Unimpressed by the note of urgency in my voice, Molly stared off into space, hypnotically twirling a long strand of red hair around her finger. "Yeah, I've seen this on a made-for-TV movie. You're gonna ask me to keep a food journal, right? And then we're gonna talk a lot about calories and you're gonna try to convince me that I'm doing a bad thing and have to stop."
Well, yes actually, I was going to talk about calories and food journals, with the intention of getting her to stop the behavior. But she wasn't having any of it.
"Here's what I don't get," she said with more animation, "If I'm already obsessed with what I do and don't eat, isn't talking about it just going to make me more obsessed?"
"The point is," I said—totally missing the point—"what you're doing is really unhealthy and can significantly harm you. It's scaring your family. (It's scaring me!) The goal is to talk about what you're doing, so you can stop doing it."
As often happens when using a symptom-oriented approach with clients like these, Molly figured out how to be "compliant" in the short-term. She kept food journals, maintained a stable weight, agreed to a "safety contract" detailing a reasonable number of calories to consume, and learned to be even more secretive about her bingeing and purging. Within four months of disclosing her behaviors, she convinced her parents that she was "fine" and dropped out of treatment.
The Battle for Control
My experience with Molly forced me to realize that I could no longer responsibly declare eating disorders off-limits in my practice and that I needed to rethink my basic ideas about how I might work with such clients. Clearly, I'd allowed my fear to prevent me from taking the time to understand her fully. Why was she so wedded to obviously self-destructive behavior? As I rehashed her case and thought about her struggle, it slowly dawned on me that her problem wasn't about food, and that it would continue to be unproductive to deal with an eating disorder as though it were simply a bad habit. I needed to do a better job of getting beneath the behavior to the mindset and inner world of eating-disordered clients and explore their deeper thoughts, feelings, and needs—in short, put their behavior into a broader emotional, psychological, cognitive, and familial context.
To have accomplished this with Molly, I'd have had to be willing to listen and learn from her, rather than imposing rules on her. "Molly, help me understand how purging or not eating helps you deal with kids who spread rumors about you or ignore you in school," would've gotten us a lot farther than "I have to get you to stop doing that behavior." I came to realize that my ineffectiveness as a therapist in this case wasn't due to the tenacity of the eating disorder, but to my own rigid and misguided clinical attitude.