In this podcast, which comes on the heels of reports linking social media use to reduced self-esteem in teen girls, eating-disorders therapist Shira Collings discusses person-centered, socio-culturally aware approaches to dealing with disordered eating and other food-related challenges in youth (and adults).
Shira Collings, M.S., N.C.C., is Mad in America’s Assistant Editor for MIA Continuing Education and the Youth Coordinator for the National Empowerment Center. She received her B.A. in Communication from the University of Pennsylvania and an M.S. in Counseling and Psychology from Troy University.
As a person with lived experience of recovery from diet culture, disordered eating, and trauma, Shira is passionate about supporting others in finding freedom with food, body acceptance, and the ability to be their full, authentic selves and live according to their values. She is an advocate for trauma-informed, person-centered approaches to mental health care.
The transcript below has been edited for length and clarity. Listen to the audio of the interview here.
Miranda Spencer: Eating problems are said to be one of the deadliest mental health issues, and there are many different types listed in psychiatry’s diagnostic manual. Why are there so many different emotional/behavioral issues associated with nutrition and eating?
Shira Collings: One commonality and underlying thread that’s present in every eating disorder and every diagnosis is restriction. Most, if not all, eating disorders begin with a period of caloric restriction, of weight suppression. Sometimes people respond with more restriction, and sometimes the restriction leads people’s bodies to feel very deprived, and they may respond through bingeing or through bingeing and purging.
There’s a lot of different factors that play a role in restriction, but a very common factor is body dissatisfaction and the social idealization of thinness and devaluation of fatness. Other times, people may lose weight unintentionally. For example, that might be through a physical illness or other factors, and they may get praised for that or reinforced for that [weight loss] in some way, and that prompts more restriction or some sort of disordered eating cycle.
I would also add that restriction leads to a host of emotional and behavioral issues that can impact someone’s relationship with food and their body and other aspects of their life.
Spencer: Eating disorders are typically associated in a lot of people’s minds with teenagers. Is that an accurate representation of the population that most struggles with this type of issue?
Collings: Eating disorders affect people of all ages. It is most commonly recognized in adolescents and teens for a variety of reasons. One of those reasons is that stereotype, and because of that stereotype, medical providers may screen for it in adolescents and teens and stop screening for it in adulthood. Eating disorders often develop in adolescence, so recognizing and treating them at that point is really important. If we can recognize them in youth and start the treatment there, that can prevent it from becoming a life-long issue.
Spencer: What is it about adolescence that makes one self-conscious about one’s body?
Collings: That’s when people are dealing with figuring out their identity or navigating who they are or what groups they belong to; dealing with different dynamics with their peers. So, for sure, that can influence people and result in restriction or body dissatisfaction.
I think if people are involved in activities that place a high emphasis on appearance and on body weight, such as sports or dance, that can definitely lead to restriction or disordered eating. Then sometimes it has to do with family messaging or family attitudes, but that’s not unique to eating disorders.
Spencer: If there’s going to be some issue displayed in adolescence, why does it end up being an eating issue rather than something else? What do we know about the origins of disordered eating in terms of family eating behavior or attitudes, versus social pressures like bullying or Instagram?
Collings: I think all of that certainly can play a role: negative messaging from family, schools, peers, and the media. Those certainly can have a big impact, but I think it’s just different for everyone in terms of what has the most impact.
Spencer: I suppose that makes it more challenging in terms of helping someone, because it’s not as if you can go to a script: It’s caused by this, and so the solution is that.
Collings: I think that’s true. At the same time, there are things that we know do play a role and are major contributors, such as restriction or weight suppression. So, that’s definitely something that we can keep coming back to, the effects of that.
And we don’t always have to know the specific setting that the negative messaging is taking place to address the fact that negative messaging about bodies and about eating and about weight do play a role and can lead to that restriction.
Spencer: Are there are other stereotypes or beliefs about eating struggles?
Collings: I think a very common stereotype is that eating disorders only affect white, thin, teen-aged or adolescent girls. But the reality is that eating disorders affect people of all sizes, backgrounds, ages, ethnicities, sexual orientations, and genders.
I think one of the most harmful stereotypes is that people in larger bodies don’t have eating disorders, or restrictive eating disorders. Or that you can tell by looking at someone whether or not they have an eating disorder, or maybe the severity or the type. I think it’s really important to acknowledge that weight suppression and restriction in any size body can be very harmful. And we do have research showing, for example, that someone in a larger body who has lost a significant amount of weight rapidly may be suffering from more medical consequences than someone who is categorized as underweight according to the [body mass index], but who is in a smaller body to start with.
And I would also add that binge eating disorder, or disorders that we commonly associate with eating, “excessively,” often if not always result from restriction. That’s usually one way that the body is making sure to get enough food or to compensate for the deprivation that it’s facing. So, the approach to treating binge eating disorder is through addressing the restriction. Not through addressing the bingeing behaviors.
Spencer: That’s really interesting, because I think about popular diets like Keto, which is mostly protein and very focused on making sure that you only eat certain things. Where do we draw the line on what is a choice and what gets into the territory of emotional distress?
Collings: I personally don’t really draw that line. We have plenty of evidence showing that any form of restriction, including a diet that’s normalized or popularized in our culture, can be harmful and can create real mental and physical health consequences. [For example], keto has resulted in many, many different types of physical health issues, mental health issues, [even] death in some cases, which is really tragic.
Spencer: Struggles around food and eating are considered a mental health problem, but you’ve also told me that disordered eating can actually cause or exacerbate mental health problems. Can you talk about that?
Collings: The idea that an eating disorder or disordered eating results from an underlying issue or means that someone has something wrong with their brain in the first place, [is] kind of a misconception; it’s a lot more complex and nuanced. The idea that it’s a mental health issue that causes starvation versus starvation that causes a mental health issue is a bit over-simplified.
I want to talk about a study called The Minnesota Starvation Experiment that was a study done in the aftermath of World War II to study how to re-feed victims of genocide, who were healing from the effects of starvation. This is a study that would not be approved by any research ethics committee today, but I think we can still learn a lot from it.
So, these thirty-six participants were selected for the experiment because they were in top psychological health. They were considered extremely physically healthy. They were conscientious objectors to World War II; this was how they chose to serve. They were put through a period of semi-starvation, which I believe was around 1500-1600 calories per day. They lost a significant percentage of their body weight, and I believe that was [for] about six months, and then after that, they went through re-feeding, healing from that starvation.
These men deteriorated and had their mental health and physical health just destroyed. Just absolutely devastated by starvation and by this period of significant restriction—many diets today prescribe that number of calories or even less than that, so it’s not even something today that we always recognize as starvation. But in this experiment, their bodies and their brains did respond to it as if it were starvation, and it was.
These participants experienced very high anxiety. Very high irritability. They lost a lot of interest in social activities and their romantic life and spending time with other people. They became obsessed with food. They collected cooking utensils sometimes or chewed tons of gum, like fifty packs of gum a day in one case. They would look at like images of food. Some of them even became chefs. They often had insomnia and couldn’t sleep. There were neurological effects. Gastrointestinal effects. And they often – some of them – even had psychotic symptoms.
Spencer: How did you become interested in working with people with eating disorders?
Collings: I’ve had my own lived experience of diet culture and disordered eating. And I’ve had family members and friends who have experienced that, too. So, that really sparked my passion for helping others with eating disorders. It’s something that I’ve recovered from, and I’ve seen how incredibly positive it can be to really break free, so I really want to support others in doing that.
I also really love that in the eating disorder field, there is such an important role for looking at systemic factors that contribute to disordered eating and supporting people in unlearning what they’ve been taught about needing to control their body size or needing to strengthen their bodies. In many ways, eating disorder recovery is about rejecting oppressive values in our culture and really living according to your own values.
Spencer: Historically, what have been the standard approaches to treating eating problems, and what are some of their limitations?
Collings: One traditional approach, historically, has been separating people from their families and assuming that family is the sole cause of eating disorders, just treating the person with the eating disorder as just an individual. A limitation of that is that families can be really helpful sources of support in someone’s recovery, and it can be really valuable to include them.
I do think it’s important to acknowledge that families do sometimes contribute to eating disorders because of their own eating habits, their own beliefs about body size, but when families are willing to recognize that and unlearn it, that can be an incredibly healing process.
Spencer: There were some sensational made-for-TV movies a couple of decades ago where someone with an eating disorder is hospitalized and force-fed. Is that no longer done? Was it ever?
Collings: I think it’s significantly less common than the media portrays it to be. It’s a lot more common, unfortunately, for people with eating disorders to not even have their eating disorders recognized or get treatment at all. But I think that’s often because we have this idea that if someone is not “underweight” according to the BMI, or really emaciated looking, then they’re not struggling, or their eating disorder isn’t severe. So, medical providers, mental health providers, often just don’t recognize that, or it’s trivialized.
Spencer: What are some of the approaches that you like to use? And does your lived experience with the problem inform how you interact with your clients?
Collings: I primarily use feminist therapy. I believe it’s important to explore the systemic and cultural factors that contribute to eating disorders, which is what feminist therapy is about. It’s exploring, obviously, the effects of misogyny and patriarchy on our mental health, but also other forms of oppression, systemic racism, transphobia, homophobia, all sorts of different forms of bias that we have, with eating disorders. Fat phobia and weight stigma are really relevant. So, I typically use that lens to explore what the impact of that has been in people’s lives and how that is affecting their relationship with food.
My work is also informed by an approach called Body Trust, which is a paradigm that emphasizes unlearning oppressive messages about our body and about weight, and as its name suggests, trusting our body to regulate its weight and regulate our eating and be the size and shape that our bodies need to be without us needing to really control it and without us needing to prescribe a set of norms or values around it.
I work a lot on externalizing shame. A lot of people with eating disorders and disordered eating tend to blame their bodies and punish their bodies for issues that our culture creates. So, I emphasize externalizing that and placing the blame in systems that have told us that our bodies are wrong, rather than punishing our bodies.
Spencer: Why don’t you tell us more about the Health at Every Size paradigm?
Collings: It’s an evidence-based [practice] for treating eating disorders. It recognizes that weight is not indicative of health. So, it looks at body size diversity as just a natural part of diversity. Just like we’re meant to be different heights, different hair colors and skin colors, we’re meant to have different-sized bodies. Some people are meant to have larger bodies, and some people are meant to have smaller bodies. And that is okay. It acknowledges that weight stigma is actually more dangerous and carries more risk than being at a higher body weight.
I do know this goes against what a lot of people have been told, that being at a higher weight carries risk or is associated with many different health problems. But Health at Every Size recognizes that many of the health issues that we may associate with being at a higher weight may very well be due to weight stigma. It also recognizes the efforts to control our weight can be very damaging and have significant impacts, and some of those efforts may actually account for some of the health issues that we typically attribute to being at a higher weight.
People in larger bodies are often prescribed eating-disordered behaviors, such as dieting and restricting—even compensatory behaviors like the things that are called detox. For people in larger bodies, that may be seen as a healthy behavior, but for people in smaller bodies, that may be seen as bulimia or anorexia. So, Health at Every Size recognizes that some of the health issues that we associate with being at a higher weight may result from some of those disordered eating behaviors that we often prescribe or see as valuable or good.
It also recognizes that weight stigma is extremely prevalent, specifically in health care settings, and there’s tons of research showing that medical providers treat larger patients significantly worse than patients in smaller bodies.
Spencer: If your own doctors and everyone around you is putting you down, that would really do a number on your self-esteem.
Collings: Absolutely. And it can also cause a physical health problem because many people in larger bodies may just not get the health care that they need because they don’t want to go to a doctor’s office and face systemic fat phobia.
Spencer: As a practitioner in the field of disordered eating, is there something that you have learned from your clients?
Collings: The biggest thing that I’ve learned is how pervasive weight stigma and diet culture [are]. The idea that thinness is better, healthier, or more valuable than fatness and that we should be pursuing being thinner and controlling our body size. And we should be eating based on that, rather than based on what our body wants and needs.
And I’m constantly learning from my clients just how hard it is to recover in that world where that’s so pervasive. Where every day they are fighting to let go of that control over their body size and have a positive relationship with all foods.
I would also add, diet culture certainly played a role in my own disordered eating, and my own disabled identity played a big role in that, too, [in] that I feel like I was often told to restrict certain foods or eliminate certain things and that would somehow cure my disability or make me better. That I wasn’t trying hard enough if I wasn’t doing those things.
But I’ve learned how much harder it is the more marginalized identities you have. I’m a person who has thin privilege. I have white privilege. I have relative financial privilege. A lot of my clients don’t. And I think there are certain marginalized identities where it just becomes very hard to recover because restoring weight might add another form of stigma that you have to experience.
Spencer: In terms of practical advice, particularly for parents and family members with teenagers and youth, what would be some of your dos and don’ts?
Collings: The first thing I would say is that it’s really important to approach the issue holistically. To involve a dietician and a doctor in addition to a therapist. Because like you said, it’s not necessarily so much a mental health problem that manifests through an eating disorder as much as the other way around.
It’s really important for parents and families to acknowledge the impact of weight suppression and starvation and that it’s very, very hard for any type of mental issue or issue with disordered eating to be worked on without those kinds of basic human [food] needs being met.
Spencer: I’d think there’s a nutrition element in this, too. If you have restrictive eating, you might not be getting certain micronutrients?
Collings: Yeah, absolutely. And at the same time, I think we sometimes focus so much on that, that we miss that calories are also nutritionally so, so needed. And we need macronutrients: fat, carbs, protein, all of it. Sometimes I hear a focus on nutritional mental health, which I think can be valuable. But sometimes it’s so focused on micronutrients or on getting fruits and vegetables that we missed that the first nutritional priority is enough calories and enough energy.
So, it can be really important to make sure that they’re being medically monitored and that we are watching out for those signs that maybe things are deteriorating, because the medical consequences are very real.
Spencer: How can parents distinguish what we might call disordered eating from less-than-ideal eating, or from allergies [or] something like celiac disease?
Collings: I would say that any form of restriction can be really harmful, and it’s definitely worth getting support around. Obviously, if there are [food] allergies and things that need to be restricted for that reason, that’s reasonable. Outside of that, I really do feel that any form of eliminating foods or even just fear or anxiety about foods [is a red flag]. Even if it’s more of a mental or emotional restriction, I would say it can be really beneficial to get support around that. Other signs to look for can include a preoccupation with body image or intense body dissatisfaction, which includes any pursuit of weight loss or wanting to lose weight.
Then, I think social withdrawal, in general, can be a warning sign if you see that with restriction of food. Those are often linked, as well as irritability and other mood changes. That’s often how restriction initially affects someone’s mental health.
Spencer: What should parents say or not say?
Collings: More often than not, [it] is really harmful for teenagers to experience any weight stigma, positive language about thinness, [or] negative language about fatness or larger bodies. And I think that can lead to dieting, which can quickly turn into disordered eating. I think it’s really important to just more generally be neutral about bodies, just that bodies can be trusted to be the size and shape they need to be.
Another big thing to avoid is categorizing foods as healthy or unhealthy [or] talking about exercise as something that has to be done to be healthy. Because I think that often makes people feel like they have to earn their food somehow, or maybe [to] exercise compulsively.
Another really big thing is not to downplay how critical it is to eat enough and have enough body fat or body weight. So, emphasize the importance of eating enough the same way we do with any other safety concern with kids.
Spencer: What are your thoughts on the issue of weight gain from psychiatric medications?
Collings: I’m glad you asked that. Because, again, that’s another type of thinking that many spaces in the eating disorder field are moving away from. I really think that the idea that weight gain, as a problem in and of itself, isn’t really science-based.
I do think that weight loss from psychiatric medication is a really big issue that we often don’t talk about. And I have seen that happen. Maybe someone is under-eating or restricting because of being put on a stimulant for ADHD. And then they are sometimes praised or reinforced for losing weight because of that. And then that can lead to more disordered eating.
I also think another issue is that sometimes those same types of medications, like stimulants, are prescribed for a binge-eating disorder by psychiatrists who aren’t always very familiar with the literature. They just see someone in a larger body and maybe make an assumption that they’re binge eating when they’re not. Or someone does report binge eating, but they don’t look at “hey, is restriction causing this?”
Spencer: You have said that eating disorders are generally different from other subspecialties in mental health, in a good way. How so?
Collings: There’s a lot more room to really acknowledge the impact of systemic and social factors on mental health and on our relationships with food and our bodies.
I think there’s also a lot of acknowledgment of the role that starvation and weight suppression can play in mental health. If someone isn’t eating enough, a lot of mental health issues that they’re experiencing may be attributable to that. Or addressing those issues as a priority can really reduce a lot of the symptoms that someone might be seeking help for. So, I really would love to see other providers learn from that and also take that approach before, or in addition to, more medicalized approaches.
Spencer: That sounds like it would be particularly important with children and youth.
Collings: Absolutely. Kids’ bodies are constantly changing. They expend tons of energy just to grow and learn. So, I feel that’s so important to look at: Are they being given what they need to do that, rather than [adults] just rushing to assume that there is something wrong with them?