The psychology of bulimia nervosa is usually not the first thing we consider when we think of the disorder. We think of bulimia in terms of specific behaviors -- particularly, binge eating and purging. These are the hallmark symptoms of the disorder.
But the powerful psychological and behavioral rituals that accompany bulimia are major factors that fuel it. Bulimia involves rituals of thought (internal dialogues) that dominate the mind. As I have seen through working with those with eating disorders, these lead to rituals of behavior that occur before, during, and after binging and purging.
Planning the Binge/Purge Cycle
I have yet to encounter anyone who invites another person over to binge. This is is an individual act. Making sure that no one is present takes planning. There must be space to gather and prepare food, plus enough time to ensure that no one will stumble onto the scene. A person with bulimia may therefore devote much time to finding a time and a place to execute a binge.
The Ritual of Getting Food
Going to the grocery store (or other food source) is a frequent ritual for someone with bulimia. A binge requires a certain amount of food (highly dependent on the individual) to be "successful." And the urge to binge may arrive before the food is at hand, making a grocery run necessary.
The person is likely to take a familiar route to the store and get predictable foods. All the while, she may be thinking, "I don't have to do this." Or she may fill her cart while thinking very little. Either way, she has already begun the process. From this point, it is hard to stop it.
Choosing food for a binge means choosing what is easy to vomit. But it doesn't necessarily stop there. A person may choose food in part because it won't make a splash in the toilet when purged; it's a way to avoid a mess. These choices contribute to the binge/purge pattern.
Bulimia's Psychology of Eating as Ritual
Many people with bulimia have a great deal of shame about the process of preparing and eating food. In therapy, someone with bulimia will talk about how often binging and purging occurs and how bad it feels. When asked about what really goes on in a binge/purge cycle, however, there is much reluctance to discuss it. This is why it is important to talk about it: Secrets fuel shame, and shame fuels the disorder.
Preparation of food will often follow a predictable pattern. For example, mash this, mix this, heat this, eat, then move to the next set of foods. And so on. The pattern deepens the shame, because it suggests that the person is doing it by design.
By the time a person begins eating, his personal cycle of binging and purging is well underway. But there is a "point of no return" at which he can halt the process if he chooses. It is common for a binging person to have a conscious thought of going "over the line" -- "If I eat this bite, I know I'm going to purge." After the bite, he may simply be resigned to the process, automatically eating more in an effort to make purging easier later.
The Ritual of Internal Dialogue
This may be the point at which the person with bulimia hears some of the most powerful messages: "Well, you've done it again. You're such a sorry excuse for a human being, you might as well go all out and eat some more." The voice is often sarcastic, and it knows a person's weak points: "I'll bet you'd really like your mom to see you now, huh? You've made her so proud."
This all comes with a note of inevitability, too. "Come on. You know what you have to do to make this right. You don't have any control, and you're a lousy daughter. If you get rid of the food, maybe you can have another chance." Normally, a person in this position is in sad agreement with the voice and continues the process as a form of penance for "doing wrong."
The Anxiety Zone Between Binging and Purging
At some point, the eating ends. There is a delay (usually quite short) between eating and purging, and it is a time of intense anxiety. The person is now on a mission, and believes he must purge at almost any cost. Ask him to write down what is happening emotionally during this time, and he probably won't be able because the stress of having food inside of him that "needs" to be purged is too great. This may be the time at which he feels least in control.
Purging Rituals
The rituals often do not end in a rush to the bathroom. Purging may also follow a specific pattern, such as gathering towels for cleaning up after vomiting, or using particular objects to trigger the gag reflex. Rituals may include a specific mode of hand-washing or rinsing the mouth.
Psychological Effects of Rituals in Bulimia
Rituals in bulimia reinforce themselves, making the cycle harder to stop. Much of this comes because of shame. The shame of executing these behaviors according to patterns darkens a person's perception of self. This feeds the voices that tell her that she is worthless -- that she might as well binge and purge, and make her actions line up with her "real" identity.
Ending Rituals of Bulimia
Ending rituals is hard. They're habits, after all. Changing these behaviors means doing things that don't seem to make sense, such as being kind to yourself when you feel shame.
The first step is telling someone about the rituals. Taking away secrecy is often a huge relief, and when the friend, spouse, or therapist who hears the information still accepts the person, the darkness can begin to lift. This acceptance works against the voices that tear the person down.
Then it's a matter of injecting kindness into shameful aspects of the rituals (and after they're carried out). It may mean eating normally after purging to replenish the body's resources. Or, it could mean stopping before reaching the "point of no return" and instead actively caring for oneself. Bubble baths are good. Putting on clothes that are comfortable and attractive sends the self a powerful message as well.
Getting Help
It's hard to end rituals of any kind in a vacuum. Get help. Talk to a qualified therapist. See a registered dietitian for new ways to interact with food. And build good rituals, such as weekly meetings with friends planned around doing things you like to do. These new, healthy rituals can take the place of the old.
