Individual Therapy: Putting The Eating Disorder Out Of A Job

continued

THE THERAPIST AND NUTRITION KNOWLEDGE

Dealing with eating disorders involves talking about food, nutrition, weight, body fat, dieting, and calories, or risking empathic failure. Therapists may need or choose to work with a dietitian who can be a useful adjunct to outpatient therapy and is a given in inpatient settings. Nevertheless, therapists should also have knowledge in these matters. Certainly, a degree in nutrition is not necessary, but therapists should be well read in these areas, especially as they apply to eating disorders. Therapists should also keep up with current periodicals and medical findings in this field. Knowledge of nutrition, dieting, and weight control will help the therapist to better understand and educate the patient.

Therapists with little or no knowledge in this domain may frustrate or alienate the patient, since this is an area of importance to her. Even when using a dietitian, therapists cannot expect patients to reserve all discussion regarding food and weight for someone else. Eating disordered patient's feelings and food are enmeshed. Therapeutic work involves working directly with the food and weight-related issues, uncovering specific and personal meanings for various patients. In this way therapists are like detectives, exploring and uncovering clues that will eventually help solve a mystery.

Here are some examples of statements relating to nutrition but needing to be responded to and discussed in a therapy session:

• I didn't eat the cheese because it would make me fat.

• I needed to burn off the calories I ate so I went back to the gym for two hours last night.

• We don't eat bread at our house, my mom has always said bread makes you fat.

• I read in a magazine that a 1,200-calorie diet was fine, so that is what I'm willing to do.

• I always throw up when I eat sugar, sugar turns to fat.

Responding to the nutritional aspect of these statements is important to establish expertise and to relate directly to the topic brought up by the patient. However, after asking for clarification and providing correct nutritional information (if possible), the therapist needs to go beyond to a deeper level of responding, such as "And what would that mean if you didn't burn off the calories?" or "What will happen if you gain some weight?"

INSIDE AN INDIVIDUAL THERAPY SESSION

The following dialogue is taken directly from two therapy sessions with a twenty-six-year-old female patient who had recently been hospitalized for bulimia nervosa. She had gone for approximately five therapy sessions with another therapist a few months prior to her hospitalization but had ended therapy, telling her therapist that she was "just not ready for treatment." She tried Twelve Step groups and, although she liked the groups, she felt that they didn't really work for her. After a few months went by, her problem became more severe and, upon realizing that it was well beyond her control, to the point of interfering with work and her relationship with her boyfriend, she decided she needed serious help. She called an eating disorder treatment program that had a Twelve Step component where she was admitted, and we met. She was a very attractive, athletic, bright, responsible, and hard-working individual who was beside herself that she could not get a handle on her binge eating and purging. I was assigned as her therapist in the hospital and we began a course of therapy after her discharge. The following two excerpts were taken from approximately the fourth and fifth sessions we had after she was out of the hospital, back home, and back at work.

SESSION 4

Patient: Since the hospital, you had said there would probably be a change and there has been a change. It's not, I don't use it as comfort it is more like a punishment now. It is an addiction but not as big an addiction all the time. It seems more controllable. Like yesterday, I did it, I didn't need to, I didn't want to, but I did it anyway.

Carolyn: That is an interesting thing to say, isn't it. "I didn't need to." I get that, "I didn't want to," that's a little weirder, so why would you do something you didn't need or want to do?

Patient: I've had that feeling many times where I think, "No I don't want to do this, I don't want to do it" and then I do it anyway.

Carolyn: So why would you do something you didn't want to do?

Patient: Habit.

Carolyn: So let's think of something other than the word habit. I get habit, I really do, but even habits are usually things you're getting something out of, like smoking. There is something you get out of it. So that's the time when I say that there are two parts of you. The one that wants to and the one that doesn't want to.

Patient: I'm sure part of it is the addiction part. The eating disorder part of me doesn't want to give it up. I know that. Because it is the black-and-white thinking again. Because once I stop, I'm stopping for good and it's never coming back.

Carolyn: Oh wow I see, that's big.

Patient: That's a long time, and that goes through my head all the time, I mean I think, "This is the first day of the rest of my life," it's not like, "Let's see how far I can go," it is more like, "This is forever, and that's a long time" and without it, that's a big fear. I mean this is my safety net and well, can I make it without my safety net? Can I let it go, well, I don't know.

Carolyn: Well, you know, you aren't ready to do that. You don't have the underlying stuff solved like, "How do I get my needs met and get off this perfectionism thing and learn to accept myself better and not have to live by rules?" All of that has to feel a little bit better for you to give this up just like that.

Patient: Oh, definitely.

Carolyn: Well, how about this? How about the concept that you say to yourself, "I'm going to put it up on the shelf, I'm going to put it up there like in a box, and it can be up there and get dusty. . . . and if I really need it I can bring it back down.

Patient: I always try to say, "I'll deal with it tomorrow," that's what I always used to think.

Carolyn: Well, that's what the one-day-at-a-time concept is supposed to be, you know. Don't think of it as forever, think of it as one day at a time. Unfortunately, they say that in OA but then there is this whole thing of the chips and the days and the starting over.

Patient: I can't count days, it drives me nuts. I mean I know I will, I mean, I can't help it now. I look at the calendar and think, okay on April 16th I started again.

Carolyn: Why will you do that, stop that (laughs). Oh what am I going to do with you?

Patient: Well, I really don't want to go back to OA and get stinking chips because that's gonna be hard.

Carolyn: I thought you liked it.

Patient: To a point. It's great when you are doing good and get recognition, but it's also a lot of reverse pressure that some of us can't handle.

Carolyn: Yes, I know. Besides, this is yours, it's a part of you, there shouldn't be an audience to give it up for or keep it for. It just really has to be known inside of you, all the parts of you that it is yours to give up when you are darn good and ready. And there is no reason. I mean, what do I need you to give it up for? I have no agenda here, I really don't, I mean I want you to be happy. I want you to be well, but it's not going to affect my life if you do or don't give it up or throw up today or tomorrow or you know, it's the long haul, I'm in it for the long haul. If I waited for everyone to be ready, really ready to give it up before they entered into treatment, I don't think I would have any patients.

Patient: Probably not.

Carolyn: But something happened to you when you went to the hospital program, something snapped and you were ready to give it up and that's okay but it was the executive part of you that went in and did treatment, not the eating disorder part.

Patient: Yeah I remember, my eating disorder part was not really there.

Carolyn: The executive self was and you know that part of you is useful. You just have to put it to its proper usefulness. You get a lot from it; your grades and determination and accomplishments and all those things, you get a lot for that. But in some areas it can be a problem if it is just acting blindly and not in touch with anything else. Sometimes it's bad when things are taken to the extreme, even recovery.

Patient: Oh I know and it has always been that way.

Carolyn: Now that you are out of the hospital and it is back, I mean the bingeing and purging are back, now perhaps you can learn from it. We need to get in touch with that part of you. We need to know what she is feeling or wanting. One way to do this is through a journal. I want you to, when you feel like you want to go and binge, I want you to take a minute to write down what you are thinking and feeling.

Patient: I've tried that and I just think, "Forget it, I don't want to write, I want to binge."

Carolyn: Well, you get to go ahead and binge after you write! The writing isn't meant to stop you from bingeing or purging. Of course, you don't want to write if you think that it is supposed to be instead of bingeing. The goal of writing is to get access to the part of you that does the bingeing and purging because she doesn't come to therapy sessions. Neither you nor I are in touch with her. So, I just want her to be able to write down what is going on for her. But you have to make sure that she knows she can go ahead and binge and purge anyway, but to please just write first.

Patient: Wow, okay, I can't believe you are telling me this, but I think you are right.

Carolyn: So you're going to try to do it then?

Patient: Yeah, yes, I mean I will. Session continued untaped.

SESSION 5

Carolyn: So what's right up there for you tonight?

Patient: Well, what's up there is the assignment you asked me to do last time, to write down what it is I'm thinking or feeling when I feel like I have to go binge.

Carolyn: Uh huh.

Patient: Well, I couldn't do that. I don't know why. I would just sit there with the piece of paper and the pen and I could not write down what it was. I could think of things in my head but. . . .

Carolyn: Like what?

Patient: Oh general stuff, stress, fear, anxiety . . .

Carolyn: And what were you thinking sitting there with the pen?

Patient: That it's just words and it is not getting at what the problem really is. Because I can handle stress during the day at work, no problem. I get through the day, and I don't really feel stress when I leave there but for some reason I'll go binge. Even if it is a perfect, great day and nothing goes wrong at work I still go binge. So there is something else besides saying I'm stressed, because I don't feel stressed.

Carolyn: Okay, so you're not stressed, so what else is it?

Patient: It's more like images, you know I'll think of food, I don't really think I want to go binge, I'll start thinking of food.

Carolyn: Yeah, I remember now that you told me that before. You start thinking of food, specific types of food that you consider what, fattening? off your diet plan? What is another way of describing them?

Patient: Well, I was thinking of bad, or junk food.

Carolyn: Anything else or why it is bad?

Patient: Because I was brought up that way. It was bad to have that kind of food around the house. We had family binges on that kind of food, so. . . .

Carolyn: I remember that.

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Patient: Only on birthdays, we would get a big cake and a gallon of ice cream and between the four of us we would eat the whole thing that same night. And if there was anything left my brother and I would race to it in the morning and have it for breakfast.

Carolyn: Because you weren't going to be able to have it for a while?

Patient: Oh yeah, we wouldn't see it again until someone else's birthday.

Carolyn: It was a very big deal. You'd race to it in the morning. I mean that is a very big deal.

Patient: Oh yeah, we'd get up extra early and it was insane.

Carolyn: Like Santa Claus had come. So you know when you are a kid your parents have control over it, so what does that tell you about this?

Patient: It's a rebellion thing, there is no one to tell me I can't, I can do whatever I want.

Carolyn: Yeah, I think you are making up for a lot of lost time.

Patient: Probably.

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