Gina Dimitropoulos; M.S.W., Ph.D., R.S.W
Anna is a twenty-one year old woman who has struggled with anorexia nervosa for several years. She blames herself for developing the eating disorder and not being able to control her eating and purging. Anna’s family and friends cannot understand how someone as smart and thoughtful as her could care so much about her physical appearance and what others think of her. They also feel frustrated that Anna cannot recognize that she is hurting herself and those around her. Such comments from others increases Anna’s deep sense of shame about her eating disorder, so she further conceals her struggles with food and weight. Anna isolates herself from others because she fears that they can’t understand her pain and suffering. She also fears that she may be seen as different or morally weak because of the eating disorder.
Unfortunately, Anna’s feelings of shame, blame and fear that others perceive her negatively are common among those experiencing an eating disorder, a severe and persistent mental illness. Anna’s story illustrates a common problem faced by those with eating disorders or other mental illnesses: stigma.
What is stigma?
Stigma occurs when an individual experiences negative attitudes or stereotypes because others perceive them as “different”. Stigma negatively affects every aspect of an individual’s life; relationships, academic achievement and employment opportunities. The stigma associated with eating disorders robs people of their dignity, increases isolation, reduces self-esteem and contributes to a decline in one’s quality of life. One of the most harmful consequences of stigma is that it may act as a barrier to people with eating disorders disclosing their problem to others and stop them from looking for and getting help.
This article looks at the many ways that stigma hurts people with an eating disorder and suggests ways to combat stigma on both a personal and a societal level.
What does stigma mean for individuals?
- Fear of being evaluated negatively by family, friends, teachers and employers.
- Self-disgust and self-loathing about their appearance and their eating and purging behaviours
- Experiencing oneself as defective, flawed or different from others because one is not meeting what one sees as familial or societal standards and expectations.
- Concerns that disclosure of the eating disorder will result in others trivializing their difficulties
- Self-blame, shame and fears of being assigned negative stereotypes may contribute to a withdrawal from one’s social support network.
Delay or avoidance of treatment due to concerns and fears that employers and educators may think of and treat them differently for having an eating disorder or for pursuing psychiatric treatment.
How is stigma perpetuated?
- Through negative stereotypes including the belief that people with eating disorders are just “vain and superficial because they care so much about thinness and their physical appearance”.
- Through entertainment news where there is a morbid fascination with the emaciated appearance of high profile models and actors.
- Admiration of restrictive eating or extreme weight loss tends to trivialize eating disorders as insignificant and about food and weight, rather than serious conditions needing medical and psychological support.
- Assumptions that people with eating disorders are to blame for their problems and that they should “just eat” or “get over it”.
General beliefs about eating disorders
Recent studies suggest that the general public lacks sufficient knowledge and information about eating disorders, leading them to incorrect beliefs about those who have them1. A large survey was done on how people regard individuals struggling with different types of mental illnesses including depression, substance abuse, panic attacks, dementia, schizophrenia and eating disorders2. The findings suggest that eating disorders are perceived by the general public as being self-inflicted, that these individuals should easily be able to pull themselves together and that they have only themselves to blame for their illness. Participants in this study held individuals with eating disorders responsible for their problems because of a belief that they have a choice to engage or not engage in the behaviours. This study also found that the general public often regards those with eating disorders as being difficult to communicate with, and that they were unable to empathize with those who struggle with this illness. The results of this study suggest that the general public tends to trivialize eating disorders, in contrast to other severe mental illnesses such as schizophrenia.
A similar study3 examined the perceptions of the general public regarding the degree to which symptoms of different mental illnesses are controllable by individuals, and the degree to which individuals are responsible for these symptoms. Scripts for a “healthy” person, and individuals with anorexia nervosa, schizophrenia and asthma were compared. The participants evaluated individuals with anorexia more negatively than individuals with schizophrenia or asthma. They believed that “self-discipline, lack of social support, and parenting contributed more to the development of anorexia than to the development of either schizophrenia or asthma”3. Respondents placed more blame on people with anorexia for their condition. Blaming and shaming attitudes were further illustrated as people with anorexia were viewed as choosing to remain ill and using their symptoms to get attention. In another study, individuals without anorexia thought that individuals with anorexia had much more control over their illness, and a greater optimism about recovery than did individuals with anorexia4. People with anorexia appeared to question the effectiveness of treatment and their own ability to overcome the illness.
The beliefs of health care providers
Perhaps of even more concern is that service providers often are as misinformed about eating disorders as the general public. One study showed that health care professionals in a general hospital hold those with anorexia nervosa responsible for their problem5. Explanations of possible causes for eating disorders influence the attitudes of health care professionals towards individuals with these illnesses. Using a sample of student health practitioners, researchers found that participants were more likely to blame people with eating disorders for their illness if the students were exposed only to socio-cultural explanations rather than biological and genetic explanations as causes of the illness.
Consequences of negative attitudes of the general public and health care professionals
- Lack of empathy for the suffering of people with eating disorders leads to the withholding of emotional support.
- Holding people responsible for the eating disorder may lead family and friends to become judgmental, critical and angry.
- Lack of knowledge amongst health care professionals and negative stereotypes towards individuals with eating disorders may prevent individuals from disclosing their symptoms and seeking help.
- The trivialization of eating disorders among both the general public and health care professionals may further hinder people from acknowledging the necessity of treatment.
The perception that people with eating disorders lack self-discipline may also lead to the belief that recovery should be easy and quick.
What can families and friends do to challenge stigma?
The first step to challenging stigma is for us to recognise how our own beliefs and talk about people with eating disorders – and other mental illnesses – may discourage family members and friends with these problems to disclose them. Moreover, negative comments and jokes about an individual’s appearance and eating patterns will only push individuals further into their eating disorder and increase their fear of being harshly judged. Family members and friends should avoid using negative terms, e.g., manipulative, selfish, liar, when speaking about an individual with an eating disorder, as this will only increase shame, blame and guilt. It is important to not only educate oneself about eating disorders but to also challenge others, e.g., co-workers, extended family, friends and even professionals, who make belittling remarks about individuals with eating disorders.
Strategies for challenging shame and blame if you have an eating disorder:
- Educate yourself about eating disorders and the process of recovery.
- Although full recovery is possible, remember that change takes time and do not criticize yourself if your progress seems slow or uneven.
- Increase your awareness of self-deprecating comments and develop strategies to improve your self-esteem.
- Participate in support groups where there are opportunities to share experiences with others who understand your struggles.
- Find stories of inspiration by listening to individuals who have recovered from eating disorders.
- Consider ways to bolster your self-confidence and the belief that you can make positive changes in your life, including overcoming negative body image and disordered eating.
- Engage in political activism to challenge the stigmatization of eating disorders and other mental illnesses.
Strategies for challenging stigma amongst service providers and the general public
One of the priorities of the Canadian Mental Health Commission (www.mentalhealthcommission.ca) is to eradicate stigma against those with mental illnesses through public education and the improvement of services and research. Challenging the stigmatization of eating disorders is in keeping with this mandate.
The first step to challenging stigma should begin with better education of those who are likely to work directly with people with eating disorders and their families. For instance, it is essential that education about eating disorders be integrated into curricula of various educational programs, particularly those designed for health professionals, e.g., physicians, nurses, dieticians and dentists, who will inevitably encounter clients struggling with eating disorders.
Another recommendation is to establish public education programs that challenge myths and stereotypes about eating disorders by replacing them with factual information. We could adopt the strategies used to challenge stigma against other mental illnesses such as depression and substance abuse. One strategy that appears to have been successful in reducing prejudice in other mental illnesses is to profile stories of individuals affected by the issue, and individuals who have recovered. Such stories may break the silence and shame that often plagues the lives of men and women who struggle with eating disorders.
Each of us has a responsibility to challenge stigma towards people with eating disorders. Only by working together can we become stronger advocates to change the way in which people with eating disorders are viewed and treated in our society.
Crisafulli, M.A., Von Holle, A., Bulik, C. 2008. Attitudes towards Anorexia Nervosa: The impact of framing on blame and stigma. International Journal of Eating Disorders, (41)4:333-339
1. Stewart, M., Keel, P., Schiavo, RS. 2006. Stigmatization of eating disorders. International Journal of Eating Disorders, (39)4: 320-325.; Crisp, A., Gelder, M.G., Rix, S., Meltzer, H.I. 2000. Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177:4-7; Holliday, J., Wall, E., Treasure, J., Weinman, J. 2004. Perceptions of illness in individuals with anorexia nervosa: a comparison with lay men and women. International Journal of Eating Disorders, (37)1: 50-56
2. Crisp, A., Gelder, M.G., Rix, S., Meltzer, H.I. 2000. Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177:4-7
3. Stewart, M., Keel, P., Schiavo, R.S. 2006. Stigmatization of eating disorders. International Journal of Eating Disorders, (39)4: 320-325.
4. Holliday, J., Wall, E., Treasure, J., Weinman, J. 2004. Perceptions of illness in individuals with anorexia nervosa: a comparison with lay men and women. International Journal of Eating Disorders, (37)1: 50-56
5. Fleming, J., Szmukler, G. 1992. Attitudes of medical professionals towards patients with eating disorders. Australian and New Zealand Journal of Psychiatry, (26)3:436-443.
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