Psychological Treatments for Eating Disorders

06/21/2024

Xenia Sotiriou, Psychotherapist

Eating disorders are diseases which are related to one's behaviour towards diet, to the abnormalities of one’s physical appearance and to one’s obsession with weight loss. Those who suffer may be scared about gaining weight and so they continue to diet or binge and purge, even when their health deteriorates.

Generally, the three types of eating disorders are anorexia nervosa, bulimia nervosa and compulsive eating. Anorexia is when a person refuses to maintain the minimum normal body weight, is afraid about gaining weight and can not comprehend his/her body image subjectively. Bulimia is a syndrome where the patient is addicted to a vicious cycle of hunger. Binging eating  disorder is an incorrect definition, which is not yet clearly defined. This definition is often applied to some models of bulimia, but in the case of BED the patient doesn’t abuse laxatives or imposed vomiting.

The following article is an attempt to present various psychological models of eating disorders and suggested treatments for the mental and physical problems that accompany such disorders. Although many models have been proposed for the treatment of eating disorders, only the four most acceptable models and their limitations will be presented. These are: psychoanalysis, cognitive behaviour, family therapy and in-patient treatment.

Eventually there will be an attempt to describe a mixed treatment model for eating disorders and to provide its potential benefits.

Psychoanalytic Psychotherapy
The two main themes of the psychoanalytic treatment model for eating disorders are the role of childhood and the symbolic nature of the symptoms. Dare and Growther (1995a) have developed a type of 'focal psychoanalytic psychotherapy’, especially for eating disorders, which addresses these two key issues without giving advice on individual problems for food disorders, but it is focused on the development of the 'focal theory', which involves a collaboration between three factors in the relations of the object, the function of symptoms and the therapeutic partnership (alliance).

Object Relations
The term "Objects relations" is used in psychoanalytic psychotherapy to describe the internalized presentation of important people of the patients’ past and their relationships with them, who are usually family members (Dare and Growther, 1995a, p 298). This shows the importance of childhood. It has been argued, that patients with eating disorders often have a central limit point, when their relationships with others changes (this can be real or hypothetical) and the inner world of objects’ relations creates a fear of approaching others. Those who suffer from eating disorders also have the desire to create an ideal relationship. This creates a conflict between the desire to approach and to avoid others. The role of the therapist is to facilitate the patient to understand his/her relationships. The therapist aims to create a dialogue in order to enable the patient to express his/her thoughts of his/her consciousness and his/her feelings and also to recognize his/her unexpressed wants, feelings, fears and desires.

Operation of symptoms
The focus here is how the patient symptoms are affecting his/her current personal relationships. (Dare and Crowther, 1995a p. 298). It is speculated that the symptoms of food avoidance and weight loss are acting as a way to control and manage the relationships of the patient with the people in his/her life. For example, the symptoms may transform the patient into a dependent needy person, who can’t meet the expectations and demands that healthy individuals can manage. As a result, the patient is afraid that if he/she gains weight other people may understand that he/she has a problem. So the patient uses his/her body as a communication medium of expressing his/her feelings. The role of the therapist is to be aware of these communication methods, to understand the symptoms and their symbolic value and to help the patient find a way to express these feelings with words. So the patient is encouraged to face his/her own feelings and to describe them verbally, rather than with the degradation of his/her body (Dare and Crowther 1995a)

Therapeutic alliance (cooperation)
This refers to the relationship between the patient and the therapist. It is central to any psychoanalytic approach because it implies that the way the patient uses the relationship within the treatment framework, is supposed to resemble his/her relationships outside it.
The therapeutic alliance also enhances the development of an emphatic, dedicated and confidential relationship. The goal of psychoanalytic psychotherapy is to encourage the patient to understand what type of feelings are expressed through physical symptoms, understand how the relationships of the past have influenced his/her desire not to express his/her feelings verbally and facilitate the verbal expression of his/her feelings instead of through the body.

Disadvantages of the psychoanalytic treatment of eating disorders
The disadvantages of this approach are:
• Central to anorexia is the fear of relationships and intimacy. The psychoanalytic treatment implies a close relationship between therapist and patient. This may cause the patient to react to the therapist and refuse treatment.
• The therapeutic approach requires the patient’s consent of the therapy with the therapist. Some anorexic are forced by the Mental Health Act, according to the law of each country to undergo treatment, when they don’t do so voluntarily.
• Anorexic patients preserve food avoidance and weight loss as a solution to their problems. Treatment for accepting food and gaining weight (even though it is not said) can feel more like a problem to the patients rather than a solution.
• Termination of psychoanalytic treatment can be difficult for the patient. If the patient has learned to trust the therapist and believes that the approach does not affect control, when ending the treatment the patient might feel rejected, proclaiming his/her belief that a relationship will only cause grief and it is not worth pursuing.
• Considering the effectiveness of this approach, it is time consuming, expensive and difficult, but a recent test proved that it is more effective than the routine care, without requirements for anorexic patients.

Cognitive Behavioural Therapy (CBT)
The cognitive behavioural formulation of eating disorders involves two basic issues. The first is the learning process through support, which is reflected upon the patient’s behaviour and the second is the formation of "dysfunctional cognitions” regarding body weight and self-esteem. Cognitive behavioural therapy (CBT) is used extensively in bulimia nervosa and refers to two central themes of behaviour and thinking. It is important to note that this approach has less been used in cases of anorexia nervosa.

Act 1. Development
This Act requires the evaluation of the history of the patient, with physical exploration, excluding patients who have serious suicide tendencies or severe physical illness.

Act 2. Introducing the 'cognitive and behavioural' approaches. This act deals with both the cognitive and the behavioural components of eating disorder.

The cognitive model
The therapist will outline the basic principles of the cognitive component of CBT
(Freeman, 1995). They are described as follows:
• The link between thoughts and feelings
• The treatment within a partnership between patient and therapist
• The patient as a scientist and the role of experimentation
• The importance of self-monitoring
• The importance of regular measurements
• The idea of ​​the program for each meeting, designed by the patient and therapist
• The idea that therapy is recommended to learn technical skills
• The idea that the therapist is not a specialist that will teach the patient how to get better
• The importance of regular feedback by both the patient and the therapist

The behavioural model
The therapist will outline the key elements of the behavioural model based on three factors:
• Breaking the viscous cycle. A discussion will take place regarding the cycle of dieting and bingeing, the psychological triggers for bingeing, the importance of eating regular meals and often the cycle of laxatives use and bingeing.
• Principles of good nutrition. This concerns the discussion of the nature of a healthy diet, the importance of frequent meals, the role of eating with friends, planning meals, minimizing the times of weightings and using the method of distraction.
• Keeping a journal. Documenting and self-monitoring is central to the CBT approach. This can be used to record the amount of food that is eaten, the time and place of binges and monitoring the mood and feelings of control.

Act 3: Cognitive restructuring techniques
Central to the cognitive behavioural approach for treating eating disorders is the role of the dysfunctional cognitions, which takes the form of automatic thoughts and improvisation. The cognitive restructuring process deals with these cognitions.

This process includes:
• Explaining that the 'automatic thoughts' are automatic, frequent, are perceived as correct by the patient and can affect mood and behaviour. An example is the thought that “if I can’t follow my diet then I'm a pure failure”.
• Help the patient capture and write his/her thoughts in the journal.
• To provoke his/her thoughts and replace them with other more helpful. This provides that the therapist asks "Socratic questions" like, what evidence / information do you have to support your thoughts and how will someone else see this situation. The therapist can assume both the role of the team-mate and the rival, in order for the healing process to begin.
• Introducing the theory of improvisation, which refers to the deeper layers of thoughts, regarding issues such as control, perfection, complacency and guilt.
• Challenging the basis of improvisation, taking his role of the teammate and asking “Socratic questions”

Act 4: Prevention
This act supports that the patient’s abilities / skills gained in therapy, can be used when the treatment is over and even if there is a relapse, the patient now has the capabilities to face it. Moreover, according to the Marriot and Gordon model of the return of the prevention (1985), the patients are taught to expect a relapse and how to deal with it, developing effective strategies of management.

Act 5: Monitoring
The CBT described by Freeman (1995) requires 18 treatment sessions with additional meetings in 1, 3, 6 & 12 months. Furthermore, when the CBT is completed, patients are encouraged to maintain some form of support, either with self-help groups or group therapy through different organizations.

The problems of CBT in the field of eating disorders.
The problems of CBT in the field of eating disorders are as follows:

  • Although they are quite effective, they still need major changes in order to be implemented in ‘anorexia nervosa’.
  • CBT requires the patients to change and actively engage the treatment by keeping a journal and constantly providing information. Anorexic patients might be forced to be treated against their will and their motives might not be helpful.
  • For the anorexic, weight loss is perceived as a solution. The therapist, who tries to help their eating and gaining weight problem, is viewed as a problem and not a solution. For the anorexic CBT suggests improvisation but they are so introvert that the ‘Socratic questions’ will not move them.
  • CBT does not promote the family relationship role in the process as much as psychoanalytic psychotherapy to the extent that it might create the problem and help maintaining it.

Family therapy
The system of family analysis regarding eating disorders is emphasized by in four main factors:

  • Symptoms as means communication
  • Homeostatic family
  • The role of boundaries
  • Conflict avoidance

Family therapy deals with these factors and emphasizes on the symptoms and the family dynamic. It does so by using both individual and family sessions, depending on the patient’s age and it’s used mainly for anorexic rather than bulimic patients.

Symptoms
During the early stages of family treatment, the therapist should emphasize on the dangers of food restrictions and weight loss insisting that problems like hunger, bingeing and vomiting are self repeated and should eventually be stopped (Dare and Eiser, 1995). In addition, the parents of younger patients should oppose to unusual trends in their nutrition, take control of the calorie inputs and bulimic symptoms and finally develop a strategy that will force the patient to eat more than the disorder dictates to the patient (Dare and Eiser, 1995 P345). Describing how nurses force the change in the patients eating habits might help, emphasizing on the mistreatment they will receive if they are institutionalised. Sometimes this approach might make the parents feel responsible for their child’s problem, but it is considered to be an effective strategy that can improve the situation, bring a blend of empathy, specific knowledge of the eating disorder and the strong feeling that something somehow has to change (Dare and Eiser, 1995 P346).  These interventions deal with the symptoms and they have been described as an important part of family therapy.

Family dynamics
Family therapy also deals with family dynamics. Sometimes the relationships within an anorexic’s family might untangle and show great interest. Especially for older patients, the therapist recommends a change within these relationships and suggests that the patient should be more independent finding new interests outside the family cycle. In addition, the symptoms of an eating disorder can penetrate and control the family, creating a focal point for them, eliminating the roles of other dynamic contact aspects. Especially the symptoms might be seen as a ‘mobile interest’ which keeps the family together. Abandoning the symptoms may give the impression that it is frightening for the family because they must find new ways of reacting. The family therapist has to deal with these matters announcing every change that has happened with the symptoms and has to encourage the family to fill the gaps with new ways and new relations between them.
Specific interventions, which are used as part of the family treatment, include instructions, explanations and reconciliation tactics between the parents and their children.  Furthermore, the therapist can aid in changing the dynamics of the family by provoking or forbidding certain unnecessary reactions. In addition, the therapist supports special members of the family indicating new ways of reaction. The reasons for these interventions are described (by Dare and Eister, 1995, P339) as:

  • The clarification of roles and communication
  • The creation of a hierarchical group, according to age and set borders  within the family
  • The encouragement of a pure alliance between the older members of the family for the purpose of an effective parental contribution.

Problems within the family treatment for eating disorders:

  • The name of the treatment “family therapy” might be considered as a diagnosis, which accuses the family of being the reason of the problem. Both the family and the patient are not willing to accept this kind of approach.
  • Parents might see the problem as their own and not the family’s. They might feel that their family cannot participate in the treatment.
  • Parents are usually willing to help with any means possible but might be afraid that the therapy will find them culpable.
  • Sometimes family treatment requires its patient to question the existing ways of family support and engagement as part of rearranging the homeostasis within the family system. This might seem as a blackmail towards the family and the patient and if not professionally continued, this can result in a conflict with the therapist.
  • For the severely sick and emaciated patients there might not be enough time to implement family therapy so they would have to be admitted to hospital instead.

In-patient treatment
The main reason for treating eating disorder patients as in-patients is the restoration of weight. The majority of in-patients are not necessarily anorexic in relation to bulimic, despite the fact that many anorexic have bulimic symptoms. Treasure, Todd and Szmukler (1995) describe the reasons for hospitalization with the following physical signals:

  • BMI under 13.5, the extreme  weight loss over 20% in 6 months
  • Low blood pressure
  • Cardiac abnormalities
  • Muscle weaknesses escorted by ‘blood clothing’
  • Risk of suicide, suicidal tendencies
  • Non family atmosphere
  • Social isolation
  • Failure of therapy as an outpatient 

At the moment, fewer patients are admitted into hospitals compared to ten years ago but the therapeutic treatment, for inpatients who want to gain weight, is considered necessary.  The main aim of the therapeutic treatment is to receive hospital care which focuses on two factors: 

  • the development of a therapeutic alliance between nurses and patients and
  • weight restoration.

The therapeutic alliance
Anorexic patients have a strong desire to lose weight and avoid food intake despite the fact that their bodies request food. Given that the purpose of inpatient treatment is to restore weight, developing a therapeutic relationship between the patient and the nurse can be very difficult.
The main goal of this relationship is the development of trust, giving the patient the feeling that the nurse is on his/her side and that their relationship is based on their collaboration. A nurse can achieve this feeling of trust by asking the patient serious questions and at the same time keeping the patient informed of the clinic’s goals and objectives. A nurse should be capable of perceiving the patients’ attempts to trick and comprehend that the patient’s absurd demands are part of its disease and not personal attacks. In addition, a nurse should be strict and insist that the patient’s behaviour should change. When this trusting relationship is developed, the alliance could be used as the basis for some therapeutic interventions that we described in previous chapters. For example, a nurse could use his/her cognitive restructuring skills and the ‘Socratic questions’ as part of research for evidence. It is also common for nurses to use these conversations to stimulate the patient as the ‘Stages of Change’ (Prochaska and Diclemente 1984) theory suggests. This theory describes people who are in a special situation regarding their attitude change and this situation is a dynamic model because it reveals how people shift continuously from position to position, from and to attitude change (see drawing below). When the “stages of change” model is used, it refers to the nurse foreseeing when the patient desires to change his/her attitude, calculating the predisposed obstacles of the patient for changing his/her attitude, by asking the pros and cons of eating. Particularly in the sense of both cognitive and motivational interviewing, the nurse can introduce the importance and the impact of food avoidance and the entanglements of gaining weight. 

 

The Stages of Change model (Source: after J.O. Prochaska and C.C. DiClemente,
Τhe Transtheoretical Approach: Crossing Traditional Boundaries of Therapy,
Homewood, IL: Dow Jones Irwin, 1984

Restoring Weight
Hunger comes with a preoccupation with food along with cognitive disorders. It is also dangerous to one’s life. Restoring weight is necessary for the patient’s health and his/her ability to deal with other means of therapy. Restoring weight for inpatients suggests encouragement to receive regular meals, eat small doses and desserts and reduce exercise. Food intake usually begins with 1000 calories a day, which is gradually increased to 3000 calories until the desirable weight is reached according to the premorbid weight and the time period of the disease. A 12 kg increase per week is usually the target which takes up to 12-14 weeks in the clinic. The weight restoration process is achieved by the utilization of several strategies which are described from the behavioural components of CBT. For example, the meals should be consumed at the table with other patients and nurses. By doing so, the patients receive support from their peers and it enables the nurses to empower their verbal encouragement and praises. In addition, the patients are introduced or reminded of the pleasure of social gatherings and the model of physical behaviour within the food intake from the nurses.

Problems with the therapeutic treatment of inpatients with eating disorders

  • Inpatient care is useful for restoring the weight when the patient is in a critical state. The probability of a relapse is very high since the patient leaves the hospital unless he/she receive a strong follow up and intensive care.
  • It has been noticed that while gaining weight the patients might appear depression symptoms and have suicidal tendencies if the procedure is not accompanied by a sufficient cognitive change.
  • It has been argued that restoring weight can lead to the development of bulimia if the weight has been gained under the pressure of the nurse or even the peer because the bulimic symptoms can enable the patient to maintain his/her desired physical appearance.
  • It is possible that when a patient is treated for a long period of time to develop social network with other patients, which might be lost when the patient is treated and leaves the hospital. This might motivate the patient to start losing weight again.
  • During the inpatient treatment, the patient might distance himself/herself from his/her family. If that relationship doesn’t change then there is a danger of relapse.

An integrated approach to treatment
Some theories concerning eating disorders can be applied within their treatment. For example, a psychoanalytic access applies in the psychoanalytic psychotherapy. This focuses on the role of children relationships and the symptoms’ functions within the complex of the therapeutic alliance between the patient and the therapist. Similarly, a cognitive formulation is applied in CBT and emphasizes in the behavioural change through self-control and counter-information while changing cognition through cognitive restructuring.  Likewise, the results of an analysis on family systems within the family treatment emphasize on the symbolic role of the symptoms and the family dynamics. But all the theories for the causes lead to treatment. In addition, the majority of treatments require a combination of approaches. While most of the interventions are mainly performed on an outpatient basis, some patients require inpatient treatment. This focuses on developing an alliance between the patient and the nurse which will lead to gaining weight. Some patients though, will be exposed to a wide range of treatments because their problem remains. For example, given the high rate of the illness’ relapses and the long term nature of the situation, some patients will go through both inpatient and outpatient treatments, private and group therapy, as well as get inducted into self-help groups. Sometimes, treatment will be offered as a means of keeping patients alive, without any realistic hope of complete recovery. Sometimes a treatment approach will appear as the right treatment for the right patient at the right moment and he/she will recover. So an integrated approach will be provided to most of the patients. To some it might be integrated in relation to the size of the treatment that is offered at any period of time, but most patients will receive an integrated treatment of different approaches that would be offered through different periods.

Xenia Sotiriou
Psychotherapist
BA (Hons), Med Educational Psychology, Adv.DIP. Psychotherapy, PhD Candidate Organizational Psychology

References

  1. De Silva, P. 1995: Cognitive-behavioural models of eating disorders. In G. Szmokler, C. Dare, and J. Treasure (eds), Handbook of Eating Disorders: Theory, Treatment and Research, London: Wiley, 141-153.
  2. Fairburn, C. Cooper, 2., and Cooper, P.J. 1986: The clinical features and maintenance of bulimia nervosa. In K.D. Brownell and J. Foreyt (eds), Physiology, Psychology and Treatment of eating disorders, New York: Basic Books.
  3. Wilson, G.T. 1989: The treatment of bulimia nervosa: A cognitive –social learning analysis. In A.J. Stunkard and A. Baum (eds), Perspectives in Behavioural Medicine: Eating, Sleeping and Sex. Hillsdale, N.J.: Lawrence Erlbaum.
  4. Eisler, I. 1995: Family models of eating disorders. In G. Szmukler, C. Dave and J. Treasure (eds). Handbook and Eating Disorders: Theory, Treatment and Research, London: Wiley, 293-307.
  5. Eisler, I. 1993: Families, family therapy and psychosomatic illness. In S. Moorey and M. Hodes (eds), Psychological Treatment in Human Disease and illness, London: Gaskill.
  6. Harley, J. 1973: Uncommon Therapy: The Psychiatric Techiques of Milton H. Erichson, M. D. M.A: W.W. Norton and Co.
  7. Dare, C., Le Grange, D., Eisler I., and Ruthertord, J. 1994: Redefining the psychosomatic family: Family process of 26 eating disorders families. International Journal of Eating Disorders, 16, 211-226.
  8. Munuchin, S. Rosman, B.L., and Baker, L. 1978: The anorexic family. In Psychosomatic families: Anorexia Nervosa in Context. Cambridge, MA: Harvard University Press.
  9. Brisman, J. (1995b). Psychodynamic psychotherapy and action oriented technique. An integrated approach. In I. Yalom & Werne (Eds.), Treating eating disorders (pp.31-70). San Fransisco: Josssey-Bass.
  10. Bruch. H. (1973). Eating Disorders: Obesity, anorexia, and the person within. New York: Basic Books
  11. Rabinor, J.R. (1993). Mothers, daughters, and eating disorders: Honoring the mother-daughter relationship. In P. Failon (Ed.), Feminist perspectives on eating disorders (pp.272-286). New York: Guilford Press.