"What is REAL?" asked the Rabbit one day, when they were lying side by side near the nursery fender, before Nana came to tidy the room. "Does it mean having things that buzz inside you and a stick-out handle?"
"Real isn't how you are made," said the Skin Horse. "It's a thing that happens to you when a child loves you for a long, long time, not just to play with but REALLY loves you, then you become Real."
-- Margery Williams, The Velveteen Rabbit
There is no "one-fits-all" psychotherapy for anorexia nervosa. In an effort to learn more about what "works" and what doesn't, my Massachusetts General Hospital colleagues Eugene Beresin, M.D. and Christopher Gordon, M.D. and I interviewed a group of women who had received individual therapy and recovered from the illness. Their perspectives on psychotherapy helped inform our work with individuals who are struggling with anorexia.
New patients don't open the door of the therapist's office bright-eyed, cheerful, and eager for treatment. For the most part, individuals with anorexia don't feel ill or see their eating behaviors as unhealthy. They want no part of therapy. The idea of sitting down and talking about themselves feels foreign and scary. From their standpoint, the therapist is out to make them fat. Particularly frightening -- almost unthinkable -- is the possibility that the therapist will raise the topic of eating more and gaining weight. Tense and shaky, or sullen and defiant, patients sometimes experience the urge to bolt out of the room.
"First, I had to trust." This is easier said than done. At the beginning of therapy, patients don't know what to expect. Some individuals sense that they are better off remaining silent and that anything they say will be held against them, as if they are standing trial in a court of law. They may feel very alone or bombarded with powerful pangs of guilt about calories eaten or ounces gained. They may be thinking: "What is this thing called therapy?" "What am I expected to talk about here?" How is therapy supposed to help me?" "What does the word 'help' mean?" This last question is important, and a patient's answer to it can fluctuate or change as therapy proceeds.
"I didn't know how I felt." Trapped in an unforgiving world of shoulds and should-nots, individuals have a hard time recognizing their feelings. They are often receptive to therapists who participate actively in sessions, helping them to better understand themselves and coaching them on how to relate to others. The very nature of the patient-therapist relationship can help individuals learn where emotions come from and how to manage them. For example, becoming angry at the therapist and being encouraged to talk about this in session can gradually instill confidence that it is natural and human -- or, as the Skin Horse suggested, "real" -- to experience and express emotions.
"I wasn't sure I wanted to grow up." Teenagers experience huge emotions and extreme moods. One moment they long for independence; and the next, for security. As they mature -- emotionally, cognitively, physically -- relationships, academics and athletics take on new importance, and pressures seem to mount. The stress of adolescence is significant, and teens often feel overwhelmed. For these individuals, anorexia can represent a way to slow down the biological clock, to get their bearings, and to maintain control before traveling on to adulthood.
"It was important to like myself better." Well into treatment, individuals with anorexia continue to consider themselves defective, inferior, or "bad." They may come to realize that anorexia gave them a sense of accomplishment or specialness. The challenge is to find ways to experience these positive feelings without focusing on weight loss.
"Experimenting helped." Insight alone does not free individuals from the grasp of anorexia nervosa. There must be a willingness to experiment -- to take risks. People with anorexia go about everyday life in a very structured, programmed way in an effort to cope with their fear of the unknown. Although it is very challenging for patients to modify their routines, they are often able to do so once they feel that the therapist values and respects them for who they really are. Risk-taking becomes possible when it is introduced in small, achievable steps that gradually build self-regard. In this way, patients -- with the guidance of the therapist -- chip away at the anorexia, a little bit at a time.
For more by Dr. David Herzog, click here.
For more on eating disorders, click here.
If you're struggling with an eating disorder, call the National Eating Disorders helpline at 1-800-931-2237.