– Layne Cook, LMSW


Over 5 million Americans suffer from eating disorders (ED), which include anorexia nervosa, bulimia nervosa, and binge eating disorder. Millions more display ED or disorder eating symptoms without meeting the diagnostic criteria for a full-blown disorder. EDs adversely affect both physical and psychological functioning, are more fatal than any other mental disorder, and are often accompanied by behavioral health problems, especially substance use disorders (SUD).

An examination on the link between EDs and SUDs by the National Center on Addiction and Substance Abuse (2003) found that 50 percent of individuals with EDs abused drugs or alcohol, compared to 9 percent of the general population. The study also revealed that 35 percent of women treated for drug or alcohol addiction reported a history of EDs, compared to 3 percent of the general population. Furthermore, EDs were 10 times more prevalent in women. Numerous similarities exist between EDs and SUDs including impaired inhibitory responses (impulsivity and compulsivity), family history, mental illness (e.g. depression, anxiety, etc.), personality disorders, history of trauma or abuse, emotion regulation (coping mechanisms), and reward stimulation in the pleasure center of the brain. Despite these similarities, there are some major differences of EDs that contribute to a higher prevalence in women, especially young women, and that need to be considered during treatment. While EDs are also a serious, growing problem in men and deserve equal amounts of attention, the discussion in this article is limited to focusing on women.

Young adult women in the United States are evaluated primarily by their physical appearance. Research shows increased rates of cosmetic surgery, weight-related problems, and mental health issues among emerging adult women. While rates of dieting, excessive exercise and EDs continue to rise so does the percentage of women who are overweight or obese. Young women receive sociocultural messages about a thin ideal from the media, family, and peers. This continuous reinforcement of the thin ideal has resulted in high levels of body dissatisfaction among young women and led to unhealthy weight management practices.

Changes in sociocultural views about weight throughout U.S. history have resulted in the evaluation of women based on their body size, race, and socioeconomic status (SES). In cultures where food supply is scarce, plumpness is seen as a marker of high social class. Before the early 1900s, when the food supply was scarce in the U.S., women desired plumpness because it was a sign of social status and class. When food became more readily available, the sociocultural views on body shape began to change because women of lower SES were able to become plump.

Thinness is now highly valued in American culture and has become an indicator of social status. Thin women are perceived as happy, having high moral character, and are more likely to succeed in American society. Thinness is most often associated with Caucasian women of high social and economic class. Media portrayal of overweight and obesity is primarily associated with minority groups, lower SES, and is seen as lazy.

Dieting has become a social norm, and there is growing cultural acceptance of young women surgically altering their body appearance and shape. This is due to the unrealistic American beauty standards and sociocultural pressures to be thin. The average woman in the U.S. is 5’4” tall and weighs 140 pounds, while the average model that ostensibly epitomizes our standard of beauty is 5’11” tall and weighs 117 pounds. Furthermore, women’s magazines have 10 times more weight loss advertisements compared to men’s magazines, which coincides with the ED gender ratio.

Given these unrealistic beauty standards, and that weight is seen as a sign of moral character and social class in the U.S., young women are especially vulnerable to negative feedback based on appearance. This leads to psychological distress, poor body image, and increased risk for EDs and SUDs. They are more likely to pursue cosmetic surgery or practice extreme weight management techniques. They may also turn to drugs to help curb appetite, increase metabolism, or cope with unpleasant emotions and low self-esteem.

During treatment for these disorders, clinicians must strive to understand young women’s experience in society and the diverse cultural context in which mental health problems occur. Clinicians need to be increasingly aware of female clients’ personal beliefs about gender and beauty and how these beliefs originated. The client’s emotional response to criticism of their appearance should also be considered, and interventions that enhance self-esteem and empower should be used to help them cope. When working with women that have body dissatisfaction, EDs, and those interested in cosmetic surgery, it is important to explain that while achieving ‘ideal beauty standards’ may result in some higher levels of happiness, it is temporary and not as important as depicted through the media.

Clinicians should also be aware of stereotypes associated with EDs, and never assume that minority groups are invulnerable. In immigrant clients, the level of acculturation should be assessed because they may feel pressured to conform to the unrealistic American beauty standards. There is a psychological component associated with body dissatisfaction, and the way young women feel about their bodies is more important than their actual size.

Proper screening for EDs upon entering treatment for SUDs is crucial. Treatment without recognition of the ED does not do the client justice and increases the risk of relapse because they continue to engage in unhealthy coping mechanisms. Given the ego-syntonic nature of ED behaviors, and that ceasing these behaviors may result in a period of heightened psychological distress, recovery is a gradual process. Many individuals still have self-image problems after the behaviors subside. Therefore, it is important to use therapeutic interventions that treat the behaviors as well as the underlying thought processes, such as Dialectical Behavioral Therapy and Cognitive Behavioral Therapy.

When treating EDs, relapse or setbacks are expected. Unlike treating drug and alcohol addiction, individuals with EDs cannot be expected to just stop the behaviors and enter into complete abstinence because food is necessary for survival. A modified form of abstinence is required and episodes should start to diminish as changes in thinking occur. Abstinence from an ED means taking care of the body, mind, and soul daily. For the body, it means eating nutritious foods that provide fuel in a healthy way. For the mind, it means being aware of emotions, observing thought processes, and using healthy coping mechanisms to deal with stress and anxiety. For the soul, it means acceptance, choosing to be happy, and making decisions that coincide with morals and values.

In my experience as a clinician at a residential treatment center working with clients that have SUDs and EDs, most report that their ED and body image issues started long before their SUD. They often say their ED is the most difficult issue to overcome, and that symptoms usually reappear when sober from drugs or alcohol. Imagine telling someone with severe alcoholism to drink one glass of their favorite cocktail three times a day, every day, and for the rest of their life. Sounds crazy, if not impossible, right? Well, that is essentially what individuals suffering from EDs are challenged to do in recovery. This poses an extremely difficult challenge for those trying to recover from an ED. It is important to have patience and empathy when treating eating disorders. You should look for progress, not perfection. Recovery is possible with the right kind of therapy and help. Nothing worth doing is easy. Take it one step at a time, grow and learn from setbacks, and be kind to yourself.