Pride Before a Fall: The Intertwining of Pride and Shame in Eating Disorders

Is there a link between eating disorders and shame? What about pride? Can understanding these emotions help us to understand how eating disorders develop, and how they are maintained? In reviewing literature for my specialization paper, I stumbled upon a qualitative study by Skarderud (2007) about the role of shame in eating disorders. I found the article quite interesting, so I fired up the “where was this cited” tool on my university library database and uncovered a wealth of studies looking at shame, pride, and eating disorders.

For the purposes of this post, I’ll comment on Skarderud’s study, also bringing in a longitudinal study by Troop & Redshaw (2012) that looks at general and bodily shame.

Shame and Pride

Skarderud, who uses a phenomenological approach in his study (meaning that he is trying to unearth the particularities of shame for those who experience it) sees shame as made up of both positive and negative elements. He states that “shame is something we want, and something we do not want” (p. 82), referring to how we (socially) see both shame and shamelessness as negative.

“Positive shame” could mean self-protection; for example, drawing a boundary around a negative social relationship. Alternatively, it could refer to being “appropriately” self-deprecating. Taken to the extreme, however, shame might result in isolation or low self-worth.

Skarderud sees shame as made up of the following components:

• Emotional
• Cognitive
• Bodily
• Behavioural
• Interpersonal

Others have looked primarily at shame primarily in interpersonal contexts, including Goss & Allen (2009), who look at how being rejected or insulted might provoke shame, which may then lead to poor clinical outcomes.

Looking specifically at eating disorders and shame, researchers have considered how shame might be implicated in the nexus of factors that contribute to eating disorders. The hypothesis here is that shame and eating disorders are cyclically related: for example, something would provoke shame; in response, the person feeling ashamed might engage in a behaviour designed to control the feeling of shame (such as restricting or bingeing and purging), which then itself provokes more feelings of shame.

Other researchers (including Skarderud) have expanded upon this cyclical relationship, bringing in pride and exploring a “shame-pride” cycle, wherein the behaviours used to manage shame may also invite feelings of pride (for example, of the ability to exercise control), at least in the short term.

Skarderud’s Study on Shame and Pride

As I mentioned, Skarderud took a phenomenological approach to studying shame and pride. He interviewed 13 women with anorexia nervosa (aged 16-39). Of these women:

• 8 had been diagnosed with AN-R
• 5 had been diagnosed with AN-BP
• BMI ranged from 10.8-17.6
• 11 had been diagnosed prior to the age of 18
• Illness duration ranged from 1-19 years (median 6.4 years)
• All were involved in psychodynamic treatment with the author at the time of the interview

It is worth noting that the author does provide a strong exploration of how his dual role as researcher and psychotherapist might have impacted both the results of the study and the therapeutic relationship. Because of his long-standing relationship with the participants (in a therapeutic role), Skarderud conceptualized interviews as co-constructed (i.e., he entered into the interview with set questions, but also followed the participants’ lead throughout and noted where his own presence may have impacted the responses).

After analyzing interview transcripts, Skarderud groups results into 2 main categories:

• Globalized shame, or a “general sense of unworthiness”
• Focuses of shame, including where and how participants sensed shame

So, what were the focuses of participants’ shame? In brief, participants experienced shame around:

Thoughts and feelings: including envy, greed, rage, sadness, and grandiosity

E.g. “Ingrid: I compare myself a lot to others. And they are so much better than me at most things. They are smarter than me in most things. And so I want to be like them. I am envious, and envy is a feeling which I think is pathetic.” (p. 87)

Failures: or perceived failures, including the need to seek help

E.g. “Helena: First of all I felt very shameful about having to start in therapy. It hurt my pride. I like to manage on my own. And I don’t like to ask for help.” (p. 88)

Bodies and Appearance: including but not limited to body image disturbances, not wanting to look at themselves in the mirror

Bodily Functions: going beyond bodily appearance toward feeling shame about bodily processes, including sexual intercourse

Self-control: including related to overeating, self harm, and self-destructive behaviour

E.g. “Rachel: I don’t do it any more now . . . I have read about self-mutilation since I have been doing it myself, and I think that some of what I have read applies to me. Other things don’t apply. I know that I cut myself because I wanted to get away, deflect extremely painful feelings. I felt so awful, and had to get out. I couldn’t come up with other ways of doing it. And it did actually work every time. That’s why I found it difficult to stop doing it.” (p. 89-90)

Sexual abuse: including from being made to feel inferior and not having resisted

The eating disorder itself: including not being able to “eat normally,” feeling accused of vanity in the social arena, and dealing with stigma

E.g. “Emily: There are 5 billion people on this earth, maybe even 6 now? Many of them don’t have enough food, so they have their own eating problem. But for the others, for those who have enough food, eating is rarely a problem. And very many eat with great pleasure. Just eating should be very simple. Everyone manages it, except for me and some others. I don’t cope with something as elementary as eating every day.” (p. 91)

Participants also expressed pride, particularly related to:

• Self-control
• The feeling of being extraordinary
• The achievement of a particular appearance
• The act of rebellion/protest embodied through eating disorder symptoms

Skarderud suggests that shame and pride interact: feeling shame related to the eating disorder does not mean that one cannot also experience pride, and vice versa.

Together, these feelings of shame and pride also made me think about how having an eating disorder does not mean one is not aware of:

• The impact behaviour is having on the self and others
• The long-term ineffectiveness of the behaviours
• How others think about eating disorders

Too often, people with eating disorders are treated as though they don’t know that eating disorder behaviours are maladaptive; essentially, this is the argument people leverage where they think all someone needs to do is “just eat.” While I’m sure I’m preaching to the choir here, I think what some of this shame and pride research does is reinforce a need to avoid such simplistic assumptions about individuals with eating disorders.

Troop & Redshaw’s Longitudinal Study on Shame and Bodily Shame

While Skarderud’s research is interesting, it is a relatively small study and cross-sectional. The study also identifies but does not delve into great detail about the role of bodily shame in eating disorders, beyond suggesting that bodily shame may actually be a more appropriate label than “body dissatisfaction” for the negative emotions (some) people with eating disorders may experience.

Troop & Redshaw explored bodily shame over an extended period of time. To do this, they followed 55 women (past or current ED diagnosis) over 2.5 years, asking the women about eating pathology, depression, shame and bodily shame (current and anticipated). Of the participants:

• 13% had a history of AN-R
• 43% had a history of AN-BP
• 20% had a history of BN
• 24% had a history of ED NOS
• 2/3 reported active illness
• 1/3 reported remission or recovery
• 91% had received treatment at some point
• Mean age was 34.6
• Mean BMI was 19.8

Both general and bodily shame were related to eating disorder symptoms when participants were first asked, as well as 2.5 years later. Bodily shame predicted several AN-related factors:

• Being underweight
• Being fearful of gaining weight
• Misperceiving body size

Interestingly, BN symptoms were not predicted by either general or bodily shame. This could have something to do with the specifics of the type of shame examined in the study. Is it possible that shame in BN looks slightly different than in AN? Could it be more closely linked to the other types of shame Skarderud looked at, such as shame related to control?

Some suggest that the shame cycle in AN could be more accurately described as linked to external shame and to a shame-pride cycle, while shame in BN may be a shame-shame cycle, tied into internal shame.

These distinctions align with social constructions of AN and BN (as I described in this post). We tend to think about AN in relation to the physical manifestation of symptoms, for better or for worse. AN symptomatology is also often conceived of as things that society values, taken to the extreme. BN, on the other hand, tends to be more covert. It is the behaviours themselves (e.g. binging and purging) that constitute societal understandings of the disorder; perhaps this could help to explain why individuals feel internal shame related to their non-normative coping strategies.

What Does it all Mean?

What all of this gets me thinking about (and what several authors of such studies have remarked) is how this understanding can enhance the way we approach and support eating disorder recovery. Really, this research provokes more questions than answers, for me. For example: How might shame, and particularly stigma, contribute to silences around eating disorders?

To begin to answer questions like these, I think we need to look at the broader social context surrounding shame and pride. To me, the kinds of things that people with eating disorders feel shameful or prideful about are microcosmic representations of broader societal values. So, is there any way we can start to minimize shame by questioning the values we hold about food, weight and bodies? Can we think critically about the moralizing of bodies (i.e. associating larger bodies with laziness and smaller bodies with control) and behaviours (i.e. associating some foods with “being good” and others with “being bad”) and how this might provoke feelings of shame? Recognizing these links might be a good start- if a difficult one- along a path toward accepting a wider variety of bodies and bodily practices.

References

Skårderud, F. (2007). Shame and pride in anorexia nervosa: a qualitative descriptive study. European eating disorders review : the journal of the Eating Disorders Association, 15 (2), 81-97 PMID: 17676677

Troop, N.A., & Redshaw, C. (2012). General shame and bodily shame in eating disorders: a 2.5-year longitudinal study. European eating disorders review : the journal of the Eating Disorders Association, 20 (5), 373-8 PMID: 22318918