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What makes psychotherapy work? It's the client!

Posted Nov 13 2008 5:26am
Despite my reputation for being "only about the food," the truth is that I'm a huge fan of therapy. And skilled therapists. I'm intolerant of poorly conceived therapy and ineffective therapists.

The biggest problem with eating disorder therapy to my mind is this: What makes psychotherapy work? It's the client!

But eating disorder patients are anosognosic: they aren't able to grasp their own state of mind and emotion and cognition UNTIL THE BRAIN IS REPAIRED.

Engaging in therapy requires a functioning brain. It requires motivation and engagement and cognitive flexibility. It requires self-awareness - and eating disorders rob the brain of that while the body is still undernourished. And by undernourished I don't just mean underweight - I mean the brain damage is repaired. I mean you need full weight restoration, behavioral stability, and then a few months of healing FIRST.

I think therapy while a person is still brain damaged or acting on ED compulsions by binging or purging is like therapy while drunk.

If you showed up for your appointment drunk or high, I don't think it would be ethical to sit and explore your issues or review your week. But people routinely show up for therapy while underweight, having recently binged or purged or over-exercised.

It is time for a zero tolerance for continuing brain damage during eating disorder treatment. An end to minimum weight goals, of "out of medical danger" as a standard for recovery, and of "improving" as a measure of success.

For all patients, from the day of diagnosis, period.
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