What Are the Challenges That Face a Psychotherapist Working with Self-Harm or Eating Disorders?”

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Essay Title: “What are the challenges that face a psychotherapist working with Self-harm or eating disorders?”

The focus of this essay will be to examine the challenges a psychotherapist faces when working with eating disorders. Whilst acknowledging eating disorders can include overeating I will base the essay around anorexia nervosa and bulimia nervosa. I will look at the various theories around the subject as well as provide examples of my own experience working within this field.

“I am dying to be thin”. And quite literally death is a strong possibility for people who have an eating disorder. Whether it is anorexia or bulimia the person affected will normally have a distorted body image. Even where there isn’t a morsel of fat on their bodies, they look in the mirror and see a fat person looking back (see Figure 1).

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Figure 1: Distorted Body Image

Having worked on an eating disorder unit in Essex for over a year I have personally experienced the frustration of working with this condition. For me, it was very hard to understand what went on within the mind of the client, who would be manipulative, secretive and cunning in order to avoid eating, or be sick after eating to enable them to lose even more weight. Often a target weight of say 6 stones would be their goal, which inevitably would be lowered again once this was achieved.

I remember the trauma that clients would go through when it came to being weighed. Sometimes, they would become hysterical if they found out that they had put on so much as an ounce. They would also try to resort to tricks such as water loading (drinking fluids in the bathroom) to avoid their true weight being revealed. Dinner times proved to be another ordeal as they were normally on set calorific diets of say 1000 calories per meal, and had to eat what was on the plate. Staff had to eat along with them and in fact staff often compensated by never leaving their plates clean, thus putting on weight themselves, whilst the clients would try all sorts of tricks such as sewing false pockets in the necks of their shirts, where the food would go instead of into their mouths. I can honestly say I don’t miss that job!

I worked predominately with young females, although there were a few men on the ward. One thing that struck me was that almost all my clients were very artistic and creative individuals who lacked self esteem. They did not lack intelligence, yet for some reason chose a destructive path which led to them displaying symptoms similar to those in Figure 2.

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Figure 2: Symptoms of anorexia/bulimia

Anorexia nervosa and bulimia nervosa are the two main eating disorders. People with anorexia have extreme weight loss as a result of very strict dieting. Some people may also make themselves sick, abuse laxatives or do excessive exercise to try and lose weight. In spite of this extreme weight loss, people with anorexia believe they are fat and are terrified of becoming what is in fact a normal weight or shape. About four out of ten people with fully established anorexia make a full recovery, and others improve. Only about three in ten continue to have major long-term illness. Untreated, about 15 per cent of all sufferers will die from the disorder within 20 years of its onset.  

People with bulimia nervosa crave food and binge eat, though they are not emaciated. Afterwards they make themselves sick or misuse laxatives to get the food out of their bodies. Sufferers are very afraid of becoming fat.  

Anorexia nervosa most commonly starts in the mid-teens. About one in a hundred 16 to 18 year olds has the illness. It is much more common in girls. Bulimia nervosa usually starts when people are a little older, but is again more common in girls. Bulimia is more common than anorexia, although people with anorexia in particular do not always ask for treatment.  

Occasionally men develop eating disorders, but...
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