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ABN8595 - SECTION 4: CLINICAL AND PRACTICAL WAYS TO TALK TO YOUR PATIENT (PART 1)

1 - Excessive interest in fashion magazines and popular magazines such as Seventeen. Purchasing these magazines and reading them often.

Excessive interest in fashion magazines and popular magazines such as Seventeen should alert the clinician. As we have reported earlier in this course, teenagers who spend too much time reading fashion magazines feel worse about their own bodies. They are presented with a kind of indoctrination into society's views of the ideal to aim for - an ideal that is presented as if it is readily attainable and relatively pervasive.

This contrasts very powerfully with where teenagers are at in their own development. Teenagers may experience a powerful surge of hormones at the same time that their bodies are growing and maturing rapidly. At times, teenagers may have a hard time adjusting to their new bodies, so different from the childhood bodies that they experienced even a few months prior.

Changes in their bodies will include complications in areas around which the culture at large has – at best – conflicted opinions. Acne, hair in private and previously hairless places, changed body odor, changes in metabolism that can allow for fat accretion – all of these normal developmental occurrences deviate from the ideals presented in the fashion magazines: slender, smooth-skinned models with perfect faces and physiques.

To add another cruel twist to this matter, these physical changes occur at an age where self-consciousness is at its most intense place. New adolescents are primed to scrutinize their own bodies – as well as every other part of their lives – with an intense degree of self-consciousness that erupts out of these hormonal surges and the rapid brain development that is occurring during this period of a person’s life.

For a mental health clinician working with eating problems and disorders, it is important to keep in mind is that a vital developmental task for the teenage years is concerned with establishing a healthy relationship with the ‘new, more adult body’ that the teenager is developing. This real body may not be perfect, according to fashion-social standards, but it is the body the teenager will sport for the rest of her/his life. That is why s/he needs to feel good enough about it - even if reflects a different shape than the "ideal" one.

From a process standpoint, the clinician can pick up evidence of the client's interest in fashion magazines in the context of asking the teenager what are his/her favorite things to do. If the client does not volunteer this activity as an interest, the clinician can note that fashion is an interest often mentioned by other teenagers, then ask the client his/her level of interest. The normalizing of this interest can sometimes allow the client to lower his/her defenses enough to give more accurate information.

However, some clients are more defended than others and they do not volunteer much information at all. Sometimes, they give so little information that even parents come to consult about their teenager not being sure about their child’s behavior. Is it or is it not disordered eating? They do not know whether to worry or not or, if their child is exhibiting behaviors that may cross over into being unhealthy to the point of needing a mental health professional involved.

These parents may even guiltily confide to the therapist that it is impossible to extract information from their daughter or son about how they eat outside of home. They may be have lost a great amount of weight - according to parents - but they still maintain that they are eating healthy foods and parents; see them making extremely healthy choices.

Eating disorder professionals have noted that when teenagers are not forthcoming with information with them and their parents, it is useful to tell parents that they need to find out what is occurring in the clique to which their child belongs. A clique’s interests will more than likely be the teenagers’ interests.

Parents may want to invite their children’s friends’ home and talk to them and other parents. If friends of the teenager are concerned, through gathering information from them, a parent will be closer to hearing what his daughter or son is doing. This allows better gathering of information in terms of his or her eating or body image concerns, or in terms of what his or her favorite magazines are to read.

If the teenager does spend a lot of her free time reading Seventeen or Vogue, or any other fashion magazine, the clinician must still gather the meaning of this in the life of the teenager. It may represent a red flag to the clinician, or it may suggest that the client:

A) Has parents that buy the issues and have them available in the home.
B) Has a peer group that invests too much time in outward appearance to the expense of other more healthy activities and values.
C) Has a certain buddy with which she (or he) bonds with, through this kind of reading.
D) Is already isolated.

The clinician's job is to find out – carefully and gently - what ‘category’ of magazine reader her patient is, and why the patient reads these magazines. She may be a photographer with interest in finding older women models, or she may be someone in the beginning stages of an eating disorder.

If there are indicators that the client is not locked into inflexible modes of thinking, the mental health professional may also slowly engage the patient in talking about the differences between ‘real bodies’ and ‘magazine bodies’. Some patients (even grown-up women) may not realize that magazine pictures are air-brushed.

It may also be helpful to educate the client concerning the use of make-up for magazine models, even when the models look natural. This is to dispel the sense of dismay a client may have concerning her own appearance in relation to the "perfect" images presented on the magazine pages. A quick look at the long list at the bottom of the page - citing the many brands of make up – may be helpful in restoring a sense of reality to the unrealistic images that are used.

Used with skill and care, humor can sometimes be a successful way to initiate more flexible thinking styles on the part of the client around these issues. “I guess we are now all expected to hire people to airbrush us before we go out the door,” or “Ten minutes to take the photo, ten hours to put on the make up so she looks like that.”

A great deal of important information can be derived from how much flexibility or rigidity there is in the client's willingness to examine these body image questions from multiple points of view. If the need to model oneself after these ideal images has been deeply internalized by the client, it is more likely that there will be resistance to input about different body ideals.

The task of engaging the client in treatment will involve finding a way to lessen the admiration for these impossible ideals, and strengthen the sense of belief in oneself when one is less than perfect. It may never have occurred to the client that one has a choice about whether one wishes to honor the ideals forwarded by the fashion magazines. Engaging the client in treatment begins with creating some awareness of that choice.

That choice will also touch upon some aspects of a deeper concern. Talking about models and magazines can also spark a conversation about the reality of one’s body. Eating disorders involve a kind of objectification of the body, turning one's body into an object devoid of life, like a piece of paper upon which one “composes” a portrait of the self to present to the world. This self-presentation becomes a thing, almost separate from the rest of the person.

The objectification that occurs in fashion magazines supports this idea of turning one’s body into a tableau, which is why there is likely a connection between the reading of fashion magazines and the diminishment of self-esteem. This is also why you will most likely not see such magazines in the waiting room of a clinician who specializes in eating disorders.

The conversations must ultimately lead to some understanding of why the client has made the choice to conform to the ideals that are presented in the fashion magazines. It may be that the client did not understand they had a choice. It may be that they view the achievement of that ideal as the most attainable way to handle the complex task of fitting in and defining themselves. It may be that they do not trust their ability to handle the complex challenges of moving into adult life.

As that information becomes available, it will allow the clinician to begin to formulate a viable response or alternative to these misperceptions. For instance, the mental health professional may want to lead the discussion towards other activities that can be pleasurable – besides looking at fashion magazines.

This conversation may spark a dialogue about activities that were once pleasurable, before the eating disorder became a problem. This can begin to present an alternative that makes sense: a life where one lives fully for the enjoyment of being a complete person – not as an object whose only purpose is to quiet the demanding voices of conforming to this fashion ideal.

If the clinician is also meeting with the client's parents, there may be an opportunity to educate parents about the worries and potential consequences of reading fashion magazine (i.e., concerns about body weight and shape, measuring down against models). This would need to be determined carefully, with a clear sense of the parents' readiness to assimilate this kind of information.

2 - Concern with looks and with weight.

During the second or third session with an eating disordered patient, eating disorders specialists often explain to their patients what their work together may look like. A way to explain their task is to talk about the patient’s worries about flab, pounds and fat. Patients almost always welcome someone that will discuss with them fat, flab and weight. Talking about their concerns about fat and weight and shape may be the first way to let them know that they are taken seriously.

If this conversation comes up during the time when you are assessing the client, there are some approaches that might be considered. The clinician may want to take the following position: although the patient will always be welcomed to talk about their concerns with weight, their talk will be a bit different than the talk they may have with others.

The primary point of difference will be the effort of the clinician to translate the language of calories of weight and food obsession into some understanding of the pain and suffering that the patient feels when he or she eats, or when he or she feels fat. In other words, the clinician’s work will consist of a bridge between the client’s focus on weight control and food reduction, and the emotional landscape that is producing the eating disorder.

This refocusing will need to occur for the patient to engage in treatment. As long as the patient focuses on his or her weight as being the problem, the solution does not consist of psychotherapy. It consists of losing weight. A bridge must be made to the idea that the patient is in some kind of emotional pain, and the focus on his/her weight is an attempt to manage that pain.

In this bridging process, the clinician might want to say that talk about flab and fat is like a language, a language that needs some translation. She will need to understand how flab, pounds and fat translate into pain and ugliness, as well as met and unmet feelings and desires according to the patient’s experience.

There are specific ways that this bridging process can get started. The clinician might say: “In my experience as a clinician, so far, fat is never only, about just fat, even when a patient may be fat, by social standards”. The clinician might add: "Fat is a code word that means different things for different patients, and I would like - with your help - to find out what ‘fat’ may mean, if anything, to you”.

With these words the mental health professional prepares a field of interpersonal relationship with the patient. In this field the relationship is between two people: the therapist and the patient. The work is for both of them - as a team – and it can only be done if the two cooperate with each other. Eating disorder clinicians need to tell their eating disorder patients that together as a therapeutic couple they will develop a language, a new language.

The patient is given the power to talk about his/her fat and say what it means to her or him. The clinician also leaves an opening for the patient to disprove the ideas of the therapist. The clinician states things in terms of "her/his experience so far”, which leaves room for another type of experience. In doing so, the clinician leaves room for the patient not to feel cornered.

Eating disorder patients are notorious for erecting defenses against their feelings and desires via food, eating, weight and weight control. While the clinician leaves room for the patient "to save face”, the clinician asks the patient for help in trying to figure out what fat and weight and inches might mean for her or him.

“I understand your pain and that you feel right now that your thighs are too big. Your feelings about your thighs are true because they are feelings. But, I have found out, and I‘d like to know what you think, that when people talk about pounds, kilos and inches it is like a code. A code like shorthand writing for hurts, for certain thoughts and for a lot of emotional ache.”

The job of the mental health clinician is to help the patient understand his inner life, the self perceptions of his outer body and the way in which he eats or does not eat.

Because these elements – perception of physical self, ways of approaching food and, inner emotional life- are intertwined, the clinician cannot reassure the patient that her weight is adequate or that his shape is fine or that he is too thin or she is too heavy. In fact, doing so would only replicate what others in the patient’s life might have done, so far. This assurance, in general, turns the patient off.

Concern of pounds, shape and weight are psychological symptoms that point to deep inner suffering. Symptoms cannot be taken away by reassurances. Symptoms need to be understood in context.
Clinicians listening to patients complain about their looks or weight need to take these concerns seriously. They need to be interested (and act interested) because under the talk of weight and pounds there is the reality of fear and emotional pain. In this context, ‘fat’, ‘flab’ and ‘thin’ are concepts that mean more than weight and pounds.

Clinicians may need to engage their eating disorder patients or patients who show problematic patterns of eating, slowly and patiently. Hearing their endless complaints is a way to show them their eagerness to understand them.

Most importantly, today’s talk about fat during a session may have a different meaning for the patient than yesterday’s talk about fat. Yesterday fat might have been ‘code talk’ for laziness “I am fat and so I am lazy” while today’s talk may stand for giving in to forbidden desires “I am fat because I ate all that chocolate!, I am this person that wants so much from life, even chocolate, a boyfriend, a career”. Clinicians need to listen to the weight complaints to read into them how desires are weaved in and intertwined with food and pounds.

Oftentimes, clinicians working with eating disordered clients will discover serious deficits in the ability of the client to understand their own feelings, and very poor skills in the expressing of feelings. As the therapy process unfolds, clinicians must explain and model the language of feelings, the connections between thoughts and feelings, and then create a bridge linking these transformed skill sets to the concepts of pounds and shape.

“It seems to me that you ate all that ice cream and that now you are feeling so fat.” It seems that you ate the ice cream as if you were applying a band aid to a hurt. But, your hurt, did not need the ice cream, it needed maybe some other kind of band aid. Do you have any idea what it could have been?

“Your feeling fat, could it be that it is about the feelings you swallowed when you swallowed all that ice cream? You cannot have actually gained 10 pounds in half an hour, but, yes, you feel like you have.”

Because treatment for a patient with an eating disorder may last anywhere between one and four years (or even six), depending on how entrenched the eating disorder is, therapists need to be aware that the process of recovery is not a straight line.

Patients, under stress, may resort back to old ways of dealing with pain and disappointment. Patients may eat compulsively or starve or go back into being able to talk only about and think of pounds, inches, kilos or physical shape. Anytime during treatment there could be setbacks that need to be explored to see if they are a part of a transference reaction, part of outside stressors that the patient is dealing with, or part of the ending of a treatment.

If a regression in terms of food and eating and body image perception occurs, the therapist will need to - again and again - remind the patient that fat and flab and feeling and feeling and seeing fat when looking into the mirror are ‘short hand and code words’ that need to be decoded in psychological and emotional terms, even if the person is fat by social standards.

3 - A recent disappointment with a girlfriend, boyfriend or at school is followed by dieting.

Often times, clinicians assessing eating disordered clients will discover that the client began dieting or lifting weights following a serious disappointment with a boyfriend or a girlfriend. The dieting behavior may have begun in the hopes of loosing a few pounds, but then became extreme and out of control; in essence, it became an end in itself.

In cases where the clinician is making a first assessment of a patient who is suspected of an eating disorder, it is the clinician’s job to find out:
a) The severity of the case that is in his office and
b) What would be an appropriate referral to make, if the therapist is not prepared to take the case on.

The therapist’s job in practical terms is to have the patient:
a) Engaged in the process of the assessment.
b) Acknowledging that there may be a problem with the way she is eating.
c) If possible become in touch with the fact that her or his dieting has indeed crossed the line of comfort.

Example:

Therapist - Your parents seem to be quite worried that you are dieting too much.
Client - I am just dieting. I eat. They worry too much.
-Parents generally do worry too much.
-Yeah.
-Why are they worried in this case? Are they not used to seeing you on a diet.
-Well, yeah, no, not really…
-mm. Can you explain it to me a bit more?
-Well, not always. I began dieting only seven months ago.
-I see; so they are not used to seeing you eat the way you are now…
-Right. They think I am anorexic.
-So, they are worried. Of course, anorexia is a serious disiease.
-I am not anorexic (defensively).
-But, they worry…
-Yes.
-And what happened seven months ago. What made you start dieting? You seem to remember clearly the date so I’m curious…
-Well…my boyfriend and I split up (sadly) but I don’t care anymore.
-It can be hard…
-It was hard. And also I was kind of fat so I decided to do something for myself.
-Began dieting.
-Yeah!
-You know, I work as a therapist so my job is to understand people’s worries and how their mind works so I can help them have the many feelings that human beings are able to have.
-mm… silence (patient looks intrigued).
-So, worrying is a part of what I need to understand. Were you worried when you and your boyfriend broke up?
-Well yes… I was so fat and he moved on to this skinny girl.
-Well, it is my experience in working with teenagers, but you can tell me if I am wrong, that teenagers worry about their looks and bodies. And maybe seven months ago, you worried too, and thought that if you had a different body your boyfriend would have not left you. Or, that being thin you could get another boyfriend, or the same one back.
-I’d be like the cool girls.
-I see…
-And when I began dieting everybody told me I looked great…
-and now your parents worry…
-Yes.
-There is nothing wrong with being thin (or fat). The problem is if in order to be that way you have to do a lot of things that keep you from having fun and being a normal teenager.
-Like what?
-Can you help me out? What are the things that keep you from being a regular teenager.
- (Patient becomes teary) I get up at 5AM to and there is a lot of foods that I am just too scared to eat, I can’t stop thinking… (patient cries)…

In the above case, the therapist followed the important principles of assessment that Dr. Schleshinger advises to use, such as to start where the patient is, not getting ahead of the patient, identifying with the fears of the patient, respecting and acknowledging that the patient is always right. (101)

In the above example, the therapist did not push the patient into acknowledging anything that the patient was not ready to acknowledge; moreover, the therapist sided with her patient about the topic of parents worrying too much; however, she ultimately helped the patient see that she worries too and normalized the feeling. By doing so the patient could open up.

Disappointments in relationships are in general, hard to take even for adults. Such disappointments are harder to take for middle school and high school students who are trying to define themselves in the world. For these youngsters the disappointment of a broken relationship may take in the meaning of being a failure especially, if the girlfriend or boyfriend moved onto dating someone perceived as cuter or with a better body.

Because dieting is almost a rite of passage for adolescents, as we have seen on page 38 of this course, (studies show that 50% of girls between age 11 and 13 believe they are overweight. (17) .By age 13, 80% of these girls have attempted to lose weight. (17) The adolescent that was dumped may intend to restore his or her sense of undamaged self by dieting. The therapist needs to evaluate the person’s sense of worth prior to the incident that propelled the dieting.

To make things worse, dating seem to be a thing of the past in this culture that is into immediate gratification and intense satisfaction. Many girls and boys these days no longer date. They hook-up. Hooking-up means having a sexual encounter with no commitment. The sexual encounter is oral sex, for the most part. Teenagers may hook up many times at the same party. Girls (for the most part) may have the illusion that the boy they hooked up with will continue a relationship with them.

Some feel bad and dirty after hooking up, but are not sure how to say no to something that has become the norm and the cool thing to do. Many of these girls may try to figure out a way out of feeling badly - by manipulating the way they eat.

In time, and with added information, the therapist will be able to figure out if this is the case, and if there is information that suggests that this sort of behavior was connected to the patient’s dependency needs that get transferred to the boyfriend. With enough information, the clinician may discover in time that this patient had other disappointments early in life with primary attachment figures, and that these disappointments resonated with this last abandonment. This could have driven the patient into an eating disorder that allowed her the illusion of telling herself: “I do not need anything or anybody other than myself”.

In the clinician’s attempt to engage the client in treatment, there are methods of helping the client see the connection between their emotions and feelings, and their problems with food and eating. One of the most straightforward of these is to look for areas in their life that they have more ready access to strong feelings, then link these experiences to what is occurring with their use of food.


Eating Disorders Factoid

Girls who diet frequently are 12 times as likely to binge as girls who don't diet.

Source: National Eating Disorders Association (Citing Neumark-Sztainer, D. I’m, Like, SO Fat! 2005, New York: The Guilford Press)


4 - Teasing followed by dieting or concern with physical appearance.

For the majority of adolescents, the disappointments and stresses of their relationships with peers is a ready starting point for making these kinds of links. Clinicians might be able to begin these conversations with offering the client an opportunity to talk about some of their social disappointments with friends or relationships in general. Or, if the client has acknowledged the presence of eating concerns, by linking in the other direction.

Example

A mom is coming back from school with her 7 year old son and his friend who is in the big-kid side. They are snacking in the back of the mini van. Mom brought two sandwiches and fruit to give them after the whole school day.

Child 1-Yumm, yumm
Child 2- I am hungry too.
- We’ll share, what do you want?
- What’s that?
- Fruit.
- Nah, I want the sandwich but my dad says too much bread is bad for you…
- Mom?
- Yes? (mom sees it coming and cringes)
- Is bread bad for you? Is too much bread bad for you?
- If you study too much or if you play too much it is bad for you. Anything you do too much is bad. Who told you too much bread is bad for you?
- My dad. Someone teased me at the school and my dad does not want me to eat too much bread and get fat.

Clinicians might need to know who their patient is, or at least who should be. Clinicians assessing children or teenagers need to be able to put at ease parents that might be anxious about their own experiences with body fat as children.

In the case above, the therapist might talk to the dad and asked him about his own experiences as a child. He might want to draw differences between his experiences and his sons’ so that the dad can see how they are not the same.

Lastly, the therapist might want to talk to the dad about the virtues of sound eating and exercising. He might give him some techniques to talk to his child when he discusses with him what “a lot of” means. The therapist might say “a lot of” is when the child feels stuffed. A lot of is when the child began eating an ice cream and was not hungry but felt that he had to finish it anyway because it is the last ice cream you will ever buy him.

Parents feel grateful when they are given guidelines to work with their children and the topic of food.

The mom in the above example did a good job at normalizing food and bringing the ‘too much’ food issue into the realm of all other things in life.

In a clinician’s attempt to engage a client in treatment, there are methods of helping the client see the connection between their emotions and feelings, and their problems with food and eating. One of the most straightforward of these is to look for areas in their life that they have more ready access to strong feelings, and then link these experiences to what is occurring with their use of food.
Clinicians might be able to begin these conversations with offering the client an opportunity to talk about some of their social disappointments with friends or relationships in general. Or, if the client has acknowledged the presence of eating concerns, by linking them in the other direction.

-“I don’t know what happened I just found myself eating one slice of pizza and then, the whole thing and then, I reached for the cookies, then, the ice cream, and then I ended up eating the batter from the pancakes just like that, not even cooking it. Then, I felt awful I was so full, and then I went and threw up! I said, I would never do it again, but I just did, this is hopeless. I am not sure why I am even coming here…it’s like a whole mess…
-“May be, we can make sense of what happened and then, may be it will not feel so hopeless, such a mess…let’s see…Let me ask you a few questions. Yes, feelings can feel messy, but that is until you organize them a bit. Did you know you were going to binge before you began eating the pizza or it just happened?
-Kind of…, like vaguely, now that you say so… it was just, not planned, but I was feeling edgy.
-I see, what was happening before the pizza…
-Well, Melanie and Lauren came over and Justin was there too. Remember I told you I thought Justin liked me? Well, he was like all over talking to Lauren and then when they left I was cleaning up and began to eat and you know the rest.
-You have a right have feelings about what happened, sounds that at the very least you were disappointed. Looking back do you know what feelings were you having at the time?

More specifically, clinicians may also want to be on the lookout for episodes of teasing or conversations about physical appearance among teenagers. Many eating disordered patients immediately - and unconsciously - move any feelings they may experience into the arena of body-size and eating.

This self-protective maneuver creates a serious and self-propagating problem for the client. It prevents the client from working on and developing better skills in handling complex feelings. The deficits in this ability to handle more complex feelings then cause the client to feel more overwhelmed when problems arise in social relationships. The feelings of being overwhelmed then turn into a stronger focus on concerns about weight and eating.

Part of engaging the client in treatment resides in the ability to break this vicious cycle, and in giving the client hope that skills in handling more complex feelings can be successfully acquired. The automatic looping to a focus on food and eating must ultimately be broken, and the client made aware of his or her tendency to do this.

To help make this linkage, clinicians might want to ask the patient to ‘replay’ slowly in his mind the events prior to the binge. This can be followed by education and other techniques to improve the skill sets required to handle complex feelings.

This approach can help the client connect feelings with food , but can also be used to make connections to other aspects of eating disorders, such as with exercising, or even with the experience of being too fat.

-Can you tell me what you were feeling as you were exercising so much? I say so much because you told me that you almost passed out.”
-I am not sure.
-I know you are not. After, all, it is difficult to think backwards. Do you think you could just kind of give it a try, even like, make it up?
-Well, I was feeling shy. I wanted to talk to Jessica yesterday and I could not. I was embarrassed so I began talking to Laure. And then, we left and I realized I had not talked to Jessica. And then, I just went to the gym and began pumping iron. I want to make the weight.
-So you went to the gym after you could not talk to Jessica?
-Yes.
-How did you feel when you were lifting weights?
-I felt powerful, I felt like I could do it?
-Do you think it is related to not being able to talk to the girl you wanted to talk to.
-Yes, I guess it is.
-Maybe we can talk about the many ways in which you already are powerful, or ways in which you may want to feel more secure.

5 - Increased time spent in sports to the detriment of other activities.

Some patients who will develop an eating disorder start their descent into an eating disorder by gradually exercising more and more. This form of unhealthy exercising may, at first, be hard to detect. It might look to parents and coaches that the person is ‘just training hard’.
A clinician interviewing an anorectic or a bulimic person might want to ask about his reasons for exercising. The clinician might want to ask about the length of time that the person spends at the gym, his or her thoughts while exercising, and the motives for exercising.

When the motives and the thoughts revolve around fat, and burning fat calories, a red flag needs to alert the clinician about exercising as an unhealthy way to manage weight.

Although there is not a formal DSMR diagnosis for it, mental health professionals are talking about anorexia athletica - when patients exercise in such a way that exercising has taken a life of its own at the expense of other areas of the patient’s life.

Such patients may come into therapy when, after an injury, they cannot exercise in the same way they are used to. Because exercising was a defense against feelings, thoughts and ideas, when they cannot longer do it, their main mode of defense is taken away from them.

These patients may be professional athletes, coaches or dancers. Without being able to exercise they may feel overwhelmed with anxiety and guilt. They may feel that they are not doing what they are supposed to keep up with their physical selves. Sometimes - since this has been their career - they are not aware that there are emotional issues attached to the way they have been using their bodies.

Example:

Therapist- Maybe you need to decrease the hours you are teaching the advance ballet-Jazz-Modern classes?
Patient -I am not sure what you are talking about with me teaching; I am a dancer, which is what I have been doing for twenty years and I need to make money.

In the above example the therapist said something that made the patient too anxious and therefore did not move the process of therapy forward. Because she suggested that the patient moves in a way incongruent with her feelings about herself, the therapist did not meet the patient where she was. The patient reacted annoyed and not even knowing what the therapist even meant, so foreign the concept was to her.

Therapist - I see. I understand. You are right about you being a dancer at the core and also it is your job, your livelihood…
- And now I have this knee thing and I cannot dance, that’s all there is to it. I feel awful.
- You have been doing your dancing for so long it is a part of you, it is you.
- Right. How would you feel if all of a sudden you could not be a therapist? And by the way, I am not even sure why I am here.
- I probably would feel awful too, if I could not be a therapist. It is also a part of who I am. Dancing is who you are…
- Yes!
- But, sometimes, our work cannot be all we are; even when it is. It seems to me that since you so love dancing and dancing is so in your blood, if you don’t have it, it seems to you, you don’t have you. Maybe you came to see me to find the you, you are, even when you are not dancing. After all it is inside YOU, whether you move or not move..
- hugghh.. .( Patient looks a bit surprised and shaken)
- Maybe, all we need to figure out here together, you and I, is what are the feelings that you have about yourself when you cannot dance, how that prevents you from feeling yourself; and also, how you can move your body without injuring it so you can still move some and be you, all at the same time.

The patient calms down and is intrigued and willing to look at this new idea of how to do things, at least for this session.
Where there is not too much resistance on the part of the client, the clinician may wish to engage in some gentle education. Clinicians may want to discuss the limits of the human body and exercising as a pleasurable activity that allows the body to feel alive and good.

This may allow entry into some discussion around the ways in which the client uses her body in a disconnected way, as if it were a separate ‘thing’ to manipulate. The movement that is hoped for here is for the client to be willing to consider her own desires to have a full and pleasurable life, instead of using his or her body to comply with the standards of perfection that are being imposed upon the body.

Of course, many patients have a negative and avoidant relationship with exercising, too. These patients refuse to do the minimal amount of physical movement. This can be seen in binge eaters and obese patients who are or are not binge eaters. In these cases the therapist may need to deconstruct with the patient the meaning of her hate towards physical movement.

Client - I hate exercising, forget it. I was at the cardiologist and he told me I need to, must do some walking. I hate it. I will not do it.
Therapist -You hate it.
- I do! I will not do it.
- Ok, you don’t have to, it is your choice
- But, I have to. I have to. It is a health thing, not even looks.
- I see. You have a dilemma. You have to do something you don’t want to. And even if you hate it, you should but you don’t want to.
- Yes,
- And you don’t seem to think that not wanting to, lets you off the hook. But at the same time you don’t want to.
- Right, right (the patient now looks less defensive and probably feels understood)
- So why instead of focusing on the fact of you hating to exercise, which you do. Or you having to exercise which is what you have been told to do why don’t we focus on why is it that you hate it so much.
- Well, when I was a kid during gym at school…

In the previous case the therapist helps the patient get out of a stand off with his medical doctor and the prescription of having to exercise and moves onto trying to figure out the reasons why this patient does not want to move. Probably in this patient’s past the therapist may find out about teasing or about rigorous schedules of exercising that left the patient feeling as if he cannot enjoy his body.

Because resistance is so high with many eating disordered clients, the assessing clinician needs to have enough skill and wisdom to avoid driving the client away from treatment as these important signs and symptoms are being addressed.

While the assessing clinician does not need to have the full set of skills that an experienced clinician in the field would have, he or she does need to have enough of a background to know how to build motivation for change and commitment to treatment or at least to get things moving enough so that he can know that the client needs help with an eating problem so he can refer her or him to the appropriate person.

In this case the clinician was skilled enough as a general practitioner to help the client get unstuck from a pattern of no moving-no exercising that was pernicious to his health. If the therapist does not feel prepared to deal with the body image and food issues that the client may bring she must tell the patient so. The wellbeing of the patient is always the therapist’s priority. The clinician must inform the patient.


Eating Disorders Factoid

35% of "normal dieters" progress to pathological dieting.

Source: National Eating Disorders Association (Citing Shisslak, C.M., Crago, M., & Estes, L.S. (1995). The spectrum of eating disturbances. International Journal of Eating Disorders, 18 (3)

6 - Increased effort in perfecting the mastery of school work.

Clinicians doing an assessment should find out if the client is putting a lot of effort into perfecting school work. This information is important because, in general, at the beginning stages of an eating disorder the patient may be spending a lot of time involved with and consumed with food issues.

However, at the beginning of an eating disorder, the patient is still functional enough and is usually able to keep up her or his grades - since the disease has not taken a total toll on the body yet. Nevertheless, patients in this situation may take more time to finish their assignments - because they spend a lot of time worrying about food and calories or weight and body image.

Clinicians interviewing or assessing patients need to find out how has the patient managed to maintain grades. The therapist may openly ask the patient - or his/her parents - if work is taking a long time to be finished, or at what time does the patient work until in order to be done with school work in the evening. The answer to these questions may prove to be the beginning of an enlightening conversation about where time goes, and what it takes to get school work done.

7 - School work declines.

A clinician might want to assess if her patient is trying to perfect her work at school at all costs: not getting enough sleep, pursuing perfection, exhausting herself. Since the need for perfection is a red flag, the clinician may want to assess how these teenagers deal with their school work.

From a diagnostic standpoint, this can be red flag indicating that the client’s brain is literally not getting the nourishment it needs, and/or that too much time is spent in eating disordered activities. This realization may be a useful piece of reality that the patient cannot deny.

As noted in the previous section on exercise, the conversation that will be aimed for will have to do with the objectification of self, as opposed to pursing goals that support one’s healthy purposes. The child who is attempting perfection with his or her grades is simply choosing another venue to express the drive to perfection. In the process, he or she is devaluing the needs and wants of the self in order to comply with extrinsic standards of perfection.

On the other hand, the child who is so wrapped up in his or her eating disorder that it is beginning to affect his or her major life roles is forfeiting a different way of valuing the self in his or her quest for physical perfection. The conversations will still need to turn to more positive ways of valuing the self.

Unfortunately, when the patient is in the grips of an eating disorder nothing - only staying ever thinner or losing weight - is what matters. It is at this stage that grades can suffer and, unfortunately it is sometimes only at this stage that parents finally realize that something is wrong.

Therapist - It seems that one of the things that have happened to you lately is that your grades have gone down.
Patient - It happens to everybody and besides I don’t care anymore.
- Yes, it happens often that grades may go up and down. After all, school can be demanding and difficult.
- I guess.
- But, you were an A student so your parents have been wondering why your grades have gone down so dramatically.
- I already told them the reason. Things are difficult.
- I know they are. And they know it too. But, it seems to me that things have been difficult for you in more than one way.
- What do you mean?
-Your parents have been called by the school because the school seems to be worried about you too.
- They are all exaggerating…
- What do you mean?
- They think I don’t eat.\
- Oh…
- I do.
- Mmm…yeah, so…?
- So I just don’t want to gain weight.
- I see…
- That’s all. I don’t want to be fat.
- So, is it true that you fainted last week?
- Yes, I was tired.
- Of course you were. It seems to me that you have been trying to get those grades up.
- Yes, I have.
- It is hard to do when you have so many things in your mind and you are so busy.
- Yeah.
- Sometimes, trying not to be fat is a job in itself.
- It is.
- And that is I think why your parents are so worried and so is your school. And that job, the one of keeping thin, at times, is not a pleasant one either; it’s a lot of work.

The patient finally opens up and talks about what she does to keep thin.

In this vignette we can see how the clinician can use the information she has about the patient that is not directly given by the patient to gear the conversation toward disclosing her eating disorder - without making the patient feel ashamed and while respecting the level of secrecy and privacy that the patient is bringing into the session.

By talking about staying thin as a job (as opposed to as being sick) the clinician might get further in the process of making the patient aware of her own dynamics than by ‘accusing’ the patient of having disordered eating thoughts and behaviors. Even if the clinician does not “accuse” the patient, she or he may feel that way anyway.

8 - Increased time spent in isolation, at home or at school.

Many patients are not forthcoming with the fact that they spend a lot of time in isolation counting calories or exercising. Patients that exhibit anorectic behaviors spend a large amount of their day exercising or counting calories. Bulimic patients spend large amounts of time purging or bingeing or buying laxatives or diet pills and exercising.

If one has clues that an eating disorder may be present in a client – or that the patient is crossing the line into disordered eating - this sign or symptom may suggest that the eating disorder has reached a more advanced stage. The patient is now engrossed in himself. The eating disorder has taken a life of its own, and has encroached on more of the client’s life.

Therapists might need to confront the patient with the fact that they are spending great portions of the day alone.

Patient - I did not do anything this weekend. I was just at home.
Therapist - mmm…How come?
- don’t know, I guess I am a loner. Or there is nothing to do. I just stay home.
- A loner?
- Yeah.
- Interesting, I would not think of you as a loner. A loner might enjoy his time alone a whole lot. Do you?
- Well… I spend a lot of time alone.
- Do you enjoy it?
- Hate it. You know I hate it. I start a regular dinner and then by the end it, it becomes a binge. Kind of… I eat my diet dinner and then I have to eat something sweet …and then…, I eat something sweet again… and then just who cares anymore? And next thing I know the whole box of cookies is gone and then it is the cake and (patient starts sobbing) I am such a pig! It’s disgusting! I hate myself. I had another binge Saturday evening (still sobbing).
- …(Therapist feels the patient’s pain and gently says )..so tell me… what was happening right before you began binging? Did you just stumble into eating that way? Had you known you were going to binge after the first sweet thing? Just remember that each binge it is an opportunity for us to learn about you.
- Well, I was going to go out but then, I decided to stay home and …nothing…
- Well, it is probably important…
- Well, I decided to stay because I did not want to go out with my friends and eat. So I decided to stay. They were going to go for pizza.
- Interesting. So you decided to avoid going out so you could avoid eating…
- Yeah..
- And then, you ate even more than if you had gone out, isn’t that an irony?
Maybe when you deprive yourself a very healthy part of you rebels and says “I am not going to live life as a person in a cage, I want connections, I am not a loner, I want food and people”.
- I guess you are right.
- Maybe next time we need to talk about strategies as to how to eat when you are out with friends …
- Yes, we do…

9 - Increased interest in cooking or collecting recipes.

This point may mean a more advanced stage of an eating disorder. The patient features the symptom of turning away from her own needs and desires.

The therapist dealing with this patient might want to point out at how we live in a culture that praises self-denial and sturdiness in many aspects while self-indulgence in others. The therapist might want to ask the patient his opinion on the matter of self indulgence and self-denial. The therapist might also ask the patient if her dreams about food or thinks about food all the time. The therapist may want to inform the patient about the meaning of thinking of food daily and about how food deprivation brings obsessive thoughts about food.

Some patients who develop anorexia nervosa become very interested in collecting recipes. The clinician that is assessing or treating someone’s with anorexia nervosa may want to point out to the patient that it is interesting that she or he is so interested in the foods that he or she, denies to himself. He may also want to inform the patient food and recipes are a common concern for those who cannot eat.

The conversation may turn into pointing out how it is much more safe to talk about food that to eat it. Patients and therapist may also talk about the desires and wants that the patient is ignoring in her or himself. Those needs and wants are fraud with fear.

The therapist and the patient can talk about how wanting something (anything) is too much beneath what the patient expects of himself. Food is the one thing she can deny himself and feel above everyone else.

Therapist- Isn’t it interesting that you love collecting recipes?
Client-What’s wrong with that?
- Nothing, nothing at all.
- So?
- I just find it interesting that you collect recipes but you refuse to eat what those recipes show.
- I eat.
- Well… you do eat but, you need to make sure of a lot of things before and after you do eat, when you eat.
- Yeah…
- It is not free eating, eating with no worries.
- No., but I eat…
- I know you do, under these circumstances you do eat, at least enough to be here right now without fainting, which for you it is a lot..
- Yes.
- But there is so much suffering going with it. Such a contrast with the happy colorful recipes you collect, as if the recipes were… They kind of represent what you want but you don’t allow yourself to have…
- If I did I’d gain weight…
- Maybe yes, maybe no. We really do not know how you would eat now, if you ate normally. The point is that you have wants and needs that you think if you gave in to them it be a disaster.
- Yes. I’d eat a lot if I ate.
- Maybe yes, maybe no. But, you feel yes. You feel all your desires are a lot, too much; maybe like you felt it was wishing to go to Harvard before getting sick…

 

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