Eating Disorder
Ava, 22, college senior
Fictional teaching case
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BMI 17.8, restricting intake to ~800 cal/day with compulsive exercise. GPA 3.9. Reports feeling 'in control' when restricting but terrified of losing control around food. Fainting episodes. Amenorrhea for 6 months. Roommate called campus counseling center. Ava says: 'I don't have an eating disorder. I'm just disciplined. Everyone in my family is heavy and I refuse to end up like them.'
Read the full case history and clinical context
Parents divorced at 10. Mother is obese and emotionally volatile: 'food was love, food was comfort, food was everything.' Father critical, appearance-focused, praised Ava for being 'the thin one.' Restriction began at 15 after a comment from a ballet teacher. Hospitalized briefly at 17 but left AMA. Currently in a highly competitive pre-med program. Identifies as queer. No current relationship.
Compare how approaches understand this case
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Showing 2 of 8 formulations.
CBT-E
Ava's self-worth is disproportionately dependent on eating, shape, and weight, and her ability to control them. This overvaluation drives the dietary restriction, which drives the physiological and psychological consequences (cognitive rigidity, preoccupation, bingeing risk). The maintaining mechanisms are the clinical target, not the developmental history.
Stage One: real-time self-monitoring, collaborative weekly weighing, and establishing regular eating (three meals, two to three snacks). Because Ava is underweight, the protocol adds a step the standard version does not have: helping her reach her own decision to regain weight, which CBT-E treats as a choice she has to make rather than one imposed on her. Stage Two: a short joint review of progress and obstacles. Stage Three: whichever maintaining mechanisms are actually active, which may include over-evaluation of shape and weight, dietary restraint, clinical perfectionism, core low self-esteem, mood intolerance, and interpersonal difficulty. Stage Four: ending well and relapse prevention.
"Right now your brain is running on fumes, and that's making everything feel more urgent and rigid. The first step isn't about weight: it's about getting your brain fed enough to think clearly about what you want."
DBT
Restriction is emotion regulation through behavioral control. When Ava feels out of control emotionally (abandonment fear, shame, anger at her parents), she regulates through the one thing she can control, which is intake. Compulsive exercise does the same job. The behaviors are maladaptive but functional, which is why removing them without replacing the function tends to fail. The honest caveat is that Ava's profile is overcontrolled rather than undercontrolled, and standard DBT's biosocial model was built for the second. Lynch's RO-DBT exists because of that gap.
Stage 1: Target life-threatening behaviors (restriction at this BMI is medical risk). Diary card tracking ED behaviors, urges, and emotions. Distress tolerance skills. Emotion regulation skills to replace restriction. Mindful eating.
"The restricting works. It does bring a feeling of control. I'm not going to pretend it doesn't. But it's also putting you in the hospital. Can we find ways to get that control feeling without the medical danger?"
FBT / Maudsley
FBT is built for adolescents, so at 22 Ava is past the range the manual was written and trialled for, and anything done here is an adaptation. What FBT would not do is the thing this history invites: it takes no position on whether her mother's relationship with food or her father's conditional approval caused this. Agnosticism about cause is not tact, it is the model's break from the older psychosomatic-family theories, and it is what makes parents usable as a resource rather than as suspects. The working questions are practical. Who can be mobilised to take charge of refeeding, and has the household organised itself around accommodating the illness?
Phase 1: Parents (or parent figures) take charge of Ava's eating. Externalize the illness: Ava is not choosing this. Phase 2: Gradually return eating control to Ava as weight restores. Phase 3: Address developmental issues (identity, autonomy, relationships).
"[To parents] This illness has taken over your daughter's ability to feed herself. Right now, she can't do it: the anorexia won't let her. You need to step in. Not as punishment, but because she needs you to fight this with her until she can fight it herself."
IFS
A manager part, 'the disciplined one', has been running the system since the ballet comment at 15, maybe earlier. Managers work proactively, and restriction is the archetypal one: it keeps the exiles from ever being activated in the first place. The exiles are the terrified child who watched her mother lose control, the shame of her father's conditional approval, the fear that without restriction she becomes her mother. Firefighters are what would show up if the manager ever failed and the exiles broke through, which is exactly what Ava is describing when she says she is terrified of losing control around food.
Build a relationship with the Protector (the restricting part). Honor its intention: it's been trying to keep Ava safe from becoming her mother. Ask what it's afraid would happen if it stepped back. Gradually access the Exile underneath: the girl who learned that her body was only lovable when thin. Help Self lead.
"The part of you that restricts: it's been working incredibly hard. Since you were about 15. Can you get curious about it rather than identifying with it? What is it afraid would happen if it stopped?"
Gestalt Therapy
Two interruptions to contact are running at once. Ava has swallowed whole, without chewing, her father's equation of thinness with worth and ballet's account of an acceptable body. Perls built the theory of introjection on exactly that metaphor, and an eating disorder is where it stops being a metaphor. The 'discipline' is then retroflection: turning against herself what she cannot express outward, which is rage at her father's conditional love, grief about her mother, and terror of her own need. Hunger, need and body all get disowned. She is out of contact with her organismic self.
Restore contact with disowned experience. Empty chair work with the critical father, with the body she's starving, with her mother. Explore polarities: control vs. surrender, discipline vs. need, thin self vs. feared fat self. Attend to what's happening in the body NOW: hunger, tension, numbness.
"I want to try something. Put your hunger in that empty chair. What does it look like? What would you say to it? ... Now switch. Be the hunger. What do you want to say to Ava?"
Narrative Therapy
The anorexia has recruited Ava with a story: 'I am disciplined. I am in control. I am not my mother.' In White's sense the story is thin, meaning it draws a whole identity from a narrow band of evidence and leaves no room for hunger, pleasure, connection or vulnerability. It was authored partly by her father, partly by ballet culture, partly by diet culture.
Externalize the anorexia: give it a name, map its influence on her relationships, her studies, her queer identity. Search for unique outcomes: times she ate with pleasure, felt comfortable in her body, resisted the anorexia's voice. Re-author.
"If we gave this voice a name (the one that says you're disciplined, that everyone else is weak), when did it first show up in your life? And has there ever been a time you talked back to it?"
Short-Term Psychodynamic
Restriction as defense against engulfment and loss of self. Mother represents the terrifying absence of boundaries (food is love is comfort is everything: no differentiation). Father represents the equally terrifying condition for love (be thin or be unloved). Ava's anorexia is a compromise formation: maintaining separateness from mother while securing father's approval. The body becomes the battleground for individuation.
Agree one dynamic focus early and hold it: restriction as a defense against need. Work the triangle of conflict, tracing how the impulse (hunger, dependency, rage at both parents) provokes anxiety and is met by the defense of control, and the triangle of person, tracing the same figure through her father, her mother, and the therapist. Watch the transference, which arrives fast in a time-limited frame: will Ava please the therapist, or defeat her? The time limit is itself a technical instrument, because a scheduled ending is a scheduled encounter with loss and need.
"You said food was everything in your mother's house. I wonder if part of what you're starving isn't just calories: it's need itself. As if needing anything makes you her."
Feminist Therapy
Ava's restriction is not individual pathology. It is a legible response to a culture that rewards women for taking up less space, a family that made love conditional on appearance, and a framework that equates female thinness with virtue and self-command. Feminist work on eating disorders, from Orbach through Bordo, insists the act is doubled: Ava is submitting to the demand and, in her own terms, defeating everyone who cannot meet it. Reading it as compliance alone loses the part of it that feels to her like power, and that part is why she does not want to give it up.
Consciousness-raising about cultural messages. Examine how gender, family, and queer identity intersect in her relationship to her body. Explore restriction as both compliance with and rebellion against cultural demands. Power analysis: who benefits from Ava starving herself?
"In a culture that tells women, and especially queer women, that your worth is your body, restriction makes a certain kind of sense. It's not crazy. But I want us to ask: whose voice is telling you to be smaller? And what would it mean to take up space?"
Where Approaches Genuinely Disagree
Normalize eating behavior first. The starved brain cannot do therapy.
The eating disorder serves a function: control, self-punishment, expression. Treating behavior without meaning risks symptom substitution.
Philosophical Lenses
These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.
Ava's restriction is not simply a pathology of body image. It is a response to the situation of being a woman in a culture that simultaneously demands women's bodily compliance and denies women's subjectivity. The 'control' she feels is the only form of freedom available within a system that controls her: an attempt at transcendence through the body that collapses into immanence. Her 3.9 GPA and her 800 calories are the same gesture: proving she can exceed the demands placed on her. De Beauvoir would say that individual therapy without addressing the structures that produce this situation is inadequate: Ava is not merely sick, she is enacting the impossible contradictions of femininity.
Ava's relationship to food is a relationship to the maternal body: to incorporation, boundary, and abjection. Restriction is a refusal of the abject: the formless, the messy, the out-of-control. By controlling what enters her body, she maintains the boundary between self and not-self that the maternal relationship first established and first threatened. Her terror of 'losing control around food' is a terror of dissolution: of the body's porousness, its refusal to stay contained. Kristeva would see the eating disorder as a crisis of subjectivity that plays out at the border of the body, where meaning and matter, self and other, are never fully separable.
The clinical gaze that diagnoses Ava (BMI calculations, calorie counts, amenorrhea as symptom) reproduces the same disciplinary logic that produced the disorder. Her body is measured, weighed, monitored, and found deficient. The eating disorder and its treatment are both technologies of the self in a biopolitical regime that governs through the body. Ava has simply taken the culture's techniques of bodily management (dieting, exercise, self-surveillance) to their logical conclusion. The question is not how to correct her deviance but how to recognize that her 'disorder' and the culture's 'health' are on the same continuum.
Sources & Method
This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.