Most clients with eating disorders struggle months, or even years, before seeking professional help for their illness. They ignore signs and symptoms indicating that their body is unwell. They disregard the concerns of friends. They ignore a decline in work or academic performance. They deny the deterioration of their relationships and sense of wellbeing. Often, someone with an eating disorder will wait until their lives and bodies are on the brink of utter collapse before they agree to seek help.
One might wonder why an individual is so resistant to name and face their disorder.
Of course, there are the obvious fears of weight gain, the social stigma of having a psychiatric illness and the overall disruption of engaging in treatment. But besides these, there is one particularly egregious theme that keeps sufferers trapped in their eating disorder and it is the idea that they are not “sick enough for treatment. This maladaptive idea will lodge itself in the clients mind pushing them farther and farther away from the care they need. It delegitimize the experience of their deteriorating life and keeps them quietly suffering months or even years longer than they should.
Let’s take a look at how this idea of not being “sick enough” might show up in a client’s language. At the beginning of treatment or possibly to a family member urging a loved one to consider treatment, a client will often express the following:
“I don’t need help because I do not do X, Y, or Z,”
“I don’t need help because I do not weigh XXXX lbs.”
“I don’t need help because it is just exercise, and exercise is healthy.”
“I don’t need help because I do not look as skinny as she does.”
“I don’t need help because I am not restricting, I just want to eat healthy.”
“I don’t need help because I do not do this all the time.”
“I don’t need help because my labs are not that bad.”
“I don’t need help because I am still doing great in school, work, sports and extracurriculars.”
On the surface, these may appear as surface attempts to brush off a loved one’s concerns, or to escape a difficult session with a therapist or dietitian. Upon closer examination, one will see that these are deep held beliefs by the client. The compassionate curiosity of a medical provider or family member will quickly reveal that the eating disorder has actually convinced the client that despite the medical and behavioral evidence in front of them, they are actually, “not that sick.”
It is critical that anyone dealing with eating disorders, be that the family or the treatment team, be aware of this psychological trap. Within the proper treatment context, a client can begin to believe that they are worthy of care and that indeed, their suffering is valid. A stance of, “I know you do not think you need care, but we know that you do and we can not ignore the evidence before us,” will often feel like a great relief to the client. They are depending on us – family members, friends and clinicians – to speak back to this disorder that is negating their pain.
What is True About Eating Disorder Clinical Presentation
- Weight: Being diagnosed with an eating disorder is not weight dependent, A client at any weight can meet medical and psychiatric criteria for an eating disorder.
- Body Shape or Look: Culture paints a very specific body type as the classic look for someone suffering with an eating disorder. In reality, the malnutrition and associated medical complications of an eating disorder can present in “normal” or “large” body types. Disordered eating and exercise behaviors do not always result in extreme weight loss or an emaciated appearance.
- Behaviors: Many people think “eating disorder” and associate this with food avoidance, restriction and “never being hungry.” While this can be how an eating disorder presents, there are actually many different ways that someone with an eating disorder may relate to food. Patients with binge eating disorder and bulimia nervosa may engage in “normal” eating when in front of others and then engage in compulsive behaviors when alone.
- Labs: If someone suffering from an eating disorder gets labs done, either because an eating disorder is suspected or maybe just for a routine physical, labs will often come back as normal. This is confusing for everyone and will mask the severity of what is going on. Don’t normal labs mean that everything is ok? Not in the case of an eating disorder. The body will go to unbelievable ends to keep the body’s levels of minerals and blood chemistry normal in order to keep the body going. Unfortunately, the normal lab values do not indicate health, but that the body is tapping into its last reserves.
- Dieting: Clients, family members and even medical professionals often misinterpret eating disorder behavior as “health behaviors.” While an adult may choose to engage in forms of restriction (eating gluten free, heart healthy, low carb, etc) for their personal preference, a child or adolescent should never be engaged in these sorts of dieting behaviors.
- Exercise: Engaging in exercise is socially deemed as a good thing – – – no matter what. In the case of an eating disorder, exercise is compulsive and loses its role in one’s life as a means of self care. Exercise should be, especially for adolescents, about play, connection and the joy of movement. Not about burning off, toning up or slimming down.
- Other Areas of Life: Many sufferers of eating disorders will falsely conclude that they are “fine” because they do not sense that the illness is affecting other areas of their life. Someone can be eating only 25-50% of their bodies given nutrition needs and still be attending school, working and doing band. Like the lab values, this does not indicate that everything is ok, but instead points to the unbelievable resilience of the human body.
In summary, we have a tendency, both as a culture and medical community, to dismiss a client as “not having a real eating disorder” unless he or she looks or behaves certain ways. This feeds into their already held belief that they are not “sick enough” to engage in the care they deserve. By listening to someone’s experience, asking kind questions and looking at medical evidence we can all learn to better identify the men and women around us who are suffering with an eating disorder. And if we are able to do that, we can gently and firmly let them know that they are indeed “sick enough” to seek care and that their life is intended to be fuller and freer than what they are currently experiencing.