anorexia nervosa is a troublesome disorder characterized by an obsession with weight and food. With a target group consisting primarily of adolescent girls (80-90%), the anorexic will crave food, but will refuse to eat or retain it because of an overwhelming fear of weight gain. The individual may stop eating almost entirely, and will deny that her behavior is abnormal and that health is deteriorating. Typically, the anorexic will say that “she feels fat,” even when she is obviously underweight.
The behavior of the anorexic may be characterized by a pattern of social withdrawal, rigorous exercise, and ritualistic eating habits. The emotional profile of the anorexic is marked by a pattern of depression, fear of obesity, and loss of self-confidence. Physical symptoms include a loss of menstruation and a weight loss of up to 20-25% of body mass. According to diagnostic criteria, a female patient is clinically suffering from anorexia nervosa when body weight has fallen to 15% below normal and she has not menstruated for at least three months. The same body weight criteria apply to male patients.
Those suffering are generally unwilling to receive treatment for anorexia, resisting any attempts at counseling. Those who reluctantly seek treatment begin the process from an adversarial perspective. Developing a collaborative relationship with an anorexic patient is no easy task. It is critical that the therapist develop a warm, friendly, honest and accepting relationship with the anorexic. The quality of the therapeutic relationship will be a factor in determining the individual’s willingness to deal with the terrifying aspects of eating and weight gain.
The relationship provides a means for examining cognitive distortions and maladaptive underlying assumptions that the anorexic applies to her internal world. It is critical that the counselor accepts the individual’s beliefs about body perception as genuine for her. Any attempt to refute, challenge, or devalue the person for holding erroneous assumptions about weight and body misperception is counterproductive. Anorexic teens are used to hearing from significant others that their beliefs are illogical and irrational.
It is the goal of the therapist to enter into a mutual fact-finding process with the anorexic client. By accepting the patient’s belief system as genuine for her, it is possible to introduce doubt about the anorexic’s basic cognitive assumptions. The individual may be encouraged to reexamine core assumptions about the value of thinness. Several lines of inquiry might be, “Is it practical for you to embrace this idea?” or “How does losing weight fit in with other values that you cherish?” Emphasizing that treatment will follow an experimental model is an important notion. The therapist’s approach with the anorexic might be, “Let’s try this out and see what happens.”
Therapy with the anorexic involves challenging faulty thinking and beliefs. For example, if the patient expresses apprehension around the issue of losing competence if she gains weights, the therapist can help her develop a working definition of competency that will establish a concept of whether or not it is influenced by weight changes. Such questions such as, “Would you appreciate your friend more if she weighed less than you?” may help cut into the double standard established by the anorexic patient.
Questioning the anorexic about what would happen if their worst expectations came to pass may minimize the imagined effects of the event. The person who demands “thinness” is obviously anxious when she considers herself “fat.” The counselor may inquire, “What’s the most horrible thing that could happen if you were to gain weight?”
Cognitive distortions are numerous in the anorexic and must be gently challenged. Distortions such as dichotomous thinking, (“If I gain weight, I’ll be considered obese.”), overgeneralizations, (“I will never get any better and my eating will never improve.”), magnification, (“Gaining any weight will be more than I can take!”) must be directly, but gently confronted in counseling. The anorexic is encouraged to design experiments to test the validity of specific irrational thoughts. For example, the anorexic individual may be encouraged to interview her friends for preferences in physical appearance, checking out how often people select a friend based exclusively on the merit of weight.
Body-size misperception is a significant feature of the anorexic disorder. The individual may be asked to reinterpret what she sees. Such counter-arguments may involve the use of reattribution techniques such as, “When I try to estimate my own dimensions, I am like a color-blind individual attempting to create my own wardrobe. I will rely on other’s objectivity to assess my actual body size.”
With the anorexic, maintaining a multidimensional approach to treatment is necessary, focusing on information processing, cognitions, and other strategies such as:
- Dealing with family issues. Some therapist’s believe that the anorexic disorder actually acts as a stabilizing force for the family.
- Dealing with personal goals and ambitions of the anorexic.
- Focusing on issues of control, perfectionism, assertiveness, and autonomy.
- Dealing with social adjustment issues.
- Assisting with problem-solving and coping skills.
Dealing with the anorexic patient is demanding and requires flexibility and creativity as necessary ingredients if the therapeutic process is to be successful. Many anorexic clients struggle with their body misperception issues throughout their life and may need to revisit the counseling process during times of high stress.
James P. Krehbiel, Ed.S., LPC, CCBT is an educator, writer, licensed professional counselor and nationally certified cognitive-behavioral therapist practicing in Scottsdale, Arizona. He specializes in treating anxiety and depressive disorders. He served as a teacher and guidance counselor for 30 years and has taught graduate-level counselor education courses for Chapman University. In 2005, he self-published Stepping Out of the Bubble: Reflections on the Pilgrimage of Counseling Therapy (Booklocker.com). His latest book, Troubled Childhood, Triumphant Life: healing from the Battle Scars of Youth (New Horizon Press) is about the impact of troubled childhoods on adult functioning. James lives and is a practicing counselor in Scottsdale, Arizona.