Studies have demonstrated that discussing eating behaviors can be difficult for adult patients. It is a topic around which they are likely to have embarrassment and shame. Therefore, the most important thing to keep in mind when discussing BED with a patient whom you suspect has the condition is, “first do no harm.” That means not bringing your own agenda to the interaction. Do not enter the situation with a predetermined plan centered on the patient losing weight or having a different relationship with food. Rather, focus on having empathy— the prerequisite for any effective caretaker interaction. This blog will focus on how to diagnose eating disorders by showing you ways to get your patients to describe their eating habits.
The psychologist Heinz Kohut defined empathy as, “the capacity to think and feel oneself into the inner life of the other person.” With that definition as a starting point, it is important to understand that in the inner life of an individual with BED, shame is likely to play a major role. Shame is often cited as the buried emotion in eating disorders and compulsive eating, as well as substance abuse and other addictive behaviors. Because shame generally leads to secretiveness, it is often challenging to get individuals with BED to openly describe their behaviors around food. They may need your help to get the conversation started. Thus, you will often have to initiate the discussion about BED and do so in a manner that sets your patients at ease.
Anything you say that patients perceive as attached to an agenda of weight loss is likely to trigger their shame and push them further into secrecy. On the other hand, with an empathetic and nonjudgmental approach, your very presence sends the message, “You are not a terrible glutton or a failure (or whatever negative label they are accustomed to calling themselves); you have just met another person who can understand you.” Your relationship can then become the conduit for them to open up about their concerns.
You will want to maintain a considerate, sensitive tone throughout the conversation and consciously use judgment-free language and demeanor. In practice, this may mean initially stepping out of the standard hierarchical doctor/ patient dialog that begins with some variation of the question, “What’s wrong?” Often, starting your conversation by sharing a bit about yourself helps create the needed sense of connection and safety. For example, a simple and effective opener might be, “I’m a healthcare provider, and I work with many individuals with Binge Eating Disorder. I think it’s really meaningful and important work.” These few words communicate both caring and that the patient is not alone.
Communicating that patients with BED are not alone is a critical component of reducing their shame and increasing their ability to open up. Giving their challenges a cultural context can be enormously helpful. For example, you might mention that in our society, there is a lot of confusion about how to nourish your body— and a lot of focus on weight. This can make it hard to even talk about weight or your relationship with food. Putting BED symptoms in cultural context in this manner helps convey the message that the patient’s binge eating and the associated shame are experiences common to those who struggle with this very real, and not uncommon, medical condition.
You might even state directly that it is normal for people who struggle with BED to feel a lot of shame and to find it very difficult to talk about it with a healthcare provider. In addition, you can help patients feel more comfortable by giving them the sense that they have some control over the conversation. Consider saying something like, “I’d like to discuss your eating behaviors with you, but I recognize that this may be a sensitive topic for some people. Is it okay if I ask you some questions about your eating behaviors?” Once they have agreed to talk about it, a couple of good, general screening questions are:
- To what extent do you worry that you have lost control over how much you eat?
- How much does food dominate your life?
The bottom line is that getting someone with BED to describe their habits usually rests on reducing their shame, and you do that by connecting with them.
While it is common for people with BED to feel a great deal of shame, the roughly half of them who have gained significant weight from the disorder may have a sense of shame that is even stronger. Therefore, upon assuming a caretaker role for patients with BED, it can be important to examine your own biases about weight. Common “weight-based” stereotypes are that obese persons are lazy, lack self-discipline, have poor will-power, and possess defects of intelligence and character.
The reality is that the issues surrounding weight are complex. Excessive eating is not always the driving force in weight gain. Genetics and medical conditions can play an even greater role than behavior in causing an individual to gain weight. It is important to recognize this and to avoid the tendency to prescribe simplistic weight loss goals and directives to patients— which ultimately only serve to increase their shame and create a no-win situation for them.
BED in particular is typically a complicated psychiatric illness, associated with other significant psychiatric comorbidity. Any adult with BED who comes to you for treatment needs to know that BED is not just overeating; it is a real medical condition and not a personal shortcoming. Consider making this clear to the patient by saying something like, “You may feel self-conscious about this, but I would like to help you feel more comfortable recognizing that this is not your fault— it’s a real medical condition, and I’m here to help you with it.”
Because weight stigma (weight stereotyping) is so pervasive and insidious in our culture, it is one of the biggest obstacles to delivering quality care to adults with BED. Here are some tips for combating weight stigma so you can leave it at the door and help your BED patients find the healing they need:
9 Tips to Combat Weight Stigma to Help Binge Eating Disorder Patients
- Know what defines weight stigma and recognize that it is a social justice issue impacting millions of patients every day.
- Train your office staff on weight stigma and develop awareness of the needs of all of your patients, which may include thinking about furniture in your office, blood pressure cuffs, appropriate methods for weighing patients, and whether weighing the patient is indicated or not during any particular visit.
- Recognize that you have the power to help create a healing partnership with your patients focused on health rather than weight.
- Find effective language to address the medical problems the patient may be experiencing.
- Increase your knowledge of the many medical and psychiatric conditions that may result in weight gain and also learn about the risks of weight cycling.
- Have an open mind and be receptive to addressing internalized weight stigma.
- Learn the principles of intuitive eating and mindful eating— an internally-regulated eating approach based on tuning into the body’s cues for hunger, fullness, and satiety while learning to self-regulate emotion without using food. (Note: It is important to be aware that many patients with BED may be unaware of or are disconnected from hunger and satiety cues. Patients may benefit from structure around meals to both assure they are eating enough and to enhance awareness of when physiological needs have been met.)
- Do not shy away from patients who are brave enough to speak up and let you know how your treatment is impacting them.
- Do not assume that patients of a larger size are either unhealthy or overeating, or that a medical or psychiatric condition is, or is not, impacting their weight or relationship with food.
Dr. Wendy Oliver-Pyatt is a world-leading expert on treating eating disorders. With more than 20 years of clinical experience, Wendy has developed a unique treatment approach that delves into the underlying issues that place a person at risk for mental health conditions and eating disorders and lead to healing, health and inner peace. Wendy, Mental Health Speaker, Eating Disorder Educator, and Mental Health Advocate, currently delivers keynote speeches for leading organizations on topics such as eating disorders, treating serious mental health issues, and healthful approaches to weight concerns. Contact Wendy for your next keynote!