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"I must be good."
That was the first on Pat's long list of "core beliefs."
Therapists Ann Kreindler-Siegel and Joyce Hennessy had asked the women in their eating-disorders therapy group to write down "all the things that you believe and have learned to live by."
Eating disorders are less about eating than about beliefs about body image and control over life decisions, the therapists said.
To get to the root of some of those perceptions, the therapists wanted the women to examine the rules they've carried in their heads since childhood.
"You're all over 18," Ann said. "You're entitled to go out and get a belief system that works instead of one that keeps you stuck."
Pat sank into a wing chair in the corner of Ann's office and read her list to the others in the group.
"I must keep my emotions under control.
"I should sacrifice for others.
"Food is good or bad.
"I must be productive.
"Work first, play if you have time.
"Never say `No.'
"What would others think?
"Asking for help equals failure.
"Idleness equals laziness.
"Others like me for what I do.
"I don't deserve the things I want."
When she stopped, the other women seemed shocked at the heft of her recitation.
"Wow, that's a hard way to grow up for a little girl," Ann said.
She suggested that Pat might add some kinder statements to her list.
"How about `I am lovable'? Could you do that?" Ann asked.
"I can write it down," Pat said.
"Honestly, I have to say, I have a hard time believing that," she added.
"We all think you're lovable," Ann said.
Others nodded in agreement, but Pat didn't notice. She was looking down at her paper.
She didn't believe them anyway. She thought they were only saying that, when they really thought she was pathetic. As pathetic as she found herself.
But she would never let them know she felt that way. What would they think if they knew what her life was really like?
Every day, before going to work at 7 or 7:30 a.m., she'd exercise for an hour or so on the stair stepping machine at the gym. Then, after working nine or 10 hours - eight hours a day would have been slacking - she'd go back to the gym for another 45 minutes.
Then Pat would go home and make a big dinner for her husband. She loved to cook, but she never ate the food she cooked for him.
Pat restricted herself to certain foods at certain times of day. She ate the same thing for breakfast, lunch and dinner for months in a row. In February and March, while the group was meeting, Pat was eating two slices of thin diet bread, toasted and dry, for breakfast around 11 a.m. Lunch was usually some cubes of cantaloupe and 1 1/2 round butter cookies at 2:30 or 3. And at dinner, while her husband ate meatloaf, potatoes, rolls and dessert, she would have a handful of raw carrot slices, a few slices of raw cucumber, half a stewed tomato, a half a slice of pita bread, half an apple and half a pear.
Even on Sunday, when her gym didn't open until 12:30, she exercised twice. She'd spend an hour when it opened, then go home for lunch. If her husband suggested a walk instead, she'd agree to the walk, but she'd still go to the gym later.
To Pat, a walk didn't count as exercise. It was just a walk.
Food and the act of eating were the topic of therapy only once during the group. It was the "mindful eating" exercise. In the fifth week, Ann surprised everyone when she brought out a plateful of orange slices and a bowl of M&Ms.
Pat froze.
Her heart pounded.
No one had said there would be food.
It was 8:15 a.m. It was not time to eat. And she couldn't eat this anyway.
"Food is supposed to be used as fuel and nurturance," Ann said. "We need to go back to feeding our bodies as if we were listening to them."
She explained that people grow up with many rules about food, and some of them are arbitrary. For example, you're not allowed to have cookies for breakfast, but you can have doughnuts. What sense does that make?
Ann passed around the oranges and the candy and asked everyone to take one slice of orange and one M&M.
Pat could barely hold them in her hand.
But she didn't let her face reflect her terror.
"This M&M and this slice of orange are about equivalent, but we sure don't think of them that way," Ann said.
She asked each of the women to hold the orange, smell it deeply, take a small bite and hold it in their mouths, savoring the taste.
Then they did the same with the candy.
Pat touched the orange to her tongue and tasted the juice, as little as possible.
Then she tasted the sugar coating only from the candy. She couldn't remember the last time she'd eaten an M&M. It had been years, and now she felt heavy and somehow unclean.
Pat didn't speak when Ann asked the group for reaction, but she agreed with another woman, who said: "It's really anxiety-provoking to be, like, with food, in a group of people."
Others nodded.
Pat said she felt badly for what she'd just done. "It's just breaking the rule, my rules."
She wished she could take a pill instead of eat. "There's no pleasure or joy in eating," she said. "To get hungry and ignore it makes me feel good, which sounds whacked out. My mind feels more powerful when I can deprive my body."
At the end of the exercise, Ann told the women to eat the rest of the orange slice if they wanted.
No one did.
During the last few sessions, Ann and Joyce encouraged the women to evaluate their therapy experiences, to look to the future with hope, and to recognize that they had developed trust in strangers, which is often hard for people with eating disorders.
In one of the last exercises, the women wrote letters to Ann and Joyce as if a year had passed, and they were describing their progress. They read them aloud.
"Wow, what a year it's been," Pat read when her turn came. "I continue to learn how to live my life, not the life others want me to live."
She described a dance class she was taking "just to have fun."
"(My husband) and I are well on our way to adopting a child "
She paused, trying to overcome the catch in her throat. She did not want to cry.
" I'm so thrilled and excited "
She stopped again, barely able to speak.
" at the prospect of becoming a mom."
She dropped her head and wept. Ann, crying too, handed Pat a tissue.
Women around the room were overcome to see her, for the first time in their weeks together, letting her stoic face give way to emotion.
When she composed herself, Pat finished reading her letter and looked up.
"I'm sorry," she said.
"Please don't ever apologize for crying," Ann said softly.
"Being able to cry helps us," Joyce added. "That you could cry shows the progress you've made All you've got to do is sit with the emotion, and it passes through, like it just did."
One of the other women said, "I'm envious that you CAN cry."
Ann and Joyce believed Pat had turned a corner, that crying showed progress.
Pat just didn't know it yet.
At the end of May, Pat weighed 78 pounds. She'd lost about 12 pounds since February, when the therapy group started.
Despite that weight loss, she felt she had improved. In the group, she had been honest and open with many of her feelings. She had trusted the other women. She realized she needed to get rid of those negative beliefs she had identified during the group.
But she couldn't seem to eat enough, to change her rules.
She started seeing Ann, the therapist, for private counseling. Pat agreed she needed more intensive treatment.
In June, she left for the Midwest, where she entered a residential program for the fourth time.
This center, with only 11 beds, is smaller than others she had tried. And therapy focuses on some of the same issues Pat confronted during the New Beginning group. Most patients stay for two to four months.
Therapists have told Pat she can get well. But because she's had her disease so long, it may take a while to recover. Some people go in and out of treatment many times until, one day, something clicks.
Pat isn't sure how long she'll be away.
But she's determined, this time, to do what it takes.
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(c) 2003, The Charlotte Observer (Charlotte, N.C.). Distributed by Knight Ridder/Tribune News Service.
