When Eating Disorder Providers Are Steeped in Diet Culture

When Eating Disorder Providers are Steeped in Diet Culture [image description: hand holding an ice cream cone with three scoops of ice cream]
Photo by Sarah Gualtieri on Unsplash

“People are concerned about the fact that I’m a therapist and have an eating disorder, and I’m like, ‘You’re concerned about me? I’m concerned about our entire fucking field.’”

— Shira Rose, FoodPsych with Christy Harrison

This quote has generated a lot of reaction. In this podcast, Shira—who lives in a larger body when she is not using eating disorder behaviors—details 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 Shira’s 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:

“The dietitian said, ‘You three get two scoops of ice cream.’ She then looked at me and said, ‘You’ll get a kiddie scoop.’”

Some of you won’t 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 wasn’t thin enough to “safely” consume more than that.

This plays directly into the eating disorder’s conviction that she needed to tightly control her food intake and her body. Her peers could eat a “normal” amount of ice cream. But she couldn’t and was singled out, because something was “wrong” with her body.

“This was the message I received my entire damn life,” Shira told me. “That I couldn’t eat like everyone else.”

— Sam Dylan Finch

The mixed messages of “eat ice cream” but “only a tiny serving” have further strengthened Shira’s 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 one’s 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:

  • Physical—BMI higher than 18.5 or another universal marker like expected goal weight;
  • Behavioral—absence of binge eating, vomiting, laxative use, or fasting; and
  • Cognitive—EDE-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 can’t 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), “To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder,” highlights an important point:

“Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how 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 ‘using.’ There is no similar test to determine if a person is ‘using’ 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 & O’Toole, 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 couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?”

Costin and Spotts-De Lazzer go on to state, “It 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.”

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 question—how do we decide when someone is well enough to treat others?

I don’t 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 ® 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.

Checking Our Own Weight Biases as Parents

 

Weight bias parenting [image description: back of teenagers walking on sidewalk]Weight bias is a preference for thinness. In the words of psychologist Ashley Solomon, Psy.D., CEDS, “Weight bias is insidiously interwoven into the fabric of our culture.”

Like many of us, I grew up in a family that possesses a great deal of weight bias. When I gained weight just before puberty my mother put me on diets. My paternal grandfather bribed me to lose weight with the offer of a car. I realize my family members meant well. They stated at the time they were worried I would not be well-liked if I was overweight. At 101 years of age, my maternal grandmother still weighs herself daily and credits the diet she started in high school as the cause of my grandfather falling in love with her.

I have already recounted how I helped my older daughter gain weight when she fell off her weight curve at the age of 12—despite her pediatrician’s misplaced admiration, “You’re just how we all want to be,” (75%ile for height and 25%ile for weight [= thin for your height])” My son and younger daughter gained weight before their growth spurts, which led to that same pediatrician warning me about weight gain and risk of obesity for the two of them. This succinctly illuminates our culture’s weight bias: obesity is a far greater concern than anorexia nervosa.

Now let’s fast-forward to 2 years after the obesity warning for my younger daughter. Nearing the end of her height growth spurt, she has fallen off her weight curve. What is an FBT-trained professional therapist and enlightened mother to do?

She is about 10 pounds below where she should be according to the weight graphs (ignoring the single spurious plot point when I got the obesity warning). She is definitely slender. She does take a medication that could reduce appetite. However, even when she doesn’t take it, she has a small appetite. She does not show any other signs of weight or body concern, eats a range of foods, and is not very active (unlike her older sister when I intervened on her behalf to restore weight).

I notice my admiration for her current shape. I notice the temptation to leave her alone and let her remain on the thin side. After all, my son has gained weight now that he is no longer in high school sports. I notice a stronger urge to react to his food choices than I did when he was thinner. And with some larger relatives in their genetic heritage, I have had the fleeting thought that I would rather keep my daughter thin. WHAT?! I caught my thoughts unconsciously falling into programmed family and societal beliefs that I do not actually agree with on an aware and conscious level.

I examine my feelings and beliefs about what weight gain means for my daughter. I quickly recognized my over-valuing of her slenderness and my own projected anxiety about her potentially being larger. After questioning her pediatrician, who is, not surprisingly, unconcerned, and obtaining a print-out of her growth and weight curves, together we (my daughter and I) settled on adding a daily liquid supplement and mild encouragement to eat more. And, my daughter seems to feel it is a fun challenge.

I do what I ask the families I work with do, which is challenge the bias that thin is better and focus on keeping my daughter on track on her own weight curve, which I know is healthiest for her long term.

Ten Facts About Weight Stigma – Guest post by Liliana Almeida, Ph.D.

 

  1. Weight Stigm [Image description: larger black woman holding towel that says "wide load"]
    Photo featuring plus-size model by Michael Poley of Poley Creative for AllGo, publisher of free stock photos featuring plus-size people.
    Weight stigma is a bias or discrimination relating directly to weight. Despite the fact that more than half of U.S. citizens are larger-bodied, our society holds a strong negative bias against fatness.
  2. The media reinforces weight stigma. The media, such as news media, displays persons in larger bodies in stigmatizing ways by depicting them sitting and eating unhealthy foods, wearing ill-fitting clothes, headless, or with their abdomens showing.
  3. Weight stigma is based on the belief that weight is under one’s personal control. This belief suggests that larger persons are undisciplined and inactive. However, when weight is attributed to uncontrollable factors such as diabetes or hypertension, people’s attitudes change. 
  4. Weight stigma exists in romantic relationships. Romantically, people in larger bodies are less preferred.  They are less preferred in comparison to those who are in wheelchairs, mentally ill, or those who have sexually transmitted diseases.
  5. Weight stigma starts as early as preschool.  Children ages 3-5 negatively characterize larger children as mean, ugly, stupid and sloppy. As children get older they start believing their larger peers are lazy, less popular, and less happy. College students report that their peers in larger bodies are lazy, self-indulgent, and less attractive, with low self-esteem and deserving less attractive partners.
  6. Teachers have a weight bias towards heavier students. They believe their larger students lack self-control and are less likely to succeed.
  7. Health professionals are also biased. Health professionals treating individuals with eating disorders report believing that larger patients do not comply with treatment recommendations and perceive poor treatment outcomes. Those strongly biased believe larger body sizes are the result of overeating and lack of motivation.
  8. Individuals in larger bodies have internalized stigma. The most common anti-fat bias among larger individuals is the belief that they are lazier and less motivated than thinner individuals. The failed attempts of individuals in larger bodies to lose weight may cause them to begin to internalize society’s beliefs that they are lazy and lack willpower.
  9. Weight stigma increases binge eating. Weight stigma causes psychological distress such as depression, anxiety, and low self-esteem. It is also associated with poor body image and increased fear of fat.
  10. Weight stigma experiences are as common as other forms of discrimination. In women, it is as common as racial discrimination. In some cases, it is more common than gender and age discrimination. 

References 

Ashmore, J.A., Friedman, K.E., Reichmann, S.K., &Musante, G.J. (2008). Weight-based stigmatization, psychological distress, & binge eating behavior among obese treatment-seeking adults. Eating Behaviors, 9, 203-209.

Chen, Eunice & Brown, Molly. (2005). Obesity Stigma in Sexual Relationships.  Obesity Research, 13, 1393-1397.

Cramer, P., & Steinwart, T. (1998). Thin is good, fat is bad: How early does it begin? Journal of Applied Developmental Psychology, 19, 429-451.

Friedman, K., Reichmann, S., Costanzo, P., Zelli, A., Ashmore, J., & Musante, G. (2005). Weight stigmatization and ideological beliefs: relation to psychological functioning in obese adults. Obesity Research, 13, 907–916.

Latner, J., Wilson, T., Jackson, M., & Stunkard, A. (2010). Greater history of weight-related stigmatizing experience is associated with greater weight loss in obesity treatment. Journal of Health Psychology, 14, 190-199.

Puhl, R., Andreyeva, T., & Brownell, K. (2008). Perceptions Of Weight Discrimination:Prevalence And Comparison To Race And Gender Discrimination In America. International Journal of Obesity, 992-1000.

Puhl, R., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, 133, 557-580.

Puhl, R., Latner, J., King, K., & Luedicke, J. (2013). Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes. International Journal of Eating Disorders, 1-11.

Puhl, R., Lee Peterson, J., DePierre, J., & Luedicke, J. (2013). Headless, hungry, and unhealthy: A video content analysis of obese persons portrayed in online news. Journal of Health Communication, 1-17.

Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: a 2-year prospective investigation. Health Psychology, 21, 131-138.

Tiggemann, M., & Wilson-Barrett, E. (1998). Children’s figure rating: relationship to self-esteem and negative stereotyping. International Journal of Eating Disorders, 23, 83-88.

Wang, S. S., Brownell, K. D., &Wadden, T. A. (2004). The influence of the stigma of obesity on overweight individuals. International Journal of Obesity, 28, 1333-1337.