This article is an attempt to describe an approximate treatment regimen (psychotherapy) of eating disorders (RPP), understandable to the client.
I hope that for those who suffer from or suspect RPP at home, this article will help, firstly, to understand how best to choose a specialist, and secondly, to learn how all work on the treatment of such disorders is usually built, and thirdly, see what you’ll need to work with directly.
Immediately make a reservation that this is only an approximate scheme.
The first one. When working with a specific eating disorder will have its own nuances. For example, keeping a food diary with bulimia and psychogenic overeating is an important part of the job, while with anorexia, on the contrary, it will not be useful.
The second one. Some stages of work, namely 4-8, may not go in the same sequence as described here.
And the third. The specific strategy, stages of work will depend on the specific client and the specific specialist.
However, despite the remarks mentioned above, I hope that for most people with eating disorders, this article is more likely to make it easier to understand what competent professional treatment or therapy should look like.
So, if you suspect yourself of any of the RPPs, then the first question that you most likely will have is “to whom to go for help?”
Here are some important criteria when choosing a specific specialist:
A. The presence of higher psychological / medical (with retraining in psychotherapy) education.
That is, you first of all need either a psychologist or a psychotherapist. Neither a nutritionist, nor an endocrinologist, nor a coach, nor a gastroenterologist treats eating disorders.
B. Additional specialization in at least one of the areas of psychotherapy.
Specialization is a deeper theoretical and practical development of some of the methods of psychotherapy, usually lasting at least 3 years. This can be gestalt therapy, cognitive-behavioral, dance-motor therapy, psychoanalysis, etc.
B. Availability of personal therapy and supervision.
Personal therapy is when a specialist goes to another psychologist / psychotherapist to work out his “white spots” and not bring his own problems to work with clients. And supervision helps, under the guidance of a more experienced colleague, to analyze real cases from practice and improve the quality of their work.
G. Specialization in the field of psychotherapy of eating disorders is highly desirable.
Since we still have, unfortunately, no large full-fledged training programs (the same as in other areas of therapy), in this context appropriate training from foreign specialists or advanced training from Russian specialists who have undergone internship abroad may be appropriate. People with RPP have their own important features, and psychotherapy with RPP has their own important nuances, so it is so important that the specialist is aware of this.
What will not be significant when choosing a specialist:
- whether he works privately or in an organization, as psychologists have the right to work as private specialists
- availability of reviews on the Internet, since people suffering from RPP rarely though advertise (even anonymously) that they turned to someone for help on this subject
- the cost of services, since it is mainly determined by regional specifics, the costs of a specialist for his activities and other factors not directly related to work efficiency.
It is also natural that after the first meeting with a specialist you can refuse his services if something confused you, didn’t fit, disappointed, etc.
If you feel that it is this specialist who can really help you, then the construction of the so-called psychotherapeutic relationships.
This is a relationship created between you and a specialist for therapeutic purposes, which is characterized by at least the following:
- they are created solely to help you treat your eating disorder (and possibly related life problems)
- they are confidential (the specialist does not tell anyone else about you, except for cases specially agreed with you in advance)
- in these relationships you will be guaranteed to listen, accept any of your thoughts and feelings, you will not be evaluated, criticized, insulted, humiliated, forced to do you anything beyond your will
- these relations have their borders (frameworks), in particular, temporary, financial and others, which you discuss at the very beginning with your specialist
- they are psychologically and physically safe
It is these characteristics that distinguish psychotherapeutic relationships from friendships, relatives, collegial, etc.
After you start creating such therapeutic relationships (and they are formed in more than one consultation), you can more accurately diagnose the type of RPP that you have. This is important in order to more accurately determine the future strategy of work. Since with different violations there will be nuances.
Types of eating disorders, distinguished by most experts today and their brief features:
A significant decrease in body weight due to dietary restrictions, a constant fear of gaining weight, a distorted perception of one’s appearance.
Regular overeating associated with subsequent compensatory behavior (in particular, inducing vomiting), a strong dependence of self-esteem on the figure and body weight.
B. Psychogenic overeating.
Regular overeating, a pronounced feeling of guilt or shame because of this, as a rule, overeating is associated with emotional factors.
G. RPP associated with avoiding or restricting food.
More often manifested in children in the form of rejection of many foods, weight loss, lack of nutrients, reduced psychosocial functioning.
The obsessive idea of proper nutrition, manifested with increased anxiety related to the topic of food, the choice of the “right” foods, a shift in vital interests in the field of nutrition and healthy lifestyle, etc.
The obsessive desire to build muscle, more common in men.
The desire to lose weight on the background of pregnancy.
Replacing food with alcohol to lose weight.
It is also worth mentioning that, despite the presence of rather strict criteria for the majority of eating disorders, each individual person has his own personal history behind his disorder. Which cannot be described by “dry” criteria.
That is why the criteria serve only as an initial guide. Much more important is what happens in the subsequent stages of RPP therapy.
After an approximate determination of the type of RPP, it is in your case that a specialist can identify the so-called "Concomitant disorders", which are often found in a given eating disorder.
For example, depression, anxiety disorder, obsessive-compulsive disorder, etc. can be a frequent “companion” of anorexia, bulimia and psychogenic overeating.
In such cases, it is important to determine where the cause is and where the effect is. And to set a task for the treatment of this concomitant disorder, too.
And the last thing that is important at the stage of diagnosing RPP is determining the severity of your condition in order to understand whether the help of other specialists, in particular doctors, is needed.
In some cases, such assistance may be useful, and in some it should even be primary.
- there are suicidal thoughts or behavior
- there are serious somatic pathologies caused by RPP
- body weight is critically low, and because of this there is a threat to health
- there are suspicions of the presence of another serious mental disorder (clinical depression, schizophrenia, alcoholism, etc.)
- and in some other cases.
Then the specialist whom you contacted initially may recommend that you go to a psychiatrist, gastroenterologist, narcologist, or go to hospital.
After the diagnosis, it is often important to collect as much information as possible about your current life and directly eating behavior.
Because this information can significantly expand your understanding of how to work further, what to focus on, what your eating disorder is related to, and what kind of time it will take the whole treatment.
This kind of information may include information about your family, work, health status, hobbies, your previous attempts to deal with this problem, as well as some significant stories from your past, including childhood.
So, for example, if at this stage of the work it turns out that in the past you experienced the trauma of losing one of your parents or prolonged abandonment in early childhood, then the working hours can be increased, and instead of six months, for example, your therapy may take a year or more.
In addition, at this stage of the work, your current eating behavior is most often considered: why, when, what, how and how much you eat, what feelings and thoughts this is accompanied by, what settings affect your nutrition.
This information allows you to more accurately determine the targets for the next stage.
Often, eating behavior therapy itself begins by observing aspects of nutrition that are not usually recognized.
To do this, a specialist may ask you to start writing down what and when you eat.
I must say that even this one, it would seem, a simple task already gives many clients food for thought.
For example, someone may notice that he eats substantially more than he previously thought. Or, conversely, a person may find that in the main meals he eats quite moderately, and overeats only in some cases.
Further, other tasks can be added to these records.
For example, start recording bodily sensations during and after eating. Or your emotions. Or thoughts.
Thus, it gradually begins to form awareness in nutrition. And a person notices and builds those connections between food and his mental processes that previously remained invisible to him.
For example, one client noticed that after eating, she often thought that she had overeaten, because of which she began to blame herself. When I asked her what exactly her thought was based on, she could not answer. That is, it was just an irrational belief. Suppose she took a soup and a second for lunch, and automatically began to consider that it was “a lot”, that she would overeat. Because of which, naturally, she blamed herself. When I asked how her body felt after such a "plentiful meal", she replied that it was wonderful: there was neither heaviness nor pain in the stomach. Thus, thanks to the observation of nutrition, her sensations, thoughts and feelings, she was able to detect a number of irrational attitudes that prevent her from feeling comfortable during and after eating.
At the same stage, the specialist can give various tasks so that you can better see the hidden mechanisms that control your eating behavior.
In the treatment of almost any eating disorder, a person has a so-called. "Irrational attitudes."
These are the settings in which, on the one hand, we believe without looking back, and on the other hand, we cannot prove them logically or from the point of view of common sense.
And the problem is that these attitudes, including in our subconscious, often lead to unpleasant emotions and irrational behavior, including in the field of nutrition.
For example, a person may have an irrational attitude "you can not eat in the evening."
Accordingly, if this person does eat in the evening, then with a probability of 99% he will feel guilt or shame. And further, also with a probability of 99%, he will either begin to limit himself in food the next day, or he will run to the gym to burn extra calories, or he will go and put two fingers in his mouth.
In the meantime, the “can not eat in the evening” setting is completely irrational. Firstly, because the feeling of hunger is a physiological mechanism that regulates our diet, and if we are hungry at 21:00, then the body needs food at 21:00, and not at 18:00. Secondly, because food eaten in the evening, it is also absorbed by the body, and not stored 100% in fat. And thirdly, because a huge number of people eat in the evening (and even at night!), But at the same time they do not grow fat, their health does not deteriorate and they do not complex at all because of this.
If a person in the process of psychotherapy was able to detect such an attitude and replace it with a rational, adequate one, then this will undoubtedly positively affect his emotional state (he will no longer feel guilty in such cases) and his eating behavior (he doesn’t will limit itself and provoke further disruption).
Settings may concern not only nutrition, but also weight, appearance, beauty, relationships with other people, etc.
Some irrational attitudes are easy to identify and correct, and some are extremely difficult.
For example, with anorexia, there is often a deep-rooted irrational attitude "everything should be under my control." And to replace it with a rational setting, it may take months, and sometimes several years of regular psychotherapy.
Another common difficulty with RPP is a distorted image of your body, your appearance.
To understand how it is, you can see this excerpt from a therapeutic work with one of the patients of the clinic for the treatment of eating disorders in the USA
In general, many RPPs begin because of a “malfunction” in the adequate perception of their own body. After that, in a logical way, there is a need to “correct” your body with a change in eating behavior.
For example, with bigorexia, a person can perceive his body as loose, lethargic, soft, as opposed to a taut, muscular and athletic body, which is everywhere shown from TV screens, magazines, photos on social networks, etc. After that, he may have the idea to start adjusting his body so that it becomes the same.
For this purpose, this person can begin, for example, to exclude all simple carbohydrates and fats from his diet, increase the percentage of protein, start consuming protein mixtures, increase the load in the gym. And over time, he can really change his body.
The only question is, will he feel better emotionally? And at what cost will such a “correction” be achieved?
If you look at how it all began, it began with a rejection of the body that it has and comparisons with a certain “ideal”, which, according to statistics, can correspond to no more than 3-5% of the population.
At this stage of the work, a specialist can offer various diagnostic exercises that will help you better understand your attitude to your body, identify “problem areas”, and understand what to do next.
Often, in this part of the work, methods of art therapy, dance-motor, body-oriented, and other types of psychotherapy are used that work directly with the person’s attitude to his body and appearance.
Such work can help to see, hear and feel your body from a completely different perspective. Understand that the body can have its own needs, that the body can “talk” with you, that the body can become a source of joy, pleasure, creativity, and not just a source of problems and an object for constant “corrections”.
So, for example, in one of the group classes, I suggested that the participants split into pairs and do a very simple exercise. One man in a pair closed his eyes, and the second put his palm on the area of the shoulder blades and quietly led along the hall in an arbitrary direction. And the task of the slave was simply to observe his feelings, images, emotions.
And after the exercise in one of the couples, the woman, who was a follower, began to cry. When I asked her to share my experience, she said that she was working as a leader, and she had only men under her command. And she must always behave with them, too, like a "man." And then, in the process of this exercise, when she felt the hand of another person on her back and could not control but trust in him, she suddenly felt for the first time how tired she was of being a man. And how strong the need is for someone to take care of her too.
This told her her body, not her mind. And this was a very significant discovery for her.
One of the axioms of systemic family therapy indicates that any symptom of an individual family member is almost always the result of the specificity of family relationships.
But even those specialists who do not work directly in a family systems approach still consider the family context. Since without this very important information can be lost and, accordingly, many opportunities are lost in the treatment of an eating disorder.
To make it clear what is at stake, I will give an example.
The mother came to the reception with a teenage girl of 17 years, which over the past year has significantly lost weight without apparent physiological and medical reasons. After several consultations, it was revealed that the girl began anorexia.
Мы начали работать индивидуально, но почти сразу же всплыла история про то, что увлечение диетами, правильным питанием и последующее похудение начались почти сразу после рождения младшего брата. Девочка, хоть и не сразу, но сказала, что ей стали уделять гораздо меньше внимания, а в силу особенностей подросткового возраста ещё и начались конфликты с родителями. This further increased the distance between the two.
When the parents noticed that the eldest daughter significantly reduced weight, they began to take her to doctors, control her diet, criticize her attempts to diet, etc. That is, in fact, they began to pay much more attention to it than before. Although often in a negative form, it is better for a child than a lack of attention.
From the point of view of the family as a system, the girl’s symptom (anorexia) in this case helped her get what she could not get in another way. Naturally, on a conscious level, neither she herself nor her parents knew about it.
And in this case, simply helping to eliminate the symptom - this means ignoring the important "message" that is in it.
And working with just one girl would not be very effective. Therefore, it was decided to start family therapy, in which parents could begin to contribute to the recovery of their daughter.
In the context of the influence of the family on the occurrence or course of RPP, there are statistics about adolescents suffering from anorexia.
If this is already a serious form of the disease with a risk to life, then in most cases such adolescents are placed in a psychiatric clinic where they are provided with medical care and purposefully restore their weight to normal.
However, after discharge, after a while, a significant portion of adolescents again begin to suffer from anorexia, because they return to the same family system in which this eating disorder originally arose.
On the other hand, of course, the family and relationships in it are not the only reason for the emergence of RPP. The reasons, as a rule, are always several.
But even if an adult client who already has his own family comes to see a specialist, studying relationships between family members often turns out to be an important and useful step in the treatment of eating disorders. And improving these relationships can help the client quickly cope with their underlying disorder.
This is a very important stage of work.
Especially for those who have RPP.
Because almost every such client reports that he does not love himself, does not accept, does not appreciate, does not respect, in general, he does not treat himself very well.
Moreover, this applies not only to the body and appearance, but also to other aspects of the self.
In the worst case, this problem takes the form of the so-called “Toxic” shame, when a person considers himself bad not for something specific or not in a specific situation, but just like that. He has a steady and constant feeling of his own badness, worthlessness.
And, no matter how strange it may sound, but in such cases, sometimes overeating, starvation, torturing oneself with diets or regularly inducing vomiting can be an intentional way to prove your own badness to yourself.
Some clients in such cases may say something like “I'm overeating, not because I enjoy it, but I can’t stop, but because I want to get to the pain, tear my stomach, to tell myself - look how insignificant you are , if I’ve gotten so hungry ... "
Of course, this does not always take such dramatic forms. And, fortunately, there is not always a feeling of total badness.
But the fact is that almost always with an eating disorder with an attitude to oneself, a person is not in the best way.
And then one of the important stages of work is to help build another, supporting and accepting attitude towards oneself.
And, of course, such a work has nothing to do with the popular “just love yourself” tips or reading positive moods in front of a mirror.
The real work of creating a positive attitude towards yourself is a long, deep and difficult job.
Which includes the study of such important issues as:
- the ability to accept a variety of feelings in oneself
- permission to express these feelings
- respect for your desires and needs
- the ability to protect and defend their needs in relationships with other people
- development of self-help skills in stressful situations
- work to eliminate perfectionism
- reduced influence of internal critic
- change in irrational attitudes associated with negative perceptions of oneself
- exemption from excessive guilt and shame
- and much more
This is not an easy job.
For example, only for a person to learn to accept his own anger and allow himself to express it, realizing that this is normal, it can take several months of weekly therapy.
However, such work always has a big “bonus”. It lies in the fact that as a result, a person can not only get rid of an eating disorder, but also improve his life in many other areas.
Moreover, we have to live with ourselves until death, and our well-being every day of our lives will depend on how we treat ourselves.
Does RPP treatment always succeed?
I'd like to write that “always”, but that would not be true.
Unfortunately, it happens in different ways.
A certain percentage of people with RPP can be cured once and for all.
Some clients are relieved of symptoms for a long time, but periodically they may experience “kickbacks”, although often they are not as strong as at the very beginning of the disease.
For some clients, the effectiveness of therapy is negligible and the symptoms do not disappear.
Well, and, unfortunately, there is a huge percentage of people with eating disorders who generally never seek help and do not undergo treatment.
What will the effectiveness of the treatment of eating disorders depend on:
A. The severity of the disorder itself.
So, if a person suffers from bulimia for the past 10 years and causes vomiting every day, then it will most often be more difficult to help than a person who has bulimia started a year ago and bouts of overeating and inducing vomiting occur several times a week.
B. The presence of concomitant mental disorders.
If, for example, psychogenic overeating is accompanied by a severe form of depression, then the prognosis is worse than if it is only psychogenic overeating.
B. The presence of somatic pathologies.
For example, with the 3rd stage of anorexia, when pathologies of individual organs or entire systems of the body may occur against the background of excessive thinness, one cannot do without placement in a hospital in any case. And if this is the 1st or 2nd stage of anorexia, one psychotherapy can help.
D. Availability of resources on which a person can rely.
This can be a supportive relationship in the family, best friend / boyfriend, favorite job, hobbies, etc. All this can help a person quickly and efficiently cope with an eating disorder. And, on the contrary, it happens that with RPP a person has simultaneously difficulties in family life, a critical situation at work, chronic fatigue, etc. In this case, it is likely that a person may prematurely leave therapy, and, accordingly, the result will not be achieved.
D. The depth of personality disorders.
In addition to the presence of RPP itself and concomitant mental or somatic disorders, it is also important how healthy or disturbed the person’s personality is. And there can be very different options.
Starting from a relatively healthy personality structure, which is expressed, in particular, in a person’s willingness to cooperate with a specialist, a high level of reflection, responsibility, awareness, ability to withstand criticism, endure strong feelings, etc.
And ending with a borderline or psychotic structure, when a person can react aggressively to any remark, try to manipulate a specialist, in every way violate the temporal, financial and other boundaries of the relationship, fall into the position of “victim”, refusing to take part of the responsibility for the result of psychotherapy on himself, etc. .
In this case, therapy may take significantly longer, and its effectiveness may be lower.
In general, if a person reached the final stage of therapy, all the key symptoms of RPP disappeared from him and he felt that he was ready to move on, then there was not much to be done.
Firstly, to determine the algorithm of actions in the event of a possible relapse in the future.
And, secondly, together with a specialist to live the feelings associated with the completion of a therapeutic relationship.
After all, as we said at the very beginning, psychotherapeutic relationships are created specifically to help you solve your difficulties with eating behavior.
And when these difficulties are behind, then it is time to end the therapeutic relationship itself.
And since when working with RPP, such relationships were most often long-term, full of different emotions, discoveries, obstacles, ups and downs, then some feelings may also be associated with their completion.
Sometimes sadness, sadness, sometimes annoyance, sometimes anxiety, or something else.
And this is normal and natural.
It’s just important to allocate time for this.
To say thank you to each other.
To say thank you to myself.
And then start moving on your own!
If you need help with nutritional issues or other psychological difficulties, you can sign up for a free Skype diagnostic consultation right now.
Consultation I conduct, Leonov Sergey.
I am a psychologist, and for the past 10 years I have specialized in the psychotherapy of eating disorders and nutritional education. More information about education and work experience can be found here.