The Basics of Eating Disorder Psychotherapy : How it Works

by Joanna Poppink, L.M.F.T.

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.

About the Author

Joanna Poppink, L.M.F.T is a Los Angeles psychotherapist in private practice who specializes in working with people recovering from eating disorders and their loved ones. She has been in practice since 1980 and is the author of “Triumphant Journey Workbook: a guide to stop overeating and recover from eating disorders.” She gives presentations on treatment, prevention and family dynamics as they relate to eating disorders to health professionals and community gatherings. www.poppink.com