Written by Randall C. Flanery, PhD, Director of Webster Wellness Professionals
Approaching someone about an unacknowledged psychological disorder cannot help but be awkward and unsettling. You can see that something is not right, and may even know the cause, but you will be understandably reluctant to speak up. The thoughts and fears that stream through your mind will be numerous: what if I am wrong, he or she will hate me, I will lose them as friend, or maybe I will make it worse. The discomfort is understandable, if misplaced. The unfortunate reality is that whatever is bothering the person will not get better, if nothing is said. The awkwardness is only magnified if your suspicion is that a guy you know and care about, might have an eating disorder.
Males do indeed develop eating disorders, although it is less likely to be recognized in males than in females (Strother et al., 2012). Of those seeking treatment, roughly 10% are male, whereas the prevalence of males with eating disorders in community studies is more like 20%. In other words, fewer men with eating disorders are seeking treatment than would be suggested by their numbers in the general population.
There are several reasons for the discrepancy between men and women seeking help for an eating disorder. The clinical presentation differs from that of women for many males with an eating disorder. Unlike women who are nearly always striving for thinness, at least half of men with unhealthy weight control habits perceive themselves to be insufficiently muscular and are attempting to gain weight (Cafri et al., 2005). The reasons for weight control may seem plausible, e.g. to avoid medical conditions like heart disease or to enhance athletic performance (Cohn & Lemberg, 2013). Men, in general, do not seek out health care with the same urgency that women do. Because of these differences, it is more difficult to recognize when a male friend is dealing with eating and body image difficulties.
Eating disorders are perceived as “female” disorders, since the overwhelming proportion of those with an eating disorder are women. Unfortunately, this fact results in the inaccurate conclusion that men don’t have eating disorders and contributes to the stigma for males who do have eating disorders. Being under-recognized and misunderstood, are serious obstacles to males getting the help that would benefit them. Effectively approaching a male about an eating disorder would go a long way to overcoming these obstacles.
The basic approach is the same as anyone with an unacknowledged eating disorder, but modified to fit the masculine experience of eating and weight concerns. The National Eating Disorders Association (NEDA, nationaleatingdisorders.org) has lots of information to help recognize, approach and get help for a loved one with an eating disorder. The National Association for Males with Eating Disorders (N.A.M.E.D., NAMEDinc.org) has information tailored for men.
The steps are as follows:
- Make a plan
- Approach the person
- Next steps
Before approaching someone, think through what it is you know, not just what you fear. If others are also concerned, decide who will be present and who will take the lead in talking to the individual. The content of the approach will be based on observations of the individual’s behavior, not inferences and conclusions you have drawn, even if they are accurate. Besides what can be observed, you also know you own anxieties about the person’s wellbeing. That concern can be shared as well with full ownership that it is your fears.
Know what you would like the next step to be, such as the individual agrees to talk to a family member, see their physician, talk to an eating disorder specialist, or seek help in some other way. Remind yourself that the emphasis is on the health of the person, on getting the person to consider treatment, and to cultivate a trusting, supportive relationship. To this end, knowing what resources are available can be helpful. Again, organizations like NEDA or N.A.M.E.D. can be very helpful.
Start by expressing concern, and then share your observations of his behavior. “I am worried about you. I have noticed you working out for a couple of hours every day, even when you have been ill.” It can’t be overstated that the conversation has to be focused on what is observable and not what you guess is occurring, nor is it a time to make a diagnosis.
The manner in which you conduct yourself during the approach will go a long way in making the conversation useful. While you may be emotionally activated on the inside, your interpersonal manner should be “cool, calm, and collected.” Focusing on the description of what you know and expressing your concern can assist in keeping yourself non-judgmental and supportive, rather than accusatory. The approach is a part of an on-going process to encourage the person return to a state of health, it is not a one shot effort.
You would like the conversation to end with an agreement to do something specific. Ideally, the individual would be willing to talk to a healthcare professional, or discuss the matter with family, spouse, or partner. An excellent outcome is to make an appointment with a physician or with an eating disorders specialist. Offering to join the person at the appointment can bring the approach to a successful conclusion.
Unfortunately, that does not always happen. Sometimes you will encounter outright denial that there is a problem, or angry refusal to even discuss the matter. Thus it might be necessary to bring the conversation to an end without a commitment to take the next step towards health. In that case, continue to monitor the situation and most definitely maintain the relationship. If an eating disorder is present, it is highly likely that other observable events are likely to occur, which would then give you an opportunity to again approach the person. Unless there is an urgent medical need for this person to see a physician, little will be gained by an intense emotional confrontation or to attempt to coerce the person into getting help during the initial approach.
In truth, most individuals with an eating disorder will acknowledge their concerns about eating, weight, or shape, if asked directly (Becker et al, 2005). Often, the affected individual has mentioned something to someone prior to initiating treatment. Interestingly, the individual with an eating disorder is more likely to share information with a peer than to their family physician or a mental health professional. As a friend, you will have more opportunity and a friendlier reception than a healthcare professional would.
The benefits of an individual with an eating disorder disclosing to someone that they are struggling with eating, shape, or weight concerns cannot be exaggerated. Disclosure leads earlier entry into treatment and that treatment is more likely to be effective. Typically, this disclosure results in the first tentative steps towards recovery before the professionals ever get involved. The disclosure is to people- friends, family members, coaches, teachers, relatives; who want what is best for their friend and have the courage to overcome their personal discomfort to ask the necessary, difficult questions: “I am concerned about you, are you struggling? Can I be of help? Can we go talk to someone?”
You can be that person, the one who helps another human being climb out of the depths of an eating disorder.
Becker, AE, Thomas, JJ, Franko, DL, & Herzog, DB. (2005). Disclosure patterns of eating and weight concerns to clinicians, educational professionals, family and peers. International Journal of Eating Disorders, 38:1, 18-23.
Cafri, G, Thompson, JK, Ricciardelli, LA, McCabe, MP, Smolak, L, & Yeselis, C. (2005). Pursuit of the muscular ideal: Physical and psychological consequences and putative risk factors. Clinical Psychology Review, 25:215-239.
Cohn, L., & Lemberg, R. (2013). Current Findings in Males with Eating Disorders. Routledge, New York.
Strother, E, Lemberg, R, Stanford, S, & Turberville, D. (2012). Eating disorders in men: Underdiagnosed, undertreated, and misunderstood. Eating Disorders, 20:346-355.
Dr. Flanery earned his doctorate in Clinical Psychology at the University of Wisconsin in Madison in 1983. He is the Director of Webster Wellness Professionals, a St. Louis eating disorder treatment center. Specific treatment interests of his are: evidence-based treatments of anorexia nervosa, bulimia nervosa, binge eating disorder, and other variants of eating disorders. He also is especially interested in tailoring treatment methods for males with eating disorders and weight control concerns.
He is an adjunct associate professor of Family Medicine at Saint Louis University School of Medicine. Dr. Flanery has more than 25 years of clinical experience treating eating disorders and obesity. He also has a broad background in the treatment of a variety of childhood and adolescent conditions. He uses evidenced-based methods to help individuals achieve lifetime healthy weight management and weight control.
Besides authoring publications on the treatment of eating disorders and childhood health problems, he has served as Director of Eating Disorders Programs and Child/Adolescent services. He is a member of the American Psychological Association, the International Association of Eating Disorders Professionals (IAEDP), Academy of Eating Disorders (AED), and the Society of Child Clinical Psychology. He is a past editor and reviewer of PsyCritiques, an online journal of reviews. Dr. Flanery is a frequent speaker to professional and public groups.