The attempt to tamp down the shadowy pro-eating disorder community has been raging nearly as long as the community itself has existed. It’s a well-intentioned effort. But every new opportunity for social media is also a new opportunity for like-minded spirits to converge in anonymity. You don’t have to look far online to see the vibrantly sad and scary pro-ana (as in anorexia), pro-mia (as in bulimia) worlds alive and well and starving themselves to death.

So despite the ostensible crackdown, you can still find plenty of #thinspo on Pinterest, with photos of whippet-skinny women and encouragement not to stop “until you’re proud” and “see a 0 on your clothing tag.” Likewise, you can find plenty of #thinspo reminders on Tumblr that “Empty stomach, you’ll learn to love it …” And a quick search for “thinspo” on Instagram turns up well over 46,000 tagged photos, with haunting streams from “just another anamia insta” (that’s anorexia/bulimia Instagrammer) and another user who declares she “needs to be skinnier.” There are gaunt images of jutting collar and hipbones, as well as devastating tableaux like a photo of a Coke and candy with the caption “I’m such a mistake and I’m not strong. I hate me,” or a user’s screenshot from a calorie-counting diary app that declares, “If every day were like today, you’d weight 76.8 lbs in 5 weeks.”

The more things change, the more they stay the same. Sites like Instagram, Tumblr and Pinterest are now grappling with the same issues that Facebook and Twitter and, back in the day, regular old blogs have for years. And unfortunately, they’re finding the challenge just as awkward and often ineffectual as their predecessors.

The hope that sites have a moral obligation to their users to create an environment that is safe and healthy and nontoxic doesn’t always jibe with the practical reality of making it happen — not when the demand for “thinspiration” is so persistent, and the cultural obsession with weight so pervasive. We see it in the way that a single tweet from Miley Cyrus about not eating a Carl’s Jr.  and Lady Gaga hashtagging #PopSingersDontEat turn into major news stories and rumors of anorexia.

It’s the right of any site to determine its content – or at least try to. But as Denise Restauri in Forbes points out, all that happens when you merely sets up roadblocks is that a community gets clever about finding work-arounds and starts “house hunting” for new places of refuge. To really effect change, what communities need are dedicated and sensitive leaders who can work with members – talk to them and point them to healthy resources. And they need to create tools that cannot just flag content but respond to it. Note, for example, what happens when you Google “suicide.” Your first result is for the National Suicide Prevention Lifeline, and the query “Need help?” Organizations like the National Eating Disorders Association need not only to be present on sites like Pinterest and Instagram, they need to show up right away when users are creating #proana or #thinspiration content.

The tragic truth is that a person who posts her self-loathing over drinking a Coke is not going to be helped by simply being blocked or forced to choose a more vague hashtag. Halfhearted attempts to cut her off from a community that cheers self-destruction aren’t enough. She needs more than rules to make her stop posting. She needs guidance out of the darkness. She needs real people who can help her stop hurting herself.

Brief background on me: academic in the arts, advanced degrees, professor at a great school, musician and writer.

Married to a wonderful man, kids who are blessings. Husband is someone I truly like and whom I respect enormously. He has been unequivocally good to me. The one problem, and it has Always been there: the sex life. For me, it is bad, almost nonexistent. I have no desire for him, and at times it is a kind of revulsion. I do have desire, but not for him.

This is heartbreaking, and I have fought it for decades. It has wreaked all sorts of problems for me, from eating disorders to over-exercise injuries, to medications for depression, etc.

Complicating the issue is that I developed feelings for a work colleague/friend.

I have, of course, done the unthinkable. I fell in love with a work colleague, a married man (albeit one who had shared the unhappiness of his marriage with me), and someone who was probably my closest friend and confidant. It is necessary for me to keep this all a secret (though I have been seeing a therapist for over a year, to whom I can talk, but it has only been moderately helpful, as she is quite nice and supportive but not overly insightful; and also an acupuncturist who has been very helpful more broadly as well).

I cannot avoid this friend/colleague. I think I’m doing better, and then we have contact, and my feelings are all reopened, whether of love and desire or of absolute anger at how he has treated me. He has truly been a wonderful friend in all areas but this. I cannot begin to tell you how many hours this has sucked out of my life, and how much energy.

Last week I punched both of my forearms furiously, leaving horrible bruises, because I had nowhere to direct the pain (and I am working desperately to avoid bulimia, which was one of my main coping techniques in the past). If I were brave enough, I would have cut myself. It is horrible enough that I damaged my arms — me, as a musician. I must wear long sleeves this week to conceal the horrendous bruises from my children and my students — this, in a week in which summer has sprung on us prematurely.

I have reduced my calorie intake as much as I can while still managing life, and have no doubt mucked seriously with my metabolism.

It’s as if when I’m not eating, I feel the pain less, but I know I cannot sustain this indefinitely, and I’m terrified of having to rejoin life. I think if I started eating more, and feeling the pain, I could not go on, yet I know I must, for my kids.

I don’t know what to do. My background and life story suggest a kind of intelligence and hard work ethic, but it has not been helping me here. I think the analogy of an addiction is not a bad one, but it is like a food addiction in that I cannot leave this job, and cannot avoid him at it. And I hate negativity; it eats at me like an acid. I do not want to avoid him through anger and pain; I want, and need, to move on, but I keep being heartbroken — longing for him, enjoying our friendship so much, and then being consumed with anger, frustration and grief — all in no particular order. It does sometimes seem to be getting better, and then it will be worse again, like a virus that never quite goes away.

Meanwhile, my husband is still around — this wonderful man — for whom I have zero feelings physically or even negative ones. Indeed, perhaps I should not have married him, but I was so terribly inexperienced, and he was so good in other ways, that I thought — well, maybe I’ll get over it, or I’ll learn, or the feelings will develop, or it won’t really matter — life’s not a fairy tale, and you’re lucky to have found him. And indeed, I was, and have been, and yet… I have not learned, the feelings have not developed, and now — it does matter.

Please help me. I seek your insights, strategies, anything. I have been struggling for decades with the marital issue, and probably more than six years (I almost don’t want to count) with these other feelings of longing, which have consumed much more energy than even the marital stuff. I must find a way to break free — for my own sanity and even to offer the hope for myself of moving on — whether to find someone else, to make peace with what I have, or to make peace with myself on my own.

Desperate

Dear Desperate,

Yes, I agree, you need to break free.

But how?

Right now, you are trapped in a punishing cycle that you cannot reason your way out of or adjust your way out of.

I think you need to physically remove yourself. The best practical hope is to get into a residential treatment center. Residential treatment would give you an opportunity to step back for a few weeks. I really think that could help.

Insurance may very well pay for it.

It won’t be as hard as it sounds. While you are in pain, and enmeshed in these unsatisfying relationships, you continue to function at a high level. You continue to have a strong will. You can put that strong will to good use now. Your psyche needs that strength.

To find and arrange to enter a treatment center, you can marshal your practical skills to come to the aid of your wounded psyche. What is beautiful about human beings in crisis, beset with the worst of troubles, is that when we seek solutions, we discover our complementary skills; it’s as though in being forced to come to our own aid, we are forced to become whole.

I know what it is like to try to solve such wrenching problems on your own, in secret. It can hardly be done. But imagine finding hope in a community of people to whom your predicament is a known illness with known cures. What you are going through is no mystery. It has a cause and it has a cure.

Imagine the relief of having a real program of change. Imagine feeling it work. Imagine getting better!

Suggestion: Read this article from PsychCentral. It is an excellent overview: thorough but not technical. It says that cognitive behavioral therapy is considered the treatment of choice for people with bulimia. Using CBT, you can learn to recognize and combat the harmful thoughts that are causing your upset.

Here is a list of residential centers you might contact or visit.

And here is a list of online support for people with eating disorders.

What else do you need? You need deep compassion for your wounded self. To find compassion for your wounded self you need to tell someone all of this: the starving yourself, the eating, the hitting yourself, the thoughts of cutting. In order to tell all of this, you need to find somebody you can trust.

You can find that person. You can do this. You are going to get better. Just start taking the steps, one at a time.

I’m being intentionally dense here. Obviously the idea was to touch on the role of appearance dissatisfaction in eating disorders, using something plenty of people wear — makeup — as an entry point for talking about the larger issue. (Certainly it’s more on target than cryptically posting the color of your bra on Facebook for breast cancer awareness.) And for something like a week designed to raise awareness about eating disorders, you need a campaign that’s simple, accessible and attention-grabbing. But not only does the no-makeup rally willfully ignore the myriad reasons women wear makeup in favor of a one-dimensional shame-based explanation, it treats bodily dissatisfaction as the cause, not a symptom, of eating disorders. And if we keep the focus of eating disorder conversations on women’s bodies, we’re doing exactly what women with eating disorders do to themselves.

We should be wary of conflating body image and eating disorders, because they’re not nearly as connected as they’re made out to be. It’s not like she who has the worst body image develops the worst eating disorder, or that people whose body image is average are immune from eating disorders. (I have yet to meet a woman with an active eating disorder who has a good body image, but then again, I don’t know tons of women with a good body image to begin with.) I’m baffled that Renfrew chose the makeup hook for its NEDA campaign, unless the idea really was just to raise awareness of the existence of eating disorders. (“Anorexic” has been a coverline of enough celebrity magazines that I don’t think we need any more awareness of that elementary sort.) Yes, makeup is deeply tied to our ideas of self-presentation. It’s also a method of controlling the way you’re seen, and eating disorders are rooted in control. But none of that shows up in the Renfrew campaign; instead, it’s all about appearance dissatisfaction, as though that alone can set off a disease that ravages one’s life.

Eating disorders are complex beasts, with not-great recovery prospects and the highest mortality rate of any mental illness. We don’t entirely know what causes eating disorders, but last year when I interviewed Sunny Sea Gold, author of “Food, the Good Girl’s Drug“ and a recovered binge eater herself, she broke it down nicely:

Therapists pretty much agree that there are three main causes of eating disorders, and most of us who get them have a combination of the three. One is your genetics. Second is your physiology, like the biology of your actual brain — your personality…. The third thing is environment. Environment is broken into two parts: the environment of your home, what your mom and dad said to you, the behaviors they modeled. The other part of environment is culture. So about one-sixth of eating disorders can be blamed on cultural environment, like the pictures we’re shown… If we magically were able to suddenly change the images we see in order to be diverse in all ways, gradually that part of the pressure would relieve itself. But it wouldn’t relieve that need of a girl to control her food intake because she can’t control her life.

It’s that last part that continues to get short shrift in the popular media. I get why the press might latch onto the thin imperative as the root cause of eating disorders: Media outlets love nothing more than to generically critique themselves (what women’s magazine hasn’t covered the problem of unrealistic body ideals formed by… the media?). Less cynically, poor body image is something most of us have experienced at some point; using this as a hook for readers to empathize with eating disorder patients works beautifully. Plenty of people have dieted to lose weight for aesthetic reasons, and the disordered thought loop that makes a satisfying eating disorder story — I was obsessed with food! — is mimicked in the dieting mind-set. So the average reader may think she’s identifying with the subject, not realizing that what she’s identifying with are the symptoms of an eating disorder: the restriction of food, or the overconsumption of it, the vigilant attention paid. But the eating disorder doesn’t lie within its symptoms. It lies within its causes.

Listen, I’m not saying that there’s no connection between appearance and eating disorders. Of course there is. And body image is an essential topic to so many women’s lives — including women who have never exhibited a single eating disorder symptom in their life. Do I even need to point out the ways in which having poor body image is a drain of our reserves? Of enormous intellectual and psychic energy? Of time, of money, of already precious resources? Of emotion? Do I need to ask how many times women have asked “Do I look fat in this?” because we lack the words to ask for support and tenderness? As long as we have poor body image, we walk through this world ashamed. So, yes, we need body image work, and we’ve needed it for a long time. And a week devoted to eating disorder education is a good time to reinvigorate that conversation.

But eating disorders do not run parallel alongside a track of bodily dissatisfaction, and the more we conflate the two, the less we’re tackling the true complexity of eating disorders, and the less we’re looking at the threads that unite patients more deeply than hating their thighs. We’re not looking at perfectionism, or the twin sisters of compliance and rebellion, and how all of these play out in the lifetime of an eating disorder. We’re not looking at biology, or heredity, or giving proper diligence to plain old depression and anxiety. Hell, we’re not looking at stress. We’re not looking at choice, autonomy or modernity. We’re not looking at the role of trauma, or sex, or comorbidity with addiction. And it is impossible to treat eating disorders without treating all of these as seriously — no, more seriously than — body image.

It’s one thing for the media to treat body image with greater weight than, say, family dynamics in eating disorders. It’s quite another for a treatment clinic to do the same. The Renfrew Center certainly doesn’t take this approach in treating its patients. When I was treated at Renfrew for my own eating disorder a few years ago, I was repeatedly struck by how little body image came up as a topic, both from the counselors and my fellow patients. That’s not to say it wasn’t important; it was more that we’d all thought about our bodies so much by the time we landed in treatment that we were chomping at the bit to give voice to the things that we truly needed to be able to talk about. I could deconstruct body standards before treatment as fluently as I can now. But before entering Renfrew I had no words to tell you about the factors that took me 25 years deep into an eating disorder before I committed to getting help.

The link between appearance and eating disorders isn’t that one causes the other; it’s that they’re both partly rooted in expectations of properly gendered behavior. (It’s worth noting here that while plenty of straight men develop eating disorders, gay men are at higher risk.) To untangle the social angle of eating disorders, we need to look beyond the mere existence of the thin imperative and look at what it says about the role of women: that we are to be perfect, controlled, managed and compliant — themes that come up repeatedly with eating disorder patients, themes that get to the crux of the matter more directly, without taking the meandering detour through our bodies.

Makeup, too, can say a lot about those issues. It’s not the worst motif Renfrew could have chosen for its campaign. Nor is it the best. I’m no P.R. expert; I have no idea how the clinic could have better channeled its extraordinary work into a simple campaign for the public to engage with. I just know that by the time I was discharged from Renfrew, I’d finally begun to learn that my dissatisfaction with my body wasn’t causing my eating disorder; it was merely a symptom of my disease, like restricting my food intake or binge eating. I’d begun to take the focus off my body and put it into understanding the roots of my perfectionism, my people-pleasing, my family history, my silent shrieks of rebellion.

I’d begun to understand that loving my body wasn’t the point. The point wasn’t even to like it. The point was to learn how to eat.

My disorder is not that bad in the scale of things. I eat too little and am moderately underweight (BMI around 17.5-18). Over the past few years, I have been losing weight. I was never fat, but it has improved my health and appearance and was not a problem initially. The problem is that I am continually resetting the goalposts of what is an acceptable weight for me. For a while (about a year and a half) I was quite comfortable with my new, much slimmer frame. I watched what I ate and so on, but I didn’t feel constantly hungry or anything — I felt quite healthy and satisfied and had treats when I felt like it. But over the past few months, I’ve become obsessed with achieving a new, even lighter weight. And the disturbing thing is that there isn’t even a solid figure in my mind — I just want to lose, lose, lose and never stop losing, the idea of putting on or even maintaining weight appalls me. So I count calories, I exercise compulsively, I obsess and obsess and spend hours every day thinking about food and then I get really hungry and I binge and binge and eat mountains of food that is bad for me, food that doesn’t belong to me, food that will make me uncomfortable and sick. (I’ve tried throwing up, but I’m not any good at it.) And then after the binge my hunger is satiated and I go back to starving for a couple of days and then the cycle repeats itself, except that the binges have been getting more frequent lately, and it’s hurting me and making me sad.

The obvious answer to all this is to just GET THE HELL OVER IT. So what if I have an extremely slim body versus a fairly slim body? I’m naturally not a big eater. Until recently I was physically comfortable with my slightly heavier weight, which didn’t leave me feeling hungry or deprived, and which most onlookers probably couldn’t even distinguish from my current size. Why am I being so shallow on this one issue? I don’t care that much about clothes, I am virtually indifferent to the opinions of others regarding my appearance (outside of thinness), and yet I am wasting my time, my health and my potential on this obsession. There are so many ways I could use my time and my mental energy, and I choose to pour them down a drain of self-worship and destructiveness. I judge other people for being fat. I judge other people for being a shape which is not as thin as mine, and I know that is a shitty thing to do, and makes me a very small person — and not in the physical way. I tell other people off for being prejudiced against fat people, for exhibiting fat phobia and discriminating, and yet I am doing the same thing with my body, my life.

My mother, when I was growing up, was very fixated on weight issues (she always used to comment on the size of other women’s tummies!) and that influenced me toward becoming very conscious of my size. But I have rejected my mother’s influence in so many other ways, so I can’t just blame her for brainwashing me. Similarly, the media shoves the thin-equals-good message all the time, but then the media is full of stupid propagandistic bullshit every day and I don’t fall for all the rest of it, so why this??? WHY THIS???

The scary thing is, I sound like I’m sorry but I’m not. If I could just go on getting thinner without getting hungry and going bingeing, I would, regardless of the probable effects on my health. I am still pretty healthy — only at the tip of the underweight range, and physically very toned and capable of doing all the things I want to do — but it’s a shitty way to live.

The act of writing this down has been therapeutic. I’d be so interested to hear your thoughts on why I seem to be too stupid to fix a problem that has an obvious, easy solution.

Thanks,

Person Being Stupid in Stupid, Predictable Ways

Dear Person Being Stupid in Stupid, Predictable Ways,

You have to get help.

You can’t think your way out of this. It’s not going to make sense to you no matter how much you think about it. All the time you spend thinking about it, it’s just going to go right on killing you until your bones are brittle and your electrolytes are so messed up there’s no turning back.

So stop trying to figure it out and get help before it kills you.

It took a lot of courage to write this letter and it will take a lot of courage to go to someone and say, I think I have an eating disorder and I think it’s killing me and I’ll do whatever it takes to get better if you will only take me on.

But that is what you need to do. Find somebody with professional expertise and start the hard, lifesaving work of saying out loud exactly what you are doing and listening to somebody else and following a program of recovery.

From what I’ve heard, this is a hard one. So there’s no time to waste. You can flirt with it and play with it but it’s not flirting. It’s not playing. It’s killing you. It will keep on dragging you to the edge of starvation and collapse until you place yourself in the hands of someone who knows how to treat this.

Why would this happen? Because there’s something wrong with your brain. Sure, your brain is smart. My brain is smart too. But my brain also thinks it would be a good idea to go buy a six-pack and sit on the railroad tracks and drink the six-pack and then call in sick and lie down among the ballast stones.

Your brain can’t be trusted to tell you to eat right. That’s the problem you have. So put yourself in the hands of someone who knows how to treat eating disorders. Do what this person tells you to do. If you do that you will be OK.

You may not know where to go. Where to go depends on where you are. We don’t get into such specifics here. That’s to preserve your confidentiality. But you might call the National Eating Disorders Association hotline at 800-931-2237 and talk to them. Also, people writing in the comments may suggest places for help. Read those comments. Get in touch with those people. Accept help.

Don’t let this take you down.

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I am an aggressively joyful person. My work is about sharing my love of food, about the magic that can happen between people at table and the magic that can happen in your head when a bite of something amazing transports you. I write about it, I teach cooking, I stick candy in random people’s faces. For me, few things are more joyful, are more powerful than the pleasure of food. And because food is good, because my field is so rife with how food reminds of home, of warmth and love, it’s an occupational hazard to have it all feel a bit romantic after a while. You know: Soup comes with mittens and a hug from Mom. Cake comes with puppies and flowers. I try my hardest to stay out of LaLa Land, but it’s unnerving to be reminded that sometimes, food is not happy but fraught with difficulty and pain. Whether or not “food addiction” truly exists, the act of eating is  troubled — and troubling — for many: those with eating disorders, or the very many who struggle with weight or health.

Reading about the addictive food study brought to mind a striking 2006 story by N.R. Kleinfield in the New York Times on diabetes in low-income communities. In it, the reporter asked a woman suffering from diabetes why she didn’t take better care of her condition.

She pointed out that many people in her world were stressed out and depressed. There are other serious health issues, like asthma and H.I.V., the signposts of many poor neighborhoods. Their cobbled-together lives drain residents of their resolve. And so they cede diabetes the upper hand and eat what tastes good to them to counteract the gravity of unhappiness.

“Listen, if I want to eat a piece of cake, I’m going to eat it,” she said. “No doctor can tell me what to eat. I’m going to eat it, because I’m hungry. We got too much to worry about. We got to worry about tomorrow. We got to worry about the rent. We got to worry about our jobs. I’m not going to worry about a piece of cake.”

The simple, private pleasure of sugar and fat in this case is no longer simple (and, given that the diabetes epidemic severely stresses our healthcare infrastructure, that pleasure is no longer private either). Over and over again in the story, the reporter came upon people too tired or too stressed to deal appropriately with their diabetes, and instead, as this woman does, make the conscious choice to compromise their health for this small moment of satisfaction.

“Chocolate cake may be a risk, but tastes good on a bleak day,” Kleinfield writes, breaking my heart with the knowledge that the dark context of suffering is what lets the soft light of a sweet treat shine so seductively. I think a healthy relationship with food recognizes its joys, but also recognizes its appropriate place. It should bring pleasure, maybe even escape from a bad day, but not escapism from a rough world.

I used to teach at a literature camp where I also volunteered to help run the kitchen, teaching students to cook. I did everything there with a sense of wildness, and, buoyed by students excited to learn everything about the world, I tried to make the kitchen a central part of the experience, bringing food into our discussions of Dickinson, teaching the lessons a writer can learn from frying a pan of eggs.

And then one year we learned that one of the students was bulimic. I was distraught. I dated a woman with terrible eating disorders once. We went to culinary school together, which I thought was awfully ironic until I realized that part of how the illness abused her was by causing her to surround herself with food at all times. And so I wondered, painfully, if the food-focused environment I was creating made things harder on our student. Here I was, leading the band, banging out rhythms on trays of pork loins, while she followed up, wild-eyed with polenta she was going to hurt herself with.

A friend came to my moral defense. “No, it’s good. You’re modeling what a positive, healthy relationship with food can look like,” she said. I was thankful for that, but it’s hard to shake the weirdness of knowing that what you find joyful is painful for someone you care about.

But, you know, when I think about it I realize that even for me it’s not always simple. I have struggled with my own weight for years. I was chubby as a child, and when I was a romantically lonely teenager, I nervously counted every fat gram as another step away from having a girlfriend. I had no idea how good I really had it, metabolism-wise, back then. Now, not 17 anymore or even 27, I find myself again learning to stand in new postures to hide my small but growing gut. I wince a little in the mirror. It’s OK. It’s not an obsession. But it’s a reminder that even the purest pleasure I know is always complicated.