What
the Therapist Does
Just as
there are myths and misconceptions
about eating disorders, there are
myths and misconceptions about the
professionals who treat them.
Common
Misconceptions About Therapists
Misconception 1. The therapist is
responsible for getting my child to
eat, to stop purging, and so on.
Misconception 2. The therapist is
responsible for getting my child to
lose weight (or to gain weight).
Misconception 3. The therapist is
supposed to make my child more
responsive to me.
Misconception 4. The therapist is
supposed to bring about a cure.
Misconception 5. Both my child and I
are supposed to be comfortable with
everything the therapist says or
asks of him or us.
Misconception 6. The therapist is
supposed to tell me what goes on in
the sessions with my child.
Misconception 7. The therapist is
supposed to tell me what my child
has said about me.
Misconception 8. The therapist has
the final say on whether or not my
child sees an internist.
Misconception 9. My child is
supposed to be happier as a result
of his treatment.
Misconception 10. The therapist has
no responsibility to me, as I am not
her or his patient.
The
adept psychotherapist creates a safe
emotional environment in which an
empowered patient can make changes.
“I’m an introspective and extremely
intelligent and open person,” stated
one of my patients. “How is talking
to you going to be any different
from confiding in my parents or
close friends?” The value of the
therapeutic interchange lies less in
the specific information that the
therapist shares with the patient or
in how the therapist listens and
more in the therapist’s ability to
get the patient to use himself
maximally in response to the therapy
relationship, himself, the disease,
and life itself. It is not enough
that your child feel good about his
therapist. The requirements for the
effective eating disorder therapist
are quite specific.
In
conducting a process that is active,
directive, and informal (I recommend
that patients, even young children,
use the therapist’s first name), the
therapist juggles
• Issues
and needs of the moment with those
of the past
• The
needs of the body with those of the
psyche
• The
patient’s wish to remain sick with
his need to recover
• The
patient’s need to focus on food to
the exclusion of emotions with his
need to focus on emotions to the
exclusion of food
• The
patient’s need to discuss why the
problem exists with the therapist’s
need to discuss how the patient can
set about to improve things
• The
goals of each party with the diverse
goals of the other interested
parties
• The
need to invite problem disclosure
with the need to create a safe
emotional environment
• The
need to be authoritative with the
need to be nurturing
The Therapist’s Roles
This
section describes the functions your
child’s therapist should perform,
which will help you keep your
expectations and demands on target.
As you read these descriptions, you
will notice that the therapist is
your child’s teacher in many of the
same ways you are. Much of what the
therapist does with your child
mirrors what you do with and for
him. Keep in mind, however, that
there are some major distinctions
between the role of therapist and
that of parent; no matter how much
the therapist cares, no matter how
deep his or her emotional
involvement, it is not the same as
yours. The anguish and frustration
of living side by side with eating
dysfunctions in one’s own child
cannot be overestimated. One
desperate parent I know of was
driven to throw all the food in her
house down the garbage disposal.
This behavior was motivated by love
and her need to protect her
vulnerable child. Give yourself
permission to feel your feelings
deeply. The therapy process is
a gentle dynamic of guiding the
patient’s observation,
self-awareness, and choice making.
These requirements pale by
comparison to parents’ requirements
on behalf of their children, which
are much more rigorous and
emotionally demanding; nothing can
be left to chance, not a stone left
unturned, when your child’s health
and happiness are at stake.
As a gatekeeper, the therapist
•
Requires a medical evaluation to
rule out organic causes for what
appear to be emotional problems.
•
Controls the direction of the work,
not the patient.
•
Assesses if and when inpatient work
should become an appropriate
alternative to outpatient treatment.
•
Retains a focus on weight-related
issues as they connect to underlying
emotional issues.
•
Reaches out to the patient who
appears to be prematurely
disengaging from treatment,
increasing the patient’s staying
power.
•
Coordinates the efforts of the
treatment team, facilitating
treatment by keeping lines of
communication open and active
between various parties.
•
Prepares the patient to outgrow the
need for treatment.
•
Communicates with parents as needed.
As an interpreter, the therapist
•
Explains how the disease diminishes
life and how the therapy process
enhances it.
•
Unmasks the cover-up functions of
abnormal eating.
• Keeps
treatment expectations realistic:
things will feel worse before they
feel better.
•
Anticipates, embraces, and discounts
the patient’s negations and
distortions, reframing unrealistic
ideas and beliefs.
• Helps
patients and families understand the
connection between family
functioning and the health of the
individual.
•
Listens to parents’ questions with
an ear to the issues that underlie
the inquiries: Why is the parent
asking now? What might these
questions indicate about the
parent’s own feelings and needs?
As a teacher, the therapist
•
Teaches alternative approaches to
coping and problem solving.
•
Educates the patient and parents
about nutrition and eating.
•
Role-models by offering her or his
own thought processes: “Here is what
I am thinking . . .”; “This is why I
ask . . .”; “Here is what I am
wondering about and why ...”
•
Teaches the patient to tolerate
free-fall sensations in recovery
(and in life).
•
Teaches the patient his right and
responsibility to ask for what he
needs in treatment and in life.
As a collaborator, the therapist
• Allows
the patient to define problems and
set the pace of the psychotherapy
work.
• Joins
with the patient: “How might you do
things differently were you the
therapist or the parent?” “Help me
think about what you just said.”
As reality tester, the therapist
• Keeps
food issues clearly in view as they
relate to feelings and to coping.
• Keeps
goals realistic (vomiting three
times as opposed to four may be an
achievement).
• Offers
the possibility of being thin (in
control) without being anorexic or
bulimic.
•
Recognizes, uncovers, and defines
resistance to treatment, offering up
these findings as therapeutic issues
to be discussed and understood, not
as invitations to engage in power
struggles.
• Starts
where the patient is emotionally.
The therapist must avoid conveying
“I am on your side” in lieu of
providing honest commentary on the
inappropriateness of the patient’s
thinking.
As a liberator, the therapist
• Grants
permission for the patient to feel
his feelings and experience his
needs and then express them both.
•
Facilitates the development of
healthier defenses, increasing the
likelihood of discarding familiar,
less functional ones.
•
Invites the patient to use his
intra- and interpersonal power
benignly and effectively.
•
Reframes confrontation as a
realistic and productive relational
process.
•
Encourages the expression of
complaints or disappointments with
therapy and therapist, bringing such
problems to resolution.
•
Challenges the patient without
overwhelming and discouraging him.
As a parent figure, the therapist
•
Maintains an unconditional positive
regard for and acceptance of the
patient.
• Sets
loving limits; maintains
unconditional honesty in
communication.
•
Teaches the patient about life and
how to live it most effectively.
•
Simultaneously connects with, yet
individuates from, the patient,
preparing and inviting him to
function as a separate and
autonomous individual.
•
Ultimately releases the patient,
with pleasure and pride in his
accomplishments.
As coach and mentor to parents,
the therapist
•
Teaches parents to listen to and to
hear their child.
•
Reinforces positive parental values
and roles.
• Is
responsive to parents’ needs as well
as to their child’s needs.
•
Educates, normalizes the disease and
recovery processes, reality tests,
and role models communications with
the child.
•
Includes parents in the process of
making changes.
•
Facilitates communication between
parents and child.
•
Supports parents and their functions
in the eyes of the child.
A Word About Confidentiality
The
therapist’s need to maintain
confidentiality is real; it protects
all parties and must be respected.
But it should not preclude the
therapist’s relating certain pivotal
information to you, about you, and
for you. In situations where the
patient is in danger of doing harm
to himself or others, the therapist
is legally bound to inform you and
other necessary people of what the
patient has said in confidence about
doing such harm. In every other
situation the artfully handled
family session is the best way
around any conflict between the need
to be informed and the protection of
confidentiality. In an atmosphere
that is open and above board, where
trust is facilitated not violated,
family sessions can eliminate
conflicts of interest as they
benefit all parties through the free
exchange of previously close-kept
information.
