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Weight control: what happens in individual therapy? WEIGHT CONTROL: WHAT HAPPENS IN INDIVIDUAL THERAPY?
"Can I go home now?" Stephanie, a nineteen-year-old college sophomore, spat out the words.
She had been in my office just ten minutes. She had spent the whole time listing reasons why she didn't need help-even though she weighed less than ninety pounds: "I don't need a shrink. I know what I'm doing. I am too fat and I have to lose weight. My diet is no one else's business. It doesn't interfere with my life. I feel fine, I exercise, and I get good grades. What I choose to do with my body concerns no one but me."
When she paused for breath, I asked, "What do you think would happen if you tried to stop starving yourself to death?"
Here eyes flashed. "I would lose the one thing that makes me special. That's what you're trying to do-take away the only thing that makes me feel good about myself!"
Stephanie seemed very afraid. "I know you feel that way now," I said. "But working together, we can look at why you don't feel good about yourself, and why you don't think you are special in other ways. I think part of you recognizes the danger you're in. But another part of you is scared to give up your starving identity."
It took many more sessions to complete the process, but in that moment we began work on the most important task of individual therapy: to help the patient find a new identity, free of the suffocating symptoms of an eating disorder.
As Dr. Arnold Andersen puts it, therapy can be a kind of "mourning period." Part of the patient-her starving persona- must pass away. The patient has to let go of her fantasy that being thin will solve all of her problems. That's very hard to do. As her therapist, I try to show that I understand her struggle and realize how difficult and painful it will be for her.
While every patient is different, often there are discernible phases in therapy. In the first phase, the patient and the therapist spend time getting to know one another. However, they also focus on the symptoms themselves. The immediate goal is to break the bulimic cycle of bingeing and purging or to reduce the anorexic's fear of eating and gaining weight.
In the next phase, work to change behavior and thinking patterns continues, but the focus shifts somewhat. Now we begin to explore the patient's characteristic emotional difficulties. During this time the "purpose" of her symptoms-why they developed, what they mean to her-may become clearer. Starving won't solve her problem with self-esteem, for example, but it does give her the illusion that she is "in control." I tell her that it's human nature to want to do something we're good at. It helps us forget, or ignore, our other problems, but if our "talent" is self-destructive, then it can get in the way of solving the real problems.
We keep working to identify and change the stresses that trigger her behavior. We explore how eating (or not eating) came to play the central role in her life and why she turns to food (or abstains from it) for emotional support rather than to her parents or a friend. We look at the purpose that starving serves in her life and why weight is so important. If she wants to stop bingeing and purging but can't, we examine the mental roadblocks that thwart her efforts at self-control.
Often we spend time looking at her relationships with her family. I want to know how she sees the interactions between family members. We then talk about what she can do to change the family's style of dealing with each other and to pull back from parental conflicts.
In therapy we try to reduce the symptoms, and ideally eliminate them altogether. For months or even years, though, the patient has defined her personality through the disorder. Without self-starvation, an anorexic may feel she is nothing. For this reason therapy must not only take away, it must offer something in return.
And it does: It offers the chance to develop a mature and rational self. Maturity has many facets. It means the ability to recognize feelings and respond to them in healthy, life-affirming ways. It means breaking free of constricted thought-patterns and solving problems creatively. And it means self-esteem: a belief in one's worth as a human being.
As a therapist I must listen, and listen hard, to what the patient has to say. If she has trouble recognizing feelings or articulating thoughts, I'll do the best I can to help her along. I also encourage her to discover her true values and goals. I take her remarks seriously and accept her feelings as real-a courtesy that perhaps too few people in her life pay her. This doesn't mean I have to agree with everything she says, but I at least acknowledge it as valid for her.
In the final phase of therapy, the patient gets ready to strike out on her own. We talk about strategies she can use to cope with problems as they arise. I make sure she knows that temporary relapses may occur in times of great stress. At such times it is important both to reach out to others and to utilize some of the tools that have been helpful in the past.
When it comes time to terminate therapy, the patient usually experiences emotions similar to those she felt during past times of separation or loss. Being aware of these emotions allows us to work through them during therapy sessions and helps the patient grow. Sometimes these feelings are so strong that they trigger a temporary return to poor eating. Helping the patient see the connection between these events works to minimize the damage.
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