What do you think about your patients whom you believe need to lose weight? Do you consider them lazy or non-compliant? Or wonder why they don’t they take better care of themselves and listen to your diet or exercise advice?

You’re not alone in feeling frustrated and maybe even professionally inadequate treating patients who struggle with food. Most doctors and health care providers are unprepared for the challenge of changing patients’ eating and lifestyle habits because they’ve had next to no education on the subject. Moreover, unless you’ve had eating problems yourself, you might think it’s as obvious as the number on the scale what patients need to do to improve their health: diet, eat nutritiously, lose weight, exercise more and, perhaps, consult with a dietician.

You also might lump together all your patients as overeaters, although they may get into trouble with food in different ways through eating that is mindless, deprivational, stress-induced, compulsive, emotional, secretive, night-time based or an all-out binge. One patient might promise she’ll cut back on diet soda or second helpings without following through, while another might succumb to nightly fast-food take out because he insists he has no time to cook for himself. Yet, another might suffer from social anxiety or phobia and turn food into her best friend.

Eating disorders therapists recognize that “just say no” doesn’t work and never has, and that healing dysregulated eating is a complex, long-term, touch-and-go, bio-psycho-social process with which most people need help. A dismaying fact: Dysfunctional eating patterns are often the last thing to go — that is, patients may only give up long-standing, habituated, destructive behaviors after they’ve made major changes in three non-food areas: life skills, personality traits, and trauma/abuse resolution.

Don’t panic. It’s not your job to make all this happen. Rather, your job is to understand why it’s so difficult for patients to make healthy food choices, eat reasonable amounts and take better care of their bodies, even when they’re trying their hardest to do so.

Dysregulated eaters improve their eating when they have effective life skills. We all need them and must pursue their acquisition as adults if they weren’t effectively Modeled or taught to us as children. Most dysregulated need to boost life skills in order to:

1. Sustain self-care. Habitually putting others’ needs first and their own last, they too often care for themselves via multiple trips to the refrigerator.

2. Manage emotions. High in reactivity and low in tolerating frustration and delaying gratification, they turn to food to cope with life’s ups and downs, including stress.

3. Live consciously. Lost in rumination about the past or worry about the future, their ability to live mindfully, including sensing cues for hunger and satiation, may be compromised by anxiety, depression, lack of self-trust or a fast-paced life.

4. Enjoy intimacy. Fearful of experiencing and sharing uncomfortable emotions and of being overly dependent, many become counter-dependent, pass on people and instead choose food as their BFF.

5. Self-regulate. Lacking a felt sense of what’s too little, too much or enough and feeling conflicted about wanting both structure and freedom leads to dysregulation around food and in other areas of life such as sleep, work or play.

6. Problem solve. Relying on emotions rather than on evidence-based solutions and critical thinking about consequences, coupled with worrying excessively about making “the right” decision, they have difficulty making consistently wise choices.

7. Set and reach goals. Prone to biting off more than they can chew, they pursue perfection, fear failure, and have trouble chunking down goals or knowing how to assess progress. They eat out of frustration, impatience, and despair. 8. Balance Work and Play. Undermining the benefits of each activity by feeling guilty when they’re playing and resentful when they’re working, they eat to relax, unwind and tune out the world.

Dysregulated eaters also lack a healthy complement of personality traits. They incline toward impatience, perfectionism, and all-or-nothing feeling/thinking, such as strict dieting followed by binge-eating. If something isn’t a success, it’s an automatic failure, never mind baby steps or plateaus. It’s no wonder that so many dysregulated eaters procrastinate, which generates brutal self-criticism and self-loathing. As people-pleasers, approval-seekers and natural care-takers, they put aside their own needs and then resent others for “making” them do so. Feeling selfish, unworthy and deep-down undeserving of taking good care of themselves, they do it for a while, then stop.

They do better around food when they replace self-judgment and self-condemnation with curiosity and self-compassion, become comfortable with mistakes and failure, hone self-trust, develop patience and fine-tune an internal sense of enoughness around food and in other areas of life.

Unresolved trauma, abuse (emotional, physical and sexual) or neglect can derail eating big time. Childhood abuse may produce adults who are overtly and seemingly compliant yet covertly rebellious. It also may make patients feel defective, powerless, unworthy and undeserving of good things in life. Additionally, they may need to put to rest (mostly) unconscious intrapsychic conflicts — around intimacy, sexuality and identity, self- soothing, body shame, care versus control, and how change occurs — before they can consistently make strides in eating more “normally” and healthfully.

Even if you can’t cure your patients’ food struggles as quickly as you or they would like, the more you take to heart what might be holding them back, the better you’ll be at helping them move forward. It’s a win-win all around.

Karen R. Koenig is an eating disorder therapist. She can be reached at her self-titled site, Karen R. Koenig.

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