Dr. Carla Garber on Eating Disorders

Dr. Carla Garber, Ph.D. Dr. Carla Garber specializes in individual and family counseling for those dealing with disordered eating. Team approach (with a Registered Dietician). Twenty years experience. Member: Academy for Eating Disorders, ANAD, EDAP. Special interests: body image and the media.

Email Your Question To Dr. Garber

Sensitivity Regarding Weight

QUESTION: Hi Dr. Garber I have been quite puzzled regarding my family during the course of my recovery. I was very emaciated at one point in life and was on my death bed. Doctors and psychiatrists didn't think I would live even if I decided I wanted recovery and wanted to get better. Nobody thought I would make it including my family. Well, I DID make it. I did survive and it has been about 4 years now since I have been in recovery. What I don't understand is that since I have been in recovery I am slightly overweight according to my height. I have sort of gone from one extreme to the next but I am healthier. What I don't understand is that my family tells me how overweight I have become. They tell me all the time they don't understand why I can't just eat and be thin. This has been a major obstacle to overcome for me. I don't understand how one person who is anorexic can go from one extreme to the next. Most people I meet who have conquered anorexia are thin to me. Why is my family doing this to me? It sometimes makes me want to relapse but I don't want to be in the hospital or in treatment centers anymore. After 9 treatment centers and hospitalizations, I don't want to go back. What do you suggest? How do I stop my family from being so hurtful? Why can't they accept me for who I am? I don't know what to do. I remember them telling me that they just wanted me alive and didn't care what size I was. The truth is.. they DO care and want me thin but I just can't go back. I have worked too hard. I just wish they would stop tormenting me. Any advice you have would be wonderful. ~Tamara

ANSWER: Dear Tamara, Yours is a very common but hurtful situation! It is amazing to me how often I see this problem. One of the things that we learn in recovery is that HEALTH trumps the number on the scale. Families, like our society in general, can have such ingrained fear of weight gain that their fear can blur their good judgement. Many parents are terrified that their children might have to face society's prejudice about weight. They mistakenly think that a few words of warning may simply prevent you from having to endure pain. What they don't understand is that these words trigger extreme shame and can make us question their love.

We ask families to pledge never to comment on food and weight. They are sometimes shocked and dismayed, but it is an important guideline for recovery. After several hospitalizations, I would bet that your family has been advised about this. So, you may have to be more assertive, Elizabeth, and remind them not to ever comment on your weight, size or food choices. It may be necessary to be a polite, broken record. It may also be necessary for you to accept that they are too wounded in this area to respect your request. If so, remember it is about THEIR WOUNDING, not YOUR WORTH. With much warmth, Carla Garber, Ph.D.

Inpatient Treatment

QUESTION: Hello Dr. Garber: I have had an Eating Disorder (first Anorexia, now I suppose it is Bulimia) for 23 years. I have seen counselors throughout the years, but have never been able to conquer the "Eating Monster". I have a little boy who is 3 1/2 years old, happily married for 9 years, own a home and am an "at-home" mom. My external life is fabulous, I feel blessed, now I need to feel fabulous inside myself. Every day, I binge/purge 4-5 times a day and I cannot stop it! I have been seeing a wonderful counselor who has helped me in so many areas of my life and is the only one who has made me aware of the severity of this addiction. Although she has helped so much, for some reason I cannot commit to stop the vicious cycle or eat in healthy manner. So, what do you think is the next step to take??? I am tired of this cycle and I want to be 150% alive for my son and husband. My counselor suggest residence, but I cannot imagine leaving my son and plus the costs are way out of our financial budget. Please help me with the next step. I feel hopeless, tired, empty....but really want someone/something to guide in the direction towards freedom. I look forward to your words of wisdom, Thank you... ~ Mary

ANSWER: Dear Mary, It breaks my heart to know that there are countless talented, vibrant and loving women and men who are not able to enjoy their lives because of Eating Disorders.

As one of those sufferers, I urge you to consider adding more muscle to your fight against the disease.

Have you tried Nutrition Therapy in addition to Psychotherapy? Nutrition Therapy is not about calories and fat grams. It's about much more, like looking at your schedule, metabolism, caloric needs, need for variety, trigger foods, body image, attitudes toward activity, your desire to restrict, to binge and/or purge, AND SO MUCH MORE. I recommend you add this to your treatment if you haven't tried this. This website can link you to referrals.

Also important to your treatment team are a physician and psychiatrist who understand eating disorders and are willing to consult with your therapist. Research shows that this type of multidisciplinary team is necessary for the best in treatment.

Even with the best of all these elements of treatment in place, sometimes outpatient work is not enough, especially if the disease has a duration of more than one to three years. If your therapist is recommending residential treatment, please explore this option with her/him. Your son would rather have you gone for several weeks, then return to him more whole.

And when it comes to the cost of treatment, please put this in perspective. I ask patients to remember groceries aren't free and monthly cell phones bills and car payments aren't cheap. Health is more important than our entertainment and computer expenses. If you had cancer, your family and your physicians would do what is necessary and worry about the bills later. Even though I used to shake my head at treatment center costs, I have come to believe that most centers I have worked with have reduced their costs to reasonable minimums. Treatment requires highly skilled medical professionals, comfortable surroundings, outstanding nutritional meals, important adjunct therapies like art therapy and equine therapy, and high liability expenses.

If professionals believe you must consider inpatient treatment, please remember that you are worth whatever it takes. I'm sure you would believe this if your son or husband were suffering. I wish you warmth, strength and success, Mary. ~Carla Garber, Ph.D.

QUESTION: Dear Dr. Garber, I have been in therapy for many years and have made my rounds as far as therapists go. I finally found a therapist whom I felt comfortable with and I went to on a regular basis for about 6 years. She finally told me she couldn't help me anymore. I have been in recovery for 8 years now but I am still very upset and hurt. I feel like I was left in the dark. I thought she really cared for me. I would like to find a therapist to help me through another 8 years + of continued recovery. I have to start all over again as far as therapists go and therapists who specialize in eating disorders are hard to come by. I know it may sound silly but I was really confident in this person and I feel like she doesn't even care about me. I thought we had a strong bond. Do you have any suggestions? As you know, most people with eating disorders want to be perfect and want everyone to like them. Even though I am in full blown recovery, I still present anger and hurt. I feel as if I have failed. Any suggestions or advice would be greatly appreciated. ~Gina

ANSWER: Dear Gina, Thank you for your question. Your situation is very relevant to many people. I hear your feelings of anger and hurt. It is especially easy to feel abandoned when such an important bond ends, especially if the therapist suggests she can't help you anymore. I hope you had several chances to ask questions about her thoughts and reasons. If you don't think you had opportunites to get answers, you might consider requesting more information. I would imagine the therapist would be very glad to hear your feelings, if you have not already shared all of them.

A relationship with a therapist is a very valued and honored professional contract. As a therapist, I can tell you that our highest priority must always be the welfare of the client. I can't speak for your previous therapist, however I can say that after several years of therapy, sometimes a therapist may believe that she/he has done everything he/she can to help. Sometimes they believe they may have taught you everything they can. Or sometimes they may have reason to believe that they are stuck or have lost their objectivity or perhaps, they feel too close or sympathetic with the client. Also, sometimes a therapist may feel very physically or emotionally fatigued or burned-out.

If any of these possibilities are true, the therapist is obligated to put the client first and suggest a new therapist, despite the feelings of dissappointment the client may have. You didn't fail. Possibly, your therapist was afraid she would fail YOU for some reason.

Congratulations on 8 years of recovery. Don't let this change threaten your progress. Talk it out, then give a new therapist a chance. You could be surprised what a new, fresh approach may offer. I hope some of these thoughts may help in your adjustment. Please take good care of yourself.

Warmly, Dr. Garber

Bulimia

QUESTION: Dear Dr Garber, I have been a binge eater for long time but have evolved to become a bulimic!!! Major accomplishment!!!!!. I live in Turkey and there are not many specialized therapists where I live. I am trying to educate myself via the internet and the complications of bulimia scare me out. As most bulimics I am also an over exerciser and find it more and more difficult to find the energy to exercise but I still drag myself to the gym everyday but am very depressed, avoid almost all social contact. Also through some contacts I have done a Hair Mineral Analysis Testing at the US ad all my electrolyte balance is upset. Also I feel irregularities in my heartbeat etc... It is such a vicious cycle and even though ? vomit not to gain weight, through the HTMA and research I have done- I have learned that vomiting upsets the metabolism slows it down and to protect itself the body tends to hold onto the food and you en up gaining weight .. anyways you already know this but I just learned this but it did not keep me from doing it anyways.

My question which I hope you will answer is if I can somehow manage to control myself and not vomit when would my body - heart, digestion, energy level, and all other imbalances would start returning to normal. It is really important for me . ~Grace

ANSWER: Dear International Friend, I felt so sad reading your letter. Obviously, you really care about your health and are battling to get better. Your question asked how quickly could your body begin to heal from the effects of Bulimia. The answer is EACH TIME YOU REFRAIN FROM BULIMIC BEHAVIOR, YOUR BODY HEALS. Each time you are able to postpone overexercising and purging, your body is grateful. Each time you sit down to a nutritious meal, your body's electrolytes will strive for balance.

I have enormous respect for the healing power of our bodies. I have seen countless people restore their health in a matter of a few months - after several years of eating disorder abuse. The body has an amazing survival instinct. As you have found from your research, your body reacts to try to nullify the eating disordered symptoms. The metabolism slows down in a desperate attempt to stay alive. As you may have also discovered from your research, purging of any kind (vomitting, laxatives and overexercise) becomes a very ineffective way of compensating. Sometimes at that point, the ritual of the addictive behavior becomes confused with a way to manage stress. So, we associate the addictive behavior with feeling better.

The SOLUTION lies in the fact that we can learn hundreds of other ways to reduce uncomfortable feelings!! These tools are MORE fulfilling - tools like relaxation, fun, meditation, recognizing our needs and asking for what we want.

I urge you to keep working with your physicians to monitor your health. I hope you have addressed your heart with them. If not, please do so immediately. As I said, symptoms (like electrolyte imbalance) can begin reversing right away. Within days and weeks, you can begin to feel more energy and clarity of thinking. So each time you abstain, HOORAY for you!!!! When you slip, LET IT GO immediately or else the guilt will pull you back into the cycle. With each success, imagine a crowd of us cheering for you!

Just because the body heals quickly, don't delay. "I'll stop next week" often turns into "I'll stop next year". After decades of bulimic symptoms, my mother's body (her colon and heart) could not recover. Please, vow today to work with your body - not against it. You can do it!! Warmly, Carla Garber, Ph.D.

BINGE EATING

QUESTION: Hello Dr. Garber, I am a 57 year old woman with a full, quite fullfilling life--the job, the man, the good friends, even the weekend house at the beach. After recently "graduating" from 15 years of therapy, I'm actually quite content with my life. I'm maintaining a 50lb. weight loss, and am now a size 10/12 at 5'10", so even that is fine, although I still want to lose more weight and am presently off and on Jenny Craig. I've been in O.A. for 30 years, hundreds of diets, and I know lots about eating disorders (I'm a therapist). Here's the but......... I still binge. I guess I don't really want to stop; I still enjoy it too much. I do it about once every 10 days, eating huge amounts, than having to sleep sitting up do to a stomach condition. And, of course, the next few days, the depression and low self esteem is awful. And so the cycle continues.......Oh, by the way, I'm on anti-depressants which have helped a lot. It's all gotten much better, but now I'm stuck. My old therapist thinks I've had too much therapy....most of my life.......I'd be very grateful for any thoughts you have.....Thank you. ~Sue

ANSWER: Dear Sue, I am glad you wrote! We hope you are gaining some benefit from this fabulous website set up by Jacquelyn Ekern. She has done such a great job of offering information, links and - above all - HOPE! And that's what I'd like to offer you.

As a therapist, you know there are no quick or easy answers. There are SIMPLE solutions, but not easy ones. After all these years of dedicating myself to this field, one of the things I've come to know is the following truth. Our relationship with food is much like our relationship with our spirituality. It is not a relationship that "just gets fixed". It evolves. It changes as it reflects our well being in other ways - well being which can vary day to day. I'm sure you're familiar with the OA reminder to HALT. This is a warning that if we are too Hungry, Angry, Lonely or Tired, we would do well to stop, assess our status and take care of ourselves if we are any or all of these.

So, one of the most important suggestions I have is to look thoroughly at those days when you do binge. Are you especially fatigued, burned out, tired of caring for others? Have you neglected yourself or pushed yourself too hard. Have you skipped meals or snacks because you are busy. It does sound as though you have a full and content life! The only disadvantage to such a rich existance is that it can be tiring. And we can get a little too busy to eat. As you may know, deprivation is the number one trigger for bingeing! The primitive/survival part of our brain is likely to eventually overcome other impulses, no matter what our intellect tells us.

Another strong suggestion I have for you is to FORGIVE yourself soon after you slip. You stated you feel depressed and have low self-esteem for the next few days. My clients get tired of hearing me say this BUT IT IS TRUE - SELF-PUNISHMENT IS A POOR MOTIVATOR FOR SELF-IMPROVEMENT. IT DOESN'T WORK. SELF-PUNISHMENT ONLY INCREASES THE CHANCES WE WILL SLIP AGAIN. Do we motivate children by telling them "You screwed up, you should feel awful"? Of course not. We can regret our choice, forgive ourselves and quickly move on.

One of the most successful techniques for avoiding a binge is to challenge yourself to postpone the eating for five minutes. Or take a five minute break, telling yourself, you can go back to it in a few minutes, but first, you are going to call someone or write a few lines in your journal. Then if you return to the binge, at least you reached out to someone or maybe wrote a few lines that might allow you to later identify a pattern of trigger feelings.

Some researchers believe our bodies may seek a setpoint. Other experts say we may be afraid of approaching a particular weight. We may have unresolved body image issues. Another reason for bingeing is the simple desire to distract from certain feelings! So, as you can see ther are MANY possible reasons.

I strongly suggest that you give yourself the opportunity to talk with a nutrition therapist. It sounds as though you are not feeling the need for any further psychotherapy. Nutrition therapy can help you to explore much of what I have written about here and MORE! Never give up. Our attitudes and feelings about food can continue to improve each day and each year of our lives, just like our understanding and attitudes about our spirituality. We are never too far along to gain new insights. I hope, perhaps something we have shared here may be helpful. Warmly ~ Carla

QUESTION: Hello Dr. Garber, I am a 57 year old woman with a full, quite fullfilling life -- the job, the man, the good friends, even the weekend house at the beach. After recently "graduating" from 15 years of therapy, I'm actually quite content with my life. I'm maintaining a 50lb. weight loss, and am now a size 10/12 at 5'10", so even that is fine, although I still want to lose more weight and am presently off and on Jenny Craig. I've been in O.A. for 30 years, hundreds of diets, and I know lots about eating disorders(I'm a therapist). Here's the but......... I still binge. I guess I don't really want to stop; I still enjoy it too much. I do it about once every 10 days, eating huge amounts, than having to sleep sitting up do to a stomach condition. And, of course, the next few days, the depression and low self esteem is awful. And so the cycle continues.......Oh, by the way, I'm on anti-depressants which have helped a lot. It's all gotten much better, but now I'm stuck. My old therapist thinks I've had too much therapy....most of my life.......I'd be very grateful for any thoughts you have.....Thank you. ~Sue

ANSWER: Dear Sue, I am glad you wrote! We hope you are gaining some benefit from this fabulous website set up by Jacquelyn Ekern. She has done such a great job of offering information, links and - above all - HOPE! And that's what I'd like to offer you.

As a therapist, you know there are no quick or easy answers. There are SIMPLE solutions, but not easy ones. After all these years of dedicating myself to this field, one of the things I've come to know is the following truth. Our relationship with food is much like our relationship with our spirituality. It is not a relationship that "just gets fixed". It evolves. It changes as it reflects our well being in other ways - well being which can vary day to day. I'm sure you're familiar with the OA reminder to HALT. This is a warning that if we are too Hungry, Angry, Lonely or Tired, we would do well to stop, assess our status and take care of ourselves if we are any or all of these.

So, one of the most important suggestions I have is to look thoroughly at those days when you do binge. Are you especially fatigued, burned out, tired of caring for others? Have you neglected yourself or pushed yourself too hard. Have you skipped meals or snacks because you are busy. It does sound as though you have a full and content life! The only disadvantage to such a rich existance is that it can be tiring. And we can get a little too busy to eat. As you may know, deprivation is the number one trigger for bingeing! The primitive/survival part of our brain is likely to eventually overcome other impulses, no matter what our intellect tells us.

Another strong suggestion I have for you is to FORGIVE yourself soon after you slip. You stated you feel depressed and have low self-esteem for the next few days. My clients get tired of hearing me say this BUT IT IS TRUE - SELF-PUNISHMENT IS A POOR MOTIVATOR FOR SELF-IMPROVEMENT. IT DOESN'T WORK. SELF-PUNISHMENT ONLY INCREASES THE CHANCES WE WILL SLIP AGAIN. Do we motivate children by telling them "You screwed up, you should feel awful"? Of course not. We can regret our choice, forgive ourselves and quickly move on.

One of the most successful techniques for avoiding a binge is to challenge yourself to postpone the eating for five minutes. Or take a five minute break, telling yourself, you can go back to it in a few minutes, but first, you are going to call someone or write a few lines in your journal. Then if you return to the binge, at least you reached out to someone or maybe wrote a few lines that might allow you to later identify a pattern of trigger feelings.

Some researchers believe our bodies may seek a setpoint. Other experts say we may be afraid of approaching a particular weight. We may have unresolved body image issues. Another reason for bingeing is the simple desire to distract from certain feelings! So, as you can see ther are MANY possible reasons.

I strongly suggest that you give yourself the opportunity to talk with a nutrition therapist. It sounds as though you are not feeling the need for any further psychotherapy. Nutrition therapy can help you to explore much of what I have written about here and MORE!

Never give up. Our attitudes and feelings about food can continue to improve each day and each year of our lives, just like our understanding and attitudes about our spirituality. We are never too far along to gain new insights. I hope, perhaps something we have shared here may be helpful.

Warmly, Carla

Post Bariatric Surgery

QUESTION: Dr. Garber, I've been in recovery for about a year and was wondering if you had much experience w/ people who were compulsive overeaters, had gastric bypass surgery, and then developed the "flip" side of the eating disorder? B/c of my new "anatomy" there is absolutely no pleasure in eating (this is completely besides all the mental/ emotional stuff) and the urge to purge is very frequent. My struggles have been w/ restricting (although I've never been under weight) and purging what I do eat. I physically cant binge anymore.I Started Eating Disorders Anonymous and it has become quite a success... but I've just never met anyone w/ my unique history. Any thoughts? ~Julie

ANSWER: Dear Julie, Thank you for your letter! You have raised a very troubling point that has become a concern for many clinicians in this field. Unfortunately, we do talk with other persons who have had gastric bypass surgery and experience the problems you have described.

Oftentimes, we find surgery alone does not change some core attitudes about food, weight and even our bodies. For example, some post bariatric surgery patients still suffer from dissatisfaction with their bodies, even though they believed their attitudes would change with significant weight loss.

Similarly, we may have struggled much of our lives with our attitudes about food, sometimes seeing it as our best friend, sometimes our enemy or, at best, a nuisance. Countless clients have said to me, "I just wish I never had to think about or deal with food." I realize that you stated in your letter the lack of pleasure with eating is besides mental and emotional stuff, but I ask you to reconsider this.

Most compulsive overeaters (and all persons who struggle with disordered eating, for that matter) have ingrained beliefs and feelings about food itself. We give it an inordinate amount of power, whetHer we are restricting or eating compulsively. As you said, Julie, it is just the "flip side" of the same coin.

until we can learn to see food as a source of nourishment and pleasure - but not the answer to other problems and not the only source of joy and fulfillment- we will continue to be at risk of disorder eating symptoms no matter what our situation.

Even back in the day when people had their mouths wired shut to lose weight ( how barbaric was that?), little stopped them from thinking about food obsessively. You may know Anorexics may eat very little, but give food top billing in their thoughts. After bariatric surgery, so much emphasis must be given to adjusting to new behaviors, physical changes and reactions that it is especially difficult NOT to over- focus on food. It is easy to begin to see food as a nuisance, especially if your appetite is altered. The mind can all too easily begin to see food as an enemy to be avoided if possible. So, Julie, I strongly believe the solution for your dilemma involves first talking with your medical doctors to rule out any abnormalities with your physical condition. Then, I urge you to find a nutrition therapist and psychotherapist who are skilled in eating disordered treatment and an intuitive eating philosophy. It can be a very involved process including many small steps to begin to see food as a source of pleasure, creativity and joy. There are many tools a skilled clinician can teach you that you may never have had the opportunity to develop, such as how to really focus on the texture, taste and uniqueness of different foods (even if you consume them in small quantities) and how to view your body as deserving of nourishment - not punishing behaviors, such as purging. Julie, I hope this offers you some food for thought and perhaps, a new direction to follow. Give it time to learn new feelings and attitudes. Unfortunately, the surgery does not operate on these. And for any others who have been able to reach the end of this letter, I hope you are all reminded that food is not a demon or a savior. It is a part of life - just like so many aspects of life that can be greatly enjoyed in combination with endless other activities that can enhance our experience of living fully and joyfully. I wish you the greatest success in your efforts, Julie. Warmly, Carla Dr.

Carla Garber, Ph.D. does not necessarily endorse the Eating Disorder Hope website or its contents. This email response service is provided by her simply to share her knowledge and experience with individuals suffering from eating disorders. It is the privilege of Eating Disorder Support to publish her thoughts here.