July 2010 Issue

Three Power Tools in Eating-Disorder Counseling
By Cathy Leman, MA, RD, LD
Today’s Dietitan
Vol. 12 No. 7 P. 14

Dietitians are key team members in the successful treatment of eating disorders. RDs, psychotherapists, and physicians realize that while successful treatment can take many forms, clients must meet certain clinical guidelines and milestones to regain their health.1,2 The team members work to move the client forward within their own particular discipline, monitoring as they go. Rarely does every component of treatment move forward at the same pace, and stalled progress is never a surprise; in fact, it’s practically expected.2

One challenge RDs face is that we represent food, the “tool” our clients with eating disorders rely on for control, manipulation, and perceived empowerment. Their food thoughts and behaviors are chaotic, unhealthy, and unrealistic and grounded in perfection and black-or-white thinking. Our work with these clients is intended to help them gain balance and a healthy food perspective.

Merely by the nature of the work we do, RDs may be the team member our clients fear most.3 Yet the knowledge base we draw from helps create a framework for clients to work within to manage or recover from their eating disorders. Dietitians must correct and challenge clients’ assumptions and ideas about food and weight, many of which are unhealthy at best and worthy of mythical status at worst. A strong, structured food and nutrition framework helps clients feel safe, secure, and empowered. Without it, they may feel they’re walking a tightrope that can give way at any time.

Additionally, the language that dietitians choose when sharing nutrition information can either pave the way for receptive listening and behavior change or elicit an immediate communication shutdown. Using real-life visuals such as photos, dinnerware, and website illustrations can either provide solid support for important educational concepts or bring a session to a screeching halt.

Perhaps your client focus is not eating disorders but weight management, general nutrition for health, or some other nutrition specialty. The same communication principles apply. When our clients are moving toward change, building trust, acceptance, cooperation, mutual understanding, and confidence is integral to the healing process.4 Without a strong client/counselor relationship, it’s difficult to address even the most basic, neutral information.

At the Core: Nutrition Knowledge
For the most part, this is where we’re comfortable and competent: educating about macronutrients and micronutrients, estimating adequate and appropriate calorie levels, ensuring balanced macronutrient distribution, explaining healthy digestive system function and the physiological effects of undernourishment or overnourishment, defining a healthy weight range, and creating meal plans. This is information grounded in fact and driven by data, a benefit of our professional discipline that helps assuage the food terror plaguing our clients with eating disorders.

The aim of nutrition counseling is to replace disordered, unhealthy eating patterns with organized, healthy eating patterns3, and the concrete, “orderly” science of nutrition supports doing just that. Yet the words we use to convey nutritional concepts, while inconsequential to us, can often unnerve our clients.

For one of my clients with an eating disorder, the word “fat” was loaded with obscure meaning, wielded superpowers, and essentially created a terrifying notion. When our conversation inevitably wound its way to the inclusion of fat at both meals and snacks, fear shot through her eyes, her body language shifted, and she would essentially shut down.

Collaborative Language: Connecting Through Vocabulary
How effective are you as a communicator? It certainly helps if you can string words and sentences together in an orderly fashion, but good communication on any level requires work and effort.

What you say may or may not be what’s heard—it’s a common pitfall of any conversation. This can be especially true with clients with eating disorders who often misconstrue information or hear it through a unique filter of distortion. In my experience, communicating information through the repetition of the facts in a controlled, neutral manner helps clients stay centered, calm, and able to wrap their minds around important concepts. Additionally, when dietitians stay calm, accepting, and neutral, we help our clients realize that they can tolerate the uncomfortable feelings with which they struggle.5

Practice conducting counseling sessions using concepts from the “Supportive” column of the chart accompanying this article. These positive, proactive communication methods empower clients. They also support self-sustaining behaviors and growth and help bridge opposing viewpoints to achieve understanding and movement toward change.

For example, when I knew my client and I were heading toward her feared topic, I would prepare her like this: “I know talking about the fat in food makes you uncomfortable (acknowledge and listen to her fear). You and I both know that getting enough fat each day, especially in snacks, is where you struggle (state the facts and recognize that you’ve previously worked together on this; facts are concrete, familiarity is comforting, your support of her is empowering). What foods did you include last week that provided the amount of fat we’re after? What foods can you add this week to continue to do that?” You’re validating her accomplishments and knowledge yet, if necessary, you can easily move into the teacher role.

Visual Reality: Supporting Real Life With Real Facts
When your client measures 3⁄4 cup of dry cereal but shaves enough off the top to end up with 1⁄2 cup, she may genuinely believe she’s being accurate. When she returns from a shopping trip convinced that she’s enormous yet shares that she purchased size 0 jeans, she may genuinely believe her body is too big.

These situations benefit from what I call visual reality. Have your client measure 3⁄4 cup of cereal into a bowl; do the same with the 1⁄2 cup and then discuss the very real differences she sees. Ask her to bring in a pair of size 0 jeans to compare with a larger size (from a secondhand store) and discuss the size difference that is unavoidably visible.

Using visual reality grounds clients in fact when what they view through their “eating disorder lens” is distorted. Because distortion is a fundamental nature of this disease, it’s crucial that you supply objective input. Other tools to consider using are nutrition labels, measuring cups and spoons, varying sizes of dinnerware, website nutrition information or photos, plastic food models—the list is endless and the resulting conversation priceless.

Consider also that initiating these conversations can give you the insight necessary to move counseling sessions forward. For example, waffles are a challenge food for one of my clients; adding syrup adds another level of fear. Prompting her to verbalize that fear led her to share that “the calories in syrup are really, really high.” Surprisingly, she didn’t know the real number, so we looked up the information together. Once she learned the true number of calories and how they fit into her meal plan, she felt more comfortable with adding the syrup.

Final Thoughts
Collaborative work with clients, regardless of their nutritional issue, is one of our most powerful tools as clinicians. Especially for clients with eating disorders, the prospect of recovery from or management of their disease can be daunting every step of the way. It’s helpful to remember that our nutrition degrees and training may be intimidating yet oddly comforting to them, and consistently drawing on our strong background helps move clients toward recovery in a healthy, grounded way.

— Cathy Leman, MA, RD, LD, is a nutrition therapist, freelance writer, speaker, and nutrition consultant.

1. American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders, 3rd edition. American Psychiatric Publishing Inc.

2. Costin C. The Eating Disorder Sourcebook, 3rd edition. New York: McGraw-Hill; 2007.

3. Herrin M. Nutrition Counseling in the Treatment of Eating Disorders. New York: Brunner-Routledge; 2003.

4. Cavanagh ME, Levitov JE. The Counseling Experience: A Theoretical and Practical Approach. Long Grove, Ill.: Waveland Press, Inc; 2002.

5. Setnick J. Eating Disorders Boot Camp Training Workshop for Professionals; 2007; Dallas, Tex.


Supportive     Unsupportive          Rationale



Teaching clients coping skills or nutrition information imparts knowledge they can apply in many situations. Simply telling clients what they need to know offers a temporary solution.



Sharing is the act of telling and requires a degree of trust. Calmly acknowledging difficult information that clients share encourages openness and lessens feelings of shame.



Listening intently and attentively is an act of respect. Lecturing, even unintentionally, can feel like a reprimand.



Open-ended questions encourage a “look inside.” Our clients have staunch inner critics, and we can avoid giving those critics power by being mindful of the words and tone we choose.



Delve into your client’s world with care and concern, lest it be mistaken for an inquisition that could be confused with policing of behavior.



Offering suggestions and guidance encourages give and take. We may know what works, yet “choice” aids our clients’ ability to identify solutions on their own.



It’s more empowering to suggest that a client identify coping strategies or self-sabotaging behaviors on his or her own rather than “saving” them by providing the answers.



Even though nutrition is an exact science, clients can do well “experimenting” to find workable solutions. Knowing they’re free to accept or discard new ideas can move them forward.