Addressing the gaps in the treatment of eating disorders in B.C.
Why should you care about eating disorders? If you haven’t struggled with an eating disorder, don’t know know anyone who has, or don’t work with them, the conversation around advocacy and awareness may seem far removed from you. However, while eating disorders may not affect you in the same way if you are not as close to the issue, there is still a place in this conversation for you, reasons you might want to care, and a role to play. This is because the seemingly specific issue of eating disorders are part of much broader conversations we need to be having in our society around issues like mental health, reflection on our collective cultural values, and how hard life can be sometimes.
Mental Health for all
Mental health is something that affects us all. We may not all suffer from mental illness to be sure, but we ALL have mental health that needs taking care of. This seems like a straightforward sentiment, but a few simple comparisons between how we prioritize physical vs. mental health can quickly demonstrate how far we still have to go for the idea of mental health to be normalized.
Think of an annual physical check-up, this is a fairly expected thing (in an ideal healthcare system with a sufficient general practitioner to patient ratio…) The idea of a mental health check-up on the other hand sounds strange to us, but why should it?
What is “health” anyway? How do we define it? The World Health Organization has been defining it as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” since 1946. This is a broad definition, but it highlights the fact that there has been some understanding for some time that health is a broad and relative concept. Still, while this definition may be generally accepted and has been added to over the years, it is much harder to see this ideal of health and wellness being upheld in the current reality of many public and private healthcare systems. We are still struggling to provide holistic healthcare to people in our current system and there are negative consequences on patient and societal outcomes because of this.
Here’s John Green to tell you all about it.
Another example that illustrates the stark contrast we have between the attention we pay to physical health as compared to mental health can be seen in healthcare insurance and benefits coverage. Many workplace health insurance plans with extended coverage may cover things like podiatry, naturopathic medicine, and massage therapy, but are less likely to cover therapy or similar mental health treatment options. This is the case even in high stress jobs with high rates of burnout (e.g. nursing). Of course it comes back to legitimate questions of priorities and funding, etc. but it is something important to think about.
While we certainly have a ways to go there has been progress in our understanding of health and in the way we view and treat illnesses (physical or mental). In Canada alone there have been several influential reports developed through the years (such as the Lalonde report in the 1972, and the following Ottawa and Toronto Charters in the 1980s and early mid 2000s respectively.) In expanding our views of health we have begun to expand our views of healthcare and how we treat people in the healthcare system. Through the years we have shifted away from placing all emphasis on the biomedical model (which focuses on the physical processes of a disease, such as pathology, biochemistry, etc., but does not take into account the role of social factors or individual subjectivity.) Broader understandings of health (mental, psychological, social, and spiritual), the determinants of health beyond the individual (and thus the individual’s sole responsibility), ways of treating illness/disease, and the importance of health promotion have become more accepted and better utilized in healthcare. However, the biomedical model (and the subsequent focus on physical disease or infirmity) is still quite dominant in Western culture and medicine.
There are still steps for us to take and progress for us to make in our understanding of health: what constitutes health and how we best support people’s health in practice and policy. Mental health is still a conversation many of us are uncomfortable with. We think of it as weakness, we don’t accept emotional health as important, we imagine it is just a matter of willpower or simple choice to overcome depression, anxiety, or substance use. The truth of the matter is that it’s much more complicated and our mental health needs just as much tending to as any other aspect of our lives.
Cultural Values - Diet Culture, individualism, and gender roles
Not everyone struggles with an eating disorder, but I would argue that the majority of people will struggle with their relationship with food, exercise, health, and their body image in their lifetime. What is normalized in our culture is a disordered relationship with food and our bodies and because it’s normalized people don’t necessarily learn to question it.
The moralization of food (labeling foods as good or bad), struggles with body image, and the focus on thinness as the ideal (a mark of self-control, success, beauty, and happiness) - these are things that most people can relate to. It has become normal for people to spend their lives yo-yo dieting, hating themselves, and restricting their choices simply because they do not feel they can enjoy life until they are thin. This might currently be the norm, but it doesn’t have to be and people like Christy Harrison RD (FoodPsych podcast presenter) are putting their efforts into changing the current culture we have around food and our bodies.
Beyond our culture’s current obsession with thinness, Western society is a culture that highly values individualism and choice. There is nothing inherently wrong with valuing these things of course, there are just consequences we can observe in our society.
The focus on individualism and autonomy of choice lends itself to a society where we tend to lay blame on people for the limitations they encounter in life. It is a very right-wing political perspective, that we all start out equal and where we end up in life is a matter of the grit we possess as individuals. That’s a lovely idea, but it severely neglects social, political, and historical inequalities that we are not past (yet). We do not all start out on an equal playing field and the idea that any achievement is in our power is grossly inadequate. This is where we see things like poverty, substance use, and other mental health issues blamed on the individual and their choices, but it is not as simple as choice and we are not as free to make entirely uninfluenced choices as we might like to believe.
Another aspect of our current culture we can critically analyze and discover flaws within, is the way in which we view gender roles and the effect this has on people. In our society we have certain expectations of men and women and we tend to divide gender along these binary lines (i.e. we historically divide gender into the categories of male or female). We uphold certain expectations for these gender roles and expect members to appear and act in ways our culture has deemed appropriate; some of these expectations have led to things such as “toxic masculinity” which is what I would like to focus on in this entry as it lends itself to poor emotional intelligence, objectification of women, and other issues that may not (on the surface of things) seem relevant to the conversation of eating disorders in any way, but do have an important effect. It is important to note that toxic masculinity is not an insult to all that is masculine, it is merely an examination of certain fixed, stereotypical masculine features that are harmful to all genders (including men).
“In contemporary American and European culture, hegemonic [or “toxic”] masculinity serves as the standard upon which the "real man" is defined… Contemporary hegemonic masculinity is built on two legs, domination of women and a hierarchy of inter-male dominance. It is also shaped to a significant extent by the stigmatization of homosexuality. Hegemonic masculinity is the [stereotypical] notion of masculinity that shapes the socialization and aspirations of young males. Today’s hegemonic masculinity in the United States of America and Europe includes a high degree of ruthless competition, an inability to express emotions other than anger, an unwillingness to admit weakness or dependency, devaluation of women and all feminine attributes in men, homophobia, and so forth (Kupers, 2005).
How is any of this relevant to eating disorders? There are several important threads I want to pull out of this conversation:
1. The devaluation of women, the normalization of sexualized violence, and the objectification of women contributes to women’s lack of control over their own bodies and lives (whether directly experienced in terms of specific trauma or indirectly experienced through the constant objectification of women’s bodies as sexual objects). This idea of domination and stereotypical masculine representations also impacts male body image with men being expected to occupy physically domineering bodies. A lot of male eating disorder issues with body image, while similar in some ways to female issues, differ in terms of body image. There is much more focus on being “strong,” muscular, and being athletically inclined.
2. The disregard of the importance of emotions (especially for men). In Western society, emotional health and intelligence is not something we pay much attention to, especially for males. The idea is that we are supposed to be “in control” of our emotions and/or push them down when they surface. This lends itself to extremely poor insight, poor emotional health, and poor coping mechanisms when it comes to experiencing and processing our emotions. We can pretend they’re not there, but that does little to address the issues that emotions serve to signal us about. This is a common theme in eating disorders, this extreme discomfort in experiencing and appropriately dealing with emotions. The avoidance of emotions is a key reason people engage in eating disordered behaviours (and other behaviours aimed at escaping uncomfortable emotions). In our society is not seen as acceptable to talk about difficult emotions and this is especially true for men. The documentary “The Mask You Live In” is an excellent exploration of the harmful ways we expect boys and men to deal with their emotions, act in our culture, and how this influences poor mental health.
It is important to know there are different ways to think about things. Cultural values and norms are constantly in flux and we can see that in the way these have shifted over the centuries. It is within our power as consumers and citizens to continue to change the values and norms our culture holds.
About Food But Not About Food, About Weight But Not About Weight
People often confuse the idea that eating disorders are about food and about weight and these disorders are concerned with these things, but not solely. Food, weight, and an obsession with thinness is only part of a very complex picture. At their core, eating disorders are coping methods. People focus on food and weight and things they can control to deal with numerous other issues. These other issues may include co-morbid mental health issues (such as depression, anxiety disorders, personality disorders, etc.), histories of trauma, or other, more common life experiences (such as bullying, societal pressures, and day-to-day life stresses.)
The thing is, an eating disorder is an escape, it provides a means to avoid the responsibilities of the real world, an escape from the stresses we all experience in a capitalist society focused on production and consumption, the stresses of a day-to-day life and our lack of control over many aspects of it, as well as the existential dread that many experience wondering what our purpose is, what the meaning of life is, etc. Not everyone who experiences stress, a co-morbid mental health condition, trauma, or the pressure to be thin (that our society is currently obsessed with) will go on to develop an eating disorder. It takes the right combination or genetic and environmental influences to result in an eating disorder, but the point I want to emphasize here is that these conditions are not so unrelatable, they reflect the very human need for every single one of us to learn to cope with life and the hardship it can bring. Some of us learn healthy coping mechanisms, some of us learn to cope through other means such as substance use, workaholism, smoking, avoidance, gambling, etc. But the core of it is that everyone seeks relief and strives to cope in some way, the means are just different.
So while an eating disorder is a very specific experience, there are aspects of this issue that apply to us all. This conversation around eating disorders is also a conversation about the state of our world as it currently is, our collective cultural values, the importance of mental health, and the hardship that is life sometimes. It is a conversation about compassion that we are all a part of and that we all need to be having together.
- S. Ritchey
Today’s blog post is by a VIVED member featured on the Love Our Bodies, Love Ourselves website (a great resource to check out). We’re honoured to have been included on their blog.
“You did not choose to have an eating disorder, but it is your responsibility to choose recovery.”
Choice is an interesting and complicated discussion in relation to eating disorders and other mental health issues. Phrases such as the above serve as attempts to summarize this complex discussion in relatively simple terms, but choice is not a simple issue; it grapples with some of humanity’s most difficult philosophical questions.
Philosophical debate aside, we live in a world that functions under the precept that we do in fact have free will and are thus responsible for the choices we make. However, there has been more recognition in recent years that there are multiple factors involved in choice that are beyond an individual’s control. Genetic, socioeconomic, and environmental factors - all of these play a role in shaping an individual’s choices. These kinds of influences affect whether or not a person may struggle with an eating disorder, but they also influence an individual’s recovery from one.
The thing is, there is not just one choice a person makes to recover - there are many choices made multiple times a day. To build towards recovery an individual is faced with fighting themselves every day and even if they have professional and personal supports, they’re still faced with being along in this fight against themselves much of the time. Therapy for an hour every week or so leaves 167 other hours a person must face conflicting choices, feelings, and impulses. An individual recovering from an eating disorder is dealing with an addiction of sorts that cannot be avoided (food is not a substance we can abstain from such as other substances people struggle with using to cope). Those in recovery are faced with multiple emotionally overwhelming moments every day, when logical thinking about the type of life they want long term feels impossible to focus on. I do not say this to skirt the issue of personal responsibility because that is certainly a huge part of recovery. I merely want to point out that choice is complicated and reaching for understanding instead of blame is challenging.
There are often many emotions for a person struggling with an eating disorder as well as for those around them in their life. The person struggling may feel an overwhelming sense of guilt for struggling which adds to their sense of being a burden, unworthy of recovery. The people around them may feel angry at their loved one’s actions or behaviours because these behaviours will sometimes have a negative impact on others and may be selfish in nature. However loved ones, family and friends, may not feel they are allowed to be angry with the person who is ill because that person is ill after all. Again, choices and the feelings that they bring up are complicated.
Mental health struggles, eating disorders, and the like are not an excuse for poor behaviour. However, it helps to understand that choice is not a simple thing and that potentially negative behaviours come from somewhere that rarely has to do with the intention of causing harm. Some people think that intention does not matter if an action has the same result, but I do think there is a significant difference between someone causing harm to another as a byproduct of a choice based around say addiction or struggle versus a choice made with the intention of causing harm (even if the outcome is the same). That is not to say we should not expect more from someone in recovery, we absolutely should, but hopefully with as much kindness as we can muster. Sometimes we must have hope for that person and push them because we know they deserve and can have more. Other times we must remind ourselves that we cannot fix people, we can only love them (as painful as this sometimes is).
It can be heartbreaking to watch the ones we love struggle with choices that are not to their benefit in the long run. Sometimes it can feel hopeless for the person struggling as well as the people who love them, but I firmly believe that there is always hope even if we have no sense of it at times. It helps to remember that even when there are clouds that cover the sky, the sun is still there behind the clouds, waiting to shine again. People may not always make the choices we think they should, they may make choices they worry about or disagree with because choice is complicated especially when we’re talking about mental illness and addiction, but as long as a person is alive, they have the capacity to different choices with each moment. They may not believe they can, they believe they are stuck in a loop doomed to repeat itself forever, but each moment we get to start again, we just sometimes forget that we have that power.
An eating disorder is a well-worn pathway in the brain, it is what seems natural and sometimes it is the only thing we can imagine, but it is only habit. Change, making new choices, that brings the discomfort of paving a new pathway. Every moment there is a chance to take a different route than the one that seems simplest. That does not mean it is easy, but it is possible. The little moments that seem insignificant begin to add up and build to something more. By making different choices we can quite literally change the way our brain works, and this change strengthens every time we choose it. It takes time and practice to develop a new voice, a voice that says something different than the eating disorder voice. A voice that says “no, I’m doing something different this time.” Eventually it is not a question or something we say with hesitation, eventually it is just the new normal.
There is no easy or straightforward way to talk about suicide and self-harm with someone who is struggling with these issues (and it’s always best to refer to professional mental health resources and supports). Proper suicide intervention training (such as ASIST) is a helpful skill set to have, but there are some general things to know that can be helpful to keep in mind when venturing into these delicate conversations with people. It is important to remember that every person and every situation is going to be unique and when in doubt, always refer someone to professional services.
That said, here are some general tips based on personal experience and the personal experiences of others (gathered informally through our Peer Support Group).
It sounds so simple, just listen, but actively listening to someone is a skill that takes a great deal of practice, especially when the topic is pain so significant someone is thinking of ending their lives. Knowing someone is suffering is difficult for us to sit with; it’s human nature to want to ease that person’s suffering and to soothe the pain they’re feeling. That is not a bad thing in and of itself, but it can tend to get in the way of actively listening to the person in that moment. We start to think about how to help because we want to help, but sometimes we become so focused on trying to offer solutions we limit the conversation and the other person being able to fully express what they’re struggling with. It is of course essential to know there are options for support, but the person who is struggling may already know about those options and may simply feel shut down if re-directed elsewhere for support (however, sometimes this is necessary). Medications, therapy, crisis lines, distraction techniques, peer support, etc. are all important options that can be explored with the person, but sometimes all they really need is for someone to listen. Don’t be afraid to ask them what they feel need (although they may not know.)
It takes practice, but trying to keep your own anxiety at bay as well as putting aside your other thoughts and feelings (as best you can) when someone is trying to talk about suicide or self-harm, allows you to be more present with them in the moment. Sometimes we can get so caught up in trying to be a good support person that we shift the focus from the person we’re trying to support to ourselves and our ability to support. Again, it’s just about bringing ourselves back to the present moment with the person and being with them in that moment.
You can be the best listener in the world and have plenty of experience supporting people through crises (maybe you’ve gone through a similar situation yourself,) it’s still going to be uncomfortable, you’re still never going to know the “right” thing to say (because there is no “right” thing to say) and that’s okay. You’re trying and that’s all that matters.
Making Space For Heavy Emotions
In general we are really quite terrible at allowing people to feel their feelings, especially when those feelings are considered unpleasant ones: pain, sadness, and anger. We try to quiet these, fix these, get rid of these kinds of feelings, but these are part of a healthy range of human emotions. These emotions tell us something: pain tells us we are hurting, sadness tells us we have lost something, and anger tells us that our boundaries have been crossed. The risk with trying to soothe someone’s suffering is that we add to the sense that these are feelings that need be gotten rid of, but it is okay to sit in pain, sadness, and anger and do nothing to “fix” them. It is probably better to feel these things all the way through instead of trying to avoid them. It is uncomfortable though and it takes practice to know that we can survive such intense hurt. Let the person know it is okay to feel what they’re feeling. They don’t need to feel anything other than what they feel in the present moment. It will pass, they just might not have any sense of that being possible in the moment they are feeling such intense emotions.
Patience & Perspective
Picture a blindfold being placed over your eyes. There is just darkness with no sense of light ever having been there or ever being there again. This utter blackness will seem absurd to anyone who is not blindfolded, experiencing that darkness, pain, and fear. However, the person who is blindfolded has no sense of perspective outside of that darkness and while it is important to remind them that there is something outside of that experience, it is also important to remember they may have a very difficult time picturing what you’re describing. This can be frustrating. There are many problems in the world much larger than each of us, but again, when you’re shrouded in darkness, you cannot see anything but the blackness around you. People who are struggling with depression are so limited in their ability to feel anything. There is just a blank desert of hopelessness before them so trying to give them some perspective on their problems is very limited in its usefulness. It takes patience to even try to understand the black hole they are experiencing, even if you’ve gone through depression yourself, when you’re not in it, it’s hard to remember how all-consuming it is. This is why it’s so important to meet the person where they are at. You’re walking alongside them and sometimes you have to slow your pace to what seems like a painful crawl to you, but it’s all they can manage in that moment.
Do You Have a Plan? (Crises VS. Chronic Suicidal Thoughts)
The first thing any suicide intervention training is going to teach you is to assess for a plan. This is of course important and I highly recommend suicide intervention training such as ASIST (Applied Suicide Intervention Training) to help everyone feel more comfortable talking about these things that we really need to talk about.
The problem with focusing intensely on a person’s plan (their access to means, and the degree of risk associated with the means that they are considering) is that we again run into the risk of shutting the person down. Unfortunately a lot of crisis services are just “do you have a plan? No? Okay you’re discharged.” Or “Have you tried A, B, C? Try A, B, C.” And while that makes sense - it’s a quick triage assessment that reflects how our busy healthcare system has to prioritize care - the issue is that this doesn’t work very well for mental health care. A lot of people who have experienced this in a crisis will never use the service again if that is the treatment they’re met with and the next time, they might take their lives or do some serious damage in the attempt.
Of course if you are worried that someone needs an intervention, don’t hesitate to direct them towards these services. They need improvement, but they’re better than nothing.
The point I want to emphasize here is that even if someone doesn’t have a plan, listen to them. Their pain is still valid. We need to do better at talking to people about incredibly difficult emotions and situations even when they aren’t crises and not making the person feel that the only way they can talk about their pain or get the help they clearly need is by resorting to extreme means.
Taking Care of Yourself & Setting Boundaries
The people who tend to want to know how to support those struggling with suicide and self-harm tend to be people who put others before themselves a lot of the time. This is not a negative quality, but it’s important to remember a few things when you’re dealing with heavy situations that can be emotionally exhausting. Like the crashing airplane principle, you put your own mask on before you go about helping others.
It sounds harsh, but you do not actually owe anyone support through a crisis. Sometimes someone struggling experiences suicidal ideation and self-harming behaviours frequently and this can be exhausting. If you don’t feel like you can focus on supporting that person, you’re dealing with your own life situations, or you even feel manipulated or frustrated by the person, it’s probably best that you take a step back. It’s not your responsibility and it probably won’t help the person struggling. In that moment they need someone who is able to listen and be with them in the pain they’re feeling. That doesn’t mean it has to be you. That is what a crisis line is there for. You can be a loved one, a parent, a friend, a support, but you are not a therapist looking after a patient (even therapists have clear boundaries). It is always okay to say “I don’t think I can give you the support you need right now, but I want to make sure you get it” and then refer them to a crisis line or chatroom or emergency services. It is less than ideal, but it is reality.
It is also okay to feel you have to call the police if you’re afraid for someone’s life. Sometimes you’re in a situation where you’re really not sure and there’s no clear way forward. The person may not want help and you may feel afraid that they’ll be angry with you, but they’ll be alive to be angry and as long as someone is alive there’s a chance that things can get better.
No matter what, these are difficult and uncomfortable conversations and that’s okay. All that matters in the end is having the courage to venture into those difficult and uncomfortable conversations with people. Having the courage to be with them in the pain they’re feeling even if it isn’t something we can imagine or understand ourselves.
- S. Ritchey
I came across a quote this morning that really resonated with me and was just what I needed to hear.
It said, “Two things define you: Your patience when you have nothing and your attitude when you have everything,” - George Bernard Shaw.
While I don't believe those are the only two things that define us, I needed to hear this. Lately, especially with work, I’ve been finding a tendency to not see patience as a virtue, but rather as a sign of being wrongfully okay with not doing enough or pushing myself hard enough…. which is funny that I should have to learn this lesson again because of how much I had to learn it during my eating disorder recovery.
However, I believe that is how life is - there are so many opportunities for us to work on valuable things, and we’re given many chances to do so, which can seem like a negative but I like to see it as a blessing. I try to….
I wanted to write today about some things that helped me to cultivate patience during my recovery journey as they're what I need to remind myself of now. I hope they may be able to help you as well, regardless of what your own journey of change may be.
Change is hard, but I believe what makes it truly hard is our impatience for the final outcome and how hard it is to hold onto hope and faith when we don't see the changes we want to fast enough.
With the help of many great therapists, and many self-help books, I found some ways to think about patience that made it easier to cultivate it and to hold onto hope when things felt like they were changing too slowly, or not at all.
1. A Turning Ship
One metaphor that really resonated with me was that of a giant ship in the process of turning. I remember it being described to me how this could not happen in one move or one instant, and that’s just how it was, but how it didn’t mean that steady progress wasn’t happening. I could see it so clearly for the ship, and in moments of frustration or hopelessness it helped me a lot to conjure up this image.
2. A Blossoming Flower
Another metaphor that helped me a lot was that of a flower blossoming. I liked how it was explained to me that of course the flower was meant to blossom, it was the natural progression of things, AND it still didn't happen overnight, or even at a perceptible rate.
I also liked the concept of how even if blossoming was the right thing for the flower, how it wouldn't be right if the flower bud was forced open too quickly.
This helped me to accept that even with things that are natural and meant to be, they aren’t meant to happen always immediately. Nature has its own timing, and it is up to us to do what we can within this natural flow, and then to learn to be patient and have faith.
3. Pause, Reflect, and Appreciate
Another practice that really helped me was to remind myself to consciously consider how far I had come, especially remembering how where I was now had seemed impossible at one point. This helped me to realize that the same would be true for my future - that just because something didn’t seem possible now didn’t mean it wouldn't happen with time and continued gradual effort.
It also helped me to feel more grateful for where I was, even if it wasn’t where I ultimately wanted to be, and to not feel quite so hopeless and discouraged.
4. Giant Bamboo
Finally, I love this message written by eating disorder therapist Carolyn Costin, which captures all of this so beautifully….
My Reflection On A Lesson Learned From Giant Bamboo
“The first year it is planted, the tiny bamboo plant is watered & fertilized,
BUT nothing happens
It is watered and fertilized for another whole year
And nothing happens
Then another year, And another
But still nothing happens
Then, on the fifth year, it shoots up to the sky
And in 6 weeks grows 90 feet
To an outside observer, giant bamboo grows 90 ft. in just 6 weeks!
But, of course, in reality this growth takes 5 years
If the plant had stopped getting water at any time during those 5 years
It would have died.
What was happening all those years unseen, under ground?
An enormous network of roots was developing to support the bamboo’s
Growth spurt. Every drop of water made a difference
Growth takes patience and perseverance
When you are seeking growth, build your roots
Know that every step you take makes an impact
You may not see the change right away
But growth is happening.
Honoring our roots this season and always….”
- Carolyn Costin
Are there any areas in your life that you wish were different, or are working on changing, where patience feels like a challenge? What are these?
Is there one metaphor or consideration, out of the four I listed, that resonated with you?
What are some ways that you can imagine using this metaphor or consideration to help you cultivate patience on your journey and to help you hold onto hope?
With compassion and so much hope for your journey of patience and change,
Sarah Rzemieniak is passionate about helping people recover from eating disorders and body image issues. Sarah previously worked as an eating disorder dietitian before recognizing that her true passion was in the coaching and counseling aspect of the work. She then became a certified eating disorder recovery coach through The Carolyn Costin Institute, where she was supervised and trained directly under Carolyn Costin, world-renowned eating disorder therapist, author and speaker. Sarah recovered from her own eating disorder, which fuels her passion for this work. She provides individual coaching in person in Victoria, BC Canada and online worldwide. More information can be found on her website: https://sarahrzemieniak.com/