Re-Thinking Eating Disorders

Language, Emotion, and the Brain

Barbara Pearlman

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429864896
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In Re-Thinking Eating Disorders: Language, Emotion, and the Brain, Barbara Pearlman integrates ideas from psychoanalysis, developmental psychology and cutting-edge neuroscience to produce a model of neural emotional processing which may underpin the development of an eating disorder.

Based on clinical observations over 30 years, this book explores how state change from symbolic to concrete thinking may be a key event that precedes an eating disorder episode. The book introduces this theory, and offers clinicians working with these challenging clients an entirely new model for treatment: internal language enhancement therapy (ILET). This easily teachable therapy is explored throughout the book with case studies and detailed descriptions of therapeutic techniques.

Re-Thinking Eating Disorders will appeal to students and practitioners working with this clinical group who are seeking an up-to-date and integrative approach to therapy.

Chapter 1
Introduction

This book came into being as a result of the concluding statement of a meeting, on the past and future of psychoanalysis, held at the Freud Museum. It was declared that the future of psychoanalysis lay in neuroscience but that it would take at least two generations for a workable therapy to come about. This is a sad reflection of how the different disciplines in mental health tend to keep to their separate worlds, as in the field of eating disorders one such therapy has been created.

Those of us who trained in the 1970s and 1980s often worked in hospitals and departments that encouraged cross-fertilisation between the organic, behavioural and psychoanalytic schools of thought. Creative therapies were integral to our work and I hope I have continued this proud tradition in creating a new way of thinking about and treating eating disorders: internal language enhancement therapy (ILET). ILET introduces a new way of approaching eating disorders. It is based on a discontinuous model of neural emotional processing in eating disorders’, which more simply means that the brain either processes emotions symbolically or concretely – but not both at the same time. In other words, we can either think about the meaning of things and what they may represent and test our understanding against reality and what we have learnt in the past, or we only understand the literal meaning. For example, ‘I have too much on my plate this week and I cannot manage to do it all’ is symbolic; we are not talking about actual plates but feeling overwhelmed by our schedule. ‘There is too much food on my plate and I cannot eat it’ is its concrete counterpart; here we are talking about food and plates and stomachs and what we cannot take in to our bodies – the symbolism has been lost.

This new therapy is based on understanding how the brain processes emotional information, developmental neuropsychology and the development of language. It employs theory and techniques from psychoanalysis integrated with those of CBT. This approach to treating eating disorders is an amalgam of widely differing theoretical approaches that generally remain separate. But, as in many fields of study, when we synthesise information from different disciplines, it can result in innovative ways of understanding and approaching a problem.

I have spent my professional life as a clinical psychologist and group psychotherapist working in the field of eating disorders and, in 2010, was awarded a PhD for theoretical research into how the brain processes emotion, from both the neurobiological and psychoanalytic perspectives, in eating disorders. For 30 years I have had the privilege of working with my patients, who have kindly given me their trust and permission to use their stories to illustrate this new approach as well as agreeing to participate in clinical research.

The neurobiology of the brain is very complex and is a field that is growing but is, as yet, still imperfectly known. However, there is increasing interest in, and research into, the neurobiological underpinnings of eating disorders (Frank, 2015; Garrett et al., 2014; Juarascio, et al. 2015; McAdams & Smith, 2015) and we now understand that neurological deficits have a direct effect on the expression of eating disorder symptoms (Fotopoulou & Tsakiris, 2017; Martinez et al., 2014). This book suggests that our understanding of these deficits should influence how treatments are designed. The neural networks described in ILET are necessarily schematic but are based on well accepted research in emotional processing.

It has been a widely held truism that ‘an eating disorder can never be cured’ – a statement that has caused much distress to eating disorder sufferers. This work describes a new way of thinking about and treating eating disorders that presents the possibility of allowing an eating disorder to fade.

As we go through the book, patients will be denominated as she, as this reflects the 10:1 ratio of female to male sufferers – although this may be an underestimation of the prevalence of male sufferers. There is no theoretical reason why male sufferers would not respond to the ILET treatment in a similar way to their female counterparts. There is an increase in the diagnosis of eating disorders among young men and that is of concern. This can be partially explained by an increasing awareness by clinicians who hold the possibility of seeing eating disorders in young men, as well as this group feeling more able to come forward for help. To add to this, high profile men have bravely spoken in public about their struggles, making it easier to admit to having an eating disorder.

Anyone who has experienced an eating disorder or who has cared for someone who has one, be that a family member or a professional, knows how confusing and difficult this illness is to understand and treat. Something happens to communication – instead of the usual ‘chit-chat’ of family life, a preoccupation with food and bodies becomes overwhelming for the sufferer and dominates her thoughts. Why is this?

When families are faced with a daughter (or, less frequently, a son) who becomes consumed in this way, by definition the young person is unable to think about the many other areas of her life. This creates the situation where parents may naturally step into this void and begin to think for their child, as they might have done when she was younger. This then can create a vicious circle where the young person relinquishes more and more control over the real decisions she needs to make and face, while the parents are increasingly drawn in to compensate. This may look as if the eating disorder patient is trying to control the only thing left that she can – her body – and the parents are trying to control and dominate their child. But if we consider that the eating disorder sufferer just cannot think meaningfully about her emotional life and is caught up in the concrete world of the body, then her parents’ actions can be understood as desperately trying to help their child by taking over the thinking tasks and are then frightened to let go lest their child cannot maintain her health and even her life. That is why it is usual to support the family as well as the sufferer, as the anxiety in the family needs to be lessened to allow a supportive space for the sufferer to grow into.

It can also happen that when there is an ill member of the family, the family system coheres around the ill member to protect her. This might mean that difficulties at the parental level may have to be put aside and that may, in turn, add to the pressures within the family. Siblings may feel unable to put their needs forward when parents are preoccupied with the ill child, so it may be that when the eating disorder sufferer gets well, it may open up other difficulties in the family that were overshadowed by the illness. This is true of other illnesses that create anxiety within the family system but in eating disorders communication itself, within the patient herself and between family members, becomes the focus.

Targeting language and communication — internal language enhancement therapy

Internal language enhancement therapy (ILET) aims to do what its title says: to restore the richness of internal language (how we think) from (under stress conditions) concrete thinking, that is, thoughts that contain only the literal meaning of language (e.g., ‘sweet’ meaning containing sugar as against being kind (see example of ILET below)) to symbolic function, defined as thoughts that contain metaphoric and ironic meaning, are tested against reality, previous experience and awareness of the consequences of actions. This increases the ability of eating disorder sufferers to understand and think about the meaning of their feelings, with the aim of promoting an independent, well functioning mind, a strong sense of self and the ability to understand their own and others’ emotional responses. As a result, parents can begin to see and trust that their child is able to think clearly and make decisions that reflect reality, rather than being preoccupied with body and food issues. All being well, this allows the parental ‘compensatory thinking’ to become redundant and for family life to return to normal, although perhaps with some changes in order to create a space for the growing mind and needs of their child.

The eating disorder conundrum

There is a conundrum at the heart of eating disorders. Therapists, from both psychodynamic and cognitive–behavioural orientations, may well have experienced sitting in a room trying to talk with their patient about the patient’s emotional world, while their patient can only think and talk about her food intake or the shape of her body. One way of thinking about this problem is that the patient and therapist are each talking a different language. The therapist is speaking in what we might describe as ‘symbolic language’, where possibly we might talk about emotional relationships or what it means to the patient to starve, binge or purge, or try to persuade the patient of the reality of her situation. The patient, on the other hand, is talking in ‘concrete’ language, where she speaks only of how fat her body feels or her refusal to eat fats and carbohydrates, and is preoccupied with calorie intake. Faced with this conundrum, depending on the therapeutic orientation of the therapist, one option may be to employ a more cognitive–behavioural approach and join the patient in talking about food intake or how to help her see her body in a more positive light. However, this approach does not target the underlying ‘concrete speak’ problem. If the patient is treated with a psychodynamic approach, then a different problem may arise. If the patient is in the ‘concrete mode’, then speaking about emotions and underlying conflicts raises anxiety because she is unable to understand the emotional meaning of what is being said and we know that increased anxiety leads to increased symptoms (Bruch, 1982; Schmidt et al., 2012). Sometimes the therapist might employ a combination of an insightful (psychodynamic) and cognitive–behavioural approach as different phases of treatment, or possibly to separate the medical, behavioural and emotional approaches within a team of professionals. However, this presupposes that the patient is able to join the therapists in their symbolic and metaphoric understanding of the inner world, which is mostly not the case. Recently, there has been an emphasis on just allowing patients with severe anorexia to talk about everyday non-threatening topics. It has been noted that symptoms do not get exacerbated but the therapy is no more successful than other treatments that anyway have a poor success rate (Schmidt et al., 2012).

Recent research tells us that these approaches, while to varying degrees helpful, do not offer a consistently satisfactory treatment outcome, not even reaching 50%, including enhanced cognitive–behavioural therapy (CBT-E) (Fairburn & Cooper, 2011; Fairburn et al., 2013, 2015). This is not surprising, given the communication problems.

However, with the increased understanding offered by advances in neurobiological research allied with insights offered by psychoanalytic theory and the development of language function, we are now able to think about eating disorders in a very different way. By translating the patient’s concrete understanding of her inner world into symbolic language, it allows the patient access to the meaning behind her concrete thoughts and behaviour. When we know what we think about what we feel, we become more rounded as a personality and in doing so discover a sense of who we are. With apologies to Descartes – ‘I think (about what I feel), therefore I am’. When left untreated, eating disorder sufferers, particularly those suffering from anorexia, may come to rely solely on their intellects and expend their energy in keeping out all emotional information that becomes increasingly anxiety provoking. The behavioural counterpart of ‘keeping everything out’ of extreme starvation is, unfortunately, all too familiar. We know that people who suffer from anorexia are really quite poor at interoception – that is, making sense of messages from the internal organs or state of how the body is feeling (Fotopoulou & Tsakiris, 2017). As a consequence, they rely more on the outside world, or exteroception, as a means to try to make judgements about the world. Thus, we see sufferers choosing to eat what others eat rather than relying on the feeling of being full or, for that matter, being able to accept the feeling of being full. This is discussed further when we come to talk about maternal preoccupation and its importance.

The average time before referral to specialist services is around two years; this is generally accepted to be too long (Schmidt et al., 2012) as, left untreated, eating disorders usually worsen (why this happens is discussed in Chapter 5). Adolescence, of course, is an ‘at risk’ time when we are constantly reacting to, and learning about, our world and our feelings. If an eating disorder begins, we may find ourselves trapped in, or flipping in and out of, concrete thinking that serves to raise our anxiety, and which, in turn, leads to more concrete thinking. When we are unable to decipher meaning, the work of learning about feelings in adolescence is interrupted and we stop learning. This makes the world a much more confusing place. Ideally, the moment parents notice a change in how their child is talking about eating and food is the time to find help, as it is much easier to treat an eating disorder early, before it becomes entrenched.

The theoretically integrative ILET approach allows us to gain a deeper and broader understanding of the workings of the mind in eating disorders or any of the illnesses that exhibit a change of state from being able to think about what makes us anxious to a state where we are compelled to act in place of thought; for example, binge drinking, cutting, or other forms of self-harm.

While this book is necessarily quite heavy on research and is perhaps most useful for fellow professionals, I hope that anyone with an interest in eating disorders will be able to gain insight into this distressing and confusing illness and emerge less distressed and less confused in the process. Once we understand that eating disorder pathology is linked with tipping in and out of, or getting stuck in, the ‘concrete’ state, then we can see that our patients are neither ‘mad’ nor ‘bad’ for exhibiting seemingly incomprehensible thoughts about food and bodies but that they are just firing on the ‘wrong’ pathway. This shared understanding can reduce the very real anxiety of both sufferers and their families.

The development of an eating disorder

In order to develop an eating disorder, quite a lot of boxes need to be ticked. As the brain develops it creates pathways to process complex emotional reactions from both the internal and external world. This enables us to think about what we feel and make sense of it. Sometimes these pathways are fragile and, especially during adolescence, can become overwhelmed by anxiety so that access to symbolic functions is denied. This can result in our minds being hijacked by an emotional response that is un-thought out (Arnsten, 2005; Aron et al., 2007; LeDoux, 1996, 2003).

As we progress through the book, I will attempt to explain in detail what happens to the brain in eating disorders and its implications for treatment. For now, we can understand it as the mind changing from the ability to think about the meaning of what is making us anxious and what we might need to understand or do as a response to feeling discomfort in our bodies to the need to do something to our bodies to solve what is now felt as a body ‘problem’.

This emotional hijacking fundamentally affects how we think. From having access to full language functions, including metaphoric and symbolic understanding of meaning (frontal lobe functions, which also include reality testing, planning, memory in language and creativity), there is a sudden shift to a state where we can only think concretely – where words lose their symbolic, metaphoric and ironic meanings. An example of this is the sentence, ‘I am fed up to the back teeth and cannot stomach any more’. If we are able to access our symbolic functions, we understand it to mean that we have had enough of a situation. But if we are in a concrete state, then we understand it to mean that ‘I have eaten too much food and I cannot bear it in my stomach’ – literally meaning that the food cannot be kept in the stomach, as opposed to the metaphor meaning that an idea or situation cannot be tolerated.

Understanding this change of state from symbolic to concrete language, following an emotionally stressful event or thought, helps us make sense of why someone suffering from an eating disorder thinks the way she does about her body shape or the number of calories in certain foods. With the change of state, the meaning of the stressful event disappears but, and this is the important factor, the sufferers do not know that they have changed state. From their point of view, they are only acting on what their brains tell them is the problem and they do not question something that feels as if it is the only and right thing to do. For example, if a good friend has just rejected you, creating distress and anxiety, then, if you remain symbolic, the meaning might be that you feel loss, upset and despair and that your life may feel empty. But when you change to the concrete state, the symbolic meaning has disappeared and the only thought available is that you feel literally empty inside your body. When you are trapped in the concrete paradigm, if your body experiences a feeling of emptiness, the logical action is to fill it up, that is, to binge. Or, instead of feeling uncomfortable emotions such as anger, envy or sadness in the symbolic state, in the concrete state you might feel that your insides are full of disgusting ‘stuff’ and you will attempt to get rid of it by starving or purging or possibly excessive activity.

An Example of ILET

As an example of this way of approaching and understanding this change in language I shall describe a vignette of a patient, whom I shall call Katherine, a woman in her late forties who had three children and an emotionally needy, but critical, partner. She had suffered from bulimia from her teenage years and had made several attempts at getting treatment. The results of these treatments were periods of absence of the symptoms but which later returned. She did not have a clear understanding of what an eating disorder was or what caused it or why she binged when she did. In an ILET session, Katherine was asked to report on her most recent binge. She described that while driving her children around, running errands for them, she noticed that she had to fill up her car with petrol. She went to a petrol station and bought her preferred binge foods and subsequently binged and vomited. In line with the ILET protocol, the therapist enquired about the exact last thought before she became preoccupied with needing to buy her binge food. Katherine replied that it was just as she noticed that the car was low on petrol and she reported the last thought as ‘I’m running on empty – I must fill up’. She recognised that her thinking had changed, as suddenly all she could think about was getting to the garage that sold her usual binge food, even though it was some way away and there was another garage nearby. She made her way to the more distant garage and filled up on petrol – and her favourite sweet things. She waited until she returned home to binge and vomit. She could give no explanation of why she had binged and vomited.

She was then closely questioned about what exactly was happening at the precise moment just prior to the sudden preoccupation with buying binge food. It turned out that her children were being dismissive of her and ungrateful at the precise moment she noticed the low petrol gauge. It transpired that all weekend she had been bu...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Foreword
• Preface
• 1 Introduction
• 2 The neurobiological contribution to understanding the development of an eating disorder: neurobiological underpinnings of eating disorders
• 3 A conceptual gap: current ideas in eating disorders and the need for a new treatment approach
• 4 Filling the conceptual gap: the development of symbolisation from a developmental neuropsychoanalytic perspective
• 5 Proposing a new model of the mind in eating disorders
• 6 Theory and practice
• 7 The problem with CBT
• 8 ILET treatment with 'Emily
• 9 Conclusions
• Postscript
• Appendices
• References
• Bibliography
• Index