The Basics of Eating Disorder Psychotherapy: How it Works
By Joanna Poppink, LMFT
What happens when a person with an eating disorder starts therapy?
This is a brief summary, from my point of view as a psychotherapist specializing in treating people with eating disorders, of what can happen in the first few weeks of therapy with a person seeking to begin recovery.
People come to my practice because they suffer from an eating disorder. They are usually frightened, often desperate, sometimes angry, sometimes shy and always in emotional pain. My job is to help them rally their strength, courage and ability to heal. We work together to make unconscious conscious and create supportive environment as they learn to live with greater awareness of themselves and function more creatively and happily in the world. New clients usually doesn?t know this. They come because they hope I can do something, maybe in just a few weeks, to make the pain stop or cure them.
When people with eating disorders arrive at their first appointments they have a lot to say. Some know it and start talking openly right away. Some people are nervous and don't know what to say. But in a few minutes they start to tell their story and feel relief when their words start flowing.
They talk about their pain. They describe their history. They tell me they don't want to live this way anymore. They tell me how difficult it was to find my name and how they almost changed their minds about coming to the appointment. They look around the room trying to evaluate me by the contents of my office. Or they conscientiously try not to look at anything, afraid they might see something they shouldn't, or maybe touch something with their eyes and provoke my anger. Or they fear to see something that will be evidence that I am not who they hope I am and so will be unable to help them.
Their eyes appeal to me for help, understanding and a place to begin.
So first, I listen. Sometimes I listen for a long time. People with eating disorders have little or no experience or knowledge in speaking honestly and being genuinely heard. They don't know what trust means. Sometimes they feel suspicion and know they don't trust. Sometimes they believe they are trusting people.
The people who think they trust can open too fast and pour their hearts out in the first few minutes. They may feel unbearably vulnerable after their 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. Sometimes their vulnerability is too much to bear and they leave. With courage and determination they may remain in therapy to explore their experience.
People who know they don't trust begin cautiously. They voice their fears and past disappointments. They speak carefully telling me why they doubt I can help them. Then they pour out their hearts hoping they are in a safe place and can survive this leap of faith. 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 also draw on courage and determination to remain in therapy.
The first session or first few sessions is where an individual takes an authentic emotional risk in the service of her recovery. If she discovers that she can bear this experience with the therapist and be okay she will decide to stay and commit to the necessary work.
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 anyone, and they know they need help. They expect the worst and hope a best that is beyond imagining. They want to run away, and they use their strength and great desire to be well to stay.
The delicate part of this first issue is that people with eating disorders often trusted 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 and appreciating the complexity of trust.
When a new patient says she doesn't trust me, I say, "Why should you? You just met me. It will take time for me to earn your trust."
At this point she feels isolated in what she experiences as a distant, cold and dangerous world. It doesn't occur to her that someone, without pressure or manipulation, would accept and tolerate her distrust and make an effort to be a reliable presence in her life.
When a new patient says, "Oh, I trust you." I say, "Why should you? You just met me. It will take time for me to earn your trust."
This person ignores or numbs herself to her feelings of isolation and danger. People with eating disorders are often successful in ignoring many of their feelings. Emotional numbing is a primary function of an eating disorder. So, to prove that the world is safe and that they have no need of fear or anxiety, these patients tend to trust almost anyone very quickly. The sad result of this method of keeping themselves safe is that they keep making the same dangerous choices in their lives.
When patients 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 and with courage and curiosity observe me and allow me to be present with 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.
A new patient may believe her eating disorder is caused by food. She may not yet understand that she binges or starves or compulsively eats and purges as a way of self-medicating herself. She can't bear to experience much of her own emotional experience in life. She eats to the point of emotional numbness, starves to an ethereal high, fills herself up to the point of physical pain and then gets rid of the binge through vomiting or laxatives or excessive exercise and doesn't know she is fighting off a terrible despair.
She and I don't attempt to find out what the terrible despair is right away. I doubt that we could succeed if we tried. But even trying in a focused concentrated way can be too threatening. She is limited in what she can bear emotionally. An important part of therapy is to help the her develop a capacity to tolerate a greater range and depth of emotions so the eating disorder is less necessary.
When a patient feels more pain than she can bear she may choose self-destructive behavior even harsher than her eating disorder. Sometimes suicide looks like a reasonable option to a person in total despair. So we proceed with the work gently.
As a patient becomes emotionally stronger and more aware of her internal life, she develops an earned confidence in herself. She can feel and think at the same time. Her fears may be strong, but they are not overwhelming. She can bear her experience, make decisions about what is best for her and communicate those decisions to others. As her healing progresses she is more capable of accepting realistic knowledge about the world and the kinds of people in it. Then she can develop and use more personal skills in functioning well in the world. And best of all, she discovers she has choices and opportunities she never dreamed possible. At this point the eating disorder behavior is not as crucial a defense as it was.
When the eating disorder behavior diminishes the recovery work continues. She is experiencing a challenging psychological event. She no longer has the familiar numbing methods available. Now she is simultaneously feeling emotions and having perceptions that are new and seem strange or frightening to her. She is a fledgling who needs to learn how to make herself safe while she stretches her wings to fly.
Being wise and responsible while taking the necessary and reasonable risks of living in this world challenges all of us. To the eating disorder person in early recovery the challenge is particularly intense. She did not learn about reasonable boundaries and reasonable risks in gentle stages as she moved through childhood and into young adulthood. In early recovery she is facing the reality of a world that requires us to recognize the need for boundaries, create them and respect the boundaries of others. She is facing the reality of a world that presents us with consequences to our actions. She has little experience or awareness of boundary setting or consequences is shocked and frightened when confronted with these realities.
This confrontation, if too severe, can tempt her to go back to the numb oblivion of her eating disorder. But gentle and consistent support and understanding during this critical period when the eating disorder is not an option helps her learn to take steps in this new and challenging world. Each step creates more emotional strength, clear thinking and self confidence...
Without the familiar methods of numbing she can let go of her disorder without feeling unbearable danger. She is participating more in life and developing trust in her ability to care for herself. Even though she feels vulnerable and new, she can use her courage to rely on her competence. She continually proves to herself that she is able to trust herself because she is trustworthy.
Understanding trust remains an important aspect of her healing and her life decisions. Through the therapy process she learned first, how to live with her misgivings about the therapist and herself. Over time she learned to recognize how and when her therapist earned reasonable trust.
This learning extends to her internal experience. For the first time in her life she learns what it takes to earn her own trust. When she develops and discovers her own trustworthiness she discovers a strength and security she never dreamed could exist.
Overeating, bingeing, purging, starving, emotional numbing on sugar or massive quantities of any substance or experience doesn't compare to the freedom and security created by strength, clear awareness and competence.
She learns to feel and be aware of her experience in the world when she knows she can rely on herself to be her own trustworthy caretaker. She learns to listen to her thoughts and feelings now that she knows what listening is. She makes decisions that are in her best interest for health and a good life when she have personal living skills and knows how and when to use them.
A patient in recovery integrates aspects of the relationship she had with her therapist into her particular way being in the world. She becomes her own caretaker. She has confidence that she can feel, know what she is feeling and listen to herself. She recognizes her frailties. She knows how to draw on her own inner reliable and trustworthy sources of life affirming wisdom. That's where she finds her freedom.
An eating disorder is a paltry, flimsy, time consuming and useless protector when compared to a trustworthy, caring and responsible self.
Joanna Poppink, LMFT, is a licensed marriage and family therapist. She has a private practice in Los Angeles since 1980 and specializes in treating eating disorders. She provides psychotherapy to individuals with eating disorders and their family members. She is also the author of "Triumphant Journey: a guide to stop overeating and recover from eating disorders." Visit her website at http://www.poppink.com.