YOU ARE HOLDING 2 CEs IN YOUR HAND! NASW is pleased to offer this FOCUS Homestudy Course from September 2009. How it works: Read CE program, complete the post-test/evaluation, mail them to the Chapter office with your check. Score 80% or better and NASW will mail you a certificate for your CEs. It’s that easy!

With this format and our HomEd audio programs, the Chapter continues its goal of ensuring that social workers, including those with mobility or other impairments, are able to meet their continuing education requirements. If you have comments, concerns or other questions please e-mail [email protected] or call 617-227-9635 x17. Understanding and Treating Overeating and as Clinical Issues Karen R. Koenig, M.Ed., LCSW

knowledge we use in therapy is science-based. Researchers are Learning Objectivies working hard to learn more about neurotransmitters, hormones, biogenetics, DNA, metabolism, , and the impact of stress 1) To identify how cultural, gender, genetic, biochemical, and trauma on the body and the brain. But this enlightened state of metabolic, hormonal, family, stress and other factors affairs was not always the case. Stop and consider how problems influence clients who are overeaters and overweight; of excess and addiction were viewed throughout history. One 2) To recognize how clients’ beliefs about eating, weight, view was that if a person exhibited compulsive behavior, he or she and their bodies affect their food-related behaviors; was inhabited by demons or devils. In fact, even today, when we eat something we believe we should not, we might chuckle and 3) To understand the impact that poor emotional say, “The devil made me do it.” How often do we hear people and management has on disregulated eating; the media talk about food decisions as a battle between the forces 4) To recognize how the development of life skills of good and evil? Overeating, or gluttony, is considered one of the supports recovery from disregulated eating problems. seven deadly sins, and self-discipline and will power have been seen as the traditional way to win the battle of the bulge.

This religious framework for viewing overeating remains to this Introduction day. Sadly, very few people, including social workers, understand that there is nothing “good” or “evil” about being thin or fat, or In 30 years of clinical practice, I have often heard social workers about undereating or overeating, or even about food in general. say that they avoid treating clients with eating disorders because These are moral terms which only oversimplify the problem they lack expertise. Although advanced training is recommended and make it harder to treat. One of my major goals of writing, in treating conditions such as and , speaking, and teaching about eating and weight issues is to dispel therapists can become more comfortable dealing with problems the pervasive myth that food issues have anything remotely to do such as binge-, chronic dieting or rigid caloric- with morality. High-fat and high-calorie foods are neither good restriction, and conditions that do not meet criteria for anorexia nor bad. Like colors and notes on a scale, they have no moral nervosa, by acquiring information and gaining awareness and value; they simply are. Yes, they have nutritional value, but eating experience. Most of what is lacking for social workers in this fruits and vegetables does not make us a more ethical person than arena is sensitivity to issues, an understanding of the underlying eating a Ring Ding! Culture, however, has imbued these behaviors complexities, experience in managing these kinds of cases, and with moral overtones and sold us a false bill of goods. confidence that a general therapist can make a difference with weight-challenged clients. Historically, another way of viewing eating and weight problems has been through the lens of the medical model. People who were To remedy this lack of knowledge and expertise, I was asked by obese were sent to fat farms and expected to lose weight and keep W.W. Norton Books to write What Every Therapist Needs To it off. Excess pounds were to be shed as if they were a disease that Know About Treating Eating and Weight Issues. The goal of the had a one-time cure. The fat farm was like medicine: spend time book is to provide non-eating disorder specialists with information there and your weight problem will be resolved. Hand in hand with and insights that will provide the competence and confidence they the medical model is the addiction approach to food and weight. need to recognize and treat food and body issues as they arise in It is not surprising that the success of Alcoholics Anonymous the course of therapy. This course covers some of the material spawned (OA). OA and groups like it are included in that book as well as in my other books. based on a 12-step model which has both positive and negative aspects. In my opinion, where they misguide disregulated eaters is in viewing as a moral failing and seeing success and failure Historical Perspectives for Viewing in all-or-nothing terms, reinforcing the idea that people are “good” Eating and Weight Issues for eating healthily and being thin and “bad” for overeating and being fat. However, the addiction model goes beyond the medical We are fortunate to live in a period of history in which much of the one in that it at least allows for relapse and chronicity of the  condition, that is, that most people will need to keep on managing gateway behavior to future eating disorders. their weight problems throughout their lifetime. • 35% of diets progress to pathological/addicting dieting which Yet another way of understanding eating and weight issues is is a chronic state of food deprivation and strict regulation. through family dynamics. In this model, dysfunctional parenting • 3.5% of adult US women and 2% of adult US men meet the is to blame for eating and weight difficulties at both ends of the criteria for binge-eating disorder (ScientificAmerican.com spectrum. Typically, we are to understand that mother is enmeshed 2/1/07, “Binge-eating is major health problem Study” by and over-involved with the child and father is off somewhere Jason Szep). in the background. The solution to developing functionality is understood to be encouraging mother to back off and father to • The diet industry spends approximately 1-2 billion dollars become more engaged with the child. I have encountered all per year to promote dieting. sorts of family dysfunction in the histories of clients with eating and weight problems, not simply this singular dynamic. Many It is ironic that, although we live in the most fat phobic, thin disregulated eaters come from families whose members have all obsessed period in the history of the world, some two-thirds of sorts of addiction problems (eating, drinking, drugs, gambling, adult Americans are considered to be overweight and one-quarter shopping, work) along with numerous other unhealthy ways of are deemed to be obese (20 pounds in excess of what a healthy interacting. Sometimes mother is unavailable due to depression weight would be for them). In part, that is because of what chronic and father is controlling. Sometimes the client is the parentified dieting, especially beginning at an early age, does to disregulate child and other times she is the coddled youngest. Sometimes appetite. Here is what happens when many people diet: because mother and father are both in the background while a grandparent they are thinking about what they can and cannot eat, rather than does the parenting. Most families have some combination of the freeing themselves from thoughts of food, they become more following characteristics: unrealistically high standards; parent, focused on it. In fact, many dieters become preoccupied with not child-centered focus; parents saying one thing and doing food, particularly when they are counting calories, “points,” or fat another; emotional abuse; parents who are emotionally restricted grams, weighing themselves daily (or more!), and using a food or immature; emphasis on the external rather than the internal; scale to make sure they are only eating a specific number of ounces poor self-regulation; and a significant lack of individuation and of food. Sadly, to many people, dieting is a full-time job. separation. Moreover, when we deprive ourselves of the calories needed to feed our cells and fuel our bodies, a natural mechanism occurs which Dangers of Chronic Dieting slows down metabolism. Because our brains react primitively, they ensure that our body conserves calories by not burning up so This fact may come as a surprise: by far the most dangerous and many of them and also storing them as fat in case the body faces dysfunctional approach to managing eating and weight is through starvation. Of course, the body does not realize that we are eating dieting! How can this be true? After all, we are told repeatedly that less because we want to look good at our best friend’s wedding. we must diet to achieve and maintain a healthy weight. Doctors Instead, it responds as if food is scarce and it is doing us a favor and health care professionals insist on it and the media reinforces by making sure we shed pounds as slowly as possible. Not only the message daily. Moreover, many of you may have dieted and do people become obsessed with food when dieting, but they also have lost weight. Using your own experience, you may say that feel frustrated as metabolism slows and becomes more dieting works. Yes, diets do work—in the short-term for some gradual or they reach a plateau. On top of that, they look around people. The problem is that they do not work in the long-term and see other people eating foods they crave and used to enjoy, for most people. Did you know that 95-98% of people who diet and feel intense deprivation. Thus, chronic deprivation eventually and lose weight, gain it back? Or that 90% regain more than they wins out over long-term weight loss goals and the diet crashes. originally lost? This is a statistic you may not have heard before Along with deprivation, dieters may also experience a rebellious because the diet industry does not want you to hear it. Yet, this rebound mentality. We have all had clients who dislike anyone percentage has stayed relatively stable since I began working in telling them what to do. They had enough of that growing up or the field of eating disorders in the early 1980s. contend with it now at work or with their families. Rather than Below are other statistics and facts about dieting of which you may think through what might be best for them in the long-term, when not be aware but which will help you understand how pervasive they are advised to do something—even something healthy—to dieting is in American culture: help themselves, they rebel. This is the kind of mentality we see when clients refuse to take medication because they do not like • There are about 17,000 diet methods and plans available being dependent on it or drop out of therapy because they insist today. they can handle their problems on their own and do not need our guidance and suggestions. Indeed, when dieting, folks often feel • Slightly under one-quarter of US adult males and one- angry and resentful that others (often authority figures) are telling third of US adult females are on a diet on any given day. them what, how much, and how often to eat and so they revolt • Weight loss clubs and programs take in about 8 million by breaking rules. Some understand on some level that they are dollars per year and “lite” products take in about 14 million hurting no one but themselves, but others cannot see anything dollars. beyond the need for them to exert free will. Either way, going off the diet feels so satisfying and gratifying in the moment, that • Dieting is considered by eating disorder experts to be the common sense vanishes.  Additionally, some clients really do not know how to feel okay believe they need to slim down because the media or even their about saying no to themselves. Depriving themselves of something health care providers tell them to. Unfortunately, women in this they love or restraining themselves creates such internal distress culture no longer have any valid idea of what they should look that they cannot tolerate the feeling and, therefore, cave in. These like. Marilyn Monroe wore a size 14 dress, but today that same clients often had parents who could not say no to themselves or size dress would indicate being fat to most men and women. their children. Or they said no so harshly that the child was thrown into excessive inner turmoil that could not be soothed. Clients Although many other countries and cultures subscribe to the “thin who cannot say no to themselves—or hear it from others—often is in” mantra, pressure is generally not at the intensity that occurs become so agitated that no becomes unbearable. They do not know in the US. American women have little latitude about what they how to comfort and soothe themselves, find positive outcomes in “should” weigh. Unlike many European cultures where sensuality self-denial or in self-restraint, or stick with restriction long enough is not measured in pounds but in how a woman carries herself and to achieve rewards. how she brings forth her inner sexuality, in this country, there is a straight line (pun intended!) between thin and sexual. South and The major reason that chronic dieting is so dangerous in terms Central American women are allowed more roundness than their of future “normal” eating is that it leads to appetite disregulation aspiring slim-hipped North American counterparts. Black culture and distrust of self. The bulk of clients who are overeaters and is more accepting of curves and a womanly shape. overweight have been on diet after diet and have lost weight and regained it. They believe there is something intrinsically wrong The truth is that much of our weight, bone and body structure is with them that they cannot attain or sustain weight loss. They predetermined by our cultural heritage. Consider the following stop trusting themselves and their instincts and berate themselves ethnicities: Asian, Scandinavian, Mexican, and North American. for not being able to do what they think they should do or what Asians are generally smaller boned than Scandinavians; Mexicans appears to be easy. They think, if other folks can slim down by are usually more stocky. Our height and bone structure is inherited dieting, there must be something gravely defective about me that and unchangeable. But many people in the US ignore their ethnic I cannot. The fact is that chronic dieting actually can put more backgrounds and want to look like the celebrities they see who weight on people because regained weight is often in the form of epitomize white Anglo Saxon culture. fat. This is one of the reasons that eating disorder experts warn so Ask a client to bring in a family photo that goes back two to four strongly against yo-yo dieting. It is a dead-end street. generations and she will have a better idea of the hand she was Later in this course, approaches that can help clients lose weight dealt in terms of weight and body structure. Think of the array and keep it off will be presented. For now, it is important to we have to choose from. Some families are broad-shouldered and understand the dangers of diets because it is natural for therapists thick-boned like football players. Children from these families working with overweight clients to offer suggestions about them often were larger than average infants and grow up to be larger and about diet programs. As Maya Angelou says, “We do the than average adults! Other families are small-boned, petite, and best we can with what we know, and when we know better, we do compact like jockeys. Children were perhaps as better.” By educating yourself about the general inadequacies and babies, matured late, and remain at the lower end of the weight ineffectiveness of diets, you will be serving your clients’ needs range all of their lives. Then there are people who are tall, long- more effectively. Of course, some clients may lose weight by boned, lithe or leggy like dancers or basketball players. Only about dieting, but most will not keep it off without the psychological 7% of American females are born with these characteristics, yet understanding and support that you can give them. 93% of us want to look exactly like them. These are the women whom we idealize as having a perfect figure—merely because they were born with the “right” proportions. Gender, Family and Cultural Factors Nowadays, there is certainly pressure on men to lose weight but, again, the emphasis is for them to slim down in order to become It is obvious which gender has the most pressure to be slim healthy. In my experience, men are more likely to see exercise and attractive. Just look at fashion, celebrities, and media as a route to weight loss, while women tend to jump on the diet advertisements, and you can see the burden women operate bandwagon or look to liposuction or bariatric surgery. On a under. Research tells us that men generally want to slim down to brighter note, there seem to be more families these days focusing improve their health and women wish to lose weight to improve on healthy eating and getting adequate exercise, although, sadly, their appearance. Sadly, in terms of making permanent change, they are still in the minority. women are at a disadvantage with this incentive. Due to excessive pressure to be thin, they end up with a motivation which does not translate into long-term weight-loss stabilization. That is, studies The Biology of Eating and Weight conclude that people who are motivated to lose weight for health reasons rather than appearance have a better chance of keeping it In her compelling book, Rethinking Thin—The New Science of off. Weight Loss and the Myths and Realities of Dieting (Picador/ Let’s face it, in today’s culture, thinness is equated with beauty, Farrar, Straus and Giroux, New York, 2007, www.rethinkingthin. success, love, and approval. You know the old saying, “You can com), Gina Kolata, New York Times science writer, brings us never be too rich or too thin.” Little girls as young as five- and sobering news. She maintains (and cites evidence to back up her six-years-old feel fat and diet. Average-weight, healthy women assertion) that 50-70% of our weight is genetically predetermined.

 That means that half to almost three-quarters of what we will through millennia and adaptation for survival to do two things: weigh over the lifespan is genetically programmed and relatively conserve calories and preserve fat. Now, I hope you can see how unalterable. Of course, it also means that half to almost one-third long-term dieting promotes weight gain (or at least works against of what we weigh is under our control through lifestyle habits such permanent weight loss). When dieting, metabolism slows down as nutritional and exercise choices. Yet, she makes a strong case and stores fat, making it hard, if not impossible, no matter how that will power and self-discipline alone will always fail to trump little is eaten, to lower weight. biology when it comes to eating and weight. In animal studies, when food restriction ends, like clockwork, To understand the full impact that metabolism has on eating and the organism experiences increased hunger and eats until its pre- weight, we need to start at the beginning. The measurement restriction weight is re-attained. This is why lost weight is regained. through which living things turn food into energy is called Our hunger comes back in full force when we have dipped below calories, the quantity of heat needed to raise a gram of water 1 a specific (for each of us) minimum weight. Moving in the other degree Centigrade. Calories are necessary to build new cells direction, science has also shown that when people are force fed and tissue, to provide heat to our bodies, and to produce fuel for to ingest far more calories than they usually consume, metabolism physical activity. Although calories have received a bad rap over speeds up to burn off the calories, ensuring that minimal weight is the past few decades, they are essential for our growth and for gained. This makes sense when you consider that much of what our our very existence. Decades ago, scientists used to believe there bodies do is to preserve the species. This speed up ensures that, was a clear, simple formula for weight gain, loss or maintenance all things being equal (which nowadays with food advertising, that was based on calories in and energy out. That is, to maintain easily accessible delicious meals, and a couch-potato culture they weight, one would have to balance the number of calories taken certainly are not), we will not gain more weight than is healthy in with the number expended. To lose weight, one would have to for us. consume fewer calories and/or increase the amount burned up in activity. Alternately, weight gain only would occur through eating Set point does not stand alone. It is influenced by genetics, age, more calories and/or using up less of them. lifestyle (sedentary versus active), nutrition, smoking, sleep, stress, and exercise. Remember that 30 to 50% of what we weigh Would that such a simple formula were applicable in every case. is in our control. It is very easy for us to get lulled into a sense of Although it is true that, in general, we can base our considerations helplessness and hopelessness when clients throw up their hands about weight on calories in and energy out, there are myriad and say they have tried everything and nothing helps them lose factors which affect this formula for better or worse. For example, weight or keep it off. Although we do not want to raise expectations perhaps you know of people who are not particularly active, yet beyond what is possible, we also have to be careful not to give up have the ability to eat whatever they want in large quantities on clients when they become frustrated and stuck. Approaches to and remain slim. Or you know folks who are diligent exercisers help clients will be described later in this course. and ultra-careful eaters, but can barely remain at a healthy weight despite their vigilance and commitment. It turns out that hormones and other biochemical processes are at work when it Appetite Regulation comes to metabolism and that there is nothing simple about weight management. Much of what we know about appetite regulation comes from One useful approach to understanding metabolism is called set scientific studies on rats, not humans, but scientists believe that point theory. Although it has its challengers and detractors, it is our systems function similarly to theirs (minus, of course, our a functional way to view the complex processes that occur in our cognitive abilities around food which often slip out of gear!). bodies relating to losing and gaining weight. Set point theory Over the past few decades, research on appetite regulation has posits that we are pre-programmed genetically to maintain a certain been an ever expanding field, yet we still have as many questions weight range and that we cannot remain for long above or below as answers and it seems that each new answer generates a whole it. Think about how a thermostat regulates room temperature. host of queries. Basically, we know that appetite and weight are That is how set point works to regulate appetite. A thermostat regulated by brain chemicals which monitor information about the keeps temperature steady within a pre-set range, going on when body’s energy and fuel needs, mostly through the hypothalamus. the air temperature drops below a minimum and off when the air This organ functions much like a store computer which processes temperature hits a maximum. Likewise, when the body’s “fat-o- data on inventory and stock needed. When energy is required by stat” reaches its lowest weight due to voluntary or enforced food the body, the brain stimulates appetite to consume more calories, intake, the body automatically slows down its metabolic rate to and when no more of them are needed and enough fat is on hand, conserve calories which are stored as fat. the brain sends out a satiation message. Said another way, the brain lowers and raises the body’s overall energy needs according The key word here is automatic. The body does not know that to the amount of fat that is stored, that is, it knows to burn more the doctor said to lose weight. It reacts as if there is a famine and when there is a great deal of fat available and slow down the food is unavailable because we are programmed through evolution burning process when stores are reduced. Think of the process as to survive! What we have here is an amazingly efficient process supply and demand. that has helped our species weather food scarcity and times of near starvation since the beginning of human history. Due to evolution, Interestingly, some folks are better at storing fat than others. There the body’s appetite regulation mechanisms seem to be hard-wired is a gene that passes on this trait from one generation to the next. It is sadly ironic that people who are overweight could be seen

 as having the best survival genes and are the ones who would be sophistication of brain scans, we can monitor and measure how the most likely to remain alive during famine. However, in this food, specifically eating certain foods, affects blood flow to the society, because we live in a land of accessible and scrumptious brain’s pleasure center. plenty, the evolutionary benefit of being efficient at fat storage makes it harder to lose weight and keep it off. To understand why food might register as pleasurable, we need to take a step back for a moment and look at its function in our Although there are numerous chemicals involved in appetite lives and in the existence of our species. Plain and simple, food regulation, some are more influential than others. One of the main evolved to taste good so we would eat more of it and survive and components of this process is ghrelin which is produced in the thrive. It was meant to bring us pleasure so that we would repeat stomach to signal its emptiness. It is the generation of ghrelin the experience of eating and not starve to death! This pleasure which gives us our sense of hunger. Think of ghrelin as the needle occurs through a release of dopamine in the brain which makes on your car’s gas gauge pointing to empty. At the other end of us feel wonderful all over. The process goes something like this: the spectrum, there are hormones such as leptin and insulin which eating specific food → burst of dopamine → eating that food influence satiation. Think of them as the needle on the gas gauge again → another dopamine hit, and on and on. This is a highly that says you are full up and good to go. effective system and has kept us alive for millennia. Remember when I said that all foods are not created equal? Here is where this When these chemicals—and other appetite-regulators—are in point is important. We do not get that hit of dopamine from all appropriate balance and proportion, we get the correct amount of foods, only those which are high in fat and sugar. Why might that food to maintain a healthy weight for our lifestyle. For example, be? If you think in evolutionary terms, you will have the answer. we know when we are full and satiated. When we are sick or Foods contributing most to survival are those that contain the most lounge about like slugs for the day, we require less fuel, and eat energy in the smallest amount of space and lead to the most fat less. When we are running around all day or engaged in sports, storage: fats and sugars or carbohydrates. They are tasty so we our body demands more fuel and we eat more. Unfortunately, will eat more of them rather than foods that will give us less energy when the chemicals regulating appetite are out of whack (due to and promote less fat storage. For survival, our brains are trained stress, medication, medical conditions, or genetics), our appetite through the dopamine response to crave nutrient-dense food. becomes disregulated, and we have difficulty eating “normally” and managing a stable weight. For instance, scientists have To complicate what seems like a simple process, however, some recently discovered that we all do not possess the same amount scientific studies indicate that people craving carbohydrates often of leptin. When a client says that he does not know when he is have low serotonin levels and, therefore, turn to foods high in full, we need to accept that this may be a case of biology, not fat and sugar to alter their moods, that is, be soothed or relax. simply inattention to body cues. Unfortunately, unless a person’s Unfortunately, dieting and weight cycling decrease the amount leptin levels are tested, he would not know that he had a deficiency of serotonin levels in the blood stream by lowering levels of and instead would be likely to blame himself for his failure to tryptophan, an amino acid which is a building block or precursor recognize satiation. to serotonin. This is one of the reasons that people may be prone to weight gain. Without a sufficient amount of serotonin in their brains, they end up seeking food to do the job that their The Role of Neurotransmitters in neurotransmitters should be doing. Eating and Weight Problems Stress, Eating and Weight Most of us know about neurotransmitters because we treat clients who have depressive or anxiety disorders which are caused by an imbalance of these chemicals. What you may not recognize is Most of us have had the experience of eating emotionally or how imbalances can cause and affect eating and weight problems compulsively. There we are watching the big game and discover as well. Neurotransmitters are chemicals that relay, amplify, and to our chagrin that we have finished the entire box of cookies or modulate electrical signals between cells in order to regulate mood bag of chips that was half full an hour ago. Doing this once in and affect. There are about 50 regulators, but four are the most a while is normal and not unhealthy. It is part of being human. well known and influential as mood modulators: What is neither normal nor healthy is chronic emotional or compulsive eating due to stress. Compulsive eating is defined as • Serotonin soothes unpleasant emotions. food consumption which is due to mindlessness. It may or may not be stress induced (such as in the example of watching your • Dopamine regulates bursts of intense concentration and favorite team compete). Sometimes we eat compulsively because generates feelings of euphoria. our mind is elsewhere and we are distracted from internal appetite • Norepinephrine causes generalized, sustained alertness; cues. , on the other hand, is food seeking behavior • Gamma-aminobutyric acid (GABA) promotes relaxation. to avoid or lessen internal distress. When emotions become too overwhelming, we turn to food to modulate affect. Although Sigmund Freud made many wrong conjectures, he was dead on when he said that humans—all organisms actually— Stress eating is biologically driven and, once again in this case, all move toward pleasure and away from pain. We know this now foods are not created equal. We generally do not crave broccoli through brain scans which monitor blood flow through specific or a steak when we are on edge or uptight. Rather we go for circuitries of pain and pleasure. More to the point, because of the carbohydrates, foods which are high in sugar and fat. That is

 because of how these substances are metabolized in our bodies • Environment: Toxic air and chemicals may alter our and how they make us feel (remember those bursts of dopamine!). biochemistry in ways that affect metabolism. They smooth out our rough edges, calm us down, and zone us out, exactly the numbness we desire when we are stressed to the max. • Climate Control: It may be that humans are gaining weight because our bodies no longer have to work hard to heat up or The subject of stress eating is actually a bit more complicated than cool down due to living in climate-controlled environments. just craving carbohydrates when the going gets rough. First of • Smoking: Quitting smoking reduces the amount of nicotine all, we know that depression and anxiety often run in families, in the system, thereby, increasing anxiety and causing people leading us to recognize that not everyone is born with the same to turn to food to relax. complement of neurotransmitters. Some of us have a sufficient amount and some of us do not. If we lack these chemicals, we will • Fertility: Obese people may be more fertile than those be more prone to be negatively affected by stress, that is, more of average weight and, therefore, more of them in each sensitive to it and less able to deal with it effectively. generation are reproducing.

Therefore, we may experience life as more stressful. Moreover, • Sleep deprivation: Sleeping less correlates to obesity. if the people who passed down our DNA to us, our parents, have a similar neurotransmitter deficit and cannot modulate their stress New research on obesity has led to a greater understanding of its effectively, they likely will be highly stressed caretakers who multiple causes and specific ways to help people lose weight and cannot soothe and manage our (or their own) distress appropriately. keep it off. Here are some interesting examples: This is what I call a double whammy from both nature and nurture, and is the case for most of the disregulated eaters I treat. • Even though we lose weight and the amount of fat in each cell may grow or diminish, the number of fat cells in the Let me explain how stress affects the individual. During ongoing body remains the same. or regularly intermittent stress, “happy messengers” such as serotonin, noradrenaline and dopamine may malfunction. In • Overeating is linked to a gene, dubbed the “willpower gene,” ongoing tense, highly charged situations, neurotransmitters simply which has been cited in problems with alcohol and drug cannot keep up the pace of modulating internal distress. This leads abuse. (Allure, 5/08) to more stress and a body and brain that cannot move out of high • Merely seeing a suggestion to exercise may produce physical gear. Excess stress can lead to fatigue, physical aches and pains, hunger. (Obesity, 2009, doi:10.1038/oby.2009.16) anxiety, depression, sleep problems, digestive conditions, and an inability to function effectively. • There may be a correlation between binge-eating disorder and Attention Deficit Disorder. (Allure, 7/08) There are actually two kinds of stress: acute and chronic. Acute stress stimulates a cascading release of hormones which interact • Women may be less able to suppress their hunger than men with the brain and the central nervous system. This burst of are. (Proceedings of the National Academy of Sciences, hormones keeps us alert and at the ready. However, when stress 1/27/09) persists more than 24 hours, these high alert hormones become • Overeating may make it harder to burn fat through exercise. chronically elevated and trigger anxiety. This increased anxiety (Journal of Applied Physiology) then signals the central nervous system to release more stress hormones, a physiologically and psychologically destructive • What you eat may influence your mood, stress and reaction called the “chronic stress response network.” Chronic energy levels, sleep-wake cycles, and mental functioning. high concentrations of certain stress hormones increase the (Environmental Nutrition, 2/2003, vol. 26, No. 2, p.1) preference for high-sucrose and high-fat foods. Consuming excess carbohydrates in order to feel better emotionally actually increases • Some overweight children have gut microbes that may fat storage (especially in the abdomen), which down the road can inhibit them from becoming obese. (Science News, 4/08) lead to feeling worse emotionally due to being overweight. • Some people have fewer brain cell receptors for dopamine, the feel good chemical that is released when we experience pleasurable stimuli, causing them to eat more to gain the Factors That May Contribute to same enjoyable effect. (Washingtonpost.com, 10/16/08) Eating and Weight Problems It is vital for therapists to understand that overeating and obesity are not the result of lack of willpower and self-discipline and how One of the major gifts that science has given us over the past difficult it is for people with eating and weight problems to make few decades is abundant research on appetite, metabolism, and and sustain progress. In many cases, if not most, their biology our bodies as biochemical machines. Not only has this research is working against them—through genes, neurotransmitter helped to a small extent to alleviate the stigma of overeating and imbalances, and stressful childhoods. The steps they often take overweight (by labeling it a physiological problem rather than a to lose weight—dieting or severely restricting caloric intake, moral one), but it has provided hope for multitudes of overweight followed by more binge-eating—are exactly the ones that put people along with avenues for weight problems to be resolved. the weight back on them and lead them further away from their Here are some general factors that science has found may impact goals. appetite and weight:

 Once clients are able to identify their beliefs about eating and How Beliefs Impact Emotions & Behavior weight, I explain that beliefs can be separated into two categories: those that are rational and healthy and those that are irrational and The Rules of “Normal” Eating describes one of the major reasons unhealthy. Rational thinking has the following four characteristics that diets do not work to keep off weight long term: they focus (p. 58, A New Guide to Rational Living, by Albert Ellis, PhD and on behavior, not on changing the beliefs underpinning our actions. Robert Harper, PhD, quoting Maxie Maultsby): Clients who have eating problems operate using a default cognitive 1. It is based on objective fact, not subjective opinion. system that is both irrational and unhealthy, and it is only when they shift these beliefs to become rational and healthy that they 2. When acted upon, it is likely to result in the preservation of can turn around their eating for good. your life rather than its destruction.

Cognitive-behavioral therapy is well known to most of you. It has 3. When acted upon, it helps you to most quickly achieve your been around since the 1960s and is defined by Mosby’s Medical, personal life goals. Nursing, and Allied Health Dictionary as “any of the various 4. When acted upon, it inhibits personal and situational methods of treating mental and emotional disorders that help a difficulties. person change attitudes, perceptions, and patterns of thinking from irrational to realistic thoughts about self and situations.” In short, rational thinking is life-enhancing. Rationality supports mental, physical, and emotional health and the attainment of Simply put, a person’s beliefs, whether conscious or unconscious, worthwhile goals. Irrational beliefs, then, promote the opposite. determine their feelings and behaviors. Change their beliefs, and Irrational thinking threatens healthy life and prevents the their feelings and behavior will be altered as well. Generally, by achievement of worthwhile goals. It is not only not life-enhancing, holding on to the same beliefs, clients ensure that their emotions but is often destructive because it generates mental, emotional, and behaviors will continue to be the same no matter how hard they and physical harm. For example, eating only until you are full try to change their actions. Though beliefs generate feelings and is rational according to Maultsby’s criteria and produces the behavior, this process is not always readily apparent. In fact, we following beliefs: Eating until fullness respects the body’s limits often experience all three—emotions, beliefs, and taking action— and is not based on whim. Eating until fullness inhibits the desire nearly simultaneously, making it difficult, without reflection, to to take in more calories than necessary, preserving health. Eating discern that the belief actually came first. until fullness supports the goal of “normal” eating and healthy As therapists, we understand that beliefs are not often self-evident weight maintenance. Eating until fullness prevents the shame and to clients. Many of them have little or no idea what they think guilt which often accompany overeating and inhibits weight gain before, during or after they engage in behavior or how their thinking which can jeopardize good health. has an impact on everything they do that is not instinctual. In order It is vital to encourage clients to brainstorm all of their beliefs about to help clients explore their beliefs about food and eating, we must food, eating, weight, and appearance, then go through and mark first explain that beliefs are the foundation of behavior, that there the beliefs which are not rational (which, sadly, is usually most are two kinds of beliefs—rational and irrational—and that each of them!). This takes time, but is well worth the effort because of us has the power to create a cognitive system that is sensible, it helps clients understand how they have been programming sound and constructive. The majority of clients grasp this concept themselves with the wrong instructions for “normal” eating and and find value in cognition exploration and restructuring. They points out exactly which cognitions are getting them into trouble. are relieved to know that there is something they can do to eat less, It establishes the link between believing and behaving and gives stop obsessing about food, and improve their self-esteem in spite troubled eaters something to work on other than counting calories of having weight problems. Most are eager to change their beliefs, and fat grams and stepping on the scale hoping to have lost a pound but find the work extremely challenging. or two. Moreover, it puts the responsibility for whatever change Before we can help clients change beliefs, however, we have they can make into their own hands. They may not be able to alter to explore where they came from. Although not all clients are their heredity or biochemistry, but they can (with attention and willing to do this, in my experience, most of them are willing to at practice) shift their beliefs. Analyzing and transforming beliefs least do some brief exploration. It is vital when we engage in this also gives them a place to return to when they relapse around food kind of examination with clients that they do not see us as blaming or stop making progress. Nine out of ten times, they will find that their parents or family care-takers. I generally explain that I am underlying destructive or unwanted behavior around food is an seeking cause and effect, not blame, using the analogy of lack of irrational belief. rain leading to wilting of flowers, that is, not blaming clouds for Here is a partial list of irrational beliefs about food, eating, weight, not relinquishing water, but drawing a correlation between the two. and body along with two examples of each belief reframed in a When clients say they do not know what they believe about eating rational way. IB means irrational belief and RB means rational or weight, it is helpful to explore what they think their parents belief. thought. In order to free up clients to brainstorm, I often write down the beliefs they generate. Or I give them this assignment for IB: Food is love and comfort. homework when they can spend adequate time on it. RB: Food is for fuel and pleasure. RB: People are for love and comfort.

 IB: Foods can be divided into two groups: good (low-calorie, IB: Thin people are happier than fat people. low-fat) or bad (high-calorie, high-fat) RB: Thin people are no happier than fat people. RB: There is no such thing as good and bad foods. RB: Thin and fat people may be happy or unhappy. RB: Foods can be nutritious or non-nutritious, but never good and bad. IB: Feeling proud or ashamed of myself depends on what I weigh. IB: Food should never be wasted. RB: I can feel proud of myself at any weight. RB: Food can be set aside or thrown away if I am no longer RB: There is nothing shameful about being overweight. hungry. RB: I am not a bad person for wasting food, therefore I have no IB: Thin people are lucky and can eat whatever they want. need to feel guilty when I do. RB: Most people, even thin ones, need to monitor what they eat for health. IB: I can keep eating and eating and never feel full or satisfied. IB: Thin people may be lucky in having a different metabolism RB: With attention and practice I can learn what it feels like to than I do, but I may be luckier than they are in other ways. be full or satisfied and stop eating. RB: Fullness and satisfaction are natural states that I once IB: My body needs to be perfect or I can’t be happy. recognized and will learn to recognize again. RB: I can be happy with myself at any weight. RB: There is no such thing as a perfect body. IB: I cannot say no to food. RB: I can learn to say no to food when I’m full or satisfied. IB: If I don’t eat sweets and treats, I’ll be anxious or depressed RB: Saying no to food means saying yes to health and self- all the time. esteem. RB: I can learn more effective ways than eating to help myself not be anxious or depressed. IB: Food is a good reward when I’m stressed. RB: Eating sweets and treats, rather than engaging in healthy RB: Food is not a good reward when I’m stressed because behaviors to decrease my anxiety or depression, can make unwanted eating causes me to feel badly about myself in these states worse. the long run. RB: I can discover effective ways to deal with stress that do not IB: I have to be a perfect eater. include food. RB: No one is a perfect eater. RB: I accept myself as an imperfect eater. IB: Eating makes me fat. RB: Eating past full or satisfied makes me fat. IB: I cannot trust myself around food. RB: Eating is a natural process that gives my body fuel and RB: I am learning to trust myself around food. pleasure. RB: Self-trust comes with experience, including reflecting on my mistakes around food and problem-solving so that they IB: If I start eating something, I can’t stop. will not happen again. RB: I can stop eating any food if I put my mind to it. RB: I can eat foods I enjoy and stop when I’m full or satisfied. It is useful to encourage clients to keep a beliefs journal in which they jot down irrational beliefs as they recognize them. They must IB: It’s bad to be hungry. then reframe them and put them into a second part of the journal RB: It’s natural to be hungry. which contains their new, rational, healthy belief system regarding RB: Hunger indicates that my body requires fuel. eating, food, body, and weight. This is arduous work and some clients are diligent about it, but most are not. We, as a society, IB: Feeling good or bad about myself depends on what and are so focused on external behavior that we are not trained in self- how much I’ve eaten. reflection. Helping clients value the work of reflection, especially RB: I can feel the same about myself no matter how much I eat. on their eating beliefs and behaviors, gives them a life skill which RB: I can choose to always feel good about myself. they need in order to improve their relationship with food.

IB: I always feel deprived if I have to say “no” to foods I love. One last word on cognitions that relate to food and weight. RB: I can say “no” to foods I love and not feel deprived. Sometimes clients are able to establish a rational belief system and RB: Feeling deprived is a choice I make or can refuse to make. still suffer with eating problems or cannot shed pounds. When this happens, I shift gears to help them explore their core beliefs, which IB: I have to be thin. are the (generally unconscious) operating instructions or default RB: I respect the natural size and shape of my body. setting they use in life. Core beliefs include cognitions such as: RB: I don’t have to be any particular size to love my body. The world is a safe/unsafe place; if I try hard I will succeed/still probably fail; I can/cannot usually trust other people; life is fair/ IB: I need to weigh myself every day. unfair; life is a hard/easy. RB: If I use appetite signals to monitor my eating, I won’t need the scale. Although I have found the most effective way to deal with RB: I can develop internal rather than external means to transforming behavior starts with changing cognitions (which then measure my eating. impact emotions and behavior), clients can also make changes by

 focusing on modifying their behavior and improving at handling This statement brings me to the definition of “normal” eating. The their emotions (more on emotional eating later in this course). word is in quotes because, unlike subscribing to a diet, there is For example, a client might notice that forcing himself to stop no one ideal way for everyone to eat. Some people eat frequent eating when he feels full over the course of a few months makes small meals all day. Others enjoy three square ones and rarely him realize that, indeed, he is more in control of his eating than snack in between them. Yet others do well with two substantial he previously thought and that he can avoid falling prey to his meals. Although it is true that the body generally suffers from fuel impulses. The pride he feels when he does not overeat ensures depletion upon awakening, some folks are hungry for breakfast that he will repeat the desired behavior. He can then go back and right off and others need to awaken slowly and do not feel like see that what he believed—“I have no control over my eating”— eating until mid-morning. is, in fact, no longer true, because he has proven to himself that he does have power to stop eating when he is full. Recognizing when “Normal” eaters, however, are guided by four specific principles. behavioral shifts happen changes beliefs because it is evidence They do the following most of the time: based on actual experience. 1. Eat when they are hungry. A few major irrational core beliefs stand in the way of making 2. Choose satisfying foods. progress with food and the scale. For instance, many people are 3. Eat with awareness and enjoyment. convinced that life should be hard or a struggle. They have a 4. Stop when they are full or satisfied. difficult time tolerating success, and need to reframe their beliefs in order to stop sabotaging their success. Another irrational belief Hunger is that having eating or weight problems is one way to show the world that they have suffered. This cognition is common in clients who have survived trauma such as rape, incest, or other Hunger is the body’s mechanism for saying that it is time to fill serious abuse. Reframing this belief helps them move beyond ‘er up. It functions in the same way as the indicator on your thinking of themselves as damaged and defective victims to car’s gasoline gauge when it points to empty. Hunger signals are survivors or uniquely normal. Yet a third irrational core belief is produced by the hormone ghrelin which generates the gnawing that losing weight means they are a conformist. This cognition feeling in our stomachs. Pangs may also be accompanied by light- surfaces, for example, with women who believe that being thin or headedness, tummy growling, feeling faint, fatigue, intrusive thinner means they will not be valued for other qualities and for thoughts of food and feeding, irritability, or headaches. clients who were relentlessly pressured to be slim or attractive in childhood and adolescence. They believe that having their parents Food tastes best when we are moderately hungry. If we are (or spouse or partner) “get what they want” (that is, for them to ravenous, we will eat too quickly, miss satiation signals, and lose weight) means their parents or whomever has won and they probably overeat. On the other hand, if we are not hungry enough, have lost. Inappropriate rebellion underlies this cognition which our body is not physically prepared for food consumption and will often extends to behaviors beyond eating. This is a core belief not sufficiently enjoy the experience. Because many disregulated that must change for clients to lead lives which are proactive, not eaters are not aware that they are hungry, a hunger scale is useful for reactive. tuning into signals. Clients can use a numerical scale from 0-10 or the words not hungry, somewhat hungry, very hungry, or famished. Over time they will learn to connect the internal physiological Teaching Clients the signals the body generates with a number or phrase. Rules of “Normal” Eating It is worthwhile to encourage clients who eat constantly and refuse to allow themselves the experience of hunger, to wait a little and Most general therapists, if they deal with the issue at all, are used see what it feels like to have hunger pains. For clients who tend to encouraging overweight or overeating clients to go on a diet or toward food restriction (then end up binge-eating), it is useful to join a diet program. Because diets are hard (after the first rush of suggest they eat small meals more frequently, especially at the excitement) and fail long term, this is often a frustrating experience initial signs of hunger. Of course, along the way, it is vital for the for clients which ends in disappointment: they cannot stick to the therapist to explore beliefs clients have about hunger: Do they see diet for more than a few weeks or months, they hate weighing in at it as a good or bad thing, do they fear it, or do they live for it? a formal program, diets keep them more obsessed with food than It is impossible to talk about hunger without mentioning cravings. they ever were, and they erroneously believe that they are moving “Normal” eaters may occasionally eat when they are not hungry forward when they are actually not. The best way to help clients because they experience a strong physiological craving. This is to teach them the rules of “normal” eating while supporting craving is organic and not related to emotional or compulsive them in learning the life skills they need to handle life without eating; it is a physical desire for a specific food. With a craving, we unnecessary dependence on food. Needless to say, this is no sometimes feel as if we are already tasting the food. It is unclear easy task. Depending upon several factors—whether a client is a what biological mechanism causes cravings, but they are real. trauma survivor, the soundness and intensity of their motivation, People who do not have eating problems generally take a small the depth and breadth of their support system, and multiple amount of the desired food and are satisfied, a difficult behavior unknown biological factors—it takes from many months to a few for disregulated eaters to learn. years to go from being a disregulated to a relatively “normal” eater.

 on in their bodies (and minds) as they eat. The idea is not to Food Choice make judgments, which they too often do, but to stay connected to appetite cues and keep asking and answering these questions The longer a client has dieted or rigidly restricted food intake, (which “normal” eaters respond to automatically): Am I still the more difficult it will be for her to know what she wants to hungry? Do I still crave this food? Am I getting bored with eat. Diets force us to turn off the internal mechanism—the natural eating? Am I deriving pleasure from what I am eating? Is the internal mechanism, mind you—which signals what we are in the pleasure diminishing? Am I feeling full? About how many more mood for. Sometimes this is a food or ingredient which our body mouthfuls can I take before I feel full? If I finish what is in front of is lacking (for example, when you crave a steak because you have me will I still be hungry, feel just right, or be stuffed? How would not been eating enough protein). Sometimes it is simply a food it be if I stopped eating right now? we have a yen for. Because we are daily being bombarded with The best advice to give clients about eating awareness and advice about what and what not to eat, it is enormously difficult enjoyment is to eat slowly and chew food thoroughly. The point of to make the shift inward to ask the self what it is in the mood for. chewing is to grind down food to release flavor. The next step is to Clients universally fear that if they ask this question, the answer allow food to sit on the tongue where all the taste buds are gathered will always be sweets and treats. Yet “normal” eaters who operate so clients can monitor when food starts to taste less flavorful. on the assumption that they can eat whatever they want (albeit Food enjoyment actually peaks at a certain point (generally, not in limited quantities and frequencies), in fact, do not eat high- all that far into eating), which is why people enjoy eating a little carbohydrate, high-calorie food all the time because this is not of this, then a little of that. That way they get to experience a how their bodies balance out their nutritional needs. mini-peak over and over. However, eventually, a sensory peak It takes a long while (a very, very long while) for disregulated occurs (the body’s way of making sure that we do not overeat) eaters to get past feeling that they were deprived for so long of and food does not taste as good after that. Only by eating slowly, the foods they love that now they must make up for lost time. chewing thoroughly, and letting food sit on taste buds can we set However, only when clients truly believe they can choose from a ourselves up for knowing when taste has peaked and it is time to wide array of foods, will they not feel deprived. The term for this stop eating. process is “food legalization.” Down the line, clients will start to see that, for the most part, when they deprive themselves of sweets & and treats, they will subsequently overeat them. Better to have a Fullness Satisfaction taste of them every day or once in a while than to restrict, binge- eat, then return to deprivation mode. It is important for clients to differentiate between satisfaction and fullness. As I said previously, insulin and leptin are chemicals You can encourage clients to reflect on what they want to eat. which are secreted by our bodies when we are full and satisfied, This means not focusing on what other people are eating, not but these states are not the same. Fullness relates to hunger and thinking about which foods are good or bad, forgetting (for the has to do with the quantity of food eaten. Hunger is at one end moment) about calories and fat grams, and tuning into what would of the continuum and fullness is at the other. Satisfaction relates be satisfying. They need to focus on whether they would like to craving and has to do with the quality of the food experience. something hot, cold, spicy, bland, chewy, creamy, icy, or crunchy. A craving for a specific food is at one end of the continuum and Once again, by teaching clients to look internally for answers to satisfaction is at the other. We can eat and be neither satisfied nor what they want to eat, we are teaching them that, more often than full, satisfied but not full, full but not satisfied, or satisfied and full. not, the solutions to their problems come from reflecting and tuning One state is not better than the other (although it is delightful to into internal processes which build self-knowledge and self-trust. be full and satisfied!). These words are merely ways of describing and monitoring food intake.

Eating with Awareness & Enjoyment One of the problems with fullness is that we tend only to realize we are full after we have arrived there, which is generally when we stop eating, sometimes because all the food is gone. It is better Most disregulated eaters tune out when they are eating and become to encourage clients to ask themselves, “Am I still hungry?” than completely disconnected from body cues regarding appetite. They “Am I full?” The stomach is small—about the size of a fist—and are either feeling guilty or ashamed of what they are eating and it takes some 20 minutes for food to begin to digest and for the consume food too quickly, or eat mindlessly in order to avoid brain to react to satiation. I often hear clients say that they feel feelings or postpone unwanted tasks. Although they will say that deprived or sad if they cannot finish everything that is on their they love to eat, most have little idea what they are tasting after the plates. When you hear these comments you will know, as I do, first few bites or whether or not they are actually enjoying food. that it is time to explore more beliefs. What do clients believe They often eat to fill a void that is not based on physical hunger about not cleaning their plates, about wasting foods, about not and have little idea what may be missing in their lives. Moreover, recognizing when enough is enough? how can they feel full when they were not hungry to begin with? Speaking of recognizing sufficiency, the issue of fullness and Eating with awareness involves putting the eating experience into satisfaction is a great way to teach clients about self-regulation. slow motion and focusing on bodily sensations. Stretching out Most disregulated eaters suffer from confusion about sufficiency food consumption helps clients become aware of what is going in many aspects of their lives, not just eating. They do not know

10 when they have given or done enough and often go to excess when We can help clients stop emotional eating by discouraging shopping, working, spending, or with using drugs and alcohol. them from doing anything else while eating. I advise clients to As disregulated eaters improve at sensing adequacy, completion, eat as many meals as they can doing nothing else. This is hard and satisfaction with food, they can then use this skill to find that work—both to get them to engage in this practice and for them to balance outside of the eating arena. Alternately, they can practice experience nothing but food—but the payoff is large. Only when self-regulation in all areas of life which will help them identify clients are able to eat and stay connected to their appetite do I when they have eaten enough and are ready to say they are done. suggest that they try adding an activity for a short time and see if they can maintain the connection. However, I still urge them to eat, more often than not, without distraction, because it is all too Food and Feelings easy to fall back into mindless eating mode.

No discussion worth its salt on eating and weight would be Doing direct therapeutic work on managing feelings goes a long complete without talking about food and feelings. They are so way toward stopping emotional eating. Clients need to know inextricably woven together from our first moments in the world, that they can bear emotional distress and ongoing attention needs that they influence us for better or worse forever after. Initially we to be paid to reframing irrational beliefs about emotions as they receive nutrition effortlessly in utero through our mothers. Taking arise. Most clients have no idea about the purpose of emotions, in nutrition is easy and natural. Next, in early infancy, we are that what they believe can increase or decrease emotional generally held and fed and begin to associate food with feeling intensity, or why they fear their feelings so greatly. Clients need secure, safe and satisfied. Neural pathways between feeding and to explore traumatic histories, if applicable, and realize how they feeling get intertwined, and (if we were fed appropriately) we have used food to self-medicate, particularly understanding that come to think of eating as a pleasurable experience. Add to that what was adaptive in getting them through trauma—using food the fact that mother’s milk contains tryptophan, a chemical which for comfort—is no longer adaptive and is, in fact, self-destructive makes babies (and adults) drowsy, and feeding and feeling become to their healthy life goals. one blissful experience! Along with keeping a beliefs journal, it is useful for clients to As we grow older, most of us find other activities that make us feel keep an emotions log. Most of us have had the experience of happy and satisfied: socializing, sports, meaningful work, nature, asking a client what she feels and receiving a blank stare in return. hobbies, and even mindful living. However, for some people, Or we suggest a client might be experiencing an emotion—when food remains special. Sometimes it is because they never learned his facial expression, tone of voice, or body language is a dead how to relax without food. Their role models ate when stressed give away—and he denies it. A journal forces these clients to or distressed, encouraging them to do the same. Sometimes a identify and connect to what they are feeling. It is not enough for traumatic childhood generates a desire for foods which, when clients to say they are stressed or upset. It is important that they broken down, chemically helped clients through horrendous identify the components of their stress and exactly what they events with their mental health relatively intact. Our culture also are feeling—overwhelmed, inadequate, frightened, confused, plays a substantial role in equating food with love, insisting that etc. Fortunately, much of the work we do in therapy focuses on we cannot have meaningful social activity or relationships without recognizing and labeling emotions and we should feel confident food and that we cannot say no to food because it is delicious and that it will eventually pay off in clients doing less emotional will make us happy like nothing else can. eating down the road.

For numerous reasons, food and feelings go together for many people. But, whereas emotionally healthy people will occasionally Teaching Clients Life Skills use food as a reward or a mood booster, emotional eaters are dependent on food for quelling internal upset and feeling upbeat. Using a two-pronged approach to deal with emotions is highly The more frequently they turn to food when they are anxious, effective. One avenue is for clients to learn all they can about depressed, confused or lonely, to name a few emotions which how they feel and how to deal effectively with internal distress. trigger non-hunger eating, the less opportunity they have for The other is for them to acquire the life skills they missed out on learning and practicing life skills which would more effectively growing up. It is vital to explain that, due to the deficiencies in our make them feel better. Moreover, by eating for comfort, they end upbringings, all of us missed the boat on learning some life skills. up feeling worse about themselves which exacerbates whatever There is nothing shameful about not having the total package at low mood they are in. one’s fingertips. These skills can be learned in a similar fashion to any others: with attention and practice. Clients generally are Emotional eating happens when we are internally distressed and enthusiastic about learning life skills because it makes them feel use food, consciously or unconsciously, to lessen our discomfort. hopeful that they can change something about themselves, even if Sometimes we turn to food even before we feel disappointment it is not their eating or weight. or fear because we know what is coming and believe we cannot handle it. Whether to diminish or prevent emotional discomfort, Below are skills which are essential not only for reducing unwanted food seeking behavior does the trick—for the moment. We go eating, but for living a happy, successful, meaningful life. These numb, unconscious, shift into an altered state of reality. However, skills are not in any particular order or hierarchy because acquiring after we are done eating, we are left with the same dreaded feelings one skill facilitates learning another and all are inextricably to deal with on top of shame, guilt, self-hate, and remorse. related.

11 diminishes them in their own eyes. I encourage clients to practice Self-Compassion self-assertion with me and encourage them to let me know the next session, between sessions, at the end of one, or the minute they All of the overeaters with whom I have come in contact are feel that I have done or said something that offends them. When extremely hard on themselves and have standards which are they become more comfortable asserting themselves with me, I unrealistic and unattainable. Therefore, when they fail to live (gently) push them to practice with others. Once they see that up to being the person they think they ought to be, they berate the world will not end because they have said no or spoken their themselves. We might say they have harsh super egos. Ironically, mind—and experience pride because of it—the more likely they these are the same people who often allow others to behave are to repeat this behavior. poorly around them and expect less from others than they do from themselves. Teaching clients self-compassion is a huge gift. It involves reviewing beliefs about how they deserve to be treated, Feeling Pride what they believe they get out of being hard on themselves, and what they fear will happen if they ease off and shower themselves Pride is such a normal, natural, automatic response for emotionally with kindness. Generally they erroneously believe that being hard healthy folks that we may take it for granted that clients recognize on themselves will lead to success although, more often than not, and enjoy it. I wish I had a dollar for every client who said their experience tells them just the opposite. they were raised by the adage, “Pride cometh before the fall.” Amazingly, many disregulated eaters are intimately acquainted with shame, but are clueless about the point of feeling pride. The Progress Not Perfection word scares them and some can barely say it. They think pride is boasting or thinking too much of themselves, that something One cannot talk about lack of self-compassion without discussing terrible will befall them if they believe or acknowledge that they perfection. Again, overeaters tend to be perfectionists. They have done well, and that shame is a better motivator than pride. believe that if they do not do something completely or to the nth Again, I take every opportunity I can find in sessions to focus on degree that they are failures. To them there are only two points on pride, exploring their fears, helping them define the word, asking a continuum: success and failure. Perfection is tied to feelings of them to identify when it is appropriate to feel it, and explaining self-worth which generally have an external, rather than an internal, the difference between pride, false pride, hubris, and arrogance. locus. If they are perfect, they are good, safe, and possess value. Pride is what disregulated eaters need to feel when they do well If they are not perfect, they are nothing. No matter that striving for and, if they lack this life skill, it is very difficult to help them move perfection is killing them, clients still magically believe that they forward because what other internal incentive will spur them on. can get there. When they realize through therapy that this goal is impossible, they are generally relieved but confused, wondering what will motivate them toward their goals if not being perfect. Saying “Yes” and “No” in the Right Balance

Black/White, All/Nothing Thinking Guiding overeaters to become “normal” eaters would seem like a process that involves learning how to say no, as in refusing a There is a strong relationship between perfectionism and all-or- second piece of pie or passing on a return trip to the buffet table. nothing thinking—and to disregulated eaters yo-yoing between Ironically, simply counseling overeaters to say no to food does food restriction and binge-eating. If they are not dieting, they little to help them, which is why diets and diet programs fail long- are eating everything in sight. If they are not being angelic, they term. However, teaching them about saying yes and no goes a are being very bad. If they start to eat a “bad” food, they cannot long way toward promoting recovery. There are two ways that merely have a few bites, but feel compelled to finish the whole yes is necessary. The first is as a life skill, that is, clients must thing. They feel virtuous and heady when they are “good,” and be able to make choices that cause them to feel good, inside and shameful and self-loathing when they are “bad.” They believe outside of the food arena. Yes affirms self-worth, leads to pleasure they are undeserving of self-compassion for their faults around (and setting off bursts of dopamine in the brain), and balances food and are usually unable to even conceive of a middle ground. out all the times we must say no to ourselves. The second way I interrupt therapy frequently to point out black-and-white thinking that yes is necessary is finding the yes in the no, which means or, alternately, to reinforce behavior when clients are able to see helping clients find ways they can refuse food when they are not things incrementally and in shades of gray. hungry or when they are full that bring them a resounding yes, such as in developing pride, experiencing trust in their judgment, or believing that they can gain control over their impulses. Our Self-Assertion work is to teach clients to say yes and no in the right balance, not only with food, but in every aspect of their lives. For the most part, disregulated eaters have poor self-assertion skills. Even if they think no, they say yes. Part of the problem is that they fear displeasing and upsetting others. Many are terrified Self-Trust of rejection and abandonment and of being shamed or dismissed as not worthy. Another part of the problem is that the more these More than anything, after decades of food struggles, disregulated clients do, the better they feel about themselves, so that saying no eaters lack self trust. Many have been on every diet ever invented

12 and the pounds have crept back on. Their weight has yo-yoed up in therapy is having these clients hold onto a self-love that is not and down the scale. It seems the harder they have tried to lose dependent on what they do but that is with them always. This weight, the fatter they have become. They watch other people shed involves chipping away at perfection and all-or-nothing thinking, pounds and despair that it will ever happen to them. Trying to reinforcing pride and self-trust, and encouraging self-reflection so reshape the very body they have never been able to trust seems that clients can decide for themselves the kinds of people they like an impossible dream. Many clients lacked parents who were want to become. Our “loving” and accepting clients is a start, but trustworthy caretakers and failed to learn how to trust others. Their this feeling does not simply transfer to them. Loving themselves parents did not trust themselves and could not model what self-trust is initially ego dystonic and involves a long struggle toward looks like. They did too much for clients as children, so that the unconditional acceptance. message was that the children could not trust themselves, or they allowed clients to become so overwhelmed that they gave up too easily. Clients must realize that trust comes from making mistakes Seeking and Asking for Help and correcting them, from falling down and picking themselves up, from asking for help when it is warranted, and from looking As with most clients who have an addiction, disregulated eaters to themselves for answers rather than to the latest fads or what often shy away from asking for help. They are ashamed of their works for other people. Self-trust, like self-esteem, is composed behavior and cannot believe that anyone would be accepting of it of competence and confidence. or of them. They are so used to being in shame-based mode that they cannot imagine other people are in the same boat or even worse off than they are. Secret binge-eating is not uncommon, Self-Reflection even for decades. The character structure of the disregulated eater is often one that believes something like this: I got myself into this Disregulated eaters either avoid looking inward or spend excessive mess with food and I will get myself out of it. No one can help me time dwelling on their actions. They often lack the skill of self- but me. I am not ready to change or I would have already. I cannot reflection—the ability to review their thoughts, words, and actions bear for other people to know how out of control I am with food. objectively to assess whether they are appropriate to reaching their No one will love me if they know how bad my relationship with life goals—because it was never modeled for them or because they food is. Sometimes the therapist is the first person a client tells are frightened of thinking about themselves and finding themselves about her eating problem. Too often family members or friends, deficient. They confuse making an objective assessment with a even well-meaning ones, dismiss or minimize eating concerns or subjective judgment. To change this perspective, our work is to try to shame the client into eating better. Over-eaters also tend encourage clients to describe their behavior and its consequences to be overly responsible and are much more comfortable helping without judging it. For example, they may say that they said yes others solve their problems than seeking help for themselves. to a request without thinking, then felt overwhelmed. The next They are counter-dependent in this regard (and many others) and step is for them to assess whether that behavior worked for them find it difficult to see themselves in the “needy, dependent” role. or not. Many clients with eating problems are not used to thinking However, this is exactly the role they must acknowledge and about what works and what does not. Instead, they consider experience in therapy to move forward. behavior and immediately condemn it, missing the key element of the analysis. Clients often avoid discussing eating “mistakes” because they are unable to reflect on them, but fall automatically Self-Care into berating themselves for their inadequacies. Helping them neutrally describe and discuss their behavior goes a long way Disregulated eaters equate food with self-care. In fact, it is their toward teaching them self-reflection. primary means of taking care of themselves. Because most have poor self-esteem, they rarely think much about the long term, that is, about the consequences of using food as self-care. That Self-Value and Love road is too dark and frightening. They believe that they do not matter, that whatever happens to them is what they deserve, that More than any other skills, disregulated eaters must learn to value there is no purpose in being proactive and doing good things for themselves and recognize that they are lovable as is. The majority themselves when inside they feel deficient and defective, and of these clients come from homes in which one or both parents expect that they will fail at effective self-care the same way they were highly critical of them and they have little sense of their own have failed at reaching so many other goals. In order to take good worth. They are afraid to love themselves because they believe care of something, we first have to believe that it is worth taking that deep down they are unlovable. Their thinking goes like this: care of. Clients do not believe this about themselves, so we have If the people who were supposed to love me, my parents, could to move them back to the drawing board and correct their beliefs not love me, what chance do I have with other people. We all about their self-worth. This is very hard work for them and for us. know these clients, the ones that compliments roll right off of Clients are afraid to value themselves because they might find out but who remember every slight and stab of criticism that came they are wrong. For many, self-care is superficial only, not based their way. They also confuse loving themselves with accepting on authentic self-appreciation and self-esteem. Shallow self-care themselves, fearing that acceptance means they will stop trying to involves activities such as having their nails done, wearing the change. Most are waiting until they are perfect (or at least at an right clothes, buying a Rolex watch, or doing what others value. ideal weight) to think well of themselves. The major breakthrough The self-care skills they have to learn go deeper and affirm their

13 uniqueness and perfectly imperfect value in the world as is. It is What Every Therapist Needs To Know About Treating Eating and important for them to experiment with different avenues of care to Weight Issues see which ones make them feel better in their core for more than just a few moments. Self-care realms include physical, mental, Nice Girls Finish Fat—Put Yourself First and Change Your and emotional. Eating Forever

Some clients are ready to tackle learning life skills head on. In that case, it is useful for them to brainstorm a list of the ones References they already possess and the ones they lack (it helps to make a list for yourself beforehand). The above skills are only a partial Ellis, A. and Harper, R., Ph.D. (1977) A new guide to rational list. Once clients have identified the skills they are missing and living. CA: Wilshire Book Company. would like to learn, you can then help them prioritize what they expect will be the ease of developing them. Sometimes clients use Koenig, K. (2009) Nice girls finish fat—put yourself first and these skills in their professional—but not their personal—lives, change your eating forever. NY: Fireside/Simon & Schuster. and they can, therefore, learn to adapt them from one venue to the Koenig, K. (2008) What every therapist needs to know about other. However, clients sometimes believe that it is impossible treating eating and weight issues. NY: W.W. Norton and this late in the game to learn new skills even as they are excited by Company. and hopeful about the idea. In this case, it is necessary to return to their beliefs about learning and transformation and about their Koenig, K. (2007) The food and feelings workbook—a full course own capacity to grow as individuals. meal on emotional health. CA: Gürze Books. Koenig, K. (2005) The rules of “normal” eating—a Conclusion commonsense approach for dieters, overeaters, undereaters, emotional eaters, and everyone in between! CA: Gürze Books. One last word on eating and weight issues. I do not find it helpful to Kolata, G. (2007) Rethinking thin: The new science of weight focus a great deal on weight in therapy, even though I treat clients loss—and the myths and realities of dieting. New York: Farrar, who are 350 pounds or more. My focus is on eating and all the Straus and Giroux. clinical issues that will help clients develop into emotionally and physically healthier individuals. Some clients come to me post- Anderson, K., Anderson, L. and Glanze, Walter. (2008) Mosby’s bariatric surgery and others consult with me in order to decide if it dictionary of medicine, nursing and health professions. New is the right option for them. The majority of my overweight clients York: Elsevier Press. have a large amount of weight to lose; others keep losing and National Eating Disorders Association from regaining the same 20-30 pounds. A few exercise regularly, but http://nationaleatingdisorderassociation.org most do not and exercise is not something we spend a great deal of time talking about except for their beliefs and feelings about it. All www. eatingnormal.com of them know what they need to do to improve their health. www. nicegirlsfinishfat.com A major difficulty in treating overeaters and clients who are www. eatingdisordersblogs overweight is that they may want to focus mostly on how to slim www. squidoo.com/eatnormalnow down. Understandably, they believe that losing weight will make http:// groups.yahoo.com/foodandfeelings them happy and give them the life they want. It is up to us to see http:// groups.yahoo.com/nicegirlsfinishfat around and beyond this goal and not to fall into the trap of going http:// groups.yahoo.com/dietsurvivors along with it. Of course, we would like to see our clients become www. eatingdisorderhope.com physically healthy and fit, but our job is often to shift the focus of www. feedingourselves.com therapy to what is clinically possible at the moment. We can feel confident that if we understand the biology of eating and weight, www. medainc.org recognize the impact that culture and gender have on weight www. theconsciouscafe.org ideals, do not buy into quick fix diet plans and programs, and teach www. rivkasimmons.com the skills that clients—fat or thin, “normal” eaters or overeaters— www. nationaleatingdisorders.org need to reach their potential in life, we will be doing our job and www. bulimia.com giving clients the support and guidance they need. www. anred.com www. eatingdisorderschannel.com Books by Karen R. Koenig, M.Ed., LCSW www. edreferral.com www. sleepdisordersguide.com/sleep-eating-disorders The Rules of “Normal” Eating—A Commonsense Approach www. edtreatmentcenters.com for Dieters, Overeaters, Undereaters, Emotional Eaters and www. joyproject.org Everyone In Between www. eatingdisorder.com www. fatgirlsguidetoliving.com The Food and Feelings Workbook—A Full Course Meal on www. key-to-life.com Emotional Health www. bedaonline.com 14 September 2009 FOCUS Homestudy Course - 2 CEs Understanding and Treating Overeating and Overweight as Clinical Issues Post-Test

Circle all correct answers.

1. Eating and weight problems 6. Non-appetite factors which may 10. The rules of “normal” eating: historically have been viewed as contribute to overweight include: (a) Work best when used in being based on: (a) Heart rate conjunction with a formal diet (a) being in the grip of demons and (b) Lack of sleep program devils (c) The fertility of obese people (b) Should be learned in a group (b) being a sinner (d) Stopping smoking setting (c) having an addiction (c) Must be followed to the letter to (d) all of the above achieve success 7. Rational thinking does not (d) None of the above 2. All of the statements below are include which of the following: true except: (a) It’s based on objective fact, not 11. Which of the following is true: (a) There are about 17,000 diet subjective opinion (a) Compulsive eating is mindless, methods and plans available (b) When acted upon, it is likely to stemming from being distracted today result in the preservation of life and disconnected from appetite (b) 35% of diets progress to rather than its destruction cues. pathological/addicting dieting (c) When acted upon, it helps to (b) Emotional eating is another which is a chronic state of food most quickly achieve one’s term for compulsive eating deprivation and strict regulation personal life goals (c) 90% of dieters lose weight and and the terms can be used (d) When acted upon, it causes interchangeably. keep it off increased personal and (c) Food and feelings have very (d) two-thirds of adult Americans situational difficulties are considered to be overweight little connection to each other. and one-quarter are deemed to (d) Learning new life skills will not be obese (20 pounds in excess 8. Irrational beliefs about food and help reduce emotional eating. of what a healthy weight would eating include the following: be for them) (a) There are good foods I should 12. Life skills are learned primarily: eat and bad foods I should not (a) In school 3. Appetite regulators do not eat (b) Through the media include: (b) If I pay attention to enjoying (c) From parents and early care- (a) Leptin food, I will have a better chance takers (b) Sucrose at knowing when I’m full or (d) From peers (c) Insulin satisfied (d) Ghrelin (c) Being hungry means my body needs fuel 13. Self-care includes treating oneself well in the following (d) I can learn to enjoy food more realms: 4. Neurotransmitters include all but and, therefore, eat less of it one of the following: (a) Physical (a) Gamma-aminobutyric acid (b) Emotional (b) Dopamine 9. Rational beliefs about food are: (c) Mental (c) Serotonin reuptake inhibitors (a) Life enhancing (d) All of the above (d) Norepinephrine (b) Help us reach our goals more quickly 5. Excess stress may lead to: (c) Deter us from harm (a) Anxiety (d) All of the above Continued on page 16 (b) Depression (c) Sleep problems (d) All of the above

15 14. Disregulated eaters have which 15. Which is not our job as characteristics: therapists: Congratulations! (a) All-or-nothing thinking (a) To help clients acquire effective You have just completed the (b) Lack of self-compassion emotional management skills Post-Test for this CE Course! (c) Lack of balance saying (b) To make sure that clients lose If you scored 80% or better, yes & no weight we’ll mail you 2 CEs. Please (d) All of the above (c) To support clients in learning fill out the Evaluation below and practicing behaviors which and send this entire page will aid them in becoming along with your payment to: “normal” eaters (d) To guide clients toward NASW, 14 Beacon Street developing the ability to self- #409, Boston, MA 02108 reflect without judgment

September 2009 CE Course Evaluation

Please indicate whether the following learning objectives were achieved:

1) Readers will learn to identify how cultural, gender, genetic, biochemical, metabolic, hormonal, family, stress and other factors in- fluence clients who are overeaters and overweight. Achieved in full 5 4 3 2 1 Not Achieved

2) Readers will learn to recognize how clients’ beliefs about eating, weight, and their bodies affect their food-related behaviors. Achieved in full 5 4 3 2 1 Not Achieved

3) Readers will learn to understand the impact that poor emotional management has on disregulated eating. Achieved in full 5 4 3 2 1 Not Achieved

4) Readers will learn to recognize how the development of life skills supports recovery from disregulated eating problems. Achieved in full 5 4 3 2 1 Not Achieved

4. Please provide comments on current course & suggestions for future courses. ______

• Complete and return Post-Test and Course Evaluation after reading the CE course. Complete and return Post-Test and Course Evaluation after reading the CE course.

• A score of 80% or better is passing and we will send a certificate of completion for 2 CEs to you. • Mail pages 15 & 16 to: NASW, 14 Beacon Street #409, Boston, MA 02108

• Please enclose check payable to NASW (Sorry, credit cards not accepted for this offer.) _ r Members $15 r Non Members $25_

Name______NASW Membership #______Address______City______State______Zip______Day Phone______Email______

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