Matt...just wanted to thank you so much for posting this thread. This is something concerning me recently regarding my daughter and I am thankful for such a wonderful outline to get me started learning about this.

It's a confusing issue, because "friendship" can mean so many things to different people. I don't think anyone is being shortchanged by not having a "friendship" with their therapist; I would actually suspect that on some level each of you DOES have that. What I am differentiating is friendship that exists between you and he/she in the clinical setting, and the much rarer dynamic of acts of "friendship" happening outside that setting in each person's social life. Having a social life with patients is a BIG no-no; having a social life with former patients is extremely rare and most therapists subscribe to the old-school idea that it should never happen. Frankly, they would be aghast that I have done it at all. What I am trying to say, although clumsily, is that I seldom do this at all--again, perhaps a dozen of VERY specifically chosen individuals out of 500+ patients.

By "friendship," I do not mean "meeting your therapist for dinner and a movie." I mean that each of you finds something in the other that causes you to feel affection, more than mere clinical respect. You share a transcendent understanding. (in my experience, the "most special" patients and I share an unspoken connection to the point that as therapy progresses we can express with a certain look what once took piles of words to say; I remember commenting once, "I know exactly what _____ is thinking right now," and then elaborating. Her eyes got big, and she burst out laughing--"Oh my god, that is SO true! That's exactly right!" and we all laughed. It also means I can better understand how certain crises will affect certain patients, because I have become familiar with their psyche and their "life maps" of symbolism, experience, and belief, and it puts me light years ahead of where a new therapist would be with the same client.)

In the case of ED and the extended involvement of the therapist, I'm still not talking about the therapist "hanging out" with the family; I am suggesting that the therapist be willing to socialize for the purpose of more effectively guiding the treatment process. I had a psychiatrist tell me once (when I worked in an inpatient hospital treatment program), "You know, Matt, if you could go home with a patient and spend one hour with their family at dinner, you would see so much more than any clinical assessment in the world could ever tell you!" In ED treatment, that idea is carried out more than being a speculative musing.

I do have a very special "core" of friends that I certainly DO meet with socially, perhaps even at a restaurant and perhaps even at my home. It's rare, they are ALL finished with treatment, we have no further professional connection, and even when we do meet the underlying theme of our conversations is support for their continued health. I see it as appropriate and ethical (ethics, you remember, exist to protect YOU from being exploited, not to prevent people from being decent to one another the way any other professional and client also could).

Wow, this "friendship" issues seems to have touched a common nerve here. We can continue to process it, or we can resume more direct attention to eating disorders specifically, whatever you all feel is most helpful.

Some additional leftover thoughts:

- Some people can't form that bond, Shen is correct. This can happen for several reasons: the patient may have Reactive Attachment Disorder. She may have Borderline Personality Disorder. There may be a psychosis that prevents the bond. There may simply be a personality clash. The patient and therapist may just not feel that way about one another. The therapist may be ethically unwilling to acknowledge or grant friendship.

- There IS an invisible line that must not be crossed. But I am suggesting that in some rare cases, that line has been too conservatively drawn; we need to not only acknowledge but expect a certain level of loving transference/countertransference, not make it taboo, and see it as a part of rape trauma therapy. These affections are not only inevitable, they just might even be necessary. The invisible line isn't one that pretends it's not there, it's one that points us both accurately toward a shared understanding of what that affectio does and doesn't mean.

- Mockingbird, have you ever read the book "Father Hunger"? It's considered a classic study into the unrecognized impact a father has on his daughter's lifelong mental health. It's terrifying and inspiring.

Empowered you stated: "For someone to be diagnosed with a true eating disorder, one has to match the medical criteria, as opposed to having an unsatisfying or occasionally-disordered relationship with food. It's the medical consequence of the disorder that earns it the diagnosis, as opposed to being, say, a "nervous eater." If that nervous eater experienced health problems or disruptions in normal life because of that habit, THEN it would be a disorder" Thank you for that clarification on that, I think what I do and when I do it is based on how I am feeling or what I am going through at the time, maybe a "punishment" if that makes any sense?

Perfect sense; at some level, ALL eating disorders are about regulating dysregulated emotional states, not about physical image. In studies, the drug Prozac was the most effective medication with ED's, but talking therapy was more effective than that even. But you have to be sure to have a therapist who is familiar with ED's, and who understands the inner emotional life of the EDS as opposed to making it about pounds, ounces, and beauty.

I have a phrase I use in therapy to help guide all my patients: "Every action (or choice) represents a need trying to be met." This phrase helps my patients get "un-stuck" when they find themselves doing things they don't understand ("I became promiscuous after my rape; what need was I trying to meet? I change my food habits when I am sad or when my mom is depressed; what need am I trying to meet? etc.")

I have a strong bond with my therapist now, but I would not call it friendship. I trust her completely. She is the one I would call if I was suicidal, for instance.
I send her emails quite often.I know that she may or may not respond. I also know, however that she reads them all and we discuss them at our meetings.
With my first therapist I got much too attached. It was the first time I had opened up to anyone and it was very confusing to have this relationship that felt intimate in one way, but completely professional in another. For me, the relationship became really obsessive. I would have done anything to have a friendship with him. That's why I felt such a strong objection to a therapist writing that in rape trauma the therapist is supposed to be your friend. It took me months to get over the obsession I had with my first therapist and if he had somehow drawn the relationship out in any way, I doubt I would have ever gotten over it.
I guess I have been pretty careful not to let that happen with my current therapist. I admire her and trust her but I don't worship her. I tell her about what is happening in my life, but I don't wish she was joining us for dinner. Ihave heard very little about her personal life and I don't expect to hear more. I think the fact that it has remained a very professional relationship is the very reason I am getting so much good out of it. It makes me feel free to say whatever I need to say without worrying that she will not like me or not be my friend any more.
Even after we feel that I am finished with therapy, I would like to know that if an issue arises I would be able to call her for help again. I suppose that with rape trauma, at a certain point you can assume the person is completely over the rape and may never need therapy again, but in life there are many things that can throw you off. If something else happened to one of your "friends" who was a former client, what would you do? What would they do?

I realize that the eating disorder topic has been broadsided here with this other issue. Because of the current problem my daughter is having I am actually quite interested in hearing more about EDs. It's too bad this other stuff isn't on a seperate string, but at this point, it's kind of too late -- we would lose toto much info if we tried to switch it now.

Friendship and obsession are very different, so to have your feelings about the topic of friendship be influenced, or to have a "strong objection to" the idea, on the basis of a past obsession with another therapist, is apples and oranges. As a therapist, I am wary of obsessive transference, and that alone will stunt the "friendship" process. An obsessed patient will hold ME responsible for how SHE feels, get upset with my refusal to rescue her from her own distress, and then become irate toward me when she feels abandoned or rejected. At my job, we will actually discharge and refer a patient to another program IMMEDIATELY when this happens--it is not a "therapy issue," it is an impediment and no therapist should attempt to proceed with that person. The ONLY correct course of action, then, is to terminate the relationship.

Often, the kernel of this obsessive dynamic is the fact that the therapist is male and the patient is female--males therapists are the recipient of tremendous amounts of transference from some female patients. Particularly it's her misplaced hope in him as a rescuer/healer, and misplaced anger at him for abandoning and rejecting her when he "fails" her in that rescuer/healer fantasy role. I've been doing this a long time, and have lost count of the number of times this has happened. Heck, it happened earlier this month at work!

I think I became obsessed with him because he was like the father I wanted. I don't know that I wanted him to rescue me so much as I craved his attention.

I also want to point out that this is the only time in my life anything like this has happened to me. I usually have a hard time getting close to people.

If I may just ask a quick question about the ED...I suspect that my daughter has been binging and sometimes purging. In fact, I know that she has. She says that she has stopped the purging. And I want to believe her. But I know that she is binging because she has put on a great deal of weight (15 pounds in about 1 1/2 months) recently. How do you know when it is time to seek help for this specifically? I keep wondering if maybe I am making too much of it and by doing so that will make it a bigger issue for her as well. I want to help...not to make anything worse.

I feel for you Lucinda. I am going through the exact thing with my daughter (age 20). I told her that therapy could help when she was feeling really down on herself, but it took a very long time before she looked into it.

I would just like to address the comment made about pt's with BPD, I was recently diagnosed with this as well as BPII and PSTD. I have been seeing the same therapist for the last four years and actually the only therapist I have ever seen. I feel very safe with him as I have complete trust in him never disclosing anything I have ever told him. He is the only person in my life that I have been able to talk to and cry about things in my life and past no one is aware of. We have a very comfortable dotor patient relationship and as a matter we do cross each others paths outside of therapy as I work at a doctors office that he recieves many referrals from so he will call and stop in to talk to them and always we are both very proffesional and do not aknowledge we know each other outside of these times. When I was first diagnosed with BPD he was extremly surprised as he said I did not fit the profile of other patients he had that had BPD. I asked him to explain and he said there would be alot of anger sometimes addressed toward him if the pt thought he was not on "thier side". I do have alot of the classic symptoms of BPD and have put my personal friends and relationships through some crappy times with my tendecy to over react to small slights that I will blow out of porportion to the point it is a huge drama and the other person isn't even aware of what brought this on. Thank God with my new mood stabilizing meds and some other meditation treatments I have begun to learn to recognize these times and step back and breath and talk mysef down for the out of control mood. My whole point is that I am very aware that in order to get the full benefits from my therapy I need to see and treat him as the therapist he is and not to let anything else interfer in any way. I will also say he is the only man ever in my life that I have truly trusted and respected and would never want to let myself ever do anything to jeopordize that.

I have a LOT of pt's with symptoms of BPD, but I am also careful to differentiate between the symptoms and the full disorder. I agree with you, m123. Some therapists see self-injury, unstable moods, and sexual abuse in a female patient and jump immediately to "Borderline" labels. I think a lot of rape trauma syndrome is missed by therapists who fail to fully understand it; perhaps a separate thread about BPD should be started.

But BPD is a real diagnosis, and has to be handled carefully. When it IS there, that doesn't mean I suddenly lack affection and empathy for my patient, but it does me I cannot extend a more robust friendship with her beyond a very controlled, task-oriented clinical context. With BPD, the preferred form of treatment is something called Dialectic Behavioral Therapy, which requires a certain objectivity toward the work, as opposed to my usual style which is right-brained and psychodynamic.

To drift this back to EDs, let me say that there are times when the therapist working with an EDS must become an authority figure--friendship does not mean "pals"--and direct the process in a more controlled manner. In particular, this is true when health risks become critical. It takes experience to know this line; no book can teach it to you. A therapist simply has to have the personal insight to sense these moments.

Lucinda, I plan to come back and address your question more fully.

I have a LOT of pt's with symptoms of BPD, but I am also careful to differentiate between the symptoms and the full disorder. I agree with you, m123. Some therapists see self-injury, unstable moods, and sexual abuse in a female patient and jump immediately to "Borderline" labels. I think a lot of rape trauma syndrome is missed by therapists who fail to fully understand it; perhaps a separate thread about BPD should be started.

But BPD is a real diagnosis, and has to be handled carefully. When it IS there, that doesn't mean I suddenly lack affection and empathy for my patient, but it does mean I cannot extend a more robust friendship with her beyond a very controlled, task-oriented clinical context. With BPD, the preferred form of treatment is something called Dialectic Behavioral Therapy, which requires a certain objectivity toward the work, as opposed to my usual style which is right-brained and psychodynamic. If the BPD issues become emotionally explosive and transference toward me becomes either obsessed or outright hostile, I do what most therapists also do: end the relationship and inform the BPD patient that I will not continue to participate in that cycle.

To drift this back to EDs, let me say that there are times when the therapist working with an EDS must become an authority figure--friendship does not mean "pals"--and direct the process in a more controlled manner. In particular, this is true when health risks become critical. It takes experience to know this line; no book can teach it to you. A therapist simply has to have the personal insight to sense these moments.

Lucinda, I plan to come back and address your question more fully.

I was told that I "exhibit symptoms but do not have the disorder"
what does that even mean?
if you have the traits, how is that different?