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Ep 95 - Disordered Eating:"I Have a Client Who . . ."Pathology Conversations with Ruth Werner

Young woman in emotional distress, covering her face with hands

This story is a delicate one. The client has an eating disorder that the massage therapist thinks is pretty advanced, and may be getting worse. This episode dives into some of the serious consequences of eating disorders and the important role massage therapy may play. It may be upsetting for people who struggle with eating disorders, so please consider this a trigger warning.


Werner, Ruth. “Eat Your Way Happy: Body Respect, Distorted Self-Image, and Massage.” Massage & Bodywork March/April 2009, page 10.

Werner, Ruth. “Orthorexia: From Virtuous to Vicious.” Massage & Bodywork July/August 2015, page 44.

Author Images
Ruth Werner, author of A Massage Therapist's Guide to Pathology
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Author Bio

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist's Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP's partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at And more information about her is available at


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Anatomy Trains is a global leader in online anatomy education and also provides in-classroom certification programs forstructuralintegration in the US, Canada, Australia, Europe, Japan, and China, as well as fresh-tissue cadaverdissectionlabs and weekend courses. The work of Anatomy Trains originated with founder Tom Myers, who mapped the human body into 13 myofascial meridians in his original book, currently in itsfourthedition and translated into 12 languages. The principles of Anatomy Trains are used by osteopaths,physicaltherapists,bodyworkers,massagetherapists,personaltrainers,yoga,Pilates,Gyrotonics,and other body-minded manual therapists and movement professionals. Anatomy Trains inspires these practitioners to work with holistic anatomy in treating system-wide patterns to provide improved client outcomes in terms of structure and function. 


Full Transcript

0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology, is a highly-regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this groundbreaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms and treatment of more than 500 diseases and disorders. Learn more at

0:00:32.5 Speaker 2: Anatomy Trains is excited to invite you to a new 2-Day Dissection Livestream Specialty Class, the Deep Front Line and the Central Nervous System. February 27th and 28th, this advanced dissection livestream educational experience is presented by Tom Myers and Todd Garcia, together in the lab for the first time in a year, in four two-hour sessions, we will explore detailed anatomy and the fascial connections in the ventral core. What Tom Myers termed the Deep Front Line, moving onto the brain, spinal cord and fascial membranes that surround the central nervous system in the dorsal cavity. This special dissection livestream format allows us to explore more deeply subjects and areas of interest. Visit for details.


0:01:26.7 Ruth Werner: Hi, and welcome to "I Have a Client Who... " Pathology Conversations with Ruth Werner, the podcast where I will discuss your real-life stories about clients with conditions that are perplexing or confusing. I'm Ruth Werner author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively and within our scope of practice, and sometimes as we have all learned, that is harder than it looks. Today, I have a client whose story comes from a massage therapist who shared her story with a Facebook massage therapy group, and she thoughtfully put a trigger warning at the head of it, and I will do the same.

0:02:25.1 RW: Today's story is about a person with an eating disorder who wants to receive massage, her situation is advanced enough that the massage therapist is not sure about her safety. If this is likely to be upsetting for you to listen to, I encourage you to skip this one, or if it's easier to read the transcript that will be with the show notes. And the story goes like this, looking for input from other therapists who have experience with a similar situation. I have an adult client who... That has an ED and is severely underweight, they've stated that they are in recovery, but they have continued to lose weight. I'm wondering at what point do we as a licensed massage therapist do something, refer out, reach out to others involved in their care, pause sessions, etcetera.

0:03:14.6 RW: Do we do anything? When does massage become contraindicated? I know EDs can affect blood pressure and a number of other things. I've worked on all different types of bodies, some thin and lean as well, but this level is new territory for me. I'm happy to say that this question prompted some really interesting and compassionate input, especially once people understood that we were talking about eating disorders and not erectile dysfunction. I'm going to talk a little bit about anorexia and other eating disorders, and then we'll talk a little bit about some guidelines or boundaries for massage therapy for people who live with these very challenging conditions. Anorexia is one of a few recognised eating disorders along with bulimia and binge eating disorder, these are the three most common versions that we see. But there are a few other eating disorders that are kind of rare, pica for instance, is a situation where people feel compelled to eat things that aren't actually edible, like chalk or clay or cotton balls, and there are a few others, but they're really rare and they may be connected to specific nutritional deficiencies. There's even a disorder that is not officially recognised, but some clinicians call it orthorexia, which has to do with an unhealthy obsession about eating very, very healthily. I have written a couple of columns for Massage & Bodywork about various eating disorders, so I will be sure to link to them in the show notes.

0:04:46.2 RW: We are told whether today's client is dealing primarily with anorexia or bulimia, and truthfully, many patients go back and forth between these two behaviour patterns, so we'll talk a little bit about both, but our main focus will be on anorexia. Anorexia nervosa, that's the technical term, is a condition in which people limit their intake of calories by eating very little, but they may also engage in levels of exercise that burn more calories than they take in. Some people with anorexia may also purge. By contrast, bulimia is a situation where a person may binge eat and then tries to limit their intake of calories through purging, either through the use of laxatives or through self-induced vomiting. People with bulimia may also exercise to excess. Both of these types may exercise to the point of injury, but keep on going. As I've said, there's certainly overlap between these behaviours and people may sort of go back and forth in the ways that they try to limit the number of calories that they absorb. One difference that we see is that people with advanced anorexia may be well below a healthy weight, where people with bulimia may appear to be at a healthy weight or above.

0:06:05.8 RW: The first thing to say about these conditions is that they are not problems with the digestive system, they are classified as nervous system disorders often appearing under the heading with mental and mood disorders, the overlap between anorexia and varieties of anxiety disorders, depression and obsessive-compulsive disorders is really high. The thing I take away most from trying to understand these eating disorders, whether we're talking about anorexia, bulimia or binge eating disorder, is that they are usually related to a sense of having extremely limited control over certain aspects of one's life. I'm gonna quote from my textbook here, about who gets eating disorders, because I covered this issue pretty well. And here's what I said, the traditional thinking about anorexia and bulimia suggests that these conditions mainly affect young white women who are over-achievers and athletes whose sports require a particular weight strength ratio, dancers, gymnasts, wrestlers, skaters and jockeys. And that's true, but it turns out to be an extremely limited view. About one-fourth of all eating disorder patients are males, and many people with these conditions are neither young adults nor Caucasian, this condition is seen, although often untreated in people of color, and in mature and elderly patients. It is also not exclusive to thin people, people of normal or excess weight can also struggle with bouts of anorexia or bulimia.

0:07:46.2 RW: The other thing I wanna emphasise, and today's contributor seems to understand this, is that anorexia and bulimia are not benign conditions. They are potentially quite dangerous. And they require attention. Eventually, these dysfunctional eating habits can become self-sustaining. The digestive system can no longer accept food in a normal way, patients can lose the ability to keep food down, to break down nutrients, to absorb nutrition, or to eliminate waste on their own. But what happens when these eating disorders arise, how does all of this come about? Well, it's probably different for each individual, but some contributing factors include a desire to exert control over one's own choices, also the perceived pressure to meet societal and media-led expectations of that experience. And there is an exercise in futility. And for some patients, the desire to participate in sports or other activities that require low weight. None of these drivers is inherently pathologic, but they become a problem when they lead to behaviours that are damaging to a person's physical health and to feelings like shame, self-loathing, a badly distorted body image, or even that an eating pattern becomes an inherent part of one's personality, and these can be damaging to a person's mental and emotional health.

0:09:16.0 RW: The complications of eating disorders can be really serious, becoming so underweight that metabolism changes is especially problematic for young people, and especially girls and women, because it can put them into early onset menopause, this means their menstrual cycle stops and their bones, which should be becoming more dense during their teen and young adult years, actually begin leaching off calcium and they become thinner. And this, of course, is a set up for osteoporosis, when this happens in female athletes, the combination of low energy, loss of menstruation and low bone density is called the female athlete triad. Prolonged anorexia and/or bulimia can upset other chemical balances in the body leading to problems with electrolytes and arrhythmia and other heart issues. If the person purges as well as limiting their calories, we see damage to the esophagus and the teeth, and loss of colon function, changes in peristalsis can become self-sustaining, so that even if a person wanted to stop vomiting, it might become difficult to do that. More people die from complications related to anorexia and bulimia, and those complications can include suicide, than from any other psychiatric disorder.

0:10:38.4 RW: So this is all very doomy and gloomy because eating disorders are serious problems and they're surprisingly easy to hide and surprisingly hard to treat. People who live with anorexia or bulimia, often eat or don't eat in private, and they wear large baggy clothes for two reasons, to camouflage what they perceive as their oversized bodies and to be warm since their normal amounts of subcutaneous insulating fat are diminished. In addition, their hair may become brittle or fall out all together, and sometimes we see the growth, of what looks like peach fuzz, soft downy hair called lanugo that we usually see on newborns, this may be an attempt to compensate for the loss of normal subcutaneous fat. Pathologically underweight people may also have hypotension, low stamina and susceptibility to cold.

0:11:34.9 RW: The most successful treatment for eating disorders, do not focus first on food intake, instead the focus is on resolving whatever issues led to those behaviours in the first place. Of course, if someone's in a life-threatening situation, then inpatient treatment may become necessary, but a person's psychological and emotional issues must also be addressed. And this might happen with the use of certain anti-depressants or any anxiety medications, but almost always we're also looking at individual or group psychotherapy support. And some healthcare providers recommend massage therapy for people with eating disorders because our work is such a great way for people to experience their bodies in a healthy and positive way. Our contributor today has a remarkable opportunity because her client voluntarily told her about her situation, and from the description, it sounds like she's pursuing massage on her own, not because someone told her to. As a reminder, here's what the massage therapist asked.

0:12:40.0 RW: "I'm wondering at what point do we as licensed massage therapists, do something, refer out, reach out to others involved in their care, pause sessions, etcetera. Do we do anything? When does massage become contraindicated? I know eating disorders can affect blood pressure and a number of other things". Well, here are a few thoughts, a client who is frail requires our presence and loving touch without challenging her ability to maintain homeostasis. So it would be good to ask this client if they ever have heart palpitations or arrhythmia, and if yes, what they do to control them, if this or other symptoms or complications of their condition affect their everyday function, it would be wise to ask permission to consult with their doctor about best strategies for massage therapy.

0:13:30.8 RW: But let's remember that the issue of control and personal autonomy is a huge driver for eating disorders, and we must not push that boundary by doing anything without our client's express permission. Clients with eating disorders may have skin that feels unusually thin because their subcutaneous fat has diminished, and this means our pressure will have much more impact than we might be used to when we work with someone who does not have this condition. This client is likely to have low blood pressure and feel cold very easily, and we can accommodate for this by making sure the treatment room is extra warm and to conclude the session with strokes that are more stimulating than relaxing. If the therapist is really concerned about this client continuing to lose weight and feels that massage therapy is no longer in their best interest, then it may become necessary to end that relationship or to refer out and strongly support that client in seeking other kinds of healthcare.

0:14:32.0 RW: But I really hope that these people can continue to find a way to work together, even if it's just with the gentlest touch and support, because truly, the most important thing massage therapists can do for clients with eating disorders of any kind is to be present, non-judgmental and loving. These clients more than any others need to feel they can control what happens to them, and this means we have to listen and respond, and kind and to create an environment of safety that might be lacking in many other aspects of this client's life. In my textbook, I was honoured to include an essay by a massage therapist in the Washington DC area named Amanda Lang, who also struggles with eating disorders, and I will quote her here, Amanda says, "Do you have a client who looks really thin or who talks about excessive exercise? Listen, with your heart and your hands. Most of all, don't judge. Sometimes nudge, but don't suggest I go home and eat some fudge... Yes, someone did that".

0:15:41.6 RW: If I weren't a massage therapist, a job that requires you to know yourself, your boundaries and your intentions, I don't think I would have gone into treatment for my eating disorders. I love my job. And physically and emotionally, I just couldn't do it. I couldn't lie, I couldn't encourage my clients to exercise when I was secretly comparing my performance to theirs, I couldn't encourage them to rest when I never did, I couldn't bring that toxic energy into the room. I still have an eating disorder, I still have body image issues, I still struggle to take care of myself, but now I don't lie about it. I tell those who care for and about me that my eating disorder is part of my emotional, physical, mental, and spiritual reality. When you touch me, you touch all those scars. Please proceed accordingly.

0:16:44.1 RW: Please ask questions, please just be with me as I navigate this new body and space. I wanna offer my special thanks to the contributor who allowed me to share this case on "I Have a Client Who... " And I wanna thank Amanda who contributed this essay and all of the caring and thoughtful people who contributed to the discussion about working with people who live with eating disorders. I truly believe that massage therapy is one of the best avenues someone who struggles with body image and health can consider. And I'm so proud to see my colleagues stepping up to this challenge with curiosity and compassion. Hey everybody, thanks for listening to "I Have a Client Who... " Pathology Conversations with Ruth Werner, remember, you can send me your "I Have a Client Who... " stories to, that's ihaveaclientwho, all one word, all lowercase I can't wait to see what you send me and I'll see you next time.