Of hooves and horses

If you hear hooves, the saying goes, think horses not zebras. The advice for doctors encourages them to think of simple pneumonia with an unrelenting, raspy cough in February rather than an exotic fungal infection from the Seychelles. For a therapist, it might mean that (as Freud put it) sometimes a cigar really is just a cigar. It's standard, fairly solid advice. Rule out the obvious before you start chasing something more obscure.

The problem is that hooves and horses don't always go together. Just because you see a horse doesn't mean you're going to hear hooves.

The Metaphor Queen will explain. An article on EmpowHer posited that the number one reason for developing an eating disorder was a "relentless boundary invasion on every level." For this metaphor, let's call the eating disorder the horse (remember Mr. Ed the talking horse?) and any possible "boundary invasions" the hooves. Also for the sake of this metaphor, let's say that we know the horse is there, we know that the person has an eating disorder, but we're still listening for the hooves.

The problem with such arguments--beyond the fact that they have nothing to do with the latest science--is that they make the facts fit the theory. For the metaphor, you automatically hear hooves when you see a horse, even if the horse is standing still. Most people have had boundary invasions. The idea of a "boundary invasion" is fairly nebulous, and different people will have different standards as to what is a relentless boundary invasion. I'm quite a private person, despite my public blogging, so I have a fairly low tolerance for people poking around in my stuff. But if you look hard enough, most people will have had a boundary invasion, whether someone read their diary, they were touched inappropriately, or their mother insisted that her child let her know where they were at all hours.

Yet if most people have had boundary invasions, why don't more people have eating disorders? If there is a deafening cavalcade of hooves, why do we only see a few horses?

Having worked with an old-school psychotherapist for several years, a PhD psychologist who was quite probably the most well-known ED therapist in my area at the time, I know a bit about straining to hear hooves just because you see a horse. I must have sifted through every childhood memory, trying to figure out what might have caused my eating disorder. Mostly, we focused on my mom. The two of us were too enmeshed. I was afraid of growing up. She was afraid of letting go. I was symbolically rejecting her by literally rejecting food.

Maybe this was partially true- I don't know. But it ignored several pertinent facts: when your kid is sick with a deadly illness, of course you're afraid of letting go. I wasn't afraid of doing my own thing until I got sick. I had no explanation for why I couldn't eat, I just didn't want to, and that had nothing to do with my mother.

We had the horse, obviously, and we kept thinking we were hearing hooves. We wasted years listening for hooves, while that damn horse stayed in the stable and I had to shovel out the shit. It wasn't until I started seeing my current therapist almost three years ago that I began to try and move the horse out of the stable. That even if there were hooves, I was still stuck mucking out the stable, which was the real problem. NOT the hooves.

An eating disorder diagnosis says nothing about the quality (or lack thereof) of parenting. Nothing. Period. Full stop.

My other real problem with this type of antiquated, outdated thinking is that it is not based on the latest scientific understanding of eating disorders. The article didn't mention the strong genetic basis for all eating disorders. It didn't mention any of the brain imaging studies or rat models of excessive exercise. It didn't mention serotonin or dopamine or leptin or ghrelin.

The truth is, we don't know exactly what causes eating disorders, but we do know that bad parenting, skinny models, and "boundary invasions" isn't it. And it's time we moved on from these ideas onto something that actually helps sufferers and their families.


sad mom said...

I went to a NEDA/STAR meeting last night which had interesting presentations by a therapist and a state health care advocate as well as exhortations to lobby for legislation and education. It was a good meeting but still missing something. People are still afraid to say the words "eating disorder" out loud. Some of the same "reasons" for developing an eating disorder were trotted out, speaking of hooves, but no mention or discussion of medical research was offered beyond a reference to the Keys study. Clearly there's a lot of work to be done.

The good news is there was a group of 30 parents and therapists eager to push for better education of health care providers and legislation of insurance coverage.

Pixll said...

Very, very intersting and though provoking idea. Admittedly I got a little lost in all the hooves and horses and horse poo at the end (my fault, not yours!).
I know there are a lot of studies etc about brain chemisty, hereditariness (?), genetics. And I know I too hate the way that people blame all sorts of different things - attempting to pin point a 'cause' for eating disorders.
But do you think for SOME people those things might have a large role to play? I know bad parenting gets a terrible rap for causing eating disorders...but do you think SOMETIMES it could be a large part of issue in SOME cases?

I'm not trying to be an ass :) I legitimately want to know. Because I still do feel like in my case...well, I do don't blame my parents per se, but my upbringing that was in their control, was child-locked-in-the-basement-esque.

That said though - I understand your point. Maybe another child, living the very same life as I, wouldn't develop an ED.....

Anonymous said...

It's hard to know what to say about all that, like the other commenter said.

Perhaps it is something more like I've heard explained to a non-scientist like me - that anorexia is like a "perfect storm" and all the conditions have to be right. And sometimes - often, in fact - childhood abuse is one of those conditions.

I worry a bit about the emphasis on family therapy. Even if my family had agreed to such a thing, it only would have destroyed me even quicker.

Both my half-sister and I have an eating disorder, and both of us were abused in the family we grew up in. My mother emphasized thinness as the most important thing we were ever to strive for and shamed us publicly if we were "too fat", when we were at normal, healthy weights. So maybe we do both have some similar brain chemistry problem - but I can't help thinking these other things didn't influence it.

On the other hand I don't think every anorexia person has abusive parents. So I just don't know.

Carrie Arnold said...

Laura Collins' latest post (Parents do cause oranges!) I think says everything I wanted to but much more articulately!

Tiptoe said...

This is completely off topic, but whenever I think of the this saying about horses not zebras, I am always reminded of Dr. Jerome Groopman's book, How doctors Think.

Too often times, we are thinking too much about the horse, and it's only those who are willing to think out of the box that will think of the zebra.

Carrie Arnold said...


I really liked that book as well. And there was a NY Times article I read/blogged about a few months ago that looked at why doctors ignore evidence-based medicine.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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