May 2010

Tactful Speaking: How to Speak to Our Patients Directly and Carefully

Elissa Zelman, Psy.D., Director of Scarsdale Office

It is often difficult for all of us to broach difficult topics with our patients. This is particularly true of our patients with eating disorders. They are so often plagued by low self-esteem, body hatred, and perfectionism that the mildest comment can be distorted and used in a destructive manner. This becomes a very difficult dynamic when the practitioners treating the eating disorder person (and their family) have to be direct and caring with the patient about his/her symptoms and the treatment plan.

Very commonly people approach us and ask how to talk to a friend or family member about eating disorders. We discuss the concept of “carefrontation” – being objective and direct, from a supportive standpoint, and recommend only including necessary information in the discussion. Using this concept is helpful not just for family and friends, but also for those of us treating the individual with an eating disorder.

It is critical to be honest with our patients to build a trusting relationship. That being said, it is also helpful to understand how common and honest phrases can wreak havoc in the mind of the eating disorder individual. For example, telling someone in treatment that they look great or healthy is often heard as “I’m fat.” So, what’s the solution as people who need to talk about the grueling details with these patients? Additionally, how do we help guide those friends and family members who need to have similar types of discussions?

Here are a couple of guidelines that will hopefully serve you in having sensitive and helpful discussions or in coaching others to do so:

  1. Begin with you discussing these things with the person from a place of concern and caring.
  2. As always, choose your language carefully. Try to remain objective, not subjective, particularly if you are discussing symptoms of concern.  For example, instead of saying “you’re not eating,” you could say “I’ve noticed that you’re cutting up your food into small pieces and eating 3 or 4 bites.”
  3. Be aware of your own biases and prejudices so they do not negatively affect the patient. For example, if you think it is healthy to cut virtually all carbohydrates from your own diet and a teenage girl is telling you she is doing the same, you might not realize the severity or significance of her behavior.  Really try to understand the subjective experience of the person talking, as opposed to comparing it to your own reality.
  4. Avoid discussions of appearance. I have learned to not make appearance comments, negatively or positively. My patients have taught me that if someone makes a positive appearance comment to them, and then neglects to do so the next time they see them, they are convinced it is because they look bad or have gained weight.  Personally, I don’t want to emphasize appearance because, “it’s what’s inside that counts” and our patients need great support in recognizing this (NEDA, 1994).
  5. Do not make assumptions. Just as our patients make all kinds of judgments, based on the presentation or appearance of someone, we do as well.  It is important not to assume someone’s health or struggle by their physical appearance.  I have heard many stories from my patients of professionals who have said they look fine and thus, don’t do appropriate medical follow-up like check blood work, or ask for more detail about their emotional state during psychological evaluations.