These various stances help them show up despite their fear. Behind each of these stances is a frightened, hopeful and very brave person. So as far as which comes first in our conversation, bingeing or purging, I don't focus on either. The client may be stressed to the maximum just by being present for that first appointment. I focus more on creating a relaxed atmosphere where the patient and I can begin to develop a relationship that is based on earned trust, genuine interest in the remarkable puzzle of her eating disorder, deep respect and compassion for her struggle and shared curiosity about what triggers an episode.
Clients usually feel terrible guilt about their bingeing and purging.
They criticize themselves severely for these behaviors. They set impossible goals for themselves in terms of stopping. They feel hopeless and despairing when these goals are not met. In my opinion they need these behaviors in order to maintain whatever lives they have going because they don't have any other coping mechanisms that are as effective as their eating disorder. If I have an agenda for them that includes their stopping or diminishing their bingeing or purging I may run the risk of accentuating their feelings of guilt, self criticism, sense of failure and despair.