when recovery is policed by the state: impact of carceral logics and oppression trauma on eating disorder treatment

remember when i promised a forthcoming essay in may? because i didn't lol.

I am a young, white, disabled, low-income, midsize trans person who has lived with restrictive and compensatory eating disorders for about 10 years. I recognize that I carry an immense amount of privilege in the ED space. Why is this important to mention? Because this is a research piece from the perspective of someone with living experience and while it is not explicitly about my story, it’s undeniable that bias plays a part in every piece of writing. I find it important to make those potential biases known. I will always encourage prioritizing listening to fat and BIPOC voices above my own, so please do your homework and look into the sources below to deepen your learning. Onward!

This paper seeks to understand and explore more deeply the role of oppression trauma and the involvement of coercive carceral bodies– including prison, medical, and psychiatric industrial complexes– in the development and treatment of eating disorders (ED). In our exploration, I bring forward writer and Professor Ruby Tapia’s definition of carcerality: “The carceral state encompasses the formal institutions and operations and economies of the criminal justice system proper, but it also encompasses logics, ideologies, practices, and structures that invest in tangible and sometimes intangible ways of punitive orientation" (University of Michigan). I also look to writer, ethnographer, and clinician Ismatu Gwendolyn, who understands policing as “[t]he coercive hands that use the threat of physical or metaphysical consequence and overhanging fear to compel the actions of the masses away from communal sovereignty and towards supporting racial capitalism… More than a white man with a badge and gun” (Gwendolyn). The concept of a carceral body encapsulates not only the formal structures and mechanisms of the criminal justice system, but also extends past the physical confines of prison walls to encompass broader ideologies, practices, and structures that function to punish undesirable human experiences. This paper will spotlight one particular site of carceral intervention: eating disorder psychiatry. By scrutinizing the dynamics within this domain, this paper aims to unravel the intricate connections between the traumatic experience of oppression, coercive practices, and the treatment of eating disorders. It seeks to illuminate how these intersecting forces shape individual experiences within the realm of mental health care, potentially exacerbating the very conditions they claim to address. Through a critical lens, this paper will explore the complexities inherent in the landscape of disordered eating, interrogating ways in which oppressive structures and coercive practices manifest within psychiatric frameworks. Additionally, I aim to underscore the urgent need for a paradigm shift within eating disorder psychiatry specifically and mental health care more broadly. I call for a reconceptualization of therapeutic interventions. True healing and care cultivate empowerment, agency, and autonomous well-being in ways that punitive measures and oppressive dynamics cannot. I draw upon insights from expert researchers, patients, and tenets of trauma-informed and client-led care to advocate for a compassionate and inclusive approach to addressing the interplay of trauma, oppression, and feeding difficulties. In shedding light on the carceral dimensions of eating disorder psychiatry, this paper ultimately seeks to foster dialogue, awareness, and transformative action toward creating more consensual and justice-oriented systems of support for individuals navigating eating disorders.

To begin our investigation, let’s go over some statistics. According to author, therapist, anorexia survivor, and Washington University Professor Rebecca Lester, eating disorders affect an estimated one in seven people. Less than one-tenth ever access treatment; a mere half will fully recover. 20% of sufferers will remain sick or die as a result of their illness. (Lester) As for the demographic prevalence, the National Eating Disorders Association (NEDA) reports that 0.9% of American women and 0.3% of American men are diagnosed with anorexia nervosa, characterized by an intense fear of weight gain that may lead to severely restricted food intake, distorted body image, and significant weight loss. 1.5% of women and 0.5% of men experience bulimia. Bulimia nervosa involves recurrent episodes of excessive food intake followed by compensatory actions such as self-induced vomiting, use of laxatives and diuretics, obsessive exercise, or fasting. Binge eating disorder (BED) occurs when an individual feels a loss of control when consuming large quantities of food in a short period without the compensatory behaviors seen in bulimia. It is the most common diagnosis, affecting 3.5% of women and 2% of men. Other Specified Feeding/Eating Disorder (OSFED) is diagnosed in 5% of the general American population when an individual does not meet the diagnostic criteria for another ED (NEDA).

A report from the Toledo Center for Eating Disorders found that, alarmingly, 54% of the LGBTQ+ respondents reported significant symptoms of disordered eating, with 75% of those respondents reporting a medical diagnosis. (Toledo Center for Eating Disorders) Equip Health reports that 20-26% of those grappling with an eating disorder are people of color (Equip Health), yet they are half as likely to receive a diagnosis compared to white peers. Contextualizing these figures, Rebecca Lester traces historical misconceptions and trivializations around eating disorders back to the Victorian Era. She argues, “If you look historically, female hysteria got refracted into a number of different diagnoses, including eating disorders. A lot of the old assumptions and ideas about hysteria: that this is a conflict about sexuality, or a desire to regress to childhood, or that it’s a way of manipulating other people, have also filtered in—even in the more biologically focused model that we have today” (Lester). Lester contends that centuries-old prejudices persist in contemporary treatment and insurance systems, with 21% of American insurance plans excluding any and all coverage for eating disorders as of 2015 (King). This practice is troubling but unsurprising given the Eurocentric, fatphobic, and classist biases prevalent in Western cultures regarding food and body image. Among the insurance plans that did not cover eating disorders were forms of coverage most used by low-income and marginalized groups - primarily government programs, Medicaid, and options marketed for affordability such as SilverCare. As Dr. Lester points out, eating disorders are not often treated with the same urgency as other conditions despite representing some of the most lethal psychiatric illnesses due to medical complications or, commonly, suicide. This fact compounds when a patient experiences intersectional forms of oppression that are also considered trivial.

In addition, heavily intertwined with the healthcare of marginalized and racialized people is the role of policing. According to data from the Substance Abuse and Mental Health Service of America (SAMHSA), approximately 2% of callers to the 988 hotline (44,000 people) experienced subjection to non-consensual call tracing and unwanted police intervention. Rob Wipond challenges this figure in a piece for Mad in America, a journal for psychiatric social justice, citing data from the National Suicide Prevention Lifeline that reported only 20% of callers reached out to discuss suicide ideation or a critical mental health concern, including an eating disorder. Most people asked to be connected with community resources or to disclose personal problems unrelated to emotional well-being. Mad in America reports that “[c]alculating the rate of interventions on suicidal callers as a percentage of the “total contacts,” then concealed a much more telling and alarming rate: about 1 in 10 of callers with suicidal feelings were getting subjected to coercive interventions. If callers with suicidal feelings now represent, say, 15% of total contacts, that would mean involuntary [police] interventions are being imposed on 1 in every 7.5 people with suicidal feelings who call 988.” (Wipond) Ismatu Gwendolyn expands on the intersections of psychiatry and policing from the perspective of a clinician in their licensure-critical essay “Therapists Are Also the Police” (Gwendolyn) They justify their qualms that mandated reporters, especially mental health care providers, are contractually obligated to report to law enforcement and coerced by the threat of losing their license to involve non-consensual police involvement in certain circumstances. Forced compliance by providers leads to punishment and, in some cases, incarceration, of Mad, mentally ill, neurodivergent, and disabled (MMIND) individuals. Ismatu further explains how both clinician and client are subjected to surveillance and punishment when state bodies take hold of regulating the healing process: “The argument is the same: that nothing less than regulation by the state is safe; that outsourcing expertise is always a better option than whatever care our communities can provide; that the power imbalances of that person being able to report you, document you, or institutionalize you are nothing to fear so long as you have nothing to hide. Therapists absolutely are part of the regulatory network of police science.” (Gwendolyn) These are just a few of the intersections and nuances that manufacture complicity and push care workers to become agents of injustice.

The pervasive stereotype surrounding individuals suffering from eating disorders, often depicted as emaciated, white, and affluent heterosexual young women, coupled with the expectation for patients to exhibit unwavering compliance, constitutes a deeply ingrained yet painfully inaccurate narrative. This narrative, harmful to both those who fit this mold and those who do not, is rooted in the historical backdrop of early research conducted predominantly between 1930 and 1990. During this period, research efforts primarily focused on clinical populations receiving treatment for anorexia in exclusive and costly facilities. (King) Despite overwhelming evidence demonstrating that only 8% of individuals with eating disorders experience anorexia nervosa and a mere 6% of those with anorexia are underweight, (Spealáin) the bulk of research concentrated heavily on severely underweight anorexic girls. This skewed focus has perpetuated a distorted image of the typical eating disorder sufferer, one that fails to capture the diverse spectrum of individuals grappling with these complex mental health difficulties. Moreover, entrenched Victorian-era ideals of the "ideal" patient have persisted into the modern-day, shaping expectations of those experiencing eating disorders and giving rise to an archetypical client that we will call the "Miracle Patient." 

Let us meet the Miracle Patient. They embody unwavering compliance, passivity, and self-sufficiency. Due to the implied scarcity of love and care, they must exhibit minimal relational or emotional needs. Any inclination toward seeking support or interdependence is pathologized as a therapeutic label, with the most common being enmeshment or codependency (Matusek). Medicalizing the human drive for connection further perpetuates the view of the biomedical model that a client is served best by a state-approved clinician rather than their personally identified circles of support. Standard “care” within the mental health industrial complex rejects interdependence as a central form of healing because it is less profitable and threatens systems of oppression that keep power siloed to those with close positionality to power. A potential client who decides to recover on their terms at home, on their own, or with family rather than under the authority of a medical provider, is not a profitable client. This Miracle Patient demonstrates consistent progress as measured by weight, blood labs, and similar biometric indicators, neglecting the nuanced qualitative needs of their recovery journey. The Miracle Patient is an eager consumer. They have an appetite for dominant psychological truths about recovery and embrace “gold standard” treatment modalities, irrespective of their deficits or individual suitability. As reported by Dr. Jennie Wang-Hall in a video interview, a client is considered “good so long as she eats.” Clients characterized as innocently endangered by their ED must comply with protocols aimed at weight restoration, regardless of need. Wang-Hall explains further that “[t]his upholds the validity of the provider/warden/white knight. The role of savior is only secure and rewarded when the person in danger complies with the paradigm through submission.” (Wang-Hall) A major tool upholding the savior mindset of clinicians is called “psychologization,” referring to a process wherein sociopolitical problems such as anti-fat bias, racism, misogyny, ableism, or income inequality are converted into an individual or psychological issue instead. Wang-Hall’s primary concern is that psychologization absolves the oppressor. By deeming the “mentally ill” as defective and individually responsible for their suffering, those who experience oppression remain inward-looking and will not challenge the dominant narrative. This paper argues that somebody with an ED who believes that their illness is their fault is unlikely to question relevant systems of oppression such as supremacy, misogyny, fatphobia, and ableism. (Petersson) 

It is crucial to recognize that even those who seemingly embody the "correct" characteristics of an eating disorder patient are not immune to coercive responses within mental health care systems. A 2019 paper spearheaded by University of Tokyo researcher Kanna Sugiura illuminates eight frequently utilized coercive practices prevalent in mental health care, ranging in severity from calling a wellness check to imposing recovery contracts to administering medication or sedatives by force. (Sugiura) Other mentioned forms of inhumane care include involuntary hospitalization, calling 911 or requesting non-consensual law enforcement or family contact, substitute decision-making, and refusal to work with clients unless they agreed to a higher level of care (HLOC). These interventions, while purportedly aimed at providing care and support, can often exacerbate harm and perpetuate trauma for individuals grappling with eating disorders. The ramifications of this type of response for individuals living with an ED include isolation from their community, further trauma, and loss of autonomy, experiences of stigmatization, dehumanization, state and police violence, and destabilization of housing, employment, and rights to their children (Suguira); therefore, it is imperative to recognize that the one-size-fits-all approach to treating eating disorders fails to address the complexity and diversity of experiences within this population. Dismantling these harmful stereotypes and implementing an explicitly client-led approach is crucial to providing effective and ethical care to all individuals struggling with eating disorders.

Expanding upon this argument, it becomes evident that the impact of societal perceptions and expectations on ED sufferers extends far beyond the realm of treatment programs. These stereotypes permeate every facet of life, influencing how individuals are perceived, treated, and supported within their communities and social circles. Consider the pervasive portrayal of eating disorders in mainstream media, which often reinforces the narrow stereotype of the tragically beautiful anorexic woman needlessly wasting away, while neglecting the experiences of individuals who do not fit this mold when it comes to class, race, size, or gender (Bassett). Such portrayals not only contribute to the stigmatization of eating disorders but also create inaccurate expectations regarding who the public deems deserving of recognition, support, and treatment. Furthermore, societal attitudes towards food, weight, and the human body play a significant role in perpetuating harmful stereotypes and exacerbating the stigma associated with eating disorders. In a culture that idealizes thinness and equates it with beauty and success, individuals who do not conform to these standards face heightened scrutiny, judgment, and discrimination (McEntee). The intersectionality of identity further complicates the experience of an ED, highlighting the necessity of a more nuanced approach to treatment and support. Individuals from racialized communities, LGBTQ+ individuals, and those experiencing poverty face additional barriers to accessing care and navigating recovery due to systemic inequalities and disparities in healthcare. Clinician and researcher Jill Matusek shared in a phone interview that nearly 20% of her Missouri clients reported struggling with relapse post-discharge, not for lack of will, but because they were experiencing food insecurity. Dr. Matusek told the story of a 32-year-old mother who underwent hospitalization for acute anorexia. This client expressed that “poverty mandates restriction. I didn’t stop eating because I wanted to be thin. I stopped eating because my daughter needed that food. If I eat, she’ll go hungry, and then we’ll both be homeless. Of course I’m terrified” (Matusek). This mother’s testimony speaks to the necessity of centering the voices and experiences of people with lived/ing experience in discussions and decision-making processes to ensure that treatment and support services are responsive to their unique needs and preferences. This effort is a matter of ethical imperative that involves actively listening to and validating the diverse experiences and perspectives within the eating disorder community while also amplifying marginalized voices that have been historically silenced or overlooked.

A tool that doctors and providers often use against these marginalized populations is the practice of classifying patients who resist coercive intervention as “noncompliant,” “defiant,” or “oppositional” for owning their autonomy. Ultimately, this practice contributes to poorer treatment outcomes (Suguira), but Dr. Jennie Wang-Hall clarifies that to the typical clinician, “a client who remains sick is committing a crime.” When clients refuse the kind of care (read: control) offered to them, “the care system's machine categorizes that client as a liability to be discarded immediately” (Wang-Hall). We see this when insurance plans refuse to cover a hospital stay if a person is labeled “oppositional” or not gaining weight at the desired pace. Dr. Matusek expressed that this practice is her greatest qualm with the ED treatment industry. She’s heard the story countless times: “With private insurance, a patient has no wiggle room for appropriate struggle. She has to toe the impossible line of being sick enough to need care but still showing progress, just not too much progress. Cross that line or express disdain in any way, and her coverage is pulled out from under her. She goes home, has a relapse, and comes back worse than she started.” Dr. Matusek is describing what is widely known in the context of the prison industrial complex as the “revolving door phenomenon” (Joy). It has become common in recent years for mental health clinicians to associate this term with their practice. As defined by Dr. Ciara Joy in a paper for Lancaster University, the revolving door phenomenon refers to the chronic nature of a patient’s hospitalization: the cyclical nature of entrance and departure through the care system that rarely results in the meaningful healing that treatment programs may promise. The revolving door phenomenon in ED programs mirrors the concept in prisons; Neither the mainstream ED treatment industry nor the prison industrial complex is invested in improving long-term outcomes or in working alongside their clients in their recovery, which allows interventions to remain carceral and divested from evidence-based healing technologies. Without adequate attunement to the role of structural oppression, the underlying causes of crime and eating disorders will go unaddressed and the incidence will remain the same. People who are released or discharged from a prison or treatment center are sent back into the same problematic environments without new structures to support health and safety. Carceral logic and systems underlie the way that our world responds to harm and suffering of many kinds. So long as the status quo remains, people will continue to be passed through ineffective interventions that further danger and pain. Both in response to what we call “crime” and eating disorders, Dr. Wang-Hall calls for “imaginative and hope-driven interventions that are rooted in collective safety and liberation.” She stresses how important it is to recognize that  “every person deserves care, connection, and support regardless of how they choose to change or not.” (Wang-Hall) 

Mainstream ED treatment frequently violates the United Nations Report on the Rights of Persons with Disabilities. Firstly, UN recommendations include the dissolution of forced treatment even in acute crisis. The report also insists on free and informed consent as many clients are not provided education about what to expect in treatment, whether in outpatient or at higher levels of care. The report stated that “legal capacity must be respected” regardless of emergencies or crises. Many care teams approach high-risk cases by using “substitute decision-making” to declare a client incapable due to their illness. ED professionals are largely caring, compassionate, and well-intentioned, but even still, most have trained in academic and clinical settings fundamentally rooted in carceral logic. Providers must be aware of UN and other global recommendations to offer humane, autonomous care outside of the constraints of the mental health industrial complex. The UN Special Rapporteur also presents systems of psychiatry as a context for torture. They note that the medical profession has a long history of eugenic murder of disabled people and that psychiatry often seeks “great and desperate cures” regardless of the suffering those cures may inflict on a patient. The Special Rapporteur defines that torture occurs under the condition that a victim or patient is under the total control of another, which is often the case in substitute decision-making. The UN explicitly states that the deprivation of legal capacity through substitute decision-making or other practices “is a condition that facilitates torture and inhumane treatment” (United Nations). Any form of non-consensual treatment may be considered torture, including restraints, therapeutic interventions, or the use of psychiatric medications without full informed consent. A punitive approach to noncompliance further exacerbates feelings of alienation and distrust toward the healthcare system. It is crucial to recognize that each individual deserves compassionate care and support, irrespective of their readiness or ability to adhere to treatment protocols. Instead of villainizing individuals who struggle with adherence, efforts should focus on understanding the underlying barriers to engagement and addressing them in a supportive and empowering manner.

Traditional eating disorder treatment often imposes rigid expectations on patients, leaving little room for individual variation or honest self-expression. Many individuals feel pressured to fit into a predetermined mold of recovery rather than having their treatment tailored to their unique needs and preferences. These unmoving prerequisites create a sense of disconnection and disempowerment, hindering the therapeutic process and perpetuating feelings of inadequacy. Moreover, the coercive practices and punitive interventions commonly employed in higher levels of care for eating disorders can have detrimental effects on patient's mental health and well-being. From restrictive meal plans to forced physical contact, these interventions often prioritize control and compliance over genuine healing and support. ED higher levels of care often employ bizarre, infantilizing, and carceral interventions. These serve many functions related to control and the performance of recovery but rarely contribute to meaningful healing or experiences of support. By far the most common practice found through my research was body tracing, in which a client is asked to trace their perception of their body size onto a large sheet of paper before laying down for their therapist to draw the actual outline of their body. The idea is to prove that a patient’s body is not as “big” as they thought. Body tracing is a common practice throughout all levels of care, reported by individuals across 84% of surveyed programs (Wang-Hall). Not only is it wildly fatphobic, but it also does not offer affirmation to neurodivergent people who may experience low interoceptive awareness. Among fat patients, 78% expressed that their fear of the emotional and physical violence that comes with recovering into a fat body was wholly dismissed or minimized by their treatment teams (Ralph). Individuals felt that the majority of care workers ignored the interpersonal anxiety or judgment that may come with “food freedom” and “intuitive eating” for people living in fat bodies and did not consider the material and resourcing challenges of living in a larger body, such as the financial strain of inaccessibly priced clothing. Regardless of diagnosis or size, some women with eating disorders “felt that to receive help, they had to fit into this non-adjustable box of treatment. They felt there was no room to be honest with themselves” (Andersen). 

Traditional ED treatment requires patients to work to fit their care program rather than their program working for them. A former patient at The Emily Clinic in Spokane, Washington wishing to remain anonymous told me that she had been sent flowers by her family while hospitalized, “but a nurse made me throw them out because glass wasn’t allowed. The option of moving the flowers into something non-glass was dismissed without reason.” The same individual told me about the experience of her roommate, a patient with BED whose dietitian had advised eating with her non-dominant hand. This was the very same advice that this person had been given by the harmful weight loss programs that contributed to her developing ED in the first place. These girls, both fifteen at the time of admission, reported that staff on the adult ward were wildly infantilizing and that patients were frequently forced to hold hands on outings. A 46-year-old former patient at Sutter Alta Bates Medical Center in Berkeley, California reported that the center “had the police called on [them] for taking a walk outside of what they called ‘joyful movement time” and was made to “earn” pain management tools for their arthritis by journaling for twenty minutes. Such practices not only violate the rights of individuals with eating disorders but also contribute to trauma and exacerbate feelings of powerlessness, disempowerment, and a potentially worsened condition. For people who have been incarcerated in psychiatric treatment facilities, suicide risk rises to 100 times the global suicide rate in the first three months post-discharge. The same study found that it remained at 30 times the global rate ten years after release (Chung). 

Not only is it often dangerous, but the mainstream approach to eating disorder treatment frequently falls short of upholding the rights and dignity of individuals with lived experience. The United Nations Report on the Rights of Persons with Disabilities highlights the importance of respecting autonomy and ensuring informed consent in all aspects of mental health care (United Nations). Yet, many treatment settings continue to rely on coercive practices and substitute decision-making, disregarding the fundamental rights of patients. Healthcare providers need to be aware of and adhere to international human rights standards in their practice. This includes respecting individuals' autonomy, providing informed consent, and refraining from coercive or punitive interventions. By adopting a rights-based approach to care, healthcare providers can create environments that prioritize dignity, autonomy, and holistic well-being for individuals with eating disorders. Dismantling harmful practices and promoting ethical, rights-based care is essential for improving outcomes and fostering healing for individuals with eating disorders. This requires a shift from punitive and coercive approaches to treatment modalities prioritizing compassion, autonomy, and empowerment. By centering the voices and experiences of individuals with lived experience, we can create a more inclusive and supportive healthcare system that honors the dignity and rights of all individuals.

Beyond societal and institutional structures of carcerality, providers themselves play a crucial role in the difference between coercive and autonomous care. Therapists’ fear of liability risk increased their tendency to engage in carceral interventions (Gwendolyn). Therapists often fear a lawsuit or liability for a client's death or declining health. While in actuality this is quite rare, providers are trained to be so fearful that they often engage in coercive approaches, including contracts, ultimatums, and relational manipulation to protect their license, their conscience, or both. Additionally, the acuity of eating disorders often tends to make providers feel inadequate. Eating disorders can be long-term, complex, and tumultuous conditions to heal. High stakes have the potential to make providers feel anxious and incompetent in their work. Both Dr. Matusek and Dr. Wang-Hall mentioned that the academic and training systems that providers are brought up in create a hyper-responsibilization that results in resentment and frustration when a client is unwilling or unable to recover from the provider’s ideal view. 

It is important to mention that coercive residential practices do not only cause harm to clients. In speaking to clinician Jennie Wang-Hall, I learned that many residential therapists early in their career are placed in crises that they are not trained to handle and that “the majority of staff who are involved in the day-to-day milieu operations of these centers are young, inexperienced, and unlicensed.” She was expected to deliver trauma-related interventions without supervision or support, but her above-and-beyond efforts “were never adequately validated or compensated despite being a clear expectation.” That made Dr. Wang-Hall’s job significantly more difficult to the point that she began suffering from burnout, depression, and hopelessness in her work. She knew the harm she was doing to clients, and it broke her heart. “I didn’t have words for it, and I didn’t understand what was happening, but I knew the treatment was oppressive. I felt guilty all the time” (Wang-Hall). 

A large part of this guilt for Dr. Wang-Hall was the coercion inherent in mandated reporting. She shared data from THRIVE Lifeline that the majority of mandated reports are made against racialized people and that over 50% of individuals across all demographics reported that a mandated response caused them greater harm. She adds that the assumption that ED clients seeking therapy need a clinician to make decisions in their place only builds on the infantilization of MMIND individuals. “What I need my colleagues to realize is that the psych ward and the county jail are holding hands. Both are prisons in their own right - institutions that create shame, disenfranchisement, and alienation” (Wang-Hall). Above all, mental health is supported when care workers and community members can honor the dignity, agency, and humanity of all people regardless of their perceived inadequacies. An abolitionist pursuit of healthcare works to uplift and hold space for differences in the tapestry of human community.

I move that there is no justice but abolition. Effective, safe, culturally and personally responsive eating disorder care requires the dissolution of psychiatric prisons in both facility and mind. Regarding the future of treatment possibilities, I look to dietician Lucy Aphramor’s approach, Well Now. Aphramor’s philosophy emerges from their trust that “health will emerge in a world where no one is starved of food, dignity, connection or security” (Aphramor). According to Aphramor, this must include eliminating prisons of all forms and the ideologies that drive them. Dismantling neoliberalism, racism, patriarchy, transphobia, and fatphobia points to an equitable and compassionate world in which “prisons are no longer relevant and eating disorder prevalence is drastically reduced.” To begin this work, providers must seek consultation on cases in which they are personally activated. They must acknowledge the role of larger systems in how they carry out client work, learn to view therapy as a collaborative and loving (yes, loving) process rather than an exclusively change-oriented one, and work tirelessly to see the humanity and dignity of patients above liability fears. Most importantly, stakeholders in all levels of care must cultivate a listening-based practice that centers the leadership and direction of the clients they serve. The word of clients backs this up: when asked what would have been the most helpful in their recovery journey, 25 recently discharged eating disorder patients reported that “It would not be helpful to them to lose autonomy and responsibility for their own treatment. Instead, they preferred involvement and shared decision-making regarding treatment rather than the therapists holding all power. They suggested that they themselves were to participate in defining goals and success criteria” (Andersen).

Guided by the input of qualitative and quantitative research, provider interviews, survivor accounts, and my own living experience in the eating disorder world, I present five thematic principles of justice-oriented ED care: cutting ties with capitalistic interests, fighting anti-fatness, and dismantling ableism, gender-based oppression, and white supremacy. 

1. Supporting recovery requires breaking free from neoliberal capitalism. Under its reign, binging behaviors become normalized through cheap and highly processed food systems, and those who engage in such behaviors are simultaneously blamed for their health status with no regard to the healthcare and food production systems that represent a considerable contribution to such health status (Pirie). Additionally, individuals are presumed and encouraged to make decisions based on productivity or their capital contribution. The “pull yourself up by your bootstraps” mentality inherent in this system makes invisible any challenges or marginalizations with the insistence that all people can achieve “the American dream.” These dynamics are visibly present in Western ideas about food and bodies - how many diet books have you seen promoting willpower as a weight loss tool? As is characteristic of neoliberalism at large, there is little regard for the humanity or realistic capacity of the person in question. 

2. Food and body healing requires that we combat anti-fat bias, defined by Washington University as “the stigmatizing belief that bodies should be thin or muscular to fit within commonly held standards of beauty, fitness, and health” (Washington University Center for Diversity and Inclusion). Anti-fatness and health superiority are insidious systems that actively perpetuate harm on anybody who dares to own their body, especially a fat body. Both of these dynamics are also inextricable from neoliberal capitalism through the pervasive diet and weight loss industry. The convergence of these systems leads to sweeping invalidation, gaslighting, and shaming – all of which are central components of an eating disorder. As Dr. Wang-Hall told me in an interview, “Body justice requires us to pursue collective liberation until it’s embedded in praxis that every single body has value and is deserving of dignity and autonomy” (Wang-Hall).

3. Eating disorder justice does not happen without dismantling ableism. Set within a culture that churns propaganda strictly outlining what it is to be well and able, it is natural that many individuals face painful challenges in an attempt to fulfill the role of the “ideal citizen.” The reality is that MMIND individuals will likely never meet this expectation as long as their brains and bodies are shunned, degraded, and punished. Said best by Liat Ben Moshe in her book Decarcerating Disability, “When disability or madness is present, it’s conceived of as a deficit, something in need of correction.” More accurately, MMIND people hold “a nuanced identity from which to understand how to live differently” (Ben-Moshe).  This system of ableism imposes such punishment upon those with and without disability. Healing from food and body struggles necessitates unlearning what it means to own and care for a so-called “good” bodymind. 

4. Healing from an eating disorder requires the abolition of gender-based feeding narratives. The toxicity of cis heteropatriarchy harms our relationships with food and body in that we are all trained to believe that our worthiness and belonging are contingent on the performance of normativity, often situated firmly in the male gaze. This is especially true for women and femmes who experience pressure, and often the requirement, to remain thin, attractive, and docile. Similarly, any forms of queering are grounds for degradation, invalidation, and violence. All of us must commit to the recognition that everybody, regardless of their identification, is prone to cling to misogynistic, transphobic, or otherwise oppressive standards for personhood in which food and body are widely scrutinized markers. 

5. Lastly, eating disorder recovery requires dismantling white supremacy. Difficulties in feeding or body image are deeply embedded in white supremacist ideals. These ideals propose that people who diverge from the prototype of Eurocentric beauty or personhood are undeserving of care, nourishment, or respect. Naturally, many people of color develop EDs as a means of coping with racial grief, standards of whiteness, and basic survival through an abusive Western culture. To create the conditions for food and body healing, white supremacy must collapse. Racialized people must be valued, honored, and well-resourced. To create the conditions for food and body healing, all people must have access to freedom, safety, and self-determination. These five tenets represent the grounds for autonomous and anti-oppressive recovery models. No person is free, even from an eating disorder, until the collective is.

works cited

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Aphramor, Lucy. “Does Your Approach to Treating Eating Disorders Aim at Prison Abolition?” Medium, 13 May 2019, https://lucy-aphramor.medium.com/does-your-approach-to-treating-eating-disorders-aim-at-prison-abolition-d27e64fcef0d. 

Aulisio, Mark P., and Amy T. Campbell. “The stigma of "mental" illness: end stage anorexia and treatment refusal.” PubMed, 13 February 2012, https://pubmed.ncbi.nlm.nih.gov/22331823/. 

Bassett, Lucy, and Maya Ewart. “Discrepancies between media portrayals and actual demographics of eating disorders in TV and film.” Journal of Eating Disorders, 18 September 2023, https://jeatdisord.biomedcentral.com/articles/10.1186/s40337-023-00892-y. Accessed 17 April 2024.

Ben-Moshe, Liat. Decarcerating Disability: Deinstitutionalization and Prison Abolition. University of Minnesota Press, 2020. 

Body Justice Podcast, and Jennie Wang-Hall. Capitalism, Eating Disorders and Decarcerating Care with Dr. Jennie Wang Hall. 17 December 2021. Apple Podcasts

Chung, Daniel T. “Suicide Rates After Discharge From Psychiatric Facilities: A Systematic Review and Meta-analysis.” NCBI, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710249/. Accessed 23 March 2024.

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