Thursday, August 23, 2012

High expectations

One thing our team is known for, and at times accused of, is setting very high expectations for the patients we work with. We are known for being very tough, and of course, as part of that, sometimes we are known for being mean.

But, there is a reason we are as tough as we are. We believe strongly that the physiology of an eating disorder must be treated first. Reality is that eating disorders have  a major impact on the brain, and simple starvation alone, as evidenced by the Ancel Keys' study, will create many of the symptoms we think of as eating disorder symptoms. A few books have a good summary of the Keys study, but probably one of the most accessible is in Intuitive Eating by Tribole and Resch.

Because we know the impact of the eating disorder symptoms on the body, mood, functioning, social interaction, etc., we set terminating the symptoms as our initial primary goal. As a therapist, I am aware that trying to do therapy with someone in the midst of ED behaviors is of very limited benefit. One way to think about it is this: If you have an ED, how well do you remember your first, or probably even first few, therapy appointments. In the moment, you felt really with it and like you were fully functioning, and you likely even seemed to your therapist like you were totally with them, but reality is that very few patients remember those initial sessions. So, therapists can walk out thinking they just did excellent therapy but sadly, their therapeutic interaction had little effect because the physiological impact of EDs is so profound.

Dietary sessions are of course focused on ending ED symptoms, but in our model, so is therapy. The best way I can summarize it for patients, and now for you, is:

        "Trying to do therapy with someone engaging in eating disorder symptoms is about as 
        effective as trying to do therapy with an alcoholic in a bar."

Imagine, I ask the inebriated alcoholic how he feels. Riiiiiight. How can therapy be done in that situation; the substance is masking the person's emotions. Same for an eating disorder.

So, the initial goal has to be terminating symptoms, as much as that is the last thing the patient wants to do. But, what we have noticed is that patients develop an understanding of this and are able to buy into this goal, for the most part. And in doing so, they are battling their disorder, and they are winning. And, then, once they have it under their control, the real therapy begins.

And, I'll confess, I enjoy this second of stage much better than the first stage too.

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