10 Things I Would Like Every Therapist to Know About Eating Disorders

….My own version of a “Top 10 List” of what I wish all therapists knew……

  1. Patients who develop eating disorders did not choose to be sick. Also, it is very rare for them to be able to choose to get better. Some patients who are older and have some maturity may indeed be truly on board with recovery. However, most of them, including the adolescents, have no interest in giving up their ED. Treatment should be focused on using external motivation if needed (consequences and reinforcers) vs. waiting for any signs of internal motivation to change.
  2. Patients who are sick with eating disorders have a brain imbalance from starvation or from severe symptom use such as bingeing and purging. This initial brain imbalance does not recover from talk therapy. This brain imbalance, however, responds to structure and re-feeding. Talk therapy comes into play once the brain is re-fed and in balance.
  3. Patients who are sick with eating disorders know very well how to “talk the talk” and to please the therapist by saying what they want to hear. Do not be fooled by this “pseudo-recovery” stance into thinking there is not a raging eating disorder hidden underneath this rational exterior.
  4. Patients with eating disorders are very invested in being the “good girl” but often struggle with intense rage and critical judgments of self and others. They often project these judgments onto the external world and think that others are as critical of them as they are of themselves. This personality trait often pre-dates the ED and needs to be addressed in their therapy.
  5. Many therapists who enter the field of treating eating disorders do so for a reason. Some may have a history of an ED but many come with a heightened sensitivity to cultural issues that judge the female body. Many therapists have a history of dieting, being sensitive to food issues, and in general disliking their own bodies. It is a trap to think that what we as therapists may experience (“I feel fat too”,  or “I also should eat healthier”) is anywhere near the realm of what our eating disorder patients experience who are under the influence of the disease (“You are a big fat pig and you must now run on the treadmill until you drop”). We may have internalized the toxic culture but our patients are sick and are under the influence of an illness. This is a very important distinction.
  6. For patients with eating disorders, it is very tempting to focus initial therapy time on figuring out the “whys” of the ED. The origins, the underlying issues, the dynamics. This is what we have been trained to do. However, the initial treatment should involve two things and two things only – 1- the re-feeding of the patient and the re-structuring of their eating behaviors and 2-effectively handling the patient’s resistance to these changes. Insight, past trauma, and psychodynamics should all be put on the back burner until the patient’s brain and body are healed from these illnesses.
  7. Our views of the parents of these patients needs to completely change. Instead of seeing the parents as “the cause of the illness” we need to see them as the patient’s best shot for recovery. The parents are the “catalysts for change” that can propel the patient into recovery through structure, support, and re-feeding. Parents need to be empowered to take on this role and we need to increase our sensitivity to their own experience during their child’s illness.
  8. Most of the behavioral/cognitive/ and emotional symptoms that we equate with the anorexic patient can be attributed to their physiological state of starvation. Once this state is relieved via proper nutrition, these symptoms disappear. The patients need to get to their full body weight to get this symptomatic relief. Being “10 pounds away from their goal” is unfairly placing them in an eternal limbo where they can never truly recover.
  9. Fathers have a very important role in their child’s treatment. Oftentimes when a family first presents for treatment of an ED, the father is “out of the loop” of their child’s struggle.  Effective treatment requires us to empower these fathers via education and support of their own unique experience. These children need their fathers actively involved in their treatment.
  10. It is a myth that eating disorder patients don’t get better. It is a myth that they will always be “a little sick”. It is a myth that treatment should take 5-7 years. These patients can fully recovery in much less time than one would think. It is our job to hold to this belief and to bring our patients to this place of truly living their lives in freedom and joy.

Working Backwards

I am always thinking about ways we can summarize and simplify the huge amounts of data that are being thrown at us every minute. The often conflicting data, the hundreds of inspirational quotations that we should follow, the reams of parenting advice……. and this is just on our twitter feed! Let alone books, research articles, and good old verbal advice. How do we make sense of all of this? How do we know what advice to follow when one finding looks as good as the next?

With these thoughts in mind, I was consulting the DSM-5, the “bible” for psychologists and people in the mental health field. It is our “map”, our way of trying to understand the complexity of human nature that often is presented in front of us. I was consulting the section on Personality Disorders to try and find some diagnostic clarity regarding a particularly challenging client, and I turned to the back of the book. There was a section on a proposed new way to classify and understand personality disorders which caught my attention. Instead of the current classification system, it proposes an overarching system of understanding personalty dysfunction: classifying if and how severely patients are struggling in four central areas of their lives: their overall sense of self, their ability to get things done, their sense of empathy, and the quality of relationships in their lives. Patients are classified along a continuum of mildly to severely impaired in these four areas. Pervasive dysfunction represents the most severe pathology.

I started thinking about the parents of my eating disordered patients and how we as a field are finally getting to the point of not blaming them for their child’s illness. I am very clear in my sessions that these parents have not caused the suffering in their child. This has been extremely helpful in the entire therapeutic process – alleviating guilt and allowing the parents to become empowered catalysts of change for their children. However, while we are moving on from blame and causal issues, we are still left with the fact that parents DO influence their children. They may not cause a particular illness, but they certainly leave an imprint on their child. In the world of eating disorder treatment, there are many times that the ED is lifted and the patient still struggles with some underlying personality dysfunction. The parents want to know – “What are we doing that is not helpful to our child?”. The child is now re-fed and their brain and body has come back to life. But the child continues to struggle. The parents continue to struggle. What next?

Instead of re-inventing the wheel each time wouldn’t it be nice if we could take what we know and work backwards. If we know that dysfunction in these four above mentioned areas can create ongoing issues, why not target these four issues? Why not help parents learn to parent better across these 4 domains? Why couldn’t we teach these (and all) parents to parent “better” in the areas that they struggle the most:

  • do they have good enough boundaries to create a child with a clear sense of self?
  • do they create enough structure (both consequences and reinforcements) to help the child manage the things they have to do, even if they don’t want to do them?
  • do they model compassion and empathy to the child through their relationship with their self and their child?
  • do they engage in truly reciprocal and mutually validating relationships with the child so that the child can take this model out into the world?

Helping a parent accomplish this on a consistent basis is extremely challenging in the world we live in. But how empowering it could be to give parents this map as well, to let them know what we know….and to show them that they can create health in their child not only by re-feeding them but also by supporting their emotional growth. Parents (and all of us) have a limited amount of energy to give – let’s help them figure out the most effective way to put this energy into action to best support their child.