by Harvey Widroe, M.D.
American Reporter Correspondent
July 11, 2007
Eat or Die, Part V
ENTER THE THERAPIST
ORINDA, Calif. -- Anorexia and bulimia are stubborn conditions to treat, and any one clinician, no matter how talented or zealous, is ill-equipped to do it alone. Successful treatment requires a treatment team including a primary care doctor or internist, a nutritionist, a psychotherapist, and a psychiatrist.
The key member of the treatment team is the therapist who, more than the others, develops and coordinates a multi-dimensional treatment plan involving all of the players. Apart from running the show, it is mainly the therapist who must sell the treatment plan to the eating disorder victim.
Sufferers from eating disorders feel very much alone. It is easy for them to feel isolated, lost, helpless, and despairing as the disease runs its horrible course. The old purge club members don't hang around when every aspect of life starts to fall apart.
The therapist's first goal is to gain the patient's trust, to set up a "therapeutic alliance." But the task is not easy. The illness is like an alien trying to maintain control of the mind of the eating disorder victim. The therapist must solicit the patient's help in fighting a clever and resourceful demonic part of his or her own self; a part of the patient that, if unchecked, can literally kill her.
For all eating disorder sufferers, effective treatment requires a psychotherapist, though not just any therapist will do. The therapist you might see for marital problems, issues at work, or life path questions are not necessarily suited for cases involving anorexia or bulimia. The therapist required for the effective treatment of patients with anorexia or bulimia needs to possess special knowledge and skills, including the right temperament and training.
A passive therapist who merely sits and waits for patients to introduce and examine important personal problems won't come close to the major issues in eating disorders. Too much shame, guilt, distrust and sense of failure will prevent any kind of meaningful connection between the passive therapist and the eating disorder patient.
Even a talkative, active psychotherapist who tries to explore certain problems in the patient's life may miss plugging into the critical details and nuances of the anorexic or bulimic patient's illness.
By active questioning and frequent comments, the effective eating disorder therapist must get into every aspect of the disorder itself, what it is, and how it operates in each patient's life. The psychotherapist must help explore what compels the anorexic or bulimic patient to continue her self destructive behaviors. The therapist must also be a teacher to help the patient understand what is going on, and to rescue the patient from confusion, isolation, fear and desperation.
Advice on how to handle every aspect of life must be given freely, whether requested by the patient or not. The therapist must explain what this illness actually is and how to think about it in new ways that may give the patient even a modicum of control over what she is doing to herself. The therapist must be patient, clear, straight forward, and assertive without being scolding or harsh. Even the most skilled of psychotherapists working with an apparently cooperative patient may face round after round of failure, and yet must persevere, since there is no room for a therapist who cannot tolerate frustration.
Life seemed gloomy to Debbie, and there was nothing positive on the horizon. At age 17 and down from 125 to 88 pounds, in her eyes she was still not thin enough to make her walrus-like self image go away. Even though her nutritionist appeared to be on her side, Debbie didn't trust her advice. She knew the nutritionist wasn't just pushing a healthy diet but also, undoubtedly, something that was supposed to be fattening her up. She still felt that loading up with a few glasses of water before each office visit kept the nutritionist fooled to some limited degree.
Commanded to see a psychotherapist by her doctor and her family, Debbie gave in. The therapist, who had been helpful to a family friend, seemed like a nice person who wanted to talk with Debbie about her family, her childhood, her dropping out of school, her friends, her hobbies. But Debbie knew this talk had little to do with her secret life of daily stuffing and vomiting rituals, obsessing about eating, an ugly self-image, and a growing fear that catastrophe was just around the corner in a form that she couldn't recognize.
The therapist didn't connect with any of that. It seemed almost too scary for the therapist to even mention; and if the therapist couldn't deal with it how could Debbie have any hope for help?
She hadn't planned to kill herself; but there was nothing to live for, and there was only a growing sense of pain and despair. So why not get relief? "Let's get it over with," she thought. On impulse she swallowed anything she could find in the family medicine cabinet.
Frightened at what she realized she had done, she ran to her mother, screaming that she had taken an overdose but didn't really want to die. Later she recalled that this time her vomiting was not self induced. Then she got dizzy, and everything went black.
After two days on an intensive-care unit, she was transferred to a psychiatric hospital. Her new therapist's opening comment, "You almost made it! You came half an inch from being dead" hit a chord in Debbie. "I know," she answered. The new therapist didn't buy the lie that it had all been an accident. From the straight-forward things she said, Debbie felt this therapist could see into her, almost read her mind. Maybe this therapist had what it took to save her.
Besides talking to Debbie, the therapist talked to the internist, the nutritionist, Debbie's parents, and a psychiatrist she added to the treatment team. Debbie protested that she had the right to get out of the hospital, but the therapist responded, "When your life is at stake, you don't have the right to go anyplace."
Actually, Debbie liked this tough-talking person who was clearly on her side. Whatever that meant, it was comforting and rekindled hope. At first they met almost daily in the hospital, and later Debbie went twice a week as an out-patient. The therapist had Debbie attend group therapy sessions with others who were fighting anorexia and bulimia - an anti-bulimia group, unlike the barf club of old.
It grew easier for Debbie to see that she did have a problem, and that help was possible.
In the last article in the series I'll examine the role of the psychiatrist in the treatment of anorexia and bulimia.
Harvey Widroe, a practicing psychiatrist, is the author of "The Smart Dieter's Cheating Guide: Eat and Watch Pounds Melt Away," with Ron Kenner.