How to Be on Your Clients Side without Taking Their Side:
Avoiding becoming the Target of Splitting or Projecting
by Linda Paulk Buchanan, Ph.D.
When individuals struggle with eating disorders, they usually have previously held beliefs about themselves and others which were often formed in childhood. These beliefs may have been adaptive initially, but can become problematic as their environments change. The title of this article came to me as I supervised students who were so focused on listening to and validating their clients that they appeared to believe everything they were told. Then the very thing that the client claimed others did to them, often happened at our center; such as feeling that staff liked other patients more than them. I found myself saying “allegedly” when the students would share stories about the patient or his past that involved another person. Supervision often became more about teaching students how to be on their client’s side without taking their side. Suffice it to say that if the patients’ perspectives were always accurate, they probably wouldn’t need to be in therapy. Valuable therapy time can be wasted chasing the client down well-worn paths rather than empowering the client to shift their thinking or perspective to be more effective.
I don’t want to be misunderstood. We are empathic, kind and validating with our clients. My clients generally feel very supported and validated because I have learned the skills which communicates to them that I am on their side without needing to take their side. In one situation, a client felt abused by another client at our center. I met with her to discuss her reaction and she was able to see her part. I asked her, “What do you need to do so that others’ don’t have the power to scare you in that way anymore?” She actually told me at the end of the session that it was the first time anyone really understood her.
Treatment involves doing a careful assessment of the client’s generally held beliefs about self and others. It is also important to note, however, that there aren’t really good ways to assess which difficulties a person is experiencing are due to a sensitive nature versus an invalidating environment. I’ve come to believe that this is really much less important to therapeutic outcome than I once thought. Although it goes without saying that people hurt each other, once the pain has been experienced it becomes the “property” so to speak of the one that felt it. Thus it is theirs to manage and ultimately heal.
A technique that I find very helpful to avoid falling into a “split” or becoming the target of a projection is a form of the Empty Chair Technique. When a person is ambivalent or projecting, you can ask if they would be willing to try an exercise in which they put one side of the dilemma in an empty chair and speak to it from the other side. In other words, they are talking to themselves rather than to you. It doesn’t really matter what you as the therapist thinks is true or what needs to happen, but you will look very much like you are on their side as you guide them through the exercise.
For instance the client might think, “I can’t trust because everyone will hurt me” versus “I am lonely.” As she begins to talk, the “don’t trust” side may explain that she’s always been hurt. The facilitator will give sentence stems to move the experience along such as “When you (lonely side) tell me that I should trust I feel…”, “What you don’t understand is…”, “When you tell me to get over it, you remind me of…”, “What I wish you’d do instead is …”
Once the client has fully expressed this side of the dilemma, then she switches roles or chairs and does the same thing from the other side of the dilemma. She might talk about being lonely. The therapist might provide similar sentence stems such as “When you say I should never trust, I feel…”, “When you tell me that no one will ever treat me right, you remind me of…”, “What I wish you’d do differently is…”
As a result of this exercise clients often see what the first steps will need to be to get unstuck, often consisting of some kind of compromise. Clients are empowered using this method because the answers come from within.
Dr. Linda Buchanan is the founder and Clinical Co-Director of the Atlanta Center for Eating Disorders, an Intensive Outpatient and Day Treatment Center for individuals with eating disorders. Dr. Buchanan received a masters degree in Counseling from Georgia State University, a masters diploma in Christian Counseling from the Psychological Studies Institute and a Ph.D. from Georgia State University in Counseling Psychology. She has published two chapters on her model of treatment of eating disorders which have been used as texts in a local doctoral program for Clinical Psychology students and published four research articles on the treatment of eating disorders including two outcome studies of the treatment provided at Atlanta Center for Eating Disorders. She has been married for 30 years and is the mother of two teenaged boys.
Exclusive Article Published in September 2015
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The “Modern Family” Treatment Model: Promoting Eating Disorder Recovery with an Expanded Circle of Support
by Jessica Setnick, MS, RD, CEDRD
The television show “Modern Family” demonstrates how an eclectic mix of people and personalities─ related by blood, marriage, former marriage, adoption, and sometimes no legal relationship at all─ can come together to form loving, supportive bonds that allow for personal and communal growth.
Because eating disorders thrive in isolation, support of family members and other loved ones can in many cases facilitate eating disorder recovery and relapse prevention. But what about individuals in recovery who do not have an intact or supportive family of origin, a stable home life, or even any living relatives?
Let’s encourage and assist them to assemble their own personal, supportive Modern Family that includes treatment providers, significant others, family members and their significant others, roommates, teammates, siblings, step-relatives, foster parents, co-workers, sponsors, hired caregivers, peers, and more.
Let’s define the Modern Family to include anyone whose relationship with the patient impacts the outcome of treatment and recovery, whether for better or worse.
Let’s acknowledge that Modern Family members bring their own personalities and experiences to the treatment milieu, and that they too have been hurt by the eating disorder and the chaos and confusion that surround it. Therefore, comprehensive treatment of the identified patient will include supportive interventions for Modern Family members as well, such as individual counseling, multi-family or caregiver and career support groups, sibling support, psychoeducation, meal therapy, grief and trauma counseling, psychiatry, and other modalities.
As treatment professionals, we should try to include as many members of the Modern Family as possible, in a manner that is suitable to each relationship. For some that may be simply asking them to attend an educational session to learn about the eating disorder in general and strategies for supporting this specific patient. For others it may include participating in family therapy sessions, setting and enforcing consequences, or making arrangements for additional types or levels of care. And for us, it means professional supervision, collegial support and attention to self-care.
When casting the leading roles, it is essential to include those who plan, purchase, cook and prepare the patient’s meals. Traditionally these responsibilities go to a nuclear family member or the patient him or herself. In the Modern Family, the meal preparer may be a step-parent, babysitter, sorority house cook, or personal chef. Why not ask for permission to include that person in the educational process and in developing and supporting the treatment plan?
When meal supervision and support after eating are in the treatment plan, consider training Modern Family members such as resident advisors, housemates, school nurses and teachers, co-workers, and second degree relatives, such as grandparents, aunts and uncles. When permission has been granted by the patient, assign specific duties and provide instructions for managing situations that might arise.
When providing education and recommendations for non-meal support, consider asking for permission to interact with Modern Family members who spend leisure time with the patient, have an advisory or supervisory role in the patient’s life, or provide transportation to and from appointments, such as a babysitter or nanny, foster parent, athletic coach, personal trainer, sponsor, religious leader or boarding school director.
In addition to Modern Family members who are supportive to recovery, there may also be a cast of unsupportive characters who have impacted a patient’s psychology, self-esteem, development, relationship with food, and desire for treatment and recovery. This may include members of the family of origin (whether the patient knew them or not), ex-spouses and other past romantic interests, previous treatment professionals, abusers, and countless others.
Whether nefarious in intent or not, incidents involving these individuals that continue to impact the present course of treatment must be addressed. Their physical presence is not necessary and may be contraindicated or impossible due to geography, estrangement, death, anonymity, safety concerns, or unwillingness to participate in treatment. Modern Family members who are not physically present can be included in treatment through journaling, expressive therapies, role-playing, empty chair therapy, psychodrama, and other modalities. As some of this trauma may have pre-dated the eating disorder, ongoing work in this area may be recommended even after eating disorder symptoms have diminished.
The Modern Family Treatment Model cannot be manualized, as it requires individualization for not only the patient but also each participant. It cannot provide a predictable course of treatment or insulate an individual from exposure to potential triggers as he or she moves into and through recovery. But it can and does promote extended recovery by providing a team of educated and supportive “Family” members as the patient travels more safely in a triggering world.
Jessica Setnick, MS, RD, CEDRD, has spent the past 17 years helping individuals and their modern families cope with and recover from eating disorders of all kinds. Known to professionals in the field as the author of The Eating Disorders Clinical Pocket Guide and Eating Disorders Boot Camp, Jessica currently holds the position of Senior Fellow at Remuda Ranch, a pioneer in including family and significant others in treatment. She can be reached at Jessica.Setnick@RemudaRanch.com.
Membership Spotlight contains articles written by iaedp members that share their expertise, specialty, or research in the eating disorders field.
Exclusive Article Published in August 2015
Submit your article for upcoming Membership Spotlight to Blanche@iaedp.com
“Non-Suicidal Self-Injury and Eating Disorders”
By Nicole Garber, MD, Chief of Pediatric Eating Disorders Unit, Rosewood Centers for Eating Disorders™
Eating disorders often occur with other mental health concerns including depression, anxiety, substance misuse and non-suicidal self-injury (NSSI). NSSI is defined as “direct and deliberate destruction of body tissue in the absence of any observable intent to die” (Nock, 2010). Studies from community samples have shown that approximately 13-43% of adolescents self-injure and 4% of adults self-injure (Nock, 2010).
Risk factors for developing NSSI include:
- poor distress tolerance
- poor problem solving skills
These are also several of the risk factors for developing an eating disorder. One study showed up to 41% of adolescents with an eating disorder also self-injured (Pebbles, 2011). Another study of adult eating disorder patients found that 32% of the patients had self-injured (Stein, 2004). Patients with eating disorders have the above risk factors for self-injury, but also include binging and purging and using more than one method to purge.Risk factors related to a patient’s eating disorder that predict higher incidents of self-harm include binging and purging, using more than one method to purge, and having a more extensive treatment history.