An Ecological Approach To Eating Disorders
Counselling for Eating Disorders
Brisbane therapy for eating disorders.
A literature review by Natajsa Wagner
THERAPY FOR EATING DISORDERS
My curiosity coupled with my most recent personal experience with eating disorders has been the catalyst for this literature review. Eating disorders have one of the highest mortality rates of any mental illness (Sullivan, 1995), with anorexia nervosa having a particularly high death rate of 15.6% (Zipfel, Lowe, Deter, & Herzog, 2000). A conservative estimate shows that 9% of Australian women are affected by an eating disorder (Wade, Crosby, & Martin 2006). Consequently, the need for support through therapy is vital. Ofparticular importance in working with clients suffering from an eating disorder is therapy that builds a co-created, strong and positive therapeutic alliance (Brisman, 1994; Constantino, Arnow, Blasey, & Agras, 2005). This is related to the germane issues of trust and control, which are important features for individuals with an eating disorder (Gilbert, 2013; Petrucelli, 2014). My own experience through gestalt therapy has allowed me to examine the process of disordered eating and helped me to identify and trust my own intra-psychic patterns and behaviours. Through this process I have been able to undertake the exploration of polarised parts of myself, whilst re-establishing an interpersonal connection. This would not have been possible without the support of the therapeutic relationship established with my therapist. It is this possibility of supporting others through relational contact in helping them to understand their own eating disorders that drives my excitement and curiosity in this work.
This review examines eating disorders in relation to social and ecological theories. It defines and discusses the importance of an ecological relational approach to eating disorders and claims that gestalt therapy is the most effective ecologically based therapy for their treatment, through a phenomenological and field sensitive approach that places emphasis on the therapeutic alliance, which is most beneficial in working within an ecological relational framework. This literature review is written in three sections. The first section defines and describes disordered eating. It pays particular regard to the definition and classification of eating disorders in the Diagnostic and Statistics Manual of Mental Disorders, (5th ed.; DSM–5) (American Psychiatric Association [APA], 2013) whilst examining three key theories and their relevance to eating disorders. The second section discusses current research findings that show that a range of psychotherapies are effective in treating eating disorders. It investigates the influence of common factors, including the therapeutic alliance in the treatment of eating disorders (Constantino, et al., 2005; Loeb, et al., 2005; Martin, Garske, & Davis, 2000). The third section of this review highlights gestalt therapy as a suitable psychotherapy for clients with an eating disorder. It gives a brief overview of gestalt therapy and pays particular attention to the philosophy and process of gestalt therapy as a phenomenological and field-sensitive approach that understands the therapeutic relationship as both a dialogical and relational process (Jacobs, 1995; Yontef, 2002). Finally, this section discusses how a gestalt approach may be used in the treatment of eating disorders.
The Ecology of Eating Disorders
Disordered Eating
The literature investigating disordered eating behaviours is expansive. Analysis of the research shows disordered eating is heterogeneous in nature and is understood as a complex set of behaviours, habits and symptoms (Gilbert, 2013; Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004; Petrucelli, 2014). These manifestations disturb the natural balance of healthy and functional eating (Gilbert, 2013; Giordano, 2005).These eating disturbances may be separate from the need to control weight, with eating disorders being used as a way to control negative emotions (Gilbert, 2013; Gillie, 2000; Petrucelli, 2014). Eating disorders allow the individual to cope with their feelings of inadequacy, and to feel safe, special, and in control (Costin, 1997). The presentation of eating disorders varies but they often occur with severe medical or psychiatric comorbidity, including low self-esteem, depression, perfectionism, obsessive compulsive disorder (OCD), mood and anxiety disorders, and emotional dysregulation (Green et al., 2009;Hudson, Hiripi, Pope, & Kessler, 2007; Sallet et al., 2010; Swinbourne & Touyz, 2007).Recent studies in Australia have indicated that the prevalence of eating disorders is as high as 15% in females and 3% in males (Hay, Girosi, & Mond, 2015). The prevalence of eating disorders has not been found to be biased towards culture, socio economic class, race, age or sexual preference (Hesse-Biber, Leavy, Quinn, & Zoino, 2006).Further exploration of socio-cultural aspects is required to provide important information on the increasing prevalence of eating disorders in our society(Alexander, & Treasure, 2012; Hesse-Biber et al., 2006).
Eating disorders are formally defined within the Western medical tradition as “a persistent disturbance of eating behaviour or behaviours intended to control weight, which significantly impairs health or psychosocial functioning” (Fairburn, & Walsh, 2002, p. 171). The information within the medical model relating to the nature of eating disorders and their treatment has been considered by some as erroneous and confusing at best (Gilbert, 2013; Jones, Saeidi, & Morgan, 2013). The DSM-5 forms part of the traditional medical model and serves as a descriptive guide for eating disorders. It provides a diagnostic framework used by many professionals, including those in mental health to understand and define a range of eating disorders. This literature review uses the DSM-5 classification for the purpose of describing eating disorders, and provides a general overview of anorexia nervosa, bulimia nervosa, binge eating disorder and feeding or eating disorder not elsewhere classified.
Anorexia Nervosa (AN)is one of the most discussed eating disorders among clinicians. Individuals experiencing AN are highly dependent on perceptions of their body shape and weight, with a high prevalence of AN in cultures that value thinness (Gilbert, 2013; Hesse-Biber et al., 2006). Those experiencing AN have an abnormal preoccupation with food, including an intense and obsessive fear of gaining weight (BjöRk & Ahlström, 2008; Sacker, 2007). In the DSM-5 AN is classified into two subtypes, restricting and binge-eating/purging. The restrictive subtype involves those who present with weight loss primarily through food restriction behaviours, including dieting and fasting, and may also be accompanied by excessive exercise. The binge-eating/purging subtype additionally engages in binge-eating and purging behaviour, such as vomiting, and the deliberate misuse of laxatives, diuretics or enemas to compensate for eating food (APA, 2013). According to the International Classification of Diseases (ICD-10) (World Health organization,1992), a person with AN has a body mass index (BMI) which is below normal levels for their age, gender, developmental stage and physical health. It is rare for a person with AN to present themselves for treatment, as they are frequently in denial or unaware of the seriousness of their condition (Schoen, et al., 2012). The duration of AN may last years and be ongoing (Gilbert, 2013). Individual experiences differ greatly from single episodes to multiple relapses (Gilbert, 2013). Recovery from AN generally happens between two and ten years, however the risk of death with people who have AN is three times higher when compared to other psychiatric illnesses (Gilbert, 2013; Treasure, & Alexander, 2013). In fact, suicide risk is elevated, with 1 in 5 deaths attributed to suicide (Pompili et al., 2006).
Bulimia Nervosa (BN) has frequently been found to develop after a period of extreme dieting or weight loss, with a majority of cases presenting with normal to overweight BMI (Gilbert, 2013). People with BN were first described in 1979 by Russel (1979) as experiencing a morbid fear of becoming fat with extreme emphasis on body shape and weight. People with BN are generally secretive about their condition due to experiencing a high level of shame, guilt and disgust around their behaviours that include binge-eating (BE), (Eating Disorder Association Inc., 2014; Gilbert, 2013; Zweig, & Leahy, 2012).BE is formally defined as the consumption of an objectively large amount of food in a discrete period of time along with a sense of loss of control over eating during the episode (APA, 2013). BE is used as a way of temporarily controlling negative affect (Gilbert, 2013; Tice, Bratslavsky, & Baumeister, 2001) and in the case of BN this isfollowed by compensatory purging behaviours that may include vomiting, laxatives, diuretics, misuse of enemas, fasting or excessive exercise (APA, 2013). Disturbed eating behaviours in people with bulimia can persist for several years. Participation in treatment has been shown to positively impact on the client's overall outcome (Gilbert, 2013), with research indicating that successful treatment is more likely in early onset (Reas et al 2000; Steihausen, & Webber, 2009). People usually present for treatment within the first five years of developing BN (Gilbert, 2013). There is limited research available on the frequency of suicide among those with BN, although they are identified as at risk (Crow, et al. 2099; Pompili, et al., 2006).
Binge Eating Disorder (BED)has been identified as more common than AN or BN and just as chronic (Hudson et al., 2007). BED became a formal diagnostic category only recently with the publication of the DSM-5. Therefore, little research has been conducted to provide evidence of the causes of BED (Fairburn & Harrison, 2005; Leehr et al., 2015). Unlike BN, dieting often follows the development of BED in many individuals and is distinguished from BN by a lack of compensatory purging behaviours (Gilbert, 2013; Spurrell et al., 1997). Bingeing in BED is classified in the same way as BN. People with BED often experience a sense of shame regarding their behaviours and try to conceal their binges (Apple & Agras, 2008; Gilbert 2013). Moreover, the literature links BED to obesity, with many people who have BED also being overweight or obese (Gilbert, 2013; Spitzer et al., 1992). The minimal research available confirms an elevated suicide risk in people with BED (Grucza, Przybeck, & Cloninger, 2007; Pisetsky, et al, 2013).
Feeding or Eating Disorder not elsewhere classified (FEDNEC) in the DSM-5 is a classification used when a person is determined as having an eating disorder of clinical severity but the full diagnostic criteria for another eating disorder are not met (Gilbert, 2013). FEDNEC does not differ greatly from AN or BED in eating pathology or general psychopathology. The research indicates that FEDNEC represent a set of disorders associated with substantial psychological and physiological morbidity (Thomas, Vartanian, & Brownell, 2009). Whilst FEDNEC are considered as clinically severe as AN or BN and are the most frequently presented and diagnosed cases, limited research has been conducted on this category particularly on the rates of suicide among people with this classification (Hay, et al., 2010). Limited researchhas suggested a higher mortality risk in FEDNEC over BN (Arcelus, et al., 2011).
Wampold, & Imel (2015) stated, “clients within disorders are heterogeneous with regard to the causal factors creating the disorder and therefore different specific ingredients are needed to address specific deficits, regardless of diagnosis” (p.229). Psychiatricdiagnosis is a starting point that is useful in defining a disorder (Gilbert, 2013;Zubernis & Snyder, 2015). It should contribute to understanding the needs of the individual, and to developing suitable case conceptualizations that are based on more than classificatory systems (Gilbert, 2013). Recent literature has shown a movement towards viewing eating disorders as widely divergent (Alexander, & Treasure, 2012; Wildes, & Marcus, 2013). The literature posits the development of multi-disciplinary frameworks that contest the traditional DSM-5diagnostic criteria by considering the needs of the individual and the factors that contribute to the development and maintenance of an eating disorder, rather than focusing purely on diagnostic criteria (Alexander, & Treasure, 2012; Wildes, & Marcus, 2013).
Theoretical Frameworks of the Aetiology of Eating Disorders
The literature beyond the general and technical classifications of eating disorders identifies three important theories.These are the feminist theory (Fallon, Katzman, & Wooley, 1994;Smolak & Murnen, 2001; Thompson et al., 1999; Thompson & Stice, 2001), attachment theory (Broberg, Hjalmers, & Nevon, 2001; Dozier, Stovall-McClough, Albus, 2008 Torisi et al., 2006) and the ecological relational theory (Felner & Felner, 1989;Hesse-Biber et al., 2006;Petrucelli, 2014). These shape and inform the aetiology of disordered eating and people’s predispositions to them (Bruch, 1973; Fallon, Katzman, & Wooley, 1994; Gilbert & Thompson, 1996;Ward, Ramsay, Turnbull, Benedettini, & Treasure; Levine & Piran, 2001). This review presents an overview of the determinants of eating disorders based on an existing theoretical framework of causality that examines the aetiology and onset of eating disorders.
The Feminist Theory asserts that gender socialization and the development of women’s roles in society contribute to the developmental predispositions of an eating disorder (Malson, 1998; Orbach, 1978; 1998). The fear women experience about fat was highlighted in the seminal, yet controversial book, Fat is a Feminist Issue (Orbach, 1978). This book discussed the fear of fat in specific relation to men (Gilbert, 2013). Since this text was published, many works have identified the strict control around diet and body image as the indicator of a woman’s place in a sexist society (Gilbert 2005; Orbach, 1998; Pearson & Pearson, 1973, 2009). The feminist theory suggests that women’s expression of self and her relational experience in society is represented through visual objectification of the body (Hesse-Biber et al., 2006). “Eating disorders interfere with a normal ability to hold the conflicting tensions of hunger and satiety” (Petrucelli, 2014, p.14). These polarities are outwardly expressed in the relationship to food by many women; their language of communication can be seen through eating disorders (Orbach, 1978, 1998; Petrucelli, 2014). Although the feminist theory has wide appeal and support, its theory has some shortcomings. It’s relevance has been challenged by failing to consider the effect of eating disorders on males (Soban, 2006). Recent studies have shown the prevalence of eating disorders in men is higher than initially thought;in fact there has been anincrease in eating disorders across genders, particularly in males (Heywood & McCabe, 2006; Markey & Markey, 2005; McCabe, Ricciardelli & James, 2007).
Attachment theory provides robust evidence that shows that the quality of attachment is strongly linked to mental health disorders, including eating disorders (Dozier, Stovall-McClough, Albus, 2008; Torisi et al., 2006; Zachrisson & Skarderud, 2010). People experiencing an eating disorder often have difficulties with the emotional regulation process, including the development of dependency and boundaries in interpersonal relationships (Gilbert, 2013; Petrucelli, 2014). These presenting symptoms fit well with Bowlby’s (1969, 1973, 1980) originally proposed attachment theory. Attachment theory classifies attachment according to various patterns and explains that insecure attachments develop through the parent-child relationship (particularly with the mother) and influence an individual’s self-protective strategies (Józefik, 2008; Zachrisson & Skarderud, 2010). It has been widely claimed that attachment patterns and processes influence the stability and developmental pattern of infants into adulthood, resulting in a strong link to the development of eating disorders (Ramacciotti, Sorbello, Pazzagli, Vismara, Mancone & Pallanti, 2001; Troisi, Massaroni, & Cuzzolaro, 2005). Current research highlights the connections between attachment insecurity and eating disorders (Zachrisson & Skarderud, 2010). Although it highlights the prevalence of insecure attachments in women with eating disorders (Broberg, Hjalmers, & Nevonen, 2001), it does not specify how or why attachment insecurities relate to eating disorders. Given the differing views and methodological challenges around how attachment theory actually connects with the psychopathology of eating disorders, further research is required, not only to specify the types of attachments present in disordered eating, but also to understand their working mechanisms (Delvecchio, Di Riso, Salcuni, Lis, George, 2014; Zachrisson & Skarderud, 2010).
The ecological relational theory draws from the social ecology theory of development initially proposed by Bronfenbrenner (1979,1989) who recognised that multiple environments and contexts influence an individual. The ecological relational theory encompasses sociocultural, relational and environmental factors, and identifies an individual’s factors, including biology, genetic predisposition and neurobiology. These inform an individual’s psychopathology and contribute to the development and maintenance of an eating disorder (Bruch, 1973; Kiang and Harter, 2006; Farber, 2007). Empirical evidence shows that modifiable environmental and sociocultural factors, including economic enterprises like the beauty/diet industry, media, families, schools and peer interaction are influential in the development and maintenance of eating disorders (Groesz, Levine & Murnen, 2002; Thompson, Heinberg, Altabe, & Tantleff-Dunn, 1999). Internalization of certain ideals, for example, the ideal of being thin, increases the probability of an eating disorder occurring in young women (Thompson & Stice, 2001). Indeed, eating disorders form part of people’s coping mechanisms which have been firmly reinforced by Western culture (Gordon, 2000; Silverstein, Perlick 1995). It acknowledges the need for further cross-cultural, longitudinal research of an ecological relational nature to improve our understanding of eating disorders and ultimately their prevention (Piran, 1999; Reiss & Price, 1996).
The feminist, attachment and ecological relational theories offer insight and comparison into the complex and multifactorial aetiology and symptomology of eating disorders (Giordano, 2005; Jacobi, et al., 2004; Striegel-Moore & Bulik, 2007). The feminist theory opposes elements of the attachment theory and its perspectives. Attachment theory can be perceived as ethically challenging by its interpretation of attachments between families (particularly blaming the mother) as being responsible for the psychopathology of an eating disorder in the early developmental stages (Zachrisson & Skarderud, 2010). Whilst attachment theory contains some relational aspects, the ecological relational thoery further re-enforces the notion that support through relational contact is an important component in the ecological functioning of people experiencing an eating disorder. Consequently it identifies that working with disordered eating needs a collaborative approach between all stakeholders in the community (Alexander, & Treasure, 2012). An ecological relational approach would accommodate multiple factors, integrating scientific research and methodology across a variety of groups within the community (family, schools, media, and clinical professionals) in order to continue to develop a better understanding of eating disorders that could result in our ability to enrich the conceptualization and interactions between therapist and client (Alexander, & Treasure, 2012; American Dietetic Association, 2006; Wildes, & Marcus, 2013). One such approach is psychotherapy.
Research on the Therapeutic Alliance
Psychotherapy lends itself to an integrated approach that is beneficial when working with people with eating disorders (Brisman, 1994; Constantino, et al., 2005; Geller, 2006; Toman, 2002; Loeb, et al., 2005). A traditional definition from Bateman, Brown & Pedder (2000) describes psychotherapy as “Essentially a conversation which involves listening to and talking with those in trouble with the aim of helping them understand and resolve their predicament” (p. xii). A variety of therapies are used for the treatment of eating disorders including: cognitive behavioural therapy (CBT), family therapy, psychodynamic psychotherapy, art therapy and interpersonal therapy. Motivational enhancement therapy and dialectical behavioural therapy have also been used (Kotler, Boudreau, & Devlin, 2003), as well as mindfulness and acceptance-based approaches (Baer, Fischer, & Huss, 2005). Psychotherapy focuses on a strong relational contact between client and therapist that is crucial when developing a working relationship with clients who seek trust, guidance and support (Gilbert 2013; Petrucelli, 2014). Therapists use the process of relational contact to hold a balance of polarities in challenge and support which fosters trust. This allows for the integration of emotions and cognitions which result in what is known as the therapeutic alliance(Cozolino, 2014;Stiles-Shields et al., 2013).
The concept of the therapeutic alliance developed from traditional psychodynamic origins, where a positive attachment between therapist and client enabled the possibility of healing to take place (Horvath & Luborsky, 1993). Today it is viewed as a pan theoretical factor where theimportance and effectiveness of the therapeutic alliance in working with eating disorders has been widely claimed (Constantino, et al., 2005; Loeb, et al., 2005;Martin, Garske, & Davis, 2000).In fact neuroscience research supports the importance of the therapeutic relationship and has found that the development of the therapeutic alliance increases neuroplasticity by bringing together the right and left human cortices (Cozolino, 2014; Cozolino & Santos, 2014). As the alliance between client and therapist strengthens, this relational development connects the body and emotion to semantic processing and linear thought (Cozolino, 2014; Linford & Arden, 2009). Building this relational alliance allows the brain to resist the process of cortex dissociation, allowing clients to internalize and assimilate the relationship, and stimulating ongoing neuroplasticity growth that has the ability to move beyond therapy into everyday life experience (Cozolino, 2014). This is of particular importance for the treatment of eating disorders, given that they are considered disorders of personality, affecting an individual’s boundaries, identity and relationships (Abbate-Daga, Amianto, Delsedime, De-Bacco, & Fassino, 2013;Petrucelli, 2014).
The therapeutic alliance is considered a key factor and a predictor of patient improvement, despite the influence of differing variables, several of which include patient characteristics, treatment types and outcome measures (Horvath & Bedi 2002; Leibert, & Dunne-Bryant, 2015; Loeb, et al., 2005;Martin, Garske, & Davis, 2000). It has been described as the “quintessential integrative variable” (Muran, Stegal, Samstag & Crawford, 1994, p.185) because it predicts outcome across a variety of therapies and clinical issues, including eating disorders (Constantino, Castonguay, Schut, 2002). Common factors in therapy such as the therapeutic alliance were first introduced in Rosenzweig's (1936) seminal paper, Some implicit common factors in diverse methods of psychotherapy. This paper cleverly indicated that all therapies were effective by way of common factors by using the Dodo’s conclusion after the race in Alice in wonderland, “At last the Dodo said, everybody has won, and all must have prizes” (Rosenzweig, 1936, p. 412). Since then, major research and the development of newly proposed models of common factors followed, showing that common factors accounted for 30% of therapy outcomes (Duncan,Miller,Wampold,Hubble, 2010; Frank & Frank , 1991; Greencavage & Norcross, 1990; Hubble, Duncan & Miller, 1999; Lambert, 1992; Weinberger & Rasco, 2007).
Despite these findings, there is contention and controversy as to whether common factors or specific treatment approaches correlate with a more positive outcome (Bohart, 2000). Findings have shown that specific treatments, including CBT, account for between 0% and 1% of client outcomes. Recent studies have shown that CBT is more effective in the treatment of BN than psychoanalysis(Poulsen, et al., 2014). On the other hand, research also supports the model of common factors and additionally confirms a new common factor of the individual therapist (Duncan, Miller, Wampold, Hubble, 2010). This research presents therapy as an individual and unique process that shows that a successful therapeutic outcome is highly correlated with individual differences between counsellors, accounting for between 8% and 9% of outcomes (Duncan, Miller, Wampold, Hubble, 2010). These results support the view that the therapeutic alliance remains a valid contributing factor in therapeutic outcomes (Duncan, Miller, Wampold, Hubble, 2010). No empirical evidence exists to definitively show that one specific therapeutic approach is superior to another for the treatment of all eating disorders (Fairburn, 2005; Hay, Bacaltchuk, Byrnes, Claudino, Ekmejian, & Yong, 2003; RANZCP, 2004). Neither has there been any research undertaken which considers how and why individual differences in counsellors account for a higher variance in outcome in the treatment of eating disorders. Research is required to understand how the therapeutic alliance, the individual therapist and extra therapeutic factors, such as culture and spirituality, impact on therapy and account for change (Duncan, et al., 2010; Stiles-Shields et al., 2013). Common and extra factors are not mutually exclusive. Indeed common and unique factors are not separate as Boswell et al (2014) has argued “the debate between common and unique factors in therapy represents a false dichotomy, and these factors must be integrated to maximize effectiveness"(p. 118). Rather than delineate the differences between common or unique factors, the challenge for researchers and therapists may be to acknowledge, accept and integrate them into further research and practice for successful therapeutic interventions and outcome.
There is general agreement that a trans-diagnostic, relational and integrative approach is needed in the treatment of eating disorders (Alexander, & Treasure, 2012; Fairburn, et al., 2009; Wade, Allen, & Byrne, 2014). This requires a solid practice of therapists that are willing to utilize and incorporate a range of different practice approaches, techniques and interventions from other systems (Boswell et al., 2014). Messer (2001) argued that “the incorporation of attitudes, perspectives or techniques from an auxiliary therapy into a therapist’s primary grounding approach”(p. 4) is needed. One such therapy that is capable of working in this way is gestalt therapy.
Gestalt Therapy and its Application to the Treatment of Eating Disorders
Gestalt therapy was founded and developed by Fritz Perlz , Laura Perlz and Paul Goodman in the 1940’s. It was influenced by the knowledge and disciplines of multiple pre-existing ideas, and theories (Kritchner, 2015). Gestalt therapy synthesized and assimilated gestalt psychology, psychoanalysis, humanism, existential philosophy, phenomenology, holism and Eastern philosophies to develop its own theoretical perspective and pragmatic applications (Clarkson & Mackewn, 1993; Yontef & Jacobs, 2013). Gestalt therapy does not rely on a theoretical framework of human functioning nor is it bound to a particular model as are many other therapies (Frew, 1997). This has been considered a limitation by some, due to the limited research to support the application of gestalt psychotherapy in clinical treatment settings (Gold & Zham, 2008). This is largely due to its focus on experiential learning over theoretical discussions and empirical validations (Gold & Zham, 2008). An opposing view is that gestalt therapy is more eclectic because it borrows from many approaches and disciplines, which enables it to draw from a variety of techniques and interventions with a creative and experimental approach (Joyce and Sills, 2010; Mackewn, 1997). Unlike other approaches, a gestalt approach is able to offer a unique, holistic and individualized approach focused on the therapeutic relationship (Flemming crocker, 2005; Yontef, 2005). “It provides a comprehensive theory and method, based on understanding and observation of healthy human functioning-organismic self-regulation” (Gold & Zham, 2008, p.32).
In the last 15 years the term 'relational gestalt' has become more widely accepted within gestalt literature, training and practice (Joyce & Sills, 2010). This shift in focus has placed emphasis on the value of the therapeutic relationship and the dialogic process between the client and the therapist. This is consistent with gestalt therapy's history of a solid relational foundation (Bloom, 2008; Hycner, 1988; Hycner & Jacobs, 1995; Jacobs, 1989) that can be seen throughout its evolution of theory and methodology (Yontef, 2002, 2009; Yontef & Bar-Joseph, 2008). It incorporates a range of experimental and phenomenological methodologies (Gold & Zham, 2008 Yontef & Jacobs, 2013) to facilitate its primary goal of awareness through contact (Bowman, 1998; Kritchner, 2015, Yontef, 1993; Yontef & Jacobs, 2013). Sharf (2014) explained that “the general goal of gestalt therapy is awareness of self, others and the environment that brings about growth and integration of the individual” (p. 248). The literature supports this theoretical field perspective that recognises the interconnectedness between an individual’s environment and experiences, both phenomenological and ontological (Lewin, 1952; Parlett, 1991; Parlett, 2005; Yontef & Jacobs, 2013). This field-sensitive approach considers the entire experience of the therapist and client, along with all the complexities of the therapist and client (Parlett, 2005; Perls, Hefferline & Goodman, 1951/1994; Shub, 1992). Yontef & Jacobs (2013) stated that “one moves towards wholeness, by identifying with ongoing experience, being in contact with what is actually happening, identifying and trusting what one genuinely feels and wants” (p. 299). It views the whole organism as comprising more than the sum of its parts, and pays equal regard not only to the whole form, but the parts which form its configuration (Kirchner, 2015). This philosophy underpins the process of phenomenological enquiry and contact through which the client is able to develop self-awareness and understand their way of relating (Latner, 2000; Parlett, 2005). One way gestalt therapy pays attention to the relational aspect within the therapeutic relationship is through dialogue.
Dialogue that is phenomenological and relational enables an experience of contact (Hycner, 1991; Parlett, 2005; Yontef, 1993). Individuals can come to know themselves by becoming aware of what is “me and not me" (Yontef, 1993 p. 126). This experience allows the client to become an active and aware participant in their life (Kritchner, 2015; Spagnuolo Lobb, 2005; Yontef, 1993). The therapist creates a supportive environment of care, trust and respect (Yontef, 2005), free of preconceptions, judgements or expectations (Yontef, 2003) by allowing the client to be who they are and, in turn, holding their own sense of self, and staying true to who the therapist is (Yontef, 1993). By modelling the therapist’s phenomenological expression, the client can experiment with authentically communicating their own immediate experience (Yontef, 1993). Mcconville (1995) stated that “it is through the physical body that we make contact with the world and experience ourselves” (p. 232). As the client begins to make contact, they re-establish a connection to their body (Blaney& Smythe, 2001; Mcconville, 1995), and the therapist supports this exploration between the individual, environment and 'creative adjustment' (Yontef, 1993; 1995).
Eating disorders can be seen as interruptions to this healthy self-regulation process (Angermann, 1998). Gestalt therapy considers many of the behaviours of eating disorders as 'creative adjustments' (Angermann, 1998; Gillie, 2000) that provide a way of coping with stress or negative experiences, and controlling ones environment (Angerman1998; Blaney & Smythe 2001; Clarkson, 2000). Creative adjustment made through conformity or habitual patterns are defined as the opposite of healthy self-regulation (Yontef, 2005). Gestalt therapy accepts an individual’s perceptions of reality, acknowledging them as a situational response to their current environmental field conditions (Angermann, 1998; Kirchner, 2015; Maurer, 2005). It encourages the exploration of creative adjustments (Bowman, 1998; Maurer, 2005; Sharf, 2014) through its experiential nature, and supports the client to deepen their level of contact (Mackewn, 1997; Parlett, 2005; Yontef, 1993) by bringing awareness to creative adjustments in the present therapeutic relationship. The individual has the opportunity to look at their actions and behaviours (Blaney & Smythe 2001) and co-create new and positive experiences where they can try out new behaviours, thoughts and feelings with choice, awareness and creativity (Wheeler & Axelsson, 2015; Yontef, 2005).
Gestalt therapy is considered, by its nature, transdiagnostic (Denham-Vaughan, 2005, p14), that is, its approach is unique in its ability to understand disorders beyond the traditional medical model of diagnosis. Gestalt theory and practice views disorders from a behavioural and psychological perspective that does not separate the individual from the diagnosis or disorder (Angermann, 1998; Gillie, 2000). Its inter-relational nature (Blaney & Smythe, 2001; Kirchner, 2015) supports an effective diagnosis through collaboration between therapist and client (Wollants, 2012). It provides a unique approach tailored to the individual, by acknowledging various elements as contributing to a person experiencing an eating disorder. This methodology is considered to be well suited to working with the multi-factorial complexities that present in eating disorders (Angermann, 1998; Blaney & Smythe, 2001; Pfluger, 2014), and is an effective part of a multi-disciplinary approach in the treatment of eating disorders (Angermann, 1998: Gillie, 2000; Pfluger, 2014).
Conclusion
This paper has argued that eating disorders are ecological in nature. They are multi-determined and interdependently enmeshed with an individual through relationships, their environment and many causal factors. There is no agreement in the literature about the aetiology of an eating disorder, nor does the research find support for a single definitive treatment approach that is suitable for all individuals experiencing an eating disorder.
A review of the literature has suggested that whilst many therapies are suitable in the treatment of eating disorders, gestalt therapy is the most effective ecologically based therapy as it effectively emphasises and focuses on the therapeutic alliance, whilst drawing on a variety of eclectic approaches and techniques tailored to the individual. A current draw back to gestalt therapy is the challenge it faces in becoming recognised as an empirically validated approach. There is a paucity of gestalt therapy research that is clinically relevant and provides evidence on how gestalt methodology can impact the treatment of eating disorders. Further research and scientific evidence needs to be undertaken to show how specific gestalt therapy concepts and techniques correlate to the effective treatment of eating disorders and how they can be used as part of a collaborative approach. What is missing from the literature is how a collaborative and trans-diagnostic approach that integrates a variety of stakeholders within the community including family, schools, media, and clinical professionals can be developed. The development of this approach holds strong promise in how we might begin to understand the complex ecology of an individual’s eating disorders.
Natajsa is a Clinical Psychotherapist in Private Practice working with individuals, couples and groups. Natajsa is an advocate for authentic conversations that connect us. Natajsa believe's that the relationship we have with ourselves and others is the essential ingredient to our emotional health, happiness and wellbeing.
As a Gestalt therapist in Brisbane she is passionate about speaking and teaching on the topic of moving from loneliness to belonging and the importance of human relationships. Her focus is on helping people develop self-awareness and understanding of our challenges, so we can create change that leads to more fulfilling and meaningful lives. Natajsa has been featured as an expert both locally and internationally and has contributed to a number of print and online media outlets including Women's Health and Fitness Magazine, Cosmopolitan Magazine & ABC Online.