A key part of the interdisciplinary treatment model, psychotherapy can help patients choose health, modify their abnormal behaviors and attitudes, manage interpersonal relationships more effectively, and cope with mental illnesses (such as major depression, anxiety disorders or substance use disorders) or behavioral problems (such as cutting, stealing, or immoderate sexual activity) that co-exist with the eating disorder. Offered by psychiatrists, psychologists, social workers and some advanced practice nurses, psychotherapy is available on an individual basis, in groups, or in family sessions.

Upon entering therapy, the majority of patients with eating disorders have trouble trusting the provider. Individuals with anorexia nervosa might be in denial of their problem and reluctant to engage in treatment. Many are convinced that their therapists are trying to make them fat. Thus, the provider focuses on building an alliance with the patient. Until a trusting rapport begins to take root, the individual is not likely to modify her abnormal eating behaviors (food restriction, binge eating, purging).

The following treatment approaches may help inform individual and group psychotherapy for eating disorders. Most psychotherapists draw on a combination of theoretical frameworks instead of using any one of them exclusively.

Cognitive Behavioral Therapy (CBT)
One of the most common modes of therapy for eating disorders, CBT has been helpful to many patients who struggle with bulimia nervosa or have returned to a healthy weight in recovering from anorexia nervosa. Available in individual or group format, this therapy model was initially developed for adult sufferers but may also benefit adolescents.

CBT focuses on the belief that eating disturbances involve unhealthy thoughts and behaviors that need to be changed. In judging their self-worth, those with anorexia nervosa and bulimia nervosa attach undue importance to body size and weight. The individual tends to think, feel and behave in extremes and to experience the world in all-or-nothing, absolute terms. For example, she may perceive foods as either “safe” or “unsafe” or ascribe to beliefs such as “If I start eating again, I’d never stop;” “If I eat a slice of cake, the calories will go right to my thighs;” “Eating a sandwich will make me fat.” In Western societies, there is a popular, but inaccurate, perception that thinness is a passport to a perfect life; some individuals may be more vulnerable than others to believing these false cultural messages.

CBT includes a strong education component. The individual learns to reframe erroneous thoughts about food and weight into positive attitudes that can guide behavior change. One of the key features of CBT is self-monitoring. The patient keeps a log between therapy sessions, recording what, where and when she eats as well as how she feels at the time. Such homework assignments can help the individual discover what triggers her abnormal food behaviors. Chances are she has been reacting to stress by channeling her emotions into eating behaviors that are dangerous to her health. Instead, she can gradually learn to step back from a problem, think about it rationally and devise a strategy for solving it.

CBT emphasizes that strict diets are counterproductive. Food restriction and resulting hunger may lead to binge eating, which can, in turn, set the stage for purging (as an attempt to prevent weight gain resulting from the calories ingested during the binge). In order to break this unhealthy cycle, the goal is to eat three planned meals and snacks each day. The individual with bulimia is often under the impression that vomiting removes all the calories consumed during a binge; this is a misconception. Some of the calories ingested during a binge are, in fact, absorbed by the body, making vomiting much less effective as a weight control practice than many patients realize. Information about the potential medical complications of eating disorders may help motivate an individual to work on changing her behaviors.

Another component of CBT involves relapse prevention. The individual learns that a slip in behavior does not necessarily mean that she is spiraling back into the illness. In the event of a setback, she can return to healthy eating by using the skills that she learned over the course of treatment and by accepting support from those who care about her.

Psychodynamically-Oriented Therapy
Available in individual and group therapy format, this model draws upon the properties of the therapeutic alliance as a way to help the patient get to know herself. The trust that an individual develops in her therapist becomes a potential vehicle for change. In trying to develop a trusting partnership, a therapist will often acknowledge the patient’s struggles by conveying the understanding that recovery is hard and takes time.

An individual with an eating disorder is typically very afraid to make changes. Therapy may include encouraging her to experiment as a way to find out whether doing something differently might have a better outcome than she anticipates. For example, suppose an individual is reluctant to eat, exercises too much, studies too hard, and avoids social activities. Maybe, as a result of therapy, she becomes willing to taste a new food, skip a day of physical activity, cut back on her study hours, or spend time with a friend “just to see how it goes.” It is often possible to chip away at an eating disorder by helping the individual to take one small “risk” after another.

In treating eating disorders, patient safety comes first and foremost. Thus, the therapist makes it clear to the individual that coaching, self-exploration, experimentation and other approaches can continue provided that her nutritional status remains in the safe range. If she loses weight or engages in abnormal eating behaviors to the point where her health is endangered, medical intervention becomes the priority.

Dialectical Behavioral Therapy (DBT)
Some individuals with eating disorders experience low or unstable moods and may turn to unhealthy eating habits in an effort to comfort themselves or to reduce their inner pain. In the long run, however, these behaviors can lead to a vicious cycle that perpetuates emotional suffering and places the patient at risk of serious medical complications. In addition, eating disorders tend to be secretive conditions that cut the individual off from other people and make it hard for her to communicate effectively.

The person with an eating disorder typically has little appreciation of her strengths; in fact, she may be very self-critical, overwhelmed with “I shoulds” or “I shouldn’ts” and convinced that whatever she feels is “wrong.” The “dialectical” (reconciling and integrating opposing views) in DBT involves helping the patient to find middle ground between extremes; that is, she can come to value herself and to acknowledge her emotions yet, at the same time, recognize the need for change. Available in individual and group format, DBT helps to build the patient’s self-awareness, self-acceptance, and communication skills so that she can gradually learn to express herself in healthy, positive ways instead of through abnormal eating practices.

Family Therapy
An eating disorder impacts every member of an individual’s family. For children, adolescents and some adults with eating disorders, family therapy is an integral part of treatment. Sessions give parents an opportunity to learn about the treatment process, to express their feelings and concerns, and perhaps to glean fresh insights into their relationship with the child. Family members are encouraged to share their views, to listen attentively and to be open to each others’ ideas. Through such meetings, participants can develop increased empathy toward each other and reach a deeper, more dimensional understanding of what the child is experiencing.

One of the basic tenets of family therapy is that an eating disorder is no one’s fault. Thus, parents learn to separate the illness from the child. For example, if a food issue disrupts a family meal or other activity, the idea is to blame the eating disorder, not the child or anyone else.

Topics that may come up in family therapy are many and varied. As an example, a parent might have questions regarding food management at home. Or maybe mom and dad disagree about how to approach the child’s eating difficulties, as when one parent considers the other “too firm” or “too lenient.” Also up for discussion may be challenges unrelated to food, such as becoming more open to making friends or transitioning from one academic setting to another.

For many adolescents with anorexia nervosa or bulimia nervosa, the Maudsley treatment model has been helpful. Developed at the Maudsley Hospital in London, this kind of outpatient family therapy places the individual’s parents in charge of her eating until she is well enough to handle this responsibility herself. In therapy sessions, parents learn to present a united front in managing their adolescent’s difficulties with food and to be empathic but firm in helping her to follow her nutrition program. The patient’s brothers and sisters participate in family therapy sessions and are advised to support her in her recovery efforts. Once the adolescent has restored her nutritional health or reduced her binge-purge behaviors under the guidance of her parents and is eating responsibly without supervision, the focus of therapy shifts from food management to other challenges she may be facing, such as increasing independence or peer relationships.

References
Practice guideline for the treatment of patients with eating disorders
American Psychiatric Association (APA). Practice guideline for the treatment of patients with eating disorders. 3rd ed. Washington (DC): American Psychiatric Association ; 2006 Jun. 128 p. [765 references].

Cognitive-behavioral training for binge eating and bulimia nervosa
Fairburn, C.G., Marcus, M.D., Wilson, G.T. Cognitive-behavioral therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In: Fairburn, C.G., Wilson, G.T., eds. Binge Eating: Nature, Assessment, and Treatment. New York: Guilford Press; 1993. p. 364-404.

Eating Disorders
Keel, P.K. Eating Disorders. Upper Saddle River, N.J.: Prentice Hall; 2005.

Treating Bulimia in Adolescents: A Family-Based Approach
Le Grange, D., Lock, J. Treating Bulimia in Adolescents: A Family-Based Approach. New York: Guilford Press; 2007.

Treatment Manual for Anorexia Nervosa: A Family-Based Approach.
Lock, J., Le Grange, D. Treatment Manual for Anorexia Nervosa: A Family-Based Approach. New York: Guilford Press; 2001.


This page was last updated on October 10, 2007.