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Part I
Conceptualization of eating disorders
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1
Psychodynamic improvement in eating disorders
Welcoming ignored, unspoken, and neglected concerns in the patient to foster development and resiliency
Kathryn J. Zerbe and Dana A. Satir
I am in chains. Donât touch my chains.
(Franz Kafka, 1912)
Some of the most searing, unspoken questions that patients have when initiating any new treatment are, âWill this prescription you are offering really help me feel better and live longer? And if so, how can I know if I am getting well? Can I trust you to want, be able to, and bear finding the parts I keep concealed from others as well as myself? What side effects can I expect to have and are they worth the while if the anticipated benefit doesnât help me live my own life fully, as I see it and want it to be?â
We would like to believe that mental health practitioners working within a developmental perspective on the family and human life cycles tune in to these often hidden concerns in our practices, anticipate their unspoken presence and try to answer them specifically and concretely. Yet, we also know that we often fall below the mark we set for ourselves, in part because what the patient (and his/her family members) seek deepest reassurance about is unconscious and can only unfold over time as the defenses that maintained survival at such a high cost are worn away and new structures for living and âmeaning makingâ are put into their place. This quagmire is particularly true for those clinicians who treat the spectrum of eating disorders (EDs) because the manifest life-threatening symptoms are frequently denied or minimized and often are an indispensable cogwheel in the individualâs quixotic survival mechanisms. We cannot know our patients with EDs fully unless we dwell in the experience of their symptoms; and yet with our good intentions, benevolent desires, and heroic efforts we aim to unearth all of the terror, yearning, and longing that will reveal a person who is prepared to face death in order to survive.
When these adaptations are sufficiently tinkered with, ED symptoms may almost miraculously diminish for a period only to return with abrupt force and fresh impedance that bewilder even the most experienced therapist. Eating-disordered patients, often described in case reports and in the literature as highly intelligent, fascinating, exquisitely sensitive, and strong willed, are difficult to treat. Many clinicians refuse to or are afraid to see even one in their practices (Thompson-Brenner, Satir, Franko, & Herzog, 2012). Even the most skilled experts experience themselves âbetwixt and betweenâ health/sickness, progress/regression, known/unknown, and ever changing landscapes of self and other (Bruch, 1978; Warren, Schafer, Crowley, & Olivardia, 2012). The epigram by Franz Kafka with which we begin this paper appositely captures this imbroglio for each member of the therapeutic dyad. Overtly, release from the chains of the illness is sought. But these same chains are rarely relinquished without struggle because they serve as the tether for a fragile sense of self. As this dilemma of the patientâs is more fully comprehended, clinicians in our experience tend to have greater forbearance and fewer tendencies to act on their countertransference feelings. With better metabolized feelings, the clinician can then find a way to help the patient relinquish the chains that bind, protect, and suffocate while knowing full well he/she will get entangled with the chains him/herself.
We suspect that the major question for ED patients that can never be answered in the short term but must always be in the long term speaks to how one goes about creating a meaningful life and living in oneâs own skin. Our patients exist in a world, often reflected in microcosm in a particular family system, which exalts outward appearances and images and insufficiently endorses those factors that promote and strengthen the ongoing search for personal knowledge and ethical/moral decision-making. Slowing down, reflecting, sensing, feeling, being â these are universal needs and fundamental desires but overtime are eschewed, relinquished, and rejected by our patients in favor of the prevailing need to perform, accommodate, and succeed. We believe that a psychodynamic psychotherapy approach is fertile soil for ED patients to begin to till ground that eventuates in a fuller sense of oneâs unique selfhood because it welcomes the ignored, unspoken, and neglected concerns essential to living a vital life that have been split off, dissociated, or surreptitiously contained within the manifest symptoms of eating, self, and body image issues.
Although psychodynamic psychotherapy is time consuming and hence costly to provide, a significant literature that includes longitudinal, evidence-based, and qualitative studies is beginning to demonstrate its value in terms of quality of life, symptom remediation, re-established developmental trajectories, and improved resilience over the life cycle. These studies offer hope, guidance, and caution for both clinician and patient who undertake the hard work of bearing down on intransigent symptoms and jump starting a personal journey thrown off kilter by an unsavory and unwavering dance with death. Treatment of EDs is not for the faint of heart, in part because of the high medical morbidity and mortality rate associated with anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating disorders (Crow et al., 2009; Fichter & Quadflieg, 2016; Steinhausen, 2002). It is not enough to be knowledgeable about EDs â the clinician must be attuned to the experience of being with these patients, which requires sensitivity to the visceral feelings in oneâs own body. Treatment requires clinicians to âbuckle inâ for a process that requires fortitude, pragmatism, and at times mutual vulnerability of unknown duration. The more insidious rationale for clinician burnout resides in the sadomasochistic relationships that are played out in the patientâs relationship to self and others alluded to previously. These hefty chains â codified in the contemporary psychoanalytic literature as âDoer/Done Toâ enactments (Benjamin, 2004; Davies, 2003) â must be repeatedly confronted and worked through in the transference to become unyoked.
In the material that follows, we provide two extended case examples to descriptively ferret out six domains of intrapsychic and interpersonal functioning that we have found key in developing a fuller sense of self with ED patients in our psychodynamic practices. We chose to describe these longer-term treatments with some composite features to ensure strict confidentiality and abjure any identifying information of particular individuals. Our goal is to maintain accuracy in the types of storyline, themes, conflicts, and developmental deficits we have encountered throughout our clinical, supervisory, and teaching experiences. Four of the domains that we cull will quickly resonate with clinicians who work with and read about this population over the long term (e.g., mitigation of shame; recognition of split-off affects and defenses; achievement of greater intimacy and capacity to play; reduction in an overly harsh superego). Two of the areas are, however, less obvious and sparsely referenced in the psychodynamic literature on EDs. Confronting the tendency to spoil forward movement (i.e., addressing success anxiety) and denying the real possibility of death posed by the illness are so significantly consequential and ubiquitous in our experience as to warrant additional attunement to transference and countertransference issues that may interfere with recognition and working through. We speculate that these less referenced topics may mirror unformulated or dissociated experiences of our patients and require a willingness of clinicians to confront painful realities, limitations, and losses that are endemic in our work.
Before turning to the specific cases, we present a brief review of the psychodynamic evidence base and qualitative research studies that inform our practices, and are likely to be helpful to others in deciphering additional domains essential to self-development and sustained resiliency in the person who struggles with an ED.
Although this report grapples with some of the psychodynamic links that keep our patients bound, we believe that the psychodynamic method must, in the case of ED patients, be integrated with other forms of therapy (e.g., cognitive behavioral therapy [CBT], nutritional support, patient education modalities, art and experiential therapies, residential and wrap-around services). Initial reports indicate a robust effect when an integrative approach is taken, and many existing models of ED treatment recommend step-wise approaches that focus initially on stabilization and containment of symptoms before transitioning into more insight-oriented/depth psychotherapies. Research also confirms that experienced clinicians consciously and intuitively blend psychodynamic and cognitive behavioral methods regardless of the theoretical orientation that they consciously espouse in order to flexibly meet their patientsâ needs, personalities, and evolving presentations. We suspect that in âreal worldâ clinical practice, clinicians who successfully assist patients in their recovery from a serious ED have a knack for and interest in exploring the existential concerns we describe while simultaneously serving as vehicles that champion growth, resilience, and freedom from the constraints imposed by a serious, long-standing eating disorder.
Research and literature review
Studies of the efficacy of psychodynamic psychotherapy for EDs are growing but limited. Qualitative and quantitative studies, naturalistic surveys, narrative and single-case designs, and consumer reports converge in their examination of the importance of psychotherapy in addressing concerns that patients have beyond symptom control, weight restoration, and improved body and self-image (for reviews see Zerbe, 2008, 2015, 2016). While there is a consensus among these reports in acknowledging the importance of support and empathic relationships when confronting concerns that lie beneath the manifest problem, there is little research that could guide what works for a particular patient based on developmental history, self-experience, and meaning/function of symptoms. As clinicians struggle to make sense of these enigmatic illnesses and how their patients are intertwined with them, there are even greater empirical gaps in training issues that might assist clinicians in questioning their assumptions and when changing course is necessary. Attachment to the therapist, reduction of a harsh superego, improved sense of security, willingness to engage in interpersonal relationships, enhanced ability to self-reflect (e.g., mentalize) and having fewer self-destructive relationships and behaviors are core areas addressed in psychodynamic psychotherapy. These domains of intrapsychic and interpersonal functioning are confirmed in some research reports which support improved outcome in ED treatment.
To date in the adolescent and adult literature there have been five controlled trials of psychodynamic psychotherapy for anorexia nervosa (AN) (Bachar, Latzer, Kreitler, & Berry, 1999; Dare, Eisler, Russell, Treasure, & Dodge, 2001; Lock et al., 2010; Treasure et al., 1995; Zipfel et al., 2014); two for bulimia nervosa (BN) (Bachar et al., 1999; Poulsen et al., 2014); and one for Binge Eating Disorder (BED) (Tasca et al., 2006; Tasca, Richie & Balfour, 2011). In Treasure et al.âs (1995) report comparing cognitive analytic therapy (a form of psychodynamic therapy) to educational behavior therapy, 63 per cent of patients had good to intermediate improvement overall. Although there were no significant differences in the endpoint body mass index (BMI) between the two groups, the cognitive analytic group improved on a number of self-assessment measures related to interpersonal functioning and sense of self-worth, suggesting important intrapsychic changes beyond manifest ED symptoms. Emphasizing the impact of the therapist-patient relationship as a positive force for change, interpreting unconscious meaning of symptoms, understanding core conflicts, and opening a door to new ways of thinking about the self, thus leading to an expansion of resiliency and symptom improvement, appeared central in other reports as well (Bachar et al., 1999; Dare et al., 2001; Tasca et al., 2006). These findings tend to support the importance of experiencing and maintaining a secure base of attachment for patients who have had insecure, disorganized, dismissive, and otherwise thwarted early caretaker relationships (Candelori & Cioca, 1998; Treasure, Corfield, & Cardi, 2012; Ward et al., 2001). In a recent randomized controlled trial comparing an integrative psychodynamic psychotherapy and cognitive behavioral therapy for adults with BN, reductions in binge eating were associated with improvements in attachment security in psychodynamic treatment (Daniel, Poulsen, & Lunn, 2016; Poulsen et al., 2014). While the causality of this relationship could not be determined, it does support the importance of a durable therapy relationship that helps patients repair early developmental traumas and develop capacities for benign introjects that foster capacities for self-soothing.
Treatment acceptance because of ambivalence about change is a major hurdle in treating EDs that can be attenuated when the therapeutic alliance is attended to in the treatment. Patients in a focal psychodynamic psychotherapy or enhanced cognitive behavioral therapy both substantially improved at a 12-month follow-up and reported positive feelings about their psychotherapists, likely contributing to a low drop-out rate (Zipfel et al., 2014). One in-depth qualitative analysis using a single-case study method, Alliance Focused Psychotherapy, based upon contemporary relational psychoanalytic principles such as repairing ruptures in the therapeutic dyad, attending to interpersonal conflicts, and confronting emotional avoidance and verbalizing and integrating feelings that had been silenced, demonstrated how a low-weight patient was able to engage in a process psychotherapy, gain weight, and address key issues of quality of life (Satir et al., 2011). Another published case study utilizing an integrative treatment for a patient with BN (four weeks of CBT, followed by 19 weeks of a psychodynamic psychotherapy), reported significant reductions in binge-purge behaviors as well as improvements in affect regulation, identity coherence, and an internalization of a sense of âgood enoughnessâ as a response to harsh super ego functioning (Richards, Shingleton, Goldman, Siegel, & Thompson-Brenner, 2016). These changes were part of a process of exploration and insight that were borne out by the therapistâs ability to reflect, experience, and survive treatment with the patient, her symptoms, and their interacting interpersonal worlds.
A significant number of patients actually undergo and benefit from treatment that ranges from â50 to 100 or moreâ visits (Tobin, 2012; Tobin, Banker, Weisberg, & Bowers, 2007). This longer duration dose of treatment and the positive dose-response effects have been studied in patients with histories of substance abuse, severe anxiety and depression, and trauma and early attachment problems (Leichsenring & Leibing, 2003; Shedler, 2010). Longer treatments tend to be psychodynamic in approach and may help patients achieve mastery over intense affects, gain a sense of effectiveness and self-awareness, understand the roots of self-loathing (Bers, Blatt, & Dolinsky, 2004), and promote new opportunities to learn about and sustain interpersonal relationships, including but not exclusively the one with the therapist (Thompson-Brenner & Westen, 2005a, b). Findings from a New Zealand study (Carter et al., 2011) indicated that a prolonged time frame of therapy is needed to show positive effects in patientsâ interpersonal functioning and produced better long-term results overall.
A notable outcome, across several different studies, is that while changes in ED symptoms in psychodynamic psychotherapies may be slower than those reported in behavioral treatments, at follow-up these differences are either no longer relevant or suggest psychodynamic treatments are superior in terms of ED symptom improvement. In one of the largest, multi-center clinical trials for AN comparing focal analytic therapy, enhanced cognitive behavioral therapy, and optimized treatment as usual (ANTOP study), patientsâ body mass index (BMI) at the end of treatment increased in all study groups, with more rapid improvements in weight gain in CBT (Zipfel et al., 2014). At 12-month follow-up, however, the data suggest greater improvements in BMI in focal analytic treatment. Similar results have been reported in trials for interpersonal psychotherapy, or IPT, for BN where patient improvement in ED symptoms at 20 sessions is delayed compared with CBT, but results at follow-up suggest treatments are equally effective in reducing binge-purge behaviors (e.g., Agras, Walsh, Fairburn, Wilson, & Kramer, 2000; Fairburn, 1997). It is noteworthy, however, that while IPT is based on analytic principles (Weismann, Markowitz, & Klerman, 2000), studies in EDs only consist of 20 sessions over 20 weeks, comparatively shorter to other analytic approaches.
One hypothesis for this timeline of change is that the psychodynamic psychotherapy process begins to shift the tectonic plates of self-other co...
