In therapy, Meginness worked on a strategy called “catching your thoughts,” he says. “When you have a thought, those are just thoughts. It’s what you do after that helps makes those decisions. I can treat it as the truth or treat it as the lie. Am I that hungry? No, I ate, I’m fulfilled. I don’t need to act on that, I can throw [that thought] out and move on.”

In therapy Meginness also addressed the difficulties in his marriage. “I had to prepare myself that when I was released, my wife might not stay with me and the kids. Could I accept that, and continue with recovery? It was really tough. [Friedman] was like, ‘You need to make the choice: Are you going to do this for yourself whether or not you go home to a family?’” Once he decided to pursue treatment no matter what, his wife recognized that he was choosing to treat his disorder. “Actually now we’re in a thriving marriage.”

Body acceptance is also a major part of BED treatment, says Lampert, especially in a culture that prizes the big reveal of “Half Their Size!” features in magazines. Her patients often say, “I don’t feel like I’ll ever be enough, so what’s the point.” But Lampert says, “You can accept your body and delight in what it does while you work on making it feel better. ‘I can take care of myself today; I don’t have to wait until I lose weight.’ Those small wins can accumulate into a mastery of ‘I can do this.’” Rivera inexplicably began to gain weight after she was in treatment with Tyson; eventually she was diagnosed with polycystic ovary syndrome, a hormonal disorder that can cause weight gain. Once that was under control, she started to lose weight again. If it wasn’t for the mental health foundation she had established earlier, she says, she may have given up. “Even though my body was changing to what I considered a negative, just being able to keep up with legalizing food and going to treatment gave me a lot of strength,” she says.

According to Tyson, a binger who stops the cycle will lose about 10 percent of their body weight. That’s not sexy enough for a reality TV show reveal, but it’s a significant health improvement, which can improve blood pressure and heart health. “It’s not a rapid 100 pounds, but what I tell patients is that the goal here is to feel in control. If you’re not eating 1200 calories three times a day during binges, will that drop your weight? Sure, but it’s not sudden.” For many bingers, weight loss is simply a nice bonus that comes with improving mental health. I may have lost 50 pounds since I first sought treatment for BED, but for me the major victory was being able to eat a cookie, or three, or seven, and let it just be that. It doesn’t mean I don’t deserve to exercise, or to eat healthily, to be loved, or to love myself the next day.

So why isn’t therapy given the same amount of press as a weight loss tool that Whole30 and CrossFit receive?

First, says Tyson, clinicians need to catch up on BED in order to be the first line of defense for their patients. “If people know they’re not going to be treated like ‘Oh, another obese patient who is not going to do what I want them to do,’ that will decrease the shame,” he says. The poor success rate of calorie-restricting diets has been well-documented, and he is frustrated by physicians who continue to recommend them to their patients. He says that the arrival of the binge-cessation drug Vyvanse, a stimulant also prescribed for ADHD that Friedman says helps some bingers manage eating-related impulsivity, has helped raised the profile of BED (Tyson is on the faculty for the drugmaker), but he warns that clinicians must not recommend the drug alone. “As long as you also recommend the therapy and the dietitian, then they stay in treatment and they’ll see success.”

“In a perfect world we’d be screening people for their eating behaviors and not so much about their weight,” says Lampert. “Their behaviors would tell us more about the place where we make change.”