The following normal guidelines are the basal foundations upon which our experiential and structural interventions are based.
Therapeutic Guidelines and Experimental Interventions in the rehabilitation of Eating Disorders
• Be Directive and Specific
It is leading for the therapist to take more accountability to be active in treatment, to create vigor in sessions, and direct the process in ways that help the patient, who has less contact 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. Action based sessions give a chance for the therapist to join the sick person in their world, since many eating disorder patients spend much time in externalization as their approach to life--a seemingly constant quest for external approval. This activity-based approach is particularly leading for adolescents who have difficulty learning from others' experiences, and seem focused on creating and learning from their own contact only. Experiential interventions teach lessons which are more well internalized, and set the stage for later learning from insight and from others' experiences.
• furnish Structures for Therapy
Nebulous and unguided therapy can create supplementary confusion and insecurity for patients with eating disorders. It is helpful to give the sick person data 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 salvage and to put in order for these times. Tell the sick person 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 insight of them and your ability to help them.
• furnish Immediate Encouragement and Support
Without hope to overcome these devastating illnesses, movement in salvage is minimal at best. It is the therapist's job to effort to provide, create, and look after hope in the patient. Tell the sick person about your vision of their future, because they often cannot see this for themselves. Remind them that their illness can be temporary and that their feelings creating hopelessness are temporary. Point out their develop 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 idea and value of the small steps of change, and help them see the develop 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.
• survey 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 leading 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 leading themes. Helping them find language and labels and helping them understand the distinction between love, acceptance, and approval can help them observation these separate experiences.
• Emphasize Having Feelings Without Self-Judgment
Helping patients feel, label, understand, accept, and express their own emotion without production emotional judgments about who they are and what kind of person they are is leading in creating an environment of self-acceptance for themselves. Many with eating disorders are tender-hearted and sensitive people who have "shut down", and come to be numb and avoidant, allowing their feelings to lead to secondary and succeed feelings of guilt, shame, selfishness, or "badness." Helping patients develop their ability to observation and contact their feelings without self-judgment is important throughout the therapy process.
• Make Honesty and Congruence an On-Going Theme
Helping patients come to be more honest and congruent without self-criticism is important 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 protection in that relationship and by helping the sick person understand the prospect of honesty. This honesty includes helping them review 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.
• 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 sick person 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 contact 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 look after and care, at least while the period of their eating disorder, since they have withdrawn from it in their customary 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 observation it, label it, and are encouraged to receive it, they put in order to again accept and look after connections with others leading to them in their public and house 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 article or observation, make them an issue in therapy. This can be done by pointing it out, labeling it for what it well is, dismantling justification of the negative pattern, having them look at the negative effects of such, and helping them ponder and then risk in selecting "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 considered dismantled.
• Help Patients isolate Themselves from Their Disorder
In the later stages of an eating disorder, it becomes the patient's identity. They begin to realize 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 sick person truly loses some aware 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 succeed 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 connected to well-intended yet self harmful coping strategies, and begin to have insight 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 growth in personal accountability for their choices and have the power to turn negative choices.
• Help Patients Actively Use Their Spirituality in Recovery
Helping patients use their own sense of spirituality or religiosity, or both, in salvage can be very beneficial for many clients. In the initial sessions of estimation and throughout medicine it is leading to have the sick person 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 curative process, along with their reliance in a higher power, God, or divine influences. There is nothing more remarkable then faith, hope, love, service, sense of purpose, and other system that are spiritual in nature. Research has shown the value of spiritually in recovery, and ignorance of such is a neglect of a remarkable curative 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 furnish you with a few examples of how to join experiential and structured process into the context of group, family, and private therapy. These interventions can create emotional energy, verbal process and feedback, and behavioral reenactments that can be very beneficial in a patient's ongoing medicine and recovery.
Group Therapy
• Hiding Behind The Wall
This group Action 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 upholstery 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 retention the cardboard or pillow in front of them in a protective and self hiding fashion. In turn, they are asked to well 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 safe 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 face of the wall. The facilitator can process the experiences, observations, and emotions that emerged while the Action as an whole group. At times, the facilitator can have private group members create past relationship scenes with house 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 survey ways to put down or keep the wall down while revealing themselves well 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 sick person 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 sick person in focus. One voice is on the "negative side" or the negative mind, and the other voice the "positive side" or validating mind. The sick person in focus is given chance to listen and contact the intense internal conflict that comes with the conflicted voices, and to express her feelings, survey her power and ability to quiet the negative mind, and to embrace the messages of the unavoidable mind. The group can process the impact of messages, listening, and the power of choice in recovery.
• The statue of the Group colse to Commitment
A person well on the road to salvage and with some leadership responsibilities and abilities in the group is asked to do a statue of the group colse to a central focal point in the room, and that client sculpts each member of the group in nearnessy 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 connected 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 riposte with sharing of feelings and reactions about where they were placed in the statue and is also given the chance to put themselves in the place they feel is more literal, for their commitment to change.
• Let's See What Is Most leading to You
The group members are asked to bring to group some items from their homes or rooms which describe or symbolize what is most leading 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 connected to each object. Following this sharing, each participant is asked to turn their back on these high-priced things by turning colse to and facing the face of the group and by facing away from the inner circle where these leading things are placed. The group is asked to process their feelings of loss, hurt, anger, sadness, and fear connected to the loss of these leading 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 leading to them. The Action 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 production 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 separate meanings and can open up discussions on emotional boundaries, taking risks, taking a stand, retention themselves back, taking a leap of faith, chance up to others, etc. Having the therapist and group members give feedback and reactions to private members at the line can also open up therapeutic interactions that can lead to acting out unavoidable movement in relation to the line.
Family Therapy
• Blind Walk through the Mine Field
A large room is ready with an obstacle procedure of books, chairs, and other obstacles strewn randomly yet rather tightly throughout the room. The sick person is led into the room blindfolded, and the house is also brought into the room. The house is asked to take chosen positions colse to the face edges of the room. The sick person 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 supplementary instructed that any touch of an object will succeed in her beginning over at the customary spot, and that the Action will take as long as needed, up to four hours. The house is instructed to help her over with only words and they are instructed to stay in their places face of the obstacle course. As the sick person and house journey through this experience, issues arise along with frustration, anger, helplessness, trust, control, coping styles, helping styles, leadership, and house roles. The sick person can be guided to discuss what it's like navigating through recovery, and the house can talk about their desires to help, their feelings of powerlessness, and their styles or approaches to hold and whether they are helpful or non-helpful to the patient.
• Stacking the Books: Ownership, Responsibility, and Barriers
In house therapy issues of personal accountability for the eating disorder as well as other issues and feelings, such as marital happiness, private happiness, and choices about condition and wellness may arise. In this intervention therapy is done colse to a table. A large stack of books over five feet tall is placed on the table. The therapist or house members can divide up books relative to accountability for separate things in the house and give a stack of connected size to each house member. Stacks of books can also be used as symbols of barriers in relationships, where sometimes house 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.
Individual Therapy
• Carrying the Burden
It can be helpful to help the sick person contact 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 accountability for person else's life or happiness. The client can be given a rock, a box, or an additional one heavy or awkward object, and be asked to carry it with her everywhere she goes for the next few days or weeks. Encouragement to observation the impact of the burden's interference in her daily life and to talk well about what she is learning and feeling along the way is very leading (the burden item cannot be so heavy that it might cause any corporal damage from carrying it).
• Wearing a Sign: production the Implicit Explicit
As themes emerge in therapy about core messages the sick person may "send out" in her relationships with others, which whether push others away or prevents her from allowing their love and hold into her life, these and other messages can be put on a large card and worn by the sick person on her front side in an unavoidable place (i.e, worn as a necklace). Processing in therapy sessions can be focused colse to the message, what she well 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 unavoidable messages. An alternative use of the signs can then be done to help turn inside messages to explicit unavoidable or affirming messages that she wears on the face for some days.
Conclusion
We utilize 40-50 separate structured and experiential interventions to help eating disorder patients understand, experience, and reinterpret separate contributing aspects of their illness. For the sake of brevity, we have only mentioned a few of these interventions in this article. We identify and greatly appreciate the need for separate therapeutic styles and approaches, as well as the need for a total and multidisciplinary agenda for the medicine 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.
Therapeutic Guidelines and Experimental Interventions in the rehabilitation of Eating Disorders
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