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Hi All
Thank you very much for your responses, allowing me to see different angles of this difficult situation; and for your kind and caring words, I feel supported, and also warned.
I find your wonderings about her criticizing the slow pace of change very helpful and fitting, yes, it would be "the others" demanding more rapid change in behavior, and she struggling to keep in control. And this refusal to continue treatment comes rather unexpectedly to me, in our sessions before she had shown interest and willingness to try something new.
And yes, more intensive, in-patient treatment could help, and so far she is not willing to do that. And if her physical state continues to deteriorate, an emergency demanding forced treatment will arise.
I would like to get a chance to continue to work with this family, and have all your ideas and experience with me.
I have been sitting now for quite a while trying to respond to your posts, I find my words inadequate, this is difficult.
Thank you again
Jan
Hi All
Also just got your email in Australia. Carla has expressed the thought that came to me. In working with clients with eating disorders for a long time, I have never had a client say to me that change is too slow and that is a reason to end therapy. It is much more typical to end therapy because change is happening to quickly and the mind is giving its typical “out of control” messages, particularly if weight gain is on an agenda. It is possible that checking out what is not changing will open up some interesting avenues. My hunch may be that change is not happening quick enough for mum or the family, that that may be leading to an increased pressure to change from the family (understandably given the distress of seeing somebody you love starve themselves). This may be the pressure to change that is driving a desire to leave therapy. Just a hunch from a long way away.
I find that one of the things that makes working with clients with anorexia so difficult is the anxiety that is created for us as therapists. I always work within a team that involves a medical person who can make calls about the medical suitability of working as an outpatient. A BMI of 15 is severely emaciated, and if the weight is dropping at around a kilo a week for a few weeks there is a likelyhood of acute medical complications. Having a physician involved makes it easier for me to diffuse from thoughts that make it harder to just be there for the patients and help to understand what is “not changing” and how this is a barrier to moving toward values for the client.
I also have no idea what iview is but would be interested in finding out.
CT
Hi Jan,
I'm guessing you've already had the appointment by now, since it's just morning in Australia and I've just received your email.
I'm really intrigued by the client saying that the therapy is not helping her enough because it's not leading to enough change. Many clients with Anorexia would say that they don't want to change, so it seems like the fact that she's saying that change isn't happening fast enough, means that there's something to work with there. Do you know what change she's looking for? Even if the change she wants is a control driven agenda, underneath that, there will probably be some some way to link that to her values, i.e., "If X(whatever she states she wants to change) were to be different, then what would you be able to do in your life?"
I've always found it a tight balance with clients with Anorexia between encouraging them to come, knowing that for some of them it's hard for them to find a way to allow themselves to be there and so for the time being the therapist has to do that. AND then on the other end, respecting when they decide they don't want to come. It's easy to hold too tight to them, or too loose.
Had she talked with you in the last session about not wanting to come or was this out of the blue. I generally ask clients that say on the phone that they don't want to come, whether they'd be willing to come in and discuss face to face and to have a chance to say goodbye. It just gives you a bit more space to help them clarify what they really want to do, cause you've got longer and when you get to the hard bits, it's not as easy to end it as it is on the phone (by handing phone over or hanging up), so you've got a little more chance of being able to work through the hard bits.
Also, it's probably not that relevant, but can you tell me what "iView" is? I've never heard of it.
Carla.
Hi Jan,
Tough as nails to talk about on a list serve,
but here's a rather obvious but often overlooked thing...
Backing up some, I"m wondering what did she say in response--when you said you respected her opinion
and see her potential and so forth?
It's okay to stop and ask her what she thinks of what you just said...
In fact, I think this is very important with eating disorder clients who feel they have no control
and no voice to do this sort of continuous checking in--
to stop and listen and stay present and reflect what you hear so that
your client can "HEAR" her own voice and STAND in her own voice every step of the way,
for several reasons (they are in a hazy sort of space, and yet they also yearn for a bit more clarity--so
there is a push/ pull that goes on continuously).
Tiny bits of dignity where a felt presence is real are like little seeds that we throw into the ground--they may not look like
anything now, but you just never know will take root.
Best of luck--hope you are getting some good local support too..
Joanne
Hi Jan,
By now you've had your session...hope it is feeling more in control. I don't think the mother is "just panicing," I think the mother's intuition is good.
I am with Henrik. With BMI of 15 and "sinking fast", as you know, her brain, her chemicals, her body is in serious trouble, and I think she's got to get intensive treatment for safety and for anything else to be at all effective. I do hope that's available.
I go to basics in these situations: I like Maslow's hierarchy:
First is physiology, and that is where I think she needs you and mother to take control for the time being.
With 5 sessions under your belt I doubt even the best alliance in the world would be powerful enough to do this outpatient at this moment. And I am so impressed by your responses to her, you're doing a terrific job in conveying valuing her and her real life.
What I'd look forward to next is you being an absolutely crucial presence and pivotal influence, during an inpatient stay if that does happen, so that once her brain and body begin to function from more adequate nutrition, she can look at you and see someone she knows really is "there, present with her."
Then, the "enough change" she wants so hard can happen, even though it's going to be her behaviors and probably not at all what she imagines, that changes.
Best of luck,
Ellen
Jan,
I can only imagine the thoughts and feelings that would be tormenting me, were I to find myself in your situation. I want to say that I greatly admire you holding the door open for both of these tired struggling people. You seem to be offering your compassion and their dignity whether they walk though or not.
Sent from the iPhone of Emily K. Sandoz
Jan,
I had to repost my response to the whole group with a reply to all.
As you know, with anorexia sometimes the person just has to be hospitalized. I have found with the eating disorders population that any looking at the self from basically any therapy (CBT, psychodynamic, systems, etc.) can be hard. However, with that said, my guess is that she has spent some time looking at herself from the view of the person who took her first breath and then her mind has jumped in and basically and said, "stop that."
Your client is of course right in that the iView does not help, it's just a nonjudmental view of the whole self. What will help is changing what she does and of course that will involve eating more, so then the mind enters back in and her behaviors go toward stuck. I wonder if she can "see" that process?
Her mother can help in this regard. Teach the mother the iView. Stress that it's just a cute name for the basic ability all of us have for nonverbally learning through experience. That point of view has no judgment, it just learns what works for moving us toward what we value. So the mother would want to show this nonjudgmental view with the daughter, just like you would show it to the daughter in a therapy session. The mother could say things like, "So which value are you moving toward by not going to therapy?" In other words, staying home and not going to therapy is serving some function for the daughter, the daughter just needs to clearly "see" what the function of staying home is. I am in no way recommending that the mother challenge the daughter. This would literally be done from the stance of the iView (nonjudgmental noticing of the function of a behavior).
The tough thing with any client is that it is the client who needs to change what she or he does. With eating disorder folks part of the control function is controlling other people. If the other people (mother, therapist) get hooked, things stay stuck. So you and the mom can use your iViews to stay as unhooked as you can (I know that's really hard) and keep looking at the girl's behavior in terms of moving toward stuck and moving toward values. This girl has values. Everyone has values. Hopefully you and the mom can help her see the value of living and the value of doing behaviors that enhance living toward values.
I have to go to an appointment now. Good luck.
Talk to you this afternoon.
Kevin
Hi, Jan
Has she had previous therapy? Does she maybe have a pattern of beginning a therapeutic relationship and then running away? She may be experiencing a huge amount of fear -- fear that she is hopeless and can't change, as well as fear of giving up her anorexia with its rewards and recovering. Perhaps if she does come back, at some point you could ask if she would be willing to be with the fear (if she's aware of it), the thought that she is a burden, etc.
Perhaps she came to therapy in the first place only because of pressure from family members, and is not yet at the point where she is ready to change. There may be a power struggle going on in the family. For example mom may be acting as the "food police," watching every bite she eats, etc. Daughter may feel out of control in her life and food intake is one thing she can control and "you can't make me eat," etc.
I used to work with eating disorders. I found the work highly challenging. Good luck!
Susan
Hi Jan,
I am not working with anorectic clients, so I am no expert on this.
Is a BMI around 15 a danger zone? Is she under medical surveillance? If so, chances are that she will be forced to undergo more intensive treatment and maybe you have to play a part in that? I know that very low weight changes the way people think and make decisions so treatment is about having enough weight to make valuable decisions based on good thinking.
The way you responded to the client seems very compassionate and accepting the fact that you cannot make her change.
To be honest I would not know anything to recommend you than to sit with your client and her mother as a sunset, witnessing their troubles, their struggle, their suffering and be open to your own struggle. Maybe if you can do that, something will open up.
It reminds me of a client of mine, who recently became very suicidal. She told me she had made very serious preparations to end her life. I knew that calling in a psychiatrist to judge her suicidality and judge whether she had to be send to an inpatient ward would seriously damage our therapeutic relationship. I told her that I was in doubt what to do. That what I wanted most was to help her lead a meaningful life, that I understood that life seemed unbearable for her right now and that if there was anything that I could do to help I was willing to do that. Furthermore I told her that I wanted some assistance for myself and would talk to a psychiatrist to see if what I was doing was the right thing. I asked her if she was willing to come back to me two days later, as an agreement to not kill herself during the meantime. She was willing to commit to that, and she did understand that I wanted back-up for me, although she became very suspicious what would happen if I brought in a psychiatrist. The psychiatrist I consulted reassured me that I had done well and that she did not have to see the client as long as I thought that the client would be coming back. We came through the crisis, without forced treatment.
I have to say that we had a history of a very good therapeutic relationship and we had made considerable progress, which helped the client to hold onto trusting me and me onto trusting her. Nevertheless, being open to what was going on on both sides proved fruitful.
Wishing you all the best with this difficult situation,
Jacqueline
Hi Jan,
Just my quick thoughts from my experience working in an out-patient clinic for adolescents:
Maybe this young woman needs more intensive care than you are able to provide? If her BMI is sinking fast she may need to be placed in
a more intensive care - in-patient facility.
This does not mean, however, that your work together is lost or has to stop altogether. Maybe she can come back to you after having
gone through a more hands-on treatment (learning how to eat, having the support 24/7 by staff who can coach her to eat etc...). And maybe
she can come and see you while she's undergoing that treatment.
Well, all this is provided there is some place for her to go. Some hospital or in-patient unit that can help her, that is.
So if I where you, I would work on that: finding an alternative, much more intensive treatment right now and help your patient and her mother along that road. And also make it clear to them that you will follow up how it goes so they feel your support...
Best of luck!
Henrik
I just had a phone call from a client whom I have seen 5 times so far, introduced iView and life manual. She is suffering from anorexia, BMI around 15 and sinking rapidly. Living with her mother who is desperate. She just told me on the phone that she does not want to come anymore, that this therapy, this "iView stuff" is not helping her enough, not enough change. That she is a burden for her surroundings, who are telling her that it cannot go on like this. I responded with sympathy, expressed respect for her opinion, expressed my openness that she can come any time. Expressed that I cannot guarantee how quickly her life will change, that I would be willing to commit myself to attempt to be an instrument for her to develop her life. Expressed my conviction that her life is full of potential, and that I wish that she can develop this potential. Asked whether I could do anything for her, maybe speak to her mother. She then passed the phone to her mother who expressed her desperation, her unwillingness to let her daughter stop therapy, her need for help as a mother. I offered to see her today with or without her daughter during the scheduled appointment which is in 4 hours (8am eastern time). Any support / suggestions would be very welcome.
thank you
Jan
Thank you very much for your responses, allowing me to see different angles of this difficult situation; and for your kind and caring words, I feel supported, and also warned.
I find your wonderings about her criticizing the slow pace of change very helpful and fitting, yes, it would be "the others" demanding more rapid change in behavior, and she struggling to keep in control. And this refusal to continue treatment comes rather unexpectedly to me, in our sessions before she had shown interest and willingness to try something new.
And yes, more intensive, in-patient treatment could help, and so far she is not willing to do that. And if her physical state continues to deteriorate, an emergency demanding forced treatment will arise.
I would like to get a chance to continue to work with this family, and have all your ideas and experience with me.
I have been sitting now for quite a while trying to respond to your posts, I find my words inadequate, this is difficult.
Thank you again
Jan
Hi All
Also just got your email in Australia. Carla has expressed the thought that came to me. In working with clients with eating disorders for a long time, I have never had a client say to me that change is too slow and that is a reason to end therapy. It is much more typical to end therapy because change is happening to quickly and the mind is giving its typical “out of control” messages, particularly if weight gain is on an agenda. It is possible that checking out what is not changing will open up some interesting avenues. My hunch may be that change is not happening quick enough for mum or the family, that that may be leading to an increased pressure to change from the family (understandably given the distress of seeing somebody you love starve themselves). This may be the pressure to change that is driving a desire to leave therapy. Just a hunch from a long way away.
I find that one of the things that makes working with clients with anorexia so difficult is the anxiety that is created for us as therapists. I always work within a team that involves a medical person who can make calls about the medical suitability of working as an outpatient. A BMI of 15 is severely emaciated, and if the weight is dropping at around a kilo a week for a few weeks there is a likelyhood of acute medical complications. Having a physician involved makes it easier for me to diffuse from thoughts that make it harder to just be there for the patients and help to understand what is “not changing” and how this is a barrier to moving toward values for the client.
I also have no idea what iview is but would be interested in finding out.
CT
Hi Jan,
I'm guessing you've already had the appointment by now, since it's just morning in Australia and I've just received your email.
I'm really intrigued by the client saying that the therapy is not helping her enough because it's not leading to enough change. Many clients with Anorexia would say that they don't want to change, so it seems like the fact that she's saying that change isn't happening fast enough, means that there's something to work with there. Do you know what change she's looking for? Even if the change she wants is a control driven agenda, underneath that, there will probably be some some way to link that to her values, i.e., "If X(whatever she states she wants to change) were to be different, then what would you be able to do in your life?"
I've always found it a tight balance with clients with Anorexia between encouraging them to come, knowing that for some of them it's hard for them to find a way to allow themselves to be there and so for the time being the therapist has to do that. AND then on the other end, respecting when they decide they don't want to come. It's easy to hold too tight to them, or too loose.
Had she talked with you in the last session about not wanting to come or was this out of the blue. I generally ask clients that say on the phone that they don't want to come, whether they'd be willing to come in and discuss face to face and to have a chance to say goodbye. It just gives you a bit more space to help them clarify what they really want to do, cause you've got longer and when you get to the hard bits, it's not as easy to end it as it is on the phone (by handing phone over or hanging up), so you've got a little more chance of being able to work through the hard bits.
Also, it's probably not that relevant, but can you tell me what "iView" is? I've never heard of it.
Carla.
Hi Jan,
Tough as nails to talk about on a list serve,
but here's a rather obvious but often overlooked thing...
Backing up some, I"m wondering what did she say in response--when you said you respected her opinion
and see her potential and so forth?
It's okay to stop and ask her what she thinks of what you just said...
In fact, I think this is very important with eating disorder clients who feel they have no control
and no voice to do this sort of continuous checking in--
to stop and listen and stay present and reflect what you hear so that
your client can "HEAR" her own voice and STAND in her own voice every step of the way,
for several reasons (they are in a hazy sort of space, and yet they also yearn for a bit more clarity--so
there is a push/ pull that goes on continuously).
Tiny bits of dignity where a felt presence is real are like little seeds that we throw into the ground--they may not look like
anything now, but you just never know will take root.
Best of luck--hope you are getting some good local support too..
Joanne
Hi Jan,
By now you've had your session...hope it is feeling more in control. I don't think the mother is "just panicing," I think the mother's intuition is good.
I am with Henrik. With BMI of 15 and "sinking fast", as you know, her brain, her chemicals, her body is in serious trouble, and I think she's got to get intensive treatment for safety and for anything else to be at all effective. I do hope that's available.
I go to basics in these situations: I like Maslow's hierarchy:
First is physiology, and that is where I think she needs you and mother to take control for the time being.
With 5 sessions under your belt I doubt even the best alliance in the world would be powerful enough to do this outpatient at this moment. And I am so impressed by your responses to her, you're doing a terrific job in conveying valuing her and her real life.
What I'd look forward to next is you being an absolutely crucial presence and pivotal influence, during an inpatient stay if that does happen, so that once her brain and body begin to function from more adequate nutrition, she can look at you and see someone she knows really is "there, present with her."
Then, the "enough change" she wants so hard can happen, even though it's going to be her behaviors and probably not at all what she imagines, that changes.
Best of luck,
Ellen
Jan,
I can only imagine the thoughts and feelings that would be tormenting me, were I to find myself in your situation. I want to say that I greatly admire you holding the door open for both of these tired struggling people. You seem to be offering your compassion and their dignity whether they walk though or not.
Sent from the iPhone of Emily K. Sandoz
Jan,
I had to repost my response to the whole group with a reply to all.
As you know, with anorexia sometimes the person just has to be hospitalized. I have found with the eating disorders population that any looking at the self from basically any therapy (CBT, psychodynamic, systems, etc.) can be hard. However, with that said, my guess is that she has spent some time looking at herself from the view of the person who took her first breath and then her mind has jumped in and basically and said, "stop that."
Your client is of course right in that the iView does not help, it's just a nonjudmental view of the whole self. What will help is changing what she does and of course that will involve eating more, so then the mind enters back in and her behaviors go toward stuck. I wonder if she can "see" that process?
Her mother can help in this regard. Teach the mother the iView. Stress that it's just a cute name for the basic ability all of us have for nonverbally learning through experience. That point of view has no judgment, it just learns what works for moving us toward what we value. So the mother would want to show this nonjudgmental view with the daughter, just like you would show it to the daughter in a therapy session. The mother could say things like, "So which value are you moving toward by not going to therapy?" In other words, staying home and not going to therapy is serving some function for the daughter, the daughter just needs to clearly "see" what the function of staying home is. I am in no way recommending that the mother challenge the daughter. This would literally be done from the stance of the iView (nonjudgmental noticing of the function of a behavior).
The tough thing with any client is that it is the client who needs to change what she or he does. With eating disorder folks part of the control function is controlling other people. If the other people (mother, therapist) get hooked, things stay stuck. So you and the mom can use your iViews to stay as unhooked as you can (I know that's really hard) and keep looking at the girl's behavior in terms of moving toward stuck and moving toward values. This girl has values. Everyone has values. Hopefully you and the mom can help her see the value of living and the value of doing behaviors that enhance living toward values.
I have to go to an appointment now. Good luck.
Talk to you this afternoon.
Kevin
Hi, Jan
Has she had previous therapy? Does she maybe have a pattern of beginning a therapeutic relationship and then running away? She may be experiencing a huge amount of fear -- fear that she is hopeless and can't change, as well as fear of giving up her anorexia with its rewards and recovering. Perhaps if she does come back, at some point you could ask if she would be willing to be with the fear (if she's aware of it), the thought that she is a burden, etc.
Perhaps she came to therapy in the first place only because of pressure from family members, and is not yet at the point where she is ready to change. There may be a power struggle going on in the family. For example mom may be acting as the "food police," watching every bite she eats, etc. Daughter may feel out of control in her life and food intake is one thing she can control and "you can't make me eat," etc.
I used to work with eating disorders. I found the work highly challenging. Good luck!
Susan
Hi Jan,
I am not working with anorectic clients, so I am no expert on this.
Is a BMI around 15 a danger zone? Is she under medical surveillance? If so, chances are that she will be forced to undergo more intensive treatment and maybe you have to play a part in that? I know that very low weight changes the way people think and make decisions so treatment is about having enough weight to make valuable decisions based on good thinking.
The way you responded to the client seems very compassionate and accepting the fact that you cannot make her change.
To be honest I would not know anything to recommend you than to sit with your client and her mother as a sunset, witnessing their troubles, their struggle, their suffering and be open to your own struggle. Maybe if you can do that, something will open up.
It reminds me of a client of mine, who recently became very suicidal. She told me she had made very serious preparations to end her life. I knew that calling in a psychiatrist to judge her suicidality and judge whether she had to be send to an inpatient ward would seriously damage our therapeutic relationship. I told her that I was in doubt what to do. That what I wanted most was to help her lead a meaningful life, that I understood that life seemed unbearable for her right now and that if there was anything that I could do to help I was willing to do that. Furthermore I told her that I wanted some assistance for myself and would talk to a psychiatrist to see if what I was doing was the right thing. I asked her if she was willing to come back to me two days later, as an agreement to not kill herself during the meantime. She was willing to commit to that, and she did understand that I wanted back-up for me, although she became very suspicious what would happen if I brought in a psychiatrist. The psychiatrist I consulted reassured me that I had done well and that she did not have to see the client as long as I thought that the client would be coming back. We came through the crisis, without forced treatment.
I have to say that we had a history of a very good therapeutic relationship and we had made considerable progress, which helped the client to hold onto trusting me and me onto trusting her. Nevertheless, being open to what was going on on both sides proved fruitful.
Wishing you all the best with this difficult situation,
Jacqueline
Hi Jan,
Just my quick thoughts from my experience working in an out-patient clinic for adolescents:
Maybe this young woman needs more intensive care than you are able to provide? If her BMI is sinking fast she may need to be placed in
a more intensive care - in-patient facility.
This does not mean, however, that your work together is lost or has to stop altogether. Maybe she can come back to you after having
gone through a more hands-on treatment (learning how to eat, having the support 24/7 by staff who can coach her to eat etc...). And maybe
she can come and see you while she's undergoing that treatment.
Well, all this is provided there is some place for her to go. Some hospital or in-patient unit that can help her, that is.
So if I where you, I would work on that: finding an alternative, much more intensive treatment right now and help your patient and her mother along that road. And also make it clear to them that you will follow up how it goes so they feel your support...
Best of luck!
Henrik
I just had a phone call from a client whom I have seen 5 times so far, introduced iView and life manual. She is suffering from anorexia, BMI around 15 and sinking rapidly. Living with her mother who is desperate. She just told me on the phone that she does not want to come anymore, that this therapy, this "iView stuff" is not helping her enough, not enough change. That she is a burden for her surroundings, who are telling her that it cannot go on like this. I responded with sympathy, expressed respect for her opinion, expressed my openness that she can come any time. Expressed that I cannot guarantee how quickly her life will change, that I would be willing to commit myself to attempt to be an instrument for her to develop her life. Expressed my conviction that her life is full of potential, and that I wish that she can develop this potential. Asked whether I could do anything for her, maybe speak to her mother. She then passed the phone to her mother who expressed her desperation, her unwillingness to let her daughter stop therapy, her need for help as a mother. I offered to see her today with or without her daughter during the scheduled appointment which is in 4 hours (8am eastern time). Any support / suggestions would be very welcome.
thank you
Jan
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