If you think elementary school students are only learning their ABCs and 123s, think again. Some are also absorbing societal messages that place importance on counting calories and dropping dress sizes.

Anna Viviani, a counselor in private practice in Peoria, Ill., who works with eating disorder clients, remembers a conversation she had recently. A school counselor told her that children as young as first and second grade are talking about dieting and body dissatisfaction. Indeed, research has shown that 42 percent of first- through third-grade girls want to be thinner. Studies have also found that 81 percent of 10-year-olds are afraid of being fat, while 50 percent of fourth-grade girls are on a diet.

Those children may eventually join the nearly 10 million American women and 1 million American men who, according to the National Eating Disorders Association, battle an eating disorder such as anorexia or bulimia. Millions more struggle with binge eating disorder and other eating disorders. “Problems with eating disorders and body image are not just a phase,” says Viviani, a member of the American Counseling Association who is earning her doctorate at the University of Iowa. “This intense preoccupation with weight, food, exercise and body image has become a national obsession, and as counselors, we need to be ready to address it.”

In light of the increase in eating disorders, Viviani advocates the topic being taught more widely at the master’s level for counseling students. “While I recognize that not every counselor will go on to specialize in the diagnosis and treatment of eating disorders, having a thorough understanding of the disease is vital, given the staggering numbers of new cases appearing each year,” she says. “As a professional counselor be it school, mental health, community, rehabilitation, college, marriage and family it is likely that they will encounter a client with an eating disorder at some point in their career.”

The key to understanding eating disorders, experts say, might come as something of a surprise. Namely, it’s not about the food. “I can’t stress (that) enough,” says Erica Riczu, an ACA member who owns a private practice in Toms River N.J., that focuses in part on eating disorders. “You can’t just place these clients on a food diary and expect them to eat properly. The food is a cover-up, a mask for deeper issues.”

Viviani likewise emphasizes that the issues at the heart of eating disorders go much deeper than food. “When one feels

that everything in life is out of control or at least not in their control food, weight, exercise is one thing that many eating disorder patients feel they can control, at least in the beginning,” says Viviani, who spent five years working in a partial hospitalization program specializing in the treatment of eating disorders. “As we work with these clients to help them feel a general sense of control in their lives, many times, the eating disorder behaviors begin to come back under control.”

Although anorexia and bulimia are the most commonly thought of eating disorders, the “eating disorders not otherwise specified” (EDNOS) category is an “extremely common diagnosis,” says Sara Hofmeier, a counselor who has worked at the inpatient, day-treatment and outpatient levels with clients battling eating disorders. EDNOS includes binge eating disorder, which Hofmeier says may soon have its own diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. “The tricky part about eating disorder diagnoses is that many people who present with anorexia or bulimia may not actually meet the diagnostic criteria for those disorders because of some of the stringent requirements,” Hofmeier says. “Many clients ultimately, at some point, receive the EDNOS diagnosis.”

Familiarity with the diagnostic criteria for eating disorders is important, Hofmeier says, but it’s perhaps more critical to understand that not all eating disorders will show up perfectly in line with the criteria. “It is important for counselors to keep an open mind,” says Hofmeier, an ACA member earning her doctorate at the University of North Carolina at Greensboro. “For each client, the eating disorder will look different, will have different symptoms, will have different features, will have different concerns and will bring about different treatment needs.”

Aside from the extreme weight loss seen in clients with advanced anorexia nervosa, there are many more subtle signs to watch for, according to Viviani, including excuses for missing meals, food rituals, avoidance of specific foods, excessive exercise, dressing in layers (especially when the weather is warm), isolation from peers and family and constant chatter about food and weight. Hofmeier adds other signs to that list: undue concern with body shape or weight, perfectionism, rigidity related to food or body image, ritualistic behaviors and cognitive impairment with low weight.

Anxiety, anxiety, anxiety

Some people actively seek out a counselor because they’re tired of struggling with eating or body image issues and want help. But for others who are struggling, realization of an eating disorder doesn’t come until much later. “The biggest thing that gets them through my door is anxiety, anxiety, anxiety,” Riczu says, adding that these clients tend to exhibit an inability to identify how they feel in their bodies. “They will say they feel anxious, but if you ask them how do they know they are anxious where do they feel it in their body many struggle to answer.” Many people with eating disorders lack obvious outward signs and can appear to be at a normal weight, Riczu says. They may also go to great lengths to hide their disorder. “I would say the best approach of all is for a therapist to ask questions,” she says. “I bet many clients don’t even know they are struggling with an eating disorder until you ask the questions.” She says this might include asking clients if they find themselves eating to cope with stress, if they count calories, how they feel when their belly is full, whether they’ve ever felt guilty after eating something or if they have a favorite comfort food.

“The most important way that a counselor can identify an eating disorder is by being aware of what constitutes an eating disorder and appropriately assessing for eating disorder symptoms with new clients,” Hofmeier says. But, she continues, because the signs and symptoms can vary so widely, it’s important that clinicians not jump to conclusions about the presence or absence of a problem. “The best way that a counselor can identify what is going on is by being present to listen to all of the client’s story and being able to ask the right questions to probe for underlying or disguised eating disorders.” Those questions relate to self-esteem and attitudes toward food, she says. For instance, does a client feel good about herself because her pants fit or because she has a sharp wit and is a good friend? When it comes to food, are lots of rules and rigid thinking involved? The answers to these and similar questions can offer insight into where the client is coming from, she says.

As for the question of what actually causes a person to have an eating disorder, no single answer will apply to every client, Hofmeier says. “Many background factors have been associated with eating disorders abuse history, certain athletic involvements, traumatic experiences, difficult periods of adjustment but these are by no means givens and should not be assumed,” she says. “Counselors should screen for experiences like these and others that may be associated with the client’s eating disorder, but the assumption should not be made that there is a single cause for any eating disorder.”

Eating disorders often develop as a result of several experiences and factors combining, says Hofmeier, adding that it’s nearly impossible to pinpoint exact causes. “It is more helpful to think of contributing factors, such as the emphasis that the family placed on weight or appearance, the media that the client was exposed to, the peer relationships the client had, any athletic involvement that placed a high degree of emphasis on body shape, general client tendencies toward perfectionism or traumatic experiences that were not fully resolved or processed in a healthy manner.” Common underlying concerns include low self-esteem or self-worth, limited ability to manage distress or emotions, the desire to achieve and the yearning for perfection, she says.

Another factor sometimes in the mix is past abuse, Viviani says. “In my private practice, I work specifically with survivors of childhood abuses and, many times, even if I have screened for an eating disorder in the initial evaluation, it is months later that the client will openly disclose their eating disorder behaviors. Unfortunately, there is shame attached to having an eating disorder that makes it very difficult for individuals to disclose their suffering.”

Many eating disorder clients have a history of not feeling heard or acknowledged, Riczu says. “I found there is usually some history of a dominant parent who shows conditional love and is very critical,” she says. “It’s like the eating disorder is ‘starving’ for something, ‘purging’ what it wants to yell or ‘filling’ the emptiness. These clients have spent their entire life hearing the messages ‘What you say isn’t important,’ ‘What you feel is wrong,’ ‘You can’t make decisions for yourself,’ ‘I’ll only love you if …’ or ‘I have to control you because you can’t handle it.'”

“At the most basic form, an eating disorder client says, ‘Well, if you won’t listen and you won’t let me have any say, I can choose to not eat,'” Riczu continues. “The anxiety that builds from having the self-concept of being unimportant, not smart enough, unqualified or a failure becomes numbed by hunger or large quantities of food. You can’t feel anxious if your belly is empty. You can’t feel anxious if you are consumed with thoughts about food. You can’t be anxious if you are planning on where you are going to purge.”

Media and societal pressures also play a role in shaping perceptions and expectations, Viviani says. “Prior to World War II, a fuller figure was preferred,” she says. “But after WWII and the rise in television, the drive for thinness became a national obsession and continues to grow. We think about all the other ‘isms’ in society, such as racism, ageism and so on, but we really need to think about weightism and how we treat people based on their weight or physical appearance. Our children watch how we as adults treat each other and model our behaviors. Then peer pressure moves in, and tolerance for different body shapes and sizes can be lost.”

Beyond administering all the assessments and understanding all the presenting issues and common causes, Hofmeier says the best thing counselors can do is simply to listen. “The most important part of identifying the ’cause’ is to focus on what is going on underneath the behavioral level of the eating disorder, and this will only come from getting the client’s story. The client will usually be able to tell you what they remember as being a part of the development of the eating disorder, so it is important to allow the client to tell you this story and listen to whatever they have to say.” Path to recovery

“Why do you want me to be ugly and unpopular again?” one of Viviani’s clients once asked her. The woman was very pretty and had many friends prior to her eating disorder, Viviani says, but those truths weren’t part of the client’s reality. “Difficulty in acknowledging an eating disorder varies depending on the level of investment and reward the client has experienced,” Viviani says. “If a client has received positive feedback on her appearance and peer relationships have improved, it can be very difficult. The perceptual distortions can be very intense in this situation. Changing the perspective of our clients takes time and patience, in addition to training.”

Due to her specialization in eating disorders, Viviani tends to see a higher percentage of clients who have already recognized that a problem exists and want her help in solving it. But other times, clients come to her because someone has told them they have a problem and they want Viviani to assure them that’s not really the case. Initially, those clients can be much harder to work with, she says. “One of the things I remind them is that I have no vested interest in lying to them about their size, weight or condition. I am very forthright with my clients and believe that level of honesty is important to them beginning to trust the therapeutic relationship.”

Riczu also sees a higher percentage of clients who have already acknowledged their problem and want help. For those who haven’t yet come to grips with the idea of having an eating disorder, that acknowledgement can be difficult. “I find that getting some concrete evidence can help, meaning getting them to have some blood work done,” she says. The results normally don’t come back as “healthy” for someone with an eating disorder, she adds.

When a counselor is able to move forward with a client in treating the eating disorder, several types of treatment are available that usually vary by diagnosis, Hofmeier says. The most common approaches include cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT) and interpersonal therapy (IPT). “CBT is useful because it gets at the underlying cognitive structure that an individual with an eating disorder may be struggling with,” she says. “It helps the individual recognize negative beliefs they may hold that fuel the eating disorder and also impact other areas of their life.”

DBT, Hofmeier says, is based on the components of mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance. “While DBT was developed for a different client population, it has been shown to be effective with many individuals with eating disorders. DBT is effective in the way that it facilitates skill building with clients that can ultimately help them move away from eating disordered coping to healthier coping.” IPT, she continues, is geared toward helping clients understand their interpersonal relationships and how their symptoms or difficulties might be linked to interpersonal or relational difficulties.

One additional therapy that’s shown effectiveness with adolescents struggling with anorexia when it’s caught early on is the Maudsley model, Hofmeier says. “Maudsley family therapy works by helping parents and caregivers gain control over the recovery and refeeding process in order to facilitate healthier understanding on behalf of their young person. The Maudsley model aims to help create a new relationship between the young person and food, thereby helping the young person to not see food as a means of control. It also can help to reinforce the idea that the sense of control felt through restricting is not actual control and can therefore help to weaken the eating disorder. Part of how Maudsley works is by helping realign family relationships for the young person, both with siblings and with parents, to help them have healthy relationships both interpersonally and with food.”

In Riczu’s office, mindfulness training is front and center. “I call my eating disorder clients ‘floating heads’ meaning they are so disconnected with their own bodies, they don’t even recognize body sensations, and if they do recognize body sensations, they automatically interpret them as ‘something is wrong,'” she says. “I start here with many of them. We focus on mindfulness techniques to get them back into their bodies, so they can notice hunger and satiation. Symptoms of eating disorders are often a way of coping with intense feelings and running away from body sensations. Teaching mindfulness techniques helps clients to learn a sense of control over their own sensations as well as makes them more mindful of their eating habits. A client can learn to say, ‘Hey, am I eating because I’m hungry or because I’m angry?’ because they have learned to recognize hunger and satiation.”

Riczu also works with her clients on resource building, using not only mindfulness training but also eye movement desensitization and reprocessing therapy to help them build internal resources, such as “safe place” imagery, to cope with stress. Symbolism is also helpful, she says. “Many of my clients can’t quite put words to their suffering, and I have found through the use of symbols, we can retell their stories in a positive light. I do this through sand play therapy, where we can battle out the eating disorder, literally, in the sand.”

Using symbolism helps clients to retell their life stories without the negative messages they have been carrying around in their “invisible backpacks,” Riczu says. “Retelling the stories must go beyond talk therapy, where clients can get stuck in defense mechanisms and left brain or black-and-white thinking. I help my clients retell their stories through symbolism and play. We create my clients’ worlds in a sandbox of miniatures where we can explore and manipulate the symbolism of food, self, family, friends, etc. This allows a whole body approach at a nonverbal level, where, often, the negative self-concepts began when language was still being developed.”

These counselors agree that effective treatment of eating disorders and body image issues consists of many components. “Psychotherapy, group therapy, family counseling, nutrition counseling and medical management are typically required to ensure recovery,” Viviani says. “A team approach to treatment with the client as part of the team is essential to success.”

Hofmeier agrees that a counselor working alone with the client isn’t optimal. “Good eating disorders treatment will occur when the counselor is working with a team of professionals that can tend to all of the client’s needs.”

Listening to the story

Sometimes, honesty really is the best policy. “I was once accused of being ‘relentlessly caring’ by a patient,” Viviani says. “She regularly lied to me to protect the eating disorder, and I called her on it every time. I named excuses as I saw them and held her accountable at every turn. Because I knew she wanted recovery and because she knew I cared, the approach worked. There were many tears and much anger along the way, but through it all, she knew that her recovery was my primary concern, which allowed her to stay in treatment and find full recovery.”

Requiring accountability shows the client that the counselor cares, Viviani says. “When I press clients for what a binge or restriction episode was about, while it can be very difficult, it helps them to dig deeper than the surface excuses of the behavior to why it really happened. It is then that the client can begin to address those underlying issues and begin to create change in their life.”

Riczu says counselors should also feel comfortable being honest with their clients about how long they will attempt to work with them on an outpatient basis. “I usually tell my clients that we will start out with a month. As long as we are stable and moving toward progress, we can continue,” she says. “But if the client is declining or is not showing much motivation, I will refer to residential treatment. I found being upfront with this from the get-go makes my clients a bit more open to residential help.”

It’s important for counselors never to assume the eating disorder is a choice clients have made, Hofmeier says. “Most clients do not see their eating disorder as something they chose and, therefore, recovery is not as simple as choosing to stop. The eating disorder can be seen as serving some function for the client, regardless of how healthy that function is, but being able to see how the eating disorder has served a purpose can potentially help the client understand it more fully. The counselor and client can then work to find new ways to have the same functions served for the client in a more adaptive manner. It is important that the counselor not convey to the client that the eating disorder is something they are choosing to do to themselves. This is likely not how the client sees it and would likely leave the client feeling as though they or the eating disorder are not understood.”

Be open to the client’s story, Hofmeier adds. “Making an assumption from the start about whether a client is struggling or not will hinder the process for both parties. When directly working with a client who is struggling, a counselor can help by accepting the client’s story for what it is. Whatever the client is struggling with is what they will need support from their counselor for.”

Also important, Hofmeier says, is counselors modeling healthy attitudes toward their clients. “Avoiding ‘fat talk’ with clients not talking negatively about their own bodies while in session or with clients sets an example of acceptance as well as downplaying the importance of physical appearance,” she says.

By looking beyond their own offices, counselors can also help fight eating disorders communitywide. “By active engagement in prevention activities, with communities or schools, counselors can make a huge difference for individuals who may be at risk for eating disorder development,” Hofmeier says. Ideas include offering media education workshops at schools and providing information and education to people regularly in contact with susceptible young people, such as pediatricians, coaches and Girl Scout leaders.

Tips from the pros

On the basis of their many years of combined experience in treating eating disorders, Viviani, Hofmeier and Riczu shared a few of their top tips. Following are 12 do’s and don’ts for other counselors working with eating disorders and body image issues.

• “Do listen without judgment,” Viviani says.
• “Do acknowledge your limitations,” Hofmeier says. “You are not expected to be the weight expert, food expert, etc., so seeking input from other professionals who are experts in those areas is incredibly important to giving your client the best care possible.”
• “Don’t rush,” Riczu says. “This is a slow process of rebuilding resources, coping and identity.”
• “Do involve the family or other support systems for the client,” Hofmeier says. “If you are working with a child or adolescent, involving the family is crucial. If you are not comfortable providing family-based services, involve a fellow counselor who is.”
• “Don’t automatically go hunting for sexual abuse,” Riczu says. “It might be there, but you can scare away your client (by assuming that).”
• “Do work on your own issues first,” Hofmeier says. “There are many individuals who struggle with an eating disorder and eventually go on to work with others who are suffering. These individuals can become great therapists or doctors or dieticians, but it is important that they have worked through their recovery first. As a counselor working with eating disorders, it is essential that you have worked through any of your own eating disorder history. In general, it is also important that a counselor is aware of their own feelings about their body.”
• “Don’t make a list of what they have to eat or how many calories,” Riczu says. “Leave that to the nutritionist.”
• “Do recognize that eating disorders can be life threatening and deserve to be taken seriously,” Viviani says.
• “Don’t use food and weight as the only measures of health and recovery for your client, but don’t ignore their physical health either,” Hofmeier says.
• “Do be present in the sessions,” Riczu says. “You might be the first person who really listens to (this individual).”
• “Don’t get discouraged. Relapses may happen, but it doesn’t mean the treatment didn’t work,” Viviani says.
• “Don’t downplay the expertise that your client has,” Hofmeier says. “While the client is coming to you because they don’t know how to recover on their own, they are the only one who knows where they have been thus far. Allow your client to tell you their story, their history and their struggle. Their eating disorder is unlike anyone else’s, and it is important to understand their whole experience so that you can help them in the best way possible.”

Reaching out

Working with local schools, physicians and nutritionists is often the best way for counselors to reach those battling eating disorders and body image issues. “Having an educated medical community that can make appropriate referrals is important, as the physical signs may often be the most noticeable in some cases,” Hofmeier says. “Also, working with school systems to help instructors and staff appropriately recognize symptoms in students and provide the appropriate support and referrals is a helpful way to ensure that kids and teens are receiving timely and appropriate services.” For those interested in helping this population, education is key, counselors say, including attending conferences sponsored by eating disorder associations, learning about therapy techniques and keeping up with literature on the topic. Viviani points to the International Association of Eating Disorders Professionals, which, she says, offers certification in the treatment of eating disorders after the counselor completes a rigorous training program. The National Eating Disorders Association, the Something Fishy Website on Eating Disorders (something-fishy.org) and the Renfrew Center are other resources that Riczu has found particularly helpful.

Although attending conferences and workshops and networking with other professionals is important, supervision is vital to making everything “fully connect,” Hofmeier says. “A supervisor who has experience in this area can help you define your treatment plan and can share with you their own clinical experience.”

As counselors build their knowledge base, one of the most critical lessons is remembering never to trivialize a client’s condition, Viviani says. “A father said in a session once, ‘If she would just go have a hamburger…’ If as counselors, or as family members or friends, we trivialize the eating disorder, we reinforce the shame and make it even harder for the person to talk,” Viviani says. “These clients are trying as hard as they can to keep up daily, so when they are told, ‘Just have a hamburger,’ it tells them that the other person doesn’t understand and that they are not supported. I have witnessed so many tears over ‘the hamburger.’ If trivialized, this client may never seek help again, or not until even more physical damage has been done to their body and spirit.”

Lynne Shallcross is a senior writer for Counseling Today. Contact her at lshallcross@counseling.org. Letters to the editor: ct@counseling.org.