Clinical Modalities for Counseling Clients With Disordered Eating

Eating disorders are not only widespread, they also have the second-highest mortality rate among mental illnesses after opioid addiction. The National Alliance for Eating Disorders reports that although millions of Americans experience one, fewer than one-third receive treatment.

Common eating disorders include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant restrictive food intake disorder (ARFID), and other specified feeding or eating disorder (OSFED).

“While each of these diagnoses varies in presentation, some symptoms to assess are restriction of food intake; purging (via vomiting, laxative use, diuretic use, fasting, or overexercising); binge eating (including feeling a loss of control); and preoccupation with food, weight, or shape,” says Adriana Labarta, PhD, NCC, ACS, LMHC, whose research interests include disordered eating and body image. 

It is essential for counselors to understand that eating disorders are not always associated with an individual’s body image, Dr. Labarta says. 

“Body image concerns can perpetuate disordered eating behaviors, with body dissatisfaction being one of the most well-known risk factors for the development of an eating disorder. However, it is important to note that not all individuals with eating disorders present with body image concerns. For example, avoidant/restrictive food intake disorder (ARFID) involves food avoidance or restriction due to sensory sensitivity, fear of choking or vomiting, or lack of interest in food/eating. Therefore, body image concerns are often not the primary factor underlying ARFID.” 

Counselors should also be aware of cultural and social considerations related to eating and body image when working with these clients. 

“Eating disorders impact people across diverse cultural and social identities, including age, race/ethnicity, gender identity, sexual/affectional orientation, socioeconomic status, and body size,” she says. “However, eating disorder research and practice have historically focused on the experiences of White women, leading to treatment gaps. As counselors, using culturally responsive approaches and exploring risk and protective factors unique to diverse groups and intersecting identities is paramount. Some factors that can influence the development and maintenance of eating disorders include acculturation, sociocultural body ideals, weight stigma, and discrimination. Helping clients establish community with others can be a meaningful protective factor to promote a sense of belonging and support in recovery.” 

She suggests two formal eating disorder assessments, the Eating Disorder Examination-Questionnaire (EDE-Q) and the Eating Disorder Inventory (EDI). “Outside of eating disorder treatment settings, it is also important to screen for eating disorders, as they are often underdiagnosed,” she adds. “Counselors can broach eating concerns and body image with clients in intake appointments by asking open-ended questions, such as ‘How would you describe your relationship with food and body?’ This question can invite clients to reflect on their experiences and help the counselor determine if further assessment is needed. 

“Eating disorders impact diverse individuals across the lifespan and often co-occur with other mental health concerns, such as anxiety, depression, trauma, suicidality, and substance use,” she continues. “Oftentimes, clients may present to counseling with a different concern without recognizing the presence of disordered eating behaviors. As a counselor, it is essential to acknowledge the prevalence of diet culture and constant societal messaging surrounding ‘health and wellness,’ which can sometimes normalize disordered eating behaviors. Some clients may present to counseling expressing concerns with perfectionism, self-criticism, or emotion dysregulation, which are common psychological risk factors.” 

Many evidence-based approaches are used when counseling clients with eating disorders, including enhanced cognitive behavior therapy (CBT-E), interpersonal psychotherapy (IPT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT), Dr. Labarta says. 

“Family-based treatment (FBT) is also an effective approach for children and adolescents with eating disorders, with a focus on involving the client’s family in the healing process. Further, there has been increased attention on transdiagnostic treatment approaches, or treatments that address maintaining factors across diagnoses, such as emotional avoidance, perfectionism, and emotion dysregulation,” she continues. “Rather than focusing on specific symptoms, these approaches address the underlying mechanisms maintaining eating disorders and other co-occurring concerns (e.g., anxiety, depression, substance use, trauma), thus helping clients develop adaptive coping skills that may decrease symptoms across disorders.” 

She offers the following example of a transdiagnostic approach: 

“Imagine that a client presents to counseling with OSFED, depression, and post-traumatic stress disorder. The client has experienced persistent weight stigma throughout their life, which has contributed to difficulties with vulnerability and trust in relationships; however, the client desires change and meaningful connections with others. The client reports engaging in a binge-restrict cycle to disconnect from feelings of isolation and self-criticism. Using a culturally responsive approach, a counselor can focus on creating safety in the therapeutic relationship, validating the client’s experiences, and recognizing the impact of weight stigma on their mental health. The client may have developed disordered eating behaviors to cope with significant trauma and feelings of isolation, thus perpetuating a binge-restrict cycle. A transdiagnostic approach can help the client become aware of the role of emotional avoidance; increase emotional awareness with mindfulness, nonjudgment, and self-compassion; and introduce helpful skills that can facilitate cognitive flexibility and emotion regulation.” 

In addition to these modalities, there are prevention-based approaches. 

“Prevention approaches are crucial to raise awareness of eating disorders, reduce risk factors, promote protective factors, and destigmatize eating disorders across the lifespan,” Dr. Labarta says. “Some prevention-based programs incorporate media literacy, self-compassion, mindfulness, and psychoeducation. Counselors can integrate prevention efforts across counseling settings and tailor them to diverse populations to address unique risk and protective factors. Prevention and early intervention serve a crucial role in providing education and connecting individuals to helpful resources.” 

Counseling clients with disordered eating typically involves integrated care, and there are key considerations when determining whether an individual needs a medical evaluation. 

“Multidisciplinary care is essential to the treatment of eating disorders,” Dr. Labarta says. “Counselors often collaborate with other health care providers like dietitians, psychiatrists, and physicians to comprehensively assess and treat eating disorders, attending to the client’s emotional, psychological, nutritional, and medical needs. There are several factors to keep in mind when determining if a client needs a higher level of care, including severity of symptoms, co-occurring mental health concerns, medical severity, safety concerns, level of motivation, and current support and resources. 

"Clients may experience concerning physical symptoms, such as significant weight loss, dizziness, weakness, digestive complications, and memory concerns, highlighting the importance of multidisciplinary treatment,” she continues. “That said, I believe it is beneficial to encourage all clients to follow up with their primary care physician for routine medical monitoring, which can emphasize the importance of a holistic approach to treating eating disorders. Furthermore, it is crucial to recognize that eating disorders impact individuals across body sizes, and size-inclusive care is essential to ensuring that all clients receive the support that they deserve.”

Including parents, caregivers, and families in the process can often be critical to healing, particularly for children and adolescents, Dr. Labarta says. She shares some ways that counselors can help them gain a better understanding. 

“Counselors can provide families with psychoeducation on warning signs, common myths, and strategies to support their loved one with an eating disorder. For example, they can equip parents and caregivers with techniques to navigate mealtimes, which are often stressful experiences for individuals with eating disorders. Also, counselors can help families be mindful of language (e.g., avoiding labeling foods as ‘good’ or ‘bad’) and improve communication with their loved ones (e.g., using ‘I’ statements to express concerns).” 

Before deciding to involve those individuals, counselors should also be aware that depending on family relationships, it could potentially hinder a client’s progress, she says. 

“Some clients may experience difficult or painful family dynamics that impact their recovery process. For example, family members may criticize or comment on the client’s body size, weight, or food/eating, which can disempower an individual in recovery. Some adult clients may choose to involve other supportive people in their lives (e.g., partners, close friends), which can promote greater awareness and understanding of the individual’s experience living with an eating disorder while expanding their social support network.” 

There are also key factors to consider when determining whether a client is making progress or if treatment may need modification. 

“Routine outcome measures, or assessments that measure clients’ progress on a routine basis throughout treatment (e.g., weekly), can help assess progress and understand whether adaptations are necessary based on the client’s response to treatment,” Dr. Labarta says. “I also believe that client feedback is crucial to understanding their lived experience in eating disorder recovery and treatment. Combining both quantitative and qualitative assessment methods allows for a comprehensive picture of progress, allowing the client, counselor, and treatment team to understand and respond to their present moment’s needs.” 

A wealth of information is available to counselors working with this population, she adds. 

“The National Alliance for Eating Disorders offers resources for clients, families, and loved ones, including a free helpline, educational content, support groups, and a national database of eating disorder treatment centers and practitioners,” Dr. Labarta says. “Professionals can also benefit from their Eating Disorders Information Gateway and ongoing continuing education opportunities on various topics related to eating disorders.” 

She also recommends the following for counselors, clients, and their loved ones: 

• Project Heal
• Association for Size Diversity and Health
• Fighting Eating Disorders in Underrepresented Populations
• Academy for Eating Disorders
• National Eating Disorders Association 

Adriana C. Labarta, PhD, NCC, ACS, LMHC, is an Assistant Professor of Clinical Mental Health Counseling at Florida Atlantic University. She received a Bachelor of Science in psychology, Master of Education in mental health counseling, a Specialist in Education from the University of Florida, and a doctorate in counselor education from Florida Atlantic University. As a Licensed Mental Health Counselor and National Certified Counselor, Dr. Labarta has experience working with diverse clients in residential, partial hospitalization, intensive outpatient, outpatient, and university counseling settings. Her primary clinical and research interests include eating disorders and body image concerns in marginalized communities. Dr. Labarta is a member of several counseling organizations and was previously selected as an Emerging Leader by the Southern Association for Counselor Education and Supervision and the Association for Assessment and Research in Counseling.

**Opinions and thoughts expressed in NBCC Visions Newsletter articles belong to the interviewees and do not necessarily reflect the opinions or practices of NBCC and Affiliates.