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" clients 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. But over the past year, she’d become unusually irritable and belligerent. 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.
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. 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."
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. 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.
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, 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.
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.
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.
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.
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 war" between parts of them invested in maintaining the behavior and parts that feel overwhelmed, angry, or frightened by it. 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."
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'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 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, she whispered, "We had no choice. We had no choice."
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.
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 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.
Can't get enough of the Networker? Subscribe to Psychotherapy Networker Today! >>
Photo © Katarzyna Bialasiewicz/Dreamstime.com
Tags: abuse survivors | Anxiety | anxiety disorder | anxiety disorders | binge eating | child abuse | Child abuse & neglect | childhood abuse | Depression & Grief | eating | eating disorder | eating disorders | food and therapy | gestalt therapy | inner parts | Lisa Ferentz | overeating | sexual abuse | treating anxiety disorders