Eating disorders: understand where psychotherapists are coming from

Many psychotherapists’ training places great importance in finding the ‘underlying causes’ of patients’ problems. If their approach is relational or psychodynamic (founded on psychoanalysis), their model is that in order to get better, the patient needs insight: ‘What caused my problem?’ And if you ignore causes, even causes from your earliest childhood, your problems will spill out in other domains.

For a clinical psychologist who hasn’t specialised in eating disorders, it is counter-intuitive to ignore early childhood or family dynamics. Surely, the not-eating, the over-eating or the purging are serving some kind of need? For instance, once you have anorexia, not eating can make you miss school, separate from your parents and peers, delay puberty, and so on. Psychologists are trained to wonder about unconscious motivations.

It is tempting for a psychologist to confuse the event that triggered anorexia with the cause. My daughter’s anorexia began with her restricting her sweet intake after some close friends turned against her and called her ‘fat’. It is easy to jump to the conclusion that bullying was the cause of her anorexia. She was quite clear that by changing her body shape from average to ultra-thin, she was protecting herself from any further abuse. She was aware of her thoughts that, as long as she was thinner than anyone else, she was safe. She even used the expression ‘I shrank back’ when recalling the shock of the name-calling incident – isn’t that a beauty if you’re into symbolism? I would have loved it if a skilled therapist had been able to do something with all this awareness, beyond appealing to her rational thinking, because perhaps it would have removed an obstacle to her recovery. Perhaps. But I don’t believe bullying was anything but a precipitating factor, a trigger. If it hadn’t been that, it would have been something else later on.

In my book I explain how 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.

Psychotherapists who don't specialise in eating disorders will also find it very worrying that parents should be 'in charge' of so many aspects of their child's life. To them, an adolescent needs to move towards autonomy. A young adult at university needs to be independent. I wonder if they would think that way if the person had cancer. Would they think it unhealthy that the parents get involved? When I speak to therapists who don't know much about eating disorders, I tell them, first of all, that the illness brings the emotional age right down. And then, I explain that eating disorders are not like, say, depression or anxiety, where you would expect a young person to take charge of their own therapy without mum or dad sticking their nose in. People with eating disorders need a lot of help. They cannot beat the illness by themselves. And with anorexia, there is the massive problem of anosognosia: when people do not think they're ill, or don't believe they're that ill.