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Challenges with body image and food can lead to more obvious struggles like anxiety and depression. But this can also affect general life satisfaction and willingness to participate in healthy behaviors, like exercise, sexual wellbeing, social connections, and even career advancement.
It’s so important to have basic knowledge around body image, disordered eating, and diet culture, regardless of your area of speciality. At some point in your career, you’ll likely have clients who are struggling with it.
Children at younger and younger ages are falling into the traps of body shaming and dieting behaviors. Adolescent and adult eating diagnosis disorders are also on the rise.
This is especially true following the pandemic, when so many people’s mental health issues have been exacerbated or expanded. I’ve been seeing a significant portion of adults experiencing the damaging effects of social media—including unrealistic filters or idealized body shapes and sizes.
It starts with self-awareness
To help clients who are struggling with eating disorders or body dysmorphia, we first need to understand our own inherited biases, damaging beliefs, or possible internalized shame and stigma around our bodies or others’ bodies and health.
Doing this work is so important because our own biases can come out in the company of our clients if we aren’t aware of our triggers.
Ask yourself:
- What are my own beliefs related to larger and smaller bodies?
- Are these assumptions, and have I ever checked them?
- What judgments do I have about body size, and where do these beliefs come from? How do I feel about my own body size, shape, or appearance?
- Does my body size and shape afford me privileges in this society? Recognize that I do have privilege in the therapy room if I’m in a smaller body or have a certain body size or appearance.
- Am I making assumptions about someone because of their weight and appearance?
Acknowledge what your choices and values are for yourself, and how that is separate from what may be right for others.
Understanding toxic messaging and health-promoting behaviors
So many pieces of diet culture go against what we know as mental health practitioners. It’s rooted in oppressive or ableist beliefs that certain bodies or lifestyles are more valuable than others, and that thinness and body shape are the most important markers of health.
This naturally sends the message that different genes, resources, limitations, illness, and disability are somehow inferior—and that simply isn’t true.
Toxic diet culture messaging is:
- A belief that appearance matters more than holistic wellness
- People are often viewed as objects to be looked at for the pleasure of others
- The belief that thinness has moral value
- Encouragement of disordered eating and other compulsive behaviors in the name of health
- Oppressing body types that don’t fit the socialized ideal picture
We have to understand what health-promoting behaviors look like as we're treating wellness. Here are some examples:
- Good sleep hygiene
- Maintaining a good social connection
- Eating a variety of food that nourishes our body
- Avoiding harmful or misuse of substances
- Doing enjoyable and fun activities often
- Regular, accessible movement
Tolerating discomfort and reconnecting with their body
Clients who have struggles with food often have trauma reactions, self doubt, poor self worth, and seek acceptance and belonging from outside sources.
They find it difficult to tolerate discomfort, which keeps them from connecting with their authentic selves. This also makes it more difficult for them to trust themselves and make the healthiest decisions for their own bodies and circumstances.
Learning to tolerate discomfort and reconnect with their body are the biggest pieces of the work. It drives so many surface-level choices, because what they’re really doing is feeling uncomfortable and staying disconnected because they don't want to sit in sadness, loneliness, anxiety, or shame.
Identifying risks at the outset of treatment
Gathering information about previous or current food struggles should be integrated into the biopsychosocial assessment as a normal course of action. It’s then normalized as part of a holistic understanding of wellness, making it easier to have conversations later on.
There is often shame, secrecy, and stigma around food, so setting up a safe space to discuss food from the very beginning helps people open up about it.
Recognizing the warning signs
There are two primary red flags to watch for in clients who are struggling with an eating disorder:
- Significant weight changes in the last six months
- Any fear, rigidity, compensatory behavior, or preoccupation that’s damaging their quality of life around body or food
If you notice any of these signs, ask questions. Explore what this means for the client, and ask about their relationship with food, past or present. Most significantly, explore how food or body image issues have impacted their life.
Challenges with food or body image tend to overlap with perfectionism, an anxious need to control, or impulsivity.
You might hear, “I have to run two miles because I had X for lunch.” You might notice that a client is feeling uncomfortable with how they’re sitting, in the room with you or on screen. They may make comments about disgust or shame around their body appearance.
Self-care or a problem?
Helping a client identify the difference between what they’re doing for themselves versus what’s causing a problem can be explored through understanding how it’s affecting their quality of life.
Unravel the narrative about how their eating or exercising is benefiting their life or costing them something.
For example, are they running five miles a day at the expense of their joints or relationships? If so, they need to get honest about that, and whether it’s something they want to continue.
Help them understand their why
If weight loss is the only consistent, single thing mentioned as their reason or intention, they probably won’t have success achieving their goals. They need to shift those around a target they personally value.
Common target values are a need for acceptance or avoidance of rejection. Identifying the real need can help them understand what they really want to target, and knowing the genuine target will support authentic progress in treatment.
Interventions
Ask open ended questions that help your client uncover their values, priorities, and goals—their authentic, intuitive knowing.
Connecting clients with a sense of intuition helps them make choices in the best interest of their personal health and values.
Questions can include:
- What is it like to talk about this?
- I’ve noticed X. Is this something worth talking about?
- I know a lot of people struggle with eating or food. Is this something we should spend time on? Has this ever been a struggle in your past?
When to make a referral
First, I believe practitioners should trust their own knowing to determine when they’ve reached the limit of their ability to support a client, just like they would in any other area.
For a higher level of care for eating disorders, it’s best to refer a client who is really struggling to navigate daily choices around food, eating regular meals, or consuming enough calories without consistent monitoring or supervision. If the client has significantly plateaued and interventions aren’t working anymore, it’s time for a referral.
The first step can be a consultation with an eating disorder nutritionist or therapist who specializes in eating disorders. That can help your client get more information about the best care for them.
Navigating the holidays with more confidence and peace
Most clinicians are talking about boundaries this time of year. Setting boundaries around body image and food is one piece of that overall practice.
This is the time of year when our celebrations are centered around food. Family members or friends often make harmful, though perhaps well intentioned, comments about body size or food choices.
It’s important to empower clients with the fact that they don’t owe anyone an explanation. They don’t have to adhere to anyone else's expectations and can set boundaries around themselves, for their health and wellbeing, no matter how uncomfortable it makes anyone else.
Prepping clients with a history of disordered eating
Simply open the conversation around possible stressors that might come their way:
- What are your holiday plans?
- Is there anything you want to avoid?
- Anything you're worried about?
- Who do you expect to be there?
This will give you a general idea of what stressors clients are facing so the two of you can make a “coping ahead” plan. Figure out coping skills, strategies, permission slips, and boundaries ahead of time, so they don’t have to think of those things while they’re in the middle of a family conversation.
Another way to broach the topic, especially for those who don’t have a history with body image or eating challenges, is to start a conversation by saying:
A lot of my clients are concerned right about comments that might be made about their bodies or food during holiday celebrations. Is that ever an issue in your family? Is it something you struggle with? Has it ever been hard for you in the past?
This creates a safe space for clients to bring up any worries they have, normalizes their experiences, and helps them feel less alone in their struggles. Even if they don’t bring up anything related to food or body image, it still opens the door for any other possible stressors that you can help them prepare for.
Setting boundaries around food and body talk is essential for clients who aren’t used to doing this. It allows them a way to communicate kindly and respectfully while shutting down topics that go against their values.
It can help them feel more confident and know that it's their right to decide whether or not they want to engage in body or food talk or not.
What boundary setting looks like in practice
Here are three different ways your client can set boundaries. Educate them about all three, and then help them identify the approach that feels right for them. You can also role play to make it easier to put these into practice.
A softer set boundary
Completely ignore or change the subject. Have you watched this TV show? How’s school going? Prep your clients with ideas for how to change the topic, and to what.
A harder boundary
I’m trying to work on a healthier relationship with food and body image. Can we talk about something different?
I'm working on listening to my body. I’d prefer not talking about diet or food choices today.
This doesn’t have to be full self disclosure, but it includes an informing statement.
A hard, direct boundary
My body’s not up for discussion. Thanks for understanding.
I don’t appreciate comments about my food choices or my bodies, please don’t make them again. Let’s talk about something else.
Helping our clients make more informed choices is always a priority
Dieting and disordered eating are inherently risky for long-term health. Educating yourself and your clients about the risks can lead to more informed choices as they work on improving their overall wellness.
You don’t have to be an expert on eating disorders to help your clients understand their values around food and body image.
Use your skills to make sure you’re aware of your own biases, explore their past and present relationship with food and diet, and teach them how to connect with a more holistic, healthy way of living overall.
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