The Choice

stringy blond hair made her face look even thinner. She stood in the
doorway of my office, her too-long sleeves pulled all the way down
over her hands. She looked like a person with a secret.
With any new patient, it’s important to be sensitive to his or her
psychological boundaries from the very ĕrst moments of our initial
encounter. I must intuit immediately if this is a person who wants me
to take her hand or keep my physical distance, if this is a person who
needs me to give him an order or a gentle suggestion. For a patient
with anorexia—a disease that is all about control, about relentless rules
for what and when you eat or don’t eat, for what you reveal or conceal
—these ĕrst moments are critical. For one thing, anorexia has an
inescapable physiological dimension. Because of the lack of nutrients
entering the body, and because the bulk of the few calories consumed
go to autonomic functions (breathing, elimination), the brain is
deprived of blood Ęow, and this leads to distorted thinking and, in
severe cases, paranoia. As a psychologist beginning a therapeutic
relationship with a person with anorexia, I have to remember that I’m
communicating with a person who likely has distorted cognitive
functioning. It’s easy for a habitual gesture—putting a hand on
someone’s shoulder as I guide her to a comfortable chair, for example
—to be misinterpreted as threatening or invasive. As I greeted Emma
for the ĕrst time, I tried to simultaneously warm and neutralize my
body language. Because someone with anorexia is an expert at control,
it’s important to disarm her need for control by offering freedom. At
the same time, it’s vital to create a structured environment where there
is safety in clear rules and rituals.
Having met her parents, I knew that the home language was full of
criticisms and blame, so I began our session with a compliment.
“ank you for coming,” I said. “I’m so happy to ĕnally meet you.
And thank you for being right on time.”
When she had chosen a seat on the couch, I told her that anything