May/June 2007

Teaching the Rules of “Normal” Eating
By Karen R. Koenig, LCSW, MEd
Social Work Today
Vol. 7 No. 3 P. 38

Our relationship with food is one of the most important we have. Therapists can help clients make it a healthy one.

Clients generally go to therapy to mend broken relationships, resolve childhood issues, find meaning and happiness in life, and learn how to cope more effectively with myriad stresses in their lives. Although eating or weight concerns may not be readily identified as problems, they often lurk in the background of sessions. Clients may guardedly allude to an eating binge, gripe about no longer fitting into clothes, or toss out an offhand comment about food rituals, such as eating in secret or weighing what they eat, but they won’t necessarily raise eating or weight as bona fide topics for therapy. It is our responsibility to help them understand that ongoing compulsive, emotional, and restrictive eating are as much grist for the mill as any other troubling and self-harming behaviors.

Therapists must have a proven model that will successfully help resolve these issues. It is not enough to tell overweight clients to join Overeaters Anonymous or Weight Watchers or even to visit their doctor to be put on a diet since 95% to 98% of people who diet to lose weight regain it in one to five years, and 90% of those people regain more than they originally lost. This statistic has remained steady for three decades.

Additionally, when people fail to keep off weight through dieting, they believe that it is their fault—that they lack willpower and self-discipline, don’t have a strong commitment to their health, and are helpless and hopeless. Nothing could be farther from the truth. Diets don’t work long-term because they distort and override natural appetite mechanisms, keep people overfocused on and obsessed with food and weight, generate extreme feelings of deprivation that lead to rebound eating, and leave dieters with lowered self-esteem from having failed when, actually, the deck was stacked against them.

Applying the Cognitive-behavioral Model to Eating
What works is an easy-to-follow, cognitive-behavioral treatment model that teaches clients the skills that “normal” eaters use to feel comfortable around food and maintain a healthy weight for life. Because the approach is skills-based, it motivates clients who feel frustrated and hopeless. The recognition that achieving a comfortable relationship with food does not happen through magic or quick fixes offers hope for permanently resolving their food issues and alters their attitude toward previous dieting failures.

Cognitive-behavioral therapy (CBT) posits that our beliefs produce our feelings and behaviors, and lasting change happens only from transforming irrational, unhealthy beliefs to rational, healthy ones. By altering our behavior, we may discover that our beliefs are invalid, and by modifying our feelings, we may notice shifts in our behavior; however, CBT encompasses a radical restructuring of the belief system which becomes the foundation for therapeutic change.

A cognitive-behavioral approach to learning “normal” eating has three facets, all of which must be addressed and attended to in order to achieve full recovery. The facets are as follows:

• reframing irrational beliefs about food, eating, body, and weight to rational ones;

• handling stress and distress effectively without focusing on food and weight; and

• practicing “normal” eating behaviors until they become habits.

By weaving back and forth among the three, clients make the small shifts necessary to let go of what is unhealthy and embrace cognitive, emotional, and behavioral health. Over time, clients think more rationally about food, eating, weight, and their body. Their emotional management skills begin to improve and new, functional behaviors supplant old, destructive ones.

Making Irrational Beliefs Rational
After explaining the CBT model, the focus is helping clients identify their beliefs about food, eating, weight, and body. This process may go slowly for clients unaccustomed to paying attention to their thinking, and the therapist should feel free to make suggestions. Exploring family of origin and cultural attitudes are the most productive ways to generate beliefs.

The next step is to distinguish rational from irrational beliefs by using the criterion of whether they are in the client’s long-term best interest; that is, are they cognitions that will enhance life? Examples of typical irrational beliefs of clients with eating problems include the following:

• I can’t stop myself from overeating.

• I’m a bad person for being out of control around food.

• I can’t trust my body to tell me when it’s full or satisfied.

• If I allow myself the foods I enjoy, I’ll never stop eating them.

• Food makes me feel better when I’m upset.

After irrational beliefs are identified, it is time to reframe them into positive, healthy, rational statements. Rational beliefs should be in the first person, present tense, and as concrete and simple as possible. Examples of the previously stated irrational beliefs reframed include the following:

• I can stop myself from overeating by paying attention to when I’m full and satisfied.

• Being out of control around food does not make me a bad person.

• Over time, I will learn to trust my body to tell me when it’s had enough to eat.

• By giving myself permission to eat foods I enjoy, I will be able to eat them in moderation.

• I can find effective ways to feel better when I’m upset besides eating.

Clients should review rational beliefs every day, the more frequently the better. Clients also need to continue adding to their beliefs’ list and reframing them as they recognize more of their “stinkin’ thinkin’.” Additionally, clients need to reframe their core beliefs, especially around instant gratification, magical thinking, perfection, reaching a specific body weight, deserving happiness, and being lovable.

Managing Stress and Distress Without Focusing on Food and Weight
Teaching clients how to meet their emotional needs without food is twofold: It helps them get their eating under control and leads to effectively meeting their authentic emotional needs. Every time clients who are stressed or distressed overeat or eat when they’re not hungry, they miss a valuable chance to improve their life. Not surprisingly, clients who learn to feel more comfortable in their bodies and around food also experience greater satisfaction with life in general.

Initially, emotional work should focus on teaching clients the purpose of emotions—to move toward pleasure and away from pain—on recognizing when they are experiencing them and distinguishing among them. Undoubtedly, clients will need to explore their fears about uncomfortable feelings before being able to experience and express them effectively. When clients comprehend how and why they abuse food to avoid and minimize internal discomfort, they can move on to allow themselves to bear and learn from emotional pain.

Using a step-by-step process to experience emotions gives clients something to do with feelings. When they get a hint that they’re feeling one, they should do the following:
• acknowledge that they might have a feeling;

• identify the emotion;

• experience it;

• recover from it; and

• deal with it (optional).

Each stage is crucial in emotional management and regulation. Because feelings are often ignored or go unrecognized, clients need help translating body sensations into emotions. Next, they require guidance in putting their finger on exactly what they’re feeling, not simply saying they’re upset or unhappy. Experiencing feelings is the most difficult step, but it becomes easier as clients address and resolve their fears of emotional pain. Recovering from experiencing an emotion means not making judgments about what was felt and, instead, applauding the self for tolerating intense affect. Clients may or may not need to do something with an emotion—a dressing down by their boss may require further discussion or clarification, whereas the loss of a loved one may call for tolerating waves of intense emotion, including grief, loneliness, and perhaps even conflicting feelings and little other activity.

Encouraging “Normal” Eating Behaviors
The word “normal” is in quotes because there are a range of eating styles—from people who eat two large meals a day to those who eat small amounts every few hours—but all “normal” eaters adhere to the following four simple rules:

• eating when they are hungry or have a craving;

• choosing foods that will intuitively satisfy them;

• eating with awareness and enjoyment; and

• stopping eating when they’re full or satisfied.

Hunger and Cravings
Teaching clients the rules of “normal” eating starts with helping them identify physical hunger and cravings. Cravings are yearnings for a specific food that seem to spring forth organically—we want kiwi fruit, peanut butter, something salty, a Rome apple, a prune Danish. Clients can be taught to recognize hunger through connecting to body cues such as intestinal grumbles, light-headedness, queasiness, hollowness in the chest, emptiness in the stomach, a mild headache, or irritation. Food tastes best when we are moderately hungry, and clients should use a one to 10 number scale to determine their hunger level—zero is not hungry, and 10 is famished.

Clients who don’t allow themselves to be physically hungry and eat constantly to avoid hunger should be encouraged to tolerate hunger as they explore their beliefs about wanting food and feeding themselves. Naturally, discussions of physical hunger often lead to exploring other kinds of hungers and fears about wanting and needing too much. In order for clients to feel comfortable with this physical sensation, they may need work on allowing themselves to have needs and meeting them.

It is often difficult for clients to separate mouth hunger from stomach hunger and cravings. Mouth hunger is generated by emotional discomfort because chewing, swallowing, and filling up on food distract from and modulate distress. Clients learn to distinguish between mouth and stomach hunger by returning to examining body signals for food as fuel.

Making Satisfying Food Choices
The second rule of “normal” eating is choosing food that is intuitively satisfying. With a daily bombardment of messages about what we should and shouldn’t eat, it’s difficult to put aside nutrition and health information and turn inward to ask the body what it desires. Overeaters fear that if they ask themselves this question, the answer will always be high-calorie, high-fat food. But, in fact, when clients stop thinking in terms of “good” and “bad” food, they are able to make more satisfying choices. Foods are neither “good” nor “bad”; they may be nutritious or nonnutritious, but they have absolutely no moral value. Moreover, eating (or not eating) makes us neither saints or sinners. These are irrational thoughts left over from the diet mentality.

Compulsive/emotional eaters must learn to tune into what their bodies want and eat the foods that will satisfy them before they can start tweaking their diets to make them more nutritious. If they intervene prematurely, before “normal” eating beliefs and behaviors take hold, they will regress and return to obsessing about food in good and bad terms. To select satisfying food, they need to discover whether they want something light or substantial, salty, sweet, mushy, crunchy, hot and spicy, bland, creamy, or icy. What food they desire is related to their hunger level, as well as to their mood, activity level, and general food preferences.

To make satisfying food choices, clients must challenge and counter the inner critic that insists they shouldn’t eat anything fattening and must only eat healthy foods. They need to think like “normal” eaters—any food is fair game that they can eat any time (except, of course, if they’re allergic to it) in any quantity. Knowing this enables eaters to make choices they believe will satisfy them and stop when they are full or satisfied. They don’t have to feel guilty or finish all their food because they’re eating from a premise of abundance and choice, not deprivation, and from self-affirmation, not rebellion.

Eating Awareness and Enjoyment
The main reason that people have difficulty eating with awareness and enjoyment is that they eat too quickly to taste their food. They’re in a rush to get rid of offending food so that they will stop feeling guilty or because they picked up a rapid eating habit in childhood. Teaching clients to slow down and taste their food will positively revolutionize their eating. Chewing food releases its flavor. Letting food sit on their tongue enables taste buds to do their job, which is to signal satisfaction to the brain. When people eat quickly, they don’t let food rest on their tongue long enough to know they’ve had enough. Instead, they keep eating and looking for satisfaction but never find it.

Stopping Eating When Full or Satisfied
Without a doubt, this fourth rule is the hardest to abide by. However, it becomes easier when clients have followed the first three rules. If they eat when they are moderately hungry, choose food they expect to enjoy, eat with awareness and toward a goal of pleasure, they will be in a good position to stop when they’re full or satisfied.

Full means they’ve eaten a sufficient amount of food and is a quantitative assessment; satisfaction is about fulfilled desire and is a qualitative judgment. Although some habitual behavior is involved in overeating, more often than not, eating beyond “enough” is linked to irrational beliefs about saying no to food, wasting it, leaving it on one’s plate, getting one’s money’s worth, and throwing it away.

Clients need to understand that everything they learned in childhood about eating must be evaluated as beneficial or not, including the eating behaviors and attitudes about food and weight of their role models. Most importantly, clients have to learn to tolerate the sadness and anxiety they will undoubtedly feel when they stop eating at fullness or satisfaction and have left over food. If they’re sad, they can remind themselves that they can eat the food again another time. If they’re anxious about not wasting food, they can consider that there are no longer food police in their life, and they alone are the arbiter of their behavior. Learning to ride out anxiety about uneaten, unfinished food is key to overcoming dysfunctional eating.

Clinician’s Own Eating and Weight Issues
Clients generally know little about us, but they can’t help but notice our weight. To help them, we must examine our own attitudes about food and body size. Are we avoiding their concerns because of our own body shame? How “fat phobic” are we? Can we help clients with their struggles in spite of our own?

Although we may not be able to resolve our eating and weight issues, we must recognize how we buy into fat phobia, diets, envying ultra-thinness, and not trusting our own bodies and appetites. Talking with clients who have similar concerns may expose our shame and make us uncomfortable, but we cannot help them if we are not willing to tackle the subject ourselves.

Getting Help
Once a client is well on his or her way toward “normal” eating, it is helpful for him or her to meet with a registered dietitian who will support nondieting and encourage intuitive eating. Continued discussion in therapy of situations that trigger food abuse is essential, as is ongoing work on experiencing and effectively expressing emotions. Self-esteem groups can be useful for clients with eating problems, especially if they are self-conscious about their weight. Additionally, reading about intuitive eating, joining an antidiet support group, online chat room, or message board, or attending a workshop will all help normalize intuitive eating and strengthen clients’ skills.

— Karen R. Koenig, LCSW, MEd, is a cognitive-behavioral therapist and educator in Sarasota, FL. She has more than 25 years of experience treating compulsive/emotional and restrictive eaters and is the author of several books including of The Rules of “Normal” Eating — A Commonsense Approach for Dieters, Overeaters, Undereaters, and Everyone In Between!

Reference

Bennett, W.I. (1995). Beyond Overeating. **NEJM##. 332(10);673-674.