Integrating Treatment Interventions:
Five Points to Enhance Clinical Practice, Part 2
By Kathryn J. Zerbe, MD
Oregon Health and Science University, Portland
Reprinted from Eating Disorders Review
November/December 2008 Volume 19, Number 6
©2008 Gürze Books
(Note: In the last issue, Dr. Zerbe posed three of the five points: helping patients face down their inner critic, listening for secrets ‘hidden in plain sight,' and addressing loss and grief to help the patient mourn the eating disorder identity. In this article, Dr. Zerbe addresses two more major treatment essentials.)
Four: Adapt Treatment to the Appropriate Phase of the Developmental Life Cycle
Patients arrive for treatment in childhood, adolescence, adulthood, and, increasingly in middle age and beyond. Taking into account the phase-specific place of the patient in the life cycle is a boon to psychotherapy because it meets the individual where he or she is at emotionally, cognitively, intellectually, and psychologically.
Persons who come for treatment in the middle years will usually have more issues of loss to deal with than someone who is younger; in order to move ahead, they will need to grieve the cost of their symptom if it has negatively impacted their life goals. An adult must be confronted by the toll his or her eating problem is taking on completing essential developmental tasks, such as developing meaning and purpose in life, forming and sustaining relationships, and adapting to inevitable change. Adolescents will need help learning how to negotiate with family members and how to collaborate without feeling micromanaged by adults, including the therapist. They may also need support and assistance in doing homework assignments during sessions. An adolescent's therapist also must avoid being seen as the "expert" because this can lead to treatment stalemate. Moreover, cognitive development must be taken into consideration as the prefrontal lobes have not yet fully developed. Assisting the patient when he or she feels overwhelmed, and setting small, achievable goals are additional strategies especially applicable for our adolescent population.
Clinical Example: Mr. and Mrs. D brought their 18-year-old daughter for treatment for binge eating disorder. The daughter had anorexia nervosa (AN) when she was younger and had overcome it with the help of a nutritionist, primary care physician, and family therapist. At this life juncture, it emerged that both Mr. and Mrs. D had parents who were overweight. They were concerned about the repercussions of overweight in their children, and made exercise, weight control, and eating major topics of discussion. The family therapist recommended that, in addition to a family process that focused on establishing intergenerational boundaries, individual counseling be sought to look more deeply into a pattern of a multigenerational preoccupation with weight and eating.
The D's daughter gradually became more comfortable about asking her parents to avoid discussions of weight at family gatherings, and confronted them when they appeared to be overly mired in concern about her physical appearance. Mr. and Mrs. D gained insight in their separate therapy processes about the multiple origins of their body shape and weight preoccupations which they displaced onto their daughter. Now in their early middle years, they were encouraged to reflect on their own fears of aging, their ultimate mortality, and what psychoanalyst Eric Erikson called the dialectic between "generativity and stagnation." With a kind yet firm demeanor, Mr. and Mrs. D's therapists kept asking how these individuals wanted to live the next portion of their lives, had them make a ‘values assessment,' and normalized the envious feelings that sometimes arise toward the younger generation as one ages. In essence, they were repeatedly asked to confront the transitory nature of life, a task usually reserved for the middle and later years, when denial of one's mortality can interfere with addressing existential concerns.
Five: Make Use of Your Own Feelings as a Guide to Understanding the Patient
Via projection, projective identification, or the contagious effect of emotions, therapists are frequently placed in the position of containing, holding onto, and metabolizing feelings and thoughts that the patient is not yet able to do for himself or herself. As early as the 1940s, the interpersonal theorist Harry Stack Sullivan observed that mothers who are anxious tend to induce anxiety in their babies; this forerunner to later infant research and attachment theory has pedagogic power for everyday clinical work.
When we experience an emotion, suffer a physical reaction (e.g., headache, gastrointestinal rumbles, preoccupation with our own body image or weight), or are beset with intrusive thoughts, memories or fantasies, we must ask ourselves what the patient is trying to communicate to us that he or she cannot yet express in words. This acceptance of our unavoidable and usually unanticipated countertransference reactions makes sitting with the patient not merely work to endure but an experience that draws us closer to the patient and his or her inner world.
Tact, timing, and judgment are clinical attributes indispensable in knowing when and how to dose what has been induced in the therapist and return it back to the patient, ‘digested' into compassionate phrasing and perceptive interpretation. Curbing one's own ‘inner critic' is as vital a quality for the therapist as it is for the patient because even after many years of immersion in clinical work, we may miss the mark, and must be open and receptive to the patient's correction. This process of emendation can also be a tremendous growth-enhancing experience for patients who for the first time are able to speak their truth to power.
Clinical Example: When Dr. E came for her thrice-weekly sessions for treatment of AN, non-purging subtype, Dr. Z frequently found that she was ravenously hungry after the session ended. Dr. E had been in treatment with Dr. Z for 4 years at the time that this psychophysiological reaction began; Dr. E had made significant improvement in many life domains, but she was not yet ready to terminate therapy. The therapist decided to silently contain and ponder this state until she could understand it better. Step by step, Dr. E was making headway by eating a little more and trying out some new foods. She was enjoying her work and her life substantially more than when she began treatment, and was taking more risks in being direct with her superiors and her small circle of friends.
One morning Dr. Z's stomach growled like a lion, and she visibly blushed. The quick and clever Dr. E was risking greater liveliness and playfulness in the sessions, and she wryly quipped to Dr. Z: "Aha! I think I have found a spot that needs to be fed in my therapist. Do you envy me for having that delicious gazpacho with my friends last weekend?" The therapeutic pair laughed together about the gastrointestinal intrusion into the therapeutic space. Dr. Z did not consciously experience hunger (she didn't even like gazpacho), competition with Dr. E's new friends, or envy of her patient's growth. Self-analysis and a clinical consultation did reveal that this psychophysiological countertransference response may have pivoted on the therapist's unconscious reaction to the patient's improvement and the knowledge that Dr. E was creeping steadily to termination. Dr. Z would indeed have an empty space in her schedule and in her heart in the future when she would be in a position to mourn her longstanding therapeutic relationship with Dr. E.
We clinicians who treat eating disorders in the 21st Century find ourselves in a unique and privileged position. Discoveries in genetics, in biological therapies that will hasten weight restoration and prevent relapse, and in adjutants to our psychotherapeutic procedures will likely strengthen what we can now offer our patients by way of therapeutic support. The keystone of such an integrated treatment, however, will always be the patient's unique life story.
These five suggestions are intended to help us attune our therapeutic ears to concerns just below the surface and to draw them out and into the open, thereby reducing the internal anguish of the person who comes to our care with a life-threatening, multi-determined, but ultimately treatable, eating disorder.