Wednesday, August 22, 2012

Removing permission to purge

A couple years ago, admittedly a little further along in treating eating disorders than probably ideal, I noticed something. I noticed that when patients with bulimia talk about their symptoms, they would view bingeing and purging as essentially one symptom. And, so, for too long, I too responded as if they were one. When they are one symptom, though, bulimia is incredibly hard to treat. It seemed it was too much to give up both bingeing and purging at one time, and progress seemed to happen slowly.

Then, one day, it occurred to me that they were two separate symptoms, and should be treated as such. And, in that session, I finally realized that purging "allowed" bingeing to happen. As long as the person had "an out" (please do not read this as saying people WANT to purge, that is not my point) with purging, they were "more able" to binge. So, I started with that one patient and talked to her about the possibility of "removing the permission to purge." We talked about how, if she were to no longer allow herself to purge, would she binge? And she admitted that, without purging as an option, she would not be as likely to binge.

So, we moved forward with this concept of "removing the permission to purge," and sure enough, she first stopped purging, and shortly thereafter, stopped bingeing. Now, as this happened, we of course had to deal with all the underlying emotions and thoughts that came up as those ED symptoms were terminated; I make it sound simple here, but it is anything but, I know. But there seemed to be a lot of power in the concept of "removing the permission to purge."

Since, I have introduced this concept to each patient I work with who engages in bingeing and purging. And, as with many things I propose, patients first look at me like I have grown a second head and most certainly lost my mind, but as we talk about the rationale, they eventually become willing to give it a try. It would be ideal if refusing purging meant one never binged again, but that simply isn't the case most of the time. Most patients have been in the position of having to "sit with" a binge, but time and again, that sitting through a binge without purging has created enough of a negative experience that the patient's bingeing decreases dramatically, if it doesn't stop completely. Patients talk about feeling more in control, more confident, and feeling less pull from the eating disorder symptoms.

Of course, once the symptoms stop, the real therapy begins, so they are far from cured. But as I will discuss in another post, the symptoms must stop first for the deeper work to begin.

So, consider it....what impact would it have on your eating disorder if you "removed the permission to purge?"

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