The Basics of Eating Disorder Psychotherapy: How it Works

I am a psychotherapist in private practice. My job is to help make the unconscious conscious and support people as they learn to live with greater awareness of themselves and the world.

When people with eating disorders come for their first appointments they have a lot to say. Some know it and start talking openly right away. Some are so nervous they don't know what to do or say or expect. But it doesn't take long before they start to tell their story. It's often a relief to start talking.

So first, I listen. Sometimes I listen for a long time. People with eating disorders have little or no experience or knowledge in really trusting anyone. Some know they don't trust, and some think they do.

Some people who think they trust others often open too fast and pour their hearts out in the first few minutes. They may feel unbearably vulnerable after such an emotional release and begin making impossible demands (like "tell me what to do to make everything fine right now"). When they hear that recovery takes time, effort and resources they panic or get angry or both. Then they disappear.

Some people are looking for someone to trust. They pour their hearts out hoping they are in a safe place. They are being brave and taking a risk. They feel a powerful sense of relief when the therapist is trustworthy and understands eating disorders. They stay to explore because they've already discovered that they can take an emotional risk in the service of their recovery and be okay.

The people who know they don't trust may be the most courageous of all. They come to therapy, sometimes in terror. They know they don't trust me anyone, but they know they need help. They expect the worst of their imaginations and hope for the best which is beyond their imaginations. They hope. They want to run away as fast as they can, but they use their strength and great desire to be well to stay to try.

The delicate part of this first issue is that people with eating disorders often put their trust in untrustworthy people long ago. Perhaps they had no choice. Sometimes the untrustworthy people were their caregivers.

So it's difficult for them to come to another caregiver, the psychotherapist, and develop a genuine relationship. They trust too fast, or they don't trust at all.

An early and important step that continues throughout therapy, is working with, talking about, living through, feeling and appreciating the complexity of trust.

When they say they don't trust me, I say, "Why should you? You just met me. It will take time for me to earn your trust."

You see, they feel isolated in what they experience as a distant, cold and dangerous world. So it often doesn't occur to them that someone, without pressure or manipulation, would accept their distrust and make an effort to be a reliable presence in their lives.

When they say, "Oh, I trust you." I say, "Why should you? You just met me. It will take time for me to earn your trust."

Some try to ignore their feelings of isolation and danger. After all, people with eating disorders try, often successfully, to ignore many of their feelings. That's the main function of their eating disorder. So, to prove that the world is safe,that there are no dangerous people in it and they have no need of fear or anxiety, they trust almost anyone very quickly.

When they know they don't have to trust me blindly or pretend to trust me, the pressure is off. They can relax a little. They may start to share more of what is going on inside of them.

Eventually, if all goes well, they will share with me not only things they've never told anyone else, but also things they didn't know themselves. This is when awareness and appreciation of themselves and their life situation begins.

People don't have eating disorders because of food. They binge, starve, compulsively eat and purge as a way of self medicating themselves. There are feelings they cannot bear to experience. Often they don't know this themselves. But when they eat to the point of emotional numbness, starve to an ethereal high, fill themselves up and get rid of it through vomiting or laxatives or excessive exercise, they are fighting off a terrible despair.

We don't try to find out what that terrible despair is right away. I doubt that we could succeed in a fast way if we did. But even trying in a focused concentrated way can be too threatening. The person might not be able to bear so much pain.

When a person feels more pain than they can bear they may choose self destructive behavior even more harsh than their eating disorder. Suicide can look like the only option to a person in total despair. The eating disorder helps the people to not feel their despair.

So the work proceeds gently.

As people become stronger and more aware, they develop an earned confidence in themselves. They are capable of accepting more realistic knowledge of the world and the kinds of people in it. They then can develop and use more tools for functioning well in the world. When they can do that the eating disorder is not such a crucial defense.

Because of this the person can begin to let go of their disorder without feeling that they are in unbearable danger. They are participating more in life, and they are beginning to develop trust in their ability to care for themselves.

At this point, even though they feel vulnerable and new, they start to rely on their new competence. They have proven themselves trustworthy to themselves.

In the therapy process they learn how to live with their misgivings about the therapist and over time learned valid reasons for giving that therapist their trust. They learn what it takes to earn trust.

This learning extends over to their own internal experience. For the first time in their lives, they appreciate what it takes to earn their own trust. When they develop and discover their own trustworthiness they discover a strength and security they never dreamed possible before.

Overeating, bingeing, purging, starving, spacing out on sugar or massive quantities of anything can't compare to the freedom and security in relying on your own strength, judgment and competence.

People learn to let themselves feel, now that they trust themselves to be their own trustworthy caretaker. They learn to listen to their thoughts and feelings, now that they know what listening is. They make decisions that are in their best interest for health and a good life, now that they have tools and know howto use them.

An eating disorder is a pretty paltry, flimsy, time consuming and useless protector when you compare it to your own trustworthy, caring and responsible self. You integrate some of the relationship you had with your therapist into your own style of being in the world. You become your own caretaker. And before you take any action you remember that first step in therapy. You have confidence that you can feel, know what you are feeling and listen to yourself now. You recognize your frailties. You know how to draw on your own inner reliable and trustworthy sources of life affirming wisdom. That's where you find your freedom.