Recently a new therapist asked me, "Do you try to get your clients to diminish their bingeing behaviors from the beginning of therapy or do you explore their feelings first? I know there are differing views on this."
When I heard this question, several points of equal value, in my opinion, arrived simultaneously in my mind concerning therapy work with eating disorder patients. 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.
Often, it's the new client who is quite active in wanting immediate results in terms of stopping both bingeing and purging behaviors. I try to create an atmosphere where she can be at ease so we can focus more on our newly forming relationship.
A rush to focus on behavior undermines the therapy before it has a chance to begin. Once we have a relationship based on earned trust, we can be allies and look together at feelings and behaviors that need attention.
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. Women come in determined to obliterate their binge or binge/purge behavior. They are also terrified that I will somehow make that obliteration happen, leaving them more alone and frightened than before. Many feel that going to therapy means facing criticism or punishment as well as forces of demand and control.
The experience of being accepted, cared about and respected is not in their expectations or imaginations. The feeling of being in a room with someone who cares, knows and actively listens to her true experiences in life, including the binges, the purges and other secret behaviors, is beyond their imagination. She tries to rally her courage to protect herself and open herself to help at the same time. She doesn't need more stress by my attempting to control her in any way.
Ways of first presenting include:
1. Subservient
She conveys a willingness to do anything the therapist says.
2. Combative anger
She is ready to fend off the therapist's perceived and imagined power and commands.
3. Defeatist
She feels she's failed before psychotherapy work begins. She is certain she will continue to fail.
4. Childishly cute and manipulative
Her strategy is to outwit the therapist's plans while getting attention and love at the same time.
5. Superiority
She 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.
6. Hope
She is relieved to be in the consulting room. She feels victorious because she got to the room. She is willing to be as open and honest as possible to bring herself to freedom and a chance for a better life.
7. All of the above
She is a complex person. Eating disorders are complex. She will switch and change depending on her levels of hope and fear.
All these stances show the grip of the powerful eating defense in her life. She wants freedom and is afraid of being bereft of her eating disorder refuge.
Coming to that first appointment is an act of hope and courage. 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 is stressed just by being present for the first appointment.
I focus more on creating a relaxed atmosphere where the patient and I can begin to develop a relationship. Our relationship is based on earned trust, genuine interest in the remarkable puzzle of her eating disorder, deep respect and compassion for her struggle and shared curiosity about what triggers an episode.
For information about her practice see: Psychotherapy with Joanna
Joanna offers a free 15 minute telephone consultation. To schedule an appointment, please e-mail:
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