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Section 14
Treatment for Anorexia Nervosa

CEU Question 14 | CEU Test | Table of Contents | Eating Disorders CEU Courses
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On the last track, we discussed three concepts related to redefining identity in anorexic clients.  These three identity defining concepts included:  exposing the false self; allowing the self; and self-neglect.

On this track, we will examine three additional techniques that I have found useful in treating anorexic clients.  These three techniques include: Mirror Mirror; Character Definition; and Restructuring Automatic Thoughts

3 Tools for Anorexics

Tool #1 - Mirror Mirror
The first technique that can be used with an anorexic client is "Mirror Mirror."  I find this technique helpful in the beginning stages of therapy when the client is just starting to open up.  In order to facilitate his or her sharing, I ask that the anorexic client answer certain questions about how he or she feels when looking in the mirror. 

Just as the narrative that we discussed on track 1 allows for the uninterrupted and objective flow of thoughts, so too does this exercise allow the anorexic client to introduce and see for themselves their own anorexic thoughts.  Jamie, age 15, had reached 75 pounds before she was referred to me.  I asked Jamie to take home a list of 10 questions and to answer them truthfully. 

Jamie returned with these 10 Responses:

  1. When I look in the mirror, I feel unaccomplished and a failure.
  2. Today I looked in the mirror and cringed.
  3. I like myself best when I’m under 90 pounds
  4. The first thing I do when I get up in the morning is weigh myself.
  5. The first thing I think when I get up in the morning is who will I have to fool today?
  6. I feel glad to be me when other girls are jealous and I can stand up to my parents.
  7. If my mirror could talk, it would say "you’re hopeless."
  8. My perfect reflection would be thinner.
  9. The last time I liked what I saw in the mirror was when I was 10.
  10. My body is gross and keeps me from being my best.

As you can see, this exercise has identified much of the negative self-talk that Jamie puts herself through.  By bringing these statements out into the open, she can better prepare herself for letting go of these internalized beliefs.  Think of your Jamie.  Would he or she benefit from "Mirror Mirror"?

Tool #2 - Character Definition
The second additional technique that I find useful with anorexic clients is "Character Definition."  This exercise is designed to aid anorexic clients in redefining their source of self-esteem.  Up until the point that they come to therapy, anorexic clients' source of self-esteem is definitively their bodies and not themselves. 

In order to move the focus away from the physical self, I recommend to parents and clients to remove full length mirrors and scales from the homes so that the client cannot obsessively measure herself.  To replace the physical self-esteem, I asked my 16 year old anorexic client Sherry to make a list of positive attributes that her and others find distinctly individual and positive about her.  This list included:  strong laugh, sweet disposition, genuinely caring attitude, beautiful singing voice. 

I then asked Sherry to review this list and tell me if her anorexia has damaged any of her real character.  She stated, "Well, I’m weaker so my voice is also weak and I have been crabbier since I’ve stopped eating.  I still really like the way I can talk back to people now.  I didn’t before."  I stated, "But when you have been assertive, that has been the result of your anorexia, not yourself.  This is not who you are.  I am sure there is an assertive person underneath the exterior, but the assertiveness coming out is not a part of you." 

Think of your Sherry.  How would you get him or her to define their own character?

Tool #3 - Restructuring Automatic Thoughts, 3 Steps
The third additional technique that I find useful with anorexic clients is "Restructuring Automatic Thoughts."  As you already know, there are many different types of automatic thoughts that anorexic clients engage in.  In track 6, we discussed abbreviations, short phrases that anorexic clients repeat to themselves in order to avoid rational thought.  Automatic thoughts work in the same way.  When a client begins to experience a certain trigger feeling, the automatic thought or way of thinking kicks into gear. 

Mary, age 17, had developed mild paranoia in addition to her anorexia.  Mary was prone to overanalyze other people’s reactions to certain stimuli and would catastrophize meaningless situations. 
--Step 1. First, I asked Mary to identify her thought when she began to feel anxious, which was her trigger emotion. 
--Step 2. Second, I asked that she identify which form or forms of automatic thought she is employing. 
--Step 3. And lastly, I ask that she write down in her daily journal a more rational explanation of the situation.

After a few weeks, Mary returned and stated, "Yesterday, my best friend Kristen walked right by me at the mall without speaking!  My automatic reaction was to think, ‘What did I do?  Why is Kristen angry at me?  I must have done something to her.’  I tried to tell myself that I was jumping to conclusions, but I still didn’t believe it.  I wanted to call her up and ask her what was wrong.  If she didn’t answer, I’d keep calling and calling until she’d finally pick up. 

"I told my mom, and she suggested writing it in my journal and dealing with it tomorrow.  I wrote, ‘I’m jumping to conclusions and I’m also personalizing things too much.  Maybe she didn’t see me.  I’ll just have to ask her about this tomorrow at school.’  I haven’t asked her yet, because I haven’t seen her, but I’m still really anxious about everything between us." 

Although Mary’s anxiety has not subsided, she is still beginning to analyze her thoughts enough to understand her own motives.  Think of your Mary.  What kind of automatic thoughts is he or she perpetuating?

On this track, we discussed three additional techniques that I have found useful in treating anorexic clients.  These three techniques included: Mirror Mirror; Character Definition; and Restructuring Automatic Thoughts.

Peer-Reviewed Journal Article References:
Groth, T., & Hilsenroth, M. (2019). Psychotherapy techniques related to therapist alliance among adolescents with eating disorders: The utility of integration. Journal of Psychotherapy Integration. Advance online publication.

Pila, E., Murray, S. B., Le Grange, D., Sawyer, S. M., & Hughes, E. K. (2019). Reciprocal relations between dietary restraint and negative affect in adolescents receiving treatment for anorexia nervosa. Journal of Abnormal Psychology, 128(2), 129–139. 

Racine, S. E., & Wildes, J. E. (2015). Dynamic longitudinal relations between emotion regulation difficulties and anorexia nervosa symptoms over the year following intensive treatment. Journal of Consulting and Clinical Psychology, 83(4), 785–795. 

Romano, K. A., & Lipson, S. K. (2021). Weight misperception and thin-ideal overvaluation relative to the positive functioning and eating disorder pathology of transgender and nonbinary young adults. Psychology of Sexual Orientation and Gender Diversity. Advance online publication.

Online Continuing Education QUESTION 14
What are three additional techniques that I have found useful in treating anorexic clients? To select and enter your answer go to CEU Test.

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