Last updated on May 27th, 2020
Psychotherapy that might help you or your child
There are a huge number of psychotherapy methods out there. It’s helpful for us parents to know a little about them, both so we can assess what’s being offered to our kids and so we can find something for ourselves.
In Chapter 12 of my book, which you can read here, I talk in detail about treatment for eating disorders and what the research shows works. I explain how individual psychotherapy is not a first line of treatment for anorexia in children and adolescents, and how (as in Family-Based Treatment (FBT or 'Maudsley') it may not be needed at all. However, it is often offered, and you will have to judge if that is appropriate or not, depending on the stage your child is at in treatment, whether it's offered as an adjunct to the main treatment. And if it's for yourself, you'll need something that suits you, and that might not be the first thing you're offered.
I’ll share what I know about some of the methods, and hope it helps you in your own search.
At the same time, be aware that even with a method that has been well researched, it really matters who the person is on the other side of the Kleenex box. One session, or a glance at their website, might be enough to test them out. My advice to you is to notice what’s going on for you during the session. Do you get a sense of being heard and supported? Of being held as an equal, with respect for your shared humanity? Do you feel calm and assurance and relief seeping back into your body? Are you more ready to give the best of yourself back home and do you feel generally energised? If so, you’ve struck gold.
If you’re assessing a therapist for your child, the same criteria apply, of course, but in addition, there is one non-negotiable: is your child eating? And I would add another one, which may be very hard to find: is the therapist willing to have parents on board? And just to be clear: for something as serious as an eating disorder, you should prioritise those treatments that research shows to be the most effective (those I describe in my book here), and only look to other treatments because the evidence-based approaches have not worked for your child, or are really not available (note that you can get Family-Based Treatment by video call/Skype). Mostly, you should think of psychotherapy for your child as an adjunct or a finale to the main show.
Psychotherapy might just make you a bit less miserable
I would really love you to get the support of a wonderful psychotherapist while you’re weathering the storms of your child’s anorexia, and if your child needs psychotherapy, I’d love her to get someone who can help her flourish. So I’m going to start with a warning so you keep your wits about you.
A number of therapists work with the model that we are deficient. Their outlook is illness, not flourishing. Their methods may make us less miserable but are not designed to lead us into a full life. These therapists can keep you coming week after week, for months or years. They see your ongoing difficulties as your failure, not theirs. Would you keep taking your car to a garage, week after week, if your car continued to gurgle and splutter?
So the quest is on for a psychotherapist who aims to make you well. Better than well – someone who can help you blossom, flourish, and enjoy life to the full.
Positive Psychology has nothing to do with ‘positive thinking’ (which gets right up my nose). Positive Psychology was the first big movement offering an alternative to the traditional therapy model that mental health is ‘merely being disorder free’. I quote this definition from Martin Seligman, a psychologist committed to scientifically proven results, and who developed Positive Psychology in a dramatic turnaround after years of being an expert on ‘learned helplessness’, i.e. depression. For him, mental health is not the absence of disorders, but rather ‘the presence of flourishing.’ (While he makes these arguments forcefully in ‘Flourishing’, his earlier book ‘Authentic Happiness’ contains most of the practical, scientifically validated methods for wellbeing.) From what I read, Positive Psychology is profoundly dedicated to the human spirit, and believes that we all come with strengths and values which we can build on to thrive. What’s not to like?
Nonviolent Communication (NVC)
The concept of strengths, values, and flourishing, is very much in tune, of course, with the intention behind Compassionate, or Nonviolent Communication (NVC). There are some fantastic certified NVC trainers out there, listed on the website of the Center for Nonviolent Communication. They are not necessarily psychologists, and NVC isn’t designed to be a psychotherapy, but these people may be exactly what you need. A while back I had a session with one of these trainers on what they call ‘core beliefs’. The efficiency of it was unbelievable, and puts your average therapy to shame. I didn’t need to waste time in details, to wallow into who did what and when. It was deep. It went to the heart of the issue. Since that session, the things that bugged me have vanished to the extent that I can’t remember exactly what they were. I have more space in my life for what matters to me.
Many certified NVC trainers specialise in mediation. If you and your partner are at war with each other, I should think that an NVC mediator would be a precious and effective resource.
Many of the tools I offer in this book are rooted in NVC. I wrote a short overview of NVC here and the entire Chapter 13 of my book, which you can read here, demonstrates principles of NVC in ways that relate directly to you and your child.
Acceptance and Commitment Therapy (ACT)
I’ve looked into Acceptance and Commitment Therapy (ACT) because of parents reporting that it has helped their child or themselves. The model seems very much in tune with everything I write about here: there’s mindfulness, there’s acceptance, there’s thoughts, feelings, values and action. You accept your thoughts and feelings rather than try and change them. I don’t know how the model is put in practice in a therapy session, but it’s worth noting that, unlike the majority of psychotherapies out there, they do seem to carry out research to validate what they do. The association’s website is a good starting point.
Christopher McCurry’s book ‘Parenting Your Anxious Child with Mindfulness and Acceptance: A Powerful New Approach to Overcoming Fear, Panic, and Worry Using Acceptance and Commitment Therapy’ is totally relevant to us as parents of a child with an eating disorder.
Likewise the book ‘The Reality Slap; How to find fulfilment when life hurts’ by Russ Harris.
Evidence-based CBT for eating disorders
There has been quite a lot of research (mostly on adults) of variants of CBT – variants that are specifically designed to treat eating disorders. CBT-E (Enhanced Cognitive Behaviour Therapy) is one of them.
It is mostly for adults but may suit some people in their late teens who have a good degree of self-awareness and have enough motivation to do personal work and eat what is required. With children and adolescents, family therapy for eating disorders should always be the first treatment to consider, because it is more likely to give the best outcomes. But CBT for eating disorders may be an alternative in families who are unable or unwilling to treat with a family-based approach like FBT, or where FBT is not working, and CBT (and other individual therapies) may be useful to complete aspects of recovery when a family-based approach has run its course.
I tell you lots you need to know about CBT for eating disorders in another post here.
Cognitive Behaviour Therapy (CBT)
Let's move on to the general form of CBT (not specialised for eating disorders). Most professional associations worldwide (including the UK's NICE) recommend CBT for a whole lot of mental health problems. People suffering from anxiety or depression, are most likely to be offered CBT as there's lots of research to back it up, and it's relatively easy for a health service to train staff in the approach.
If your child is offered CBT to treat an eating disorder, it's really important that this is not general CBT, but a form that has been specially developed for eating disorders (see above). There are big differences, and many CBT therapists don't realise it!
For people who are unacquainted with the process of noticing their thoughts and feelings, CBT is probably a good starting point, but then, ACT or DBT will do that too and may take you further.
Personally I worry that CBT is a little lacking on the emotional side, and I worry that human-to-human kindness might not feature. I don’t see CBT as geared to empathy, and I don’t think it goes deep. I don’t like how CBT requires you to challenge your thoughts with the aim of changing them. The fact that much of it is done through worksheets makes me very prickly. To be fair, good CBT therapy involves experiments to change behaviours, so you change through experience, not just talk. Still, the way I usually come across CBT, it doesn’t seem to involve the whole brain, only the verbal, rational part, and frankly, most of us wouldn’t need therapy if our rational brains were in charge. I also worry that because CBT follows a simple process, health service staff who have had very little psychological training are allowed to use it. These people may not have the wider skills, knowledge and empathy to support someone who is suffering.
I think this is what happened when my daughter was given CBT at age 11 (thankfully, only as an adjunct to the rest of the treatment she was getting). She experienced it as a way of criticising or dismissing her thoughts and feelings. There didn’t seem to be an acknowledgement of something as fundamental as, say, her need for safety. On some occasions, when she was in terrible distress, she would weep that there was nothing she could do, no help to be had, because if she expressed her feelings to her CBT therapist, all she would get is another worksheet to fill in.
CBT might be wonderful for you or your child. Some parents swear by it. Some have found therapists who don't rely on worksheets and whose methods are wonderfully appropriate even to a young child.
Dialectical Behaviour Therapy (DBT)
DBT is frequently be on offer in the world of eating disorders. It was developed to help those suffering from Borderline Personality Disorder (BPD), which shares many symptoms with anorexia[vi]. At first glance, it takes CBT’s strengths and expands into areas I find helpful, such as distress tolerance, emotion regulation, acceptance and mindfulness. I don’t much about it, but what I’ve seen fits nicely with the concepts I write about in this book. There are many resources on the internet to teach yourself both ACT and DBT. If I needed psychological support tomorrow, I’d be very happy to search for a therapist in either of those approaches.
"The DBT was not seen as a cure for my daughter’s binge-purge anorexia; just as an extra support to help her manage her anxiety. It really helped her."
But what about your child? I believe there’s no evidence that DBT is effective in the treatment of anorexia, but there is some evidence it may help with bulimia or binge-eating disorder.
I want to flag up Bon Dobbs’s s website and books as they seem to be excellent resources for people supporting a loved one suffering from Borderline Personality Disorder. The tools he offers have many similarities with those in this book, and you may relate to the symptoms, explanations and examples he provides.
Emotion-focused family therapy (EFFT)
Emotion-focused therapy is committed to the position that parents don't cause eating disorders. It helps parents help their child to eat and to support them in the next phases of recovery. It might be offered as an adjunct to family therapy (such as FBT). It coaches parents to understand their child's emotional reactions and to respond to them usefully. One parent wrote "The model assumes parents can be effective in caring for their children and assumes that when they are not…it is not the fault of the parents or some abstract "dysfunction" in the family but rather…that the parents' efficacy can be strengthened with particular support and skills." You can read parents' positive experiences of emotion-focused therapy here. If you have lots of time and go here you will find strong negative opinions, mostly from UK parents who have not personally experienced the approach, and experiences from Canadian parents who have. To summarise, the Canadians were mostly negative about a short introductory session in November 2013, but when they attended a two-day course in February 2014 they had high praise for it. I am not aware of any major piece of research on this approach (there's a 2009 case study here and there may be more).
I love the EFFT videos that coach parents in responses to their child's anxious questions. See for instance:
Adele La France explaining how EFFT works for eating disorders, along with some emotion coaching:
Natasha Files gives emotion coaching in mentalhealthfoundations.ca/parent-coaching
More coaching from Natasha Files on specific questions:
They're very much in line with what you'll find in my book, except that I find it helpful to make my validation more interactive, in the form of guesses. Including question marks, in my view, invites our child to express themselves and makes it less likely that we will receive an angry, 'Don't be so patronising! You don't know how I feel.'
Compassion-focused therapy (CFT)
I like what I've heard from Dr Paul Gilbert, the creator of compassion-focused therapy. I like the element of kindness, compassion, and I believe the approach taps into inner strengths and core values. I very much like his presentations on the internet, and they have helped me clarify how I myself explain to audiences the role of compassion.
Whether compassion-focused therapy can treat eating disorders is much more tentative. When I asked Dr Gilbert in 2014 he referred me to two studies. First there's Gale, Gilbert et al (2014), which concludes, from questionnaires on 99 eating disorders sufferers, that there were improvements with 73% of those with bulimia , 21% of people with anorexia nervosa and 30% of people with atypical eating disorders. Next, there's Kelly and Carter (2015), a randomised controlled trial on 41 people with binge-eating disorder, which "offers preliminary support for the useful of compassion-focused therapy".
In the UK, when CBT doesn’t fix you, you tend to get access to a slower form of therapy rooted in psychoanalysis. There are many variants, and the method is usually labelled ‘psychodynamic’. Worryingly, a clinician can decide that your child needs psychodynamic psychotherapy (possibly mixed with play therapy or some other eclectic combination), even though it is not recommended as treatment for anorexia. The health service is a work in progress.
The roots of psychodynamic therapy are in psychoanalysis (often referred to simply as ‘analysis’), which rests on Freud’s theories of the unconscious. If you're being offered psychodynamic therapy for yourself, I suggest you have a real good chat with the therapist about how long it's going to take before you feel better, what the mechanism of healing is, and what is the research to show the approach is effective.
I can’t drum up the enthusiasm to research this for you. I’m not the most objective person, having seen a relative of mine consult a top Jungian analyst for years and still consistently behave like an arse. I also had a brush with a ‘Let’s examine your past’ therapist who seemed utterly disconnected from any of the attributes that make us glad to be human. I’m being totally unscientific, I know, so now I’ve heavily influenced you, please go out with an open mind and make up your own evaluations.
Adolescent-focused therapy (AFT)
There is evidence for adolescent-focused being roughly on a par with CBT for eating disorders. In other words, it shouldn't be your first choice when you start treating your child (at least, according a the most up to date review of the research, forming the basis of England's NICE guidelines). But it could be useful if a family-based approach isn't suitable for you, or hasn't been working. It could also be useful for after you've gone through the family-based therapy steps.
I explain it in some detail in another post here.
Eye Movement Desensitisation and Reprocessing (EMDR)
EMDR[vii] is one of the main validated methods for the treatment of post-traumatic stress disorder (PTSD), and I say more about that here. It is recommended by professional bodies worldwide, including the World Health Organization[viii]. I mention this because you will come across people in the health service who mistakenly lump EMDR with un-validated, ‘alternative’ therapies, and refuse to even talk about it. In the UK, our National Institute for Excellence (NICE) isn’t up to date, in my opinion, as it should be recommending EMDR for a quite a few other issues than PTSD. In Scotland, it’s been a policy of the educational department to train a huge number of educational psychologists in EMDR, and they seem to use it on a range of problems.
EMDR isn’t a validated treatment for eating disorders, let me be clear[ix]. But it might have value, at some stage, as an adjunct. It might be worth a try if your child’s eating disorder was triggered by a known traumatic event. It might be worth a try, ahead of mealtimes, to reduce anxiety. Given that so many of our children begin to restrict after a bullying incident, to me it makes sense to do EMDR around that, especially if they fear returning to the same situation. At the same time, keep your focus on nutritional restoration.
EMDR seems to me like a rare beast in the gamut of therapies: it’s mainstream, and yet it’s not a talking therapy. There is talking, yes, but there’s no need for detail, which is an advantage if people have disturbing memories or shame. What the therapist is interested in is the emotions attached to what you tell yourself. What do you believe about yourself, as a result of whatever happened to you (or to someone else)? For instance, ‘I am not safe’, ‘I am not good enough’, ‘I can’t trust people’, ‘I should have behaved differently’, ‘I'm responsible’, ‘I'm helpless’. Your beliefs – around safety, responsibility, choice, self-esteem – may have made sense and served you well a while back, but may now be standing in your way. The trick is to create new connections in your brain that serve you better.
The healing (reprocessing) doesn’t use the rational brain, it’s done at the level of the body. The therapist alternatively taps your knees or shoulders, or you follow the left-right-left-right movement of a pointer with your eyes. The theory is that the bilateral stimulation, somehow, enables the brain to create new neural pathways (similar to rapid eye movement (REM) sleep). The mechanism of how it works is not yet understood, but there have been plenty of reliable studies, including brain imaging work, to validate the method. And, just like the NVC session I had, it works fast and efficiently, gliding from one issue to another so that the root issues are quickly uncovered.
In short, it’s a gentle, easy, and cost-effective type of therapy to attend, and it heals at a deep level. When you leave, you’re really OK (checking for this is part of the method). It’s not like CBT where the work of ‘correcting’ your thoughts is homework for the rest of our life. By the end of an EMDR session, when you bring your mind back to the issues that previously distressed you, including fears about the future, you have no stress reactions at all. You will have replaced a belief that has stopped serving you well with one that is in line with your present values and your sense of self-worth. That makes the approach deeply empowering.
At the moment my daughter is enjoying a totally normal life, but if in later years we find that she has some traumatic memories of her anorexia days, EMDR would be my therapy of choice. Or EFT (see below).
It would also be my recommendation to you, the parent, if you feel bruised and battered and shocked. Because I once experienced the benefits of EMDR, I would have chosen this approach for myself if I could have found a well-recommended therapist in my area. On the Around the Dinner Table forum, some parents who were suffering from PTSD after years of caring for their child, report that they have benefited from EMDR.
Emotional Freedom Technique (EFT, or 'tapping')
I find Emotional Freedom Technique (EFT) similar to EMDR. It might be wonderful for you, and if your child is willing to use it before or during a meal, it might help reduce fear levels.
Most of the comments I've made about EMDR apply to EFT as well. Note it has the same initials as Emotion-Focused Therapy (described earlier) but it's not the same thing. Like EMDR, it might look a bit strange and we don't have any solid understanding of how it works, but there is lots of evidence that it works with many problems where stress or emotions are involved, including post-traumatic stress disorder, depression and anxiety. There is also evidence that various biological markers are altered with EFT.
You can look up research, including numerous randomized controlled trails, and several meta-analyses, on www.energypsych.org/research. There's another very long list of research on www.eftuniverse.com. EFT is currently under review by NREPP (national registry of evidence-based programs and practices) in the US and by NICE (national institute for health and care excellence) in the UK.
For myself, in spite of all the protestations of my sceptical mind, I have benefited month after month from EFT consultations. It dealt with my distress whenever things were hard with my daughter, and it's contributed to more growth and happiness because any hangups from the past go once and for all once they're addressed. If you're looking for a personal recommendation, the certified advanced practitioner I've been consulting is Odet Beauvoisin. Geography is no obstacle as she does phone or Skype. I like how well qualified and precise she is and I love her human qualities.
I say more about EFT for post-traumatic stress disorder here.
Cognitive Remediation Therapy (CRT)
You may have heard about Cognitive Remediation as a possible treatment for anorexia. A few small studies have shown signs of promise. It would be more appropriate, for now, to treat it as an adjunct to treatment.
The method is designed to reduce the mental rigidity, or ‘black and white thinking’, which anorexia creates. To give you an example, people are presented with a sheet of words like ‘red’, ‘blue’, or green’, each printed in a colour that doesn’t match the meaning of the word. If the word ‘red’, is printed in blue, you have to say ‘blue’.
When my daughter was at a good weight but still ‘stuck’ with anorexic thoughts and behaviours, the hospital tried Cognitive Remediation Therapy (CRT) after adapting the materials to suit my child’s age and situation. During that time, she continued her trend of reducing the options on her diet plan and she lost weight. I don’t think there was a causal link: my theory is that the therapy had no effect on her whatsoever, though she did get very skilled at calling black ‘white’ and white ‘black’.
By the time you read this, neuroscience may have dramatically moved on and perhaps there will be methods that make no sense to us parents but that really work. Meanwhile, I’d like to offer you a nugget of hope: my daughter fully recovered her mental flexibility and emotional intelligence as we took over nutrition and exposure to fearful situations at home. And in this case I do see a causal link.
Repetitive transcranial magnetic stimulation (rTMS)
This is not a talking psychotherapy, but action directly on the brain. There is promising research going on right now with adults chronically affected by anorexia. See for instance this account from Kings' College London. As I edit this page at the end of 2019, rTMS seems to still be rather experimental, and not widely available.
[vii] EMDR: Eye Movement Desensitisation and Reprocessing, founder Francine Shapiro. You can find a certified EMDR therapist through: www.emdria.org (international association); emdrassociation.org.uk (UK); emdr-europe.org (which includes EMDR therapists specialised in Children and Adolescents).
[viii] The World Health Organization recommends EMDR in ‘Guidelines for the management of conditions that are specifically related to stress.’ (2013, in press): “Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed desciptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.”
In the UK, NICE (National Institute for Clinical Excellence) recommends EMDR treatment for Post-Traumatic Stress Disorder (PTSD): http://www.nice.org.uk/nicemedia/pdf/CG026publicinfo.pdf
[ix] Specific protocols for EMDR for eating disorders are being developed by devoted clinicians, but have not yet been adequately tested in controlled trials.