Introduction/background
I met D in April 2024, when she was 17 years old. She was attending school and living in Greece with her parents and younger brother.
At the age of 14, D was at her highest weight. During the COVID-19 lockdown, she started following a diet without assessment or support from a nutritionist. She began eating more fruit and vegetables and gradually became increasingly restrictive.
Over the following year, she lost a significant amount of weight through food restriction and excessive exercise. She attended boxing training three times a week for approximately one and a half hours and participated in competitions. She also attended traditional dance classes once a week for around one and a half hours.
Although the restrictive diet resulted in weight loss, D continued to receive comments about her body and wanted to lose more weight. Eventually, she was eating only one meal a day. However, this was not sustainable, and at times she would return to eating three meals a day.
At the age of 16, her family began commenting on how much weight she had lost. D told me that they repeatedly said, “You must eat.” She continued joining them for meals and appeared to be eating, but she was inducing vomiting in secret immediately afterwards.
Her parents eventually recognised what was happening and went to see a psychiatrist, who prescribed her antidepressant medication. D told me that she did not notice any difference.
Initial contact
When I met D, she was malnourished.
She was eating meals but inducing vomiting afterwards and had developed a significant fear of carbohydrates, which she had largely excluded from her diet and only consuming them as a part of a binge eating episode.
We began working together after she stopped attending sessions at a treatment centre where she had previously received support.
The instructions from that centre were as follows:
D was given a meal plan each week, consisting of very specific foods. The remaining foods were kept locked in a room, which actually became an even greater trigger for her to binge and purge.
She was allowed two binge-and-purge episodes each week, with the days and times already scheduled in advance. There were many other instructions as well.
After countless arguments and tensions with her parents, which created additional stress for everyone, and after several attempts to leave the house in the middle of the night, D eventually took what felt like a huge step for her.
She told her parents that they needed to leave that particular treatment centre and find somewhere else where she could receive the help she needed.
“My parents initially decided to take me to a treatment centre to deal with it during my second year of high school. They practically had to drag me there…
From the very first session, I felt terrified of and disgusted by my therapist. I felt even more pressured than I had before…”
How anorexia was affecting her life
D felt that nobody understood her. She felt alone and isolated. That was when she began listening to the voice of anorexia, which she named Ed.
D frequently lied in order to protect Ed. She reached her lowest weight. Although she was not at a weight that required hospitalisation, it was still extremely low. Her hair was falling out, she experienced brain fog as a result of starvation, and she was severely malnourished. She frequently felt dizzy and experienced fainting episodes.
Despite being at such a low weight, she still described herself as “fat,” reflecting significant body-image distortion. She became increasingly isolated and avoided going out to eat because she felt ashamed.
Food was divided into categories of either “good” or “bad.” Bingeing and purging occurred every day, often two or three times a day.
The blood vessels in her eye burst because of the pressure involved in inducing vomiting. At that point, she felt that she had completely lost control. She was also weighing herself very frequently, and the number on the scales affected her mood, behaviour, and eating patterns.
Assessment and formulation
From our first appointment, I requested a medical evaluation, including blood tests and an ECG from a doctor such as anthropometric measurements, from a colleague of mine in her town.
Once I received the results, I was able to begin planning our nutritional strategy. Zoe was D’s therapist, and I knew that together we could support D from our respective professional roles.
I also arranged sessions with D’s parents and involved them in her recovery. They were educated about how to support her during meals, including appropriate portions, avoiding comments about how much or what she was eating, and avoiding comments about her body. The family was encouraged to eat the same food together rather than preparing separate meals for D.
As D was still attending school, we planned her meals around her nutritional needs and what she could tolerate at that stage. We created a list of safer foods and avoided keeping certain fear foods at home initially.
D was encouraged to have fear foods with a trusted “safe person” outside the home when she felt ready. My aim was to create a safer environment around food at home, without hidden or forbidden foods. We also established a “safe meal” to have after a purging episode. She took electrolytes following purging episodes.
I also asked D to throw away her scales. Ι did not want her constantly checking and reacting to a single number. I referred her to my colleague for body-composition monitoring, with the intention that the results would be sent to me without D knowing the numbers.
However, boxing created an additional challenge because, during competition season, members of the commission had to check her weight to determine her competition category. This meant that weight remained an unavoidable topic before competitions.
Eventually, D decided to stop competing. This became another important turning point in her recovery.
Our Work Together
Gaining D’s trust was not easy and required time, patience, effort, and consistency.
I also underwent fortnightly supervision throughout our work together, which provided valuable support and guidance. I offered sessions to her parents, and regular communication helped me develop a clearer understanding of her presentation.
It became apparent that there were discrepancies between what D was telling me and what her mother was reporting. I therefore maintained regular communication with both Zoe and D’s mother so that we could understand more fully what was happening.
One of the biggest challenges was D’s lying in order to protect Ed.
My primary focus was restoring and maintaining her nourishment. I asked D to keep a food diary so that we could identify patterns, triggers, and difficulties around eating and understand what was happening at different stages of her recovery.
We gradually worked towards building complete, balanced meals containing protein, carbohydrates, and fruit and/or vegetables. Initially, our focus was on establishing one meal a day.
Once we were confident that D could complete that meal without engaging in compensatory behaviours afterwards, we gradually moved on to the next meal. This allowed us to progress at a manageable pace while challenging the behaviours maintaining the eating disorder.
We also developed practical strategies to help D manage difficult situations, urges, and emotions without relying on eating-disorder behaviours. As her confidence increased, these strategies were incorporated into her daily life.
As trust developed, we gradually addressed her avoidance of certain foods and rigid rules around eating. We worked towards increasing flexibility and reducing fear around foods she had previously considered “unsafe” or “forbidden.”
We touched on the thoughts, emotions, and fears surrounding food, eating, weight, and body image, but I did not explore these areas in depth because this falls outside my professional scope of practice.
My role was primarily focused on nutritional rehabilitation and eating behaviours. When deeper emotional or psychological issues arose, I would acknowledge them and encourage D to explore them with Zoe. I also maintained communication with Zoe to ensure that our work remained consistent and complementary.
It was particularly helpful that Zoe and I kept our professional boundaries clear. My role was as the nutritionist, so my work with D focused on nutrition, food, eating behaviours, and fears around food.
If D began talking extensively about issues outside my role, I would remind her that these were things she should discuss with Zoe. Zoe did the same when something fell outside her area of work. I have great respect for Zoe and her profession and was careful not to intrude into her therapeutic space.
I believe these clear boundaries helped us work effectively as a team and gave D consistency about who she could turn to for different aspects of her recovery.
Recovery was not linear. There were periods of difficulty and setbacks, which we used as opportunities to understand triggers, review strategies, and continue moving forward.
Challenges and setbacks
The first year involved many setbacks.
During periods of relapse, D would restrict her food intake and deprive herself of energy. This increased her hunger and contributed to episodes of binge eating, followed by guilt, remorse, fear of weight gain, and purging.
We discussed many times that purging was not simply removing calories; it was also causing the loss of important electrolytes that the body needs, particularly for normal heart function. With Zoe’s support, D also began to recognise that purging had become a form of punishment.
One strategy we used was to establish boundaries around the urge to purge. We initially focused on delaying the response by setting a timer for a specific number of minutes. Gradually, the delay was increased. After she achieved this, we established a date when she would not use compensatory behaviours.
I found it particularly helpful to celebrate even the smallest wins and remind D of what she had already achieved. This gave her motivation to continue.
We also used practical exercises and role-play, such as, “Let’s say I am a person who insists that you eat this food—what would you do or say?” We created lists of the pros and cons of anorexia and regularly reflected on what D had achieved and what she still wanted to improve.
The most difficult period of our work, when Ed was particularly loud, was between April and July 2025, with the peak occurring in May during D’s national school examinations. These exams determined university admission, and D was highly motivated to succeed. She was a perfectionist, aimed very high, and had chosen a university with a very high entry score, which she ultimately achieved.
Her anxiety, perfectionism, need for control, and fear of failure created an environment in which Ed became much louder. At that point, I realised that I needed to take a step back, reduce expectations, and help her survive this particularly demanding period.
We therefore set very small and realistic goals, such as two nutritious meals and a snack each day and delaying the urge to purge for 20 minutes. Her sleep and bowel movements were also affected, and I recommended supplements to support her during this period.
There were also frequent interventions with her parents around behaviours at home. For example, we worked on not hiding food, removing the scales, and avoiding comments about D’s body, weight, or eating behaviour.
Much of the deeper work with her parents was carried out by Zoe, who provided them with additional support and guidance.
What changed
D’s recovery involved much more than physical changes or weight restoration.
Over time, she began to rebuild her relationship with food, regain her independence, and reconnect with parts of life that anorexia had restricted.
Relationship with food
D gradually began to view food as a source of nourishment and enjoyment rather than something to fear or control. She became able to enjoy a wider variety of foods, including previously feared foods, with much less guilt.
Flexibility around eating
Foods became less rigidly divided into “good” and “bad.” She became more comfortable with different meals and eating situations and learned that eating did not need to follow strict rules.
Reduction in restrictive and compensatory behaviours
D made progress in challenging restriction and binge–purge cycles. Gradually, she became more able to nourish herself without feeling compelled to compensate.
Social life
D became more able to go out, eat with others, and enjoy social occasions without the same level of fear or shame.
Emotional wellbeing
D gradually regained physical strength and improved her day-to-day wellbeing. She also became better able to recognise thoughts and fears associated with anorexia as part of the illness rather than automatically accepting them as the truth.
Relationships and support
With support from her therapists, family, and friends, D developed greater trust and openness. She became less isolated and more able to share her difficulties.
Study and independence
As anorexia became less central to her life, D was able to focus more on education and personal goals. Moving away for university represented an important step towards independence.
Self-compassion and quality of life
D gradually became more accepting of herself and more able to recognise that her worth was not determined by her weight or appearance. She began reclaiming experiences she had previously missed, including enjoying food and making memories with people she loved.
Greater independence from Ed
One of the most meaningful changes was D’s changing relationship with Ed. Rather than allowing this voice to dictate her choices, she gradually learned to challenge it and make decisions based on her own needs and values.
“Asking for help is a huge step, even if, at first, you feel ashamed or worry that people will see you as “someone with problems.” Taking that first step can be incredibly difficult, but you deserve support, understanding, and the chance to recover. You do not have to face it alone.”
A pivotal moment: When things began to swift
In my opinion, the biggest turning point came approximately six months into our work together.
After noticing repeated discrepancies in communication between D, her mother, and Zoe, I took the initiative to arrange a session with all four of us. My aim was to confront Ed as a team and encourage D to listen to us. Αnd more importantly, to her own voice rather than allowing Ed to control her.
We wanted her to feel accepted, supported, and safe enough to be honest. We made it clear that we recognised when she was lying, communicated openly as a therapeutic team, and genuinely cared about her.
During that session, D burst into tears and began to open up. She acknowledged her difficulties, admitted that she had been lying, and allowed herself to become more vulnerable. For me, this was a significant breakthrough and marked a turning point in our therapeutic relationship.
Until then, most of her food diaries had appeared almost flawless. Everything seemed perfect. However, I do not believe in perfection, and I felt that this apparent perfection needed to be explored rather than simply accepted.
Following that session, D gradually began to trust me more, confide in me, and communicate more openly. What mattered was that we maintained open communication, worked collaboratively, and continued providing consistent support.
That session gave me a renewed sense of hope. I felt that D was beginning to let us in and that we had a real opportunity to challenge Ed together and support her recovery.
During my anorexia, Ed and I were inseparable. He constantly told me what to do, and whenever I ate something extra or something different from what he expected, I was “punished”
Where is she now?
In October 2026, we completed our sessions. For the past year, D has been living in Crete, where she is studying.
She is now eating three main meals and two snacks each day. She is no longer afraid of food. She eats pasta and chips without fear and without initiating a binge-eating episode. She has not binged or purged for months. She has also completed her therapy sessions with Zoe, and I have seen tremendous progress.
When I first met D, I saw anger and rage, a young woman who was afraid to enjoy food and did not know how to nourish her body. She had a strong desire to become thinner and was doing whatever she could to achieve it.
Now I see a strong young woman who enjoys food and eats what she wants without rigid rules. She exercises because she wants to feel stronger and healthier, not to burn off calories. She is social, brave, and even shares her story with others.
I no longer worry about how I am going to eat, what I am going to eat, or why I am eating. I am free, and I am finally able to enjoy it.
The Role of Family Support
Family support became an important part of her recovery, although it wasn’t always perfect — and that was part of the process.
In the early stages, her family understandably made some mistakes. At times, they would hide foods they believed were “unsafe” or comment on the way she was eating, often with the intention of helping but without realising that these responses could unintentionally reinforce the eating disorder’s rules and anxieties.
Rather than seeing these moments as failures, we used them as opportunities to learn. Her family attended sessions, including sessions with Zoe, where we explored how they could respond in a way that supported recovery rather than the eating disorder.
They became more aware of the language they used, the reassurance they provided, and how their own understandable worries could sometimes influence her experience.
Over time, her family became a consistent source of practical and emotional support. They ate meals with her, encouraged her through difficult moments, spoke with me between sessions when they needed guidance, and remained present when things felt challenging.
The aim was never to create a “perfect” recovery environment or expect everyone to get everything right all of the time. Instead, we focused on sustainability and consistency — helping the family develop approaches that they could realistically maintain and that would support her long-term recovery.
There were still difficult days and setbacks, but the family learned how to navigate these together, gradually shifting from trying to protect her from every uncomfortable experience to helping her build the confidence and resilience to face them.
My Reflections as her nutritionist
Working with D taught me that my role was not simply to help her “eat more,” but to support her nutritional rehabilitation and gradually rebuild healthier and more flexible eating behaviours.
A key learning point was the importance of taking a gradual, structured approach. We used food diaries to identify patterns and difficulties, worked on one meal at a time, introduced more complete meals, challenged rigid food rules, and reintroduced foods D considered “forbidden.”
I also learned not to rely solely on what appeared in a food diary. At times, D’s records looked almost perfect, while communication with her mother and Zoe showed that she was still struggling. This taught me to look at the wider picture and maintain open communication within the therapeutic team.
It was also very helpful that Zoe and I maintained clear professional boundaries. I respected her profession and did not intrude into her therapeutic space, just as she respected mine. This allowed us to work collaboratively while ensuring that D received appropriate support for both her nutritional and psychological needs.
Most importantly, I learned that small behavioural changes can represent significant progress. Each meal completed without compensation, each feared food introduced, and each step towards independent eating helped D regain freedom from the eating disorder.
This case highlighted the importance of patience, consistency, collaboration, professional boundaries, and keeping the person—not the diagnosis—at the centre of the work.
Key takeaways
Recovery is not always linear. Progress may involve setbacks, challenges, and periods of uncertainty. These do not necessarily mean that recovery has failed; they can be part of the recovery process.
The client is more than their diagnosis. It is important to see the person beyond the eating disorder and recognise their identity, strengths, values, relationships, and individual needs.
Small behavioural changes can have a meaningful impact. Completing one meal without compensatory behaviours, introducing feared foods, or reducing reliance on the scales can help build confidence and support further progress.
The therapeutic relationship matters. Trust, patience, consistency, and a non-judgemental approach can create a safe environment in which clients feel able to be honest and engage more openly in recovery.
Multidisciplinary and medical support is essential in anorexia nervosa. Given the potential physical and psychological complications of anorexia, collaboration between relevant healthcare professionals is important to support nutritional rehabilitation, monitor medical safety, and address psychological needs. Clear communication within the team can help ensure that care remains coordinated and consistent.
Conclusion
D’s story is a powerful example of how recovery from anorexia nervosa can involve far more than nutritional rehabilitation alone.
When we first met, she was a 17-year-old girl whose life had become increasingly controlled by fear of food, rigid rules, calorie counting, restriction, over-exercising, bingeing and purging.
She struggled with a distorted perception of her body and found it difficult to recognise how unwell she had become. The voice she called Ed had become powerful, critical, and controlling, influencing the way she ate, exercised, and viewed herself.
Today, D’s relationship with food and with herself is profoundly different. She no longer counts calories or divides foods into “good” and “bad.” She can enjoy carbohydrates, sweets, takeaways, and foods she once feared without feeling that she needs to compensate afterwards.
She no longer binge-purges, and exercise has become something she chooses because she wants to feel strong and healthy, rather than something she has to do to “burn off” calories.
Most importantly, food is no longer at the centre of every decision she makes. She has learned to nourish herself, listen to her body, and participate in life without constantly negotiating with Ed.
Her recovery was not the result of one person or one intervention. It was a collaborative process involving D, her family, her therapist Zoe, and myself, with each of us contributing within our respective roles.
Zoe’s psychological work was an essential part of D’s recovery and complemented the nutritional work we did together.
D also had to do the hardest part herself: face her fears, challenge Ed, tolerate uncertainty, and repeatedly choose recovery even when the eating disorder was telling her not to. Her family learned alongside her, making mistakes, adapting, and becoming a consistent source of support.
For me, this case has reinforced that recovery does not require perfection. It requires patience, consistency, flexibility, and a willingness to keep going when things do not go according to plan.
My aim throughout our work was never to create a perfect patient, a perfect family, or a perfect meal plan. It was to help D develop sustainable skills that she could carry with her beyond our sessions and into adult life.
D, I could not be prouder of the young woman you have become. Watching you grow from a frightened young girl who was afraid of food into a strong, independent young woman who can enjoy food, exercise, friendships, university life, and all the experiences that come with it has been an incredible privilege.
You have worked tremendously hard. You have faced some incredibly difficult moments, and you kept choosing yourself. You are no longer living your life according to Ed’s rules. You are making your own choices.
You are free.
