Psychoanalytic Approaches to the Treatment of EDs

Let me begin this post by saying that I find value in almost every approach to psychotherapy that I have encountered. I believe that, with respect to eating disorders, an integrative mindset -- one that accounts for biological, familial, cultural, and psychodynamic factors - is essential. My purpose here is not to devalue other approaches to the treatment of mental illness but, instead, to address some of the most common critiques of psychoanalytic thinking about eating disorders.

One of the most common concerns I hear is, “There’s no scientific evidence.” Another objection is that eating disorders are like physical illnesses and should be treated as such; the idea that an eating disorder has “meaning” (which is a fundamental tenet of psychoanalytic thinking) is seen as insulting to the suffering person. In this blog post, I’ll take up both of those criticisms in more detail.

Source: Tom Wooldridge

As it turns out, there is evidence that psychoanalytic approaches to the treatment of mental illness are effective. Many of the critiques aimed at psychoanalytic approaches are critiques of Freud himself – which is strange, given that his ideas were developed a century ago and have been evolving in theory and practice since that time. For an overview of contemporary psychoanalytic approaches and the evidence supporting them, see, for example, Shedler’s review article, “The Efficacy of Psychodynamic Psychotherapy,” published in the American Psychologist [1].

With respect to the treatment of eating disorders in particular, several time-limited and problem-focused treatments based on psychoanalytic principles have been investigated. (There are no randomized controlled trials investigating psychoanalysis – that would be extremely expensive and difficult, given the complexity and length of such treatments. With that said, I certainly don’t think that RCTs are the only meaningful data available to us. See the blog post, “Bamboozled by Bad Science” [2].) The Society for the Advancement of Psychotherapy published a review, “A Systematic Review of the Efficacy of Psychodynamic Treatments for DSM-5 Eating Disorders” [3] that states:

“The few randomized controlled trials (RCTs) and pilot studies of psychodynamic psychotherapy for EDs suggest that dynamic therapies, when determined to perform as active treatments, rather than inert controls, are as efficacious as other forms of outpatient psychotherapy for EDs (Thompson-Brenner et al., 2009).”

I often hear eating disorders compared to cancer and other biological illnesses. This metaphor has a lot of truth to it. Eating disorders can feel like an invasive force that takes over the sufferer’s life. What’s more, there is certainly a biological self-preservation process that is activated through the experience of starvation, as demonstrated in the Minnesota Starvation Experiment [4]. This means, in my view, that (1) it is essential for patients who are in a state of starvation that weight restoration and restoration of normalized eating behaviors be a foremost treatment priority – acknowledging that it is not always feasible for this to happen as quickly as we might wish and (2) family involvement is often beneficial. These two conclusions are in no way contrary to a psychoanalytic approach. I also think, based on the research and on clinical experience, that weight restoration often leads to the amelioration of many psychological symptoms – though rarely all of them.

Ultimately, mental illnesses and physical illnesses are not equivalent, as many theorists have pointed out. The idea that they are does a grave disservice to our patients who deserve attention to their emotional suffering and help learning about the meaning of that suffering.

In my own clinical experience, I’ve seen too many patients who went through the refeeding process and quickly relapsed not only because important support structures were not maintained but, also, because their underlying psychological struggles were not addressed. I have also seen many families attempt refeeding without proper guidance, leading to trauma for all involved parties. In support of the idea that eating disorders are, in many cases, related to underlying psychological difficulties, I recommend the paper, “Personality subtypes in adolescents with anorexia nervosa” in Comprehensive Psychiatry [5], which, with respect to AN, “identified three personality subtypes: high-functioning/perfectionist, emotionally dysregulated, and overcontrolled/constricted. Each subtype showed specific identity and affective features, comorbidities with different personality disorders, and clinical implications.”

If you're interested in learning more about psychoanalytic approaches to the treatment of eating disorders, please have a look at my recently published book, Psychoanalytic Treatment of Eating Disorders: When Words Fail and Bodies Speak, an edited collection of papers on this topic.