Table of Contents
Chapter 1 – An Overview of the Disorder
The development of an eating disorder
Is it, or is it not, about food?
The anorexic voice
Chapter 2 – Therapeutic Approaches
Cognitive behavioural therapy
Chapter 3 – Elements for Consideration
A Jungian perspective
Abbildung in dieser Leseprobe nicht enthalten
Western culture today favours masculine, linear, and strategic opportunities, approaches, and answers, in many aspects of life, leaving little room for guided intuition, spiritual vision, or feminine energy. It is from personal experience, through therapy, conversation. education, and conducting research, that it became quite clear that this linear, strategic approach is also favoured in the treatment of eating disorders; a phenomenon that is without doubt multi-faceted and multi-dimensional. The counselling approach that is most-favoured and most-documented for the treatment of eating disorders, is cognitive behavioural therapy (CBT). CBT incorporates tasks, strategies, and exercises in order to obtain results, leaving aside the more abstract, intuitive techniques. It is the opinion of the author that while CBT has proven to be successful in treating eating disordered thoughts and behaviours, it falls short. As beings, we are much more than the sum of our actions and so, counselling needs to incorporate other elements above and beyond CBT techniques if true change is to occur.
The body of the thesis will contain three main chapters which will provide (1) an overview of elements for consideration with regard to eating disorders, (2) a detailed description of a number of treatment paradigms for eating disorders; and (3) the missing puzzle pieces that could compliment the CBT approach for a more successful outcome. The purpose of this overview is to provide a greater understanding of eating disorders and how they might be better treated in the counselling setting.
Eating disorders have long been known as “difficult” cases across all modalities of treatment. People suffering from or experiencing an eating disorder, particularly anorexia nervosa, can seem incessantly defiant, and their symptoms, elusive. And this perception is not just limited to, or solely based on, the experiences of the family members or loved ones of sufferers, but it also aligns with the beliefs of professionals in the field. Hilde Bruch, a German-American psychoanalyst, who’s life work was centred around treating people with eating disorders described the condition as,“…an enigma, full of contradictions and paradoxes” (Bruch, 1978). More recently, Professor Christopher Fairburn of Oxford University, who has also spent a many number of years researching and studying both the nature and treatment of eating disorders, was asked, “Is evidence-based treatment of anorexia nervosa possible?”, and his response was, “barely” (Skårderud, 2009).
Over the decades, eating disorders have been understood and treated quite differently, from being considered a type of hysteria in the times of Freud and Jung, to undergoing electroconvulsive therapy, modified insulin therapy, being administered with large doses of antipsychotic medications such as chlorpromazine, to more modern attempts such as inpatient refeeding programs, family based therapy and cognitive behavioural therapy (Roche, 2010). Although our knowledge of eating disorders has improved significantly over the years with an abundance of literature now readily available, it is as if the cure still remains to be seen as simply a mirage on the horizon, as ambiguous as the disorder itself.
Considerable amounts and varieties of research have been conducted, yet the National Institute for Clinical Excellence (NICE, 2004) treatment guidelines still advises us that there is no definitive evidence that describes the preferred method of treatment for eating disorders (Bezance & Holliday, 2013). The extensive research also implies that if someone has been suffering from an eating disorder for seven years or more, that there are no treatments available to them that are backed up by any ironclad scientific evidence (Conti, Rhodes, & Adams, 2016). This harsh reality is extremely disheartening and disappointing, for sufferers and professional alike, to hear that, over the last 30 years at least, no real improvements have been made for this population. Eating disorders can be pervasive and life threatening, severe and enduring, and chronic. They infuse hopelessness into the lives of those whom they encapsulate and they sever most of the relationships between sufferers and their outside world.
As is the truth for all physical and mental health conditions, there is a vast spectrum wherein eating disorders may take up residence. Not all cases are comparable therefore; we should not be approaching every case in the same manner or with the same technique, simply because that is the approach that has been most broadly researched (Touyz & Hay, 2015). Cognitive behavioural therapy (hereinafter referred to as CBT), has been referred to as the “gold-standard” method of treatment for bulimia nervosa and binge eating disorder which in itself is contradictory because not only do approximately 50% of cases report that they maintain binge eating behaviours, both following treatment, and at a 5 five year follow up, but there is also a 25% treatment abandonment rate (Woolhouse, Knowles, & Crafti, 2012). “Gold-standard” has been defined as “a supreme example”, “a model of excellence”, and “the best, most reliable, or most prestigious”. If the statistics above represent a “model of excellence”, this is concerning.
Another factor worth noting about the current literature is that the primary source of information is coming from the perspective of the researcher. While researchers and clinicians provide unquestionably invaluable knowledge, it would be beneficial to incorporate the experiences and insights of those who are living with the condition and who have perhaps attempted different treatment modalities and been unsuccessful to date (Musolino, Warin, Wade, & Gilchrist, 2016).
While reviewing the literature for this thesis, it was the opinion of the author that, while the therapeutic relationship was spoken about and emphasized, its importance seems to remain overlooked. In all cases of counselling and psychotherapy, the quality of the relationship between the client and the therapist is paramount to achieving a successful outcome.
Furthermore, in particular with eating disorders, it has been documented that a collaborative and supportive connection must be established to deepen our understanding of our clients’ experiences and needs so that they may begin to rebuild their sense of self, rather than simply focusing on their symptoms (Malson, Bailey, Clarke, Treasure, Anderson, & Kohn, 2010).
Malson et al. further discuss Fardella’s Recovery Model in which he encourages professionals to continue to work with clients on restoring their sense of self even past the point of symptom elimination (Fardella, 2008). To further support the imperativeness of the therapeutic alliance in the treatment of eating disorders, neuroscientific research shows positive changes in the right side of the brain when someone is engaged in a quality therapeutic relationship. It would seem that in applying Carl Rogers’ core conditions of empathy, congruence, and unconditional positive regard, along with using reflection as a main tool, the brain as a social organ actually responds and changes form (Hershberg, 2011). It has been suggested that this right brain to right brain connection provides a sort of simulation or reenactment of the mother-child connection, providing that safe environment that allows for exploration and growth, and laying a foundation for the development of self-trust and the restoration of a sense of self (Wylie & Turner, 2011).
Cognitive and family-based approaches are favoured and have maintained their positions as the “best” treatment methods and while challenging irrational thoughts (a main focus of CBT) and advising parents how to maintain control in refeeding their children (a component of family-based therapy) are important, they shouldn’t be believed to be solitary factors in attaining recovery nor should we settle on these methods and stop searching for better, more successful possibilities. To echo and further develop the previous point regarding the therapeutic relationship, Strober and Johnson refer to a “basic truth” that, fundamentally it is the therapist’s knowledge and wisdom of eating disorders, their treatments, and the lived experiences of sufferers, that will build the bridge upon which hope and faith can be transported to their clients during therapy. “Without this,” they state, “the bond that tethers our patient to our treatment is a fragile one” (Strober & Johnson, 2012).
If the current “gold-standard” treatment only “barely” offers a 50% success rate for only some of its participants, we simply need to do more. Literature pertaining to Alcoholics Anonymous and their methods ascertains that addicts must pursue recovery with a certain desperation; that of a drowning man. It describes desperation as the motivation to move forward and fight. Perhaps professionals could take heed of this advice in the pursuit of a cure. There should be no half-measures, shortcuts, or middle-of-the-road solutions. Half-measures will never allow anyone, client or therapist, to lay down the robust foundations that are required for self-trust, self-determination, self-belief, and self-worth to emerge (Iliff, 2008). Cognitive approaches have dominated the fields of psychology and psychotherapy for the past three decades and it is believed that researchers are coming to a realization that while it is very researchable (hence its ability to produce the most data), the long term efficacy of these cognitive methods is limited. It might do us all no harm to allow ourselves to be swept along with what the neuropsychological scientists and therapists are calling the “emotional revolution” and see what wisdom it brings with it (Schore, 2011).
In line with the above introduction, this piece of work aims to provide a deeper understanding of eating disorders and how best they might be psychotherapeutically treated, taking into account different elements of the literature that is currently available. Successful methodologies will be explored and explained and in turn suggestions as to how we might improve treatment modalities will be highlighted. As previously mentioned, not all eating disorder cases are comparable, and the same fact can be applied to treatment methods; they each operate from a different belief, with a different goal in mind, and a different opinion on what “recovery” looks like, therefore it is the author’s belief that no singular treatment can be truly effective or sustain long term success without the support of other treatments.
Chapter 1 – An Overview of the Disorder
The development of an eating disorder
Eating disorders are a complex mental health condition. According to the DSM (Diagnostic and Statistical Manual of Mental Disorders), they can be described as, “an illness that manifests itself in a variety of unhealthy eating and weight control habits that become obsessive, compulsive, and/or impulsive in nature.” The DSM recognises three main types of eating disorders; Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). The DSM-V now also recognizes additional categories such as avoidant/restrictive food intake disorder (ARFID), orthorexia (an obsession with eating foods one considers to be healthy), and what used to be referred to as EDNOS, (Eating Disorder Not Otherwise Specified), can now be found under OSFED (Other Specified Feeding and Eating Disorder), or UFED (Unspecified Feeding and Eating Disorder), (American Psychiatric Association. (2013).
The term anorexia refers to “loss of appetite” and nervosa comes from the Latin word for nervous. Anorexia nervosa has been defined as a psychiatric disorder characterized by an unrealistic fear of weight gain, self-starvation, and distorted body image. The individual is obsessed with weight loss, limits their food intake, and over-exercises while becoming increasingly unaware of the dangers of their behaviours or the effects they are having on their body. They refuse to reach or maintain a normal body weight. Although the sufferer is obsessed with weight loss, they continue to feel overweight. This “feeling of fat” is what keeps them striving to lose even more weight (Costin, 2007). This feeling also becomes an umbrella under which all of their difficult emotions are housed. In someone experiencing anorexia, “feeling fat” can be decoded and understood as meaning, scared, lonely, stupid, or unloved, amongst a whole host of other unwanted negative and overwhelming emotions. Their bodies become the vessels through which they communicate and in maintaining extreme thinness they believe that they have mastered life; communicating to the world that they need nothing from anyone now that they have reached this superhuman level of functioning. Contradictorily however, they feel worthless (Bruch, 2001).
An eating disorder manifests and develops into a coping mechanism that the sufferer becomes intertwined in, and with. The disorder causes the sufferer to live a life in isolation, denial, deceit, and fear; a fear that prohibits them from asking for help, and from accepting assistance or guidance even from family and friends. They are gripped by an illness that is helping them to cope with life; it becomes their companion, they trust it, and they begin to believe that they cannot live without it. Therefore, a lot of sufferers can live their entire lives without seeking treatment (Bryant-Waugh & Lask, 2004).
Two personality traits are thought to be particularly common in people who develop eating disorders - perfectionism and low self-esteem - and typically both will have been present well before the eating disorder begins (Fairburn, 2008). People suffering from anorexia struggle against feeling enslaved, exploited and not permitted to lead a life of their own. In this blind search for a sense of identity they will not accept anything that their parents or the world around them, has to offer. The underlying psychological need behind anorexia is to gain a sense of self; it is a quest for autonomy (Bell, 1985). Children who grow up learning to seek validation externally, will learn to value themselves on accomplishments rather than who they are and so can find great accomplishment in goals such as weight loss (Costin, 2007).
The two most common precipitating factors with anorexia nervosa are dieting and exercise. Most cases, with hindsight, begin with a seemingly innocent change in eating patterns in that someone will begin to eat healthier or undertake a certain diet in an effort to lose weight. They may or may not at this stage also begin exercising. However, due to the perfectionist characteristic that is present, he/she must be better than him/herself each day, therefore less and less is eaten, and more exercise is taken. Food groups are eventually omitted and labelled “dangerous” while just a handful of foods are considered “safe”. Sufferers become obsessed with diets, food plans, cookbooks, and most dominantly, calories. Numbers begin to rule their life and they become entrenched in counting and calculating every item that passes their lips, if they allow it (Kalodner, 2005).
The main perpetuating factor of anorexia nervosa is that it becomes the person’s coping mechanism. It usually develops in a time of need, when a person is unable to cope with life or a certain situation, and they become totally reliant upon it. While they are engrossed in the eating disorder behaviours, they avoid real life and miss out on developing normal coping skills. Other perpetuating factors include poor body image, low blood sugar, low self-esteem and worth, stress, anxiety, malnutrition, poor assertion skills, cognitive baggage, habit, lifestyle, and the ego-syntonic features i.e. I feel safe, I feel powerful, I feel strong, I feel special, I am happy, I have control (Jade, 2009). As opposed to ego-dystonic; where a person is aware of their illness and is distressed by its symptoms; ego-syntonic disorders are when the person suffering doesn’t necessarily think that they have a problem in fact they think that other people are overreacting to their behaviours. Anorexia nervosa is described as such because patients experience their symptoms as the truth. Most patients will respond negatively and defensively to suggestions that they are ill (Fairburn, 2008).
Eating disorders have been misunderstood for most of their history. It wasn't until the 1930's that researchers finally understood that self-starvation was caused by psychological and emotional disturbances. Today, eating disorders are best understood as a combination of emotional factors interacting with biological and physiological imbalances in a vulnerable individual living in a cultural climate that places an emphasis on external appearance and thinness. Over time it appeared that dealing with underlying issues however, may not be enough to break serious behavioural patterns. Specifically, CBT seeks to change the dysfunctional beliefs and attitudes associated with eating disorders in order to facilitate a return to normal eating (Costin, 2007).
Eating disorders are certainly not a lifestyle choice. Nor are they a fad diet. They are a psychological illness that can result in death. Like with other mental illnesses, as humans we might display some form of behavior around food, exercise, or weight control from time to time, but an eating disorder includes a host of extreme and irrational behaviors and beliefs that negatively affect the sufferer and their ability to function in the world (Jade, 2009). There is no single cause that determines why someone might develop an eating disorder; rather it is a combination of many contributing factors (genetics, developmental factors, environmental factors, family, personality, neurobiological, cultural, and trauma). As Dr. Francis Collins, Director of the National Institutes for Health (NIH) once said, “Genes load the gun, the environment pulls the trigger”.
The connection between eating disorders and genetics is something that is still being researched today. In fact, as part of the global AN25K initiative, Genetics of Eating Disorders in Ireland (GEDI) are currently looking for data to aid this research. In her article linking eating disorders to an evolutionary hypothesis, Shan Guisinger (2003), offers a very interesting viewpoint; that the symptoms of anorexia nervosa, particularly, food restriction, hyperactivity, and denial of starvation, are in fact emulating the natural responses of our ancestors who were fleeing famine stricken lands. In order to survive, they had to muster up boundless amounts of energy even though they were severely malnourished, in order to move forward and locate food elsewhere and in essence; they would “deny” the fact that they were starving so that they could proceed. The research suggests that the genetic predisposition to eating disorders is present in all of us and that it has maintained a place in our genetic make-up because once upon a time, it did in fact save our lives (Guisinger, 2003).
Research to find a connection between genetics and eating disorders has been ongoing since the 1980’s, drawing from studies conducted with identical twins and also from studies pertaining to the chain of familial anorexia, in an effort to prove that it is indeed a hereditary disorder (Dring, 2015). Links have also been made between the parent-child relationships and the development of eating disorders; some look to the mother-child relationship while others focus on the father’s role within the family. From a psychodynamic perspective it might be viewed that a young girl who develops an eating disorder, is expressing an unattended trauma belonging to the mother (Vlahaki, 2012). With more limited studies conducted on the father-child relationship, there is less content but eight studies did find some core themes around managing conflict, communication, control, emotional regulation, self-esteem, and perfectionism, all of which influence a child’s autonomy, attitude, and overall psychology (Gale, Cluett & Laver-Bradbury, 2013).
Is it, or is it not, about food?
Of all the personal accounts found in the research, certain themes have emerged that are consistent with the idea that eating disorders are not simply about food; a holistic approach to treatment that focused on emotions rather than just food and weight was highly valued by participants (Munro, Thomson, Corr, Randell, Davies, Gittoes, Honeyman & Freeman, 2014); the eating disorder provided them with strength, safety, control, happiness, guidance, individuality, achievement, and success (Tierney & Fox, 2010); treatment paradigms that were inclusive of both the physical and psychological realms were most beneficial (Bezance & Holliday, 2013); the eating disorder behaviours posed as a projection of inner, emotional disturbances and anxieties (Brady, 2011); that if weight restoration was the primary focus of treatment, then relapse would most certainly follow shortly after discharge (Tierney, 2008); self-esteem, self-respect, allowing emotions, and being part of an active and supportive social circle, were important factors of recovery (Bjork & Ahlstrom, 2008); while all narratives expressed dieting behaviour initially, the eating disorder became a way of coping with their external world (Przybyl, 2010); and finally, through his extensive work on the connection between eating disorders and metaphors, Skårderud (2007) provides with a fine array of reasons as to why eating disorders are about more than food – control, protection, self-worth – to name just a few (Skårderud, 2007).