“Looking From the Outside In, You Can Never Understand it. Standing On the Inside looking Out You Can Never Explain It”
Melissa Libbey
Introduction
Eating disorders (EDs) are on the increase in Ireland and worldwide (Bodywhys, 2024). They carry a risk of suicide and mental health illnesses, and they have the highest mortality rate of any mental health illness. Females are ten times more likely to develop anorexia nervosa and bulimia nervosa than men, “being born female is the single best predictor of risk of developing an eating disorder” (Maine in Maine, et al., (eds), 2014). There are several distinct types of EDs, e.g. Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Avoidant Restrictive Food Intake Disorder (AFRID), and Other Specified Feeding or Eating Disorder (OSFED). Eating disorders become immensely powerful as they take hold of a person, they have no boundaries and can affect anyone.
EDs are complex and could not exist without a cultural context that overvalues thinness, advertising in Western culture sells thinness to females as the only way of looking good. The unrealistic expectation of thinness reinforces the negative feelings females have about their bodies, as shame and femininity are interlinked in Western society.
Numerous people with eating disorders are not grounded, or living in their bodies, the body is the enemy, and the person punishes and controls their body through their eating disorder. The client’s search for meaning in their lives is a vital part of recovering from an eating disorder. On their recovery journey, the person finds their voice, this helps them work towards a life worth living. The person learns to let go of their negative feelings from the past and live mindfully in the present.
Facts about Eating Disorders
- Eating disorders (ED) are serious mental illnesses, not life choices.
- People with EDs have higher rates of suicide ideation.
- More people die from EDs than any other mental health illness.
- Males with EDs are under diagnosed, under recognised and under treated, due to atraditional belief that EDs are a female illness.
- Between 20-50% of transgender people are at a substantial risk of developing disordered eating, and many report that eating disorders help them cope with body dysphoria. (Keski- Rahkonen, 2003, & Malina, 2021).
- People with autism are at a higher risk of developing EDs such as AN, and ARFID, compared to people who do not have autism.
- People with ADHD are more likely to develop binge eating disorder and bulimia.
- The connection between different neurodivergent traits and EDs is complex and multi-dimensional.
The Person with an eating disorder
Identifying people with an ED as anorexic or bulimic for example, labels them, dehumanises them, and defines the person only by their ED, and tells us nothing about the whole person. In therapy de-identify the client with an ED, e.g. she/he/they have anorexia (AN) rather than she/he/they are anorexic. ‘Go around the illness to find the person.’ I collaborate with my clients to find out what is behind their ED, what is their ED trying to communicate? Find out about their life, their childhood, family, education, community, and the wider context of their lived experience, to explore why/how the eating disorder developed. The context of the person’s life experiences is crucial to finding answers to the ‘why’ of their ED. Context can include pre-birth, pregnancy, birth, postnatal experience of mother, infant attachment experience, childhood abuse, EDs in the family, exposure to drugs, poverty, access to education, and opportunities in life.
The ED is not the primary problem; it is an attempt to solve the person’s problems. An ED can serve a client, it can keep them alive, and it is helpful before it becomes harmful. The ED will last as long as it serves the client, so acknowledgement of the intelligence and wisdom of a person’s ED is vitally important. The therapeutic process is like a jigsaw, the client and therapist gather the pieces for the journey of recovery, and they work together in building the jigsaw. Understanding the ‘why’ of an ED informs the ‘how’ and helps prevent relapse.
Eating disorders are a family illness, they affect every family member and can disrupt family harmony. Parents worry, siblings feel neglected, and if the person with the eating disorder is in denial, the situation is worse. The person can have mood and behaviour issues, particularly at mealtimes. Some families feel anger, despair, shame, and stigma about their child’s eating disorder. Family therapy focuses on the child’s treatment, and the family’s responsibility to care for their child (when under 18). With anorexia, food is medicine and is essential for the patient so they can restore their cognitive functioning to have insight into their illness.
Neuroscience and Neuroplasticity
Neuroscience provides a new perspective on human behaviour. “The term neuroscience is broadly defined as the scientific study of the nervous system” (Beeson and Field, 2017, p. 72). Neuroscience is providing information on the negative impact of eating disorders on the brain. Understanding how the brain works and how addictive behaviours take hold and become embedded in the brain, is crucial for understanding EDs and recovery. The repeated behaviours of EDs alters the neurons in the brain and affects how the brain functions, this explains changes to the brain in ED patients, and in turn, explains their compulsive behaviours.
The wiring in the human brain makes us avoid things we fear, for example, the person with AN is afraid to eat, but the brain can be rewired for recovery. Neuroplasticity refers to the brain’s ability to change and adapt, and the brain’s ability to repair itself is phenomenal. Neuroplasticity is the prime mechanism for ED recovery. Therapy involves working with clients on learning to think in diverse ways, to assist them in re-programming their brains to form new neural pathways. Think of the brain as a meadow, like a field of tall grass with addictive pathways going through it; new neural pathways can be formed in the brain to change the addictive behaviours.
Shame and Stigma
Unfortunately, there is still shame and stigma attached to EDs, due to a lack of awareness and understanding of what EDs are about. Treating EDs is not as simple as getting a person to stop the behaviours of restricting/starving/binging/purging etc. Behind the eating disordered behaviour lies a serious mental health illness that can result in death. People, particularly those with BN and BED experience intense feelings of shame and self-disgust at their binging and purging behaviours and can find it difficult to verbalise what is going on for them.
Shame has a history, targeting shame in therapy is essential and beneficial to the client. The stigma of eating disorders occurs at three levels for a person with an ED: the person feels shame about their ED, society shames them, and the structure of some medical treatment programmes can shame them. Psychoeducation is essential for all those involved with a person suffering from an ED, to eliminate the stigma and shame, and to encourage people to seek help.
Conclusion
EDs are not a choice, they are significant mental health illnesses, and they are enormously powerful. EDs are a family illness, and the ED does not develop in isolation. There is a complex interplay between genetics and the environment in the development of an ED, and it is unlikely that the societal expectation to be thin is the only predisposing factor. There is a biological brain basis to EDs, one can have a genetic predisposition to developing an ED, and their environment triggers it. Some people with EDs do not want to recover, their ED serves them, and in some cases keeps them alive. The client presenting with an ED has many layers behind their ED behaviour.
Clients with AN need food and nutrition to fuel their bodies and restore cognitive functioning, to enable them to engage in therapy and work towards their recovery. The anorexic brain is anxious, unsure, and disturbed, the ED voice is extraordinarily strong in AN, and the volume of noise in the brain can be extremely high. Clients with severe AN need immediate treatment, as starvation shrinks and damages the brain as well as the body.
Recovery from an ED is possible, and a multi-disciplinary team approach is the best treatment option. The role of a nutritionist or dietician is invaluable in the treatment process. Support for the person with the ED is essential for treatment and recovery; educating and enabling their families and friends, so having informed support people involved will help prevent the client from relapsing. The therapist and the client build a toolkit of resources together, so the client has a plan in place to support them.
References
Arnold, C. (2022). The invisible link between autism and anorexia, The Transmitter: Neuroscience News and Perspectives. Available at: https://doi.org/10.53053/ACDX9285 (Accessed: 02 August 2024).
Bodywhys. (2024). Statistics, Bodywhys. Available at: https://www.bodywhys.ie/media-research/statistics/ (Accessed: 28 June 2024).
Beeson,E.T. and Field, T.A. (2017) ‘Neurocounseling: A new section of the Journal of Mental Health Counseling’, Journal of Mental Health Counseling, 39(1), pp. 71–83. doi:10.17744/mehc.39.1.06.
Eating disorders and autism (2024) Eating Disorders Victoria. Available at: https://www.eatingdisorders.org.au/eating-disorders-a-z/eating-disorders-and-autism/ (Accessed: 02 August 2024).
Eating disorders and LGBTIQA+ communities (2024) Eating Disorders Victoria. Available at: https://www.eatingdisorders.org.au/eating-disorders-a-z/lgbtiqa// (Accessed: 02 August 2024).
Keski- Rahkonen, A. (2023). Eating disorders in transgender and gender diverse people:
characteristics, assessment, and management. Current opinion in psychiatry 36(6), 412-418.
Maine, M., Davis, W.N., and Shure, J. (2014). Effective Clinical Practice in the Treatment of
Eating Disorders. The Heart of the Matter. London: Routledge.