Articles: Challenge diet mentality to treat binge eating &
Sexually kinky clients present ethical issues {Below}

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Challenge diet mentality to treat binge eating

By Howard S. Farkas, Ph.D.
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 on 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.

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Howard S. Farkas, Ph.D., is a clinical psychologist and the author of 8 Keys to End Emotional Eating. He is founder and president of Chicago Behavioral Health, LLC, a private practice specializing in the treatment of emotional eating. He is also on the faculty of Northwestern University Feinberg School of Medicine where he teaches in the clinical psychology graduate program.

His email is: h-farkas@northwestern.edu

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Sexually kinky clients present ethical issues

By Ryan G. Witherspoon, Ph.D.
February 4, 2020

Kink can be broadly defined by the compound acronym BDSM, which stands for bondage and discipline, domination and submission, sadism and masochism. It refers to a broad spectrum of erotic behaviors and relationships that incorporate ritualized, consensual and erotic power play.

Long hidden underground, in recent decades kink has become increasingly normalized as research and clinical evidence have mounted countering its historical pathologization.

Nationally representative statistics suggest that 10 percent to 15 percent of adults in North America engage in kinky behaviors. Clinicians working with kinky clients should be mindful of certain ethical issues that may arise, such as those involving cultural competence, countertransference, risk assessment and boundaries.

Kink-oriented people can be conceptualized as a stigmatized and invisible sexual minority group. As with other such groups, it is imperative that clinicians seek to build their level of cultural competency in working with this population. This requires clinicians to reflect on their own level of kink-related knowledge and expertise, as well as assessing the extent to which kink may or may not play an important role in therapy for a given client or time.

Research shows that most kinky people seek therapy for reasons unrelated to kink, in which case in-depth knowledge of kink may be unnecessary. However, some clients may seek therapy specifically to help with kink-related issues. In these cases, clinicians are advised to engage in their own research and/or seek additional training regarding kink, in order to ensure that the client receives culturally competent and appropriate care.

Should clinicians feel unequipped to provide this care, consultation with a kink-knowledgeable expert may help the clinician determine whether referring the client out would be more appropriate. It must also be noted that some clients may be reticent to disclose their kink interests or involvement due to fears of stigmatization or pathologization – or they may disclose early or abruptly as a way of testing the clinician.

Considering the transgressive and sometimes provocative nature of kink,

clinicians may develop strong and potentially negative countertransference

feelings. This may stem from the clinician’s own sexuality-related

experiences, beliefs or biases.

Careful monitoring of this countertransference is encouraged, as well as

being mindful to avoid pathologizing kink itself. Sometimes, these potentially

negative feelings a clinician holds may be enacted unwittingly via

microaggressions, which could negatively impact therapy outcomes.

Clinicians are advised to carefully consider their tone, the timing of questions and assumptions, as well as to follow the client’s lead regarding when and to what extent to focus on kink in treatment.

Another facet of cultural competence relates to assessing the level of potential risk a client may be engaged in. The kink community has widely accepted standards for how kink-related risks are assessed, negotiated and consented to. Clinicians working with this population should have, or acquire, enough kink-related knowledge to help a kinky client differentiate for themselves between kinky behaviors that play healthy or harmful roles in the client’s life.

In addition, kinky relationships may also involve abusive dynamics, similar to any close relationship, which may make differentiating these factors more difficult for those with limited competency with this population.

Finally, clinicians who themselves are kinky may face boundary and dual-role issues with kinky clients. Even in a large city, the kink community may be small and close-knit, which could place clinicians within the realm of “small town” ethical dilemmas.

Dual role issues and disclosure dilemmas may arise working with kinky clients and participating in the same larger community. Consultation and developing a strong kink-affirming referral base are advised.

Thanks in part to the popular 50 Shades of Grey series of books and films, and despite the inaccurate and dismal portrayal of kink in those works, interest in kink is expanding in popularity.


Clinicians are increasingly likely to encounter kinky clients or similar issues in their practices, despite the fact that the vast majority of clinicians have not received any education or training regarding kink.

In addition, kink-affirming and competent care is a growing niche specialty for clinicians. For these and other reasons, clinicians are encouraged to educate themselves about kinky behaviors, communities and culture as part of the broader spectrum of consensual sexuality.

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Ryan G. Witherspoon, Ph.D.. is a psychotherapist, researcher and author who lives in Los Angeles. He is currently co-authoring a book on clinical work with kink-oriented clients. His email address is: ryanwitherspoon@gmail.com.

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