Eating Disorders – Guidelines for Therapists

Current family-based therapies recognize that although we do not necessarily know what causes eating disorders, there are many factors that contribute to their development.

The three main types of eating disorders

Anorexia nervosa: People with anorexia tend to have a distorted image of their bodies, believing that they are overweight even if they are dangerously thin. They refuse to eat, often count calories obsessively, and exercise excessively. Generally speaking, those with anorexia tend to be perfectionistic and often come from families where there are high expectations.

Bulimia nervosa: People with bulimia tend to eat excessive amounts of food and then purge the food from their bodies through the use of diuretics, laxatives, vomiting and exercise. There tends to be a great deal of guilt and shame attached to this disorder, therefore their activities are done secretively. People with bulimia often tend to be impulsive in nature.

Binge eating disorder: This is the same as bulimia to the extent that people tend to eat excessive amounts of food and often experience episodes of “ out of control” eating. However, they do not purge their bodies of food. Again, as there tends to be a great deal of guilt and shame, and their activities are often done in a secretive fashion.

Eating disorders affect both men and women

Although we often think of eating disorders primarily affecting girls and women, this is not necessarily so. Boys and men also struggle with very similar societal pressures to look a certain way. However, it may often be disguised, especially in its initial stages, through working out, e.g., weight lifting or running. Although perspectives are changing, when people think or talk about eating disorders, they still tend to consider it to be much more common in the female population.

Asking for help

The nature of the symptoms in both anorexia nervosa and bulimia nervosa often means that clients seek help either under pressure from others such as family members or because they have been struggling for a long time and are at the point where they feel they can no longer deal with it on their own.

People with anorexia are often in denial of their illness and people who have bulimia experience shame and secretiveness around their bulimic symptoms. They often have a great deal of trouble trusting those who want to help them because often times previous relationships, especially within their family, have been intrusive, controlling or abusive, or perceived to be so. The relationship with the therapist requires vulnerability and a loss of control.

Therefore, it is critical when a person presents for help that they be assured that there is no judgement and that their confidentiality will be respected unless there are safety concerns, either of a physical or psychiatric nature.

Challenges for therapists

My job as a therapist is to help my client understand that recovery is a process, not an event, and that the work will require patience, honesty, hard work and commitment on both of our parts. Dealing with the issues involved is very complex work. The obsession with body image is the most powerful issue and one of the most challenging to change. Cognitive behavioral therapy (CBT) is a very beneficial form of treatment.

Many studies have documented that the treatment of people with eating disorders, more than any other psychiatric disorder, evokes feelings of helplessness, anger, frustration, fear and stress (to name a few) in therapists. The work is demanding and often met with a great deal of resistance, especially as the client begins to gain weight or get better.

Since people with eating disorders often have had a great deal of practice in being secretive, controlling (in terms of when, what or if they eat) and have learned all sorts of ways to keep people from knowing what is going on for them, it is very easy for splitting to occur. They tend to know “every trick in the book.” Therefore consistency and good communication are paramount.

The team approach to treating eating disorders

Treatment of an eating disorder often requires a multi-disciplinary approach. A physician is often needed in order to rule out any physical causes or illness as well as to monitor blood pressure and heart rate to determine imminent physical risk.

A nutritionist is often an important component of treatment so that the person can develop a healthy eating plan, food diary, etc. A therapist, be it a social worker, psychologist or a psychiatrist focuses on the underlying psychological issues as well as helping to identify and address the immediate needs of their client such as depression, anxiety, social and familial relationships, self esteem, abuse, etc.

This multi-disciplinary team approach is essential in terms of forming a collaborative relationship, or therapeutic alliance with the client in order to help them move forward with recovery but it also serves as mutual support for the team members, especially when the going gets rough.

Family therapy is often beneficial, not only in terms of providing education and support to the family about the illness but also to help insure and reinforce the client’s compliance with the treatment recommendations.

Group therapy has also proven to be extremely valuable because the client gains support from others who are experiencing the same things they are, but the dynamic of being in a group means that other members will confront more easily than in individual therapy.

Although working with clients that have an eating disorder can be long term and challenging work, it also brings with it an enormous amount of joy and satisfaction. To watch a client grow from being in a (very often) life-threatening situation to a thriving, healthy individual is gratifying and heart-warming but it also requires us as therapists to dig deep, to examine and face our own feelings around body image and to address any countertransference issues as they arise.