Barriers in Pursuing Eating Disorder Recovery
Why is it so hard to reach out for help when struggling with an eating disorder or even know you might have an eating disorder? Maybe you have known you haven’t had the best relationship with food and your body but are hesitant to take action steps to shift that relationship. Maybe you know someone who seems to struggle with an eating disorder and are confused about why they struggle to make changes. There are many reasons. Here are just a few possibilities:
The Eating Disorder Has Served Some Sort of a Function
This might sound weird at first because we often want to see eating disorders as these terrible things that we want to get rid of due to the negative effects on one’s self concept, relationships, physical health etc. However, if we view the eating disorder as a coping skill (maybe not the most adaptive one, but nonetheless a coping skill), we can understand why you felt you needed that coping skill in the first place or what you were coping with.
Maybe the eating disorder was trying to protect you from painful feelings and restricting or binging numbed those feelings
Maybe exercise or purging feels like a release or physical manifestation or expression of anger that has been repressed or gone unvoiced
Maybe the night time binge has been a way to unwind from work or dissociate after a stressful day
Maybe you experienced food insecurity as a child and now you find yourself restricting to make food last or because it was shamed or seen as selfish to eat until full or maybe you are now binging when you do have unlimited access to food out of fear it won’t continue to be accessible
Maybe this is the first time you have received so much external validation or don’t feel overlooked at work or school
Maybe you are transgender and the eating disorder has allowed you to manipulate your body to align more and outwardly affirm your gender identity
Maybe your social connections have come from the gym or bonding over dieting and fear you will lose these connections if you give up your eating disorder
Maybe you were bullied as a kid for your weight and the eating disorder serves as a protection from further bullying
Maybe you experienced a trauma that has left you feeling it's not safe to be in your body or don’t deserve to nourish yourself and the eating disorder has mitigated that deep sense of lack of safety
If we can understand the often multi-faceted function of the eating disorder, we can also address any underlying trauma, depression, anxiety or relational patterns that might have contributed to its development. However, the fact that it is serving a function, can decrease motivation, consciously or subconsciously, to make changes (which makes complete sense!). This is where the deeper work can come in to identify what function(s) it has served for you, heal the underlying trauma or life experiences, and find new ways to cope. Motivational interviewing can also be helpful to highlight the ways in which the eating disorder may no longer be serving the same function it used to, or maybe the cons have just started to outweigh the pros of the function.
Reinforcement From Society
Eating disorders are a mental illness that, unlike others like substance use, is often praised or reinforced by societal standards such as the thin ideal and wellness culture. As a clinician who works with individuals struggling with eating disorders, I can’t tell you the amount of times I have heard clients say they received comments in response to weight loss, restriction, excessive exercise along the lines of:
“I am jealous of your self-control”
“You are so disciplined”
“You look so healthy”
“You like food too much to have an eating disorder”
“What's your secret?”
“You are so fit”
While these comments are often well-intentioned, they reinforce disordered eating and anti-fat bias. Many times people will report missing getting these comments they received while in their eating disorder or fear/assume that it means people will think the opposite if they change their behaviors or gain weight. This reinforces the intense fear of weight gain that is often associated with eating disorders.
Anti-fat bias is a systemic issue that discriminates against people in larger bodies and places moral value on a person based on their body size by assuming fatness is inherently bad. People in larger bodies may even be at higher risk of developing an eating disorder due these societal pressures and prejudices (Da Luz et al., 2017). Individuals in larger bodies are more likely to experience weight stigma from medical providers and have dieting and weight loss praised and even prescribed.
Examples of ways weight stigma shows up include assuming fat folx are lazy, sad or unhappy, don’t take care of themselves, assuming fat equals unhealthy, overattributing their body size/shape to their food intake/activity, judging someone eating sweets (compared to someone eating the same food in a smaller body), giving unsolicited advice on nutrition or exercise, assuming someone wants or need to lose weight, attributing any medical conditions to one’s weight or thinking weight loss will automatically cure any medical symptoms, complimenting weight loss assuming weight loss is inherently good, complimenting weight loss, using words like flattering to say clothes make someone look thinner, and even discrimination in compensation with studies showing fat people are paid less for doing the same job as someone in a thin body. Not to mention accessibility concerns like airplane seats, amusement park rides, small seats in doctors offices and restaurants, stores carrying limited clothing sizes. And these are just scratching the surface on the ways anti-fat bias and weight stigma show up in society. All of these things send the message to someone to shrink themselves and that they are not okay or worthy the way they are. Whether implicitly or explicitly communicated, these messages get internalized over time and can have lasting negative impacts on one’s psychological and physical well being.
While I could write multiple other articles on anti-fat bias and weight stigma and this just barely scratches the surface, it could not be skipped over in naming reasons it is difficult to reach out and access eating disorder support. Not to mention I am someone in a thin, white, able body so centering others with lived experience and expertise on this matter would be a better way to dive into learning more about fatphobia and weight stigma
Fear of Judgment, Invalidation, and Stigma from Others
Did you know that less than 6% of individuals with eating disorders are medically underweight (Flament et al., 2015). That means that around 94% of those struggling with an eating disorder are not underweight. Individuals who are not visibly underweight (which we have already established is the large majority of those with eating disorders) often fear being invalidated in reaching out for help or speaking to their experience of having an eating disorder. Sadly, that fear is not unfounded based on my clinical experience. Many medical professionals, friends and family misunderstand what eating disorders are and miss the signs and symptoms in individuals of all body sizes and shapes. Individuals actively struggling with eating disorder behaviors and the intense psychological distress that comes with that have been told “but you don’t look underweight”, “You like food too much to have an eating disorder” or “but I’ve seen you eat”. These comments are so invalidating and make it hard for individuals to feel emotionally safe opening up about their struggles.
While eating disorders such as Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, Orthorexia, Other Specified Feeding and Eating Disorder and ARFID might mistakenly be seen as a women’s issues, it is estimated that men make up about 1 in 4 cases of Anorexia and Bulimia (Hudson et al., 2007) and binge eating seems to be the most common eating disorder behavior by men with similar rates to women (Mitchison & Mond, 2015). I share these statistics because while men clearly experience eating disorders, men are more likely to experience increased rates of stigma and shame around struggling with a mental illness in general, especially eating disorders (Griffiths et al., 2015). They are less likely to seek support and often have less options for support.
Eating disorders are complex emotional disorders that are characterized by thoughts/preoccupations and behaviors related to food, body weight/shape, exercise, but that does not mean those thoughts and behaviors are always outwardly visible to others. There are often many hidden behaviors in one’s eating disorder due to shame, not wanting to let go of the eating disorder (as identified above it serves a function), and not recognizing the behaviors as disordered or unhealthy.
While we as a society have come a long way in recognizing the prevalence of mental illness and the importance of addressing one’s overall mental health, we still have a long way to go. There is still so much shame and fear of being seen as weak or attention-seeking. Even if we logically do not agree with mental illness making someone weak, we can still have those beliefs internalized from a young age from families or systems we grew up in or exist in today. It is also important to mention accessibility barriers and lack of resources such as finances, not being able to take time off work, lack of social support/childcare, lack of LGBTQIA visibility and affirming services, cultural factors that might increase stigmatization or discrimination, in addition to the weight stigma discussed above.
Cognitive Rigidity or Lower Capacity for Flexible Thinking
This commonly occurs when someone is malnourished. Once again, malnourishment does not necessarily mean underweight. You cannot look at someone and know if they are restricting, binging, purging, excessively exercising, or engaging in other disordered eating behaviors. When someone is not getting a balanced diet, their brain and ability to function on many levels is impacted and it might be harder for someone to hear concern from others, see beyond the small world the eating disorder has created. Evidence has been found that in those that are malnourished, neurocognitive impairments including a lack of cognitive flexibility can occur (Phillipou et al., 2015, Chan et al., 2013). This means that one’s ability to adapt and integrate new information, see alternative perspectives, and change one’s perspective in the face of new or unexpected environments is impaired and contributes to the rigidity often seen with eating disorders. This might not apply to all individuals struggling with disordered eating or it might be hard to know what is due to malnourishment and what is compounded with the factors already discussed above.
Reaching Out for Help Is Brave
Wherever you are in your recovery journey and relationship with food and your body, reaching out for help is brave and should be taken seriously. If you have been told some of the examples of comments above from others, praised for pursuing weight loss or just ready to not spend so much time in your head thinking about food and your body, finding a Health At Every Size aligned provider is a good place to start. If you aren’t sure how to find the right therapist for you, check out my other article that walks you through how to do that and if you want to learn more about how to support a loved one with an eating disorder, check out this article! Taking steps towards recovery can be scary due to the reasons discussed above, AND you deserve to find freedom from the restraints of the eating disorder whatever that might look like for you.
If you or someone you know is struggling with disordered eating or an eating disorder, seek professional help and take the first step into recovery. Eating disorder therapy can provide you with the education, tools, and support to reach full recovery. Reach out to schedule your free consultation call today here!
This is not an exhaustive list of possible barriers to reaching out for support. What else would you add? Let me know!
References
Chan, T., Ahn, W.-Y., Bates, J. E., Busemeyer, J. R., Guillaume, S., Regrave, G. W., & Courtet, P. (2013). Differential impairments underlying decision making in anorexia nervosa and bulimia nervosa: A cognitive modeling analysis. International Journal of Eating Disorders, 47(2), 157-167
Da Luz, F., Sainsbury, A., Mannan, H., Touyz, S., Mitchison, D., & Hay, P. (2017). Prevalence of obesity and comorbid eating disorder behaviors in South Australia from 1995 to 2015. International Journal of Obesity, 41(7), 1148-1153.
Flament, M., Henderson, K., Buchholz, A., Obeid, N., Nguyen, H., Birmingham, M., Goldfield, G. (2015). Weight Status and DSM-5 Diagnoses of Eating Disorders in Adolescents From the Community. Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 54, Issue 5, 403-411.
Griffiths S, Mond JM, Murray SB, et al. Young peoples’ stigmatizing attitudes and beliefs about anorexia nervosa and muscle dysmorphia. Int J Eat Disord 2014;47(2):189–95.
Hudson JI, Hiripi E, Pope HG, et al. The prevalence and correlates of eating disorders in the National Comorbidity Survey replication. Biol Psychiatry 2007;61:349–58
Mitchison D, Mond JM. Epidemiology of eating disorders, eating disordered behaviour, and body image disturbance in males: a narrative review. J Eat Disord 2015;3:20
Phillipou, A., Gurvich, C., Castle, D., Abel, L., & Rossell, S. L. (2015). Comprehensive neurocognitive assessment of patients with anorexia nervosa. World Journal of Psychiatry, 5, 404-411.