Emotion-Focused Family Therapy for Eating Disorders

Family working on Emotion-Focused Family Therapy

Contributor: Timberline Knolls Team at Timberline Knolls Residential Treatment Center

Emotion and Its Avoidance

Although there are numerous factors that contribute to the development and maintenance of an eating disorder, it can be said that eating disorders, as with most maladaptive behavior, develop out of an attempt to manage difficult emotions. This exists in the avoidance and tight and restrictive symptomatology of anorexia nervosa, as well as in the chaos and indulgence often present in disorders that rely on binging and purging cycles.

Emotion-Focused Therapy (EFT)

Individuals with eating disorders are often identified as having poor emotion regulation skills and little ability to identify what they are feeling [1]. Each of these, in addition to the ability to respond to others in healthy and adaptive ways, is viewed as important in the mastery of one’s emotional experience, which is the ultimate aim of emotion-focused therapy (EFT) [2].

Through the development of empathy and through what is termed “chair work,” a clinician will assist someone who is struggling with an eating disorder in processing their emotions at the moment. This is done by promoting recognition and acceptance of uncomfortable emotions, encouraging self-soothing, and replacing destructive emotions with healthy alternatives.

The “chair work” discussed previously is a modern-day EFT adaptation of the Gestalt principle that “unfinished business” or significant unmet needs do not fully recede from awareness [3]. This technique is utilized by employing an actual empty chair in the therapeutic space to represent others in the clients’ lives, or perhaps even other parts of themselves. In the process of treatment, they might physically move chairs to switch between parts or to assume others’ perspective in order to facilitate healing conversations.

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In using EFT with clients who are suffering from eating disorders, three specific tasks are outlined to address:

  1. the individual’s inner self-critic
  2. unfinished business in significant relationships
  3. self-interruption of emotion (avoidance) [2].

In this way, a person who is struggling with an eating disorder might be able to get in touch with the toxic voice inside themselves, expose its motives, and render it unnecessary in light of their newfound emotion regulation skills.

Why Include Family in Treatment?

As with treatment for most addictions, without attention to family processes, the progress that has been made with the individual often falters upon their return to the original environment that initially enabled their maladaptive patterns. Treatment for eating disorders that is inclusive of family members is essential for long-term recovery.

The following are some additional compelling reasons to include family when considering the eating disorder population:

  1. The emotional “style” of the family is contagious.
  2. Family members are often over-involved already.
  3. They are often unhelpful and ineffective as is and serve to only further the problematic symptoms [2].

Emotion-Focused Family Therapy (EFFT)

Couple enjoying sunset and discussing Eating Disorders in Transgender Community

The family therapy application of emotion-focused therapy for eating disorders is a more recent development, but it has been successful in increasing parents’ attitudes regarding their role in treatment in both a two-day intervention and an eight-week model.

According to Dolhanty and Lafrance (2019), there are four fundamental aspects when utilizing emotion-focused family therapy (EFFT) in the treatment of eating disorders [2]:

Recovery Coaching

In this first stage, parents and caregivers are taught practical ways to support the behavioral recovery of someone who is suffering from an eating disorder. This is done through specific meal-support strategies and instruction on how to encourage the interruption of their loved one’s disordered behavior through attention to word choice, tone of voice, and body language.

Emotion Coaching

Through basic education on emotion, as well as the function it serves in perpetuating their loved one’s illness, caregivers are taught the actions needed to manage their own emotional needs more effectively so that they can model appropriate behaviors for their child.

The five tasks of EFFT in this stage are (a) attend, (b) label, (c) validate, (d) identify and meet the need, and (e) problem solve. Through this model, a parent will be able to recognize emotions in their child, provide language to describe it, and thereby express understanding for why the emotion might be surfacing.

It also encourages the parent to offer an antidote for their child’s suffering, be it a hug or another type of physical or emotional comfort. The answer to the problem may have become clear in the previous four tasks, or it may require further conversation to empower the loved one to make a proactive choice to solve the problems that they can.

Relationship Repair

Relationship repair is an important process that is required when relationships with caregivers are distant or hostile, or when one party blames themselves for the maintenance of the illness. In processing through this stage in treatment, all members are able to release themselves from the grips of maladaptive self-blame and move forward together.

Working Through Blocks

Woman sad and holding lightsJust as the individual in treatment likely needs to focus on their aversion toward emotions, the caregiver’s avoidance of their own emotions must be addressed before effective family treatment can be implemented.

Blocks to treatment can look like a caregiver’s refusal to become involved, denial of the issue, overcontrol, criticism, or enabling behaviors. All are regarded as efforts to deny their own strong negative effect, namely fear, shame, helplessness, hopelessness, and resentment.

These fears may be dispelled through a caregiver’s own “chair work,” and in coming to terms with their own unmet needs and unresolved emotional pain.

Emotion-focused family therapy for eating disorders highlights a number of important issues when considering including family in treatment. The most important takeaway, however, is that treatment should be highly individualized and suited to a person’s specific needs, often including treatment for the whole family.


Sources:

[1] Brockmeyer, T., Holtforth, M. G., Bents, H., Herzog, W., & Friederich, H.-C. (2013). Lower body weight is associated with less negative emotions in sad autobiographical memories of patients with anorexia nervosa. Psychiatry Research, 210, 548–552. http://dx.doi.org/10.1016/j.psychres.2013.06.024
[2] Dolhanty, J., & Lafrance, A. (2019). Emotion-focused family therapy for eating disorders. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy. (pp. 403–423). Washington, DC: American Psychological Association. https://doi-org.proxy.stetson.edu:2443/10.1037/0000112-018
[3] Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Empty chair work for unfinished interpersonal issues. In Learning emotion-focused therapy: The process-experiential approach to change. (pp. 243–265). Washington, DC: American Psychological Association. https://doi-org.proxy.stetson.edu:2443/10.1037/10725-012


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At Timberline Knolls Residential Treatment Center outside of Chicago, Illinois, we provide specialized care for women and adolescent girls who are living with eating disorders, substance use disorders, and various mental health concerns. Our residential treatment and partial hospitalization programming (PHP) help our residents achieve lifelong recovery by combining clinically excellent treatment with spiritual and emotional growth. We provide care that is holistic, personalized, and nurturing, empowering women to be active participants in their wellness journeys.


The opinions and views of our guest contributors are shared to provide a broad perspective of eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published on February 26, 2019.
Reviewed & Approved on February 26, 2019, by Jacquelyn Ekern, MS, LPC

Published on EatingDisorderHope.com

About Baxter Ekern

Baxter is the Vice President of Ekern Enterprises, Inc. He is responsible for the operations of Eating Disorder Hope and ensuring that the website is functioning smoothly.