Anorexics and Bulimics Anonymous: Does It Make Sense?

The question of whether eating disorders should be considered addictions is a thorny, but intriguing one — one I’ve been meaning to tackle in a post for years, and have kept putting off. It’s important because:

1. It’s part of the broader question about whether eating disorders are "diseases," or "proper" illnesses with genetic, neural, and other physiological bases. (This should be beyond doubt by now, but in some quarters still seems not to be.)

2. It has significant implications for how eating disorders are treated and recovery is understood (the "once an alcoholic, always an alcoholic" model springs naturally to mind).

Maybe starting smaller will help me work my way up to the big addiction question. This route into it was prompted by a message from a reader, Rosa (not her real name), who was finding some aspects of the ABA group’s support helpful and some problematic. So in this post, I’ll explore a subcategory of the addiction question: Does a 12-step program based on the Alcoholics Anonymous model make sense as a treatment for anorexia or bulimia?

As far as I know, there is no systematic research on the efficacy of ABA or any other 12-step programme for anorexia or bulimia, such as EDA (Eating Disorders Anonymous). (For a study of Overeaters Anonymous, see Kriz, 2011, and for more on how ABA differs from other 12-step programmes, see the additional resources at the end of this post.) My understanding of the basic principles underlying the ABA (Anorexics and Bulimics Anonymous), and of the form their meetings take, is based primarily on their ‘Preamble for meetings’ document, which includes the adapted 12 steps and 12 traditions. You can read the ABA version here and Alcoholics Anonymous documentation here. Other ABA resources are available on their website, here. I’ll divide my reflections broadly into pros and cons, as I see them. Rosa has also kindly allowed me to quote from her messages, so I offer her perspective in her own words.

Pros:

1. The Serenity Prayer: acceptance, courage, wisdom

The meeting begins with the well-known "serenity prayer" written by the American theologian Reinhold Niebuhr in the early 1930s:

God, grant me the serenity to accept the things I cannot change,

Courage to change what I can,

And wisdom to know the difference.

Setting God aside for a moment, this is a fairly lovely sentiment. Making efforts to change what is making ourselves and/or others unhappy, and accepting the limits on the possibility for such change, is a large part of what any recovery from an eating disorder must involve. Serenity, courage, and wisdom are qualities that many of us may find easy to aspire to, and this is a great way to raise our sights from the minutiae that crowd the everyday to contemplate a higher level of aspiration for our lives.

2. The illusion of control

We learn that the payoff we receive from this disease for our obedience to commands is nothing more than a mirage: an illusion of control over our lives and our future.

Control may not always be central to disordered eating, but it’s always in there somewhere. Whether you felt a lack of control in other areas and found that eating or not eating could give you a feeling of control, or make you care less about lacking it elsewhere, or whether you found your way into disordered eating habits by other paths, but realize that it’s difficult to shed the idea that eating this way gives you valuable control — or gives you a valuable escape from dealing with questions of control in other realms — control will figure somewhere in your illness and your recovery. (See my two posts on control in anorexia and recovery, here and here.)

So making control central to the ABA program is fitting, and the description of why half-hearted attempts to relinquish the illusion of control are bound to fail is cogent too: trying to stop bingeing and purging, but persisting with restriction of intake between these episodes; eating more, but compensating for it with more exercise. If what you do is guided primarily by the fear of getting fat, you’ll almost certainly never really get out.

Elsewhere, however, the ABA document has an interestingly mixed position on control and its opposites. Recovery is about becoming "empower[ed] […] to live without any illusion of control"; "sobriety is surrender"; "we cannot be sober through willpower." Yet at the same time, "We also learn to truly own our lives and to take charge of ourselves in a way that had not been possible before"; sobriety as surrender "is not a passive state of submission but rather a highly active, entirely voluntary letting go that requires intensive work on a daily basis."

So we have to relinquish concepts of control and willpower, while at the same time owning ourselves, taking charge of ourselves, and working intensively towards a willed letting-go. This may seem impossibly contradictory, but any philosophical exploration that ends in rejecting the idea of a metaphysical freedom of will ends up in a paradox close to this one: You know the difference between voluntary and involuntary, willed and unwilled, is no more than a matter of perception, yet you have to keep acting anyway. Many people — including many scientists and philosophers who study free will — choose the "as-if" route out of the paradox: You act as if you believed in free will (Blackmore, 2005, pp. 8-9).

ABA hovers somewhere between suggesting we need to give up the idea of control altogether and suggesting that it’s the bad, illusory kinds of control we need to give up, so that we can cultivate the good kinds instead. Whether or not this conceptual haziness is helpful to the practice of getting better is debatable. How it actually plays out in the practice of meetings and the responses of participants is questionable too. For Rosa, the meetings made her "completely unable to make any kind of decision. I have labeled all kind of control as 'bad' and consequently feel I have no tools for managing my life. I feel powerless and pathetic, and I am now constantly overthinking existential concerns about what a higher power is, what is God, what is the meaning of life, which I feel is just persisting to stop me from actually living life."

3. Body, mind, and spirit

The only requirement for [ABA] membership is a desire to stop unhealthy eating practices that we have come to realize are progressively destroying our lives, physically, mentally, and spiritually.

Presenting the three like this, as intimately linked, is true to the reality that the mind is part of the body, and that spirituality is part of both. Like AA, ABA state that their program is "deeply spiritual, but not allied with any religion." Separating out these two is also important: Personal practice is just as much a spiritual enterprise as organized religion is (and arguably a more honest and less dangerous one).

Step 12 reads:

Having had a spiritual awakening as the result of these steps, we tried to carry this message to others suffering from eating disorders, and to practice these principles in all our affairs.

Recovery (from an eating disorder) can be — perhaps must be — a spiritual experience: The feeling of reunifying mind and body after their long enmity is as meaningfully spiritual as anything I can imagine. It can also feel like waking after a long, uneasy sleep — like rediscovering that the world is brighter and fuller of possibility than one could have remembered, even, in one of the most potent metaphors of them all, like coming back to life. And I suppose what I do in this blog is something akin to carrying to others the message I’ve derived from my awakening.

I’ll come back to the proposed links between physical, mental, and spiritual in the "cons," though, along with more questions about religion.

4. The pragmatics of meetings

The meetings are structured around individual sharing and listening. Participants are encouraged to listen without interrupting, and to preserve anonymity and confidentiality outside the sessions. Rewards (tokens) are given for "sobriety milestones" (measured in days, months, or years), and participants are invited to propose topics for discussion. Talking about your suffering and your achievements with empathic, nonjudgemental others is likely to be a positive thing for most people, even (or especially) if an initial reluctance, discomfort, embarrassment, or shame needs to be overcome. Accepting that you are not alone in how you suffer, nor alone in your desire to lessen your suffering, is a powerful thing. Rosa says that "I find the peer support really helpful, and it has enabled me to ask for help in other aspects of my life. I am also really touched by the love that people have shown me from the group. […] The love and support I found in the rooms did show me there was something far more loving and real about life after the eating disorder obsession."

On the other hand, it can also be difficult, especially with something as riddled by comparison and perfectionism as eating disorders often are. Rosa observes that "I often compare myself to the other people in the group, find myself riddled with judgements about their recovery," and that "people are very hard on themselves and how they work their program (often looking for 'perfection')." This suggests that for some people, sharing your experiences with others who are not themselves ill may be a better way of coming to understand and be understood, and of overcoming your shame. The times at which either or both are appropriate are bound to vary between individuals.

It’s also worth noting that no membership fees are charged, that collections are made to cover the meeting expenses only, and that group leaders "are but trusted servants; they do not govern." Whatever we may wish to challenge or criticize in the 12-step principles and practices, the material enrichment of the organization does not seem to be one of its aims.

5. Other sources of support

The ABA text includes a list of tools that have worked for participants in the difficult process of recovery, which is a great idea: Practical suggestions from those who have gone before can be invaluable in all aspects of recovery. This section is finely balanced between pro and con; there’s lots of good stuff here, but many of the items could also be far richer still if they looked out further beyond the ABA structures.

The suggestions include:

• Prayer even without belief in the Power (I’ll come on to the spiritual and religious dimension in a moment)
• Taking quiet time for oneself (always a good idea, but here conceived in terms of time for "receiving [a] gift")
• Reaching out to others (especially before and after meals — having someone in mind for this makes a lot of sense)
• Finding a sponsor (someone further along than us, but the responsibility associated with this may, as for Rosa, be frightening, and shouldn’t be embarked on lightly; see the ABA notes on sponsorship here)
• Going to meetings (but only this type of meeting is listed)
• Reading (but only their own textbook, etc.)
• Journaling (about one’s feelings and the learning process of recovery)
• Service work (save yourself by helping someone else)

It doesn’t feature in the Preamble document, but another suggestion is that members find someone outside the program to be a "meal-support provider," someone who will prepare your food for you according to a plan developed in collaboration with a dietician. The rationale for this is outlined in the FAQs for newcomers and detailed, mostly very sensible, advice for providers is offered here. The FAQs also encourage members to seek support from health-care professionals beyond the dietician.

6. Fear, guilt, shame, making amends, and admitting our mistakes

We learn that the disease’s principal weapon is overwhelming and paralyzing fear, and that it holds us in its lethal grip by inducing profound guilt and shame within us. The disease lies to us at every turn. It even convinces us that we are to blame for our own sick condition, that we freely choose to do the insane things we do, and that we are unlovable.

Fear, guilt, and shame are experienced by most people as cause and/or effect of having an eating disorder. They all need working through. Understanding that they are predictable parts of being ill and of getting better is crucial to the process of getting better. The questions of blame and free choice raised here of course link back to point (2), and to what it means to take responsibility for actions carried out within the context of an illness. I’ll come back to this later, but one of the consequences of how we answer questions about free will is how we relate to those whom our words and actions have hurt during our illness. For ABA (and AA), even if we cannot be blamed for our illness or be considered to have chosen our actions, we must still make amends for them:

Step 8: Made a list of all persons we had harmed, and became willing to make amends to them all.

Step 9: Made direct amends to such people wherever possible, except when to do so would injure them or others.

Doing what we can to put right the damage done sounds like an obviously good thing. As Rosa says, it "force[s] me to face up to behaviors and be accountable." But when you start making it specific, to me it becomes a little more questionable.

Here are a few of the people I harmed during my anorexia. I harmed my parents, by subjecting them to prolonged worry and fear, and to conflicts between themselves about how best to deal with my illness. I harmed my brother by being impatient and unkind to him, by being an awful role model, by saddening and distracting our parents as he was growing up. I harmed my first partner, whose depression I probably sometimes exacerbated (though I know I sometimes soothed it, too). I harmed a boyfriend I was briefly together with in Germany, who offered me nothing but love and openness and received hard criticism and withdrawal in return. I harmed a friend who lived with me on my boat for a year, for draining her second year of university of some of the fun it might otherwise have had. And the list goes on. I have apologized to these people, talked to them, and I try to be a kinder, more open person now and in the future. Does this count as making (direct) amends? Maybe. But perhaps the difference is one between looking forwards and looking back.

The past can be altered only by altering our memories of it, and that can happen by reflecting on past events and changing our interpretations of them directly (e.g., by helping someone I hurt move from feeling "you treated me awfully" to "you treated me awfully, but you felt awful about doing so, at the time and now, and wish you had done otherwise"). But it can also happen by changing the context in which we remember times past — from sadness to happiness, for example ("you treated me awfully then, but now we love and understand each other and have lots of fun together"). So talking, exploring, and being honest seem to me the most important things here, and they may or may not put the 12-step questions about past fault, blame, agency, and freedom center stage.

Relatedly, the 10th step reads: "Continued to take personal inventory, and when we were wrong promptly admitted it." Regularly assessing our actions and their consequences and admitting our mistakes are excellent personal practices to cultivate. There’s a risk, perhaps, of becoming obsessively fixated on cataloging every possible good and bad moral mark in our private inventories. But the general idea is probably a helpful one.

In summary

ABA encourages some very good things: active recovery combined with acceptance of the limits of change; questioning the kind of control the disorder really gives you; linking mind and body; sharing your experiences with others in similar situations; and understanding that fear, guilt, and shame are systematic constituents and consequences of eating disorders, but can be overcome by accepting this fact and by righting wrongs done in illness. Some of these encouragements might not be straightforwardly positive, but for me, they all seem along the right lines. Now, what about the things that (to my mind) are not?

Cons:

1. Origins in substance addiction

The origins of the ABA program in support for substance addiction are easily traced. Group members’ primary purpose is "to find and maintain sobriety in our eating practices, and to help others gain sobriety." No definition of sobriety is offered, and the term itself sets up a dichotomy between sober and intoxicated, which may be too rigid for the changes in attitude to food and oneself that occur in illness and recovery. The polarities maybe feel wrong too: sobriety to deadening extremes is what my memories of anorexia feel like, and the return to life, warmth, energy, and emotion as an intoxicating remembrance that the world exists, and I need not shut myself eternally off from it. (The highs and lows of bulimia may fit rather better here.) In the abstract, I can make the other way round work: You’re not in your right mind when you’re ill, and you return to a clear, calm mind once it’s over. Perhaps the problem here is a tendency to associate being "not in one’s right mind" with unpredictable, emotionally volatile behavior, whereas of course insanity can be deeply methodical, as in some psychopaths and serial killers.

I suppose maybe the question I’m circling around here is: Who gets to define sobriety? And should I want to aspire to it? I think for me, sobriety as an aspiration feels like a puritanical imposition of a value system that means nothing to me. That’s of course a very personal response, but it may be an important one to acknowledge when anorexia’s version of sobriety has shaped one’s life.

Then there are the various mentions of drugs and addiction. The disordered behaviors are "addictive in nature — that is, out of our own control," says the ABA document; but this is to turn addiction into a vague notion of loss of control, raising all the thorny philosophical questions we considered earlier. The question of chemical dependency, or indeed of dependency otherwise manifested (behaviorally, emotionally, etc.), is turned immediately into the control question. Not to say that one necessarily has to venture into the medical realm to conceive meaningfully of addiction — but the document seems to want to have it both ways, never broaching the biomedical questions, but also deriving legitimacy by association with them — for example in the declaration, "without physical sobriety it is impossible to recover from any addiction, including anorexia and bulimia." The concept of "physical sobriety" implies some kind of factual basis in physiology, but actually this probably just amounts to tautology: You can’t recover from any addiction unless you’re recovered.

Sometimes it feels like the alcohol analogy results in confusions: the wrong things being compared. So for instance, they say that the "drug" is "the feeling of being in control of our food and body weight and shape." (This is central to their self-definition as distinct from other 12-step programmes; see the resources at the end of the post.) Understanding this kind of dependency is crucial, but shouldn’t the "drug" be what you take/do to get that feeling, not the feeling itself? Otherwise it’s like saying that for alcoholism, the drug is the intoxication, not the drink. This is actually an interesting possibility (and trivially true at one level): Most importantly, it raises the possibility that if we eliminate the immediate vehicle (the food), the drug itself (control) will merely be transferred to another realm (e.g., ingesting something different, working obsessively, etc.). But maybe this needs exploring if it’s not to merely cause confusion.

On a related note, although earlier we looked at how the physical, mental, and spiritual elements are considered interlinked, in some cases there’s an inclination to downplay the physical aspects in order to emphasize the others: Eating disorders are "primarily mental or spiritual diseases, although they also comprise a physical component" (original italics, here and throughout). This is questionable for alcoholism, and it is questionable for eating disorders, exemplifying as they do the complete inextricability of the physical from the psychological: the (not) eating from the secretiveness, the thinness from the depression, the cold from the withdrawal… There’s little point in such hierarchies, especially when their likely effect is to discourage focus on the most promising thing to focus on early on: physical regeneration through the simplicity of planned eating. (See my triad of posts on meal plans in recovery, starting here.) The question of how to invest recovery with a spiritual purpose — whatever spiritual means for you — when illness has stripped meaning from everything but the obviously meaningless is a vast and crucial question. But the question of how to eat and behave differently is not secondary to it: They are inseparable.

The central question raised by the eating disorder and alcoholism parallel is perhaps the question about abstinence versus moderation. Sobriety in ABA explicitly does not mean abstinence; they recognise, of course, that you can't abstain from food (or abstain from abstention from food) as you can with a substance not essential to survival, like alcohol. How retraining a healthy and happy kind of moderation differs from learning to abstain, and whether abstinence is even always the most helpful aim for people with alcohol or other addictions, must wait for my post on eating disorders and addiction more generally.

2. Judgmental/hyperbolic terms

The ABA text is full of judgement. So is this blog, of course. I write from a conviction that not having anorexia (or another eating disorder) is better than having it. Sometimes strong language is needed to break through the illusions and to create the momentum needed for change.

Maybe for you, these turns of phrase feel right:

• "Insane eating, starving, exercise, and purging behaviors/practices" (Step 1)
• "In obedience to a deceptive, immensely powerful voice within our own minds […] of a disease that is chronic, progressive, and potentially fatal"
• "This cunning and baffling disease"
• "We fail to recognize that we are in mortal danger when we carry out its insane commands"; "the disease lies to us at every turn"
• "Principal weapon is overwhelming and paralyzing fear"
• "It holds us in its lethal grip by inducing profound guilt and shame within us"
• "A mental obsession that compels us to restrict our food and/or to binge and purge, coupled with a physical 'allergy' in our bodies that ensures we will continue restricting or bingeing and purging, once we have begun"

There’s truth in all of them, of course. Being lied to by anorexia at every turn is something I can easily imagine writing myself. I do the personification of the illness quite often (and explored it explicitly in my post on metaphor, here), but maybe it’s the intertwining of extremely judgmental metaphor with superficially medicalized terminology, like disease and allergy, that bothers me here. The combination of the two barricades off a lot of conceptual space without allowing for reasoned engagement: It feels pointless to ask whether allergy is the right analogy (or more than just an analogy), because the point of the whole thing is mainly to ramp up the invective with a smattering of pseudo-medicine.

The heightened register also involves assumptions about the "function" or aetiology of anorexia and bulimia: We end up ill by trying "to numb our emotions and escape from ourselves." These instincts may often be central, but my sense is that they often become more so as the illness progresses, whereas it can easily begin with something much more mundane, like wanting to lose one’s puppy fat. It is certainly true that illness leads us to "fall out of touch with others" and to lose the capacity to "be fully alive in our present time and space," but saying it means we fall "out of step with the universe of which we are a part" is maybe a bit strong. Illness, after all, is as much a part of the universe as health.

Finally, the hyperbole brings us back to the complexities of fault, blame, agency, control, and hence morality:

• The "disease" convinces us "we are to blame for our own sick condition, that we freely choose to do the insane things we do"
• "[We] made a decision to turn our will and our lives over to the care of God" (Step 3)
• "Made a searching and fearless moral inventory of ourselves" (4)
• "Were entirely ready to have God remove all these defects of character" (6)
• "Humbly asked God to remove our shortcomings" (7)

Does it help to make it all such a morally loaded thing? Why should you have to make amends if you never freely chose in the first place?

Does the act of doing penance, the moral as well as pragmatic act of distinguishing self from illness, offer a sense of control that is helpful for recovery? Quite possibly. But ultimately, it’s maybe yet one more illusion that needs to be let go of: that you can ever wipe your moral slate perfectly clean and start again from unsullied innocence. We can no more achieve moral perfection than we can physical perfection.

3. Spirituality and religion

As I mentioned earlier, the program is described as "deeply spiritual, but not allied with any religion." From the opening word of the Serenity Prayer, however, and the closing of each meeting with the Serenity Prayer or the Lord’s Prayer, the program is deeply informed by religious concepts (not least the very concept of praying) and formulae.

However much you insist that "God" means whatever you take it to mean, choosing this word rather than an alternative ("the universe," say), and describing your relationship to it as mediated through prayer (asking for help or giving thanks to an object of worship), puts you squarely in the domain of religious spirituality — and a monotheistic religion at that (one which posits a single, personified deity pulling the universe’s strings, rather than, say, a deity distributed across the entire universe).

The evidence of a religious inheritance suffuses the whole framework, most obviously and famously in the invocation of a Higher Power:

Step 2: Came to believe that a Power greater than ourselves could restore us to sanity.

This is not explicitly religious, but it expands on the first step (the acceptance of personal powerlessness) by beginning to define the entity that will exert the power we cannot.

But it crops up in other guidance too. Let’s take a little journey through the religious landscape of the ABA literature.

Step 3: Made a decision to turn our will and our lives over to the care of God, as we understood God.

Here God is named again, but opening things up to personal interpretation. Nonetheless, God is the name given to the divinity central to monotheistic religions (a God as opposed to multiple gods). (Elsewhere, the literature also refers to "the creator.") As such, the wording directs and constrains those interpretations even as it invites them.

Step 11: Sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God’s will for us and the power to carry that out.

Now the idea of prayer is made explicit, and what we are praying for is an understanding of the purpose mapped out for us by God (however we understand God) and the capacity to fulfill that purpose. The notion that human lives have purposes that are determined in advance (especially by supernatural entities), and that our role is to identify and realize those purposes, is fatalistic in a strongly religious way. In principle, the idea is compatible with a materialist, deterministic view of the universe: Everything we do is determined by everything else that has come before, and what feels like exerting free will to make decisions is actually just doing what was always going to happen. But determinism doesn’t equal predictability, and living your life as though its path were set out for you — let alone as though that path had any inherent meaning to it — is (in my view) to live by a fiction. Perhaps a reassuring one, perhaps not: it can lead easily to the fear that one hasn’t found one’s true purpose and never will, that one is failing to live up to one’s potential simply because no single way of life has that magical aura of inevitability we might be looking for.

Tradition 2: For our group purpose there is but one ultimate authority — a loving God as expressed in our group conscience. Our leaders are but trusted servants; they do not govern.

If there’s one fiction less plausible than an omnipotent divine creator, it’s an omnipotent and benevolent divine creator (this is known as "the problem of evil," and there have been many responses to it, none of them remotely satisfactory). Encouraging humility in those who lead the group is good; encouraging members to care for each other is probably good (unless it compromises individual healing — I’ll come back to this). But wrapping both up in the garb of an ultimate authority called God seems unnecessary, maybe counterproductive if turning oneself into a mere "servant" to this God obscures the individual human realities that are actually at issue here.

In this circle of healing we learn […] to trust in a Higher Power who loves us unconditionally, and to turn our will and our lives over to this loving power. As we recovered, we come to experience this Higher Power — the spirit of life itself — at work within us, empowering us to live without any illusion of control.

Here the Higher Power is bound together with the idea of relinquishing illusions, specifically the illusion of control. This relinquishment may be helpful, though possibly not right at the start of recovery, where enactment of control by constructing a recovery plan might well be more important; and it may or may not be helpfully promoted by invoking the Higher Power. After all, if relinquishing control actually just means handing it over to the Higher Power, then control isn’t really illusion; it exists, but you don’t have it. I’m not sure that this is tenable philosophically or psychologically.

We learned that sobriety is a gift from our Higher Power and that we can ask for this gift on a day-by-day or meal-by-meal basis. We learned that when we honestly asked for the grace to surrender for this meal, we received it.

We’ve already taken a look at some of the possible problems with the idea of sobriety. If for now we more neutrally call it health, thinking of it as a gift that is given may or may not be a helpful metaphor. I remember having a powerful sense of privilege early in recovery: that I lived in a time and place where once I chose to eat again, I could eat whatever I wanted, as much as I wanted, with no external constraints like availability or affordability of safe, nutritious food. But that isn’t a metaphor.

Health is not an object to be transferred from one place or person to another. It is the result of numerous complex dynamics of physical and psychological systems reaching a homeostatic equilibrium. This happens (or doesn’t) within the organism that is you, and in your interactions with your physical, social, and cultural environment.

Achieving it after anorexia or bulimia may often require something compatible with the idea of surrender, if not necessarily of divinely bestowed grace. Asking for it every single time you sit down to eat (see the "prayer before meals" here) seems a bit of a bleak way to imagine the rest of your life, though. Giving thanks for it every time, maybe, but asking for it presupposes it might not come, which seems an unnecessary level of uncertainty if you are actually better. This is echoed in the statement, "sobriety is experienced only one day at a time (or one meal at a time!)." For me, much as I tend to believe I like the idea of living in the moment, to apply this notion to life beyond recovery is an unappealing idea. As Rosa says, "12-step recovery states once an anorexic, always an anorexic, and unless you work the 'program,' you are on shaky ground and will most likely relapse." Being healthy (when one is) should be the periodically appreciated, but often just self-evident bedrock of one’s life, the quality that makes other things possible, rather than drawing attention to itself every mealtime. Life can be lived at different timescales, and not being able to raise your gaze from this meal right now does not seem like anything much to aspire to.

4. Cult-like aspects

Tradition 1: Our common welfare should come first; personal recovery depends on A.B.A. unity.

This may seem a little cult-like in its suggestion that recovery cannot be an individual endeavor, perhaps even that if you leave the group or otherwise impair its "unity," your personal recovery will suffer or be prevented. This is a dangerous implication, and I don’t know how much discouragement there is, in practice, against group members leaving a group if they find it unhelpful.

Tradition 5: Each group has but one primary purpose — to carry its message to the anorexic or bulimic who still suffers

I may be being a bit over-sensitive here, but the idea that the primary purpose of a recovery group would be anything other than helping its members recover seems suspicious to me. Of course, the implication is that the program works so well that carrying its message to those who are still ill is the only morally right way to behave. But there’s as yet very far from enough evidence to conclude that this particular program will work brilliantly for everyone, and for those people for whom it doesn’t work personally, being expected to spread the word to others would seem perverse.

It strikes me, too, that the efficacy of the group might actually be altered or impaired by making proselytizing its main purpose: You may end up prioritizing spreading the word over actually doing a decent job with those to whom the word has already been spread. In this sense, it may acquire the missionary zeal of those who are so convinced of the correctness of their faith that they infiltrate other cultures to enlighten them with it.

Is anyone here for their first time? (If so, ask a sober member to speak to the newcomer, outlining “what we used to be like, what happened, and what we are like now” as a result of joining this Fellowship and working the Twelve Steps.)

Along similar lines, the invitation here excludes all aspects of the sober volunteer’s recovery experience that aren’t directly attributable to participation in this program. This might risk instilling in participants that nothing can help them but this, and that changes which come about in other contexts and by other means, for example by their own initiative, are without value and shouldn’t be pursued or discussed with the rest of the group.

Finally, Rosa describes her experience of ABA as one of having her entire life taken over. Her "spiritual aspirations" alienated her from friends and family. Her whole social group became people who had problems with food: "Working the Program involves praying, reaching out (calling other people in the fellowship), writing and
attending meetings. It is something you must be willing to go to any lengths for." And since "working the program" is presented as the only thing that can save you from relapse — not just during what others might call recovery, but for the rest of your life — suddenly the whole thing starts to seem rather sinister.

It "does not let people stop halfway. However, it also means that people are in recovery forever. The 12 steps must be taken every single day. No excuses. It is very all or nothing." Of course, in reality members may not stay (some may not stay precisely because they are so strongly urged to), and Rosa describes the unsettling effect of lots of new people coming and going, while the "core of about 6 regulars who have found strong recovery" remains constant. There are times, for some people, when focusing all one’s energies on recovery is right and necessary, but there may also be many contexts in which sustaining life beyond illness and recovery matters a lot too.

To quote Rosa again: "I feel all I am thinking about at the moment is recovery from anorexia — it haunts my every day and waking thought, and I am unable to concentrate on anything else. I also am reluctant to commit to always going to meetings when I feel like recovery should be living life." Making the transition from recovering to living is always a delicate thing, but time and space for it do need, at some point, to be created. Around the same time that she first wrote to me, Rosa left the program. She said the immediate effects of leaving were to lose "the fear that I am 'failing' at recovery or the constant to-ing and fro-ing about whether eating disorders have a moral element to them (i.e., when in the disorder you have behaved in abominable ways that you must make amends for) or whether 12-step [programs] really address mental health issues or are more appropriate for a drug addict/alcoholic." She has stayed in touch with some people from the group who have made a lot of progress in their recovery and are "convinced that the program has completely changed their life and they would not be alive without it." As she says, "it could be argued the program only didn't work for me because I didn't do it properly." She was unable to fully take "Step zero" ("surrendering all feelings of control over food, weight, exercise, and body shape"), and was unwilling to go "to go to any lengths" as she was told she must. Three weeks ago, Rosa started professional treatment.

To me, one final unsettling aspect of the entire thing is implementation of the core principle of anonymity. I asked Rosa whether she thought it might be possible for me to speak to one of the people she mentioned as having drawn significant benefits from the meetings, to offer a contrasting perspective to her own. She said that "As it is an anonymous program and the principles and traditions are taken very seriously by the group members (another thing which I found very difficult to cope with), I am not sure that they would agree to talk about it as it is against the program to go public about it." Secrecy and eating disorders are all-too-natural companions, and anything that encourages them to stay together may be dangerous. Protecting the anonymity of members by not giving their name or other identifying details to anyone outside the group is a valuable principle, and is all that is dictated by the original AA organization (see their ‘Understanding anonymity’ document here). AA make clear that "A.A. members may speak as A.A. members only if their names or faces are not revealed. They speak not for A.A. but as individual members." But somewhere in the translation to ABA and/or in individuals’ interpretations of the anonymity principle, a more secretive instinct to conceal the workings or benefits of the program may creep in too. This trend would seem important to resist.

Not least because, as with Rosa, it can induce guilt at questioning the program, guilt about finding it made things worse rather than better, guilt at attributing to the program what was really just a personal failure to take the plunge, guilt at not having overcome anorexia completely enough to commit to really overcoming anorexia… In reality, of course, how to find what it takes to take that plunge, to do that bootstrapping, is the million-dollar question, and there simply is no solution that works for everyone. And it is always a bad thing to feel you can't talk about anything to do with your illness and your recovery. If that means "betraying" a group, then there was a far deeper betrayal, in the other direction, long before you spoke.

In conclusion

So, this has been a lengthy foray through the ins and outs of the ABA document and the group practices it provides the blueprint for. As with any existing method for aiding recovery from eating disorders, there are strengths and weaknesses to be identified, and you may well weigh them differently from how I have. To me, the strongest positives are the encouragement to be honest, in a group setting, about how the disorder has affected you, and to draw support from other people in similar situations.

The main thing that troubles me is the idea that ceding control is the only way forward. To me it seems obvious that recovery can proceed only by making a concrete plan for acting differently, which doesn’t feel a lot like giving up all control. And although relinquishing control is compatible with the idea of the meal-support provider, that aspect seems far from central to the program — and in practice, meal support may actually be delegated to one’s sponsor, involve phoning the sponsor before every meal, or sending photos of the food to the whole group, all of which raise urgent questions about whether control is being ceded or merely spread around differently. So what actually tends to change at the level of everyday habits for group members? What does surrendering all control mean in pragmatic terms? For example, do those with anorexia commit explicitly to weight restoration? Do those with bulimia undertake to reduce and eliminate binge-purge behaviors? How do their trajectories compare with those who have some kind of dietician’s or other meal support without the program context? I’d be fascinated to know more about the process by which acceptance of powerlessness translates for ABA members into physical and psychological healing — and how often it does. Then the other thing I resist is the notion that "sobriety" has to be precariously reconfirmed for your whole life henceforth. Like those who insist on speaking of remission rather than recovery, this seems a bleak recipe for a personal future. And it certainly bears no resemblance to my own present.

If you have ever been part of an ABA group, or anything similar, and you are willing to share your perspectives, I’d love to hear whether what I say here resonates with your experiences, and whether there are things you’d add or take issue with. After all, what’s written in official documents is one thing; how that plays out with real people is quite another.

Meanwhile, thank you, Rosa, for giving me a reason to ask this question and try to answer it.

***

Update 25 March 2018: Additional resources

An anonymous reader has kindly shared some more ABA resources which may be of interest to you. The first resource is a document called “Sobriety is surrender”. It sets out the distinctions between ABA and other 12-step programmes for eating disorders: the replacement of the concept of abstinence with that of sobriety; treating the need for control, not food itself, as the drug; and proposing the practical strategy of meal support from another person. It gives more detail on common traps people fall into in trying to maintain partial control over their own eating, as well as tactics that members have found helpful in ceding control to their meal supporter, and then how to take back partial control once the time is right. The document also gives practical suggestions for dealing with the return of emotions during recovery. And it makes clear that the ABA line is that self-weighing (or knowing one’s own weight) is to be ceased entirely. (See my different take on this here.)

In light of the post I recently wrote on normality, I was struck by this line: “We surrender to the nutritional guidelines followed by normal eaters.” I found myself reflecting on the difficulty many people might have in finding anyone whose version of normality is robustly healthy enough to take on the profound responsibility of being the meal supporter: to be a normal eater these days, sadly, means to be mildly disordered in one’s eating.

Some lines of wisdom that stood out to me, though:

No one has ever died from feeling their feelings

It takes as long as it takes.

Baby steps, and I’m not in a hurry.

I also liked the distinction between trying and doing (“For full sobriety we do not ‘try’; we surrender, fully, by the grace of a Higher Power”); so often the former is the enemy of the latter (whether or not you subscribe to these notions of surrender and the higher power).

The second resource is an audio recording of one of the founders of the ABA, Joan J., in the series “Anorexic and bulimic sober speakers”. She talks about why the ABA was founded (4:50) and the differences between ABA and the other 12-step eating-disorder programmes (6:10) (though the reader who shared the link remarked that in this she actually misrepresents EDA; see the comments section below). She especially highlights the distinction between abstinence and sobriety and the ABA definition of the “drug” (not food, but the insane eating practices aimed at control). She emphasises the importance of not eliminating foods, and explains the point of having meal support as opposed to making food plans (10:33). She uses explicitly religious language (“God gave us ABA”, 16:56; “unless I am surrendered to God around my food, my exercise, my weight, and the shape of my body, […] I am not sober”, 19:20), including in talking about her own “sobriety”: “By the grace of God I have been sober now for a bunch of 24 hours” (19:44). This is a very interesting way of describing long-term remission! It’s also clear that long-term remission is not in fact what Joan has achieved; she introduces herself right at the start by saying, “My name is Joan, I’m a chronic anorexic of the hopeless variety and a compulsive overeater” (00:01), and she later says, “I still have an anorexic mind, needless to say” (10:19).

This makes clear that sobriety, for a co-founder and long-term sober member of ABA, looks nothing like remission, let alone recovery. And this is worrying. To admit it is indeed pretty much the opposite of “needless”, for it suggests that maybe to get really well she needs something quite different from sobriety.