Male Therapists Treating Women With Eating Disorders — Fish Out of Water?
Social Work Today
Vol. 4 No. 1 p. 24
By Matthew Robb, MSW

“Given the social phenomenon of men objectifying women, it’s no surprise that so many women feel disempowered and harshly scrutinized,” says New York social worker Stephen S. Zimmer, CSW. “What this means for male eating disorder specialists is that we need to be the polar opposites. We need to do everything we can to empower our female patients—to ask questions, to understand, to help them gain more control in their lives.”

Zimmer knows this lesson well. He entered the field of eating disorder treatment during its infancy, before the term “bulimia” had filtered its way into the clinical lexicon and when therapists still regarded emaciated teen girls as 85-pound riddles wrapped in mysteries inside enigmas. Zimmer recalls a time when his own supervisor (a social worker) deemed social workers ill-suited for complex psychosomatic cases such as these, barking at him: “Refer them out!” The path to recovery, it was said, began and ended with the psychiatrist.

Over the next 27 years, Zimmer witnessed enlightenment displace ignorance and social workers move from the periphery to the forefront of a revolution in diagnosis and treatment of eating disorders. It was a watershed period, one that found Zimmer and his colleagues comparing notes, wondering aloud, and hypothesizing on matters of “gender-based interactions.” Hundreds of clinical cases later, they had confirmed an initial hunch: When a male therapist treats an eating-disordered woman, the connection is quite different from when the therapist is female. The implication for today’s practitioner? Male (and female) therapists who factor these differences into their interventions will be rewarded with more nuanced, more successful therapy.

Therapist as Student
Zimmer is both senior clinical consultant to the Renfrew Center Foundation and a 25-year private practitioner in New York City. Together with Renfrew psychologists William Davis, PhD, and Doug Bunnell, PhD, the pioneering trio contends that male therapists can only understand where female patients are—that is, they can only grasp the complex interplay of biopsychosocial and cultural influences that shape their eating disorders—by understanding from whence they came.

“Think of something as commonplace as a woman walking alone on a sidewalk in New York City,” Zimmer says. “She may experience incidents that men rarely see—the catcalls, the ogling, the sexually graphic taunting and dehumanizing insults—things that would never happen to a man, nor would they likely happen to her if a man were with her.” His point: American women are whipsawed by antagonistic demands that pound at their self-esteem like an angry surf. A six-pack-abs-and-implant society that elevates thinness to godliness while demonizing those who don’t pray at its altar is a breeding ground for pathology.

“It’s hard to be a woman in our society and not have food and body image issues,” Zimmer says. “We have the world’s most overweight population, yet culturally we aspire to be impossibly thin and then emotionally punish ourselves when we inevitably fail.” Zimmer’s observations mirror research that finds nearly 80% of 17-year-old girls and 85% of adult women unhappy with their appearance.

While men lack the experience of being a woman, Zimmer says that skilled male therapists can bridge the experiential gap. “I’m still able to appreciate their world—and maybe do so in a fresh way,” he says. “Indeed, I think not having lived through all these body shape pressures forces male therapists to ask more questions, to think outside our ‘male box,’ to allow ourselves to be students and our patients to be teachers—all of which is central to good therapy.”

Being a good student is key, Zimmer adds. “They really appreciate it if we’re willing to learn their language—the language of compulsive food behaviors and the obsessions around food. When you allow your patient to be the expert and literally teach you what’s going on inside them, that’s empowering.”

Bunnell agrees. Bunnell, who divides his time between his duties as clinical director of Renfrew’s Wilton, Conn., outpatient facility, his private practice, and as president of the National Eating Disorders Association, offers his insight. “There’s certainly a concern that a male therapist isn’t going to understand how painful it is for a woman to feel fat,” he says. “So, what this means is that he needs to work harder to demonstrate that he understands this powerful connection, to be somewhat more active and ask questions that really get at that issue.” Even though roughly 90% of all eating-disordered patients are women, Bunnell says that male therapists should be heartened by studies that show male and female therapists are equally skilled in treatment outcomes. Adds Zimmer, “I don’t feel that not understanding is a disadvantage. Eventually, all therapists get to places we don’t understand. The art of good therapy is to ask the questions and arrive at an understanding.”

Understanding Motivation
An eating-disordered patient’s choice of therapist is often symbolically meaningful and provides fertile ground for discussion. “When a woman chooses a female therapist for help with an eating disorder,” Zimmer says, “she frequently comes with a clear sense that she needs to see a woman, often because of a problematic relationship with an absentee or domineering, even abusive father. But, there are also many women who want to see a male therapist for the opposite reason. Either their relationships with their mothers were so toxic that it was impossible for them to begin a trusting therapeutic relationship with a woman, or they had a positive relationship with their fathers or other men in their lives.” The motivations run the gamut, including this explanation from one of Zimmer’s female patients: “I wanted a male therapist because I can’t deal with the envy from other women.”

Bunnell offers another perspective. “Some women seek male therapists because these women admire ‘typical male values’ such as productivity and hard work. Other times, they talk about not wanting to work with female therapists because they fear overidentification with the therapist’s body and shape issues. In fact, some of the women I see in my practice have an almost derisive attitude about the way women supposedly treat each other. They value the perception that men are more direct and truthful.”

Sensitivity and Awareness
Davis offers his perspective of the male therapist-female patient dynamic. “The first issues that jump out are those of sexuality, seductiveness, and potential for exploitation,” he says. “A fairly high percentage of eating-disordered patients report some incidence of sexual abuse, although these incidences vary a great deal and sexual abuse itself is not predictive of an eating disorder.” The key, he says, “is for male therapists to be mindful of the issues of safety, intrusiveness, and power.”

Davis relates an early interaction with a female patient “who had been badly sexually abused.” Recalling the end of their initial interview, he says, “I reached out to shake her hand, and she shrunk away from me. I apologized to her, and we took the time to process her history and how hard it was for a man to approach her.” The lesson? Seemingly innocuous actions—even a passing compliment—can carry powerful totemic impact and sow the seeds for future therapeutic impasse.

Continuing his discussion, Davis notes a potential strength that male therapists might tap. “Female eating-disordered patients can provoke in their female therapists primary issues of competition, of ‘cultural countertransference,’ if you will. Because both patient and therapist have internalized beliefs about the way women should look, this might engender in a female therapist an unconscious ‘Your thighs are bigger than my thighs’ rivalry. For me, however, I can ask a female how she feels about her thighs and relate to her without any competition whatsoever.” However, Davis cautions both male and female therapists that exploring these issues requires “tremendous sensitivity and awareness, as they are exposing to a woman.”

Bunnell concurs. “It’s important for men to develop comfort and sensitivity in asking the difficult questions—questions about menstruation, sexual history, sexual abuse, bloating, laxative use, and more. These are issues that most male therapists aren’t automatically attuned to, meaning that we must make special adjustments to demonstrate our comfort and familiarity.” Says Zimmer, “Unless eating-disordered women are obviously emaciated, you may never know they even have an eating disorder. And, if they are eating disordered and you don’t find out, your treatment is likely to be superficial at best.”

Accepting, Not Judging
Male practitioners must perceive yet another potentially dicey gender association, Zimmer says. “My newer patients sometimes assume my judgment. In traditional families, the father is often focused on achievement, assuming the role of judge by rating and valuing his daughters based on his perceptions and definitions. It’s no wonder my female patients sometimes look at me askance, expecting judgment from me after they share sensitive personal information.” Zimmer’s response is elegant in its simplicity: “Not only do I not judge what they say, but I comment on their expectation of my judgment as a springboard for further discussion.”

To illustrate, Zimmer provides the example of a family dynamic in which parental interest focuses on the son’s academic performance and the daughter’s appearance. “This dynamic means that we therapists really need to listen to the person we’re sitting with because females get the opposite treatment all the time. When you start relating to some young girls this way—when you are really interested in what they’re thinking and feeling—at first, they don’t even know how to respond. They hardly believe you.”

Adds Davis, “While a female colleague might experience her female patient as a peer, I sometimes experience my patients in more of an idealized father-daughter, older brother-younger sister transaction. When I see a young anorexic girl, I’m very much aware of a paternalistic protectiveness, of wanting to protect her.”

Thinking Globally
While beginning therapists—male or female—may be tempted to specialize early on in the treatment of eating disorders, Bunnell suggests rethinking this inclination. “ Therapists must have a broad experience in psychotherapy, psychodiagnostics, and understanding the full range of psychopathology,” he says. “You can’t understand treating people with eating disorders without understanding the underlying functions that the disorders serve in their lives.” In short, either a personal experience with eating disorders or an abiding intellectual curiosity are no substitutes for clinical finesse—for the ability to connect dots and plumb the depths of human behavior at the individual, family, and sociologic levels.

“These are serious disorders needing specialized treatment,” Bunnell says. “They often come in packages bundled with other psychiatric diagnoses: depression, anxiety, substance abuse, sexual trauma, or personality disorders.” Bunnell partly blames Hollywood for its portrayal of eating disorders as fleeting problems that afflict “vain white women.” He adds, “These are nasty, life-threatening disorders with the highest mortality rate of any psychiatric illness. These disorders can last a lifetime, wreaking havoc on a person’s psychological, emotional, and physical development and ripple out to touch their families and everyone who knows them.”

Bunnell underscores the therapist’s key role as listener, educator, arbiter, and coach. “When you bring the dads in to deal with the family issues, they don’t instinctively get the connection between eating, body shape, and self-esteem. Moms often grow up with these issues and understand this connection in the core of their being; they sort of grasp how it makes some sense.”

Beyond Gender
Whether male or female, therapists—just like their patients or clients—are not blank slates. We have our own experiences, perceptions, biases, strengths, and limitations. The differences among us far outweigh those between us.

Echoing the consensus of his colleagues, Bunnell says: “The more therapy I do, the less I think gender is an all-encompassing issue. There are some key differences, but not so many hard and fast rules.” Nodding in agreement, Zimmer says, “Sure we behave somewhat differently according to our genders. There are always going to be different flavors to our work, but we’re not that focused on male-female distinctions.”

Gazing at a culture that finds women objectified, Zimmer offers this parting thought: “I think that many women find it quite therapeutic to engage with male therapists who are willing to listen and learn from them. It’s a relief and pleasure when their therapists can acknowledge what they don’t understand—and will change the way they behave in response to their patients’ needs. All of this is reassuring and can give a woman hope for her future as she goes out into the world.”

— Matthew Robb, MSW, is a Frederick, Md.-based freelance writer.