Margo Maine on the Eating Disorder Epidemic Among Middle-Aged Women

Margo Maine on the Eating Disorder Epidemic Among Middle-Aged Women

by Deb Kory

Psychologist and eating disorder expert Margo Maine discusses the silent epidemic of eating disorders among middle-aged women, the collaborative feminist model she uses to treat them, and the limits of the medical model of treatment.
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The Equal Opportunity Disease

Deb Kory: Margo Maine, you are a clinical psychologist who has specialized in eating disorders and related issues for over 30 years, and you’ve authored several books about eating disorders, including: Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond, Treatment of Eating Disorders: Bridging the Research-Practice Gap, and Father Hunger: Fathers, Daughters and the Pursuit of Thinness and you’ve also edited and written for several books about clinical treatment of eating disorders. You’re the senior editor of Eating Disorders: The Journal of Treatment and Prevention and in addition to serving as a psychologist both in private practice and at Connecticut Children’s Medical Center, you’ve done advocacy work to address federal policy related to eating disorders.

Having just read your book, Pursuing Perfection, I now know that eating disorders for women in mid-life are a kind of silent epidemic. Can you talk about your work in this area and why you feel it’s so important to dispel the myth that eating disorders are primarily experienced by wealthy, white teenagers?
Margo Maine: It is certainly an equal opportunity disease. I’ve been treating eating disorders for about 35 years now, starting in graduate school working at the local children’s hospital. I ended up doing my dissertation on them and then started up a program for treating adolescent eating disorders that included the parents in treatment as well. Many of the moms admitted to a little bit of dieting. Nobody admitted to an eating disorder, but in many cases, you knew there was something more there. So that was in the background of my mind.

And then probably about 20 years ago, a couple of the moms of daughters I had treated called me, and now that their daughters were better and kind of launched, they came back to talk about themselves and their own eating disorders. That was a real eye opener for me.


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DK: Did most of the teens have mothers with eating disorders?
MM:
The moms wouldn’t mention hiding M&M’s in the closet or laxatives in the glove compartment.
I wouldn’t say most of them did, but I would say at least a third. But nobody was talking about it. The kids were the identified patients and the moms wouldn’t mention hiding M&M’s in the closet or laxatives in the glove compartment. We’d ask questions about the mothers’ eating habits but they were all “just fine.”

So my interest blossomed out of this early work and I started to see more adult women as the years went by. But the case that made me decide that I needed to bring this out of the shadows was a woman who came to me about 12 or 13 years ago. She had an eating disorder most of her life, and it was very much a family created eating disorder. She went through a normal weight gain in pre-adolescence, but that didn’t sit well with her family. They didn’t like her looking a little bit pudgy, and at the age of 12 they started bringing her to Weight Watchers.

When she went off to college and developed anorexia and came home having lost so much weight, nobody said or did anything. In fact, they were happy with her weight loss. She ended up getting better on her own, graduated from college, went on to have many successes in life, but the disordered eating was always there as a coping mechanism. She had two pregnancies, and after the second pregnancy she wasn’t able to lose all of her weight, and that just launched the eating disorder, which had been subclinical for a while, into full gear with purging, restriction, and over-exercising.
DK: So, it came back with a vengeance.
MM: Yes, though not all at once. She started with one thing, and then that didn’t get her to lose enough weight, and then she added another, and then the symptoms were really out of control by the time she came to me.
DK: How old was she by then?
MM: She was in her early 40s and was very scared. She didn’t really know what was wrong with her and she didn’t know where to go for help. She certainly couldn’t go to anybody in her family, so she decided to make an appointment with her OB/GYN. She’d had two successful pregnancies and she trusted him.

She had lost 25 pounds in the previous year between medical visits, and she was a small person to begin with. In terms of the standard BMI [Body Mass Index], she wasn’t off the charts, but for her she was. All the nurses said she looked great and how did she lose the weight, etc., and she’d been prepared for that. But then she was sitting in the examining room waiting for the doctor to come in, and he walks in and says to her, “So how does your husband like your new body?”
DK: Seriously? That’s horrifying on so many levels.
MM: It was devastating to her. Here she was, so scared of what she was doing to herself, and she’d come to him for help. She wasn’t sure if she had an eating disorder, or if she was just kind of “crazy,” but she knew she was out of control, and then that comment made her very, very depressed. She wouldn’t talk to him and left feeling almost suicidal and just kind of closed the book on it. But within a week or two, got on the internet, started researching and found my name. I was only a few towns away, so she came in for treatment and did really well in treatment. But that case really brought to the forefront for me how pervasive eating disorders can be in a woman’s life. This was a very high-functioning woman, she had two masters degrees, she was very respected in her profession, very active in her community—
DK: Somebody with a voice.
MM: Yes, and yet she’d had an untreated eating disorder on and off for her entire life, and for the decade before she came to see me, was very out of control and physically at risk and in need of medical help.
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“I used to be a mess, but now I’m a high-functioning mess”

DK: And it sounds like her attempt to get help was met with total failure.
MM: Absolutely. The other thing about a lot of the women I treat, they tend to be very high-functioning. A new fifty-something patient of mine who’s had an eating disorder since she was a teenager said to me, “I used to be a mess, but now I’m a high-functioning mess.”

That’s how a lot of these adult women are. No one has a clue that anything is going on because they’re so good at functioning well and taking care of everybody else, but the despair they have about their bodies, what they’re doing to their bodies, is really astounding.
DK: In truth, I know very few women who don’t have some kind of body dysmorphia at the very least. Those who don’t have usually done a lot of work around it, including therapy, to get to a place of body self-love. And I’d say that most women I know had a period of disordered eating at some point in their lives—be it anorexia, orthorexia, binge eating or over exercising. I know that your clients probably self-select based on your specialty, but would you say that pretty much all the women who come through your door have body image issues and/or disordered eating?
MM: Oh, yes. I’m always amazed when I do presentations to clinicians about eating disorders and I hear people say, “Oh, I don’t treat eating disorders.” Really, you don’t treat eating disorders? Thirteen percent of women over 50 have eating disorders.
DK: Thirteen percent? Really?
MM: Yes.
DK: Wow.
MM: But they believe they don’t treat eating disorders.
DK: This was one of the reasons I sought you out for this interview. It seems like many clinicians are missing the boat here because we ourselves are immersed in a disordered culture. Many women therapists have struggled with body dysmorphia and disordered eating, which is pretty much the norm in American society, so if we aren’t actively fighting against the culture of dieting and the worship of thinness, we are likely not only to miss this in our clients, but to in some ways feed the problem. It seems to me that you’d have to assume that every woman who comes into therapy has a relationship to food and to her body that needs to be explored.
MM: I completely agree with you that all mental health clinicians need to be bringing it up, as do medical providers. They need to ask a few questions, just a few, to open the subject. Clients may not be ready to talk about it yet, but they will know that it’s a safe place to talk about it.
DK: What are those questions that clinicians should be asking?
MM:
People may say they aren’t on a diet, but then when you specifically ask them, “What have you eaten today?” and it’s 3 o’clock in the afternoon, and they haven’t had anything to eat, then you know there is a problem with their eating.
I have five questions that I suggest clinicians—and particularly physicians—include into their assessments. 1. “Has your weight fluctuated during your adult life?” 2. “Are you trying to manage your weight? 3. If so, how?” 4. “What did you eat yesterday?” You don’t ask them if they are on a diet, you ask them what they ate yesterday. Or if it’s later in the day you might ask them what they’ve eaten today. Otherwise people may say they aren’t on a diet, but then when you specifically ask them, “What have you eaten today?” and it’s 3 o’clock in the afternoon, and they haven’t had anything to eat, then you know there is a problem with their eating.

And 5. “How much do you think or worry about weight, shape, and food?” I often ask people to quantify it in a percentage, as in “What is the percentage of your daily thoughts that are about weight, shape, and food?” Some women will answer that it’s the first thing they think of when they wake up in the morning. They think about what they’re not going to eat, when and how they’re going to exercise, how they’re going to exercise to get rid of what they eat. It’s a powerful part of their lives, but if you don’t ask the questions, you’ll never find out. It’s kind of like what the American College of OB/GYNs has done with domestic violence—it’s a topic that all OB/GYNs are supposed to ask about at every visit.
DK: And what about with men? Are these questions that you would suggest people ask men as well?
MM: I do. There are a lot of men struggling with body image—more so than ever before, and the numbers are compelling. There are some studies that suggest that as many as 25 percent of men have some disordered eating going on.
DK: Wow. Again these statistics are pretty startling.
MM: In my personal experience, it doesn’t seem like it’s 25 percent, but there are a couple of really good studies that suggest it’s that high.
Overall, 10 percent of people suffering from eating disorders are men, and certainly men are getting much more pressure today around body image and appearance.
Overall, 10 percent of people suffering from eating disorders are men, and certainly men are getting much more pressure today around body image and appearance. They have a lot of pressure to not look old because of discrimination against older men in the workplace, so there is a greater emphasis on looking young and powerful. Increasing numbers of men are doing cosmetic surgery, but I think the difference for men is that it tends to be about power and influence whereas with women it’s more about appearance—that’s our “power and influence.”
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You Can't Tell by the Body

DK: Why do you think eating disorders so often go undetected? Do clinicians and physicians think that if you can’t “see” the eating disorder—as with someone who is severely anorexic—that it’s not problematic?
MM: With physicians and medical providers, the only eating disorders they think of are the extremely emaciated anorexics that they may have seen in their ICU or the morbidly obese person who comes in who they’re convinced has an eating disorder when they may not. With eating disorders, you can’t tell by the body.
Eating disorders come in every shape and size.
Eating disorders come in every shape and size. That’s why the BMI is not a very sensitive instrument by which to assess somebody’s health status. You can be basically anorexic at a high weight because you started at a high weight, your body might have been meant to be at a high weight because of your genetic background, but you’re undereating or perhaps taking medication that has caused weight gain. There are all kinds of factors that influence weight gain, but we know that at least half of the influences on adult weight maintenance are biogenetic, so that’s kind of programmed in, and then behavioral factors are added to that.

So some people go to the doctor and are at a higher weight, and they are put on diets when in fact they’ve already been severely dieting, they’re already undernourished, which is why sometimes they binge, but they’re not necessarily binge eaters, they’re more anorexic.

It’s important for clinicians to know that anorexia is in fact the least frequent of the eating disorders in the general population as well as in adult women, but it’s the one that’s easiest to identify because there is a marked weight loss. Bulimia is the next least frequent, but it’s hard to identify because of the secretiveness of bulimia. People with bulimia are often deeply ashamed of what they’re doing to their bodies and they don’t want anyone to know, so they are good at covering their tracks and are often symptomatic for decades without anyone knowing.

The mother of a former patient of mine called me to get help for her bulimia. She was in her early 50s and said that she’d been bulimic since she was about 20. She’d had two marriages and three children and relationships with physicians over the years and no one had a clue.
DK: What about dentists?
MM: Dentists have some opportunity to assess that, but not everyone with bulimia ends up with dental problems, or sometimes it happens very late in the process. Dentists are trying to step up though. I know when I go to my dentist they have you fill out a form, and it specifically asks you about eating disorders, and I’m so proud of them. I don’t think all dentists do that.
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OSFED

DK: So what are the more common eating disorders?
MM: The most frequent disorder is OSFED—otherwise specified feeding or eating disorders—which is basically variations of anorexia or bulimia or combinations of the two or binge eating disorder. Again, weight is not going to necessarily tell you that much about whether someone has binge eating disorder or OSFED. What I’ve noticed in my clients, and there’s also some research recently that showed this, is that adult women tend to morph in their symptoms over time; that they might have started out anorexic or bulimic earlier, but they get a little bit better from that, and then the symptoms kind of merge into what would be OSFED, a combination, or subclinical disorders.
DK: My experience is that subclinical disorders are so prevalent. I’ve had so many women clients come in and say, “I was anorexic in my teens, but I’m fine now.” But “fine” often means, “I’ve learned how to control it in such a way that nobody thinks that I have a problem with eating, but I’m on a permanent diet and cannot cope if I don’t exercise every day.” Do you know what I mean?
MM: I agree with you completely. That’s exactly what it is—they have learned how to keep themselves in check so that they’re hopefully not binging and if they do binge, know how to get through it, know how to restrict for a few days to get themselves out of that trouble, but they’re really not out of the eating disorder.

The subclinical women were as impaired psychologically and bothered by what was going on in their lives as the ones who were full-blown eating disordered.
There was an interesting study done in Austria a couple of years ago that found in one sample of women over 60, four percent of them met the clinical criteria for full-blown eating disorders, another four percent met the criteria for subclinical, but when they asked them questions about mood and anxiety and depression, they were the same. In other words, the subclinical women were as impaired psychologically and bothered by what was going on in their lives as the ones who were full-blown eating disordered. That says a lot, and is an important take-home message because a lot of people, when they have subclinical cases or OSFED, don’t see themselves as being as seriously impaired as people with anorexia and bulimia, but they often are. Another study showed that the medical side effects of OSFED might even be more severe than anorexia and bulimia.
DK: Why would that be?
MM: My theory around that is that OSFED people are less likely to be identified, either self-identified or identified by their caregivers, so the symptoms last a lot longer, they’re probably impaired longer, and that cumulative impact can be devastating. That’s my guess.
DK: So they’re not getting their nutritional needs, but they’re also maybe not getting the kind of emotional support that they need because they’re not recognizing they have a problem?
MM: Right.
DK: I wonder if it’s also that so many people are struggling with this that they don’t actually know what healthy eating and body image even looks like? I know you probably can’t really answer this, but how much of the population would you guess is struggling with subclinical eating disorders?
MM: I’d guess that it’s about 70 percentish.
DK: Wow.
MM:
I think it’s safe to say that in our culture at least 70 percent of women are struggling with subclinical body image issues and disordered eating,
There’s a study of women 25 to 45 years that found that 75 percent of those women were unhappy with their bodies and were dieting much of the time. Seventy-five percent. Another study looked at women over 50 and they found that 80 percent of those women had a tendency to base their self-worth on their weight, on dieting, and some were seriously bulimic. So I think it’s safe to say that in our culture at least 70 percent of women are struggling with subclinical body image issues and disordered eating, but as you said, it is so accepted that nobody talks about it and, therefore, nobody gets help.
DK: In Pursuing Perfection you point out, very poignantly I thought, that if you’re a drug addict, people look down on you when you’re engaged in your addiction, or they at least know that it isn’t healthy; but if have an eating disorder that causes you to lose weight, you get widespread acclaim from all around—even by doctors—for engaging in unhealthy behaviors that make you miserable. Unlike with drug addiction, the world really conspires to keep you in disordered eating.
MM: Exactly. No one wants to call it out because then they would have to out themselves, too. It is really incredibly sad. I mean, how often when you go out with a group of women does anybody just order off the menu? Instead it’s, “could you please hold this and that? Salad dressing on the side,” etc. That’s become normal.
DK: That’s so true.
MM: I don’t go to gyms anymore because I don’t want to hear all of the body-self-loathing and dieting talk that goes on there
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Feminism & Rebellion

DK: That brings me to another aspect of your work, which is the use of feminist theory. I know these days that the medical model is definitely a big part of treating anorexia—people need to find their way back to a healthy weight and be monitored and checked out for medical problems. But in my mind, it’s hard to imagine actually getting better from an eating disorder and body dysmorphia without really understanding the objectification and abuse of women’s bodies in this culture. And it’s something that can be better understood through the feminist lens and reading history and seeing how, over time, women’s bodies have literally morphed in shape to fit cultural ideals. When you understand it in that context, it’s easier to actively fight against it. I think you said somewhere in your book that only a rebellious woman can look at herself in a mirror and love her body.
MM: It’s an act of rebellion. A true act of rebellion.
DK: And it’s a daily practice because, again, from the gym locker room to the workplace to the checkout line at the grocery store, the world really does conspire to keep women hating their bodies. So, I’m wondering if you could talk a little bit about both the benefits and limits of the medical model and whether it is possible to get better without feminist theory?
MM:
I don’t go to gyms anymore because I don’t want to hear all of the body-self-loathing and dieting talk that goes on there.
Well, first of all, eating disorders are tricky because there is a necessary medical component to treatment. People have to get medical evaluations, we have to ensure that people are medically safe, and that can take a lot of time, a lot of finesse from clinicians like you and me to help a patient navigate that.

Sometimes when I meet with an adult woman for the first time, she hasn’t been to the doctor in years because she fears what she’s going to hear about her body, and she doesn’t want to get on the scale. So, one of the early conversations I have during the intake is, “I want you to be able to get a medical assessment. If you don’t have a doctor, let’s try to find you one. If you do have a doctor, I am happy to call them and tell them that we have started working together and that they should not be weighing you.” That is such a relief to them. They don’t have to go through that process of being weighed, often out in the hallway, with people commenting on their weight. But we do have to find ways to intersect with the medical community, and it takes a lot of time and energy, most of which is uncompensated. I think that’s part of the reason why there aren’t as many people treating eating disorders. We have to do a lot of stuff that we don’t get paid for.
DK: There’s a great deal of collateral work with doctors and nutritionists and sometimes treatment centers.
MM:
I spend a lot of time deprogramming with clients after medical appointments.
I spend a lot of time deprogramming with clients after medical appointments. It’s just something you have to add into the treatment, helping them understand that the physicians don’t know much about eating disorders, and they can’t guide them through the recovery process. They can help gauge whether there are medical problems or a Vitamin D3 deficiency, but they are only one part of treatment.

CBT is the one treatment that insurance companies see as the standard, and it’s the most readily reimbursed, but with CBT and other manualized therapies, you have six or 12 sessions and you’re supposed to be cured. Or three months of DBT and you’ll be all better. The insurance reimbursement stops then because ostensibly that’s when a cure should be achieved. In that way CBT has adopted a medicalized framework of treatment and cure, but it’s not a medical therapy. Most of the studies show that only about 35 to a maximum 40 percent of people get better with CBT. If you or I were to go to a physician who told us they had a cure for us that had a 35-40 percent chance of cure, we’d probably want something else.

Eating disorders are much more complex than any 3-month manualized treatment can tackle and often require long-term treatment with many systems of care. We work in partnership not only with the client in determining appropriate treatment, but with the other clinicians brought into the treatment.
DK: Is CBT the standardized treatment for eating disorders in medical facilities?
MM: CBT and family-based treatment (FBT), which is a particular model that conceptualizes the eating disorder as primarily a behavioral issue, and prescribes that parents learn to manage their child’s eating.
DK: Is that the Maudsley Approach?
MM:
Most of the studies show that only about 35 to a maximum 40 percent of people get better with CBT. If you or I were to go to a physician who told us they had a cure for us that had a 35-40 percent chance of cure, we’d probably want something else.
It’s a variation of Maudsley, generically called FBT now, and it has some genuine strengths in that it gives parents some practical things to do, but it isn’t an appropriate model for everybody. It’s a power-oriented treatment where the parents tell the kids what to do, and there isn’t any talk about emotional issues or problems in the family—it’s more like the eating disorder has sprung up and needs to be dealt with.

But I and many of my colleagues treat families sometimes who have had emotional, physical and even sexual abuse, or families where the parents are eating disordered—in these cases this approach is often inappropriate. In families like these everyone needs help and the eating disorder is very much a family-created illness.
DK: Isn’t that so often the case, though?
MM: Well, I have seen eating disorders develop in very, very healthy families where there isn’t a lot to do other than to help them learn how to get their kid through the eating disorder. But sometimes it’s extremely complex and the medical model doesn’t really allow for that kind of openness and discussion. Instead it can very objectifying—the patient is a puzzle to be solved through various medicalized interventions.
DK: And how does that differ from the feminist model?
MM: Within the feminist model, it is a collaboration and a partnership—it’s really about “we.” It’s about us together, and it’s very empowering. But to get back to your question about whether people get better in a non-feminist treatment approach, I think people can get symptomatically better. I don’t think they can get better and stay better unless they’re really, really lucky. And some of them will be lucky because the disorder wasn’t that horrible to begin with, and they get treatment, and they kind of get past it.

But for most people, to really recover, they need to understand why this happened for them, and they need to grapple with a lot of gray issues in their lives, and that isn’t something that happens in the medical model, which is based on symptom control and weight management.

In the ‘80s, the definition of recovery was whether a woman had gotten her period back, whether she had weight restored, and whether she was married.
When I was doing my dissertation back in the ‘80s, I interviewed women who had recovered from eating disorders and, needless to say, the treatment wasn’t very advanced at the time. The definition of recovery was whether a woman had gotten her period back, whether she had weight restored, and whether she was married.
DK: Whether she was married?!!
MM: Well, I’ve been married a long time and I don’t necessarily see it as a sign of good health, you know? It does say that a person has the potential to have a relationship, but that’s no guarantee that it’s a healthy relationship.
DK: I guess I shouldn’t really be that surprised. There is still a widely held, and largely unchallenged belief in our field, and in our culture at large, that people can only find true happiness through coupling and, ultimately, marriage.
MM: Yes, we’re not much further along thirty years later. Weight is still a primary measure of patient health, even though for many of our patients, weight is not the primary factor in their illness or recovery. In the feminist model we work collaboratively with the patient to decide what the signs of recovery and relapse are.
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“We’ve Just been drinking the Kool-Aid longer”

DK: It’s my understanding that a big part of eating disorder recovery is abstaining from toxic pop culture. Avoiding women’s magazines, health magazines, celebrity news, things that are likely to trigger body dysmorphia. Or, like you were saying, avoiding locker room chatter where women are picking apart their bodies and discussing diets.
MM: Yes, absolutely. I think we’ve done a pretty good job of understanding how the media and the culture affect young teenagers around body image and self-esteem and all that. Well, guess what? We adults aren’t any different. We’ve Just been drinking the Kool-Aid longer.
DK: So part of your treatment is educating patients about the cultural and media influences that contribute to their eating disorder?
MM:
I help them understand that while they think they’ve been making active choices, they’ve actually been acting out the script that is given to women.
Yes, and I tell them they’ve been drinking the Kool-Aid. These are smart people—I don’t want to in any way diminish them—but they have bought in hook, line, and sinker to a culture that tells us that we as women have to be a certain way and look a certain way, and it’s very disempowering. So I help them understand that while they think they’ve been making active choices, they’ve actually been acting out the script that is given to women. Over time it’s very empowering.

That kind of critical perspective, understanding the impact of culture, is very much a feminist discussion and it’s what keeps women strong. They see that they have to stand up against this culture that tells them to be less than who they—both literally and figuratively.
DK: Are teens open to the feminist perspective?
MM: They’re usually not at the beginning, but after a certain point, once they’re really engaged in their recovery, they become more receptive. Feminism is still the F word, and a lot of girls who do not want to associate with feminism think it’s for women who don’t shave under their arms and hate men. They don’t think of it as sexual and reproductive rights, equal pay, the right not to be sexually harassed in the workplace and so many other struggles the feminist movement has fought. I’ve had a number of young women in their 20s say to me that they want equal pay, but they’re not feminists.
DK: What do you think that’s about?
MM: Well, I think some people don’t really understand sexism until it affects them directly. I had an interesting experience a few years ago where three women who were probably all in their early 30s independently found out that male counterparts were getting paid more than they were for similar jobs. And the meaning they each made of it was that they were inadequate because they weren’t thin enough.
DK: Right, because it couldn’t have been a structural issue. They must have brought it on themselves.
MM: Yes. So I did a lot of educational work with them around what really happens in the workplace around salaries, the inequality in both pay and power, the many double standards and unrealistic expectations that are built into the very fabric of work life. When a woman realizes that a man is valued more in the workplace, it’s not uncommon for her to try to make it right by losing weight, which then can fuel an eating disorder.
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Weight is the Politically Correct Form of Prejudice

DK: Particularly for middle aged women who might have put on some weight during menopause, who might not be as quick with words and numbers, who might be having hot flashes all day and drastic mood swings because of all the changing hormonal activity.

Let’s talk about obesity for a second. I treated a client who was between 300-400lbs at any given point, and had yo-yoed up and down for much of her life. The way she was treated any time she went to the doctor for any ailment—it literally didn’t matter—was appalling. Nobody could see past her weight and they attributed it to all of her problems. She went in for her knee? Lose weight. For a flu? Lose weight. For pain of any sort anywhere? Lose weight. As if she wasn’t constantly being reminded of this in every interaction she had out in the world. People on the street felt like it was OK to yell insults at her. She had a hard time maintaining a job because of discrimination.

I was scrambling to find ways to be an advocate and counter this awful treatment, and then I read Health at Every Size, which turned out to be kind of a mind-blowing book.
MM: A bible.
DK: It deconstructed a lot of the myths about obesity and shed so much light on the fat hysteria in our culture. And it made me question the whole role that many therapists play in trying to help people lose weight.
MM:
I don’t think that people with our skills should be employed in helping people lose weight.
It’s a complicated subject, but I don’t think that people with our skills should be employed in helping people lose weight. I think we should be employed in helping people understand their relationship to food and to their bodies and we should help them learn to care for themselves in positive and healthy and sane ways, but that doesn’t necessarily translate into weight loss.

Even the people who do the bariatric surgeries and the most intense kind of work in obesity find that a good outcome is a very modest weight loss—10-15 percent of body weight is considered a good outcome. That is not very impressive. People go through that intense and often traumatic experience just to lose 20-25 pounds.

It’s been interesting to watch this bariatric surgery surge. Insurance companies often won’t pay for eating disorder treatment, but they pay for expensive surgeries and the long-term outcome doesn’t seem to be that good, but we don’t get the long-term statistics. We get the statistics up to about a year and a half, but it’s between 18 and 24 months when folks tend to start regaining their weight and having more difficulty with their symptoms. And people who are really struggling don’t go for any of the outcome follow-up because they feel so bad and so ashamed.
DK: So they’re not participating in the research.
MM: Right. I honestly think we have to be very careful about being sucked into the war on obesity. Obesity is associated with some health problems, but we don’t know that those health problems are the result of obesity or if obesity is a result of a health problem. It’s correlational and not causation. People can really improve their health parameters—cholesterol, blood sugar, cardiac status, etc.—by eating better, by getting some exercise. But for people who are big, it can be hard to move their bodies, and they’re often very ashamed, so they won’t necessarily go to a yoga class at a local studio. As you said about your client, people are astonishingly judgmental and even rude to big people, which can isolate them from taking part in the kinds of classes that many people rely on for their exercise. As I said in one of my earlier books, weight is the politically correct form of prejudice.
DK: That is devastatingly true.
MM: When I have patient who is obese and needs to see a physician, I always offer to call their doctor and introduce myself and let them know, “What she needs from you is a good medical assessment, but she doesn’t need to be told to lose weight. She already is embarrassed about coming to you and feels deeply ashamed about her body, and there isn’t anything you can say that’s going to be helpful to her about that. Leave that to me.” If you say it clearly, lots of doctors really get it and are happy to partner with you.

The anti-obesity movement really feeds a lot of eating disorders. The whole BMI craziness—the BMI has nothing to do with individual health. It’s a population statistic.
DK: Do you think it should just be abolished?
MM: I think it should be abolished. Pediatricians are supposed to monitor it at every visit and talk to parents about putting their kids on diets. These are kids who are going through normal uneven development. Most kids don’t develop perfectly— they get fat before they get tall, they get tall before they get fat, or they have a long neck for a while or big feet for a while.
DK: I see a lot of teens in my practice and all of them struggle in one way or another with their changing bodies and many of them flirt with eating disorders. How do you intervene there to try to help them get through that?
MM:
So often people turn to eating disorders because they have no clue how to self-soothe.
That is a very normal process for kids, getting used to their bodies and living in this culture where other kids are going to be talking negatively about their bodies. I think some education around these changes and the normal course of development, talking with them about their fears and worries, and working with them on self-soothing. So often people turn to eating disorders because they have no clue how to self-soothe, and starvation feels soothing to them, or the calm after bingeing and purging.
DK: Teaching them self-soothing techniques at that age could head off a lifetime habit of disordered eating.
MM: Yes, and learning how to express your emotions directly and knowing that it’s okay to have emotions. It’s important to help them figure out what helps them feel good, what helps them get calm, and to develop some tolerance for their big emotions. If kids knew how to self-soothe, you’d have far fewer eating disorders, drug issues, substance abuse, self-harm, all of that.
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Can People Fully Recover?

DK: Can people fully recover from eating disorders in a sustained way, and what is the best approach therapeutically for doing that that?
MM: I do believe that people can get fully better, and in my practice over the years, we’ve seen a lot of people get fully, fully better. They may still have issues to deal with, but it doesn’t turn against them in the same old way. It doesn’t become, “I can’t eat, I hate myself.” Rather it’s a signal that they have to put their recovery to work and perhaps reach out for some extra help, come back into therapy for a bit, etc. But it’s not that they’re coming back into therapy because of their eating disorder, it’s that they’re having life struggles that could trigger disordered eating if they don’t get help.

To the question of what’s the best therapeutic approach, that really is different for each person, and it may change over time. It can’t be quick.
There’s no such thing as a quick fix.
There’s no such thing as a quick fix. It has to be different interventions at different times. One of the limitations in treatment outcome research is that it assumes that everybody goes to one kind of treatment for a particular length of time and that’s it.

But most people with serious eating disorders have a little bit of treatment early on which may or may not help, and then they have some other treatment over here, and then maybe they go to a partial hospitalization program or residential treatment, and then maybe they end up in outpatient treatment, maybe they do some group therapy. It’s a tapestry that blends together into what is right for them, and it’s not a one size fits all. Of course the medical model wants it to be one size fits all, wants it to be CBT or DBT or FBT and that’s it, but the reality is that treatment needs to be varied, long-term, and is different for everyone at different stages of life.
DK: Does it usually take more than just individual psychotherapy?

MM: Yes, more often than not it takes more than individual therapy. Certainly there are people who get what they need and recovery with individual therapy, but if it’s a serious eating disorder, they might need a dietician, they will certainly need a doctor, they will benefit from things like art therapy, creative therapies.
DK: Art therapy is especially helpful?
MM: Yes, nonverbal work is really helpful for them. And family therapy, medication— a whole range of treatments.

But the keystone for most people is the individual therapy, and their own trusting relationship with somebody that they can feel safe with and be honest with about what is really happening. Someone to guide them through the process and stay with them and help them break out of their shame.
The driving force that creates and sustains eating disorders is shame.
The driving force that creates and sustains eating disorders is shame. So therapy is all about what do we do about that shame.
DK: Well it’s been so interesting and informative to talk with you about your work. Thank you for taking the time to share it with our readers.
MM: It’s a pleasure, thank you.

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Margo MaineMargo Maine, PhD, is a clinical psychologist who has specialized in eating disorders and related issues for over 30 years and is co-founder of the Maine & Weinstein Specialty Group. She is author of: Pursuing Perfection: Eating Disorders, Body Myths, and Women at Midlife and Beyond, (with Joe Kelly,Routledge, 2016); Treatment of Eating Disorders: Bridging the Research-Practice Gap, co-edited with Beth McGilley and Doug Bunnell (Elsevier, 2010); Effective Clinical Practice in the Treatment of Eating Disorders: The Heart of the Matter, co-edited with William Davis and Jane Shure (Routledge , 2009); The Body Myth: Adult Women and the Pressure to Be Perfect (with Joe Kelly, John Wiley, 2005); Father Hunger: Fathers, Daughters and the Pursuit of Thinness (Gurze, 2004); and Body Wars: Making Peace With Women’s Bodies (Gurze, 2000).

Maine is a senior editor of Eating Disorders: The Journal of Treatment and Prevention. A Founding Member and Fellow of the Academy for Eating Disorders and a member of the Founder’s Council and senior board advisor to the National Eating Disorders Association, Dr. Maine is a member of the psychiatry departments at the Institute of Living/Hartford Hospital’s Mental Health Network and at Connecticut Children’s Medical Center, having previously directed their eating disorder programs. She serves on several advisory committees, including the Renfrew Center Clinical Advisory Board, the Renfrew Foundation Conference Committee, and the Walden Clinical Advisory Board. Dr Maine is the 2007 recipient of The Lori Irving Award for Excellence in Eating Disorders Awareness and Prevention and the 2015 recipient of the Lifetime Achievement Award, both given by the National Eating Disorders Association, and is a 2016 Honoree of the Connecticut Women’s Hall of Fame.

Dr. Maine lectures nationally and internationally on topics related to the treatment and prevention of eating disorders, female development, and women’s health. She has devoted much time and energy to addressing federal policy related to eating disorders through her work for the National Eating Disorders Association and the Eating Disorders Coalition for Research, Policy, and Action, having served as vice-president and chaired the policy section of the FREED Act (Federal Response to Eliminate Eating Disorders), which was introduced into Congress by Representative Patrick Kennedy in February, 2009 and by Senator Harkin in 2010.
Deb Kory, PsyD, is the content manager at psychotherapy.net.  She received her doctorate in clinical psychology from the Wright Institute and has a part-time private practice in Berkeley, CA. She loves both of her jobs and feels lucky to be able to divide her time between therapy, writing and editing. Before deciding to become a psychotherapist, she worked as the managing editor of Tikkun Magazine and published her writings in Tikkun, The Huffington Post and Alternet. Currently, she is working on turning her dissertation, Psychologists: Healers or Instruments of War?, into a book. In it, she describes in great detail the historical context and events that led to psychologists creating the torture program at Guantanamo and other "black sites" during the War on Terror.
Wonderful and insightful interview. Really provided much food Made me wonder why there wasn't more outrage communicated by mental health professionals at Trump's history of objectification of women.
Bernard Schwartz Ph.D.
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CE credits: 1.5
Learning objectives:
  • Illustrate the different types of eating disorders and their prevalence among women.
  • Identify limitations in the traditional medical model for treating eating disorders.
  • Describe the feminist framework for collaborative treatment of eating disorders.
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