I was also demonstrating to her that she is not her bulimia. She was beginning to understand that symptoms of bulimia are not character traits. They are symptoms of an illness and different from her deep and unique identity. She can recover from an illness and no longer manifest those symptoms. Her identity will remain and can blossom.

Then I asked her, "If I did have the power to take your bulimia away right now (and we both know I don't), but if I did, what do you suppose that would be like for you?"

She said, "I wouldn't like it. I'd hate it. I think I would be very frightened and not know what to do with myself."

So then the conversation turned to the fact that bulimia exists to help her take care of herself. Even if we could, we would not take away a defense that would leave her defenseless. Our plan was to create an opportunity, through understanding, to develop beyond her current limits. Then she could use other methods to care for herself that are far more useful and healthful than the symptoms of bulimia.

Her developing an easy manner with me so she could talk about her bulimia without guilt or shame (at least not overwhelming guilt or shame) gave her a platform on which to stand to gain internal equilibrium in the face of her symptoms. It gave her the experience, often a first experience, of being with a trustworthy companion who is a witness to her growing strength and awareness and validates her healing and maturation. And it stimulated a curiosity about herself and her symptoms, often leading to quite courageous steps as she learned to tolerate painful feelings rather than acting out through bulimia.

Sometimes a client and I together do a little problem/puzzle solving. For example, to a bulimic many events, both business and social, seem to be centered around food. When these events involve the presence of a bulimia triggering person (such as a parent or parental figure) the patient may only know about bingeing and throwing up as a way to get through the experience. We talk about how she might anticipate those feelings and plan ahead for caring for herself so bingeing and purging might not be as necessary.

Over time, as I think you can see from the gradual development of this style of working, the patient is explores her feelings that are associated with bingeing and purging. There is no failure involved. Sometimes she'll binge and purge and sometimes she won't. Sometimes an episode will be quite severe. None of this is success or failure in my eyes and eventually it isn't in hers either. All of these incidents become opportunities to discover and develop more self understanding, personal strength and new ways to care for herself that serve her better than the bulimia which she is outgrowing.

Of course, a lot more is involved in treating bulimia, but this is a beginning response to your question, "What comes first?" What comes first is respectfully being with each other so the client can develop the ability to be respectful of herself.

References

next: The Eating Disorder Recovery Challenge Plus a Zen Story