Eating disorders are among the most common mental illnesses in women (Hudson, Hirpi, Pope, & Kessler, 2012; Mangweth-Matzek & Hoek, 2017) and have the highest mortality rate of any psychiatric condition (Arcelus, Mitchell, Wales, & Nielsen, 2011). There are three primary eating disorders outlined in the current version of the diagnostic and statistical manual (DSM-5). First, anorexia nervosa is characterised by preoccupation with food, weight, and body shape, as well as caloric restriction. Due to chronic low energy intake, those with anorexia can sometimes have noticeably thin bodies, but this is not always the case. Second, bulimia nervosa, on the other hand, is also associated with the same cognitive obsessions but is hallmarked by binge eating and purging. Purging includes any behaviours performed as compensatory mechanisms for perceived over-consumption, such as vomiting, laxative abuse, or exercise. Bingeing refers to feeling out of control while eating large quantities of food, usually in a short amount of time. Third, binge eating disorder is a condition comprised of binge eating, but not compensatory behaviors. Those with binge eating disorder, however, often experience extremely high levels of shame and guilt and can sometimes, but not always, have a higher weight status as the result of increased caloric intake (American Psychiatric Association, 2013).
Women with eating disorders endure cognitive, physical, and psychosocial impairment as a result of the conditions (Bohn, 2008; Mehler, Birmingham, Crow, & Jahraus, 2010; Polivy, 1996). For many, these symptoms begin during adolescence, and some receive treatment during the teen and early adult years (Favaro, Caregaro, Tenconi, Bosello, & Santonastaso, 2009). However, eating disorders are notoriously difficult to treat. Even the most effective and efficacious interventions have high relapse rates, and the number of women who achieve a state of permanent recovery is very low. As such, some researchers consider eating disorders to be chronic conditions whereby afflicted individuals vacillate between periods of symptom relapse and remission throughout their lives (Fairburn, Cooper & Cooper, 1986; Herzog et al., 1999; Russell, Szumkler, Dare, & Eisler, 1991). Additionally, the financial burden of both initial psychological intervention, as well as prolonged maintenance and monitoring, can serve as a barrier to full recovery for women with these conditions (Samnaliev, Noh, Sonneville, & Austin, 2014). However, while women with eating disorders are severely impacted by their conditions, they often are still able to engage in social relationships, schooling, and, notably, work.
In the United States, individuals with diagnosed eating disorders are protected from workplace discrimination and are entitled to reasonable accommodations through the Americans with Disabilities Act (Americans with Disabilities Act, 1990). Research suggests that employment can have myriad benefits for individuals with disabilities, (Fleming, Fairweather, & Leahy, 2013; Rubin, Chan, & Thomas, 2003), but the nature of workplace life may complicate the relation between work and well-being for women with eating disorders. Specifically, stress and stigma are frequently experienced and difficult to avoid at work, and both the experience of stress and perceiving stigma have been shown to exacerbate eating disorder symptomology and even predict relapse (Griffiths, Mond, Murray & Touyz, 2015; Grilo et al., 2012). Given that a large portion of adult life is spent at work (Waldo, 1999) and the relatively high prevalence of eating disorders in adult women, the intersection of working life and symptom management is of great importance. However, there is extremely little work done that examines the repercussions of managing an eating disorder (or any other clinical mental health condition, for that matter) in the workplace.
‘…there is extremely little work done that examines the repercussions of managing an eating disorder (or any other clinical mental health condition, for that matter) in the workplace.’
In order to examine this critical gap, it was necessary to let women tell their own stories of the ways in which their eating disorders had interacted and interfered with workplace life. I interviewed seventy women who had been diagnosed with either anorexia, bulimia, or binge eating disorder and had managed their conditions at work. Participants were encouraged to share as much as they felt comfortable and were free to discuss stories from different jobs and various periods in their recovery journeys. My co-author, Katina Sawyer, and I developed a theoretical model of the way in which individual characteristics of our participants uniquely predicted different stigma, stress, and identity management strategies for the complex navigations and negotiations of workplace life. We additionally identified the specific organisational and interpersonal stressors faced by women at work, which served a moderating role in women’s selection of specific management strategies. We then examined the organisational and personal outcomes of engaging in these various techniques. This work was presented at both the annual conference for the Society of Industrial and Organizational Psychologists in Orlando, FL in April of 2017 as well as the International Conference on Eating Disorders in April of 2018. This work is still being finalised, but, broadly, these were the findings:
Certain demographic characteristics of the women in our sample appeared to predict the types of management strategies in which they engaged at work. Specifically, disease type, recovery progress, perceived visibility of the disease, and attitudes toward stigma all had a unique influence on the ways women engaged in the workplace. However, regardless of individual characteristics, workplace stressors were largely the same for all of the women in our sample.
Some were labeled as organisational stressors, or global aspects of work life that contributed to the stress and stigma experienced by participants. Notably, food-centric work events such as the lunch hour, office parties in which food was present, happy hours and events outside of work, and business meetings over meals presented unique challenges for women with eating disorders.
Additionally, health-focused workplaces that featured wellness competitions that prioritised weight loss or dieting, or had health propaganda in the office such as scales and posters, also proved problematic. Scheduling conflicts were also challenging for these women, and some specific occupations appeared to be more stressful for participants than others. Interpersonal stressors included coworker insensitivity, specifically diet talk and general trivialization of mental health at work, as well as leader intolerance with the condition.
Individual characteristics seemed to be influenced by these workplace stressors, and the combination of these two factors affected how women with eating disorders managed stigma, stress, and their identities in the workplace. Participants in our study often felt torn with regard to whether or not, when, how, and with whom to disclose aspects of their condition at work. As such, they disclosed differentially, often only doing so when their once-invisible identity took on visible characteristics. Additionally, many chose to avoid workplace stressors (organisational and interpersonal) entirely or engage in mindfulness strategies to manage them. Many chose to engage in recovery-centric behaviours, but others chose to prioritise professionalism over recovery. These strategies appeared to be differentially selected depending on individual characteristics.
Techniques varied in effectiveness for these women and resulted in differential organisational and personal outcomes. The affected organisational outcomes included work performance, job attitudes, and organisational commitment. Impacted personal outcomes included eating disorder symptoms, social connectedness, and emotional distress. Specifically, women who were able to effectively balance the stress of work as well as their recoveries felt incentivised to maintain their recovery efforts for the sake of enjoying the benefits of their careers, as well as the authentic social relationships they were able to establish at work.
Conversely, those who felt overwhelmed by the stressors of work life sometimes returned to disordered eating symptoms as coping mechanisms. These personal outcomes seemed to predict a prolonged course of the condition and sometimes even relapse for these women. For some, the general work environment of diet culture, deadlines, and emotional sterility was too triggering, and a few of the participants in the study revealed that they had left the workforce entirely for the sake of their health. Others, however, found ways to navigate work life that were conducive to both occupational success and recovery.
Overall, our research suggests that women with eating disorders are willing and able to make important contributions to and flourish within the workforce, but only when stress and stigma are well-managed. In order to make employment more enjoyable and healthy for women with eating disorders, workplaces must be conscious of the ways in which the culture of the organisation is may hinder proper eating disorder maintenance and recovery, specifically by reconsidering organisational health incentives and monitoring the way that diet culture, weight stigma, and mental health trivialisation are perpetuated in the workplace. Women recovering from eating disorders are engaged in a prolonged healing process and must feel safe, comfortable, and supported in order to properly manage the symptoms of their conditions. Leaders can help women with eating disorders by being tolerant of lingering symptomology and generously granting accommodations to women with these diagnoses. Offices in general can work with individuals with eating disorders to ensure that food-centric work events are comfortable and enjoyable for them, perhaps by ensuring that there is at least one “safe food” for them at the event. Coworkers can best support women in the office with eating disorders by monitoring and minimising their language surrounding food, bodies, and eating and by making the person with the condition feel welcome by inviting her to social events, even if she rejects these invitations initially.
Women with eating disorders should consider working with therapists to specifically learn how to successfully navigate workplace stressors. Though our work identified disclosure, recovery-centric behaviours, and mindfulness as particularly effective stress, stigma, and identity management strategies, we understand that what works for some may not work for others, depending on their level of comfort. Additionally, we encourage women with eating disorders to familiarise themselves with their rights as per the Americans with Disabilities Act. A list of reasonable accommodations can be found at: https://askjan.org/media/downloads/EatingDisACSeries.pdf. We are hopeful that this study will lay the framework for future research on managing mental health conditions in the workplace and help organisations, clinicians, and women with eating disorders find effective ways to flourish in both their recoveries and their careers.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association.
Americans with Disabilities Act of 1990, Pub. L. No. 101-336, 104 Stat. 328 (1990)
Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of General Psychiatry, 68, 724-731. doi:10.1001/archgenpsychiatry.2011.74
Bohn, K., Doll, H. A., Cooper, Z., O’Connor, M., Palmer, R. L., & Fairburn, C. G. (2008). The measurement of impairment due to eating disorder pathology. Behaviour Research and Therapy, 46, 1105-1100. doi:10.1016/j.brat.2008.06.012.
Fairburn, C., Cooper, Z., & Cooper, P. (1986). The clinical features and maintenance of bulimia nervosa. The British Journal of Psychiatry, 144, 238-246. doi:10.1002/oby.20301
Fleming, A. R., Fairweather, J. S., & Leahy, M. J. (2013). Quality of life as a potential rehabilitation service outcome. Rehabilitation Counseling Bulletin, 57, 9-22. doi:10.1177/0034355213485992
Favaro, A., Caregaro, L., Tenconi, E., Bosello, R., & Santonastaso, P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70, 1715-1721. doi:10.4088/JCP.09m05176blu
Griffiths, S. B., Mond, J. M., Murray, S. B., & Touyz, S. (2015). The prevalence and adverse associations of stigmatization in people with eating disorders. International Journal of Eating Disorders, 48, 767-774. doi:10.1002/eat.22353
Grilo, C., Pagano, M., Robert, S., Markowitz, J., Ansell, E… Skodol, A. (2012). Stressful life events predict eating disorder relapse following remission: Six-year prospective outcomes. International Journal of Eating Disorders, 45, 185-192.
Herzog, D., Dorer, J., Keel, P., Selwyn, S., Ekeblad, E., Flores, A., … Keller, M. (1999). Recovery and relapse in anorexia and bulimia nervosa: A 7.5-year follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 829-837. doi:10.1080/21662630.2016.1202125
Hudson, J., Hirpi, E., Pope, H., & Kessler, R. (2012). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 72, 164. doi:10.1016/j.biopsych.2006.03.040
Mangweth-Matzek, B. & Hoek, H. W. (2017). Epidemiology and treatment of eating disorders in men and women of middle and older age. Current Opinions in Psychiatry, 30, 446-451. doi:10.1097/YCO.0000000000000356
Mehler, P. S., Birmingham, L. C., Crow, S. J., & Jahraus, J. P. (2010). Medical complications of eating disorders. In C. M. Grilo & J. E. Mitchell (Eds.), The treatment of eating disorders: A clinical handbook (pp. 66-80). New York, NY, US: Guilford Press.
Polivy, J. (1996). Psychological consequences of food restriction. Journal of the American Dietetic Association, 96, 589-592. doi:10.1016/S0002-8223(96)00161-7.
Russell, G., Szmukler, G., Dare, C., & Eisler, I. (1991). An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Archives of General Psychiatry, 44, 1047-1056. doi:10.1001/archpsyc.1987.01800240021004
Samnaliev, M., Noh, H. L., Sonneville, K. R., & Austin, S. B. (2015). The economic burden of eating disorders and related mental health comorbidities: An exploratory analysis using the U.S. Medical Expenditures Panel Survey. Preventative Medicine Reports, 2, 32-34.
Waldo, C. R. (1999). Working in a majority context: A structural model of heterosexism as minority stress in the workplace. Journal of Counseling Psychology, 46, 218-232. doi:10.1037/0022-0188.8.131.52