Eating Disorders and the Therapeutic Relationship

Eating disorders, the most lethal of all the mental health disorders, kill and maim 6 to 13% of their victims, 87% of whom are children under the age of 20. “Best practice” treatment strategies for patients with anorexia nervosa, bulimia nervosa, and binge eating disorder all too frequently fall short of achieving timely and sustainable recovery outcomes. Beyond eating lifestyle dysfunction, eating disorders represent impairment of the patient’s Self, as seen in the loss of self-trust, self-control, self-regulation, self-care, and emotional resiliency, so necessary in coping with adversity and engaging in confidence-building life opportunities.

The development and recovery of the re-integrated Self in eating disorder treatment is best facilitated through the mindful and versatile use of the therapist’s self within a quality therapeutic relationship, the inclusion of parents and families in the treatment process where appropriate, and an appreciation of the fact that within the context of clinical treatment, healing changes in the patient’s behaviors and attitudes represent healing changes in the patient’s brain.

Eating Disorders and the Loss of Self

From infancy to adulthood, self-development occurs primarily within the context of human relationships, be they personal, familial, or professional. The loss of the connection with the eating disordered individual’s authentic Self becomes apparent cognitively, emotionally, physiologically, neurologically, and socially, typically rendering victims resistant to accepting diagnosis and engaging in treatment. Losses of connection can be seen in:

  • A lack of neurobiological connectivity within brain domains and within the distributed connections between the cranial-based self and the embodied-self.
  • The loss of the patient’s healthy relationship with food.
  • The loss of connection to significant others due to social withdrawal.
  • Attachment dysfunctions in eating disordered individuals, which often exacerbate challenges in treatment engagement and continuity of care.
  • Experiencing disconnection from feelings and sensation; eating disordered individuals may not recognize eating disorder symptoms as signs of dysfunction, denying the existence of a problem.
  • Withdrawal from significant others that may result in parents speaking of their eating disordered children as “strangers.” Where weight and behaviors typically reside on the continuum of normal, eating disorders ironically surface all too rarely in physician’s offices during medical examinations and in laboratory tests. Nondisclosure of dysfunctional behaviors is typical in psychotherapy offices as well, in light of the patient’s fear of stigma, rejection, or having to face the reality of the need to recover.

Self re-integration, a pivotal predictor in the achievement of positive mental health (Siegel, 2006) and a benchmark of full eating disorder recovery, becomes enhanced by treatment modalities that facilitate connections between people, mind-brain-and-body systems, and brain domains.

Because eating disorders are principally disorders of connection, the healing energy within the success of any treatment methodology occurs within the context of the therapeutic relationship.

Parents and Families As Recovery Advocates

Eating disorders insinuate themselves into relationships between family members. As family system disorders, eating disorders show up everywhere within the context of daily living, side by side with significant others, at kitchen tables, in restaurants, in family bathrooms, at school, and in places of employment. Though generally not responsible for causing eating disorders, which originate in genetic and temperament susceptibilities, parents who participate in their child’s treatment and engage in psychoeducation enjoy the potential to promote disease prevention and/or recovery. Becoming knowledgeable about eating disorders, the complex nature of their treatment and recovery, and their own role in their child’s recovery (particularly when the child remains in outpatient care while residing at home), parents can become ‘most valuable players’ in their child’s treatment team.

Recovering patients, faced with the demands and challenges of eating healthfully throughout each day, average no more than 50 minutes per week in face-to-face contact with helping professionals. Educated parents can become helpful in filling this void. With the understanding that the nature of parental support offered will need to change to align with their child’s changing needs as they progress, family participation in therapy gives both patient and family a voice, and an ear, in expressing and listening to feelings and in resolving conflicts and problems. By reconnecting with their child and learning how to understand, coach, and support their loved one, parents enhance their child’s emotional development and self-care.

The bonding and trust that develops in family treatment greases the path for the patient’s eventual separation and individuation, increasing the child’s capacity for autonomy and healthy self-regulation. Family sessions also diminish the potential for manipulative “splitting” and/or confidentiality breaches that could otherwise jeopardize a multi-disciplinary team treatment process. If not part of the solution, family members risk becoming part of the problem.

The Patient/Therapist Relationship in Research

Because eating disorders are principally disorders of connection, the healing energy within the success of any treatment methodology occurs within the context of the therapeutic relationship. The trust that develops between therapist and patient within the treatment process ultimately re-ignites the patient’s trusting reconnection within their own exiled Self. The mindful therapeutic relationship ideally becomes the prototype for other healthful, quality relationships elsewhere in the patient’s life outside of the treatment system. Dr. Christopher Germer, in Mindfulness and Psychotherapy (Germer, 2005), considers mindfulness in therapeutic practice to be the pathway to establishing a healthy, healing treatment relationship. He speaks of the therapeutic relationship as “an intervention in itself” with empathy accounting for “as much, and probably more outcome variance than does the specific intervention.” He describes good therapeutic relationships as “the most potent of all the treatment interventions for healing within a mental health venue,” (Germer) providing the pathway out of an eating disorder.

According to Dr. Allan Schore, it is through the quality of the human relationship that “deficits in internal working models of the self and the world are gradually repaired” (Schore, 1996). Schore describes a phenomenon that exists between therapist and patient called “empathic resonance” (Schore & Schore, 2008), “which results in the patient’s right brain hemisphere becoming neurophysiologically altered in form and function in response to a mindful, quality connection to the functioning of the therapist’s right brain hemisphere. Right-brain to right-brain human attachments through mindful psychotherapeutic connectedness often result in the patient feeling ‘felt,’ creating a state of neural activation with coherence in the moment that has been shown to improve the patient’s capacity for self regulation” (Siegel, 2006).

A quality patient-therapist connection lays the foundation for the patient’s development of the Self, in addition to the foundation of a complete and lasting eating disorder recovery.


  1. Germer, C. K., Siegel, R .D., & Fulton, P. R. (2005). Mindfulness and psychotherapy. New York, NY: Guilford Press.
  2. National Eating Disorder Association. (n.d.). Retrieved from
  3. Schore, J. R. & Schore, A. N. (2008). Modern attachment theory: The central role of affect regulation in development and treatment. Clinical Social Work Journal, 36(1), 9-20. doi:
  4. Siegel, D. J. (2006). An interpersonal neurobiology approach to psychotherapy; Awareness, mirror neurons, and neural plasticity in the development of well-being. Psychiatric Annals, 36(4), 248-256. Retrieved from

© Copyright 2018 All rights reserved. Permission to publish granted by Abigail Natenshon, LCSW, MA

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