Traditional care for eating disorders often centres around weight and calories. Recovery programs continue to focus on altering a young person’s calorie intake and, consequently, their BMI. Recovery is measured by weight and numbers, rather than well-being.
Yet, research shows us that eating disorders are not only about body weight, shape, and eating behaviours. Instead, psychological and social factors, such as cognitive traits and interpersonal difficulties, play a central role in the development and maintenance of the disorder. When these are overlooked, ‘recovery’ is only superficial, and young people may find themselves in cycles of recovery and relapse.
As eating disorders endure and co-occurring disorders develop, they become more complicated to treat. Some young people may develop severe and enduring eating disorders.
In this blog, we explain how lasting recovery requires addressing past traumas, interpersonal difficulties, and other underlying experiences that maintain eating disorder symptoms. We outline some of the effective treatment modalities available, and question why so many recovery programs still focus on weight and numbers.
How Important Are Interpersonal Difficulties in the Development and Maintenance of Eating Disorders?
As our knowledge about eating disorders continues to expand, interpersonal difficulties have become an increasingly central theme. Different studies have shed light on the bidirectional relationship between disordered eating behaviours, interpersonal difficulties, and character traits that make interpersonal challenges more likely.
Interpersonal Difficulties and Anorexia Nervosa
A 2018 study found that around two-thirds of people who had experienced anorexia nervosa recalled having social difficulties before its onset. They also recognised that these difficulties had played a role in its development. In the same group, 90% said that anorexia had impacted their relationships in a negative way.
Research has also connected certain personality traits to anorexia nervosa. These include a fear of negative evaluation by others, feelings of inferiority, loneliness and social anxiety. These traits mean that young people may find it more difficult to form close friendships, take part in social activities, and have broad social networks. Social isolation is common among young people with anorexia and often intensifies after the onset of the condition.
With limited social networks and social support, young people may place increasing time and focus on their eating habits. Social isolation can make it hard to maintain a broader perspective and value different aspects of everyday life, such as friendships and hobbies. This allows disordered eating thoughts to increasingly dominate their lives.
Interpersonal Challenges and Binge Eating
Interpersonal difficulties are also important in the development and maintenance of binge eating disorder and bulimia nervosa. Binge-eating or out-of-control eating episodes are often a response to experiences of emotional distress, especially when a young person is unable to use other coping mechanisms. These distressing experiences are frequently triggered by interpersonal problems.
Research has found that interpersonal difficulties are significantly linked to binge eating episodes and mediated by distressing emotions.
Addressing Interpersonal Difficulties in Eating Disorder Recovery
Addressing interpersonal difficulties should be a central part of eating disorder treatment and recovery. If left unaddressed, relationship difficulties, loneliness and social isolation may continue to drive disordered eating behaviours, preventing full recovery. Even if young people’s disordered eating behaviours become fewer, interpersonal challenges may cause them to restart at a later date, leading to relapse and further distress.
While many eating disorder treatment approaches still minimise or overlook interpersonal relationships, some newer modalities give them more focus.
Enhanced Cognitive Behavioural Therapy
The broad version of CBT-e (enhanced cognitive behavioural therapy) identifies interpersonal difficulties as a factor that may underpin disordered eating behaviours. It includes a module that addresses these challenges, and clinicians may choose to include it in each individual’s treatment program.
However, despite the prevalence of interpersonal challenges among young people with eating disorders, the focused form of CBT-e, which only addresses eating disorder pathology, is still the go-to CBT treatment.
The Maudsley Model of Anorexia Nervosa Treatment for Adolescents and Young Adults (MANTRa)
MANTRa is a treatment approach that centres around interpersonal difficulties and cognitive traits. Based on the cognitive-interpersonal maintenance model of anorexia nervosa, MANTRa assumes that shape and weight concerns are not the root cause of eating disorders, but symptoms of underlying psychological distress. It holds that certain cognitive traits and interpersonal difficulties make young people more vulnerable to developing eating disorders and help sustain symptoms.
In MANTRA sessions, young people learn coping mechanisms that promote growth and change. This includes addressing interpersonal difficulties, practising new thinking styles, and developing a positive self-concept.
Radically-Open Dialectical Behavioural Therapy for Anorexia
Radically open dialectical behavioural therapy is a type of DBT that’s designed for mental health disorders associated with over-control. Excessive self-control may cause young people to be hypervigilant and anxious in relationships, hiding their emotions and closing themselves off. This can contribute to the social isolation often seen in anorexia nervosa.
RO-DBT addresses over-control by promoting openness, flexibility, and connection, supporting young people in expressing their emotions to others and embracing intimacy, rather than fearing it.
Interpersonal Therapy, Dialectical Behavioural Therapy, and Out-of-Control Eating
Interpersonal therapy and dialectical behavioural therapy are two evidence-based treatment modalities for binge eating disorder and bulimia nervosa. They both focus on or include interpersonal challenges. Interpersonal difficulties is one of four core skills modules in dialectical-behavioural therapy, while interpersonal therapy solely addresses improving social functioning.
Improving young people’s social relations helps reduce the stress of interpersonal adversity that can exacerbate binge eating symptoms. It also helps young people to grow in self-esteem and develop support systems, becoming less reliant on disordered eating as a coping mechanism.
Interpersonal Issues and the Therapeutic Relationship
One of the reasons that addressing interpersonal issues early on in eating disorder treatment is so important is that it impacts the relationship between a therapist and a young person. Interpersonal challenges like fear of negative evaluation and social anxiety may limit the way a young person engages with a therapist, preventing the development of a close and trusting bond.
This can impact the effectiveness of all parts of the therapeutic process. Research suggests that, when not adequately addressed, interpersonal difficulties at the start of treatment can have a detrimental impact on treatment outcome.
Why Do We Continue to Focus on Numbers?
Despite clear evidence of the importance of interpersonal difficulties in maintaining eating disorders – and the necessity of addressing them in treatment recovery – many eating disorder recovery programs continue to focus on weight and numbers.
There are a few reasons why this might happen. Some eating disorder programs may be based on older ideas about the causes and nature of eating disorders, which we now know are untrue or, at least, don’t paint the full picture. This might cause programs to focus on eating behaviours and body shape concerns and overlook the root causes.
Another reason has to do with treatment availability, resources, and insurance. By focusing on weight and numbers as the definition of eating disorders, it’s easier for treatment and insurance providers to classify only a small proportion of people as ‘ill enough for treatment’. Insurance providers can deny treatment coverage to young people depending on their weight and BMI, and stop provisions when significant changes in weight are observed.
On the other hand, when we move away from the idea that eating disorders are only about body shape and weight, we accept that many more young people require support, regardless of the body they live in. Sadly, this acknowledgement may be resisted by treatment provision with limited resources and insurance providers that seek to maximise profits.
Trauma-Focused Eating Disorder Treatment at The Wave
At The Wave Clinic, we offer a trauma-focused approach to eating disorder care that addresses the thought patterns, emotions, and experiences that underpin disordered eating behaviours. We emphasise the fundamental role of interpersonal relationships in maintaining eating disorders. We prioritise interpersonal skills, building connections, and family involvement in the treatment process.
The majority of young people with eating disorders have experienced at least one form of childhood trauma. These experiences impact their relationships, trust in others, vigilance, emotional processing, and perceptions of threat. Each of these domains can influence disordered eating behaviours.
We address experiences of trauma from the start of the treatment process, promoting whole-person recovery and preventing relapse.
Some of our treatment modalities for eating disorders include:
- Trauma therapy, such as cognitive-processing therapy
- Enhanced cognitive-behavioural therapy (CBT-e)
- Radically open dialectical behavioural therapy (RO-DBT)
- Dialectical behavioural therapy
- Interpersonal therapy
- The Maudsley model of anorexia nervosa treatment for adolescents and young adults (MANTRa)
- Family therapy
- Nutritional support
Contact Us
At The Wave, we do things a bit differently. We make a difference in the lives of young people from across the globe through expert, trauma-focused care.
If you’re interested in finding out more about our programs, get in touch today.
