Chapter 7

Eating Disorder
Treatment
Eating Disorder Recovery Handbook

7.1 An Introduction to Counselling

Objective
Counselling is one intervention that can be effective in helping people deal with
and overcome eating disorders. The aim of this worksheet is to explore what
counselling is, how it works, its benefits and how it can assist people with eating
disorders.

Task
Read the following information in order to gain better insight into the different
types of counselling that are available to help with recovery.

What is counselling?
Counselling is a specialty within psychology where trained professionals use
psychological theories, knowledge and techniques to help clients live through,
cope with and overcome any distress they might be experiencing. Individuals,
families, groups and couples seek the help of counsellors for all kinds of reasons:
stress, anxiety, chronic or acute emotional problems, relationship issues, lack
of purpose in life, alcohol and drug abuse, low self-esteem, career decisions,
relationship problems and, indeed, eating disorders.
Although some counsellors become specialists and focus mainly on working
with, for example, families or people affected by eating disorders, they are
generally trained to be well versed in a variety of therapeutic skills and techniques.

What types of counselling are there?

Some counsellors employ one or more counselling techniques depending on
the nature of a client’s problem. The specific approach the counsellor adopts is
mainly based on the particular school of psychological thought that informed their
professional training. While some adopt a behavioural or cognitive-behavioural
approach, others might be more oriented towards humanism, existentialism or
psychodynamics. By making yourself familiar with these terms and learning which
approach might offer you the best support with your eating disorder, you will be
better equipped to utilise counselling as part of your recovery (see Appendix A:
Counselling Types and Terminology).
Whichever type of counselling you choose, the relationship between you
and your counsellor will be key – you need to trust your counsellor enough
to share  your thoughts and feelings, while also feeling completely accepted
by them.

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What will a counsellor do?

Counsellors will have a sincere interest in your life and experiences, so that they
can use the knowledge they gain about you for your benefit. To a counsellor, the
question ‘How can I use what I know about my client to help empower them?’
is always significant.
Initially, counsellors might ask you questions about your particular
circumstances and issues. However, your time with the counsellor will be yours,
so you are likely to do more talking than they are. This can be scary at first,
especially if you are used to bottling things up inside. However, your counsellor
will be aware of this and will support you as you find your voice. As you find your
voice, try to be completely open and honest, so that you can gain the most from
the therapeutic process.

What are the benefits of counselling?

The benefits of counselling depend on many factors, including how motivated
and committed you are to the process. Some of the main benefits include:
• Confidentiality, trust and sincere interest: Even well-meaning friends
can’t always be trusted to keep private information private. A counsellor
will offer you complete confidentiality under most conditions. The
exception is if they feel you might be at risk of causing harm to yourself
or others, in which case they might need to break confidentiality. Even
then, most counsellors will discuss this with you first in order to gain your
consent.
• The chance to express yourself freely, without fear of judgement:
Unfortunately, this is not always possible in ordinary relationships. We
can find ourselves not only being judged by others but also adapting to
how we feel a person wants us to be. Your counsellor will accept and
respect you as you are; they are not there to judge.
• Insight into yourself: This includes insight into your thinking and
emotional patterns, such as those that might knock down self-esteem
and hamper your recovery.
• An opportunity to alleviate stress and anxiety: This is gained through
having an attentive and empathic counsellor and the appointment space
and time set aside for you to talk.
• Support: A counsellor will support you to work through loss, pain and
emotional setbacks, as well as gain a new, healthy perspective on life.
• Effective strategies: Counselling provides you with the opportunity to
learn effective strategies for communication, resolving interpersonal
conflict and challenging eating-disordered thinking and behaviour.

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Reflection time!
It is important not to expect any quick fixes from counselling, but to see it as
a ‘journey’. Journeys take time. They have ups and downs, steps forward
and steps back. Unearthing and confronting deep-seated, negative self-
images and beliefs that contribute to the eating disorder will be challenging.
However, the important thing is that you will have started your journey and
you are not alone on that journey.

Counselling was a huge part of my recovery and I don’t think I could

have fully recovered without it. I was with my counsellor for seven years
due to the extent of the issues I had to contend with. This might seem
a long time, but when it comes to recovery it takes as long as it takes.
You can’t rush it.

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7.2 An Introduction to Cognitive

Analytic Therapy (CAT)
Objective
Cognitive analytic therapy (CAT) is collaborative work between a therapist and a
client, analysing the obstacles that have hindered changes in the past in order to
understand better how to bypass those obstacles in the future. Questions such as
‘Why do I always end up feeling like this?’ become more answerable. The aim of
this worksheet is to help you determine if CAT might be right for you.

Task
Read the following information in order to gain better insight into CAT and how
it can help with recovery.

What is CAT?
CAT is safe and user-friendly, being widely applicable across a variety of settings,
disorders and difficulties, including depression, anxiety and other personal
problems. The process attempts to describe and explain how problems have
evolved and how the techniques designed to deal with them may be ineffective.
CAT is designed to enable clients to understand how the difficulties they
experience can be worsened by the coping mechanisms they have developed.
Clients’ personal histories and life experiences are analysed in order to observe
the problem in its entirety. The therapist helps clients grasp how these coping
mechanisms originated and how they can be adapted and improved. Then,
initiating the client’s own strengths and resources, plans are developed to start
a change.

How does CAT work?

The work is active and collaborative. Diagrams and written outlines are developed
to help clients detect, question and modify old, unconstructive patterns. Agreed
insights are then recorded in documents, which become a manual for behaviour
during and after the therapy. In this way, clients develop new skills to help them
cope with life situations more productively, well after the therapy ends.
Practically speaking, CAT is:
• Time-limited: Therapy ranges from four to 24 sessions, but is typically
16. It is designed as a brief intervention, but can also work for longer
treatments.
• For individuals: It can also be used effectively with couples and groups,
however.

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• Cognitive: It makes full use of the client’s capability to perceive and

question everything they know about themselves, their assumptions,
feelings and behaviour.
• Analytic: Through the shared work of the client and therapist,
unacknowledged, unconscious factors are explored, and their influence
is analysed.
• Integrated: A cohesive body of theory has been developed to gain a
holistic account of the client’s personality and development. It highlights
the interplay between mental processes, feelings, emotions, actions and
consequences.
• Evidence-based: It is open to research and evaluation.
• Self-awareness-based: It is an effective way of developing self-
awareness and personal growth.
• Empowering: It uses and extends a client’s capacity for self-help,
and supports them to develop a unique means for understanding and
changing their unhelpful coping procedures.

What is the aim of CAT?

CAT aims to comprehend and improve chronic and self-inhibiting patterns of
emotional expression. It strives to detect key emotional patterns of relating to
the self and others, and considers how these patterns impact the client’s current
problems and any associated distress. CAT therapists aim to bring about a broader
perspective on the client’s psychological world and explain this perspective to the
client so that they gain better control over it. The key to successful CAT is getting to
the bottom of the client’s habitual coping mechanisms and understanding
how they got there; although unhealthy, they were once needed because they
proved a successful coping tool for the client in the past.
The goal of CAT is to equip the client with the tools and know-how necessary
for them to manage their psychological states on their own, outside of sessions.

The three Rs of CAT

The three Rs of CAT are reformulation, recognition and revision:
• Reformulation: The client and therapist develop a shared understanding
of the client’s problem, which is explicitly written down or drawn.
• Recognition: The client’s awareness of patterns, roles, feelings, thoughts
and behaviours that make life difficult are realised.
• Revision: Areas of difficulty are changed or adapted.

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In addition, at the end of therapy both the therapist and client write ‘goodbye’
letters, reviewing what has been achieved.

Reflection time!
What are your thoughts about CAT? In particular, do you have any questions
about this type of therapy? To learn more, you could visit the Association for
Cognitive Analytic Therapy website: www.acat.me.uk/page/home

CAT helped me discover how my rigid patterns were feeding my

eating disorder and keeping me trapped in a vicious cycle.

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7.3 An Introduction to Cognitive

Behavioural Therapy (CBT)
Objective
Cognitive behavioural therapy (CBT) is a branch of psychotherapy that is based
on the idea that all thoughts (cognitions) and actions (behaviours) are related.
Therefore, if you change one, you can change the other. The aim of this worksheet
is to help you determine if CBT might be right for you.

Task
Read the following information in order to gain better insight into CBT and how
it can help with recovery.

What is CBT?
CBT aims to help individuals break down problems or situations into more
manageable parts and examine the ways in which thoughts, emotions and
actions are related in each.

What does CBT do?

CBT allows individuals to examine the relationships between their thoughts,
feelings and actions, and in doing so allows individuals to understand that if they
change the way that they think and feel, they will change the way that they act.

How is CBT administered?

CBT can be attended either in private or group therapy sessions. These sessions
are approximately 60 minutes long, and they usually occur weekly or every
fortnight. CBT is a relatively short-term treatment, usually lasting no more than
six months or so.

Why does CBT work with eating disorders?

For individuals suffering from eating disorders, understanding the relationships
between thoughts, emotions and actions is highly important. Once these
relationships are understood, the individual can replace the negative thoughts
and emotions that have led to unhealthy food and eating behaviours with more
positive thoughts and emotions that will help lead them towards a healthy
lifestyle. However, in order for these relationships to be clear, it may take several
weeks of tracking thoughts, feelings and eating behaviours before the individual
will accept this proof. Often, therapists will ask individuals to keep a journal or

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food diary in order to more accurately record their thoughts, feelings and actions
towards food and eating during a given period of time.

Does CBT cure eating disorders?

Perhaps not, though it may well aid recovery. It is important to remember that
recovery from an eating disorder is a long journey, and there may be relapses
along the way. When relapses do occur, attending ‘top-up’ therapy sessions may
make a difference.

What exactly does CBT teach?

In addition to teaching individuals how to identify the links between their
thoughts, emotions and actions, CBT also teaches individuals how to avoid and
tolerate stressful situations, and how best to deal with stress in order to avoid
a relapse. It also teaches individuals that they hold the power to their recovery,
which can be comforting to individuals who feel that their lives are otherwise out
of their control.

How is CBT accessed?

CBT is only offered by qualified, trained therapists, so a referral from a GP,
hospital or clinic is one way of accessing this type of therapy. Engaging a private
professional is another means of accessing CBT.

Reflection time!
What are your thoughts about CBT? In particular, do you have any questions
about this type of therapy? To learn more, you could visit the website of
the British Association for Behavioural and Cognitive Psychotherapies:
www.babcp.com/Public/What-is-CBT.aspx

CBT didn’t help me to begin with, when I was too entrenched in the
eating disorder to even consider challenging my thoughts. However,
after counselling and extensive work beforehand, I found CBT to be the
next invaluable stage for my recovery.

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7.4 Mirror Therapy

Objective
It has been found that a therapy known as ‘mirror exposure’ can ease some of
the negative thoughts and behaviours of people with body image problems that
are serious enough to put them at risk of developing an eating disorder. The aim
of this worksheet is to help you determine if mirror therapy could benefit you.

Task
Read the following information in order to gain better insight into mirror therapy
and how it can help with recovery.
Women and men with body image issues often use mirrors to check their
perceived flaws, reinforcing their negative views of their appearance. The basic
idea behind mirror exposure is that learning to look realistically at your own
body in objective terms can alter the automatic, negative judgements that would
normally arise in those with eating disorders.
One of the key elements of mirror therapy is for individuals to look at
themselves in the mirror and describe their bodies in non-judgemental, but
honest, ways. So, instead of looking at themselves and saying, ‘I have a big
belly,’ they might note that their lower abdomen is rounder than their upper
abdomen. The goal is to help people let go of their constant self-criticism and
learn how better to respond to distressing thoughts about their bodies.
To test the effectiveness of mirror exposure, Dr Sherrie Delinsky of
Massachusetts General Hospital in Boston followed 45 women between
the ages of 17 and 31 who had body image disturbance (defined as extreme
concerns about weight and shape that affected their feelings of self-worth).1
The women were divided into two groups: one received three sessions of mirror
exposure therapy, and the other served as a comparison group, which discussed
body image issues with a therapist.
Women in the mirror exposure group stood in front of a three-way mirror
and were asked to describe themselves to a therapist, using objective, realistic
terms rather than criticism. The women were directed to focus on their whole
body, describing areas they liked as well as ones they disliked. They were also
given homework assignments designed to limit any routine visits to the bathroom
scales or to the mirror for a ‘check’.
After one month, women in the mirror exposure group showed a
general  improvement in body image concerns, self-esteem, dieting and
depression. The improvements were greater than those in the comparison group.
Although this study focused on women with body image disturbance, Delinsky
believes mirror exposure therapy could help treat eating disorders.

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Mirror therapy in people with disordered eating

Results of a small study carried out by Adrienne Key and colleagues of St
George’s NHS Trust, London, showed that women with anorexia who included
mirror treatment in their body image programme felt better about their body
six months later, while those who didn’t have the mirror treatment felt no better
about themselves.2
The researchers explain that 30–60 per cent of women who are successfully
treated for eating disorders still have a problem with body image, and this can
affect whether they make a full recovery. ‘One of the biggest predictors of relapse
is disordered body image. Women who come out of treatment with a good
body  image will probably have benefited from treatment, but those who still
have body image problems will probably be back,’ one of the researchers stated.
In this research, all the women who took part had the binge/purge form of
anorexia and they had reached their target weight. One group had standard
treatment to help improve their body image. This consisted of eight weekly
sessions of 90 minutes, during which they talked and wrote about their body
image problems and sexuality. They were encouraged to wear items of clothing
and to take part in a range of social activities that they might otherwise avoid.
The second group also had this programme but, in addition, each week
they were asked to stand fully clothed for increasing periods of time in front
of a full-length mirror. At first, the women did little more than walk past the
mirror. However, gradually, they spent longer looking at themselves and, as they
felt more comfortable with what they saw, started to wear more figure-hugging
clothing. At each stage they talked with their therapist about what they saw and
how they felt. The mirror exposure brought strong emotional responses from
many of the women.

Desensitisation works
At the start of the study, at the end of the group sessions and at six months, all the
women in the study completed a range of questionnaires related to body image.
Those who had taken part in the standard programme for improving body image
showed no significant changes in body image at the end of treatment or at six
months, compared with the start of the programme.
However, those who had the mirror treatment were less dissatisfied with their
body at six months than at the start of the study, and scored higher on other
tests related to anxiety and awareness. A few did not respond well to the mirror
therapy; they had a history of sexual abuse and the researchers agreed that, in
some cases, mirror treatment may not be the answer.

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Reflection time!
Could mirror therapy be the answer for you? As with any type of therapy,
while it might be useful for some, it might not for others. Never make yourself
do anything that feels as if it is making your condition worse. At the same
time, remember that many approaches will be difficult at first because you
are standing up to the eating disorder. If you do opt for mirror therapy, it
would be more beneficial for it to be part of a counselling programme to
ensure that you have a therapist to help you process any thoughts or feelings
that might emerge from exposing yourself to your image.

Mirror therapy is one of the hardest things I have ever done. It was,
however, an important part of learning to accept myself.

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7.5 Art Therapy

Objective
Art therapy is a mental health profession that uses the creative process of art
to improve and enhance the physical, mental and emotional well-being of
individuals of all ages. It is based on the belief that the creative process involved
in artistic self-expression helps people to resolve conflicts and problems,
develop  interpersonal skills, manage behaviour, reduce stress, increase self-
esteem and self-awareness, and achieve insight. The aim of this worksheet is to
help you determine if art therapy could benefit you.

Task
Read the following information in order to gain better insight into art therapy and
how it can help with recovery.

What is art therapy?

Art therapy is often used in hospitals, prisons, education centres and mental health
clinics, either on a one-to-one basis or in a group. It is especially beneficial for
emotional and psychological disorders as it provides a means of communication
to express feelings that are too difficult to verbalise. It is also of great use for
personal development and growth by helping you to identify problem areas and
then transform negative images into positive ones.
Here are some ideas of art projects that can help with self-awareness, positive
expression and motivation for recovery:

Road drawing Draw a road that represents a time line, focusing on significant
chapters of your life. Challenging times might be represented
by mountains, whereas calmer times might be bordered by level
fields or a sunset. The journey should be represented in a personal
way, using drawings, colours, textures and metaphors to suit your
instincts and personality. The road can be periodically updated,
highlighting a capacity to change and progress towards recovery.

Express emotion Spend a moment to reflect on a frequent feeling that you’ve

recently experienced. Try to express this feeling on paper by using
lines, shapes, colours and textures.

Abstract family List the main people involved in your life. Represent them on paper
portrait in an abstract way, using metaphors to portray your perception of
them. For example, an explosive personality that continually seeks
attention might be represented by a firework. You might even like
to consider the order and distance between each member of the
group in relation to their impact on one another.

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Eating disorder Sometimes a person with an eating disorder can feel that the
and me eating disorder is its own entity. Perhaps it would be helpful to
represent your eating disorder beside the actual you, giving
consideration to the colours, textures and size differences between
the two identities.

Tree of life Create a tree of life, recognising the strength of deep roots,
continual growth and adaptation according to surroundings,
the cycle of the seasons and the beauty in nature’s differences.
Remember, during autumn and winter, leaves will wilt and wither,
leaving the tree looking bare and lifeless, but it is these leaves that
help to nurture the growth of the tree, enabling it to flourish in the
next spring. This cycle of life could represent the ups and downs in
life, which could be seen as the necessities that enable growth in
the future.

Stepping stones Create a piece of work that represents your eating disorder/
fears/anxieties (using colour, shapes, texture, metaphors, etc.).
Now choose a different material to represent stepping stones to
place on top of your picture, showing you a safe path that can
be crossed to recovery. By placing these stones over your picture,
you’re representing your ability to take control of the situation –
appreciate your struggles and then empower yourself to find a way
past them.

Positive Choose a positive affirmation statement that you would like to

affirmation keep close to you and place this statement on a piece of portable
artwork that you could keep in your bag, wallet or room. You
could even consider incorporating your affirmation into a piece of
jewellery. The process of making this may help you to believe in the
statement, take ownership of its meaning and feel proud of your
achievements.

Blanket of support Represent your support network in the form of a blanket, with
different elements associated with the various people or forms of
support in your life. This could be done as a drawing, perhaps with
you surrounded by the blanket, or as part of a larger project that
involves the actual creation of a blanket (e.g. in patchwork).

Future ambitions Represent a future dream or ambition on paper for inspiration –

you could use drawings, cut out pictures or use items associated
with your ambition. Use this as a motivating reminder of why you
would like to overcome your eating disorder.

A rainbow Create a piece of art based on a rainbow – appreciating that every

colour is relevant and necessary. This could act as a metaphor
to remind you that all emotions and experiences play a part in
creating a whole person in their full glory.

The above ideas are only suggestions for you to consider. Choose a project that
you feel is relevant to you.

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Reflection time!
Art therapy is not the answer for everyone, but it may just be the perfect
expression for you. Don’t feel that you are restricted by your artistic talents,
or lack thereof. This is a personal project and is not intended to be displayed
in a fine art gallery. Art therapy is a process of growth and personal discovery,
and you may well redo portions of the project many times before you feel it
properly conveys the thoughts and emotions that you are trying to express.

I created my own ‘Recovery Book’, which I use to express myself.

Sometimes I draw intricate pictures, and other times I just scribble;
either way it helps me express myself.

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7.6 Animal Therapy

Objective
Animals aren’t judgemental and are completely honest in their affections.
Spending time with animals can remove you from the pressures and expectations
of society and return you to the simpler, more grounded instincts of nature.
Animal therapy has been used successfully to help people overcome eating
disorders and can include pets, such as cats and dogs, or horses and dolphins.

Task
Read through the following descriptions of animal-assisted therapies to decide
which animal best suits your personality and situation.

Dogs in animal-assisted therapy

A dog is often known as a human’s best friend and this shows in the frequency
that dogs are used for animal-assisted therapies. Dogs have developed the
ability to read our body language and know what we need the most. Not only
that, they are loving and devoted animals, and they aim to please in all they do.
Therapy dogs have received training in how to provide the care needed from
them. Spending time petting and interacting with these dogs has been shown to
relax people – reducing blood pressure, stress, pain, depression and feelings
of isolation. Naturally reticent people can be more outgoing and social when
interacting with dogs. Similarly, those who are dealing with depression are often
able to smile and escape their feelings of hopelessness during the time they
spend with therapy dogs. It’s not just therapy dogs who can distract you from
your internal conflict, however; spending an hour or two of quality time with your
own pet dog can also have a grounding and encouraging effect on you.

Cats as healing companions

Felinotherapy, or cat therapy, is a relatively new form of animal-assisted therapy.
The aloof demeanour of cats may not immediately stand out as accepting or
healing, but the benefits of cats as therapy animals have been noted. You know
where you stand with a cat – if they like you, they will approach you; if they don’t
like you or are not in the mood for interaction, they will avoid you. There are
many mental health benefits of caring for a cat, including increased self-esteem,
better self-perception, improved self-control and lower levels of aggression and
anger. Stroking a cat can reduce depression and stress, resulting in a happier,
more relaxed state. Furthermore, the purring of a cat, with a frequency of between
25 Hz and 150 Hz, has also been found to be healing, promoting regeneration
of bones, ligaments and tendons as well as relieving chronic and acute pain.

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Equine therapy – the healing of horses

Horses have been used often to help in the recovery from eating disorders. Horses
are very sensitive to human emotions and often their behaviour mirrors the state
of the person they are with. This shows that person what they are feeling, and
learning to approach and interact with the horse teaches you how to recognise
your own emotional and psychological state and modify your coping strategies
to be more effective. You don’t need to know how to ride a horse in order to
participate in equine therapy. In fact, horse-assisted therapy is more about caring
for and interacting with the horse – grooming them, cleaning their stables, feeding
them or leading them through mazes or obstacles. Once you have built up a
relationship of trust with a horse, you will realise that not only does the horse not
care what you look like, but it also does not care what its own body shape is. It is
content to live in the moment – a lesson most people have yet to learn.

Dolphin-assisted therapy for eating disorders

Dolphins are highly social animals and are well known for their aid in therapeutic
settings. A study focused on dolphin-assisted therapy for eating disorder recovery
focused on wild dolphins.3 Participants were transported daily by boat to a known
location of a pod of wild dolphins and allowed unstructured time to spontaneously
and freely interact with the dolphins. By the end of the two-week programme
there was a marked difference in depression, interpersonal sensitivity, obsessive-
compulsive tendencies and somatisation. During the three-month follow-up, there
was also a greater decrease in body dissatisfaction, ineffectiveness and impulse
regulation than in the group who had no interactions with the dolphins.

Reflection time!
Some people are dog people, while others are cat people. Some like the
outdoors and others would prefer to stay in the comfort and security of their
homes. Some people love mountains and others the ocean. Regardless of
your personal preferences, there is bound to be an animal that is suited
to your likes, dislikes and location. Animals are the most honest, non-
judgemental, unconditionally loving companions you are likely to find to
help you through the worst times.

I love animals and they have helped me in so many ways. When I

get an urge to binge or purge, time with my cats has replaced acting
on these urges. I also go to my local farm shop, where they have horses
and donkeys; they give me a sense of calm.

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7.7 Writing for Recovery

Objective
An eating disorder can often become a distraction from life and difficult
emotions, isolating us from the need to communicate and engage with others.
This can lead to confused or buried thoughts and emotions, often left to fester
and distort in the mind. Writing can be a good outlet for these feelings, allowing
for cathartic expression but also encouraging positive reflection. The aim of this
worksheet is to give you some ideas about the different ways you can express
yourself through the written word.

Task
Read about the different ways you can use writing to help your recovery, and
choose at least one to try yourself.

Writing a journal
Regularly writing about personal experiences and feelings can be very therapeutic.
A journal is a personal diary, allowing for honest expression without judgement.
It shouldn’t matter if the writing isn’t a ‘perfect’ example of good grammar or
spelling, or even if the content makes sense to others. The space should allow
for free-flowing expression, doodles and lists relevant to feelings at the time
things are written. Used regularly, this kind of writing can be a powerful tool to
unlock and heal painful memories, emotions and events, allowing for reflection,
understanding and acceptance.
Here are some journal writing ideas to inspire you:
• I feel good today because…
• I hate it when...
• My eating disorder helps/hinders my daily life in the following ways…
• When I look in the mirror I feel/see…
• My vision of healthy eating is…
• What does ‘recovery’ mean to me? How do I define my vision of
‘recovery’?
• Right now, I see/hear/smell…and this makes me feel/think…
• Today, I am thankful for…

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Poetry and song writing

Often, those affected by an eating disorder have a creative/sensitive side inclined
towards writing poetry and song writing. When shared with others, this outlet
can encourage empathy and understanding, which is especially important when
someone is feeling isolated and misunderstood. Here is a poem that someone
with an eating disorder has kindly shared.

Misinterpreted Story4
I’m the misinterpreted story
In the winter newspaper
Perverted by the press
Distorted by the reader
I’m the depressing one
That no one really wants to hear
That you feel sorry for
And then forget, ignore
Because I’m not your problem

I’m the discarded story

Littering the floor
Not important enough to keep
Too much bother to pick up
I’m the one quietly watching you
Blissfully ignorant of my crying
Watching you in frustration
While you wake, eat and sleep
Without my nightmares

I’m the scrunched up story

Slowly covered by snow
Blocking my view of normal life
Losing shape and colour
I’m the one disintegrating
Wanting to go unnoticed
But always frightened
Of the loneliness and cold
Numbing camouflage

I’m the hidden story

In the depth of storm
Freezing up and suffocating
Losing sense and strength
I’m the one pleased to be lost
Giving reason for no attention
Wishing to wither away
With no feeling or redemption
Rather than be uncovered and thrown away

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I’m the corroded story

Beyond reading or repair
As the rain beats down on me
Uncovered and blurred
I’m the one blowing aimlessly
In the hissing wind
Not knowing where I’ll land
Or what’ll come of me
With no self-control

I’m the old misinterpreted story

Scared of next week’s newspaper

Writing tasks
Eating disorder treatment, whether it be counselling, CBT, self-help or other,
often suggests the use of writing tasks to better understand ourselves and our
situations in life. Here are some examples of such tasks, some of which you
might like to try:
• Write a love letter to yourself: Describe all of the things that are good
about you, both physically and psychologically.
• Write five things that you appreciate about someone special to
you: Then ask them to write five things they appreciate about you. Read
them – accept that the other person feels this way and try to appreciate
these things about yourself also.
• Positive affirmations: Many people benefit from writing and reading
personal positive affirmations – for example, ‘I want to be strong, happy
and healthy.’
Research suggests that writing something down increases our understanding
of what has been written, reinforcing the meaning behind it. Therefore, it’s
important to recognise that cathartic writing about negative feelings, although
sometimes helpful, can also emphasise these negative thoughts and so should
be balanced with positive writing towards recovery.

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Reflection time!
What have you learnt from these writing exercises? Will this change any
of your perceptions or behaviours, aiding recovery? Sometimes, writing
can be a very powerful way of sharing information that you feel unable to
explain verbally. Do you feel able to share any of your writing with someone
trustworthy?

I have pages and pages of writing – letters to myself, letters to family,

letters to my counsellor. I wrote one letter five times before I was happy
with it. Writing has been essential for me learning to express myself.

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7.8 Helpful and Unhelpful Aspects

of Eating Disorder Treatment
Objective
Treatment of eating disorders is as complex as the condition. The good news
is that research conducted by specialists such as Professor Julia Buckroyd5 is
helping to identify what aspects of treatment are helpful and unhelpful – from the
point of view of people with eating disorders. The aim of this worksheet is to help
you determine the helpful and unhelpful aspects of your treatment.

Task
Before we look at what Buckroyd has found in her research, let’s take some time
to consider what you have found helpful and unhelpful in your own treatment.

Some of the helpful aspects of my treatment are:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Some of the unhelpful aspects of my treatment are:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Many people with eating disorders have reported that working with a counsellor
who was able to get to the psychological root of the eating disorder, such as
childhood abuse or an addictive personality, allowed them to make noticeable
steps towards recovery. Those in recovery also reported improvement when
working with a counsellor who was able to candidly discuss body concerns and
nutritional information, and who made efforts to show how treatment would
directly affect real life. Here are some more helpful aspects of treatment reported
by people with eating disorders:

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• Social support: from peers with an eating disorder, relatives, close

friends and even strangers.
• Relational support: a trusting and supportive relationship with a health
professional, feeling understood, being listened to, an opportunity to
talk, being seen as a person and not an illness, feeling cared for.
• Mental health professional characteristics: seeing the mental health
professional as an expert, the mental health professional providing
encouragement, guidance, modelling, validation.
• General treatment characteristics: being active in their own treatment
and collaborating with their counsellor, structure within the treatment,
affordability and accessibility, focus on the whole family, follow-up.
• Specific treatment characteristics: self-monitoring, behaviour
change, gaining control, cognitive restructuring, nutritional knowledge,
information about the detrimental effects of eating disorders, emotional
expression.
• Personal changes due to treatment: insight, self-acceptance, changes
in life circumstances, positive life events.
People with an ill-fitting treatment option are often left feeling overlooked and
unsupported. Those who met with counsellors who were not experienced with
eating disorders found treatment to be more focused on what the counsellor
wanted than the client. Such counsellors were often too rigid or too focused
on the eating issues as opposed to the underlying psychological issues. These
experiences made those in recovery feel distressed and misunderstood, and they
saw little or no improvement. Here are some more unhelpful aspects of treatment
reported by people with eating disorders:
• Lack of social support: distressing or misguided influence of others with
eating disorders and unsupportive family and friends.
• Lack of relational support: being overlooked as a person, not cared
for, or the counsellor being hostile or lacking warmth.
• Deficiencies in mental health professional characteristics: lack of
expertise or counsellor’s own mental health issues getting in the way.
• Deficiencies in general treatment characteristics: treatment missing
client’s needs or being too rigid, lack of continuity and follow-up,
inappropriate length, focus on eating and not psychological needs,
loss of control, superficial therapy, lack of structure, reliance on client’s
discipline.
• Deficiencies in specific treatment characteristics: lack of information
on eating disorders and nutrition.

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• Painful experiences due to treatment: hopelessness, low mood,

shame, vulnerability, self-judgement, feeling alone.
Factors such as sharing with peers who have an eating disorder and gaining support
from family and friends appear to be very important in terms of whether treatment
is helpful or unhelpful. The mental health professional also plays a key role; in
particular, the relationship formed with your counsellor is critical. It is important
to have trust, which is most often gained through having a warm counsellor who
will listen without judgement and allow you to have an active role in the treatment
plan and content. You need to be engaged in order to fully reap the benefits of
treatment and to maintain motivation towards recovery. Expertise specific to eating
disorders is also important due to the complex nature of the condition.
People with eating disorders tend to appreciate a broad focus that allows for
not concentrating solely on eating, which is already a preoccupying theme in
the client’s life. Given the complexity of eating disorders, follow-up is a crucial
element for supporting recovery and preventing relapse. Buckroyd’s research
also shows that clients valued both symptom focus and focus on underlying
emotional issues that are being expressed via disordered eating. The absence
of either of those two aspects was seen as unhelpful, supporting the usefulness of
combining both approaches.

Reflection time!
Take some time to write a list of things that might enhance and improve
your treatment, but which you are currently not receiving. Choose one point
in this list that you have some control over. For example, could you ask
your counsellor to offer a balance of symptom-related and emotion-related
support? Maybe you can reach out to a friend so that you have a stronger
support network? Make the decision to add at least one more helpful aspect
to your treatment.

My relationship with my counsellor was key to recovery as she

became a role model for how I should treat myself – with care and
compassion. Interestingly, after some years, this relationship became
unhelpful because I was holding on to her when I no longer needed
her. The skills she had taught me allowed me to recognise this, however.

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