Eating Disorder Treatment Approaches

[ScarletKnight62]

HMMM. Are they eqaually important? Im not so sure about that. It depends on the situation, the clinical history, and the individual client. I would argue that it also depends on the treatment goals set by your client. First priority is always going to be to stop the behavior, and you have an ethical responsibilty to use the best and most empirically supported methods in this situation. Especially if they are in serious danger of physical/medical decompensation from the ED. There is a also a weak correlation in the lit about resolution of uncouscious conflicts or providing the "corrective emotional experience" and subsequent behavior change.

I think it's important to be well-trained in both. I would call them close to equally important because CBT is very effective at stopping symptoms and behaviors, however I find it to be pretty superficial and if you just get rid of the symptoms, there are still a lot of underlying problems there which I think dynamic therapy better addresses. So, for most patients, I'd want to use both.

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[cara susanna]

Emmm, I disagree, but I don't think this should turn into a psychodynamic vs CBT thread, so I will leave it at that.

 

[erg923]

I am too am actually a critic of the "CBT box" the profession has gotten itslef into. However, you are making a two large assumptions here. They are especially agregious considering you have no formal clincal training or training in CBT or psychodynamic psychotherapy. However, your statement shows a fundamentally poor understanding of the framework and implementation of CBT. Aaron Beck has often corrected this assumption and has often said that CBT is NOT ahistorical. Some of the techniques certainly can be, but the overall framework and conceptulization is not!

Second, did it ever occur to you that perhaps the underlying etiology of the disorder derives soley from faulty, maladaptive, irrational thought processes in certain uncomplicated cases? In an otherwise in uncomplicated case, perhaps cogntive restructuring of the thought process is all the person really needs?

Lastly, if your assumption was correct, (CBT is "superficial" and merely fixes "symptoms") I would expect the literature to bear out a significantly higher relapse rate for EDs when treated with CBT vs when they are treated with a combination of the two, or soley with psychodynamic therpay. A quick EBSCO search did not yield this in the literarture. Why is this?

 

[erg923]

Emmm, I disagree, but I don't think this should turn into a psychodynamic vs CBT thread, so I will leave it at that.

yea yea...ok lets move on.

 

[ScarletKnight62]

You are making a two large assumptions here. They are especially agregious considering you have no formal clincal training or training in CBT or psychodynamic psychotherapy. I am actually a critic of "CBT box" the profession has gotten itslef into, as well. Howeevr, your statement shows a fundamentally poor understanding of the framework and implementation of CBT. Aaron Beck has often corrected this assumption and has often said that CBT is not neccasarilly ahistorical.

Second, did it ever occur to you that perhaps the underlying etiology of the disorder derives soley from faulty, maladaptive, irrational thought processes in certain cases? In an otherwise in uncomplicated case, perhaps cogntive restructuring of the thought process is all the person really needs?

I definitely was not trying to start the CBT vs psychodynamic debate, just saying what I am interested in pursuing, and once you asked, I felt the need to explain further why.

In regards to the second question you asked, I think that type of thing is extremely rare if it even exists. Eating disorders are extremely complex, deep-rooted problems, not simply an irrational thought process. I'm not saying that there isn't an irrational thought process in place, there most definitely is, but I think it always goes further than that, hence the need for something that goes deeper. In my opinion, CBT doesn't go far enough, and that's why I'd like to be well trained in dynamic therapy as well. It's definitely extremely useful, just not focused enough on root causes and self-awareness in my opinion. It's starting to shift that way with the third wave, with things like "mindfulness meditation" and the like, but it's not quite there yet.

So, to get back on focus, basically I was just wondering what kinds of programs I should look into for this, but as you stated previously, that doesn't matter so much as my internship placement. Thanks for the help!

 

[cara susanna]

Edit: Ahh, n/m, I don't want to get OT. Maybe we should start a debate thread for this.

 

[Therapist4Chnge]

*MOD NOTE: I split these comments out for further discussion. *

 

[Ollie123]

I've read the "superficial" discussion before, but has there been any research done showing this?

I realize its probably difficult to study, but if its true I'd expect either higher relapse rates for CBT, or less improvement in positive characteristics (not familiar enough with positive psych to know the common measures for this).

Just curious if the science on this is out there and I just don't know about it, or if this argument is more based off personal views rather than literature.

 

[cara susanna]

I guess I don't get how it's superficial. What else is there to change other than thoughts?

If there's sexual abuse, then, yeah, treat that as well. But you don't have to treat it only psychodynamically.

 

[psychmama]

One point to consider is whether ED is connected to attachment problems and affective dysregulation (at least for some patients). These are things that I imagine can be addressed quite well using an integrative approach -- perhaps elements of CBT, DBT and relational psychodynamic work?

 

[cara susanna]

Oh, I think mindfulness-based treatments would work really well, but I include that with CBT since it's under the same "umbrella."

 

[Eruca]

I would argue that this is too dichotomous to be very helpful. In addition, not all psychodynamic clinicians practice the same way, nor do all CBT practitioners. Both approaches are practiced in varying degrees on a spectrum. Also, the non-specific factors of psychotherapy play a large part in outcomes, where the relationship may sometimes be more important than the specific approach. Hopefully this is done with some kind of working conceptualization to help guide the trajectory of the therapy, regardless of orientation. An integrative approach, in my opinion, does the best job - IF the clinician is indeed invested and engaged and is comfortable working in this fashion.

I'll also just add that most of the third generation therapies (e.g., ACT, MBCT, etc) utilize a more acceptance-based approach to cognitions, such that the goal is not to change, counter, or suppress the thought (traditional CBT), but to change an individual's relationship to their thoughts.

 

[cara susanna]

Yeah, I know. They also view emotions differently from how traditional CBT does.

 

[Eruca]

What else is there to change other than thoughts?

Hm. Okay. I was just responding to the topic at hand, but then also responding to the above question/comment.

 

[cara susanna]

Oh, I see, sorry. I forgot I posted that, heh. That was bad phrasing.

 

[ScarletKnight62]

I agree with Eruca. I think it is definitely important to use an integrated approach, which is why I was interested in both CBT and psychodynamic therapy for the treatment of eating disorders. I am also interested in humanistic and relational approaches, which I feel fall closer to dynamic therapy than to CBT (which is why I didn't explicitly include them in my earlier posts).

In my opinion, EDs are very similar to addictions in that they come from the mismanagement of feelings. I think that it's ideal to use something like CBT to target symptoms, which it does well, but use psychodynamic therapy or something similar to find out the root cause of what is causing the self-destructive behaviors and raise self-awareness.

Eating disorders are not just thinking "I am fat, I should lose weight". That's more of what I meant by the superficial comment, that CBT would be more involved in questioning those thoughts and try to counter them whereas a psychodynamic approach may include looking at where the core belief of needing to change and feeling inadequate started and may address it more thoroughly than CBT would, which seems to focus a lot more on the here-and-now (although as someone mentioned earlier, that isn't to say it's ahistorical). I also think it's important to stress the relationship between the therapist and client, which I don't think CBT focuses on to the same extent. I think it's monumentally helpful for the patient to re-experience hurtful or traumatic events that may have played a part in the development of their disorder in the context of a caring relationship, namely with the therapist.

Basically I don't think it's doing enough to just try to suppress or challenge maladaptive thoughts. Especially with something like an eating disorder. But again, like Eruca said, every therapist is different. I doubt there are many who don't use some integrative approaches for some patients. I never meant to make this a dichtomous issue with a "right" and "wrong" side, I was saying I'd like to be well trained in both as I feel both are very useful.

 

[cara susanna]

Oh, I don't think this thread was to attack you--you just brought up a good discussion topic. Though, yeah, it's a very generalized question because there are many different types of CBT and many different types of psychodynamic therapies.

The mindfulness-based therapies, especially DBT, would address emotion dysregulation though.

 

[futurepsydoc]

I am too am actually a critic of the "CBT box" the profession has gotten itslef into. However, you are making a two large assumptions here. They are especially agregious considering you have no formal clincal training or training in CBT or psychodynamic psychotherapy. However, your statement shows a fundamentally poor understanding of the framework and implementation of CBT. Aaron Beck has often corrected this assumption and has often said that CBT is NOT ahistorical. Some of the techniques certainly can be, but the overall framework and conceptulization is not!

In my opinion, ERG is right on here. CBT should always include a full diagnostic work-up and an individualized case formulation. Childhood events and other important experiences influence the latter a good deal. We should always consider such factors in CBT treatment planning. This includes sexual abuse, attachment problems, and/or other significant trauma. These issues are crucual when addressing the maldaptive schemas that underly psychopathology, as well as the negative automatic thoughts and behaviors that are being targeted. The argument that CBT does not consider or value such experiences is false and perpetuated by a lack of understanding within the community.

With regards to eating disorders, the evidence clearly supports the efficacy of CBT (i.e., long term, short term). Please read the work of Chris Fairburn. This will give you an understanding of how effective CBT is in treating people with eating disorders.

Having said all of that, Interpersonal Psychotherapy is also considered an evidenced based treatment for Eating Disorders. While this model is dynamic in nature, I do not get the sense that this is what Scarlet Night was referring to when she said: "There are still a lot of underlying problems there which I think dynamic therapy better addresses." It sounds like they were referring to a more a traditional form of psychodynamic therapy that targets impulses, drives, and the unconscious. If that is true, please show where evidence for its effectiveness in treating Eating Disorders exists.

Last, combining psycotherapy techniques and/or "integration" is a tricky business. While I am sure that most therapists draw upon multiple frameworks when treating clients, we all need to remember that the literature on this is scarce and we know little, if anything, about its effectiveness.

 

[cara susanna]

Well said.

 

[psychmama]

It sounds like they were referring to a more a traditional form of psychodynamic therapy that targets impulses, drives, and the unconscious. If that is true, please show where evidence for its effectiveness in treating Eating Disorders exists.

I promise that I'm not trying to start a fight... but I would point out that even "traditional" psychodynamic theory has moved a long way from merely looking at impulses and drives. There's been many developments since Freud, just as CBT has matured and developed quite a bit from its origins in behaviorism or even the early days of Aaron Beck.

In my opinion, the day may come when the CBT and Psychodynamic camps agree on more than they disagree on with eachother. I wonder if some of the advances in neuroscience (e.g., mirror neurons) will help to bridge this gap?

 

[JockNerd]

I'm going to use this thread as a springboard for my own personal belief about clinical work, which is that we shouldn't be training people in schools (CBT, psychodynamic, Rogerian, or otherwise) and sending them out to treat everyone who comes their way. Instead, clinicians should be trained across theoretical orientations, accompanied by multicultural training, and should be ready to treat a smaller set of specializations backed by a large literature base (which is doable by this specialist model, but not by the generalist model) from a multitude of perspectives to best fit that problem with that client, at that time, in that circumstance.

 

[erg923]

I agree totally, obviously. And I have posted alot in the psychiatry formum debating similat issues in which I have argued for the intergration of frameworks, and the importance of using was is most effective for each individual client. Because, lets face it, we are simply not very advanced in our conceptualization of psychopathology. Until science catches up, we have a repsonsibility to intergrate techniques and frameworks according to the client. And basically, be able to "try it all" if the case calls for it, or other approaches have failed to ring true with the client. Sometimes people are not amiable to deep explorative type therapies, just as not everyone is gonna be amiable to directive, technique based approachs. It always depends, and most variance in outcome is still attributiable to the relationship, regarless of what framwwork is used.

However, I am not really worried about a lack of knowledge or a lack of focus on all these issues during graduate training at the present time. I think this was probably much more of an issue earlier in our profession's history. 50s, 60's and 70's especially. As much as I feel that our profession has gotten "boxed in" lately, I still think graduate training programs do a good job of stressing the importance of integration of data sources and integration of techniques when working with patients.

 

[futureapppsy2]

Alternately, there's Family-Based Therapy (FBT), aka the Maudsley method (see the work of Lock & LeGrange among others), where refeeding (used as a nutritional support as well as a type of exposure therapy) is the center-piece, and therapy is used as caregiver support or post-recovery "coping" support/relapse prevention.

 

[Cosmo75]

I also think the CBT vs. psychodynamic argument is too dichotomous and cross-training is important. I conceptualize and treat primarily from a CBT framework, but have found that the majority of the time with patients I needed to be adaptive and change my approach based on the individual's needs. I will always use what the research suggests works best, but in the session it will never go like those robotic sessions in Judith Beck's book

 

[Eruca]

^ hah, exactly Cosmo! "I am. cbt therapist. please fill out thought record." (said like robot).

I do agree that learning to integrate approaches, while keeping a flexible but consistent conceptualization is a LONG process that takes years of refinement. (I'm still working out the bugs!) This is all rolled up in developing your own style as a therapist, irregardless of orientation, and comfort level with - well, the emotional intimacy of the client-therapist relationship. (it's quite true that some relationships achieve greater depth than others) When in doubt about what to do next, I go back to Rogers. Also, I think you can talk about the past, but focus on related feelings/thoughts in the here & now. They aren't mutually exclusive. I'm predominately a third waver in regard to approach... though if you look closely at my conceptualizations, you'll find modern psychodynamic, IPT, relational-cultural, and a few others. And the point, as I understand it, is to pull from this to guide your treatment in session.

Also, sessions in the real world tend to go quite differently from taped research sessions. But that touches on something a poster said earlier that can be long debated from many angles. I practice evidence-based treatments, but I also go with what feels right in the moment. Does it work? Well, my clients keep coming back!

Man, this job sure is a lot harder than anyone told me before graduate school, where once you have a case load it's mainly trial by fire! (even with great supervision) Great thread.

 

[Therapist4Chnge]

*MOD NOTE: I edited the title to be more appropriate for the discussion.*

I have about a book to post on the subject, but I'm moving.....so I'll get back to this in a few days. Don't burn the thread between now and then!

 

[cara susanna]

I was hoping to hear your perspective, T4C, because IIRC that is the population with which you work.

I actually agree that the type of therapy should depend on not only the disorder in question, but also the client and his/her needs.

 

[psychmama]

I'm also enjoying this thread.

One of the best classes I've taken in terms of helping me integrate theories has been a course in short term dynamic therapy. While focused on psychodynamic principles, the class pulled in concepts and techniques from various realms and taught me a lot about working with patients in a more short term, goal-focused way. One point I took away from that class is the importance of linking past experiences and relational patterns, current functioning (intraspychic and interpersonal), and the here & now interactions between patient and therapist. I've found that making these connections explicit and talking about them is very helpful for many people struggling to understand why they keep falling into self-defeating behaviors in their present lives.

 

[futurepsydoc]

I promise that I'm not trying to start a fight... but I would point out that even "traditional" psychodynamic theory has moved a long way from merely looking at impulses and drives. There's been many developments since Freud, just as CBT has matured and developed quite a bit from its origins in behaviorism or even the early days of Aaron Beck.

In my opinion, the day may come when the CBT and Psychodynamic camps agree on more than they disagree on with eachother. I wonder if some of the advances in neuroscience (e.g., mirror neurons) will help to bridge this gap?

Psychmama, I agree with your position. Psychodynamic therapy has changed drastically since the days of the "couch." Modern psychodynamic approcahes have definitely been developed. These require a good deal of effort and activity on the part of the therapist. Supportive and expressive techniques are applied based on the patient's needs and condition, face to face contact is the norm, and the sessions are more focused than in the past.

As I mentioned above, IPT appears to be flourishing in clinical trials for Depression and Eating Disorders. Its application and reach may expand far beyond these particular conditions. Personally speaking, I think it will. This work provides strong empirical evidence for a psychodynamic therapy. It is a good thing for the field.

Taking this a step further, theorists from other pyshcodynamic camps have also been developing clinical research programs, such as Kernberg, Crits-Cristoph, Luborsky, and Leichsenring. It is without question that their ideas of therapy, while dynamic in nature, are not the same as Freud's drive or structural theories. Each has his own brand and integrates years of descrpitive and empirical work to justify their practice. What I appluad most about all of the aforementioned individuals, however, is their willingness to empirically test their treatments. I have never personally doubted the value of psychodynamic therapy or theory as a whole. Its continued presence in the culture serves as evidence to its utility. Rather, at a time where reimbursement and accountability are at an all time high, we need and should develop solid treatment plans rooted in evidence. To not do so, in my opinion, seems somewhat unethical.

The fact that dynamic therapy is beggining to churn out empirical support is promising. Hopefully, this will translate to reimbursement for those delivering dynamic treatment. As a result of this scientific work, I would also think the "CBT vs Psychonamic" conversation will broaden over the next 20 years or so. Hopefully, this discrouse will lead to a more "integrated" field of "clinical psychology." In my humble opinion, we are already devided by too much bickering.

For example, in CBT you have strictly behavioral camps, strictly cognitive camps, and now third-wave camps (e.g., ACT, DBT). Anyone who is a member of ABCT knows what I am talking about. In psychodynamic work, you have your followers of Freud, Kohut, Sullivan, Kernberg, and the like. If you consider the back and forth within each camp (CBT or Pyschodynamic), as well as the disdain and arguing across them (CBT vs Pyschodynamic), it is a wonder how we get anything done as a "field." And thats only the tip of the iceberg. As us students all know from being on here, we have the following conflicts that also need resolution: Ph.D. vs Psy.D., Doctoral Level Clinicians versus Master's Level Clinicians, Psychologists versus Social Workers, and taking center stage at the APA, Psychology versus the American Medical Association.

For a group of professionals that provide undconditional positive regard, interpret peoples thoughts, alter others' behavior, help people resolve their conflicts (e.g., interpersonal, professional, and unconcsious), offer an environment for personal growth, and attempt to be genuine whenever possible, we seem to have some serious issues communicating with each other, therapist to therapist. Any unconcsious conflict going on there? Maybe some dyfunctional beliefs? Clearly, there seems to be a need for behavior change.

Thats my .02

 

[psychmama]

great post futurepsydoc! You put this far more eloquently than I could have. We psychologists are a fractious bunch!

 

[Eruca]

Some great points, Future. I'm finding the debate(s) to be interesting, sometimes distasteful, and then other times exciting. The third-wave therapies fit my world view better than traditional CBT, and modern psychodynamic is quite a bit more palatable than Freudian. I'm also a fan of IPT. It all makes for awesome food for thought.

The part I think is exciting is just the idea of 'coming of age' in a time when clinical psychology is changing & growing, with all the fits and tantrums that come from new developments. And maybe I get a kick out of a little drama. I'll point to the Dec 08 issue of Clinical Psychologist - where the traditional CBTers, and third-wavers (most notably Steven Hayes) where having it out. So fun to read! (as was the case at last years ABCT, as noted earlier). I'm just sitting back watching them duke it out, and learning a great deal in the process.

 

[cara susanna]

They also had a clinical roundtable at ABCT last year basically fighting it out between ACT, DBT, RET, and traditional CBT. It was pretty funny.

 

[Therapist4Chnge]

I am a big Kerberg fan, though I wish the dynamic community produced more research. Many do case studies which is a start, but I think we can do more.

 

[psychmama]

I'm excited because my internship site has Kernberg teach a series of lectures for the psychology interns and psychiatry residents. I'm looking forward to that.

 

[Therapist4Chnge]

I'm excited because my internship site has Kernberg teach a series of lectures for the psychology interns and psychiatry residents. I'm looking forward to that.

That is a great site!

I am SOOOOO jealous, as it is a great training site, but it didn't end up being a good fit for me, outside of the Kernberg lectures.

 

[psychmama]

T4C,

Yeah, there are a few things about the site that I wish were different. Overall, though, it's a good fit for me. So I'm pretty happy.

 

[futurepsydoc]

great post futurepsydoc! You put this far more eloquently than I could have. We psychologists are a fractious bunch!

Thank you for the compliment Pyschmama. I sincerely appreciate it.

They also had a clinical roundtable at ABCT last year basically fighting it out between ACT, DBT, RET, and traditional CBT. It was pretty funny.

This was the meeting that I was envisioning when I wrote the post. I was there. It was kind of crazy. Communication was "fractured" to say the least.

Some great points, Future. I'm finding the debate(s) to be interesting, sometimes distasteful, and then other times exciting. The third-wave therapies fit my world view better than traditional CBT, and modern psychodynamic is quite a bit more palatable than Freudian. I'm also a fan of IPT. It all makes for awesome food for thought.

The part I think is exciting is just the idea of 'coming of age' in a time when clinical psychology is changing & growing, with all the fits and tantrums that come from new developments. And maybe I get a kick out of a little drama. I'll point to the Dec 08 issue of Clinical Psychologist - where the traditional CBTers, and third-wavers (most notably Steven Hayes) where having it out. So fun to read! (as was the case at last years ABCT, as noted earlier). I'm just sitting back watching them duke it out, and learning a great deal in the process.

I couldn't agree more. The arguing in the literature is intriguing and sets a unique stage for us future psychologists. We definitely have a role in the outcome of these matters. We can do this through our research, our practice, our support of public policy (e.g., U.K. and the current funding for CBT), and the like. Most importantly, the "Drama" definitely makes our reading more bearable, especially when your exhausted from research, classes, and seeing patients.