Eating Disorder Treatment: What Social Workers Need to Know
by Mary Anne Cohen, LCSW, BCD
For many people, trusting food is safer than trusting people. For many, loving food is safer than loving people. Food never leaves you, never rejects you, never abuses you, never dies. It is the only relationship where we get to say when, where, and how much. No other relationship complies with our needs so absolutely!
Every person’s eating problem is as unique as a fingerprint, and so one size treatment does not fit all. The goal is for the clinician to co-create an individualized and comprehensive treatment approach in collaboration with our clients that will help them break the chains of emotional eating and body image distress.
Social work clinicians increasingly see clients with eating disorders in their agencies or their private practices. Sometimes, the client specifically seeks help with binge eating, bulimia, anorexia, chronic dieting, or body image struggles. Other times, clients do not discuss their eating problems until therapy is well under way, and the person has come to trust the therapist with the shameful “confession” of having an eating struggle. And, sometimes, eating disorders are not full blown but “subclinical,” and clients have not fully realized the impact of their eating disorder behaviors on their self-esteem.
Given that at least 30 million people of all ages and genders in the United States are diagnosed with an eating disorder at some point in their lives and given that clinical social workers are one of the nation’s largest providers of mental health services, social workers need to be aware of the latest diagnostic and treatment information on eating disorders.
What We Know for Sure: The Perfect Storm
A perfect storm for the development of an eating disorder includes six interrelated factors. Identifying and understanding how these factors express themselves uniquely in each client will help us create effective interventions.
1. Media and social pressure
Our culture fosters the relentless pursuit of thinness. Through advertising, social media, and the media’s coverage of fashion models and celebrities, we get the message that young, skinny, and white is the ideal image. Many other cultures also define success according to weight and appearance. A poignant and heartbreaking documentary, The Illusionists, notes that women in Africa and Asia spend vast amounts of money on skin-lightening products with sometimes detrimental effects to their health. In America and Western Europe, on the other hand, Caucasians are invested in tanning sprays and tanning salons, which also can negatively impact their health. Some people even become obsessed with tanning, giving rise to the label “tanorexia.” The media breeds within us perpetual dissatisfaction. If you are a woman of color, you want lighter skin. If you’re a white woman, you want darker skin. We can never get it right!
The poet William Butler Yeats wrote:
To be born woman is to know
Although they do not talk of it at school
That we must labor to be beautiful.
And labor and angst we do! And men do too!
2. Genetic predisposition
Eating disorders are biological as well as psychological illnesses. To date, scientists have identified more than 400 different genes that are implicated in overweight or obesity, although only a handful appear to be major players. Genes contribute to weight by affecting appetite, satiety, metabolism, food cravings, body-fat distribution, and even the tendency to use eating as a way to cope with stress.
A family history of anxiety, depression, and addictions can predispose a person to eating disorders. Therapists in the field of addictions have applied the metaphor of a gun to describe the multi-faceted reasons that people turn to drugs and alcohol. This is applicable as well to illustrate the development of eating disorders.
Sandra, a 19-year-old with bulimia, came from a family where her father was a binge eater and had an alcohol use disorder. This genetic background predisposed Sandra to an addictive relationship with food, and so the threatening “gun” was created. The gun was loaded when Sandra was 15. Her parents divorced, and her dad remarried and moved to another state. She started turning to overeating for comfort and companionship. It was only after she left home to go to an out-of-town college that her sense of isolation, anxiety, and depression mounted. This emotional upheaval triggered the gun. Sandra began to binge and purge and developed a full-blown eating disorder.
For Sandra, an empathic and nurturing relationship with her therapist helped to soften and avert the impact of that “bullet.”
3. A traumatic life event
Physical or sexual abuse, the early loss of a parent, or other traumatic events set the stage for people developing an eating disorder as a coping mechanism for pain and a way to dissociate from their anguish. When the boundaries of a child are violated through abuse, a child concludes that adults cannot be trusted. The child learns that trusting food is safer than trusting people.
When Dave was nine years old, his beloved uncle sexually abused him and directed Dave not to tell anyone because he wouldn’t be believed. Dave began having insomnia and turned to overeating to quell his anxiety and confusion. Although he continued to be a good student, his insides were in turmoil, only relieved by the “sweet” comfort of food. This coping mechanism persisted through adulthood until his work in therapy helped him grieve the losses he suffered as a result of the abuse. Then, he was able to find other ways of self-soothing beyond the food.
4. An obsessive compulsive personality
People with obsessive compulsive disorder (OCD) are driven to perfection. OCD is a biological illness, and social work clinicians see this especially in anorexics, compulsive exercisers, and orthorexics who strive to eat only “clean” food. But no amount of exercise, weight loss, or “clean” eating is ever good enough to quell the anxiety of the person with OCD who can never get it perfect enough. Therapy and medication can help dial down the unrelenting quest for that elusive perfection.
Ashley came from a family devoted to sports. The children were pushed to choose a sport and devote their free time to practicing and staying lean and muscular. Ashley developed bulimia in college when she was drawn to creative writing and wanted to leave her life of sports behind. Her family’s disapproval locked her into a cycle of guilt, overeating, undereating, and purging until she went to therapy to sort out this conflict.
5. Weight loss diets
Diets have been called the “gateway” to eating disorders. When people experience emotional distress, they often turn to the “solution” of dieting to make themselves feel better and more in control. Although diets initially can lead to weight loss, they invariably set up cravings and rebellion and then break-out bingeing. The restriction of dieting will eventually lead to overeating, which may lead to purging and then even stricter dieting. A vicious cycle is created, and people find themselves trapped in a lifetime of chronic dieting and bingeing.
6. Family attachment and communication problems
The seeds of eating disorders usually begin in childhood. From the very first moment of our lives, a connection exists between eating and deep emotions. The vital emotions of trust, dependency, security, generosity, and the acceptability of our needs begin at birth in the feeding experience with our parents. Love has its origins in the satisfying feeling of being well-nourished.
How we feed ourselves, how we take care of ourselves, how we tend to our own needs is based on these early patterns of how our parents cared or did not care for us as children. When we are taught that our needs and our hungers are acceptable and approved of, we, in turn, learn to care for our needs and our hungers in loving and self-protective ways. With that secure foundation, we do not need to resort to eating disorders to fortify ourselves. This capacity to soothe one’s self may be the key ingredient in preventing an eating disorder!
But when we are shamed, neglected, or made to feel inadequate, we come to treat ourselves in a similar manner. Eating disorders are attachment disorders. When early attachments fail to nourish, addiction to food or substances becomes an attempt to repair the hurt self — to provide comfort, consolation, and to fill up the vacuum within. Emotional eating takes the edge off anxiety and is easier to control than the uncertainty of human connection.
Developing healthy attachments through friendships, love relationships, support groups, and psychotherapy provides good medicine for the body, heart, and soul! The freedom to live a life unburdened by obsessive thoughts about weight and size and compulsive behaviors about food and eating is a tremendous relief, freeing the person to embrace life with more curiosity, zest, passion, imagination, and love. The role of the social work clinician is to help people sink their teeth into life, not into their relationship with food.
Mary Anne Cohen, LCSW, BCD, is Director of The New York Center for Eating Disorders and author of French Toast for Breakfast: Declaring Peace with Emotional Eating and Lasagna for Lunch: Declaring Peace with Emotional Eating. Her latest book, published by NASW Press (2020), is titled Treating the Eating Disorder Self: An Integrated Comprehensive Approach for the Social Work Clinician. For more information, visit www.EmotionalEating.Org.