Author: Randy K. Hardman, PhD and Michael E. Berrett, PhD
In this article we describe general guidelines as well as a few examples of the experiential and structured interventions that we use when facilitating individual, group, and family therapy with eating disorder patients. The purpose of these experiential and structural interventions is to help patients explore the emotional relationship and spiritual issues associated with their eating disorders. Within the context of therapeutic treatment, these specific experiential interventions are only one small component of our program, but they have proven to be invaluable in helping patients see, understand and choose something better in their pursuit of recovery.
GENERAL THERAPEUTIC GUIDELINES FOR EATING DISORDER TREATMENT
The following general guidelines are the underlying foundations upon which our experiential and structural interventions are based.
• Involve the Family System
It is important, where possible, to involve families in treatment, unless the family is on the farthest extreme of dysfunction and unhealthiness. It is important to find resources within the family to help meet the patient’s needs. It is important to help the patient make emotional connections within the family, to increase empathy and compassion within the family, and to help the patient individuate from the family in a healthy way that allows family connections to remain intact.
• Be Directive and Specific
It is important for the therapist to take more responsibility to be active in treatment, to create energy in sessions, and direct the process in ways that help the patient, who has less experience to draw upon, and whose life style has been more externalized, approval and peer-acceptance based, rather than anchored in self-definition and internalized principles.
• Use Activity-Based Sessions
It is helpful to use more activity-based sessions and fewer “talking only” sessions when treating eating disorder patients. Activity based sessions give a chance for the therapist to join the patient in their world, since many eating disorder patients spend much time in externalization as their approach to life–a seemingly constant search for external approval. This activity-based approach is particularly important for adolescents who have difficulty learning from others’ experiences, and seem focused on creating and learning from their own experience only. Experiential interventions teach lessons which are more easily internalized, and set the stage for later learning from insight and from others’ experiences.
• Provide Structures for Therapy
Nebulous and unguided therapy can create additional confusion and insecurity for patients with eating disorders. It is helpful to give the patient information about the process of therapy and the process of change. It is helpful to predict struggles and to help them anticipate the ups and downs of recovery and to prepare for these times. Tell the patient what’s going to happen, the sequence of events, why you are doing what you are doing, what they can expect, and the changes they will go through. This increases their trust in your understanding of them and your ability to help them.
• Provide Immediate Encouragement and Support
Without hope to overcome these devastating illnesses, movement in recovery is minimal at best. It is the therapist’s job to attempt to provide, create, and nurture hope in the patient. Tell the patient about your vision of their future, because they often cannot see this for themselves. Remind them that their illness can be overcome and that their feelings creating hopelessness are temporary. Point out their progress and their successes. Help them find and label improvements as such, no matter how small they are. Help them set short-term, sometimes very short-term goals, and help them find evidence of progress. Teach the concept and value of the small steps of change, and help them see the progress in specific moments along the way. Help them see not only what they are doing differently, but the internal process taking place inside of them as well.
• Explore the Differences Between Love and Acceptance Versus Approval
Those with eating disorders have so often learned to deeply believe that “approval is everything and disapproval is the end of everything.” They often have minimized and compartmentalized themselves into one or two explicit parts of themselves–their bodies and their external performance. It is important to stress that what they do and who they are, are not the same. Acceptance of “all of the self,” taking the focus off what others think, and helping them turn to the inside to find value are important themes. Helping them find language and labels and helping them understand the difference between love, acceptance, and approval can help them notice these different experiences.
• Emphasize Having Feelings Without Self-Judgment
Helping patients feel, label, understand, accept, and express their own emotion without making emotional judgments about who they are and what kind of person they are is important in creating an environment of self-acceptance for themselves. Many with eating disorders are tender-hearted and sensitive people who have “shut down”, and become numb and avoidant, allowing their feelings to lead to secondary and consequent feelings of guilt, shame, selfishness, or “badness.” Helping patients enlarge their ability to notice and experience their feelings without self-judgment is critical throughout the therapy process.
• Make Honesty and Congruence an On-Going Theme
Helping patients become more honest and congruent without self-criticism is necessary for recovery. Stress the need to stop any pretending, hiding, or lying, and stress the need for being genuine and open with themselves and other people. Honesty and openness in the therapeutic relationship comes by building trust and creating safety in that relationship and by helping the patient understand the expectation of honesty. This honesty includes helping them reveal secrets so that they can process their beliefs and feelings out loud, begin to allow help from others in overcoming shame, and break the childlike cycle of “hiding under the blanket of shame.” Secrets to be told may include past trauma and abuse from long ag: it may include mistakes made, thoughts or feelings which seem to them unthinkable and unforgivable, as well as telling the whole truth about their eating disorder. Telling secrets helps in being “grown up” as opposed to feeling the fear of “being little”, and “sweeping out all the corners” in the private stash of misery can bring relief and peace. The love and acceptance of individuals in the group can be healing.
• Teach Patients to Avoid Only One Thing-Avoidance
Eating disorders are disorders of avoidance. Help patients learn about avoidance, its many faces, its damaging consequences, its seductive yet short-lived rewards, and its relationship to eating disorders and other addictive patterns. Help the client understand their fears, their unhealthy responses to fear, and the need to “feel the fear and do it anyway”. Discuss with the patient their fears of failure and the all-too-common patterns of failing, to avoid failure. Give patients challenges and urge them to take risks and to face their pain. Teach and help them experience vulnerability as a healthy precursor to growth within oneself and emotional intimacy within relationships.
• Persistently Show Nurturance, Kindness, and Caring
Those suffering from eating disorders have most often had an absence of nurture and care, at least during the duration of their eating disorder, since they have withdrawn from it in their primary relationships, and since they most often feel unworthy of love and therefore have difficulty “letting it in”. Some have lacked nurturance throughout their lives and have actively resisted the caring given to them because they have deemed themselves undeserving of it. It can help to make this pattern explicit by pointing out the reality of care, love, concern, and acceptance within relationships and help them see that it is available to them in their lives-not only from the therapist’s point of view, but from many others who love them as well. As they learn to notice it, label it, and are encouraged to receive it, they prepare to again accept and nurture connections with others important to them in their social and family circle.
• Make Unhealthy Behavior and Relationship Patterns Explicit
As patterns of dishonesty, manipulation, pushing others away, justification for unhealthy choices, patterns of helplessness and powerlessness, and food and behavioral rituals show up in the therapeutic relationship by report or observation, make them an issue in therapy. This can be done by pointing it out, labeling it for what it really is, dismantling justification of the negative pattern, having them look at the negative effects of such, and helping them ponder and then risk in choosing “new ways” of living. The self-deception, justification, and rationalization of the eating disorder builds a strong wall which needs to be directly addressed and carefully dismantled.
• Help Patients Separate Themselves from Their Disorder
In the later stages of an eating disorder, it may become the patient’s identity. They begin to perceive and live congruent with that perception – that they are their eating disorder. This self-definition brings with it fear, disgust, self-contempt, helplessness, withdrawal and guilt. In the later stages of the illness, the patient truly loses some conscious control over their behavior and choices. They need help to understand that much of their behavior is due to the illness of the eating disorder, and that it is not the result of personal deficiency or flawed willpower. Again, a theme here is, “you are not your illness and you are not implied by your behaviors, thoughts or feelings.” As they begin to view their illness linked to well-intended yet self harmful coping strategies, and begin to have understanding and even compassion for their painful journey into the eating disorder, they then can feel a sense of hope and self empowerment in their lives. They can assume an increase in personal responsibility for their choices and have the power to change negative choices.
• Help Patients Actively Use Their Spirituality in Recovery
Helping patients use their own sense of spirituality or religiosity, or both, in recovery can be very beneficial for many clients. In the initial sessions of assessment and throughout treatment it is important to have the patient teach the therapist about their spiritual and religious beliefs. It is then beneficial for the therapist to help the client live congruently with those beliefs, and to help them actively use their beliefs in the healing process, including their belief in a higher power, God, or divine influences. There is nothing more powerful then faith, hope, love, service, sense of purpose, and other principles that are spiritual in nature. Research has shown the value of spiritually in recovery, and ignorance of such is a neglect of a powerful healing resource. Caution must be used to allow patients to guide this process and to help clients use their own value framework without imposing the therapist’s beliefs on the patient. Respect is crucial.
EXPERIENTIAL AND STRUCTURAL INTERVENTIONS
The following interventions will provide you with a few examples of how to incorporate experiential and structured process into the context of group, family, and individual therapy. These interventions can generate emotional energy, verbal process and feedback, and behavioral reenactments that can be very useful in a patient’s ongoing treatment and recovery.
• Hiding Behind The Wall
This group activity can be done with a few members of the group inside the larger group circle or it can be done by having every group member participate throughout the room. The facilitator can bring in large pieces of 3’x4′ cardboard or large cushion pillows to be used as props–visual representation of the wall. Group members are asked to break up into dyads and sit facing their partner with one member of the dyad holding the cardboard or pillow in front of them in a protective and self hiding fashion. In turn, they are asked to honestly tell their partner why they’re hiding, what they are hiding, what they do not want other people to see, why they are afraid to show their real selves, what they are trying to protect themselves from, why they put the wall up in the first place, etc. Their partner can ask clarifying questions and give feedback about how it feels being on the outside of the wall. The facilitator can process the experiences, observations, and emotions that emerged during the activity as an entire group. At times, the facilitator can have individual group members create past relationship scenes with family members and friends in front of the group, where they interact while hiding behind the wall. Participants are then asked to return to dyads and explore ways to put down or keep the wall down while revealing themselves honestly to their partner. Specific questions can be asked again to facilitate the personal sharing without the wall.
• Enactment of the Negative Mind
In small groups of three people, each patient struggling with strong negative voices in their mind is invited into the middle of the triad. When cued, the other two members begin to talk into the opposite ears of the patient in focus. One voice is on the “negative side” or the negative mind, and the other voice the “positive side” or validating mind. The patient in focus is given opportunity to listen and experience the intense internal conflict that comes with the conflicted voices, and to express her feelings, explore her power and ability to quiet the negative mind, and to embrace the messages of the positive mind. The group can process the impact of messages, listening, and the power of choice in recovery.
• The Sculpture of the Group Around Commitment
A person well on the road to recovery and with some leadership responsibilities and abilities in the group is asked to do a sculpture of the group around a central focal point in the room, and that client sculpts each member of the group in proximity to the central focal point based on their perception of each person’s commitment to “change” and commitment to giving up their eating disorder and related self-destructive behaviors and beliefs. It is a great structural and experiential way to give feedback and allow for self-exploration and “looking in the emotional mirror”. Each group member is invited to respond with sharing of feelings and reactions about where they were placed in the sculpture and is also given the opportunity to put themselves in the place they feel is more accurate for their commitment to change.
• Let’s See What Is Most Important to You
The group members are asked to bring to group several items from their homes or rooms which represent or symbolize what is most important in their lives. Each member places those items in front of them as all the group members sit in a circle on the floor. Each member, one by one, tells the group about the items, their symbolic meaning or what they represent, and shares feelings related to each object. Following this sharing, each participant is asked to turn their back on these precious things by turning around and facing the outside of the group and by facing away from the inner circle where these important things are placed. The group is asked to process their feelings of loss, hurt, anger, sadness, and fear related to the loss of these important things in their lives, and to talk about how their eating disorder is something which turns them away, or takes them away from that which is most important to them. The activity can also address issues of commitment and congruence or incongruence between their stated messages of “what’s important” and their incongruent behaviors. Therapy discussions can also address grieving losses and making hopeful plans for the future.
• What Does the Line Mean for You
The therapist uses masking tape to make a 10-foot line in the middle of the group room floor. Individually, each member of the group is asked to stand up to the line, one at a time, and they are asked what the line means to them. The line can have many different meanings and can open up discussions on emotional boundaries, taking risks, taking a stand, holding themselves back, taking a leap of faith, opening up to others, etc. Having the therapist and group members give feedback and reactions to individual members at the line can also open up therapeutic interactions that can lead to acting out positive movement in relation to the line.
• Blind Walk Through the Mine Field
A large room is prepared with an obstacle course of books, chairs, and other obstacles strewn randomly yet rather tightly throughout the room. The patient is led into the room blindfolded, and the family is also brought into the room. The family is asked to take chosen positions around the outside edges of the room. The patient is placed on one end of the room with instructions to find her way to the other side of the room without touching any object on the floor with any part of her body. She is further instructed that any touch of an object will result in her starting over at the original spot, and that the activity will take as long as needed, up to four hours. The family is instructed to help her across with only words and they are instructed to stay in their places outside of the obstacle course. As the patient and family journey through this experience, issues arise including frustration, anger, helplessness, trust, control, coping styles, helping styles, leadership, and family roles. The patient can be guided to discuss what it’s like navigating through recovery, and the family can talk about their desires to help, their feelings of powerlessness, and their styles or approaches to support and whether they are helpful or non-helpful to the patient.
• Stacking the Books: Ownership, Responsibility, and Barriers
In family therapy issues of personal responsibility for the eating disorder as well as other issues and feelings, such as marital happiness, individual happiness, and choices about health and wellness may arise. In this intervention therapy is done around a table. A large stack of books over five feet tall is placed on the table. The therapist or family members can divide up books relative to responsibility for different things in the family and give a stack of related size to each family member. Stacks of books can also be used as symbols of barriers in relationships, where sometimes family members can’t see each other because of barriers. Feelings and reactions about barriers and responsibility, or barriers to each other in objective form and experiencing those things not only emotionally, but physically as well, arise.
• Carrying the Burden
It can be helpful to help the patient experience what it physically feels like to carry a heavy burden to help them get in touch with deeper feelings about carrying inside burdens. The burden might be their eating disorder, guilt for some act in the past, shame, self-hatred, or responsibility for someone else’s life or happiness. The client can be given a rock, a box, or another heavy or awkward object, and be asked to carry it with her everywhere she goes for the next few days or weeks. Encouragement to notice the impact of the burden’s interference in her daily life and to talk honestly about what she is learning and feeling along the way is very important (the burden item cannot be so heavy that it might cause any physical damage from carrying it).
• Wearing a Sign: Making the Implicit Explicit
As themes emerge in therapy about core messages the patient may “send out” in her relationships with others, which either push others away or prevents her from allowing their love and support into her life, these and other messages can be put on a large card and worn by the patient on her front side in an obvious place (i.e, worn as a necklace). Processing in therapy sessions can be focused around the message, what she really wants to say, direct communication, other people’s responses to her explicit messages, new ways of meeting needs in a healthy way, and her desires to change. As she becomes acutely aware of the messages and “gets tired” of giving the same old messages, she can begin to replace it with new positive messages. An alternative use of the signs can then be done to help change inside messages to explicit positive or affirming messages that she wears on the outside for several days.
We utilize 40-50 different structured and experiential interventions to help eating disorder patients understand, experience, and reinterpret different contributing aspects of their illness. For the sake of brevity, we have only mentioned a few of these interventions in this article. We recognize and greatly appreciate the need for different therapeutic styles and approaches, as well as the need for a comprehensive and multidisciplinary program for the treatment of eating disorders. What we have also discovered as therapists over the many years of working with eating-disordered patients, is the power and impact of experiential and structured interventions as one aspect of their treatment. These interventions often by-pass the extreme analytical or emotional avoidance defense mechanisms of patients, giving them a “new look” or an “emotional perspective” on their problems, as well “a taste” of what new solutions might be available to them in recovery. Specific interventions should be used according to groups and individual needs and adapted accordingly. Therapists can create interventions in the moment as inspired or feel to do so.
Revised and Re-edited July 2014