What Does Weight Have to Do with It? Dispelling the Myth of Sick Enough

Recently, I decided to take a deeper look into what is being written about eating disorders. Why, you ask? Because as a psychologist specializing in the treatment of these disorders, I find it helpful to stay up-to-date on both the research and cultural writings that may influence the folks that I work with. So what did I find? Well, it seems to me that a disproportionate amount of research is being generated about anorexia, versus other eating disorders. Additionally, the vast majority of publications about eating disorders among celebrity and lifestyle magazines focus on people struggling with a low body weight. And FINALLY- most of the conversation about eating disorders is being generated from celebrity and lifestyle magazines. "You still read more about anorexia in the celebrity section of publications than in health sections," says Nancy Zucker, PhD-professor of psychology and neuroscience at Duke University. These facts are alarming, but not actually all that surprising. After all, the warriors that I work with speak often about feeling that their ED doesn’t exist in the eyes of others, due to their body size. And anyone who has ever been on an inpatient unit understands the “sick enough,” phenomenon that occurs. This feeling, the intense drive to be very thin, to appear very ill, or to be “more sick,” than other patients can occur with such intensity on these units that patients themselves are sometimes surprised. Marya Hornbacher addressed this several times throughout her infamous memoir Wasted: “I didn’t know in advance that I would never feel like I was good enough, like I was a “successful” eating disordered person until I was at deaths door. Actually, not even then.” And again, “When I got to treatment the first time… I was not visibly sick, the very picture of sick, [and] because I did not warrant the coveted title of anorectic, I was embarrassed.” The coveted title of anorectic. Hornbacher is not unique in feeling this way. Kelsey Osgood, author of “How to Disappear Completely,” refers to an inpatient ED treatment center as a “scorpion-battle competition.” In reference to the literature written on this subject, (the idea that prompted my whole inquiry!), she says, “Nine times out of ten, writing about anorexia beguiles the at-risk population for all the wrong reasons and the person writing about his or her own struggle fuels the fire by producing a long, hubristic poem…a homage. The writers know they’re up on the invisible podium to speak out about their journey to the brink of death (oh, yeah, and back).” Another complicating factor to the sick enough dilemma? Many managed care companies still include a weight criteria for hospitalization. Despite our (ED professionals) best efforts to lobby for more awareness about the nature of eating disorders (i.e. that weight has little correlation with intensity of symptoms or severity), the managed care battle rages on. Hence, medicine can often propagate thoughts of not being “sick enough,” if one is not at a low body weight. So here is the dilemma: those with eating disorders, underweight or otherwise, often struggle with feelings of fraudulence, of not being sick enough. People who have never lived at a low weight (i.e. most individuals who struggle with life-threatening eating disorders) continue to feel unheard and underrepresented. Professionals in the eating disorder community advocate against weight being the main symptom for an eating disorder. AND YET- we continue to find ourselves living in a society that focuses on, and even glamorizes, low-weight eating disorder sufferers. So what can we do about it? In a word? Activism. We must continue to spread awareness that most individuals struggling with eating disorders do not have the symptom of low weight. For all of you warriors out there- this means rejecting messages about eating disorders that only talk about the symptom of low weight. It means not purchasing memoirs that are 4/5 eating disorder war-storying, 1/5 recovery-focused. It means speaking out against before-and-after pictures in the online recovery community.  It may also mean speaking up at doctors’ appointments. For example, if you a struggling with an eating disorder, and your doctor says something along the lines of “Your weight looks fine,” you may have to pause and provide him/her with some education about how this fact is basically irrelevant. This type of comment from a doctor may be well-intentioned, however it often has the effect of promoting the aforementioned fraudulent feelings. Hence the doctor could very well be grateful if you provide feedback. Additionally, continue to challenge the thought “I’m not sick enough,” by reminding yourself repeatedly about the thought distortion that this stems from. Acknowledge to yourself that society can promote this thought, but then remind yourself that you know better. You are likely more educated about eating disorders than most people in society, hence you can identify the belief “eating disorder symptoms must include a low body weight,” as inaccurate.  Doggedly ask yourself the questions, “What would sick enough be for me? When would I achieve this? Why is that my answer? What would the significance of a low body weight mean? What am I searching for through weight-loss?” Challenging your thought distortions may not provide instant relief, however slowly, over time it will change your automatic thoughts. And finally-fellow ED professionals, it is our ethical duty to speak out against the messages that suggest that weight is the main determining factor in these diagnoses. Messages that eating disorders are about weight can come from various sources- articles in magazines, movies, social media influencers, and the list goes on. Additionally we must be sure that we are speaking up around medical doctors, and other practitioners that do not specialize, when we hear misunderstandings being verbalized. Together we can challenge the idea that eating disorders and low body weight go hand-in-hand. We can raise up the voices of those in recovery who feel misrepresented or misunderstood. We can fight to improve awareness, and in turn, help eating disorder treatment and recovery outcomes. We can and we will. Fight on warriors.-Dr. Colleen Reichmann