Q: I’m noticing that binge eating is a problem for many of my clients, especially those with trauma histories. How can I best help them? And when should I refer to a specialist?
A: You’re not alone in wondering what to do! In the US alone, approximately 2.8 million people (3.5 percent of women and 2 percent of men) struggle with binge-eating disorder (BED). It’s by far the most common eating disorder, five times as common as anorexia, bulimia, and orthorexia combined. It’s also the most underdiagnosed. Few therapists or healthcare professionals learn how to assess or treat it. And because of the stigma, many clients don’t report binge-eating behaviors, mistakenly viewing it as an issue of personal control or willpower. Even when they seek treatment for it, instead of the needed psychological, somatic, and psychoeducational interventions, practitioners too often focus on weight loss, especially with clients in bigger bodies, resulting in more harm than good.
I’ve been treating BED for more than 30 years. In that time, awareness of the disorder has grown exponentially. In 2013, it was recognized as a formal diagnosis. It’s now understood to require specialized care, akin to any other eating disorder. It’s also understood to have many causes. Genetics, epigenetics, culture, biology, history, and psychology all play key roles. Childhood trauma factors into up to 75 percent of people presenting with it. Sixty percent of people with BED have been diagnosed with one or more co-occurring mental health issues, including anxiety disorders, substance-use disorders, depression, attention-deficit disorder, and complex PTSD.
Mental health providers who are not eating-disorder specialists may feel hesitant to address binge-eating and body-image issues with their clients. But with a little additional training in working with body shame and weight stigma using a nondiet-based approach, they can build on their existing knowledge of the co-occurring disorders that often accompany BED, and learn to work effectively with the disorder.
Take Away the Shame about Binge Eating
Most clients feel profound shame and confusion about binge eating. Typically, they’ve tried to stop many times before they’ve reached your office, and their inability to control this behavior is a source of deep embarrassment. When we help them understand that binge eating develops principally as an adaptation to complex trauma, and from the deprivation created by dieting, self-compassion begins to develop. Especially for clients with childhood trauma, binge eating may serve as a way for their autonomic nervous system to escape into a dorsal vagal state. (The dorsal side of the vagus nerve responds to cues of danger by pulling us away from connection, out of awareness, and into a state of self-protection.) When clients face present-day hurdles like poverty, racism, homophobia, and weight stigma, binge eating may provide a temporary safe haven.
Helping clients understand the psychological benefits they’ve gained from these behaviors can bring relief. For my client Melanie, a 49-year-old executive and mother of two teenage girls, understanding the “benefits” of BED was an important part of our work together. “The moment I decide to binge, I’m free,” she told me in one of our sessions. “I can feel my body relax and then kind of disappear. Then I see the evening ahead of me. Just me, the TV, the food, and then sleep—a kind of sleep you can’t get without bingeing. I won’t think about all the things I’m going to screw up tomorrow, or who doesn’t like me, or who’s going to leave. Nobody can get to me when I’m in that place.”
Binge eating is a survival tool that develops when little else is available. As a result, changing the behavior is often terrifying. Breaking the cycle can feel impossible, not because clients are weak or lack willpower, but because they’re trying to change a protection they’ve relied on for a long time. On an unconscious level, this can feel threatening. When Melanie understood the reasons binge eating was protective for her, her shame about going to food to cope lessened. She was able to offer compassion and gratitude to the part of her that felt the impulse to binge.
Identify the Patterns
Patterns of binge eating exist for most clients. Identifying times of higher risk and learning what triggers those moments empowers clients to find alternative ways of handling their needs. When do your clients decide to binge? What feelings arise right before food thoughts come? What do your clients hope food will do for them in these moments? What do they imagine might happen if they don’t binge? What sensations are they hoping to escape or change? These questions help clients identify the parts of themselves that typically seek refuge in a binge. For many, a binge feels like protection from being overwhelmed by terror, shame, or hopelessness.
My client Annie frequently binged on the commute home from work. She didn’t realize she’d been in a fight-flight sympathetic activation state most of the day, so the transition to a slower, quieter rhythm in the evening was hard to tolerate, and she became flooded with anxiety and shame. Binge eating helped her calm down and disconnect from the anxieties that had built up during her day. As she learned to identify when she was getting triggered at work, she could check in with herself and handle the situation right away, without a day-long buildup of fear and shame. Her urge to binge on the commute home lessened greatly.
Healing is long-term work for many BED clients, but polyvagal strategies for regulation can help them develop the ability to come out of a dorsal or sympathetic activation and feel safely grounded in their bodies and more present and connected to themselves. This makes it easier to explore trauma narratives and somatic reactions driving a binge. As they develop an awareness of their vagal state through breathwork and awareness exercises, they’re better able to shift into a ventral vagal state (grounded, mindful, joyful, curious, empathetic, and compassionate) and make more protective decisions about their needs. Somatic interventions such as EMDR, Somatic Experiencing, meditation, and mindfulness practices offer ways of building this body awareness, which in the Internal Family Systems (IFS) therapy model is called being “in Self.”
IFS is a powerful tool for addressing BED. According to IFS, parts form in childhood and are a normal aspect of human psychology. When relationships with caregivers and important others are dangerous, erratic, or absent, parts take on trauma-based narratives, such as “I’m unworthy of care” or “love is scarce and conditional.” Binge eating can be a part’s way of soothing and distracting a person from pain and shame. So when using IFS to treat BED, parts that binge are befriended, heard, and relieved of the trauma-based burdens they carry.
For Annie, the part of her that was triggered at work, which we called her list-maker critic part, was terrified she’d be judged as lacking and be fired from her job. This fear was directly related to her belief that she was to blame for her father’s leaving the family because she’d failed to live up to his expectations. The work of unburdening the list-maker critic part from this belief allowed her to be more in her adult Self at work, better able to assess her performance, believe in her skills, and trust her long-held professional relationships. She no longer needed to escape and soothe with bingeing after a perceived failure at work.
Build Body Trust
The biggest environmental contributor to the development of eating disorders is the sociocultural idealization of thinness and a particular body type. Common and often traumatizing experiences driven by weight stigma include bullying, teasing, and many forms of rejection and discrimination. Weight stigma is rooted in racism, misogyny, and gender stereotypes, influencing narratives about the right kind of body to have. It’s parroted and exploited by many industries and companies to maximize profit, using the shame of stigma to offer solutions to the supposed problem of the imperfect body.
For therapists working with clients with BED, part of the treatment focus needs to be on helping clients develop a compassionate and protective relationship with their body, regardless of its size. For many clients, the idea of having compassion for their body can be difficult to imagine. They often mention getting healthy as a motivation for weight loss, but we don’t know how weight loss and health are related in any given person. Additionally, weight loss that happens from dieting is rarely maintained. In fact, research increasingly tells us that most weight-correlated health problems are more strongly associated with weight cycling—repeated weight losses and gains due to dieting—than to body weight itself.
The truth is that dieting is both unsustainable and dangerous for most people. With a 90 percent failure rate, and 75 percent of most dieters gaining even more weight than was originally lost, food restriction and prescriptive weight loss are doomed strategies, which promote a narrative that the body must be controlled and fixed, reinforcing body shame and distrust. This can be especially damaging when our client’s body holds traumatic experiences.
Many BED clients have been bingeing and restricting for a long time and are terrified of being out of control without the guardrails of a diet. Research and clinical experience have shown that the best tool for healing this cycle is learning to eat intuitively. Eating intuitively and learning to trust the body to determine the appropriate weight for each individual client is the best path to a sustainable and peaceful relationship with food. We need to help our BED clients build a relationship with their body as an ally. Learning body cues for hunger, fullness, satiety, and nutritional needs, and allowing all foods (no “good” and “bad” foods) helps clients discover that their bodies know what and how much to eat.
Because weight stigma is so insidious in our culture, therapists must do their own healing to work effectively with BED clients. If your relationship with your body is critical or shaming, consider working with someone to develop a more compassionate and trusting relationship with it.
When to Refer
Education about weight stigma and related trauma, building a community that supports clients’ efforts, and challenging internal and external body-shaming messages can help BED clients feel less alone and better able to access their resilience. Sometimes, however, in cases of significant trauma or when BED has developed in early childhood, changing behaviors can prove too threatening to address without residential care or intensive outpatient programs. In both higher levels of care, clients benefit from specialized nutrition counseling and support groups. If you decide to refer, make sure you have access to a network of providers who know how to work from a nondiet and strengths-based understanding of BED.
Many BED clients are long term, and the work can be challenging. You’ll need to draw on expertise in areas you’re already familiar with while expanding your knowledge of using a nondiet-based paradigm, addressing the trauma of weight stigma, and helping clients heal body shame. While many tools are needed, the rewards are great. Helping clients understand their bodies as heroes in their recovery journey is the best part of our work.
Photo by Kevin Malik/Pexels
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Amy Pershing, LMSW, ACSW, CCTP-IIl, is the founding director of Bodywise Binge Eating Disorder Program, the first BED-specific treatment program in the United States. She teaches internationally on the treatment of BED, weight stigma, and trauma. She’s the winner of the Pioneer in Clinical Advocacy award and author of Binge Eating Disorder: The Journey to Recovery and Beyond. Her new workbook on attuned eating, cowritten with Judith Matz and Christy Harrison, is forthcoming.