Almost all counselors encounter clients who engage in behaviors such as extreme dieting, excessive exercise, fasting, emotional overeating and binge eating. These symptoms can be mild and overlooked at first, or even considered normative in our culture obsessed with thinness and appearance. Sometimes it is difficult to tell the difference between a client experimenting with the latest fashion diet and a client who quickly writhes down the path to a destructive eating disorder. There are two reasons this can happen.
One reason is a lack of awareness among the advisors. Few counselors receive extensive training in the management of eating disorders so they may not be aware of the need for further assessment if a client has initial problems with food, weight, and body image. The problem is that without effective assessment and treatment, these types of symptoms can lead to full syndrome eating disorders such as anorexia nervosa, bulimia nervosa, and binge eating disorder.
Once eating disorders have developed, they often turn into serious, complex, chronic disorders with significant biopsychosocial consequences, including potentially fatal medical complications, poor treatment outcomes, high remission rates and high mortality rates. Anorexia nervosa, in particular, is associated with the highest mortality rate of any psychiatric illness, and both anorexia nervosa and bulimia nervosa are associated with suicide attempt rates that are significantly higher than those of the general population. Suffice it to say that even the most highly trained, experienced counselor will not be able to work with this population on his own. All clinical guidelines call for a team approach to managing eating disorders. Therefore, whether or not we are specialists, we need to build relationships with other providers in our communities and know when to make recommendations for specialized services.
The second reason why initial symptoms might be overlooked or dismissed is that we are not just counselors, but also individuals who live in a society where we are all bombarded with messages about weight and appearance on a daily basis. We are all exposed to cultural ideals that equate thinness with beauty, happiness and success and that impose strict standards for an ideal body shape. We all have to cope with these pressures for ourselves, and few of us are exempt from developing prejudice and blind spots about these issues. Because of countertransference reactions in this emotionally charged area, we can inadvertently misjudge a client's pain from our own struggles and experiences. Therefore, when working with clients who have issues like body image, chronic diets, and the pressures to be thin, it is extremely difficult to separate our personal values from those that are best for our clients.
Even if you may never intend to work as an eating disorder specialist, all counselors need adequate preparation in order to recognize disordered eating symptoms in their clients, to know when and how to give appropriate recommendations to the importance of being multidisciplinary Systems to understand approach to the treatment and effective management of personal values. To illustrate this, I'll add three scenarios that highlight some of the complex concerns that counselors may face when working with clients who have problems with food, weight, and body image.
Scenario 1: The intermittent fasting goals in April
April attends an initial meeting with Karyn, a licensed professional advisor with three years of experience. April reports that for the past six months she has been on an extremely intermittent fasting diet and allowed 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 light weight. She also participates in binge / purge episodes three or four times a month (in which she does not go vegan, but eat anything she wants). Your body mass index (BMI) is in the low to normal range.
Although April reports 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 behavior, improve her body image, and improve her self-esteem. She wants to work exclusively with Karyn, although Karyn does not have a special background in dealing with problems related to weight or binge eating.
Karyn believes April's goals seem reasonable for individual treatment as she does not appear to be underweight. Because the symptoms in April did not meet the criteria for diagnosing anorexia nervosa or bulimia nervosa, Karyn did not consider the problems severe in April. In fact, Karyn knows a little about intermittent fasting and its current popularity, so she believes she can help April evaluate her eating plan.
Implications for counseling practice:
The ACA Code of Ethics states that consultants must know the scope of their competence and practice in their areas of training and experience. Karyn is taking a risk in her April treatment agreement because without an additional medical examination she cannot know to what extent her eating behavior is disturbed in April or how her symptoms will affect her physiologically. Medical complications are likely to arise in April, although she does not appear to be underweight.
American Psychiatric Association guidelines state that when treating eating disorders, we should always work as part of a treatment team that includes at least a therapist, nutritionist, and health professional. If Karyn agrees to work in isolation and ignore the need to collaborate, she would not be able to adequately address the medical components of weight loss in April – and without a medical referral, she would be working outside of her scope of competence, causing potential could damage by April. Plus, she seems to be ignoring the fact that the April behavior could potentially lead to a serious eating disorder.
One way to address these potential problems is to have Karyn inform April that she must agree to see a doctor for assessment in order to begin treatment. Based on these results, Karyn may also need to work with a nutritionist and possibly refer to a psychologist who has more expertise in the treatment of emerging
eating disorders.
Scenario 2: Nila's secret and Asha's dilemma
Nila is a 15-year-old who advises 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 pushy in her life, always tells her to lose weight, and tries to control all of Nila's food intake.
A few weeks after starting therapy, Asha notices that Nila has a swelling in the neck area and a large scratch on the fingers of one hand. When asked, Nila reveals that she tried to diet according to her mother's requirements but "just can't stick to it". She then dealt with binge eating by sneaking food out of the pantry and eating it quickly so her mother wouldn't know. She hides the envelopes in her book bag and throws them away later. Nila then uses self-induced vomiting, a technique she learned while watching YouTube videos, to try to "get rid of the calories." She asks Asha not to tell her mother because she doesn't want her mother to control her food intake any more.
Asha is not sure which step to take as Nila is in a normal weight range and appears to be healthy overall. Asha decides not to inform Nila's parents and continues to work with Nila individually because she wants to respect Nila's privacy.
Implications for counseling practice:
In resolving the question of whether Nila's parents need to know about their binge / purge behavior, Asha must respect the parents' legal right to know what is disclosed in meetings, Nila's ethical right to privacy and autonomy, and duty the counselor's line to ensure effective treatment and protect Nila from future harm. In making this decision, Asha recognizes that Nila has an ethical right to privacy and could potentially be harmed if her mother controls her food intake even more.
However, Asha should also be very concerned about Nila's diet / binge / purge cycle emerging as it is a potentially risky behavior. While binge / purge behavior is not currently life threatening, Asha needs to consider the serious and potentially fatal nature of eating disorders, the chronic and compulsive nature of the diet / binge / purge cycle, and the medical and psychological consequences of an eating disorder occurring. Since Nila is a teenager, her health could quickly deteriorate due to weight loss and cleaning behavior.
American Academy of Child and Adolescent Psychiatry guidelines require extensive medical evaluation, collaboration with a treatment team, and family involvement in the management of eating disorders. In order for one of these treatment aspects to occur, the parents would have to be informed about Nila's disordered eating behavior. Nila cannot take care of her herself. In this case, Nila's parents would have to be informed, even if this goes against Nila's wishes.
However, in order to respect Nila's right to privacy and minimal disclosure, Nila should be included as much as possible when informing her parents. If possible, the information should be shared in a family meeting. If Nila can attend the meeting when information is released, she is less likely to feel betrayed by Asha. If Asha can form an alliance with the parents while maintaining trust in Nila, Asha can begin to work with the family system to create better communication. The parents need support to give Nila greater, developmentally appropriate autonomy and privacy. At the same time, Nila must accept her parents' support to help her manage her eating disorders.
The entire family would benefit from education about the harms of diet, especially for children and adolescents, and how food restrictions are directly related to binge eating and
is often the trigger for binge eating / cleansing cycles. With Asha's help, the family can focus more on overall health and communication, and far less on control over Nila's food, weight, and body shape.
Scenario 3: Jamie's nutritional recommendation
Jamie is a counselor who works for a community counseling agency. Jamie's client Dan reports frequent binge eating that causes him a lot of suffering, guilt and shame. Dan is a 45 year old male who is in a heavier body. Jamie believes that Dan needs to eat less and lose weight to feel better because of his height. Instead of evaluating an eating disorder, she persuades him to pursue weight loss as his treatment goal.
Contrary to what she sees as Dan's "weaknesses", Jamie is heavily invested in weight maintenance, her daily exercise routine and "clean eating". She takes pride in her own self-discipline, and believes Dan's problems stem from a lack of willpower and effort on his part. She feels quite uncomfortable with Dan's height and tells him that if he lost weight, he would be better off in his career and in his relationships.
Dan reluctantly agrees to cut calories and exercise more, despite trying "hundreds of diets" over the years. Over time, he feels discouraged, and worse than before, because he cannot stick to the weight loss plan or stop his binge eating. He stops treatment believing he's a failure.
Implications for counseling practice:
Although binge eating disorder is by far the most common eating disorder (it occurs in 3.5% of women and 2% of men), it was overlooked in this example by Jamie because her client is male and a larger one Body size. Not only does Jamie neglect the assessment of an eating disorder, but he also appears to have no awareness of effective binge eating disorders.
American Psychiatric Association guidelines for the treatment of eating disorders state that dietary restriction is indeed contraindicated; Indeed, diets are known to induce and maintain binge eating. There are biological and psychological reasons for this relationship. When Dan (or someone on a diet) restricts food, he begins to deprive himself of the energy required to maintain his current weight. As a result, the brain sends out warning signals telling its body to slow down because it believes it is entering a time of famine. It also tells Dan to consume more fuel to prevent what he perceives as starvation. To conserve energy and fight weight loss, his body's metabolism will decrease, it will think more about food, and it will become increasingly hungry.
Second, the more Dan imposes restrictions and hardships on his life, the more he will experience psychological reactance – an internal struggle that always takes place when we find that our personal freedoms are being restricted. He will begin to think about, crave and eventually overeat the very foods that he has classified as "taboo". He will likely eat more, not less, due to dietary rules. And for Dan, who has a long history of binge eating, his hunger, withdrawal, and diet rules will most likely serve as triggers for ongoing binge eating. This will lead to a cycle of guilt / shame, diet, broken rules, joking, and more guilt / shame.
Jamie not only appears to be driving a potentially harmful treatment plan, but also struggling to control her countertransference responses. Like so many people in culture today (including many mental and medical professionals), Jamie seems to have a preference for people in larger bodies. Believing that losing weight is the "answer" to Dan's problems, she places this value on him even though he is seeking treatment not to lose weight but to reduce his symptoms of binge eating. Jamie's discomfort with her client's body is a form of weight discrimination that can lead Dan to feel judged and further marginalized.
Studies show that weight stigmatization rather demotivates than promotes changes in health behavior. In response to weight stigma, people tend to eat increased amounts of food and are less likely to stick to a diet plan. To avoid further stigma, they tend to avoid exercise because they fear additional judgment from others. They also tend to delay medical care to avoid stigma from health professionals who may further criticize, blame, or shame them for their weight. Jamie's personal values in this case lead her to disregard Dan's dignity and well-being. In sum, her prejudices and lack of knowledge about effective treatment for eating disorders actually cause harm to her client.
Important snack bars
The following is a summary of considerations for counselors when they encounter clients who have problems with food, weight and body image:
Remember that anyone can develop an eating disorder. Don't assume that only underweight white women have eating disorders. For example, binge eating disorder is the most common eating disorder and occurs in people of all sizes and shapes, involving both gender and race / ethnicity.
During the intake process, ask questions about the client's attitudes and behaviors towards food, weight, and body image. Be aware that early symptoms can potentially lead to complex eating disorders with full syndrome.
Regardless of your treatment attitudes, you should be aware of the resources and willing to make appropriate referrals so that clients can receive special care when needed.
Effective treatment for eating disorders involves a multidisciplinary approach.
Counselors, like all humans, can have strong prejudices about food, weight, body image, and the importance of appearance. We have to be careful when imposing these values on our customers.
Weight stigma is a form of discrimination that serves to marginalize and shame people. It is not a value supported by the consulting 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 Counselors' Guide to Prevention and Treatment, edited by Laura H. Choate, American Counseling Association, 2013)
American Psychiatric Association Guide to the Treatment of Patients with Eating Disorders (2010): tinyurl.com/APAEatingDisorders
"Practice Parameters 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 Quality Committee, Journal of the American Academy of Child and Adolescent Psychiatry, 2015
National Eating Disorders Association: nationaleatingdisorders.org
Academy for Eating Disorders: aedweb.org/home
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Laura H. Choate is the Professor of Consultant Education at Louisiana State University in Baton Rouge, endowed by Jo Ellen Levy Yates. She is the author of five books, the most recent of which is Lifespan Depression in Girls and Women: Mental Health Treatment Basics (2020). She has 40 publications in magazines and books, most of which are related to the mental health of girls and women. She is a member of the ACA ethics committee. Contact them at [email protected].
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