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Weight control: key emotional issues in individual therapy WEIGHT CONTROL: KEY EMOTIONAL ISSUES IN INDIVIDUAL THERAPY
Here are some quick glances at the key emotional issues every patient confronts at some time and to some degree:
Feelings of fear: Like a broadcast from a powerful pirate radio station, fear, especially the fear of fatness, overwhelms and blocks out every other emotional signal. In therapy we work on decreasing these fears so that the patient can pick up other signals-joy, anger, even sorrow.
An important part of the process is talking about inner feelings that may never have seen the light of day. It's natural for people to suppress powerful fears, keeping them buried or vague so as to avoid having to deal with them. Sometimes, though, just articulating fears or "bad" feelings decreases their power. Giving them a name empowers the patient to make a conscious effort at overcoming them.
Strangely enough, a patient may fear not just failure but success as well. She worries that succeeding at something means people will demand more of her-more than she feels she can deliver. At a deeper level, fears of success may come from separation fears connected with fantasies of competing with a parent-figure. The very fact that individual therapy provides an intense relationship with another human being in itself reduces another dominant fear: the fear of intimacy.
Feelings of anger: For a woman in our society, expressing anger and aggression-natural feelings- can be taboo. Thus even when she is genuinely, righteously angry, she often swallows her feelings. But suppressed feelings erupt in other ways, like air in a balloon that's being squeezed. As Tina's story demonstrated, an eating-disordered person takes it out on herself through food. As she learns the art of assertiveness, her fear of her own anger decreases.
Feelings of depression: Depression and eating are closely linked. Bingeing may in fact be a person's misguided attempt to treat her depression, using food as medicine. In many cases, feelings of depression are what drive the patient to seek help in the first place. Therapy can help point out that, although a bout of depression can be draining, there are better ways of coping with it than eating.
Therapy explores where the depression comes from. What's more, it introduces alternative methods for dealing with it. Even simple suggestions can sometimes be helpful. I ask my patients to remember the "Three N's": Say NO to unreasonable demands. Do something NEW. Do something to NURTURE yourself. Of course, it's important that we distinguish between the feeling of depression and the clinical syndrome of depression. The former is a response to temporary situations; the latter is a psychiatric illness, for which effective medical treatment is available.
Feelings of being fat: Feeling fat though actually being emaciated is so common among anorexics that, as we've seen, it's one of the diagnostic criteria for the disorder. Patients need to learn that feeling fat is a genuine part of their illness-the feeling is really there, no doubt about it. It's just distorted. It's another example of a crossed wire in the emotional circuit. However, simply confronting the patient -"Look in the mirror! You're not fat!"- doesn't work. Better to find out what being fat means to her, and how she interprets this distorted feeling. As patients learn to recognize and trust their feelings, they see a clearer image of their body shape and size. As one recovering patient told me, "I feel like I got a new prescription for my emotional contact lenses."
Feelings about control: Because her life is chaotic, the anorexic focuses all her energy on controlling what she eats. Often this means controlling everyone else around her too. In time the disorder controls her. A bulimic "controls" eating by skipping meals; when she binges, she tries to reassert control by purging. In therapy we work to restore a sense of healthy control over eating.
Distorted thinking: The need to be in control often leads to certain limited ways of thinking-everything becomes "black or white," "all or nothing." Individual therapy offers the patient a chance to explore other ways of thinking. If she says, "I know that if I gain an ounce I'll go on and gain thirty pounds," we'll talk about why she feels her only alternatives are extremes. The goal is to help her rediscover balance and moderation in thought as well as behavior.
Poor self-image: Susie Orbach, a well-known eating disorder therapist, believes that "low self-esteem" is much too mild a description of this symptom; self-hatred is more accurate. She has a point. Patients are often so perfectionist that one mistake, one little slip, can shatter them. They feel like failures because they can't meet their own impossibly high standards. Therapy allows a patient to experiment with feelings, to take risks. In scaling back her standards to a more realistic level, she discovers that a mistake needn't destroy her, that she isn't a horrible, rotten person after all. A therapist helps by praising the patient for her success rather than being overly critical of her failures.
Social failure: Patients often have difficulty making friends or feeling comfortable around other people. These feelings may contribute to the development of an eating disorder. What's more, once the disorder has taken hold, these feelings can help maintain and reinforce the anorexia or bulimia. Fear can make a patient avoid situations that pose the slightest risk of rejection. Making and keeping friends is a skill, and like other skills people need to learn it and practice it. Therapy can help patients do so. After all, no one rides a bicycle very well the first time she tries.
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