![When Eating Disorder Providers are Steeped in Diet Culture [image description: hand holding an ice cream cone with three scoops of ice cream]](https://www.eatingdisordertherapyla.com/wp-content/uploads/2019/12/sarah-gualtieri-tr9GO9WXNRI-unsplash-200x300.jpg)
âPeople are concerned about the fact that Iâm a therapist and have an eating disorder, and Iâm like, âYouâre concerned about me? Iâm concerned about our entire fucking field.ââ
â Shira Rose, FoodPsych with Christy Harrison
This quote has generated a lot of reaction. In this podcast, Shiraâwho lives in a larger body when she is not using eating disorder behaviorsâdetails how she has suffered from fatphobia in the world and in treatment centers. She shares that she has been significantly harmed by both well-meaning treatment providers and highly-regarded treatment centers.
This blog addresses two questions:
- How is fatphobia affecting therapy and patients?
- When is someone well enough to treat?
Shira is my friend and colleague. I regard her above quote to be a challenge to all treatment providers who have not faced their own fatphobia, including those who seemed afraid of Shiraâs weight gain, tried to reassure her she was not gaining weight or would not gain weight, tried to help her keep her weight down, and limited her portions. These actions have harmed her by making her afraid to eat enough to sustain her healthy body weight and making her unable to fully recover after a 19-year history of an eating disorder.
Weight Stigma in Treatment
One incident Shira experienced in treatment was relayed to her friend, Sam Dylan Finch who described it in a blog post:
âThe dietitian said, âYou three get two scoops of ice cream.â She then looked at me and said, âYouâll get a kiddie scoop.ââ
Some of you wonât understand the gravity of that comment. To be clear, a dietitian told a patient with anorexia nervosa to eat less food than her peers, because she is a patient in a larger body.
The message here being, of course, that Shira needed to eat a child-sized portion of ice cream, because she wasnât thin enough to âsafelyâ consume more than that.
This plays directly into the eating disorderâs conviction that she needed to tightly control her food intake and her body. Her peers could eat a ânormalâ amount of ice cream. But she couldnât and was singled out, because something was âwrongâ with her body.
âThis was the message I received my entire damn life,â Shira told me. âThat I couldnât eat like everyone else.â
â Sam Dylan Finch
The mixed messages of âeat ice creamâ but âonly a tiny servingâ have further strengthened Shiraâs eating disorder. The message treatment providers delivered over and over again was that her body needed to be controlled in order to avoid fatness. She yearned to be able to eat freely.
Shira also acknowledges that there were times in the past when she thought she was fully recovered. She only discovered years later after a relapse that what she thought was fully recovered was only partially recovered. How is this possible? Because we live in a culture where it is considered desirable and virtuous to maintain a low weight, deny ourselves tasty foods, limit the amount we eat, and exercise intensely. No other mental illness is so unfortunately reinforced by our cultural ideals.
And in terms of who is well enough to treat people with eating disorders, is recovery from oneâs own eating disorder the only criterion that matters? How would we ever be able to vet that? How do we define recovery anyway?
I agree with Shira that there are many providers in the field who have not faced their own fatphobia. Focusing exclusively on providers who have had an eating disorder and whether or not they are recovered ignores a large portion of the provider community who do not have diagnosable eating disorders but may still be casualties of diet culture, wrestling with internalized weight stigma. These providers may be doing much more harm, but their impact has unfortunately received limited attention.
Providers With History of an Eating Disorder
Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. A study by De Vos and colleagues (2015) found that 24 to 47 percent of eating disorder clinicians reported a personal eating disorder history. An unpublished 2013 Academy for Eating Disorders online survey indicated that out of 482 respondents from professional eating disorder organizations, 262 (55%) reported a personal history of an eating disorder and half of those reported working directly with eating disorder patients. If we added subclinical eating disorders and disordered eating I have no doubt the rates would be higher.
Some have suggested over the years that providers with histories of eating disorders should never work in the field. This would be a mistake. Many professionals with their own personal histories (disclosed or not) have made major contributions to the field and to our understanding of eating disorders. Carolyn Costin, MEd, LMFT, CEDS and Mark Warren, MD, MPH, FAED are two public examples of prominent recovered professionals. In the broader field of psychology, one need only look at Marsha Linehan, Ph.D., who developed the leading evidence-based treatment for borderline personality disorder and other conditions based on her own experience of recovery from a severe mental illness to see that blanket restriction like this make no sense. In various surveys, patients have consistently reported it is helpful to work with providers who have had an eating disorder.
Defining Recovery
But even more complicated is the fact that we do not have a solid definition of recovery. In eating disorder research studies, recovery is often defined by three components:
- PhysicalâBMI higher than 18.5 or another universal marker like expected goal weight;
- Behavioralâabsence of binge eating, vomiting, laxative use, or fasting; and
- CognitiveâEDE-Q subscales about shape and weight concerns within 1 standard deviation of age-matched peers.
With dieting widespread (a 2018 study reported 36 percent of Americans were dieting), how many providers with disordered eating and their own extreme weight control behaviors go under the radar? How many providers may be engaging in their own intermittent fasting, keto diets, counting calories, or excessive exercise? I would agree with Shira that we should be equally if not more afraid of these providers.
Who is Fit to Treat Eating Disorder Patients?
If the field canât decide who is recovered, who is to decide who is fit to treat eating disorder patients? Are therapists who acknowledge they have clinical eating disorders worse than fatphobic dieter providers who deny their own food issues and go on to shame patients, recommend any kind of dietary restriction, and limit the weight gain necessary for full recovery? How do we decide when someone is well enough to treat others?
The following quote from Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS in their article for Gurze (2016), âTo Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder,â highlights an important point:
âEven if the field reaches its consensus on a definition of recoveredâand then holds it up as the criteria for being able to be work with eating disorder patientsâhow would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or âusing.â There is no similar test to determine if a person is âusingâ his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & OâToole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldnât those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?â
Costin and Spotts-De Lazzer go on to state, âIt seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post-traumatic stress disorder, or another diagnosis in their past.â
Perhaps we should be focusing on assessing providers for awareness of weight bias instead.
Further, if we shame Shira for being a provider with an eating disorder, how do we make it safe for other providers to acknowledge their own struggles and receive help if they have a lapse or relapse? Shira has reported that a significant number of providers have shared with her that they have struggled or are currently struggling. This says a lot.
So back to the questionâhow do we decide when someone is well enough to treat others?
I donât have the answer to this question. The field has been unable to even define recovery.
Am I more afraid of fatphobic dieting therapists who may not be aware of their potential for harm than therapists who believe in and espouse Health At Every Size ÂŽ while acknowledging their own mental illnesses? Ultimately, yes, I am.
I think we need to look inward and address the rampant weight bias in the field. With dieting so widespread we have a lot of work to do. I believe everyone deserves treatment to full recovery and safety in their bodies. We need to address structural issues that limit access to care and safety. We need to make it safe for providers to receive help for eating disorders. I think it behooves every professional working with eating disorder patients to look at their own weight bias and work to practice from a weigh-inclusive approach. Only this way can we reduce the harm done to people like Shira.
Sources
Costin, C. & Spotts-De Lazzer (2016). To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder. Gurze Salucore, Eating Disorders Resource Catalogue.
Stych, A (2018). Percentage of Dieters More Than Doubles. Bizwomen: The Business Journals.