By Adrienne Katzow, PhD, The Counseling Center
Sep. 11, 2019: Women's mental health concerns related to body image and eating disorders can arise during different periods of their lives. Problems often appear during adolescence, when physical changes provoke anxiety, and again during the college years, when adult responsibilities often prove challenging. Women who anticipate becoming mothers may also be vulnerable as they navigate the stress of trying to get pregnant, handle the dramatic bodily changes that occur with pregnancy and adjust to becoming new mothers.
Eating problems play out on a spectrum—from concerning issues that have little impact on daily life, to a diagnosed condition that interferes with healthy living, to a life-threatening condition requiring serious medical intervention. Behaviors include restricting food, over-exercising to lose weight and binging\purging (in various forms). Severe and consistent restriction of food intake can lead to anorexia nervosa. A recent variation of this disorder is orthorexia nervosa, an obsessive focus on healthy eating and food, which is often a way to camouflage an underlying eating disorder. While this disorder is not formally recognized as a medical diagnosis, it is very prevalent.
All eating disorders tend to involve feelings of shame. Often people struggling with these issues go to considerable lengths to hide unhealthy behavior. Often, too, these disorders re-emerge for women at different points over their lifetimes; they may seem to resolve the issues at one point only to find that they resurface during periods of increased emotional stress or physical change.
Women who are coping with anxiety or depression during the prenatal and postpartum periods of pregnancy can be especially vulnerable to the reemergence of body image issues and eating disorders at different points. The excessive focus on a pregnant woman’s appearance, whether it be comments about what she “should” eat, how much weight to gain, or her body’s changing shape and size, can be particularly challenging and anxiety provoking for a woman with a history of an eating disorder. For another pregnant woman, she might actually experience relief from her eating disorder while pregnant, as there is a feeling that the body is allowed to change, but then find the postpartum experience filled with anxiety and a re-emergence of eating problems. It is fair to say that the entire process of pregnancy and birth can give rise to a spike in anxiety which can become managed through disordered eating behaviors. Although women receive considerable support while they’re pregnant, once the baby is born and the focus shifts away from the new mother to the child, support can disappear just when women most need it in the postpartum period.
Psychotherapists understand eating disorders as a way of managing overwhelming emotions and of regulating and gaining control over them. Disordered eating allows the struggling person to deal with emotions that they otherwise feel helpless to manage. Attention is deflected from the upsetting feelings and instead directed on to food and exercise. The woman may not be able to control her emotions, but she can control her food intake and physical activity. As a woman experiences the stress of a challenging job, of a competitive school, or of a difficult relationship, a therapist can help her see how hyper-focusing on food and weight becomes a coping mechanism….. a way of trying to make what is unmanageable feel manageable.
The treatment of eating disorders is complex and multi-pronged. While for some people it is enough to just see a psychotherapist with specialized training in eating disorders once or twice per week, for many patients a more comprehensive treatment team needs to be assembled. This team could involve the psychotherapist, a medical doctor who monitors the client’s physical health, and a nutritionist. In addition, group therapy might be recommended as a helpful support.
The length of treatment can vary, but in general this is not short-term work. Sometimes the eating disorder is only one piece of the patient’s mental health picture, and the underlying areas of trauma and conflict need to be explored and understood for the eating issues to be worked through and resolved. A patient’s ability for self-examination, her openness to treatment, and her capacity for insight all play a role in determining how long her treatment lasts.
Most patients with eating disorders have a great deal of ambivalence about “giving up” symptoms which feel so central to their functioning. The patient wants to change but is also fearful of changing. Individuals have developed patterns of behavior that have worked for them and it’s often more comfortable to maintain the status quo—however painful that may be—than to risk confronting the underlying issues and finding healthier ways to manage their emotions. Quite often patients are unaware of the connection between their behavior and their emotions. Much of the therapist’s work may involve helping patients translate the language of their body, eating and food into the language of their emotions and needs. For patients who are not able to articulate their feelings, this can be challenging work.
Psychotherapists approach the treatment of body image and eating problems in different ways though, these days, many would agree that an integrative approach can be most effective. A therapist can focus on helping the woman understand how her disordered eating behaviors have become a way of coping with stress or transitions in her life, but have also interfered with different parts of her life. Therapy becomes about understanding the behaviors -- where they came from in the patient’s history and how they became a way to manage overwhelming emotions, while also focusing explicitly on decreasing the behaviors and developing healthier coping skills. These days, many therapists opt for a “relational” style in which the therapist collaborates with the patient, is in the trenches with her. In this type of work, therapists seek to create a safe place, and remain supportive, as they explore what is going on with the patient outside the therapist’s office, as well as examining how unhealthy ways of managing emotions and behavior might also be played out in relationship to the psychotherapist. When patients bring these issues “into the room,” it provides the psychotherapist with a rich arena in which to point these patterns out and ultimately facilitate real change. At its best, therapy can be a crucible for change, an essential part of any patient’s journey towards growth and recovery.
Serious eating disorders can be physically dangerous and it’s important that patients be made aware of the possible current and long-term medical consequences of their behavior. If a teen is no longer getting her period as a result of her eating disorder, learning that her behavior could impact her ability to have children years later may motivate her to seek help. If a woman is experiencing dental issues from the acid build-up on her teeth caused by purging, bringing that issue into the light of discussion may allow her to see her situation more clearly. Shame associated with eating disorders pervades our culture, and it pervades the medical system as well. Often dentists and gynecologists don’t follow up with more probing questions when a patient denies a behavior, and medical side-effects can go unaddressed. With care, a psychotherapist can help steer patients to medical providers who are knowledgeable about eating disorders and will be able to approach patients with care and without judgment.
What can family and friends do to support someone who is suffering from an eating disorder? As a first step, parents, a spouse, or another significant, caring person might participate in helping the sufferer get a professional evaluation and diagnosis. Loved ones can also join group therapy or support groups that help answer questions such as: Am I enabling this behavior? Am I unconsciously contributing to it? It’s a good rule of thumb not to focus on food—not to comment on what the person is or isn’t eating, or on how much weight they’ve lost or gained. Such comments are likely to make the person more sensitive, self-aware, and anxious; less trusting and apt to confide. And yes, however well-intentioned, what people say can make the situation worse.
There is tremendous anxiety about eating and food choices in our culture and this anxiety provides fertile ground for the development of eating disorders. The current tendency to talk about “clean eating” versus “dirty eating, ” in which foods are given moral or emotional value, helps to promote this unhealthy notion that food and emotional worth are somehow linked. A better approach may be to focus on “intuitive eating,” in which food is emotionally neutral and patients learn to connect with, take ownership of, and trust their feelings of hunger, fullness and satisfaction. Unlike other kinds of addictive behavior, such as alcoholism, the patient with an eating disorder cannot turn away from food entirely, which makes the process of recovery all the more difficult. But, with in-depth treatment, patients do learn to forge a new relationship with food and to detach eating from the core of their self-worth.
At The Counseling Center in Westchester, we can provide support and guidance to help you manage a range of issues and anxieties affecting your daily life.
Pictured here: Adrienne Katzow
Photo courtesy The Counseling Center
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