This is a straightforward summary, from the psychotherapist's point of view, of what can happen when a person with any eating disorder starts therapy.

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 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.

The people who think they trust others often open too fast, pour their hearts out in the first few minutes, make impossible demands (like "tell me what to do to make everything fine right now"). When they hear that recovery takes time and effort they panic or get angry or both. Then they disappear.

The ones who know they don't trust may actually be in a more advantageous position. They know they don't trust me or anyone. But perhaps they want to and are willing 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.

So, 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 to ignore many of their feelings. That's what their eating disorder is for. 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.

That's 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 even know this. 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 focussed 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 not feel that 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.