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.