Schema Story: Eating Disorders

Schema Therapy is effective for treating eating disorders because many of the concerns faced by patients with eating disorders are often related to attachment needs. Schema Therapy largely addresses these attachment needs, and in recent years, more and more research supports its efficacy in treating eating disorders. (1) (2) (3) (4)

When Ning came to my office, her height and weight were normal. Her parents were both healthcare professionals and believed she was just overly anxious about exams, which led to the bad habit of biting her fingers. However, she often bit too hard, causing her fingers to bleed continuously, so they brought her in for assistance. When I pointed out that Ning actually had an eating disorder and occasionally engaged in binge eating, her parents were shocked.

Why Binge Eating?

Many people think that eating disorder patients must have a noticeable outward appearance, but that's not always the case. Many patients have a normal height and weight (of course, things can change over time if the illness lasts long enough), but most patients delay seeking medical help until their bodily functions are compromised. Ning’s issues weren’t just related to exam stress; they were long-term. She always thought she was fat and ugly, weighing herself every day, planning each meal meticulously, calculating calories, and considering cooking methods. Since she lived in a university dorm and only saw her parents on weekends, they had no idea how strictly she controlled her diet.

At the same time, she had a compulsive exercise habit, insisting on doing an hour of exercise every day, even if she was exhausted from activities, and would only allow herself to rest after completing this exercise, even if it was eleven o'clock at night. But on the other hand, she would occasionally binge eat, consuming large amounts of snacks, usually ones she avoided, like chips and ice cream. She once ate ten cups of ice cream in one night, and her stomach hurt so badly that she almost needed to call an ambulance when her roommates saw her face contorted in pain.

Of course, her parents were completely unaware of all this. Especially binge eating, which is usually done privately; eating disorder patients typically don’t binge in front of others because it feels shameful. In fact, most eating disorder patients have Shame Schema and feel deep down that they are worthless, often tending to punish themselves. Although questionnaires may not necessarily reflect this, therapists with experience in eating disorders will know that most patients also have Enmeshment / Underdeveloped self-Schema. Much of the therapy process is about helping the client gradually rediscover themselves and regain their autonomy.

Ning’s parents were both doctors, and they felt guilty and ashamed that their daughter had developed this illness without them realizing it. At first, they refused to believe the diagnosis until I presented various diagnostic questionnaires and explained them to them. Only then did they accept the reality of their daughter's condition.

Ning was very loyal to her parents. Throughout the entire process, she consistently protected her parents' dignity, never once criticizing them. This was actually more puzzling to me—what perfect parents exist in this world? It’s normal for children to have some dissatisfaction with their parents. I know that when working with eating disorder cases, building a relationship is the most important thing. If she wasn’t ready to talk, I would wait for the right moment. I talked to her about her concerns: weight, exercise, and anxiety.

Most eating disorder cases are forced to attend therapy sessions and show little interest, making it hard for therapists to engage. But Ning was a very cooperative case. She was motivated to recover, so she answered every question, and soon we were discussing how she felt like a failure, like she was worthless.

"I’m not the best dancer, and my grades are average. I have no strengths."

When I pointed out that the university she was attending was actually quite good, and that dancing didn’t necessarily require being the best to be considered a strength, she disagreed. "In my dance group, many people are better than me….’ Her voice is full of contempt.

Basically, whenever I affirmed her, she would compare herself to those who were better, and the conclusion was always: "I’m worthless."

When I invited Ning to do a chairwork, where she sat in one chair and spoke to an empty chair opposite her, expressing her thoughts about herself, she cried as she spoke: "You’re useless, a piece of shit. After all these years, despite your parents' hard work, you’re still a worthless failure!" The Punitive Parent Mode emerged. Although she hadn’t switched seats, her internal sense of shame and defeat was palpable.

I said, "It seems like your heart has already moved to the chair across from you. Is that right? Please move to the other chair."

Ning obediently moved to the opposite chair, sat down, and cried as she looked at me, saying, "I think she’s right."

"Please tell her," I asked.

"You’re right…" she replied.

"Can you tell her how you feel?" I asked gently.

"I feel ashamed." Ning curled up on the chair, hugging her legs, as if trying to shrink herself.

Often, when eating disorder cases do chairwork, they experience different body sensations, like itching all over, nausea, or restlessness. There are often difficult-to-clarify, complicated emotions and conflicting thoughts, all of which seem to manifest as body sensations. Ning’s response, in particular, was similar to someone trying to hide when feeling ashamed.

"Do you think she helped you?" I asked, pointing to the empty chair where she had been reproaching herself.

Ning hugged herself, shaking her head, and kept crying.

I repeatedly invited Ning to say "You didn’t help me," but she couldn’t. She just hugged herself, rocking back and forth, silently crying.

Eventually, I came to understand that her Vulnerable Child Mode might be younger than what others typically have, lacking even the language to express herself and only able to cry. So, whenever she sat in the Vulnerable Child position, crying but unable to speak, I would sit beside her, place my hand on her shoulder, and gently say: "I know this part of you is painful and unable to speak, just like how in real life, you sometimes feel indescribable pain. Though this part of you can only cry, I also need to respond to the Punitive Parent on your behalf." I speak assertively to the empty chair across from us: "Please stop talking! Ning is not trash, and she doesn’t need to feel ashamed! If you keep talking, I’ll kick you out!"

Ning needed some time to slowly calm down.

In the early stages of therapy, my main job was to co-regulate her emotions with her. I suspected that she had rarely been hugged, cared for, or soothed in managing her emotions as a child. Though we were both women, our relationship was still quite new, so I wasn’t yet at the level where I could offer her a hug, but I did place my hand on her shoulder, accompanied her in her sadness, and provided her with tea and tissues, patiently comforting her.

Using Food to Numb Herself

Three months passed, and she finally started talking a little about her childhood. Her parents were both doctors at a public hospital, busy with their shifts, and her primary caregivers were domestic helpers. She felt that the workers were kind to her, but they couldn’t offer the patience and warmth that family members could provide. Her childhood memories were vague, with few things standing out. Every day was about attending class, taking extra lessons, and participating in extracurricular activities—a typical schedule for children of working parents, who arrange various classes for their children so they won’t be wasting time with the domestic helpers.

Her life was already carefully planned out. Ning was used to a structured life, where everything was predictable, which was the kind of safe environment a child needs. However, her parents' excessive lack of involvement made her feel lonely and isolated from a young age. The rigid structure of her life continued into her adolescence—during the stage when her developmental need becomes independence, she still lived the same way.

"When do you feel like you get more attention from your parents?" I asked.

"When I cry, when I’m in trouble, or when I fail," Ning said, looking down.

"Could you explain that?" I asked.

"When I was a child, if my parents were home, they would come check on me when I cried… When my grades dropped, my mom would find me a tutor… When I lost a dance competition, my mom would find me a better teacher..."

"It seems that when you had problems, you got help and attention, but when you were happy, calm, or bored, they didn’t pay attention to you?" I asked.

"When I’m helpless = I get attention, and I’m no longer lonely," I thought to myself. Her helpless surrender mode likely gave her the sense that she was loved.

"We don’t talk when we eat as a family," Ning said.

Ning was very lively among her friends and had many friends. It was hard for me to imagine her eating silently at home. Her parents weren’t unloving; they just didn’t know how to love her. They were very serious people, even a bit awkward and quiet, excelling academically but not very playful. Ning, on the other hand, was sensitive and enthusiastic, but at home, her enthusiasm seemed to have nowhere to go.

Ning was used to being quite detached from her body. Not only did she not notice that she was bleeding when biting her fingers due to anxiety, but she also often ended up with bruises without realizing how it happened. Like many people with eating disorders, Ning rarely felt hunger or fullness, because her eating habits were determined by her mind, not her body. She had learned to use thinking to decide when and what to eat, and for her, this gave her the most control over eating.

"I see my mom eat more than I do, and she’s fatter than me, so I feel a bit more at ease…"

"When I go out to eat with friends, I usually look up the menu online in advance to decide what I want to order. If I get to the restaurant and they don't have the dish I was planning to order, it throws me off. In those moments, I’ll look at what my friend is eating and think, 'Well, she’s thinner than I am, and she’s eating this, so maybe I should order it too…'"

"Then when I see her not finishing her meal, I feel like I should stop eating too."

Eating, in Ning's life, isn’t just about putting food into her body, but also about taking in the sense of control.

She uses managing her eating as a way to manage the anxiety and unease her feelings about unpredictable things in her life. She is extremely afraid of any uncertain situation, so her daily life is meticulously planned, with her schedule tightly packed, almost to the point of every hour being accounted for.

"If I can't even manage my weight, what can I possibly do?"

When she was willing to record her meals every week, I invited her to act out a binge-eating episode. "What did the voice in your head say at the time?" When I asked her to sit in the chair and perform the disordered eating voice, Ning reenacted the inner voice of a Punitive Parent.

"You haven’t achieved anything today, you shouldn’t be eating so well. You should go run for an hour, at least that way there’s some justification."

I asked her, "How did you make her binge eat?"

"I didn’t. She’s useless. I told her not to eat, but she went off and binged anyway!"

I realized that to uncover the truth, I needed to have her switch to the opposite chair. "Please get up and leave that Punitive Parent behind. Sit in that chair please."

Detached Self-Soother Resisting the Punitive Parent?

Ning sat across from me, and I asked her, "When you hear the Punitive Parent on the other side telling you that you haven’t produced anything, how do you feel?"

"Very ashamed…" Ning cried again, but her body wasn’t as tense as before.

"And then what? She said you went and binged?" I asked, genuinely confused.

"I felt like nothing I did mattered, and somehow, I ended up going to the fridge to find something to eat. I ate an entire family-sized box of ice cream…"

"So, was it good? How did you feel when you were eating?"

"I only remember the first bite. It was good. After that, it was like I was just shoving the ice cream into my mouth, eating so fast that I didn’t really taste it, didn’t feel much."

"And how did you feel afterward?"

"Guilty. I felt so fat… so ashamed."

"So, it was like eating didn’t make you feel any better?"

"Yes."

"Can I ask you to tell the Punitive Parent across from you how you felt when they put you down and criticized you?"

"You’re right. I’m useless, a worthless person." Ning said as she cried.

"How did you feel after saying that?"

"Helpless."

"This is the feeling of a helpless surrender, does that feel familiar?" I probed further.

"Yes…"

Then, we paused our chair exercise, and I invited her to do a throw-back imagery.  Letting that feeling of helplessness, guiding her back to past memories. She closed her eyes and recalled: "When I was in my first grade, I went to a classmate’s house to play, and I had so much fun. But then, my mom said they were too rich for us to associate with, and she wouldn’t let me go again. I felt really disappointed… helpless…"

I stopped her and asked, "Can you imagine, if your mom hadn’t intervened and your helper kept taking you to your classmate’s house to play, what would have happened?"

"I would have had so much fun, it would have been so great… way more fun than practicing piano, dancing, and going to tutoring every day…"

"So, now in your mind, can you see your mom and your younger self? What are they like?"

"My mom is sitting on the couch, and I’m standing beside her. She casually says, 'That classmate is too rich. We shouldn’t associate with them.'"

"Can I step into that situation?"

"Sure."

"I stepped in, walked over to your mom, and said, 'Ning’s mom, I’m Ning’s future clinical psychologist. I’m here as the future you asked to come and see Ning. I want to tell you that Ning had so much fun at her classmate’s house. Her daily life is too rigid, and at only six years old, she really needs time for free play.'”

"What did your mom say?"

Ning paused, then replied, "I think she would nod and agree because it’s you saying it."

"And how did little Ning feel when she heard that?"

"She was jumping up and down, so happy."

After this imagery rescripting, Ning began to feel more willing to present her Happy Child Mode in front of me. The Happy Child Mode, just like the Healthy Adult Mode, is just as important—especially for someone with an eating disorder who fears the unknown and seeks control. Both models are healthy, and often, by activating the Happy Child mode, clients gradually relax their pursuit of control, leading to improvements in eating disorder issues.

Gradually, I came to understand that an eating disorder doesn’t have just "one voice," in Ning’s case it is at least two: the Punitive Parent who urges Ning to control her eating and exercise, and the binge-eating: Detached self-soother mode. The latter is used to resist the former, and I realized I needed to focus on reducing the presence of the Punitive Parent.

I saw Ning for nearly a year, and while her mood improved, she no longer bit her fingers and the bingeing reduced to once a week, it still hadn’t disappeared, and her control over eating was still inconsistent. I sought supervision because I found that no matter what I did, I couldn’t reduce Ning’s a Punitive Parent mode. In the end, I realized that the issue wasn’t the Punitive Parent but rather Flagellating Overcontroller Mode (5).

Flagellating Overcontroller Mode

This mode often involves self-attack with the goal of achieving a fictitious sense of control. This self-attack can also be an attempt to motivate self-improvement. Its mantras are "If I punish myself, I will succeed" or "If I acknowledge and face my shortcomings, I will be a better person." This approach helps to avoid being attacked or insulted by others and alleviates the internalised Punitive Parent Mode.

With this mode, individuals feel that they have more control and predictive ability over their painful feelings, while also alleviating their inner guilt and shame.

The punishment can be carried out through excessive self-criticism, self-harming behaviours, or depriving oneself of certain rights (such as food, rest). This mode is particularly common in cases of eating disorders. Individuals may not be able to express anger at home, so they direct their anger inward, seeking control and relief.

For example, in cases of childhood abuse, this mode conceals the truth of the abuse, shifting the anger toward themselves in order to avoid retaliation from their parents. In environments where punishment is inevitable, this mode provides a fictitious sense of control. It is also possible that parents may be attentive in other aspects, frequently reminding the individual to be grateful for the sacrifices made by the parents, which generates a sense of guilt in the individual, preventing them from expressing anger. This mode maintains the individual’s attachment to their parents while denying their basic needs.

Another possibility is that the individual grew up under the care of a narcissistic father or mother. They deeply feel that if they don't make their parent happy, they will be punished, rejected, or, to some extent, abandoned. From a young age, they learn to manage their anger, knowing that they cannot express dissatisfaction with their parent in order to maintain their attachment bond.

The individual may have grown up in an unpredictable family environment where the parents were highly irritable, emotionally unstable, prone to sudden disappearances, or the household was frequently harassed due to debts. In these situations, this mode provides a sense of predictability, allowing the individual to interpret the unpredictable environment with a mindset of "It’s my fault, I must change." It also provides methods to respond to these helpless situations, giving the individual a sense of fictitious control.

The Flagellating Overcontroller Mode is a relatively new concept proposed and researched by clinical psychologist Dr. Susan Simpson. This mode often resembles the expression and language of a Punitive Parent but serves a different function. The Punitive Parent is often an internalized representation of the real parents, whereas the Flagellating Overcontroller is a coping mode created internally by the patient. Its function is: "I will punish you first so that you won't be punished by the Punitive Parent." In other words, this mode is used to block the Punitive Parent mode. The therapist must recognise it, demonstrate its function to the client, and through re-parenting techniques, fulfil core needs, so that the client no longer needs this mode. In fact, the "Punitive Parent " I encountered earlier was likely the "Flagellating Overcontroller."

In Ning's case, when I used the chair exercise to demonstrate why this mode exists, Ning exclaimed, "It’s crazy—I’ve been using punishment to avoid being punished!" Upon hearing this, I immediately invited her Healthy Adult mode to come forward and have a conversation with this mode. Ning said, "It’s because you (the Flagellating Overcontroller) used this method to 'protect' little Ning (the Vulnerable Child), but in reality, you are humiliating her. That’s why she uses binge eating to temporarily relieve her emotional distress (the Detached Self-soother)!" Then, the Vulnerable Child disappeared, replaced by the Helpless Surrender, who remained trapped in the cycle of dieting and binge eating. "You are the one who started this!"

When I heard this macro-level summary and clear analysis from her Healthy Adult, I couldn't help but mentally applaud because she had described the entire conceptualization of modes. I was very happy because I knew that things were going to improve from here. What I needed to do next was to help strengthen her Healthy Adult mode.

However, Ning's most commonly appeared mode is her Helpless Surrender, which made our therapeutic process more complicated. Her Healthy Adult Mode rarely emerges, so strengthening it becomes difficult. When Ning is in the Helpless Surrender Mode, she feels like she is a useless person, and nothing she does matters. I said to her, sitting in the chair of this mode, "Thank you for always helping Ning gain attention and care from her parents. When Ning was little, she felt very lonely. It was only when you were around that she felt a little loved, because her mom and dad would suddenly pay attention to her. But now, Ning is grown up and no longer needs to use this method to gain attention, especially from me. She knows how much I enjoy working with her. Even listening to her share her happiness is a meaningful experience."

Ning's face showed a mix of shyness and emotion. I asked her, "Are you afraid that if you get better, you won’t see me anymore?" She admitted it. That was her Abandonment Schema at play. "Of course, I really enjoy working with you, and at the same time, I really hope that you will get better. My responsibility is to help you gradually reach a point where you no longer need to see me. You don’t have to worry, the road is long, and we will walk it slowly."

The Difficulties of Treating Eating Disorders

Eating disorder cases are among the ones that make me cry the most. The biggest challenge in treatment is not just that the client often has many schemas, but the persistent strength of the Enmeshment Schema. Building a relationship with eating disorder clients is difficult in itself, as they may not want to engage in therapy. Eating disorders are often their main way of coping with current life’s difficulties. In other cases, patients may become emotionally detached, triggered by their Mistrust/Abuse Schema, and keep a large distance from the therapist, making it difficult to make progress in therapy. At the same time, when they establish a deep connection with the therapist, any small misstep can cause enmeshment with the client. The client may have a lot of transference toward the therapist, and the therapist may also experience countertransference, so the therapist needs to be very sensitive, loving, and maintain a clear boundary and conceptualization, and guide the direction of treatment through this understanding. During the process of ending therapy, the Abandonment Schema can be triggered, causing the client to sometimes experience a state of "not wanting to recover" in order to avoid losing the therapeutic relationship. Therefore, treating eating disorder cases really tests the therapist's skill, including how to warmly build healthy boundaries with the client.

The symptoms of eating disorders, such as excessive food control, forced exercise, extreme focus on body shape and weight, binge eating, etc., gradually improve with treatment. However, the work is not completed quickly because eating disorders are often recurrent. If the client encounters setbacks later in life, relapse is common. So, I shifted my focus to foundational work—reducing shame.

For Ning, the most effective method was when I shared personal stories with her, openly showing my vulnerable side, which helped her believe me when I said, "You don’t have to feel ashamed. Vulnerability is not weakness." I demonstrated that vulnerability is not shameful and can be shared with others. Over time, she began to understand that Healthy Adult Mode is not ‘the invincible superwoman." A healthy and mature person is not someone without vulnerability, but someone who can embrace it and move forward courageously with it. We also did many other exercises, such as role playing setting boundaries with some people, learning to protect her rights, and how to say no.

Two years have passed, and now I only see Ning once a month. Her life is much more colourful than it was in her first year of college. She has broken free from her previous limit of thinking, "The best life is the one that is fully predictable." She travels alone, learns new things, and her binge eating has disappeared. Although she occasionally slips back into the habit of overly controlling her eating, we are still working on better perceiving her interoceptive system, like hunger and fullness. Eating disorders are complex, and the pace of treatment varies for each case. Typically, treatment is measured in years. I feel very honoured and proud to have been able to walk with Ning to this stage, watching her slowly rebuild her internal modes and try new ways of living.

Reference:

1. McIntosh VVW, Jordan J, Carter JD, Frampton CMA, McKenzie JM, Latner JD, Joyce PR. Psychotherapy for transdiagnostic binge eating: A randomized controlled trial of cognitive-behavioural therapy, appetite-focused cognitive-behavioural therapy, and schema therapy. Psychiatry Res. 2016 Jun 30;240:412-420. doi: 10.1016/j.psychres.2016.04.080

2. Joshua, P. R., Lewis, V., Kelty, S. F., & Boer, D. P. (2023). Is schema therapy effective for adults with eating disorders? A systematic review into the evidence. Cognitive Behaviour Therapy, 52(3), 213–231. https://doi.org/10.1080/16506073.2022.2158926

3. P. Matthew, (2015). A narrative review of schemas and schema therapy outcomes in the eating disorders. Clinical Psychology Review 39 (2015) 30–41

4. Simpson, G. S., Morrow, E., Vresswijk, M. v, Reid, C. (2010). Group schema therapy for eating disorders: a pilot study. Frontiers in Psychology. doi: 10.3389/fpsyg.2010.00182

5. Simpson, S. & Smith, E. (2020). Schema Therapy For Eating Disorders. Theory and Practice for Individual and Group Settings. Routledge.

It is a translated version, extracted from the book ‘Schema Therapy’ in Chinese, which is scheduled to be published in Sept 2025 in HK.

*Special thanks to Dr. Susan Simpson’s help in reviewing the draft.*

Beatrice Ng-Kessler

Registered Clinical Psychologist (HK and UK)

Advance Certified Schema Therapist, Supervisor/Trainer (ISST)

Certified Mindfulness Trainer from Canada