Children & Families: Eating Disorder Therapy for Teen Girls
By Adrienne Ressler, LMSW, CEDS-S, F.iaedp
Social Work Today
Vol. 22 No. 3 P. 6

“Hello, gorgeous!” This greeting is not one most teenage girls would use to address the reflection looking back at them from the mirror. In fact, most use the mirror as a tool for taking stock of their worth—conducting a critical search for flaws, fat, and proof of their failure to live up to the standards they have set for themselves. Their hunger for perfection and acceptance is insatiable, giving rise to body shame, self-loathing, and anxiety.

Teen girls are particularly vulnerable, coping with their developmental transitions while on a collision course with the effects of COVID and general unrest throughout the world. This combination of chaotic experiences often causes detachment from and confusion in the experience of living in their changing and growing bodies, ultimately creating the perfect milieu for an eating disorder to thrive.

Body image plays a central role in eating disorders due to the body, in today’s culture, being the visible target by which individuals are judged. Body image has been defined in numerous ways. I use the following three components to explain body image to patients because it is simple to understand and discuss: Body image reflects the way you see yourself, how you believe others see you, and how you feel living in your body.

Many individuals who suffer from an eating disorder tend to experience their body principally as an object to be evaluated for its appearance rather than for its effectiveness. Known as self-objectification, this outlook keeps appearance at the forefront of their minds.1

This viewpoint impedes what is happening inside the body (interoception), what is happening to the body in space (proprioception), and what is happening around us (exteroception). Dysfunction of interoception is increasingly recognized as an important component of different mental health conditions, including anxiety disorders and eating disorders.2

The Social Worker’s Role in Eating Disorder Treatment
Two key but often overlooked factors in the treatment of eating disorders that social workers can integrate into their practice are the following:

• helping teens make peace with their bodies—that is, seeing the body as an ally rather than an enemy; and

• teaching the value of self-compassion as a replacement for ongoing negative self-talk.

Equally important with this population, as with all clients, is for social workers to examine their own biases and how these might affect their ability to have the emotional openness needed to become attuned to clients, leading to trusting and authentic relationships. Adolescents are extremely skilled at picking up other people’s thoughts and feelings, so it is imperative that deep thought be given to the possible presence of biases that may hinder the attunement process.

Developing empathic connections between social workers and clients requires balancing feeling states in the gray area of emotions. In the words of social worker Virginia Satir, “When I am in touch with myself, my feelings, my thoughts, with what I see and hear, I am growing toward becoming a more integrated self. I am more congruent, I am more ‘whole,’ and I am able to make greater contact with the other person.”3

Entering Their World
Teens with an eating disorder are usually resistant to change and therapy. While a younger client may be more difficult to connect with, all clients will benefit from conversations that show interest in them as a person. The following are tips on how to enter their world and set the stage for a working relationship.

• Request they keep a journal of how they felt during the therapy session. Writing should take place after each session and discussed in the next session.

• Ask clients to share their favorite TV shows, movies, actors, hobbies—it’s a first step to entering their world. Then reciprocate.

• Find out whether they have pets. Teens love pets and may be more willing to engage when talking about them.

These conversational practices, among others, address the important question central to effective treatment: “Help me understand what it’s like to be you.”

Engaging Body Awareness
Once this foundation has been established, social workers are in a better position to help their clients with an eating disorder develop body awareness. Take note of emotion words such as angry, sad, scared, and love. Ask them to notice their use of these words and close their eyes and relax. Wait a few seconds, and ask them to slightly raise one hand. Then say, “Allow your hand to move to the part of your body where your anger is stored. Don’t think about it, let your hand move of its own volition.”

If it feels right, ask a few questions. “How close to the surface is your anger? How much space in your body does your anger take up? Do you notice if your anger has a color?”

After a few seconds, they can open their eyes and a discussion can take place about what occurred.

There are also several practices social workers can introduce that serve as a vehicle for teens to begin or sustain their relationship with their body and themselves in everyday life. Keep in mind that, as obsessed as teens are with their bodies, they are not “living there.” Encourage them to do the following:

• Stop the negative self-talk. Ask them to notice when they are not being kind to themselves and change their words to ones that are not harsh. Tell them not to worry if it doesn’t feel authentic. They need time to believe in this version of themselves. They deserve to be the person they were meant to be. Offer resources such as Befriending Your Body by Ann Saffi Biasetti and Self-Compassion: The Proven Power of Being Kind to Yourself by Kristin Neff, PhD.

• Use the mirror to appreciate, not punish. Before looking in the mirror, ask them to practice relaxing their eyes. Close and open them wide several times. Feel them relax and think of softening them. Only then look in the mirror. Then, have them give themselves a friendly greeting. Next, they can widen their scope to include their whole body. Don’t focus on any one body part. It’s important they see themselves as a whole person. Continue this exercise a few times daily.

• Practice self-care and nurturing as a way of life. Practice slowing down to listen and experience the body’s signals and sensations.

• Think of themselves as their own best friend and treat themselves accordingly.

• Keep themselves surrounded by people who love and appreciate who they are, not because they have met certain conditions to be worthy of their approval or love. Remind them that they have control over their environment.

• Add relaxation breathing and moderate physical movement of any kind to their daily routine. The breathing, which will help them stay calm and centered, serves to ground them in their bodies. Movement also connects them to their body and provides a sense of aliveness and energy that will help them love, accept, and nurture themselves.

• Remind them that the images they see in the media are totally unrealistic for the average person to attain. For celebrities, buffing, sculpting, and dieting their bodies into submission is their day job and comes with a support staff to make it all happen.

The Reality
The heartbreak and loss of lives to eating disorders is horrific. Each year, more than 10,000 people in the United States die as a direct result of an eating disorder. One out of every five patients with anorexia nervosa dies by suicide. While this article has focused on teenagers, it is important to note that eating disorders do not discriminate—they affect people of all ages, races, genders, sexual identities, and body sizes. Social workers can play a vital role in treating this population and engaging in prevention efforts.

— Adrienne Ressler, LMSW, CEDS-S, F.iaedp, is vice president of professional development at The Renfrew Center Foundation. Established in 1990, The Renfrew Center Foundation is a 501(c)(3) nonprofit that aims to increase awareness of eating disorders as a public health issue by educating policy makers to take action to remove barriers to treatment and by conducting research into the pathology and recovery patterns of people with eating disorders.

References
1. Ainley V, Tsakiris M. Body conscious? Interoceptive awareness, measured by heartbeat perception, is negatively correlated with self-objectification. PLoS One. 2013;8(2)e55568.

2. Khalsa SS, Adolphs R, Cameron OG, et al. Interoception and mental health: a roadmap. Biol Psychiatry Cogn Neurosci Neuroimaging. 2018;3(6):501-513.

3. Satir V. The therapist story. J Psychother Fam. 1987;3(1):17-25.