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Anorexia nervosa and bulimia: How to help

Marilyn Duker and Roger Slade

ISBN: 0-3352120-3-4 2003 xii+274 pages UK: Open University Press

Lucie Ramjan
School of Applied Social and Health Sciences, University of Western Sydney, NSW

As a registered nurse working with adolescents with eating disorders, I was pleased to be asked to review this book on how to help anorexia nervosa and bulimia sufferers. This insightful and diligently written book clearly demonstrates the wealth of knowledge, expertise and experience of the two authors in the recovery of people with eating disorders. This second edition draws on and extends the authors' previous work in, Anorexia nervosa and bulimia: how to help (1988) and makes references to Slade's The Anorexia nervosa reference book (1984). It makes an extremely valuable contribution to the health care literature, especially in the area of self-help.

The authors divide the book into three easy to read sections. Part One provides the reader with an overview of the 'anorexic' and 'bulimic' personality. The reader is informed of the sociological complexity of eating for the person with anorexia or bulimia and the immense turmoil a sufferer experiences in maintaining food/body control. For the sufferer this control defines who they are; that is their sense of self worth.

Through the authors' eyes, we see anorexia and bulimia, as having a marked resemblance to alcoholism and drug addiction. Taking laxatives or inducing vomiting after a binge episode are the bulimic's 'quick fix' (p.157) and the anorexic's 'quick fix' includes the 'fasting high' they experience when they starve or the 'high' following excessive exercise (p.32). Conversely, the anorexia sufferer can experience sensations of a 'food hangover' when they consume food (p.164). Sufferers are metaphorically 'hooked' (p.32).

Part One also examines the theories underpinning food control and how these affect treatment options. The 'starvation whirlpool' theory (p.35), in particular, demonstrates the manner in which a sufferer's intellectual capacity reduces to a state in which everything becomes 'polarized'. In this 'polarized' state the sufferer feels a 'greater clarity of mind' (p.36), as there are only two categories in decision-making, and everything, including their sense of self-worth, is seen in terms of food regulation or exercise. The force of the 'whirlpool' strengthens as the sufferer persists with starvation and overactivity, inevitably leaving the sufferer without choices as it gathers its own 'momentum' (pp.35-38).

The authors explore the hazards of an authoritarian style of treatment involving coercion that can lead to further destructive forms of control including purging, vomiting, laxative or diuretic abuse (p.48). They succinctly describe these maladaptive behaviours in terms of the sufferer's personal journey through phases on the 'anorexia nervosa/bulimia board game' (pp.50-60). The authors consistently advocate the importance of being understanding and empathetic towards the sufferer's situation and believe this can be achieved without 'a total assault on the person the sufferer currently is' (p.61). Weight gain alone does not signify recovery.

The final chapter in Part One explores treatment modalities and the limitations and constraints of these on recovery for sufferers with anorexia or bulimia. The disadvantages of taking control away from sufferers through hospital treatments-like 'behaviour-modification' programs, with which I am well acquainted-are explored.

In most cases hospitalised anorexia and bulimia sufferers are treated using 'behaviour-modification' techniques. They are expected to comply with eating disorder programs, which rely on 'rewards' and 'punishments' to modify behaviour. These programs generally result in sufferers' eating and increasing their weight as they 'eat to get out', or in complying with program rules; but sufferers inevitably return (the revolving door syndrome). This reminds me of Goffman's (1961) book Asylums, which richly depicts life in 'total institutions'. 'Total institutions' are 'controlled environments' where people placed within are forced to comply with rules and regulations in order not to face retribution.

A leading eating disorder specialist (in Sydney, Australia) Professor Pierre Beumont remarks: 'punitive programs have proved ineffective, and…doctors have been slow to listen to the advice of former sufferers' (Guilliatt 2002: 24). This is something Duker and Slade clearly have not neglected in their book. The sufferer is the most important source of information regarding their illness and recovery.

Part Two of the book provides a comprehensive analysis of different weight ranges and how, not only is a sufferer experiencing physiological changes, cognitively their thinking is also considerably varied at each of these stages. The book provides constructive advice on how to communicate with genuine empathy during differing weight bands. The authors argue weight gain should be at the sufferer's own pace unless they are precariously unstable and it is beneficial for therapy to occur alongside. This method of weight gain, according to the authors, is therapeutic as the sufferer retains some control and personal autonomy and feels like a mutual partner with the helper in recovery (p.88). Similarly, people with anorexia in a study by Garrett (1998) felt that recovery often took place within a therapeutic relationship where a 'new identity' could emerge and they could feel a sense of normality. 'Healing rituals' during recovery assumed a new meaning as avenues for coping with the disorder (Garrett 1998: 187).

In Part Two, the authors also explore the aetiology of eating disorders from the perspectives of history, society and culture, biology and psychology. They explore in depth 'the culture of control' and how family values such as the 'Protestant work ethic' actually endorse eating disorders in our society (pp.120–122). As a society we tend to value and praise the qualities shown by the person with an eating disorder, such as self-control, commitment, high achievements and expectations and personal responsibility. The final chapter in Part Two explains how the person with anorexia or bulimia actually 'becomes a person' through their food/body control (p.134). 'Anorexia nervosa/bulimia in all its dimensions [is] a solution to an existential problem' (p.136).

Researchers have discovered that for recovery and treatment to be successful the helper must establish a therapeutic relationship with the sufferer (Deering 1987; Halek 1997). A successful therapeutic relationship requires the helper to be able to communicate effectively while building rapport and trust with the sufferer (McQueen 2000). For trust and a therapeutic relationship to be established, the helper must demonstrate that they are honest, genuine, caring, nurturing, empathetic, non-judgmental, committed and most of all consistent (Deering 1987; Halek 1997).

Duker and Slade concur with the above research. Part Three of their book details how people can help sufferers recover from their illness. I feel this is a critical part of the book particularly for health professionals. It outlines comprehensive advice and practical skills to assist the sufferer along the long journey towards recovery or an improved sense of self, through the establishment of a therapeutic alliance. The authors argue therapeutic communication is the most important tool, as the helper must understand the sufferer's point of view and adjust their thinking and responses to acknowledge this understanding. Dialogues provide the reader with real life situations and ways they could respond if confronted in similar circumstances.

In Chapters 11-14, the last chapters of the book, the four weight bands are revisited and practical suggestions are given of how a helper can provide sufferers with support and information at each of these stages. Re-feeding in hospital may be needed and the methods of re-feeding are explored. They provide the helper with advice on the correct communication techniques to alleviate a sufferer's panic and fear in these situations. Duker and Slade also consistently and aptly approach the issue of the importance of 'food' as being equivalent to 'medicine' when conversing with sufferers (p.193). This is a logical step but one most helpers rarely exhibit. They also stress the importance of support throughout weight gain, but more so as the sufferer reaches a more viable weight as the 'anorexic mindset' persists (p.218).

Finally, recovery from an eating disorder, the authors admit, continues to be a bumpy journey of 'highs' and 'lows', setbacks and triumphs as a sufferer re-discovers their 'true' self and gains the 'self confidence' they need to be themselves.

In Australian society eating disorders are afflicting greater numbers of men and women and our child and adolescent population seem particularly susceptible. This is a major health concern, especially for a society that continues to culturally endorse the ideals of the 'body beautiful'. Duker and Slade's (2003) book is an excellent resource for today's health professional, in particular those who care for the growing number of eating disorder patients. It could also be a valuable resource book for undergraduate and post-graduate teaching in Australian nursing courses. This need has been highlighted by a mental health nurse, Geanellos (1999), who described the paucity of undergraduate and postgraduate nurse education for mental health issues in Australia. She commented on 'the displacement of emotionally disturbed adolescents into services that are not age-appropriate and whose staff are inadequately prepared to work with them' (Geanellos 1999: 139).

I have learnt a great deal from reading this self-help book, information that will be useful in my own clinical practice as a nurse. I whole-heartedly recommend this book to any health professional or layperson wanting to understand and help someone through the phases of these chronic illnesses.

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