Infidelity: Defining the Narrative of Your Relationship

Infidelity: Defining the Narrative of Your Relationship

by Dr. Paul Hokemeyer

Susan was a beautiful and vibrant 54-year-old woman who had just celebrated 32 years of marriage to Steve when she found out he’d been carrying on a 10-year affair with Marsha, a 42-year-old business associate.

“I was devastated,” Susan blurted out between tears. “I mean I know these things happen – but to other people. I never thought it would happen to me.”
Too ashamed to tell anyone, she came to me with her secret and laid it at my feet. It was a position of honor that I find myself in frequently and one that I never take lightly. As a marriage and family therapist who specializes in the treatment of addictive disorders, infidelity is a phenomenon I’ve become an expert in treating. Over the years I’ve found it’s one of the more common injuries that occurs where an addiction has corroded the intimacy bond that is crucial to healthy relationships.

And while no two cases are ever the same, an infidelity always involves three distinct features that must be addressed and treated.

Breach of Trust: When one person in a committed relationship goes outside its agreed perimeters to partake in emotional or physical intimacy with someone else, the foundation of the primary relationship is severely damaged. The passive party to the infidelity feels violated, completely confused as to how the person they trusted with their emotional and physical vulnerability could betray them.

Shame: The fundamental characteristic of shame is that it’s emotionally and physical painful. It feels like a punch in the stomach. Shame arises when we are given a demeaning label that we can’t eliminate through our actions. So the passive party to the infidelity gets labeled a victim while the active party gets labeled an aggressor and infidel.

Guilt: In contrast to shame, which derives from fingers pointing in towards us, guilt is an internal construct that arises when we point fingers at ourselves. It’s our internal and moral code of conduct that causes us to self-regulate our actions in the world. Like shame, guilt exists in both parties to the infidelity. The passive party feels like they did something “wrong” to cause their partner to wander, while the active partner feels diminished for their actions.
Treating Infidelity in Relationships

In treating infidelity, it’s important that the parties work with a therapist who they trust and who reflects back to them their own morals and values rather then dictating down to them notions of “right” or “wrong.” In this regard, therapy becomes a collaborative process where the individuals and the couple figure out how the infidelity fits into the complete trajectory of their marriage, their individual lives and the lives of their children.

To do this, they need to go back and look at what brought them together, what religious and community values they share, where they differ, and what they want for their future. It’s a process that requires a high tolerance for discomfort, the ability to process anger, resentment and hostility in constructive rather than destructive and punitive ways; and, a willingness to be open to incorporating a new reality into the narrative of their relationship.

For relationships exist as a narrative. They consist of a beginning, middle and an end. While an infidelity will certainly impact the story line of a relationship, it need not define its entirety. Parties to an infidelity need to make sure that they remain in control of their author’s pen and finish the script in a way that honors who they are and what they want in this world.

Processing an infidelity in their relationship requires couples to let go of fantasies of what they thought their lives should be and integrate the truth of what is. Is this a difficult and humbling process? Yes, it unquestionably is, but it’s also a process that enables individuals, couples and families to embrace richer and more meaningful lives. Need it be humiliating? Absolutely not.

In this regard, the parties need to make sure they work with a therapist who helps them work through the shame and guilt of the breach of trust in a way that gives them a voice while working towards a solution that results in a happy and rewarding ending to their relational story.

Narcissism: The Character Pathology Underlying Addictions

Narcissism: The Chronic Character Pathology of Underlying Addictions

by Dr. Paul Hokemeyer

I was closing down my Manhattan office late last Friday afternoon when my phone began ringing. I looked at the caller ID to see if it was someone I knew, but I only recognized the Aspen, Colorado area code. Thinking it was a friend with whom I skied last winter, I eagerly answered the call.

“Well hello!” I said with more enthusiasm than appropriate for a professional encounter. The silence that followed indicated my caller was a bit put off.

“Um. I’m calling for Dr. Hokemeyer,” a soft-voiced woman tentatively responded.

I pooled out the professional composure I had tucked away for the weekend and responded as officiously as I could, “This is he.”

“Oh.” The woman sounded shocked. “I wasn’t sure I had the right number. I’m calling from Aspen.”

“Yes, I recognized the area code. What can I help you with?”

“I need to hire you.” Now she spoke with the strength and confidence of a seasoned trail lawyer.

“Ok. But you’re in Aspen and I’m in Manhattan. I only do phone sessions after we’ve had some time to establish a face-to-face relationship. But before we even get to that point, why don’t you tell my what prompted your call. What are you struggling with?”

The tone of my caller’s voice suddenly turned frosty. “I’m struggling with my complete jerk of a husband— soon to be ex-husband I hope. He’s a complete narcissist and falling down drunk. I’ve gathered from your work that you’re an expert on both topics and I need you to testify at our pending divorce trial that his narcissism led to the demise of our marriage— that he’s an alcoholic and unfit to have custody of our two boys.”

Now it was me who was taken aback. Yes, I’m an expert on a whole host of personality disorders that are endemic to men, women and families of wealth and power and that fuel a variety of addictions; and yes, narcissism typically heads the list, but the notion of testifying at an out of state trial for a couple I’d never treated was definitely outside my comfort zone. As a result, I graciously declined the engagement and referred her to several local resources that could help her navigate her anger towards her husband, and deal with his alcoholism and her frustration with the divorce process.
But her call made me stop and think about the incredibly destructive toll narcissism takes on relationships and families. It also made me appreciate the frustration that family members and partners feel when narcissism stands in the way of their loved ones’ recovery from a variety of addictions, including alcoholism, drug addiction, sexual compulsivity, and disordered eating. So what exactly is narcissism and how is it most effectively treated?

Narcissism Defined

Narcissism is a character trait that defines a person’s self view and view of others. Like the narrow lens in a microscope, it causes a person to focus on the world in a very self-centered way. It causes them to lose sight of notions like we, us and compassion for others. It’s a trait that takes hold early in a person’s life – typically as the result of a major breach of trust by a primary caregiver. Through this breach of trust, the person vows never to be vulnerable again and sets out to be a self-sustaining, autonomous entity.

Although narcissism is resistant to change, it can be “softened” through a variety of clinical interventions to a point where it no longer has a negative impact on the quality of the person’s life and relationships. Through this softening, the person can then embrace a comprehensive program of recovery for life, rather than feeling distant and detached from the healing force of others.

Recently, the diagnostic criterion for what constitutes narcissism was revised in the DSM-V. In looking for pathological narcissism, clinicians look for people who evidence the following traits:

They are what they possess: The person defines himself or herself from the outside in. They find their self worth in objects, external recognition, and adoration from others.
They are emotionally volatile: The person is only happy when they are being praised and acknowledged as special. They can’t tolerate being criticized and react with anger when they’re questioned.

They are externally driven: The person lacks a moral or intuitive compass. They are driven by commercial notions of success rather than spiritual principles.
They are emotionally shut off: The person lacks empathy and compassion. They only concern themselves with others when they feel their concern will advance their own narcissistic agenda.
They are manipulative: The person can be highly charming and charismatic, but only to manipulate and exploit others for their own gain.
They are grandiose: The person feels they are unique and special. Their condescending and critical attitude towards others is a tool they use to build themselves up.
They are entitled: The person feels they are deserving of special treatment and rewards without having to pay dues or earn them.
They need constant attention: The person is constantly seeking external validation and needs to be the center of attention.
Treatment Options

Although narcissism is difficult to treat, there are some highly effective clinical approaches that enable narcissistic patients to gain insight into their characteristics and learn new ways of relating to themselves and others. Unfortunately, the greatest obstacle to getting effective care is the very personal traits that got them into trouble in the first place.
Unlike other patients, who ask for help and are open to suggestions from professionals, narcissistic patients have a hard time admitting they are anything less than perfect. They have difficulty being challenged and frequently fail to attach to the clinical team who is treating them. As a result, it’s important that the professionals treating narcissistic patients possess an above average intellect, a persistent and compassionate heart and a deportment that will allow them to challenge the patient in a firm, yet flexible manner.

The most effective forms of psychotherapy for the treatment of narcissistic personality disorder include the following psychotherapeutic approaches:

Interpersonal psychoanalysis: Through the patient and therapist relationship, the patient begins to explore his or her significant relationships and gains insight into how they perceive and are perceived by people.
Family therapy: An extremely effective form of therapy that involves the patient’s family. As a team, the family works to resolve conflicts and relationship problems.
Cognitive behavioral therapy: Gives the patient tools to change their thought distortions and negative beliefs. Through these tools, the patient replaces unhealthy and negative beliefs with healthy, positive ones.
Group therapy: Occurs in a group of other patients who share the same emotional and personality issues. Provides the patients with insights into how they relate to other people and as a member of a group.
Ideally, these treatment interventions will occur simultaneously and continue for as long as clinically indicated. In my experience, it takes at least one year for patients receiving treatment in a private office setting and at least 60 days in an intensive and comprehensive in-patient setting before they will begin to experience an improvement in their personalities and their relationships.

Is it worth the time and effort? Absolutely. Narcissism fuels the addictions that destroy lives and families. Are narcissists lost causes? Absolutely not. They are human beings who in spite of their external bravado are incredibly sensitive and terrified of being hurt. With the proper clinical care they can transform into loving partners and parents, sober men and women, who add great value to the lives of others and the world around them.

Luxury Treatment: Guidelines for Culturally & Clinically Competent Care

In the following article, which first appeared in, I address what patients and families should look for when seeking addiction and mental health services from providers that hold themselves out as purveyors of “luxury” treatment.

Luxury Treatment: Guidelines for Culturally and Clinically Competent Care

Posted May 7, 2014 in Addiction Treatment Methods by Paul Hokemeyer

Addiction professionals are offered many opportunities for cultural sensitivity in treating the patients they serve. These can be broken down by a host of segments we can rattle off the tops of our heads: race, religion, gender, sexual orientation, disability and even diet. But what about wealth? When have any of us considered wealth, power and celebrity to be identity markers that require unique cultural and clinical interventions?

There are plenty of facilities that charge hefty fees and provide luxurious settings and amenities, but ask what they’re doing to address the unique issues elite patients bring into treatment and you’ll be met with a vacant stare.
Unfortunately, too few treatment professionals ever have. When it comes to women, men and families of wealth there’s huge resistance to acknowledging that these human beings bring unique issues into the realm of treatment. Yes there are plenty of facilities that charge hefty fees and provide luxurious settings and amenities, but ask what they’re doing to address the unique issues elite patients bring into treatment and you’ll be met with a vacant stare.

As a clinician whose research and clinical impressions on the treatment of elite substance abuse patients have been widely published, I believe that everyone, regardless of his or her place on the power and income spectrum, deserves care that meets them where they are, rather then where the clinician based on their limited knowledge and experience expects them to be.

The truth of the matter is that elite patients, and the systems in which they live, are exceedingly sophisticated, complicated and nuanced. Typically the patients and families I treat have been through several programs and clinicians before they find effective care. Their emotional lives and the lives of their families have been ravaged by what is known as Addictive Interactive Disorder – meaning, their addictions manifest in several forms.

These often include prescription drug dependence, alcoholism, stimulate abuse, gambling, sexual infidelities, disordered eating and other destructive compulsions. They frequently hide behind facades of bravado and entitlement and are masters at manipulating the people, places and things in their external lives.

These often include prescription drug dependence, alcoholism, stimulate abuse, gambling, sexual infidelities, disordered eating and other destructive compulsions. They frequently hide behind facades of bravado and entitlement and are masters at manipulating the people, places and things in their external lives. In addition, their addictions and destructive personality traits are supported by legions of enablers, “handlers” and other people who are financially dependent on the patient and terrified of change. In short, these patients with issues endemic to their socio-economic class must be treated with an appropriate clinical and cultural acumen.

Distinct Cultural Markers

Like other minority groups, elite patients have distinct cultural markers that are highly relevant to their treatment for substance abuse and mental health disorders. For starters, they are suspicious of outsiders and resist attaching to their clinicians.

This resistance to attach is perhaps the greatest hindrance to treatment and as such, requires clinicians to possess a keen mind, a honed intuition, a heightened level of maturity and an empathetic heart. In addition, elite patients occupy positions of power in the world. In contrast to other minority groups who occupy positions of powerlessness, elite patients enjoy high levels of external success and its accompanying influence. As such, they react negatively to authoritative clinical stances and must be approached collaboratively to acknowledge and build on their strengths rather than criticizing their weaknesses.

Money is an Energetic

Money is a highly charged and complex energetic. Like electricity, money’s energetic has both productive and destructive qualities; and like electricity, money’s energetic must be properly used and contained. For example, the patients I treat often use money in the following ways:

To control and manipulate others
As a substitute for an authentic ego identity
To “buy” their way out of problems
To distance themselves from others
As a substitute for intimate connections with family and friends
To medicate over the guilt they feel from being absent parents and partners
However, most clinicians fail to address these unhealthy dynamics while the patient is in treatment. As a result, once back out in their lives, the patient resumes using their wealth and power in ways that continue to erode the integrity of their interpersonal relationships and ultimately lead to their relapse.

Money is a Taboo Topic

The denial, rationalization and minimization of a significant aspect of the patient’s life cheat the patient and perpetuate the destructive interpersonal and addictive cycles.
The failure to address these critically important issues is in large measure because of the fact that money remains a taboo topic in our culture. As a result, clinicians are resistant to raise issues of wealth, power and celebrity with their patients. Instead of addressing these topics as a dynamic that plays out in significant ways in their patients’ lives, they shy away from them and rationalize they don’t matter. The denial, rationalization and minimization of a significant aspect of the patient’s life cheat the patient and perpetuate the destructive interpersonal and addictive cycles.

Moreover, elite patients are resistant to discussing their wealth, power and celebrity with their clinicians; or, they use their elite status to impress, and distance themselves from their treatment team. Those who are resistant to discuss their wealth do so out of fear of being judged, objectified, manipulated and even extorted. Those who wear their wealth on a sleeve of bravado do so out of insecurities and low self worth. Both positions require smart clinical interventions that simultaneously honor, but also test the patient’s reality. Elite patients must be held, but they must also be challenged.

Elite Patients Require Distinctive Clinical Care

Elite individuals, their families and referents seeking effective treatment for substance abuse and mental health issues should look for clinically competent programs rather than those that merely provide luxury amenities. Central to this competency is the level of maturity and professional acumen of the entire treatment staff. A lovely view, gourmet food and high thread count sheets are good, but smart, committed and seasoned professionals are better.

First and foremost, look for clinicians who:

Understand the powerful energetic that wealth, power and celebrity interjects in their patients’ lives
Are not afraid of talking about money and it’s inherent energetic
Evidence clinical acumen and personal maturity
In my own practice, I look for dedicated and intuitive clinicians who have spent a significant portion of their professional careers and personal lives honing their craft. These are the men and women who have mastered the fine art and science of the psychotherapeutic process – not babysitters afraid of clinically confronting sophisticated and challenging patients.

The clinical team must be willing to use a variety of psychotherapeutic techniques that enhance, and at times will fall outside, the classic 12-step model. These include the Socratic Method of Inquiry wherein the clinician utilizes logical thinking and reason, Feminist Theory, which requires the clinician to work collaboratively with the patient, and experiential techniques that connect the patient with their emotions.

In addition the clinical team must be willing to use a variety of psychotherapeutic techniques that enhance, and at times will fall outside, the classic 12-step model. These include the Socratic Method of Inquiry wherein the clinician utilizes logical thinking and reason, Feminist Theory, which requires the clinician to work collaboratively with the patient, and experiential techniques that connect the patient with their emotions. Used together this mélange of treatment approaches will honor their patients’ intellect and external successes while showing them how they can benefit from change.


Clinically and culturally competent care does not have an economic threshold. All patients, regardless of their place on the socio-economic spectrum deserve addiction treatment that honors who they are in the world rather than pandering to or diminishing their existence. Addiction treatment programs that market to high-end patients have a moral and ethical responsibility to deliver this heightened level of care. Luxurious amenities alone are woefully deficient in meeting this standard. Clinical care must be delivered through a sophisticated team of clinicians trained in the unique needs of their unique patient population.

Bulimia and its role in the death of Amy Winehouse


This article can be found at  It is reposted here in its entirety because it sets forth in an honest and powerful way the insidious nature of eating disorders and the forces that keep them ravaging the lives of those we love. 

We Need to Talk About Amy Winehouse’s Eating Disorder and Its Role In Her Death
There is a tacitly accepted set of rules that our culture follows when it comes to women in the spotlight. They are required to be thin. They do not eat a normal diet and that in and of itself is seen as normal, not even dangerous. Disordered eating is so normalized in our culture, especially in celebrity culture, that few people even acknowledge that it’s not healthy, and very potentially fatal. Eating disorders fall in line with what society expects of a celebrity—we love thinness so much, yet we know we’re supposed to be repulsed by the means of achieving that thinness—it’s easier to scrutinize their lifestyle or their partying than ever examine the toll of staying under a certain weight.

Amy Winehouse learned those ugly rules of womanhood early, as footage from Asif Kapadia’s devastating, much-praised documentary Amy reveals. A teenaged Winehouse, snacking with her friends, laments between mouthfuls that she’s a pig and she cannot help herself. In a voiceover during this sequence, the singer’s mother Janis Winehouse recounts the moment a young Amy tells her mother about discovering a great new “diet”—eating and then vomiting—that allows her to eat without gaining weight.

The film avoids editorializing at this point or any other—the format, consistent with Kapadia’s earlier, also critically-acclaimed documentary, Senna, involves audio interviews and raw footage, but no commentary—yet no editorializing is required in order for a viewer to feel distraught—the next few sentences to come out of Janis’s mouth are enough. She muses that she essentially ignored the statement and forgot about it, thinking it was a silly teen girl activity that Amy would soon grow out of. She says that when Amy told her father, Mitch Winehouse, as well, he also dismissed it.

This casual dismissal—the first mention of Amy Winehouse’s eating disorder—is wrenching, and comes almost halfway into the film. For many viewers, this may be the first they have ever heard about Winehouse’s eating disorder. As well-documented as her struggles with alcohol and drug addiction were, the tiny little fact of her severe, untreated, decade-long eating disorder was rarely mentioned. When her thinness was mocked in the media, it was almost always with the implication that hey, addicts are always skinny little wrecks. If her puffy face was ever evaluated—and it was, because every aspect of her physical appearance was eviscerated during the height of the media’s obsession with her—it was through the lens of someone looking for signs of alcohol addiction (which commonly causes bloating in the face) and not signs of self-induced vomiting.

Winehouse’s struggles with substance abuse were highly public and often ridiculed and, as many others have noted, the film does an outstanding job of laying bare the damaging impact that media coverage and celebrity-worship can have on the real, flesh-and-blood artists. She is quite literally attacked by paparazzi during highly personal events such as visits to rehab and her husband’s prison stint.
Amy also documents in thorough detail the many attempts by those surrounding the singer to get her help—both for altruistic reasons (read: because they cared deeply for the sparkling, kind, immensely talented woman) and for selfish motives (read: because they cared deeply about the fame and money that Amy could bring them as long as she was able to comport herself in the studio and on tour).

What the film is surprisingly lacking in, though, is anything beyond passing mentions of her bulimia. That segment transitions into an interview with someone working in the studio while Amy was recording Back to Black. They recount that the (very tiny) singer ate a large meal, disappeared for 45 minutes, and returned with smeared makeup. Some bathroom snooping followed, which revealed that Amy had “redecorated the bathroom,” having vomited up what she’d just eaten. This, the interviewee notes, was a point when she and others involved in the recording process realized something was really wrong. Then the film transitions away from any serious discussion of her eating disorder and never returns, other than in passing mentions perhaps three or four times. The disease is always treated as incidental and almost, to my perception, as something as permanent and untreatable as late-stage cancer, with an air of nothing can be done.

Eating disorders, for the most part, are a highly contained and easily managed means of utterly ruining oneself. A person with bulimia nervosa can carry on bingeing and purging while otherwise maintaining a high level of functionality. The same goes of those with anorexia nervosa, binge eating disorder, and purging disorder. Bingeing, purging, or starving are highly unlikely to put you into debt, and leave you unintoxicated and able to carry out the tasks of a job, and tend to the demands of a relationship and daily chores of life. These facts make it very easy for the friends, family, and colleagues of those with an eating disorder to overlook the disease, as the footage and interviews we see in Amy remind us.

When Amy suffers and survives her first overdose, a close acquaintance summarizes the urgings of a doctor and those around her to explain that a “petite” young girl cannot maintain the level of drug and alcohol abuse that led to the overdose. However, we’ve seen the footage. Amy wasn’t always petite, and would likely not have been referred to that way even at the time she began performing in clubs and signed a record deal. Early videos of her performing for industry folks as an 18- or 19-year-old show her with broad shoulders, a heavy chest, full thighs and torso—generally an “average-sized” woman with a solid frame. This “petiteness” was not natural; it was fought for.

But to anyone other than Amy, it was easy to overlook and intimidating to address. An interview with her brother Alex in the Guardian confirms the known-but-not-discussed quality of Amy’s bulimia: “We all knew she was doing it, but it’s almost impossible [to tackle] especially if you’re not talking about it. It’s a real dark, dark issue.”

Yet, Amy Winehouse’s eating disorder wasn’t simply “yet another bad decision.” The environmental and genetic factors at play in Winehouse’s childhood and adolescence put her at extremely high risk for developing an eating disorder, and the lack of early intervention, education, and stable guidance meant that the disease was able to firmly take root and flourish as she was put in higher- and higher-stress situations. According to the National Association for Anorexia Nervosa and Associated Disorders, “There isn’t one conclusive cause of eating disorders. Multiple factors are involved, such as genetics and metabolism; psychological issues—such as control, coping skills, trauma, personality factors, family issues; and social issues, such as a culture that promotes thinness and media that transmits this message.”

Depression is the most common mood disorder to be comorbidly diagnosed with an eating disorder, and those with eating disorders are commonly known to use their disordered “behaviors”—restricting caloric intake (commonly referred to simply as “restricting”), bingeing (which, by the definition found on the website for the National Eating Disorders Association, is characterized by “frequent episodes of consuming very large amounts of food” and a related “feeling of being out of control during the binge eating episodes”), and purging (which does not always take the form of self-induced vomiting; overexercising and laxative/diuretic abuse are also forms of purging)—as ways to cope with depression, anxiety, manic depression, post-traumatic stress disorder, obsessive-compulsive disorder, and other psychological disorders.

Winehouse was put on antidepressants early in life and, in one interview shown in the film, spoke with a depth of understanding on the subject of depression as a disease.

She said that as a child, “I don’t think I knew what depression was. I know I felt funny sometimes and I was different.” As she grew older and began taking the antidepressants, her understanding clearly deepened, and in the interview she rejects the notion that there’s something wrong with those who suffer from depression: “I’m not like some messed up person, you know? There’s a lot of people that suffer depression that don’t have an outlet.” Her outlet, she says, is playing guitar and writing music. Environmental factors, such as an unstable home life marked by an often-absent father and a mother who admits that it was a struggle to say “no” to her daughter, also likely played a role in Winehouse’s eating disorder.

So, there we have the psychological and genetic risk-factors and the environmental ones, not to mention the ignored cry for help and the implied societal pressures of being a woman at all, let alone a young woman who is growing into a performer on the world stage.

Then there’s the substance abuse.

Winehouse was notorious for her alcohol abuse even early on in her career, and her addictions to crack cocaine and heroin were spurred by her damaging, abusive relationship with eventual-husband Blake Fielder-Civil, whose betrayal spawned the creative high-point during which Winehouse penned all of the breakup-inspired Back to Black.

According to the National Eating Disorder Association, “research suggests that nearly 50% of individuals with an eating disorder (ED) are also abusing drugs and/or alcohol, a rate 5 times greater than what is seen in the general population.” Many people with eating disorders use substances as a form of appetite suppression, while “in other cases, eating disorders and substance abuse can be relied upon for avoidance-based coping.” Additionally they note that “substance abuse can develop before, during, or after treatment for an eating disorder,” and that reliance on drugs and alcohol is “both ineffective and counterproductive in that emotions remain unaddressed, problems go unresolved, and healthy strategies to cope are not developed.”

Winehouse’s many visits to treatment centers and her many attempts to go clean all center on recovering from drug and alcohol abuse, but they seemingly never address the comorbid eating disorder, despite the fact that it was ruinous to her health and was the disease she had been suffering from for the longest amount of time.

At one point, Amy’s manager and others she’s working with even draw up a contract that she must sign, stating that they won’t allow her to attend any events for the Grammy Awards—she was nominated for six—unless she gets and stays clean. At this point, she has already overdosed. She signs and obliges. She is clean during the Grammy Awards. No one in the film considers, mentions or perhaps had any real understanding that she could drop dead because of the severity of her eating disorder. It’s a silent form of destruction, and so it is, tragically, often not considered a “disease” worth treating.

Indeed, even after her death, those in the media were seen expressing resentment at the way Winehouse suffered in public, rather than feeling regretful for participating in the circus that amplified and intensified her diseases. Douglas Wolk, in his review of At the BBC, calls the album “a stinging reminder that she spent the better part of her too-brief career making her audience complicit in her self-destruction.” Yet, extreme fame and media coverage, caretakers who didn’t take care of her, and the aggressive demands of audiences were complicit in her self-destruction.

In early videos, we see Winehouse denigrating her appearance and hiding from the camera. She’s still a huge personality, but when she’s applying makeup, she criticizes her spotty skin, her face. When, after having been asleep in a car with no makeup on, the singer discovers that she’s being filmed, she hides behind blankets and refuses to be seen. She’s in her late teens in these videos, and those familiar with the signs will see on her face the trademark swollen salivary glands of someone who repeatedly self-induces vomiting. A regular viewer, however, might notice nothing except that she’s shy.

Over the course of perhaps two years, roughly gauging based on the footage included in the film, a bulimic Winehouse winnows herself down from the type of figure commonly seen on the sidewalk to the type of figure commonly seen on a red carpet.

In one interview, Winehouse’s former bodyguard recounts how close they were. She used to tell him all the things a young girl might talk to a parental figure about—including worries such as why she no longer gets her period and secrets like the fact that she can never have children. Amenorrhea, the absence of menstruation, and infertility are both symptoms of a severe eating disorder, and amenorrhea in particular is used as a factor in the diagnosis of anorexia nervosa. Not so with bulimia nervosa; the two diseases share many of the same symptoms, including the loss of a menstrual period, but this is not a diagnostic criteria for bulimia, the reason being that, again, those with bulimia are rarely severely underweight.

During Winehouse’s “clean” period, when she is living in St. Lucia and is not abusing drugs but is still drinking large amounts of alcohol, the press jumped on her “recovery” and crafted it into a redemption story. The whispers of her bulimia were allowed to be more directly addressed now that she was ostensibly “better,” and this coverage reveals in yet more ways how misunderstood eating disorders are.

One article in The Daily Mail contains photographs of Winehouse in St. Lucia, sporting a bloated stomach, which can accompany severe cases of eating disorders due to malnutrition and internal injury. In some of the photographs, she is eating, and one caption reads “Healthy appetite: Amy Winehouse looks well on the way to recovering her curves on a holiday on the Caribbean island of St Lucia.”

The article includes quotes from a man Winehouse was seeing at the time, which indicate a very limited diet and extreme malnutrition, punctuated by occasions of bingeing and purging:

She lived off Crunchie bars—up to 10 at a time—packets of Haribo sweets and bottles of orange Lucozade Sport…She would have a massive McDonalds and then throw it all up in the bathroom. I found my toothbrush covered in sick, and asked her about it.

The inclusion of these details in the article reveal how morbidly fascinated society is with the gory details of eating disorders and how utterly misinformed we are about the facts of them. Photographs of a person with bulimia—who is known to eat large portions of fast food and then throw it up—”polishing off nearly a full plate of food” are not at all a sign of recovery, as they may well be bingeing on food that they will then purge.

One of the biggest challenges when attempting to treat a patient with an eating disorder is the fact that EDs are egosyntonic, that is, the patient views the eating disorder as being in harmony with the rest of his/her personality and ego—it is an acceptable and positive part of the self. Many sufferers don’t want to get better.

According to Psychiatric Times (and anyone who has ever had an eating disorder), “Patients with eating disorders are notoriously difficult to treat and are also known to have high relapse rates.” This can be attributed to a number of factors—many of which have been addressed earlier in this piece—such as the facts that: eating disorders are misunderstood, the treatment of them is incomplete, the doctor and patient do not address the core issues at play, and of course, the disease itself is egosyntonic.

There’s substantial evidence in the film that Amy wanted to receive treatment for her drug and alcohol addictions, such as a moment when she muses that she likes it in the rehab center, as well as her willingness to sign her managerial ultimatum. None exists, at least not in the film or any documents I’ve found online, that suggests she felt the same about treating her eating disorder. And this is not surprising. She started the behaviors when she was a teenager, was not discouraged when she revealed her eating disorder to her parents, and continued the behaviors into an adulthood that demanded a very specific body type, which would be picked apart by literally billions of witnesses.

Eating disorders are hard to handle. They’re extremely difficult to treat, have high rates of relapse, are often invisible and rarely impugn on a sufferer’s ability to carry on a normal life, are often kept a secret, have causes and effects that are consistently misunderstood, and are rarely cited as an actual cause of death.

Amy Winehouse’s official cause of death was alcohol poisoning, but this can be understood as the equivalent of someone with AIDS who has died of complications from pneumonia. Similar to the way HIV compromises a body’s ability to fight infections, bulimia damages the body to the point where it is no longer able to keep up basic functions and is more susceptible to external threats.

The National Association of Anorexia Nervosa and Associated Disorders describes this phenomenon thusly:
Although eating disorders have the highest mortality rate of any mental disorder, the mortality rates reported on those who suffer from eating disorders can vary considerably between studies and sources. Part of the reason why there is a large variance in the reported number of deaths caused by eating disorders is because those who suffer from an eating disorder may ultimately die of heart failure, organ failure, malnutrition or suicide. Often, the medical complications of death are reported instead of the eating disorder that compromised a person’s health.

A doctor interviewed in the film describes Winehouse’s death as a combination of alcohol poisoning and the weakened state of her body due to an eating disorder, but that assertion never made it into the official “cause of death” statement released to the public after Winehouse’s passing.

The impact of such technically accurate but holistically incomplete reporting is that the general population is not conditioned to perceive eating disorders—especially bulimia—as deadly.
Had Winehouse’s cause of death included the phrase “complications from bulimia,” the world would likely—or hopefully—have begun to engage in some very different, more complete conversations about health. The more our body-obsessed culture acknowledges the realities of eating disorders, the more we can hope to put the world on a path to a better and more accurate understanding of this devastating set of diseases, as well as the illnesses’ unique, complex sufferers. The unwillingness to truly regard Amy Winehouse’s eating disorder shows that we still have a long way to go.

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