Bulimia and its role in the death of Amy Winehouse

 

This article can be found at http://pitchfork.com/thepitch/861-we-need-to-talk-about-amy-winehouses-eating-disorder-and-its-role-in-her-death/  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.

Wealth, Privilege and Adolescent Addiction

Addictions impact people in every socio-economic class. When they strike families of wealth and affluence- high functioning families- the issues and challenges to getting clinically and culturally competent treatment are great. In this article I explain what families need to look for when seeking out qualified professionals.

Read more

Dr. Paul Hokemeyer in the Robb Report: Wealth & Addiction

Dr. Paul discusses the unique clinical needs of ultra high net worth patients in this Robb Report article:

Courtney Humphries
JANUARY 01, 2015
Some surprising new weapons are in development to aid those battling addiction.

By many standards, Mark held the world in his palm. He had gone to Harvard Business School, was good-looking, with plenty of charm. By the time he was 42, he was a hedge fund manager making $15 million annually and had a wife and two children. But along with his rapid wealth and success came stress and self-doubt. To manage it, Mark began hooking up with women he met online and visiting strip clubs where he paid women for sex. He also slipped into a daily cocaine habit. After a while, the cocaine was the only thing that made him feel in control—the glue that held him together.

Until everything else fell apart. When his wife discovered a text conversation with an escort describing the cocaine used in their last encounter, she left with the kids to their vacation home. Mark, his addictions now unchecked, went on a two-day binge of sex clubs, cocaine, and martinis. When he woke up at a hotel without his wallet and keys, he realized he needed help. He checked into a 56-day treatment program at Caron Renaissance Ocean Drive, a clinical treatment center in Boca Raton, Fla., where he finally began the process of addressing his addictions.

Paul Hokemeyer, PhD, a senior clinical advisor at Ocean Drive, says that Mark’s story (his name and personal details have been changed to protect confidentiality) is typical of the patients he sees. “They have reached a point where they have an enormous amount of financial success, but the quality of their lives is in tatters,” he says. Addiction—whether to alcohol, prescription pills, or cocaine—often goes hand in hand with accomplishment. “The brain has registered that substance as the thing that enables them to succeed in the world,” Hokemeyer says.

Increasingly, scientists are uncovering the biological underpinnings of addiction. Some people are more susceptible to addiction, either because of a genetic predisposition or because of life experiences such as neglect or abuse in childhood. But addiction itself changes the brain. If someone looked inside Mark’s brain, they would see that cocaine had taken over its reward pathways, interfered with decision-making, and robbed him of his ability to make better choices.

Even people who are motivated to quit find that kicking an addiction can take months to years. But scientists are developing innovative treatments that could someday help people like Mark unravel the deep habits that keep them reaching for their next fix. One day, for instance, he could get a cocaine vaccine as part of his treatment, essentially inoculating him from its powerful high.

Vaccines are currently in development for cocaine, nicotine, heroin, and methamphetamine. “It would protect the brain from the large rush of the drug,” says Michael Owens, PhD, a pharmacologist at the University of Arkansas for Medical Sciences, of the meth vaccine he is working on.

Some of these vaccines work much like an infectious disease vaccine: An addicted patient gets a few injections of a molecule similar to the drug, attached to a foreign protein designed to rouse the immune system. The body responds by producing antibodies against the foreign substance. The next time a person takes a hit, these antibodies find and attach to the drug in the bloodstream. The antibody-bound drug molecules have a harder time crossing from the blood into the brain, keeping them from having a strong effect.

The trick is to stimulate the immune system potently. A cocaine vaccine developed by Thomas Kosten, MD, at Baylor College of Medicine is the farthest along in clinical trials. It has shown promise in keeping more people in treatment, but was only able to stimulate enough antibodies to be therapeutic in about half of the subjects. Scientists are also looking at a different kind of vaccine; rather than stimulate the body to produce antibodies, they manufacture molecules called monoclonal antibodies that attach to a specific part of the drug, which are directly infused into an addicted person. Researchers at the Scripps Research Institute in La Jolla, Calif., are developing a monoclonal antibody vaccine for cocaine, and Owens is developing one for methamphetamine. The treatment is expensive to produce, but could be more effective than a traditional vaccine. Owens says an infusion might last three or four weeks.

Like many treatments in development, a drug vaccine is not meant to be a cure for addiction. “It’s not a standalone medication. [The patient] must really be involved in some sort of behavior modification program or cognitive behavioral therapy to deal with the issues that keep them going back to the drug,” Owens says. But it could provide a crucial edge to people who are trying to change.

– See more at: http://robbreport.com/health-and-wellness/prevention-treatment/fixing-fix#sthash.4vyqg0qP.dpuf

Women & Treatment: Models of Success

This article first appeared in Rehabs.com

“A woman is like a tea bag. You can’t tell how strong she is until you put her in hot water.” – Eleanor Roosevelt

Too often when professionals talk about addiction and other behavioral health issues among women, we share only half the story. We lament about the toll they take on our female patients and their family’s well being. We pine over the obstacles to treatment and long-term recovery- and we forget to share the incredible narratives of their success.

Taking Inventory

I must confess that I’m guilty of that which I’m criticizing. As an expert for the Dr. Oz Show and a guest on Katie Couric’s show, I’ve discussed at length the unique challenges women face when dealing with addiction. Just recently, I spoke at a conference in London on this very issue to over 200 professionals from around the world.

In reviewing my remarks, I was shocked to find I’d devoted around 80% of my time discussing women’s vulnerabilities and a paltry 10% discussing their strengths. Fortunately, I realized the errors of my ways before taking the podium and devoted my time celebrating the sharpness of the female mind, the resiliency of her body and generosity of her spirit, traits the give women an upper hand in reclaiming not just their own well being, but also the well being of their families.

And my comments were not based on wishful thinking. The academic research and my clinical experience unequivocally show that women enjoy higher rates of recovery than men and transcend their gender-based challenges with a deep resolve and strength of character. Yes women have challenges, but so does everyone else when they decide to address their addictions. The real news is how extraordinarily well women succeed with their task.

The top reasons for their success are as follows:

Telescoping
Women progress more quickly from using an addictive substance to dependence, addiction and treatment than men. As a result, they get themselves into recovery programs much faster than their male counterparts. This hastened pace with which they seek help spares them and their loved ones years of physical decay and emotional heartache.

Mental Health Issues
Women suffer from higher rates of mood and anxiety disorders than men. These underlying conditions have established and highly effective treatment strategies that can be immediately implemented to provide enormous relief. Once these issues are addressed, women are much more likely to take an honest look at their addiction.

Relationship Oriented
Women are more likely than men to use self-help programs like Alcoholics Anonymous and are also more likely than men to benefit from the group therapy model that’s utilized in treatment. They are quick to ask for help and listen to the advice that’s given. They chose the long term well being of their family over their short term discomfort and are able to subrogate their pride and egos to the good of the family unit.

Higher Rates of Success
Women and men are equally likely to complete treatment, but the women who complete are 9x more likely to be abstinent than women who didn’t. Women have a much greater capacity to stick with the challenges presented by treatment once they make the commitment to change. Even though the first few months of recovery are hard, they see how their efforts are benefiting those around them and stay committed to the task.

Lower Incidence of Relapse
Women in substance abuse treatment are less likely to relapse than men in treatment and have better long-term recovery outcomes. Women are better at following directions then men. Unlike men, they can put their egos off to the side and see how their commitment to change will benefit their family and their selves.

The Female Success Story

Never forget that, in the realm of recovery from addictive disorders, women are models of success, strong cups of tea and inspirational change agents. Moving forward, I’m resolved to do a better job in celebrating these strengths instead of just focusing on their problems. I suggest you do the same.

If you know a woman who’s struggling with an addiction or mental health issue, forward her this article. Based on the research and my nearly two decades working in the field, she’ll take your efforts to heart and be grateful that you care.

Compassion Fatigue

One of the greatest gifts I receive in my work as an addictions therapist is to witness individuals and families surmount incredibly difficult challenges and embrace a life of recovery. Often the breakthrough occurs at the bitter end, when I’m scratching my head in disbelief that they can endure such intense levels of frustration and pain.

Witnessing the thrashing that occurs at addiction’s hands is grueling. I’ve spent countless sleepless nights wondering if a patient will “make it” or “get” the breakthrough they need to begin the healing process. Fortunately, as a professional I’ve been trained to deal with the frustrations that come with this work.

As a young clinician, I had wonderful mentors who taught me to never to give up on the human spirit. “You never know when the seed you planted will take hold,” was the steady advice of Dr. Stanly Evans, a man of enormous integrity and a pioneer in the field of addiction treatment. Another, Sid Goodman, creator of the highly effective Florida Model and Family Restructuring programs, constantly reminds me to be fearless and tenacious in challenging a family’s resistance to change. “You must think systemically,” he constantly instructs me when I’m baffled with what to do in a particular case. “The patient is the family and the family is the patient.” But even with this exceptional support, there are times when I get exhausted, crushed by the weight of a disease that diminishes the dignity and souls of my patients and their families.

What is Compassion Fatigue?

Compassion fatigue is a well-established concept in the realm of health care providers. First observed in nurses who worked in emergency rooms, it describes the sense of helplessness and hopelessness that can overtake a person providing care for someone whose suffering seems never-ending and insurmountable. It’s also a condition that I observe frequently in the families and loved ones of the patients I treat.

Marsha* is an example of a wife and mother whose emotional spirit and physical health were beaten down by the seemingly hopeless addictions that plagued her husband and daughter.

A once beautiful and vibrant woman, Marsha presented for treatment disheveled and profoundly depressed. Coffee stained her blouse, mud caked her shoes and silver roots defined the brittle locks of her auburn hair. Although she had a master’s degree in English and for years taught American literature at a local college, she could barely put together a coherent thought. “I’m just exhausted…tired…no energy.” It didn’t take long for me to realize why. Her 17-year-old, heroin-addicted daughter was expelled from school for selling OxyContin and had been in and out of five $30,000-per-month rehabs in the last three years. As if that wasn’t enough, Marsha’s husband of 27 years was on the verge of losing his middle management job at an insurance company for excessive absences due to his late stage alcoholism. “It seems he loves cheap vodka more than he loves me and our kids” Marsha sighed as she finished telling her story.

Exhaustion, frustration and an overwhelming sense of hopelessness: these are just a few of the symptoms described by people who suffer from compassion fatigue. The following is a more thorough list compiled by the American Academy of Family Physicians.

Common Symptoms of Compassion Fatigue

Abusing drugs, alcohol or food
Anger
Blaming
Chronic lateness
Depression
Diminished sense of personal accomplishment
Exhaustion (physical or emotional)
Frequent headaches
Gastrointestinal complaints
High self-expectations
Hopelessness
Hypertension
Inability to maintain balance of empathy and objectivity
Increased irritability
Less ability to feel joy
Low self-esteem
Sleep disturbances
Workaholism
You can determine if you are suffering from compassion fatigue by taking a self-assessment test. If you respond with a 1 (very true) to more than 15 questions, it’s critical that self-care is your first priority.

For Marsha, self-care meant finding something to anchor herself to when the gales of her daughter and husband’s addictions thrashed against her. Since she was a child, Marsha had internalized the belief that if she fixed those upon whose love she depended, then all would be well. It was a message she learned as an infant, completely reliant on the conditional love of a narcissistic and anorexic mother. But while her selflessness enabled her to survive her childhood, it trapped her in relationships that crushed her spirit and enabled those she loved to march uninterrupted down paths of self-destruction.

Fortunately, for Marsha and millions of other people like her, there is a way out of these devastating relational patterns. The key of liberation is to acknowledge that your unhealthy response to other peoples’ behavior is a habit – and most importantly – that it’s a habit you can break.

In his best selling book, The Power of Habit, Charles Duhigg, an investigative reporter for The New York Times, distilled habits into three key components. The first of these components consists of a cue. This is the cause of your reaction. The second is a routine. This is the effect. It’s the behavior you engage in or the reaction you have in response to the cause. The third is the reward. This is the benefit you derive or the instantaneous relief you feel once you’ve had your reaction.

In Marsha’s case, the cue for her reaction to save and protect others was the unmanageability of her life, caused by the insanity and chaos of her family’s addictions. The routine she fell into was to become a caretaker extraordinaire. When a crisis struck (and there always was a crisis), Marsha became super mom and super wife. Like a caped crusader she swooped in and solved their problems. The reward she got from her behavior was having a moment, if only fleeting, of mastery and control – and perhaps most importantly – of being validated as a person who mattered.

Unfortunately her habit, while enabling her to survive as child, had outgrown its usefulness. Now instead of adding value, it became deeply rooted in her family’s disease.

How Can We Overcome Compassion Fatigue?

Fortunately, Marsha possessed within her the tools to change. To recover, she needed to become hyper conscious of when her cue arose and implement different routines to address it. So instead of looking to control the externals of her life, she needed to enhance the mastery of her internal, emotional state.

Central to accomplishing this skill was her coming into therapy and talking about what was going on in her life with a person who was completely present for her. Second, she needed to find and cultivate a life outside the stagnate confines of her family. In Marsha’s case, this expansion occurred slowly. Initially and reluctantly she started attending Sunday mass at her community church. A month later she was back at work, teaching English as a second language to families in need. Finally, she was able to get her daughter into a treatment program that had a robust family therapy component as a central part of its curriculum. The work that she and her family were able to do in this program broke the strangle hold of their addictions and liberated them in a spirit of mutual respect, love of self and each other. They were finally able to hear each other out and set boundaries that were clear, consistent and enforceable.

Six months have passed, and is Marsha’s life perfect? No. But, it’s infinitely better than the life she found herself in upon entering treatment. Although her husband did lose his job, he was attending AA meetings and was cobbling together periods of sobriety. Her daughter was clean and living in a half way house in Florida and had just started a part time job in a coffee shop in Delray – a wonderfully robust recovery community. The greatest transformation, however, was that which occurred in Marsha. No longer were her eyes flat orbs surrounded by craters of darkness. In them shown a light of recovery and hope –evidence that her compassion fatigue had been replaced by compassionate strength for her self and others.

*The name and identifying details have been changed for patient confidentiality.

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