Therapy Eating Disorders: Increasing Structure in Outpatient Treatment of Anorexia Nervosa and Bulimia

Medical Evaluation and Structure

It is important to have clients see a physician for a thorough physical examination, including comprehensive lab work, to assure their medical safety while outpatient psychotherapy treatment is taking place. Addressing any medical risks and subsequent medical needs with a physician is an essential structure for outpatient therapy for eating disorders. This medical attention is an important way to increase the professional presence and support for the client in a more multi-disciplinary approach to treatment. It is important for you, as the therapist, to identify physicians with whom you can have ongoing discussions, at least on a periodic basis, to talk about assessment, medical needs, and progress of these individual clients. It is important for both of you to be saying the same things to the client. In the medical evaluation, it is important to do the following:

– Carefully examine lab work, to identify any potential electrolyte imbalances, including sodium and potassium irregularities, which could cause heart arrhythmia or other organ damage. - Address gastrointestinal difficulties or irregularities including slowing of gastric emptying, which occurs in many eating disorder clients, as well as extreme patterns of diarrhea, constipation, bloating, and esophageal damage such as dilation or rupture, constant sore throat, or reflux. - Explore coronary problems and potential risks associated with long-term eating disorders which can include significant arrhythmia, chest pain, slow heart rate, low blood pressure, reduced body temperature, weakness, and fatigue. EKG or other tests may be warranted. - Discuss amenorrhea or other irregularities in the menstrual cycle and closely examine histories of being underweight for body type or extreme weight loss or changes over time. - Look for dental and bone problems like osteoporosis, tooth decay, and gum erosion, and question for constant headaches, fatigue, and abdominal pain.

It is also important for the physician to address the need for psychiatric medication such as antidepressant or anti-anxiety medication for those who are suffering with an eating disorder. In the assessment, you or the physician can make a referral to a psychiatrist for a complete evaluation, or your client’s selected physician can address and monitor the use of the psychiatric medication.

Dietary Intervention and Structure

When considering treating a client with eating disorder behavior, it is essential to have the proper dietary guidance and consultation in order to help the client successfully address the nutritional aspects of the eating disorder. It would be wise to find a dietitian who has worked with eating disorder clients and has expertise that will ensure proper treatment.

By utilizing a dietitian you will not have to expend as much energy talking to the client about food and diet. Also, clients tend to believe dietitians more than therapists with regard to guidance on normal body weight, dietary concerns, and living in a healthy way. Utilizing a dietitian also increases the size of the client’s support network, offers additional intervention, and provides one more member of the treatment team working together with the therapist in taking care of the client’s needs.

A dietitian, with the right set of expertise and skills, will be able to provide treatment for your client in ways that you will not be able to. A dietitian will be able to provide a structure for eating that will allow you to focus mainly on the emotional and problematic areas of the client’s life.

When looking for a dietitian to work with outpatient clients who have eating disorders, consider the following:

– Find a dietitian who has had experience working with eating disorder clients and who treats them differently than clients with other dietary issues. - Look for a dietitian who can provide structure and yet simplicity in her approach to eating disorder clients – one who does not focus on dieting, watching fat grams, and counting calories, but who understands the obsessive nature of eating disorders and can provide needed structure and guidance without increasing obsessive ruminations. - Find a dietitian who is familiar with the exchange program, food pyramid, and intuitive eating and can mix and blend these approaches to meet the needs of her eating disorder clients.

A good dietitian is an invaluable asset to a therapist in the treatment of a client with eating disorders.

Emotional Support and Structure

Emotional structures and support for the client can come in many forms. Emotional support can come from providing material goods, including and accepting a client, creating a sense of belonging in a group, offering referrals to other sources, and by just “being there” for them. Emotional support can be significantly increased by utilizing family and friends in the structure for clients. It is easier to provide emotional support on a regular and consistent basis if one has a structure or a model from which to work. It is important to create an emotional structure that will allow consistent and regular emotional support. Ideas for Creating Structure for Emotional Support:

– Ask the eating disordered client, family members, or friends for help. Ask them to contribute in maintaining a home and relationship – to take part in tasks in the family system or in the regular activities of friendship. It is important for a client to feel needed and to feel that they have “something to offer.” Clients often feel like a burden and feel guilty and “psychologically in debt.” It is not only “okay” for family members or other loved ones to ask the client to help them, but it is important. No matter how simple the request is, whether it is to sweep the floor, take someone for a ride, or listen to someone else’s struggles, there is a need for everyone to feel important and to feel that they are not only receiving, but are giving to others, and that what they have to offer is of worth. - It is important to help family members and friends ask the client how they are doing emotionally and ask about their emotional condition on a regular basis. It is also important in these discussions for family members and friends to express their feelings to the client, and explain that the invitation is to have an emotional dialogue and communication rather than just talking about thoughts or behaviors. Bringing structure and regularity to this emotional sharing, such as making a commitment for family, friends, and loved ones to “check in” on a daily basis to see how the client is doing, may help provide some structure with the emotional support. - Helping family members and friends delineate a “small role” or a small task in helping to support a client in the recovery process is important. It will help family members and friends feel less helpless, less resentful, and less panicked if they have their own small way of helping, no matter how insignificant it might seem. Having a specific, small role is helpful. For example, in a family a younger child might be asked to just ask the eating disorder client to play with them a couple of times a week as a way to include the client in the family. - Family meetings can be a helpful way to structure emotional support. Topics in these meetings might include: discussing jobs; roles; accountability; making refinements; clarifying “double messages,” confusion, or incongruence; and giving a constant reminder or invitation to talk and give reassurance that family or friends are present and available to the client. - Asking clients to express emotion on a regular basis is important. This might be on a daily basis. Forms of expression may include writing, letters, journaling, talking on the phone, talking face-to-face, meditating, relaxation, or imagery.

Behavioral Structure

Behavioral assignments within the context of outpatient therapy are an important component of structure for eating disorders. They can also be the most difficult to utilize and sustain in an outpatient setting. Behavioral structure can help a client to begin to feel a sense of control over her disorder and to have hope for the possibilities of getting well.

It is helpful to use concrete and specific structures in the early months of outpatient therapy. Obviously, you have to assess the appropriateness of the behavioral intervention for the specific client, but the key to behavioral structure is the emphasis on commitment, follow-through, and accountability because avoidance is a major coping strategy for eating disorder clients. It has been our observation that nearly all women with eating disorders need some behavioral structure. They will benefit if they know that the structure is there to support them and help them in their recovery.

Family Intervention and Structure

It is important to involve families in treatment wherever possible. This means that the client should be treated, even in individual therapy, with the family context in mind. Eating disorder clients are a part of the family system. Consequently, eating disorder treatment requires a recognition of the role or function of the eating disorder within that family system. Families can become involved in treatment in the following ways:

– They can become educated about eating disorders by reading books and articles. - They can attend support groups if they are available. Support groups can provide an atmosphere that allows family members to talk about the stress, emotional damage, and difficulties an eating disorder has caused them. Support groups are a good outlet where family members can express their feelings and deal with their own personal pain without attacking their loved one. - They can be involved in therapy. Initially, this may be difficult, depending on where the eating disorder client is in the recovery process. When appropriate, involve the family in therapy to empower them to deal with the eating disorder. Teach them how to support their loved one through recovery, develop correct boundary systems, and look at the inter-generational roles that have been handed down and which can impact family dynamics. Teach them to look at their own personal issues with self-esteem and selfimage, as well as any other issues with body and food, or other family dynamics that can trigger or cause the eating disorder to worsen. - It is important to address family rules about food, body image, societal image, and expectations about how one is to live and eat. If problems are found in the family system, it would be advisable to make recommendations for further treatment for family members, whether individually or otherwise, to aid in the family’s healing. - Multiple family therapy is another valuable option for treatment. If you have several clients who are struggling with eating disorders, it might be helpful to have families come together to learn from each other about eating disorders and their impact on them as families and on the clients. Often, clients learn a great deal from watching other families go through the same dynamics that they are personally going through with their own family. - In family treatment, it is important that family members know what their roles are in helping a client get over their eating disorder. Everyone should have a job, no matter how small and insignificant it may seem. Having a job helps family members feel less helpless and therefore less resentful and panicked, and can help put them in a better place to help the client in ways that are truly needed. The job of one small child in helping an eating disorder client might simply be saying “I love you” to the client on a daily basis. - Family meetings where the client moderates the discussion about jobs, roles, accountability, and making refinements helps the family to feel empowered and helps the client to have self-respect. - Family council meetings are also an important means of helping the client and family members decipher and get rid of double messages and confusion, and begin to communicate clearly, directly, and more effectively with each other. - It is important for the family to provide meals served on a daily and regular basis. It is also important that these mealtimes not force the client to eat, but provide structure, security, regularity, expectations, and agreements which will help the client eat.

Eating disorder clients need to be treated with the family in mind in their therapy, regardless of how much face-to-face family therapy takes place. Make sure the family is not blamed for the eating disorder. The vast majority of parents of a child with an eating disorder are good parents who extend themselves on behalf of their children. The client’s goal in treatment should be to become emotionally independent while learning to enjoy meaningful connections with family members.

Group Intervention and Structure

Group therapy is one modality that is important in the comprehensive, multimodal, and multidisciplinary team approach for outpatients suffering from anorexia and bulimia. There are many types of groups possible including support groups, structured groups, themeoriented groups, and experiential therapy groups. The mainstay for group treatment in eating disorder outpatient treatment is the open process oriented therapy group. There are many advantages to group intervention for eating disorder clients working in an outpatient setting. In addition, group treatment rounds out a full outpatient treatment program which includes individual therapy, group therapy, family support groups, medical treatment, and dietary counseling. Some research has suggested that clients with eating disorders may respond better to homogeneous rather than heterogeneous psychiatric therapy groups. Some of the advantages of group intervention are as follows:

– It allows women with eating disorders to be exposed to other women with eating disorders. They no longer feel like they are alone in their struggles and conflicts. - It allows clients to feel connected and gives a sense of belonging, which they have often not felt for a long time. - It allows them to learn things from each other that they cannot learn from a therapist or in individual therapy. - They can see other clients struggling, which can be a constant teacher and reminder of what they don’t want, thus leading to positive motivation toward recovery - They have the opportunity to see others’ successes and victories in the recovery process, which increases levels of hopefulness about the possibility for getting well themselves. - It allows for one more meeting time per week to offer more structure and support, which helps clients maintain their progress between less frequent individual therapy sessions. - “It takes one to know one,” is a prophetic clich for group therapy with clients who have eating disorders. Since they know each other’s patterns, thoughts, and games, they have the opportunity to give more accurate confrontation and help each other become more honest. - Clients have opportunity for healing from shame and guilt which surrounds their eating disorder habits, past mistakes, or history of abuse by revealing what previously were secrets and feeling love and acceptance despite past difficulties, behaviors, or problems. Sharing in this manner can lead to feelings of acceptance, comfort, and healing.

Running outpatient eating disorder groups can be challenging, especially since there is a high propensity for people with characterological disorders to end up in these groups. As many as 30% of those suffering with eating disorders severe enough to require inpatient treatment have personality disorders. It can also be challenging due to differences in levels of motivation and levels of recovery. Some people ready to work hard in therapy may feel that group therapy becomes encumbered by those who do not seem able or ready to take advantage of that format. Still, group therapy is very important for outpatient treatment. Due to the concerns and struggles in running an outpatient eating disorder group, the following guidelines and suggestions are given:

– Do screening with participants in group to ensure they have an adequate level of motivation prior to being allowed in the group. - Make sure that the clients are involved in regular individual therapy and other modalities of full, comprehensive outpatient treatment before they are allowed to participate in a therapy group. - While the client is involved in outpatient group therapy, individual therapists and group therapists should collaborate to capitalize on the therapeutic progress in both. Collaboration will allow accelerated progress in treatment. - Care should be taken not to allow “war stories” to be shared in group. New members in a group may tend to use the group format to compare eating disorder behaviors in an inappropriate and unhealthy way. - A structured group program such as Dialectical Behavioral Therapy created by Marsha Linehan (Understanding Borderline Personality Disorder, The Guilford Press, 1995) may be useful in allowing clients to take responsibility for the work that gets done in group. - If the group is having difficulty generating work, the therapist should feel free to create structure and generate some energy and work in the group to help clients get through any slow times that occur.

Issues to Address in Outpatient Therapy

The following issues are important to address in treatment of clients with an eating disorder:

Relationships: Relationship issues and patterns are important to address in the beginning phases of therapy. It is important for an outpatient therapist to intervene in relationships before the client gets to a place where she is frequently stuck and where family relationships are very seriously damaged. The eating disorder can create such emotion, tension, dishonesty, anger, resentment, hurt, and misunderstanding in relationships that it is important to begin early to involve loved ones of the client so they can become a more supportive, firm, and loving system for the client. It is important, early in the relationship, to build trust with the client and to “get emotional money in the bank.” This is very important due to the trust difficulties typically seen with eating disorder clients. It is important to build a relationship so that the difficult work can be done and you can model healthy dynamics and relationships.

Address the negative mind: It is important early on to teach the client about “a negative cognitive set.” You can teach clients a cognitive behavioral approach to understanding the difference between thoughts and feelings and recognizing the impact thoughts have on their feelings. You can help them become aware of the negative mind and the negative self-talk that happens inside, and the damage this does to their self-esteem by fostering self-hatred and negative feelings about themselves. In the same frame, it is important to separate the client from her eating disorder and help her learn to fight against the negative mind and the eating disorder instead of fighting against herself.

Spiritual connections: Many clients have spiritual difficulties due to feeling guilt, unworthiness, and the lack of closeness to a Higher Power or anyone else. Due to poor relationships in the past, old pain often gets in the way of believing that there could be a loving God who cares about them and is not manipulative, abusive, or would not reject them because of their felt unworthiness. Clients often push people away and withdraw, not only from their relationships with themselves and others, but also from their relationship with “a higher power.” Spiritual connectedness gives the client a sense of purpose and value in themselves and a belief and hope in their innate ability to recover and to find purpose and meaning in life.

Perfectionism and personal expectations: Often, persons with eating disorders struggle with a need to become more and more perfect-they believe that if they could just “do it the right way” or if they could just control their world, then everything would be okay. This issue needs to be addressed in treatment to help them become less rigid and more capable of understanding their own personal expectations, as well as what they believe others’ expectations of them are. They need to understand how perfectionism interferes with their growth and development. They also need to see how this contributes to their need for the eating disorder. Since no one can be perfect, clients’ inability to achieve that goal creates such dissonance and feelings of failure that they will use the eating disorder to cope with these feelings. Since perfectionism is their solution to beliefs that they are “not good enough”, addressing these beliefs directly is important.

Adaptive functions of eating disorders: It is helpful to go over the adaptive functions of eating disorders with clients to show them that their eating disorder has become a way to mask or cope with their pain, their feelings, their stresses, and their fears. Addressing and helping them understand what it is they are trying to avoid in life can give them insight and help increase their ability to deal with their life in a healthy, functional way. They will begin to see that the effects of coping in a healthy way are far more positive and good for them than hiding and running away through their eating disorder and other behaviors.

Acknowledging, understanding and accepting feelings: It is important to help clients begin to feel again, since they have been so adept at shutting off their feelings. One way to do this is to have the client journal and keep a diary so that they can become more aware of their thoughts and feelings. This will also provide more insight into issues in their lives and their relationship to the felt need to restrict, to binge, or purge. Allowing feelings without self judgment for those feelings is critical.

Expanding their world instead of constricting: This notion goes along with relationship development but goes further in terms of helping clients look at other facets of life and other support systems they could develop in order to expand rather than constrict their world. This exercise helps clients feel more hopeful and encourages them to expand their talents and look for good things in themselves and in their relationships with others instead of shutting things out of their lives that could bring them joy. This exercise also encourages them to take risks by stepping out of their comfort zones which helps them to build more confidence. Helping clients find again their dreams and passions can expand their possibilities, excitement for life, and hope for the future.

Identity and attention needs: Often, a woman’s eating disorder is an attempt to develop a sense of identity-a niche for herself where she can be special and exceptional. These issues must be addressed for the client to be able to understand the destructiveness of the eating disorder. They need to be able to address how their needs are met through illness and that their needs can be also met through wellness.

Walk the talk: Help clients develop more congruency in what they say and what they do. Part of therapy must focus on helping clients develop more congruent behavior that matches “the talk.” Honesty, integrity, and self respect come out of efforts to be congruent.

Predicting treatment ups and downs: It is important that clients be given an understanding early on about what they will experience in treatment. Help them understand what the process of change is and give them a model of what they will go through so they will not be surprised. Teach them that their recovery difficulties can be predicted, so they won’t get discouraged or feel guilty about inevitable struggles, mistakes, and bumps in the treatment process.

Teach the concept of teamwork for recovery: One of the most important aspects of treatment is having a team approach that includes medical, dietary, psychological, and spiritual considerations. Family, community, and friends also need to be included in treatment whenever possible. It is also important to help the client expand their circle of support, not only in quantity and breadth, but also in depth. Teach them how to ask for help to replace the hollow and empty promises of an eating disorder.

Facing shame: An important issue to address in the context of therapy is a client’s intense feelings of shame, self-hatred, and self-contempt that are often at the very core of the eating disorder. Many with eating disorders feel unacceptable to themselves and to everyone else and they tend to be very rigid in their thoughts and beliefs about themselves. In the context of their self-contempt, they tend to be very self-punishing. To make that mental process explicit and to have it be an ongoing therapeutic discussion is important in the therapy of eating disorders.

Comparing and competing: It is important to address clients’ intense tendency to compare to and compete with other people-especially other eating disorder sufferers. Clients all too often compare themselves with others in hopes to feel good, or as self damaging ways to make themselves feel bad. Their competitiveness is part of the same pattern where they say to themselves, “Somebody has something that I don’t have,” (which is usually eating disorder related) “and that means they are better at the eating disorder than I am.” It is important to help them, over the course of time, to address the underlying purpose or function of the comparing and competitive jealousy. Help them begin to challenge that negative purpose.

False guilt and boundaries: Another therapeutic theme for many clients is excessive false guilt in which they feel bad about themselves and experience intense feelings of guilt over things that do not, in fact, belong to them. They feel guilt over the inability to be perfect, or they feel guilt over their powerlessness to change struggling family members. Address the false guilt and help them understand the difference between the feelings of having done something wrong and the feelings of being powerless to fix, change, or make a situation better. Many of those with eating disorders have emotional boundary issues and dilemmas. It is essential to help them address internal and external boundaries and to address responsibility for their own, internal self, and not the internal selves of other people.

Finding middle ground: Black and white thinking, mind reading, and personalization are common cognitive distortions of eating disorders. It is important to establish or adopt a strategy that lies “somewhere in the middle” rather than out on the extreme ends of the spectrum of choice. Any kind of work to help a client see an alternative “middle of the road” perception, strategy, or emotion is a helpful focus in outpatient therapy.

Telling the truth: Addressing dishonesty, deception, and secrecy is a very important therapeutic issue in the treatment of eating disorders because one of the keys to recovery is for clients to take ownership or responsibility for themselves. It is also in the honest expression of their feelings and thoughts that hope for recovery comes. Sharing what is really going on or what they have really done, with honesty, directness, and clarity rather than keeping it vague, hidden, and secret, is a major change for them. For many clients, giving up their secrecy is the point when things start to improve for them.

One message at a time: Direct communication that does not include multiple messages is a very important therapeutic theme and intervention in outpatient therapy. Clients often communicate very indirectly and sometimes send double messages about what they are trying to express. Helping them to communicate specifically, directly, with only one message at a time, even if it is to themselves, is a very helpful ongoing intervention. It is important to have the client look at the double messages they give in their communications. They often say they want to get well yet they seem to act in favor of the illness. Oftentimes they say things they do not mean since they are often in an image-based role of pleasing other people and therefore are frequently dishonest with themselves and others. Honest communication can open the door to change.

Explore painful childhood decisions: Addressing family issues with the client from the perspective of a child and demonstrating how, as a little girl, she may have interpreted things, made decisions, or arrived at emotional conclusions based upon some of those interactions, can be a very healing and important part of therapy. Through this exercise clients begin to see that some of the beliefs, feelings, and strategies of their childhood have continued on into their adulthood and now perpetuate the eating disorder. They need to see that the eating disorder is an expression of those early emotional and often painful decisions or conclusions.

Separations: Addressing the separation between who clients are and their eating disorder is an important step in the recovery process. If the client can begin to see the eating disorder as separate from themselves and not as part of their identity, then they can begin to empower themselves to change the eating disorder pattern without the risk of losing themselves. It is also important in terms of helping them correct, let go of, or amend the eating disorder consequences that have impacted them and others for many years.

Taking risks: Because eating disorders are so fear and avoidance-based, it is important, at the appropriate time in recovery, to put a great deal of emphasis on risk-taking in which the client faces fears, challenges themselves to do things differently, and steps out of their comfort zone and rigidity. This risk taking can be on an emotional, behavioral, communication, or relationship level. Having an ongoing emphasis on taking risks and facing fears is very helpful whether they succeed or struggle. Avoidance often maintains low self esteem and therefore, facing fears is imperative to recovery.

Inpatient Structure The complexity of eating disorders and their associated issues should be apparent from this article. Treating eating disorders in an outpatient setting can yield success, but it takes a dedicated, multi-disciplinary approach and may take longer than some may hope for. Severe eating disorder illness may need to be treated in a controlled and structured inpatient facility where the rigid cycles of self-hate and self destruction can be supervised and addressed around the clock. Outpatient therapy can then again be used to support and aid the client’s ongoing recovery from the eating disorder through aftercare which is so important.



DBT for Eating Disorders – This video demonstrates how to implement techniques of Dialectical Behavior Therapy, particularly emotion regulation skills, when working with clients with eating disorders.


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