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The American Journal of Family Therapy
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Feminist-Informed Emotionally Focused
Couples Therapy as Treatment for Eating
Disorders
Candice A. Maiera
a The University of Iowa, Iowa City, Iowa, USA
Published online: 25 Sep 2014.
To cite this article: Candice A. Maier (2014): Feminist-Informed Emotionally Focused Couples
Therapy as Treatment for Eating Disorders, The American Journal of Family Therapy, DOI:
10.1080/01926187.2014.956620
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The American Journal of Family Therapy, 00:1–12, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0192-6187 print / 1521-0383 online
DOI: 10.1080/01926187.2014.956620
Feminist-Informed Emotionally Focused
Couples Therapy as Treatment
for Eating Disorders
CANDICE A. MAIER
The University of Iowa, Iowa City, Iowa, USA
Research has documented associations between relationship qual-
ity and eating disorders; however, few have explored treating eating
disorders with couple therapy. Emotionally focused therapy (EFT)
is a compelling framework for treating couples where one partner
has an eating disorder. A feminist approach to EFT offers the pos-
sibility of adding to the knowledge base of etiological factors that
contribute to the development of eating disorders. A case example is
given demonstrating how EFT can be adapted to address the fear,
shame, and secrecy often associated with eating disorders within
the context of larger social schemes which contribute to eating
disorders.
INTRODUCTION
Eating disorders consume a large part of the emotional functioning in
romantic relationships. Although typically studied as a disorder of ado-
lescence, research has now begun focusing on eating disorders in adult
women (Gianini, White, & Masheb, 2013; Kiriike et al., 1998). Since many
of the women studied in these samples are older, they are more likely to be
involved in romantic relationships. In couples where one partner exhibits an
eating disorder, functioning in areas of intimacy, communication, and con-
flict strategies are likely to be impacted (Van den Broucke & Vandereycken,
Address correspondence to Candice A. Maier, The University of Iowa, 360 Lindquist
Center North, Iowa City, IA 52242. E-mail: candice-maier@uiowa.edu
Color versions of one or more of the figures in the article can be found online at
www.tandfonline.com/uaft.
1
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2C. A. Maier
1997). Although this population has been found to report lower relationship
satisfaction and increased marital discord (Kiriike et al., 1998), little has
been written on treating eating disorders with couple therapy.
The overwhelming majority of persons with eating disorders are women
(DSM-V, 2013). Women with eating disorders often report insecure or anx-
ious attachments to their parental figures growing up (Amianto, Daga,
Bertorell, & Fassino, 2013), which, according to attachment theory, impact
the close relationships adults seek later in life (Bowlby, 1999). Further, re-
search has shown links between relationship functioning and eating dis-
orders (Kiriike et al., 1998; Van den Broucke & Vandereycken, 1997). For
instance, Kiriike et al. found in their sample comparing single and married
women with eating disorders that 69% of the married patients reported that
their eating disorder was triggered by marital problems, separation, or di-
vorce. Given the links between eating disorders, romantic relationships, and
attachment-based issues, emotionally focused therapy (EFT) may be a useful
clinical approach in treating couples where eating disorders and relationship
distress are present.
The purpose of this article is to apply a feminist-informed framework to
describe how EFT can be helpful in treating couples where one partner ex-
hibits an eating disorder. Feminist perspectives on eating disorders make ex-
plicit the patriarchal society that has effectively subjugated women through its
emphasis on women’s physical appearance (Nagel & Jones, 1992) and thin-
idealism (Gilbert & Thompson, 1996). In this article, a feminist-approach
allowed for an important focus on the multitude of societal pressures on
women that result in chronic dieting, binge/purge behaviors, and hyper-
vigilance about weight and appearance which in turn, impact relationship
dynamics (Gilbert & Thompson). Although some adherents to EFT posit that
the theory is already inherently feminist (Vatcher & Bogo, 2001), it is crucial
that eating disorders be framed within the values of the dominant (Western)
culture due to the historical pathologizing of women’s eating disorders as
stemming from the individual. While EFT emphasizes the importance of seek-
ing healthy connections in intimate relationships and incorporates both men’s
and women’s emotions and individual experiences (Johnson, 2004), there is
a larger need to contextualize eating disorders as a reflection of cultural val-
ues that emphasize women’s appearance as pertaining to their self-worth and
value, in addition to how these influences are internalized and impact couple
relationships. Thus, this article will (1) review the prevalence of the present-
ing topic on eating disorders, (2) propose a thesis for a feminist-informed EFT
model in treating couples where the female partner has an eating disorder by
reviewing existing literature, (3) provide reactions to the existing argument
that EFT is already inherently feminist and (4) synthesize these points into
a new thesis which incorporates both arguments and reconciles common
truths.
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Feminist-Informed EFT and Eating Disorders 3
EATING DISORDERS
Eating disorders affect up to 24 million people of all ages and genders each
year in the United States and have one of the highest mortality rates of
any mental illness (National Association of Eating Disorders, 2014). Women
are more than ten times as likely to develop an eating disorder when com-
pared to males and are likely to have developed an eating disorder during
adolescence or young adulthood (National Association of Eating Disorders).
Additionally, it is common for eating disorders to go unnoticed due to the
level of denial individuals and families often present with after discover-
ing symptoms, in addition to situations where eating disorders are misdiag-
nosed due to co-occurring psychiatric disorders, such as depression, anxiety
(McElroy, Kotwal, & Keck, 2006), substance abuse disorders (Harrop & Mar-
latt, 2010), and obsessive-compulsive disorders (Altman & Shankman, 2009).
EFT FOR COUPLES
Emotionally focused therapy is a systemic, experiential approach to therapy
that emphasizes inter- and intrapersonal patterns which maintain a couple’s
overall functioning. EFT is rooted in attachment theory (Bowlby, 1999) which
posits that safe emotional connections with others are a fundamental need.
These attachments begin in childhood with parents and caregivers, and later
are established in romantic relationships with significant others. Through
an EFT lens, adults form attachments with romantic partners to meet these
basic attachment needs. Relationship distress, thus, can be conceptualized as
disturbances in these fundamental attachments (Johnson & Greenman, 2006).
To alleviate distress within these relationships, EFT uses three stages
which consist of cycle de-escalation, restructuring of interactional positions,
and consolidation/integration (Johnson, 2004). In the first stage, the thera-
pist attempts to establish a rapport and create an alliance with both partners.
During this time, the therapist may also gain insight into underlying themes
of conflict. The therapist begins to identify the interactional patterns which
maintain relationship distress, and help the couple to recognize any un-
acknowledged emotions underlying these patterns. The therapist works to
reframe the couples’ presenting problems in terms of these interactional pat-
terns, or the emotional cycle by which attachment needs are unmet (Johnson
& Greenman, 2006).
In the second stage, the therapist restructures interactional positions
by helping couples to identify their needs or unacknowledged emotions
and see how these emotions are playing a part in their interactions. During
this time, the therapist validates both partners’ self-expressions and aims to
create a new emotional engagement whereby the partners are more open
and somewhat emotionally vulnerable. The final stage consists of identifying
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4C. A. Maier
new solutions to old relationship patterns. New positions are established and
new cycles of attachment emerge (Johnson, 2004).
EFT for couples has been proposed as a useful treatment for a range
of mental health concerns, from depression (Watson & Greenberg, 2005) to
generalized anxiety disorder (Priest, 2013). However a gap in the literature
exists using EFT for couples with eating disorders. While EFT has been pro-
posed as a useful clinical approach for individuals with eating disorders in
one particular article (e.g., Dolhanty & Greenberg, 2007), it may be help-
ful to utilize emotionally focused couple therapy with the eating disorder
population. For example, research on close relationships link many of the
dynamics that occur in relationships to mental and physical outcomes (Carr
& Springer, 2010). Since couple relationships and marriage are presumed to
be the most significant relationships in adults’ lives, it is crucial to focus on
these relationships in treatment and explore and how particular relational
interactions and patterns may be linked to the course of eating disorders.
EATING DISORDERS CONCEPTUALIZED THROUGH EFT
Due to the emergence of CBT’s influence on research and treatment in
recent decades (Gaudiano, 2013), its growing popularity has overshadowed
other options for treating eating disorders. While many studies have linked
emotional regulation (Gianini et al., 2013; Pringle, Harmer, & Cooper, 2010),
and attachment issues (Amianto et al., 2013) to symptoms manifested in
eating disorders such as anorexia nervosa and bulimia nervosa, there is
sparse literature on using EFT as treatment for eating disorders (Dolhanty
& Greenberg, 2007). Further, there are even fewer articles that place this
disorder in a relational context (Van den Broucke & Vandereycken, 1997).
In general, it is important to recognize the mental and physical health of
adults is closely related to experiences of romantic relationships (Carr &
Springer, 2010) and that EFT can be used as a compelling framework for
understanding the emotional difficulties that coexist with eating disorders
(Dolhanty & Greenberg). Thus, given the existing literature that links eating
disorders to relationship distress, it is important to explore ways EFT can be
used with this population.
EATING DISORDERS CONCEPTUALIZED THROUGH A
FEMINIST-INFORMED EFT FRAMEWORK
Many reasons exist for not incorporating a feminist-informed EFT approach
with couples living with the difficulties of eating disorders. First, many re-
searchers believe EFT is already feminist (Vatcher & Bogo, 2001). However,
the sociopolitical origins of feminist theory provide an additional framework
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Feminist-Informed EFT and Eating Disorders 5
for conceptualizing eating disorders in a larger cultural context. Although the
prevalence of males with eating disorders is increasing and unfortunately
overlooked and neglected in society (Anderson, 2002), the overwhelming
majority of individuals directly impacted by eating disorders are female
(DSM-V, 2013). A multitude of factors contribute to this statistic and can
be argued from feminist perspectives. For instance, women often report ex-
periencing societal pressures to diet and control their weight as young as six
years old (Collins, 1991). Additionally, it was reported over two decades ago
that over 80% of 10-year old girls fear being fat (Mellin et al., 1997). Research
indicates that fat phobia can lead to weight manipulation such as dieting
(Andersen, 2002), which has the potential to lead to larger eating disorder
symptoms such as binging/purging, skipping meals, smoking cigarettes, and
using laxatives (Neumark-Sztainer, 2007). Furthermore, a feminist-informed
lens while utilizing EFT can help to further normalize and validate women’s
experience without pathologizing their symptoms in a couple’s context.
INTEGRATION
Eating disorders may involve extreme emotions and behaviors surrounding
weight and food issues that impact intimate relationships. Many individuals
with eating disorders hide their symptoms from their partner (NEDA, 2014).
This secrecy is oftentimes associated with shame and leaves the partner of
the eating disordered individual feeling confused, emotionally disconnected,
frustrated, and overwhelmed (Kiriike et al., 1998). While it is important to
note that these behaviors are not only unique to women and can impact
men who exhibit eating disorder symptoms as well, the fact that the over-
whelming majority of individuals with eating disorders are women suggests
that larger sociocultural factors may be contributing to the etiological ex-
planations for the development and maintenance of eating disorders and
thus, supports a larger need to contextualize eating disorders in a feminist-
informed framework.
Although therapists should not assume that individuals with eating dis-
orders will have relational issues, there are implications for both partners that
should not be ignored (Cockett, 1995). What follows is a case example us-
ing a feminist-informed EFT approach to uniting couples in the treatment of
eating disorders. For this example, a heterosexual couple where the female
has an eating disorder will be presented.
TREATMENT OF EATING DISORDERS WITH FEMINIST-INFORMED
EFT: A CASE EXAMPLE
Jackie and Ben decided to pursue therapy after several months of feeling
emotionally distant and disconnected from one another. When they came to
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6C. A. Maier
therapy, Ben described the relationship as feeling “fake” or “empty.” Jackie
had an idea of what was managing this emotional distance but had not
disclosed to her partner that she was living with symptoms of an eating
disorder. The couple reported that they rarely attended social events and
had an unfulfilling sexual relationship. Both partners were allowed time to
share their current experience of the relationship and have their experiences
validated. An assessment was conducted to screen for psychiatric disorders,
domestic violence, and substance abuse. Neither partner reported any cur-
rent or previous history of domestic violence or excessive substance use.
Although Jackie reported several depressive symptoms, she was not taking
any psychiatric medication. Ben stated his interactions with Jackie in the past
year had been a main source of worry and he even wondered if Jackie had
been involved in an affair. Although anxiety and stress were reported, Ben
did not meet clinical levels.
Phase One: Identifying a Cycle
The first step while meeting with the couple was to delineate presenting
issues surrounding the eating disorder (See Figure 1). After building a rap-
port and helping both partners to feel safe in therapy, the therapist began
to identify a cycle which maintained symptoms from the eating disorder.
Because Jackie had not fully disclosed her eating disorder to Ben, the thera-
pist identified the interaction cycle as being based in anxiety. The therapist
discussed the secrecy and disengagement that often accompany eating dis-
orders (e.g., emotional cut off) as fueling Ben’s worries and concerns, which
in turn impacted Jackie’s moods, increased both partners’ fears about the
relationship, and ultimately led to an increase in eating disorder symptoms
for Jackie. As Ben pursued Jackie, she withdrew, which increased Ben’s need
to check in more with Jackie and ask questions aimed at the security of the
relationship.
A second step in this approach was to identify maladaptive emotional
schemes as maintained by the effects of the eating disorder. By the second
session, Jackie had admitted that part of the emotional distance and frustra-
tion both her and Ben were experiencing in the relationship had something
to do with the fact that Jackie was living with the effects of bulimia nervosa.
Her cycles of binging and purging and mood swings due to feeling fat or
thin, restriction of food consumption to excessive food consumption, and
feeling guilt and shame over these behaviors were parallel to the relation-
ship cycle by which these behaviors would manifest themselves in emotional
distance, followed by brief periods of relative calmness. Jackie reported that
she felt like “the sick one” in the couple and blamed much of the relationship
dysfunction on herself. As the couple began to soften, the therapist was able
to understand the couple’s experience with the eating disorder and access
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Feminist-Informed EFT and Eating Disorders 7
FIGURE 1 Contextualized EFT phases for couples with an eating disorder.
underlying feelings, emotions, and attachment/security issues associated with
the eating disorder.
Reframing Jackie’s attempt to control her behaviors and regulate affect
through her eating disorder within the larger cultural context of gender role
stereotypes helped to validate Jackie and help Ben to further understand
ways in which societal discourses around the thin-ideal (or muscular ideal
for men) are harmful to the couple and their relationship. This reframing
represents the third step of this phase. This step may also include some
psychoeducation about eating disorders and patriarchal discourses that
maintain (and in some cases, even encourage) eating disorder symptoms
to continue. As the cycle became more apparent to the therapist, s/he
was able to tie attachment emotions to the behaviors of the cycle so that
both partners began to understand how their anxiety in terms of needing
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8C. A. Maier
safety in the relationship drives their behaviors (e.g., for Ben, pursing; for
Jackie; withdrawing and regulating her emotions through food restriction
or overconsumption, etc.). When the cycle was tracked in such a way, Ben
and Jackie were able to communicate their fears of abandonment and sense
of being overwhelmed by one another’s behaviors. Ben communicated
feeling “lost” in Jackie’s own cycle of maintaining her eating disorder and at
times reported feeling impatient. In turn, Jackie communicated the immense
amount of guilt and shame she felt as a result of her extreme mood swings
that accompanied her eating disorder. Promoting the identification of these
previously disowned needs associated with the eating disorder is a central
part of EFT which helps to soften the couples’ affect and lessen the amount
of anxiety in the therapy room (Johnson, 2004).
Phase Two: Restructuring the Cycle
As anxiety decreased between Jackie and Ben, both partners were able to
discuss their own needs, which reduced Ben’s need to “check in” so often
with Jackie, and Jackie’s desire to withdraw and regulate her affect through
her eating disorder. During this phase, the therapist continued to facilitate
an awareness of larger cultural contexts and functions of the eating disorder,
while remaining mindful not to contribute the couple’s relationship difficul-
ties to “Jackie’s eating disorder,” etc. Rather, after a period of helping the
couple to communicate their feelings and underlying needs in the relation-
ship, the therapist engaged both partners in a conversation around ways
in which society influences or encourages women to control their bodies
through manipulating their weight and body. It is important during these
times, however, that the therapist is not lecturing to the couple or preaching
a message that does not quite fit the couple’s experience. Indeed, there are
many factors that contribute to the onset and maintenance of eating dis-
orders and it is possible that a couple may not agree with the therapist’s
feminist-informed framework around the treatment of eating disorders. In
these situations, it is important for the therapist to tread lightly and have
somewhat of a subversive approach as to not distance the couple or rupture
the therapeutic alliance. At the same time, however, facilitating an aware-
ness around such topics and taking collaborative stands against oppressive
societal structures are important in this approach.
At this time, the therapist has allowed both partners to express their
fears and needs in the relationship, talk openly about the eating disorder
symptoms, and understand one another with more compassion. As Jackie
and Ben began to express themselves more freely, they were both able to
reach out to one another for support instead of entering into the similar
pattern of pursue-withdraw. Jackie understood Ben’s persistent questions
as expressing his need for a safe connection, and Ben understood Jackie’s
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Feminist-Informed EFT and Eating Disorders 9
emotional distancing as an attempt to regulate herself and fears associated
with her eating disorder. Both understood one another’s behaviors as an
ultimate way of managing anxiety and realized that instead of being a
hindrance, the relationship could be a source of happiness, security, and
growth toward the recovery of the eating disorder.
Phase Three: Consolidation of New Cycle and Interactional Positions
As the new structure emerged, the couples’ behaviors effectively changed.
Instead of reacting when Ben felt emotionally cut off from Jackie, he gave
Jackie the space she needed and offered gentle reassurance. This space
made Jackie more likely to come to Ben with her personal struggles which
ultimately led her to admitting she needed professional help to deal with
her eating disorder. Jackie was able to admit herself into a day treatment
program for eating disorders which provided the structure and supervi-
sion she needed with an intense focus on skills for recovery. Jackie was
able to discuss her experiences openly with Ben instead of shutting down,
and Ben was able to share his emotions tied to his worry and concern
for her and the relationship without reacting. Instead of getting stuck in
their previous pursue-withdraw cycle, the couple was able to reduce their
anxiety and recognize each other’s needs to feel safe and secure in the
relationship.
FURTHER DIRECTIONS
Eating disorders have one of the highest mortality rates of any mental illness
(NAED, 2014) and can greatly impact relationship with significant others.
With some notable exceptions (Bulik, 2011; Van Buren & Williamson, 1988),
few studies have examined how couple therapy can be a useful treatment
of eating disorders and virtually no empirical studies have tested the va-
lidity of applying a feminist-lens to specific therapeutic approaches while
working with this population. There is a larger need to understand eating
disorders from a feminist lens in the context of couple therapy due to the
fact that eating disorders disproportionately affect women (DSM-IV) and the
existing relationships between eating disorders and intimate relationships
(Bullik, 2011). Individuals with eating disorders enter relationships at similar
rates to individuals without eating disorders and a substantial proportion of
those seeking treatment for EDs report that their partners are an essential
part of the recovery process (Bullik). Therefore, conducting a randomized
clinical trial of feminist-informed EFT for couples to determine if it signifi-
cantly reduces symptoms of EDs compared to a waitlist control group would
help to provide new empirically supported interventions for treating this
population.
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10 C. A. Maier
CONCLUSION AND LIMITATIONS
This article sought to explore the overarching arguments for using a feminist-
informed EFT approach with couples where the female partner has an eating
disorder. A case example demonstrating how feminist-informed EFT can be
used in a couple’s context, as well as a brief research proposal for how this
approach can be empirically tested was also provided. The case example is
based on two assumptions that limits the applicability to all couples living
with the effects of eating disorders. First, it assumes that the eating disordered
partner is willing to be honest with herself regarding the seriousness of her
condition, as well as be willing to disclose to her partner her status of living
with an eating disorder. The case example also assumes that the couple is
able to explore societal factors that contribute to the eating disorder, such
as sociocultural pressures which encourage weight loss and body control
techniques (Stice & Presnell, 2007).
It should also be noted that the outcomes of the case example may
stem from other factors, such as client and therapist variables that are not
necessarily model specific, but due to common factors of couples therapy.
More research is needed to explore factors to determine whether feminist-
informed EFT therapy for couples is specific to the modality or if other factors
play a more important role.
ACKNOWLEDGMENTS
Thank you to Dr. Volker Thomas and Dr. Jacob Priest for guidance and
support with this article.
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