Eating Disorder Myths—and How to Help a Loved One

It usually starts with dieting, but underneath that dieting is this biopsychosocial vulnerability that gets triggered: There’s the biology of it, there’s the psychology of it, and then there is the social factor.

The biological component is that people can be genetically vulnerable to an eating disorder. That’s why most people, at least in our country, might go on a diet at some point in their lives, but most of them don’t develop eating disorders. Eating disorders can overlap with certain personality traits—like perfectionism, cautiousness, impulsivity, all-or-nothing thinking, rigidity, or even competitiveness. It depends on the person; it’s very individual.

Then there are the psychological factors, which might be low self-esteem or emotional sensitivity. A mental, physical, emotional, or sexual trauma can be another psychological factor, as well as if someone has another mental illness, like depression or anxiety.

Interpersonal relationships fit into the social part of the biopsychosocial. How are their relationships? Also: What is their social world like? Are they on social media a lot? Are they looking at fashion magazines? Are they in a sport that demands leanness as part of the competition? These may be added risk factors.

Most of the time, someone will have many of those vulnerabilities, and then they’ll go on a diet, which creates the tipping point.

It’s really tough. It takes a long time for somebody to develop enough confidence in themselves after an eating disorder to accept their body when they’re eating enough. To let go of feeling only perfect is good enough. In therapy, we’re using the one hour to go up against however many hours in a week they’re up against the culture all around them.

One thing I do is help people to see themselves as a whole person, not just as body parts. To see body image as only one spoke on the wheel that represents their values, instead of the hub of the wheel: It’s okay to not have the perfect body image. That is not pathological. It’s even okay to wish your body looked a certain way that it doesn’t look. What’s problematic is if enjoying life and participating in it revolves around having a perfect body image. I try to help people move body image from the hub to a spoke on the wheel along with the people, activities, and experiences they value.

Sometimes people think, Oh, when I’m recovered, I’ll think my body’s perfect. That’s not true at all. Full recovery is possible and it does not mean perfect body image. Our bodies aren’t sculptures; they’re not going to be perfect. It also doesn’t mean you can’t work on fitness in recovery. What it does mean is that you accept the imperfectness and the humanness of your body. If you’re sick, you take a day off of exercise. If you have an event to go to, you can eat the food that’s at that event. You place your other values above the rigid rules of an eating disorder.

The best intervention I can think of is to accept that health—mental and physical—comes in all shapes and sizes. There isn’t one shape or size that is right for everyone. If a client comes to me and they consider themselves overweight, they’ll say, “Look at me: I’m not healthy.” And I’ll say, “How would I know whether you’re healthy or not by looking at you?” That question just shocks them, because they assume that because their weight doesn’t match up with the ideal of society, that means they’re not healthy. As if weight is a proxy for health. It is not.

I work with clients all the time who are students, and they’re listening to people talk about the diet they’re going to go on before a formal, or summer, or some kind of event. They have to be able to walk away and to say to themselves, “Dieting wouldn’t be good for me. I can’t join in on that.” They have to be able to separate themselves. Sometimes the healthiest thing someone with an eating disorder can do is to eat that dessert. Or to be able to say to themselves, “I am doing the healthy thing by not exercising. I’m doing the healthy thing by having an extra snack when no one else is.” That’s hard to do, but it is a really important part of recovery.

Trauma interferes with a person’s sense of safety and trust in the world. It can also interfere with self-esteem and feeling a positive sense of control. Sometimes when someone has gone through a trauma, they’re looking for very simple ways to feel in control and to feel a sense of safety. In some ways, eating disorders seem to offer that, because it’s like, Well if I eat this many calories today, it’ll be a good day, and I can trust that I’ll feel good at the end of the day, and I’ll feel safe. These are my safe foods.

It also can be a way of punishing the self. If you’re a victim of trauma, you may have internalized negative feelings about yourself. It’s counterintuitive but being a victim can come with shame. So the eating disorder might become a set of punishing behaviors. The rules of the eating disorder can be a huge distraction from the trauma, too. Following the eating disorder rules can be a way to avoid dealing with the trauma itself and the stress of confronting it.

It’s not contagious like a flu. But it can be contagious in the sense that you could learn behaviors from someone in a social setting, like throwing up as a way to manage weight or emotional distress. I’ll ask clients, “When was the first time you ever threw up?” and sometimes they’ll say, “Well, my friend told me that’s what they did.” Definitely some people with eating disorders have learned behaviors from peers, even in treatment settings.

We psychologists have a history of looking to family for a causal relationship with children’s problems, but that’s not always the case. With eating disorders, it’s especially not always true.

Families can be a big part of recovery. For younger children who have eating disorders, we really try now to use what is called family-based therapy (FBT), which trains families to provide treatment in their homes. The Maudsley City Hospital in London developed it when the doctors there realized they would get kids well and discharge them to family, and the kids would relapse. Then they’d come back in, and the hospital would get them well, they’d be discharged to family, and they’d relapse again. So the hospital started training the families on the model the treatment specialists were using for treatment inside the hospital. They observed that when families learned how to do what hospitals do, they did it really well. FBT is now the most empirically validated treatment for anorexia nervosa in children.

The training is usually weekly outpatient therapy, during which parents are trained to provide the treatment based on fully supervised meals to reach weight restoration. Food is the medicine. It’s not the same thing as family therapy, but you bring the whole family in for every session. Each week you talk about how the week went with eating normally, what’s going well, what’s not going well, how the parents are doing supporting the child in the return to health. You’re basically putting the parents in charge, empowering them to be helpers when there’s a bump in the road. It’s successful because who’s going to be more devoted to a child than their family? It starts with parents having full control, then the child or adolescent regains healthy control, and it ends with full independence.

The goal isn’t to blame anyone. Eating disorders are about food, and they’re not about food. We start with the food part, because when somebody’s been starved, or purging, or taking laxatives, that has medical consequences. Getting them medically and nutritionally stable first has the added benefit of helping the brain heal, so you have a more sound brain to work with during therapy. After somebody’s weight and eating is stable, you focus on the non-food aspects of the illness. That might include looking at perfectionism, anxiety, relationship problems, depression, etc.

The other benefit of it is that when kids hit some other adolescent challenge, they’ve relied on their own parents to help them instead of relying on a treatment team, and it helps the family address any kind of problem as it comes.

Usually FBT is provided by individual therapists who specialize in treating eating disorders. There are also treatment centers in the US that specialize in family-based therapies. People can look up Maudsley therapy, or family-based therapy to find treatment in their local community. UC San Diego has an intensive treatment program where parents and children go for five days to learn FBT. When they go home, they work with their own therapist, but it gives parents a good jump start. The outpatient program Nourish for Life at UCLA, where I consult, uses a family-based therapy model. There are similar programs all over the country: Stanford, UC San Francisco, and the University of Chicago all have programs, too. There’s also an organization called F.E.A.S.T. that has a family-run website about family-based therapy.

It is more unusual to develop anorexia or bulimia after your mid-twenties, but we are seeing eating disorders develop more frequently during big life transitions. Where either somebody is dealing with a lot of loneliness or sadness—like death of a loved one, or parents becoming empty nesters—or they decide to take “control” by getting really fit, going on a diet, and starting to exercise. In either scenario, if someone is genetically vulnerable, this set of changes can inadvertently kick off an eating disorder. Unlike a diet, once an eating disorder starts, it is hard to stop.

Anorexia nervosa is unlike other mental illnesses in that it’s egosyntonic, which means that it goes along with the ego. People think they want it, so often they don’t seek out treatment on their own. More frequently it will require a loved one, friend, or partner to tell them that they don’t seem healthy. Because there is distorted ideal body image in our culture, often they’re getting a lot of compliments at first, and then they don’t realize it goes too far. Because it’s egosyntonic they think other people are trying to talk them out of something they want.

With bulimia nervosa, usually people are uncomfortable with the loss of control around food. That discomfort motivates them to get help. So if they’re bingeing, they want to get help, and if they’re purging, they want to get help.

People with binge eating disorder, which is the most common eating disorder, are the least likely to want to get help—despite binge eating disorder having the most successful, quickest treatment rate. They’re reluctant to get help because there is lot of shame associated with it. Often they’re not underweight, so they feel ashamed and don’t want to tell anyone they have an eating disorder. People with binge eating disorder are more likely to seek help for depression, anxiety, or relationship problems but may not even tell their therapist that they’re binge eating.

First, know that early intervention leads to better outcomes. If someone has an eating disorder, the sooner they get help, the better it is going to be for them. The less time your brain spends in a certain negative loop, the better. Same with your body.

It depends on the relationship and the age of the person. If it’s an adult, I would be compassionate and direct: Say what you see. Say, “I’ve noticed, this, this, and this, and I’m concerned and wondering if you would be open to talking to your doctor about it or going to talk to a therapist about it.” The Academy for Eating Disorders and the National Eating Disorder Association have great information for partners, families, and friends about how to talk to a loved one, so read up on those websites before you talk to someone to become familiar with what tends to work.

You also don’t want to make assumptions, because you don’t know if someone has an eating disorder or if they have something else going on.

In the case of a child, I recommend that the parent go to their pediatrician, because pediatricians can plot out a growth curve—where they think the child is going to be based on their developmental trajectory with height and weight. One of the easiest ways to identify anorexia is when a child or adolescent falls off their growth curve. So a parent could go to the pediatrician alone and ask for a consultation. If the doctor is concerned, then it’s time for action. It’s not a matter of asking the child if they want to get help; it’s a life-threatening illness, so parents are responsible to get them help. It’s like if your child is running into traffic. You have to stop them.

If someone thinks they hear their child throwing up or anything of that nature, it gets trickier. I would go to a pediatrician or to a therapist who specializes in eating disorders and say, “This is what I’m seeing; what do you recommend I do?” It might make sense to set up an appointment with all of you together to start a conversation.