Tag Archives: Eating Disorders

Food for thought

By Laurie Meyers January 25, 2018

With January now behind us, the annual barrage of diet and fitness commercials has started to fade. Many people who made New Year’s resolutions to lose weight or “get fit” have already labeled themselves failures for indulging on leftover holiday chocolate and not making it to the gym more than twice per week. Other determined warriors in the fight to attain the perfect size and shape may stick to their resolutions and lose the desired amount of weight, only to find that they’ve gained it all back (and then some) within six months. This cycle of dieting and weight loss, followed by weight gain, is a process that many Americans go through over and over again, often in search of an unattainable or unsustainable ideal.

“The primary message we get from popular culture is that our worth is based on our appearance and the ability to achieve a thin and beautiful cultural ideal,” says Laura H. Choate, editor of the book Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, published by the American Counseling Association. “When individuals internalize this message — that they are only worthwhile or acceptable if they are able to achieve this ideal — they develop a negative body image, which can lead to dieting and disordered eating behaviors.”

According to the National Eating Disorders Association, in the United States, approximately 20 million women and 10 million men will struggle with a clinically significant eating disorder at some point in their lives. Experts say that many millions more will engage in disordered eating — patterns of behavior that resemble those of eating disorders but which do not meet clinical criteria. Symptoms of disordered eating may include chronic dieting, frequent weight fluctuations, extremely rigid and unhealthy food and exercise regimens, emotional eating and a preoccupation with food, body and weight issues that causes distress.

Ashamed to eat?

Licensed mental health counselor Tamara Duarte, a private practitioner in the Vancouver, Washington, area who specializes in treating women with eating disorders and body and food issues, says that we live in a culture that has normalized chronic dieting. She refers to this phenomenon as the “dieting roller coaster.”

Women come to Duarte, an ACA member, having spent years pingponging back and forth between restrictive diets and binge eating. After attempting to limit their consumption only to “good” food, these clients have typically fallen off of their diet wagon and ended up in a binge cycle, during which they eat all of the foods they consider “bad,” Duarte explains. Feeling guilty, the women go back to dieting and start the cycle all over again.

Duarte also sees clients who have gained weight as they have aged and want to get their former bodies back — even if it is through unhealthy means. “People come in and tell me that they used to have a restrictive eating disorder and wish they could go back to that time so that they could be thin,” Duarte says.

What all of these clients have in common is a sense of shame about food and their bodies, Duarte says. Fear of being or becoming fat is so prevalent in our society that this shame has become normalized, she says. The irony is that much of the research has found that dieting ultimately leads to weight gain, Duarte notes. Chronic dieting (even at a subclinical level) may even be harmful to the body, and Duarte and other eating disorder experts say that the benefit of weight loss through dieting is unclear.

Like many who study or treat disordered eating and eating disorders, Duarte wants to remove the stigma attached to different-sized bodies. “Fat is just an adjective,” she says.

Part of breaking free of disordered eating — and eating disorders — is learning body acceptance, Duarte says. “Helping a person to accept their body as is can be a very slow, complex process,” she admits.

“I read something posted on Instagram once that said, ‘You cannot obtain recovery while actively trying to change the size and shape of your body,’” Duarte continues. “I really liked that, and I introduce that very early on in the counseling process. Throughout counseling, we look at the beliefs the client has about their body and where those stem from. Typically, thoughts like ‘I’m ugly and unlovable in this body’ stem from society or family members. It’s interesting because none of my clients so far have thought others are unlovable because of their body size, so I question what makes them different. We also look at how screwed up society is for picking one body size as being beautiful and acceptable. With a recovering mind, they are able to recognize how erroneous these thoughts are.”

Duarte also asks clients to get rid of their scales. “Not relying on an arbitrary number to tell them whether they are ‘good’ or ‘bad’ frees them up to connect in with themselves to figure out how they are feeling,” she explains.

Intuitive eating and Health at Every Size

Duarte has personal experience both with eating disorders and the power of that “arbitrary number.” She had been in recovery for more than 10 years when she happened to gain about 45 pounds because of some medication she was taking. Uncomfortable in her new body size, Duarte was ready to put herself on a diet and workout regimen. But then she attended some seminars on intuitive eating, an approach created by dietitian Evelyn Tribole and nutrition therapist Elyse Resch, both of whom specialize in eating disorders. Intuitive eating rejects dieting. Instead, it advocates listening to the body’s signals of hunger and fullness and getting rid of the idea of “good” and “bad” foods, among other principles.

Duarte also learned about Health at Every Size (HAES), a program and social movement inspired by the book written by Linda Bacon, a nutrition professor and researcher. HAES advocates the acceptance of bodies of all sizes, rejects dieting and calls for addressing health concerns directly with healthy behaviors. Both intuitive eating and HAES also encourage physical activity in whatever form a person naturally enjoys.

“I immediately recognized the power of teaching IE [intuitive eating] and HAES to clients,” Duarte says. “Both HAES and IE teach that when you listen to your body and feed it what it wants, when it wants, how much it wants, your body will naturally go to its set point range — the weight range where it works optimally. HAES tells me that I am OK no matter what my body looks like and that I can love and accept it right now.”

After learning about intuitive eating and HAES, Duarte started following the principles found in each approach. “At that point, I had a laundry list of good foods and bad foods, so I did the work to incorporate my ‘bad’ foods back into my diet,” she says. “An incredible thing happened: As I allowed myself to want and have these foods, the power they used to hold went away. Pizza was pizza. In the past, I would not allow myself pizza, and if I did decide to allow it, I would eat like five pieces because it tasted so good and I was telling myself I wouldn’t have it again. When pizza became accessible, I realized I only wanted one or two slices, and then I was able to step away because I knew that the next time I wanted pizza — in 10 minutes or 10 days — I would be able to eat it.”

Duarte also realized that although she enjoyed going to the gym, the activity she loved best was going on walks with her dog. So, instead of carving out time to devote to workouts, she started spending more time walking her dog.

“I really enjoy my walks when I go on them, and I am kind to myself when life gets busy and I can’t or don’t want to fit them in,” she says. “I no longer berate myself because the walks are for self-care, not to manipulate the size and shape of my body. I enjoy the array of foods I eat. I love opening a menu and deciding based on what I want instead of what I ‘should have.’ I never thought I would have this kind of relationship with food or my body.”

For those who might wonder whether Duarte lost weight, she responds that it doesn’t matter because her body shape and size have no bearing on her happiness or success.

Combating body hatred

Knowing from personal experience that intuitive eating and HAES can be very effective, Duarte now incorporates the approaches into her counseling work. “Every single client that calls my office for a free consultation ends up telling me that what they want most from counseling is freedom,” she says. “Freedom from the eating disorder, the never-ending thoughts about weight and food, freedom from self-hatred. I know that HAES and IE [are huge pieces] of the puzzle when it comes to freedom.”

“I don’t have to tell my clients about my experience with HAES and IE,” she continues. “I just have it with me when I am helping to guide them through it. It influences the way I feel and think about my clients’ bodies as well. I do not hold judgments about people’s bodies because of what I have learned in my journey, and my clients know I don’t judge them. When I tell my clients that their body is acceptable no matter what it looks like, I mean it, and they know it.”

Duarte discusses how HAES and intuitive eating helped guide her treatment of a teenage client she calls “Sara,” who was restricting her food intake and using exercise and vomiting to purge. “Sara believed that her body was wrong and ugly because it didn’t look like her family members, who were taller and built leaner than she was,” Duarte says. “One of the first things I had Sara do was put her scale away in a place that she wouldn’t have easy access to.”

Duarte introduced Sara to intuitive eating and its philosophy that foods should neither be demonized nor celebrated. Sara was particularly resistant to this concept, but Duarte successfully encouraged Sara to slowly add “forbidden foods” back into her diet.

Duarte also used mindfulness to help Sara with her purging behavior. “We worked on mindfulness, so she was able to identify when the urge to purge was coming on,” Duarte says. “She would write down for me everything that she was thinking — why she wanted to purge and why she didn’t.”

The urges would usually pass, and over time, Sara was able to get through them by using tools she had learned in session. Duarte teaches all of her clients distraction and self-soothing skills drawn from dialectical behavior therapy. Examples of distraction activities include dancing to a favorite song, writing or drawing, calling or texting a friend and going for a walk or a drive. Self-soothing might involve clients taking a shower, painting their fingernails (an activity that Duarte says is great for people with bulimia because they can’t induce vomiting with wet nails) or giving themselves a foot massage.

With time — and the help of the tools she had learned — Sara no longer experienced urges to purge. It took awhile for Sara to grow comfortable with her body, but she began to enjoy the increasing sense of physical strength that came from no longer restricting her food intake, Duarte says. Over time, that physical feeling of strength also became psychological.

“She struggles from time to time with not liking how she looks, but she’s able to identify what’s really going on at those times,” Duarte says. “Typically, Sara is stressed or scared, and instead of feeling [that], she focuses on her body and her need to change it. [But now] she uses the tools we have worked on in session, and she feels her feelings effectively, and most often, the body hatred goes away too.”

Alternatives to emotional eating

Licensed professional counselor Rachael Parkins is a practitioner at the Bucks Eating Support Collaborative in Bucks County, Pennsylvania, where she currently runs a support and therapy group for emotional eating. The group meets weekly and serves as a place for women to share their challenges, support one another and get professional guidance from Parkins. Group members may be struggling with a variety of concerns, but food is their common method of coping with emotions and issues such as stress, insecurity, self-esteem and body image, Parkins explains. Most of the women are working with a dietitian, and group members also have access to an intuitive eating coach.

The goal of the group is to learn how to handle emotions in a healthy way by working on methods such as distress tolerance. Group participants identify distressing emotions, such as loneliness, and Parkins helps them identify alternative ways to cope with what they’re feeling. Sometimes, this can be as simple as group members going out of their way to be kind to themselves and practice self-care, such as putting on lotion or taking a bubble bath. Other methods are more concrete, such as journaling or completing a decatastrophizing worksheet. In that case, participants write down their worst thoughts, evaluate the worst-case scenario and the likelihood of it happening, and identify other possible outcomes.

Parkins also encourages group members to acknowledge the small victories they experience in pursuit of their personal goals by recording them in a log. For example, a group member might state a goal of practicing better self-care. For this particular group member, an action such as getting out of bed and taking a shower might represent a small victory. Another participant might want to stop procrastinating. Calling to set up a doctor’s visit could be a small victory, even if the group member doesn’t keep the appointment.

Parkins also helps group members break free of comparisons, both with other people and themselves. She explains that participants regularly hold themselves and how they look up not only to the perceived “successes” of others in their lives, but also to their own past selves. Parkins says it is not uncommon for group members to express a desire to go back in time to when they were thinner, even if it was a miserable point in their lives.

“They have this idea in their head that if they get to this size or number on the scale, that’s going to bring happiness,” she says. “Losing weight might be desirable, but as an emotional focus, it’s never enough. I’m helping people accept that losing weight is not the answer.”

Signs of a problem

Although not every client who diets is engaging in disordered eating, counselors should regularly assess for eating and body issues, says Choate, a professor of counselor education at Louisiana State University.

“We know that a large proportion of the population experiences problems related to eating and negative body image, so it is reasonable for counselors to assess for these issues with all of their clients,” she says. “Because clients with eating-related problems might come to counseling with other issues — depression, anxiety, relational problems — asking questions specifically related to eating patterns and body image is a good way to explore to see if these problems are contributing in any way to the client’s presenting issues.”

Choate suggests asking the following questions:

  • Is the disordered eating pattern causing problems in the person’s life?
  • Does the disordered eating pattern interfere with the person’s relationships with others? With the enjoyment of life activities? With completing daily routines?
  • Does the client’s weight, shape or appearance unduly influence self-esteem?
  • Does the client believe that she or he is less acceptable if weighing a few pounds more than in the past or, conversely, that she or he is more acceptable if weighing a few pounds less?

When assessing clients for signs of an eating disorder, Duarte says, it is essential that counselors not be misled by the stereotypical presentation of extreme thinness. The stigma attached to larger bodies often can obscure the reality that eating disorders may occur in people of all sizes, she says. In part because our society generally expects that people who do not fit into an idealized size range want and need to lose weight, counselors may be less likely scrutinize dieting behavior and weight loss in larger clients. Like Choate, Duarte believes that counselors should assess all clients for signs of disordered eating.

Choate also offers one final caution for counselors. “While there are some eating-related problems that might respond well to counseling alone, it is important to be aware that eating disorders are chronic, and anorexia in particular has the highest mortality rate of any psychiatric disorder. Treatment of these disorders requires specialized knowledge and training, and because eating disorders all involve a medical component, the involvement of a multidisciplinary treatment team is required. This would include, at minimum, a physician or medical professional, a dietitian and the counselor.”




Defining eating disorders: Changes in diagnosis

Laura H. Choate notes that in the past, most individuals with eating disorders fell into the diagnostic criteria of eating disorders not otherwise specified (EDNOS), which led to changes in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

The criteria for anorexia nervosa and bulimia nervosa were expanded to include more people. Binge eating disorder was added as a stand-alone disorder (rather than remaining as previously listed as a subcategory under EDNOS). EDNOS was renamed “other specified feeding or eating disorder” and includes issues such as:

  • Atypical anorexia nervosa: All criteria for anorexia nervosa are met; despite significant weight loss, the individual’s weight is within or above the normal range.
  • Bulimia nervosa of low frequency or limited duration
  • Binge eating disorder of low frequency or limited duration
  • Purging disorder
  • Night eating syndrome




Multicultural considerations

Although often perceived as a “white” problem, eating disorders and disordered eating do occur among women and men of color, says Regine Talleyrand, an American Counseling Association member whose research focuses on eating disorders among women of color.

“Counselors should be aware that women of color do experience concerns regarding beauty and body esteem,” she says. “[However], the traditional methods of evaluating these factors — weight, body parts, preoccupation with thin body ideals — may not capture the real body appearance concerns of all women of color.” Talleyrand, an associate professor and coordinator of the counseling and development program at George Mason University in Virginia, says that characteristics such as hair, skin color and facial features may be more relevant when evaluating body image in women of color.

In addition, high rates of obesity and binge eating among Latina and African American women highlight the need to look beyond “traditional” eating disorders such as anorexia and bulimia when working with women of color who struggle with eating, weight or body issues, Talleyrand says. Because African American and Latina women are even more likely than white women to display eating disorder symptoms at any size, counselors who are evaluating clients of color for disordered eating should also look beyond the stereotypical underweight image, she emphasizes.

Of course, the factors influencing the risk of eating disorders in all populations go beyond appearance. These factors are often culturally specific. In particular, racism and oppression may play a significant part in eating disorder risk among Latina and African American women, Talleyrand says. In fact, the development of eating disorder symptoms — particularly binge eating — has been linked to racism and oppression experienced by African American women, she adds.




Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Eating Disorders and Obesity: A Counselor´s Guide to Treatment and Prevention, edited by Laura H. Choate

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Anorexia Nervosa” by Shannon L. Karl

Journal articles (counseling.org/publications/counseling-journals)

  • “Special Section: Assessment, Prevention and Treatment of Eating Disorders: The Role of Professional Counselors,” Journal of Counseling & Development, July 2012




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor:ct@counseling.org




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The powerful perspective of body satisfaction

By Juleen K. Buser and Rachael A. Parkins December 22, 2014

Every January, right as the new year begins, we are saturated by commercials for diets, advertisements for exercise machines and stories of people whose lives were transformed upon Branding-Box-body-satisfactionattaining the elusive goals of slimness and fitness. This message is an undercurrent throughout the entire year, of course; it just becomes especially blatant and constant in the days leading up to and immediately after New Year’s resolutions.

But the messages about being thinner, fitter, sleeker and more attractive are rarely absent — particularly for women. In fact, in a quite alarming example of the consistency and doggedness of this message, a few years ago I (Juleen Buser) watched a newscaster comment on National Eating Disorders Awareness week. This alert about the annual marking of a week to increase awareness of the agony and perils of eating disorders was almost immediately followed by a commercial on the latest weight loss tool promising to help women shed those extra pounds of flab and fat.

The problem of body dissatisfaction among women is pervasive and persistent. In a 2014 study published in the scientific journal Eating Behaviors, Elizabeth Fallon, Brandonn Harris and Paige Johnson reported that 13.4 percent to 31.8 percent of adult women experience body displeasure. Moreover, these authors noted that young, middle-aged and older women all reported body dissatisfaction.

A prominent strand in the literature is the role that the media play in fostering and maintaining this rampant, steadfast body dissatisfaction. A meta-analysis conducted by researchers Lisa Groesz, Michael Levine and Sarah Murnen in 2002 pointed clearly to the detrimental impact of the media as it relates to female body image.

As counselors, we are bound at some point to encounter a client who has dealt with the negative impact of the media’s obsession with body size and shape. Ruth Striegel-Moore, Lisa Silberstein and Judith Rodin wrote a seminal article in 1986 (“Toward an understanding of risk factors for bulimia”) that discussed how incredibly common it is for women in Western society to struggle with body dissatisfaction. The concern is so typical, in fact, that it may actually be unusual to identify a woman who expresses happiness and satisfaction with her body.

We, the authors of this article, wanted to hear the perspectives of women who expressed the uncharacteristic view of body satisfaction. We thought that much could be learned about mental Body image authorshealth from women in college who were able to assert satisfaction with their bodies despite the many media messages lauding the ideal of thinness. Thus, we embarked on a research project in which we interviewed nine college women about their experiences of body satisfaction.

We asked these women questions about their emotions and cognitions regarding their body size and shape, their history of body image attitudes and views, and how they cope with the external pressures for thinness. In what was often viewed as an unexpected inquiry, we also asked them questions about the connection between their spirituality and body image. We chose women who specifically expressed having both body satisfaction and a spiritual belief system because we were curious about the ways in which spiritual beliefs might play a role in body satisfaction. The full empirical findings of this study are available in an article we published in the April 2013 Adultspan Journal, “‘Made this way for a reason’: Body satisfaction and spirituality.” This Counseling Today article is an adaptation of that article; here, we focus more closely on the practical counseling implications of our findings.

The importance of the body

Our findings uncovered a striking contradiction. Many of the women we spoke with felt that their bodies were both more important and less important than the societal messages about female physical appearance.

They viewed their bodies as more important than the societal narratives in that the media images of thinness did not disrupt their core belief in personal beauty. Some women talked about Photoshopped images and the erroneousness of the media’s idea of beauty, explaining that they were able to distance themselves from the models by recognizing that their bodies were simply different than the ones in the media. To these women, their bodies and the bodies in the media were incomparable.

On the other hand, they also placed less importance on their bodies in that many of these women did not emphasize physical size and shape over other significant areas of life. Media narratives often would have us believe that a physically fit, attractive body should be a primary value for women. Some of the women we interviewed communicated aspects of their lives that they felt were more valuable than their physical bodies. For example, one participant said: “I mean, your weight compared to, like, the time you could spend with your family. … Why are you wasting your time staring in the mirror for an hour?” 

These findings around the importance of the body have potentially powerful implications for counseling. When working with women who express body dissatisfaction (that common, persistent displeasure counselors are bound to encounter in clients), the views of these women who were able to hold onto body happiness could be helpful. Counselors may be able to pair the beliefs that many of the participants of this study possessed with different therapeutic methodologies. For example, counselors might use cognitive therapy techniques that help clients alter distorted thoughts by replacing them with more rational beliefs. A client who found she was frequently comparing her body with the bodies often seen in the media may be able to use thought replacement, for instance. She could substitute thoughts that engender body comparison with a statement such as: “My body is incomparable to that image because it is falsified, making it unattainable.”   

Counselors can also work with clients to shift their focus and priorities. Clients may benefit from focusing less on their body shape and size and focusing more on other aspects of life. For example, clients might come to counseling with the identified problem of a distorted body image and a self-image closely tied to body size and shape. A counseling session may be the ideal opportunity for a counselor to help shift these common distortions by pointing out the dissimilarity between the client’s long-term goals and the value the client is placing on her body image. For example, counselors can draw from principles of acceptance and commitment therapy (ACT) when working with clients struggling with body dissatisfaction.

Adria Pearson, Michelle Heffner and Victoria Follette, authors of Acceptance and Commitment Therapy for Body Image Dissatisfaction, applied ACT to the treatment of body displeasure and noted the benefits of helping clients move beyond a focus on body size and shape to live a life in tune with personal values. For example, a counselor might ask a client to create a list of morals, values and attributes that she would like to work toward having or may currently see in herself. This would be a crucial opportunity to point out to the client the incongruence between her morals/values and the concentration she may be placing on her outward appearance.

Spirituality and the body

Initially, almost all of the participants in our research project were a bit staggered by the notion of a connection between their spirituality and their body image. Yet, despite early confusion over or even rejection of this connection, many were able to see and give examples of how their body image and spiritual beliefs could be correlated.

One way in which these two components were tied together for some participants involved the idea of spiritual control over one’s body. Specifically, these women accepted certain limitations concerning their ability to control their physical bodies. They gave ownership of these limitations to a higher power, noting that God “made me how I am” and “I just feel like maybe I am a certain way for a reason, and God wants me to be happy with myself.”

Again, these findings are rich with potential counseling implications. First of all, the participants’ initial surprise, confusion and hesitation concerning a potential connection between their spirituality and body image suggests that counselors may have to take the initiative in broaching these topics. Although such a connection may be relevant, clients simply may not think about the intersection of these two domains and, consequently, could miss a very salient and therapeutically beneficial exploration.

Counselors can begin the conversation with open questions that give the client a chance to think about (likely for the first time) possible connections between spirituality and body image. Potential questions and comments include:

  • “You mentioned having a spiritual faith a few sessions ago. I am curious about ways in which your spiritual beliefs might play a role in how you feel about your body.”
  • “Tell me about your spiritual practices (for example, prayer, meditation). What things do you focus on during those times? Do your feelings about your body relate to these spiritual practices?”
  • “Are there ways that God or a higher power influences the way you feel about your body? Tell me more about this connection.”
  • “What aspects of your spiritual faith are relevant to body image concerns? Are there certain [theological principles, sacred texts, underlying philosophies, etc.] that discuss the physical body?”

For certain clients, this connection between spirituality and body image may be personally meaningful and significant. In such instances, counseling can delve more fully into a discussion of the ways that a client’s spiritual beliefs could foster body satisfaction. When discussing the spiritual belief systems of clients, however, counselors will want to be cautious not to offer spiritual guidance or instruction to the client. Rather, counselors can remain in an encouraging role, asking open questions and fostering client exploration of spiritual and body beliefs.

For example, a client struggling with body displeasure may believe in her complete ability to control her body size and shape. Disordered eating behaviors may result in part from this belief in personal agency over weight and shape. Yet, this client may possess a spiritual belief system that contains theology about the sovereignty of a higher power.

In such a case, a counselor could help the client explore the ways in which her spiritual views (of little control) might relate to or inform her body image views (of complete control). A client may then begin to apply her spiritual beliefs about divine power to her body size and shape. She may ultimately see her physical body as created by a higher power and thus not fully within her control to manage through a strict diet and exercise regimen. This spiritual belief system may give her the relief of accepting her body.


Inundated by media images of thinness, many women are vulnerable to the ensuing effects of body dissatisfaction and unhappiness. Yet, for some women, attitudes of body satisfaction persist despite these external pressures and societal mores. As counselors, we can learn from these women. The factors that allow them to hold onto a belief in the beauty of their bodies can help us in our work with clients who are struggling with beliefs about the inadequacy and unattractiveness of their bodies.


Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Juleen K. Buser is an assistant professor at Rider University in Lawrenceville, New Jersey, and a past president of the International Association of Addictions and Offender Counselors. Her research focuses on both adaptive and maladaptive coping strategies such as eating disorders, nonsuicidal self-injury and spiritual coping styles. Contact her at jbuser@rider.edu.

Rachael A. Parkins is a primary therapist at the Renfrew Center in Radnor, Pennsylvania. She received her master’s degree in clinical mental health counseling at Rider University. Her research includes emphases on eating disorders, body image, coping and spirituality.

Letters to the editor:  ct@counseling.org

Disordered eating and body bashing

By Kiphany Hof March 17, 2014

Today I ate a piece of chocolate cake, and I survived. This sounds silly, I know. But not too long ago, there were countless days in a row when I truly thought my life was measured by the number on the scale, the size of my jeans, the number of calories I ate or my ability to refuse chocolate cake.

Sadly, this is no exaggeration, and many of you know this because you too are dealing with or have dealt with living in a self-made prison where the bars are made of supermodel standards, fear of rejection, endless exercising, obsession with body image, overeating, undereating, laxatives, diuretics, self-induced vomiting and self-loathing. Would you be able to tell, just by knowing someone, if they are one of the inmates in this prison of torment that destroys both body and soul? Are you one of these people who secretly hope that your warden of self-criticism will unlock the door and free you?


I am writing this article because I am a former inmate in the jail of disordered eating and body bashing. I was stunned at the number of people I met, both men and women, who were cellmates of mine, although I did not know it at the time. You too might be surprised at the number of occupants.

This article is not a forum for me to tell my story, however, because my story is really the story of thousands of other men and women across the nation who are locked up and rotting in that same prison. Rather, I hope to catch your attention, even if for the briefest of moments, and remind you that freedom to live freely in a world made up of self-acceptance and contentment is possible, even when you eat chocolate cake.

The etymology of the word disorder is “dis” — meaning “not” — plus the verb, “order.” Translation: not ordered. Ironic, isn’t it, when we consider how much time and effort we expend to “order” ourselves around eating, exercising and the attainment of an acceptable and attractive body?

Even the term “body awareness” is somewhat ambiguous in interpretation. In its positive context, awareness of the way our bodies are uniquely created and the multiple miracles our bodies perform each day is cause for celebration. In its negative context, awareness of how much we hate our bodies and fantasize about them being different is awareness I am sure most people would rather not have.

Personally, I do not think the term “eating disorder” is an accurate description of what happens when someone’s behaviors become so ordered that she or he is more consumed with appearance than with consuming a required, life-sustaining substance: food. It is not about the eating, the calories, the fat grams or even about the food.

What is it about then? When and how did the detailed “order” of it all cross into the “disordered” spectrum?

There are many theories and possible explanations behind the hows and whys of eating disorders and negative body image. Some blame the media for saturating our visual world with unrealistic expectations about the perfect body. Others focus on the influence of societal pressures to look, behave or speak a certain way. Still others believe familial influences contribute to disordered eating and negative thinking.

All of the above may contribute to either a positive/negative, healthy/unhealthy or rational/irrational image of our bodies. Although the roots of our body perceptions may differ, we share a common thread of wanting to be accepted, recognized, admired and wanted by someone at some point in time. Sadly, everyone is painfully aware that physical appearance can either deliver or deny these desires. However, physical appearance is not the only route to fulfillment; it is just the most visible and advertised journey to get there. And that journey is oftentimes costly.

Take a few moments to venture on your own body image journey this week. Are you walking the path of freedom, or are you an inmate in the prison of body hate? Are you visiting someone who is locked up in his or her own fear, guilt and shame? Have you been a person who contributes to the building of those prison walls? Will you choose to celebrate your body this week, without judgment, as you become more aware of its impact on your life? Will you choose to help others unlock the cell door? Will you ask for help in being freed? Will you look beyond the body and see the simultaneous pain and beauty of a human soul? Will you question the meaning of “ideal” and expand your field of vision?

I encourage you to reflect on your own thoughts and feelings about your body and notice who defines them: Is it you or others? As you ponder, challenge yourself and others to find their own personal freedom; it is there, waiting for you to embrace it.




Kiphany Hof, a provisionally licensed mental health practitioner, works as a counselor at University of Nebraska Kearney Counseling Care, a mental health clinic that offers personal counseling to students. Contact her at hofkj@unk.edu.




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.


Behind the Book: Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment

Heather Rudow March 11, 2013

78076Laura Choate, associate professor of counselor education at Louisiana State University, is the editor of Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, a new book published by the American Counseling Association. Choate believes the book is a unique resource for counselors that sheds new light on how to treat and prevent eating and obesity-related disorders.

What inspired you to write Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment?

Rates of body dissatisfaction-disordered eating and problems with body weight and shape are increasing in populations across the life span. For example, young women are particularly at high risk for eating-related concerns such as binge eating, and obesity rates are increasing rapidly in the general population, putting individuals at risk for negative health outcomes. Furthermore, those individuals who experience body dissatisfaction and subthreshold eating disorders are at high risk for the development of potentially life-threatening, full-syndrome eating disorders such as anorexia nervosa and bulimia nervosa. The book provides insight into these problems and offers detailed information for the prevention and treatment of these concerns.

How does this book compare with similar books on market?

There is little information available in the field written primarily for a counseling audience. Many of the best-practice treatments are located in manuals that are hard to access. This resource provides essential foundational information for counselors such as sociocultural influences, gender differences, ethical issues, information on current assessment and diagnostic concerns, effective prevention programs for communities and schools, and best-practice treatments for a range of eating-related problems.

The book is distinct from others on the market due to the fact that it is written specifically for counselors. It contains both detailed prevention and treatment guidelines; it has a school and community focus; and it is accessible for practitioners who may not specialize in the area of eating disorders and obesity.

Some special features are as follows:

  • The book contains chapters from authors in the field who are well known among eating disorders professionals but who might not be known to counselors, such as Margo Maine, Linda Smolak, Douglas Bunnell, Diane Wilfley, Marian Tanofsky-Kraff, Eric Stice, Heather Shaw and Niva Piran. The book also contains chapters by authors from Canada and Australia. Counselors will benefit from an interdisciplinary perspective on eating disorders prevention and treatment that is tailored specifically toward their needs
  • The book contains information on sociocultural dynamics, assessment, diagnosis, conceptualization, prevention and treatment. Counselors will have information on a variety of topics located in one resource.
  • The book is written in an accessible format, with chapter highlights, case examples, and recommended online and print resources. Because it is reader friendly, counselors will be able to access and use the information.

How did you choose contributing authors, and how did this enhance the content? 

The idea for the book came from my experience as guest editor for the special section on eating disorders prevention and treatment published in the summer 2012 issue of the Journal of Counseling & Development. Based on the response to that collection of articles, I decided to compile a book on both eating disorders and obesity, and to address the areas of foundation, assessment and practice frameworks, prevention and evidence-based treatments. I invited some of the authors from the special section to contribute chapters based on their fit with one of these four areas, then sought out specific leading experts in the eating disorders/obesity prevention and treatment field to round out each section. The authors are practitioners as well as researchers and come from psychiatry, psychology and counseling disciplines, and all are doing important work in the U.S. as well as in Canada and Australia. I was honored to have a chance to work with each of them.

How did you get involved with subject?

The idea for this edited book originates from a variety of influences. First, my desire to compile this type of book stems from being a mother of elementary-age children who are exposed daily to harmful media images and messages regarding narrow cultural definitions of how they “should” look and act. Because I want my children and all others to be equipped with the skills they need to stay healthy and resilient in the face of cultural pressures around eating, weight and shape, this book is dedicated to assisting counselors and their clients to become empowered to effect positive change in this area within the multiple systems  —family, school, community — in which they are embedded.

The origins of this book are also grounded in my professional experience as a licensed professional counselor and counselor educator. I have been involved in the prevention and treatment field in a variety of roles. I have counseled clients, supervised and taught graduate students, published articles regarding body image resilience and eating disorders treatment, and presented at local schools to adolescent girls as well as to professionals at state and national conferences. I have observed that counselors are often unclear as to their role in preventing eating disorders and obesity and in providing early intervention and treatment, and they often lack training in best practices in this field. Therefore, the overarching purpose of this book is to provide a much-needed resource specifically targeted to counselors that provides accessible information practitioners can implement in their daily work with clients across the continuum of care. The book strategically includes chapters that address assessment, prevention and treatment, including information for working with children and adults as well as with clients from diverse cultural groups.

What are the most important take-away messages for the reader?

Readers will have access to current information on assessment, diagnosis, prevention and treatment of eating-related problems, eating disorders and obesity. Each chapter contains information to provide a knowledge base as well as essential resources for further education and training in that particular area of the field. 

Who is the best audience for the book?

This book is intended for all counselors, not just those who specialize in eating disorders and obesity treatment. Therefore, all school counselors, mental health counselors, counselors with interest in health and wellness — specifically eating disorders and obesity — child and adolescent counselors and counselor educators will benefit from this book.

Why is this book important to the counseling profession?

Both practical and comprehensive, this long-needed book provides a clear framework for the assessment, treatment, and prevention of eating disorders and obesity. Focusing on best practices and offering a range of current techniques, experts in the field examine these life-threatening disorders and propose treatment options for diverse clients experiencing problems related to eating, weight and body image.

Parts I and II of the text address risk factors in and sociocultural influences on the development of eating disorders, gender differences, the unique concerns of clients of color, ethical and legal issues, and assessment and diagnosis. Part II explores prevention and early intervention with high-risk groups in school, university and community settings. The final section of the book presents a variety of best-practice treatment interventions, such as cognitive behavioral, interpersonal, dialectical behavior and family-based therapy, which are empirically supported and have been used successfully in a variety of settings.

Click here to purchase a copy of Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.


Binge eating disorder to be recognized in the DSM-V

Heather Rudow December 11, 2012

(Photo: Flickr/46137)

As the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is set to be released in May, counselors are preparing for the changes that will come along with it, including the inclusion of binge eating disorder as a mental illness.

Binge eating disorder had previously been listed as “under review” because symptoms can sometimes be similar to mood disorders such as depression and anxiety.

The disorder is identified by “a sense of lack of control over eating during the episode” with the individual also exhibiting three or more of the following:

  • Eating much more rapidly than normal.
  • Eating until feeling uncomfortably full.
  • Eating large amounts of food when not feeling physically hungry.
  • Eating alone because of feeling embarrassed by how much one is eating.
  • Feeling disgusted with oneself, depressed or very guilty afterward.

However, Eric Cowan, a professor in the Department of Counseling and Graduate Psychology at James Madison University, has reservations about the new classification.

“Binge eating has long been recognized by clinicians as a compensatory symptom and one possible manifestation of any number of underlying disorders,” says Cowan, a member of the American Counseling Association who co-wrote a Knowledge Share article about bulimia in the December issue of Counseling Today. “However, I think that making binge eating a discrete diagnosable disorder will create a problem for some clinicians.”

Cowan says he is concerned that there will be too much overlap between individuals whose disordered eating could be considered a mental illness and those who tend to display what he calls “problematic eating” behaviors but are otherwise normal.

“This is especially true,” Cowan points out, “in that our culture’s relationship with food, both physically and emotionally, could be considered disordered. In other words, because the criteria for binge eating disorder are behaviorally based and a person either meets the criteria or not without regard to other contextual and relevant factors, it could pathologize behaviors that in the past we have considered as within the range of the ordinary. We don’t have this issue with other eating disorders. Both anorexia and bulimia have associated behaviors and symptoms that are clearly disordered, such as the severely altered perception of one’s own body or purging behaviors. Binge eating disorder, on the other hand, is somewhere on the continuum of eating behaviors that includes mere habitual overindulgence.

With the DSM-IV, says Cowan, if counselors judge that their client’s binge eating is a “significant factor in the client’s presentation, they could classify it as [an] Eating Disorder [Not Otherwise Specified]. The binge eating might occur with other eating behaviors that did not meet the criteria for anorexia or bulimia. With binge eating now a [concrete] disorder, counselors will now have to parse out these symptoms. It is possible that binge eating disorder could be the client’s only diagnosis, regardless of whether it reflects the most salient aspects of the client’s presentation or pathology.”

As with all diagnoses, Cowan warns that there is now a danger of losing information, as counselors must fit clients’ symptoms into narrower categories.

Clients may also be impacted by the change in that more of them will fit the criteria for a mental disorder, he adds.

“In reclassifying these behaviors as pathology,” Cowan continues, “we are not merely diagnosing, we are also communicating, both with other mental health professionals [and also with clients] about how they should think about themselves.”

Some practitioners contend that adding binge eating disorder to the DSM will allow clients to receive treatment with insurance coverage and allow mental health professionals to seek insurance reimbursement. But Cowan disagrees.

“I don’t think that not having binge eating disorder in the DSM-IV hindered mental health professionals from getting insurance reimbursement,” he says. “Almost always, significantly disordered eating is a symptom of underlying problems of thought or affect that are themselves discrete diagnosable disorders for which insurance reimbursement is accepted. Not to mention that binge eating could always be classified as Eating Disorder NOS.”

But what strikes Cowan most about classifying binge eating as a mental illness in the DSM, he says, is “that these symptoms are invariably a manifestation of a more fundamental disorder of self. The binge eating behaviors stand in for underlying processes involving affect regulation, self esteem and so on. Though the DSM system does not intend to address causation, the myriad ways in which these self disorders can manifest must make us cautious about reifying any one configuration of symptoms and assuming that because we have named it we have also better understood it. All normal behaviors that are taken to an extreme can be classified as pathological. We have to be careful about where, for the sake of helping our clients, we draw the line on the continuum.”

 Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.