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Eating Disorders: Techniques for Treating Binging & Purging
Bulimia continuing education counselor CEUs

Section 5
Interpersonal Relationships in Binge Eating Clients

CEU Question 5 | CEU Test | Table of Contents | Eating Disorders

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On the last track, we discussed three binge trigger categories. These three binge trigger categories included:  food and eating; body weight and shape; and negative emotions.

On this track, we will examine three concepts of interpersonal relationships with regards to the binging and purging client. These three concepts of interpersonal relationships include:  early childhood development; as a means to please; and secrecy.

3 Concepts of Interpersonal Relationships

Concept #1 - Early Childhood Development
The first concept of interpersonal relationships with regards to the binging and purging client is early childhood development. Clients who have been neglected or abused as children tend to believe that the cause of the abuse or neglect was themselves. Children who are not taught how to behave or who are repeatedly ignored by parents will look to external cues on how to behave. Most significantly, this includes peers and media role models. If the external cues are signaling to the client that he or she needs to be thinner, the client will attempt to achieve this end through whatever means possible. 

Nina, age 15, was sent off to boarding school at the age of nine. Prior to her high school years, Nina had never had a close relationship with her parents. Her mother and father were constantly at activities, so Nina and her younger brother were raised by the nanny. 

Nina stated, "I always thought that there was something wrong with me! That I had done something to disgust my parents and make them not love me! I didn’t want to make the same mistake again and chase off any potential friends at school. So I watched them and I noticed the thin girls were much more popular. I wanted to be like them! So when I was fourteen I heard about a girl who had vomited to be thinner. I thought that maybe I could do that, so I did!" 

Nina’s behavior had been triggered by the actions of her peers and by the emotional neglect she felt in her early childhood development. Think of your Nina. How did his or her childhood development affect her bulimia later in life?

Concept #2 - As a Means to Please
The second concept of interpersonal relationships with regards to the binging and purging client is when a client uses bulimia as a means to please. Many clients who have been diagnosed with bulimia share a common personality trait of being "people pleasers." They tend to be active, highly ambitious individuals prior to the onset of their eating disorder. Sometimes, in their own minds, they are still performing in that role, that their behavior in fact does please those around them. Like the client who has been neglected in early childhood, the people pleasing client wishes to behave in such a way as to illicit acceptance, either from peers or parents. 

Cynthia, age 17, had started binging in order to please her mother, Jane. Cynthia stated, "Mom always points out skinny people to me in the mall and on television. I know she won’t come out and say it, but I know she wants me to look like those women! And that’s ok. I mean, it’s not too much to try a little harder!" 

When I asked Jane if she had wanted her daughter to start this behavior, she stated, "No!  I know how bad this forced vomiting can be for your teeth. I don’t want Cynthia to have no teeth at all. That would just look awful!"  Cynthia’s mother had placed a high premium on becoming beautiful, and to fit into her mother’s ideal, Cynthia had begun to adopt these behaviors.  Think of your Cynthia. Is he or she using bulimia to fit into a certain ideal?

Concept #3 - Secrecy
In addition to early childhood development and bulimia as a means to acceptance, the third concept of interpersonal relationships with regards to the binging and purging client is secrecy.  Bulimic clients are often characterized by extreme secrecy in regards to their binging and purging habits. They feel as though they cannot trust their partners or loved ones and so try to maintain a façade of composure.

In reality, the client is subject to severe mood swings which ultimately affect the stability of the relationship. Stealing, which is common occurrence in forty percent of bulimic cases, encourages low self-esteem and hiding. Ultimately, the client fears that if he or she should reveal his or her eating behavior, the relationship will crumble.

Theresa, age 23, had been married to Michael for over a year. Theresa had been diagnosed with bulimia at the age of 21 and still had yet to tell Michael about her behavior. Theresa stated, "I wait until he’s not at home and then I binge and purge to the max! I couldn’t stand for him to see me like this, it’s too humiliating! What if he leaves me? I couldn’t stand to be alone for the rest of my life!" 

Theresa’s shame in her own behavior causes her to believe that Michael, her husband, will react with the same disgust and repulsion. 

Cognitive Behavior Therapy Technique:  Three Screen Comparison and Acceptance
To help Theresa become more honest with her husband Michael about her eating disorder, I asked that she try the "Three Screen Comparison and Acceptance" CBT exercise. I asked Theresa to imagine herself telling Michael about the eating disorder. I then asked her to think of the best possible outcome, the worst possible outcome, and the compromise between the two.

--Best Outcome: Theresa stated, "Well, the best possible outcome would be that he is completely accepting of the disorder, hugs me, kisses me, and tells me everything is going to be ok. He isn’t even shocked. 
--Worst Outcome: The worst case scenario would be if he finds my behavior completely repulsive and divorces me for it. 
--Middle Ground: And the middle ground of those would be that he’s shocked and dismayed, but still supports me throughout treatment."

I then asked Theresa to think of each of these scenarios individually and work on accepting all three, no matter how unlikely. Think of your Theresa. Could he or she benefit from the "Three Screen Comparison and Acceptance" exercise?

On this track, we discussed three concepts of interpersonal relationships.  These three concepts of interpersonal relationships included:  early childhood development; as a means to please; and secrecy.

On the next track, we will examine three aspects of binging as a result of anxiety.  These three aspects of binging as a result of anxiety include:  generalized anxiety; fortune telling; and source identification.

Peer-Reviewed Journal Article References:
Gallagher, M. E., Tasca, G. A., Ritchie, K., Balfour, L., Maxwell, H., & Bissada, H. (2014). Interpersonal learning is associated with improved self-esteem in group psychotherapy for women with binge eating disorder.
Psychotherapy, 51(1), 66–77. 

Luo, X., Nuttall, A. K., Locke, K. D., & Hopwood, C. J. (2018). Dynamic longitudinal relations between binge eating symptoms and severity and style of interpersonal problems. Journal of Abnormal Psychology, 127(1), 30–42. 

Thompson-Brenner, H. (2016). Relationship-focused therapy for bulimia and binge eating: Introduction to the special section. Psychotherapy, 53(2), 185–187. 

Online Continuing Education QUESTION 5
What are three concepts of interpersonal relationships? To select and enter your answer go to CEU Test.

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