Why are psychiatrists so ignorant about eating disorders?

ShameScale

I recently accompanied a friend to an intake appointment at our local eating disorder treatment centre.  The program operates out of a psychiatry program at a major hospital in our city.  It’s a medium sized city, and a fairly well known treatment program which is publicly funded and free to access.

I was completely disgusted by a good portion of what the Dr said.   Sadly, many of the things he said were things I have personally heard from other doctors.   I found it pretty triggering and it wasn’t even my appointment.

Let me share a few thoughts about what NOT to say to someone in recovery from an eating disorder (especially if you are a Dr who is supposed to be an expert!):

  1. Do NOT ask people about their history with traumatic events and then proceed to tell them that their abuse is connected to their eating disorder, but that your eating disorder program does not treat trauma.   This makes absolutely NO sense.  If aren’t willing to help someone address the roots of their coping techniques, don’t bother asking intensely personal information.  It comes across as invasive, asking questions for the sake of personal curiosity rather than to actually help someone.

Instead:  All eating disorder programs and specialists should be willing to help patients cope with the traumatic events they have survived.  If they hadn’t experienced those traumas they likely wouldn’t have turned to eating disordered ways of coping in the first place!  You don’t have to be a trauma expert, you just need to be trauma informed.  Validate!  Believe people!  Let them talk about the links between their traumas and their eating disordered behaviours.   I can almost guarantee that nobody will achieve lasting recovery without addressing the root causes of their problematic coping techniques.  Conversely, do not refuse to allow people with eating disorders to access PTSD services.  Do not forbid patients from discussing addictions either.

People don’t exist in boxes.  Someone often copes with PTSD, eating disorder AND addiction.  They shouldn’t be forced to lie about some things to access services for other related issues.   Services NEED to be intersectional or they are borderline useless and can further stigmatize vulnerable people.

2.  Do NOT shame people about their weight, body shape or the foods they eat.  People of ALL shapes, sizes, genders, races and socioeconomic statuses can suffer with eating disorders.  Do NOT promote restrictive eating by underestimating what a healthy amount of food is.  Do NOT set goal weights so low that someone will still be underweight when they finish treatment. Conversely do NOT assume that everyone who has a BMI over 25 is unhealthy.  Fat people can be healthy.   Encouraging someone who is fat to drastically restrict causes shame and further disordered eating.  All bodies look different, people can be healthy at different sizes.  The goal should be to reduce body shame and increase normalized eating.  This will NOT look identical for each person in recovery.  Do NOT place moral values on food such as labeling certain things as “junk” and “unsafe” or off limits.  Believe me, the person with an eating disorder has enough of these nasty thoughts in their head already.   This attitude needs to start with children from a very young age, where they can be taught that food is not something that makes them good or bad.  Our value as humans is not correlated in any way with the food choices we make.  All people have inherent worth or value, no matter their body shape, size or food choices.

Instead:  Promote body positivity within eating disorder treatment.  Do not assume that all recovered bodies will be a certain size.  Encourage people to gradually learn to return to intuitive eating, and trusting their bodies.   Explain that some people in recovery from restricting eating disorders may be extremely hungry while they restore their weight.  This is normal.   It’s okay to eat slightly more than your meal plan if you are genuinely hungry.   Focusing only on BMI, weight and portion sizes can turn into another type of obsessive compulsive eating behaviour.   Teach people that normalized eating can vary from day to day and that is okay.   You aren’t a bad person or shameful because you ate 3 cookies instead of 2.  You aren’t broken or weird if you are still hungry after a 1 cup serving of cereal.  Meal plans are important in early recovery, but they are NOT the be all and end all of treatment.     Don’t treat people who are thin as morally superior to people who are overweight.  Ideally, don’t make comments on people’s bodies at all.

3. Do NOT assume you can tell whether or not someone has an eating disorder based on their appearance.  If someone is struggling with disordered eating symptoms, they deserve care, help and compassion.  It makes NO sense to only provide services to the very sickest people who are basically on the verge of death.  By this point the health consequences can be severe and the behaviours are SO entrenched it can be extremely difficult to recover.  As with most illnesses and mental illnesses early intervention and prevention are KEY.   Providing services based on how medically unstable someone is only encourages people to compete to see who is the sickest.  It makes people who have larger bodies feel they don’t deserve help or aren’t sick enough to MATTER.  It perpetuates the stereotype that only young, white, rich VERY thin women can have eating disorders.  An eating disorder is a serious mental and physical illness and ALL people who suffer, regardless of race, gender, size etc deserve treatment.

Instead:  Stop using BMI alone as a measure of health.  The newest version of the DSM has removed BMI criteria from the anorexia criteria.  Doctors need to follow suit.  Even if someone is at a BMI of 19.5 or 20, or even higher, they can still be struggling with anorexia. Being weight restored or reaching a minimum BMI of 18.5 is NOT the only indicator of recovery.   Ideally body positivity should be encouraged and fostered at all stages of the recovery process.  Governments need to increase funding for eating disorder treatment to make it more readily accessible to folks who are at risk or at the early stages of illness.   Fight fatphobia and discrimination based on weight (and class) when you see it happening around you.

4. Do NOT make negative comments about food at ALL.  I can’t even count the number of times I’ve heard people say things like “I’m so bad for eating this cake”  or even “I feel so guilty for eating a sandwich instead of a salad.”   Don’t promote fad diets.  Don’t promote cutting out whole food categories. Don’t promote the idea of “clean” eating as morally superior.  Don’t imply that eating a salad is virtuous and eating cake is dirty.  Just stop.  PLEASE.  People around you are listening.  Impressionable people. Young kids whose opinions about food are just forming.   Friends and family members who may be struggling with eating disorders themselves.   This may be controversial, but unless you have a food allergy, there is NO need to obsessively eliminate particular foods from your diet.  Everyone has preferences, but that is NOT the same as conferring MORAL value on food.

Instead:  Remember that food can serve many purposes including enjoyment, nourishment, connection (sharing a meal with friends and family), ritual, celebration etc.  but food’s purpose is NOT to cause shame and guilt.  Be vigilant about situations when food is given a moral value (good or bad, clean or dirty).  If you feel confident, let people around you know that judgmental comments about food are not welcome and can be triggering for those in eating disorder recovery and those who are predisposed to developing eating disorders.

We all deserve to have a positive relationship with our bodies and the food we eat.

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