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Helping Clients Identify and Resolve Underlying Conflicts About Eating and Weight
By Karen R. Koenig, LCSW, MEd

Although we know that disregulated eating and obesity are influenced by factors such as stress, genetics, abuse, lifestyle, chemical imbalances, and even environmental toxins, intrapsychic conflicts may also play a major role in promoting these conditions. Unconscious dilemmas can prevent clients from losing weight or cause them to yo-yo between healthy and unhealthy eating. In fact, conflicting desires can create a pattern of doing and undoing that precludes clients from ever reaching or sustaining their eating and weight goals.

Clients generally recognize the manifest reasons they wish to eat “normally” or lose weight: disease prevention, improved self-esteem, increased longevity, and greater physical comfort. However, they usually are unaware of their latent fears about improving their eating and downsizing their bodies. When clients understand and resolve these unconscious conflicts, their self-defeating patterns make sense, and they are in a far better position to get healthy and stay healthy.

Disregulated eaters’ most common unconscious conflicts center around the following:

• how change happens;

• how to make effective choices;

• coping and self-comfort;

• what they deserve;

• what enough is;

• getting close to others; and

• their identity.

How Change Happens
How clients view change is key to whether or not they achieve success. Too many people are waiting for a miraculous transformation or seeking out therapists to change them. In truth, many overweight clients have struggled to lose 25, 50, 100 or more pounds only to regain the pounds and repeat this painful cycle again and again.

Clients’ misguided perceptions of how change happens include magical, wishful, unrealistic, and perfectionist thinking. Moreover, they often cling to a success-or-failure model that inhibits them from moving forward. As we know, lasting change involves having realistic expectations, using effective life skills, and making incremental progress. Clients must learn to set goals that are appropriate and achievable, that progress comes in fits and starts, and that recovery is a slow and arduous process.

Rather than cheerlead when clients eat healthfully or lose weight, our job is to help them understand the nature of the change process and reframe underlying, erroneous beliefs that keep them from achieving and holding on to success.

How to Make Effective Choices
Many clients eat reactively instead of proactively. They shrug off or challenge the “shoulds” and rules of nutritional eating and of establishing a healthy weight. These clients rebel against what is best for them even though they know that doing so feels good only in the moment and will hurt them in the long run.

Some of them had food and weight struggles with parents or felt undue pressure to look good. Others had parents who were rigid, overbearing, or controlling and, as children, the only way they could muster a sense of self was to resist or defy parental demands. Today these clients are conflicted about whether to listen to external wisdom—to exercise and eat healthfully—or to rebel against anyone telling them what to do. Many of them sabotage their best efforts by doing the “right” thing and being “good” for a while and then resorting to doing the “wrong” thing and being “bad.”

Clients need support while working through their rebellious feelings. The goal is for them to recognize that what started out as an interpersonal battle with early caretakers is now being carried on intrapsychically and thwarting their ability to grow and change.

Coping and Self-Comfort
Fearing that they will be overwhelmed by stress and internal disequilibrium and become debilitated, clients who regularly turn to food when they are in emotional distress are often terrified to give up their dependence. No matter how motivated they are to eat better and weigh less, deep down they feel frantic about the idea of not having food to tend to stress and distress. Food is their emotional life raft.

The best strategy is to help them articulate and explore their fears, rather than suppress them as some motivational experts exhort, and teach them the life skills they require to cope and comfort themselves effectively. As these life skills become a more integral part of their emotional management repertoire, clients are less likely to feel conflicted about coping without food and more inclined to choose appropriate self-soothing behaviors.

What They Deserve
When we treat clients with long-term eating and weight problems, we are treating more than feeding disorders. For some clients, disregulated eating and being plus size are symbols of their inability to properly care for themselves. Internally, they are grappling with whether or not they are worthy. Their conflict centers on whether they are defective and whether they can be “fixed.”

This deep-seated sense of feeling undeserving of success, love (by self or others), and fulfillment is in direct competition with their wish to be whole, happy, and loved. When they lean toward feeling worthy and fixable, they eat well and take care of their bodies, but when uncertainties arise, they slide back into food  and body abuse. Our work here is at the deepest level of clients’ feelings and beliefs about themselves. When this core dilemma is resolved in favor of non-defectiveness and lovability, sustaining “normal” eating comes more easily.

What Enough Is
The issue of sufficiency runs through the treatment of most clients with eating disorders, not merely in gauging what is the right amount to eat or weigh, but determining what is enough in other areas of life. They are confused and have mixed feelings about being good enough, doing enough for others, and working hard enough. Even when they wish to take better care of themselves—foodwise and otherwise—underlying conflicts tug them in two directions: They are unsure where to draw the line between themselves and others and thus struggle with what is expected of them.

Another facet of this dilemma is clients holding a deprivation vs. an abundance mentality. If they believe there is not enough of something—love, food, approval—to go around, they focus on getting as much as they can yet still end up feeling unfulfilled. For these clients, there is no internal ping of enoughness.

Guiding clients toward a worldview of abundance and helping them sense internal sufficiency moves them toward finding authentic answers to the question of what is enough. Teaching them about boundaries and self-care gives them the tools to experience satisfaction and create better balance in their lives.

Getting Close to Others
Disregulated eaters often have mixed feelings about sexuality and intimacy. Wanting to look and feel attractive, they may fear that attractiveness will bring on unwanted sexual advances. When clients are raised in families lacking emotional intimacy or in which they abused, they have real reasons to be fearful of relationships. Frequently these clients yearn to be close to people but also worry about rejection and abandonment to the point where they become emotionally paralyzed or sabotage close relationships.

When clients talk about their weight as a buffer between themselves and others, they are speaking not only metaphorically but also concretely. Exploring fears of sexuality and intimacy gives clients a chance to understand the emotional push and pull that underlies their unfulfilling relationships. As fears about closeness decrease, clients have less need to act them out through their eating or their size.

Their Identity
Clients with eating problems who have suffered abuse or trauma may see their food issues or weight as a way of letting the world know they are different or vulnerable. Longing to be normal, they hold firm to a familiar identity of abnormal.
These clients fear that, if they resolve their eating problems, people won’t know how much they have suffered. Their mixed feelings about how to think of themselves and present themselves to the world—Am I a fractured or whole person, Am I a victim or empowered, Am I a child inside or an adult?— keep them struggling with food and with the scale. Our goal is to help them come to terms with their history and forge a new, healthier identity that is centered around a positive, rather than a negative, sense of self.

While the medical community, dietitians, and fitness trainers do their part to encourage clients to become healthier, therapists should not underestimate their role in shaping clients’ physical well-being. No matter how much up-to-date information our clients have about nutrition, health, and weight or how motivated they appear to eat better and work out, underlying, unconscious conflicts can—and will—sabotage their hard won gains. It is our job to help them understand and resolve their underlying, unconscious dilemmas, so they can attain—and sustain—their eating and weight goals for life.

— Karen R. Koenig, LCSW, MEd, is a psychotherapist, eating coach, and author of Nice Girls Finish Fat and What Every Therapist Needs to Know About Treating Eating and Weight Issues.