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Starving and purging, besides offering temporary comfort, paradoxically felt "right" because by hurting her body, Cathy was both comforting and punishing herself. Immediately afterward, as she said, she felt a sense of relief, even of self-control. But the calm was short-lived, followed closely by all the old, bad feelings, redoubled—self-loathing, embarrassment, shame, guilt, worthlessness—all of which primed her for more self-harm, continuing the cycle.

Eventually, if therapy is working, clients begin to see the paradox and futility of using self-harm as a way to cope, soothe, and gain control. "Almost every day, I do something I'm ashamed of," Cathy said, once she began to understand her own behavior. "I feel compelled to do it—and then I feel worse. And since I have no other way to calm myself down, I do the same thing all over again to cope, to numb out, and feel better. I just keep going round and round in this endless, no-win circle."

Of course, it's one thing for a therapist to grasp something of the inner dynamic of eating disorders, but another thing entirely to help clients themselves recognize the vicious cycle they're in and find a way to interrupt it. Before clients can begin to look objectively at the larger pattern of their behavior, they need to feel safe and secure, gain some sense of inner composure, and experience more self-acceptance. And these things, in turn, go hand in hand with a strong, nurturing relationship with the therapist. The worst way to begin therapy with these clients, I learned, is to focus on behavior—food journals, calorie counting, weigh-ins. Their problems aren't primarily about food, but about pervasive, longstanding emotional pain. Furthermore, since they're already fighting themselves—and often members of their families—about their eating behavior, insisting that they begin following a series of rules just makes them feel they have to fight the therapist too.

A Different Lens

So, given all these potential pitfalls, what's the best way to begin therapy? I think it starts with the therapist's willingness to look at eating disorders through a different lens: shift from "You're doing something incredibly dangerous" to "You're doing something incredibly creative and meaningful." Honoring, rather than denigrating the client's behavior prevents a stalemated power struggle. So in the earliest stages of treatment, I told Cathy, "I want you to know that it isn't my intention to take this behavior away from you. In fact, I'm clear that I don't have the power to do that. I'd like to work with you to figure out what you get from starving and purging. I don't think you'd keep doing it if you didn't get something very important from it."

This approach gave Cathy the opportunity to experience me as nonjudgmental and supportive, providing a sense of safety in which a healthy attachment to me could develop. When I expressed compassion for her behaviors, I was modeling the essential ingredient of empathy, which in time, she could internalize and begin to feel for herself.

Clients' lack of empathy toward themselves emerges from an "inner civil war" between parts of them invested in maintaining the behavior and parts that feel overwhelmed, angry, or frightened by it. It's helpful to introduce the concept of fighting self-parts by reflecting back to clients their own usually vague references to their inner struggles around eating behaviors. When Cathy alluded to "fighting with myself," I encouraged her to flesh out what she meant.

"So when you fight with yourself, can you think about each point of view as a different 'part' or facet of yourself?"

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