Michelle writes…
Once, I had a therapist for depression who assumed that I had binge-eating disorder because I am fat. It took me over a year to realize this. From the beginning of therapy, I made it clear that I was not there to talk about my weight, and it was off-limits as a topic. So, for over a year, I paid her lots of money and we never talked about my weight.
Then, while I was still in therapy for depression, I began to see a dietitian who specialized in Health At Every Size, and treated people with eating disorders. My eating was all chaotic and out-of-whack years after a bout with food restriction (aka “dieting”), and I was unhappy about it. She assessed me and told me that I did not currently have an eating disorder, binge or otherwise, though she agreed that my dieting episode, years
previously, had been on “the slippery slope” of anorexia nervosa.
After a few weeks, I felt more comfortable talking to the dietitian than the therapist. We talked about body image, which had been off-limits in therapy since I did not feel like paying by the hour to educate my therapist about fat prejudice, and the topic of sexual harassment came up in one of our conversations. It rattled me with surprising force. The dietitian looked at me and said, “I think you need to talk about this in therapy.”
So, I went to the therapist and told her I wanted to talk about body image and sexual harassment, as a corollary to the work I was doing with a dietitian. She told me she was not experienced in this area, but she checked with the head therapist of centre, who was, and who gave her the go-ahead to proceed, with indirect supervision.
We talked about body image stuff. Then we talked a little bit about eating, and I tried to explain why I was seeing the dietitian. She started to say, “Now, when you binge…”
I stopped her. “I don’t binge. I don’t have an eating disorder.”
She nodded. We talked a little more about eating. Again, she started to say something about psychological techniques to use when the urge to “binge” came up. I told her again that I didn’t binge, I did not have an eating disorder, and I’d been assessed by a dietitian who specialized in eating disorders. Besides, the closest I’d ever been to an actual eating disorder would have been anorexia nervosa, not binge eating. While the two are sometimes connected, getting advice for binge-eating disorder when your problem is food restriction is totally backward. And the psychologist had never even assessed me for an eating disorder. She just assumed I had one, and she assumed it was binge eating.
In an even, professional, and quietly condescending tone, she explained to me that, while “dietitians may know a lot about nutrition and possibly even have some counselling skills,” it was not wise to depend solely on the advice of a dietitian when it came to psychological matters — like eating disorders. Even if the dietitian specialized in treating them. Even if she, the psychologist, had no experience with eating disorders. Even if I didn’t have an eating disorder.
I left feeling funny. I’d known this woman a long time. I paid her money, but in a way, we were almost friends. We were of similar ages, similar cultural backgrounds, and both interested in the same academic fields. Sometimes she told me brief, personal stories from her own life to illustrate a point. I liked hearing them. At the end of a session, I’d write
her a cheque and she’d print up my receipt, laughing and chatting easily all the while.
That day, I went home. We’d booked another appointment for a few weeks hence, as usual. After a day or two, I called her voicemail and cancelled it. I told her I’d reschedule, probably the following month. I never called her again.
First, Do No Harm 
Raye
/ December 7, 2007“Besides, the closest I’d ever been to an actual eating disorder would have been anorexia nervosa”
You cannot be close to anorexia if you are fat. That goes against the DSM IV-TR definition of anorexia. You can call yourself anything you want, but if you want to use a defined medical term, you have to actually fall under the definition.
A fat person can have disordered eating, but good luck getting into a clinic for anorexics (you’d be laughed at!).
fillyjonk
/ December 7, 2007A fat person can have disordered eating or an eating disorder (they’re not quite the same). But it’s true that a fat person who doesn’t eat but doesn’t become underweight would be diagnosed as EDNOS, due to the DSM not taking into account the fact that BMI is baloney.
Deniselle
/ December 7, 2007If it was the eating disorder specialist/nutritionist who said her behaviors would fall under anorexia, then I don’t think we can criticize the writer for using the term. She wasn’t self-diagnosing; it was simply the eating disorder she was closest to.
Basically, like fillyjonk said, the definition is fucked up because BMI doesn’t say anything about your eating behaviors, and the anorexia definition requires an underweight BMI. However, lots of fat people do exhibit anorexia behaviours and I think there should be more public discussion about definitions of this kind. Definitions are always made by people, and our knowledge of eating disorders is pretty limited still.
The therapist sounds like she was well-meaning, but unable to see past the fat. Not so much fat-hating as fat-ignorant, I’d say. I hope you found a better therapist with a wider perspective, Michelle.
fillyjonk
/ December 7, 2007It’s certainly a problem with the definition, which is patently absurd and totally fails to take into account many aspects of human physiology. It’s infuriating, actually. I don’t really think using the term “anorexia nervosa” to refer to pathological self-harm through compulsive starvation without reaching 80% (I think) of your ideal body weight casts any doubt on the nutritionist’s knowledge about eating disorders.
littlem
/ December 7, 2007It’s been an observation of mine that therapist think that they’re the ONLY people in the world with professional training and, as such, they know EVERY damned thing.
It’s in the face of examples like these that I feel inclined to calmly say to practitioners, “You know, I’m well aware as a client (I don’t use the word “patient”; I’ve learned a thing or two about mnemonic anchors) that a psychology or psychotherapist’s job is, insofar as possible, to ease clients into adjusting to the status quo.”
Then shriek,
“But what if the status quo itself is F**KED UP?!?”
Then at least you know they’re listening.
And they know that you’re not clueless. Nor passive enough to just swallow whatever bullsh** is fashionable in the DMSR-IV (or whatever the h*ll) this month.
‘Cause Ceiling Cat knowz that dokcumentz is NVR rong or incompleet.
Jeebus.
charlie
/ December 7, 200785%, I think, Fillyjonk.
I didn’t eat more than 150 calories a day for 6 months, had grown all over body hair, and had to wear several layers of clothing to maintain body temperature, and the psychiatrist diagnosed me as anorexic – even though at my lowest I had a BMI of 20.5. During 6 months I lost only 20 pounds, but by the end it was obvious physically that I was in distress. I was having trouble opening doors, my hands tingled if I lay down, I couldn’t get better from a cold.
If they’d got me at month 3 when I felt like Superwoman, before I started getting sick, I was still *thinking* like an anorexic, and the treatment I responded to was similar. So whatever you call it, it’s similar in the head.
I imagine the difference between me longer term anorexics is repeated patterning: because I tapped out sooner physically than others, the hold of the addiction wasn’t as strong. I wanted to be better.
queendom
/ December 7, 2007Your experience is – unfortunately – no exception. As I have said elsewhere I have binge eating disorder. People, including therapists, have no problem believing that – hey, after all I am fat! However, they usually ignore completely that I have had many times in my life when I restricted my food intake quite severely for some time and lost up to 100 pounds in six months. I also tend to get quite obsessive about exercise. I always mention those things when I talk about my eating disorder with a (mental or otherwise) health professional. However, except for one wonderful therapist every single health professional I have ever met in my life thought that any weight loss was great for me and surely a sign of recovery.
The problem with that is that part of me is a total sucker for praise – so if someone tells me how great it is that I lost weight, particularly if a health professional tells me so, my immediate reaction is to keep up the “good work” even though I know better until eventually I end up in a phase when I binge again for several months, gain back all the weight, and feel generally rotten about myself. In addition I have had times when I felt quite bad during weight loss (I struggle with chronic depression) – however, everyone assumed that I was doing really, really well; after all I had lost weight.
I know that I am not alone with these problems, and I know that most health professionals mean well and behave the way they do because they just don’t know any better. However, I cannot help but feel angry about this situation, particularly since many of the respective health professionals also display the quietly condescending manner that you described.
As a result of all this I, too, have tried to keep body image and eating disorder matters out of therapy – which is obviously far from ideal for someone with binge eating disorder. In addition, it also does not work very well because many of my issues are linked to having been bullied for years because of my weight.
Thorn
/ December 7, 2007Raye, I really hope you were just being sarcastic, because otherwise you sound an awful lot like a troll, and we don’t permit trolling here. Just FYI.
Anyway, fillyjonk and littlem and Deniselle have already pointed out the problems with the DSM and other diagnostic documents compiled and edited by a specially selected group of doctors (a group almost entirely composed of straight, white, largely conservative men), so I don’t have to, but I would remind you – that tome you’re quoting? Not so long ago listed homosexuality as a mental illness, so really – let’s not act like we’re talking about the Constitution of the United States here.
Michelle – that’s really crummy. I had a similar situation – I went to see a therapist recently, and mentioned that I’d been doing a bunch of thinking about HAES and the like, and what did she do? She recommended I attend this class run by a nutritionist which many of her patients “just love” and how it’s totally great, and btw, the nutritionist is a “larger gal” as well. Right. So I looked up this class, and the first sentence of the description? Talked about “sticking to a diet.” Yeah, right, that’s totally HAES. snort!
I’m sorry you wound up discovering your therapist’s prejudices after such a long working relationship with her, though. That must have been really hard.
Becky
/ December 7, 2007You cannot be close to anorexia if you are fat. That goes against the DSM IV-TR definition of anorexia.
First of all, you can be close to anorexia without meeting all the criteria. That’s why she said she was close to anorexia, not anorexic. Secondly, it doesn’t really go against the definition. The DSM criteria doesn’t actually mention BMI. It talks about falling below 85% of a normal body weight. So a person who weighs 200 pounds can meet that criteria if 240 pounds is a normal body weight for that person. It’s just that doctors don’t seem to understand that 240 pounds can be a normal weight.
Cindy
/ December 8, 2007Photographer Lauren Greenfield spent huge amounts of time in a residential therapy center making the documentary “Thin.” I went to a lecture she gave at Texas Woman’s University, and she said there were people in treatment for anorexia who weren’t skin and bones.
Deniselle
/ December 8, 2007queendom, it’s one of my pet peeves with anorexic friends that people, even smart people who know a bit about mental problems, immediately think they’re getting better if they gain a bit of weight.
Would you say the opposite is true of binge eating disorder? If you lose weight, people assume that you have achieved “control” and gotten well? I’m shocked that this even applies to experts.
sso
/ December 8, 2007“it’s one of my pet peeves with anorexic friends that people, even smart people who know a bit about mental problems”
YES. i absolutely hate it when people say to me, “oh, but you’re all better now, right? i mean, you don’t look sick…you’re at a healthy weight!” actually, no i’m not “all better now,” nor am i at a “healthy weight.” besides weighing less than what i know to be the natural weight for my particular body, i’m actually even still below the arbitrary BMI cutoff for anorexia (which I believe is 17.5 – mine is just under 16). we’re so used to seeing extremely thin women in the media, people seem to have lost the ability to recognize it for what it is. when people keep telling me i look “healthy” and terrific, it makes it SO much harder to want to work towards a healthier weight.
Rachel
/ December 8, 2007You cannot be close to anorexia if you are fat. That goes against the DSM IV-TR definition of anorexia.
So, since the DSM criteria also specifies a loss of menses, does this mean men can never have anorexia?
And, actually, if Raye had a clue as to what he/she is talking about (he/she doesn’t) he/she would know that there are no “anorexia clinics” per se, but rather, lots of eating disorder facilities that embrace a wide range of people with eating disordered behaviors – at all sizes. You see, this is because people who are actually trained and educated in the area of eating disorders often realize that food and weight ultimately have nothing to do with the nature of an eating disorder.
I had a similar experience with a former psychiatrist who erroneously diagnosed me with bulimia. Because I was at a slightly higher than average weight, he just assumed that my binges were characteristic of those of bulimia, in which thousands of calories are consumed in one sitting. My idea of a binge, however, was anything over 100 calories. Since my goal was to eat nothing – and I did for days on end – the simple fact of eating anything, even a stick of 5-calorie gum was seen by my disordered self as a loss of control and a binge.
Oh, and he later told me I still needed to lose weight. This alone shows the extent of his competency.
sso
/ December 8, 2007“there are no “anorexia clinics” per se, but rather, lots of eating disorder facilities that embrace a wide range of people with eating disordered behaviors – at all sizes”
very true. i’ve been inpatient on multiple occasions, and at all times, the other residents represented a wide range of body shapes and sizes, and all types of eating disorders.
Queen B
/ December 9, 2007Weight is not an indication of psychological health – period.
Cath
/ December 10, 2007Raye: apart from all the other good points, it’s also possible that a fat person can have had anorexia in the past, and feel that their major psychological danger is in relapsing.
Rachel
/ December 10, 2007Saying a woman has to weigh X amount before she can be diagnosed with anorexia nervosa is like saying a woman can’t possibly be pregnant if she doesn’t have daily morning sickness. Weight is and should be irrelevant in a diagnosis if the person displays the classic signs and symptoms.
nonegiven
/ January 13, 2008I got down to 107 (BMI=17.26) so I had anorexia nervosa? I dieted down from 133 (21.46) and it was also below 85% of that. For a while there, I could go to a restaurant with a date and eat a small dinner salad and then manage to get down 5 bites of the entree before I felt queasy. Can you get over it without treatment? If I had it.
Anorexia is just the medical term for not eating, for whatever reason, ED, obstruction, side effects of meds, physical illness, etc. I assume nervosa refers to cause.
Bilt4hugin
/ January 14, 2008I have a question:
A family member who had WLS a number of years ago is experiencing vitamin / nutrient absorption problems so I joined an online group that discusses, post, WLS complications and one of the things that I’ve seen coming up in that group is people who have lost EXTREME amounts of weight after surgery and are now dealing with actual, possibly clinical, anorexia issues. This got me wondering (amongst many of the other LIFE CHANGING complications that never seem to get mentioned when someone starts hitting us over the head with the WLS 2X4 while yelling ‘Just lose the weight, Fatty!’) if any one knows whether there have been any studies / notice given to people who have gone from one extreme to the other because of, or ancillary to, WLS?
Nobody in Particular
/ January 17, 2008I’m very late to this, but “Raye” is a regular on the Dan Savage sLog threads dealing with FA bloggers, in which s/h/it regularly uses such sensitive and intelligent terms like “fatties.” I’d ban it as a troll if I were you.
Ina
/ January 31, 2008You know what’s sad? At the height of my eating disorder, I refused to let myself get under 130 pounds (at 5’7”, I was a size 2-4) because I knew that if I got lower, I could be hospitalized for “anorexia”.
I binged and purged until I got to 145, so I could starve myself back down. I took advantage of the criteria. Nearly killed myself, too.