What’s That About?

“It’s about control.”

This statement has been applied to everything from OCD to eating disorders to self-injury to domestic violence. But, really, what does this statement mean?

When I hear that X is about Y, I generally interpret this statement in one of two ways: 1.) Y is a theme of X or 2.) Y is the most salient feature of X. For example, if someone says that Romeo and Juliet is about undying love, my interpretation is that undying love is a primary theme of Romeo and Juliet. Or if someone says: “My birthday is about me,” I interpret that as “I am the most important person on my birthday” in terms of attention, presents, and deciding how to celebrate.

In regards to the cliché that a certain psychological problem is about control, both of these interpretations make sense to a certain extent. Control is both a theme and a salient feature of OCD insofar as sufferers are overly preoccupied with controlling their external environment, as well as their thoughts and actions related to their particular obsession. For example, a person with OCD may spend hours scrubbing her body and cleaning her home in order to control the spread of germs and prevent herself or others from becoming ill.

Control is both a theme and a salient feature of eating disorders insofar as sufferers become preoccupied with controlling their dietary intake, exercise, and weight. Individuals with anorexia tend to be “over-controlled,” rigid, and perfectionistic not only with food but in other areas of their lives, while individuals with bulimia experience periods of “dyscontrol” of their emotions and food intake, resulting in binge /purge episodes.

Control is both a theme and a salient feature in the lives of individuals who engage in self-injurious behaviors such as cutting. Many, though not all, individuals who cut have experienced physical or sexual abuse, which results in feeling a lack of personal control over one’s life and one’s body. People who cut usually experience overwhelming emotions that they are unable to control. Some people use self-injury as an interpersonal message with an intent to control or manipulate others.

Control is both a theme and a salient feature in cycles of domestic violence. Through subtle and overt messages, abusers control and manipulate their victims. It is easy for abusers to control their victims because the victims are usually smaller and physically weaker than they are. In most cases, abusers have financial and / or emotional control over their victims. And, sadly, victims feel a devastating loss of personal control over their own lives.

I am concerned, however, that people who claim that a mental illness or psychological phenomenon is about control have an entirely different interpretation of this phrase. For most people, I think “It’s about control” translates to “it is caused by a lack of control or a need for control.” This interpretation has no empirical backing and, when espoused by treatment professionals, leads to ineffective treatment.

For instance, many therapists believe that eating disorders are “about control,” meaning that they believe that the etiology of eating disorders is rooted in a subconscious need for control. As a result of this theory, their treatment entails helping the patient gain a sense of personal control in other areas of her life, and advising her parents to “back off” of the power struggle around meals, with the assumption that eventually the patient will no longer feel the need to control her food intake.

There is no scientific basis for this theory or this treatment approach, and I have never met a person who has recovered this way. I’m sure such people exist, I’ve just never seen them. I would presume that these individuals went through years of treatment, suffered numerous medical and psychological problems, and spent many thousands of dollars before finally recovering. Recent scientific evidence suggests that eating disorders are biologically-based, genetically transmitted brain diseases that are triggered by an energy imbalance and perpetuated by malnutrition. There’s no room for “control” in this etiology.

While I’m on the subject of about, there’s another use of the word about that perplexes and frustrates me. Case in point: a very well-regarded eating disorder recovery website has the following mission statement on its homepage:

“We are dedicated to raising awareness about eating disorders… emphasizing always that eating disorders are NOT about food and weight.”

What does this mean? Surely, it cannot mean that food and weight are not themes in eating disorders. Nor can it mean that disturbances in food and weight are not a salient feature of eating disorders. By definition, individuals with eating disorders manifest disturbances in eating behavior, weight loss, or excessive preoccupation with weight. I can only assume, then, that this statement means that eating disorders are not caused by food and weight (or disturbances thereof). If this is the meaning of the mission statement, then the statement is undeniably false.

The latest scientific research tells us that eating disorders are, in fact, set into motion by disturbances in eating and weight. A person with a biological predisposition to anorexia nervosa or bulimia nervosa will not develop the illness unless he or she experiences a disturbance in eating and/or weight. Anorexia nervosa and bulimia nervosa are triggered by under-nutrition, which may initially be intentional (e.g., the decision to diet, “eat healthy,” or exercise more) or unintentional (e.g., the result of an illness, surgery, injury, medication, or another mental illness such as depression). The cycle of starvation in anorexia nervosa is maintained by malnutrition, and the illness is most severe and most deadly when the patient is underweight. The restrict/binge/purge cycle in bulimia nervosa is also self-perpetuating and is triggered or exacerbated by disturbances in eating behavior and preoccupation with weight. Full nutrition, weight restoration, cessation of restricting, bingeing, and purging behaviors, and decrease in preoccupation with weight are essential for full recovery. In conclusion, eating disorders are absolutely about food and weight. To neglect this perfectly obvious fact is to sabotage treatment.

Scientist-practitioner ranting notwithstanding, I think I do understand what that mission statement is intending to communicate. I think it is trying to convey that eating disorders are not just about food and weight; they also entail tremendous psychological suffering. I think the statement is trying to emphasize that correction of disturbances in eating and weight is not sufficient for full recovery, as psychological issues must be addressed as well. Finally, I think the statement hopes to convey that eating disorders are serious mental illnesses that bear little resemblance to typical dieting and body image woes.

While I applaud the website’s attempt to convey the aforementioned messages, I think the way the statement is worded has the potential to create a misunderstanding (or, at the very least, it doesn’t bring people closer to an accurate understanding). I’m guessing that eating disorder sufferers and their families, as well as the general public, will misinterpret the message, most likely in the manner I described. The consequences of such misinterpretation can be tragic.

We have a responsibility to people with eating disorders to provide them, and their families, with accurate information. Further, we have a responsibility to educate the public about eating disorders in order to reduce stigma, garner support, facilitate early detection, and lobby for more effective treatment. To start, let’s make sure the messages about eating disorders that we send, whether in person, in print, or on the internet, are accurate, understandable, easy to interpret, and scientifically-sound.

Isn’t it about time?