Understanding Relational Therapy and Why It Matters in Eating Disorder Treatment

When people ask what it means to be a relational therapist, I often smile, because it’s a term I myself didn’t know until a few years ago. The foundation of relational work builds on multiple influences. One of the most enduring is Carl Rogers, whose humanistic, person-centred approach deeply influenced my orientation and values. However, the specific model often referred to as relational-cultural theory (and by extension relational therapy) emerged later from feminist and relational development scholarship, particularly the work of Jean Baker Miller and her colleagues at the Stone Center for Developmental Services and Studies.

The old-school psychoanalytic model often featured a distant therapist, a power imbalance, and the client reclined on a couch, with minimal acknowledgment of how the therapy relationship itself did much of the work. In contrast, Rogers challenged that paradigm: he asserted that therapy is a human-to-human encounter, and that three core conditions—empathy, congruence (therapist genuineness), and unconditional positive regard work together to create a climate for meaningful growth.

Rogers’ person-centred approach emphasised that the client is the expert in their own life and that the therapist’s role is not to direct, but to facilitate a safe, accepting, attuned space. The relational dimension of all human growth was implicit in his work.

The relational-cultural model, by Miller and colleagues, formalised the idea that connection (rather than separation or autonomy) is central to healthy human development. It arose within feminist psychology in the 1970s at the Stone Center, featuring Jean Baker Miller, Judith V. Jordan, Irene P. Stiver and Janet L. Surrey. They emphasised that disconnection (both relational and cultural), is a major source of suffering, and that growth-fostering mutual relationships heal.

In practice, a relational therapist is someone who acknowledges that the therapeutic relationship itself is not incidental but part of the repair. The therapist focuses on attunement, authenticity, mutuality (while maintaining appropriate boundaries), and understands the ways the client’s relational patterns (attachment, trauma, interpersonal struggles) show up in therapy. The relationship becomes the vehicle through which connection and healing can happen.

One of the contemporary theorists who most deeply embodies and expands the relational tradition is Diana Fosha, PhD, founder of the Accelerated Experiential Dynamic Psychotherapy (AEDP) Institute. According to her Institute, AEDP is healing-based, “radically relational, transformation-oriented, experiential” psychotherapy grounded in positive neuroplasticity, attachment theory, affective neuroscience, and developmental research.

Fosha’s core premise is that healing happens in relationship, through emotional processing that unfolds in the presence of an attuned, regulated other. She names concepts such as undoing aloneness, a “transformational process that arises from emotional experience felt together”, and “existing in the heart and mind of the other.” Moment-to-moment relational experience is understood as a driver of neurobiological change.

What also moves me about Fosha is not only her theory, but her transparency about its origins. In an interview I heard, she spoke about her first book, published in 2000, and how much of its thinking emerged from her own experiences as a client in therapy, experiences where she either did not receive, or occasionally did receive, the kind of attuned presence she later articulated so clearly. She admitted that earlier in her career she would never have shared that publicly. But over the years she came to believe that naming her own relational experiences gave integrity and honesty to the approach she was developing.

Hearing her speak about this had a profound impact on me. For me, integrating Fosha’s orientation means recognising the relational field not only as the context for healing, but as an active agent of change, especially for clients whose deepest wounds are relational or attachment-based. Fosha’s disclosure, and admittance of the hesitation she had initially felt about it, demonstrate her commitment to authenticity - and I (and I'm sure many others), felt genuine affiliation and connection to her by hearing about it. 

Now, having done my best to lay out an overview of what a relational approach to therapy is, I will attempt to explain why I believe it is so valuable in regard to the treatment of eating disorders. I will additionally try to describe how the mechanism underpins my work. My hope is to both demystify the process in order to establish better understanding of the benefits for clinicians, and also to give language to clients in the hope that it will clarify and empower their experiences.

People often ask why eating-disorder treatment intimidates therapists who otherwise feel comfortable working with intense struggles such as trauma or mood disorders. Firstly, in their most acute forms, eating disorders can be life-threatening. Medical fragility and compromised health require careful, often team-based intervention. No ethical clinician treats acute cases alone; supervision, medical collaboration, and continuous consultation are essential.

But the hesitation, I believe, is also personal. Getting up close and personal with the symptoms of an eating disorder confronts our own relationships with food, body and ultimately our shame around it all. When I train educators and therapists on best-practice when supporting people who may have difficulties pertaining to eating and body image, I begin by asking them to reflect on the last time they ate for comfort or distraction, felt compulsive around food, or struggled with body-image.

These experiences are universal. They show up even in Jewish liturgy. On Yom Kippur, we explicitly confess “the sins committed through food and drink.”

Food is evocative in a deep way; it can be comforting, symbolic, pleasurable, nurturing, energising - dare I say even relational in some way. Eating sustains us, it fuels us, it offers us joy and satisfaction, distraction and routine. It is the first way infants experience connection to their mothers, through the umbilical cord in the womb and later if breast fed, through the mother’s milk, and if formula fed a bond is formed between infant and the person who bottle feeds them. 

It is easy to understand why humans can end up eating in comforting, compulsive and addictive ways. The feelings of nourishment and embodied fullness elicited from food can become alluring. The dopamine released from consuming food can easily replicate the feeling of serotonin (the hormone that causes a feeling of connection). An activated nervous system looking for a sense of safety can access food fairly easily in most cases, and in most cases will receive the response it yearns for from the food - well, at least temporarily. 

Parallel to this, we also operate in a world where societal beauty standards and systemic body ideals do not align with the experiences of a population who seek comfort, connection and regulation through eating. The idealization of an unrealistic, unsustainable and unhealthy body size turns food and eating into the enemy. Those who eat, certainly those who eat too much, or too much of certain foods become pariahs in this discourse. 

What a painful dichotomy: a species who longs to indulge in the sweet comfort and nurture of deliciousness, but who is also raised to fear the results of such seeking. I have heard it said by many “my dream is to be able to eat whatever I want, whenever I want, but to not gain weight”. 

The global obsession with body shape and size and the miserable pressure it exerts, sneaks into the consciousness of even the most confident, self aware and healthy minds. Much like the innate sense of comfort and joy that eating can bring. This emotional polarisation is what in therapy talk we call a “dialectic”. Holding two opposing truths at once. 

Another truth that can add even more complication to the mix, is shame. It can feel very shameful to admit that we struggle with a desire to eat for reasons beyond hunger. Although (as I have suggested) it is somewhat intrinsically human, contemporary rhetoric likens it to loss of control, greediness and a lack of discipline. Likewise, it can feel shameful to admit that looking in the mirror elicits feelings of embarrassment, dissatisfaction or even self-loathing. Those experiences may feel easier to delegate to the insecure, the vain and the mentally unwell. 

So for a therapist to bravely admit that they also struggle with these things (be it infrequently or frequently), can feel like an admittance of failure, instability or lack of professionalism. Many mental health professionals may not even be wholly aware of the nuances of their relationship with food and body, living in a somewhat blurry state of denial and dismissal. 

So, when a client walks in and describes feeling and acting in ways, which for them bring deep and desperate despair, and those feelings and behaviors either echo or explicitly describe feelings and behaviors a therapist may know personally, for someone unprepared, the experience can be quite destabilizing. Perhaps even threatening.

And in such moments we must then bring out the cavalry: “They can’t really be so bad, I mean, loads of people do that - I do that… They can’t possibly find that so hard to stop, I mean, I can stop myself when I want to do that… they look great, better than me actually, it’s ridiculous they can’t see it… well we all know that is so unhealthy, surely that’s enough to stop - that’s what I tell myself… `well, they are kind of fat, if I looked like that I would also want to lose weight… I also hate my body and am doing all I can to lose weight, so I totally get and support what they are doing!”... The list goes on. 

Unexamined internal reactions can lead therapists to minimize, shame, dismiss and even validate and enable their clients’ experiences. Relational work requires us to un-blend from our own feelings and experiences so we can attune accurately and not impose our stuff onto our clients. When their presentation elicits feelings of shame, self-questioning or confronting identification, it is hard not to become protective of our own experiences and feelings, which can lead to us dismissing theirs (positively by affirming things that are causing them harm, or negatively by not comprehending the severity of things that are causing them harm). This self-protective denial can block us from meeting their experience with an open-mind and full presence, and the anxiety their presentation can cause us to feel internally as all this unfolds, can undoubtedly feel quite intimidating.  

A major skill in eating disorder therapy is being able to pick up on subtle nuances that the client may signal. These may be vague connotations, quiet hints, shifts in demeanor or posture, facial expression, movement, the use of specific words or sentence structure, vocal tone… When  attuned without being clouded by their own shame around food and body, a therapist can even use their own experiences of struggle around food and body to help inform what they are picking up on: “When I speak like that/ move like that it is because I am feeling nervous and self-conscious. She did that as she told me that she was “fine” and had had “an ok week with food”. I felt that her “fine” and “ok” were full of other information. I want to know more. I can feel that my question about how her eating was this week elicited emotions she is not currently feeling safe to share. I get that, I know shame. How can I meet her heart in this and let her know I recognise she isn’t sharing everything, that there is more and she doesn’t want me to know because that feels threatening, without increasing her feeling of threat, shame and fear?”

Internal Family Systems (IFS) is an evidence-based psychotherapy model developed by Richard C. Schwartz, which understands the mind as a system consisting of multiple ‘parts’ that protect a person from emotional pain.

Through an IFS lens, eating-disorder behaviours are protective. Restricting, bingeing, purging, calorie-counting, obsessive thinking are ‘parts’ that get called managers or firefighters - guarding younger parts known as exiles who carry shame, terror, or attachment wounds.

If you push too fast, the system becomes more rigid. The client retreats further into the disorder, or pushes you away.

This is where relational therapy becomes invaluable. Before any behavioural change is possible, the client must feel safe - with themselves and with the therapist. Safety is a nervous-system experience of being accompanied rather than judged or controlled. This can only happen if the therapist is attuned to themselves enough in these areas, not to judge or control. Only when a client feels this kind of relational safety do we gain access to the scaffolding beneath the eating disorder.

My belief in the relational approach is not just born of my own experiences as a clinician with a sprinkle of intuition, it’s backed by evidence. Several research studies have examined the intersection of relationship-focused therapy for eating disorders. One study found that individuals with Bulimia and Binge Eating often present with interpersonal difficulties, and relationally focused treatments show meaningful benefit. Another piece of research conducted by The National Eating Disorder Association emphasises relational therapy as a powerful antidote to the inner critic, isolation, shame, and emotional disconnection experienced by many people with eating disorders, and how its application can reduce not only those symptoms, but subsequently the disordered eating behaviors too.

These sources affirm what I’ve seen clinically; when we bring relational attunement into eating disorder work, we are not simply modifying food behaviours, we are repairing the deeper ruptures in attachment, regulation, shame, and relational disconnection that can drive those behaviours.

Eating disorders often emerge where emotional needs for safety, attunement and connection may not have been met. As Anita A. Johnston writes in Eating in the Light of the Moon (2000), emotional experiences that are not mirrored or held can create a kind of emotional hunger that feels too frightening or forbidden to name.

Johnston describes restriction as the shutting down of needs; bingeing as an attempt to fill emptiness, purging as a symbolic expulsion of unbearable feelings, counting and obsessing as creating predictability when relationships feel unpredictable, and compulsive eating as a substitute for co-regulation. Her central argument is that eating disorder behaviours are not about food, they are metaphors or symbolic attempts to regulate when relational expression feels unsafe.

Relational therapy directly targets this dynamic. When clients experience attunement and emotional presence in therapy, their nervous systems settle. They feel less alone, and therefore more open to delving into the exiled and critical inner narratives and painful yearning that lays the foundation of their disordered patterns - and subsequently as those things are tended to, they become more resourced and can learn ways to sooth and comfort themselves without turning to food behaviors. 

REFERENCES

Schwartz, R. C. (1995). Internal Family Systems Therapy. Guilford Press.

Psychology Today (2024). “Carl Rogers.” 

https://psychology.town/fundamentals-of-mental-health/carl-rogers-person-centered-theory/

Yao L, Kabir R. Person-Centered Therapy (Rogerian Therapy) [Updated 2023 Feb 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589708/

Yeshiva University Online. “Carl Rogers and Humanistic Psychology.”

Johnston E. (2025) “Relational-Cultural Therapy.” https://peoplepsych.com/relational-therapy/#:~:text=In%20large%20part%2C%20relational%20therapy,led%20her%20to%20relational%20therapy.

McCauley M. (2013) Wellesley Centers for Women (WCW Online). “The Development of Relational-Cultural Theory.” 

https://www.beyondintractability.org/essay/relational-cultural-theory#_edn2

Rogers, Carl R. (1942). Counseling and psychotherapy: newer concepts in practice. Boston: Houghton Mifflin. ISBN 978-1406760873. OCLC 165705.

NBCC TPC Journal. “A Relational-Cultural Framework.”

AEDP Institute. “Diana Fosha.” https://aedpinstitute.org/diana-fosha/

Machzor for Yom Kippur, Al Chet confessional liturgy.

Thompson-Brenner H. (2016). Relationship-focused therapy for bulimia and binge eating: Introduction to the special section. Psychotherapy (Chic). 

https://pubmed.ncbi.nlm.nih.gov/27267502/

Scaringi V. (2025) National Eating Disorders Association (NEDA). “Relational Therapy: The Antidote to Your Nasty Inner Critic.” https://www.nationaleatingdisorders.org/relational-therapy-antidote-your-nasty-inner-critic-and-need-lifeline-over-holidays/

Johnston, A. A. (2000). Eating in the Light of the Moon. Gurze Books.