Summary: Article about why the OA 12-step approach is ineffective in treating eating disorders

WHY OVEREATERS ANONYMOUS DOESN'T WORK

Overeaters Anonymous (OA), a fellowship based on the Twelve Steps of Alcoholics Anonymous, is one of the oldest and most accessible resources for people with eating disorders, and it’s free. Some people love the program and recover in it, but for many, OA does not work . People with eating disorders often blame themselves for their failure in OA, attributing it to their weaknesses. This article describes how lack of success in the program is due to practices that reinforce the eating disorder.

Strong Foundation, Shaky Structure

The basic principle of the Twelve Steps – that a God of one’s own understanding replaces the compulsions of the eating disorder or addiction – is the only solution I have seen that creates real and lasting recovery. My language for this is slightly different; I would say that the identity of the eating disorder must give way to a healthy, loving sense of self in the psyche, which arises through the process of integrating God or Love into one’s heart, mind and world view. Unfortunately, OA, the Twelve Step program most often sought out for help with eating disorders, does not facilitate this integration. In fact, it has practices and structures that are counter-productive to recovery. This is because certain aspects of OA operate just like the eating disorder itself.

With some variation from person to person, the basic cycle of an eating disorder is:

1) The inner critic gets activated , leading to vitriolic self-recrimination and an intense desire to escape the pain.

2) The person then diets, restricts food, and/or exercises in an attempt to appease the superego and feel good again. This leads to hunger and deprivation.

3) Bulimics and compulsive overeaters may binge at this point. Anorexics may or may not eat.

4) For all three types of eating disorder sufferers, eating ultimately leads to feelings of self-hatred and shame, re-activating the inner critic. At this point, the cycle repeats.

To recover, a person needs to interrupt the cycle with alternatives to the critical and des-tructive thoughts, feelings and behaviors. This is accomplished through:

• Developing an identity outside of the eating disorder

• Defusing the power of the inner critic

• Accepting the feeling self

Although Overeaters Anonymous offers tools for all of the above, practices within certain OA fellowships actually trigger the eating disorder cycle. Many of the practices that are not helpful are those that were directly adopted from Alcoholics Anonymous. Programs that adapt Twelve Step concepts for the unique needs of people with eating disorders offer more of the tools that create recovery.

Recovery Requires A New Identity

One reason eating disorders are so vexing to loved ones, therapists, and to the sufferer is that they are not simply diseases. The eating disorder wrongly becomes the person’s identity, with its own complete system of thoughts, feelings and behaviors. This is why an otherwise intelligent woman may make unwise decisions. The ED system has taken over to the degree that the severe anorectic would rather die than eat, and the compulsive overeater just can’t stop even though she knows better. People with eating disorders may not have a thought all day that is outside the realm of “What did I eat? Do I look fat? What am I allowed to have for lunch? Why do my pants feel so tight?” So to say, “I have a disease” is not accurate for them; there is no “I” that doesn’t have a disease. In order to get better, the sufferer needs to develop a sense of self outside of the eating disorder - the true self.

In OA, part of recovery is admitting that a) you are a compulsive overeater, bulimic, or anorexic and b) you will never fully recover. This is a tenet lifted directly from AA, where the belief is: once an alcoholic, always an alcoholic. At an OA meeting, one would never say, “Hi, I’m Jane and I’m recovered.” The preferred phrase is “in recovery.” Likewise it is considered part of being “in recovery” to repeat, “I’m a bulimic,” (or whatever the eating disorder is). The concept is that you will always have this problem, and that to say otherwise means you are trying to handle it on your own. You are being arrogant, and setting yourself up for the eating disorder to take over.

Encouraging people with eating disorders to repeat, “I’m a bulimic,” and telling them that they will never recover only bolsters the eating disorder. The person who has an eating disorder is already identified with it. That is the problem. Her task is to loosen the eating disorder’s grip on her psyche, not strengthen it.

There is a benefit to admitting to being anorexic (or bulimic, or a compulsive overeater), but for that benefit to be realized assumes a certain level of observing ego, which many people with eating disorders do not have. Once the sense of self as separate from the eating disorder has developed, it is useful to admit that a disease is present – not that the disease is the person, but that the person has the disease. At that point, she can say “I’m a bulimic,” and have it mean “I’m a person who has bulimia.” Until then, saying, “I’m a bulimic,” just means, “I am lost in this eating disorder”. It is likely to bring up feelings of despair and disempowerment, triggering the inner critic (the engine of the eating disorder, described below) and moving her backward on the road to recovery.

Recovery Requires Defusing The Inner Critic

The engine behind the eating disorder identity is a huge, harsh superego or inner critic. If you’ve never had an eating disorder, it may be difficult to fathom how mean and hateful the superego of an eating disordered person can be. The critical voice says, “Not another bite until you lose ten pounds, you disgusting pig!” This wrath creates a dismal internal landscape where constant, derisive injunctions make it impossible for the person to feel accepted, respected or loved. Sadly, people with eating disorders feel that their mean superego is truthful and accurate. They listen to it and heed its directives. To recover, a person needs to defuse the inner critic’s power in her psyche. In OA, certain practices (discussed below) add to the power of the inner critic. Needless to say, this makes the eating disorder worse.

The harsh inner critic is what sets up the compulsion that torments eating disorder sufferers and confounds those who want to help. The dominance of the inner critic - with its denial of the permission to eat and its statements (conscious or unconscious) that the person doesn’t deserve food - sets up a violent relationship pitting the mind against the heart and body. There is so much control, such a vise grip coming from the inner critic, that the part of the person that has normal human feelings and gets hungry has to burst through simply to be heard. The felt sense is that if that part doesn’t come out, it will die .

The phenomenon of the over-controlling mind sets up the compulsion that takes over. The stomach says, “I’m empty. Feed me.” The mind says, “Don’t eat that sandwich, you already had a piece of bread with breakfast, you fatso!” A battle ensues between the hungry stomach and the nay-saying mind. Tension builds, then the dam bursts and the person stuffs chocolate in her mouth and drinks a quart of milk out of the container, re-belling against that controlling force. “She’s saying yes now,” says the hungry part. “Eat everything you can before she starts saying ‘No’ again!”

Years of dieting and self-recrimination about what to eat and what not to eat have dulled the signals from the stomach. But the stomach was made for helping people with this decision. It has its own sound effects and sensations that tell people exactly when they need to start and stop. It also sits very far from the brain - and far from the inner critic with its self-hating thoughts. In order to heal an eating disorder and ramp down the tension that creates the compulsivity, the person must remove the eating decision from the mind and return it to the body, cooperating with the stomach so it gets filled when it’s hungry and left alone when it’s full.

Programs such as OA that advocate a food plan keep the eating decision in the realm of the mind. They do not alter the fundamental competition for dominance between the mind and the compulsions. An advocate of food plans may tell you, “The food plan was made with my body in mind, according to what is healthy for my body.” That is true, and in the sense of nutrition, a food plan is more in harmony with the body than what a person with an ED would eat naturally. But the plan is on paper, and to follow it, one must rely on the mind. (“It’s made with my body in mind.”) The question is, “May I eat this? Is it on my food plan?” not “Do I need this? Is my stomach hungry?” If the plan is great on paper but hard to follow, it doesn’t matter how much it is in harmony with the body. If a person can’t follow it, the plan, the plan is not helping her. Sadly, this is a set-up for failure of the kind an eating disordered person already suffers. People with ED’s know what they should eat; they just can’t do it. When a person has a food plan and does not follow it, her inner critic is triggered, just as it is in her eating disorder.

There is another layer of inner critic that a person has to deal with in OA. One of the principles of the Twelve Steps is that the group becomes the voice of a higher power, substituting for the voice of the eating disorder (or other compulsion). This method is very helpful in AA and many of the other Twelve Step programs, where the pressure of the group acts as a deterrent from the compulsive behavior. This does not translate as well in OA and other groups using food plans. Some groups are really nice about it, but the ethic is still there – stay on the food plan, or you are not “with the program.” In many cases, the person delivering the message of failure is the sponsor, in whom the sufferer has placed her trust. Now if the person falls short of the program, there is an even larger inner critic telling her she has fallen short. In this sense, the OA group replicates the eating disorder on a big scale.

Some people do need a food plan at the beginning of treatment. In addition, some people benefit from cutting out white sugar and/or white flour for a period of time since they act like drugs in the body and brain. For a food plan or food restrictions to be effective, however, they must be delivered with constant reminders that they are done with love, not punishment, and that rather than representing failure, a breach is an opportunity to learn. To be effective, guidelines around food need to be presented as stepping stones, subordinate to the greater project of listening to hunger and fullness signals. If, however, they are presented as a way of life, they become a trap that will keep the eating disorder in place.

Some OA groups also use fear as a motivator, adopting the AA tenet that says, “If you go out (of the program), you will get in trouble, and perhaps even die.” Eating disorders also feed on fear. A common inner critic line is, “Don’t eat because then you’ll get fat and no one will love you. You will end up alone!” The words are different in OA and there are some OA groups who do not operate this way. The groups that use fear, however, are operating in the same emotional mode as the eating disorder.

Recovery Requires Self-Acceptance

At the core of the eating disorder cycle is self-hatred, a constant rejection of the person. This rejection can be directed toward anything and everything – her body, her words, the feelings that emanate from her heart. Most of all, the hatred is directed to the core of her humanity, that part that was vulnerable and felt either rejected by caregivers, or responsible for their problems. (This is another type of rejection: If she had to take care of them, there was no one there to take care of her.) To get better, a person needs to embrace her vulnerable, feeling self instead of pushing it away.

Here is another place where OA adopted something directly from AA that doesn’t work for many ED sufferers. The model in AA is that there is a self, a set of compulsive behaviors and feelings, that goes along with the drinking. If the individual doesn’t drink, that self won’t get activated and life becomes manageable. In OA, the idea is similar. If you handle those compulsions and if you don’t take that first compulsive bite, you can keep that self at bay – but it often doesn’t work.

There is a saying in OA: “In AA, you can lock up the tiger and throw away the key. In OA, you have to take the tiger out three times a day.” This sets up a kind of torment. The tiger metaphor is another way of saying, “You can’t not eat.” That should be a sign that there are major, fundamental differences in the recovery of someone with a substance abuse problem and someone with an eating problem. That should be a sign that the programs of recovery for such people would differ on key points. But the torment is, in OA they know that recovery from an ED is different enough to make up that saying about the tiger, but they still believe in the original AA idea – that there’s a tiger that should be locked up and the key thrown away.

The problem is with the model – having a self from which you need to distance yourself in order to recover. The problem is in thinking of it as a tiger you have to lock up. It would be easier in some ways if you could just not eat, but you can’t. As a result, the recovery model that asks for the kind of abstinence that works so well in AA breeds failure for many people in OA. EDs need a new model where the tiger is tamed, befriended, and ultimately transformed into a pet that can be held and embraced.

People with eating disorders reject themselves so much. They need an alternative to that rejection, and the illness provides one. Being forced to confront the eating disorder at every meal is an opportunity to check in with bodies, hearts and minds to feel what needs attention internally. Eating three times a day is not a curse. It is one of the hidden blessings in having an eating disorder, giving us an opportunity to look underneath the compulsivity, attend to the person in pain and ask: How did the tiger become a tiger? What needs to be done differently so this tiger doesn’t get so aggressive? What happened, and who is hurting because of it?

Solutions

Fortunately, there are programs that embrace the concept of replacing the compulsions with a sense of Love or God and whose practices are tailored to the unique needs of eating disorder sufferers, not a direct adoption of the AA model. Eating Disorders Anonymous is one such program. It says the following on their website, (www.eatingdisordersanonymous.org): “Diets and weight management techniques do not solve our thinking problems. EDA endorses sound nutrition and discourages any form of rigidity around food. Balance – not abstinence -- is our goal.” The EDA pamphlets, website, and meetings all contain principles and tools that provide alternatives to the eating disorder cycle. Recoveries Anonymous (http://www.r-a.org/) is another program that adapts principles from AA rather than adopting them directly.

Of all the tasks in eating disorder recovery, the hardest – and most important - is building self-esteem. A person will be much more successful in recovery if she finds a program that, instead of setting her up for failure, understands what kind of support she needs and makes it easier, not harder, to love herself.