Do you think it is easier for someone to recover from an ED when they have a more normative or stereotypically desirable body? Versus, say, an obese person who will never stop hearing extremely triggering stuff about their body type everywhere they turn? . . .
This post was originally written in response to the above question that was posed to Tetyana on the SEDs Tumblr (you can see the full question and Tetyana’s response here).
This is an interesting and timely question, and one that drives much of my research: I’m interested in knowing which bodies are easily accepted as “recovered,” and how body privilege (i.e., unasked for benefits associated with having a body that is perceived as “normal” in sociocultural context, to oversimplify) might play into the experience of recovery.
Tied into the question, I’ve been wondering, lately: Can one only hold themselves up as a beacon of hope and recovery when their body conforms to that slim middle ground where body and weight stigma is minimal (e.g., neither “too fat” nor “too thin”?). In our society, body size is taken as indicative of a number of things, including but not limited to:
- Eating patterns and behaviours
- Health
- Moral value
- Status as productive member of society
- Level of activity
We are peddled the wares of a consumer culture while, in the same breath, told to restrain ourselves. You’ll see an advertisement for SlimFast on one page, and a recipe for a triple chocolate cake with caramel filling and buttercream icing on the next. You’ll be told to indulge in December and hit the gym in January.
You’re instructed to work hard on your body (e.g., by eating certain things, exercising in certain ways), but in a way that is not too “excessive” or “extreme” or else people will question your motives, because of course, your motives have to be “good.” In doing this, you are told that you will achieve a normative body that lives in the slim (pardon the pun) middle ground that is acceptable and non-threatening to others.
When I think about the question posed, I think about how my own body is interpreted in doing the research I do: I research eating disorder recovery. I have traditionally identified myself as recovered for the reason that I enjoy a life full of things that are not at all related to food and exercise, one that is starkly different from the hellish life I lived in five years ago.
My body is easily “read” as recovered because it is normative. I have body privilege. I recovered into a body that fits into that space of not-too-fat and not-too-thin. Interpretations of my body vacillate based on who I am with and what I am talking about, but ultimately my body has lead to perceptions of my legitimacy in ways that I can’t ignore; legitimacy to different groups and to different degrees, but generally living in a “middle” body allows me to access spaces to do research that might not otherwise be available to me.
For example, when I talk about weight stigma, I might be taken seriously in part because of my body size. I am privileged to be able to speak about these issues without being labeled an “angry fatty.” At the same time, my body is generally read as “recovered,” allowing me to talk about eating disorders without anyone suggesting that I am still struggling, even if they know my history.
Despite evidence that body size is not the same as health (see, for example, this, this, and this), and evidence that stigmatizing larger bodies does little (read: has the opposite to intended effect) to combat health issues (see this, this, and this, to start) people still use bodies as currency. The double binds I mentioned above still exist and continue to constrain our ability to understand people who occupy non-normative bodies as having legitimately suffered from eating disorders, let alone being able to recover.
Scouring the literature for qualitative work around this difficulty, I kept coming up short. However, there is some evidence around how body appearance and subjective norms around what “severe enough” looks like in eating disorders impacts decisions to seek treatment. We can think about the implications of these kinds of insights and apply them to the idea of eating disorder recovery (which we can agree is ill-defined and elusive…)
WHAT DOES THE LITERATURE SAY?
Narrowing Landscape of Acceptable Bodies
In the critical qualitative literature around body size, we can see how bodies and morals are tied together. For example, Malson, Riley & Markula (2009) describe how bodies are framed in popular and scholarly messages. The article foregrounds an issue of the Journal of Community and Applied Social Psychology on body management.
The authors point out that looking at body image from a narrow, individual perspective (e.g., by measuring body image using a quantitative scale) may miss the reasons behind dissatisfaction with bodies. This makes it difficult to actually change “negative body image” or disordered eating because instructing individuals about how they should feel about their bodies does little (read: nothing) to change the broader social landscape where bodies are tinged with morals (see also this post).
Further considerations raised in the article:
- “Obesity epidemic” discourses (including the “war on fatness”) make legitimate a kind of global surveillance over bodies that makes normal submitting bodies to continual scrutiny, in the name of health
- Body size can become “a signifier of belonging, personhood and citizenship” (p. 333)
- Body size and health are assumed to follow from diligent self-surveillance and work, making it a personal responsibility despite conflicting evidence about the links between food intake, exercise, and size
Within this context, is it any surprise that our body size might impact:
a) Our willingness to seek treatment for an eating disorder if said eating disorder does not change the body to make it visibly “eating disordered” according to social understandings of what an eating disorder looks like?
b) Our ability to understand ourselves as recovered if our body does not fit into the middle ground between “too thin” and “too fat”?
Seeking Treatment
With respect to the first point, Meyer (2005) published an article about why some individuals with eating disorders might not seek treatment. She surveyed 294 young women (aged 17-32, mean age 19.33) in the US, screening for:
- Eating disorders psychopathology (using the Eating Disorder Examination Questionnaire)
- Attitudes about therapy (using the Thoughts about Psychotherapy Scale)
- Personal opinions about attractiveness (Beliefs about Attractiveness Scale Revised)
- Defensiveness (Defense Style Questionnaire)
- Demographics and eating concerns
Some key results:
- 25% of the sample showed elevated (subclinical) eating disorder psychopathology
- 11% scored in the clinical ranges
- Of those in the clinical range, only 15% were currently involved in treatment
- Only 3% of the subclinical group were involved in treatment
- Overall, 56% saw their behaviours as not being severe enough to require therapy
In this study, participants who thought their behaviours did not require treatment actually showed less buy-in to sociocultural norms around attractiveness (counter to an “everyone with eating distress has horrible body image” argument). It is interesting to consider why, then, these participants felt as though they did not need treatment.
Meyer suggests that those who did not seek treatment were in denial (or in kinder terms use immature defense mechanisms). I would challenge this perspective (or at least complicate it) and suggest that there might be something else going on here: what is it about how EDs are represented that might lead someone to think that they don’t fit into a certain category of people warranting treatment?
Relatedly, Becker et al. (2010) looked at barriers to treatment seeking. The authors analyzed transcripts from interviews with 32 ethnically diverse individuals (29 women, 3 men) with “affirmed current or past concerns, symptoms or problems regarding eating or weight.” They identified barriers to treatment seeking including geographic distance, cost/insurance issues, and social inhibitors. Among these social barriers to care, participants identified:
- Stigma and shame associated with seeking help (i.e., if the individual comes from a cultural background where seeking help is not socially sanctioned and/or problems are “kept in the family”)
- Stereotypes around eating disorders, including dismissal of symptoms by family, friends, and health care practitioners if they did not fit what society deems as the “profile” of an eating disorder
(Saren has written about this in a past post here.)
While in this article the social barriers to care relate primarily to participants’ ethnic identities, these barriers indicate the unfortunate reality that social perceptions impact upon the identification of eating disorders and their affirmation as socially legitimate concerns both in society more broadly and in health care settings.
Importantly, if one’s eating disorder goes undiagnosed, what are the implications for understanding recovery? Even if one’s eating disorder is eventually clinically validated, if one’s body does not respond in the “expected” way to treatment (e.g., showing the outward body performance of recovery–fitting into that space between thin and not thin), how might we interpret the body?
BACK TO RANTING
I wrote a book chapter about this “unrecoverability” that should be coming out in the near(ish) future; it is about how standards for recovery operate in our fatphobic culture in a way that make it difficult for people to determine what set of standards to follow when seeking to recover from distress around food, weight, and bodies. Getting back to the question at hand, I personally think, based on both my own experiences and much of the critical feminist eating disorder scholarship I’ve read, that there is body privilege is associated with recovery. Would recovery have been more difficult if my set point were higher? I think it is likely.
I think I’ve taken this in a completely different direction than anticipated, and perhaps haven’t answered the original question. I’d be curious to know if by “easier” the individual asking the question means physically, psychologically, socially, or a mix of all of the above? I don’t know of much about the physical side of things, and as Tetyana noted it would depend on how the researchers defined “recovery” and could be hard to examine based on the difficulty of determining normative bodies.
Psychologically and socially, though, I would say that yes, I think it would be harder to recover when one’s body does not conform to social norms, whatever those norms are (cross culturally). The literature has focused on how things like family and cultural messages around bodies and weight can make recovery more difficult, and I think this can be exacerbated by actual body size, though I can’t specifically think of studies that explicitly make this link.
I’d love to hear more thoughts on this from readers. What role do you think cultural messages about bodies play in recovery? How might these messages constrain the ability to recover, or even to feel “legitimate” about your eating disorder and recovery if your body does not fit cultural standards?
Perhaps most importantly, what kinds of questions do you feel researchers should ask to get at this kind of issue?
References
Meyer, D. (2005). Psychological Correlates of Help Seeking for Eating-Disorder Symptoms in Female College Students Journal of College Counseling, 8 (1), 20-30 DOI: 10.1002/j.2161-1882.2005.tb00069.x
Malson, H., Riley, S., & Markula, P. (2009). Beyond psychopathology: Interrogating (dis)orders of body weight and body management Journal of Community & Applied Social Psychology, 19 (5), 331-335 DOI: 10.1002/casp.1019
Becker, A.E., Hadley Arrindell, A., Perloe, A., Fay, K., & Striegel-Moore, R.H. (2010). A qualitative study of perceived social barriers to care for eating disorders: perspectives from ethnically diverse health care consumers. The International Journal of Eating Disorders, 43 (7), 633-47 PMID: 19806607
First, this is a brilliant and ultra important post – I will be spreading it around my social media hubs. 🙂
Secondly, I know I am repeating what I said on Twitter but as much as the literature and images of what an ED looks like lacks the complexity it needs, I find challenges in seeing what recovered bodies look like. It’s extremely hard for me to see recovered people and still think “well, they are thin…” especially when I think my set point is higher and therefore I default to thinking it is not as great. Yes, this is the ED talking but I think about this every time. I think about it when I see photos of my recovery heroes and wonder “Yes, they are recovered – and their bodies are socially desired and ‘ok'” It’s further compounded with the fact that at my lowest weight, medical charts deemed me OK – so I didn’t gain weight from this really frail body because I never had it. Yes, I was small in the worst parts of my ED, and for *me*, I was too small but starting recovery at a weight that most recovered people *end* at can be quite hard to accept.
Thanks for all your posts challenging the status quo – these perspectives are so needed both for us recovering but for people who don’t know a lot about eating disorders.
Jill
Oh and hey – I wrote about this concept here: http://anedfortherestofus.blogspot.com/2014/06/what-recovery-looks-like.html
shameless plug!
Thanks, Jill. I read the post you linked to below, too, and I am so glad to read others unpacking this issue of what recovery “looks like.” I don’t know that I’d so easily dismiss your concerns about seeing a certain type of bodies represented in recovery discourses as being “the ED talking”- I think more than that it is also societal projections of ideal bodies talking. It’s a funny tension, because in some ways the way that recovery messages operate assume that people in recovery from eating disorders will somehow be immune to the social imperatives toward a certain type of body.
You wrote: “starting recovery at a weight that most recovered people *end* at can be quite hard to accept.”
Yes! Absolutely. This “unexpected” body trajectory really challenges the idea of setting weight goals in treatment, too- why set a standard of 20-21 BMI as a blanket target when in reality bodies vary so much more than that, have different histories, and follow diverse trajectories? I don’t know for sure how many treatment programs etc. are more diligent at working individually with patients to negotiate more realistic targets… Regardless, the rhetoric of the “expected” recovery BMI remains.
The complexity of the weight/ED recognition dynamic is part of what led me to focus on some of the treatment barriers literature in this post (well that and the fact that despite my best efforts I couldn’t find any literature that directly addressed the issue at hand). I ask, again: if one’s body is never “read” as eating disordered, how can one recover? (Note: I’m not saying it isn’t possible, it is just a philosophical question about recognition, legitimacy, and the impetus then placed on the individual to self-regulate the relationship with food and weight and bodies generally).
Anyway, there I go again on my soapbox… thanks for reading the post! 🙂
Hi,
I appreciate the comments about my ED talking in terms of body acceptance – it’s something I work on hard to overcome because comparisons were a huge part of it, and it still is, but the overarching issues in our culture play a strong role for sure.
For physical recovery, I can see where a BMI or weight point could be a factor in getting better for those who are under or over weight – but it’s just that. If weight is “restored” and one’s body is functioning properly (for example, menstruating for females, other functions), it doesn’t mean the person is recovered by any means. And then this begs the question about those who don’t necessarily need a weight adjustment but are still suffering physical consequences as a result of the ED – how does that recovery render medically, particularly in the physical body?
I too could soap box about this all day 🙂
It’s tricky for sure- I think it’s less that a weight point for an individual to attain full recovery is unnecessary and more that applying a single standard for weight restoration for “normal bodily functioning” ignores the natural variation in physiology over the life course & how this intersects with recovery processes. Then again, I’m no biologist or doctor…
Thank you, a great post and very important issue.
Personally I think way too many people don’t even ask for help because they think they are ‘too fat’ for ED treatment – in Australia many people still are rejected for treatment if they aren’t emaciated. Public programs rarely admit above about BMI 14. Health professionals still buy into the myths about weight and ED’s, many times I’ve heard of friends told they couldn’t possibly have an eating disorder because their weight was ‘fine’, or they ‘didn’t “look” anorexic’ or some such nonsense – this is from the very people who SHOULD know better! Again and again I hear people saying they can’t go for treatment or ask for help ‘yet’ because they are ‘not sick enough’ because their weight is ‘too high’. It’s tragic that people face such difficulty being taken seriously until it’s too late – or at the very least until they have spent far more time suffering the torment and becoming much sicker than had they had timely intervention.
I have nothing to contribute with regards to ethnicity, but age is definitely another barrier – I know quite a few older people with EDs who are deeply ashamed/embarrassed to have an ED ‘at their age’ and fear being ‘laughed at’ by professionals or fellow patients or not being taken seriously.. or fear being deemed ‘too old’ to ever recover so ‘not worth’ helping.
As for normative bodies, I don’t think it’s necessarily easier to actually recover. I think it’s difficult to define what recovery IS, but I think when people get there, they will know. I think many people with EDs are struggling with distorted perception to the degree that even if they had a ‘normative’ body, it wouldn’t ease the *internal*, mental struggles. With external issues like getting help, being heard, escaping judgement on body size and so on, yes it might help – but I think actual recovery will happen regardless of body size as long as the person is nutritionally restored.
I really would love to read your book or book chapter 🙂
Thanks for reading! Absolutely, I agree that way too many people are not asking for help because they feel that they couldn’t possibly be suffering from an eating disorder because of their body size. I’ve heard similar stories from participants, whose doctors told them that they “looked ok” or even that the doctor “wasn’t concerned about anorexia or anything.” So upsetting. I’m always so happy to hear from clinicians who ARE aware of the need to look beyond body size, perhaps because they seem few and far between.
You wrote: “It’s tragic that people face such difficulty being taken seriously until it’s too late – or at the very least until they have spent far more time suffering the torment and becoming much sicker than had they had timely intervention.”- I completely agree. This is one of the things that makes me so sad about the state of affairs, eating disorder treatment wise. Why wait until the disorder has progressed to an even worse place? Moreover, the body might never manifest the “expected” physical signs of an eating disorder, regardless of “how sick” the person becomes. If the eating disorder is significantly impacting someone’s well being, they deserve support (whatever that support looks like for them, as appropriate). Period.
Age is definitely another sticking point- I think this also speaks to the discourse that people “should know better” than to develop and eating disorder (ARGH don’t even get me started on that one, as if developing an eating disorder was under someone’s volitional control…) So by corollary, eating disorders stay the purview of the young, who are seen as more influenceable. Sigh.
I’ll let you know when the book is out! Thanks again for reading and taking the time to comment! 🙂
Thought-provoking post, Andrea. I agree that there is some inevitable body privilege in the recovery world, as you pointed out from your own research work, and I feel the same is true as an ED therapist: would my clients trust me as much if my body were outside the “normal” range? I can’t say for sure, but I imagine it would affect my work in some way.
This comment is slightly tangential to the main point of your post, but regarding what you wrote about body image: “This makes it difficult to actually change “negative body image” or disordered eating because instructing individuals about how they should feel about their bodies does little (read: nothing) to change the broader social landscape where bodies are tinged with morals ” — I really believe that true body image work is not about helping people “love their bodies!” in that frou-frou kind of way… if they get there at some point, wonderful. But I really believe it has to be about A) increasing the significance they put on their non-physical attributes, and B) continuously reminding them that while the mainstream messages won’t change, they can get angry about the ridiculous state of those messages in our culture.
I have seen both of those make significant impact on “body image” issues across the weight spectrum.
Hi Valerie, thanks for your comment! I thought I’d chip in. Andrea has actually written about the effects of therapists’ bodies on, well, therapy here: Matters of Appearance: Eating Disorder Patients’ Interpretations of Therapists’ Bodies. You might find it an interesting read?
I also agree with your point regarding decreasing the significance of physical attributes and validating their anger (although I think messages can change, in fact, they do change, it just takes time). I came across a study that supported the latter point recently:
These findings suggest that the presence of body image-related negative experiences does not necessarily lead to impairment in women’s QoL, which is rather dependent upon one’s ability to observe these unwanted experiences as transient and subjective. Therefore, intervention programmes aiming at increasing women’s QoL should focus on targeting emotional regulation processes in order to develop the ability to pursue life goals and values, even in the presence of unwanted experiences concerning body image.
I do think that decreasing importance of weight/body is still probably easier for someone with body privilege. That’s whole point of privilege, I feel. I don’t know though, I mean, this hasn’t been researched in studies from what I’ve seen (i.e., the effect of a higher weight on self-perceived ease of recovery). My next post is a follow-up to this one and explores the question further but from a slightly different perspective (my background is more quantitative than Andrea’s, so we tend to approach questions differently).
Thanks for commenting, Valerie! I think that you might be right in terms of real body image work going beyond the kind of airy-fairy love-your-body-it-will-all-be-fine perspective, but I wonder whether most or all body image work (e.g. that which is done in society more broadly, not necessarily in the therapy context) is “real body image work”?
Most of what we see tends to be large-scale campaigns along the lines of “healthy is the new skinny!” or messages that suggest that moving toward body appreciation or “love” is a side effect of becoming more media literate. Perhaps this is the case for some, but definitely not all! I think that one thing missing here (in these broader messages) is an acknowledgment that media literacy and positive body image are not necessarily synonymous. Can becoming more media literate and able to critique mainstream body messages help? Yes, of course. But it does not necessarily mean people’s actual relationship to their body will be good most or all of the time. I also think that it isn’t enough to make the change within individuals (not that I think you are suggesting this but it bears repeating)- while mobilizing people to “get angry about the ridiculous state of those messages in our culture” is a part of it, I think another part of it is leveraging this discontent for broader systemic change not only in media messages but elsewhere in peoples’ lives (e.g. the more subtle messages received at schools, through friends, etc.). As Tetyana said below, I also think that the ability to value other parts of the bodily experience may be easier when in a normative body. When living in that middle place where messages about bodies (might) feel less salient (e.g. not “too thin” or “too fat”) there is more grey area around which prescriptions for how to manage one’s bodies most applies. Of course, this can cause other difficulties, especially in eating disorder recovery (e.g. do you still have to follow a meal plan or do you jump on the cultural dieting bandwagon once your body is no longer read as eating disordered and is now “normal”?) but I could ramble about this for days…
Again, all of this also applies to those who felt that body image played into their eating disorder in the first place, but also for those who struggle with body image issues but do not have disordered eating…
Anyway. I’m probably not saying anything you don’t already know, just chiming in with a little ramble based on what your comment made me think about!
Thank you both Andrea and Tetyana for your detailed, thoughtful responses — your knowledge and passion for this work is so evident. Just wanted to “co-sign” pretty much all your comments, and especially Tetyana’s points about real “body image work” being more about emotion regulation and values-based living in the face of difficult thoughts/feelings than anything else. It’s why I love the model of Acceptance & Commitment Therapy, which basically says that we have quite limited control over our thoughts and feelings, so changing them is less important than learning how to move toward the life we want even in the presence of that stuff.
And I also agree with the comment that it’s easier to decrease importance of appearance in someone with body privilege… I have not explored my own “privilege” to the extent that I probably should, and the fact is that it’s difficult at times to feel like a beacon of hope for someone who has a way different body than I do. It can make me feel almost a little fraudulent (don’t think that’s exactly the right word, but you know what I mean.)
Thanks for mentioning the other post about clients’ interpretations of therapist bodies — I had not read it and it is on my list to read today! I follow the blog somewhat sporadically, but want to commit to following more regularly because your content is so in-depth and great! Thank you.