Individuals with eating disorders often collapse the two primary purposes of our mouths — to eat and to communicate — into one. They express their fears, desire for control and self-image through their bodies and the control of food. Psychotherapy helps them regain their voices and their health.
Individuals with eating disorders have typically fused their self-image and their body image so that their self-work is dependent on their weight, shape and ability to control both. They have a negative body image, often that it is too fat or that some imperfection makes it unbearably ugly, and that translates for them into a negative self-image — they are worthless, a failure, unlovable. They may not be able to express that self-image in words, but they act on it and express it through not eating or by bingeing and purging or overeating.
In treating adults with eating disorders, psychotherapy can take several forms, depending on the type of disorder.1 For individuals with anorexia nervosa, therapists focus initially on providing extensive meal support to begin to restore essential nutrients and build physical reserves. At the same time, patients engage in group therapy with others who have anorexia to gain a more realistic sense of themselves.
In group therapy sessions, patients examine their body images and how those images affect their behaviors and their health. They may do body tracing, where they draw what they think is an accurate, life-size representation of their body and then compare their drawing to an actual tracing of their body. The contrast challenges the thoughts that they have around their size and provides a very tangible way of seeing just how far off their perceptions are.
Exposure therapy helps patients overcome the anxiety caused by eating in public by taking them to restaurants and providing support so they can see that eating out is safe. If they are anorexic, they may see eating as a sign of weakness or allow themselves only very restricted food options. Individuals with binge-eating disorder may not eat in public or eat only small amounts. Bulimics may be uncomfortable if they feel they will not be able to purge shortly after eating. Restaurants, then, can generate significant anxiety for almost anyone with an eating disorder. Going to restaurants, making that a normal experience, helps them come to understand that other people are not watching or judging them.
Acceptance/commitment therapy, an offshoot of cognitive behavioral therapy, works with patients’ values to give them a framework they need to make different choices. When a patient with anorexia leaves a treatment program, she will still be struggling with many of the same issues she had when she arrived. By focusing on her values, though, she has a reason to eat even if she does not want to. It may be that she wants to graduate from college and she needs to eat breakfast so she can stay out of the hospital and complete her program. A young man may want to move out, get a job and become independent. He needs to stick to regular meal times to stop bingeing and go out with friends to rebuild a social network.
For children and adolescents with eating disorders, particularly anorexia nervosa, research strongly supports the use of family-based therapy if the patient has sufficient body-weight for outpatient treatment. In these instance, parents can take over direct therapy with therapists acting more as consultants. Parents assume responsibility for meal preparation and encouraging the child or teen to eat. Underlying issues that may have been the root cause of the eating disorder are addressed later, once the child has recovered enough to handle the topic and the parents have learned the skills to facilitate a discussion.
If an anorexic child has too little weight and must be treated as an inpatient, the parents will participate in family therapy and work on communication and the family dynamic while the child regains weight and strength. The team then will move toward family-based therapy upon discharge. Family-based therapy seems to succeed by balancing a controlled environment, particularly when focused on weight gain, with the validity of achieving success within the home setting.
In addition to the therapies discussed here, interpersonal psychotherapy, cognitive-behavioral therapy,2 psychodynamic psychotherapy and dialectical behavior therapy can also help patients with eating disorders. These therapies are positive steps to help those who are at risk regain their voices and their health.
1. Brown TA, Keel PK. Current and emerging directions in the treatment of eating disorders. Subst Abuse. 2012. 6:33-61. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411516/
2. Murphy R, Straebler S, Cooper Z, Fairburn CG. Cognitive Behavioral Therapy for Eating Disorders. Psychiatr Clin North Am. 2010 Sep;33(3):611-627. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928448/