Struggling with binge eating? Feeling out of control of your eating and don’t know where to turn? I have an excellent starting point for you. I discussed what binge eating disorder is and how to get help on a recent podcast on the Embodied & Well Mom Show that I did on with the fabulous Lindsay Stenovec, MS, RDN, CEDRD of San Diego’s Nutrition Instincts. I have provided a transcription of the main part of the podcast in this blog post. Enjoy!!
Lindsay: I’m thrilled to have Dr. Marianne Miller on the show today. She’s an incredible resource as an eating disorder therapist in San Diego. She’s kicking off our San Diego series as we highlight providers that we have here locally here in San Diego that I’m so grateful to have as resources in our community. So, without further ado let’s get going on this interview. Welcome Marianne! Thank you so much for coming on the show.
Marianne: Thanks for having me.
L: So, I would love to have you introduce yourself to our listeners and just hear you talk about what you do, and how you help people, who you help?
M: I’ve been in practice for over 20 years, and I was in academia. I was a professor of marriage and family therapy and was actually the director of a graduate MFT program for four years. I had a side practice of where I was seeing clients with eating disorders, and I just started really loving my clinical work with clients in recovery a lot more than the academic work. So over the years, there was a shift and so I decided to leave academia about a year ago and go into private practice full time and just absolutely loved it. It’s so inspiring and I feel so passionate about helping people recover. Wherever they are, or whatever type of eating disorder they struggle with, it just gives me a lot of joy.
L: We are so thankful for the private practice community that you are working in private practice as well, and a resource to those in need in our community.
M: Thank you, Thank you. I appreciate that.
L: Yeah, I know as you said I know you work with all kinds of—all across the board when it comes to different types of eating disorders and disorder eating, but on this show, we were going to talk a little bit about your work with people suffering with binge eating disorder.
L: So I would love to just hear you kind of in your own words, with the work that you do, you know, how do you define binge eating disorder? How common is it? How would are listeners know if they were suffering with from it, or know someone who is suffering from it?
M: Okay, that’s a really good question. So binge eating disorder is when people have what’s called a binge, where they eat an excessive amount of food. What might be a binge for one person may not be of the same amount of food for another person, but it feels like an excessive amount of food to them, to where they are uncomfortable. Then afterward they feel a lot of shame and regret and negative thoughts about themselves, and a lot of distress after the binge. With binges, they occur on days that the that aren’t typical overeating days. Like holidays are normal overeating days for most Americans. So, it would be outside of Thanksgiving, or you know, any sort of holiday, Fourth of July, that people tend to eat a lot. It tends to happen on a more regular basis from some people it could be once a week, some you know a few times a week, or every day, or multiple times a day just depending on what they’re struggling with. But the important piece to remember is that they are feeling a lot of remorse, a lot of sadness, and negativity, and a lot of shame about themselves after they have this binge episode. It’s typically in a short amount of time where people aren’t even tasting the food, they are just shoving it down.
L: Okay, well Thank you for that introduction. How common it is?
M: Binge eating disorder is a specific disorder that came up in the most recent DSM-5 which is the Diagnostic and Statistical Manual of Mental disorders. DSM-5 came out in 2013 and so it wasn’t a diagnosis prior to that. For eating disorders, it was the typical anorexia, bulimia, and then eating disorder not otherwise specified (EDNOS). Some people who had binge eating disorder were lumped into the eating disorder not otherwise specified (EDNOS) diagnosis. It wasn’t an official diagnosis. In 2013 binge eating disorder became an official diagnosis. There’s an estimated six percent of the population in the United States have binge eating disorder [my correction—prevalence rates range from 0.2-3.5% in women, and 0.9%-2% in men; up to 6% total], which is higher overall than bulimia and anorexia, which can range from 1 to 3 percent [averages, depending on the source]. So, it happens more frequently. Percentage-wise there are more men who have reported to having binge eating disorder then other eating disorders, although in general I think eating disorders in men are underreported, and eating disorders overall are underreported, but that’s what the data research shows right now.
L: Thank you for sharing that. I think a lot of people can be surprised by those statistics.
M: I know
L: Because it is a more recently diagnosable challenge, which doesn’t reflect whether or not it’s serious or severe or anything of that nature, it’s just a technicality there.
M: Yes, exactly. It can cause people so much distress and shame.
L: Yeah, I think given that a lot of our listeners are parents and specifically mothers, it’s probably fitting to also mention that it’s also it’s the most common obviously population-wise, but it’s the most common to suffer during pregnancy and postpartum and actually pregnancy and postpartum, especially postpartum is the most risky time for first-time onset.
M: Oh wow.
L: So that’s something for listeners to be aware of and I think also sometimes there’s an experience of remission if someone has bulimia going into pregnancy are in remission of compensatory behaviors but a maintenance of binge eating where they meet criteria for binge eating disorder, which is great.
M: Right, and that’s what I forgot to mention is that binge eating disorders there are no compensatory behaviors, so there’s not anything they are doing to try to make up for the calories that they ingested. So, there’s no compensation for behaviors and binge eating disorders verses bulimia there are compensatory behaviors.
L: Thank you for distinguishing that as well. So, what are some of the ways you might work with someone to address binge eating? I know a lot of people wonder what can they expect if they call a therapist to talk about this. How do you work with them, and what can they expect?
M: That’s a great question. So, when I first get a phone call, I get more information about what sort of eating disorder behaviors are going on for the person and how long have they been going on. I tell them that the way that I do treatment is kind of like a three-legged stool. So if you picture a three legged stool, one of the legs is I use cognitive behavioral therapy, which deals with your cognitions which are your thoughts so you deal with any unhelpful cognitions that could be getting in the way of you recovering and stopping your behavior and then behavioral interventions that’s behavior part of cognitive behavioral therapy or CBT and looking for ways to change the behaviors.
Sometimes what we do is what’s called a behavior chain analysis so we track back. So, a lot of time my clients have binges in the evening and so we track back, okay it really wasn’t what was going on in the moment that was happening immediately prior to the binge, but it could maybe something was happening earlier that day, starting in the morning or even the day prior or a couple days prior, the stress that was building up to lead to the binge.
And then the second leg of the stool is dialectical behavioral therapy (DBT) I use some techniques in that, and DBT is from Dr. Marsha Linehan, who came up with this model and it’s used a lot with people in eating disorder recovery. The way I use it is for emotion and anxiety management. It’s really based in mindfulness, and mindfulness is moment-to-moment, non-judgmental acceptance and getting people to really be grounded in their senses, and so we use a lot of techniques for people to really focus on what they’re seeing, what they’re hearing, what they’re smelling, what they’re touching.
I like to use things even in my office and I have people use them at home like thinking putty or squishes, or silly putty or things for them to play with. I find that it is really helpful when people are feeling distress and they are having a lot of distress coming up to play with those things, and I can see where they can use them at home. And when people are feeling distress, which can trigger binges, we try to build up a lot of coping skills through CBT. A lot of those DBT skills are based in mindfulness, like lighting a candle, watching the flame of a candle flicker, or for some people it’s listening to music or using an essential oil diffusor and really accessing the five senses to help ground them. And there’s other DBT skills that I help teach them they can really build up their tool box.
The third leg of the three-legged stool is family-of-origin work. So, I find that beliefs about body, beliefs about food, beliefs about how people should look, or what they should or shouldn’t eat, such beliefs don’t appear out of thin air. A lot of times there are patterns, and people’s families-of-origin have patterns that have been passed down over generations. So, we look back to look at that to see how people, for lack of a better word, “inherited” these particular patterns.
Sometimes the process is learning how to set boundaries and speak up for yourself and to stop overfunctioning. Mom are often socialized to overfunction for everyone and I work with them to realize, “I don’t have to put my kids to bed every night of the week, if I have a spouse I can ask my spouse to put my kid three days out of the week, and I can do it four, and maybe those nights I can do self-care.”
Sometimes I find that when people fall into these binge eating patterns, they go throughout each day feeling so deprived and neglected for many different reasons. They think, “well I just want to treat myself to eating whatever,” and then because a lot of emotional things have built up, it turns into a binge. They treat themselves or they eat a “fun food” and they feel guilty and then they eat more to appease the guilt, and it just snowballs. Those are the kind of three psychological perspectives in my eating disorder treatment, those three legs are what I would be dealing with, and addressing.
An additional hope would be to get my clients to see a dietitian who specializes in eating disorders. They can really help them learn how to do intuitive eating where there practicing more on listening to their bodies and tying more into their hunger and fullness cues. Also learning more about the restrict-binge cycle that people get into, where they are dieting all day or they are restricting. Then physiology and nutritionally they are malnourished, and by the time they get through to the evening, their body is screaming, “I need calories! I need calories!” And that can lead to a binge, and they can feel ashamed. So, it’s breaking the cycle, and having that dietitian on board is certainly helpful. Does that answer your question?
L: You answered that beautifully!
M: Okay, Good! (Laugh)
L: I actually made a note as you were going through it, and I was like, oh I should ask about specific coping skills that you use.
L: DBT outlines those, so you know it’s just like a framework, and there are some really cool tools and you have listed some really lovely coping skills, I think the eating disorders or not it is helpful for everyone.
M: Yes, Yeah for everyone, absolutely.
L: It’s one of those when I first learned about, I was like, oh! they should be introducing this in kindergarten!
M: I know, Right? Actually, some of these kids, I had a ten-year-old that I saw the other day and she said yeah my school teaches mindfulness. And I was like, Man! I wish my school taught mindfulness way back! That would have been such a helpful skill.
L: Yes, I know! Can you imagine? I think it is starting to get be used more in schools and in the workplace and things like that. So, kids are learning more about themselves, they’re learning more about emotions. I mean my son can name his emotions at three years old. He’s like, “I’m angry and I can be angry if I want.”
M: That’s awesome! That shows that your doing a great job in your parenting. That you’re validating his feelings, which is so important. That’s another thing that I do a lot of in therapy is validating my clients’ emotions because what I found was with a lot of binge eating clients, they, whether it’s from family-of-origin experience or whether it’s something that they have just learned to do on their own, that they really invalidate their emotions. So, first we have to unlock the box that the emotions are in, and then we let them out, and really validate their emotions and their experience. And I teach them how to own and validate and live in their emotions, and then if they feel overwhelmed by their emotions then I use some DBT skills to help deal with the overwhelming emotions.
L: Wonderful outline, and I love your visualization of the three-legged stool. I’m sure that helps clients feel really confident when walking in your door these are the key things were going to be doing and be look at
M: Yes, absolutely.
L: I love that. You know I know that you also have a spiritual component to your work with clients when it’s something that they also want. I would love for you to share more about that piece as well.
M: Yes, well since I was in graduate school, I was really fascinated with spirituality in therapy. I did my dissertation for my PhD on integrating spiritually into therapy training. I was in full-time academia for 12 years. I continued my research and academic writing, publishing, and presenting on spirituality in therapy at conferences. I taught classes on the topic—it was kind of my wheelhouse. I trained therapists on how to do it.
I have some clients that come to me that it’s absolutely what they want in every session—they want a spiritual integration piece. Then there are some clients who that’s the furthest thing on their mind, they don’t want to talk spiritually at all. I’m totally fine with wherever they are on this spectrum. I have clients from all different faiths that come in, or they don’t have a faith and they say well they are spiritual but not religious and that’s fine. Whatever they want to integrate in terms of using spirituality as their resource.
It’s really, really important for me to integrate it in a very ethical way. It means it’s not about my spiritual or religious beliefs, it’s about theirs. I’m tapping into theirs, and I’m following their lead. I always check in with them and ask, “is it okay for us to talk about this?” If they say yes or if they change their mind half way and say I don’t want to talk about this anymore. I say “okay, that’s fine, whatever works best for you.”
So, we look at spiritual resources, kind of like coping skills; for example, if I have a Catholic client who uses Rosaries to pray, it can actually tap into some mindfulness processes. So, I have people touch the beads of the Rosary and say a prayer for each one. Or if I have a Muslim client who does the prayers five times a day, it can be a really grounding and centering time for them. If they have an eating disorder or anxiety issues or whatever it can help them really focus on their faith and push out all those any sort of negative voices that are in their minds. Again, I find, some of my clients find it very helpful. Other clients believe that nature is where they feel most spiritual. So, it’s about considering t how can you connect with nature in a way that helps you feel more grounded and helps you feel more at peace. Really tapping into that as a resource.
I also look for are any ways that spirituality or religion has been harmful. Are their any harmful spiritual religious beliefs or has there been any spiritual abuse? What I mean by spiritual abuse, I mean the extreme would be if people grew up in a cult or something like that, but also if people were taught something like for women their bodies were a shameful thing, or sexuality is a shameful thing, which could affect eating disorder behaviors. Just unpacking that, and dealing with unhelpful thoughts going back to the cognitive behavior therapy piece.
I’m very clear with clients that I’m not a theologian; that’s not my area of expertise. My area of expertise is the psychological, mental, emotional, and relational well-being of my client. If they have a spiritual belief that is affecting them, it’s something we are going to look at if they feel comfortable—ONLY IF they feel comfortable. Or if they have a spiritual teaching that can be destructive in those areas, then we’re going to look at that. That’s really, really important for me.
I think that most therapists are not trained to look at spirituality, so that’s the thing I can definitely offer. Especially with eating disorder recovery and binge eating recovery, it can sometimes feel really overwhelming and like a long road ahead of them, and having some sort of spiritual beliefs and faith are grounding. Tapping into it, whatever it looks like, can really give people hope. They can think, “Okay, I’m not alone, God or my higher power, or the universe is looking out for me, or my ancestors looking out for me.” However, they conceptualize it.
L: Thank you for explaining that. That’s got to be so supportive for people, putting that component into the work, which is really healing and really powerful.
M: Absolutely, I see therapy as a really sacred space, even if we don’t talk about spirituality at all. I conceptualize it as a sacred space because these people are being so vulnerable to me and opening up their hearts and sometimes telling me something they never told anyone in their lives. So, I really want to protect that and see it as sacred.
L: I know in addition to that you also affirming therapist and supportive of the LGBTQ community. I would love to hear more about that as well, especially anyone listening who is looking for that who needs that for them to know that there is a resource as well.
M: Yes, thank you for bringing that up. I love, love, love, working with LGB, queer and transpeople and that community. One thing that I do when I work with people from that community is really highlight any discrimination that they have experienced and validate them in that discrimination, and I really assess where they are in their coming out journey. I have clients that are completely out to everyone and then I have clients who are not out to anyone, I have clients who are maybe out to one person. I have clients who are out to handful of people but maybe not their family-of-origin. Wherever they are in their coming out journey that is a big part of our conversation and that’s not something I push them to do because it’s their journey. I can’t come out for them, because there are a lot of implications of coming out.
Several of my clients do come from religious families and sometimes there are religious beliefs that aren’t affirming for LGBTQ people. I am very, very aware that if they did come out to the family that the consequences could be dire. I mean for some of them they could be cut off from their families and so I really look at building what’s called a chosen family for themselves so they can have resources and people in place that they can eventually come out to and that they feel safe with—people who are very affirming and loving.
In the LGBTQ community, there’s a higher prevalence rate for eating disorders than in the general population. So that is something to very much assess because with trans people, I’ll talk about trans people first. If you have a body that doesn’t fit your gender identity, you may want to try other things. Especially if you’re not out or if you haven’t transitioned yet, you don’t feel like you can because of your family situation. What you do is you try to change your body through eating disorder behaviors. What I try to do in therapy is say “Ok, Let’s focus on the gender dysphoria piece, this disconnect between what your body looks like and your gender identity. So are there other ways for we can lessen gender dysphoria. Maybe we can cut your hair in a certain way or have you wear clothes that are more congruent with your gender identity, instead of having to try to change your body through eating disorders behaviors, which opens up a whole ball of other eating disorder problems.”
LGTBQ folks, just dealing with the level of discrimination they receive, it’s distressing and it can be a trigger for stress and negative thoughts and feelings about themselves and their bodies. So, again, to be able to validate them in their experience with that is really important as we’re treating the eating disorder. Just looking at the ways these areas overlap.
L: Oh yeah absolutely! Thank you for going all through that and it’s really so wonderful to see more and more resources in the community, and the more we have in the eating disorder experience in our LGBTQ affirming, it holds space for all of that in your clients it’s really, really critical. So, thank you for the work that you do.
M: Thank you. I just wanted to add with the people with the religious piece, I have clients that say, listen, I grew up in one religion that says that who I am is not ok, but I still want to have my faith and how can I do that, and that’s something that I really work on with people with. And again, it’s in my scope of practice, which is their psychological, emotional, mental and relational health. I’m not a theologian, and I’m not going to unpack that, but you know a lot of times my clients do their own research and I refer them to The Center in San Diego, and the LGTBQ-affirming faith organizations. I encourage them to talk to different clergy people who are in the affirming churches, or there are some YouTube pastors and other clergy people on line that they can access. So, just directing them to different resources.
L: Wonderful, Wonderful. Thank you so much Marianne! Is there anything else that you want our listeners to know on any of the topics that we talked about today? Anything else you want to share with them?
M: Well, I think a lot of my clients who have binge eating, not all of them, but many of them have larger bodies. So, I think it is a huge piece that needs to be addressed, and then I address in therapy is their body size and how much weight discrimination there is in society. It’s not just from the magazine covers and or online and pictures on Instagram. It’s hearing from physicians. I cannot even tell you how many times I’ve had clients being a shamed by their physicians, or physicians make assumptions that they have this host of medical problems when that may not be the case. I really educate clients on the Health at Every Size or HAES approach.
With clients, it’s important to get to a place where you can really love your body and where it is today and build your health from there. It’s really coming from a place of self-respect, self-acceptance, and self- love. When society teaches people, sometimes people’s families-of-origin teaches people, that if you have a larger body, you have to change it because your body is bad and so therefore you are bad. So that’s where that shame piece is huge and so critical for therapists to address.
The Health at Every Size approach is very important. Even if I have clients who want to lose weight, which many of the people who have binge eating disorder do, but I say let’s step away from that conversation about weight loss and really focus on loving and accepting your body for the way it is right now. Learn how to think critically about the kind of messages that you receive from society or people in your life.
Sometimes your family-of-origin, because you have a larger body, you receive the message that you’re not smart, or you’re lazy, you get all these negative messages, which is categorically not true. It’s not about will power, it’s about societal discrimination. Fat jokes are the thing, it’s the PC thing to joke about fat people, and so I teach clients to think critically. Like, you’re watching a show and people are making comments about people’s weights and body size, ask yourself, “what message is that sending?” That process helps people stand back and then start thinking, “okay this isn’t me, it’s society that is broken, and the system is broken,” and then I point them toward finding more affirming and accepting physicians. I tell them, let’s keep you away from physicians who are shaming you and let’s get you into ones who are going to treat you like an actual human being with respect, which is one hundred percent what you deserve. So, I get all fired up about that.
L: Sometimes people listening right now may not even, you know they might think those messages about larger bodies is the truth—that there’s something wrong with them.
M: Right, No—that’s a lie.
L: The system is set up to pathologize bodies, just pathologize them right off the bat and even with the shows I watch with my son. You know Disney movies the way the characters are portrayed. Characters with larger bodies are portrayed, there are messages being sent constantly. It’s just awful. It’s just when you see it and you just realize how much it is in every area and even people who are active in certain areas in social justice work have often times never even been exposed to this pain either.
M: And it’s important to start teaching your kids early. Just say, ok those Disney movies are portraying a person with a larger body as stupid or silly, that’s not true, that’s very disrespectful to people. To teach the kids to do that because it’s everywhere, and it sickens me
L: Yeah absolutely. So thank you so much for bringing that up. For those people who are listening, you can check out sizediversityandhealth.org, which is a really wonderful resource. There are books by Linda Bacon called Health at Every Size and Body Respect, which are really good resources.
M: Yes, Yes, and I’m so glad because when I was growing up as a teen there was no message like that, and so the work like Linda Bacon has done is so important. I’m thankful. It makes me more hopeful for the next generation that there will be more thought and attention to that then when I was a kid growing up.
L: Yeah, I really hope so. Thank you so much. Is there anything else you want to add to the conversation or share? It not, I would love to have you share with listeners where they can find you especially for San Diegans because your going to kick off the San Diego provider series
M: Yes, well I am going to be doing training in June [now September of 2019] at the Center for Discovery PHP and IOP in Del Mar. It’s more for professionals, dietitians, and therapist and people in the field doing some training on LGBTQ and eating disorder and spirituality. So, I’ll be doing that. Then I have a weekly blog series in which I highlight eating disorder professionals primarily in San Diego. I do highlight some people who provide virtual help, as well as dietitians, therapists, people who work for eating disorder treatments centers in the area. And then I do have some articles on there on body acceptance, dealing with family, integrating spirituality and eating disorder recovery. That’s my website drmariannemiller.com just click on the blog and you can find all those resources there. It’s fun. I really like doing the blogs
L: I know I love that idea. It inspired a series with the podcast, I’m like, why are we not providing providers?
M: Yeah, it’s good, I think that’s really great that your doing that. And then I’m on Facebook as well Dr. Marianne Miller, LMFT and I’m on Instagram at @drmariannemiller and you can find out more about me and my perspectives. And you can always call me and contact me by checking my website out and my phone number and email information is there as well.
L: Cool! Awesome! Do you provide virtual work?
M: I have, it’s not my main go-to, actually I found most of my clients want to have face-to-face sessions, but I have done virtual therapy with some people in the past so I’m definitely open to that so yep.
L: Okay, well awesome. Thank you so much for taking the time to come on
M: Thank you for interviewing me, it’s been great! Great time.
L: That’s good, alright Well Thank you.
M: Thank you.
Hey everyone, I really appreciate you reading my blog and reading my podcast transcript! Have a wonderful day. :)
If you are struggling to find eating disorder treatment in San Diego, give me a call for your free 15-minute phone consultation at (858) 699-3754, and I will help you get where you need to be!