F” – 103
Basic Tenets of a Recovery Food Plan – 106
Healthy Relationships – The 4 A’s – 109
Relationships in Recovery – “Rules of the Road” – 112
Compliance vs Acceptance – 114
The Transition Home – 119
Summary – 120

Chapter 5: Continuing Care after Treatment
12 Step Groups and On-Going Recovery – 124
Open Letter for OA Text – 127
S.M.A.R.T. Recovery – An Alternative or Add on to
12 Step Programs – 132
Continuing Care Resources – 138
Chapter 6: Additional Information
Understanding Insurance for treatment – 141
Abstinent Recipes- 145

Chapter One
The Addiction Thesis for Eating Disorders
"What we see depends mainly on what we lookfor."
- Sir John Lubbock

1
Eating Disorders – Addictive or PsychiatricIllness
The committee of the American Psychiatric Association assigned
the task of defining the criteria for chemical dependency, recently
extended these to include all substance dependencies*. It goes
further to recommend a minimum of three of the seven criteria be
met to justify the diagnosis of dependency. * See Table 1.0 APA
Criteria for Dependency
When we examine an eating disorder from an addictions
perspective, the criteria seems to fit equally well. Although some
would argue that food is not an addictive substance, that debate
goes beyond the scope of this chapter for the moment. The point
is both substances and behaviors are capable of emerging as
addictions. Some of us in the professional community have come
to delineate between substance dependency and addictive
patterns of behavior by coining the term “process addictions” for
the latter. As far as I’m concerned, “a rose is a rose” no matter
what you care to name it.
Perhaps the following quote from the American Society of
Addiction Medicine’s task force on addiction best summarizes the
true nature of addiction, and in effect, an eating disorder.

2
“Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in these
circuits leads to characteristic biological, psychological, social and
spiritual manifestations. This is reflected in the individual pursuing
reward and/or relief by substance use and other behaviors. The
addiction is characterized by impairment in behavioral control,
craving, inability to consistently abstain, and diminished
recognition of significant problems with one’s behaviors and
interpersonal relationships. Like other chronic diseases, addiction
involves cycles of relapse and remission. Without treatment or
engagement in recovery activities, addiction is progressive and can
result in disability or premature death.” *American Society of
Addiction Medicine, 2012
To see if “the shoe fits”, you might take the quote above and simply
insert the phrase eating disorders in lieu of the word addiction.
Likewise, the words restricting, purging, binge eating, and so forth
could be inserted. In my professional experience, the shoe fits
quite well. It may be time to look at an eating disorder with respect
to its’ real nature rather than surface appearances. The
implications for treatment and long-term recovery areprofound.
Let’s take a moment and review the seven criteria the APA lists as
symptomatic of dependency [aka addiction]. I’ve added a few
comments for each criterion relating it to an eating disorder.

3
Table 1.0
DSM V: Diagnostic Criteriafor Substance Use Disorders*
1 – Tolerance (marked increase in tolerance amount; marked
decrease in effect)
Anorexia – need for continued weight loss or restriction of
caloric intake to experience same effect and avoid negative
emotional state. Bulimia and Binge Eating Disorder – need for
increased frequency and amount to achieve the same physical
/ emotional effect.
2 – Characteristic withdrawal symptoms; substance taken to
relieve withdrawal
In many instances, perhaps not as "dramatic" as drug
withdrawal, the phenomenon of craving, as well as symptoms
of irritability, loss of concentration, headaches, and a variety
of other physical symptoms similar to hypoglycemia and
alcohol withdrawal, may be experienced. Depression and
anxiety are common effects of withdrawal from binge eating and
bulimia. Weight restoration is often associated with short-term
anxiety and depressed mood among those suffering with
anorexia.

4
3– Substance taken in larger amounts and for longer periods
thanintended
Anorexia - decreased body weight is never enough – continued
pursuit of thinness persists despite achievement of weight
goals.
Bulimia and Binge Eating – “I’ll quit tomorrow” phenomenon or
continuing with binge eating and/or purging much longer than
planned, resulting in missed work or social obligations.
4– Persistent desire or repeated unsuccessful attempts to quit
Bulimia and Binge Eating – attempts to stop may include
restricting in order to avoid binge eating or “the need to undo
damage” with purging. Anorexia - intending to increase intake,
but too fearful or unable to judge adequate amount. Repeated
attempts to restore weight marked by repeated periods of
relapse.
5– Increased time/activity/energy spent to obtain, use, and
recover
Common to all eating disorders – time, money, energy to
sustain eating disordered behaviors and increased time needed
to recover from effects

5
6– Social, occupational or recreational activities given up or
reduced
Common to all eating disorders – social isolation, as well
as, diminished activities that interfere with eating disordered
patterns.
7 – Use continues despite knowledge of adverse
consequences (e.g., failure to fulfill role obligations, uses when
potentiallyphysicallyhazardous)
Common to all eating disorders – continued eating
disordered behaviors, despite physical, emotional, social, o r
financial consequences.
*DSM IV R- American Psychiatric Association/American Society of
AddictionMedicine
*Meeting a minimum of three criteria is sufficient for a diagnosis
of substance dependency [DSM IV-R]. DSM V-now defines a
substance use disorder with three subtypes: mild, moderate, or
severe. See: DSM V SUBSTANCE USECRITERIA
In recent years the addiction model, at least as it applies to bulimia,
binge eating, and anorexia has been the subject of an expansive

6
body of research. A terrific summary of this appears in the newly
published text “Food and Addiction” edited by Kelly Brownell and
Mark Gold, Oxford University Press, 2012. The concentration of
this effort has ranged from an exploration of the nature of certain
properties of [mostly refined] foods to the neurobiology and
physiology of [eating disorders] addiction. There appears to be an
interaction between the nature of the substance [addicting or non-
addicting] and the nature of the person [addict or non-addict].
Hence, it is difficult to pin the blame only on the substance without
consideration of the person. For example, morphine is quite
addictive but not all patients receiving this drug to control pain
become “addicts.” Still others, who have a history of addiction, are
more vulnerable to becoming dependent on the drug. We know
today sugar and its’ many derivatives is addicting as a substance.
However, addiction to sugar is both dose and length of exposure
dependent, as well as, being influenced by the person consuming
it. This is to say it takes “two to tango” - with the substance needing
to interact with a predisposed and willingsubject.
The most compelling evidence to date seems to have come to light
with the brain mapping capabilities of modern radiographic
imaging (PET Scan/brain imaging). Sparing the reader the technical
side of this, researchers have been able to locate and display areas
of the brain reacting to substances and stimuli in ways that
differentiate the addict from the non-addict. Furthermore, we now

7
better understand the “reward system” in the brain. We can clearly
see differences between dependent and non-dependent subjects.
Dopamine has been shown to be a primary “feel good” chemical in
the brain. Researchers have uncovered a stunning similarity
between chronic cocaine and stimulant abusers, and compulsive
eaters and bulimics – namely all have shown deficits in dopamine
concentrations and dopamine receptors on their PET scans. The
control subjects [non-addicts] did not display the same deficits. In
yet another study, the two groups were exposed to just pictures of
cocaine or, for overeaters, highly palatable desserts. The visual
cues alone caused a marked increase in dopamine activity among
the cocaine and ED subjects, but not so with their non-addict
peers. So, both an external cue [visual], as well as, the actual
consumption of the substance can elicit changes in brain
chemistry. This is what behaviorists call classical conditioning.
I’ve included an article I wrote summarizing the chemistry involved
with many eating disorders. The focus of the article looks at the
role of one of the basic neurotransmitters we spoke about –
dopamine. As mentioned, dopamine has been studied with respect
to its role in addiction. The progression from use, to abuse, to
dependency likely involves the interplay of amount, duration, and
individual predisposition – whether we speak of a drug or an eating
disorder.

8
Dopamine- the “Feel Good Brain Chemical”*
In an article on the role of dopamine and dopamine receptors from
a March 2010 edition of "Neuroscience" - a well-known and
respected professional journal, the researchers found a significant
difference between laboratory animals that were "over-fed" and
exposed to unlimited amounts of sugar laden and highly processed
[junk] foods versus controls fed regular rat chow. Indeed, the junk
food rats developed an "addiction-like reward deficit" with
dopamine concentrations. The virtual destruction of D2dopamine
receptors in the brain accounts for this.
Translation - over time, when overeating highly "palatable" foods
(e.g. sugar, high fat) they [rats] developed deficits in their ability to
properly assimilate the neurotransmitter dopamine. Deficits in
dopamine are seen with cocaine addicts when they are "crashing"
and withdrawing from cocaine - they become depressed and their
appetite becomes almost insatiable. Likewise, the deficit in
dopamine for binge eaters and bulimics tends to increase over
time with the result being a biological (addictive) propensity to
repeat episodes of disordered eating with greater frequency. Of
course we’ve come to know this phenomenon as tolerance. For the
bulimic, the misguided attempt to deal with this is purging or
alternating between periods of binge eating and restricting, for the
compulsive overeater, controlling this addictive cycle gives way to

9
another "diet". Whether this mechanism plays a role with forms of
anorexia is still a subject for speculation. I suspect the addictive
process with restricting is similar.
Much like the cocaine user who becomes an abuser and then an
addict, neurotransmitters (dopamine receptors) are eventually
destroyed. The only relief is...more cocaine for the fewer receptors
available. The phenomenon of tolerance takes hold and theaddict
needs more of the substance to achieve the desired effect until no
matter how much substance is available it no longer works as it did
in the beginning stages. In fact, in most end stage addictions the
best one can hope for is to postpone withdrawal symptoms.
Addiction thus becomes a full-time career.
The "food addict" may begin abusing food and develops a similar
"tolerance" to refined carbohydrates (sugar, flour) or greater
volumes of food and, likewise, alters the brain's (reward) structure
(dopamine receptors) and the physical addiction to overeating
takes hold. A similar mechanism exists with purging, as applied to
endorphin metabolism. With anorexia the starvation process
creates a sort of tolerance as the body fights to survive and the
anorexic must restrict more and more to maintain the sameeffect
[e.g. avoid weight gain and control despair and anxiety]. Thereare
a few studies to suggest the stress hormone cortisol plays a rolein
this process much like the neurotransmitters in the brain.

11
As with cocaine addicts, it's likely that over any extended period of
time, the mechanisms responsible for manufacturing and making
available dopamine at normal levels will re-emerge... provided the
"addict" adheres to a prescribed course of treatment (e.g. abstains
from the offending substance - cocaine or, for the food addict, the
combination of high-glycemic foods and over feeding [exorbitant
volume]. Likewise, proper nutrition and restoration of a
reasonable BMI would likely have a similar effect for the restricting
forms of eating disorders.
The first step in recovery is recognizing the importance of
abstaining from the offending substance[s] and behavior[s]. Those
with an eating disorder may need to consider a food plan that does
not evoke a physical craving. The current body of research suggests
the more highly processed a food substance is the more likely it is
to heighten the potential for abuse and dependency. The
exponential increase with childhood obesity and early onset
diabetes is directly related to this phenomenon. The evidence has
become overwhelming.
References:
Marty Lerner, PhD .2012
http://www.selfgrowth.com/experts/marty-lerner-phd
Laboratory of Behavioral and Molecular Neuroscience, Dept. of
Molecular Therapeutics
- Published 3/2010 in Nature Neurosciences
Neuroanatomy of Addiction, George Koob, 2012 in Food and
Addiction by Brownell and Gold, Oxford Press, 2012

10
Dopamine, Brain Chemistry, and Anorexia
While we’re touching on the subject of the anorexic side of the
coin, I thought I might add some of the more recent thinking about
the role of brain chemistry and anorexia. There is a divergent group
of brain imaging folks who believe dopamine also plays a role in
disrupting the experience of hunger and appetite with those who
restrict.
There are basically two theories on the table today. The first
suggests overeating types of eating disorders involve dopamine
serving as the “reward” and feel good chemical released when
overeating. However, with the restricting forms of eating disorders
such as anorexia, the experience of increased dopamine
concentrations when eating is unpleasant. Hence, the feelings
associated with eating are negative for someone with anorexia and
rewarding for someone with compulsive overeating orbulimia.
Another group of scientists are looking into the effects of fasting
or restricting on dopamine levels for anorexics - the idea being a
similar surge of “feel good” dopamine, but this time stimulatedby
restricting to the point of starving. In other words, there may be a
phenomenon for some people to “feel rewarded” by severely
restricting their calorie intake. Accordingly, the more one restricts,
at least in the early stages of anorexia, the more dopamine is

12
released, the more rewarded they are, and the more reinforced
restricting behavior becomes. No one knows why some are prone
to this end of the eating disorder spectrum as opposed to the
other. In sum, this hypothesis suggests that dopamine “rushes”
affect anorexics and overeaters alike, but for one group starving
releases the chemical and for the other binge eating does the trick.
Here is an excerpt from Walter H. Kaye, M.D., one of the
researchers at the University of California, San Diego who is
looking into the above theories. His comments also touch upon a
possible explanation for the body image distortions inherent with
anorexia.
“The reason (anorexics) can go on a diet and lose all weight is that
their brain is not responding in a way that is driving eating.”
Whether it’s not responding to the sensory aspect, it is not the
right signal about food, or it’s not rewarding, we don’t really
understand, but there’s something different about these
homeostatic mechanisms.”
“The area of the brain known as the insula, is important for
appetite regulation and also for something called interceptive
awareness, which is the ability to perceive signals from the body
like touch, pain, and hunger. It’s possible that some of the
problems anorexics have regarding body image distortion can be

13
related to alterations of interceptive awareness. There may be
some disregulation of insula function. This may, in part, explain
why a recovering anorexic can draw a self-portrait of their body
image that is typically 3 times its actual size.” To quote from
someone with this experience who is now recovering, “I was down
to 80 pounds at five-foot six,” she says. “My self-portrait was so
distorted I was able to lie down inside the drawing, but that’s how
I saw myself."
A reprint from an article published in Bloomberg News serves as
an excellent summary of the evidence pertaining to the addictive
nature of highly processed [junk] foods. Written by investigative
journalists Robert Langreth and Duane Stanford, the article
explores the social, economic, and biological impact of food
addiction and provides a rather convincing indictment of the
companies profiting from these products. Here is a [reprint] of the
Bloomberg article
The Case for Commercial FoodAddiction
REPRINT- Bloomberg News, April 2011
Robert Langreth and Duane Stanford, investigativereporters
A growing body of medical research at leading universities and
government laboratories suggests that processed foods and sugary

14
drinks made by the likes of PepsiCo Inc. and Kraft Foods Inc. (KFT)
aren’t simply unhealthy, they can hijack the brain in ways that
resemble addictions to cocaine, nicotine and other drugs. “The
data is so overwhelming the field has to accept it,” said Nora
Volkow, Director of the National Institute on Drug Abuse.
“We are finding a tremendous overlap between drugs in the brain
and food in the brain.”
The idea that food may be addictive was barely on scientists’ radar
a decade ago. Now the field is heating up. Lab studies have found
sugary drinks and fatty foods can produce addictive behavior in
animals.
Brain scans of obese people and compulsive eaters, meanwhile,
reveal disturbances in brain reward circuits similar to those
experienced by drug abusers. Twenty-eight scientific studies and
papers on food addiction have been published this year, according
to a National Library of Medicine database. As the evidence
expands, the science of addiction could become a game changer
for the $1 trillion food and beverageindustries.
If fatty foods, snacks, and drinks sweetened with sugar and high
fructose corn syrup are proven to be addictive, food companies
may face the most drawn-out consumer safety battle since the

15
anti-smoking movement took on the tobacco industry a generation
ago.
‘Fun-for-You’
“This could change the legal landscape,” said Kelly Brownell,
director of Yale University’s Rudd Center for Food Policy & Obesity
and a proponent of anti-obesity regulation. “People knew for a
long time cigarettes were killing people, but it was only later they
learned about nicotine and the intentional manipulation of it.”
Food company executives and lobbyists are quick to counter that
nothing has been proven with what PepsiCo Chief Executive Officer
Indra Nooyi calls “fun-for-you” foods, if eaten in moderation. In
fact, the companies say they’re making big strides toward offering
consumers a wide range of healthier snacking options. Nooyi, for
one, is as well known for calling attention to PepsiCo’s progress
offering healthier fare as she is for driving sales. Coca-Cola Co.
(KO), PepsiCo, Northfield, Illinois-based Kraft and Kellogg Co. of
Battle Creek, Michigan, declined to grant interviews with their
scientists. No one disputes that obesity is a fast growing global
problem. In the U.S., a third of adults and 17 percent of teens and
children are obese, and those numbers are increasing. Across the
globe, from Latin America, to Europe to Pacific Island nations,
obesity rates are also climbing.

16
Cost to Society
The cost to society is enormous. A 2009 study of 900,000 people,
published in The Lancet, found that moderate obesity reduces life
expectancy by two to four years, while severe obesity shortens life
expectancy by as much as 10 years. Obesity has been shown to
boost the risk of heart disease, diabetes, some cancers,
osteoarthritis, sleep apnea and stroke, according to the Centers for
Disease Control and Prevention. The costs of treating illness
associated with obesity were estimated at $147 billion in 2008,
according to a 2009 study in HealthAffairs.
Sugars and fats, of course, have always been present in the human
diet and our bodies are programmed to crave them. What has
changed is modern processing that creates food with concentrated
levels of sugars, unhealthy fats and refined flour, without
redeeming levels of fiber or nutrients, obesity experts said.
Consumption of large quantities of those processed foods may be
changing the way the brain is wired.
A Lot Like Addiction
Those changes look a lot like addiction to some experts. Addiction
“is a loaded term, but there are aspects of the modern diet that
can elicit behavior that resembles addiction,” said David Ludwig,a

17
Harvard researcher and Director of the New Balance Foundation
Obesity Prevention Center at Children’s Hospital Boston. Highly
processed foods may cause rapid spikes and declines in blood
sugar and increased cravings, his research has found.
Education, diets and drugs to treat obesity have proven largely
ineffective and the new science of obesity may explain why,
proponents say. Constant stimulation with tasty, calorie-laden
foods may desensitize the brain’s circuitry, leading people to
consume greater quantities of junk food to maintain a constant
state of pleasure. In one 2010 study, scientists at ScrippsResearch
Institute in Jupiter, Florida, fed rats an array of fatty and sugary
products including Hormel Foods Corp. (HRL) bacon, Sara Lee Corp.
(SLE) pound cake, The Cheesecake Factory Inc. (CAKE) cheesecake
and Pillsbury Co. Creamy Supreme cake frosting. The study
measured activity in regions of the brain involved in registering
reward and pleasure through electrodes implanted in the rats.
Binge-Eating Rats
The rats that had access to these foods for one hour a day started
binge eating, even when more nutritious food was available all day
long. Other groups of rats that had access to the sweets and fatty
foods for 18 to 23 hours per day became obese, Paul Kenny, the
Scripps scientist heading the study wrote in the journal Nature

18
Neuroscience. The results produced the same brain pattern that
occurs with an escalating intake of cocaine, he wrote. “To see food
do the same thing was mind-boggling,” Kenny later said in an
interview.Researchers are finding that damage to the brain’s
reward centers may occur when people eat excessive quantities of
food.
Sweet Rewards
In one 2010 study conducted by researchers at the University of
Texas in Austin and the Oregon Research Institute, a nonprofit
group that studies human behavior, 26 overweight young women
were given magnetic resonance imaging scans as they got sips of a
milkshake made with Haagen-Dazs ice cream and Hershey Co.
(HSY)’s chocolate syrup.
The same women got repeat MRI scans six months later. Those
who had gained weight showed reduced activity in the striatum, a
region of the brain that registers reward, when they sipped
milkshakes the second time, according to the study results,
published in the Journal of Neuroscience.
“A career of overeating causes blunted reward receipt, and this is
exactly what you see with chronic drug abuse,” said Eric Stice, a
researcher at the Oregon Research Institute. Scientists studying

19
food addiction have had to overcome skepticism, even from their
peers. In the late 1990s, NIDA’s Volkow, then a drug addiction
researcher at Brookhaven National Laboratory on Long Island,
applied for a National Institutes of Health grant to scan obese
people to see whether their brain reward centers were affected.
Her grant proposal was turned down.
Finding Evidence
“I couldn’t get it funded,” she said in an interview. “The response
was there is no evidence that food produces addictive-like
behaviors in the brain.” Volkow, working with Brookhaven
researcher Gene-Jack Wang, cobbled together funding from
another government agency to conduct a study using a brain-
scanning device capable of measuring chemical activity inside the
body using radioactive tracers. Researchers were able to map
dopamine receptor levels in the brains of 10 obese volunteers.
Dopamine is a chemical produced in the brain that signals reward.
Natural boosters of dopamine include exercise and sexualactivity,
but drugs such as cocaine and heroin also stimulate the chemical
in large quantities. In drug abusers, brain receptors that receive the
dopamine signal may become unresponsive with increased drug
usage, causing drug abusers to steadily increase their dosage in
search of the same high. The Brookhaven study found that obese

21
people also had lowered levels of dopamine receptors compared
with a lean control group.
Addicted to Sugar
The same year, psychologists at Princeton University began
studying whether lab rats could become addicted to a 10 percent
solution of sugar water, about the same percentage of sugar
contained in most soft drinks.
An occasional drink caused no problems for the lab animals. Yet
the researchers found dramatic effects when the rats were
allowed to drink sugar-water every day. Over time they drank
“more and more and more” while eating less of their usual diet,
said Nicole Avena, who began the work as a graduate student at
Princeton and is now a neuroscientist at the University ofFlorida.
The animals also showed withdrawal symptoms, including anxiety,
shakes and tremors, when the effect of the sugar was blocked with
a drug. The scientists, moreover, were able to determine changes
in the levels of dopamine in the brain, similar to those seen in
animals on addictive drugs. “We consistently found that the
changes we were observing in the rats binging on sugar were like
what we would see if the animals were addicted to drugs,” said
Avena, who for years worked closely with the late Princeton

20
psychologist, Bartley Hoebel, who died this year. While the animals
didn’t become obese on sugar water alone, they became
overweight when Avena and her colleagues offered them water
sweetened with high-fructose corn syrup. A 2007 French
experiment stunned researchers when it showed that rats prefer
water sweetened with saccharine or sugar to hits of cocaine --
exactly the opposite of what existing dogma would have
suggested.
“It was a big surprise,” said Serge Ahmed, a neuroscientist who led
the research for the French National Research Council at the
University of Bordeaux. Yale’s Brownell helped organize one of the
first conferences on food addiction in 2007. Since then, a protégé,
Ashley Gearhardt, devised a 25-question survey to help
researchers spot people with eating habits that resemble addictive
behavior.
Pictures of Milkshakes
She and her colleagues used magnetic resonance imaging to
examine the brain activity of women scoring high on the survey.
Pictures of milkshakes lit up the same brain regions that become
hyperactive in alcoholics anticipating a drink, according to results
published in the Archives of General Psychiatry in April. Food
addiction research may reinvigorate the search for effective

22
obesity drugs, said Mark Gold, who chairs the Psychiatry
Department at the University of Florida in Gainesville. Gold said
the treatments he is working on seek to alter food preferences
without suppressing overall appetite.
Developing Treatments
“We are trying to develop treatments that interfere with
pathological food preferences,” he said. “Let’s say you are addicted
to ice cream, you might come up with a treatment that blocked
your interest in ice cream, but doesn’t affect your interest in
meat.”
In related work, Shire plc (SHP), a Dublin-based drug maker, is
testing its Vyvanse hyperactivity drug in patients with binge-eating
problems. Not everyone is convinced. Swansea University
psychologist David Benton recently published a 16-page rebuttal
to sugar addiction studies. The paper, partly funded by the World
Sugar Research Organization, which includes Atlanta-based Coca-
Cola, the world’s largest soft-drink maker, argues that food doesn’t
produce the same kind of intense dopamine release seen with
drugs and that blocking certain brain receptors doesn’t produce
withdrawal symptoms in binge-eaters, as it does in drugabusers.
*Vyvance has since been approved for distribution by the FDA

23
for the treatment of Binge Eating Disorder as of 2015.
Industry Response
What’s still unknown is whether the science of food addiction has
begun to change the thinking among food and beverage
companies, which are, after all, primarily in the business of selling
the Doritos, Twinkies and other fare people crave. About 80
percent of purchase, New York-based PepsiCo’s marketing budget,
for instance, is directed toward pushing salty snacks and sodas.
Although companies are quick to point to their healthier offerings,
their top executives are constantly called upon to reassure
investors those sales of snack foods and sodas are showingsteady
growth. “We want to see profit growth and revenue growth,” said
Tim Hoyle, director of research at Haverford Trust Co. in Radnor,
Pennsylvania, an investor in PepsiCo, the world’s largest snack-
food maker. “The health foods are good for headlines, but whenit
gets down to it, the growth drivers are the comfort foods, the
Tostitos and the Pepsi-Cola.”
Little wonder the food industry is pushing hard on the idea that the
best way to get a handle on obesity is through voluntary measures
and by offering healthier choices. The same tactic worked for a
while, decades ago, for the tobacco industry, which deflected

24
attention from the health risks and addictive nature of cigarettes
with “low tar and nicotine” marketing.
Food industry lobbyists don’t buy that argument -- or even the idea
that food addiction may exist. Said Richard Adamson, a
pharmacologist and consultant for the American Beverage
Association: “I have never heard of anyone robbing a bank to get
money to buy a candy bar, ice cream or pop.”
To contact the reporters on this story: Robert Langreth in New York
at rlangreth@bloomberg.net; Duane D. Stanford in Atlanta at
dstanford2@bloomberg.net
Closing Thoughts –The Nature of the “Beast”
I’ve chosen a few articles to articulate the physical addiction thesis
representing a sample of what is now appearing in the scientific
literature. One might then assume it reasonable to give
consideration not just to the amount of food prescribed, but its
possible effects on the body. As mentioned, addiction is a complex
interaction between substances and individuals. There is both a
potential for physical dependency, as well as, a psychological one.
Despite the fact people with an eating disorders may vary as to
which of these plays the greater role, suffice it to say both must be
addressed.

25
Likewise, we need to acknowledge the addictive nature of
restricting and the compulsive pursuit of weight loss and resulting
fears surrounding weight gain seen with anorexia. Here the nature
of the substance, food in this case, may be less a factor than the
psychological and physical effects of restricting and resultant
weight loss. However, I would suggest consideration of both the
quantity, as well as, types of food prescribed are equally
important. Given the risk of replacing one form of an eating
disorder for another, a recovery program giving credence to the
characteristics of foods tends to minimize some of this risk. Yes,
quantity is important, but so is the integrity of the food. Programs
encouraging participants to consume “high calorie” foods to insure
rapid weight gain may be setting someone up for developing yet
another form of their disorder. Furthermore, there are other
physical consequences of rapid weight gain and an ill-advised re-
feeding protocol – some of which can be lifethreatening.
For the compulsive overeater and the like, including controlled
portions of junk foods into the food plan carries the risk of giving
short-term success followed by a full blown relapse back into the
eating disorder. Some might argue this point, but I would suggest
it's similar to teaching an alcoholic controlled drinking. He or she
might be successful in a structured setting for a period of time, but
in all likelihood, experience an even worse problem than they had
before beginning treatment.

26
Like many addictive diseases, someone with an eating disorder is
prone to “negotiate” with their disease and, in effect, only change
its' form. Examples of this phenomenon abound in the addiction
world. An alcoholic gives up drinking by replacing alcohol with
tranquilizers. Giving up cocaine, someone resorts to “only smoking
pot.” The compulsive gambler pledges to only “invest” in the stock
market or to only buy a lottery ticket. No longer restricting, the
anorexic begins compulsively exercising to “make up for” the
increased calories consumed while rationalizing they are no longer
starving themselves. Further, the bulimic sufferer can be deluded
into thinking they have found the solution to binging and purging
by restricting. Of course this tends to lead to an even worse relapse
sooner or later.
In my experience, most people with an eating disorder will
eventually experience different forms of the illness throughout the
life cycle of their illness, until they find their footing in recovery.
Regardless of their body weight or appearance, most go througha
bulimic phase, a restricting one, and a compulsive overeating stage
over the course of their disease. For example, someone suffering
with bulimia believes by restricting and not “needing” to purge,
they’ve solved their bulimia problem. Trading in bulimia to become
anorexic is not recovery and vice versa. The denial factor usually is
analogous to trading deck chairs on the Titanic in an effort to avoid
drowning.

27
The bottom line here gets down to recognizing the addictive
nature of an eating disorder and at the same time, accepting the
need for more than a one-sided approach to treatment. To be
clear, the need to respect the addictive nature of certain foods, as
well as, the relentless focus on body weight or body image is a
necessary beginning. However, a program of recovery that limits
itself to only the food and weight piece of the puzzle will likely land
short of the mark. To paraphrase our beloved friend Albert
Einstein, “the same mindset that created the problem cannot be
the same one that formulates the solution.”
Additional References and Suggested Reading:
• Brain Chemistry, Robert Lefever, M.D. and Marie Shafe,
Ed.D.Reprint available upon request via
mlerner@MilestonesProgram.Org
• Opiate-like effects of sugar on gene expression in reward
areas of the rat brain, Spangler, R., Wittkowski, K.M.,
Hoebel, - Laboratory Of Behavioral Neuroscience, The
Rockefeller University, N.Y., N.Y. 2004
Reprint available upon request via
mlerner@MilestonesProgram.Org
• Anatomy of a Food Addiction, Anne Katherine
Text available for Purchase via Amazon.com
or Milestones Bookstore
• Food and Addiction, A Comprehensive Handbook, Edited
by Kelly Brownell and Mark Gold, Oxford Press, 2012
Text available via Oxford Press orAmazon.com

28
Chapter Two
Common Denominators for Eating Disorders
"Everyone is kneaded out of the same dough,
but not baked in the same oven."
Yiddish Proverb

29
Defining the Problem…
Ok, let’s take a moment and “think outside the box” and ask what
all these different “flavors” of disordered eating have in common
rather than what separates them? Is it not true most people,even
medical and mental health professionals, tend to identify and
define an eating disorder in terms of how someone looks or how
overweight or underweight they appear? After all, how can one
suffer with an eating disorder if they don’t appear eating
disordered? And, how is it possible someone can admit to having
an issue with abusing food, excessive dieting, or compulsive
exercising, and not show outward signs?
Even more striking is this perception is too often supported by
many of the treatment programs and self-help groups intendedto
help people find their way into recovery. In effect, this seems to
overshadow the fact that, recovery is about more than just
changing someone’s weight or eating behavior. For most people
with a bona fide eating disorder, body weight and body image
perception are a set of symptoms and [excuse the pun] not the
whole enchilada. Fact is, not all underweight people suffer with
anorexia and not all overweight people suffer with a binge eating
disorder. Suffice it to say there may be a difference between a
weight disorder and an eating disorder. Again, I refer the reader to

31
the APA guidelines [criteria] for dependency to delineatebetween
a weight problem and an eating disorder. (See ChapterOne)
It would seem many people who do not have first-hand experience
of an eating disorder “miss the boat” in this respect. Truth be told,
this is similar to what most people once believed about alcoholism
and drug addiction: alcoholics all wear sneakers, trench coats,and
live under bridges, while all drug addicts live on the streets and
steal money for drugs, and so on. We know differently today. The
overwhelming majority of chemically dependent people cannot be
“picked out of a crowd.” That said, I’d suggest we revisit the
stereotypes many of us have with respect to eating disorders.
This leads us to a retooling of the defining characteristics of all
eating disorders and an assumption I would present to the reader
for consideration.
Eating Disorders are best defined by the degree the relationship
with food and/or body image diminishes the quality of
someone’s life.
A helpful suggestion for newer members of 12-Step programs is to
“identify and not compare.” The reasoning behind this suggestion
is to not provoke the newcomer into a form of denial by telling
themselves something along the lines of “I’m really not as bad as”

30
or “I don’t do what they do every day.” I suspect we could go on,
but you get the idea. The “identifying” piece is about relating to
the experiences and feelings of the other members. To be clear,
anyone suffering with an eating disorder can relate to the feelings
of despair after repeated attempts to “control” their addiction.
Both the anorexic and the compulsive overeater can relate to the
feelings of shame and fear, as it relates to their discomfort with
their body and relationship with food.
What binds people together is more relevant to recovery than
finding what’s unique or different about them. This places
everyone on equal footing regardless of age, gender, socialstatus,
race, religious background, etc. In the end, the common thread
that runs through the community at Milestones has to do with
seeing similarities, not differences and an honest desire to find the
way to recovery. Understanding that as a group, they are able to
do for the individual what they were not able to do alone, is one of
the most important concepts within a therapeutic community.
There is a collective energy, or if you will, a power greater than the
individual at work here.
“If it walks like a duck….”
Just about anyone who has attended a support group such asOA*
or ABA* for a few weeks will likely hear “their story” told by

32
another member. The effect of one person’s experiences shared
with a fellow having the same experiences is, to quote a related
program, “unparalleled.” Once the initial layer of the onion is
peeled, namely the “what makes me different than these people,”
the stage is set for identification rather than comparison. The
question then becomes, “so what do I have in common with
everyone here?” From that point forward, the focus begins to
center more on the solution – “what do I need to do to recover?”
Doing otherwise leaves someone with over analyzing the problem
and little energy left to begin work on the solution.
*OvereatersAnonymous[http://www.oa.org]
*AnorexicsandBulimicsAnonymous[http://aba12steps.org/]
Aside from meeting at least three of the criteria for dependency
we read about in the previous section, eating disorders tend to
have in common the relentless attempt to control how we feel.
Although we’ll look at this more in depth in the next section, I
would suggest that all eating disorders are motivated by an intense
desire to fix or avoid an unpleasant feeling. Although the feeling
may vary within and among persons, the end game remains the
same – control, fix, and change the feeling / discomfort du jour.
One variant on this theme comes from a summary statement made
by a very famous psychoanalyst, Carl Jung. Although I may be

33
accused of butchering his quote for the purpose of making a point,
let’s look at what Carl said:
“All neurotic behavior is an attempt to avoid legitimate
suffering.” – Carl Jung
Restating his rather astute observation, I would suggest…
“Addictions are an attempt to avoid legitimate suffering and, by
this line of reasoning, eating disorders become another way to
avoid legitimate suffering” –
Jung was referring to the symptoms of “his neurotic patients". Let’s
take the compulsive hand washer and his constant fear of germs.
For Carl Jung, this often represents a person’s attempt to control
germs because he is unable or unwilling to admit feeling out of
control in other areas of his life. Perhaps a stretch for some of you,
but consider how often a ”habit” like smoking, biting your nails,
compulsively shopping, or overworking is really a means of
avoiding or distracting us from something uncomfortable and
beyond our control. Again, the point is we often engage in
potentially compulsive or addictive behaviors in a misguided
attempt to “manage” unpleasant feelings. The notion ofaccepting
rather than immediately “fixing” our discomfort is foreign to many
of us.

34
Over time, too much avoidance and distraction have the potential
of becoming addictive, as our tolerance for discomfort becomes
less and less and our need to find relief grows stronger. Unless we
find a more appropriate and less destructive means of reacting to
“legitimate suffering” we are prone to creating a number of
compulsive and addictive behaviors.
Although I would hardly count myself in the same category as Carl
Jung, I do believe he was on to something back in his day. After all,
people do not starve themselves, make themselves sick, take
handfuls of laxatives, binge eat until they’re in pain, exercise to the
point of exhaustion, or engage in any number of painful actions
unless they are attempting to avoid or change their emotional
state. As mentioned, what we see with eating disorders is a
progression of first attempting to feel better followed by an
attempt to delay or avoid feeling bad [withdrawal] in the later
stages. I’ve seen this to be as true for someone in the midst of
anorexia as someone struggling with a binge eating disorder. The
same can be said for almost alladdictions.
Another similarity within the ED population has to do with the
incidence of coexisting mood disorders. More often than not
recurring depression, anxiety, and marked mood swings come with
the territory. In addition, more than half the people seeking
treatment have histories of abusing alcohol, drugs, and/or other

35
forms of self-abusive behaviors like cutting. Regardless of the
particular eating disorder, it’s rare to see someone with an ED
without an accompanying mood disorder, chemical dependency,
or self-abuse issue.
Table 2.1
Similarities among the EatingDisorders
- The majority of people with an ED meet the established
criteria for [addiction] dependency per the same criteria
typically reserved for substance dependencies*.
- ED behaviors are initiated in an attempt to avoid or change
uncomfortable feelings - usually negative feelings and
emotional states.
- Most eating disorders typically are associated with a mood
disorder that often pre-dates the beginning of the eating
disorder.
- Regardless of ED type, at least half the people coming to
treatment for an ED also have abused alcohol, drugs, or
relied on additional forms of self-medication.

36
- Having an ED makes someone vulnerable to “switching
addictions” throughout the life cycle of their ED.
- Independent of the form of ED, control issues are a central
theme needing to be addressed – first with food and
weight, and later with other areas of daily living such as
relationships.
- With the exception of some subtypes of anorexia, most
people suffering with an eating disorder react to certain
foods [e.g. sugar derivatives, refined flours, highly
processed junk foods, etc.] differently than their non-
eating disordered peers. *see D2 receptors and eating
disorders
- Both psychological and physiological factors are inherent
among all forms of eating disorders. Physical dependency
and psychological dependency interact to create an
addictive relationship with food, body weight, and/or
dieting.
- Long-term recovery from an eating disorder requires
significantly more than a temporary change in someone’s
body mass index [BMI / weight / appearance] and eating
pattern.

37
- Recovery often requires the ongoing participation in a
support group or a continuing care plan after formal
treatment ends.
- Appropriate [non-habit forming] medication[s] usually are
needed to treat co-occurring depression or a similar issue
accompanying an eating disorder. In many instances, the
mood disorder is a “stand alone” diagnosis that exists with
or without the ED.
- Most people with an eating disorder have some level of
impairment with an ability to differentiate between
hunger [physical needs] and appetite [psychologically
driven]. – internal versus external cues of hunger
- As with other addictions, remission is a more realistic
expectation with treatment outcome rather than a “cure.”
In effect, addiction is a life-long disease that can be
arrested by remaining engaged in consistent recovery
related activities. Remission can be life-long or short-term.
Co-Existing Addictions and RelatedProblems
Those of us who have been in and around the recovering
community are quite aware of the prevalence of eating disorders
within the fellowships of Alcoholics Anonymous, Narcotics

38
Anonymous, and related 12-Step groups. This recognition of the
correlation between eating disorders and addictions - chemical
dependencies and process addictions* alike, is gaining increasing
attention in the popular press and research literature.
Although there are no exact figures, a conservative estimate of the
percentage of chemically dependent women who would“qualify,”
as eating disordered likely is in the neighborhood of twenty to forty
percent. There are no gender-specific studies regarding “cross-
addiction.” However, there is evidence to suggest that, of all the
cases diagnosed in the general population, at least ten percent are
male. Certainly, when we speak of “disordered eating,” we are
including all those suffering from the most widely recognized
eating disorders including anorexia, bulimia and binge eating
disorders. Although many individuals suffering with an eating
disorder may appear significantly overweight or underweight, like
most alcoholics and drug addicts, one cannot identify someone
with an eating disorder simply by appearance. *Processaddictions
include compulsive gambling, shopping, sex, and those thought to
involve habitual patterns of behavior and not attributable to a
drug, chemical, or other substance.
When we look at an addiction, and in this case we’re looking at
eating disorders, we’re really apt to discover the existence or
predisposition toward another dependency – if not several. One
way to conceptualize this cross addiction phenomenon is depicted

39
in Table 4.1. The table represents a hypothetical list of other
addictions that may or may not be secondary to the eating
disorder. These may be co-existing at the time of treatment or
represent prior forms of self-medication or addiction. This
particular pyramid is fairly representative of the collective issues
often seen in the treatment setting, coinciding with an eating
disorder. Naturally, there are individuals that do not fit this model
and come to treatment with no history of co-existing addictions.
However, such folks would be well advised to be on the lookout for
the potential to exchange the form of their eating disorder or
develop a new dependency in the course of their ongoing recovery.
TABLE 4.1 – Sample – The AddictionPyramid
EATING DISORDER
CHEMICAL DEPENDENCY
C O - D E P E N D E N C Y
N I C O T I N E / C A F F E I N E
G A M B L I N G / C U T T I N G / S P E N D I N G
Interspersed with co-existing addictions and related forms of self-
medication are mood disorders. The most frequent of these
include recurrent depression, anxiety disorders such as panic
disorders, phobias, generalized anxiety, and bi-polar disorder. The
prevalence of mood disorders associated with an eating disorder
is estimated to be in the range of 80% or more. This is greater than

41
any other addiction including drugs, alcohol, or any of the process
addictions. Very often a combination of the appropriate therapies
is necessary to treat these issues at the same time as addressing
the eating disorder. Regardless of whether a mood disorder pre-
dates the beginning of an eating disorder or came about as a result
of one, it’s imperative to diagnose and treat it.
As a point of information, the majority of patients presentingwith
a depressive disorder usually identify their depressive symptoms
as predating the onset of the eating disorder. In such instances the
depression may be considered an independent illness and, if left
untreated, will likely persist beyond the treatment of the eating
disorder. The implications are two fold – first, the medication piece
may need to be life-long as the diagnosis is one of recurrent
depression and not a single episode and, second, thecontinuation
of the medication is one of minimizing the risk of recurrence of
another depressive episode and relapse back to the eating
disorder. Still another group of eating disorder patients present
with depressive symptoms directly related to the eating disorder
and, as such, represent a single episode of depression or
depression secondary to their eating disorder. For this group,
medication can be recommended for periods up to a year or so
with the depressive symptoms improving significantly with the
remission of the eating disorder. However, unlike recurrent
depression, antidepressant medications are not necessary for
long-term maintenance of recovery with this group. A

40
conversation with the prescribing physician regarding yourhistory
and diagnosis, apart from the eating disorder, will help you
understand what needs doing on the medication front.
Defining - Medication or Drugs?
It may be helpful to delineate between using medication and using
a drug. Medication is intended to put people on a par with reality
and capable of benefiting from other forms of therapy. Drugs tend
to dull a sense of reality and usually are taken to deaden or alter
feelings. Some prescription medicines can be abused as drugs,
such as stimulants intended for attention deficit disorders, but are
used instead to get high, while others are of great benefit when
taken as directed. * Medications, then, can be a tool in recovery or
misused as a means of furthering ones’ disease. In fact, the same
prescription drug can be used as a medication for one person and
as a recreational drug or “diet pill” for another.
The more frequent diagnoses and issues accompanying an eating
disorder are shown in Table 4.2. These represent a sample of
issues we frequently see at our facility, as well as, what other
programs need to consider with ED treatment.

42
TABLE 4.2 – Dual Diagnoses + ED
- Alcohol Abuse and Dependency
- Major Depression - recurrent and single episode
- Bi-Polar Disorder
- Anxiety Disorders – phobia and generalized
Anxiety
- Drug Dependency - Prescription Meds, Street
Drugs, etc.
- Alternating Eating Disorders – Binge Eating >
Bulimia
- Nicotine Dependency
- Borderline Personality Disorder
- Obsessive Compulsive Disorder
- Process Addictions – Compulsive Gambling,
Shopping, Sex
- Impulsive Control Disorders - Shoplifting
- ADD – with or without hyperactivity

43
Cross Addiction and Co-Existing Issues
The take away from this topic is simply to recognize addictions and
compulsions are often misguided attempts to manage or control
our feelings. That being the case, it would seem likely when we
stop using one means of doing this we’re prone to “go back to the
well” and rely on another. The important thing here is to accept
the need to work on the problem [nature of the person] and not
just the symptom [the addiction]. Be patient, be cautious, and be
honest with yourself. Some of these issues can be tackled along
with your eating disorder treatment and some will be taken on
later in the course of your recovery. Which one and when will
depend on how they threaten your eating disorder recovery and
whether you can “buy time” to work on them at a later date.
Body Image and Body Dysmorphic Disorder
I’ve always been fascinated by the “disconnect” between how we
experience our speaking voice and how it sounds when we listen
to it from a recorded device. Likewise, there’s the tendency to view
different photographs of ourselves and wonder how we could look
so different in each one, yet almost everyone else hardly notices
any change. How can we see the same picture so differently from
others? Is it possible our perception is influenced by factors we’re
not totally aware of? To be clear, this phenomenon of perceiving
and experiencing ourselves differently from the “outside world” is

44
common to all human beings. The issue, however, rests with the
tendency among many people exaggerating this “discrepancy” in
the service of self-criticism and a distorted sense of self. Few
populations exemplify this distortion of reality as those suffering
with an eating disorder.
Body image distortion, as it relates to eating disorders, and its
“cousin”, body dysmorphic disorder, is perhaps the most
pronounced example of how these “disconnects of perception””
dominate the thoughts and feelings of ones’ daily life. Toillustrate
this “in the eyes of the beholder” phenomenon, many of you may
be familiar with the “old or young woman” optical illusion (see next
page).
Although there may be an infinite number of “theories” as to how
the brain processes the physical world vis-à-vis our senses, the fact
remains there is no clear cut understanding to account for the
relentless perception of either an undernourished or healthybody
being overweight, or a pop star enlisting an army of surgeons to
alter his nose repeatedly until he must wear a mask in public. At
the very least, it would be reasonable to say many of those
suffering with anorexia, bulimia, and in many cases binge eating
disorder, have in common some degree of “confusion” as to how
they really appear.

45
What do you see? Is it a profile of a young
and beautiful lady, or do you see an old
woman with a huge and ugly nose?
Body Image and Body Dysmorphic Disorders
are typically not about vanity per se. Fact is, body image issues can
be found in all subtypes of eating disorders, although most
commonly associated with anorexia. As we’ve seen, eating
disorders are often associated with people with exaggerated needs
for control, perfectionism, and insecurities that appear to focus on
appearances. To be sure, there is a difference between someone
with a “weight problem” and one with a bona fide eating disorder.
The latter usually having to deal with the confusion over perceived
body image and a pathological relationship with food and weight.
Most of the “dieting off and on” folks do so without a serious
disruption to their lives. They are what some refer to as the
“worried well.” Such is not the case with an eating disorder. That
being the case, let’s look at one hypothesis.
Through the years, I’ve come to experience mood disorders, in
particular forms of depression, as the “chicken before the egg”
regarding body image and body dysmorphic disorders. In reality, it
is more the rule than the exception that a mood disorder
accompanies, if not “pre-dates” the onset of an eating disorder. To
be clear, our mood will more often than not color our perception.
In other words, the more depressed, the more negative our view

46
of ourselves. The “smoke and mirrors” effect of an eatingdisorder
then goes something like this: “I look in the mirror and I see myself
as and that’s what really makes me feel depressed. If I were
able to change the way I look then I wouldn’t be so depressed.”
Hence the anti-depression fix becomes changing the body or
numbing the pain with further restricting or binge eating, etc. The
angst of how we experience our body is believed to be the problem
and the solution becomes changing the body at any cost – evento
the point of engaging in life threatening behaviors.
I’m not proposing the solution to a body image issue is simply
“buying into” this theory or finding the right “medication.” What I
would suggest is at a minimum conceding your “perception” is a
confused one and giving consideration to putting your energyinto
a recovery process. That process would give equal time to
following a treatment plan that includes a healthy food plan,
abstaining from your eating disorder behavior[s], with professional
help if necessary, and also finding a way to appropriately manage
your depression. Last, but not least, I would be remiss not to
mention that more than half of the people we see at Milestones
also have relied upon alcohol, drugs, or other compulsions in
addition to their ED in a misguided attempt to “control” their
depression and perceptions.
In sum, body image disturbances are a prominent feature of most
eating disorders. Whether they are a symptom of an underlying

47
issue with a mood disorder such as depression or generalized
anxiety disorders, a manifestation of past trauma, or any number
of factors often associated with eating disorders may not be
important. What matters is the need to acknowledge body image
disturbance as a symptom of the disease – more so for some, and
less so for others. Another point to consider is resolving the
depression or underlying mood disorder does not guarantee the
resolution of a distorted or negative body image. That said feelings,
thoughts, and perceptions about our body become less
troublesome over time if following a recovery program. By
incorporating the principles of a 12-Step program and some ofthe
principles discussed, we can learn to live with our imperfections.
The frequency and intensity of negative experiences with our body
will diminish. Self-focus and a renewed interest in other people
and things beside ourselves will usually follow.
Internal and External Cues: What also makes usdifferent?
My experience has been eating disorders almost uniformly involve
a broken thermostat-like mechanism that governs internal cues
[symptoms] of hunger and fullness. In other words, unlike our
“normal eating” contemporaries, we are often confused when to
eat, what to eat, how much to eat, and/ or when to stop eating.
Whether suffering with anorexia, bulimia, or compulsive
overeating, there is a tendency to be more governed by external
stimuli - such as the sight of food, smells, time of day, stressful

48
events, body image, etc. These influence our behavior around food
more than the internal cues such as blood sugar levels, stomach
contractions, an empty stomach, and so on. Just how much do
these factors mediate our eating behaviors?
We seem more susceptible to being conditioned to associate
certain emotions or external events with turning on or off our
appetite. Again, another way to look at this may be that our
circumstances and psyche tend to “trump” our physical needs or
internal signals when it comes to our eating. To date, science has
yet to figure out whether this is a learned behavior or one some of
us prone to eating disorders are born with.
Given both the effect certain foods exert on our brain chemistry
and this external orientation regulating our appetite, we need to
have a plan to take both factors into consideration. Again, there is
the nature of the person and the nature of the substance
interacting here.
The “plan” needed begins with some structure and realistic
boundaries around our eating. In my humble opinion, it is why an
“intuitive eating” approach is not the best route to take with food
planning and eating in general. There is a need for limits around
the types of foods we eat, a reasonably consistent schedule of
when we eat, and an acceptance of some of the physical and

49
psychological differences that separate us from our “normal
eating” peers. The same can be said for people suffering with a
variety of other substance and process addictions. Although the
differences may be unique to their particular problem, they too
differ from their non-dependent peers. By way of example, allow
me to tell you a little bit about my friend Harry.
My Friend Harry….
Everyone with an eating disorder has known a Harry or Harriet, if
you prefer. You know the type. Harry never worries about weight
or what he eats. Perhaps you sit at the local diner staring at the
“low calorie plate” in front of you - typically an all-beef patty
without the bun, a wilted piece of lettuce with a scoop of large curd
cottage cheese atop a pear half with a Diet Coke - and glance across
the table at your friend Harry. There’s Harry with his cheeseburger,
fries, and a cherry coke. As an evil fantasy crosses your mind of a
sudden and painful demise for Harry, you quietly slide the
remainder of his meal over to your side of the table, while
paramedics work to restore his pulse. As you finish the last fry and
take the final bite of his burger, you gently place the bill in his
lifeless hand and tell the server “he’s got the check.” Suddenly
you’re startled from your daydream when the waiter returns and
asks,“anyone want dessert?” Harry replies, “How’s the
cheesecake today? What a nightmare.

51
Ever notice your “Harry or Harriet” taking a “taste” of the cake and
leaving it at that, or perhaps pushing away their half-finished plate
because “they’re full”? Chances are Harry relies more on his
internal guidance system than being led around by all theexternal
stuff. With eating disorders this guidance system is pretty much
broken. It's not so much that Harry has a “better metabolism” than
you. Fact is our friend’s behavior around food is not hijacked by all
the external and emotional stuff the way we are.
Growing up, I remember when my mother would become nervous
or agitated over something she would tell us “I’m so upset I can’t
even think about food.” Sounds like she’s a Harry or Harriet type.
Although that may be the case for some people, lots of us might
have the opposite reaction, soothing ourselves with “comfort
foods.” Still others would find it not only difficult to eat when
upset, but also find the act of eating by itself unsettling. We’re
looking at emotional eating or restricting as a reaction to events
and stimuli outside ourselves, hence, external cues and
perceptions trumping our biological cues.
A Quick Footnote about Harry….
By the way, Harry also habitually left over half a Martini and
seemed to be able to “take or leave” most things that people
usually consume. In fact, Harry never seemed to become too

50
dependent on anything or anyone. Imagine that! Oh well - maybe
in the next life.
The Restricting Side of the EDCoin
Then again, you may be at the other end of the eating disorder
spectrum. With more of an anorexic pattern, there is either a
denial or misinterpretation of our physical needs or, more
typically, a phobia of what will happen to us if we “give in” to our
hunger and feed ourselves. The “phobic” response to eating and
the never ending pursuit of being “thin enough” seems to come
with the territory. Fact is, there is a general mistrust of what the
body is telling us internally and an over reliance on external
perceptions and stimuli that further our “Dis-Ease.” Even when
“listening” to your body, you’re likely to continue to mistrust both
the message and the messenger.
In sum, over feeding and under feeding are simply different sides
of the same coin. Both are perpetuated by a chaotic array of mixed
messages from our internal selves and what we perceive on the
outside. All this makes for a relentless battle between our bodies
and our minds. Not a fun place to be.
One of the positive outcomes of recovery comes when we accept
we are not a Harry or Harriet type. In some circles this is referred

52
to as a cucumber becoming a pickle never to return to being a
cucumber again. Being a pickle, however, does have its
advantages. With acceptance of our reality, the adoption of a
reasonable food plan becomes a preferred place to be ratherthan
a prison sentence. *Clean eating, along with the other components
accompanying a recovery lifestyle become a matter of preference
and not something we do because “we have to.” You’ll find the
same experiences among people enjoying long-term recovery
from alcohol, drugs, and other dependencies - namely their
“recovery” has become a blessing and not a curse. I’d further the
analogy to someone with any chronic disease. If we we’re
discussing diabetes treatment then eating within the bounds of a
healthy whole-food plan, moderate exercise, managing stress, and
developing a personal sense of spirituality would be the exact
prescribed program called for. If you think about it, this formula
would serve anyone with a chronic disease and go a long way to
restoring someone’s health and quality of living.
[*]It’s important to remind the reader our reference to “abstinent
food plans” and “clean eating” are about healthy and adequate
nutrition and not in the service of further restrictingcalories.

53
And the Good News Is…
The good news is long-term recovery from an eating disorder is
entirely possible. The bad news is it requires hard work. Following
the right course of treatment, following an appropriate recovery
program, adherence to a healthy food plan, and addressing the
problems often accompanying an ED, are key to achieving this goal.
Few do it alone. There is a roadmap, a way out of the woods, so to
speak.
I often suggest to people engaged in the treatment process at
Milestones to consider doing as near 100% of what is being
suggested as possible. Those doing their best will likely take with
them enough of what’s needed to stay in recovery. However,
should someone be cutting corners, modifying and devising their
own version of a treatment plan – namely doing only what they
believe applies to them, they usually end up in relapse either
before or shortly after they finish treatment – or they leave with
only a “diet” instead of program for recovery.
That being said, the primary purpose of this text is to set the stage
for recovery. Doing so first necessitates defining the problem.
Hopefully we’ve made a reasonable start in doing just that. Next is
asking yourself if you’ve reached the point of willingness –
specifically to commit your energy and faith into “living in the

54
solution” rather than staying stuck in the problem. Should you be
at that point, the suggestions and information forthcoming will
help you get where you want to go.
**********
Additional References:
Available upon request
mailto:mlerner@Milestonesprogram.Org
What comes first, the Chicken or Egg? – Why, It’s the Egg!
There is a physics experiment that may serve as a metaphor for
recovery. This demonstration is intended to prove it possible to
place our recovery first and still have time to get everything else
done. If I can borrow your imagination for a few minutes you’ll see
what I mean.
First picture a large Tupperware Bowl, with the lid off, filled with
uncooked rice, about a half inch from the top. The rice symbolizes
all the stuff we need to get done on any given day – the laundry,
preparing meals, going to and from work, our jobs, getting our hair
done, feeding our dog, cat, or kids, going to the dentist, taking a
shower, getting the oil changed in the car, and on, and on, and on.
Next, take four hard-boiled eggs. Each egg now represents one of
the four basics of recovery - S.E.R.F. Please make sure the eggs are
hard boiled so they don’t make a mess. Place the eggs on top of
the rice and try and close the lid. It won’t close. So… youeliminate
one of the eggs. Still won’t close. Ok, you take away another one,

55
no cigar. Eventually you might get it to close with one or two eggs
left. Not much recovery left here. Maybe your SERF is reduced
to EF.
And now…. Take an identical size bowl that’s empty and place it
next to the original one. Now take all four [SERF] eggs and place
them in the empty bowl FIRST. Now pour the same rice from the
original bowl over the eggs on the bottom. And, finally, place the
lid on the bowl. Guess what – it fits.
Believe it or not, this is something we actually do as a
demonstration from time to time at Milestones. In reality, we’ll
find ourselves with more than enough time to take care of what
needs doing when we put our recovery first and allow the rest of
our daily stuff to fall into place. Being consistent with the SERF
basics is one of the paradoxes of recovery – namely putting
ourselves first-positions us to better take care of everything else.
As has been mentioned repeatedly throughout this guide Doing is
Believing.

56
Chapter Three
Recovering from an Eating Disorder
"Some of us think holding on makes us strong,
but sometimes it is letting go."
-Herman Hesse

57
The Roadmap
When all else fails, follow the directions” – anonymous
Ok, now we’ve come to the instructions. You know, the written
materials [aka instructions] most people either discard or only
glance at while putting together whatever it is they’re trying to put
together. If you’re like me, you usually end up with a bunch of parts
left over and something that doesn’t quite look like the picture on
the box. This may be a time to do it differently. A word of caution
- it’s not unheard of for people with, shall we say, control issues,
to be slightly defiant and a tad bit stubborn [a little sarcasmhere].
If this doesn’t apply to you then I would suggest you may be inthe
wrong place or, more likely, are having one hellacious issue with
denial. Fact is, most people who suffer with an eating disorder,
have more issues with control and trust [what a surprise] than their
non-addict peers. These two issues are a central theme of what
needs to be addressed in the recovery process. We’ll talk about
control and trust in a few pages.

58
A Word About “Therapy”
“So What, Now What?” - unknown
Least we’d be remiss if we didn’t provoke a little controversy here.
Allow me first to confess to being someone with both professional
and some personal experience with eating disorders and
addiction. This leaves me with a distinct, and perhaps subjective
take on what works and doesn’t work. Likewise, our clinical team
at Milestones has come to appreciate a similar perspective. That is
to say the approach to recovery that works best is one ofteaching
the skills needed to keep it. Doing so does, however, require
putting these skills into practice on a daily basis. The saying that
best describes this philosophy is simply “teaching someone how to
fish is far better than feeding them a fish.” Hence the goal is doing
recovery rather than knowing about it.
What Works and Doesn’t Work?
“Quitting is easy; I’ve done it countless times.” - unknown
Let’s begin with what doesn’t work. Traditional forms of
insight oriented, psychoanalytic, and various other therapies
relying on a revisiting and reframing of the past are among the
least promising approaches. In other words, coming to

59
understand what “caused” your eating disorder and
“connecting the dots” has little effect on a successful outcome,
unless it directs someone to take action in thepresent.
Through the years I’ve come to know a number of people
struggling with anorexia, bulimia, binge eating, and a number
of other related issues. Almost all had some form of traditional
counseling or therapy prior to coming to a residential program
like ours. With few exceptions, they had tons of insight as to
when, where, why, and how their addictive relationship with
eating or dieting began. For some it was related to control
issues, using their need to control food and weight in lieu ofnot
being able to control other parts of their lives. For others it
had to do with a misguided attempt to deal with a traumatic
event such as sexual or physical abuse. The list can sometimes
be endless. Perhaps the question one should ask is “so what, now
what?”
Their accounts suggest self-medicating with food or restricting
after developing a deep sense of distain for their bodies. In the
end, identifying the causes had little to do with overcoming their
ED. In my opinion, by the time someone reaches the point of
wanting to stop an eating disorder it has acquired a life of its own.
The same can be said for all addictions. I know of almost no
exceptions. In fact, intellectual understanding of the problem only

61
adds to the frustration and pain of not being able to stop – even
when you want to. To paraphrase a concept from the text of
Alcoholics Anonymous: “we reach a jumping off point, where we
can no longer live with our addiction or live without it.” Anyone
suffering with an eating disorder has probably experienced this.
Not to be excluded, therapies that focus on “feelings” and
expression of emotions may be helpful to some folks, b u t
appear to have limited value. Not to say they don’t result in
someone feeling better for a period of time, but the
assumption that getting in touch with ones' feelings and
expressing them is the key to resolving an eating disorder is
simply mistaken. Getting in touch with feelings has long been
the Holy Grail among many therapists, counselors, and eating
disorder programs. Feelings have their place in many arenas
such as marital counseling, anger management, anxiety and
mood disorders, etc. However, my experience has been they
have limited value in the recovery world, unless they are in the
service of directing someone to a specific course of action,
which at times can mean simplywaiting and exercising restraint.
Taken together, cognitive behavioral therapies, dynamic or
analytic therapies, behavior modification, rational emotive
therapies, pharmacologic therapies, gestalt therapies,
massage therapies, wilderness therapies, homeopathic

60
therapies, alternative therapies, and so on – all may be
helpful to varying degrees. However, there is one important
caveat, namely none of these alone provides a definitive
“cure” for an eating disorder or any other addiction that I’m
aware of. Not to beat the proverbial dead horse, but
combinations of many of these techniques may have varying
degrees of benefit - so long as there is no expectation that any
one approach alone represents the “silver bullet” eradicating a
severe eating disorder or related addiction.
Therapy or Therapeutic Setting?
Recovery, to be sure, begins with stopping the addictive
behavior. The next challenge is staying stopped. Doing so often
requires the help of something other than simply good
intentions or resolutions. Few can do this alone. In the eating
disorders world many, if not most, need the collective energy
of a group of other people in a similar dilemma – all who want
to recover. Although a 12-Step or other related support group
may provide this in the long run, often it requires treatment
within a structured and supportive setting to get started.
Powerful and effective as they may be, 12-Step, SMART
Recovery, and similar community based groups offer great
long-term support, but are not intended to replace treatment
when it’s needed.

62
A residential or day treatment program can enhance the
chances of getting an initial handle on your eating disorder.
Apart from the benefits of an experienced treatment team, the
appropriate treatment setting is essential for making the
transition from an eating disordered life to a recovery one
possible. The work of creating, facilitating, and managing a
therapeutic community then becomes the primary mission of
any program. Once in place, the work of learning and putting
into practice longer-term recovery skills begins. We often like
to say – “the magic is in the community.” Here’s an excerpt
from the Milestones literature summarizing a mission
statement for our program and facility:
“Milestone's primary purpose is to provide a
comprehensive program to address the
specific needs of individuals suffering with an
eating disorder and the issues often
accompanying them. Providing a safe,
structured, and effective course of treatment,
the facility offers apartment - style residences,
on-site support and a multi - specialty team of
licensed professionals. The program also offers
residential, as well as, day treatment levels of
care. We are a therapeutic community whose
mission is to provide a healthy, safe, and more

63
sustainable lifestyle. Many refer to this as a
recovery lifestyle. The program follows a
"blended" approach to treatment - addressing
both the addictive and emotional aspects of an
eating disorder. Residents attend a fullschedule
of group and individual activities during the day,
as well as, participate in various support groups
during evenings and weekends. Grocery
shopping, meal preparation, and "real world"
experiences are an integral part of the
program.” [*]

64
The Secret to Recovery
Here’s a brief story from a few years ago. Ok, a couple of decades
ago. Anyway, I was a student intern at a fairly renowned
psychiatric hospital and the chief of the psychiatry division, who
appeared to be a rather charismatic and bright fellow, was
taking us on rounds. All of a sudden, out of nowhere, comes
this raging patient who parks his face right in front of the chief’s.
He starts shouting, “how come you won’t tell me the secret?
How come you told John and he’s better now and getting out?
How come you won’t let me know the secret? What’s the
secret to getting better? What’s the secret, tell me.”
Here’s a little background on myself at this point to put this
in perspective. First off, since childhood I always had the
impression I would be “told more about something” or let in
on “the family secret” when I was older. You know the drill.
So, my immediate flashback had to do with the notion that
there was always some secret, some magical answer, drug,
formula, whatever, that would be revealed to me “one day.”
Then, when you become an accountant they bring you into a
room full of accountants and tell you the accountant secret, or
you finish law school and they tell you about the secret
handshake, or you pass your flight test and they tell you the
secret pilot code. Got it? Ok, back to the story.

65
Now the chief of psychiatry, without moving so much as a
muscle or batting an eye asks the patient, “So you want to
know the secret, the secret to mental health, the secret to
getting better?” Meanwhile we interns are soiling our
underwear about now. “Yes”, screams the patient, “tell me, tell
me.” Without hesitation, the chief replies, “ok, you want to
know the truth, the secret?” Again, “yes, tell me, please tell
me the secret.” The chief looks directly in his eyes and says -
“hard work.”
To me this was so profound. Why? Because like most of us who
are predisposed to some form of an addiction or compulsive
behavior somehow believe there is a quick fix, answer,
remedy, solution to what ails us. Maybe we think it will be this
new drug, a new diet, this new relationship, a new therapist, and
on and on we go. It wasn’t until several years later that I came
to realize just how right this teacher was. Fact is he was talking
to all of us. If you really want to now the secret and you’re
ready to learn the truth, then be prepared to do the work.
As the saying goes, “faith moves mountains, but be sure and
bring a shovel.”

66
Living in the Solution: The HardWork
Rather than a specific therapy, there is a philosophy that appears
to hold the key to binding all this treatment and recovery stuff
together. Interestingly enough, an anthropologist named David
Reynolds introduced me to this “philosophy” several years ago. Dr.
Reynolds, who last I heard lives in Hawaii and holds a faculty
position at UCLA’s medical school, wrote a book in 1984 with the
title Constructive Living. The good professor chronicled specific
psychiatric approaches taught in Japan referred to as “Morita
Therapy”. He then took these concepts along with another
approach, “Naikan Therapy,” interpreted and summarized their
essence for his book. Having been exposed to what Reynolds refers
to as Constructive Living and putting some of these principles into
practice; it’s become an integral part of the program philosophy at
Milestones. In fact, I have remained both teacher and student with
respect to most of the concepts suggested by this lifestyle. Over
the years I’ve come to recognize all the parallels between a 12-Step
program and a Constructive Living one. I encourage you to keep
an open mind and give careful consideration to what follows. It is
intended only as a brief and simple description of what this
program entails.
*Morita therapy is credited to Japanese Psychiatrist, Dr. Morita
and is the principle impetus for Constructive Living therapy. Naikan

67
therapies are attributed to another Japanese physician. It centers
on the practice of a specific focus for meditation and reflection. It
is akin to the concepts of “mindfulness” and gratitude – both
corresponding elements in a 12-Step philosophy. A more detailed
explanation of these techniques can be found in the Constructive
Living text referred to earlier.
Principles of ConstructiveLiving
There are a few basic elements that deserve mention before we
proceed with the “laws of human behavior” about to be outlined.
Many of these fly in the face of what most of us mental health
professionals were taught – at least as it applies to psychotherapy.
I want to add a little disclaimer here and propose a couple of ideas
to consider regarding this Constructive Living (CL) approach.
- The CL approach is not psychotherapy
- CL is basically a form of discipline
- Progress is better measured by behaviorsrather
than feelings
- Feelings usually follow behavior

68
At first glance these concepts may seem simple enough. However,
there is more to this stuff than meets the eye. There seems to be
an implied assumption in the world of mental health treatment
that goes something like this: if we can change how someone feels,
or if we can change what thoughts they have, then we can get
someone to change what they’re doing. I suspect most of us hold
onto the belief that goes something like this - if a therapist or
someone I looked to for help could fix how I feel, then maybe I
would be able to _. You fill in the blank. Try this one on for
size: “If or when you can help me feel better about my body I will
buy shorts and exercise.” “When I don’t feel so big I’ll let myself
eat.” "When I’m not so nervous, I’ll speak in front of the class and
be able to do the presentation.” “When I get [aka feel] motivated,
I’ll study.” No doubt we can make an endless list of “when I feel, I
will.” Experience has shown repeatedly when we put a “state of
mind” as a condition for doing something we’re likely to be stuck
in the problem. Conversely, when we develop the discipline of
doing what needs doing despite the feelings or intrusive thoughts
we are moving toward the solution. Let’s take a few minutes and
look at the basic principles of this philosophy and explore it. I’ve
taken the liberty of paraphrasing some of the CL principles David
Reynolds talks about in his text. They are:

69
- Feelings are not directly controllable by self will
- Feelings need to be recognized and accepted “as is”
- Every feeling, no matter how unpleasant, has a
purpose
- Feelings fade over time, unless re-stimulated
- Feelings [and thoughts] can be indirectly
influenced by behavior
- We are responsible for what we do no matterhow
we feel
If you really consider these, they tend to appeal to our common
sense and really don’t require a degree in rocket science. However,
taking a more detailed view and truly contemplating these you’ll
notice a much more profound meaning. What is being proposed
are a set of what could be called, universal truths about the human
mind and how it operates. It suggests trying to control our feelings
by directing energy into simply “willing” ourselves to feel
something is a wasted exercise. Try sitting down in a chair when
you’re feeling sad and “will” yourself to feel happy for any
extended period of time. Try willing yourself to fall in love with
someone you’re not in love with. Likewise, controlling your
thoughts by imposing self-will is quite limited as well. Ever tell

71
yourself not to think about something? I usually end up obsessing
about something the more I try or am told not think about it. The
“magic sauce” in all this is that our thoughts and emotions can be
indirectly influenced by what we do. In other words, what we do
has the greatest [probable] impact on what we think and feel over
time. The cart is placed before the horse when we get it backwards
by insisting we fix our feelings first. Believing our feelings and
thoughts must be changed before we’re able to change our
behavior can be a very costly mistake.
Once again, eating disorders and addictions are about fixing
feelings. Now we can add another idea, this time regarding the
solution – “recovery is about transcending our need to fix how we
feel and doing the next right thing no matter what we’re feeling.”
This challenges the belief that controlling our feelings and thoughts
is the primary goal of psychotherapy. Instead we’re proposing the
reverse - controlling our actions and letting the feelings and
thoughts take care of themselves. “Doing is believing” as I like to
say.
Feelings and thoughts, as we’re reminded, are never constant.
Much like weather patterns, our emotions and thoughts are always
changing. They come and go. In this sense, nothing stays the same.
Trying to exert control over these is like trying to control the
weather – not possible. Behavior, with very few exceptions is

70
within our control. Being consistent with what we do is achievable.
The few exceptions I know of have to do with some physiological
stuff – like holding your breath for five minutes or not shivering in
the cold weather or making yourself fall asleep when you suffer
with insomnia, and so on. It’s a short list.
And for the Perfectionist…
Just a brief note to those who tend to sit on the perfectionist side
of the ED fence – “sometimes the “what needs doing” is about
“what needs to not be done.” Most of us who suffer with some
form of an addiction or compulsive disorder tend to display the
trait of dichotomous thinking and behavior. In other words, we
tend to be all or none types, thinking and doing in terms of feast or
famine and living in a black and white world with little room for
any shade of gray. This being the case, some will need to use more
restraint in their recovery program, being less perfect with certain
elements and being mindful of not “over-doing”. Others may
benefit by being more vigilant or compulsive with recovery
behavior. As it relates to an eating disorder, this balance will work
best combined with a prescribed food and exercise plan, a
balancing of work and play along with our overall recovery
activities. Given these extremes, we see people who either weigh
and measure their food to the nearest atomic particle, the over-
doers, or skip weighing or measuring entirely and “count” only the

72
amount of food they consume when sitting down - as if standing
and eating doesn’t count. Ok, a little extreme, but maybe not.
Finding the middle ground and the right shade of gray is a big part
of the learning curve.
The discipline with this approach rests with the assumption that
most of us know at any given time what needs doing based onour
circumstances at that moment in time and space. I suspect in
“recovery-speak” this translates to “doing the next right thing.”
Again, sounds simple doesn’t it? Unfortunately, simple doesn’t
always equal easy. Sometimes restraint and doing nothing is the
next right thing and other times doing what we need to do despite
our discomfort is called for. We usually know what our truth is, but
that doesn’t mean we have to like it.
Triggers and the Paula GoldbergTheory
“Feelings fade over time unless re-stimulated”
One of the primary laws pertaining to the human memory is that
feelings and memories diminish in intensity and frequency unless
they are re-stimulated. It’s one of the most important principles
within the context of Constructive Living we spoke about earlier. I
thought I would let you in on how I remember this law and how it
can apply to your recovery. And yes, it’s another story from my
very distant past.

73
The dateline is eighth grade at Lawrence Junior High School
somewhere in New York. I am about 14 years old and suffer with
what was, at the time, referred to as juvenile onset obesity. In
other words I was a compulsive eater who was twice the size of
what would be considered “normal” for a 14 year old. So nowinto
the classroom enters Paula Goldberg, a very “hot” looking 14 year
old dressed in a mini skirt and knee high boots. No doubt you get
the picture. Kind of like the scene from the “Go Daddy.Com”
commercial with the supermodel and computer geek in a lip lock.
Fast forward the movie and I began a “diet” of raisins, cottage
cheese, and diet soda for the next several months until I became
this rather good looking, “svelte,” high school freshman. Now,
eventually, I ask Paula out to the junior, then senior prom.
Throughout high school we were, as they say, an item.
Comes time for high school graduation and off to college. Now
we’re both about to go to different colleges. I figure it’s time for
me to “sow some wild seeds” and not limit myself to Paula. I figure
it’s time to break up with her. Here’s where it gets a little
interesting. I invite her to meet me at the Town Diner [remember
Harry, this is the same place].
So we sit down at the table and Paula says she wants to tell me
something. I tell her “I have something to tell you too Paula, [big
mistake here] but instead I tell her “you go first Paula.” Paula
proceeds to tell me “Marty, you know I care about you, but I think

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