Thursday, January 26, 2006
It's hard to be a body - Eating disorders in the Jewish community
It's hard to be a body - Eating disorders in the Jewish community
By Lois Goldrich
(NJ) Jewish Standard - January 26, 2006
Anne — today a successful New York lawyer in her 50s and a former Fair Lawn resident — says she was anorexic "before there was a name for it." She remembers two years in particular, beginning when she was 17, when she "chose not to eat."
"I got really bony," she says. "I was 5'3" and about 90 pounds." Still, with eating disorders not yet a hot topic in the public arena, the problem was not picked up by family and friends.
"People thought it was great that I was so thin," she says. "We didn't think of it as an illness or a problem."
The disorder put a halt to Anne's menstrual cycle. "Now that I think about it," she reflects, "I may have been afraid of growing up. I was afraid to leave for college, but I didn't want to admit it." After years of therapy, she now thinks she may, unconsciously, have been trying to keep herself small and undeveloped.
"I had been overweight for a short time and I couldn't deal with it," Anne remembers. Afterwards, even when the extra weight was gone and she kept losing, she "always felt fat."
"When I was growing up, I didn't recognize my own capabilities," she says. "I didn't value my own ability to write or express myself. The only thing that seemed to matter was how you looked."
"I thought I was the only one in the world who had this problem," she says. "There's no scarier place than inside the head of an anorexic. I don't want other girls to have to go through this."
Unfortunately, many do.
Twenty-six-year-old Sara, living in Mahwah but raised in Glen Rock, relates that she was bulimic/anorexic from the time she was a freshman in high school until her sophomore year in college. She only stopped because, after a bout with pancreatitis, "I finally realized I could die."
Sara now visits area schools to talk about her experience. Last year, she was spoke to the students at Ma'ayanot Yeshiva High School in Teaneck as part of the school's effort to teach its girls about healthy eating. Also on the program was Nancy Graham of the Renfrew Center in the Ridgewood, a group that educates about and treats eating disorders.
Sara says she had been sick with asthma much of her childhood. Today, she understands that a large part of eating disorders is tied into the issue of control. "I couldn't control my health," she says, "but I could control my weight."
Sara's weight dropped to 92 pounds — on a 5'6" frame. Her parents and friends were extremely concerned.
"I was taken to psychiatrists, hospitalized, treated in outpatient programs, and underwent group, family, and art therapy," she says. "I was also admitted to a residential treatment center six times."
Sara, now a nurse, doesn't believe anyone else can have a major effect on someone determined to lose weight. "There's only so much someone can do," she says. "I didn't want to get better. I saw myself as heavy and wanted to see my bones, to disappear."
On the other hand, she doesn't recall any one reason she felt this way. "It wasn't about appearance," she says, adding, "the last thing you want is attention. You become isolated. If it was only about looks, you would stop when you were the right size.
"Doctors don't get it," she says. "They blame families."
As for the pervasive influence of cultural factors — more specifically, in a society that teaches "you can't be too thin" — she fears that "anorexia is accepted in today's world," and this worries her a great deal.
Jodi Rubin, a therapist at the Renfrew Center, which Sara attended, reports that "the number of people seeking treatment [for eating disorders] has increased — especially among those in midlife, people in their 30s, 40s, and 50s."
Rubin thinks "the older groups have been struggling with this for many years or have had mild disorders throughout their lives but have now been sensitized by media coverage, and by [programs such as] `Desperate Housewives,' to seek help."
She is adamant that "the common misperception that anorexia relates to vanity is just wrong." Rather, she believes that the disease is just a symptom of an underlying issue involving depression, anxiety, or lack of self-esteem and that eating disorders in general are simply ways to cope with problems in self-image, relationships, and the like.
Echoing Sara's conclusion that "anorexia is almost accepted because of the value our society places on looks," she emphasizes that the condition itself is "not about looks or appearance."
In addition, "the problem crosses religious lines," says Rubin, who notes that more African American women — who used to value voluptuous bodies — are now being treated for these disorders.
Rubin says that there are four main influences on body image: social/cultural, family, psychological, and biological. When all four converge, she says, there can be a "perfect storm, resulting in an eating disorder."
"We are all struggling in some way," she says, "depending on how broadly we define the issue."
Janet Bauer, director of professional services for the Wayne-based Jewish Family and Children's Services of North Jersey, says that to understand eating disorders — which include anorexia nervosa, bulimia nervosa (binging and purging), and compulsive overeating — "you need to start by defining the issue."
According to Bauer, "An eating disorder is a survival mechanism using food or lack of food to cope with emotional issues," such as low self-esteem, depression, feelings of worthlessness, identity issues, family communication problems, and feelings of loss of control."
Bauer points out that there are "basically two ways to cope with emotional stress: We can self-soothe through food, or we can stop eating. We all have this pattern to some degree."
She says she hasn't seen more eating problems in the community served by her organization, "mostly middle- and upper-middle-class families," than exist in the population at large. She also says that the people she sees with food disorders rarely come in saying they have any eating issues.
"It almost never presents on its own," she says. "People come in with other presenting problems, or parents come in because they're worried about their children."
While anorexia is found mainly among girls between the ages of 15 and 24, men are certainly not immune — especially those competing in sports that tend to place an emphasis on the athlete's diet, appearance, size, and weight requirements. According to the Website of the National Eating Disorders Association (www.nationaleatingdisorders.org), in the United States, "as many as 10 million females and 1 million males are fighting a life and death battle with an eating disorder such as anorexia or bulimia. Approximately 25 million more are struggling with binge eating disorder."
Bauer says that anorexia results from "a major body image distortion — anorexic young women don't have a realistic view of what their bodies look like, regardless of their weight."
She adds that these women are "good at hiding." Bulimia is somewhat harder to hide. Bulimics may chew their food and then spit it out; they make take laxatives; or they may engage in compulsive exercise.
Bauer is equally troubled, however, by the rise of morbid obesity — a concern echoed by social workers and psychologists who work with the Jewish community.
Rabbi Abraham Twerski, founder/medical director emeritus of the Gateway Rehabilitation Center, a nonprofit drug and alcohol treatment system in western Pennsylvania, believes that "within every problem there is a component of self-esteem that needs to be corrected."
"Animals in the wild eat for nutrition and stop when they're done," he says. "They don't have eating disorders."
Twerkski, who served for 20 years as clinical director of the department of psychiatry at St. Francis Hospital in Pittsburgh, has written more than 40 books, including "The Thin Within You." Now "90 percent retired," he lives in Monsey, N.Y., and visits the Gateway Center once a month.
"For some people, food can be a tranquilizer, used essentially as a drug," he says, pointing out "while some people at a shul kiddush make a l'chaim and they're done, others need to keep drinking." Similarly, "anorexics may get a rush from losing weight, similar to narcotic addiction."
Twerski estimates that some 20 percent of young Jewish girls have, or will develop, an eating disorder. And while he suggests that there is probably a genetic component to all addictions, he talks about the importance of "ingredients."
"Just as you need ingredients to bake a cake and without one of the ingredients you cannot do it," he says, "addictions need critical amounts of each ingredient as well. If you've got a strong genetic makeup, you may be less affected by psychological and social factors. Or, if you are strong psychologically — have high self-esteem, handle pressure well — you will be unlikely to develop a problem."
Twerski also points out a problem that appears to be unique to segments of the Orthodox Jewish community — in particular, those who rely on a shadchan, or third party, to arrange marriages for their children. He says that some young men specify the dress size of a prospective spouse, and this is more likely to be a size 2 than a size 12. In addition, some want to know the dress size of the girls' mothers, to get an idea of how the girls will look when they're older.
"This is causing an increasing number of cases [of anorexia] among middle-aged women as well," he says, adding that both the affected girls, and their parents, may be "in denial."
The rabbi tells two stories. First, he discusses the case of an observant girl who was sent to board with a local family in a major northeastern city in order to attend a particular yeshiva. The family she was staying with realized that she was bulimic and told her school. The principal, in turn, called the girl's parents, who told him, "Forget it. Don't worry about it." Later, when the situation worsened and the principal called the parents again, they withdrew their daughter from the school.
The second story concerns a rabbi's wife who reported to Twerski that her husband did not appear to notice that she disappeared several times during each meal. Suffering from bulimia, she was afraid to tell her husband, lest he think she was mentally ill. Twerski suggested that she be honest with her spouse, telling him that she would seek help for the problem. This story has a happy ending. The issue was talked through, treated, and resolved.
Despite the media attention paid to anorexia, Twerski suggests that "obesity is the number one health problem in the country."
"We come from an `ess, ess, mein kind' culture. Parents express their love by feeding their children," he notes. "They push food at you thinking to make you healthy."
He says his own father showed his love by personally cooking him a lot of eggs. Also, noting that historical memory lives on beyond its relevance, he suggests that the fear of tuberculosis in Europe led Jews to proudly display their extra weight. "If you were thin, you were suspected of being ill," he says.
Interestingly, Twerski suggests that Cathy Guisewite, author of the comic Strip "Cathy," is the country's best authority on eating disorders and says he would be delighted to coauthor a book with her. (He coauthored four books with "Peanuts" creator Charles Schultz.)
Zeva Citronenbaum, a social worker in Rockland County, N.Y., who serves mainly Orthodox and chasidic clients through a privately funded non-profit mental health center, recently co-sponsored a presentation with the Renfrew Center called "Balancing Your Relationship with Food: A Discussion about Emotional Eating." The center approached her, she said, because they wanted to work through someone known to the community, so that "people would feel safe."
According to Citronenbaum, while the portion of the program presented by Nancy Graham of the Renfrew Center dealt mainly with anorexia and bulimia, her segment was devoted to overeating, which she said was a more common problem in her area. To prepare for the presentation, the Monsey social worker set out to collect material from Torah and rabbinic sources on the importance of eating properly.
"It's amazing," she said. "All of it is in the Torah — desire, emotion, depression, exercise. It's all there. You just have to know how to interpret it and use it."
Citronenbaum says that people who eat too much or too little are misreading Jewish sources, which stress balanced, healthy eating.
She points out that the topic of mental health is still both "taboo and underfunded" in the community at large, and even more so in the Orthodox community. While she has not seen a large incidence of anorexia among the young girls seeking shidduchim in her own area, she suggests that "this may be a bigger thing in Brooklyn, where people are more fashion conscious."
The problem that concerns her most is that "overeating is accepted in the frum community. It's no big deal. It goes along with the old Jewish philosophy that fat equals healthy, and an overweight child is a happy and healthy child."
Dr. Michael Salamon, senior psychologist/director of the Adult Developmental Center in Hewlett, N.Y., (and member of the executive board of The Awareness Center) points out that there is big difference between clinical eating disorders and problems that are pervasive in society. While only a small percentage of people have diagnosable eating disorders, some 30 percent are obese.
Why Jews? "First," he says, "we believe that food makes you feel better. Also, in the absence of the Temple, we now have the Shabbat and holiday table, where there is a requirement to eat certain amounts of different kinds of foods and invite others to eat as much as they want — food as a means of celebration."
On the other end of the spectrum, however, "our culture is trying to sell women an image rather than the reality of health."
"My father was in the `shmatta' industry," he says. "Today's size 4 was last generation's 8 or 10. People are trying to match the Nordic ideal of beauty, but even most Nordic women have pear shapes."
Salamon has been told by 16- to 19-year-olds in the observant community, where there is pressure to marry young, that "thinner girls get the better husbands." He decries what he calls the "superficiality of the shadchan approach, where matchmakers don't know clients and what they do know has nothing to do with bringing or keeping a couple together."
In once case, he says, he was told that a prospective groom requested a picture of a girl's grandmother, assuming that the girl's mother was probably dieting to help get her daughter a match and therefore her picture would not be reliable.
He says he's seeing increasing numbers of young girls — and now middle-age women — who have created unhealthy modes of eating: "fasting in the morning, taking a bite of a power bar in mid-afternoon, and eating one piece of fish for dinner." While they will ultimately become physically ill, he says, the presenting symptom is generally something like anxiety or compulsive behavior.
"This is not a geographic phenomenon," he says, pointing out that he has seen girls with the problem who have come over from Israel. Like the other experts, Salamon believes that the incidence of eating disorders among Jews tends to match that of the general population; however, he notes that the particular pressures and causes may differ.
Salamon says that while he sees anorexic girls (he estimates that 5 to 8 percent of girls are dangerously thin), he sees many more who have "given up" and have begun to overeat to soothe their anxiety.
Dr. Naomi Mark, a mental health professional on the Upper West Side of Manhattan, agrees that the Jewish community is highly influenced by secular culture, which today stresses the primacy of materialism and thin bodies.
"Add to this the fact that Orthodox Jews generally put great value on high achievement and the quest for excellence ... and [we get] children who are highly driven to succeed, please their parents, make an early marriage, and have a lot of children."
She says that "while all adolescents face challenges, secular girls have a broader period of time in which to achieve success. The expectation is that the Orthodox girl will do it at an earlier age. In school, she will have both academic and matrimonial pressures."
In that regard, she says, the shidduch system is a kind of "social control. Girls must be cognizant of their reputation, appearance, etc., or a favorable match won't be made. Some girls are more vulnerable than others and have a higher propensity for anxiety. They want to appear perfect."
Mark says "this is both a `doing' and an `undoing.'"
"The `doing' part is that they're able to master their weight. The `undoing' is that, unconsciously, this is also a way to resist growing up, to stop their growth."
Mark adds, "There may be more of a need for these Orthodox adolescent girls to try to reassert control (albeit in a self-destructive way) in a world where, for them, so many issues are decided outside of the realm of their control."
She points out as well that girls tend to internalize their stress (and often hurt themselves), while boys generally "act out." In addition, Mark cites the difficulty some Orthodox girls may have in developing a healthy body image and coming to grips with their sexuality when interpreting the attribute of "tzniut" (modesty).
Says Mark: "It is not necessarily the emphasis on tzniut alone that creates difficulty but rather, at times, when the [worthy] value of tzniut gets distorted and misunderstood as a rejection of the body and sexuality."
Author Jonathan Rosen — whose many writings include the book "Eve's Apple," the story of a young woman struggling with anorexia — says that while he was certainly interested in the reality of eating disorders, "I was surprised that anorexia became my subject." Rosen is also the former cultural editor of The Forward and current series editor of the "Jewish Encounters Book Series," a collaboration between Schocken Books and Nextbook.
In an interview with The Jewish Standard, Rosen said he knew many smart young women at college [Yale] who were "at war with their own bodies." Based on that experience "and my own perplexity," he said, he decided to engage in "novelistic sociology" and pursue this mysterious subject.
While Rosen offers the disclaimer that he is far from an expert on the subject, his research has yielded several interesting perspectives on the illness.
He notes that while there have been many advances in understanding the illness, it remains "at root, mysterious."
"It is a real illness but fascinating because of its metaphorical nature," he says. "It's hard to be a body."
Rosen points out that while anorexia is a universal disorder, it is apparently related to socioeconomic factors. "We don't see "nearly as much among poor women," he points out. "Since Jewish women tend to be more educated and upwardly mobile," he suggests, they may be more susceptible to this condition.
Rosen is particularly intrigued by the fact that after the '60s, after sexual liberation, the incidence of eating disorders increased. "You would expect the opposite," he said. "But comfort with the body is not easily achieved in modern culture."
"When I was an undergraduate at Yale," he recalls, "women were under the dual pressure to be great students and conform to ideals of beauty. This had not yet been addressed by the feminist movement, which was then tackling the idea of equality."
Furthermore, he adds, "what we want intellectually, and what our bodies want, aren't always the same. Many professional women I know are overwhelmed and surprised by the biological urge to have kids. We persuaded ourselves that we are in an age beyond biology, when of course we never are."
Rosen suggests that Jews have absorbed the Christian dichotomy between soul and body as an aspect of Jewish consciousness. Traditionally, in Judaism, the two were intertwined; while in Christianity, "the soul and the body were not even on speaking terms," he says.
But, in a metaphorical fashion, aspects of anorexic thought seem bound up with certain aspects of Jewish life, he feels.
"A homeland is like a body. We got used to being in exile and made it a virtue, and for a long time we were uncomfortable about things — like weaponry, etc. — that went with having our own county, which takes up space, exhibits appetite, aggression. To shrink from this can seem a kind of `political anorexia.'"
Rosen's anorexic heroine is, figuratively, stripped of flesh, reminiscent of the degraded bodies of Holocaust victims. According to the author, in the aftermath of the Holocaust, Jews have experienced a shared trauma and fascination with bodies stripped of dignity, even of flesh.
While anorexia represents an inversion of the natural order — the heroine is described as viewing "illness as the road to health, control as the path to freedom, denial as the way to fulfillment" — Rosen says this is "an exaggeration of what we do all the time."
"We dam rivers and build cities where we shouldn't, which leads to flooding. We do the same thing to our own bodies."
Since writing the book, Rosen has received "many heart-breaking letters from women, from their teens to their 30s," who felt it was an accurate portrayal. "There is a lot of suffering out there," he says, "[and] much of it invisible."
Dr. Shulamis Pollak, director of guidance at Ma'ayanot Yeshiva High School in Teaneck, believes strongly in being proactive about teaching the issue of health. The school has a mandatory year-long 10th-grade health class that covers topics such as nutrition; and seniors — who are are offered an elective in health and fitness — attend two programs that deal specifically with body image and proper eating.
Pollak is especially proud of the "Mechanechet" program, through which all students meet once a week throughout their four years at Ma'ayanot to discuss special developmental issues. The 11th-grade curriculum focuses heavily self-understanding, with emphasis on how the girls feel about their bodies. It also explores the pressures and influences that play a role in shaping body image.
According to Pollak, there is an ongoing debate about whether schools should invite recovering food addicts to address the students. While Ma'ayanot has had such presentations in the past, "we are opting to do something different this year," she says.
Those who oppose such presentations say that, unlike other mental disorders, such as depression, the behavior of food addicts is something students may choose to emulate.
Pollak points out that girls who get information from people recovering from anorexia/bulimia occasionally try to copy the maladaptive behaviors or may say, "She's OK now; I can do this, too, just until I get thin enough."
Pollak says that rather than focusing on the conditions themselves, she prefers to educate students about healthy ways of eating and of dieting, and then to provide some information about the warning signs of eating disorders.
"I would tell parents to be wary of weight loss that doesn't make their child feel better or that the child does not see. Parents should look further into what might be the source of pain for their child, if the child still doesn't feel good about herself after significant weight has been shed. Also, they should be aware of how their child is losing weight, especially with fad diets."
According to Pollak, who has had many years of experience working with teenage girls, those "who have the disorder often don't realize that they are in trouble. If we can help the child realize that losing weight won't dissolve her underlying pain, and that professional counseling might, it's usually easier getting through to the parents once the kids understand that they need help."
The month of February will be "health month" at Ma'ayanot, during which the girls choose programs that touch on a wide range of health issues, including nutrition, healthful cooking, and aerobic exercise. In addition, Ma'ayanot "offers its seniors a unique program on what to do when you need to make it out there on your own," says Pollak, "for example, if you're spending a year in Israel or going off to college." The workshop teaches girls "how to make the right choices, what to eat in restaurants, etc."
Pollak points out that going away may create two problems. "The girls may begin to overeat, or a fear of overeating may cause them to eat too little." Girls in their senior year also learn how to recognize eating problems among their friends.
Shalva Schwartz, a social worker at the Hebrew Academy of Nassau County, says the school uses a curriculum created by F.E.G.S.-Long Island in programs designed for middle-school students. (F.E.G.S. was established in the 1930s as the Federation Employment and Guidance Service, Inc. It is now a health and human services agency.) The curriculum avoids addressing the signs and symptoms of specific disorder and emphasizes instead positive body image and issues such as the dangers of dieting. A Jewish component of the program incorporates material on noted Jewish women, from biblical times to the present.
At a recent program, a trained instructor did yoga with the students "to encourage them to feel good about their bodies." The school also held a Health Day, which included a component on body image.
"We discussed what it is, what influences it, and what we can do to create a more positive image of ourselves," says Schwartz, adding that "the girls came up with their own solutions ... through exercise, manicures, etc."
Also during Health Day, the school screened a video showing students how images of models are touched up to make them look better.
Schwartz points out that "the purpose ... is to show the girls that even what we see in the media is, most of the time, not real. Yet we feel bad about the fact that we don't look that way, when, many times, even the model doesn't look that way.... The media is trying to sell an image that doesn't really exist."
As at Ma'ayanot, health is a regular part of the 10th-grade curriculum and special programs have been arranged, including visits from survivors of eating disorders. "The students responded very well to that," she said. "They asked for the speaker to come again."
Throughout the year, says Schwartz, "we focus on the topic of self-esteem and how it can influence all our decisions."
Schwartz says that when the school suspects an eating disorder, it calls the parents, who get the child appropriate help.
While "no girls at this age are happy with their bodies," she says, "we have done a lot of education so [that] students and parents are recognizing problems earlier, and getting help earlier, which leads to much more successful outcomes."
The Renfrew Center's Rubin suggests that in detecting eating disorders, weight is not the only thing to watch out for. "The signs include psychological factors," she says, "such as [a tendency toward] perfectionism."
Anne, who weathered anorexia some 30 years ago, says that anorexics "engage in black and white thinking, all or nothing, no gray areas. I thought about food 24/7."
Acccording to Rubin, if parents suspect that their children have eating disorders, they should talk to them about how they're feeling. It's also important that parents project good values, she says, modeling a healthy attitude toward their own body image and relationship to eating.
As Sara, a former anorexic/bulimic points out, "If mothers are over concerned with their weight and diet all the time, their daughters will [do this] too."
Today, Sara tells high school girls that while it is not their job to be their friends' psychologist, if they recognize that something is wrong, they should tell someone — whether parents, teachers, the school nurse, or another school professional. She also talks to them about staying healthy and maintaining a healthy lifestyle.
"You have to educate kids before they get to the point where they develop disorders," she says. "Don't pressure them too much about eating or exercise. Teach them to love themselves as they are."
Rubin stresses that "parents can take steps to strengthen the `family' area [of the child's life] so it can serve as a buffer against other psychological, social, and cultural factors." Echoing that view, Mark emphasizes that "parents must keep open the lines of communication with their teens and able to talk to them and understand the pressures they're under."
Salamon, likewise, cautions that "parents must know how to recognize signs of anxiety in young children."
"There's great denial in the population as a whole," he says, "but maybe even more in the Jewish community. Parents say of boys' problems, `His rebbe will take care of it in school,' and of girls' problems, `She'll outgrow it.' Parents must deal with the issues that present."
Mark believes that "day schools are becoming more sensitive to this issue. While some have invited speakers on eating disorders, others are stressing the concept of a healthy balance in eating and — in a culture that overstimulates us — discussing how to balance pleasure and health."
She believes the goal is to "create a world where people can be who they are and teach that there are multiple ways to live and to succeed. There is a place in the community for all different kinds of people."
Rosen would urge that we train ourselves to be "more aware." As the father of daughters, he has heard that a good father-daughter relationship may help to prevent eating disorders.