ABN8595 - SECTION 9: HANDS-ON EXERCISES FOR PATIENTS SUFFERING FROM BN, AN ED NOS AND BODY IMAGE PROBLEMS
Many times patients suffering from body image distortions, eating disorders, or eating problems need to "hold-on to something therapeutic" between sessions. Sometimes, these patients benefit from doing hands-on exercises between sessions.
In my book Mujer-Cuerpo, Dieta: La Voz de la Obsesion, I created some exercises that could benefit a certain subtype of patients to become more comfortable with their body.
Experience indicates that psychological, hands-on exercises are more effective if patients create a relaxed mood when doing them. The first step, then, is for the patient to create a relaxed ambience for herself or himself before she begins the exercise.
These exercises are not just a relaxation technique; they are a way to enter into the thoughts and feelings of the patient. They may serve as a tool for professionals in the field, a springboard to certain topics, feelings or thoughts.
The Voice of the Obsession
Your patient is torturing himself. He thinks his abdomen is not toned enough. She believes she is too fat. The Voice of the obsession is berating and humiliating your patient.
The Voice of the Obsession is a familiar voice to many eating disorder patients. It would be an illusion to believe that just because the patient has come into therapy the voice of his obsession will abate. This exercise’s objective is to transform the voice of the obsession from one that berates the client into a friendly voice that alerts the patient that ‘something’ inside of her requires supportive attention.
As a mental health professional, you can first help your patient figure out exactly when the voice of the obsession has begun to berate him or her. Help him or her locate the moment. What was going on before he/she began thinking he/she was fat? Ask him/her to play the events surrounding the beginning of him/her berating him/herself, in detail. Maybe he or she can locate the moment, maybe not.
What is important in this context is to understand that The Voice of the Obsession is talking. Your patient needs to hear the voice out - and take care of it. The Voice of the Obsession is trying to say something to your patient. What is it?
Ask your patient to do the following:
1) Breathe a few times until he or she feels the tension is leaving his/her body.
2) Realize that the voice of the obsession is at work.
Your patient needs to realize that, once again, he/she is torturing him/herself. Whether your patient has, in reality, eaten or not, binged or not, purged or not, the truth is that he/she is now torturing herself. Your patient needs to come in touch with that fact that he/she is mentally torturing him/herself - without further berating him/herself for the act of berating him/herself.
3) Play the last few hours in her head to get clear about when exactly he/she began to torture him/herself. What prompted the self-attack? The trigger for the self-berating could be a conversation (with another person or inside his/her head), it could be a thought, a feeling, a conversation inside his/her own head, with him/herself, a smell, a certain thought, Was it prompted by eating something ‘forbidden’? Was it prompted by not following a certain rule about exercising?
4) Your patient needs to remember the feelings he/she felt before beginning to torture him/herself with the topic of food, eating and body. What was he/she feeling before he/she began to torture herself?
You can model for your patient letting him/her know that feelings are acceptable. You can and go down a list of feelings. He or she may not be used to thinking of these feelings. They may be too forbidden for him or her to accept. You can ask your patient if he/she felt:
Patients with eating disorders may have a narrow window of feelings they accept. Envy or tiredness may be feelings that they don’t recognize in themselves.
5) Ask your patient to suspend judgment.
6) Ask your patient to try not to be afraid of his/her own feeling.
He or she needs to congratulate himself for having found those feelings inside himself. He or she needs to congratulate him/herself for having been able to put them into words.
7) Ask your patient to reflect for three minutes on why those feelings sent her running into the voice of the obsession. The voice of the obsession acted like refuge for your patient, a refuge from more real feelings.
8) Your patient can decide whether to talk about this exercise with you or not during the next session.
Sometimes, patients cannot locate an exact moment when they started to self-berate. In such a case they can still do the exercise without exact knowledge of the time.
9) When your patient feels that he/she has gotten what he/she needed from the exercise, he/she can go on with her day, feeling, hopefully, relieved from psychic pain.
Only a subset of patients will agree to this exercise about tossing the scale. Some can do it only after being in treatment, for some time.
The scale is a very precious instrument that lives in patient’s homes; for some, for many years. Although it is a precious instrument for the patient, it is a torturing instrument as well. To abandon this instrument is not easy. It allows for illusory control. However, to achieve a healthy relationship with food it is important to be free from the slavery of the scale.
The goal of this exercise is to discards the scale from the patient’s life.
1) Ask your patient to relax.
2) Ask your patient to remember all the instances in which the scale had been an important tool for him/her. When did he/she star using it? When did he/she start weighing him/herself daily? Are the memories pleasant? Are they not?
2a) Your patient throws the scale away.
3) Ask your patient to write all the feelings and thoughts and ideas he or she might have. Does he/she feel relief? Does he/she feel fear? Ask your patient to target especially all the negative emotions he/she might feel.
4) Your patient needs to remember that the scale has never helped him/her not to eat compulsively, binge, starve, or purge. He/she needs to remember that the scale has not helped him/her ease his/her concerns about weight and body image – at least not for long.
(If your patient wants to throw the scale away but is unable to, you can plan a certain date for it. Your patient might also feel better putting the scale away in a certain box in the attic, instead of tossing it, altogether. This, of course, is fine too). You can help your patient create a ritual for the tossing of the scale. After all, the scale has been a ‘friend’ to your patient for a long time, not a good friend, but a friend.
5) Your patient needs to write now all his/her positive feeling about having tossed or put away the scale: Does he/she feel happy? Does he/she feel free? Does he/she feel exhilarated?
During the following days your patient and you might monitor his/her moods and his/her self-states. It is important that the patient notes what’s going on. Scale weighting can be an addiction, and like all addictions, it is not an easy one to break.
If your patient’s addiction to the scale is relentless, do the following:
1) Ask your patient not to change any of his/her ways during the first week of this exercise. Patients should weigh themselves as they desire. However, they need to write down how many times they use the scale per day-night period of time. This may be done for a week. No corrections need to be made. It is what it is. They weigh as many times as they do.
2) During the second week ask your patient to guess what the scale will say and note it next to the recorded times of his/her weighing. Is he/she accurate in her appreciations? He/she needs to note if he/she is or isn’t and needs to note his/her feelings about it.
3) During the third week your patient needs to stop and reflex=ct. Has she been accurate in her guessing? If she has why does she need the scale? If she hasn’t what has the scale changed for he, when she read it?
Your patient and you may look at the log that your patient created. What is he trying to find in the scale number?
4) Your patient needs to write his/her motivations and motives for wanting to weigh him/herself; and to hold on to the scale.
5) On the fourth week, looking at how many times he/she weighed him/herself during the first two weeks, he/she and you may want to decide how much he/she feels comfortable cutting back.
If your patient weighed him/herself eight times a day, he/she might want to go to six or maybe five times per day.
6) Again, he/she needs to record what he/she thinks he/she weighs and what he/she actually weighs. This will be proof that:
- A) He/she already knows what she weighs or that,
- B) He/she can feel thin when the scale doesn’t show it or, fat, when the scale says thin.
Your patient needs to cut back in weighing him/herself weekly unless he/she needs to go more slowly.
7) On week eight, your patient might keep cutting back and writing - or decide to finally put away the scale.
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