I’ve blogged previously about the role of the “thin ideal” in Anorexia Nervosa (AN). Conventional wisdom holds that young girls develop AN as a result of excessive dieting in pursuit of thinness, which is considered beautiful in western culture. I don’t believe that the thin ideal causes, or even contributes much, to the development of AN. However, I do believe that the thin ideal delays diagnosis, makes recovery more challenging, and normalizes and trivializes life-threatening symptoms.
I had a recent experience with a patient’s family which illustrates the way in which the thin ideal can interfere with recovery from AN. The patient, whom I will call Norah, presented in my office for eating disorder treatment at the age of 17. I diagnosed Norah with AN and began treating her with Family-Based Treatment (FBT). Norah turned out to have a relatively mild, short-lived case of AN (yes, such cases do occur, though they are not the norm), which responded quickly to a brief course of FBT.
Within a few months, Norah was virtually symptom-free and doing quite well overall. Her vital signs were good, she was getting regular periods, she no longer body-checked or weighed herself compulsively, her mood had improved, and she ate three solid meals each day with her parents or friends, consuming a wide variety of foods with no resistance. Sounds great, right?
There was just one problem: Norah’s weight had plateaued about 5 pounds below the target weight I had set for her based on her historic growth curves. This happened despite the fact that she was eating quite well, not purging, and engaging in minimal physical activity. Many teens in recovery from AN have huge nutritional requirements during re-feeding, so this was not entirely surprising. Besides, Norah had always been petite and naturally thin with a fast metabolism. Most likely, she just needed a lot more food.
Norah is a senior in high school who is planning to go away to college next year. I strongly recommended to Norah’s parents that they require her to reach full weight restoration prior to leaving for college, and that they increase her daily caloric intake to help her reach that goal. I explained that full weight restoration and return to normal growth and development are essential to recovery, and I provided them with literature on this subject. Given how tiny Norah is, a loss of even a few pounds would be enough to push her over the edge. In fact, it only took a loss of a few pounds to send her spiraling down into AN in the first place. In order to be well enough to live independently, I explained, Norah needs to gain these last five pounds and learn to maintain her optimal body weight.
Upon hearing this recommendation, Norah had a fit. She screamed and cried and lamented the injustice of it all. Why should she have to weigh “more than I’ve ever weighed before in my whole life?” (yes, one whole pound more than her historic high). I was not entirely surprised by Norah’s reaction. Although Norah had been unusually compliant in treatment thus far (and yes, such cases do exist, though they are not the norm), even a compliant anorexic has her limits.
Norah’s tantrum was foreseeable. After all, she has Anorexia Nervosa. Of course she would not want to eat more or gain more weight. Plus, Norah is a teenager with big dreams – a high school senior desperate to leave town, escape from her parents’ watchful eyes, and explore greener pastures. The mere possibility that she might not be allowed to go away devastated her.
What was not foreseeable was her mother’s reaction. Norah’s mother did not agree with my recommendation: she did not wish to require Norah to eat more food or gain more weight. Sure, she would like for Norah to gain more weight, but she was not willing to make that happen. She did not think it was fair to Norah, who had worked so hard in school and in recovery, to have to gain more weight in order to be allowed to go away for college. “After all,” said Norah’s mother, “Norah was not happy with her body at that weight, and that’s something we all need to take into consideration.”
No. Actually, we don’t need to take that into consideration.
Imbedded in Norah’s mother’s comment are several assumptions:
1.) That it is perfectly normal and rational for a teenage girl who has always been small and thin to dislike her body and aspire to be thinner
2.) That the rational solution to this teenager’s drive for thinness is to allow her to remain even thinner than before, thus interrupting normal adolescent growth and development
3.) That requiring the teenager to reach her optimal body weight – even when her optimal body weight conforms to the societal ideal – will somehow harm her psyche
None of these assumptions are true, of course. But the thin ideal makes these assumptions seem reasonable to parents and pediatricians and therapists and dieticians alike.
In an ideal world, these assumptions would always seem ludicrous to sensible adults, regardless of the patient’s size or weight. It should not be considered normal or rational for a teenager of any size or shape to dislike her body and aspire to be thinner. Losing weight should never be seen as a solution to body dissatisfaction, especially when weight loss disrupts normal adolescent growth and development. And requiring a teenager to reach and maintain her optimal body weight should not harm her psyche, regardless of whether her optimal weight lies within the realm of what society considers beautiful.
Sadly, we do not live in an ideal world. I am a member of society, just like everyone else, and I’m not immune to the impact of the thin ideal. Norah’s case seems particularly striking to me precisely because her body has always conformed to the thin ideal, and would still conform to the thin ideal after complete weight restoration. Therefore, it seemed particularly dangerous – and ridiculous – not to require her to achieve full weight restoration, because – hey – even at her optimal body weight she’d still be thin.
Here’s where the thin ideal colors my thinking. If Norah had been a large girl whose healthy body naturally gravitated towards a higher weight, her mother’s reaction might have made sense to me. If the poor girl had a stocky body type that placed her on the higher end of the growth charts, it may have seemed rational to allow her to stop five pounds short of full weight restoration. Her body dissatisfaction and drive for thinness would have seemed legitimate rather than disordered. I may have “taken into consideration” the fact that Norah “wasn’t happy with her body before.” Mother’s remark would not have changed my recommendation, but it would have given me pause. I’m not proud of this, but there you have it.
In response to Norah’s mother’s comment, I reminded Norah’s parents, as I had done at the start of treatment, that they are the leaders of Norah’s treatment team and I am a consultant to them. My job is to use my expertise in adolescent AN to guide them, inform them, and empower them to make the right decisions for their daughter. Along with these explanations, I also acknowledged that any recommendation I make is only as good as the parents’ willingness and ability to carry it out.
Ultimately, Norah’s parents chose to reject my recommendation. I suspect that the thin ideal played an important role in their decision. As for me, this situation highlighted the role of the thin ideal in my own belief system and shed light on an important point: an anorexic patient’s body dissatisfaction, drive for thinness, and resistance to weight restoration are symptoms of a serious illness, regardless of her size or weight. And that is something we all need to take into consideration.