Q: Let's switch to a different client. You're working with someone who's battling bulimia. She's shown good progress; she hadn't binged and purged for a week and half. She comes in distraught because she binged and purged the night before. How do you address this?
I'd approach with a lot of curiosity, checking her perception of it. If she's judgmental and negative, I would offer my non-judgmental perspective from a neutral stance. I find that to be more helpful, because for most, the most intense judgment will come from themselves.
I'll ask about the day a little bit, and I may hear that the client was with a certain person or at a certain location. If it's a purely emotional, relational binge and purge that was all because of an interaction, I'll probably say, "Wow. It sounded as though your pattern of eating was really right on. But then you had this interaction. So...have you seen your therapist yet to talk about that?" But my more specific questions are going to me around what the person ate 24 hours before, the person's thoughts about food, and any behaviors related to exercise or the scale that set that person up for a binge and purge. I'm still going to hear a little bit about the relational stuff, but I'm not going to go there.
Also, there's usually a lot of fear that this will happen again. So I strategize: If there was some biological or nutritional reason that set the person up to binge, then we talk through how to prevent it in the future.
If I see any performance or perfectionism in the person, I'll say, "That part of your personality could get triggered in our work. If you come in and you haven't decreased your binges, or eaten on the "right" schedule, or binged and purged, you're going to feel as though you've failed -- that you didn't perform for me." I name it before it even happens. In the scenario with the student, I'd probably check it: "How did you feel about coming in and telling me this? What do you think about my reaction? Do you feel as though there's a failure going on here? What's that like?" They usually want to perform for me, not just for themselves. They want to be perfect, and that's not what I expect at all.
Q: Do you find a difference in working with those with bulimia versus those with binge-eating disorder?
Yes, I would say so. I find that for those who have a continual pattern of binge eating, without purging, shame around the binging comes into play a lot. For many binge eaters, their weight is going to reflect the binging. They feel that they're carrying it in a culture that makes a lot of assumptions about weight.
It's a lot slower for me to help them make specific changes with food or to deal with the reality of their binging. I want them to be more comfortable as eaters, and to know that I am comfortable that they eat. I have to be a voice that's different, but it just takes time. When a person binges and purges, it's hidden -- secretive. But for binge eaters with higher weights, they believe it's not hidden -- that people know and are making assumptions.
Q: How do you involve parents when they're in the picture?
That varies widely. But I start by seeing if this teenager or young adult can "prove to us that they are taking care of themselves." That's the way I phrase it. If the client can show some level of nutritional self-care, then we may not need to involve the parents. But if the client isn't able to make the changes, and there are health risks involved, then I need to bring in the next level of support. We can't ethically watch that happen when there's someone available to give that support.
If the client is a binge eater and the parents are involved, there's an interesting dynamic. The parents need a lot of education. So even if I'm not medically concerned, the client may want some parental involvement to figure out how mealtimes and conversation about food and weight in the house can be different, So I, or a family therapist, can do some of that.
Q: You're trying to change the environment to which they're returning every week.
Yeah. In that case, I want the parents to be involved earlier.
Q: You seem to assume the participation of a counselor and/or a medical practitioner. What are their roles?
In a comprehensive treatment team, there needs to be a medical practitioner, whether it's a nurse practitioner or a doctor. The mental health practitioner would be a counselor, a marriage and family therapist, or a psychologist. Sometimes there's a personal trainer or forms of alternative medicine. But the core group that I want to see includes a medical practitioner and a mental health counselor of some sort.
Q: Is it fair for someone with an eating disorder to ask how long she should expect treatment to last?
Research shows that 5-7 years is the typical length of time in treatment to resolve an eating disorder. But that depends on how long the person has engaged in the behaviors, and on whether she has a comprehensive team. If a person is underweight, getting to a healthy, "ideal" weight is one of the best predictors of recovery. Someone from that client population would know that my goals would involve that, and that it could move him toward recovery quicker.
I would also ask what recovery means to that person. Is he hoping never to think about food at all? Then it's going to be a longer process. Does he want to get to the point at which he isn't obsessed about food and isn't engaged in any eating disorder behaviors? That's going to be a shorter term.
