Psychotherapy in Eating Disorders Treatment

Continuing our discussion of a team approach to treatment, I'll begin with a reminder that at minimum, a comprehensive treatment team should include a physician, mental health professional and nutrition therapist (see recent prior posts for more about the roles of these professionals). Medication as prescribed by a medical doctor, psycho-pharmacologist, or other prescribing professional may also be a helpful part of comprehensive eating disorders treatment (the subject of a future post). Psychotherapy is considered an essential aspect of eating disorders recovery, however, the type of therapy and the therapeutic approach may vary depending on diagnosis, symptom severity, level of care, and patient readiness for change.

Of course, therapist training and comfort will also play a role in the selection of a psychotherapeutic approach. In addition, family and/or individual therapy modalities may be included, depending on variables such as age of the patient, whether or not a patient lives at home with the family, familial involvement in recovery, and therapist training and orientation. Family therapy has been well-researched in the treatment of eating disorders and I will comment on this modality more in my next post.

In addition, I will attempt to address each of the major theoretical perspectives on eating disorders treatment as time goes by in future editions of Treatment Notes, however today, I would like to comment briefly on the topic of individual therapy for patients with eating disorders.

While a variety of individual approaches have been noted in the literature, far fewer have been adequately researched as they apply to eating disorders treatment. It is important to comment, however, on the results of such studies and to inform eating disorders work with the established Treatment Guidelines recommended by the American Psychiatric Association. That being said, let me make a couple of parenthetical comments:

1. Treatment Guidelines are just that - guidelines - so of course there is an implicit understanding that guidelines may need to be tailored to fit an individual patient's needs, cognitive functioning, level of maturity, motivation for change, level of insight, and pace of treatment.
2. The vast majority of therapists utilize an "eclectic" or "blended" theoretical approach to eating disorders treatment (with some studies showing up to two-thirds of eating disorders therapists identifying themselves as "eclectic" in approach), combining the most effective elements of multiple therapies to fit an individual patient's needs.
3. As treatment professionals, we do well to inform our work with the latest research findings, including those that have implications about therapeutic approach.
4. Training and the availability of opportunities to enhance and/or continue that training will also influence a professional's selection of treatment modalities.

With this in mind, the following highlights several of the most prominent psychotherapeutic approaches to eating disorders treatment:

• Cognitive-behavioral therapy (CBT): the most frequently researched individual approach to eating disorders treatment. CBT is considered to be one of the most effective treatments for bulimia nervosa and binge eating. A frequent choice for anorexia treatment as well. Principles are similar for treatment of all EDs, however, there has been a dearth of empirical research into individual therapies for the treatment of anorexia in general. Motivation, severity of symptoms, medical risk and the ego-syntonic nature of anorexia symptoms may present challenges to the usefulness of CBT treatment for some anorexia patients.
• Psychodynamic psychotherapies: Psychodynamic approaches to ED treatment have the longest history  of use. They tend to be longer term in duration. Unfortunately, the effectiveness of these therapies with eating disorders is not well studied. In addition, "insight-oriented" therapies should be approached with caution in patients in a weakened physical state, those who have difficulty with the identification and expression of feelings, and those who demonstrate reduced distress tolerance.
• Interpersonal therapy: Shown to be an effective short-term approach in the treatment of depression, it has more recently been adapted for use with some success in the treatment of eating disorders.
• Dialectical Behavior Therapy (DBT): a contemporary theory that has recently begun to be investigated as an effective treatment for eating disorders (see Treatment Notes dated May 28, 2008 for details about DBT and eating disorders).
• Feminist Therapy: this approach rests on the proposition that cultural expressions of gender are central to the understanding and treatment of EDs. This approach certainly has "face validity", however, no random trials have been conducted (Touyz, Polivy & Hay, 2008).
• Non-specific Supportive Clinical management: less directive than CBT while retaining many behavioral elements. Involves clinical management of symptoms, psychoeducation and psychological care that does not strictly adhere to one therapeutic modality. Early results from clinical trials appear to be promising.
• Cognitive remediation therapy: currently under investigation. Uses cognitive exercises to assist with enhancing cognitive flexibility, an area of impairment for many ED patients.
• Motivational Enhancement Therapy: Based on the Prochaska & DiClemente "Stages of Change" Model, helps clients to resolve ambivalence to change and take steps toward altering problematic behaviors. Widely used and may be helpful as an adjunct to other therapeutic approaches.
• Experiential therapies: will be examined more closely in future posts.

Source: Touyz, S.W., Polivy, J. & Hay, P (2008). Eating Disorders. Cambridge, MA: Hogrefe & Huber Publishers.

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