What happens when a person with an eating disorder starts therapy?
12th April, 2008
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 role 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 don’t usually 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 may 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 their recovery. If they discover that they can bear this experience with the therapist and be okay they 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 client says they don'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 they feel isolated in what they experience as a distant, cold and dangerous world. It doesn't occur to them that someone, without pressure or manipulation, would accept and tolerate their distrust and make an effort to be a reliable presence in their life.
When a new client 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 them self to their 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 clients 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 clients 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 client may believe their eating disorder is caused by food. They may not yet understand that they binges or starve or compulsively eat and purge as a way of self-medicating their self. They can't bear to experience much of their own emotional experience in life. They eat to the point of emotional numbness, starve to an ethereal high, fill their self up to the point of physical pain and then get rid of the binge through vomiting or laxatives or excessive exercise without knowing they are fighting off a terrible despair.
They 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. The client is limited in what they can bear emotionally. An important part of therapy is to help the client develop a capacity to tolerate a greater range and depth of emotions so the eating disorder is less necessary.
When a client feels more pain than they can bear they may choose self-destructive behaviour even harsher than their eating disorder. Sometimes suicide looks like a reasonable option to a person in total despair. So we proceed with the work gently.
As a client becomes emotionally stronger and more aware of their internal life, they develop an earned confidence in their self. They can feel and think at the same time. Their fears may be strong, but they are not overwhelming. They can bear their experience, make decisions about what is best for their and communicate those decisions to others. As their healing progresses they are more capable of accepting realistic knowledge about the world and the kinds of people in it. Then they can develop and use more personal skills in functioning well in the world. And best of all, they discover they have choices and opportunities they never dreamed possible. At this point the eating disorder behaviour is not as crucial a defence as it was.
When the eating disorder behaviour diminishes the recovery work continues. The client is experiencing a challenging psychological event. They no longer have the familiar numbing methods available. Now they are simultaneously feeling emotions and having perceptions that are new and seem strange or frightening to them. They are a fledgling who needs to learn how to make their self safe while they stretch their wings to fly.
Being wise and responsible while taking the necessary and reasonable risks of living in this world challenges all of us. To someone with an eating disorder the challenge is particularly intense. They did not learn about reasonable boundaries and reasonable risks in gentle stages as they moved through childhood and into young adulthood. In early recovery they are facing the reality of a world that requires us to recognize the need for boundaries, create them and respect the boundaries of others. The client is facing the reality of a world that presents us with consequences to our actions. They have little experience or awareness of boundary setting or consequences and is shocked and frightened when confronted with these realities.
This confrontation, if too severe, can tempt them to go back to the numb oblivion of their eating disorder. But gentle and consistent support and understanding during this critical period when the eating disorder is not an option helps them 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 they can let go of their disorder without feeling unbearable danger. They are participating more in life and developing trust in their ability to care for their self. Even though they may feel vulnerable and new, they can use their courage to rely on their competence. The client continually proves to themself that they are able to trust their self because they are trustworthy.
Understanding trust remains an important aspect of their healing and their life decisions. Through the therapy process they learned first, how to live with their misgivings about the therapist and their self. Over time they learned to recognize how and when their therapist earned reasonable trust.
This learning extends to their internal experience. For the first time in their life the client learns 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 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.
The client learns to feel and be aware of their experience in the world when they know she can rely on their self 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 when they have personal living skills and know how and when to use them.
A client in recovery integrates aspects of the relationship they had with their therapist into their particular way being in the world. They become their own caretaker. They have confidence that they can feel, know what they feel and listen to their self. They know how to draw on their own inner reliable and trustworthy sources of life affirming wisdom. That's where they find their freedom.
An eating disorder is a paltry, flimsy, time consuming and useless protector when compared to a trustworthy, caring and responsible self.
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