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Thursday, 21 April 2011

Top Tips For Working With Eating Disorders: Counsellors Must Get Anxious Too

I wrote a few days ago that clients must be a little and sometimes a lot anxious for therapy to work. We therapists must be able to tolerate our own anxiety too.

My own experience mentoring therapists is that can get very anxious. Someone may be losing a lot of weight and nothing the therapist does seems to stop this from happening. Someone with bulimia may be reporting very frequent purging. Someone with anorexia is gaining a little weight and then there is a setback; weight goes down, someone seems to “stop trying”.
Or a person with a weight problem is doing very well. The therapist is anxious, can she keep it up? The client seems to be a little less motivated; is she heading for a relapse?

Carers’helplessness can make a therapist very anxious too. The carer come to us saying “This therapy isn’t working! My son/daughter won’t talk to me! Why aren’t you able to stop her or him from losing weight now!”

Or maybe our client tells us that their parents seem to be at war with each other. Why has a parent bought their anorexic child a gym club membership for Xmas? What on earth is going on?

Therapists can get very anxious because they simply do not know what to do next with someone who seems to be very stuck; we start off by considering ourselves as the client’s white knight and then we start thinking of ourselves as a bad therapist. None of this anxiety is going to help the client in the end.

One way of preventing anxiety is to suspend any emotional interest in recovery, weight loss - or even weight gain if it comes to that. This surprises people. Surely is it natural for us to praise the anorexic who gains weight and to praise the obese person who loses it? The whole slimming industry is based around rewarding people for weight loss - with gold stars, medals and badges of honour. We pat anorexics on the back for weight gain, which they hate - and only confirms to them that they might be getting fat.

And surely it is useful for us to want our people to recover? Yes, but we must have personal investment in this. Our clients must want it – not us! So we must simply be willing to stay beside them on this journey. While praise and criticism may work a little in the short term, it hardly helps in the long term. By rewarding weight, for example, we are rewarding the wrong thing – people are not always happy if you reward weight change because you are not rewarding what really counts, their efforts, or their willingness to learn new things. You are simply teaching them to look to you for praise and to be scared of your disapproval if they fail. This is hardly good practice and it does not teach people how to motivate themselves when the going gets tough.

This kind of struggle for position with a therapist was well described in a recent conversation with a therapist who had this to say about her anorexic client:

“The Client made me feel like I wanted to rescue her and not be yet another person who let her down. This level of anxiety required containment as was achieved through the establishment of a relationship that was one of listener yet provider of education, settler of tasks and presenter of hope.”

The therapist needs to deal with the fear of letting the client down because sometimes our clients come with impossible expectations of therapy and a therapist that can never be met. It is clear that therapists can be neither to be the white knight nor the abuser. If we focus too much on being good enough for our clients we may miss what the disorder is communicating about our client and their motivations.

By the same token it isn’t really helpful to get anxious if weight falls during recovery from anorexia. It could just be a blip and we need to wait and see before getting in to a panic. Weight does not always follow a straight line and it is better to wait and see what is really going on. If I am working with someone whose weight is truly falling week by week, I tend to stay calm as a cucumber. I would say “the Voice seems to be shouting at you at the moment. What do you feel you would like to say to it?”If weight is going really low, I might say something like this “It seems to me that one way of taking care of yourself is to get so weak that you will have to go to hospital. Another way of taking care of yourself could be to eat a little more. I wonder which of those feels best for you.”

So we therapists need to be able to tolerate uncertainty (Waller 2010 CBT Today) without panicking. If we are worried about the weight of a client we are not able to focus on what the undesired change is telling us. It is much harder to be half way recovered from anorexia than it is to be in denial about how unwell you are. You may have gained weight, but you will have lost everything that the disorder did for you without feeling any of the benefits - yet.

If someone seems to be stuck, there are many reasons why this is so. Taking supervision is a very good idea of course and sometimes you may have to consider putting therapy on hold. You can say “We have come as far as we can – for now”.

And if someone fails with yet another weight loss plan you are coaching them in - it could be that you are not in touch with everything they believe is bad about weight loss. One obese person confessed to me that he felt that people who don’t let themselves overeat at holiday times “are boring”. Why would he want to be like that? The therapist panics and misses the opportunity to listen to what the client has to say.

An anxious therapist is one who gets easily angry and into blaming mode: they aren’t trying; they aren’t ready: they are rebellious and naughty. This therapist is not resourced and will not serve their client well. If I am mentoring an anxious therapist I will turn my attention to the therapist’s anxiety rather than the client’s apparently difficult behaviour. What does this anxiety remind you of? What are your beliefs about uncertainty?

Calm down and let the bad ideas go, and maybe something inspirational will come to you both. From ”sufferers” out there in the community, some with long standing problems and some just newly captured by an eating disorder, I hear a lot of bad things about therapists who get angry and abusive, who give people clearly inappropriate treatment, or unwelcome labels without thinking what they are saying or what that will mean, who haven’t listened, or who simply do not speak the unique language of an eating disorder. How can any eating disorder therapist fail to understand the Voice? Most of this boils down to anxiety. We all need to be able to tolerate anxiety without panicking.

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