Philosophy and Approaches to Treating Eating Disorders

Popular Diets: What's the Best Approach? This chapter provides a very simplistic summary of three main philosophical approaches to the treatment of eating disorders. These approaches are used alone or in combination with one another according to the treating professional's knowledge and preference as well as the needs of the individual receiving care. Medical treatment and treatment with drugs that are used to affect mental functioning are both discussed in other chapters and not included here. However, it is important to note that medication, medical stabilization, and ongoing medical monitoring and treatment are necessary in conjunction with all approaches. Depending on how clinicians view the nature of eating disorders, they will most likely approach treatment from one or more of the following perspectives:

• Psychodynamic

• Cognitive behavioral

• Disease/addiction

It is important when choosing a therapist that patients and significant others understand that there are different theories and treatment approaches. Admittedly, patients may not know whether a certain theory or treatment approach is suitable for them, and they may need to rely on instinct when choosing a therapist. Many patients know when a certain approach is not appropriate for them. For example, I often have patients elect to go into individual treatment with me or choose my treatment program over others because they have previously tried and do not want a Twelve Step or addiction- based approach. Getting a referral from a trustworthy individual is one way to find an appropriate professional or treatment program.

PSYCHODYNAMIC MODEL

A psychodynamic view of behavior emphasizes internal conflicts, motives, and unconscious forces. Within the psychodynamic realm there are many theories on the development of psychological disorders in general and on the sources and origins of eating disorders in particular. Describing each psychodynamic theory and the resulting treatment approach, such as object relations or self-psychology, is beyond the scope of this book.

The common feature of all psychodynamic theories is the belief that without addressing and resolving the underlying cause for disordered behaviors, they may subside for a time but will all too often return. The early pioneering and still relevant work of Hilde Bruch on treating eating disorders made it clear that using behavior modification techniques to get people to gain weight may accomplish short-term improvement but not much in the long run. Like Bruch, therapists with a psychodynamic perspective believe that the essential treatment for full recovery from an eating disorder involves understanding and treating the cause, adaptive function, or purpose that the eating disorder serves. Please note that this does not necessarily mean "analysis," or going back in time to uncover past events, although some clinicians take this approach.

My own psychodynamic view holds that in human development when needs are not met, adaptive functions arise. These adaptive functions serve as substitutes for developmental deficits that protect against the resulting anger, frustration, and pain. The problem is that the adaptive functions can never be internalized. They can never fully replace what was originally needed and furthermore they have consequences that threaten long-term health and functioning. For example, an individual who never learned the ability to self-soothe may use food as a means of comfort and thus binge eat when she is upset. Binge eating will never help her internalize the ability to soothe herself and will most likely lead to negative consequences such as weight gain or social withdrawal. Understanding and working through the adaptive functions of eating disorder behaviors is important in helping patients internalize the ability to attain and maintain recovery.

In all of the psychodynamic theories, symptoms are seen as expressions of a struggling inner self that uses the disordered eating and weight control behaviors as a way of communicating or expressing underlying issues. The symptoms are viewed as useful for the patient, and attempts to directly try to take them away are avoided. In a strict psychodynamic approach, the premise is that, when the underlying issues are able to be expressed, worked through, and resolved, the disordered eating behaviors will no longer be necessary. Chapter 5, "Eating Disorder Behaviors Are Adaptive Functions," explains this in some detail.

Psychodynamic treatment usually consists of frequent psycho-therapy sessions using interpretation and management of the transference relationship or, in other words, the patient's experience of the therapist and vice versa. Whatever the particular psychodynamic theory, the essential goal of this treatment approach is to help patients understand the connections between their pasts, their personalities, and their personal relationships and how all this relates to their eating disorders.

The problem with a solely psychodynamic approach to treating eating disorders is twofold. First, many times patients are in such a state of starvation, depression, or compulsivity that psychotherapy cannot effectively take place. Therefore, starvation, tendency toward suicide, compulsive bingeing and purging, or serious medical abnormalities may need to be addressed before psychodynamic work can be effective. Second, patients can spend years doing psychodynamic therapy gaining insight while still engaging in destructive symptomatic behaviors. To continue this kind of therapy for too long without symptom change seems unnecessary and unfair.

Psychodynamic therapy can offer a lot to eating disordered individuals and may be an important factor in treatment, but a strict psychodynamic approach alone—with no discussion of the eating- and weight-related behaviors—has not been shown to be effective in achieving high rates of full recovery. At some point, dealing directly with the disordered behaviors is important. The most well-known and studied technique or treatment approach currently used to challenge, manage, and transform specific food and weight-related behaviors is known as cognitive behavioral therapy.

COGNITIVE BEHAVIORAL MODEL

The term cognitive refers to mental perception and awareness. Cognitive distortions in the thinking of eating disordered patients that influence behavior are well recognized. A disturbed or distorted body image, paranoia about food itself being fattening, and binges being blamed on the fact that one cookie has already destroyed a perfect day of dieting are common unrealistic assumptions and distortions. Cognitive distortions are held sacred by patients who rely on them as guidelines for behavior in order to gain a sense of safety, control, identity, and containment. Cognitive distortions have to be challenged in an educational and empathetic way in order to avoid unnecessary power struggles. Patients will need to know that their behaviors are ultimately their choice but that currently they are choosing to act on false, incorrect, or misleading information and faulty assumptions.

Cognitive behavioral therapy (CBT) was originally developed in the late 1970s by Aaron Beck as a technique for treating depression. The essence of cognitive behavioral therapy is that feelings and behaviors are created by cognitions (thoughts). One is reminded of Albert Ellis and his famous Rational Emotive Therapy (RET). The clinician's job is to help individuals learn to recognize cognitive distortions and either choose not to act on them or, better still, to replace them with more realistic and positive ways of thinking. Common cognitive distortions can be put into categories such as all-or-nothing thinking, overgeneralizing, assuming, magnifying or minimizing, magical thinking, and personalizing.

Those familiar with eating disorders will recognize the same or similar cognitive distortions repeatedly being expressed by eating disordered individuals seen in treatment. Disordered eating or weight-related behaviors such as obsessive weighing, use of laxatives, restricting all sugar, and binge eating after one forbidden food item passes the lips, all arise from a set of beliefs, attitudes, and assumptions about the meaning of eating and body weight. Regard-less of theoretical orientation, most clinicians will eventually need to address and challenge their patients' distorted attitudes and beliefs in order to interrupt the behaviors that flow from them. If not addressed, the distortions and symptomatic behaviors are likely to persist or return.

FUNCTIONS THAT COGNITIVE DISTORTIONS SERVE

1. They provide a sense of safety and control.

Example: All-or-nothing thinking provides a strict system of rules for an individual to follow when she has no self-trust in making decisions. Karen, a twenty-two-year-old bulimic, does not know how much fat she can eat without gaining weight so she makes a simple rule and allows herself none. If she does happen to eat something forbidden she binges on as many fatty foods as she can get because, as she puts it, "As long as I have blown it I might as well go the whole way and have all those foods I don't allow myself to eat."

2. They reinforce the eating disorder as a part of the individual's identity.

Example: Eating, exercise, and weight become factors that make the person feel special and unique. Keri, a twenty-one-year-old bulimic, told me, "I don't know who I will be without this illness," and Jenny, a fifteen-year-old anorexic, said, "I am the person known for not eating."

3. They enable patients to replace reality with a system that supports their behaviors.

Example: Eating disorder patients use their rules and beliefs rather than reality to guide their behaviors. Magically thinking that being thin will solve all of one's problems or minimizing the significance of weighing as little as 79 pounds are ways that patients mentally allow themselves to continue their behavior. As long as John holds the belief that, "If I stop taking laxatives I will get fat," it is difficult to get him to discontinue his behavior.

4. They help provide an explanation or justification of behaviors to other people.

Example: Cognitive distortions help people explain or justify their behavior to others. Stacey, a forty-five-year-old anorexic, would always complain, "If I eat more I feel bloated and miserable." Barbara, a binge eater, would restrict eating sweets only to end up bingeing on them later, justifying this by telling everyone, "I'm allergic to sugar." Both of these claims are more difficult to argue with than "I'm afraid to eat more food" or "I set myself up to binge because I don't allow myself to eat sugar." Patients will justify their continued starving or purging by minimizing negative lab test results, hair loss, and even poor bone density scans. Magical thinking allows patients to believe and try to convince others to believe that electrolyte problems, heart failure, and death are things that happen to other people who are worse off.

Treating patients with cognitive behavioral therapy is considered by many top professionals in the field of eating disorders to be the "gold standard" of treatment, especially for bulimia nervosa. At the April 1996 International Eating Disorder Conference, several researchers such as Christopher Fairburn and Tim Walsh presented findings reiterating that cognitive behavioral therapy combined with medication produces better results than psychodynamic therapy combined with medication, either of these modalities combined with a placebo, or medication alone.

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Even though these findings are promising, the researchers themselves concede that the results show only that in these studies, one approach works better than others tried, and not that we have found a form of treatment that will help most patients. For information on this approach, see Overcoming Eating Disorders Client Handbook and Overcoming Eating Disorders Therapist's Guide by W. Agras and R. Apple (1997). Many patients are not helped by the cognitive behavioral approach, and we are not sure which ones will be. More research needs to be done. A prudent course of action in treating eating disordered patients would be to utilize cognitive behavioral therapy at least as a part of an integrated multidimensional approach.

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