Genetics & Perfectionism: Professor Tracey Wade Talks Research on Bulimia Recovery

I recently had the honor of talking with Distinguished Professor Tracey Wade of Flinders University in South Australia. Professor Wade is the Director of the Flinders Institute for Mental Health and Wellbeing as well as the Director of the Flinders University Services for Eating Disorders and the Blackbird Initiative for eating disorder research. In her 30 years as a clinician, she has co-written 3 books and has over 200 publications in peer-reviewed journals. She is a Fellow of the Academy of the Social Sciences in Australia and an Inaugural Honorary Fellow of the Australian Association for Cognitive and Behaviour Therapy. She is currently the Associate Editor for the International Journal of Eating Disorders. Professor Wade is the recipient of many significant honors and awards for her outstanding contributions to the fields of eating disorders, cognitive behavioral therapy, and children’s wellbeing. In this conversation, Professor Wade talked with me about the roles of perfectionism and genetics in bulimia, and how practicing body neutrality can help those struggling with bulimia to show compassion for their bodies.

Let’s start with the work you and your colleagues are doing with Blackbird Initiative. The name of the program is so beautiful. Will you please explain where the name for the program came from and what it means to you and those who benefit from all your efforts?

I've always been captured by the Beatles song that was written by Paul McCartney called Blackbird. I felt that it really described a lot of the people that I had seen with eating disorders who felt very trapped in the eating disorder. And this line in the song says, "take these broken wings and learn to fly." And so that challenge about really just having to jump and give recovery a chance even though it feels really frightening. And, it also links in with Emily Dickenson's poem, which talks about how hope is a thing with feathers. And so it's understanding the difficulties and the anxiety and the fear, but also recognizing the hope and the possibility for recovery.

In regards to the actual research, will you please start with what you see as the most critical risk factors for bulimia?

With Bulimia Nervosa, we know that as with all psychological disorders, there is genetic risk. But I guess what's of interest is what triggers that genetic risk. Just because you might have that genetic risk doesn't mean you will only get an eating disorder or get Bulimia Nervosa. And so for a long time, we've been looking at twin studies which can tell us if the things that triggered the genes are shared environment or non-shared environment. Now shared environment, we typically think of things that are the same when the twins are growing up, which is family type factors quite often. The non-shared or things that they don't share can be interactions with peers, interactions with school, peer teasing, and as it turns out, the results are fairly clear that it's the non-shared environment that seems to be an important trigger.

We went through a stage in eating disorders where we used to blame the family for causing eating disorders. And that just doesn't look like it's true. Of course, there can be some unhelpful families. I'm not saying that it's never a risk factor. But what our research suggests is that it seems to be particularly people feeling the pressure to be thin and to present with a certain body type and they're responding to external pressures, whether it's from the media, peers, or other influences. We also know there are quite often people as children who are a little bit more anxious. And, there's also a sense that this is a group that often feel a bit more ineffective. They are often quite capable people, but they don't perceive themselves as being capable. And the other thing that seems to drive that--we know that if there's increased levels of perfectionism, then that can drive feeling more ineffective because you're putting such pressure on yourself to achieve, that pressure makes us all feel that we're not quite good enough to achieve our goals. And we know that leads to greater concern about weight. Weight, shape, and control of the eating become the focus. It's a nice concrete focus to try and deal with all those issues that I've just talked about, the perfectionism and the ineffectiveness, the anxiety, it becomes a very concrete way of saying "I could be an okay person if I can at least control this part of my life." So it's a complex sort of interaction. 

The other thing that we know is that peer teasing about appearance and weight is a very strong trigger, for those particularly who are genetically vulnerable. So there are quite a few different elements and no one person may have all of those elements in their life, but they all sort of interact together to increase risk.

I am particularly interested in your work with perfectionism and how it relates to bulimia. Will you talk a bit about the clinical definition, whether the trait is genetic or learned, and how perfectionism can lead to bulimia?

The definition is when people are striving for demanding and self-imposed goals and standards, but in a perfectionistic way. By that, I mean quite all or nothing and often unrealistic. For example, "I have to get high distinctions in all my subjects this semester." And so it becomes quite an all-or-nothing. There are a lot of musts and shoulds. Also, we know that self-worth becomes contingent on achieving those goals. So "if I don't get those high distinctions, then it means that I as a person am less worthwhile and that I'm somehow defective." And a lot of perfectionists feel quite defective, they feel that they're frauds. And so they work harder and harder to try and achieve. And the other thing that goes alongside that is often this is a group of people who pay more attention to failure rather than to achievement. When they do achieve, they brush it off and say, "Oh, well, that must have been too easy or anyone could do it." But when they fail, they look at that and they say, "I am deficient. I have to do better." And so it becomes quite a vicious cycle. We know there is a little bit of genetic contribution, but it seems mainly environmental. What our young people who have suffered from perfectionism tell us is that they have these high standards, but it immediately creates anxiety. All these high standards, can I meet them? That leads to depression because of the feeling that they're getting overwhelmed and they're not quite able to meet their expectations, and then that leads to self-criticism and feeling ineffective--that they're not as good as they want to be. And of course, then they think the way to feel better is to work harder and harder and harder. So, it becomes a very self-perpetuating cycle in the end. And, how it leads to Bulimia Nervosa I think is through that cycle. Perfectionism does spark off the anxiety, the oppression, the self-criticism, and the ineffectiveness. One of the ways people strive harder is by striving hard with control of their weight, shape, and eating. That becomes one of the domains in life and there can be many domains. But that's one of the domains in life that they think, "If I can achieve here, then I will feel better about myself and about life." So it becomes a way of achieving and trying to feel better about oneself.

What are the best ways to treat perfectionism during recovery from bulimia?

We have an intervention that we have trialed and evaluated many times. And the nice thing about it is even without talking about eating, when you actually intervene with perfectionism, disordered eating decreases significantly. So it can be quite powerful. I think the first really important thing in treating it is to distinguish between striving for excellence versus striving for perfectionism. The two things are actually quite different. 

Striving for excellence is something that probably a lot of us experience, and it's not harmful. The evidence says it doesn't harm us whereas striving for perfectionism is associated with depression, anxiety, and disordered eating. And I think it's because, again, this striving for perfectionism is associated with this all-or-nothing. It's either good or it's bad. Whereas people striving for excellence see it more as a journey, that it's a step at a time over a long period of time to get a bit better, to keep working hard and to keep trying. But people with perfectionistic standards, if it doesn't attain their standards, it's immediately unacceptable. They feel bad, and they can get into a bit of a spin, so they lose their way and they self-criticize. And so one of the things we know is that self-criticism actually decreases people's likelihood of achieving valued goals. So the other thing we talk about when we treat perfectionism is using self-compassion rather than self-criticism and seeing how that impacts their productivity, and whether that's a way of getting more out of life. 

And the other really important part of the treatment is identifying the unhelpful beliefs that people have about perfectionism. So a very common belief is that "the harder I work, the better it will be." But actually, if anyone's done first-year psychology, they know about the Yerkes-Dodson curve. That's very clear, it says that at some point, the harder you work, the better your output, but then it actually starts to decline. And it's because we get burnt out. We get tired. We need a break. It's not true that just hard work produces a better outcome. We need breaks and self-care to get those better outcomes. So we look at those sorts of beliefs and then we ask people to experiment and to try different ways and see if it's more helpful, not just in terms of eating, but also with productivity, with the feeling that they're achieving something worthwhile.

Do you believe that people who struggle with perfectionism can ever utilize this trait to their advantage during bulimia recovery? And if so, how?

I think we have to stay clear of perfectionism. But I think perfectionists on the whole know how to work hard. And so I think that's what can be utilized for recovery. But, people have to be careful in that working hard not to criticize themselves when things don't always work out. And we know recovery is not a straight line. We know that it goes up and down. And so this is really important that people can practice self-compassion upon that recovery journey whilst working hard and aiming high, we should aim for recovery. 

We shouldn't aim lower than that, but, it's really that we just have to be careful to actually use that self-compassion as part of that journey and understand that there will be ups and downs. There has to be that combination of working hard, being ambitious with our aims, but really in that context of self-compassion and in giving ourselves time and space to do that recovery.

How can parents recognize or even prevent perfectionism in their child?

I think perfectionism does appear early. You can see it even under five. And these are the kids often that have to have their belongings organized just so in their bedroom and they're rule-followers. So they really like rules and order. And they get upset if rules get broken. So I think those are sort of examples of what you'd be looking for. And also, you start to see the self-criticism, the feeling that "I'm never doing it well enough. I'm never good enough" and sometimes not wanting to do things because they're afraid of not achieving, even if it's quite small things--it starts to worry them, they start to get anxious, and they worry about what people think about them. So I think those are the things to look out for. And we have a study at the moment where we're asking parents to work with their children who are under twelve who are showing some perfectionistic traits, and we're asking them to apply our cognitive behavior therapy with their child. So we've got six modules that we help them work through, but we ask them to do it in a playful manner. Again, this idea of trying different ways of doing things and seeing if that works better for the child and helping the child unpack those lessons. So rather than criticizing, if they're nicer to themselves, do they actually get more done? Do they feel more productive? Do they feel happier? So we're hoping that our trial shows that that's helpful, and then of course we'll make those materials available for parents to use with their children.

I brought up genetics as it pertained to perfectionism but what is your current thought about the role that genetics plays in bulimia, if any? And if genetics does play a role in bulimia, then how do we address or account for that in reaching full recovery?

Genetics, on average, we say that it's it accounts for fifty percent. But again, it's a vulnerability. It's not a predestined destination. The environment is very important for moderating genetics. And the things that we're working on now are called epigenetics, which basically what we've discovered in the last twenty years or so is that the environment doesn't alter our genetic makeup, but it does alter the expression of genes. So it can turn genes on or off. So if you think about that, it can actually stop an unhelpful genetic expression from being expressed. And so the other way we think about this is with orchids and daisies, if you think about a daisy, it can grow anywhere. It doesn't need much water, it thrives. The environment doesn't much matter with orchids, they are obviously very beautiful but they need a bit more care. The environment needs to be a bit more sustaining and protective for them to be able to thrive. So we think that's what needs to happen in recovery from Bulimia Nervosa. People have to think about these protective environments because they may have more genetic push to an eating disorder, they need to think about the environment to protect that. And that's not being weak. That's just being realistic that they need to really be thoughtful. And that might be about how they use social media, for example, that can be a a real environmental switch for body dissatisfaction. It can be making sure that you are not spending time with people that you find unhelpful or triggering. And, it can mean that you have to take a bit more time out from work or pressure to self-care and manage emotions. So the genetics are certainly important, but they're not some sort of predestined destination, we can be very thoughtful about rearranging our environment so we can get the most out of our lives and also really blossom to be the people that we have the potential to be.

Recovery from bulimia is almost always accompanied by changes in the body. Even when the change relates to positive health and even if weight changes are temporary, it is very difficult for the patient. For some people practicing “body positivity” can help but I actually prefer “body neutrality” particularly during early recovery. Will you please explain how you help those in recovery from bulimia by utilizing a body-neutral practice and specifically how we can retrain our brains to be kinder to our bodies?

 I think body positivity is really difficult for just about everybody. Regardless of whether you've had an eating disorder or not, I think it's actually unrealistic to expect any of us to be positive about our body even some of the time. There's always bits that we won't like or won't appreciate. And so it becomes another pressure, it becomes something else to fail at. And as you say, your body does change when you're recovering from the eating disorder. And that is very confronting for people. That's something that can't be ignored. So we've been very keen to look at body neutrality because we think that's a more helpful way forward. And for the way that we've defined it, basically what we did is just look at all the websites--there are many out there that talk about body neutrality and looked at how they defined it. And there are three components. The first is that you have to practice more mindfulness about your body. Your feelings will come and go. Sometimes you'll like it. Sometimes you won't. But they don't mean anything. The day you feel positive about your body, you still weigh the same and look the same on the day you feel negative about your body. Nothing objectively has changed. It's just the fact that our emotions come and go and they're often affected by what else is going on around us. So it's it's just this mindful acceptance. "My body is what it is, and feelings come and go, and I'm not going to be pushed around by those feelings."

The second component of body neutrality is about the functionality of the body and appreciating that functionality. So moving from a focus on appearance and what we look like to what our bodies do for us, what they achieve for us, and that we can move around. We can lift things. We can sit down. We can run. We can achieve quite a lot with our bodies and we have to appreciate what our bodies are doing for us. And we often talk to the people in therapy, in our clinic, and for so long they've seen the body as the enemy. And now it's really time to see it as the friend, it's trying to help us out. It's trying to do its best. Even if it's letting us down, even if we have parts of our body that don't work so well, or some sort of chronic disease, it's still trying its best. And it's an ally, it's not an enemy.

The third part of body neutrality is this idea that appearance obviously does affect our self-worth, our self-esteem, but we have to work not to let it be the main factor. There are so many other things that are important about us as people. Our hobbies, our work, our study, our friendships, our personality--we might be good gardeners or be good with pets. There are a whole lot of things that we can celebrate about who we are. And that can impact our self-worth. And it's really nurturing those other domains of life, spending time on developing them. Appearance will be there, but it should be one of many things. And, certainly not the main thing and certainly not the only thing. So it's nurturing all those other parts of who we are and giving them space to grow and to be expressed and not allowing that focus on appearance to essentially drive us into that hole where it all becomes about appearance and we stop going out or we stop doing things because of it. And so it's embracing that full identity and that multifaceted identity that we all have.

I read on your website that one of the strengths of the Blackbird Initiative’s program is “leveraging lived experience to create better outcomes.” This is really at the heart of what I do as a recovered eating disorder recovery coach and why we created the Conquering Bulimia recovery course. If there is one thing you would like patients and the people who love them to know about bulimia recovery, what would it be?

 I think to believe that it's always possible, that's what I'd like people to know about recovery. And I guess I'm just reflecting on a story I heard from someone on Friday night who had a very long journey with an eating disorder, five years and she had just about given up and she'd gone for treatment and made a few steps on the way to recovery, but she was feeling that she was giving up on the idea. And then she found someone that she could work with and that she related to, and sometimes that takes time. And that may not be a therapist, it may be a recovery coach, it may be a friend, it could be a variety of people, but I think we have to understand that you can't do recovery on your own. I think that's just too difficult. It's just such a difficult journey. And finding that person or people who can just support you in that journey, and that journey is possible. That's what I would want people to know.

Download Professor Wade's Handout on Body Neutrality here

Author: Merrit Elizabeth

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