This article originally appeared in The National Psychologist, February 4, 2020
Binge eating disorder (BED) is the most common eating disorder among adults in the United States. More than 8 percent of American adults meet some or all of the criteria for binge eating disorder at some point in their life, more than all other eating disorders combined.
Despite the need for effective treatment, binge eating disorder has been very resistant to psychotherapy. Cognitive behavioral therapy (CBT) has been shown to be the most effective form of treatment, but even that approach has demonstrated remission rates of only 40 percent to 60 percent, meaning about half who seek CBT treatment for BED do not benefit.
CBT emphasizes interventions for binge eating that are focused directly at stopping the unwanted behavior. However, research has shown dieting to be a causal factor in the development of binge eating disorder. From a patient’s perspective, interventions that are aimed at stopping the behavior may not feel very different than restrictive eating, which may play a role in limiting the effectiveness of CBT.
The causes of binge eating are usually assumed to be a combination of social, psychological and physical factors that create a predisposition to the behavior. Binge episodes are then triggered by various emotional experiences that cause distress, and the food is a way of coping with those negative feelings.
However, if we view binge eating as a response to the perception of a particular emotional threat, then the focus of treatment can shift from the behavior to the cause. In that case, identifying and addressing this perceived threat can allow the clinician to use strategies to reduce or eliminate it and render the need for a response unnecessary.
Over the past 15 years of working primarily with emotional eaters, I have found that the perception of being controlled, especially as it applies to the social pressure to diet, is a fundamental cause of a reactive binge response as a way of rejecting that control.
Although this behavior is unwanted, it can feel nearly impossible to resist. By helping my patients challenge their perception of this belief, they have been able to stop emotional eating in a very short period of time.
Central to this approach is the understanding that the need for acceptance and the need for self-determination, are in tension with each other.
To belong, we adapt to the wishes of others, giving up a degree of autonomy. To be autonomous, we act according to our own wishes, without regard to the judgment of others. We try to find an acceptable balance between them while still satisfying each need.
The social pressure to diet is emotionally compelling as a way to feel accepted by others. However, dieting usually requires self-denial, creating an imbalance that favors belonging at the expense of autonomy.
Such a tradeoff will always feel unfair, especially when the expected results of weight loss are repeatedly undermined by episodes of emotional eating. This creates a need to restore balance by rejecting the perceived control and defiantly eating precisely those foods that are forbidden.
This understanding of binge eating as a way to correct an imbalance between competing emotional needs allows the therapist to identify a cause-and-effect relationship that can be addressed more effectively. By eliminating the perception of control and supporting the patient’s sense of autonomy, the unwanted response becomes unnecessary; there’s nothing to rebel against.
The focus of the sessions shift from trying to suppress the binge eating impulse to regaining their sense of having control over a choice. By viewing all foods as “on the menu” and then following their preferences, patients feel free to choose what they actually want.
Knowing that they can have anything they want, as they would with an actual menu, eliminates the urge to want everything. In my experience, this approach results in more successful and sustainable treatment outcomes in a shorter period of time.