Originally published by Stephen Guise on his personal website.
I had the pleasure of interviewing Dr. Anita Sanz, who has been a clinical psychologist for over 20 years. Anita blogs at the cleverly-titled Sanz Planz, and has authored the book, “A Year To Change.”
I was eager to see what insights Anita has gained over so many years of helping people help themselves, and I was not disappointed. In this interview, we talk about perfectionism, eating disorders, depression, and the myriad of ways a person can approach change. Note: This was a video interview, but due to a poor software choice on my part, it sounded like we were in a cave. As such, I have transcribed the interview below.
S: Tell us about yourself.
A: I am Anita Sanz, a psychologist, working in a private practice since 1997. I specialize in the treatment of eating disorders and depression; I work with any of the issues people walk in the door with, but those are two issues that I tend to work a lot with. And perfectionism is definitely related to both of those diagnoses. I also teach abnormal psychology and health psychology with my husband at Stetson University here in Florida.
S: Very cool! Well, as some readers may know, I’m writing my next book on “imperfectionism.”
S: Yes, “How To Be An Imperfectionist,” which is based on an article I wrote by the same name. Let’s start out with: What have you seen in regards to perfectionism and people with eating disorders? How do the two interplay?
On Eating Disorders And Perfectionism
A: Probably the most obvious way has to do with comparisons, and I mostly work with women with this disorder, but there are also men who have eating disorders. Women compare themselves to other women and feel like they are not measuring up, whether that’s to the models they see via the media or just other women around them. They will have usually some type of image in their mind of what they should look like, and it tends to be that that’s where you’ll see the perfectionism beginning to sneak in. They measure themselves — their size, their shape — against that ideal, and it tends to be unrealistic.
Trends portrayed in the media are unrealistic for the most part. And then when you throw in a little bit of perfectionism on top of that, those images are unattainable by most people, particularly without doing something harmful in terms of your eating or exercise or something like that. That’s one way I definitely see an interplay. And never feeling good enough, that a number on the scale is good enough, that the size of clothing you get down to is good enough, keeping a certain number of calories from going in, or getting them back up if there’s purging that’s involved. There’s a lot of perfectionism involved in eating disorders.
S: Now, what’s really interesting to me is I’ve seen pictures of people with anorexia and bulimia and a lot of these women have gone so extreme that they’re unattractive because they don’t weigh anything; they’re just emaciated (and it looks unhealthy). So I’ve always been curious about this perfect image they have. I wouldn’t think that they would want to look the way that they do. So is the perfectionism more about calorie counting or do you think that they really want to look like that?
A: I think some do actually want to look like that, but most don’t. I think most actually recognize that’s very unhealthy and that most people would view that as being very sick. Some of the anorexic women I work with are bothered when they begin to look unhealthy like that. But for some, they’ve adopted anorexia as a lifestyle. They’re very goal-driven to get to the lowest waist possible, and they use some of those skeletal images almost as what they call “thinspiration.” That is what they are attempting to achieve. So there’s kind of a grotesque beauty they see in that. But I don’t believe that’s true for most of the people I work with — they don’t have such distorted body image that they believe that’s beautiful. So I think that’s the minority.
S: So do you think at that point, if they don’t see that as beautiful, but they’re still headed down that road, that maybe habits are playing a role there?
A: I’ve always viewed anorexia as a slippery slope disorder. It’s like a lot of addictions, in that you can get to a certain spot on that slope and — even though you can recognize that this is unhealthy or this might kill you eventually — you can’t dig your heels in, to stop the behavior or stop the addiction. And anorexia I believe is one of those types of conditions, where someone can know, “if I don’t stop this now, I’m going to die from this,” and yet still not be able to eat. The goal is always to attempt to try to intervene and to get them to be able to eat enough or to stop exercising so much that they’re in calorie deficit before they get to that point. Because otherwise we have to do truly heroic, life-saving types of measures. There are not many other disorders where that slope seems to be so steep. We have a lot of time we can work with someone before they get to a point where they feel like, “I can’t stop doing this.” With anorexics, their cognitive distortions about their own disorder are such that you can’t really work with them cognitively. All the therapy that I know won’t reach them.
S: So you get to the point where cognitive behavioral therapy just doesn’t cut it?
A: It will not cut it, and part of that has to do with the effects of malnutrition on the brain. Combined with the types of body distortion, it’s hard to get the brain to work correctly when it is only receiving, you know, 400, 300, 200 calories, or less a day. I’m always working with a team of professionals including dietitians, and primary care physicians who are monitoring them to see if they’re getting any benefit from the therapy, and when we need to move to the next intensive level of treatment.
S: Wow. It’s fascinating. Sad, but fascinating.
A: Yeah, it is one of the most challenging disorders to treat because of that experience of knowing that there could come that point where where what I know will not be enough to help that person. It’s my responsibility to know when I’m helping someone, or if they need more than what I can do.
Depression: Chemical Imbalance Or Behavioral Consequence?
S: Let me shift subjects a little bit. Something I’ve always wondered about is the role of chemicals and hormones in depression, and that juxtaposed against our behavior and perspective. So the question I’m asking is kind of a chicken or the egg scenario. Are you familiar with Amy Cuddy’s work?
A: Just tangentially, so feel free to fill me in.
S: She gave a TED Talk on confidence and essentially, she ran an experiment where she had people stand in confident poses, like: outstretched hands, hands on the hips, or other poses where you take up a lot of space. She had them do that for 2 minutes, and before and after they did that, they tested their cortisol and testosterone levels. They found after just 2 minutes of assuming a confident pose, their cortisol levels dropped 15% and their testosterone levels rose an average of 20%! I would call that a “confidence cocktail” because cortisol is the stress hormone and testosterone is your aggression, risk-taking, willingness-to-do-things hormone. So that’s a pretty powerful example of our behavior influencing our actual chemical composition in the brain, at least temporarily. I know depression is commonly treated with medication to change brain chemistry. I’m curious about your thoughts on if drugs are absolutely needed in some cases or if CBT is enough?
A: I was trained to think of human beings in a very holistic way, which means to look at people from every different level. So I would never think of a person or their depression as just the mind, the body, the environment, their relationships, or a spiritual issue — it’s all of those things. There are feedback loops just as you were discussing about body language. Intentionally smiling can actually affect mood. It may even be that exercise — which is a natural anti-depressant — is sending some type of message to the brain in addition to changing the hormones and releasing endorphins.
There are all these interesting little feedback loops; we can convince our brains through our biochemistry that either things are not as bad as they seem or that we’re not as stressed as the environment suggests we ought to be. When I teach people different methods of managing performance anxiety, a lot of it is tricking the brain into thinking you’re not in the situation where you really should be nervous: breathing differently, holding your body differently, sending messages to the brain that would lower adrenaline and cortisol release. It would tell your brain in essence that you’re really not in a situation where all eyes are on you and you need to be anxious.
Understanding that every single thing we do affects our brain chemistry, our brain chemistry affects our behavior, our environment affects our behavior and brain chemistry, how we think about things affects our behavior and brain chemistry… all of those things are affecting each other.
And so we’re very complex, but that’s a good thing. That means there are multiple levels where we can intervene. With someone who is depressed, I’m going to be looking at, for example, what are they doing with their bodies? What type of food is going into their bodies? Because how active you are and the quality of the food that goes in I believe has the ability to chain the brain. Laying around and being vegetative sets up a completely different set of chemicals and hormones in the body. It just lets you know that there are lots of ways we can intervene.
CBT is wonderful. Working with feelings is wonderful. Working with changing the body is wonderful. Working with things that go in as the basic building blocks that affect the amino acids that our brain can work with to create the neurotransmitters that we need… it’s all important. And we can mediate all of that with the thoughts that we think. There are so many ways to change how we feel. There are many forms of treatment out there, and there could be one that’s more effective for you.
S: Wow, that’s very well explained. I like how you covered all of the different facets. I think you got them all too!
A: Well, on my website, I divide everything up between mind, body, heart, soul, and spirit. And soul is my word for the self — self, self confidence, and self esteem. It’s just all the different ways we relate to the world. And we relate as physical beings, as cognitive beings, as social beings, as beings within our own entity (we have our own sense of self in the world), and then we have a way of understanding who we are in the world, and our sense of importance and meaning and value to the world. And all of those levels to me are important. You have to assess them. If you have assessed them well, you can find ways of intervening regardless of what problem a person walks in with.
On The Importance Of Expectations
S: A big focus for me has been expectations. I think they place such a huge role in, well, just the way we look at the world. I was curious: of the depressed clients you have, what do their expectations generally look like?
A: First of all, you’re absolutely right. Expectations are phenomenally important, and probably one of the most important things for me to try to get a handle on when I meet somebody. In people who are very depressed, what I tend to find is that their expectations tend to be unrealistic and/or very rigid.
S: That’s what I would expect.
A: Black and white; all or nothing; having unrealistic expectations of themselves or others or the world. So having constant feelings of failure, and disappointment, or disillusion is something that they’re dealing with, and can lead to depression.
S: That’s really fascinating to me because I dramatically changed my life by dramatically lowering my expectations. I used to want to get into the best shape and do it in one day! And I would put so much pressure on myself to work out. And then long story short, I decided to do one push-up and it turned into a 30-minute workout, the same workout I couldn’t do before that. I did at least one per day for 6 months and over time, it decreased my resistance to exercise, habitualizing the behavior. Since then I’ve gotten into the best shape of my life.
A: That’s exactly the right way to do it, Stephen. And you and I both believe in the power of micro movements. Because I’ve read a little bit about what you’ve done and that’s exactly what I prescribe to people. I call them something else. Other people call them different things, but that’s exactly what I would recommend. You break things down into doable steps so that they can be accomplished. I really subscribe to a lot of principles in the Buddhist philosophy in terms of mental health. And one of those principles crashes through unrealistic expectations. It states that a peaceful way to go through the world is to be open and curious.
S: Love it.
A: And willing to deal with and respond to whatever it is, without the need for it to be different. And that’s much less stressful, because then things don’t have to be different from what they are. We’re not predicting bad, we’re not predicting good. We’re saying we’re human, we really don’t have that capacity to predict anyway, so we’re just going to go with whatever it is that comes our way, to the best of our ability. That is, to me, a very anti-depressant way of going through the world that I try to help people adopt.
On The Power Of Curiosity And Taking Imperfect Action
S: I love that. And I love that you mentioned curiosity. I strongly believe that curiosity is one of the most powerful perspectives to have. I look at people like — I wrote an article about it — Steve Jobs and James Cameron. They’re wildly successful and at the top of their fields, and I think a key reason why is they’re too curious to be afraid.
A: Right, if you’re curious, you will take risks that others might not, but you might find some things that others might not. As hard as it can be, I think this is where perfectionists get in trouble — they won’t take risks. They won’t do anything unless they know they’re going to do it not just well, but perfectly. And so that eliminates that whole idea of being curious, because you can’t go out and try something that you’ve never done before, because you might suck at it.
I don’t think you can grow very much if you aren’t willing to jump off the cliff and hope on the way down that you’re going to learn how to fly, or that you’re going to land on something soft, or that you’re going to learn, “don’t jump off that cliff again.” The best decisions I’ve ever made in my life have been when I said, “I don’t know what I’m doing completely here, but I’m going to try. I’m going to go for it. I will learn as I go.” Trying to have all your ducks in a row before you do everything is not possible. A balance between preparation and risk-taking is a pretty good way of going.
S: Well said. It’s been the same for me. Right now, I can call myself a best-selling author, and it started by not knowing what I was doing and buying a $10 domain to start my blog, and I had just learned about blogging that day. You never know where the path will take you until you take that first step into it. Another thing about perfectionists that I’ve analyzed is they also — and this is myself when I’ve been perfectionistic — look for the perfect scenario to do work. “Oh, I’m not at 100% energy. I feel like doing this instead.” I’ve found it’s really ok to work in imperfect situations because that’s mostly what we’ve got.
A: I would agree with you, and I’ve never seen a perfectionist who wasn’t also a procrastinator. The two go hand in hand. They know that whatever the thing is they have to tackle has to be perfect and so the anxiety gets so great that they just get paralyzed, until the anxiety finally drives them to do whatever it was they were supposed to get done. So again, the micro movement. If you’re a writer, you work steadily. You write every day. Those little micro movements don’t sit well with a perfectionist because it doesn’t seem good enough. How could filing for 5 minutes accomplish anything? But a person who does that every day, is going to have all of their filing done by the end of the year, and the person who lets it pile up is going to be in trouble.
S: I absolutely agree!
A: Much less stress! I’m so happy when anyone is willing to tackle the subject of perfectionism or imperfectionism, because we can all be imperfect and do that well. And I wish people could embrace being imperfect more, and realize it’s a very good thing instead of trying to avoid it like the plague. If I could get people to feel good about that, making mistakes, knowing that’s what we’re here to do, and to learn from, I don’t think I’d have as many people needing to come see me.
S: Well, I’m glad you’re out there tackling this issue and making a difference. I’ve experienced both sides of it personally and I’ve seen it in a lot of my readers.
A: Thanks for all you do too, and congratulations on the success of your book. That’s fantastic!
S: Thanks very much, and thanks for chatting with me!
A: I’m glad we finally made this happen!
S: Yeah, it only took about three years (seriously, it did). It wasn’t perfect, but…
A: it doesn’t need to be!
Anita K. Sanz, Ph.D. is a licensed psychologist currently in private practice in DeLand, Florida, specializing in the treatment of depression, women’s issues, and eating disorders. She teaches Abnormal and Health Psychology at Stetson University. Her website and blog Sanz Plans was created to provide support for people seeking to make positive changes in their lives. Information about her book can be found here: A Year To Change. She is married to Don Sanz, also a psychologist, and has a daughter who is an aspiring actress. She writes poetry and answers questions on Quora in her free time.