Systemic Factors In Psychotherapy With Adolescent Girls With Anorexia Nervosa


The present article analyzes the influence of social environment factors on the emergence, dynamics of development and treatment of anorexia nervosa in the adolescent girls. It presents the data of some studies about the socio-cultural conditionality of the disease as well as studies of some small social groups, which confirm the significance of micro- and macro-social impact on the growth of risks of anorexia manifestation. We describe the influence of bullying in school and in social networks communities on the dynamics of symptoms in anorexia nervosa. The results of the analysis of psychotherapy with 13 girls with anorexia nervosa and families are presented. We have identified the features of their interaction with the family, group of peers and social networks in the Internet. We analyze the influence of relationships within those social groups on the symptoms dynamics in anorexia nervosa, propose the targets of psychotherapy, and substantiate the need to work not only on the individual but also on the systemic level in the provision of assistance. The opportunities of positive dynamics in the treatment of anorexia nervosa in adolescents by means of changes in the social environment around girls require further investigations and accumulation of the data obtained during the psychological assistance.

Keywords: Anorexia nervosaadolescentssociocultural factorspsychotherapysystemic psychotherapy


Anorexia nervosa is the most widespread and severe disorder of eating behaviour in adolescence. It is characterized by the obsessive fear of gaining weight, manifesting in a number of compulsive actions oriented to weight loss, a strong dependence of self-concept upon body mass, the absence of self-criticism to one’s own status, and in the number of cases – in self-harm aimed at self-punishment (Hay & Morris, 2016). The question of the factors, affecting the formation of anorexia nervosa in adolescents, is discussed among experts also regarding the identification of the vector of psychological assistance for those patients. Traditionally, they distinguish genetic, family, individual and social reasons of the occurrence of the disease. However, all of them are connected. For instance, adolescents inherit personal traits in the form of perfectionism, increased anxiety, a cognitive tendency to perceiving fine details but not a “general picture”. But the family may stand as a factor of environment as the child is brought up by the adults with the those features, being within the frames of some special requirements to him- or herself (Hay & Morris, 2016). Analyzing family factors, scientists assert that families with adolescents with anorexia nervosa have a number of dysfunctions: the absence of family support, an excessive involvement, the conflict resolution difficulty, the negation and avoidance of problems, and trouble in acceptance (Heffner & Eifert, 2004).

Despite the significance of personal and family factors, sociocultural factors play a large-scale role in the occurrence of anorexia nervosa. Experts state that anorexia nervosa is characteristic of “pro-Western” societies who emphasize the ideas of thinness as a condition of attractiveness and successfulness. Woodside in 2003 (as cited in Hay & Morris, 2016, p. 5) described some Indian patients who considered the symptoms of gastrointestinal tract to be the reason of their refusal from eating till the moment of their starting treatment within the group of patients with “Western” anorexia who, in turn, had the fear of growing stout and the worry about their own body image. Katzman, Hermans, Hoeken, & Hoek (2004) present the result of the study fulfilled n the island of Curacao where some individual cases of anorexia nervosa are identified in the inhabitants. The analysis of the group of those women shows that all of them have a similar way of living and the identity features: being of a mixed race, they distance themselves from the traditional values of the local population, visit west, and have a high level of income and education. Similar researches are undertaken in Japan, Pakistan and Hong Kong. If anorexia nervosa has not earlier been observed in the traditional societies, countries with emerging economy and countries with oriental culture, then nowadays, it becomes a global disorder (Heffner & Eifert, 2004).

Not only attachment to the pro-Western culture increased the risk of anorexia nervosa but also involvement in the definite environment did. Bould et al. (2016) held a longitudinal study in schools analyzing the difference of anorexia nervosa occurrence in various educational institutions. They made the following conclusion: girls in schools with a high proportion of female students and students having highly-educated parents have a higher chance for anorexia nervosa regardless of individual risk factors.

Thus, girls, being brought up in the societies and mini-communities characterized by the intentions of high requirements to appearance, learning and behaviour, in which acceptance and appreciation are associated with successfulness, suffer from anorexia nervosa more. Diverse psychotherapeutic records about the work on the elimination of a patient’s sense of inferiority, the increase of self-esteem, coping with obsessive thoughts and compulsive activity, and the deconstruction of conviction related to appearance are a basis of assistance toward adolescent girls, as well. However, during psychological aid, it is important to take into account a special significance of relations within the social groups at that age: in the family, when communicating at school, among peers and in the on-line groups in social networks.

Problem Statement

These conclusions set a task to psychological aid to adolescents with anorexia nervosa, taking into account a social context both on the macro-level and on the level of micro-groups. A number of studies have shown that experience of bullying makes children more vulnerabler to eating disorders and that adolescents with a special attitudes to eating face a higher bullying risk from peers (Copeland et al., 2015; Duarte, Pinto-Gouveia & Rodrigues, 2015; Lee & Vaillancourt, 2018). Depression caused by the difficulty in interaction with peers influences the dynamics of eating disorders. The psychotherapeutic support cannot ignore the question of relationship within a social group; one can attain a substantial improvement at the expense of the stress decrease during the communication with peers.

The communication in the online communities affects an adolescent prone to eating disorders which keep the ideas of eating disorders, mainly, anorexia nervosa, such as: Pro-ana. Those web-sites include forums and chats, advice and inspiring texts devoted to anorexia contain detailed instructions about the initiation and maintenance of the disease. The Pro-ana members encourage one another in weight loss and formation of the social environment which does not condemn any starvation but it maintain and promotes disordered behaviour. Gailey (2009) holds the study in relation to the members of those communities and state that such groups help consolidating a controlling behaviour, and women take health risks more consciously and confidently resting upon the subculture developed by Pro-ana. All that range of a significant communication of an adolescent within different social groups has got influence both on the ideas maintaining anorexia nervosa and on coping with them. In the narrative approach, they propose ideas of “resistance” to the discourses about appearance and successfulness imposed by the socium (Maisel, Epston, & Borden, 2004).

Research Questions

The psychological studies and analysis are important in relation to that how the ideas of acceptance of self-value acknowledgement are associated with the outer world in the social environment surrounding the adolescent, how they are transmitted, how he or she may resist them, and how to develop alternative values, being non-excluded.

Purpose of the Study

The present study is aimed at analyzing the influence of social environment factors on the emergence, dynamics of development and treatment of anorexia nervosa in adolescent girls:

  • The identification and description of the social systems where the interaction may deteriorate or improve the pace of changes and coping with symptoms.

  • The description of the interaction of the girls with anorexia nervosa in the following systems: (a) the family system; (b) a group of peers; (c) an online communication group.

  • The detection of targets for the development of psychotherapeutic aid for girls with anorexia nervosa.

Research Methods

We studied the psychotherapeutic work with girls with anorexia nervosa and their families. We analyzed the proceedings of psychotherapy with 13 families; the girls’ age was from 13 till 18 years old. Among other thing, during the psychotherapeutic work we analyzed the influence of significant social groups on the dynamics of the state of the girls (self-regard, perception of oneself and one’s own body).


The interaction within the family system was characterized by the following features:

  • The tension in the parental subsystem, using the triangulation of the girls according to the parent relationships, addressing the themes of eating. One of the parents during the treatment could change the strategy, missing some agreements with the doctors, suggest the girl to turn down any treatment, or he or she depreciated the latter, accused the other parent of any problems that led to anorexia nervosa, sabotaged the approved diet, and doubted the competence of the second parent.

  • The disruption of intrafamily communications about the issues of eating and appearance expressed in the equivocal messages, appearance evaluation, irony; communication messages could both be addressed to the child and proceed from the child.

  • A high level of pressure on the adolescent in the form of a forcible eating, blackmail and manipulation combined with the periods of emotional distancing and non-involvement in the process of eating. The child’s pressure on the parents in the form of accusation, the initiation of sense of guilt and threats of more severe symptoms.

The interaction within the group of peers (usually at school) was characterized by the following:

  • The stigmatization of a girl’s status up to bullying expressed in the distancing from peers, refusal from communication, isolation, depreciation based on appearance or diagnosis, in some cases, accusation of deceit together with depreciation (“you are not a real anorexic. We saw you eating”; “I gather, the other girl is an anorexic more than you, she is thinner”, etc.). in the number of cases, parents and teachers were involved in those processes who discussed a girl’s state of health in public (for instance, in the parental chats: “Parents, pay your attention, A. suffers from anorexia nervosa, and she can persuade your children to go on a diet”).

  • The presence of communication groups according to interests related to weight loss, including up to a half of girls in the class, competition in weight loss, discussions of the family reaction, and interaction with psychologists.

  • The inclusion of the issue of appearance and weight loss in the process of making a couple, the romantic relationship and adolescent flirting ((with a boy) “Please, stand next to one another! I’ll be measure by eye how much weight is each of you”).

  • The increase of the tension and discussion of the theme of eating in the group in case of the joint eating outdoors, or commemorating birthdays including sweet.

The interaction within online groups (mainly, in

  • The discussion of a girl’s appearance by the visitors of the personal page based on the photos, urging to cut out the photos and selfies regularly.

  • The creation of “talks” about the theme of eating and weight loss, developing ideas and symptoms of anorexia nervosa and romanticizing mental disorders.

  • The determination of bloggers as a significant figure who developed the ideas of the relation between successfulness and appearance, participation in online marathons for weight loss and “the resilience development”, sometimes, participation or watching the live air when self-punishment actions and manipulation with one’s own body were demonstrated.

Such peculiarities of the interaction of adolescents with anorexia nervosa within different social systems required some reflection in the character of psychological aid.

  • The complex psychotherapy including work with the system, first of all, with the family is necessary because the system processes can contain the symptoms of anorexia nervosa (conflict among parents, communication disruption, etc.). Along with that, the personal psychotherapy with the adolescent is not less important, with the accent on one’s own identity development and differentiation. In some cases, it is necessary to interfere the situation, engaging parents and experts in the systems of the interaction of peers aimed at the tension and stress decrease that affect the girl’s status.

  • It is crucial for adolescents with anorexia nervosa to identify and reflect upon stressful situations and develop the capability to oppose any aggressive activity and communications.

  • The employment of some elements of the cognitive and narrative psychotherapy is necessary in distinguishing between “facts” and “a personal opinion of friends” and in regulating the “negative” thoughts intensity.

  • It is necessary to raise the communication competency of girls with anorexia, develop the abilities to cope with conflict situations and clear dysfunctional messages.

  • One of the effective directions is the development of environment with the ideas of anti-anorexia and relationships within such opposed-to-symptoms communities including social networks.


That fact that anorexia nervosa is the disease closely associated with the sociocultural context and social groups which the adolescent enters, finds an insufficient representation if the psychotherapeutic practice which can quite often indirectly work with the systems. The opportunities of positive dynamics in the treatment of anorexia nervosa in adolescents by means of changes in the social environment around girls require further investigations and accumulation of the data obtained during the psychological assistance.


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14 July 2019

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Psychology, educational psychology, counseling psychology

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Zhuykova*, E. B., Pechnikova, L. S., & Ryzhov, A. L. (2019). Systemic Factors In Psychotherapy With Adolescent Girls With Anorexia Nervosa. In T. Martsinkovskaya, & V. R. Orestova (Eds.), Psychology of Subculture: Phenomenology and Contemporary Tendencies of Development, vol 64. European Proceedings of Social and Behavioural Sciences (pp. 793-798). Future Academy.