Kristina Tavilla
April 19, 2015
SB 721
Critique of the Psychodynamic Approach to Treating Anorexia
Nervosa and Bulimia in Adolescents
Introduction
The National Eating Disorders Association defines eating disorders as serious
emotional and physical problems that can have life-threatening consequences (1). A 2009
American Journal of Psychiatry study found that the mortality rates for anorexia nervosa
and bulimia nervosa are 4%, which constitutes the highest rates for any mental disorder
in our nation (2). According to the American Psychological Association, the international
prevalence of anorexia nervosa among females in late adolescence and early adulthood is
0.5% to 1% and bulimia nervosa involves approximately 1% to 3% of adolescents and
young adults (3). Not only are eating disorders prevalent, they are also associated with
significant comorbidity, functional impairment, suicidality, and health service usage (1).
Eating disorders are a majorly severe public health problem for adolescents.
Unfortunately, this disorder represents a difficult and costly condition to treat, and there
is insufficient evidence in literature proving that any type of program is effective in
preventing and treating eating disorders (3). Focus on intervention treatment for patients
with eating disorders has relied heavily on psychodynamic theory (4). The effectiveness
of psychodynamic therapy for peoples with mental illnesses such as eating disorders has
shown mixed results, and the theory itself involves concepts that are not all well defined
(5). Current outcomes for anorexia nervosa are poor, indicating that only about 25% of
patients with the disease recover using psychological treatments (9). Given the rising
prevalence of eating disorders and the bleak statistics of the effectiveness of treatment, it
is clear that this approach needs to be reevaluated and modified.
Inherent Flaws in Psychodynamic Theory
Intervention strategies that utilize psychodynamic theory propose that “an
individual's biological and temperamental vulnerabilities, the quality of early attachment
relationships and significant childhood experiences that may have been accompanied by
frustration, shame, loss, helplessness, loneliness or guilt lead to susceptibilities to a range
of depressive syndromes later in life, including narcissistic vulnerability, conflicted
anger, excessively high expectations of self and others, and maladaptive defense
mechanisms, “ (6). This approach generally involves therapy and the use of
interpretation to help individuals seek out the conflicts that underly their problems (7).
The National Eating Disorder Association defines it as recovery by understanding its root
cause (1). So-called “talk-therapy” is defined by the National Cancer Institute as the
“treatment of mental, emotional, personality, and behavioral disorders using methods
such as discussion, listening, and counseling,” (8). Symptoms are constructs of the
patient’s needs and issues, and they will “disappear” with the completion of working
through these underlying issues with psychodynamic therapy (1). This approach to the
treatment of eating disorders is flawed because it incorporates elements of the Health
Belief Model which is ineffective at tackling such a complex disorder with varying
social, psychological, and biological implications (2). Psychodynamic therapy is overly
individualistic, relies too heavily on the therapist-patient relationship, and focuses on
insight as motivation for health behavior change.
Overly Individualistic
Psychodynamic theory is largely based on the concept of the self, and mainstream
models of treatment currently focus on the individual dynamic and interpersonal
relationships (9). Traditionally, the psychodynamic model has overemphasized the
individualistic frame of reference underlying the Health Belief Model that places the
problem and decision-making on the individual (10). This is a problem because it
ignores other issues and places the primary burden for change on the individual (10).
Historically, Hilde Bruch, a psychoanalyst, viewed anorexia nervosa as a disorder
associated with difficulties with separation-individuation, in which parents view their
child as an extension of their selves. Jerrold Brandell found three themes that have
emerged in review of current psychodynamic literature that exhibits this strong emphasis
on the self and familial relationships. These themes include “conflict regarding the
patient’s capacity for individuation and for resolution of the mother-infant symbiosis,
feelings of loss of control of the patient’s capacity to determine her own life, reflecting an
impoverishment of mature defenses, and difficulties in consolidating a gender identity,”
(12). Most reports of psychodynamic therapy in anorexia stress the significance of the
interpersonal relationship between the patient and the mother as a critical factor in the
development of the disease (12). A main critique with this approach to understanding
eating disorders is that it can be interpreted as placing blame on parents for their child’s
eating disorder, when evidence has shown that there are many other cultural, social, and
biological contexts (9). Brandell recognizes that it is an “overly simplistic description
that does not fully portray emerging transferencelike reactions within the treatment
situation,” (12). This remains a main concept of psychodynamic theory, and it translates
into the framework for intervention of eating disorders (9). Consequently, treatment
plans tend to be “highly focused on cognitive and biological explanations in which
developmental histories, and internal mental lives are not considered… the patient is
often a passive recipient rather than an active co-creative participant in the therapy,”
according to authors Tasca and Balfour (9), who advocate for a more comprehensive bio
psychosocial framework in eating disorder treatment. The patient should also be an
active participant in their own recovery (1). Psychodynamic therapy has thus been
criticized for being overly individualistic, focusing too much attention on the individual
while ignoring the broader factors at play (9).
Too Much Value Placed on Therapist-Patient Relationship
Another complicating factor involving the tendency of psychodynamic therapy to
overemphasize the individual and interpersonal relationships is that it places too much
significance and value on the therapist-patient relationship (4). The relationship between
the patient and the therapist is considered to be the “vehicle for change,” in
psychodynamic therapy (9). The problem is that therapists often experience difficulty in
managing counter-transferences to patients (10). Countertransference is the
“psychotherapist’s reaction the patient’s transference,” or the feelings of the
psychotherapist toward the patient (11). Many therapists feel a sense of hopelessness and
anger toward their eating disordered patients, and this can in turn have a negative effect
because it can cause the patient to turn away from treatment (10). The relationship
between the therapist and the patient is extremely important in predicting beneficial
health outcomes. According to the National Eating Disorders Association ,”it is important
for individuals struggling with an eating disorder to find a health professional they trust
to help coordinate and oversee their care,” and these health professionals should include a
full team of psychologists, psychiatrists, social works, nutritionists, and medical doctors.
(1). Psychodynamic therapy places too much trust in just the psychiatrist as the primary
source of treatment (4). Also, a therapeutic relationship can be difficult to maintain with
anorectic patients (12). Treating anorectic patients through a psychodynamic approach
can be difficult because “these women show primitive psychological defenses when
confronted with personal conflict, stress, and adversity, and they do not appear to be
willing to reflect on their own experiences or to participate in a process of self-inquiry,
and are particularly suspicious regarding psychological intervention,” (12). The
therapist is the one who is supposed to help identify for the patient “recurring patterns of
behavior” that are a result of the hypothesized unconscious conflict of the patient (14). If
the patient is unable to move forward in therapy as a result of reluctance or an insufficient
relationship with the therapist, he or she cannot progress (14). This element of
psychodynamic therapy is based on the Transtheoretical Model of Health Behavior
Change which “posits that health behavior change involves progress through six arbitrary
stages of change: pre-contemplation, contemplation, preparation, action, maintenance,
and termination,” (15). The necessary step of uncovering “emotionally painful and
previously warded-off experiences,” within the therapeutic situation relies heavily on the
therapist and the individual’s desire to do so (14). Often, anorexic and bulimic patients
do not want to comply with this type of intervention (12), leaving them stuck and unable
to change. In a meta-analysis study, authors found that because of its limitations,
treatment in children and adolescents should be extended away from the traditional
context of individual therapy (16). The current practice of placing too much importance
in psychodynamic therapy can hinder progress for adolescent patients with eating
disorders, and it may be an explanation for why many patients do not recover (10).
Insight as Motivation to Health Behavior Change
Another fundamental problem with a psychodynamic approach is that it contends
that insight is a motivating factor in health behavior change (16). The practice involves
the therapist using interpretation in order to increase the patient’s insight into repetitive
conflicts that sustain their bad behaviors. The relationship between the therapist and the
patient, as described above, is used to uncover unconscious forces of conflict, with the
primary goal being development of insight (16). This approach is inapplicable to the
treatment of eating disorders because of two conflicting factors: denial and resistance.
Denial and resistance to change are consistent characteristics in patients with anorexia
nervosa and bulimia nervosa (17). In a 1998 literature review analysis, authors found that
the “egosyntonic quality of symptoms can contribute to inaccuracy in self-report,
avoidance of treatment, difficulties in establishing a therapeutic relationship, and high
rates of attrition and relapse,” (17). The authors recognize that treatment approaches are
difficult in tackling such a complex disorder, but psychodynamic therapy has proven to
be unsuccessful. Furthermore, there have been few other attempts made to assess denial
and resistance in eating disorders (17). The theory that insight can be used as a
motivation for health behavior change has a basis in the health belief model (18). Again,
this framework focuses on behavior at an individual level, suggesting that people make a
“mental calculus” about whether the benefits of a behavior out-weight the costs, and then
they decide whether or not to act (18). The goal of psychotherapy is to provide insight to
the patient in order to make him or her understand the underlying causes of the issue, and
then they will hopefully be able to use that insight as a motivating strategy to get better
(16). However, as we have seen in the existing literature on eating disorders, this is often
not the case because of the pervasiveness of denial and resistance to treatment in eating
disordered patients (17).
Recommended Public Health Proposals
It is clear that the psychodynamic intervention to treating eating disorders does
not reduce the burden of the disease. Individual psychotherapy alone is unable to meet
this need, and mental health professionals are “not likely to reduce the prevalence,
incidence, and burden of mental illness without a major shift in intervention research and
clinical practice,” (19). Public health advocates stress the need for multidisciplinary
collaborations as a key consideration for treating eating disorders. (19). This can be
accomplished by implementing social cognitive theory, developing a broader model of
delivering interventions, and applying cognitive dissonance theory to change health
behavior.
Application of Social Cognitive Theory
One of the main tenets of psychodynamic therapy is a focus on the individual, and
this has been proven to be ineffective at treating eating disorders because it ignores the
larger cognitive, biological, and cultural factors (9). The application of a more
comprehensive theory like social cognitive theory to eating disorders has proven to have
successful implications in Cognitive Behavioral Therapy (CBT) (20). An approach
involving social cognitive theory can be defined as a “multifaceted causal structure in
which self-efficacy beliefs operate together with goals, outcome expectations, and
perceived environmental impediments and facilitators in the regulation of human
motivation, behavior, and well-being,” (21). Bandura defines self-efficacy as “beliefs in
one’s capabilities to organize and execute the courses of action required to produce given
levels of attainments,” (21). While the health belief model in the context of
psychodynamic therapy views insight as the primary motivating factor for behavior
change (16), the social cognitive theory posits that self-efficacy is the most powerful
determinant of behavior change. While the health belief model focuses on the individual
(16), social cognitive theory focuses on outside factors and their effects on the individual
(21). Proponents of social cognitive theory recognize that “human health is a social
matter, not just an individual one,” (21). CBT is a “goal-oriented, short-term treatment
that addresses the psychological, familial, and societal factors associated with eating
disorders,” (1) and thus embodies the basic tenets of social cognitive theory. CBT has
four detailed “steps” with laid-out goals to suit the individual thoughts and behaviors of
patients (22). The core psychopathology of eating disorders is cognitive in nature in
many ways, and this can be seen most vividly in how patients are intensely concerned
about their weight (22). A patient’s thoughts, emotions, and behaviors are all
interconnected and CBT can provide the foundation to changing these factors (1).
Specifically, transdiagnostic enhanced CBT has improved symptoms in treatments for
adults and youth (KASS). Transdiagnostic CBT address the needs of each individuals’
unique thoughts and behaviors instead of treating the eating disorder diagnosis (22).
Research suggests that CBT is the most effective psychotherapeutic treatment for bulimia
nervosa (22). Also, in a study that evaluated the effectiveness of two methods of
administering a cognitive-behavioral self-help program for binge eating disorder,
researchers found that there was a significant impact with almost half of the participants
ceasing to binge-eat (24). The American Psychological Association task force has
concluded that there is moderate support for the use of CBT in anorexia nervosa, and that
it has been successful in improving eating attitudes and weight outcomes and reducing
relapse (25). Cognitive behavior therapy can help individuals suffering from eating
disorders attempt to restructure or change the way they think about things (22).
Developing A Broader Model of Delivering Interventions
As we have seen, there has been too much emphasis and importance placed on the
therapist-patient relationship in the psychodynamic approach to intervention treatment of
eating disorder. A counterproposal to this narrow intervention is to develop a broader
model of delivering interventions. These models could include technologies (internet,
telephone, smartphones), use of special settings (hospitals, clinics), opportunities for
nonprofessionals (health advisors, parents, families), self-help (online resources, media,
books), and the media (radio, television) (19). While many of these interventions already
exist, more research should be conducted in order to evaluate their effectiveness. The
hallmark characteristic of this extensive and comprehensive approach is that it has the
“ability to reach many individuals in need of services, “ (19). This includes those who
may not benefit from individual person to person therapy as well as those who cannot
access help. A different focus could open different windows of opportunity to effect
change. Among all models of delivering interventions, the media has been proven to be
“the most effective way to implement widespread intervention with great capability to
reach large segments of the population,” (19). The media can be responsible for
achieving concrete change in society, as has been seen with other public health
interventions like the Truth Campaign (26). Population-based interventions, in
combination with individual-based interventions, can work together to impact progressive
change for the treatment and prevention of eating disorders among adolescents (19).
Cognitive Dissonance as a Tool for Motivation to Change
Cognitive dissonance based-approaches have achieved success in increasing
motivation among people with mental illness (27). The theory is based on the idea that
when there is an inconsistency (dissonance) in an individual’s health beliefs and
behaviors, there will be psychological discomfort, which will motivate them to change
their attitude or behaviors to reduce this consistency (28). As an example of how
cognitive dissonance can be successfully implemented as a strategic intervention, we can
look to a large-scale study that was conducted on a university campus. The researchers
found that cognitive dissonance intervention aimed an at-risk population of adolescent
girls with body image issues “effectively reduced bulimic pathology and risk factors for
eating disturbances” (27). The intervention group discussed the origin of the irrational
thin-ideal, and were asked to complete a one-page statement about the costs of the pursuit
of the thin-ideal. They also were involved in counter-attitudinal role-play with the
attempt to induce cognitive dissonance. They also were instructed to engage in “body
acceptance exercises at home” in which they focused on the positive aspects of their
bodily appearance. Participants showed expected decreases in “thin-ideal internalization,
body dissatisfaction, dieting, negative affect, and bulimic symptoms, with these effects
persisting at 1-month follow up,” (27). Another piece of evidence of the proof that
cognitive dissonance can be a vehicle in changing motivational change in eating
disordered patients lies in the Body Project. The Body Project incorporates cognitive
dissonance delivered by peer-facilitators and has also decreased symptoms in anorexic
and bulimic patients. –REFERENCE BD In individuals with eating disorders, a cognitive
dissonance based approach emphasizing self-esteem will likely be more effective in
promoting health and initiating motivational change (27).
Conclusion
While psychodynamic therapy includes important aspects that can help public
health advocates understand and treat eating disorders, it has its limitations and should
not be the sole framework for treatment (10). It is clear that in the treatment of eating
disorders among adolescents we should not rely upon theoretical models like the Health
Belief Model and the Transtheoretical Model that are individual-based and simplistic.
Psychodynamic theory is formed on concepts that are not applicable undividedly to
eating disorders. These tenets include the overemphasis on the individual, the weight
given to the therapist-patient relationship, and the belief that insight leads to behavior
change. This oversimplification of a complex disorder can potentially not only restrict
the understanding of it, but it can also admonish the success of interventions aimed at
young adults. A more appropriate and effective intervention would involve social
cognitive, broader models of disseminating help, and cognitive dissonance on changing
destructive thoughts and behaviors in patients. While it is a difficult task, it will be an
effort in the right direction. Applying social cognitive theory through cognitive behavior
therapy and cognitive dissonance will prove to have better results compared to
psychodynamic therapy in treating eating disorders because of the complex nature of the
disease.
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