ABN8595 - SECTION 7: THE THERAPIST'S ROLE
When addressing eating disorders, mental health professionals may face a complicated array of roles. The mental health professional who works with eating disorders may have to address simultaneously, or sequentially -depending on the needs of the moment - the patient in question and the family in which the patient lives.
The mental health professional may need to provide emotional support and guidance to the parents of the eating disordered patient. Simultaneous with lending support to the family, the therapist may be trying to engage her patient into entering into a working alliance. Even the clinician whose task will only consist of assessing the ED client and making a successful referral to an ED specialist will need to be able to engage in the balancing of these different roles.
The therapist’s goal in establishing a working alliance would be to establish the proper context for the patient to feel comfortable. The patient needs to know that the goal of the therapist is to be helpful, not necessarily to strip her or him of his eating disorder, in one sitting. Eating disorders have adaptive functions.
If patients believe that the mental health professional wants to rid them of their eating disorder they may resist and not come back for treatment (especially in the case of the private practice practitioner). If the patient feels that the therapist is interested in the patient’s experience and pain - instead of in removing the problem – he/she may be more inclined to enter into therapeutic alliance.
The context needs to be one of proper trust and appropriate dependency. This context will allow patient and therapist to develop a therapeutic alliance. Once this is done, the patient and the therapist can begin to work unraveling the multiple meanings of the eating disordered behavior, thoughts and feelings.
The mental health professional needs to figure out, as well, what are the most pressing health issues for which this patient might need attention right away.
As mentioned before, many times clinicians are initially contacted by the family of the patient. Clinicians in this situation are asked to educate the family while understanding the tender predicament the family is in.
While some families welcome information and want to understand the dynamics of an eating disorder, others only want relief of symptoms and nothing to do with the treatment.
Eating Disorders Factoid
Fathers are important in influencing their daughters towards bulimia, particularly fathers who themselves wanted to be thinner.
Source: Reuters Health (Citing Agras, SW, Study conducted at Stanford University)
Due to a better understanding of eating disorders, we now have available better ways of addressing patients and their families. There are more effective assessment tools and techniques, which in turn allow for better treatment.
A comprehensive assessment done by the competent clinician will need to include:
A) History of body weight
B) History of body dissatisfaction
C) History of dieting
D) History of behaviors intending weight control and the control of physical shape
E) Assessment of patient’s self-perception including, a history of changes in self- perception
F) Assessment of patient’s personality and, a history of psychological functioning. This psychological history needs to include checking for anxiety, depression, suicidal ideation, OCD signs or symptoms, sexual abuse, substance abuse and use of drugs to induce weight loss. It should also include getting familiar with the changes that the eating disorder may have brought on the patient’s basic personality.
The mental health professional will be in a different position if she or he is a member of a team in a hospital or at an institute that specializes on eating disorders than if he is in a group or solo private practice. In the first instance the mental health professional will have available to him or her the information gathered by other team members, such as the psychiatrist, the psychologist, the intake nurse, other nurses in the unit if the patient is hospitalized, as well as the treating medical doctor.
On the other hand, as a solo practitioner, the treating professional would need to have in place ongoing resources and a referral system to provide the patient with specialized care and services.
A mental health professional needs to assess an eating disorder patient fully. In order to perform the assessment, the professional may utilize many tools. Some professionals utilize them all, while some others use only some of the tools in this list to make the assessment.
A) Individual face to face interview
B) Family interview
C) Self-administered questionnaires
E) History of Family Functioning (how has the family of the patient functioned as a family), past and present.
F) Stressors: past and present.
G) Medical History
During this assessment the mental health professional needs to assess the patient’s mental health individually, as well as the patient's functioning as a family member and his/her ability to have and maintain friendships.
One key topic to clarify with patients at the beginning of treatment is goals. Some patients come to treatment with goals that are not therapeutically indicated and with which a therapist cannot comply. The patient’s stated goals may be substantially different from those of the mental health professional.
A patient may want to learn how to eat food with less fat content. He/she may want to learn how to purge in a more efficient manner. He/she may want to find out how to endure more time without eating. Patients may want to learn how to lose more weight or exercise more.
Nevertheless, the patient may not state these more unhealthy goals quite so frankly and directly. They may exist as part of a hidden, personal agenda that the patient partially or completely withholds from the therapist. The therapist may find out in the course of a couple of sessions that what the patient wants is not weight restoration or freedom from purging. Although virtually all eating disorders endure suffering and want relief from the suffering, many patients may not be able to clearly state a goal for their therapy, past the fact that they have been brought in by family members.
However, patients - sometimes using some help from the mental health professional - will readily accept that they want to be less obsessed with food, body and weight. Being less obsessed with food, weight and body shape is definitely an important goal to have. Mental health professional and client can hold on together to this goal. Many times, this goal is the first purpose that the client and therapist share together within the therapeutic partnership.
Sometimes patients come to see therapists and state there is no way they would gain any weight, even if their current weight is extremely low - or even if their lives depend on it. This type of resistance is a common feature to eating disorders, and represents one of the greatest dangers and difficulties.
One way of bypassing the resistance that many patients suffering from eating disorders feel about weight gain (while beginning to establish a working alliance) is to let patients know that as a clinician, the professional understands the difficult predicament the patient is in: not wanting to gain weight and being told that that is what she/he needs to do to be cured from an eating disorder.
When a clinician is performing an initial evaluation of an eating disordered client – with the goal of making a successful referral and transfer of care to an eating disorders specialist – it is not always either necessary or advisable to create detailed treatment goals with the client. The goal can simply consist of a plan to have the client meet further with someone who is better prepared to address the client's concerns.
However, with clients who are profoundly resistant, the point of transfer is a particularly dangerous time, since it is a time when clients may use the interruption in treatment as a convenient reason to remove themselves from treatment. Therefore, it can sometimes be very constructive to help a client recognize a set of positive goals that can be accomplished in treatment – in order to increase the client's wavering commitment to addressing the problems. These treatment goals must be presented as somewhat provisional in nature, and must also be carefully framed to align with needs and wants that resonate positively with the client.
Eating Disorders Factoid
The odds of engaging in unhealthy weight-control behaviors such as fasting, skipping meals and smoking more cigarettes was double for adolescent girls who were the most frequent readers of magazine articles about dieting and weight loss, compared with those who did not read such periodicals
Source: MedlinePlus (Citing a 1999-2004 study conducted at the University of Minnesota)
In making a determination of whether to pursue or defer the creation of treatment goals, the assessing clinician must weigh a number of factors. The client's level of resistance must be carefully considered. The client's ability to align with the goals of positive change must be examined. The presence of external sources of pressure and support – from family members, for instance – must be factored in.
Additionally, the clinician must be cognizant of his or her own skills or limitations in presenting treatment goals that will support motivation for treatment, so as not to make errors that decrease motivation for treatment. The treatment goals must be presented in a way that increases hope on the part of the patient that the distressing aspects of the client's disorder can be helped, without excessively evoking the fears of the client about becoming "fat" or losing the emotional protections that the eating problems represent.
The second part to bypassing the resistance to weight gain is - with medical clearance of health issues - for the therapist to contract with the patient. (Medical clearance is a must. Medical clearance means that the medical doctor in charge of the case sees no immediate danger in the patient having a weight agreed to in a contract, even the low weight likely to be acceptable to the client.)
Even if the weight in question would not be a healthy weight to maintain long-term, it should be healthy enough that beginning work can be done without the patient being physically endangered.
In such a contract, the patient would not be asked to gain weight - at first.
She or he would be able to remain at the same entry treatment weight, provided that he or she does not drop any more pounds. Therefore, what will be defined in the contract is an agreement that the patient will not drop any more weight.
Again, the clinician in an assessment and referral role may not necessarily become involved in this aspect of the overall treatment plan. However, it is helpful for the assessing clinician to be aware of the role of a contract in the overall treatment strategy.
Furthermore, clinicians must be aware that some clients will engage in complex bargaining behaviors as they sort through their ambivalence about treatment. They may threaten to leave treatment if they have the sense that "unreasonable" demands will be placed upon them in terms of the weight they must be and the calories they must take in to meet that weight.
For such clients, the clinician in an assessment and referral role may find it helpful to establish agreements with the client in the form of a contract. This preliminary contract may not tackle the weight and caloric intake problems as thoroughly and directly as the ongoing treatment team, but might begin to familiarize the client with the use of contracts within the treatment process.
Again, it is important for the clinician to be comfortable and skilled in using contracts within the treatment process as a precondition for employing this sort of strategy from the assessment and referral role.
When a contract of this sort is used within a comprehensive treatment plan, the patient will be followed medically - daily, weekly or biweekly - according to what is established by the doctor. The clinician and medical doctor will be in close contact throughout the treatment. If the patient cannot maintain the lower expected weight she came in with, and agreed upon keeping, other medical measurements would need to be taken.
These medical measurements are not a punishment for the patient. Of course, this will need to be made clear to the patient by the treatment team. It needs to be clear in a non-threatening matter that the medical measurements to be taken (a certain nutritional value that he needs to ingest, tube feeding, etc.) are a safety measure.
However, sometimes a patient’s weight is so low that the professional does not have the luxury to contract with the client. The client simply cannot stay at such low weight. In these cases, what can be contracted is the second less good alternative, from the patient’s point of view.
When the weight of the client is so low that imminent risk or client incompetence is evident, then the clinician in an assessment and referral role has an easier task in terms of what needs to be done. The client will need to be evaluated for involuntary hospitalization.
When imminent risk or incompetence has not been created – but the client insists on remaining at a weight that is not permissible – then the clinician is in a much more difficult position. In such instances, the contracting within treatment will lead to an outcome where the patient needs to accept that she will have a base weight that is not her preference.
However, it is considered a wise idea by those who believe in this approach to involve the patient in a discussion in deciding the maximum weight tolerated and accepted by the patient (assuming it is a weight that is also accepted by the physician). When this is the approach taken, the patient should not be forced much beyond that number.
The reason why it is wise for the patient to be involved in this decision making process is that in the long run, this involvement allows patients to feel more in charge and less ‘done to’. Not only does it help the patient learn to manage her body and her weight, but also teaches patients that taking part in their recovery is welcomed and crucial.
Eating Disorders Factoid
Research on interrupting the binge-eating cycle has shown that once a structured pattern of eating is established, the person experiences less hunger, less deprivation, and a reduction in negative feelings about food and eating.
Source: NIMH (Citing Apple RF, Agras WS. Overcoming eating disorders. A cognitive-behavioral treatment for bulimia and binge-eating disorder. San Antonio: Harcourt Brace & Company, 1997)
The clinician in the assessment and referral role may be the first experience that the eating disordered client has with a mental health professional. The choices made by that professional will inform the client of what he or she may generally expect in the treatment process. Respect for the client's autonomy and involvement of the client in all aspects of decision making – including in contracting – can therefore be seen as important components of a successful foundation for treatment.
Ultimately, patients who are cleared by a medical team to stay in a low weight as a beginning strategy may be better off on the long-run. These patients may not only see the therapist as more caring and cooperative (which will strengthen the therapeutic bond), but also may feel less defensive, and more ready to cooperate during the next face of treatment, when there is a need for gaining some more weight.
However, some treatment approaches and mental health professionals do not allow for this choice at all. The referring clinician should be aware of this possibility as they provide information to the client during the referral process, and try to prepare the client to maintain a flexible attitude in responding to the treatment plan as it is developed over time.
Clinicians who work with eating disorders may have a variety of different approaches. Some may use a behavioral approach in their treatment to patients. Others may use a behavioral-cognitive approach; some clinicians prefer a psychodynamic approach. Some yet are more eclectic in the way they treat their eating disordered patients.
For behavioral approaches to eating disorders, the first priority with an anorectic patient is weight restoration. (29) More often than not, patients are asked to gain weight as soon as they enter into treatment. Then, when they are not at a dangerous weight, they are asked to follow a behavioral approach in their treatment. In these kinds of treatments, patients need to follow certain rules and behaviors around food, eating, and/or purging.
According to how they follow the rules and according to how they respond to treatment, patients under this approach gain or lose privileges. The inpatient units (if the patients are hospitalized or at the institution where they provide day hospital programs) have certain requisites of how much patients need to eat or gain every week until they are discharged and after discharge time.
When patients see a private practitioner who uses a behavioral approach, they may have to fill out logs and follow a certain program for weight gain. Whether weight restoration is the first order of things to take care or not, it depends on the specific approach of the therapist or, the treating team.
Whether weight restoration is a first order of events or not, all people affected with AN need to, ultimately, restore their weight to a normal level, to be free from the disease. We do know that an abnormal low weight interferes with physiological functions of the brain and, other organs, too.
All patients suffering from eating disorders also need to repair their personal relationship with food. Food needs to become a normal part of life, not a part of life to be feared and avoided. In the case of patients suffering from BN, the behavioral approach and the cognitive approach, too, point out that the first - and possibly most important - thing to do for the patient is to help him or her quit purging.
The cognitive behavioral approach to BN maintains that it is the purging that allows patients to become entranced in a cycle of bingeing followed by more purging behavior. This cycle becomes perpetuated. Bulimic patients that will not find an easy way to purge may be less likely to binge, say some mental health professionals in the field. Mental health professionals using a cognitive approach confront their patients with distorted thinking about their weight and about their physical shape.
Eating disorders patients, more often than not, use many distorted ways of thinking. In doing this, they create fertile ground for bad feeling. Patients who use distorted ways of thinking might over generalize, use catastrophist thinking, dichotomous thinking or make inferences that are just not true.
These patients may conclude that they will gain weight if they don’t exercise daily, which means absolutely every day, or twice a day. Skipping one day may feel catastrophic for them. They may also assume that people who do not exercise tend to be fat and, therefore they must exercise - and do it everyday.
Similarly, they may also believe that if they eat one normal meal (not to say half a cookie) they will loose total over their food intake. They may also conclude that if they eat one cookie they might as well eat a whole bag. There is no middle ground, there is only perfection.
Mental health professionals using cognitive restructuring need to teach their patients how think differently. Cognitive restructuring is important. Patients learn more realistic, less rigid and more fluent ways of thinking when they work with a cognitive approach. If patients are going to learn how to perceive and interpret the reality of their bodies, their eating and their looks in a different way, they may benefit from some cognitive restructuring.
Patients also need to learn to deal with their feelings when they have a ‘fat day’. When they have such a day, the mirror is not the place to seek reassurance. Patients also need to learn that when they do feel fat, chances are that there are unconscious feelings preempting their perception.
Even patients who are fat or obese must learn that feeling fat is not only about body size. They must also learn that is about feelings - that fat is imbued with meaning, and it is this meaning that needs to be understood.
A psychodynamic perspective maintains that an eating disorder is fueled by unconscious conflicts in the psychic of the patient. Food and eating have unconscious meanings that need to be unraveled.
Professionals working with eating disorders from a psychodynamic perspective may be more apt to negotiate the acceptable bottom number of the patient’s weight. Under this approach, therapists may be more apt to give the patient some leeway and time to resolve some of the underlying problems that fuel his or her eating disorder.
Many times professionals will use a combination of psychodynamic and cognitive approaches to deal with eating disorders. Some mental health practitioners have developed tools and strategies to use when doing work with eating disordered patients. (9)
Some of the tools developed by the Women’s Therapy Center are:
1) Empathic understanding of the patient’s plea.
The mental health professional needs to show compassion, but at the same time, she needs to show curiosity for the person’s personal and peculiar situation. She needs not to be judgmental, or unduly pathologize the patient.
2) Psychoeducational work
The mental health professional will help the patient understand the anatomy - so to speak - of her eating disorder, i.e., what her eating disorder is all about. Although some patients may know a lot about calorie content, they may not be aware of how an eating disorder affects their brain chemistry. They may not be aware either of how dieting may increase the chances of a patient’s bingeing. It is important that therapists do not treat an eating problem just as a nutritional problem.
3) An Anti-Diet Approach to Eating Disorders
This approach is the corner stone of the Women’s Therapy Center Institute philosophy and approach. Patients need to learn how to feed themselves. In order to do this, they need to eat when they are hungry, whatever they want to eat.
Under this approach, anorectic patients may try forbidden foods more slowly and take risks more slowly than in a behavioral program. For a person to recuperate from an eating disorder she or he, needs to eat from the inside-out, so to speak. She needs to know that if she wants chocolate, apples are not going to do it, and that if she feeds her hunger (not her emotions) she would be able to eat the chocolate and feel satiated with a normal portion.
With an anti-diet approach, patients take charge of their eating. Defendants of a behavioral approach disagree. They believe that patients with eating disorders are not able to take charge of their eating.
Psychodynamic cognitive therapists who have worked with eating disordered patients believe that the clients respond to this approach. They also believe that in order to get better there is a need to be exposed to food and consume it to learn that food is not the enemy.
Patients with BN believe however, that if they could stop the bingeing, they would stop the purging. They believe that the core problem is the bingeing (and they feel ashamed). (15)
One common denominator to eating disorders is dieting. Dieting precipitates bingeing episodes, and dieting precipitates feeling out of control.