On eating disorders and what the therapist's body is doing in the session
The patient is reading you
A person with an eating disorder has spent years studying bodies. They walk into a therapist's office and study that one too. They're looking for clues about whether it's safe here and how they're supposed to relate.
What they find means something. A therapist in a larger body can stir up a patient's fear of her own appetite let loose. A therapist in a thinner body can stir up envy sharp enough to wreck trust. Neither body is the right one or the wrong one. The point is that the reading is always happening, whether or not anyone says so.
The usual instinct is to treat this as noise and get back to the patient's material. I think it's closer to the center of the work. A patient needs to be able to use the therapist's body, to have feelings about it and survive having them, as a way of learning to tolerate shame about her own.
When the body is the only language
Many people with eating disorders have trouble identifying what they feel. The clinical term is alexithymia. Ask how they are and you'll get a report on what they ate.
That isn't evasion. The body is saying what the mind can't yet put into words. Body states are an earlier kind of feeling, one that comes before language, and a symptom can hold a whole part of the self that has never been spoken.
This changes what the therapist listens with. If the communication is non-verbal, the route into it runs through the therapist's own body: the sudden heaviness, the tight chest, the urge to check the clock. Paying attention to those states is a way of hearing what the patient has no words for yet.
Noticing you've been pulled under
There's a tell worth watching for. If weeks go by and the actual eating never comes into the room, the therapist has probably been drawn into a dissociative process alongside the patient. Everyone is being very thoughtful and nothing is being touched.
The response isn't an interpretation. It's a report from your own side of the room: "I notice a lot coming at me, but no real connection."
Something interesting tends to happen when a cut-off part of a person is seen instead of analyzed. They get curious.
It helps to remember that whatever a patient does with food, she will do with her therapist. The patient who seems unreachable isn't withholding a relationship. She's showing you the only one she feels capable of having.
A subject, not only a container
Hilde Bruch, who wrote The Golden Cage, broke with Freud on eating disorders. She went looking for the unconscious fantasies he described and couldn't find them. What she found instead were people who felt helpless and had no sense of owning their own lives. So she stopped interpreting from above and started finding things out alongside her patients.
That shift asks more of the therapist than it first seems to. You can't collaborate with someone while staying hidden. It means being unafraid of the details of what a person does with food, including the strange ones. It means having looked hard at your own relationship to your body before asking someone else to look at theirs.
It also means expecting to feel shame and dysregulation in this work, and treating that as information instead of failure.
The developmental research is useful here. When a mother's face goes still and unreadable, her infant doesn't wait patiently. The infant withdraws. A therapist performing perfect neutrality can become that still face. A patient who learned early that her needs had to go underground will not bring them to someone she can't read.
The therapist has to stay a person in the room, with a body and reactions of her own, and not shrink into a container for the patient's feelings.
The hard part
Philip Bromberg describes the goal with these patients as linkage between self-states. Not fusing them into one, but helping a person feel like herself while being many. He also names the bind: the patients who are hardest to reach need real interpersonal engagement, which is the very thing they make hardest to give.
What I haven't worked out is how a therapist knows what her own body is saying before she does. The patient has usually read it by the time she sits down.
By Julia Mattis, LMSW
