Jan 29, 2015Making It Through
To support an athlete who has struggled with an eating disorder, you might wear many hats: counselor, nutrition advisor, motivational speaker, friend. These roles are vital both during primary treatment and in the after-care phase.
By Kristen Martin
Kristen Martin, LCSW, is the Coordinator of Team ENHANCE (Enhancing Nutrition, Health, Athletic Performance, Networking, Community, and Education) in the women’s athletic department at the University of Tennessee. She can be reached at: [email protected].
Jenna was a top performer in everything she did. As valedictorian of her high school class, her speech at graduation charged her peers to go after their dreams, and her parents looked on with pride and great expectations for her future. Jenna was offered full rides from several colleges, and chose to accept a track and field scholarship at a school highly respected for both academics and athletics.
She was brimming with excitement as her freshman year began. She signed up for tough classes, moved into a dorm, and immediately started making friends. She was especially eager to meet her teammates, and with a highly decorated athletic career so far, she was confident she would make big contributions.
But college turned out to be a very different world than what Jenna was used to. Every young woman on her team arrived with outstanding credentials, and most had been star athletes at their high schools. To feel like she belonged and to maintain the level of success she was accustomed to, she decided she would need to work harder, be more disciplined, and make greater sacrifices than ever.
How many athletes do you know who resemble Jenna? She’s highly accomplished, driven to succeed, and willing to do whatever it takes. Those are all great qualities if expressed in a healthy way, but they can also be risk factors for falling into unhealthy behaviors, particularly when it comes to dietary choices. If an athlete in your setting develops an eating disorder, you can play an important part in their recovery, both during and after treatment.
Jenna was filled with determination as her college career began. She pushed herself harder and harder and seemed to thrive under the discipline of a tough student-athlete schedule. She was up early every morning for a team workout, then off to classes, then over to practice, followed by a session with the strength and conditioning coach. After her cooldown, Jenna raced to the cafeteria for dinner (carefully self-monitored for nutritional content and to avoid weight gain), then on to mandatory study hall to complete her homework.
This lifestyle meant giving up some things–parties, extracurricular clubs, various other social activities–and Jenna sometimes envied the fun and free time others seemed to have. But she knew her hard work would prove worthwhile. She was always the best at what she did, and that required uncommon commitment.
Jenna’s professors were impressed with her work in the classroom, and her coaches were pleased with her athletic progress. They encouraged her, praised her, and set the bar higher each week. Jenna stepped up to each challenge with a flourish. At home after her freshman year, she continued her workout regimen, disproving her high school coach’s warning about the “freshman 15.”
But by her junior year, the endless drive for personal improvement was beginning to show a dark side. Jenna spent extra hours in the weightroom and continued working on her sport even beyond team practice sessions. She felt heavy and slow compared to the new student-athletes arriving each year, and wasn’t satisfied with her body size.
She added more exercise to her morning schedule, sometimes ate just an apple on the run for lunch, and counted her calories more carefully than ever to combat what she saw as increasing body fat. Even though she experienced dizzy spells from time to time, she continued to perform in the top third of her team.
Then one day after practice, Jenna collapsed. She was rushed to the emergency room, where an examination revealed an electrolyte imbalance and heartbeat abnormalities. She was extremely weak, showing significant weight loss, and had stopped menstruating. Her gums showed signs of long-term bleeding, and her abdomen was unusually bloated.
Jenna’s parents, coaches, teammates, and friends couldn’t believe all this had happened under their noses, without their knowing it. It was then that doctors told Jenna she had an eating disorder.
THE ATHLETE’S DILEMMA
Stories like Jenna’s are more common than you might think. Several studies of college female athletes in the past decade have found that at least a third suffer from some degree of disordered eating, and two to three percent have a diagnosable full-blown eating disorder. An eating disorder is marked by limitations of food intake such that the body’s needs are not being met, typically due to dietary restriction, binging, purging, compulsive exercise, or any combination of these.
Jenna’s case also illustrates a key fact about eating disorders: They stem from a distorted perception of self, both physically and emotionally. Always driven to achieve more, athletes set expectations higher and higher, and sometimes end up acting in desperate, irrational, unhealthy ways to avoid “letting down” themselves or those around them.
It’s not necessarily about food–eating disorders are primarily psychological, and often linked to depression, anxiety, or general feelings of inadequacy. Controlling food is merely the mechanism through which the individual attempts to cope with underlying emotional issues.
Many athletes face a dilemma with regard to their eating habits. They are expected to be physically fit, strong, and in optimal health during training and competition, and that requires taking in a great deal of energy and a proper balance of fats, carbohydrates, proteins, and essential vitamins and minerals. But at the same time, they may feel constantly challenged to become leaner, faster, or lighter, which can lead them to restrict their eating and undermine that nutritional balance as well as their overall health.
Athletes are often highly driven, compulsive perfectionists who define themselves by their sport and their level of success. They compete for themselves, their families, teammates, and communities, which creates immense pressure. While ordinary people might decide that skipping lunch isn’t worth the hunger pains, or an extra hour in the weightroom isn’t worth the next-day soreness, an athlete may decide this behavior is the only way they can keep up with expectations.
Society consciously and unconsciously reinforces these habits in countless ways. Athletes are praised for their total dedication, commitment to preparation, and willingness to sacrifice and go the extra mile. To a certain degree, those traits are desirable and even necessary, and every coach wants athletes to have them. But problems arise when they’re taken too far.
Athletes with eating disorders are masters at hiding their behaviors from others. They are typically intelligent and know how to be manipulative. One student-athlete who was treated for an eating disorder described her experience as “a dark, gloomy inner world. I would go out the door, and people would see me as a smiling, glowing person. I hid behind that image. Eating disorders are such a secret. No one wants to have an eating disorder–it has a hold on you, and you can’t break through it, although every day you think you can.”
Athletic trainers may be better positioned than anyone else in an athletic program to identify the signs–however discreet–that an athlete is struggling with food. It might be a sudden, unexplained drop in performance, persistent fatigue, rapid or unhealthy weight loss, or observations of restricted eating in dining halls or on team trips. Or you might see the psychological signs, such as withdrawn behavior around teammates, symptoms of depression, or ongoing anxiety about food, weight, body type, or performance.
In any case, if an eating disorder is detected, itís essential to seek intervention from a counselor, psychologist, physician, or nutritionist as quickly as possible. These specialists constitute the “treatment team,” and they have a toolbox full of resources to help athletes manage the disorder and address the underlying causes. They can also help with decisions on continued athletic participation, special dietary guidelines, and other primary areas of an athlete’s treatment.
Athletic trainers can play an important role in the athlete’s recovery as part of the “support team.” But to provide the best care, you must fully understand the issues that underlie most eating disorders, and what conditions put athletes at risk for relapses into unhealthy behavior.
A healthy psychological profile hinges on having a positive sense of one’s own identity. When an individual loses this, which is common for someone with an eating disorder, that person is vulnerable to external triggers that can create unhealthy thoughts.
These triggers might include comments from others, a rough game or bad practice, feelings of sluggishness, cultural symbols that set an unrealistic standard for the ideal body type, and many others. Triggers are unique to each individual, and the athlete will work with their therapist to identify their own triggers, put each one in perspective, and find ways to reframe or cope with them.
Being aware of an athlete’s triggers is one important way you can support their recovery. This will require an athlete trusting you enough to share their personal insecurities, so it helps if you have a good relationship built on open lines of communication. If you cultivate that type of bond and reassure them that you’ll respect their privacy, you’ll be in a position to help them handle triggers in a healthy way.
For instance, let’s say a track athlete is warming up at a meet, and a friend comes over to say, “Hey, you look really good.” Although the friend was trying to be positive and encouraging, the athlete grows noticeably upset. If you know that any reference to physical appearance triggers negative thoughts in this athlete, you can immediately help her understand her negative response and reframe her thoughts in a more positive way.
Recovery is a continuing and never-ending journey for an athlete with an eating disorder. Many learn to find a sort of comfort in their disorder–they develop a strong relationship with it, and that relationship has served a purpose. Understanding the relationship and replacing it with other, healthier ones usually happens through the course of treatment and beyond.
Sometimes an athlete has to grieve the loss of the relationship because it has been so heavily relied upon for so long. As they transition to the post-treatment phase, when they have ostensibly returned to a healthier physical and psychological profile, continued support is absolutely essential to their progress.
The athlete’s treatment team (physician, nutritionist, and therapist) will still be part of the picture during the after-care phase, but the support team–which might comprise the athletic trainer, coaches, parents, teammates, and close friends–takes on special importance as the athlete transitions back to a more “normal” life.
During this time, the athlete typically faces some questions essential to self-definition:
• Do I truly want to be an athlete? Why or why not?
• Am I continuing in my sport because other people want me to, because I need the scholarship, or because I have a passion for what I’m doing?
• Would I be labeled a failure if I were to quit?
• Are there other parts of my life that define who I am?
Depending on the depth and quality of your relationship, the athlete may come to you asking for help sorting these questions out. There are no one-size-fits-all responses, but it can be very useful to think about these questions in advance and how you might help the individual answer them for him or herself.
The athlete in recovery must set healthy individual goals and identify points of success to celebrate along the way. These goals must be realistic, and the athlete needs your support to closely monitor progress and head off any unhealthy behaviors that may trigger a setback. You and other members of the support team should meet with the athlete regularly to see how things are going, and to provide acknowledgement and affirmation for all the little successes they achieve.
Indeed, an athlete in recovery from an eating disorder often must completely redefine what success means. Many athletes deal in absolutes, perceiving nothing between complete victory and complete failure, so they must adjust to the idea of making consistent small steps toward the over-arching goal of healthy eating behavior. Relapses are simply learning experiences. A temporary setback merely signifies an opportunity to learn how to handle a new trigger and utilize a new internal reinforcer or coping skill.
If the athlete returns to his or her team, teammates also need to learn how to support the recovery process. Most teammates will want to help however they can, but they might feel like they are “walking on eggshells” and not know how to provide support without becoming the “food police” or making a bigger deal of the athlete’s status than the athlete is comfortable with. Some team members may even develop feelings of resentment, believing the struggling athlete has created a distraction or isn’t doing all he or she can to help the team.
This is one area where your intervention is crucial. You can help the athlete’s teammates understand the progress he or she is making, teach them ways to provide constructive support, and raise awareness of the athlete’s triggers. You might ask team members to be compassionate if their struggling teammate needs to take extra breaks in practice, or encourage them to provide positive reinforcement when the athlete reaches a milestone or goal in their training.
As time passes, medical and nutritional monitoring frequency will be determined by the therapist or physician. The amount of support the athlete needs will vary as well, so itís important to keep the communication lines open, since the transition back to a more normal schedule can be very stressful and create “land mines”–unexpected new triggers for unhealthy thinking and behaviors.
Changing coaches, graduating, ending an athletic career, and preparing for life after graduation often lead to anxiety, self-questioning, and pressure to meet others’ expectations, which in turn can make the athlete seek the comfort of old habits. Ongoing support needs will be different for each athlete, so encourage them to talk to you regularly about how they feel and how you can help with their emotional and physical health.
A LONG ROAD
After receiving treatment for an eating disorder, an athlete needs to remain honest and committed to lifelong self-awareness and learning. It takes a long time to resolve issues with self-image, food, and body awareness, but those issues can snowball into larger problems if they’re ignored. Successful intervention is about learning to change behavior and life outlook, and that takes years of effort.
One of the most important aspects of recovery is for the athlete to trust the process through its ups and downs, and this is an area where your support can be very meaningful. During the darker moments, when an athlete may feel the bar has been set too high or that they’ll never “get better,” some words of encouragement, a shoulder to cry on, or whatever support the situation seems to call for can mean so much.
Though the journey is long and difficult, the athlete should always be reminded that getting through the hard times will ultimately make them stronger. By showing them they’re not alone, in good times and bad, you can help them stay on the path to better habits, a full recovery, and a lifetime of better health.
Visit these Web sites for additional information about eating disorders and how to provide help and support to those who are facing them.
The Academy for Eating Disorders: www.aedweb.org
The International Association of Eating Disorders Professionals: www.iaedp.com
The National Eating Disorders Association: www.nationaleatingdisorders.org
Sidebar: A GLIMPSE INSIDE
Recovery from an eating disorder is always a very personal process, and for those providing support, it can be frustrating and challenging to not understand just what’s going on inside the athlete’s head. In the paragraphs below, a young female athlete reflects on her own journey through treatment and recovery from bulimia.
Making myself sick was a way for me to cope with what was happening in my life. I was a textbook case of someone who needed to learn to recognize and handle difficulties in healthier ways.
I was a swimmer. Each member of our team was weighed once a week in front of everyone. Many of us would starve ourselves three days before that, then eat a ton afterward and repeat the vicious cycle. I was doing all this because it was going to make me great. At the time, I thought weighing less meant swimming faster. I would get sick, not eat, get sick again, and feel out of control.
I had to become aware of my core issues. I remember thinking that once I was in counseling, I would be better–but that was just step one. And I wasn’t telling the whole truth to my therapist. I had lots of denial. I was married to my eating disorder and afraid to give it up. I didn’t want to gain weight, and it took me years to understand that it really wasn’t a weight issue. I had to recognize the payoffs of my eating disorder–why I liked it, and also why I hated it.
I had an eating disorder for 12 years before I even started to receive treatment and turn the corner. I had such distorted thinking, and such an unhealthy relationship with food. When you are beginning to recover, the body isn’t used to digesting food properly. You have to go through a lot to get your body working again, and that’s hard for an athlete who knows her body so well. You often feel worse before you start to get better.
That’s where the support system comes in. I would always be with a friend after I ate dinner because I needed someone to make me accountable. I couldn’t be alone. It takes a lot to work through the shame at first so you can even tell someone about it. But if you want to make a real recovery, you can’t do it on your own.