Individual Therapy: Putting The Eating Disorder Out Of A Job

Writing this chapter on individual therapy was different from the rest, since it is impossible to ignore the quantity and quality of information that comes directly from my personal experience. My own battle and subsequent recovery from anorexia nervosa during the ages of fifteen to twenty-one and my experiences as an eating disorder therapist since 1979 add a strong personal influence to this chapter. In treating eating disordered patients I use a very informal approach going by my first name and sharing information about myself and my own recovery. I work from a psychodynamic and cognitive behavioral perspective intermittently and at times simultaneously. I believe that the nature of an eating disorder makes tending to specific behavioral change important, and the attention I give in treatment to this aspect varies in degree depending on how healthy the patient is.

Early on in my career I realized that if treatment were left to typical psychoanalysis, patients could take years explaining their childhoods, how they get along with their parents, their inability to control their anger, or any number of past experiences, all the while continuing to exist on frozen yogurt and salad, or bingeing all day, or purging their dinner every night. Eating disordered patients can starve to death or have heart failure while trying to figure out "why" they are doing this to themselves. Therefore, my individual sessions with patients vary greatly in nature because, along with an ongoing exploration of developmental deficits and underlying issues, I deal directly with thinking patterns, behaviors, and symptom management. The section "Choosing a Therapist" on pages 134–137 should be helpful to patients unsure of where or how to begin this process.

HOW DOES THERAPY CURE?

Every experienced, effective therapist comes to her own understanding of how therapy cures and then works from that understanding, even if she does not consciously recognize it. To do justice in describing, not just the technique but the art of individual therapy with eating disordered patients, I have drawn not only from the literature but also from the knowledge and experience I have gained and utilized with success over the last twenty years. For simplicity's sake, the term patient is used in this chapter to denote an eating disordered individual who is in treatment, and the word therapy is used instead of the more proper term, psychotherapy.

Therapy with eating disordered patients involves providing education, insight, and a corrective emotional experience, allowing the patient to rectify faulty thought patterns, fill in developmental deficits, and internalize missing psychological functions. In individual therapy it is the relationship between the therapist and patient, rather than any certain technique, that is the most curative aspect. In essence, the therapist uses his or her training and the therapeutic relationship to put the eating disorder "out of a job." Until patients can "do it on their own," the therapist lends his ego and self-organization, capacity to anticipate, to delay gratification, to use sound judgment, to relate to another, to regulate tension and moods, and to integrate feelings, thoughts, and behavior. Once patients have internalized these abilities into their self-structure, they no longer need to use substitute or self-destructive measures (eating disorder behaviors) to meet needs or provide important psychological functions.

CONTACTING AND TRANSFORMING THE EATING DISORDERED SELF

Anyone who works closely with eating disordered individuals realizes that in each patient, to a greater or lesser degree, there is a separate adaptive, disordered self (the eating disordered self) with a separate set of perceptions, thoughts, needs, and behaviors. (The eating disordered self is also described in chapter 5.) Therapists must help each individual discover how and why her eating disordered self developed and how its specific behaviors have served a function and helped the patient adapt. An important goal of therapy is getting the patient to contact, transform, and ultimately integrate the eating disordered self. Many techniques can be used for this process. Having patients journal, particularly before engaging in one of their eating disorder behaviors, for example, immediately before binge eating, is often an effective way for both patient and therapist to contact and eventually learn about the eating disordered self.

Examples of journal entries:

Right now I feel like there is a monster inside of me, controlling me and telling me to binge and I can't make it go away.

I wake up and tell myself that I'm not going to binge and purge today and then, even when I don't want to, I find myself doing it again. It's like there are two of me. At some point one of us goes away and the other takes over.

Another technique is to have patients write dialogues between the eating disordered self and what I call their healthy self. This can be done any time but is particularly helpful right before the person engages in some sort of disorder behavior, for example, before a binge or purge. Dialoguing with the eating disordered self helps patients discover what's going on inside of them and bring it to their conscious awareness.

Here is an example of such a dialogue:

Healthy Self: I don't want to binge tonight, I don't need you.

Bulimic Self: Yes, you do.

Healthy Self: Why?

Bulimic Self: Because you don't want to get fat.

Healthy Self: Yeah, that's true, but I exercise enough, I am not going to get fat. I kind of believe that, my therapist believes it, and I believe her.

Bulimic Self: Baloney, you two don't know anything, I know.

Healthy Self: You know what? All you've done for me is screw me up. You know nothing. You are confusion, hatred, madness, guilt, humiliation, and more. You drain my brain and my body and I am tired of you.

Bulimic Self: Well, what are you going to do? I am not going to leave. You need me and I still think you want me.

Healthy Self: No, I don't want you but I am confused as to why I need you. I can't see it, except I am afraid to let you go, in a strange way I like that I can count on you.

Bulimic Self: That is right. We can't count on you because you never speak up. I am the one who can say, No, no way, no more, or leave her alone. You never do it. If I relied on you, where would we be?

Healthy Self: But I know more now, I want to try again. I need you to let me try, even if I am scared and mess up some.

Bulimic Self: It scares me to let you be in charge as it has never worked, but I might. But I'm not going anywhere, in case you need me.

It is important to discuss patients' dialogues and the feelings they had writing them. This helps the patient discover what the eating disordered self is trying to express, what it wants, and how to get it constructively. The ultimate goal is the integration of the eating disordered self into the person's total self-structure so that it is not acting unconsciously and operating at odds with the person's best interest.

SUMMARY OF HOW THE THERAPIST WORKS

• The therapist needs to help each patient discover the adaptive function or purpose their eating disorder behaviors serve.

• With genuine empathy the therapist experiences past and present with the patient as though both of them were "in the trenches together." The therapist serves as parent, guide, teacher, and coach.

• It is the therapist's task to uncover what developmental arrests or deficits exist for each patient and help "re-parent" the patient so she gains the needed functions for self-growth.

• Through modeling as well as through analyzing and managing the transference relationship, the therapist assists the patient in internalizing missing psychological functions such as the ability to express feelings, the ability to self-soothe, and the ability to internally validate oneself.

• As strange as it might seem, a therapeutic task in treating eating disordered patients is to get the patients dependent on the therapist instead of on their eating disorder. The next step is to wean them off the therapist and onto other relationships in order to meet their needs. Weaning patients off the eating disorder is much harder than transferring their relationship with the therapist to healthy relationships with others.

CRITICAL TECHNIQUES FOR SUCCESSFUL TREATMENT

• Alliance with the patient

• Sustained empathy

• Patience and long-term thinking

• Limiting control battles

• Making behavioral agreements

• Challenging cognitive distortions

• Balance between nurturing and being authoritative

ALLIANCE AND EMPATHY

The most important thing for a therapist to remember when treating a person with an eating disorder is to establish an alliance and maintain consistent empathy with the patient throughout the course of treatment. Therapists should always strive to know what it is like to be "in their patients' shoes." Empathic failure can lead to treatment failure. Therapists should continually check for understanding. Patients need to be reminded that the therapist is there to help them reach their goals in a healthy rather than a destructive way. In the very beginning of treatment I tell patients, "I cannot take this away from you. You and I both know I can't do that. I can't make you give up your eating disorder, but by working with me, I hope you will come to the place where you want to give it up. Once you really want to, it is you who will do the giving up, rather than me forcing you to do it."

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In the first session I let patients know that I recovered after struggling with anorexia nervosa for several years. Patients are reassured that not only will I understand them, but there is hope that they can be recovered, too. It is common for patients to come into therapy with the experience of constantly being misunderstood and with the idea that they have a disease from which they will never recover. I let them know that what they are doing makes some sense and fulfills some purpose in a way that together we will work to understand. I let them know that they can get out of the vicious cycle of their eating disorders and to do so does not mean getting fat or losing weight.

Individual therapy should empower patients with the belief that they can be fully recovered. Not everyone holds this view.

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By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

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