When considering our understanding of eating disorders and disordered eating it’s important to consider whether any of the many myths, misconceptions and stereotypical images that permeate public consciousness have entered into our awareness unchallenged. In this blogpost we’ll consider some of those myths, the impact they may have in therapy, and the reality of the situation.
Eight eating disorder myths therapists need to understand
These statements are ideas around eating disorders that form the stereotypical view of how they work and who is affected. While as a counsellor you’re bound to know the situation is more complex than these statements imply, we dig into what it means to have these assumptions in the public mindset and how they may enter into the therapy room.
1. Eating disorders stem from body image issues
While some clients’ disordered eating may come from body image issues and a desire to be thin, this is often not the case and rarely the whole story even when it is. Eating disorders can present for the same reasons any mental health issue manifests, but issues that may often present include shame (often stemming from trauma – whether relational including emotional neglect or experiences such as sexual abuse), feelings of not being good enough, anxiety and perfectionism, overwhelming distress that is hard to tolerate and feelings of not being heard or seen in relationships. Eating can become something the client can control when they otherwise lack power, a voice or the capacity to cope in other ways.
“Locking away appetite, anger, the fullness of life, anorexia helps cover up whatever struggles inside… it becomes a shield to fend off despair and longing.” – Carol Lee in her memoir To Die For
So to presume a client’s eating disorder stems from aesthetic reasons is reductive and risks “missing” the client. If they haven’t had the support they’ve needed in their life, have disconnected from others to protect themselves and then found a relationship with food to be what’s got them through (damaging though it may be) – to have someone focus solely on appearance, even if that’s what they cite as a motivation, may become another relational disappointment and experience of disconnection. Instead, we can have curiosity for all of the client’s experiences and feelings that drive their eating behaviours. Crucially, we can facilitate a strong relationship founded on genuine connection and care that they may have craved but never received.
Eating disorder expert Professor Julia Buckroyd believes that disordered eating can be a form of communication within a relationship. Clients may not be able to express themselves in words and so instead their bodies and their actions become their language which is, sadly, often doomed to fail. This is where therapists can help, in working with the client to translate what is being unconsciously communicated and finding healthier ways to express themselves within relationships. Here’s Julia introducing her talk at our upcoming conference:
2. Eating disorders only affect teenage girls and young women
The most common media image of eating disorders is that of a teenage girl or young woman, usually white. While most eating disorders develop during adolescence and are most common in individuals between the ages of 16 and 40 years old, eating disorders can affect anyone – of any age, gender, sexual orientation and ethnicity. This public perception can stop us considering the possibility of eating disorder in other client groups.
Some statistics that may surprise you (via eating disorder charity Beat):
- Around 25% of those affected by an eating disorder are male.
- Children as young as six have suffered with anorexia, and research also shows women in their 70s developing the condition.
It may be harder for men to confide in loved ones if they are struggling with disordered eating due to the misconception that this is a women’s issue. This can lead to further shame (which can then worsen the eating issue) and a delay in accessing support. As therapists we can be open to any client having these issues, asking appropriate questions around eating and being ready to support them if they are struggling. Sharing some of these statistics can also be validating in this situation – knowing that they are not the only one can be a big relief. If anything, the 25% figure may be higher as many men struggling with eating disorders may be undiagnosed.
This powerful video from the University of Nottingham shares some men’s experiences with eating disorders and first accessing support.
3. Anorexia and Bulimia are the most common eating disorders
While they’re the most talked about, and absolutely need to be understood and taken seriously, anorexia and bulimia are not the most common eating disorders. It’s tricky to pin down exact numbers when not all diagnoses will be made nor recorded, but a 2017 study by Hay et al showed Binge Eating Disorder to be one of the most common, accounting for 22% of cases, and OSFED (Other Specified Feeding or Eating Disorder) to be the most common – accounting for 47% of eating disorder cases.
This shows that as therapists we need to expand our awareness beyond the most known about disorders to include other lesser known eating disorders, including presentations of anorexia and bulimia which don’t fit clinical criteria for diagnosis. We also need to hold in mind that disordered eating can worsen over time, and that a client may experience one eating disorder then another – or have overlapping diagnoses.
4. You have to be underweight to have an eating disorder
Perhaps this myth comes from the centering of anorexia as the image of eating disorders – the presumption is that those with an eating disorder will be underweight. However for most people with an eating disorder this isn’t the case – instead they are likely to sit in a “healthy” weight or “overweight” category.
This shows how invisible eating disorders can be – we can’t assess based on appearance, nor put concern aside on the basis of a client not being underweight. This may be an issue for clients – feeling not believed or not able to confide in friends or family because of the risk of that. They may bring that same anxiety into therapy.
“I ate and ate and ate in the hopes that if I made myself big, my body would be safe… I was trapped in my body, one that I barely recognized or understood, but at least I was safe.” Roxane Gay in her memoir Hunger
5. Everyone diets or has some issues with food
On its own, this statement might be true – we all experience our relationship with food changing at various points in our life. This is good to be aware of. If a client’s eating is impacted by a change in routine, stress or bereavement – this can be important to process, even if they’re not in the territories of ongoing disordered eating. Linda Cundy will be exploring how grief can disrupt our relationship with food, and how this is affected by attachment, at our upcoming online conference on disordered eating and eating disorders.
There is a risk though if we find ourselves relating to clients who mention over-indulgence or going on diet plans. We need to be careful not to assume the client’s experience with food mirrors our own, instead enquiring over what they mean by “over-indulgence”, what happens for them when this occurs and what’s driving it. Binge Eating Disorder is not just occasional overindulgence but compulsive and distressing to experience. We also know that diets can contribute to the development of disordered eating and eating disorders – restriction can become addictive, but can also be a trigger for bingeing.
The key point here is that while there may be accepted cultural norms around food, guilt and weight loss – it’s helpful to unpack these for ourselves, considering our own relationship with food first – and then always being ready to look closer when clients share their experiences or thoughts around eating. Chances of recovery are better the earlier that eating disorder treatment is sought and engaged with so we need to be aware of any red flags.
The client may already be in therapy with us, but we need to be asking the right questions around eating as it may not always be something that clients feel able to bring up, or they may brush over it without going into detail. For clients’ wellbeing we wouldn’t want their disordered eating to progress, but this is also a serious on a physical level – with risks to health and even to life. If we can work with this, then we do – but if it is beyond our competence it’s crucial that we refer on.
6. Anorexia is the only eating disorder that kills
Of all the psychiatric disorders, eating disorders have the highest mortality rates – with anorexia having the highest mortality rate of any psychiatric disorder in adolescence. However, it’s not just anorexia that can kill or have long-lasting health impacts, with eating disorders including bulimia affecting cardiovascular function with a risk of sudden cardiac and respiratory arrest. There can also be issues with the gastrointestinal system, blood pressure, osteoporosis and dental issues. These issues can continue beyond recovery.
There can also be a false belief that once an individual is at a healthy weight the risk to life is gone, but this is not the case. Damage to the heart can be long-lasting but eating disorder clients are also at risk of suicide – as this BACP article by therapist Kel O’Neill explains.
Most of us hold awareness of the tragic mortality risk from anorexia but we also need to be aware of risks from other eating disorders and also health risks. When appropriate (and discussions with informed supervisors are crucial to make this call) – we need to ensure clients are getting the appropriate support outside of therapy.
7. The first step towards eating disorder recovery is understanding its cause
More and more we are recognising that “it’s not what’s wrong with you, it’s what happened to you”. We’re moving away from mental health diagnoses being the end of the story, and instead seeking to understand what’s behind the distress – understanding the long-term impact of trauma.
As explained earlier in this article, we can support clients in exploring the feelings and experiences driving their eating disorder – helping move them toward connection (with themself and with others) and increased capacities to deal with their distress. For many clients this will be possible.
Yeva Feldman will explore this movement toward connection in her talk at our upcoming conference, which she introduces here:
For some clients, however, the priority may be medical intervention involving weight restoration due to the physical risks outlined previously. This can be necessary as a first step at times, and so can come before any understanding of the “why” for the client.
Still, weight restoration does not equal recovery and that’s where therapy can give hope for genuine, long-lasting recovery, with the possibilities for understanding and relational healing that may mean clients don’t “need” their eating disorder anymore.
8. Eating disorders are things to be scared of
After reading the last two points with reference to mortality, health risks and medical intervention – you may be left feeling anxious – scared of the risks involved with clients with eating disorders, and if you can manage them. In some cases, you might not be able to work with certain clients – and then you would refer on. At other times though, if you feel adequately trained and supervised and there isn’t a need for a team approach – this will be work you can do.
What you don’t want to do though, is bring your fear into the room. If a client is already in a state of disconnection, the therapist being scared of their eating disorder will only heighten that disconnection – and perhaps trigger feelings of shame around being “too much”.
It’s okay to feel that fear. It can be worth listening to – perhaps highlighting that you don’t feel sufficiently trained to work in this area, and that’s ok, or that you do but that it needs exploring and processing in supervision or your own therapy. But in the room, with the client, is where you ground yourself to stay present, with all the relational qualities that make clients feel safe and return to you time after time. Eating disorders aren’t things to be scared of – they are issues to be understood within a client who needs to be connected with.
Why therapists need to understand eating disorder stereotypes, stay aware and look deeper
As you can see from the exploration of these misconceptions, it’s crucial that therapists unpack any assumptions held about who gets an eating disorder and how they are impacted. This is a safety issue but also relational – with an open and ready mind meaning there is more chance of trust and connection for clients to open up about their eating issues and what lies behind them. We hope you’ve found this article helpful – if you have please do share it with your peers and let us know in the comments any of your thoughts.
Saturday 12th November 2022 (with catch-up) – Online
With Professor Julia Buckroyd
This workshop will offer a general introduction to working with clients who have eating disorders or disordered eating. It offers a conceptual framework for understanding the misuse of food, using attachment theory, and then to offer a wide range of strategies for working with clients.
Central areas for consideration include emotional language, attachment history, self-esteem, body-esteem and identity, relationships and self-soothing.
Friday 1st March 2024. ONLINE via Zoom and CATCH-UP for 28 days. Event Times: 10.00am – 4.00pm GMT (London)/ 11.00am – 5.00pm CET (Paris)/ 5.00am – 11.00am EST (New York).…
Friday 22nd March 2024. ONLINE via Zoom and CATCH-UP for 28 days. Event Times: 10.00am – 4.00pm GMT (London)/ 11.00am – 5.00pm CET (Paris)/ 5.00am – 11.00am EST (New York).…
Friday 19th April 2024. ONLINE via Zoom and CATCH-UP for 28 days. Event Times: 10.00am – 4.00pm GMT (London)/ 11.00am – 5.00pm CET (Paris)/ 5.00am – 11.00am EST (New York).…
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