By Travis Stewart, Licensed Professional Counselor
When someone recovering from an eating disorder experiences high urges to use anorexic or bulimic behaviors like restricting, bingeing or purging, the instinct is often to avoid talking about the urges. Similarly, clinicians can fall into the trap of moving the patient away from urges through changing the subject or discussing the negative consequences that would result. And while there is certainly a need to move away from acting on urges we’ve found success in moving our patients TOWARD talking about and understanding their urges.
Imagine a patient has just learned she has to stay in treatment longer than expected and is having high urges to restrict her meal. What follows is an approach sometimes taken in the field of eating disorder treatment without first exploring and understanding urges:
Patient: I don’t want to eat lunch today. I’m not hungry.
Clinician: What eating disorder thoughts are you having about food?
Patient: It’s not my eating disorder. I don’t need food. If I eat I will get fat.
Clinician: Have you tried challenging those thoughts?
Patient: But I WILL get fat.
Clinician: Let’s try to see if we can use some skills to lower your anxiety about lunch.
Patient: You guys are just trying to make me fat!
Clinician: But if you don’t eat you will have to stay in treatment even longer. I know you want to get out of treatment and back to your life. Will you try the skills with me?
Patient: It won’t help. I’ve tried them all and they don’t work.
And on it goes. While the need to use skills is evident, the patient is not in a state of mind to do so. Additionally, the clinician is frustrated and feels ineffective as they try to move the conversation AWAY from the urges at hand – the very thing the patient is most focused on. Attempting to move away at this point is like trying to get someone to ignore a scorpion sitting on her lap.
Here is what it might look like to move TOWARD the urge:
Patient: I don’t want to eat lunch today. I’m not hungry.
Clinician: I can understand that. You’ve felt pretty upset today… Tell me, if you could do whatever you wanted at lunch today, what would you do?
Patient: What do you mean?
Clinician: If you weren’t supervised and could do whatever you wanted at lunch, what would you do?
Patient: If I was alone? I wouldn’t eat anything.
Clinician: Would you just skip lunch or would you restrict more than that?
Patient: I wouldn’t eat anything the rest of the day.
Clinician: Is that all? If you could really act on your eating disorder without any consequences, what would you do?
Patient: I would restrict all day tomorrow as well. I’d keep restricting until I lost all of the weight you guys have made me gain.
Clinician: That’s honest. I’m guessing that would feel really good. It’s been really difficult today in light of the news about staying in treatment. There’s a part of you that really wants your eating disorder, right?
Patient: Yes.
Clinician: When you are fully engaged in your eating disorder how do you feel?
Patient: What do you mean?
Clinician: How would you describe the emotional experience of skipping meals and limiting calories?
Patient: It’s like a high. I feel successful and strong.
Clinician: That makes sense. When you restrict it gives you the feeling of accomplishing something really difficult, doesn’t it?
Patient: Exactly!
Clinician: And that’s not something you have felt very often in life, especially today. I can understand why you want to skip lunch. When you found out that you had to stay longer in treatment I’ll bet you felt powerless and out of control and like maybe treatment wasn’t accomplishing anything. Skipping lunch would make you feel strong, safe and accomplished. No wonder your urge to skip it is high.
Patient: Yeah. I never thought about it like that.
Clinician: Yes. It makes a lot of sense when you explore what your urges are telling you. Underneath are some very legitimate needs that you don’t feel are being met. Maybe in our next session we can talk about some ways you might be able to meet those needs without your eating disorder.
In this second scenario the clinician is working to validate the emotions of the patient and help the patient connect with what her eating disorder does for her. Rather than moving the discussion AWAY from the pull of the eating disorder behavior the conversation moves TOWARD it, seeking to understand why it is so powerful in this person’s life. This allows for several things to happen:
- Aligning with the patient instead of against the patient
- Increasing the patient’s understanding and self-awareness
- Decreasing shame – as the patient begins to understand what the ED behaviors do for her (i.e. make her feel strong, safe and accomplished) she won’t feel so much shame about having urges. In fact, she can begin to realize that her urges make sense in the context of her circumstances.
- Improving the patient’s ability to state her real needs – as she recognizes her urges she can begin to say, “I’m afraid and need to feel strong and safe right now” rather than “I don’t want to eat.”
- Identifying a new direction – as the clinician and patient recognize the legitimate underlying needs you can begin to discuss healthier, more effective ways to meet them. This, then, is the ideal time to talk about skills.
In short, I believe it is important for both patients and clinicians to move TOWARD the eating disorder urges rather than run AWAY from them. This doesn’t guarantee that the urges will immediately decrease. And it certainly does diminish the importance of using skills. In fact, when the clinician and patient move toward urges with curiosity and confidence it helps the patient see just how helpful skills can be in the right context.
Travis Stewart is a Licensed Professional Counselor who has worked in the field of eating disorders since 2003, both in residential and outpatient settings. He received his Master’s of Counseling from Covenant Seminary in 2003 and began working with McCallum Place in 2011.
