A parent whose child is starving to death in the grip of anorexia nervosa is in no doubt that this is a real and tangible problem. It is not a question of co-constructed meaning, uncertainty or multiple realities but a life and death fact.
Authors Donovan and Khor (2025) family therapists working with eating disorders, note family therapy’s long history working in this domain and the current ‘ongoing symmetry with contemporary themes and principles of systemic theory and practice’. They contend that exploring practice with eating disorders is a vehicle to provide insights into the enduring debate about a purely social constructivist understanding of our work which emerged in the 1990’s and look to alternative and more useful meta-theoretical frames that do not abandon social constructivism but extend the theoretical frame to engage with a very tangible external reality. By focussing on eating disorders, the authors hope to supplement social constructionism ‘with theoretical perspectives that extend our focus and might even serve as a helpful corrective’ that is applicable across our field.
The Debate about Reality
Family therapy is no stranger to bitter debate. The debate between those who proposed the metaphor of narrative, conversation and dialogue in place of the more mechanistic cybernetic metaphor is one of the most noteworthy. Minuchin (1999) in his critique of Harlene Anderson’s social constructivist position stated that her approach created a ‘therapeutic ambience where dialogues are serene. There are no emergencies, no suicides, no phobias, obsessions, addictions, violence’. Those working with families with a deathly ill child suffering anorexia nervosa would include “no risk of death by starvation”.
Co-constructionism and Critical Realism
The authors propose a way forward through two theories. One is the co-constructivist approach of Bebe Speed which ‘takes for granted that a structured reality exists but recognizes that it is
mediated in the sense that different aspects are highlighted according to ideas generated in our social groups.’ She speaks of the idea of choosing between ideas based on their objective adequacy and that rather than ever knowing ‘the truth’ we must ‘nudge what we know ever closer to object adequacy’. This means work with eating disorders and by extension other presenting difficulties, should be informed by research to refine and promote our better understanding.
An alternative perspective is that of critical realism of Roy Baskher and promoted by Pilgrim and Pocock in family therapy. They too support the idea of a ‘structured, stratified, reality independent of our knowledge’ with our understanding being a human social product which is historically and culturally situated and consequently open to error. However, assuming there is a world operating independently of our perception ‘provides rational grounds for meaningfully choosing between competing accounts of it.’ The model suggests reality should be understood ‘in terms of multicausality and as multi-layered with different aspects having consequences
by virtue of the mechanisms that connect them.’
In Conclusion
While the authors focus is on eating disorders this paper provides a valuable direction for those who understand that reality is not always as we apprehend it but equally appreciate the value of research. Bringing the humility of the post-modern stance with the rigour of scientific enquiry allows us to ‘nudge closer to objective reality’ while leaving space for the voice of those who are so easily discounted and marginalised.
Donovan, M.& Khor, J (2025) Family Therapy Intervention and the ‘Real Problem’ of an
Eating Disorder: Implications for a Systemic Philosophy of Practice Journal of Family Therapy, 2026; 48:e70010 1 of 8https://doi.org/10.1111/1467-6427.70010
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