Wednesday, August 13, 2008

Book review: Why She Feels Fat

If you pick up Why She Feels Fat, by Johanna Marie McShane and Tony Paulson, because you want to understand the inner life of someone with anorexia, bulimia, or binge eating disorder, you'll be sadly disappointed. Actually I think you'll be disappointed no matter why you pick it up. There are dozens of books exactly like this already in print. The world certainly doesn’t need another one.

I expected to read an insightful exploration into the biology and psychology of eating disorders. I expected to find an answer to the question posed by the title. Why do people with anorexia and bulimia feel fat even when they’re not? The phenomenon has been well documented; Walt Kaye tells the story of bringing two 70-pound anorexic women into a class of med students and asking them to describe each other. Each sees the other as way too thin, gaunt and unattractive. Each sees herself as way too fat. This is a fascinating demonstration of distorted brain chemistry at work.

But these aren’t the kinds of questions the authors take on. Their answers to the question posed in the title are the same old same old we’ve been hearing for many years now about eating disorders: She feels fat because she was sexually abused, because her parents divorced, because her mother is overly critical and her father is absent. She starves, binges, and/or purges because—wait for this groundbreaking revelation—it’s a way to control a disappointing or painful world.

There's nothing about biology, genetics, or any of the new research on eating disorders that is changing the way we understand and treat them.

There's nothing new about the so-called insights offered by this book: They're all the rationalizations and delusions of eating disorders, offered up without analysis or true understanding. When my daughter was ill with anorexia, I heard them all. The difference is that I didn't take them at face value. These authors appear to do just that.

The section on treatment is just as outdated and even harmful. "The job of the therapist is to help your loved one understand, acknowledge, and resolve the issues that are fueling her illness," write the authors. In the meantime, if your loved one starves to death, or has a heart attack, well, never mind. At least they'll get to the bottom of the problem.

The job of the therapist is not to answer the question why. It's to heal the eating disorder.

If the authors were up on the latest research on treating eating disorders, they wouldn't write, as they do, "Medication may be necessary either for the short term to facilitate treatment or for the long run to achieve emotional balance." While there are n o doubt people for whom medication is helpful, none of the big studies have shown any reason for routinely prescribing meds like Prozac and Paxil for those with eating disorders. This is not only wrong-headed advice--it's one size fits all advice.

The authors also recommend working with a dietitian or nutritionist--again, standard advice for someone with an e.d. They continue down the conventional path by recommending that the nutritionist and patient develop an eating plan together. This might be good advice for treating bulimia, but it's definitely not good advice for treating anorexia. And that's another of the problems with this book: The authors don't differentiate among the eating disorders.

I could go on, but you get the idea. No stars for this book.


Carrie Arnold said...


From what I've seen of the book (the online preview at Amazon, and a quick flip through at Borders), I totally agree.

(As a writer, when people tell me they read five pages of my book and say it sucked, I make sure that any comments I make are about portions I actually read).

Dangit, you're lighting the fire under my feet to write a book about the biology of AN/BN/EDs.

Harriet said...


I hope you do!

Carrie Arnold said...

I wish I could go see you in Syracuse, too. But I suppose I'll have to come visit some other time (and also let you get settled in). If you ever come to the DC area let me know- there are some fantastic cupcake places. I think of you everytime I wear my t-shirt.

Hope the move is going/went okay.

Anonymous said...

i liked Gaining, by Aimee Liu

Harriet said...

What did you like about it, anon?

Anonymous said...

I'll take a stab at answering, but I'm sleepy and swamped so apologies for any incoherence that follows...

Don't know if you read Gaining - the author, who is I think in her 50s now, and a novelist, and wrote an 'overcoming anorexia' memoir in her 20s (haven't read it) finds that she's still using the same thought patterns decades later to deal with life. She looks back across her young adulthood and, using a combo of personal reflection, tracking down old acquaintances and looking at some recent research, argues that there are biological commonalities that make people more susceptible to responding to life with eating-disordered behavior or some proxy - needing to always color in the lines, keeping oneself close and bounded (physically and mentally), etc. She writes about getting good at guessing who has an eating disorder in their history by how they react in casual conversation.

None of this is groundbreaking on the research front but, from a non-academic perspective, reading it was a great big "a-ha" moment. My favorite example is where she mentions working herself to death as a college student and assumes that everyone making decent grades is beating themselves down to make it happen. Money quote:

"It never occurred to me that among other high achievers, compulsive perfectionists were the exception rather than the rule."

I was the same - it really did not occur to me there was another way to do things. Thinking about that mindset as another piece of a behavioral puzzle - and finding out others had the same moment - was instructive.

It's also an engaging, endearing read since it's written by a writer, and it's reassuring to know that my current attempt to deal with life - by embracing it - is an ongoing struggle for fellow "recovered" folks but that the effort is worth it.

Anonymous said...

I dunno. . .

I haven't seen the book and try to stay away from books like these -- like Anon, I also enjoyed Gaining and the mix of recent science and personal testimony. The book is also supportive of Maudsley, Harriet and cites many studies.

I think ED treatment is not one size fits all, as you said. For some MOTIVATED and adult ED sufferers, it may be beneficial to work with a dietician. I know I am -- but I am willing to take her recommendations and trust her. It is a different story for an adolescent/adult fighting treatment tooth and nail or for anyone with ambivlaence.

Also, I believe there are psychological factors contributing to "feeling fat." But whatever these may be, they are mutually exclusive from the refeeding part of the ED -- they cannot be used as justificiation not to get well.

I think I am agreeing with you in that nutrition is the #1 priority. But I believe therapy can be useful along the way (just to vent, CBT skills, DBT skills, support, etc.) and after.


Anonymous said...


My daughter started out in the treatment program run by one of the authors of the book. I bought a copy of the first version of the book when she started treatment. The individual therapists in the program were, for the most part , very dedicated caring individuals. However, the treatment approach they used follows closely the philosophy espoused in this book. We tried several times to discuss Maudsley with them or at least a different approach to nutrition but they had such a different orientation and no interest in discussing any of the research studies I brought up. Indeed, it almost seemed to confirm in their eyes that I was an over-involved neurotic Mother when I questioned their judgement or talked about journal articles. Our child was evaluated , saw a therapist we never met, the nutritionist met with our D without us, the program talked with her (she was 15 at the time) about sending her to residential care without our knowledge, etc etc. The child must figure out why she doesn't eat(with the help of the therapist) The parents are told "don't be the food police" and we were told "your daughter is doing great work in therapy" when we continually expressed concern that she was expected to make her own shopping lists, cook and serve her own foods, and keep track of her own meal plan (which we didn't see). After three months she was still below her 85% and more obsessive and rigid about food than ever before. Ultimately, the responsibility was mine for leaving her there for so long when it wasn't working. There was no emphasis at all on the parents or family helping to structure an environment where the child could regain her health. We made many mistakes in our D's care and interestingly the program was right in some of the things they told us but, because they never built any alliance with us or showed any interest or belief that we were anything other than the problem, we didn't benefit from even those things they said which had merit.

Just recently I threw this book in the trash. In my family (I grew up helping my Mom work at Library booksales) throwing away a book is a worse sin than flag burning. This may be the only book I have ever thrown away.


ps hope your move has gone well--sorry about the diatribe above

Harriet said...

God, I'm sorry, SC. That sounds like hell. I hope throwing the book out was cathartic in the best sense of the word.

Lock and Le Grange are working on an accreditation for Maudsley therapists. So folks like this won't be able to say they "do Maudsley" unless they truly do. The sooner the better.

Anonymous said...

I watched an interesting clip on youtube about brain patterns of anorexics. Something about less blood flow to the right side of the brain which could explain the distorted perception and obsessive, circular thinking.

Of course I don't know if it's true, but an interesting theory nonetheless.

This book sounds about as dreadful as they can get. Who on earth is willing to publish stuff like that? From what you've said, I'm pretty sure Oscar the Grouch could write a better book.

Harriet said...

Yes, there is some fascinating research being done with functional MRI scans on people with anorexia and other e.d.s. One study I looked at saw changes that persisted long after recovery, which leads to the questin of whether those brain changes preceded the disease and precipitated it. It's all very interesting. Someday we will look back on our current understanding of e.d.s and realize we knew very little and judged a whole lot.

Anonymous said...

I think the book was very good because for once, it's like someone understood what I'm going through. It was written in an easy-to-understand way for people like friends & family to comprehend and feel overwhelmed by complicated impersonal medical terminology. This book is down-to-earth where most of the other ED (non-fiction) books I've read where dry and too technical.

I read through it once, and it bothered me enough to where it took a couple of weeks to pick it up again because so many points hit home.

Female, 42-years old, 14-year off/on anorexic