5 Therapeutic Strategies for Treating Anorexia Nervosa

People with anorexia can become focused on a sense of wanting to cleanse themselves, as it were, to a point of nothingness.

Sue was a patient in a secure psychiatric facility. She was likable, articulate, well educated… and dying.

Her mind was slowly killing her, turning her body into a rack of skin on bone. Though that’s not how she saw it, of course.

Sue was happy to talk to me about “anything” – just not that. Why should she? I was just some 20-year-old guy working in the hospital. I only spoke to her a couple of times. Later I was shocked to hear that she’d been released from her section, gone home to her parents, and died shortly after. She was 25 years old.

Anorexia nervosa is the deadliest of emotional illnesses, with one in ten sufferers eventually dying from it.¹ More women than men are affected,² although men may be catching up somewhat.³

Anorexia has traditionally been seen as hard to treat.⁴ But there is hope. Of those who survive anorexia, 50% recover, 30% improve, and only 20% remain chronically ill.⁵

So people do recover from anorexia, or at least learn to live with it as it loosens its grip on them. And with better treatment options than ever before, there’s no reason we can’t help more people recover.

Some people who develop anorexia also have a history of bulimia nervosa, and the two conditions can be distinct or comorbid. But in this piece I’m specifically looking at anorexia.

Ultimately we need to ensure the anorexic client is safe, and that may mean working as part of a care team, including a nutritionist. Either way, we need to know what kind of support they have in their life other than you.

But first: What are we actually dealing with?

Anorexia: Signs and symptoms

Someone who has entered an anorexic phase will often:

• present as extremely underweight and frail – prolonged anorexia can even cause osteoporosis
• wear baggy clothing to try to hide their body shape because they feel they are grossly overweight or because they don’t want people “lying to them” by telling them how thin they look
• stop (or fail to begin) having periods due to hormonal disruption
• develop fine Lanugo hair on the face or arms, possibly the body’s way of trying to conserve heat⁶
• have brittle head hair or experience hair loss
• have rotten teeth due to vastly insufficient nutrition or damaged tooth enamel due to acid exposure during repeated vomiting
• exercise compulsively, at least whilst they are strong enough
• complain of feeling “fat”, being “hideous”, or not wanting to be seen.

But what’s going on psychologically? How can we best go about helping the anorexic emotionally? Well, before we reach that point we need a good understanding of where the anorexia may have come from.

The causes of anorexia nervosa

It does seem that anorexia is only triggered in people with some kind of pre-existing susceptibility to becoming anorexic.

For example, the vast majority of people who are exposed to idealized body shapes in mass advertising or the media, who experience trauma or bullying while young, who are abused, or who have a history of excessive anxiety or dieting do not become anorexic. Yet all these influences can certainly contribute to triggering anorexia in those most vulnerable to it.

Certainly, treating unresolved trauma from bullying or abuse may speed up someone’s recovery from anorexia. But it still appears that certain traits within the person themselves are predictive of whether or not they develop anorexia. We’ll look at these traits in a moment, but first let’s take a closer look at a factor many of us assume triggers anorexia: mass media images.

Media images of thinness

It’s a popular assumption that anorexia is often caused or exacerbated by societal expectations of idealized body shapes. But I’m not so sure about this. Certainly some eating disorders, such as bulimia, may have to do with comparing ourselves to stick-thin catwalk models or celebrities. But many anorexics don’t seem to focus on other people’s appearance at all.

As Walter Kaye, MD, Director of the Eating Disorders Treatment and Research Program at the University of California, says, “Lots of people diet or want to lose weight, but relatively few of them end up with anorexia nervosa or bulimia nervosa.”⁷

So simply having more plus-sized models or pushing the idea that standards of beauty are cultural constructs won’t necessarily lessen the prevalence or impact of anorexia.

So what kind of person is more likely to develop anorexia?

Understanding the anorexic mindset

People with anorexia become focused on a sense of wanting to cleanse themselves, as it were, to a point of nothingness. Perhaps this is to regain some lost sense of smallness or safeness they felt in childhood – or perhaps never really felt.

So while media images may certainly influence the development of eating disorders, there’s more to the picture. We need to understand why only certain people develop full-blown anorexia.

Research suggests an association between anorexia nervosa and high-functioning autism, or Asperger’s syndrome.^8,9

This makes some sense. Rigid rituals and rules. Self-imposed routines which must be obeyed. A sense of disembodiment. Lack of context with and connection to others. Repetitive behaviors and thoughts and a strong proneness to perfectionism. Dr Iain McGilchrist suggests that a right-brain hemispheric deficit characterizes both anorexia and autism.¹⁰ However, this association isn’t observed, or at least not nearly as strongly, with bulimia.

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Anorexia may drive the client to want to punish or purify the self, and to impose strict rules and schedules. These mindsets can be hard for many of us to get our heads around. No wonder we often resort to clichés about ‘societal expectations of thinness’, which may be of little to no interest to the anorexic client.

If your client does seem to exhibit sharp, all-or-nothing, rule-bound expectations, the following approaches should be useful.

Step one: Focus on their motivation to change

The fact that your client, unless they’ve been coerced to come see you, is motivated to change is encouraging. We can focus and amplify their motivation.

So why do they want to change? One anorexic client told me she’d noticed her young daughter was starting to skip meals. She felt now was the time to finally, as she put it, “kick the anorexia into touch” – which relates to step three below.

Another client was tired of feeling so weak and ill, and yet another wanted to start her periods again and feel able to have children. Many clients have told me they are sick of being controlled by the anorexia, and want to live long, healthy, happy, and productive lives.

So where is the fuel for your client? What’s their motivation, and how can we shape therapy around what really drives them?

Whatever our strategy, we need to be sure to work from their perspective.

Step two: Don’t ditch the rules, change them

As I said, we so often find that those prone to anorexia are also prone to a kind of sharp, lacerating style of thought. They tend towards black-or-white thinking and may have little capacity to sit comfortably with ambiguity or uncertainty, or tolerate situations in which they feel they do not have control.

I might ask the client whether they feel that they generally try to organize their life around rule making and keeping. Do they tend to feel angry or guilty if self-imposed rules are broken?

Rather than trying to get your client to ditch all rule making in one go, we can work within their rule-infested mindset. How?

Well, we can suggest that some rules can encompass wider contexts and can be less all-or-nothing. Perfectionism is an imperfect approach to much of life.

For example, an ‘85% rule’ might be that for 85% of the time I eat healthily and that’s all I aim for. This isn’t a sharp rule, it’s a sustainable rule. If I break my rule and eat 25% unhealthily for one day, I can correct this by eating 90% healthily for the following two days – then I am back on track for my 85% rule. This might sound strange, but for someone who lives their life through rule making it can make perfect sense.

So rather than trying to ditch all rules around eating, you might work towards gaining more flexible rules. One analogy I often use in order to demonstrate increased fairness to the self is that if you walk a hundred steps then pause, or even take a few steps back, you’ve still walked all those other steps and made progress. You don’t have to go back to the beginning again by induced vomiting or extreme starvation.

In a sense, when we focus on helping our clients be more flexible in their psychology, anorexic patterns should start to fade as a natural byproduct of more nuanced, wider contextual thinking.

Which brings us neatly onto step three.

Step three: The anorexia is not them

It’s a peculiar truth of human experience that we can come to identify so deeply with our habits of mind and body. We start to feel our condition to be who we fundamentally are.

This kind of parasitic pattern in which, if you like, the pattern pretends to be the person is common to long-term smokers or drinkers, but also to those going through anorexia. If an anorexic client strongly feels they are the condition, then when a therapist ‘threatens’ to help them recover, the client may hear it as “I will get rid of you!”

And that can feel really scary.

Labelling people with psychiatric diagnosis can sometimes strengthen the feeling that they are the condition. So we need to be careful how we talk about anorexia to the client.

We can help remove the condition from the client’s sense of their core identity using carefully worded questions, such as:

• How does it try to convince you that you’ve committed some terrible sin?
• What would its voice sound like?
• Does it have very narrow ideas?
• Does it make out like you can never be thin enough?
• How does it try to manipulate you or push you around?
• What will you be freed up to do once it’s gone and no longer bothers you?

The client who said she wanted to “kick the anorexia into touch” was already externalizing the pattern, and that meant she was further along the road to freedom from it.

I will, once I feel the client is ready for such ideas, often describe anorexia as a kind of parasite that pretends to be all of what the person is but really isn’t them at all. In this way, rather than defending the anorexia and resisting attempts at rescue, the client can start to turn on it, which, after all, has little concern with their survival.

But of course, anorexia also has to do with how the client relates to their body.

Step four: Help build up connection to their body

I’ve noticed that many anorexics seem to have lost touch with an embodied sense of who they are. It’s almost as though they were separated from their body, which becomes a ‘thing’, but not them. A thing that needs to be whittled away.

An approach I’ve found effective is to talk, during deep relaxation, about the body as a loyal entity that tries to help us as best it can. It’s the vehicle in which we travel through life. The muscles, fibres, and skin all need support from us, the same way they provide support to us. By giving them what they truly need, we can be as loyal to our bodies as they try to be to us.

Feeling increased loyalty towards and care for bones, teeth, skin, hair, eyes, heart, and lungs can help us make healthier decisions. It becomes more about ‘looking after the team’ or ‘family’ of the body.

If you use clinical hypnosis or mindfulness in your practice, this can be a really effective strategy.

Just as we may ask smokers to listen to what their lungs or heart might have to say about having to deal with thousands of toxins, and build up a sense of caring for these vital parts of the ‘team’, so too we can help the anorexic client start to feel a sense of protectiveness over their body and its constituent parts.

And finally…

Step five: Help them choose life

When working with clients we need to help them move towards healthy behaviours, not simply away from what harms them. Anorexia steals much from a person in the sense that it diverts them away from truly meeting their vital emotional needs. These needs might include intimacy or a sense of connection to other people, community, or true meaning.

By discussing with your client the needs we all have, and how they may have felt the anorexia was meeting some of those needs in some ways (such as the need for a sense of control), we can explore how they can start to meet their human needs in healthy ways.

So often problematic emotional patterns are unconscious but self-defeating attempts at meeting one or more vital human needs. When needs are met in balance, anorexia can start to feel like less of a raison d’etre, and this is the first step to recovery.

The principles and strategies we’ve looked at here are just some of the possible approaches that can help anorexics.

Working for sustainable change

The anorexic mindset is one of unsustainable pressure. We can ease that pressure by making it clear to the client that they may have small or near relapses, and that’s okay.

As they recover and claim a better life for themselves, you could remind them that occasionally the anorexia may, as it were, “call them up”, almost out of the blue, and try to con them back into its deceitful arms. But they will always be a match for it. They will always be able to see through its clichés and lies.

Towards the end of therapy you could suggest that the dishonest promptings of anorexia will always sound weak, distant, and deceitful, because it is not who they really are, nor ever truly were.

I think back sometimes to Sue, all those years ago in the hospital, and wonder just how she could have been helped. How she could have broken through her kind of Stockholm syndrome, defending what eventually would kill her.

What kind of life could she have lived?

Deeply relax your clients quickly and simply

Patients suffering from anorexia often benefit from gaining the objectivity afforded by deep relaxation, as it can allow them to see themselves in a new light. Learn how to use your voice to relax your clients with our online course Uncommon Hypnotherapy.

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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