What comes first, binging or feelings?
Recently a colleague asked me, "Do you try to get your clients to diminish their bingeing behaviours from the beginning of therapy, before you together have explored the feelings that are fuelling that behaviour? I know there are differing views on this, and I would be interested in hearing yours."
When I heard this question, several points of equal value, in my opinion, arrived simultaneously in my mind concerning therapy work with eating disorder clients. Since writing is linear I can only communicate one point at a time. Please understand that these considerations are simultaneous.
My first thought was that I don't try to 'get' my clients to do anything. I want them to heal and develop the capacity to live a fulfilling and satisfying life. But what that means to them and how they specifically accomplish that falls into the realm of their personal values, decision making and evolution.
Therefore I do not address the bingeing or purging in terms of control in Anyway.
Often it's the new client who is quite active in wanting immediate results in terms of stopping both bingeing and purging behaviours. In fact, I'm usually the one who is putting forth effort, gentle and consistent, to create an environment where we focus more on our newly forming relationship.
To me, a rush to focus on behaviour undermines the therapy before it has a chance to begin, regardless of whether that focus comes from me or my client. Once we have a relationship based on earned trust, we can be allies and look together at feelings and behaviours that need attention.
From my experience I see that many clients with active eating disorders have built up in their minds, before their first appointment, what they think therapy is supposed to accomplish for them, and how it will all unfold. A client may come in determined to obliterate their binge or binge/purge behaviour. They are also terrified that I will somehow make that obliteration happen and that they must surrender to 'the all powerful one' (the therapist). Many feel that going to therapy means facing some kind of terrible criticism or punishment as well as forces of demand and control.
Often the first way a new eating disorder client presents them self shows how much she wants help and how terribly afraid she is at the same time. I've described some of them below. All of them represent how the client is rallying their courage to begin therapy. They are trying to protect them self and come forward for help at the same time. This requires courage. The client doesn’t need more stress by my attempting to control them in any way.
Ways of first presenting include:
Client conveys a willingness to do anything the therapist says.
2. Combative anger
Client is ready to fend off the therapist's perceived and imagined power and commands.
Client feels they have already failed before psychotherapy work even begins. They are certain they will fail in any program they think the therapist will attempt to establish.
4. Childishly cute and manipulative
their strategy is to outwit the therapist's plans while getting attention and love at the same time.
The client will listen to perceived controls and ideas coming from the therapist but acts as if the therapist is a puny force compared to her sophistication and intelligence.
All these stances are manifestations of client terror caused by the thought of being bereft of an eating disorder. They demonstrate power of the client's guilt, fear, shame and despair in terms of maintaining their eating disorder.
Since most new clients are certain they are going to face some kind of painful punishment or criticism in therapy, their coming to that first appointment is a tremendous act of hope and courage. These various stances help them show up for that first appointment despite their fear. Behind each of these stances is a frightened, hopeful and very brave person.
So as far as which comes first in our conversation, bingeing or purging, I don't focus on either. The client may be stressed to the maximum just by being present for the first appointment.
I focus more on creating a relaxed atmosphere where the client and I can begin to develop a relationship that is based on earned trust, genuine interest in the remarkable puzzle of their eating disorder, deep respect and compassion for their struggle and shared curiosity about what triggers an episode.
Clients usually feel terrible guilt about their bingeing and purging. They criticize themselves severely for these behaviours. They set impossible goals for themselves in terms of stopping. They feel hopeless and despairing when these goals are not met. In my opinion they need their eating disorder behaviours in order to maintain whatever lives they have going because they don't have any other coping mechanisms that are as effective.
If I have an agenda for them that includes their stopping or diminishing their bingeing or purging I may run the risk of accentuating their feelings of guilt, self criticism, sense of failure and despair. I believe this is why so many people with eating disorders leave therapy. The increased burden of negative feelings about themselves becomes intolerable.
Once a bulimic client in my practice said she thought she wasn't making any progress because she was still bingeing and throwing up and, after all, we'd been seeing each other once a week for two months. Because we had developed a friendly way of talking about her bulimia, as if we were talking about a third friend with rather curious habits, I could say, "Isn't that just like bulimia? You want results immediately." She laughed and said, "I'm like that about everything. I have to have everything work out perfectly and right now." So we had a moment together, in harmony with one another, as we both appreciated one of the symptoms of bulimia. I was also demonstrating to her that she is not her bulimia. She was beginning to understand that symptoms of bulimia are not character traits. They are symptoms of an illness and different from her deep and unique identity. She can recover from an illness and no longer manifest those symptoms. Her identity will remain and can blossom.
Then I asked her, "If I did have the power to take your bulimia away right now (and we both know I don't), but if I did, what do you suppose that would be like for you?" She said, "I wouldn't like it. I'd hate it. I think I would be very frightened and not know what to do with myself."
So then the conversation turned to the fact that bulimia exists to help her take care of herself. Even if we could, we would not take away a defence that would leave her defenceless. Our plan was to create an opportunity, through understanding, to develop beyond her current limits. Then she could use other methods to care for herself that are far more useful and healthful than the symptoms of bulimia.
Her developing an easy manner with me so she could talk about her bulimia without guilt or shame (at least not overwhelming guilt or shame) gave her a platform on which to stand to gain internal equilibrium in the face of her symptoms. It gave her the experience, often a first experience, of being with a trustworthy companion who is a witness to her growing strength and awareness and validates her healing and maturation. And it stimulated a curiosity about herself and her symptoms, often leading to quite courageous steps as she learned to tolerate painful feelings rather than acting out through bulimia.
Sometimes a client and I together do a little problem/puzzle solving. For example, to a bulimic many events, both business and social, seem to be centred around food. When these events involve the presence of a bulimia triggering person (such as a parent or parental figure) the client may only know about bingeing and throwing up as a way to get through the experience. We talk about how she might anticipate those feelings and plan ahead for caring for herself so bingeing and purging might not be as necessary.
Over time, as I think you can see from the gradual development of this style of working, the client is explores her feelings that are associated with bingeing and purging. There is no failure involved. Sometimes they'll binge and purge and sometimes they won't. Sometimes an episode will be quite severe. None of this is success or failure in my eyes and eventually it isn't in theirs either. All of these incidents become opportunities to discover and develop more self understanding, personal strength and new ways to care for themselves that serve them better than the bulimia which they are outgrowing.
Of course, a lot more is involved in treating bulimia, but this is a beginning response to your question, "What comes first?" What comes first is respectfully being with each other so the client can develop the ability to be respectful of herself.
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