Early in my career the mere mention of an eating disorder by a prospective client would make my appointment book magically fill up. The studies I’d read indicated that 66 percent of clients with anorexia, bulimia, and bingeing and purging relapsed within the first year, and that their mortality rate, at 20 percent, was the highest of any psychiatric disorder. So I lumped eating-disordered clients with other “treatment-resistant” patients—like “borderlines”—to be avoided at all cost by any savvy private practitioner. But even the most vigilant initial screening could protect an anxious therapist only so much. Thus, it wasn’t until an afternoon many months into treatment that I discovered that one of my favorite clients had an eating disorder. Molly was a smart, talented, beautiful, 17-year-old redhead, who got straight A’s, starred in all the school plays, and scored winning points on the soccer and lacrosse teams. She’d first come to see me because, despite all outward appearances of success, her parents had began to sense a “personality change” in her. In the past year, their accommodating and easygoing child had become unusually irritable and belligerent. She was fighting with her mother, refusing to participate in family outings, and distancing herself from her closest friends. The therapeutic task seemed clear and quite familiar: to help Molly through the developmental angst of adolescence.
Even though she clearly didn’t want to be in my office, we slowly began to build a rapport and she started to let me into her world. Some months into our work together, she opened up about an altercation with a friend at school.
“She was giving me crap in the hallway again, because she thought I was flirting with her boyfriend—which I wasn’t. She called me a whore in front of my other friends and told them not to trust me. Now a bunch of them aren’t speaking to me.”
I must have looked concerned because she leaned toward me and added, “It’s no big deal. This girl has been spreading rumors about me for a long time.”
Trying to understand how she was handling this situation, I said, “Wow, that’s a lot to endure. How have you been dealing with it?”
She nonchalantly shrugged her shoulders and replied, “Like I always do—I make myself throw up, and then I feel better.” Sensing my anxiety, she added for good measure, “Or I don’t eat for the day.”
“Is this something new for you?” I asked, trying to appear calm.
“No. I’ve been doing it on and off for years.”
This was a complete shock to me. I suddenly felt frightened, confused, and even a little angry, as if she’d somehow misled me. Didn’t she get the memo that I didn’t work with eating disorders?! Clueless about what to do, I went to red alert. I felt an immediate and intense need to get her to stop starving and purging. I didn’t focus at all on the meaning of what she was doing—all I saw was behavior that was out of control, pathological, and dangerous. Just like that, what had been a warm and productive therapeutic relationship turned into a power struggle.
“Molly,” I began, trying to keep the panic out of my voice, “We need to talk about what you do and don’t eat, and how I can help you to eat more appropriately. We need to focus on your maintaining a healthy weight. Right now, you’re doing something incredibly dangerous.”
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.
Ironically, as a trauma specialist, I’d probably seen many clients who were using food to self-soothe, hurt their bodies, reclaim power and control, or covertly communicate painful experiences—I just hadn’t realized it. Over time, as I became more open to acknowledging and treating eating disorders, I began to notice several recurring themes. These clients often fought with friends and family members about their “weird eating,” their habit of running to the bathroom immediately after meals, their obsessive concern about their weight. However, I became aware of an even greater internal struggle between the parts of them that stubbornly clung to and even took pride in their ability to exercise “self-control” around eating and the parts that felt self-repulsion, shame, guilt, and self-hatred. They were at war with themselves, and the battleground was their own bodies.
Working with Cathy
These days, after nearly 20 years of working with eating-disordered clients, I’ve incorporated ideas about the emotional significance of the disorder into my work with clients who struggle with their relationship with food. Consider 35-year-old Cathy, a striking brunette who was a divorced mother of a 10-year-old boy and 12-year-old girl and a successful business executive, who came to see me for help with managing the discord with her children, her work colleagues, and her personal relationships. Now I incorporate questions about bingeing, purging, and starving into my initial assessment with clients, whatever their presenting difficulty. Thus, in the first session, Cathy wound up telling me about her secret struggles.
“Sometimes, I feel kind of superior to other people, because I can go a whole day without eating,” Cathy admitted. “And if I do eat, I’m glad I know how to get rid of it, so I can feel better. But afterward, if I’m really honest about it, I feel worse. I feel crazy, and I hate myself for having this albatross around my neck. I feel like I have to ‘do’ my eating disorder, but I hate myself for having to do it.”
This inner sense of polarization and conflict seemed to leave Cathy—like so many of my eating disordered clients—with a fragmented sense of self.
Reflecting back to her what she’d told me, I said, “It sounds like there’s a part of you that takes pride in starving—feeling powerful and in control. And at the same time, I’m hearing that another part or parts of you struggle with it, hate it, maybe even feel hijacked by it?”
“Hijacked is a really good word!” she said, nodding her head in vigorous agreement.
Encouraged, I continued, “What’s it like for you to have such competing agendas inside?”
Cathy’s eyes immediately welled up with tears. “It makes me really sad and angry. No wonder I’m exhausted and feel so stuck.”
If she wasn’t wholly integrated and connected to herself, how could she successfully connect to me or anyone else? It wasn’t surprising that all her interpersonal relationships were so conflicted. She was isolating herself from other people because of chronic guilt and shame and the amount of time taken up with bingeing and purging. At home, she felt disconnected from her kids, who spent their free time pursuing their own interests and friendships. She’d “given up” on the dating scene and made excuses for not participating in work-related social outings. Despite her impressive professional and academic accomplishments (typical of many eating-disordered clients), she found it hard to form emotional intimacy or genuine connection with others. Indeed, such clients tend to keep people at arm’s length, making therapeutic alliances difficult to build and sustain.
Taking the focus off food and exploring the historical context of her behavior with Cathy, I asked about family rituals, expressions of parental affection, dynamics during family dinnertime, vacations, and holidays. Emotionally neglected as a child, she felt her parents minimized and dismissed her feelings and needs, labeling her “overly sensitive” and “a burden.” Crying was “unacceptable,” as was talking at the dinner table or not finishing everything on her plate. Cathy had no memories of being physically comforted and couldn’t remember her parents ever saying “I love you.” According to her, her parents’ greatest emotional priority was “making sure their Scotch bottles were never empty.” Her only meaningful attachment was with her grandfather, who breached that trust by molesting her when she was 9.
Cathy had been a volatile child, often exploding in anger, sometimes refusing to eat, having regular nightmares, and frequently sleeping in the hallway outside her parents’ bedroom when they refused to let her in their room at night. Her parents responded to her distress by ignoring and then punishing her. In time, like many children, she shut down and turned her rage inward as self-blame and self-hatred. “My parents ignore me and punish me because there’s something wrong with me,” she’d said to herself as a child. “If I were prettier, smarter, different, then they’d love me.” In an attempt to win over their affection and attention, she said, “I outwardly perfected the ability to smile, even though I felt utter despair inside.”
I began to see that for clients like Cathy, family-of-origin trauma, neglect, and abuse often played a pivotal role in their narrative of suffering, frequently providing the internal “logic” behind their eating disorder. Even when eating-disordered clients haven’t been abused, they may reveal old bereavements, traumas, or developmental disruptions that left them with unresolved feelings of shame, betrayal, deep insecurity, or worthlessness. Whether the result of overt abuse and neglect or not, such feelings often contribute to a distorted sense of self-blame, self-hatred, and the need to punish the body.
By inflicting physical pain on her through sexual abuse, Cathy’s grandfather taught her to disrespect and dislike her body. Her sense of disconnection from her body was amplified when her parents forced her to finish food, even though she felt physically full. Cathy carried into her teen years and adulthood a sense of contempt for and alienation from her body.
“Throughout my adolescence, I dated boys who emotionally mistreated me and pressured me to do things sexually that I didn’t want to do,” she told me. “But I remember feeling numb and going along with it, never saying ‘no’ or ‘stop.’ This happened over and over. At the time, I didn’t understand why, but in my head, I thought, ‘It doesn’t matter what happens to your body. You’re just a lowlife and you deserve being treated like garbage.'”
The combination of self-blame, the need for self-punishment, and the dislike of one’s body powerfully frame an eating disorder. These clients discover that they can chastise themselves by punishing their bodies through self-starvation, excessive overeating, or purging.
Abusive, neglectful, or emotionally unavailable parents don’t comfort or soothe their children. As a result, their children never learn to soothe or comfort themselves, and they have no idea how to manage or regulate their emotions. “I felt bad all the time,” Cathy told me. “I was angry, terrified, and alone. I wanted the emotional pain to stop. Sometimes I drank to feel better; to be numb. I experimented with cutting to make the bad feelings disappear. Then I discovered a kind of euphoria and a feeling of control, when I starved myself, and a release of the rage, when I purged. These were my only options for comfort.”
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?”
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.'”
I asked, “Can you access the most self-loving part of you, to help the 9-year-old part to see that differently?”
Cathy started to cry and said, “Mom made me feel like I didn’t deserve anything because she wouldn’t give me any attention. But that was about her—not me. And the abuse wasn’t my fault. I had no choice. He threatened to hurt me. I tried to tell my mother, but she didn’t believe me. She didn’t care. I had no choice.” Then, holding her arms around herself and leaning toward the chair with the 9-year-old, she whispered, “We had no choice. We had no choice.”
It was a breakthrough for Cathy to realize that starving was a reenactment of parental neglect, and purging was fueled by the self-blame related to memories of her grandfather’s sexual abuse. For many clients, the behavior has a deeper meaning, often connecting to unresolved pain or trauma. Clients who binge may be creating a “protective shield” of fat, making themselves physically larger in the world because they feel inherently vulnerable or unsafe. For some clients, gaining weight is a creative way of avoiding sexual intimacy, thus warding off flashbacks to earlier abuse and preventing feelings of revictimization in the bedroom. Other clients binge to punish their bodies for “participating” in sexual trauma. Still others may be reenacting the physical pain of sexual trauma through the violent act of bingeing. Inviting an open curiosity about purging sometimes reveals the client’s need to “cleanse” a body that feels “dirty” or “damaged.” This was true in Cathy’s case. Since purging is often viewed by clients as “gross” or “embarrassing,” the act might be communicating a deep sense of shame, saying through the behavior, “I’m bad.”
Once Cathy connected her current behavior to her past trauma, I asked her to think about how she’d feel toward her daughter if she’d been violated and betrayed at 9 years old. “If my daughter had been hurt like that, I’d hold her, tell her it wasn’t her fault, and do everything I could to comfort her,” she said. We incorporated this into a role-play, so she could express those words of comfort and nurturance out loud.
“It’s powerful to hear my own voice say this,” she said, “I wish my mother had said this to me when I was a child.”
Taking it one step further, I asked, “Would you blame your daughter or tell her to hurt her own body as a result of being abused?”
Cathy looked at me as if I were crazy, and then she understood. “Never,” she said. “That’s the last thing I’d do.”
During this work, she identified a scared 5-year-old part. Younger parts often give us important information about attachment patterns. In Cathy’s case, her parents’ chronic neglect didn’t allow her to sustain healthy, trusting, and consistent attachment, which meant she never learned appropriate self-soothing strategies and was forced to resort to unhealthy ones. Giving clients alternative ways to self-soothe that don’t evoke guilt, shame, or revictimization is a key part of the work, and should be introduced early in treatment. Of course, it’s easier for them to behaviorally integrate self-care once some amount of self-compassion has developed. I always assess for medication to alleviate anxiety and depression, while introducing methods of self-care designed to rekindle respect for the body. Aromatherapy, listening to soothing music, gently massaging the hands with scented lotion, wrapping the body in a soft comforter and rocking, reading positive affirmations may all seem obvious self-soothing strategies to most of us, but are often quite foreign to clients who’ve spent years waging war with their bodies.
Since so many eating-disordered clients are bereft of healthy attachments, I work with members of the extended family and significant others to rebuild and strengthen safe interactions and intimate communication. Working with family members to enhance empathy and compassion, teaching them about the cycle of self-destructive behaviors, and encouraging them to move away from a pathologizing and hopeless mindset can be crucial to the success of treatment. When particular family members are unsafe, it’s necessary to find a surrogate social-support system for attachment. In Cathy’s case, her parents’ drinking worsened as she got older, and I trusted her instincts when she said it would be ‘useless and very unsafe’ to bring them into therapy. Getting her connected to Al-Anon became a powerful way for her to find a loving group of people who fully embraced and accepted her. In addition, she chose to reconnect with her religious faith, and found great comfort and support within that community.
Helping clients recover from eating disorders isn’t a short, linear process, and relapse is inevitably part of the journey. Cathy worked diligently with me for five years. Learning to trust me and build a sense of attachment took many months, and there were times when she relapsed. When work was particularly stressful, for example, or when her 12-year-old expressed an interest in dating, Cathy’s fears about what it meant for her daughter to become sexually active triggered old emotions, and she occasionally purged.
In time, she found alternative ways to soothe upsetting emotions, and these discoveries eventually led to a sense of resolution and healing. She loved journaling and processed her childhood neglect and abuse through original poems, by writing letters to her parents (which she didn’t mail), and by communicating with her younger internal parts. Over time, starving and purging lost their purpose. She no longer needed them to soothe or punish her body and could find new comfort, pleasure, and security from healthier resources.
Make no mistake: treatment with eating-disordered clients is hard and challenging. Nevertheless, I now approach these clients with optimism, an open mind, and an open heart. Over the years, they’ve taught me that therapy has the greatest impact when I step away from the temptation to get into a power struggle and empower clients to do a large part of the healing work themselves. These days, my appointment book really is filled up—often with eating disordered clients, who, I now know, really can get better.
Photo @ Pexels/Markus Spiske
Lisa Ferentz, LCSW-C, DAPA, is a recognized expert in the strengths-based, de-pathologized treatment of trauma and has been in private practice for more than 35 years. She presents workshops and keynote addresses nationally and internationally, and is a clinical consultant to practitioners and mental health agencies in the United States, Canada, the UK and Ireland. In 2009 she was voted the “Social Worker of Year” by the Maryland Society for Clinical Social Work. Lisa is the author of Treating Self-Destructive Behaviors in Trauma Survivors: A Clinician’s Guide, 2nd Edition (Routledge, 2014), Letting Go of Self-Destructive Behaviors: A Workbook of Hope and Healing (Routledge, 2014), and Finding Your Ruby Slippers: Transformative Life Lessons From the Therapist’s Couch (PESI, 2017).