Types of Therapy for Eating Disorders
Psychology has many approaches to the study of human behavior, some of which have been adapted to the treatment of eating disorders. A few of these approaches have been meticulously studied and their effectiveness has been well documented; others have been less studied, but are still widely used. Most therapists and programs use a combination of techniques. Here is a brief overview of the eating disorders field’s most common therapies and others that are often used as adjuncts to treatment.
Cognitive Behavioral Therapy
More studies have been published on Cognitive Behavioral Therapy (CBT) than any other form of treatment for bulimia, and it has been shown to be highly effective using a manualized approach. Some therapists have training in CBT and others also use it to some degree, although it is being continually revised and defined for treating eating disorders patients. The state-of-the-art version is called CBT-E (for enhanced), and encompasses about 20 sessions of one-on-one, individualized therapy. After an initial assessment and introduction to the treatment plan, the focus is on stopping the bingeing and purging, which involves keeping a self-monitoring record of all food consumed as well as the context and associated feelings. Simultaneously, patients are educated about “regular eating,” and significant others are involved for support. As the treatment progresses, it addresses the over-evaluation of shape and weight, including issues of body checking, “feeling fat,” and the eating-disordered mindset. Finally, problem-solving skills are systematically developed for relapse prevention (Fairburn, 2008). The CBT-E manual is not intended to be combined with other methods of treatment, but practically speaking, most therapists and programs use their own hybrid of CBT rather than CBT-E exclusively.
The primary aim of Interpersonal Psychotherapy (IPT) is to help patients identify and address current relationship issues and is particularly appropriate for individuals who are either socially isolated or in unfulfilling relationships. In studies, it has comparable long-term outcomes to CBT, though the behaviors might not stop as quickly, because the early phases of IPT are not as concerned with eating. Instead, the patient is assisted in understanding how their eating disorder is fueled by such influences as: grief (death, the loss of a relationship, etc.), role transitions (going away to school, changing jobs, divorce, etc.), disputes with family, friends, or coworkers, and interpersonal deficits. The therapy focuses on goals, questioning beliefs, making connections, improving internal and external communication, and redirecting attention from food and weight to the underlying issues (Tanofsky-Kraft, 2010).
Dialectical Behavior Therapy
Dialectical Behavior Therapy (DBT) is an expanded form of CBT. It is based on developing skills for effective behaviors, and includes modules for mindfulness, avoiding self harm, emotion regulation, and distress tolerance. Originally developed to treat borderline personality disorder, it is proven to be effective for a subset of patients with bulimia. It is especially useful for those bulimics who have difficulty with emotion dysregulation, which means being so upset that they can’t think clearly or make good judgements. DBT would also be an especially suitable treatment for bulimics with other self-harming behaviors, such as substance abuse, cutting, suicidal thoughts or attempts, or trouble with anger management. DBT treatment typically involves group sessions designed for learning skills, and individual sessions to work on applying them to personal goals (Safer, 2009).
Traditional family therapy is a well-established approach in which the individual with the problem and the family members meet with a therapist. Together, they explore how the family dynamic contributes to the eating disorder and ways to help the recovery process. Oftentimes, communication skills are emphasized, like honesty, assertiveness, independence, speaking directly, and listening. Some therapists make use of Attachment Theory, which concerns the emotional bond between two individuals—most specifically a child and parent. Regardless of their approach, most therapists have family sessions, especially when the recovering bulimic lives at home. Likewise, couples therapy is standard when the person is married or in a committed relationship.
Family-Based Treatment (FBT) is an approach originally developed for treating anorexics at Maudsley Hospital in London. Used primarily for adolescents living at home, FBT for bulimia relies on parents to take charge of their child’s eating. Through love, understanding, and collaboration, parents help their child control the symptoms of bulimia and resolve the issues that led to it. The goals are to: first, reestablish healthy eating; second, help the adolescent eat on his or her own; and third, to have a positive relationship that is no longer focused on resolution of the eating disorder. Usually parents work with a therapist, who follows a manual that includes forms, worksheets, and a schedule (Le Grange, 2007).
Only a few controlled trials of the psychodynamic treatment of eating disorders have been done, but it is a widely practiced approach that has evolved from the work of Sigmund Freud, incorporating an ever-expanding blend of modalities. Central to this approach is the relationship that forms between therapist and client. It emphasizes self-discovery and understanding feelings, and because the individual’s recovery unfolds gradually, psychodynamic therapy typically takes longer—usually at least one year and frequently a few years or more (Zerbe, 2010). In psychodynamic therapy, issues are explored on many levels, for example: food might be seen as a transitional object, a binge might represent a daughter’s inability to feel her mother’s love, and purging may be a form of punishment for being “bad.” Practically all therapists will have had training in psychodynamic principles and will assimilate aspects of it into their treatment.
In addition to the predominant approaches used by your therapist, he or she and other members of the treatment team might provide adjunct forms of treatment, including, but not limited to, any of the following:
• Nutritional therapy – meal plans, nutritional supplements, facts about food and weight, etc.
• Feminist-oriented therapy – empowerment to fight gender-related issues
• Experiential therapies – art, music, psychodrama, dance, etc.
• Acceptance and Commitment Therapy (ACT) – a branch of CBT stressing acceptance and mindfulness
• Mindfulness – meditation, yoga, journal writing, guided imagery, etc.
• Psychoeducation – media literacy, facts about eating disorders, advocacy, etc.
• Pharmacotherapy – use of medications (see pages 60–62)
• Body image therapy – addressing issues with weight and shape
• Eye Movement Desensitization and Reprocessing (EMDR) – uses elements of other therapies (CBT, psychodynamic, etc.) and bilateral stimulation (moving the eyes back and forth as directed by the therapist) in a series of sessions
• Biofeedback –monitors and helps to modify the body’s reaction to stress
• Internal Family Systems (IFS) therapy – methods for accessing the “higher” Self
• Equine therapy – working with horses to restore notions of self-care and confidence
• Ropes courses – for personal empowerment, achievement, getting over fears, etc.
• Therapeutic touch – balancing and promoting the flow of human energy
• Body work – massage, Reiki, acupuncture, exercise, strength training, etc.
Reprinted with permission from Bulimia: A Guide to Recovery
By Lindsey Hall and Leigh Cohn
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