If you treat trauma, then you’re likely also treating body shame and binge eating disorder.
And if your clinical training didn’t cover assessing and treating eating disorders…you’re not alone.
Binge eating disorder is the most underdiagnosed eating disorders, yet it occurs at very high rates in trauma survivors. Why is it so often overlooked? And how can clinicians, regardless of specialty, effectively recognize eating disorders and respond?
Amy Pershing, LMSW, ACSW, renowned expert in binge eating disorder with over 30 years of clinical experience, recently sat down with Victoria Franz, clinical psychologist and business development manager at PESI. Here’s their discussion on complex trauma, body shame, and binge eating disorder.
Why do therapists treating trauma often miss that their clients have binge eating disorder?
There are three reasons that I think are especially powerful.
1. Clients tend to feel a lot of shame about their binge eating behavior. We often shame people for overeating, especially if they’re considered overweight. We might judge them to be bad, weak, or disgusting. There’s a lot of judgment around overeating, so clients are very hesitant to talk about it.
2. If therapists aren't specifically trained in working with binge eating, they can inadvertently minimize binging and see it as a diet or willpower issue. However, binge eating often serves a very powerful dissociative purpose for clients.
3. We’re trained in trauma and not in eating disorders, and thus we’re not trained to assess for binge eating. We need to learn to assess how our clients’ behaviors began and how they may be using these behaviors to soothe, dissociate, or even to self-harm.
How do you recommend clinicians treating trauma inquire about their clients’ relationship with food?
It can be as simple as putting out the question. Tell me a little bit about your relationship with food. Is food something you might go to or withhold when you’re feeling stressed, anxious, or depressed?
If your client confirms that they struggle with food, you can ask further probing questions, like whether they tend to over-eat or under-eat. They may already have a sense of how this disordered behavior fits into their life. Your role as the therapist is to bring a lens of compassion and make space for clients to talk about how their relationship with food may serve them.
The key thing is to invite the conversation from a very non-shaming, normalizing space.
What can you tell us about the role of trauma in the development of binge eating disorder?
Our bodies hold everything that has happened to us, and binge eating can be a very powerful way for young people to deal with the somatic aspects of trauma. Food is one of the few things available to kids, and for most of my clients who struggle with binge eating, this behavior has been around in one form or another for most of their lives. Food can activate a hypoarousal response, which provides a means of escape and soothing when nothing else is available.
When healing binge eating disorder while doing trauma work, we have to take into account how scary it is to change this behavior. There's a lot of safety that clients get from their relationship with food, so treatment has to focus on helping them develop other ways to be safe before changing that relationship with food.
If a therapist approaches binge eating disorder from the perspective that their client has a willpower problem, what does that look like for the client? What happens in treatment?
There are a number of issues that emerge. One is that it sets up binge eating as a behavioral issue and not something that is systemically part of survival for our clients. It also implies that with willpower, clients can stick to a diet.
What we know is that diets don’t work. They don’t work for people without
eating disorders, and they especially don’t work for people with
Most of the clients with binge eating disorder who come into your office are going to have long diet histories, and they're going to see themselves as failures in many ways. If we repeat the narrative that indeed they have been failing and that there is some way that they should be able to stick to a diet, we are essentially prescribing something that is guaranteed to fail.
Could you say a bit more about what you mean about diets not working?
Diets don't work because the body doesn't know the difference between a diet and a famine
When we start a diet, the body behaves accordingly. When we tolerate hunger, the body fights back in a myriad of ways. All kinds of physiological processes will happen that actually increase the drive to go to food.
Instead of a diet, what I find works much better is helping clients develop a relationship with their bodies so that they know their body is where their wisdom lies, and that's essentially the work of healing both from a diet history and from trauma.
You’ve talked before about “the body as home” and contrasted that with the idea of “the body as billboard.” Can you say more about this?
Culturally, we’ve been taught that how our bodies look is much more important than our physical health or well-being. We also have norms about thinner bodies being better and more virtuous; there are very specific parameters about what kind of body is acceptable. This is the concept of “body as billboard.”
For people with complex trauma histories, and especially those in bigger bodies, changing their body becomes a way to redemption: “If I fix the billboard, I fix me.” As long as we're in this narrative, we maintain the story that there's something wrong with our clients and they can fix it by doing what is expected of them. For many of our clients who are trauma survivors, that is a fundamental trauma narrative. But of course, no matter how good the billboard may be, it’s never good enough.
To shift from “our body is our billboard” to “our body is our home” is a primary goal of treatment. The way I think about “body as home” is that each client needs to write their own body manual. Everyone's body is unique in all of its myriad ways of talking to us. How do I feel my hunger? How do I feel fullness? How do I feel my desire for movement? How does my body somatically tell me what I’m feeling? Each client has to learn how their body talks and to meet that with mindful compassion.
How can therapists deal with their own body shame as they work with clients?
Body shame is normative. It's unusual that people feel at home in their bodies. The first thing clinicians need to do is acknowledge this. All of our clients live in a body, and most of them go out into the world and feel shamed in that body. It’s particularly true if they’re in a bigger body or a body of differing ability.
Next, clinicians can acknowledge our own struggles. It’s not shameful to struggle – in fact, it gives us street cred. I talk with my clients not excessively, but where it’s appropriate to disclose my own body struggles.
I always remind the clinicians I train that body shame is never a reflection of the truth about your body. It's a way to sell products, so always ask who benefits from your shame
. Be a critical consumer when you’re watching or reading anything that makes you feel body shame. Ask yourself the same questions you’d ask clients. How does my body shame hold me back? What would change in my life if I was okay with my body? What might be different?
Finally, I always encourage clinicians to see what happens if you bring compassion to your body. It's literally been doing its best every moment of your life, so what happens if you offer it some gratitude? What changes? Get curious about what happens.