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Treating the Eating Disorder Self: A Comprehensive Model for the Social Work Therapist Interview

Mary Anne Cohen, LCSW, joined us for an interview on her book, Treating the Eating Disorder Self: A Comprehensive Model for the Social Work Therapist. What follows are our questions in italics and her thoughtful responses.

Your introduction to Treating the Eating Disorder Self: A Comprehensive Model for the Social Work Therapist begins with, “For many people, trusting food is safer than trusting people.” Please elaborate. 

Let’s first acknowledge that people develop eating disorders for many varied reasons such as a genetic predisposition or restrictive dieting that can backfire into bingeing, purging or starving. Most often, however, eating disorders are a creative solution to handling emotional stress. This stress can include a person’s coping with heightened anxiety, depression, or obsessive/ compulsive tendencies. Stress can also stem from daily accumulations of feeling rejected and misunderstood or from overwhelming and deep traumatic experiences of abuse and neglect. But food is always there to ease this stress – bingeing, purging, and starving are all self-soothing behaviors.

Food is the most commonly abused “drug,” and is, after all, the cheapest, most available, socially sanctioned mood-altering medication on the market! For many people, trusting food is safer than trusting people because food never leaves you, never rejects you, never abuses you, never dies. It is the only relationship where we get to say where, when, and how much. No other relationship complies with our needs so absolutely.

In Treating the Eating Disorder Self, I describe two hundred case examples from my practice to illustrate how therapists can help clients along the journey from using emotional eating toward embracing life with resilience, grit, humor, and all its imperfections!

You describe some psychological triggers that encourage eating disorder development. One area you note is the use of food as anesthesia. What do you tell your clients about this?

I tell them, “Your eating problem has been your attempt to make yourself feel better. Wanting to feel better comes from a healthy and creative intention and that’s a good thing! But let’s see if we can expand your ways of taking care of yourself so that hurtful eating is not the only game in town to comfort yourself.”

Emotional eating (a term that I originated in 1982) can be considered anesthesia because these behaviors dial down or blot out difficult emotions that the person cannot or does not want to face: anger, loneliness, rejection, anxiety, depression, sexual conflict, or grief. Food helps a person detour, distract, or deny these inner feelings.

In the long run, however, no amount of chocolate chip cookies is going to solve the pain of your mother dying, or your husband losing his job, or the diagnosis of an autistic child. The numbing anesthesia of eating disorders is a temporary solution until we can help the person gently rip off the band-aid of coping with food so they can begin to face more directly their sorrowful emotions.

Janet’s mother was dying, and she could not bear that she was going to lose her forever. It was particularly sad because Janet never felt she had gotten enough loving attention from her mother during her life. Now the reality of “too little, too late” was hitting her hard. Janet came to therapy as her binge eating began to spin out of control. Gorging on chips helped her cope, but in her therapy she began to speak about her guilt, anger, sadness, and even relief that her mother was going to die. The day she cried was a turning point in Janet’s letting out her feelings rather than stuffing them down. Of course one session of tears did not resolve her anguish, but it opened the door to expressing her feelings rather than eating over them and gave her a release that the chips could not provide. We cannot heal what we cannot feel, and Janet was beginning to experience and “digest” her emotions.

What do you consider the vital ingredients that help deepen a therapeutic relationship?

A client might say, “What’s so important about deepening the therapeutic relationship? All I want is to get help to stop bingeing and throwing up!” But, in truth, learning to receive and accept nourishment from the relationship with the therapist can provide many more emotional nutrients than that pint of ice cream!

Psychotherapy is a “healing conversation.” It provides an opportunity for our clients to repair their inner emotional wounds. The nurturing and collaborative relationship with the therapist “sets the table” for clients to understand their early history and how that history relates to their present eating difficulties. By integrating insights from their past and the present, emotional eaters improve their capacity to regulate their emotions, learn to tolerate discomfort, trust in others for security and support, and deepen their capacity to love.

These three ingredients are vital to help deepen the therapy relationship and encourage intimacy to bloom between therapist and client:

The power of hope – Clients come to us hungry for hope. And hope is the most important ingredient we can offer our clients — that their eating disorder can get better, that they can live more at home in their bodies, and that their relationship with food will become easier and less fraught with struggle. Hope is the opposite of despair. Hope kindles clients’ interest in beginning the journey of therapy, and it sustains the bumps and inevitable set-backs along the way.

To help our clients generate hope with their eating struggles, we encourage them to do just one thing differently. Because change is composed of a series of progressive steps, taking even one step forward can provide a glimmer of hope. No step is too small to acknowledge. Hope begets hope, and we continue to build strategies with our clients to create small victories. May those with eating disorders come to appreciate and claim their hunger for connection and their hunger for life!

Curiosity –  Sparking curiosity is an essential ingredient that a therapist needs to kindle in a client. Curiosity is the key that opens the door to the self and stimulates psychological growth, self-discovery, creativity, and new perspectives.

Curiosity is the antidote to the constricted inner world of the emotional eater who has subsumed the meaning of life behind struggles with food and weight and numbers: How can I lose 20 pounds as quickly as possible? How can I fit into a size 8? I’ll just have an apple for lunch — it’s only 100 calories.

But with this added ingredient of curiosity, clients discover how their eating disorder may have helped as well as hindered their life. This expands their perspective beyond the constricted focus on calories, weight, and the number on the scale.

Ellie, a physician’s assistant with an extensive medical background, allowed herself to become pregnant seven times and had seven abortions. She also presented with a significant history of bulimia. How does her “bingeing and purging” on pregnancies relate to her bulimia? Why would an educated woman with medical knowledge and resources allow this to happen repeatedly? We need to encourage Ellie’s curiosity and self-reflection so we may uncover the meaning of her compulsive pattern and protect her from further risky behavior.

Authentic connection – The most heartening evolution in the treatment of eating disorders is that psychotherapists are less constricted by a posture of reserved detachment in which the therapist is the all-knowing expert and the patient is the passive recipient of the therapist’s wisdom. Psychotherapists have become more interactive and more “real” and not afraid to have a deeply heartfelt connection with their patients. And sometimes, as in the case of Paula, the shared humanity of the moment needs to override the traditional framework of how we conduct therapy.

The morning of 9/11, Paula, an anorexic young woman client, rang my office bell and told me a plane had hit the World Trade Center. We went up to my roof deck silently together. Paula, who always seemed emotionally constrained – as restricted with her feelings as she was with her food – reached for my hand and began to pray. There we were – a Jewish therapist and a born-again Christian – huddled together as she prayed to Jesus. In sharing this moment of fear yet also connection, Paula began to cry on my shoulder. I held her. And this moment paved the way for her to become more trusting and comfortable with me. As we continued to move forward in her treatment, she was better able to “flesh out” her emotions rather than only discuss the “bare bones” of her situation.

In my own psychotherapy practice and supervision of therapists, I encourage the collaborative partnership that clients and therapist create. When tears and laughter abound in sessions, eating disorder clients are enlivened to become more vibrant and genuine with their thoughts, feelings, and imaginations. Our authenticity and compassion help undo the pain of early attachments that led many of our clients to learn that trusting food is safer than trusting people.

Please tell us about the healing power of tears.

Vomiting, bingeing, and starving can be a substitute for crying as can the use of laxatives, compulsive exercise, cutting, or other self-harm behaviors. I discuss in my book how stifling tears leads to emotional eating: furtive bingeing, secret purging, or self-starvation to exile one’s pain.

Tears are a language just like eating disorders that can express matters of the heart. Sharing tears as well as laughter deepens the therapeutic relationship and the intimate connection between therapist and client. It brings a humanity and vitality to our work and imbues it with a special spark.

Emily was a binge eater who came to therapy to get her overeating under control. When we began to discuss her history of overeating and her life experiences, she mentioned casually the early death of her father. Emily was four years old when her father died, and her family explained, “Daddy went to Heaven.” Daddy was never spoken about again.

“Tell me about him,” I asked. “There’s nothing to tell,” Emily replied. And with that, she began to cry as the accumulation of 32 years of stifled tears came surging up in a tidal wave of pain. With each following session, Emily cried deeply about the death of her father. Then one day she exclaimed, “I wonder if after so many years my fat has been like frozen grief. I think with all these tears, my grief is becoming liquid!”

Grief—frozen by fat, frozen by the numbing of overeating, starving, or purging—can be held in the body for years and even decades. Time does not necessarily heal all wounds. Unspoken loss continues to exert its power. There is no expiration date to memories or pain.
 Loss and grief can play a significant part in people’s emotional eating. And I came to see how helping people mourn their sorrows provides a significant step towards releasing them from their eating disorder.

Often when clients begin to cry, they are able to dislodge the “knot” in their throat through tears and grieving, and discover another healing method beyond the pain-relieving medication of emotional eating.

What are some of the things a client’s body language can tell a clinician?

The intimacy between patient and therapist extends beyond verbal communication. We are more than just two minds and two voices. We are also two bodies. And bodies come alive in session! I observe how the patients who sit before me speak to me in body language. I have had many nursing mothers proudly uncover their breasts to feed their babies in my office; a vegetarian patient oblivious that her chronic garlic breath smelled up the whole room; a patient whose little daughter climbed on my lap to cuddle in session and gave me a case of head lice; a man who tracked mud into my bathroom, leaving it for me to clean up; and the girl in treatment for anorexia who blockades herself behind my couch cushions with only her toe peeking out.

In session, tears spill, noses are runny, sweaty bodies exude their odor, farts occasionally ring out, perfume may sweeten the office, as does the aura of cigarette or cigar smoked before session—these are the earthy components of the therapy relationship. The patient who may feel inadequate, like a nobody (she has “no body” that she loves), is witnessed in her bodily humanity and accepted without judgment by the therapist.

Patients often send me nonverbal messages, a body language message that needs to be translated into words: blushing, yawning, squirming, face picking, nail biting, a leg rocking rhythmically. When the patient’s body speaks and the therapist listens, the connection is deepened, attachment comes alive, hope takes root.

Justine comes to sessions always displaying her ample cleavage. She is a binge eater, and I know she always feels physically and emotionally hungry. What is her cleavage trying to tell me? Is she trying to seduce me? Or compete with me as another woman? Is she really looking for mothering from me and using her breasts as an invitation to be baby and mommy together? I do not know the answer, so I wait and watch and listen and try to make meaning out of Justine’s nonverbal expression. No digital session on a computer screen could capture the energy of these moments with her.

What steps do you take to become culturally competent?

Eating disorders do not develop in a vacuum but within a larger social and cultural context. Bingeing, purging, starving, and chronic dieting do not discriminate on the basis of race, gender, socioeconomic status, or sexual identity.

In my book, I discuss how these disorders manifest in the African American, Latino, Asian, Muslim, Orthodox Jewish, and Native American communities as well as in lesbian, gay, bisexual, transgender, queer and questioning communities. I will also ask my clients how their racial, sexual, ethnic identity is linked to their eating disorder and body image.

The clinician needs to be aware of the unique and special issues relating to socioeconomic status, immigration, assimilation, and discrimination that affect each individual client. We also need to appreciate the sense of isolation and alienation that many minority groups experience in mainstream American culture.

Working with clients who differ from the therapist in race, ethnicity, culture, and sexual orientation poses special challenges. White therapists, who are products of their cultural conditioning, may be prone to engage in racial or sexual micro-aggressions, and they must make a concerted effort to identify and monitor micro-aggressions within the therapeutic context. This process is similar to the importance of becoming aware of potential transference and countertransference issues between therapist and client and how they may unintentionally interfere with effective therapy. A therapist’s willingness to discuss racial, ethnic, and religious matters is of central importance in creating a therapeutic alliance with minority clients.

People often experience conflict when a discrepancy exists between the ideals and expectations of the two different cultures in which they live. Carmen, a client diagnosed with binge eating disorder, explained how the traditional role of the Hispanic woman was to be a home maker with many children. She spoke of how this goes against the current American ideal for a woman to be more independent, work outside the home, and earn money. For a first-generation woman, like Carmen, straddling both worlds can cause anxiety and stress especially as issues of loyalty to the values of her family of origin may compete and clash with her hopes for enhanced self-determination. Eating disorders often develop to distract and “solve” the unease and guilt of those caught in the middle of two cultures.

Helping our clients embrace and appreciate their diverse heritages enriches an inner sense of belonging—to one’s culture, to one’s body, to one’s self.

Social media can enhance and/or damage a person. Please note some positives social media provides to help with recovery.

Social media has become the centerpiece of many young people’s lives — the way they gather information about the world, the way they interact with others, and how they form their sense of self. For many clients, the digital world can be alluring, enthralling, captivating, and maybe even addicting.

But social media can be a double-edged sword for those with eating disorders since online communities can be part of the problem or part of the solution. Constant use of social media exacerbates feelings of loneliness and isolation as users tend to “compare and despair,” concluding that others are skinnier, prettier, or happier. Also, dangerous toxic online communities promote eating disorder behaviors, damaging comparisons with others, and low self-esteem.

Fortunately, there is also a vibrant upside of social media with a growing availability of helpful and healing online information on eating disorders. These healing communities have served to reduce the stigma and shame for those seeking therapy.

Social media also provides pro-recovery communities and support. Body positivity posts, the Health at Every Size movement, intuitive eating groups, online chat rooms, treatment referrals, as well as e-books, podcasts, self-monitoring apps, YouTube videos, Facebook groups devoted to recovery communities, Instagram posts with hashtag communities like #edrecovery (with over 3 million posts), and other online recovery groups have all increased people’s access to helpful and healing resources for eating disorders. Celebrities have shared their personal struggles online which may also help break through the isolation felt by so many sufferers.

This is the positive side of social media, and directing our clients to these pro-recovery Web sites can enhance eating disorder healing and increase body positivity.

Of course, our favorite resource is Eating Disorders Resource Catalogue! Begun in 1980 they offer comprehensive eating disorder information, podcasts, a free catalog as well as a newsletter with articles, book interviews, a list of conferences as well as treatment referrals.

Another favorite site is Eating Disorder Treatment and Information Center, founded in 1991, offers treatment referrals and a free monthly newsletter. The newsletter includes book reviews (Mary Anne Cohen is the professional book reviewer) and conference and workshop updates.

We point our clients and fellow professionals toward these resources so we can help them learn to sink their teeth into LIFE, and away from their emotional relationship with food!

About the author:

Mary Anne Cohen. LCSW, BCD is Director of The New York Center for Eating Disorders since 1982 and author of two previous books: French Toast for Breakfast: Declaring Peace with Emotional Eating and Lasagna for Lunch: Declaring Peace with Emotional Eating. Her latest book, Treating the Eating Disorder Self, integrates 200 case examples from her practice. She has appeared on national television, hosted her own radio show on eating disorders, supervises fellow professionals, is the professional book reviewer for, and is an ongoing columnist for Image Magazine.










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