The "Real" Relationship in Therapy

One difference between normal relationships and therapy is the clinical scrim that blocks the patient from knowing the therapist as one would an acquaintance, friend or family member. Starting with the almost silent, omniscient analyst in classical Freudian psychoanalysis, the theoretical foundation of therapy began with the patient's responses and reactions to a relatively blank slate. The trove of adaptations to the initial psychoanalytic model either justify a small amount of visibility through the screen or enable the therapist to hide behind a systematized (the current code word is evidence-based) technique. No matter the newfangled, popular approach, there is one question that lingers in any patient's mind: is this relationship real?

There are two general ways to answer this question. In traditional treatment, the therapist will ask the patient what triggers the question and what are the underlying motivations and feelings behind it. In evidence-based treatment, the answer is that the question is moot: the stated objective is solely to minimize or eliminate distressing symptoms.

Most clinical literature about eating disorder treatment recommends a completely paradoxical approach. The emphasis from the outset is that the relationship in therapy needs to be real and that self-disclosure--a nifty bit of psychological jargon ripe for (mis)interpretation--is not just advisable but necessary for treatment to be helpful. Necessary! How can something considered strictly forbidden since the inception of psychotherapy suddenly be essential for psychological disorders only first categorized a few decades ago?

I remember reading articles about being "real" in eating disorder treatment for the first time without fully taking in the subversive context. To the therapy universe, this is heresy. But it certainly explains a few things. If the experts agree that eating disorder treatment must flout the most basic tenets of traditional therapy, no wonder most therapists have so much trouble treating people with eating disorders. If these experts really have tapped into the well of recovery, no wonder eating disordered patients in treatment focus on the question whether the relationship is real. Nothing has ever been real for them except for the disorder itself.

I have written about most of the reasons why therapy in this context needs to be different, but they bear repeating. Patients with eating disorders have trusted no one but the disorder so the therapy relationship has to be meaningful, powerful and real to break through that barrier and open the door to even contemplating recovery. With a keen ability to read others and to be excellent caretakers, patients will almost instantly recognize a lack of genuine interest or a therapist hiding behind a professional wall and respond in kind by retreating behind the eating disorder. A patient, embarking on true recovery, needs to believe in something previously impossible: a real connection with someone--in this case the therapist--and that can't happen behind the therapeutic screen. Moreover, one of patients' common complaints about previous therapists is that they just weren't real, they just didn't care. And that's where the clinical literature has it right. Patients with eating disorders have withered under the assault of worthlessness and self-criticism unless they constantly engage in the symptoms, but somehow they feel cared for by the disorder itself. And a patient needs to know she can find that elsewhere. As a therapist, being real means more than following some guideline in a book. You really have to care.

An ethical therapist with no experience with eating disorder treatment will no doubt shudder after reading this post so far. The exhortation to dive in headfirst, arms open wide, feels like a recipe for disaster. The clinical, personal, theoretical and legal reasons to stay firmly, safely behind the scrim look very good on paper and moreover won't jeopardize a bustling practice. The psychological term--written and vehemently argued about through generations of therapists--is the boundary crossing. In the most general terms, this means neglecting the therapeutic frame I mentioned in the last post. Practically speaking, the result is the transformation of the professional relationship into a personal one. The steps that lead towards crossing that line always seem innocuous at first: extending a session a little longer or spending some time discussing the therapist's personal problems. (Just watch the first season of the TV show In Treatment for a textbook case.) The worst scenarios involve the transition to a fully personal relationship or even a romantic one. No matter the transgression, what links these examples is that the therapist's needs and desires come first. The ultimate responsibility of the therapist is to remember that she has her personal life outside the office. Really caring for the patient as a therapist means NOT letting the patient take care of you.

Without the natural give and take of relationships, without the potential to care for each other, with clear boundaries in place, the most basic question still looms: how can this relationship be real? Yet, when the therapy works and the patient does truly feel cared for and starts to get well, it is impossible to see it as anything but real. Effective, meaningful therapy is, in many ways, a re-experiencing of past relationships in the context of something both cathartic and brand new. In eating disorder therapy, this concept helps a patient remember and relive distant relationships in which she was allowed to be herself. So the artificial boundaries actually enable a patient to return to a time before the eating disorder took over, a time when she really could be herself.

When two contradictory experiences in therapy--creating artificial boundaries along with a "real" relationship--feel simultaneously possible, I try to think outside the box of therapy to all the types of relationship we experience in our lives. The idea is to draw on the concept of therapy as a re-experiencing of prior relationships and use those experiences to better understand the moment. The only other relationship that combines the deeply felt caring with strict boundaries is that of a parent and child. When this relationship works well, the parent cares deeply and powerfully for the child but needs to draw strength and support from elsewhere. Relying on the child like an adult stunts psychological and emotional development immeasurably. In no way does therapy compare or replace the parent-child dynamic, but the powerful healing that takes place in eating disorder treatment does tap into a similar experience. Freed from caring for the other person, freed from the tyranny of the disorder and free from self-punishment as the only source of solace, the patient can restart the emotional and psychological process of knowing herself. In an environment where she can be real and true and honest, she gets the chance to continue her own personal development which was stopped by the presence of the disorder in her life.

Of course, the relationship is real. But real not just for now because this isn't meant to be a blip in the course of a lifelong tragedy. This is meant to help her feel real for good.

In recent posts, I have written more about how a chronic eating disorder leads to the derailing of one's psychological and emotional development. Several older posts have referred to the risk factors for developing an eating disorder. I want to switch gears in the next post and start a series of posts about children’s susceptibility to disordered eating and eating disorders and ways to avoid this fate.