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 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.