For most people who seek outpatient treatment for eating disorders, a therapist is the lynchpin of the change process. But which therapist and what type of psychotherapy? Patients and family members can face a bewildering range of choices. Clearly, a patient should choose a therapist who is experienced treating eating disorders. And the patient should feel comfortable working with that therapist.
What about different therapy methods? One therapeutic strategy used in eating disorder treatment is Cognitive Behavioral Therapy, or CBT. The basic premise of CBT is that behavior starts with thoughts. A person’s thoughts drive feelings, which in turn drive behaviors. Changing inappropriate or unproductive behaviors, such as disordered eating, starts by identifying the thoughts and feelings driving those behaviors. The therapist and client work together to change those thoughts and feelings, in order to change the eating disorder behavior.
I recently interviewed Boulder therapist Joan Unruh, LPC CAC III, who specializes in eating disorder treatment. She gave me this example of how thoughts and feelings drive disordered eating behavior:
It starts with the thought. How you interpret an event, such as pizza is being delivered. The person without an eating disorder might think “Great! Pizza! Fantastic!” It trickles down to how that person feels. She feels excited, happy. She may feel hungry; she may set the table and put out plates.
A person who has an eating disorder thinks about the event as something totally different: “I’m not allowed to have pizza; pizza’s on my “bad” list; it’s so fattening, it has so many calories; it goes straight to my thighs.” All of those thoughts she may or may not even be aware of are running through her head. So the next step the CBT talks about is the feelings level: how does that person who’s thinking that way feel? She feels scared, maybe angry that she doesn’t have a choice about eating the pizza. So the behaviors that follow might be manipulative avoidance, picking at the pizza, purging it back up.
Unruh emphasizes that, for CBT therapy to work, it’s important to change how the person thinks. That’s the model. The eating disordered person has developed a personal system of dysfunctional rules around food and eating, and the goal is to change that system. The behavior has to change, but it can’t change in a vacuum. The therapist and client have to go back and visit the thoughts that precede it.
Examiner: Have you ever met someone who understood that sequence of events?
Unruh: Usually they have an awareness of the thoughts, but it’s part of their system of rules. We break it down and do a variety of techniques around changing the thoughts. I give them homework to observe and notice, track the thoughts as they’re happening. Get them on paper. Seeing it on paper can be eye-opening.
Examiner: What does the process involve?
Unruh: The traditional CBT model is daily journaling of these thoughts, dissecting them and challenging them. I use a simpler model: just notice your thoughts and feelings; write it down. They can start to look at what they've written and think “that’s ridiculous”. At the therapy session, we discuss the thoughts and feelings associated with different events. It’s important to get someone to see how frequently this occurs.
Examiner: What would you say the success rate is for this kind of intervention?
Unruh: Pretty successful in terms of slowing down behaviors or decreasing frequency. Beliefs are at a level below the thoughts, but there’s only so much I can do about helping change their beliefs about food rules, or their self-worth. People with a relatively intact sense of self-esteem are more likely to be successful. Of course, people who choose therapy are motivated to change and see these issues. Clients who don’t want to do the work drop out. Some clients are just really committed to the eating disorder behaviors and are not ready to change. I think commitment is a huge piece for outpatient therapy. I typically get a person who is on the fence: 60% of them wants to be recovered, while 40% is still getting something out of the behavior. Usually my most successful client is a binge eater who doesn’t purge. Purging serves a whole other function for people.
Examiner: Do you see a difference when kids are brought by their parents?
Unruh: Usually kids are not coming in against their will. They may really want to work on it, and when the parents are also on board, it can be really successful.
Examiner: Can you name any specific behavior changes that indicate success?
Unruh: With CBT for me it’s about homework and clear goals, by the second appointment. I have goal sheets, and we quantify the goals: how many times did you binge and purge this week? How bad was the purge? The client may say “I binged, but I was able to stop half way, or I only ate one box of cookies instead of 2”.
Examiner: Do you find people have unrealistic expectations?
Unruh: Oh yes. These are very subtle behavioral changes, and they’re so tightly wound with belief systems and emotions. I have people track them, in a journal or calendar. If we can have them track it themselves, they can see the subtle changes. I can go back to notes from early sessions and show changes, and almost every single time they say “Wow, I don’t remember it being that bad”. If you can show them the transition, they see they had to do one step before they could do another step. It’s not going to be a linear process, and that’s what they might find frustrating.
Examiner: What aspect of therapy do you find especially helpful?
Unruh: I would say frequency of sessions, if they can come every week. Also having a dietitian and a doctor following them. For my practice, doing the homework. I think that’s key. Usually something written and specific, such as “I want you to go to the bakery and buy a beautiful cookie, and go home and turn off the TV and the radio, and I want you to sit down at a table and spend 20 minutes enjoying this cookie.”
Examiner: What can patients and families do to make it be successful?
Unruh: Come to therapy. It reminds you of your commitment to recovery. I notice that patients who can’t come due to money or sports or travel, I feel like they’ve crashed and burned in 2 weeks. Do the homework. Be up front with your therapist. Tell them what’s not working. For parents I would say, instead of dropping off your kids, sit in the waiting room. Those little subtle interactions before and after a session can help. Or just the fact of the parent sitting there, the kid might think “oh maybe it’s OK for Mom to come in for 10 minutes.” Don't just meet your kid in the parking lot. Have some face time with the therapist.
Examiner: Do you find that for your clients there are particular mental syndromes that go along with eating disorders?
Unruh: Usually there’s some OCD, anxiety or a perfectionist personality type. It’s usually not someone who is a go-with-the-flow type person. Anxiety is more common than depression. And there’s usually an addiction somewhere in the family, such as alcoholism.
Many therapists, including Joan, offer prospective clients an initial complimentary consultation, to see if they are a good fit for what the client needs and expects. In addition to a therapist, a person with an eating disorder should be evaluated by a physician, to screen for any adverse medical effects. This is especially important for children, as the eating disorder can impact growth. Additionally, patients should meet periodically with a registered dietitian who in familiar with eating disorders, and can monitor nutrition and diet status.
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