THERAPY INFORMATION
A Brief Overview of Therapies Used in the Treatment of Eating Disorders: A Consumer's Guide
Patricia Santucci, M.D.
There are over 400 schools of psychotherapy, each claiming a distinct theory and set of treatment techniques. Psychodynamic and cognitive-behavioral therapies probably represent the most widely used.
There is no one definitive form of therapy recommended for eating disorders. Often the therapist will evaluate where the patient is. Some individuals may be very knowledgeable and have had experience with some intervention. For others,therapy is a totally new experience.
Most often a supportive psycho-educational format launches the process. Most therapists will either combine or progress to a cognitive-behavioral or psychodynamic approach. A variety of professionals may collaborate to make sure that medical, dental, and nutritional components are addressed. If this sounds pretty complex, you are correct. Now just to add confusion to the entire picture, assume all these therapies can be done in individual, group, family, couples, and maybe even via the Internet! Don't panic. That's why there are professionals out there to help sort out what will work for you.
There are several treatments that hold promise and should be strongly considered. But who gets what and why? Many therapists will take an eclectic approach and combine different forms of therapy in order to develop your treatment plan. Some will work together with a treatment team with professionals providing an area of specialization, such as medication, nutritional counseling, family, or group therapy. Your therapist, however, may have a certain philosophy or be trained in a specific approach. Make sure you ask and understand the goals in treatment. Remember your treatment should always be individualized to meet your needs.
Above all, one of the most important things in therapy is what we call the therapeutic alliance. It's the key to any successful therapy. Some studies have suggested that this therapeutic relationship may be as important, if not more important,than the specific technique in determining outcome. People get well in many ways but one thing is for sure; the relationship of trust and mutual respect serves as a foundation for treatment. You be the judge!
Often individuals have an image in their mind regarding what happens in therapy. Below is a partial list of terms and some additional comments that might be helpful in understanding the various therapeutic approaches. This list is by no means complete or comprehensive, but it may help you be a more informed consumer in order to select an approach that fits you.
It is important to note that formal psychotherapy may be ineffective with starving patients and should not be used alone to treat severely malnourished patients. It may help the patient to become motivated and gain weight, but medical, nutritional, and supportive treatment should be initiated during this stage. Once malnutrition has been corrected and weight gain is starting to occur and the patient no longer acutely medically compromised, various forms of psychotherapy can be very helpful.
Understanding the Language
Bio-psycho-social model: Since the causes of eating disorders seem multiple, this philosophy approaches eating disorders as an interactive process which involves genetic and biological factors, psychological factors, and socio-cultural and family factors. This might seem like a shotgun approach--and it is. Eating disordered patients are complex and often have serious and chronic conditions that require various treatments at different stages.
This approach often allows the therapist to bring a variety of different theories and approaches to treatment. Within this broad model, however, treatment can still vary widely. Ask if the therapist has a specific approach and whether there has been training using this approach with eating disorders.
Medical Model: Mood disturbances and anxiety states are quite common in eating disorders. The need for nutritionally and medically stabilizing individuals is seen as an important first step.
In anorexia, the assessment for antidepressant medication is often done following weight gain since starvation itself can worsen the symptoms of depression. In addition, there is some evidence that medication should be considered for prevention of relapse for patients who have restored their weight or who continue to show signs of depression or obsessive compulsive problems.
In bulimia nervosa, antidepressant medications are effective for many patients as one component of the initial treatment in combination with therapy. They appear to help with some of the psychological symptoms and also directly decrease the binge/purge cycle. There are a number of other medications that may be useful in the treatment of eating disorders. One should not rely on medication alone for the treatment of eating disorders.
Cognitive Behavior Therapy (CBT): CBT has been used increasingly in recent years. It is a very directive and time-limited therapy. The therapist and patient work together to identify irrational beliefs and illogical thinking patterns associated with body image, weight, food, and perfectionism. There is a focus on the behavioral components of the illness such as binge eating, purging, dieting, and ritualistic exercise. Outcome studies show that CBT compares favorably with antidepressant medication and is often considered the treatment of choice for bulimics. Its short-term structure with the availability of manuals has made it a useful resource.
Psychodynamic Therapy: This is based on the idea that people can achieve greater understanding of the psychological forces that motivate their actions. Insight through psychological exploration then opens up the possibility for change in personality and behavior. The assumption is that the present is shaped and governed by the past. This approach is frequently used for eating disorders when the person is at the appropriate stage to benefit from this type of intervention.
Feminist Psychodynamic Psychotherapy: This model is based on the assumption that social conditioning of women results in repression of certain needs and aspects. The therapist engages the patient in dialogue that encourages her to find her own truths and have her own voice. The importance of interpersonal relationships and intimacy are a focus. The therapist acts as a resource and doesn’t claim to know all the answers, encouraging the open exchange of ideas and fostering the development of self.
Interpersonal Therapy: This is a short-term therapy that was initially used to treat depression and modified to treat eating disorders. Individuals are taught to evaluate their interactions with others with an understanding that interpersonal conflicts may not have caused the eating disorder per se but may indeed maintain the disorder. Problem areas, other than the eating disorder, are identified and a treatment contract is formulated. The focus is here and now with less attention paid to the eating disorder behavior and symptoms.
If a patient replied in therapy that her eating was terrible, the therapist would not focus on the details of the disturbed eating behavior but rather the importance of understanding why this had happened. The patient would be asked if it could be related to one of the identified interpersonal problem areas. The expectation is that as one improves interpersonal function, there is improvement of the eating disorder.
Family Therapy/Marital Therapy: There are a variety of approaches to family therapy. Some will view therapy as treatment WITH the family, others as treatment OF the family. Certainly family therapy should be considered whenever possible, especially for adolescents who still live with their parents and patients still with ongoing conflicts or marital discord. Some have suggested the younger the patient the more significant the use of family therapy. In addition, if the eating disorder patient is a mother, special help should be paid to mothering skills to decrease the risk of transmitting an eating disorder.
Psychoanalysis: In its true form is the couch therapy. Sessions are usually held 4-5 times a week, and a completed analysis may take 3-5 years. The focus is on self-understanding and correction of developmental lags so that there can be reorganization of the personality. Free association and dream analysis occur in this type of therapy. Analysis is not for everyone, being more suitable for individuals at the healthier end of the spectrum.
Focal psychoanalytic psychotherapy: This is a short-term approach where the therapist takes a non-directive approach. No advice is given regarding the eating behavior, symptoms or problems. The focus is on the meaning of the symptoms in terms of the patient's history and experiences with his or her family.
Dialectic Therapy (DBT): Although DBT is a cognitive behavioral treatment, it differs from standard CBT. There is a focus on helping patients to observe and label their emotional reactions to trauma, validation and acquiring a balance between acceptance and change. This is a fairly new type of approach which is being modified for the treatment of bulimia and binge eating disorder. It holds promise especially for those who have experienced post-traumatic stress or exhibit chronic or severe suicidal behavior because of lack of basic skills for self-regulation.
Supportive Psychotherapy: Most forms of therapy will have a supportive component. This approach is different from exploratory work because the goal is not insight-- it is lessening of anxiety. Usually this is done through reassurance, advice, bolstering the individual's personal strengths and encouraging more adaptive defenses.
Nutritional Therapy: Nutritional rehabilitation and counseling often will help patients gain weight and stabilize their eating patterns. Depending on the level of training, interest, and expectations by the treatment team, the dietitian often deals with body image, education about nutrition, risk regarding the eating disorder, concerns about weight and irrational fears related to the eating disorder. Some dietitians will shop for food, help prepare and eat meals with patients and their families.
Psycho-educational Therapy: Usually this is included in most treatment so that there is understanding of the definition of the illness, why individuals develop the illness, what predisposes them and what might precipitate the illness. Nutrition, medical issues, socio-cultural issues such as the drive for thinness in our society, etc. are often covered.
Addiction Model: There is a high prevalence of substance abuse among persons with eating disorders and the likelihood that either condition may precipitate the other. There is much debate as to whether eating disorders are true addictions. There is also a great deal of variability from chapter to chapter and sponsor to sponsor.
The presence of a currently active substance abuse problem does have implications for treatment. Ideally, treatment which focuses concurrently on both the eating disorder and the substance disorder should be attempted in a setting where the staff is competent to treat both.
For patients with anorexia nervosa, treatment which focuses only on a narrow and zealous application of the 12-step program, or other approaches which exclusively call for abstinence without addressing nutritional, cognitive, or behavioral problems are of concern when used as the sole approach. Many addiction programs, however, will attempt to offer a blended model incorporating the medical model and cognitive behavior therapy.
For patients with bulimia nervosa, considerable controversy exists regarding the role of the 12-step programs or other approaches that focus exclusively on the need for abstinence when they are the only intervention and do not address nutritional, psychological, or behavioral problems.
Self-Help: Self-help may be a valuable first step for treatment. The major goal is to provide support and communication between individuals who are at different stages of recovery. Sometimes family and friends are invited or they may have their own support group. Usually leaders are recovered or volunteer professionals who offer their service at a no-cost basis.
This group becomes a safe place where you can learn about the disorder, share feelings, find someone who has had similar experience, and realize that recovery is possible. With an informal structure, one can attend as needed. For more information, please visit ANAD's section on support groups. In addition, there are now some self-help manuals, on-line web sites, news groups, and chat rooms focusing on the treatment of eating disorders. In the prevention area, there is an on-going study of an on-line self-help form that may help students reduce the risk of developing an eating disorder. While a substantial amount of worthwhile information and support is available, it is important to critique the content.
Expressive Therapy: The expression of oneself through the arts is another form of therapy which is useful, particularly when there is difficulty of putting feelings into words. Whether it is dance, movement, art, drama, drawing, painting, etc., these avenues allow the opportunity for communication that might otherwise remain repressed.
Light Therapy: Many individuals with SAD (seasonal affective disorder) also have dysfunctional eating. Recent studies have shown that light therapy has improved mood and decreased bingeing and purging. The positive effects can last for about 4 weeks.
Eye Movement Desensitization and Reprocessing (EMDR): EMDR is a unique form of psychotherapy. It was originally developed in the 80s to help patients with traumatic experiences, recovering memories of past trauma and post-traumatic stress.
Although an old adage in the eating disorders field warns, “no single treatment approach works for everyone,” an interesting new treatment worth considering is developing in the eating disorders field. While traditional treatment of eating disorders has concentrated on individual psychotherapy, Christopher Dare and Ivan Eisler at Maudsley Hospital in London have developed an original family-centered approach. Instead of being criticized as a dysfunctional social unit, the family of the sufferer assumes responsibility for making the patient eat. No one is blamed for having triggered the illness; rather, the illness is treated as a medical condition and the family must care for the sick member.
This family-centered treatment progresses in three distinct phases, in which power shifts from the family back to the patient after she/he reaches an acceptable weight. The first phase focuses on empowerment and eating. The family separates the patient from her/his illness and learns strategies to successfully battle the disease. Placed in the position of a “therapeutic bind,” the family is urged to take immediate action, which provokes anxiety; yet this anxiety is balanced by the therapist’s acceptance and expertise. Food functions as medicine in the Maudsley method, and the parents act as doctors who administer the feared remedy. For this method of re-feeding to succeed, the parents must establish an alliance and agree to enforce consistent food rules. In order for the patient not to feel like an enemy of the food-wielding parents, s/he is encouraged to turn to siblings for support.
The second phase of treatment starts when the patient complies with the parents’ food guidelines and makes steady weight gain. At this point, the parents help their child assume increased responsibility for eating. According to the Maudsley model, once the patient maintains a stable weight of near 95% of his or her ideal weight without substantial parental supervision, the patient should begin individual therapy. At this point in their recovery, they can focus on issues and anxieties surrounding adolescence, a life phase that they have avoided by having an eating disorder. They can explore their identity and independence and learn to construct clearer family boundaries.
Despite its unconventional approach of enlisting the family as the primary player in the recovery team, the Maudsley treatment offers some definite benefits. Parents are more likely to resist food manipulation by their child, since they take on active roles in treatment and are instructed by therapists not to tolerate resistance. They are encouraged to offer incentives and support for cooperation. Moreover, since their child’s life is in imminent danger, they will expend an enormous amount of energy to successfully coax their child to eat and regain health.
Despite these remarkable outcomes, there are still some crucial factors to examine. Data from Maudsley studies indicates that this treatment is less effective for older adolescents and for adults, along with chronically ill patients, and those who binge and purge. In addition, some families may not be able to put in the enormous time and effort that is required to supervise meals and settle the accompanying food battles. Another variable to consider is the enmeshed parental relationships that eating disordered patients are often involved in. The highly involved parental
role in the Maudsley treatment may further exacerbate these dysfunctional patterns. The patient may also experience more difficulty in gaining a sense of autonomy following treatment.
Despite these possible drawbacks, the Maudsley therapy is now gaining popularity with researchers in the United States. Currently, psychologists at the University of Chicago, University of Michigan, Columbia University and Stanford University are testing this treatment.
Recent Treatment Developments
Internal Family Systems (IFS): New therapy exploring the internal family of the individual with an eating disorder.