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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