Individual Therapy: Putting The Eating Disorder Out Of A Job

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PATIENCE AND LONG-TERM THINKING

Therapy for an eating disorder is usually long term, two to seven years. I have had a handful of patients recover in a few months, but this is very rare. Therapists who treat eating disorders need to have patience and be willing and capable of hanging in for the long haul, through thick and thin, both literally and figuratively. It is important to remember that the patient is in the driver's seat and the therapist has the road map; both are in for a lengthy, challenging, sometimes painful, but rewarding road to recovery.

Additionally, it is important to remind all involved that seeing a patient once a week is not much time devoted to recovery. When a parent once suggested displeasure and frustration that his anorexic daughter was not better after four months of therapy I responded by saying, "I have only seen her for sixteen hours, not four months!"

LIMITING CONTROL BATTLES

From the beginning I establish with patients that I will, as much as possible, avoid control battles. I explain the general idea that "the fight will not be between you and me, it will be between you and your eating disordered self. I am here to help strengthen your healthy self so that your healthy self will take care of the eating disordered self." If a patient says she likes her behaviors and is not ready to give them up, I reply that I am not interested in taking them away from her. This is tricky with an emaciated anorexic who is unwilling to gain weight. In this case I am careful to pick and choose my battles wisely. For example, I may not take issue with a vegetarian or fat-free meal plan but I will not allow the patient to lose weight to a dangerous level without intervention. If this happens I inform the patient that since she has become incapable of fighting off the eating disordered self that is killing her, I now have to step in and take over. (What "take over" means depends on the age of the patient and the strength of the therapeutic alliance.)

There are some issues that I will strongly "fight" over. For example, I feel strongly that the scale is a weapon that eating disordered patients use against themselves. Therefore, I usually only agree to weigh patients because they want me to and/or it is the only way I can get them to agree to stop weighing themselves (except in the case of anorexia nervosa, where there must be a certain weight maintenance or gain protocol, the individual is at risk, and hospitalization may be necessary). If I do weigh patients I do it with their backs to the scale, in a way as to not reveal the number to them, and I will not tell them their weight. If appropriate, I may give them indications about what their weight is doing, or I may set with them a goal weight that I agree to share with them once they have reached it. I believe that knowing the number on the scale serves no purpose, and I usually stand firm in not revealing it, even though I realize that they can go anywhere else and weigh themselves. (This is where alliance and empathy come in handy.) Part of my work involves getting my patients to give up the scale as a measure of evaluating their self-worth or evaluating their progress in treatment. Each therapist will naturally develop her own "battlegrounds" and will decide on a case-by-case basis how far to "hold the line." Please refer to chapter 13, "Nutrition Education and Therapy," for more information on weighing.

MAKING BEHAVIORAL AGREEMENTS

Behavior goals can be simple or complex, easy or challenging. The importance of setting behavior goals is to give patients an increasing ability to gain control so that eventually they can commit to and keep healthy goals they set for themselves. Sometimes patients are so out of control that what seems like a small step, like writing in their journals one night prior to bingeing, or eating a piece of fruit, is a great step and the beginning of regaining control. Patients must be told and consistently reminded of how these tiny behavioral steps are going to help them recover from an overwhelming illness that can involve hundreds or more behaviors a day. It must be explained to them that (a) it is not the specific behavior but the ability to do it that's important, and (b) once the function of the behavior is discovered, healthy substitutes can serve the same purpose. Both "a" and "b" often take place in therapy with no conscious recognition of what is happening, only that the patient is getting better. Once certain abilities are internalized and needs can be met in healthy ways, patients are no longer dependent on the therapist to sustain the cure.

Making contracts with patients is a useful technique for working on specific behaviors. The following are examples of behavioral agreements therapists can make with patients.

Patient agrees to:

• Call therapist's office or pager before self-inducing vomiting.

• Write down everything eaten and feelings about eating it.

• Do at least three other activities to relieve anxiety before purging (e.g., go for a walk, call a friend, hit a punching bag).

• Write down thoughts and feelings before a binge.

• Reduce laxative intake by five per day.

• Write an angry letter to anyone appropriate and bring to session.

• Eat fresh fruit at lunch this week.

• Set a timer to delay a binge.

Through exploration, execution, or even resistance, these agreements can help lead patient and therapist to deeper psychodynamic issues.

CHALLENGING COGNITIVE DISTORTIONS

In challenging cognitive distortions (false and incorrect beliefs) about food, eating, and weight-related behaviors, considerable resistance should be expected. Allow the resistance or justification to be verbalized and try to understand it, pushing for further and deeper explanation from the patient after each response. For example, if an emaciated anorexic patient says that her stomach is fat, ask her to show you. If she shows you where she sees it sticking out, provide a reality check by telling her that you don't see it that way at all but you understand that she does. Don't stop here! Continue to search for understanding from the patient's perspective by saying something to the patient such as "Even if your stomach did stick out, what would that mean?"

This will cause the patient to have to search further into the meaning her stomach size has for her. At this point, patients often resort to, "Well, I just like it better when it doesn't stick out." The therapist must not give up but continue probing by asking, "Why is that?" or "Do you like other people better when their stomachs don't stick out?" This kind of dialogue should continue as long as possible and will often lead into a sort of stalemate. This is not a bad result, and the therapist should not be discouraged. The therapist should ask the patient to write in a journal about the issue and should gear up to have the same or similar conversations with the patient for a long time to come. Patients need to have things repeated over and over, and patience on the part of the therapist is not only a virtue but also a necessity.

To avoid power struggles and the development of a winner-loser mentality, it is important for patients to understand that the therapist is not overly invested in the idea that they will change to the therapist's set of beliefs, way of thinking, or point of view. The therapist does best when maintaining a collaborative, caring, and empathic approach expressing a desire to help patients get better by helping them understand their behaviors and discover the truth that will allow them to make more appropriate and healthy decisions for themselves.

NURTURANT/AUTHORITATIVE THERAPY

In his book, Treating and Overcoming Anorexia Nervosa, Steve Levenkron described his style of treatment as nurturant/authoritative therapy. I believe this concept is vital in the treatment of eating disorders. Patients need so much comfort and caretaking that those treating them must go beyond the traditional roles of a psychotherapist. Patients need to learn how to be needy and how to ask for help. They need to learn the difference between self- care and selfishness and how to be less rigid and demanding of themselves. On the other hand, they are lost and confused and often need a strong but compassionate authority figure to help them out of their self-imposed prison. The therapist needs to let patients know that they will not be allowed to self-destruct and that they can lean on the therapist for support and direction. This kind of role puts the therapist in a more authoritative and directive stance. Interpretations and even advice must be forthcoming and long silences avoided.

The therapeutic stance of being a blank slate or of waiting for the patient to speak can be frightening to eating disordered patients who desperately need to feel that someone who cares is in charge and knows what he is doing and can help others do the same.

The line between nurturing and being authoritative with a patient is a constantly fluid one. In some sessions I am a passive recipient while patients cry, telling them I know how hard it is, reassuring them that things will be okay. The therapy sometimes serves as a container for emotions. Other times, I challenge the patient and ask the patient to take a risk that unsettles her. I'll challenge patients for not trying hard enough. I'll challenge them to add a can of tuna to their daily diets or to call me before purging. I'll explain what I think some of their recent behaviors have meant.

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The therapist has to know when to challenge and how far to push a patient, and then be clear that working through the patient's response is the key. Whether the patient does or does not meet the challenge is not the most important therapeutic issue. It is the meaning the challenge has for the patients and the meaning of their responses that are important. Working through why the patient responded the way she did, what the challenge, meant to her, how she felt about the challenge, and about accomplishing it or not accomplishing it are the important issues in the therapy. Nothing will be accomplished by pushing and challenging, unless a certain bond in the therapeutic relationship has been established and a high level of trust exists.

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