Individual Therapy: Putting The Eating Disorder Out Of A Job

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EXAMPLES OF TOPICS DEALT WITHIN INDIVIDUAL THERAPY SESSIONS

POOR SELF-ESTEEM/DIMINISHED SELF-WORTH

Nothing I do ever seems enough, I don't think there is a thin enough I can get to.

It is interesting that on the surface many patients present a self to others that looks very together and self-confident but in therapy admit that there is an emptiness in them and they feel insignificant or unworthy. This brings up an important difference between self- esteem and self-worth. Someone can seemingly have a good measure of self-esteem, allowing her to be on the debate team, go to modeling school, or perform to live audiences. Yet, whatever the person does, it is not good enough. There is an ongoing conflict between "I'm worthy" and "I'm not." These patients set high and unrealistic requirements for themselves just to be acceptable, hence, five more miles, one more hour of exercise, and nothing less than straight A's are common mantras. No matter how successful the individual is, the accomplishments never seem to be internalized.

Discovering and working through all the reasons why and how individuals developed their poor self-esteem and requirements for self-worth are important and helpful, but not critical for recovery. The therapist can deal with these issues from a here-and-now perspective as long as there is an understanding of the nature of the underlying problem.

BELIEF IN THE THINNESS MYTH

I will be happy and successful if I am thin.

Society presents advertising and other media that perpetuate the myth of thinness. If people are confused, lonely, or struggling and think thinness will solve their problems, then why not go for it? The problem is that thinness alone doesn't do the trick, and if individuals have to give up their health and even their souls just to get it, what do they have in the long run? They may gain thinness but they lose themselves. They may feel happy or successful about their thinness, but nothing else.

In individual therapy, where there should be no consequences for telling the truth, patients can explore what the struggle for thinness does for them. For some patients, being thin has brought them the most attention they have ever received. If this is true, they will need to discuss, "Is it worth it?" and "Is there a healthy way?" For others, being thin does not measure up to the myth, but they fear that letting go would mean defeat or some fate worse than the one in which they find themselves.

FEELINGS OF EMPTINESS/NEED FOR DISTRACTION

Eating helps me forget my problems.

In this respect, eating disorders are similar to drug and alcohol addictions. Bulimics and binge eaters describe how they can tune out the world and their problems when bingeing and/or purging. Individual therapy can help patients learn that when the original problems are addressed and dealt with, the need to binge, purge, or starve is no longer necessary. However, it is often the case that the underlying problems may be worked on and greatly improved with no reduction in eating behavior symptoms. Patients may change many aspects of their lives that contribute to the eating disorder but still be unable to stop their negative behaviors. This is why cognitive behavioral therapy, symptom management, and psychodynamic therapy dealing with the underlying issues all need to be used concurrently.

DICHOTOMOUS (BLACK-AND-WHITE) THINKING

I am perfect or a failure. I am thin or fat. I starve or binge.

Dichotomous thinking, leaving no room for the in-between, is a common feature of eating disordered individuals. A goal in individual therapy is to help the patients see how and why they may have developed this way of looking at the world and how their dichotomous thinking sets them up for continued problems and pain. For example, helping a young anorexic woman uncover why she has such a need to please, to be the best at everything, to be perfect is important. Exposing her faulty thought patterns is important as well. She may not be aware of the impossibility of the task she has set for herself by thinking, "If I work hard enough, I will not make a mistake" or "If I eat fat I'll be fat; if I don't eat fat, I'll be thin."

DESIRE FOR ATTENTION AND TO BE SPECIAL/UNIQUE

If I give up my eating disorder I won't be special anymore, I have nothing else that is unique.

The symptoms become the goal when patients don't know what they would have without their eating disorder, and giving it up makes them feel as if they would have nothing to take its place. The ability to pursue the goal, do the behaviors, and follow the self-imposed rules becomes a unique special way of behaving and getting attention. A patient who said, "If I get better, people will think I'm okay," was telling her therapist that her eating disorder was getting her the attention she needed but was unable to ask for. Another very young patient once asked, "If I get better, does that mean I can't see you anymore?" Understanding developmental needs and deficits and how to correct them are important in this area. Every therapist's task is to help patients find a way to be special, unique, and get attention in some other way.

NEED FOR POWER AND CONTROL

I know I purged often to get back at my dad. It would be the only thing that got him really mad, that he could do nothing about.

If there is one consistent feature seen in all eating disorders that causes and perpetuates their existence, it is the need for control and power. Eating disorder behaviors can make certain individuals feel in control and powerful. These people will not give up the behaviors to become out of control and powerless. The therapist can help the patient resolve old issues that result in the need for control. In the above example, working on the father-daughter relationship may help alleviate symptoms. The therapist should also help the patient find a sense of control and personal power in other ways, while showing that eventually the eating disorder leaves her out of control and powerless.

Therapists need to be assertive in convincing patients that, in fact, they are out of control with their symptoms and not in control as they desperately want to be. The therapist will need to ask questions such as:

Is it really control to not even be able to eat?

Is it control to run every day or weigh five times per day, or are you compelled to do so?

Is it control to avoid going to a party because there will be food or throw food away because you are afraid of it?

CHOOSING A THERAPIST

Qualified therapists have varying degrees and training. Psychiatrists, as well as nonmedical therapists such as psychologists, social workers, marriage and family therapists, and other licensed counselors, are called therapists. It is important that the therapist is licensed and has training and experience in treating eating disorders. Nonmedical therapists will usually have one or more psychiatrists or other physicians whom they refer to for medication assessment and treatment. The psychiatrist's role and medication will be discussed in chapter 14.

To find a qualified therapist, ask your family doctor, a nearby university or college counseling center, any women's organization or resource center, or an employee assistance counselor. Another way is to call one of the eating disorder organizations or treatment centers listed in Appendix A and ask for a professional in your area.

Once you have a name or several names, call and, either on the phone or in the first session, be prepared to ask a variety of questions to find out more information using the guidelines that follow.

GUIDELINES FOR INTERVIEWING A THERAPIST

• Find out the extent of the therapist's training and/or experience treating eating disorders.

• With what other treating professionals such as physicians and dietitians does the therapist work?

• What are the therapist's policies and procedures (e.g., frequency of sessions, length of sessions, fees, insurance coverage, billing practices, and so on)?

• What are the therapist's thoughts or beliefs regarding medication?

• What is the availability of medical/hospital backup if needed?

• What is the therapist's treatment approach or philosophy?

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The most important thing is the comfort level and the relationship the patient has with the therapist. If the patient is a minor, the parents should be comfortable with the therapist as well, but the patient-therapist relationship is the more important one. It should be a goal to find a therapist on whom both patient and parents can agree. If you do not feel comfortable with the relationship or the treatment plan, seek more information or consult another therapist, but avoid unnecessarily postponing treatment.

When selecting a therapist, expect treatment to be long term, as much as two to seven years. This means matters must be carefully planned and cost must be considered. Health insurance companies may provide coverage and even resources for treatment, but do not give up hope if your resources are limited. Free or low-fee support groups are available in many areas. Community or college counseling centers often provide therapy on a sliding fee scale.

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