Dear Therapist: Your Client Has an Eating Disorder.

Unless you’re an eating disorder specialist, you might think that you don’t have the expertise to wade in and offer a lifeline for those with eating disorders. Yet chances are nothing could be further from the truth.

In fact if you don’t specialize in eating disorders, then you’re less likely to walk in thinking that “knowing what you know” is all the preparation you’ll need. Shaun Liu Shaun Liu

What You Already Know as Therapist

  1. When clients tell you the problem, it reflects their distress but it doesn’t necessarily reveal their predicament or problem(s). You reserve judgment and give some time for the full story to unfold.
  2. You know the DSM-5 (or ICD-10) forwards and backwards. You can fill out the forms, apply the psychometric tests and assign all the labels. However, you never treat the label as a stand-in for the unique complexity of each individual.
  3. The behaviors of eating disorders are dangerous and often deadly.
  4. There’s scientific proof, of varying validity, that several psychoeducational treatment modalities help those with eating disorders achieve full remission.
  5. Nothing about the healing process for any mental illness is linear. Nothing about an individual with a mental illness is isolated from their sociocultural, familial and environmental interfaces.

What You May Not Know

  1. The DSM-5/ICD-10 checklists for anorexia (AN), bulimia (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), pica, rumination, and the grab bag unspecified feeding and eating disorder (USFED) bundle distinct behaviors into separate categories. Those categories represent one lone underlying eating disorder spectrum.
  2. All eating disorders are a type of anxiety disorder wherein the threat identification system in the brain has misidentified food as a threat.
  3. The fight/flight/freeze response to the misidentified threat of food generates a multitude of avoidant and compensatory behaviors that invariably shift, wax and wane, or abruptly swap out over time. 1, 2 It’s these behaviors that get all the focus within the DSM/ICD frameworks and they miss the forest for the trees: approaching and eating food without restriction (no matter the assigned eating disorder label) is the foundation on which you build your treatment support. Much of the diagnostic separation in DSM/ICD is weight-focused (anorexia=underweight, bulimia (purging and non-purging)=average weight, binge eating disorder=above-average weight) even as the avoidant behaviors around food are common to all these diagnostic classifications of eating disorders. 3
  4. Consensus-based reality is not fully interchangeable with absolute validity. For you to help someone with an eating disorder you must remind yourself that culturally-normative fears are rarely scientifically supported. 4 Everyone may fear their children’s abduction while happily strapping them into a car seat several times a day, but statistics confirm that the real risk of potential harm resides in that car seat. 5

    When the client mentions macronutrients, the “evils” of sugar, the “empty” calories of ultra-processed foods, or needing to build muscle mass to “be healthy”, it will help if you reinforce scientific fact rather than culturally-normative fears. Yes, you didn’t go into the sciences but research informs all facets of your professional career and that means your attitudes around food and weight will need to go under your find-the-bias microscope.
  5. An eating disorder is as invisible as all other chronic mental illnesses.
  6. A person’s mass, socioeconomic background, gender and/or race won’t tell you whether an eating disorder is present or absent.
  7. Your client will rarely frame his or her distress as the misidentification of food as a threat precisely because that is nonsensical, and sociocultural norms are used as a filter through which the experience might be explained to others. That is why fat phobia is a dominant filter today (because we are a fat-hating society), whereas a desire for religious purity was a dominant filter for eating disorders 300 years ago. 6

Treatment Modalities

  1. Cognitive behavioral therapy (CBT) is evidence-based for eating disorders. 7, 8, 9, 10 Enhanced versions of CBT are better for clients with marked mood intolerance, perfectionism, low self-esteem and/or interpersonal difficulties, but generate inferior outcomes when compared to basic CBT for those who do not face these complications. 11
  2. Exposure and response prevention (ERP) shows tremendous promise precisely because it addresses the core challenge of food as phobia. 12, 13, 14
  3. Motivational interviewing (MI) helps to avoid you being the lone voice pitting yourself against the eating disorder. Clinical results support its use in an intuitive (non-manualized) way for eating disorders. 15
  4. Dialectical behavior therapy (DBT): Initial trial data confirms that DBT is a helpful modality for those with eating disorders where other modalities have not gained any traction. 16

In most cases, you will weave in and out of multiple modalities and approaches as you see fit, just as you do with most of your clients. Other scientifically valid approaches include MANTRA, ACT, ICAT, etc. 17

For an excellent synopsis on why barriers persist to applying scientifically-valid treatment modalities for eating disorders, please read: Treatment Protocols for Eating Disorders: Clinicians’ Attitudes, Concerns, Adherence and Difficulties Delivering Evidence-Based Psychological Interventions (hat tip: Tabitha Farrar for this reference).

Do’s and Don’ts:

  1. Don’t get sucked into offering any advice on diet or activity. Your stance must be unwavering: ask the client to speak with their relevant treatment team specialists on diet and activity. Your ability to provide the client with tools to work with the panic, as you would with any client dealing with anxiety, is how your expertise is best deployed.
  2. Be hyper-aware of your own fattist and healthist attitudes. 18 You cannot resonate on any level with their anxieties of extreme hunger, greed, slothfulness, self-loathing, thin privilege, etc. And if you cannot neutralize those biases, then avoid working with any client with an eating disorder.
  3. Recognize that the misapplication of “mindful” or so-called “intuitive” eating is the application of conscious restrictive behaviors. It reinforces the pattern of food avoidance for those with eating disorders. 19
  4. The more you structure the process around meta-cognition, replacement strategies, distress tolerance and pure exposure and response prevention guidance, the more likely the client will reach remission.
  5. Don’t apply target weights to a recovery process. While this may be very obvious to you, it bears repeating that an eating disorder is not a weight disorder. Your client must practice unrestricted eating every day for life. The body finds its own way to an optimal weight set point. Let the client’s medical advisers attend to blind weigh-ins or specific symptom intervention as they see fit.
  6. Remember that these clients don’t need to “get in touch with their hunger”; their hunger is short-circuited by the threat response to food. 20
  7. Even for those who say they have a problem with binges, the focus is on consumption of all foods with no restriction. Don’t let their distress about eating sway your focus on their constant efforts to reapply food avoidance after each and every “binge” session. 21
  8. To reiterate, someone BMI 37 can be facing as severe an energy deficit due to an eating disorder as someone BMI 17. Weight does not correlate to health status.

    Fat is not a storage unit; it’s an exceedingly complex hormone-producing organ in our bodies. The body has two methods of staying alive when we diet and generate energy deficits in our body: catabolism (destruction of all cells (not just fat cells) to release energy), and metabolic suppression (shut down of entire systems in the body to lower the demand for energy). The more efficient the metabolic clamping (which varies from one individual to the next) the more likely the body’s mass can even increase despite calorie restriction. Metabolic suppression is as damaging as catabolism. 22

Without the psychoeducational guidance you provide, relapse is often fast and hard. You will make the difference for long term improved quality of life, whether your client works towards harm reduction or remission, or weaves between those two states as needed.

1. Eddy, Kamryn T., David J. Dorer, Debra L. Franko, Kavita Tahilani, Heather Thompson-Brenner, and David B. Herzog. Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. American Journal of Psychiatry 165, no. 2 (2008): 245-250.

2. Eddy, Kamryn T., Pamela K. Keel, David J. Dorer, Sherrie S. Delinsky, Debra L. Franko, and David B. Herzog. “Longitudinal comparison of anorexia nervosa subtypes.” International Journal of Eating Disorders 31, no. 2 (2002): 191-201.

3. Castellini, Giovanni, Carolina Lo Sauro, Edoardo Mannucci, Claudia Ravaldi, Carlo Maria Rotella, Carlo Faravelli, and Valdo Ricca. "Diagnostic crossover and outcome predictors in eating disorders according to DSM-IV and DSM-V proposed criteria: a 6-year follow-up study." Psychosomatic Medicine 73, no. 3 (2011): 270-279.

4. Koertge, Noretta, ed. A house built on sand: Exposing postmodernist myths about science. Oxford University Press, 1998.

5. Stickler, Gunnar B., Margery Salter, Daniel D. Broughton, and Anthony Alario. "Parents' worries about children compared to actual risks." Clinical pediatrics 30, no. 9 (1991): 522-528.

6. (original references within this post)

7. Norton, Peter J., and Esther C. Price. "A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders." The Journal of Nervous and Mental Disease 195, no. 6 (2007): 521-531.

8. Compton, Scott N., John S. March, David Brent, Anne Marie Albano, V. Robin Weersing, and John Curry. "Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review." Journal of the American Academy of Child & Adolescent Psychiatry 43, no. 8 (2004): 930-959.

9. Hofmann, Stefan G., Anu Asnaani, Imke JJ Vonk, Alice T. Sawyer, and Angela Fang. "The efficacy of cognitive behavioral therapy: a review of meta-analyses." Cognitive Therapy & Research 36, no. 5 (2012): 427-440.

10. Fairburn, Christopher G., Zafra Cooper, Helen A. Doll, Marianne E. O’Connor, Kristin Bohn, Deborah M. Hawker, Jackie A. Wales, and Robert L. Palmer. "Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up." The American journal of Psychiatry 166, no. 3 (2009): 311-319.

11. Fairburn, Christopher G., Zafra Cooper D Phil, Dip Psych, Helen A. Doll D Phil, Marianne E. O’Connor, Kristin Bohn D Phil, Dip Psych, Deborah M. Hawker, Jackie A. Wales, and Robert L. Palmer. "Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up." American Journal of Psychiatry 166, no. 3 (2009): 311-319.

12. Steinglass, Joanna E., Robyn Sysko, Deborah Glasofer, Anne Marie Albano, H. Blair Simpson, and B. Timothy Walsh. "Rationale for the application of exposure and response prevention to the treatment of anorexia nervosa." International Journal of Eating Disorders 44, no. 2 (2011): 134-141.

13.  Hildebrandt, Tom, Terri Bacow, Mariana Markella, and Katharine L. Loeb. "Anxiety in anorexia nervosa and its management using family‐based treatment." European Eating Disorders Review 20, no. 1 (2012): e1-e16.

14. Carter, Frances A., Virginia VW McIntosh, Peter R. Joyce, Patrick F. Sullivan, and Cynthia M. Bulik. "Role of exposure with response prevention in cognitive–behavioral therapy for bulimia nervosa: Three‐year followup results." International Journal of Eating Disorders 33, no. 2 (2003): 127-135.

15. Treasure, Janet. "Motivational interviewing." Advances in Psychiatric Treatment 10, no. 5 (2004): 331-337.

16. (original references within this post)

17. (original references and more details on these treatment modalities within this post.

18. Puhl, Rebecca M., Janet D. Latner, Kelly M. King, and Joerg Luedicke. "Weight bias among professionals treating eating disorders: attitudes about treatment and perceived patient outcomes." International Journal of Eating Disorders 47, no. 1 (2014): 65-75.

19. (explanation and original references within this post).

20. ibid.

21. (explanation of misinterpretation of binge eating disorder and original references in parts one and two of this post).

22. (explanation and original references within this post).