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In Treatment What Comes First: Bingeing or Feelings?

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Recently a colleague asked me, "Do you try to get your clients to diminish their bingeing behaviors from the beginning of therapy, before you together have explored the feelings that are fueling that behavior? I know there are differing views on this, and I would be interested in hearing yours."

When I heard this question, several points of equal value, in my opinion, arrived simultaneously in my mind concerning therapy work with eating disorder patients. Since writing is linear I can only communicate one point at a time. Please understand that these considerations are simultaneous.

My first thought was that I don't try to 'get' my clients to do anything. I want them to heal and develop the capacity to live a fulfilling and satisfying life. But what that means to them and how they specifically accomplish that falls into the realm of their personal values, decision making and evolution.

 

Therefore I do not address the bingeing or purging in terms of control in any way. Often it's the new client who is quite active in wanting immediate results in terms of stopping both bingeing and purging behaviors. In fact, I'm usually the one who is putting forth effort, gentle and consistent, to create an environment where we focus more on our newly forming relationship.

To me, a rush to focus on behavior undermines the therapy before it has a chance to begin, regardless of whether that focus comes from me or my patient. Once we have a relationship based on earned trust, we can be allies and look together at feelings and behaviors that need attention.

From my experience I see that many clients with active eating disorders have built up in their minds, before their first appointment, what they think therapy is supposed to accomplish for them, and how it will all unfold. Women come in determined to obliterate their binge or binge/purge behavior. They are also terrified that I will somehow make that obliteration happen and that they must surrender to 'the all powerful one' (the therapist). Many feel that going to therapy means facing some kind of terrible criticism or punishment as well as forces of demand and control.

Often the first way a new eating disorder client presents herself shows how much she wants help and how terribly afraid she is at the same time. I've described some of them below. All of them represent how the client is rallying her courage to begin therapy. She is trying to protect herself and come forward for help at the same time. This requires courage. She doesn't need more stress by my attempting to control her in any way.

Ways of first presenting include:

1. Subservient
Patient conveys a willingness to do anything the therapist says.

2. Combative anger
Patient is ready to fend off the therapist's perceived and imagined power and commands.

3. Defeatist
Patient feels she's already failed before psychotherapy work even begins. She is certain she will fail in any program she thinks the therapist will attempt to establish.

4. Childishly cute and manipulative
Her strategy is to outwit the therapist's plans while getting attention and love at the same time.

5. Superiority
She will listen to perceived controls and ideas coming from the therapist but acts as if the therapist is a puny force compared to her sophistication and intelligence.

All these stances are manifestations of patient terror caused by the thought of being bereft of an eating disorder. They demonstrate power of the client's guilt, fear, shame and despair in terms of maintaining their eating disorder.

Since most new clients are certain they are going to face some kind of painful punishment or criticism in therapy, their coming to that first appointment is a tremendous act of hope and courage. These various stances help them show up for that first appointment despite their fear. Behind each of these stances is a frightened, hopeful and very brave person.

So as far as which comes first in our conversation, bingeing or purging, I don't focus on either. The client may be stressed to the maximum just by being present for the first appointment.

I focus more on creating a relaxed atmosphere where the patient and I can begin to develop a relationship that is based on earned trust, genuine interest in the remarkable puzzle of her eating disorder, deep respect and compassion for her struggle and shared curiosity about what triggers an episode.

Clients usually feel terrible guilt about their bingeing and purging. They criticize themselves severely for these behaviors. They set impossible goals for themselves in terms of stopping. They feel hopeless and despairing when these goals are not met. In my opinion they need their eating disorder behaviors in order to maintain whatever lives they have going because they don't have any other coping mechanisms that are as effective.

If I have an agenda for them that includes their stopping or diminishing their bingeing or purging I may run the risk of accentuating their feelings of guilt, self criticism, sense of failure and despair. I believe this is why so many people with eating disorders leave therapy. The increased burden of negative feelings about themselves becomes intolerable.

Once a bulimic patient in my practice said she thought she wasn't making any progress because she was still bingeing and throwing up and, after all, we'd been seeing each other once a week for two months.

Because we had developed a friendly way of talking about her bulimia, as if we were talking about a third friend with rather curious habits, I could say, "Isn't that just like bulimia? You want results immediately."

She laughed and said, "I'm like that about everything. I have to have everything work out perfectly and right now." So we had a moment together, in harmony with one another, as we both appreciated one of the symptoms of bulimia.

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.

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