5 Best Practice Tips for Treating Clients with Eating Disorders

I recently put on a training where I taught therapists who don’t specialize in eating disorders how to work with clients struggling with eating disorders and body image issues. At the end of the training, I summarized some key takeaways with a list of “Do’s and Don’ts”. Many clinicians shared that this was super helpful for them! I wanted to compile the list here for other therapists who may be interested in treating eating disorders.

If a therapist or dietitian says they treat eating disorders, and then describes these fats as “good” or “bad”- RUN! Anyone who speaks ill of a croissant cannot be trusted.

Presenting! My Top 5 Strategies for Supporting a Client with an Eating Disorder!

(or a friend, or a family member. Or maybe we should all adopt these strategies for everyone we encounter and the world would be a better place).

1) There are no “good” or “bad” foods

Food is not morally good or bad. It’s not capable of morality. It’s food.

It is a complex series of organic and inorganic compounds that, when broken down by our digestive tracts, give us energy.

Most of the food we eat breaks down into carbon molecules, except proteins which break down into nitrogen. We all need enough of these molecules to sustain life.

When someone has an eating disorder, their relationship with food becomes so unhealthy that the goal has to be neutralizing the moral view of food before anything else can be accomplished.

Clients with eating disorders like anorexia are so rigid and fearful of eating “unhealthy” foods that their bodies are suffering from the severe stress of malnutrition. This includes clients with atypical anorexia, whose bodies may not be underweight, but their restrictive food intake is severe enough that malnutrition is taking a severe toll on their health. This can occur even in clients in large bodies. Body size cannot tell us if someone is experiencing malnutrition or not.

When severe food rigidity becomes so extreme that the body is suffering, we need to neutralize food first. We need to get comfortable with eating a range of foods. Break it down into carbon and nitrogen. Understand that food gives us energy to sustain life. We need an adequate amount to be healthy. An example I think can be helpful is:

Imagine encountering a group of people who have been suffering from famine. Their bodies have been damaged by malnutrition. You would never call any food they could get access to “bad” or “junk” food. You would recognize that all foods have the molecules they need to stay alive.

Only once all foods are considered “good” foods, a client can explore some very gentle nutrition with a registered dietitian (RD). But this is a much later conversation. The first goal is to soften a clients attitude towards food.

Taking “good” and “bad” moral judgements out of the conversation is a good place to start

2) Focus on how the body feels, not how it looks

Instead of focusing on what the clients body looks like, we want to move the focus to their internal experience, i.e. their interoceptive cues about how they feel.

Often clients with eating disorders are so consumed with doing things “perfectly” from an external perspective, they lose touch with what actually makes them feel good.

They lose touch with what they like. They block out what sensations they are experiencing. They. numb out from their present moment experiences, both good and bad, focusing instead on how others may be perceiving them and making decisions for an imagined audience (social media really reinforces this slant in perception).

One thing we focus on in therapy is reconnecting with that quiet voice inside of them that says “I like this” or “I don’t like this”. “I want” or “I don’t want” can be incredibly difficult statements for someone who lost their ability to tap into how they really feel and what they really want.

We start by reconnecting to the body and let it show us the way back to an embodied sense of self.

3) Focus on what the body can do

We want to shift from seeing the body as an ornament, to seeing it as a tool.

Instead of viewing our bodies from the outside based on their ability to live up to some aesthetic standard, we want to focus on how they allow us, our little spirits, to touch and interact with the world. Can your body let you see a beautiful sunset? Can your body walk up a big hill? Can your body hear beautiful music? Does your body allow you to touch the hand of someone you love?

This can get tricky when thinking about clients with disabilities and the ways the body can limit our experiences. But we can still help our clients celebrate the ways their bodies allow them to experience life, and help them mourn the abilities they lost or never had.

All of our bodies will eventually lose their abilities. Keeping the ephemeral nature of abilities in the forefront of our minds can help us appreciate all our bodies are able to experience and do today.

4) Focus on behavior, not weight

Focus on promoting healthy behaviors, and leave the outcome to the person’s body itself.

So often our culture teaches us to “go on a diet” or (now that diet culture is cancelled and people subscribe to wellness culture instead) “start a wellness program”… but the ultimate goal is weight loss. So many people (with eating disorders or without them) view their weight as the most important measure of their health. We really want to shift this way of thinking.

How can we help clients focus on healthy behaviors, and let go of the results?

Often clients are afraid this will lead to weight gain, or weight maintenance, when they really want to lose weight.

It’s important to remember that intentional weight loss is always contraindicated in eating disorder recovery.

We can’t help a client make food a less important part of their psyches by continuing to encourage deprivation. We encourage clients to practice healthy, balanced behaviors in regards to food, movement and sleep, then leave the results up to their bodies.

Sometimes clients with a history of weight cycling (yo-yo dieting) have lower basal metabolic rates. Their bodies are perpetually primed for famine and have lowered their energy expenditure, in order to keep them alive should any future famine (aka diet) arise. These people’s bodies may settle at a higher set point as a result.

Instead of trying to manage and control the body, we treat it with respect, both emotionally and physically, and let it settle where it’s healthiest and most comfortable.

5) Get clothing that fits!

I can’t tell you the number of clients I have spoken to who are reluctant to buy themselves clothes in a slightly bigger (or sometimes smaller) size.

They feel that there is something wrong with them for allowing their body to change, not this piece of fabric.

They take their clothing as prescriptive: this is the size I was and should remain. If I don’t fit into these pants, there is something wrong with me. I should change my body, or wear them anyways and be uncomfortable all day.

The idea that their body is just right, and their clothing should serve them (not the other way around) feels preposterous.

This is especially true with underwear. No one (or few) people will see a clients underwear besides the client themselves (unless they have a very colorful social life, which good for them if so lol).

This makes buying underwear that fits even more difficult. It is just for their comfort. It can be especially easy for them to think- this doesn’t matter! Because often clients with eating disorders are so used to neglecting their own needs and feeling selfish for taking care of themselves, they can easily neglect their body's need for comfort.

So please, ask if they have clothing that fits and they feel comfortable in.

There you have it! My 5 top tips for supporting a client with an eating disorder. Stick around next week for my top “Don’ts”.

If you’re a therapist treating a client with an eating disorder and you feel unsure about any aspect of their treatment, reach out to me! I would love to help you feel confident assessing and treating an eating disorder.

If you’re a client who feels like other therapists haven’t really understood how to help you with your eating disorder and you want someone who gets it, reach out to me.

Eating disorder are highly treatable. Full recovery is possible.
I’d love to help you get there.

Book a consultation today.

The contents of this blog are for informational purposes only. This blog is not intended to be a substitute for professional advice, diagnosis, or treatment that can be provided by your own mental health practitioner. If you have any specific concerns about your mental health, you should consult your doctor and you should not delay seeking medical advice, or treatment for your mental health, because of information on this blog.


 
 
 
 

Megan Bruce

Megan Bruce is a licensed therapist specializing in eating disorders, anxiety and perfectionism, and quarter life challenges. She is based in San Francisco and sees clients in-person and virtually in the greater California area.

 
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