Helping your Patients Overcome Eating Disorders by Addressing their Social Interactions

By Charles Fishman M.D, author of ‘Enduring Change in Eating Disorders; Intervention with Long-term Results

Claude Bernard, a brilliant French physiologist in the 19th century, came up with the term “the wisdom of the body”. Doctors need to attend to the wisdom of the body in the same way that there is wisdom of the symptoms when it comes to eating disorders. After all, anorexia is the most fatal disease per capita of the psychiatric diseases. When the symptoms emerge, it is an indication that there are social stresses that are leading the person to fall into the eating disorder.

As a general and child psychiatrist for many years, as with many issues in life, I’ve realised things are not necessarily as obvious as they seem to be. One of the most significant findings since the 1970’s has been that for parents, friends and supporter’s to help eating disorder sufferers overcome their disease they need to delve deeper into the issue.

Eating disorders are all about relationships and how people relate to one another

To treat eating disorders you need to consider the person and the relationships they have with the people close to them as well and how they personally handle stressful situations and conflict.

This led me to write ‘Enduring Change in Eating Disorders; Intervention with Long-term Results‘, where over a span of twenty years I looked back at people I had treated and come to the finding that relationships were the underlying root of eating disorders.

Profound and lasting change comes from therapy where the family and significant people in the person’s life are seen as the context within which the person is treated. This approach is Intensive Structural Therapy (IST) and moves away from the very narrow focused treatment just on the individual.

IST examines five specific patterns :

  1. Conflict avoidance
  2. Triangulation (where somebody is caught between somebody else, where they are damned if they do or damned if they don’t)
  3. Rigidity
  4. Diffusion of conflict (where conflict between two people emerges it is diffused when another person distracts the people that are at conflict)
  5. Perfectionism

These factors were described by Minuchin, Rossman and Baker, Psychosomatic Families; Harvard University Press, 1979.


What is behind eating disorders becoming more prevalent? There are five common misconceptions about eating disorders which need to be addressed by those in the medical field:

1. Eating disorders are not primarily a result of someone thinking they are overweight.
An eating disorder is like the yellow canary in the mind of the sufferer. It tells them that there are social issues in her or his life that are causing distress and leads towards them outwardly manifesting this through the eating disorder.
2. Eating disorders are not about dieting.
Eating disorders can be bought on by a person, especially a child, starting a diet and not being able to stop. But there are millions of people that start diets and stop. Why is it that certain people go on to develop eating disorders? Eating disorders are, after all, quite rare.
The difference is that some forms of diets, bulimia or laxative abuse are the result – the cause is distress in relationships.
3. Eating disorders are not about being a perfectionist.
Perfectionism is not a unique phenomenon. As with the earlier issue, what is significant is why certain people develop this life threatening problem and not others? If you consider the IST model then perfectionists often are living in a context where one of the patterns in the family is perfectionism and rigidity. The significant issue for the therapist and for the family is to look beyond the eating disorder to the environment in which it is being maintained.
4. Eating disorders are not an individual problem. Family and significant others are vital resources for healing.
We all live our lives with the belief that we are the captains of our ship and we determine our course. The fact is we are profoundly influenced by the individuals around us.
Think about the number of times that things you thought were profoundly true were upon reflection because the people around you felt that way and had the same belief system.
5. Eating disorders are chronic diseases but treatment doesn’t have to be long term.Thinking that a long existing problem has to be treated over a long period of time can be a slippery slope. It can even lead to a self-fulfilling prophecy: if you believe that it will take a long time there is a greater chance that it will.

In my experience, eating disorders can be treated rapidly. For example with IST treatment lunch sessions with children work well. The family has lunch together and by the end, the youngster is often beginning to eat. With experience and research, children can eliminate their eating disorder within weeks or months. Of course each case is different based on the relationships that needed to be healed, but the treatment has been proven successful over decades.

Doctors need to address the relationships that need to change so the behavioural symptoms disappear. The person’s family and other close relationships are essential resources to facilitate healing. Therapy needs to be inclusive to address specific social patterns.

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Book: Enduring Changes in Eating Disorders

Enduring Change in Eating Disorders - Book Cover

Endorsements from Clients

  • Hello Charles! I am unsure if you will even remember who I am haha, but this is [name withheld] – I saw you in (I think) 2017 with anorexia.

  • My wife and I felt quite emotional last Monday after our short Zoom session. All three of us hugged. It felt like the end of a relatively short but profoundly enriching journey with you which started in June at your home office on Waiheke Island.

  • Dear Dr Fishman Thank you so much for this website. I have a long history of swinging between bulimia and compulsive over-eating. I am currently a compulsive over-eater.