In this section, we will explore some of the socio-cultural elements that interact with eating disorders and in particular BED. This topic is covered in somewhat more extensive detail in's introductory overview of eating disorders: Anorexia Nervosa and Bulimia Nervosa: An Introductory Guide to Eating Disorders, which trainees are encouraged to take to round out their knowledge base with regard to eating disorders.

We will then attempt to make useful bridges between what is understood about these socio-cultural factors, and the other components of an eating disorder: biological, nutritional, psychological and emotional.

There is a complication. The biological, nutritional, physiological, emotional, and socio-cultural components, factors and causes of BED need to be understood in context. In essence, unless we understand the context of this disorder we will not understand the disorder, or the patient who suffers from it.

And the context is a complex one, since the biological, nutritional, physiological, emotional, and socio-cultural components, factors and causes of an eating disorder not only exist as multiple forces, but they also interact with each other in complex ways.

Because treatment often involves getting to the source of problems, the overlapping of the various forces can make it difficult to follow any single part of the problem back to its source. If change is to be created, each of the forces must be understood, so treatment can target what is wrong.

Therefore, the next part of this training will be to examine the forces at play from the socio-cultural context. Unlike some aspects of overall healthcare treatment – which are directed by research around specific, limited and controllable variables - some of the understandings presented in this section will be somewhat uncertain, even speculative. This is because the effects and influences of socio-cultural factors are very complex - with so many complicated variables in play - that even high level multi-factorial analysis yields very uncertain results.

This means that the ideas that will be presented here must be viewed as theories, not facts. As better or more detailed understandings are uncovered, the theories will evolve and provide better knowledge to support the work of the clinician.

However, it is still important to provide this information as a starting point for the clinician.

In order to be able to target these socio-cultural factors in informed ways, it is necessary to have a relatively deep understanding of what these factors are, and how these factors work and interact with one another. This allows the informed clinician to make good choices about interventions at each point of contact with the eating disordered patient.

The overall context concerned with BED includes gendered life, which is one of the first contexts that human beings enter into. Adults respond differently when a baby is presented to them – based upon whether the baby is a boy or a girl. Thus, the baby begins the process of being engendered - right at birth.)

BED occurs in both sexes although there are not enough studies yet that can tell us how exactly BED differs in women and men. However, the idea of what is means to be a female or a male – with all of the attendant ideals, norms and expectations –may bring variations in how men and women experience their BED.

Men can more easily make light of or find permissions for their over-eating (men will be men, or eat like a man, or I eat like a horse). This can make the disease harder to identify in men. Women, on the other hand, live with higher standards and greater pressure in areas concerned with body weight.

While some of these different gender ideals, norms and expectations may be relatively stable over time; others can change relatively quickly. This change may happen in conjunction with new fads or other kinds of cultural shifts. However, it seems that the norm that asks women to be more delicate in their eating may create more pressures for women than for men.

BED/ED Factoid

A survey of parents found that one in 10 would abort a child if they know it had a genetic tendency to be fat.

Source: National Eating Disorders Information Centre of Canada (Citing Fraser, L Losing It: America's Obsession with Weight and the Industry that Feeds on It, 1997, Dutton Press)

What are the cultural aspects of our Western societies that interact with and have effects on BED?

If BED begins in the patient as part of an intrapsychic or familial drama – with eating playing the dual role of emotional comfort and a risk to the person's health and self-esteem – the drama inevitably moves into the larger world and culture in which the patient lives. In this larger culture, there are ideas, ideals and values that interplay with the patient's emotional landscape.

If we were to turn our focus on the most important of these items, they would be the following three values that play themselves out in eating disorders:

- The Value of a Thin Physique
- The Value of Individual Achievement
- The Value of Perfection

In's introductory course to AN and BN, we examined how the rise of these values have contributed to the substantial increase in eating disorders over the past couple of decades. These three values are intimately intertwined in the development of disordered ideas about the relationship between one's body and eating.

In essence, these three values at play in Western culture work in tandem to define a cultural ideal: the person with supreme self-control, whose willpower and orientation to high achievement allows him or her to shape and sculpt his/her life towards the highest standards of excellence, including creating the desired trim, buff and athletic look in his/her body.

For the average, normal person – let alone the person who struggles with BED and/or a genetic predisposition to obesity – this is an oppressive standard against which to compare one's self. Yet, it is not a secret that influential forces within our culture value and promote the ideal of thinness. This longed for; unnaturally thin physique appears to be based on images portrayed by the media.

Body size is about the most alarming insecurity that the media generates. A negative body image is generally believed to be a precursor to the development of an eating disorder. (42) Conversely, a healthy body image is a protective factor against the development of an eating disorder.

It has been noted that thinness has come to occupy a too important position in our culture, becoming almost an imperative. Being fat was, at one time, a sign of economic power. Royalty were fat because they had adequate and dependable supplies of food. Today fat is equated with lack of control and lack of will power.

Although the contributing factors to BED seemed to have been less studied than the contributing factors affecting BN patients or AN patients, in part due to the newness of the diagnostic criteria of BED, clinicians working with this population can attest to their suffering on a daily basis. Clinicians hear how their obese patients suffer from almost daily discrimination.

For the typical patient suffering from BED, with its corresponding depression and difficulties maintaining good self-esteem, this additional social pressure compounds the struggle to maintain a positive sense of self. The social discrimination may feel even worse to those who binge eat and may feel that ‘they deserve’ the punishment.

A culture that values thinness as much as ours is bound to reject and also mistreat those who do not comply with the rules concerning the proper social aesthetic currently in vogue. That is why it is extremely helpful for clinicians working with BED and obese patients to talk about how the value of a thin physique is relative to this time and era, not a universal value.

Likewise, the ideal that values individual achievement may lead to a narcissistic quest to be ideally attractive, a quest to which many in our culture subscribe. However, those who are obese – either through genetic determinants or through a history of eating to self-soothe – will derive a message of personal failure and shame from not meeting the social ideal.

Additionally, this particular idealization of individual achievement and performance has been seen as a partial culprit for the diminishment in a sense of communal feelings. This lack of communal feelings may contribute to women and men feeling alienated.

By contrast, within cultures in which the well-being of the group supersedes the needs of the individual, individuals are valued not for their individual selves, but as part of the group to which they belong. This value allows for the formation of a strong sense of community, and a sense of belonging to something meaningful that is larger and more durable than the individual self.

With the sense of self connected to and supported by the presence and successes of the whole community, there is less pressure on the individual to aim for individual standards of perfection. In fact, in many community based cultures, individuals may be punished or ostracized by the community if they stand out too much as individuals. Theoretically, in such cultures there may be less vulnerability for the individual person to acquire an eating disorder based upon a drive to individual perfection.

Clinicians treating BED patients often talk about their patients' feelings of alienation. Patients who are obese have told me about their feelings of alienation when food shopping in a supermarket. Across continents women are speaking of how total strangers removed items from their shopping carts saying, "You don’t need to eat this!" Others speak of strangers telling their pre-school child in an elevator: "Your mom has such a pretty face; it's a shame she let herself go and got so fat!”.

It is little wonder that obese BED patients feel alienated. Likewise, it is not surprising that those who are not yet obese can view a failure to adhere to this norm with a certain amount of dread.

Clinicians working with BED need to know that working with patients BN and AN patients is not the same as working with BED patients. As painful as it is to feel fat, it is probably more difficult to live in this fat phobic world being fat or obese.

Although the value of individualism seems to be a factor in a culture that reveres thinness, it is also important to understand its underpinnings in interactions with other contexts. It has been proposed that people in our culture sometimes look for simple solutions to solve complex problems.

The problems experienced by people in our culture may be multiple and diverse, and may belong to many different realms of reality: ethical, moral, social, and economic. The individual – in cultures that value individualism – may receive many messages that each person is responsible for how successful he/she is in handling these complex problems.

However, many of these problems exceed the capacity of the individual to solve, potentially leaving the individual feeling like a failure. The individual, rather than tolerating an absence of control, begins to look for areas of his/her life that can be controlled – hoping that success in that area will magically and miraculously serve to correct the larger ailments.

Some theoreticians believe that this aspect of the interaction between the individual and his/her culture leads to an obsessive search for physical perfection as a substitute for solutions that are more real and more substantive. This is thinness as life success. In this case for those people who are less than thin, failure is a sure thing from the start.

This aspect is enhanced and magnified by the next context issue we will examine, the value of perfection. We live in a culture whose core values include ideas about having ‘the best’ and striving for ‘perfection’. Wines and teas and steaks need to settle, brew or be cut to ‘perfection’. Schools for our children, even pre-schools need to be the best or, at the very least the perfect-fit for our children. Performances in small and big companies need to be nothing short of perfection.

Not surprisingly, we live in a culture that has exploded with the need to perfect the body, too. The body has become the temple where perfection is shown, or needs to be achieved. Perfection has become a badge of honor that can be achieved with hard working tenacity.

The value of individual achievement means that perfection can be achieved by the high performing individual – if he or she simply brings enough drive and willpower to the table. In a complicated disease such as BED, this value creates special problems. It may be that making one’s mind up and working hard at it does not bring the desired change in physique – particularly if the person's genetics do not predispose them to being thin.

From a clinician's perspective at least, what leaves BED and obese patients vulnerable is that - when there is no social space for a body that, according to the current standards, is less than perfect - self-esteem and worth plummet.

One might be tempted to underplay the effects of these socio-cultural factors, to assume that the impact is not so large as to be a primary factor. There is evidence that this is an incorrect assumption.

An example of the fear of fat is given by EDIN’s brochure. EDIN (Eating Disorders Informational Network) a non-profit organization that does outreach and fosters information and awareness on the topic of eating disorders has a new flier. In the brochure it says that "Young Girls say they are more afraid of becoming fat that they are of cancer, nuclear war or losing their parents. (134)

In this social climate it is obvious that BED patients may be suffering acutely, in ways that may make addressing the BED more complex and more difficult. However, it may be important to insert a word of caution. Although many risk factors have been implicated in the development of eating disorders like AN and BN, little is known about the factors implicated in BED. (34)

BED/ED Factoid

80-90% of women dislike the size and shape of their bodies.

Source: National Eating Disorders Information Centre of Canada (Citing Hutchison, M. Transforming Body Image, 1985, The Crossing Press)

There are several other socio-cultural factors to mention: 1) the presence of a well-funded industry built around dieting, 2) the food industry and its advertising, 3) the culturally determined role of food, 4) the influence of the media, 5) larger scale influences from the culture at large. Let's look at these one by one, starting with the presence of an industry based upon dieting.

The Dieting Industry

Many professionals in the field have shown that there is whole stable of research backed literature that is consistently disregarded by the medical world and the diet industry. This literature points to evidence that it is better to have a heftier- but stable - weight than it is to force the body into a false set point.

However, if this research was to be acknowledged, the diet industry would run the risk of losing half of its potential clients. Instead, the diet industry promises tools to help its customers get the pounds off – and markets these tools with a huge advertising budget. The underlying message is that the right diet program can help those "high achieving" "high willpower" Americans to look like their favorite reed-thin celebrity.

It is difficult to assess the exact impact of the economic and socio-cultural importance of the diet industry in the lives of young people who are obese. However, it is always important to gather information about dieting history in those who suffer from BED. Unfortunately, for a subgroup of obese children, there is apparently a developmental pathway leading from weight problems to dieting to binge eating. (89)

BED/ED Factoid

Americans spend over 40 billion dollars on dieting and diet-related products every year.

Source: National Eating Disorders Association (Citing Smolak, L. National Eating Disorders Association/Next Door Neighbors Puppet Guide Book.)

The Food Industry

Like dieting, the role of food has come to hold an interesting position in the larger culture in America. As well-funded as the dieting industry is, it is a very small segment of the economy compared to the food industry. Restaurant chains, snack food companies, and the rest of the food industry spend an enormous amount of advertising money to keep food constantly on the minds of Americans.

From all signs, they are being successful. Food, like weight and dieting, are constants in women’s lives and conversations. More and more these topics are becoming a conversation piece in men’s lives, too.

Under the umbrella of keeping healthy and staving off heart disease, men are advised to watch what they eat and to exercise. It is interesting to note that almost every woman’s magazine shows a delicious meal to prepare on one page - a meal that will most likely be prepared by a woman - while on the next page it discusses the diet plan that the same woman should be following.

These double messages around food and weight control are a constant part of the media onslaught that people face today. The message is clear for both sexes. Enjoy larger portions and an unlimited variety of delicious snack foods, but just don't gain weight. Under these conditions, it is difficult for a sane and reasonable message about food and weight to be heard.

Cultural Ideas and Values about Food

Above the larger cultural issues, there are other cultural elements concerning food and eating that should also be examined. Different sub-groups within the larger culture also bring ideas and values about the role and purposes of food and eating.

It has been suggested that Jewish, Catholic and Italian cultural origins may lead to a higher risk of developing an eating disorder due to cultural attitudes about the importance of food. (97) The interplay between one culture's values about the importance and nurturing aspects of food, and another culture's values about the importance of thinness can create dueling and interacting pressures.

When one is seeing a patient suspected of having an eating disorder and who comes from a specific culture or sub-culture, a thorough assessment should always include investigation of the role and importance of food within that patient's culture or sub-culture. From there, one can assess the interplay with the message from the dominant culture.

The Influence of the Media

Studies among teenagers have shown that poor body image and dieting is correlated to the amount of time that teenagers spend reading magazines such as Seventeen. (36) The more time teenagers spend reading popular magazines, the worse their body image becomes - and the more they are prone to dieting.

Studies concluded that since teenagers are so affected by the written word it is worth speculating whether teenagers would also respond to positive articles that provide them with sound non-dieting advice. (36)

BED/ED Factoid

The odds of engaging in unhealthy weight-control behaviors such as fasting, skipping meals and smoking more cigarettes was double for adolescent girls who were the most frequent readers of magazine articles about dieting and weight loss, compared with those who did not read such periodicals

Source: MedlinePlus (Citing a 1999-2004 study conducted at the University of Minnesota)

Larger Scale Influences

There are a number of historical influences that may have participated in the shaping of a culture in which in which a larger (or even average body) is considered abnormal. These influences are more connected to a sociological analysis than to a psychological analysis. For this reason, the coverage of this area will be brief rather than extensive.

However, there are compelling reasons for bringing this information into a course on BED. The sociological context within our current culture is – to a great degree – one of the important influences that has supported and encouraged the increase in the incidence of eating disorders. There are effects and pressures on patients with BED from the presence of a whole culture that values thinness - and champions a quest for perfection through thinness. Obesity or plain being overweight is seen as a "sin".

Patients with BED may present with a high degree of suffering, depression anxiety and also resistance to change. However, change may be helpful in terms of their fundamental cognitive constructs around their body image and concepts of an ideal body weight.

Patients with BED may see their weight as their only problem – and they will find evidence in their cultural landscape that supports this position. This is not to say that a culture that honors and champions thinness will be kind to someone that is less than thin; however, to see binge eating and weight as the only problem in someone’s life may be using binge eating in a masking way.

This point goes back to the model of seeing binge eating under the lens of the masking theory. (92) It suggests that the patient, rather than blocking feelings by binge eating, attributes all negative affects to the BED - in order to mask any other problem he/she may have.

This is where a deeper level of understanding of the forces at play in the development of BED comes into effect. Changing the patient's ideas about their body weight will require discourse. The discourse is not only between the clinician and the patient, but also between the clinician and the sociological forces that have been evolving to make BED more common and more difficult to treat.

Sometimes, a clinician needs to help the patient accept the body she or he has. Sometimes, there needs to be an acceptance of the pain that the patient endured when she or he was growing up.

To the degree to which the values of the culture have contributed to the warped ideals of the eating disordered patient (and the resistance to change, even when these ideals produce a life-threatening outcome), the clinician needs the ability to enter into a deep discussion with the patient about the meaning and effects of those values. At times, obese individuals refuse to change as a resistance to society as a whole.

The knowledge of the historical background of these values improves the clinician's ability to deconstruct those values. It allows for a more knowledgeable discussion of these values, and allows the clinician to make a more compelling case for change. Likewise, if the patient is obese but is healthy (and not a BED patient), the professional may want to help him or her realize that it is much more harmful to try to change a hefty but healthy weight than to try to lower it and engage in "yo-yo dieting".

Whether the clinician uses motivational interviewing or some other approach to increasing motivation for change, the larger the knowledge base - and the more thoroughly the clinician understands that knowledge base - the greater the degree of authority in building a case for change.

BED/ED Factoid

Body Dysmorphic Disorder affects about 2% of people in the US and strikes males and females equally.

Source: Anorexia Nervosa and Related Eating Disorders, Inc.

Sociologists have noted that we are in the time of the "Third Wave". This is the third of three major sociological changes that have reshaped society and culture in the Western world. The beginning of the first major restructuring of modern culture - the "First Wave" - is also known as the Industrial Revolution. This created a major new division between the public and the domestic sphere. Labor was no longer a communal affair, as it had been in the villages. Men left the home and went to work. Women stayed at home

For the first time women were alone and isolated in nuclear families without the connections they felt when they lived ‘in the villages’ or, during the Middle Ages. In this new family structure, the concepts of individuality and subjectivity and personal growth - for better or for worse - began to flourish. The protections of communal identity and communally defined roles and self-worth began to diminish, replaced by definitions of worth created through one's competitiveness in a competitive society.

This new social order and context promised new modes of creating happiness and fulfillment. However, the new order also restrained people’s sexual freedom, bred gender limitations, marginalized people according to income and used people instrumentally for capitalistic gains. In essence, the new order bred its own sources of frustration and unhappiness.

In lieu of support and shared purposes provided by one's larger community, the new model began to rely on the strength of the nuclear family. The nuclear family began to harbor all that is related to emotions, feelings and nurturance. However, because no family can fix what is wrong with the macro social context, families began to harbor the same frustration of desires and alienation that they were supposed to fix.

At the same time, other types of progress were occurring. New inventions created increased creature comforts – some of which came with new sets of problems. In the fifties, women for the first time had access to a refrigerator. Now, they could store as much food as they wanted. However, modern amenities did not assuage feelings of loneliness and disconnection.

Some social historians argue that during the industrial revolution commodities began to be manufactured in mass. Thus, the need for mass consumption appeared. At this time, these historians believe marketing made its appearance and people began to feel the need for things they never knew they needed before.

Some feminist scholars that have studied the influence of industrialized world and marketing in women’s psychology believe that new industrial world and its new marketing strategies were the culprits, at least partially, of women’s unhappiness with their bodies.

Advertisements for the new items included information that may have taught women to hate their natural hair, their natural odor, in essence, natural aspects of their female body. The same directed marketing may have influenced them to dislike their natural weight, too. They began to buy artifacts to get rid of their bodily hair, sprays and bars to get rid of their smell and pills, special foods or powders or pre-made dinners to control their appetites or feed their families.

According to this analysis, the new industrial world tried to sell the new manufactured goods by advertising them as products that would help with the nuclear family with “bliss and happiness”. Definitions of what was necessary to achieve happiness could be manipulated by outside forces, instead of being determined by more personal or communal forces. This is the effect of the market consciousness.

"We live at the end of a century in which the competitive economic market has demonstrated its powerful ability to shape the dominant consciousness of the planet. That market consciousness has convinced many that the highest goal of life is to consume, that the proof of one's own self-worth is how much power and money one has at one's disposal, that the "natural" inclination of each person is toward selfishness and egotism, that every other person is a potential rival for scarce economic or emotional resources, that societies should be constructed primarily to protect the individual so that s/he may pursue her own self-interest without external constraints, that progress means the increasing scientific conquest of nature and its transformation into forms that can be used or sold to others, that the goal of knowledge is to increase control and domination of the world, and that the rational way to look at others is in terms of what they can do for you to advance your own agenda." (72)

These changes – and the forces driving these changes – have been so thoroughly incorporated into the cultural landscape, that viewpoints challenging or questioning the direction of the dominant culture are at best marginalized and at worst demonized as radical and dangerous. It has been posited that even the ethos of the mental health profession has been unable to maintain clarity about how far these values have insinuated themselves into treatment modalities and philosophies.

"There has never been nor could there ever be an ethically and politically neutral definition of mental health. When therapists argued that they were merely seeking to empower individuals so that they could make their own choices, they were already deeply enmeshed in the market-oriented way of viewing society, one that privileged individuals and imagined that they could be healthy without regard to the quality of human relations and social realities around them. In this way, the definition neatly replicated the logic of the competitive market itself, which saw human beings as isolated monads equally fit to compete against each other for societal goods." (71)

If people in the mental health professions are having more difficulty in sorting through the sociological changes responsible for some of the deterioration in overall mental health, it should not be surprising that eating disordered patients absorb - without too much questioning – certain ideals and values that contribute to mental health problems.

These sociological forces, if anything, appear to have intensified over the past decades. Not surprisingly, the incidence of BED has increased, but not just for women. As noted earlier, BED is on the rise among younger men, as well.

There is some thought that men have recently been subjected to some of the same manipulation by mass marketing. In the last decade or so, men seem to have been physically objectified in the same manner than women have been objectified for years – with products and services conveniently available to help men in their quest for perfection.

There are now men’s only magazines, and men’s fashions magazines. These issues talk about looks, fat intake, exercising and dieting, just as women’s magazines have for years. It seems that the consumer culture has recently learned that it could tap into men's fear and worries, and make them insecure about their bodies just as they had done with women decades ago. (132)

Predictably, in the last decade more heterosexual men have begun to come into health care facilities and inpatient units showing signs and symptoms of eating problems and disorders - in greater numbers that ever before. Although overweight men have been denigrated for much of the 20th century, the discrimination and prejudice has become far worse in the last five to ten years.

Prejudice toward obese men is acceptable, and job discrimination a common occurrence. Obese men are teased, ridiculed and also abused. They are also discriminated by the medical establishment and insurance companies. While women have confronted these issues for a longer time than men, women have had some measure of support from the Women’s Movement. Men, on the other hand, have not developed this level of organized support, as far as weight and shape goes. (2)

During the last decade, certain male feminist psychologists, mental health professionals, and writers have attempted to validate eating disorders as male disorders, too - with the intention of unburdening men from the stigma and shame that BED may have brought them. (2)

These healthcare professionals stated that for men, it is not easy to open up and admit having emotional problems, much less easy to admit issues around body image and self in relation to appearance. (2)

Some authors believe that certain specific aspects of our culture drive men to think that they are supposed to keep their college weight through life, even if it is not the natural thing to happen. (2)

This same culture, apparently, calls for a ‘new man’, a more emotional and available man, more tender and less cut off from his feelings. However, simultaneously - according to some thinkers - this culture seems to ask some men at least, nothing less than an almost perfect body, a Spartan warrior’s body. (2)

Certain researchers consider that from the 80% of men who desire a body different than the one they have, 40% wish to be thinner than they are, but the other 40 % wishes to be heavier. (2)

The role of the health professional in prevention with respect to socio-cultural factors

The role of healthcare professionals in this complicated state of affairs is important and complex. The healthcare professional working with BED needs to be empathic, as well as real. However, the professional also needs to stand as an expert, working from a position of authority.

At the same time, the professional needs to be honest as far as to what is and what is still not known in the diagnosis of BED. The clinician’s authority and expertise are created and put to the test by the skills in intervening – and the thoroughness of the knowledge base from which interventions proceed.

Healthcare professionals need to be prepared to discuss with their patients – and their families/support systems - the socio-cultural and psychological factors influencing BED. They need to able to enter into a complex dialogue with the patient concerning the pressures to be thin, pressures that can come from family, friends, and the culture as a whole.

This dialogue must examine – with the participation of the patient – the meaning, purpose and outcomes of these forces in the internal emotional life of the patient. Unlike with other eating disorder patients, professionals working with BED patients need to acknowledge the very real and concrete pain of living in this era in a larger body.

The goal of this dialogue is to reorganize these forces and pressures in a manner that allows the patient to embrace a healthier ideal of the self. Acceptance works miracles and it is often only when there is acceptance that a patient may be able to revert from unhealthy patterns of behavior to healthy ones.

The choice of the word "dialogue" is deliberate. Eating disordered patients can be terribly resistant to coercive or pressurized approaches to get them to alter their behavioral choices when it comes to eating. BED patients are notorious among clinicians for refusing going on a meal plan.

The change that must occur for the patient to move to a healthier position will take place in the inner landscape of the patient's emotional world. The patient must be helped and invited to come to this changed place; he or she will find ways to resist being forced or coerced. Sometimes, this resistance can be interpreted as the need to be accepted by others just the way one is. Clinicians may do well in keeping this in mind while they work with resistant BED patients.

The dialogue must be patient, deliberate and responsive to the cues and messages from the patient about how quickly or slowly to proceed. The dialogue must include a method of validating the norms of attractiveness inherent in the patient’s surrounding world. Even if those norms must ultimately be reconfigured because the patient may never attain his or her ideal, patient and clinician need to talk and the patient may need to mourn the body she/he will never have.

At the same time, the ideal and unattainable body may need to be put in perspective as to whether it really brings happiness. (Isn't it the case that many perfect-body celebrities are constantly checking into rehabs?)

A good starting model for this discursive process is Motivational Interviewing, a technique employed used most frequently by professionals who work with patients with substance abuse/addiction, and which was developed by Miller and Rollnick. (79) They define motivational interviewing as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

Motivational interviewing has two basic phases. In the first phase the emphasis is on building motivation for change and in the second phase the emphasis is on strengthening the commitment to change through setting goals, considering change options, developing a plan, and eliciting commitment.

Motivational interviewing focuses on helping to motivate individuals toward making changes using such strategies or techniques such as:

- Normalizing patient uncertainties
- Rolling with resistance
- Asking open-ended questions
- Discovering patients' beliefs
- Reflective listening
- Conducting empathetic assessments
- Amplifying patient doubts
- Developing discrepancy between personal goals and problem behavior
- Conveying confidence in patient’s abilities to change
- Supporting patient choice and self-efficacy
- Reviewing past treatment experiences
- Working with patient to develop a treatment plan
- Providing relevant feedback
- Summarizing and reviewing potential sources of non-adherence
- Negotiating proximal goals
- Discovering potential roadblocks
- Displaying optimism
- Involving supportive significant others

In the case of BED, the dialogue would be concerned with helping the patient to explore his/her ambivalence about body weight, being healthy, abstinence from bingeing, following a meal plan– as defined by the larger culture and interpreted by the patient - versus the unconscious desire to keep bingeing, be physically and emotionally unhealthy, etc.

Patients need to be given the information pertinent to their health and learn about the consequences of their choices by the mouth of their medical team; however, motivational interviewing gently directs the patient to examine for him or herself the outcomes of various choices.

In such a dialogue, the clinician must be prepared to explore – with the patient – the socio-cultural information about what the "right" body weight is, what the "correct" reasons are for attempting to reach a lower weight and if that is even possible giving genetics and physical frame.

Patient and clinician need to discuss too the benefits of being freer from BED, according to the medical field, and what "real" benefits the patient could expect from investing in and working on a healthier life style. The techniques of motivational interviewing – open-ended questions, reflective listening, rolling with resistance – help the patient to begin to discover questions about their own choices, as well as the purposes of socio-cultural factors.

Done correctly, the patient will begin to educate him or herself about how some of the historical and socio-cultural factors have created difficulties for the members of present day Western culture. With a trusting relationship, the clinician can slowly and gently support the deconstruction and restructuring of these meanings to a healthier position.

A clinician may explain to a patient how in the past obesity was seen as a sign of power, a sound economy and the possibility of being a good provider. With these symbolic meanings, obesity had different connotations. Although this will not mean that a patient will instantly feel good about his body, it could possibly help the patient put his situation into perspective.

While this socio-cultural exploration is occurring, health professionals must understand - and may need to explain to their patients - that food may be used as way of coping with negative emotions, at the same time that food has a positive adaptive function. The dialogue concerning this issue will also be oriented towards resolving ambivalence and conflict.

Health professionals also need to be aware of the history of the individual with regard to any possible sexual abuse that may be an unspecific factor in the development of the eating problem. The need to binge may have a deeper psychological meaning for the patient with a history of sexual abuse. Having a "different" body - and the blaming of all wrongs on the actual body the patient has - may be used as a way to compensate for the loss of a sense of "goodness" that can occur as a consequence of sexual abuse.

Some clinicians have also thought that extreme obesity due to binge eating may be used by some sexual abuse survivors to remove the external signs of sexuality and or attractiveness. This may be a method of feeling safer by looking unattractive and less sexual. This may be similar to what occurs for some early adolescents, when their nascent sexuality confuses and frightens them so much that they diet to try to return to a pre-pubescent state.

To add one additional contextual feature, clinicians working with men with BED need to have available to them the same patience that clinicians have been providing to women when they deal with eating problems. They must also always keep in mind the additional pressures for men of having to submerge their emotions and internal needs.

The dialogue for men, therefore, will have some additional external forces and pressures to reconfigure. Psychologically, men will need additional help in learning to embrace the whole of who they are, without getting cut off from certain emotions and without getting trapped in the pressures of externally driven ideals coming from consumer culture.

According to some clinicians, men who suffer from BED seem to need professionals who are able to do away with the “Boys will be boys” attitudes and stereotypes that make it easier for this subset of men to eat compulsively and in an unhealthy manner without taking care of their physical bodies.

BED/ED Factoid

35% of "normal dieters" progress to pathological dieting.

Source: National Eating Disorders Association (Citing Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3))