With last month's paperback release of "Unbearable Lightness," Portia de Rossi's brutally honest memoir about her eating disorder, I couldn't help but wonder: How goes de Rossi's recovery? Judging from public appearances, the Australian actress currently known as Portia Lee James DeGeneres appears to be as she described herself in the memoir's final pages, "recovered from anorexia and bulimia."
But as a therapist specializing in eating issues, I've learned that appearances can be deceiving, especially among bulimics. I've also learned that the very concept of "recovery" is suspect in my field. The majority of health care providers who treat eating disorders never promise full recovery. Instead, they propose the possibility of living "in recovery." In other words, they believe the risk of relapse is no different than it is for alcoholics and other addicts -- a fact of life for a lifetime. In their professional opinion, the best anyone with an eating disorder can expect is symptom remission.
Until I read de Rossi's memoir, I'd never heard of Carolyn Costin, the psychotherapist who helped her at her worst. According to "Unbearable Lightness," Costin is one those rare therapists who holds out hope of full recovery for eating-disordered patients.
If you've been following this blog, it'll come as no surprise that I put in a call to Costin at her premiere eating disorder treatment center, Monte Nido. That's the Malibu, Calif. boutique-style facility where she counseled de Rossi almost daily for several months. (Not the treatment center of choice for celebrity substance abusers. That's Promises.)
My inquiring mind wanted to know how this teacher turned therapist made a hopeful prognosis out of such an intractable diagnosis. What follows are questions and answers from our recent long-distance conversation.
Q. You and Portia have a few things in common -- for one, anorexia.
A. Yes, when I developed my eating disorder [four decades ago], anorexia wasn't a household word. It took a while for anyone to figure out what was wrong with me. When I hit my lowest weight -- I went from 138 to 79 pounds -- I had this thought: "I'm not in control of [my eating] anymore. It's in control of me." So I went to my school counselor. She'd never seen anyone with an eating disorder before, much less treated one. She had no idea what to make of it.
Q. What kind of treatment was available back then?
A. Besides 12-step programs for compulsive overeating, not much. I went to a psychologist who tried to get me to drink a regular Coke to see what I'd do. I freaked out and never went back. That's when I decided: I'm going to try to [get well] myself.
Q. So what did you do?
A. Many things. I was studying psychology, and I decided to do mini behavior-modification projects on myself. I read books on nutrition and Eastern philosophy. I was also studying to be a teacher and started working with troubled youth. Helping others with serious problems helped me take the focus off the number on the scale ... All that I was doing for myself helped me create the program that would help other people find a better purpose than just being thin.
Q. So, like Portia, you essentially recovered on your own?
A. My parents had a lot to do with it. My mom was very empathic and accepting, so I didn't get into a big battle with her. I warn parents [of patients]: Be careful not to get in a big battle or your child will go underground and start lying. I predict with clients that they're probably going to lie to me, and they still do it. They have to find someone they really trust, develop a secure relationship and hang in there for the long haul ... through periods of doubt, when they lose their motivation, when they think it's not worth it.
Q. You were way ahead of your time -- treating eating disorders in the '70s, then founding your own treatment centers. What were you seeing that other professionals weren't?
A. I wanted to have a place that I would have liked to have gone to when I was suffering from my own eating disorder. I saw too many people get better in the hospital only to relapse upon returning home. It was clear to me that people with eating disorders needed hands-on experience with food. They needed to be able to go into a kitchen and portion their meals, learn how to give themselves the proper amount of food, not just be served it on a tray. After a prophetic dream, I realized that I needed to create an eating disorder facility in a home-like setting with an atmosphere more conducive to healing.
Q. How do you understand the prevalence of eating disorders today?
A. If we did not have a cultural epidemic of dieting, we would not have eating disorders. Not that everyone who goes on a diet develops an eating disorder. However, for sure, dieting is a big risk factor for developing one. I don't think there's any doubt that our obsession with weight in this country, our whole culture of thinness, has fueled younger and younger women to feel like they have unacceptable bodies unless they meet the thin ideal.
Q. Sounds like your personal experience has deepened your professional understanding of eating disorders.
A. You can't talk someone out of an eating disorder. You have to speak their language.
When people start getting better, they hate it. With any other illness -- insomnia, depression -- a person feels better and thanks you. But when you help people with anorexia gain weight, they feel miserable. "You're going to feel bad," I tell them, "but don't think you'll always feel like this." When Portia started gaining weight, she had wardrobe people making comments: "Wow, you went up a size!" She had photographers taking pictures of her eating. It's hard enough to handle yourself, but for a celebrity, it's even harder.
Q. As hard as it was for Portia, you held out hope for her from day one. You hold out hope for all your patients.
A. When I told her she could recover, she was in tears. "You're the first person who told me I could recover," she said. "I thought I was doomed for the rest of my life." I tell people, "Look, don't throw in the towel." I hang in there with them. I've seen some people ill for 15 years become completely recovered. The only people who don't get better are people who stop trying."
Q. How did you reach your radical conclusion of full recovery?
A. When I realized I fully recovered -- I gained my weight, I don't live like that anymore -- I started thinking, "So can you." Seeing people get better, meeting people from around the country who said, "I'm recovered, too," made me feel I was right. Then the research [supporting recovery] started slowly coming out. So now, to me, there's no doubt. The good news: you can be fully recovered. The bad news: you have to have patience. It can take a really long time ... A lot of people still believe in the recovering model -- that you have an eating disorder for life. But when you have this mindset, when you believe you're defective, you live your life that way. It's a self-fulfilling prophecy.
Q. You say you're 100 percent recovered, but do your symptoms ever reappear? Are there any vestiges of your eating disorder?
A. I still have my temperament. I'm rejection sensitive -- that's a hallmark of people who have anorexia. People with bulimia tend to be impulsive. We teach people about their temperaments. They may be impulsive later on in life, but that doesn't mean they're not recovered. That's their personality. Take your traits and figure out how to make them work in the best way.
Q. In your more than three decades treating eating disorders, what have you found to be the secret to full recovery?
A. I have a new book coming out in October, "8 Keys to Recovery from an Eating Disorder." When I was asked to write it, I said, "Only eight?"
The first key is hope, motivation and patience. You need to know you can get there, that you can be recovered, that it takes a long time. And you need to continually reevaluate your motivation. Other keys: finding meaning and purpose. Conscious eating -- listening to your body, getting awareness of hunger and fullness back in your life. Learning how to challenge the critical eating-disordered voice inside yourself and strengthening your healthy core self. Exploring with someone you trust what's fueling your eating disorder. Really looking for the underlying issues, so you don't get rid of your symptom only to have it pop up again.
Q. I don't know if that's eight, and I don't know if you've read my book, "The Self-Compassion Diet," but what about self-compassion?
A. Self-compassion is huge! What these people [with eating disorders] are really good at is empathy and compassion for others. What I teach them, maître, really means self-acceptance or compassion for oneself. In the beginning, it's going to feel wrong, like self-indulgence. But it's not indulgent or weak to be self-compassionate. It takes a lot of strength.
Photo by Art Streiber
Jean Fain is a Harvard Medical School-affiliated psychotherapist specializing in eating issues, and the author of "The Self-Compassion Diet." For more information, see www.jeanfain.com. Got a thing or two to say about any of the above? Please share in the comments section.