Tag Archives: Eating Disorders

Fast-food frenzy: Treating emotional eating

By Scott Gleeson April 11, 2023

A close-up of someone eating; two hands are grabbing food from a table with pastries, hamburgers, chips, and fries

Flotsam/Shutterstock.com

Emotional eating may be one of the most disguised forms of escapism clients turn to when dealing with stress or trauma. Carolyn Russo, a licensed mental health counselor (LMHC) in Seattle, says fast-food drive-thrus have become a type of coping mechanism for clients who are stressed or struggling emotionally. That’s in large part because the consumption of processed foods has become more and more normalized in U.S. culture since it was popularized in the 1950s. According to surveys published by the Centers for Disease Control and Prevention in 2018 and 2020, more than one-third of adults, children and adolescents consume fast food on a daily basis.

Emotional eating can also be a blind spot for professional counselors because it largely falls under the realm of nutrition, which is outside of a therapist’s purview. So a clinician’s instinct may be to pass off all or most eating-related emotions to a registered dietitian. However, Russo says that ethical tendency for therapists to stay in their own lane or look past a client’s eating habits can lead to a missed opportunity when assessing clinical care.

“We’re trained as clinicians to be looking at other coping mechanisms and different patterns like a client’s failed relationship after failed relationship, not a client’s relationship with food,” notes Russo, a member of the American Counseling Association. “Emotional eating can be a little sneakier and more hidden because all forms of eating are intertwined in our culture as acceptable. We eat food at social gatherings and it’s so accessible.”

Russo says she’ll always use an intake session with a client to gain a better understanding of what their relationship with food looks like. Even if emotional eating doesn’t present itself initially, she still regularly assesses clients’ relationship with food while building the therapeutic alliance with them.

“The reality of the situation is our culture revolves around food, so it may not be something clients are even able to be honest with themselves about at first,” Russo says. It’s common in American culture for people to say, “Are you happy? Let’s celebrate by going out to dinner” or “Are you sad? Have another candy bar.”

Because people’s emotions often influence their eating habits, a client’s relationship with food is not something counselors should ignore — even if their presenting concern is not related to an eating disorder, Russo continues. “For therapists, we have to identify the emotion that clients are eating or shoving down. Otherwise, we run the risk of having that coping mechanism stand in the way of processing that real emotion like sadness, loneliness, lack of acceptance [or] fear of vulnerability, these really deep and hard emotions. It can lead clients to stay [stagnant].”

The cycle of emotional eating

Natalia Buchanan, a licensed professional counselor (LPC) who runs a private practice called Emotional Eating Therapy in Austin, Texas, has been working with clients who struggle with disordered eating since 2007, and she specializes in emotional eating. She finds that clients who emotionally eat are often susceptible to a bad recipe: They don’t have the tools to cope with their feelings and their bodies naturally crave high-fat foods. That’s why drive-thrus become an offshoot form of therapy.

“Too often I see clients psychologically go into a feast-or-famine mode, where they starve themselves or don’t plan a meal, and then their body takes over at some point to where they’re not wanting an apple or a Caesar salad; their body is wanting lots of calories,” says Buchanan, an ACA member. “Then they’re in this cycle where they want it again because the receptors in their brains say, ‘Oh yeah, that felt good last time.’ But then every time we eat fast food, afterward it’s not a [lasting] rewarding feeling.”

Buchanan says she is still seeing the ripple effects of clients’ poor eating habits that are a byproduct of quarantine and isolation phases of the COVID-19 pandemic. “I think many are still feeling the fallout from” the pandemic, she says. “But the positive is that we’re becoming more aware of how prevalent it [emotional eating] is.”

Brad Novak, an LMHC in Munster, Indiana, approaches emotional eating through a lens of deep empathy because he found himself using fast food to help him cope with his pain after his divorce six years ago.

“I was emotionally eating and wasn’t fully aware,” Novak recalls. “I’d go through the drive-thru and come home and eat dinner still. I was definitely in a place where I was leveraging comfort foods to feel good when I was coming home to an empty house or to my ex-wife when things weren’t good between us. I was afraid of ending my marriage for years and McDonald’s french fries became my way of coping several times a week.”

Now, as a clinician who specializes in eating disorders and emotional eating, Novak says targeting the behavior is the first step, but fully identifying emotional eating can still be difficult because guilt and shame can often mask a client’s potential accountability.

“For me, I didn’t even know I was doing it, so I realize how difficult it can be for clients to see that they’re turning to it,” Novak says. “The first step for me was acknowledging the behavior and coming to terms with [the fact that I was] using emotional eating as a maladaptive coping mechanism.”

“Before and during eating fast food, the feeling can be euphoric or numbing but then afterward there’s a lot of guilt and shame. The original emotion gets multiplied and you’ll feel worse,” he continues. “Then, that level of shame is in secret because eating is a part of life and something we’d need to do anyway.”

Russo, the clinical training director and core faculty at the Family Institute at Northwestern University, acknowledges that once the behavior is targeted and accounted for, the shame cycle can be challenging to offset and the emotions underneath can be difficult to untangle because of the all-or-nothing thinking. In other words, a client can get stuck being aware of the behavior but unable to stop because they feel as if they’ve already failed at a certain dietary goal.

“It’s hard to get out of that [cycle]: You’re ashamed of eating; then you eat more because you’re ashamed,” Russo explains.

Russo advises clinicians to build clients toward acceptance while simultaneously supporting their goals. “That’s where the acceptance piece comes in. Knowing it’s OK to not be perfect,” she says. “It’s more about understanding the primary emotions. If shame is consuming you, we can’t target those original emotions.”

Deborah Haugh, a licensed clinical professional counselor (LCPC) in Chicago, says helping clients accept themselves in the here and now can be integral for growth. Otherwise they’ll get tripped up in associating their self-worth with attaining a goal. “Turning to food for comfort sometimes leads to a loss of control over one’s impulses and feelings of shame,” she explains. “Our society can be obsessed with control, self-improvement [and] status, and folks who are overweight are often criticized, shamed or ignored by others to [where] that message becomes internalized.”

Haugh finds that psychoeducation on both emotional eating, which she notes is an “unhealthy coping mechanism for dealing with difficult feelings,” and shame can be a meaningful intervention.

“Life can be full of struggles, losses and sometimes trauma,” Haugh says. “What’s important is how we cope and understand and move through those struggles.”

The counselor’s role

Eunice Melakayil, an LPC and the clinical director at Serenity Found Therapy in Oklahoma City, stresses the importance of clinicians collaborating with nutritional professionals to ensure the client receives adequate care in recovering from emotional eating. At the onset, she informs clients about the limitations of counseling in treating nutrition. “I define my role as a guide in providing tools for living a mindful lifestyle, especially with being intentional in what we eat and do,” Melakayil says. “This also includes providing guidance in seeking mindful ways to take care of our bodies, including seeking medical services as needed.”

Melakayil helps host and run nutrition-focused therapy groups that provide treatment for emotional eating. “We believe doing a group eating program would bring the most benefit since members will have other members to walk the journey with,” she says.

Melakayil often refers clients who need nutritional advice to training courses provided by the Am I Hungry? mindfulness eating program, which was founded by a registered dietitian. She says separating the mental health and nutritional training roles is not only ethical but also vital from a collaboration standpoint to ensure clients receive proper treatment.

Buchanan says she often sees mental health professionals struggling to decipher when to turn to a nutritional expert and refer out. “It’s important for a therapist to not offer advice where they’re not trained and to see [if] something may be out of their depth,” she stresses. “A clinician with a diet mentality and no understanding can make it worse for a client. That’s why collaboration [with dietitians] can be so important.”

The connection to childhood

Jamie Mykins, an LPC in Orlando, Florida, knows the struggle of emotional eating on a personal level. She lives with pulmonary arterial hypertension, a life-threatening illness. Several decades ago, she lost 50 pounds by making more nutritious eating choices, and she now uses her own personal growth as a way to build alliances with clients. She says her own journey with emotional eating allows her to be more empathetic when working with clients who battle poor relationships with food.

“If it’s between Sour Patch Kids and strawberries, I want the sugar dopamine effect. Emotionally, Sour Patch Kids feel like a treat, whereas strawberries in comparison can feel too healthy,” says Mykins, noting that she will share a similar sentiment in session to build rapport with clients. “It’s tricky because food is also a part of self-care for clients. So it’s important to learn how to love food in a way that feeds you physically, not just emotionally.”

Mykins often sees a direct correlation between clients’ childhoods and their unhealthy relationships with food. “If we suffered trauma as children as so many do, eating is one of the first coping mechanisms we develop,” she says. “You can’t really turn to drugs or alcohol when you’re 6 or 7 years old. So when we’re looking at emotional eating in clients, we have to recognize that chemical dependency came super early on.”

“Clients can be programmed to believe food is a reward and we can be programmed that way too,” Mykins adds. For example, she was rewarded by her mom with ice cream if she did well on her report card when she was a child.

Russo finds that viewing emotional eating through a psychodynamic perspective can help clients work through feelings of shame and lack of control because they can see the patterns in their family or upbringing that have led to them using food as a coping mechanism. “Often I’ll have clients who had caregivers who didn’t validate their emotions and they experienced a lot of neglect,” she says. “That childhood emotional neglect leaves a permanent scar on a person and then as an adult, there are active ways to fill that void. That’s why, as therapists, helping clients to be the emotional coach they didn’t have is important.”

Haugh agrees that a client’s childhood is a good area for clinicians to explore because it can outline the genesis of when food became a source of comfort or perhaps of deprival that now plays out in adulthood. “Our relationship with food is developed in childhood,” she explains. “Food may have been used to treat or reward for doing something [of value] or as a way to soothe hard feelings. It is also common for food to be a central element in celebrations like birthdays and holidays, which for some was a time when kids could get more attention and freedom.”

“And for some children, scarcity of food was associated with basic hunger, fear and anger over unmet needs,” she adds. This leads to some clients overindulging as adults to mitigate long-held feelings of fear and anxiety around lack of food growing up.

Caitlin Ziegler, an LPC in the Milwaukee area, specializes in working with clients struggling with eating disorders and disordered eating. She says identifying wounds from a client’s upbringing can help to pinpoint what’s missing and that incorporating what’s missing into treatment can provide motivation for clients to let go of the behavior.

“Emotional eating is about filling some type of void; there’s something missing for the client and eating gives them something more than getting full,” Ziegler notes. “For a majority of clients, that void started in childhood as a form of comfort they couldn’t get somewhere else. Outlining ways to heal the void is where [therapists can be] most effective.”

Effective treatment approaches

John Deku, an LCPC at Centennial Counseling Centers in St. Charles, Illinois, says exploring a client’s past can be helpful, but too much focus in that area can delay addressing the behavior head-on. Instead, he often relies on motivational interviewing, behavioral modification and acceptance and commitment strategies for treating emotional eating.

“I find addressing what is underneath the emotional eating to be a double-edged sword,” Deku says. “Clients may want to explore their past for weeks, months or even years to find what caused the emotional eating. Most of the time, clients feel some satisfaction but end up asking, ‘So what do I do about it?’” He likes to address this question as soon as the client is ready to think pragmatically about it and is willing to change their emotional eating habits.

“I think clients can get hung up on trying to make the change feel ‘right,’ rather than letting go of what hasn’t worked and finding the bravery to try new things,” Deku adds.

Novak caters the treatment approach to the individual client because everyone has their different journey toward effective change. He says he leans heavily on mindfulness approaches looped in with dialectical behavior therapy, cognitive diffusion to outline if a client’s behaviors don’t align with their values, and the interpersonal effectiveness of acceptance and commitment therapy to help clients “gain some distance from their thoughts.”

“Emotional eating can be impulsive in nature, so one thing I’ve tried with clients is giving them the tools to break from the impulse,” Novak continues. “If a client has [a] desire to eat fast food on [their] drive home out of convenience, I’ll suggest putting their wallet in the trunk. Just that extra step of pulling over and getting your wallet out helps offset that impulse.”

Novak has also put a lot of consideration into the terminology he uses with clients, and he says that he is “on the fence” about labeling emotional eating of fast food as an addiction. “I’m mindful of not introducing addiction words with clients because there isn’t enough research on it in my opinion,” he says. “But the behavior is nearly identical to addictive behavior.”

Neither is Buchanan prone to using the term “fast-food addiction” because that sounds more condemning and less like an accepting, balanced approach. “I struggle with the idea of calling it fast-food addiction,” he says. “The only other addiction you can equate it to is sex because people need to have sex, but even then it’s different than eating. If I’m [a person with alcoholism], I don’t need to have a drink to survive like I do with food. So to me it’s more about the relationship with food. If it is addictive, what makes you sober? We have to be careful not to villainize foods because that can work against improved behavior.”

It’s also important to identify that emotional eating is situated between regular eating habits and eating disorders, Buchanan notes, because that distinction outlines severity, need for collaboration and what roles clinicians can play. And if a client doesn’t have a diagnosable eating disorder, then their emotional eating may go unrecognized or be disguised, he adds.

“I cannot tell you how many people have been in therapy for five years and will say they binge Wendy’s or Sonic in the parking lot,” Buchanan notes. “They’re ashamed of it. That’s why psychoeducating can be so important because then clients will have an understanding of their behavior and come to terms with it when they’re emotionally ready.”

Deku often makes it a priority to differentiate between a diagnosable eating disorder and emotional eating to inform his treatment and collaboration approaches. “I don’t find professional collaboration as necessary with emotional eaters as I do with [clients with] eating disorders,” he says. “Eating disorders can be dangerous and historically, they’ve had some of the highest rates of mortality compared to other disorders. … I find that emotional eaters tend to know what is healthy or unhealthy but they struggle to change habits. They may feel they’re stuck in their routines and not know how to cope without food.”

Melakayil says she’s found the Am I Hungry? mindfulness eating program to be a universal resource for clients who struggle in their relationships with food. It also helps to create a clear separation between therapists’ and nutritional experts’ roles in treating emotional eating.

“The program helps in deepening one’s understanding of root problems or identifying their true need — connection, conflict resolutions, breaking habits, working through traumas, restoring or resolving relationship issues,” she says. “Meeting one’s true needs helps reduce emotional eating and promotes intentional or mindful eating over time.”

Mykins stresses the value of defining healthy eating and self-care based on what feels true to clients, not based on external influences. She says, as much as any treatment plan, therapists can play a clear role by helping clients release the notion of being perfect.

“As clinicians, we need to be able to say, ‘we’re human,’ and so are our clients,” Mykins says. “Finding that line where we know we’re going to make mistakes but also push ourselves to be the best version of ourselves is what I strive for with myself — and with my clients.”


Scott Gleeson is a licensed clinical professional counselor in the Chicago suburbs, specializing in trauma and relational dynamics. He spent over a decade writing for USA Today, where he won national writing awards from the Associated Press and NLGJA: The Association of LGBTQ Journalists. His debut contemporary novel, The Walls of Color, and its sequel, Spectrum, will hit bookshelves in 2024 and 2025, respectively.


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.

‘But my clients don’t get eating disorders’

By Laura H. Choate January 11, 2021

Almost all counselors encounter clients who engage in behaviors such as extreme dieting, excessive exercising, fasting, emotional overeating and binge eating. These symptoms can be initially mild and overlooked or even viewed as normative in our thinness-and-appearance-obsessed culture. Sometimes it is hard to tell the difference between a client who is experimenting with the latest fad diet and a client who is quickly spiraling downward on the path toward a destructive eating disorder. There are two reasons this can happen.

One reason is a lack of counselor awareness. Few counselors receive much training in the area of eating disorders treatment, so they might not be aware of the need for further assessment when a client has initial problems related to eating, weight and body image. The problem is that without effective assessment and treatment, these types of symptoms have the potential to escalate into full-syndrome eating disorders such as anorexia nervosa, bulimia nervosa and binge eating disorder.

Once eating disorders have developed, they frequently become serious, complex, chronic disorders with significant biopsychosocial consequences, including potentially lethal medical complications, poor treatment outcomes, high rates of remission and high mortality rates. Anorexia nervosa in particular is associated with the highest mortality rate of all psychiatric disorders, and both anorexia nervosa and bulimia nervosa are associated with suicide attempt rates that are considerably higher than those for the general population. Suffice it to say, even the most highly trained, seasoned counselor is not equipped to work with this population alone; all clinical guidelines call for a team approach to the treatment of eating disorders. Therefore, regardless of whether we are specialists, we need to establish relationships with other providers in our communities and know when to make referrals for specialized services.

The second reason that initial symptoms might be overlooked or dismissed is that we are not just counselors, we are also individuals who live in a society in which we are all bombarded daily with messages about weight and appearance. We are all exposed to cultural ideals that equate thinness with beauty, happiness and success and that dictate strict standards regarding an ideal body shape. We all have to manage these pressures for ourselves, and few of us are exempt from developing biases and blind spots around these issues. Because of countertransference reactions in this emotionally charged area, we might unintentionally misjudge a client’s pain due to our own struggles and experiences. Therefore, when working with clients who present with issues such as body image, chronic dieting and pressures to be thin, it is extremely difficult to separate our own personal values from what is best for our clients.

So, even though you might never intend to work as an eating disorders specialist, all counselors need adequate preparation to recognize disordered eating symptoms in their clients, to know when and how to provide appropriate referrals, to understand the importance of a multidisciplinary approach to treatment, and to effectively manage personal values. To illustrate, I include three scenarios that highlight some of the complex concerns that can arise for counselors when working with clients who have problems related to eating, weight and body image.

Scenario 1: April’s intermittent fasting goals

April attends an initial session with Karyn, a licensed professional counselor with three years of experience. April reports that she has been on an extreme intermittent fasting diet for the past six months, allowing herself to eat only during a two-hour window per day. She adheres to a vegan diet because she believes it is the healthiest option for keeping a low weight. She also engages in binge/purge episodes three or four times per month (during which she does not adhere to a vegan diet but eats anything she wants). Her body mass index (BMI) is in the low to normal range.

Although April is reporting occasional dizziness, she does not want to give up her diet because she still has not reached her weight loss goal. Instead, she wants to get rid of her binge/purge behaviors, improve her body image and improve her self-esteem. She wants to work exclusively with Karyn even though Karyn does not have a specialized background in treating issues related to weight or binge eating.

Karyn believes April’s goals seem reasonable for individual treatment because she does not appear to be underweight. In addition, because April’s symptoms do not meet criteria for a diagnosis of anorexia nervosa or bulimia nervosa, Karyn does not consider April’s problems to be severe. In fact, Karyn knows a bit about intermittent fasting and its current popularity, so she believes that she can help April evaluate her diet plan.

Implications for counseling practice:

The ACA Code of Ethics states that counselors must know their scope of competence and practice within their areas of training and experience. Karyn is taking a risk in her agreement to treat April because without additional medical assessment, she has no way of knowing the extent of April’s disordered eating behaviors or how her symptoms are affecting her physiologically. It is likely that April is experiencing medical complications even though she does not appear to be underweight.

American Psychiatric Association practice guidelines state that in treating eating disorders, we should always work as part of a treatment team that includes at minimum a therapist, a dietitian and a medical professional. By agreeing to work in isolation and ignoring the need for collaboration, Karyn would not be able to adequately address the medical components of April’s weight loss — and without a medical referral, she would be working outside of her scope of competence, which could cause potential harm to April. In addition, she seems to ignore the fact that April’s behaviors could possibly be progressing to a severe eating disorder.

One way to address these potential problems is for Karyn to inform April that in order to begin treatment, she will need to agree to see a medical professional for evaluation. Based on these results, Karyn might also need to work with a nutritionist, in addition to possibly making a referral to a mental health professional who has more expertise in treating emerging
eating disorders.

Scenario 2: Nila’s secret and Asha’s dilemma

Nila is a 15-year-old who is in counseling at her mother’s insistence. Nila tells her counselor, Asha (a child and adolescent counselor in a general private practice), that her mother is too intrusive in her life, is always telling her that she should lose weight, and tries to control all of Nila’s food intake.

A few weeks into therapy, Asha notices that Nila has swelling in her neck area and has a large scrape on the fingers of one hand. When asked about this, Nila reveals that she has been trying to diet according to her mother’s demands but “just can’t stick to it.” Subsequently, she has engaged in binge eating by sneaking food from the pantry and eating it quickly so her mother will not know. She hides the wrappers in her book bag and throws them away later. Nila then uses self-induced vomiting, a technique she learned from watching YouTube videos, to try to “get rid of the calories.” She begs Asha not to tell her mother because she does not want her mother to become even more controlling of her food intake.

Asha isn’t sure of the next best step to take because Nila is in a normal weight range and seems to be healthy overall. Asha decides not to inform Nila’s parents and keeps working with Nila individually because she wants to respect Nila’s privacy.

Implications for counseling practice:

In resolving the issue of whether Nila’s parents need to know about her binge/purge behaviors, Asha has to balance the parents’ legal right to know what is disclosed in sessions, Nila’s ethical right to privacy and autonomy, and the counselor’s duty to provide effective treatment and protect Nila from future harm. In making this decision, Asha recognizes that Nila does have an ethical right to privacy and could possibly be harmed if her mother becomes even more controlling over her food intake.

However, Asha should also be very concerned about Nila’s emerging diet/binge/purge cycle because this is a potentially high-risk behavior. While the binge/purge behaviors are not currently life-threatening, Asha needs to consider the serious and potentially lethal nature of eating disorders, the chronic and compulsive nature of the diet/binge/purge cycle, and the medical and psychological consequences of any emerging eating disorder. Because Nila is an adolescent, her health could deteriorate quickly due to weight loss and purging behaviors.

American Academy of Child and Adolescent Psychiatry practice guidelines call for a comprehensive medical examination, working with a treatment team, and family involvement in the treatment of eating disorders. For any of these treatment aspects to occur, the parents would need to be informed of Nila’s disordered eating behaviors; Nila can’t arrange for them herself. In this case, therefore, Nila’s parents would need to be informed, even if this goes against Nila’s wishes.

In order to respect Nila’s right to privacy and minimal disclosure, however, Nila should be involved as much as possible when her parents are informed. If feasible, the information should be shared in a family session. If Nila can be in the session when information is disclosed, she is less likely to feel betrayed by Asha. If Asha can establish an alliance with the parents while also maintaining trust with Nila, Asha can start to work with the family system to create better communication. The parents need assistance in allowing for increased, developmentally appropriate autonomy and privacy for Nila. At the same time, Nila will have to accept her parents’ assistance in helping her manage her disordered eating symptoms.

The entire family would benefit from education about the harms of dieting, particularly for children and adolescents, and how food restriction is directly linked to binge eating and
is often the trigger for binge/purge cycles. With Asha’s help, the family can start to focus more on overall health and communication and far less on control over Nila’s eating, weight and body shape.

Scenario 3: Jamie’s diet advice

Jamie is a female counselor who works for a community counseling agency. Jamie’s client Dan reports frequent binge eating that causes him a great deal of distress, guilt and shame. Dan is a 45-year-old man who is in a higher-weight body. Jamie assumes that Dan needs to eat less and lose weight to feel better about himself because of his larger body size. She does not assess for an eating disorder but rather persuades him to pursue weight loss as his treatment goal.

In contrast with what she deems as Dan’s “weaknesses,” Jamie is highly invested in maintaining her own weight, daily exercise routine and “clean eating.” She feels a certain pride in her own self-discipline and thinks that Dan’s problems result from a lack of willpower and effort on his part. She is quite uncomfortable with Dan’s body size and tells him he would be better off in his career and relationships if he were to lose weight.

Dan reluctantly agrees to restrict his calories and to exercise more, even though he has tried “hundreds of diets” over the years. As time progresses, he feels discouraged and even worse than he did prior to treatment with Jamie because he can neither adhere to the weight loss plan nor stop his binge eating. He drops out of treatment, believing he is a failure.

Implications for counseling practice:

Even though binge eating disorder is by far the most common eating disorder (occurring in 3.5% of women and 2% of men), it was overlooked by Jamie in this example because her client is male and has a larger body size. In addition to neglecting assessment for binge eating disorder, Jamie seems to lack awareness of effective treatment for binge eating.

American Psychiatric Association practice guidelines for the treatment of binge eating disorder state that dietary restriction is actually contraindicated; in fact, dieting is known to trigger and sustain binge eating. There are biological and psychological reasons for this relationship. When Dan (or anyone on a diet) restricts food, he begins to deprive himself of the energy needed to maintain his current weight. As a result, the brain sends out warning signals telling his body to slow down because it thinks it is entering a time of famine. It also tells Dan to take in more fuel to prevent what it perceives as starvation. In an effort to preserve energy and fight against weight loss, his body’s metabolism will decrease, he will have more thoughts about food, and he will become increasingly hungry.

Second, the more Dan imposes restriction and deprivation on his life, the more he will experience psychological reactance — an internal battle that ensues anytime we perceive that our personal freedoms are being restricted. He will start to think about, crave and, eventually, overeat the very foods that he has ruled “off-limits.” He will likely eat more, not less, because of dietary rules. And for Dan, who has a long history of binge eating, his hunger, deprivation and dietary rules will most likely serve as triggers for continued binge eating. This will lead to a cycle of guilt/shame, dieting, broken rules, binges and more guilt/shame.

In addition to pushing a potentially harmful treatment plan, Jamie seems to be having difficulty managing her countertransference reactions. Like so many people in today’s culture (including many mental health and medical professionals), Jamie appears to have a bias against people in larger bodies. Because she believes that losing weight is the “answer” to Dan’s problems, she imposes this value on him even though he is seeking treatment not for weight loss but for reducing his symptoms of binge eating. Jamie’s discomfort with her client’s body is a form of weight-based discrimination that can cause Dan to feel judged and further marginalized.

Research indicates that weight stigma actually demotivates, rather than encourages, health behavior change. In response to weight stigma, people tend to eat an increased amount of food and are less likely to adhere to a diet plan. To avoid further stigmatization, they tend to avoid exercise, fearing additional judgment from others. They also tend to delay medical care to avoid stigmatization from medical professionals who may further criticize, blame or shame them for their weight. Jamie’s personal values in this case are causing her to display a lack of respect for Dan’s dignity and welfare. In sum, her biases and lack of knowledge of effective treatment for binge eating disorder are actually causing her client harm.

Key takeaways

The following list is a summary of considerations for counselors when they encounter clients who experience problems with eating, weight and body image:

  • Remember that anyone can develop an eating disorder. Do not assume that only underweight white women have eating disorders. For example, binge eating disorder is the most common eating disorder, and it occurs in people of all sizes and cuts across both gender and race/ethnicity.
  • During the intake process, ask questions about the client’s attitudes and behaviors toward eating, weight and body image. Remain aware that initial symptoms can potentially progress to full-syndrome, complex eating disorders.
  • Regardless of your treatment setting, be aware of resources, and be prepared to make proper referrals so that clients can receive specialized care when needed.
  • Effective eating disorders treatment involves a multidisciplinary approach.
  • Counselors, like all people, can have strong biases in the areas of eating, weight, body image and the importance of appearance. We have to be careful about imposing these values on our clients.
  • Weight stigma is a form of discrimination that serves to marginalize and shame people. It is not a value supported by the counseling profession.

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Recommended resources:

  • “Ethical Issues in the Treatment of Eating Disorders” by Laura H. Choate (in The Cambridge Handbook of Applied Psychological Ethics, edited by Mark M. Leach and Elizabeth Reynolds Welfel, Cambridge University Press, 2018)
  • “Assessment and diagnosis of eating disorders” by Kelly C. Berg and Carol B. Peterson (in Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment, edited by Laura H. Choate, American Counseling Association, 2013)
  • American Psychiatric Association practice guideline for the treatment of patients with eating disorders (2010): tinyurl.com/APAEatingDisorders
  • “Practice parameter for the assessment and treatment of children and adolescents with eating disorders” by James Lock, Maria C. La Via and the American Academy of Child and Adolescent Psychiatry Committee on Quality Issues, Journal of the American Academy of Child and Adolescent Psychiatry, 2015
  • National Eating Disorders Association: nationaleatingdisorders.org
  • Academy of Eating Disorders: aedweb.org/home

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Laura H. Choate is the Jo Ellen Levy Yates endowed professor of counselor education at Louisiana State University in Baton Rouge. She is the author of five books, the most recent of which is Depression in Girls and Women Across the Lifespan: Treatment Essentials for Mental Health (2020). She has 40 publications in journals and books, most of which have been related to girls’ and women’s mental health. She is a member of the ACA Ethics Committee. Contact her at lchoate@lsu.edu.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

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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.

Digesting the connection between food and mood

By Lindsey Phillips December 31, 2019

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.

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.”

 

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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

 

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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.

 

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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

 

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

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.

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.

Conclusion

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.

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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