After a few moments of silence, she said, "I guess I can. There's a part of me that wants to keep doing the behavior and another part that's tired of it."
"When you think about those two parts, how old do they seem?" I asked.
"That's a strange question," she replied. "But actually, the part that wants to keep doing it is probably about 9, and the part that doesn't want to anymore feels like an older teenager."
I asked her if she'd be willing to take a minute to focus on both the 9-year-old and the teenage parts, and notice how she felt toward them.
"Sitting here right now, I think I feel angry at the 9-year-old. She's making my life so much more stressful. I'd like the teenage part to win, and I'd like the 9-year-old to just go away. She embarrasses me."
This initial response is quite common—these clients are often ashamed of the childish, out-of-control self that engages in the eating disordered behavior.
"I wonder what it's like for you to be embarrassed and repulsed by a part of yourself?" I asked.
Cathy said, "It's scary and exhausting."
Resolving this inner struggle becomes a focus of treatment: helping clients shift from feeling repulsed by the part that engages in the behavior to curious about it and empathic toward it. Cathy actually took this concept a step further when she volunteered, "I think there's an even younger part of me, maybe 5 or 6, that feels terrified about starving and throwing up. I never thought about that before."
Once clients begin to conceptualize their parts, the therapist can "externalize" them, allowing clients to communicate their needs and feelings in a variety of creative ways. I invite my clients to draw or collage their different parts, along with collages of imagined safe places for all of their parts. The safe-place collages—constructed of words and images of beautiful spaces, like a beach or garden, that evoke serenity—can help clients ground themselves and contain self-destructive emotions. I use the Gestalt "empty chair" technique, putting one part in an empty chair and then inviting the client to communicate with and learn from that part. I incorporate two-handed writing and drawing exercises that allow for ongoing "dialogues" between parts. All in all, I'm trying to suspend the bitter conflict between the self-injuring parts and the parts that want to stop the behavior. I try to help both "sides" engage in a mutually curious, cooperative, self-loving dialogue.
This ongoing communication will inevitably begin to reveal the distorted thoughts that fuel self-blame and feelings of worthlessness, as well as their often traumatic origins. During a session between her adult self and the empty chair that contained her 9-year-old eating disordered self, Cathy asked, "Why are you so determined to keep me from eating?" She listened inside and heard the 9-year-old say, "You don't deserve to eat today. Mom says you don't deserve anything. And beside, you're bad." "Why do you think I'm bad? I don't understand." Cathy's eyes grew wide as she said, "What I'm hearing inside is, 'You're bad because he touches you and you let him. And then we have to throw up to get rid of him in our body.'"