Strategies for Treating Eating 
Disorders

An interview with Emille Boland

by Mary Montaut.

I have always had an interest in eating disorders. In the late 80’s I counselled for a Medical Centre and worked exclusively with people with eating disorders. More recently part of my private practice is with such clients. I had a lot of experience initially with people with compulsive overeating who tend to present themselves for counselling or therapy more easily than people with anorexia or bulimia. Anorexic people do not tend to present for counselling. They will be sent or coerced into counselling and obviously that can be a problem. Often adolescents, whose parents are very worried about them, send them for counselling, but it tends not to work because they still have the notion that the family is ideal and they do not want to say anything disloyal about the family and so they are not willing to open up. I have come to the conclusion that family therapy is really the best way to go with adolescents with anorexia. Certainly the parents’ issues need to be addressed as well as the anorexics.

Coping Mechanism

Some anorexics in their 20’s actually present for counselling in private practice. In the end, though, many do not follow through. It is too threatening for them to give up the behaviour, which I find very sad, but they choose to live that kind of half-life. I see it as a coping mechanism. The trouble is the longer they are using that behaviour to cope, the harder it is to give it up. Change is very frightening for them. Sometimes all you can do as a therapist is help people to keep other sides of their life going and to put anorexia in perspective so it does not have to be the whole of their lives. They are not strong enough at that time to give it up, so you respect the symptom. A small number do recover and therapy, by necessity, can be very slow.

The Secrecy

Sometimes people who start off with anorexia then move to bulimia, but people with bulimia are not exclusively those who have had anorexia; sometimes people will just develop bulimia. Usually bulimia starts a little bit later, but you can get teenagers with it and I have had a few men also, with both anorexia and bulimia, though it is more typically a woman’s complaint. In some ways bulimia is the most secret of all eating disorders. It is hard to believe, but people can live that way for years undetected by family or partners. Usually there is a lot of shame attached to bulimia so it is actually very hard for them to come forward. The first step is admitting they have a problem Then when they present for therapy it has a much better chance of working. Bulimic people’s lives are much more organised – they may be married, they may have children, or they may have a career going. With both bulimia and anorexia, people are usually very successful in whatever they do.

Low Self-Esteem

I have had a lot of third-level students with anorexia and bulimia that are doing extremely well academically and who have even won awards to Europe or America; but even though their study and mental side is really developed, they find it hard to cope with the social side of life. Bulimics’ lives appear to be going well, but I suppose the symptom shows how split off they are, how hidden their own uncertainty or self doubt really is, and usually there is low self esteem. With any of the eating disorders, you will find that people have a very poor self-image and it is hard to shift that. One of the ways I work with this is through visualization. Body image can really be challenged and helped through this method also. I do not find cognitive work shifts things at a deep level.

Practical Issues

Depending on what stage a person is at when they come, you may have to spend time looking at just what they are doing around food. Some of the focus in the beginning may be on practical things. People with bulimia or compulsive over-eating will more or less starve themselves all day, and the evening is usually the time when they break out. And so, from the moment they get up in the morning, the plan is there for the binge in the evening - or the opposite, they are planning not to binge today, but the obsession is still going on, and they end up possibly bingeing anyway in the evening. Oftentimes it is a question of looking at what else they can do with their time, on a more practical level. The symptom is often a way of dealing with tension, so one of the ways I like to work is to teach them how to relax, this creates a stopping-off place, a safe place. I think it is very important to break the cycle. The client feels their eating is out of their control, that they have no power to stop themselves. By actually going back over their day and the lead up to the binge with them, as if you were watching them on video, they often come to realise just when they decided to binge. In this way they see that they really have control and choice. Bingeing is never the same after that. We then explore what else they might do instead of bingeing. Often people will come up with suggestions about what they can do to ‘treat’ themselves in a different way - maybe treat themselves to a magazine, a bubble bath, a piece of music – I recommend they make a list and put it somewhere where they can easily see it. Their favourite way of coping will be to binge, but if they have something concrete to prod them in the right direction, it is a major boost. Eventually developing their creativity can be a healthy way of overcoming an eating disorder.

Feelings of Emptiness

Often there is a great feeling of emptiness. Even though they may be married or in relationships, they really are very isolated and alienated from themselves. Right across the board with eating disorders, there is a huge loneliness. They really need to connect with themselves first, because they do not know what the behaviour is about, they do not know what is wrong in their lives that is making them do this awful thing. So they have to begin to realise what it is about. I think the behaviour is very addictive and it is very hard to get off the treadmill. As a therapist you are coming into a “triangulated situation” where the client’s main relationship is with the food or with not eating. You are going to have to try to connect and gain their trust so that eventually they will be able to risk giving up the behaviour. Then the real work can start. So that is the challenge. I have had most success with people who know that they really want to stop. They must have reached this place themselves, just as with any other client, because as we know therapy is a hard road, you meet painful things when you stop using whatever coping mechanisms you have. So they have to be able to say, “Whatever this costs me I am going to do this” and with support they can.

Unrecognised Needs

I think that eating disorders are about people not recognising their own needs, or not being allowed to have needs as they are growing up within their family. This of course is influenced by the society we live in and is twofold. Appearances may have been very important and certainly, the family rituals around food. In some way, the anorexic person is rejecting the whole thing that went on in the family and yet on the other hand still taking it on; it is a kind of bind. Often there is difficulty in acknowledging emotions, emotions were not allowed, or only certain emotions were. Certainly anger is one that most people with an eating disorder have tremendous difficulty dealing with and subsequently turn it back in on themselves. It is hard for someone with anorexia to say that there is anything wrong in the family. Someone with bulimia can say that there were certain things that they were not happy about, but they are usually ambivalent. They have difficulty around good and bad, and so split that in themselves – they have this persona that is really doing well and on the other hand, behind that, there is a symptom which tells them how bad they are. Very often there is terror of the body and its emotions. People will work on the behavioural levels, but it is extremely hard for them to move to the next level. In exploring their fears – fear of fat, fear of food, fear of their body, you begin to help them connect with their body. Although this is scary for them, it is also essential. It is risky for them – it is risky for the person with anorexia to give up the bubble they are living in.

Group Work

If people are in the grip of these coping mechanisms, it is hard for them to let go of the addiction. For them to make a relationship is hard work – the food is there, they can buy it at any time, or they can play around with calories in their head, but to relate to somebody else, such as a therapist, is somehow quite scary. So I think group work is really very good because they meet other people who are in the same position, or possibly a little ahead or behind them. Because it is a very isolating kind of symptom, it is a great relief actually to know that there are others out there coping in the same way. I think that joining a group is one of the most helpful things that they can do for themselves. Within the group they can accept challenge from each other, because they know that they are on to each other, they understand.

Support groups for families can also be a great source of strength and help.

Pain

While compulsive overeating is a terribly painful symptom for people to be living with, in some way I find in therapy that they are more accessible. Someone with compulsive overeating may or may not be overweight – sometimes we forget that. But somehow it is not as big a secret as bulimia. Sometimes people’s weight fluctuates so there is more honesty about it, the pain is visible. With anorexia too the pain becomes visible. But with the bulimic the pain is hidden. The bulimic is perhaps the most inaccessible until they actually decide themselves to come for help. I think it is the pain that brings people with eating disorders into therapy. There may be a feeling of being “crazy” or “mad” inside. They are driven and they do not understand why, and so the pain of the symptom, and the desperation in all of these three conditions, can bring people to look for help.

Compliance

The saddest bit of all for me is if a young person makes some progress in therapy and perhaps begins to eat in a more balanced way. Then the family are happy, “she is back to normal, she is our little girl again” . The girl misses out so much because she did not get to the root of the problem. She is ‘behaving well’ and eating a bit better so the family do not need to worry about her so much. She, however, has lost out. The symptom is saying, look at me, listen to me, there is a part of me that is not happy, but she goes back to the family pretence and misses out on finding her real self. Yet everyone is happy with her, she is playing the game again, whereas the symptom is a way of not complying. It is like the clients who go to hospital; they eat because they know that way they will be let out, but they have vowed to themselves that they will drop the weight as soon as they get out. On the other hand, if a person’s weight goes down a lot, they are so much in the grip of starvation that it actually does affect how their brain works, so they cannot actually stop. However if their weight comes up a bit, then they can actually make some real choices, whereas if their weight is very low they cannot, because they are just on a treadmill where the body is in a kind of frantic state, trying to deal with the starvation, and so their emotions are not available. Certainly if I am working with a teenager, I will have a medical person involved, whether it is a GP or a psychiatrist, because with both anorexia and bulimia, they can drop weight very quickly and if you are only meeting them once a week, you are not going to see it. They are very good at covering themselves up and wearing lots of clothes. I do not see it as my job to police them, so it is up to the medical side to watch what is happening around the weight. I would see myself working more with the meaning of the symptom, and trying to get to the emotions, trying to help them see other ways of coping in their lives, to learn other ways to deal with whatever the problem is really about.

The Work of Therapy

I think a lot of therapists are afraid when they hear that someone has an eating problem – it frightens them. I suppose what I want to say to therapists is not to be afraid, because it is similar to working with any other client. If you have someone who is adult enough to have presented themselves for therapy, maybe you could encourage them to see their doctor if you fear for them, but also counsel them. I do not think that I have a magic wand that other therapists do not have. Whatever the issues are, past or present, maybe an early bereavement, abandonment, perfectionism or difficulty asserting themselves now, it is the same as working with any other client – there is a lot of overlap. Understandably their sense of identity can be very shaky. Also issues around independence and dependency are likely to arise. If you take their history and get a sense of where they see themselves, this will give you an idea of where they are. Counselling is about self-responsibility and the eating disorder client deserves a chance too.

Hunger

Statistics suggest that most women – between 80 and 90 per cent – eat restrictively, so most women can in some way understand what goes on in someone with an eating problem. As women, we tend to look to our bodies to give us self-esteem, and that is really what is going on with an eating problem as well. If they arc rejecting their body, they are rejecting themselves and so they blame their body for any failure they experience. As far as I am concerned an eating disorder is just an exaggeration of what most of us do. The only difference being that these clients, unlike most of us, have not learned more effective ways of meeting life’s challenges. The projections on to the body signal a very painful ‘stuck place’ . I think there is so much emphasis on diet and dieting, women are encouraged to lose pounds for spring or summer or whatever, and the diet sheet is dictating to them what they should be doing with their body. It takes the person away from their own hunger. With any of these eating disorders, the person has to learn again what hunger is. They have lost touch with their bodies so they do not know what physical hunger is. Often they do not know what else they hunger for besides food, whether it is a spiritual hunger or an emotional hunger. They are not able to distinguish. A lot of the work in therapy would be about that, just finding out again what it is they are hungry for, what is missing in their lives, what they want, and connecting the behaviour with the emotions behind it. A person with bulimia might be completely unaware of why they decide to have a mega-binge tonight, usually it because they have not been able to “digest” what went on during the day emotionally.

(Susie Orbach’s book ‘Fat is a Feminist Issue 1‘ is an excellent book to read in this topic.)

Healthy Symptom

I do not think any particular model of therapy has the answer, the relationship is central to the process. The behaviour is unconsciously motivated so I find using guided imagery and/or gestalt helps us move into what the symptom is saying. If there is a trauma from childhood, I find that regression therapy does work, but again, it depends on the client – you can reach those things in various ways. I see the symptom as a healthy part which is saying it is not happy. Unless the person listens to that part, they may manage to function but they do not enjoy their lives because they do not know who they are, they do not know what they want and very often they are living to someone else’s agenda. Their symptom is a mystery to them, they do not know why it developed. If however they begin to understand what is behind it, they can begin to reclaim a part of themselves that is well hidden. Then they can let out their real selves, rather than the stream-lined acceptable version.

I apologise for the ‘Labelling’ used, but because of the nature of the article it was necessary.

Emille Boland is a therapist working in private practice in Dublin. She is also a teacher and a Reality Therapy Supervisor.