“Be curious, not judgmental.” – Walt Whitman
Fear of the unknown often holds people back from seeking therapy. In order to demystify the process, I will describe below some of the questions I might ask in a consultation or first session with a patient, along with my reasons for asking these questions. Of course, no real interview is as structured as this, but these questions will give you the “flavor.”After I consider the unique responses of each person to the questions, I begin to fashion a treatment plan which I share with the patient towards the end of our initial session. I want this first session to begin the partnership and collaboration that true healing involves.
Your Present Situation
- Tell me what brings you here and how you hope I can help.
In my opening question, I am trying to understand two things: Did you come to see me voluntarily or were you pressured by someone else? This gives me some indication of how willing or scared you are to begin therapy.
Treatment is most effective when the desire for change comes from within yourself and not from outside coercion.
- How did you feel about coming for this consultation?
I want to learn something about your fears, hopes, shame, and anxiety. This will help me appreciate whatever inner resistance you had to overcome in order to seek therapy.
- Why are you coming for help now?
I want to know if there are events in your life that have made you want help at this time. Some people can make the connection themselves, others cannot pinpoint “why now?” although their problems can often be traced to a recent loss in their life. The death of a loved one, an illness, a move or a separation can cause people to become more vulnerable to developing an eating problem or can worsen an already existing struggle with food.
- What is a typical day like for you with food?
I am looking for patterns: Do you eat very little during the day only to overcompensate at night? Do you nibble constantly throughout the day as if food were an intravenous tube?
Weight History
- What is your current weight? What do you want to weigh?
Asking people what they want to weigh reveals how realistic a view they have of their bodies. When a very thin woman tells me she needs to lose twenty-five pounds, I know she is struggling with a body image problem that we will also need to address in therapy.
- What is the highest weight you have been as an adult? What was the lowest?
I want to discover how you reached your lowest weight and whether it was stressful for you. This will help me get a realistic idea of your natural weight.
- What was your highest and lowest weight as a teenager?
Many people’s eating problems began during adolescence. I try to determine what might have been the trigger, such as a fear of one’s developing sexuality or fears about leaving home.
- Did you have eating problems as a child?
If you tell me your eating struggles began as a child, it indicates the problem may go deeper than the case of a widow, for example, who only developed a weight problem after her husband’s death.
A sudden weight gain or weight loss may indicate a traumatic event in the child’s life such as sexual abuse.
- Were you ever teased about your weight? By whom?
Getting weighed at school in front of the whole class or worrying about fitting into a gym suit are often painful memories for people. If a family member teased you about your weight, that will add to your pain and self-consciousness.
- Does your occupation require a certain weight?
Patients who are dancers, actresses, models, flight attendants, aerobics teachers often come to therapy because their jobs are pressuring them to lose weight, and this is causing an unnatural obsession with food and eating.
Diet History
- Have you ever been on a diet?
Dieting seems to be the norm in our society, especially for women. In my entire life, I have only met four women who never dieted!
- How did your dieting begin?
I want to learn what role your parents played in your dieting. The mother of one patient forced her to diet at age ten, subjecting her to upsetting weekly weigh-ins while her thinner sister was given free reign of the kitchen. This patient remained fat – in part – as a silent protest to her mother’s intrusiveness.
- Do you have a way you prefer to diet? Do you fast, skip meals, take diet pills, or avoid certain foods?
Generally, the more restrictive your method, the harder it tends to be for you to make peace with emotional eating; the more moderate your method, the easier it will be.
Connect With Mary Anne Cohen, LCSW, BCD in Brooklyn, New York
Binge History
- Have you ever binged? When did it start?
Bingeing often occurs when two factors are present at the same time: You have suffered an emotional loss in your life and, simultaneously, you begin a weight loss diet.
- When are you most likely to binge?
This will help identify the emotional state most likely to cause your eating problems. Is it loneliness, boredom, anger, depression, sexual tension?
- On what foods are you most likely to binge?
Are there certain foods that provoke a binge such as cake, ice cream, chips, bread? This alerts me to a possible addiction.
- Where are you most likely to binge—at home, work, school, in your car?
Very often, the location or timing of the binge has a specific meaning for the person that, when understood, will help to break the cycle. One woman I worked with only binged in the bathroom stall at college. Another only threw up before going out on a date.
18.What is the longest you have gone without a binge? What helped?
I want to know what support systems made it easier for you to avoid eating problems at that time.
- Do you binge around your menstrual period?
If this is the case, I suggest that women increase their intake of complex carbohydrates and eliminate protein at the evening meal. This raises the body’s endorphin level and reduces cravings.
Purging History
- Do you make yourself vomit? Since when? How often?
- Do you take laxatives or diuretics? Since when? How often?
- How often can you eat normally without purging?
I want to understand whether you consider all foods dangerous or only certain foods must be purged. The wider the range of foods you consider forbidden, the more severe your eating problem may be.
- How often do you exercise? How compelled do you feel to exercise? Do you use it as a way of undoing a binge?
I then ask about other related behavior:
- How often do you drink? Do you use drugs? Do you feel you ever had an alcohol or drug problem? What about spending too much? Shoplifting?
Since so many eating disordered people are cross-addicted, this question rounds out the picture of possible substance abuse or other addictive behavior.
Family History
- Does anyone in your family suffer from alcoholism, drug abuse, eating problems, anxiety, or depression?
There are strong genetic tendencies among addicted families, one of which is depression. Eating disorders can be a symptom of depression and as such can be successfully helped through psycho- therapy and possible anti-depressant medication.
- Have you ever been physically abused? Sexually molested?
An alarming number of people with eating disorders have been abused as children. Food is the safest, most available drug for numbing painful feelings. If you have been abused, we need to address this gently but fully in therapy to help you heal your eating problem.
Connect With Mary Anne Cohen, LCSW, BCD in Brooklyn, New York
Rounding Out the Picture
- Have you ever been in therapy for an eating problem before? What was it like?
If you were in therapy before, I want to learn what went right, what went wrong, and why you left. This can help me better under- stand your needs. The two most common complaints I hear are: “My therapist didn’t talk to me enough. I didn’t get enough feedback.” And “I learned a lot about myself, but it didn’t help my eating problem.” My belief is that patients do not resolve their eating problems through insight alone.
A therapist needs to be an active participant to help you weave together both your emotional issues with concrete strategies for changing your eating behavior.
- Is there anything that would be helpful for me to know that we have not discussed yet?
I never fail to ask this question because some of the responses can be amazingly revealing. One patient “forgot” to mention that her son had died two years ago and her husband was beating her. Another patient “forgot” to mention that although she did not vomit outright, she would bring her food up and swallow it repeatedly.
Concluding the First Interview
In formulating a treatment plan for a new patient, two key elements usually emerge in the interview—one is behavioral and the other is emotional.
First, patients need a plan of action to begin giving some structure to their eating. To this end, I ask patients to keep a daily journal of what they eat, when they eat, whether they are hungry, and how they are feeling when they eat (or purge or starve). The second element that usually emerges is an emotional issue that has been camouflaged by the eating problem.
I explain to new patients that therapy can be extremely helpful in unraveling and resolving these emotions.
Having the courage to go for a consultation with an eating disorder therapist will open the channels for healing. Sharing your story with an experienced and compassionate therapist helps to break the chains of isolation and will begin to help you declare peace with emotional eating.
Further Reading: How to Overcome Your Fear of Therapy
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