To Participants of A Psychotherapy Workshop on the Treatment of Bulimia

Dear Colleagues,

You have asked me to discuss the treatment of Bulimia. I must confess that initially, I was somewhat daunted by the task. Where do I begin? First of all, I suggest that we review what we know or have been told about the Bulimic individual. According to Christopher Fairburn, her average age is 23.5 years; her attitudes toward her shape and weight are considered to be grossly abnormal; her eating habits are markedly disturbed and have been for several years, although her weight remains within the normal range.

Her most prominent feature is said to be affective in nature; she is almost always depressed. She tends to be plagued with pathological guilt and might tell you that "worry" is her middle name. She has difficulty concentrating, tends to obsess, and plagues herself with endless "should's" and "should not's." She is anxious, she is tired, and she doesn't really like herself much. She is also often irritable, although like a "nice" girl, she generally tries to hide those aspects of herself that one might consider unpleasant. It is not uncommon for young women with her diagnoses to experience panic attacks. After all, the world can be a very frightening place when you're in hiding. She often feels hopeless and alone. And that's just the tip of the proverbial iceberg. And like the tip - there is so much more submerged beneath the surface.

She could be your daughter, your grandchild, your sister, or your wife. She might have big blue eyes and golden hair. She might love music, draw beautifully, and have missed just about every ball that has ever been thrown her way. Perhaps you see her every day and have not yet recognized her.

Her family background varies, although it's generally characterized as enmeshed, overprotective, appearance-conscious, triangulated, and rigid. Her father is often moody and self-depreciating while her mother tends to be described as anxious and depressed. There tends to be a family history of obesity and often the family encounters a high amount of stress.

When she arrives in your office for the first time, you can be assured that her arrival was a long time coming. She often arrives under duress, bowing to the demands of significant others. Rarely does she come to you of her own volition. She is anxious and ashamed. She is also ambivalent. While she knows that her bingeing and purging is harmful, she fears her weight spiraling out of control even more. Her illness is not without its benefits, and the thought of surrendering them leaves her cold.

No matter how gentle your smile, how warm your welcome, you remain a threat to her. She desperately hopes that you can save her, and yet her potential savior is also her enemy. She wonders how you can possibly understand her, and doubts your ability to care about her even more. Will you attempt to seize her already tenuous hold on her life? Can she trust you? How would you feel about her if you were to discover her darkest secrets? Will you betray her? Abandon her? Despise her? How can you possibly help her with the emptiness and pain that she has experienced, it seems, her entire life?

What will you see when you encounter this young woman? Will you see her in the morning when you are relatively refreshed and alert? Or will she find herself sitting in your office at the end of the day, when you are feeling depleted, perhaps bored, and eager to go home? Will you feel excited by the prospect of learning and assisting this stranger before you? Or will you be at a place in your life where you feel discouraged, disheartened, inadequate, or burned out?

While unspoken for the most part, her demands of you will be tremendous. There is much she will need to learn from you and you from her. She will require your support, your understanding, your full attention, your genuine concern and most of all - your patience.

You will need to earn her trust. It won't be given. She has learned all too well to recognize insincerity and will recognize it in you, perhaps even before you do yourself. You will need to soothe her pain and anxiety, while at the same time teaching her how to manage it herself. You will need to demonstrate that you not only recognize and appreciate her fear of gaining weight, but that you expect her to be afraid. You must help her to believe that you understand that asking her to give up bingeing and purging is, as Alan Goodsitt contends, "like asking someone who can't swim to let go of the life preserver and try swimming."

Her healing will often be turbulent and frightening. Metaphorically speaking, while you can't rescue her from the raging waters necessary to complete the journey, you'll need to teach her how to whitewater raft.

You must encourage her to talk about her distress around eating, around abandoning a life long pursuit of the perfect diet, and around so many other issues that have created pain in her life. While she must consistently hear that you expect her to do the very things she most fears, she must also know that you want to hear about that fear; that you won't reject it or her. She must also come to recognize that it is only she who can make the difficult changes which are necessary, most of which must occur not without, but in spite of, her fear.

A major therapeutic task will be to help her become aware of, and accepting of, her true feelings, both negative and positive. She must also come to recognize her needs, particularly those related to independence and dependency, needs which she has probably come to despise within herself.

She must begin the process of determining her own value system and recognize that some of the very values she has failed to adhere to may never have truly been her own, but instead, were inflicted upon her. You must point out that she is capable of creating her own guidelines for living, and that because they are her own, she will be much more able to follow them. She must determine what her own goals are, and differentiate between those which spring from her own true desires, and those that come from some other source. She will need to recognize that we seldom pursue the objectives of another as successfully and as earnestly as we pursue our own. And in regards to treatment goals, it is she who ultimately must determine them. You can only guide her. What does she want to be different about her life? What is she hoping for? In the end, it is she who will determine the destination, while you assist her in charting the course.

When encountering unknown persons in your office, I ask you to remember that he or she is seldom comfortable, and almost always uncertain as to how they will be received. Will you be disinterested, judgmental, detached, or bored? Or will they find you responsive, accepting, and warm? There is much that is out of your control about this first encounter. And yet, it is critical that you are able to provide reassurance to the stranger who has bravely entered this unknown land (your land), that they have truly found a safe place.

next:The Incorporation of Holistic Treatment into a Brief Treatment Framework