For most of her life, the woman would not let herself eat cake. She feared that if she started, she would never be able to stop. The presence of cake at every birthday party she attended tormented her. She grew so preoccupied with thoughts of cake that she had food fantasies about eating it.

The woman’s unhealthy relationship with food eventually led her to Michele Smith, a licensed professional counselor who operates a private practice called The Runaway Fork in Westfield, New Jersey. With Smith’s guidance, the woman decided to conquer her fear by eating a sheet cake while she was alone.

The client took her first bite, but it wasn’t the experience she had fantasized about. It tasted artificial and waxy. She thought perhaps it was only the frosting that she didn’t like, so she took another bite, this time focusing more on the cake itself. It only confirmed the horrible taste from her first impression. The woman ended up throwing out the entire cake.

The client’s craving for cake had caused her years of suffering, yet when she finally ate it mindfully, she discovered that she didn’t even like it, says Smith, who is also a licensed mental health counselor in New York.

“There’s all this unnecessary suffering around food, weight and body,” Smith continues. At the same time, “there seems to be a lack of services available for everyday people who do not have eating disorders [but] who want to discuss and heal their relationship with food, body and weight.”

For this reason, Smith, a certified mind-body eating coach and a member of the American Counseling Association, created her private practice to help people who struggle in their relationship with food. She doesn’t have a precise phrase to explain this special niche she has carved out with her counseling practice, but she says it differs from nutritional counseling, which focuses on helping clients figure out what to eat. Instead, Smith attends to who clients are as “eaters.” This includes connecting their relationship with food to other life domains and psychosocial factors — such as anxiety, depression and trauma — that professional clinical counselors work with every day.

Researchers are not completely sure how food fits into the overall mental health equation, but recent studies suggest a strong connection. In general, food can promote wellness in three ways: 1) by providing the brain with nutrients it needs to grow and generate new connections, 2) by tamping down inflammation and 3) by promoting gut health.

In 2017, the world’s first study of dietary intervention for clinical depression, called the SMILES trial, found that a modified Mediterranean-style diet (which encourages whole grains, fruits, vegetables, legumes, low-fat/unsweetened dairy, raw unsalted nuts, lean red meat, chicken, fish, eggs and olive oil, while discouraging sweets, refined cereals, fried foods, fast foods and processed meat) resulted in a significant reduction in depression symptoms when compared with the typical modern diet loaded with fast food, processed foods and refined carbohydrates.

A randomized controlled trial published last year in PLOS ONE supports the findings of the SMILES trial. Researchers found that adults who followed a Mediterranean-style pattern of eating for three weeks reported lower levels of anxiety and stress and a significant decrease in their depression symptoms.

These and other findings suggest that counselors should no longer think of mental health in isolation but rather as part of a complex system that includes what people eat.

A missing piece of the mental health puzzle

Lisa Schmidt, a licensed associate counselor, certified whole foods dietitian nutritionist, and instructor in the School of Social Work at Arizona State University, points out that people seldom think about what they eat. “The act of eating is considered a nuisance. It’s something people don’t have time for until they’re just so hungry, they have to eat something, and when you get to that point, you often make very poor nutritional choices,” she says.

For instance, people may grab fast food and eat it in the car on the way to their next meeting or to pick up their kids. Then, when they have trouble sleeping later that evening, they assume it is related to their feelings of anxiety, thus overlooking any possible connection to food, Schmidt adds. 

“Most people don’t know that the kind of foods we choose [to eat] can help us regulate our nervous system and perhaps is the missing link in mental health care,” Schmidt notes.

Schmidt, an ACA member in private practice in Scottsdale, Arizona, says that mood-related disorders often have a food component to them because nutrition-poor diets affect mood. The standard American diet, often aptly referred to by its acronym SAD, frequently leads to people being hungry and tired and having dysregulated moods, she continues. People often alternate between periods of escalation, during which they fuel themselves with caffeine, processed sugar and refined carbs, and periods of starvation. This unhealthy pattern leads to dysregulated moods, Schmidt explains.

In addition, stress (which is common in fast-paced, disrupted lifestyles) dysregulates people’s nervous system responses. When people are stressed and in fight-or-flight mode, their bodies secrete glucose into the bloodstream, fueling them to run away from real or imagined danger. Then the pancreas secretes insulin as it tries to regulate blood sugar levels, Schmidt explains. These swings in blood sugar levels affect mood and can lead people to become “hangry” — hungry and angry, she adds.

Two researchers at the University of North Carolina at Chapel Hill recently set out to study the underlying mechanism behind the complicated “hangry” reaction, and their results challenge the theory that hanger is the result only of low blood sugar. They found that hunger-induced feelings can lead to tantrums and anger when people are in stressful situations and are unaware of their bodily state. In other words, hunger pangs might turn into other negative emotions in certain contexts.

This suggests that people should slow down and pay attention to both their physical and their emotional cues. Smith advises her clients to carefully set the scene before eating, telling them that eating should be stress free, relaxing and pleasant. To achieve this, they might consider using a candle or playing calming music. They shouldn’t be using their phones, watching television or walking around, she says. And although some families use dinner as a time to reprimand their children, there shouldn’t be any arguing while eating, Smith adds.

Because the quickest way to relax the body and mind is through breathing, Smith instructs clients to take as many deep breaths as they need to calm down before they begin eating. She also recommends that clients put their forks down between bites or use their nondominant hand to help them slow down and fully experience their food.

Mindful eating also involves approaching the meal with all of the senses, Smith says. She often illustrates this type of eating in session by having clients — especially those prone to eating quickly or eating distractedly as they work or stare at a screen — engage their senses while eating a Girl Scout Thin Mint cookie. During this activity, Smith asks clients to forget about their ingrained diet rules, negative self-talk, or whatever else might be in their heads and focus on their bodily experience of eating.

First, she has clients look at the cookie so the brain will register that food is present. Next, she has them touch the cookie and notice its texture. Then Smith asks them to smell the Thin Mint because scent affects our pleasure or displeasure with food. Once clients put the cookie in their mouths, they slowly roll it on all parts of their tongues without biting into it. When they finally bite the cookie, they listen to the sound it makes and notice how it tastes and when the taste starts to diminish. At the end of the exercise, Smith asks clients to rate their experience as pleasant, unpleasant or neutral. 

This simple exercise is an eye-opening experiment for most of Smith’s clients, who often admit they would normally just throw the cookie in their mouths and not think twice about it. When people learn to slow down and eat mindfully, they become better at noticing when they are full or if they are no longer tasting their food. Smith says one of her clients discovered through the exercise that she actually didn’t like Thin Mint cookies, even though she had eaten them all of her life.

It’s one thing to tell clients what mindful eating is; it’s another thing for them to experience and feel it for themselves, Smith says. “Mindful eating as a practice can be helpful at reawakening [our] appreciation for food,” notes Schmidt, author of Sustainable Living & Mindful Eating. “As we wake up to how we feel and what we experience, we have the possibility of change.”

The emotional toll of restrictive eating

“Every diet is some form of food restriction,” Smith asserts. “When you eliminate certain foods or when you deem certain foods bad or forbidden, you’re actually going to create the overeating through that sense of deprivation.” For example, the night before someone starts a no-carb diet, he or she might binge on bread as a “farewell” (often referred to as “Last Supper” eating). People on diets never reach habituation, so when they are exposed to restricted foods, they may overeat them, which only reinforces the idea that they can’t be trusted around a particular food, Smith adds.

Licensed clinical professional counselor Heather Shannon wrote a book chapter on nutritional stress management strategies for volume one of the book Stress in the Modern World: Understanding Science and Society. She says the all-or-nothing, judgmental thinking that is common with most diets often creeps over into character judgment: “I’m bad because I ate that carb” or “I feel horrible that I cheated on my diet by eating that cupcake,” for example.

Shannon, who offers coaching and teletherapy as a psychotherapist at Lotus Center in Chicago, had one client who was fit and healthy but fixated on losing three pounds. One morning, the client woke up feeling great, but the second she stepped on her scale and saw she had gained one pound, her mood changed. She went from feeling wonderful to feeling horrible in two seconds.

Fixating on an outcome, such as the number on the scale or the number of times a person has gone to the gym that week, is a big part of anxiety, Shannon says, and it opens up the possibility of good and bad labeling (e.g., “I’m bad because I went to the gym only once this week”). Instead, she helps clients focus more on their habits and which habits make them feel good, healthy and connected to their bodies. “If you’re treating your body really well, then whatever the results are is how your body is supposed to be,” she says.

Smith, a certified intuitive eating counselor, helps clients let go of the dieting mentality and reawaken their intuitive eater. In the intuitive eating model, there are no “good” and “bad” foods. Smith describes it as “a non-diet, flexible style of eating where you follow your internal sensations of hunger and satiety to gauge what, when and how much you eat.”

Smith points out that not every client will automatically be ready to put all foods back on the table. Under those circumstances, counselors can instead help raise awareness around dieting and how it may be interfering in clients’ lives. For instance, counselors might ask: How has your diet affected or changed your relationships with others? How much time and money have you spent on diets? How has it affected your social life and mental health? What in your life has changed because of dieting?

Schmidt also tries to help clients adjust their mindset around food. “Nourishment is not determined by one episode,” she says. “It’s an eating pattern over time.” For this reason, she advises clients to follow the 80-20 rule, in which 80% of the time people make choices that are whole foods (mostly plant-based), and then they don’t need to worry about the 20% of the time that they have a treat or indulge.

“We eat for reasons that are other than just to feed our bodies,” Schmidt says. “We eat as part of celebrations, and food is pleasurable. So, adopting a very restrictive, Spartan way of eating” — particularly one that demonizes any particular food group — “… can become disordered eating and cause problems for some people. … And research shows eating this way will fail 95% of the time.”

Instead of adopting the latest diet fad, people should find a way to eat that they can follow for the rest of their lives and that simultaneously supports their health and mood, Schmidt says.

Using foods to cope with moods 

If clients understand biological hunger and still reach for food without feeling hungry, then they are often engaging in emotional eating, Smith says. This may mean that a client eats because of unresolved trauma or grief. Maybe the client has perfectionist tendencies and uses food to manage his or her anxiety. Or perhaps food is the way a client copes with being in a marriage or job that makes them unhappy.

Smith works with clients to figure out what they are feeling — such as anxious or lonely, for example — when they experience emotional hunger. “This is where the mental health piece comes in,” she says. “You’re talking about eating, but the root cause of the eating is really psychological issues. … They’re people pleasing. They need boundaries. They need to be assertive. They need to say no to people and they can’t, so they use food to cope.”

Shannon, author of the ACA blog posts “Nutrition for Mental Health” and “How Does What You Eat Affect How You Feel?” finds the internal family systems approach effective for uncovering underlying issues associated with emotional eating, especially if clients have a playful side. She first helps clients identify the part of themselves that is overeating by asking what this eating part of them feels like in their bodies. One client might feel it in their stomach, whereas another client might sense it as a coach whispering in their ear.

Shannon also instructs clients to personify the part of them that is overeating by naming it (for example, the Snacking Part, Cake, or even a human name such as Maria). Then, both she and the client can easily address and reference this personified part.

Shannon might ask the part, “What is going on when you overeat?”

And the part almost always provides an answer. For example, “Well, I feel like I work too hard, and I need this because it’s my pressure release valve” or “I feel like I can’t count on people, so I’m counting on food.”

Smith and Shannon both caution against having clients keep a food journal that tracks food intake or weight. They say that activity takes clients out of themselves rather than tuning inward. In addition, they warn, it can promote obsessiveness. But they agree that clients can benefit from journaling about their emotions and feelings associated with food. For example, a client could write down what he or she feels right after overeating as a way of identifying what emotions are associated with the behavior. 

Schmidt has clients keep a food and mood journal, but not to track food intake or to promote weight loss. Instead, the goal is to help clients build an awareness of when they’re eating and how they feel before and after eating. This ultimately gives them a better understanding of how food affects their mood and how mood can affect their eating habits.

She provides an extreme but not unusual example: While journaling, a client noticed that they did not eat anything until 2 p.m. They felt terrible but only had 10 minutes to eat, so they ingested a protein bar and soda. Immediately afterward, they felt good, but an hour later, the client was starving, mad and stressed again.

“Most people … spend less than two minutes a day thinking about what they’re going to eat. They just react,” Schmidt says. “So, building awareness of all our habits, including our fueling habits, is really important.” 

In addition, if people are not fueling their bodies in a healthful way, it will create difficulties for them, Schmidt says. Chronic pain, substance abuse, anxiety and depression are all issues for which food is a huge component, she asserts. Schmidt had a client who would eat seven to nine bowls of Froot Loops for breakfast while in recovery from drug use. People recovering from substance use may often transfer their addiction to food, especially highly processed, sugary types of foods, she says.

Smith encourages her clients to approach their relationship to food with a compassionate curiosity. Clients can view nutritional changes as an experiment to figure out how their bodies react or what works best for them, she explains. Also, if clients haven’t fully mastered their new coping skills and continue to engage in emotional eating, then Smith advises them to be compassionate with themselves and say, “I’m reaching for food, and I know I’m not hungry. I look forward to the day when I can cope with my emotions without using food.”

Staying within scope

Smith has noticed that many counselors shy away from discussing any issue related to food with clients, reasoning that it falls outside their scope of practice and because becoming a certified eating disorder specialist or nutritionist requires specialized training. But she encourages counselors to rethink this mindset. “It’s not out of [counselors’] scope of practice to talk about people’s relationship with food. It’s such a critical part of everybody’s day. So, to not look at it is missing a big part,” Smith says.

“You don’t have to talk about the grams of protein per se, which is out of our scope … to really help somebody,” she continues. “Because [clients are] dying to talk about it, and they need that space. And it’s connected to so many other life domains [e.g., trauma, grief, anxiety, depression, stress] which counselors are more than equipped to talk about.” 

As a certified health coach, Shannon says she would never prescribe foods for clients or tell them what they should or shouldn’t eat, but that doesn’t prevent her from talking about food in session. In fact, on her intake form, she screens for potential issues with food by including general questions such as: What do you generally eat for breakfast, lunch and dinner? Do you snack or skip meals? Do you overeat or under eat? Then, in her first session with clients, she discusses this information and asks follow-up questions to gain a better understanding of clients’ relationship with food and the way this could be affecting their mental health.

“Even if you’re not a nutrition expert, we all know some basic stuff. We all know whole foods are better than processed foods. We all know excess sugar is not helpful,” Shannon says. For this reason, she recommends that counselors screen for basic nutritional information to see if food might be a piece of the client’s mental health puzzle. 

Rather than telling clients what to eat, Shannon takes a behavioral approach and asks, “What are you eating, and how is that working for you? What do you think might work better?” Sometimes, she will also provide clients with helpful resources and advise them to talk to their doctor or a nutritionist about other options they could pursue.

Schmidt finds that discussing alcohol use with clients can serve as a great segue into talking about their diet in general. In her experience, alcohol often comes up with clients who have mood disorders, and because alcohol is a nervous system depressant, it is not advised for these clients. While discussing their alcohol use, Schmidt will ask other questions about their diet, such as if they eat breakfast consistently or if they eat lots of processed, high-sugar foods. From there, she might suggest that clients try to limit the amount of food with added sugars that they eat and experiment with eating fresh fruit as a snack or dessert most days of the week. Schmidt will also use the Healthy Eating Plate (created by Harvard Health Publications and nutrition experts at the Harvard School of Public Health) as a way to help clients visualize how to build meals that support balanced moods.

Schmidt recommends that counselors interested in the food-mood connection experiment with their own eating habits to see how this affects their mood. “It is particularly difficult for a counselor who has a poor diet to talk about the food-mood connection with a client,” she says. Similar to how counselors practice meditation themselves before teaching it to clients, Schmidt believes counselors should first reorganize their own way of eating to include mostly foods derived from plants, to limit caffeine, and to limit or eliminate alcohol.

After counselors have experimented on their own with the food-mood connection, Schmidt says, then they can ask clients to do a chain analysis. For example, if a client is having panic attacks, the counselor might ask, “What do you remember doing just before the panic attack? Did you have anything to eat or drink? If so, what did you eat or drink?” Maybe the client will say that he or she remembers drinking coffee or alcohol before the panic attack happened. The counselor could follow up and ask whether the client noticed any change in how he or she felt after drinking three cups of coffee or drinking alcohol to excess before having a panic attack. This technique will help clients connect their dietary choices, which are ultimately under their control, to the way their mood is affected, Schmidt says.

Smith acknowledges that counselors’ scope of practice does limit just how far they can go in addressing food issues with clients. For instance, counselors cannot provide nutritional advice to clients. “That creates this barrier that is hard to get around,” she says. “So, then, you do have to reach out to other professionals like nutritionists and dietitians and really work as a team.” She says counselors can either work with a nutritionist to determine what nutritional treatments and approaches are best for the client, or work with clients to ensure they are advocating for their own dietary preferences (such as using plans that focus on well-being instead of weight loss) with the nutritionist or speaking up when they feel a certain nutritional approach is harming or not helping them.

But at what point should counselors refer to a nutritionist? Counselors have referred clients to Schmidt, in her role as a nutritionist, because they suspected their clients had an eating disorder or were binging on foods. Schmidt thinks it is a good idea to also refer to an eating specialist if clients talk about food or their bodies frequently in counseling, are extremely overweight or underweight and the condition is disruptive for them, or have suddenly lost a significant amount of weight.

When finding referral sources, Schmidt recommends that counselors look for professionals trained in the Health at Every Size approach, which promotes size acceptance and serves as an alternative to the weight-centered approach.

Smith agrees that “the focus always has to be on wellness, not weight loss.” She advises counselors against referring clients to dietitians, nutritionists or doctors who track calories, encourage weigh-ins, or engage in fat shaming. Instead, she suggests looking for health professionals who teach intuitive eating and operate from a weight-neutral model.

Adding in the nutritional piece

People routinely look for mental shortcuts or a magic bullet to solve their problems, and this tendency extends to food consumption. From research, we know that people will tend to eat 30% more of a food that they deem “healthy,” Schmidt notes. Researchers even have a name for this tendency to overestimate the overall healthfulness of an item based on a single claim such as being low calorie or low in fat: the health halo effect. This halo effect appears to encourage people to eat more than they otherwise would because they feel less guilty about consuming the food.

Clients often come to see Smith because they are confused and don’t know what to do. They have dieted for years with little or no success, and they are confounded by all the conflicting nutritional advice. For Smith, it comes down to a core question: “How does this [food] feel in your body?”

“You’re making peace with food,” she says. “This is your journey of one, and only you can know whether pizza feels good or depleting and when and under what circumstances.” Counseling can help clients tune in to their own unique nutritional needs and preferences and connect this piece to how their mood is affected, Smith says.

Schmidt advises counselors to focus on the big picture and not get caught up in one particular approach to eating. Instead, it is about helping clients make their own connections between what they are eating and how it affects their moods.

Also, because everyone is unique, the nutritional advice that has benefited a counselor personally may not help the counselor’s clients. However, the majority of clients (and all people) need to eat more fruits and vegetables, so if counselors encourage them to do that, it could have a huge impact on clients’ health and mood, Schmidt asserts.

“Having a personal connection to food and its life-giving properties is one of the most amazing gifts we can give ourselves, as well as elevating the status of food and eating for our clients,” Schmidt says. “Helping clients understand that the process of food and feeding is a central part of their recovery is a message that’s independent of what they should be eating.”

“Nutrition is always a piece of the puzzle,” Shannon adds. “So, by understanding the nutrition …
even a little bit, you’re going to be potentially twice as effective working with your clients.”

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

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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.