Eating Disorders Throughout the Lifespan
May 21, 2004
Friday, 9AM - 12:30 PM
Massachusetts General Hospital
Eating Disorders in Mid-Life
Margo D. Maine, Ph.D., Maine & Weinstein Specialty Group, West Hartford, CT
When eating disorders or body image conflicts are mentioned, the face we imagine is one of youth. It may be a preteen, an adolescent, or a young adult woman, but we rarely visualize an ageing face in that picture. Yet more and more older women, approaching or beyond “midlife,” are admitting that they too struggle with their bodies and their eating and are seeking professional help. Once again, the old rules about eating disorders are no longer useful, but the dominant thinking of both the public and professionals does not reflect current reality. Western women live in a culture of Body Wars (Maine, 2000) that do not end when they turn 25 or 30. Just as women become invisible as they age, their problems are also discounted, minimized, and ignored. The picture of a young, vibrant teenager who succumbs to an eating disorder is tragic, but eating disorders are just as destructive in the lives of adult women. The Universal Language of Fat
The sad truth is that the language of fat (Friedman, 2002) is spoken by women of all ages, at all stages in their lives. Because adult women are so invisible in our culture, this issue has also been invisible in the world of research. We lack accurate, comprehensive data on the exact numbers affected, but, more than likely, the incidence patterns in younger women hold true for adults. Eating disorders and body image despair are homogenized through all socio-economic, racial, and ethnic groups, and are now reported in as many as 40 countries, due to the far-reaching impact of globalization. (Gordon, 2001)
Although hard data on adult eating disorders are absent, we do have compelling information about the extent of dieting and body image concerns, both of which are precursors to clinical eating disorders. For example:
Contemporary western culture consistently values women’s bodies and appearance above other attributes. Sexualized images of female bodies saturate everyday media, shaping the prevailing ideal. Today’s women are always on display, endlessly criticized for transgressing that ever-shifting fine line between being too sexy or not sexy enough, and completely dismissed when they no longer look young. Rarely do we see an older face, be it in film, fashion, advertising, print media or television.
In this age of body technology, when cosmetic plastic surgery can be purchased at a mall during a lunch hour, women are sold the myth that they can (and should) be in complete command of their bodies. The female body has never been more exposed while its natural processes, like the symptoms of menopause, are to be completely masked or corrected. The rhythmic cycles of the female body, many of which are associated with weight gain, such as premenstrual bloating, pregnancy and the slower menopausal metabolism, are great challenges in this era of body control and unrealistic beauty images. If a woman’s power is still defined in terms of beauty and a youthful body, the 8-12 pounds she naturally gains at menopause can be a source of great distress and anticipated disempowerment. Contemporary women struggle with the catastrophic consequences of ageism and weightism.
The Shape of Adult Eating Disorders
Many common threads can be found among women of different ages suffering from significant eating and body image issues. They often share ambivalence about their power and place as women, with deep conflicts between their masculine and feminine strivings. They all must navigate a path in an overpowering consumer culture that teaches them to want and to need, but not to know their true wants and needs. Being bombarded by strict and unrealistic media images of beauty does not end at adulthood. For some women, the focus on appearance and youth intensifies as their bodies age, progressing through the natural stages of change that include weight gain, graying hair, and wrinkled skin. The pressure to buy or pursue the right body persists and can function to distract women from more significant issues in their lives.
Instead, women often find themselves dealing with these pressures in isolation, with little support or validation, but more and more responsibilities and burdens. The “deadline decade,” the years between 35 and 45, can be particularly disruptive. For some, the biological clock is ticking away, and decisions about relationships and childbearing are heightened. For others who have focused on family, their career clock may be ticking as loudly. For the women who have tried to do it all, the what-about-me clock is ticking. This decade is potentially transformative, as women may be in their sexual prime at this time, but is also filled with endless obligations, responsibilities and stress for most contemporary women, leaving little time to reflect on the impact of all these events and transitions.
A woman’s life transitions are often shaped by feelings like “my life is out of control.” When things are in transition, feel ambiguous, and look uncertain, we all seek a solution - something stable or something to control. In the era of Body Wars, the body is the answer to all angst, no matter a woman’s age.
Obstacles To Getting Help
In light of all these adult realities, it is much harder to make the commitment to address their eating and body image disorders – in fact, with family, work, and community responsibilities, it may seem impossible to take any time to focus on their needs and their recovery. The harsh reality is that adult women have had more years of denying their true appetites, hungers, and feelings; this alone may keep them from seeking help. Of course, we must also acknowledge the secondary gain that accompanies body image obsessions and weight loss, as well as the universal desire today to look young and avoid the loss of power that an ageing female body brings. For some, resistance to getting help is fueled by despair and a belief that they are doomed to never be truly happy. For others, a sense of omnipotence develops as they continue to dodge the bullets of serious medical consequences despite their body abuse.
Add these dynamics to the medical bias that eating and body image disorders are adolescent issues and it is easy to see why we have not grasped the extent of this issue in women’s health. We still confront a lack of basic knowledge in most medical professionals when it comes to eating disorders. Most get little useful training and experience so they maintain old biases and beliefs about who is at risk for them. Despite how easy it would be to add a few questions at each medical visit regarding weight management, dieting, and nutrition, few providers screen patients, even the high risk ones, for eating disorders. The war on obesity has captured their attention and skewed their perspective, severely limiting their ability to help us bring adult eating disorders out of the closet.
Clinical Issues in Midlife Women
Although they are likely to be more self-motivated, adult women also may have lived with this problem for decades, having translated all of their negative feelings into the language of fat and lacking skills to recognize and satisfy their true needs and hungers. Midlife women have the same exquisite sensitivity to others that we associate with eating disorders in vulnerable teens and young women; they are easily shamed, shunned, and dismissed, disappearing quickly if we do not work hard to embrace them and show that we take them as seriously as we take adolescents with these problems Consequently, I now react with the same sense of urgency to a call from a woman at midlife as I do to the call about an 11 or 12 year old child who is at risk to permanently stunt her physical growth.
In groups and formal treatment programs, midlife women often feel invisible and inconsequential due to the emphasis on younger patients and their developmental issues. They also may play a maternal or nurturing role to others, both the younger patients and to the staff, as they are skilled in meeting others’ needs and not their own. Just as our culture dismisses them, midlife women struggling with eating and body image issues readily dismiss themselves. I find myself taking a very active and direct approach with this group of patients. They need much validation, and can readily sense if we don’t grasp the serious ness of their problems.
Often adult women seek help when they are fearful that their eating and body image issues may adversely affect their parenting and the wellbeing of their children. Parenting is a very motivating subject for women with eating and body image disorders and we can use it to the advantage of recovery. It is easy to demonstrate how their own self care will benefit their children and to emphasize the importance of their role modeling related to weight concerns, body image, dieting and eating, especially for female children.
Of course, we prefer that patients enter treatment totally due to self-motivation, yet we need to accept any reason that helps women to break their resistance and denial of how these issues are affecting the quality of their lives. For example, several years ago, a woman in her early 50s sought my help as she wanted to have cosmetic plastic surgery, but knew that if she continued to vomit, the effects of the surgery would be minimal. I agreed to work with her despite my concerns about her plans for surgery. We addressed her issues with ageing and how these had affected her longstanding eating disorder and body image concerns. Despite a 30 year history of daily bulimia, she achieved some degree of recovery.
With such a long history of symptoms, I use a harm reduction model and integrate both psychoeducation about the risks of their symptoms as well as insight-oriented psychotherapy, informed by a feminist and relational perspective. It is critical that we help women with such severe histories to find hope. A harm reduction perspective helps women to see progress in the small steps they can take to change their behavior and challenges the dichotomous thinking found in women of all ages with eating disorders. It also helps us as treaters to conceptualize the difference we can make, despite the severity and duration of the problems we see in those women who have suffered over decades. Some may recover quite fully, others less so, but in most cases we can improve the quality of their lives.
As with our younger patients, eating disorders and body image obsessions can both reflect significant family issues as well as contribute to them. Midlife women struggling with these issues need to contextualize their symptoms within their cultural experience as women, but also within their families. Addressing family of origin issues is just as critical as it is with younger patients. Jennifer and Sally had to explore their family dynamics, especially the relationship both had with their fathers to begin to understand their drives to perfection and the meaning their bodies had assumed. Ann had to address the impact of her father’s depression and withdrawal on her. All three women came from families that had difficulty dealing with uncomfortable affect. The drive to achieve and excel was emphasized while feelings and emotions were minimized, so they lacked the skills and resources they needed to handle the challenges of adult life.
Today’s Pioneers - Midlife Women with Eating Disorders
Today’s women hunger for familiarity and security and may find it in the rituals of disordered eating, weight preoccupation, and body image despair. Aspiring to meet the culture’s narrow “beauty” standard may feel the safest or surest way to acculturate and organize their lives. Rather than unlocking the secrets and potential in this land of ambiguity, as other successful immigrants do, contemporary women measure success by how strictly they manage their bodies and restrict their eating.
The implications of the increasing incidence of eating and body image concerns at midlife are many. In order to address this critical problem affecting the health and wellbeing of contemporary women, we need:
Margo Maine, Ph.D., an expert in the treatment of eating disorders, is the author of Father Hunger: Fathers, Daughters and Food and of Body Wars: Making Peace with Women’s Bodies. Cofounder of Maine & Weinstein Specialty Group in West Hartford, CT, she is Senior Editor of Eating Disorders: The Journal of Treatment and Prevention, a founder and fellow of the Academy for Eating Disorders, a founder of the National Eating Disorders Association, and board member of the Eating Disorders Coalition for Research, Policy and Action and of Dads and Daughters. Her new book, co-authored with Joe Kelly, B.S., The Shape We’re In: Overcoming Women’s Obsessions with Weight, Food, and Body Image, will be released in 2005 by John Wiley.