A distorted body image leads bulimia sufferers to binge and purge habitually.
“Some nights I’m alone, so I binge. I don’t answer my phone. You wouldn’t believe how fast I can eat. Almost too quick to taste it. I gorge myself until I feel I might literally bust. But I know it doesn’t matter, because I can get rid of it anyway.” So said Sharon. And yet she knew it did matter.
And, if you’ll forgive the expression, she was sick of it. Purging herself with laxatives, or more commonly though her long-practised expertise in purposeful vomiting, was robbing her of health and self-respect. She was tired of deceiving her friends and family. Fed up with it all.
Bulimia nervosa is perhaps the most common eating disorder.1 Some clients may tell you they used to be anorexic but now they are bulimic (or vice versa), but while some people conflate the two disorders, they are different conditions.
Bulimia vs anorexia
While both bulimic and anorexic clients often have extreme body distortion, the way they react to this is different. Anorexia nervosa sufferers starve themselves continually, whereas bulimics eat excessively in a short timeframe but then seek to purge the calories they’ve consumed, either through purposeful vomiting or the use of laxatives – or both.
Both anorexic and bulimic clients may exercise excessively, and a subset of bulimics, known as non-purging bulimics, simply fast or exercise frantically after overindulging in a bid to make up for the huge amount of calories they consumed.2 But usually (not always),the bulimic client purges after gorging.
Research suggests a strong association between anorexia and Asperger’s syndrome.3,4 When you think about it, it’s not entirely surprising. Repetitive behaviors and thoughts, rigid rituals and routines, and perfectionism (or, as Dr Iain McGilchrist suggests, a right-brain hemispheric deficit)5 characterize both anorexia and autism. However, this association isn’t observed – or at least not as strongly – with bulimia.
Unlike many anorexic clients, whose condition becomes obvious due to an increasingly emaciated appearance, bulimia sufferers often keep their behaviour and feelings secret, and their weight and appearance may even appear quite stable.
One and the same client may go through alternating periods of anorexia and bulimia, and of course anorexics may engage in purging, but in this piece I’m going to exclusively focus on strategies for the bulimic client. Eating disorders have been traditionally seen as predominantly a female disorder, but evidence suggests that men are suffering more now too.6
Eating disorders don’t exist in isolation. The emotional problems your bulimic client suffers may be a cause or an effect of bulimia. Or, in a kind of vicious cycle, it may be both.
Why do people become bulimic?
We sometimes see comorbidity between eating disorders such as bulimia and suicidal ideation and self-harm.7 (Of course, we can see bulimia itself as a form of self-harm.) Low self-esteem , social phobia, fear of abandonment, or an inferiority complex may all drive and maintain, and sometimes result from, bulimia. Feeling in the grip of any emotional condition can damage our sense of independence and fracture our self-esteem.
And, like many emotional and behavioural problems, bulimia may stem from an unconscious attempt to solve problems in your client’s life – so we need to learn about the client, not just their condition or label.
If life generally feels out of control, then bulimic or anorexic behaviours may seem to promise some succour for your client, at least initially. If I decide what and when I eat, and even what I choose to digest, that might seem to give me at least some sense of control. Indeed, many binges are planned rather than spontaneous.
Your bulimic client may have personality issues such as maladaptive perfectionism, which may need to be treated alongside the bulimia. Some clients find a kind of numbing or escape from problems or difficult feelings while they binge. Endorphins may be released during the pain of purging. We always need to look at why people do what they do. What are the pulls of the pattern?
Sharon was prone to the kind of all-or-nothing thinking that tracks alongside perfectionism. But, thanks to the bulimia, she had other problems too.
An unhappy body
The first time Sharon visited me her voice was hoarse, her throat dry and sore. “I had a terrible binge at the weekend,” she told me in a cracked and pained whisper. “It hurts to talk.”
Ask your client about any physical effects from the bulimia. These may include tooth decay (from the rush of acidic stomach contents against the teeth), swollen salivary glands, and intestinal disorders, among other serious consequences.8
Bulimia is a physical health issue as well as a mental health one.
So what are some of the must-dos when treating bulimia?
Step one: Discover what’s driving the bulimia
Is it body image? A sense of wanting to be ‘pure’ or ‘worthy’, or to numb difficult feelings? Was the bulimia ‘caught’ from someone else as a kind of learned behaviour that has become a habit, as often happens with smoking? Your bulimic client may not be able to give you all the answers if you ask about these things directly, but by asking generally about their life you should be able to glean much vital therapeutic information.
Is the bulimia a symptom of unresolved trauma? If so, you will need to take steps to deal with your client’s trauma as comfortably as possible. Finding out when it began and the circumstances around that time can give you a sense of why it started.
What are your client’s bulimia triggers? Loneliness? Boredom? Anxiety? Frustration? Sharon told me she would make up her mind to binge when she felt alone, “like a failure”.
By asking your client about their life generally, you will get a sense of to what extent they are meeting their primal emotional needs. This is information we need from all our clients, of course. Once we find out which universal needs are lacking, we can begin to work with our client to help them meet those needs as wholesomely as possible and thereby, to some extent, negate the ‘need’ for the bulimia.
If your client’s bulimia is really intractable, it may be that it is held in place by what’s known as ‘molar memory’, a kind of two-rooted memory containing both positive and negative aspects. I won’t go into that here, but check out this link from the Human Givens Institute to learn more about this fascinating kind of memory.
You can look at more ways to discover what has caused or is causing the problem here. On top of this, you can find out something else really useful.
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Step two: Why didn’t it happen?
Exception questions are a goldmine of potential therapeutic information.
“When did you feel like you were about to binge but you just didn’t?” I asked Sharon. At first she could think of no such exception, but after a while she offered:
“Well, sometimes I feel like I’m going to, but something else happens. Like this one time, a friend called and for some reason I picked up and we had a really great chat and afterwards the urge to binge just wasn’t there!”
Wow. That tells us something really important about what need the bingeing may be trying to fulfil.
“Another time I felt like I was – and I know this sounds weird – outside of the bulimia, and it was trying to get me to binge again and I didnt want to. I just started doing something else and it went away.”
Ask exemption questions to find out what kinds of circumstances help your client step aside form the bulimia, then form strategies out of those exceptions.
And talking of stepping aside…
Step three: Remove the bulimia from your client’s core identity
So often we talk about ‘bulimics’ or ‘depressives’, or even ‘smokers’ versus ‘non-smokers’, as if people are defined by these monikers. And yet part of therapy may involve removing a toxic label from a person’s sense of who they are.
It may be crass and clichéd to say “you are not your bulimia”, but we can be more subtle than that and help our clients:
- gain a sense of distance and separateness from the bulimia by talking about ‘it’: “How does the bulimia trick you into hurting your body? What will it be like when you find you can ignore it more? If the bulimia had a human voice, what might that sound like [for Sharon it was “whiny and moany”] and what would you say back to that voice?”
- become more aligned to all their personal resources outside of and beyond the bulimia.
Just talking to our clients about their problem, without helping to remove it from their core sense of who they are, can, if we’re not careful, lead them to feel they are just their problem.
But we need to remember that all behaviour becomes habitual when it’s repeated.
Step four: Help them break the pattern.
Even when you’ve helped your client overcome the causes of their bulimia, it may continue simply as a habitual pattern. Sometimes symptoms persist even when causes have been dealt with.
Sharon had described a naturally occurring pattern interrupt: her friend calling when she’d been about to start binging. We can start to introduce pattern interrupts to first disrupt the pattern, then gradually weaken it as a prelude to stopping it altogether.
If you are skilled in clinical hypnosis, you can use it to help your client access the steps to the behaviour then start mixing them up or ‘scrambling’ them so that it feels less compelling. In this way, the mechanical element to a problem can be derailed, as it were. This is a standard hypnotherapy technique, and any decent hypnotherapy training will teach a variation of it. Alternatively (or in addition), you can simply set tasks to help interrupt and break the pattern.
I helped Sharon deal with the causes and habits of bulimia, but I also wanted to give her a sense of life after bulimia, because it had been with her for so long.
Step five: Rehearse a better future.
If you’ve lived with someone who treats you badly for 20 years, it may take real confidence to leave them even if you want to. This was effectively the situation Sharon found herself in. I discovered that Sharon felt underconfident, as though she could barely even imagine not having bulimia long term.
We talked about life without the bulimia. I asked Sharon to imagine her daily life when bulimia was no longer really on her mind – when it was like “some old, rather demanding person that used to be in your life.” She smiled and told me all the things she’d be doing instead of bingeing and purging, how her body would be thanking her and growing stronger and healthier, and how her relationship with food would normalize as she called time on her relationship with the bulimia.
“Yes! You can dump the bulimia and have a good relationship with food instead,” I suggested.
I asked her to close her eyes and experience that future hypnotically. We even rehearsed her “almost relapsing” and “it trying to hoodwink” her, but her “seeing through it” and “standing up to it”. We rehearsed all the ways it might try to trick her into taking it back.
Sharon grew stronger, but there was something else I wanted her to know.
Step six: It won’t be the end of the world.
It may seem unduly negative to talk to clients about relapse, but if there’s one thing I don’t want clients to be in this situation, it’s black-or-white.
“Now Sharon, you have got rid of that bulimia and that’s great, but it will try to get you back. Maybe sometime when you’re tired or feeling neglected, or not meeting your emotional needs so well. It may do a good job at convincing you that you need it in some way, even though you know that you don’t.” Sharon nodded.
“It’s been three months since you binged. You have a healthy sense of food and your life is balanced now, or at least more so, right?” She nodded her head and smiled.
“But imagine if I walk a mile. I’ve come a long way. Now if I stumble back a couple of steps, does that mean I haven’t walked all that other distance?” Sharon shook her head this time. “Does that mean I have to walk back that whole mile and start all over again? Or can I simply recover and continue adding to that distance I’ve already walked?”
She got the message. If she did relapse, it didn’t mean she had to “start all over again”. It wouldn’t be the end of the world.
A beautiful insignificance
I met Sharon a few years later, and she had relapsed twice since I’d seen her. “But hey, nobody’s perfect, right?” she said brightly.
She also told me what once had seemed such a big part of her life had whittled down into “a beautiful insignificance”.
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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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Notes:
- http://www.anorexiabulimiacare.org.uk/about/statistics
- https://www.scienceofeds.org/2013/04/18/nonpurging-bulimia-nervosa-where-does-it-fi/
- https://www.hindawi.com/journals/bn/1992/259318/abs/
- https://www.spectrumnews.org/features/deep-dive/the-invisible-link-between-autism-and-anorexia/
- See: McGilchrist, Iain (2009). The master and his emissary: The divided brain and the making of the Western world. Connecticut: Yale University Press, p. 405.
- https://www.eatingdisorderhope.com/treatment-for-eating-disorders/special-issues/men
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4833374/
- https://www.medicalnewstoday.com/articles/322853.php
