1.) The approach is based upon theory rather than empirical data.
Decades ago, when psychologists and psychiatrists first began treating eating disorders, psychodynamic therapy was the only tool they had. Science has come a long way since then. While there is still so much about the illness that we don’t understand, we have learned a great deal in the past decade about the etiology of eating disorders and how to treat them more effectively. Why use theory-based practice when we have evidence-based practice?
2.) It confuses symptoms with causes.
For example, one psychodynamic theory posits that girls develop anorexia nervosa due to their fear of growing up and their desire to remain child-like. In reality, the ammenorhea and boyishly-thin bodies of anorexic girls are symptoms of the illness.
3.) Insight and motivation are over-emphasized, especially early in treatment.
Insight and motivation are crucial to sustaining wellness later in the recovery process. But patients with anorexia nervosa suffer from anosognosia, a brain-based inability to recognize that they are ill. The problem with emphasizing insight and motivation early in treatment is the presumption that the patient must “choose” to get well and that, if she does not make that “choice,” no one else can make it for her. Precious weeks, months, even years are wasted trying to form an alliance, cultivate motivation, and develop insight.
4.) It presumes that the patient’s family dynamics are at least partially to blame for the eating disorder, and that correcting the family dysfunction will help the patient recover.
There is no reliable scientific evidence to support these theories. Families of eating disorder patients do typically present for treatment with high levels of conflict and tension. The conflicted parent-child relationship, however, is most likely the result of the eating disorder rather than the cause. Having a child with any serious illness creates enormous strain on even the healthiest, most functional families.
5.) It presumes that there is a “deeper meaning” in symptoms which are the result of malnourishment and/or faulty brain chemistry.
A great deal of time and money is wasted attempting to discern this deeper meaning. Meanwhile, the patient’s brain and body are failing, placing him or her at risk of permanent medical and psychiatric problems. I advise patients and families: Don’t waste time on “why.” The reality is that we don’t know exactly what causes anorexia nervosa or bulimia nervosa.
We still do not know the cause of many types of cancer, but we begin aggressive cancer treatment immediately upon diagnosis because the longer it goes untreated, the more grim the prognosis becomes. We can remove a tumor or give chemotherapy without knowing how the tumor originated. The same principles apply with eating disorders – the patient’s nutrition and weight must be normalized immediately, and dangerous behaviors must be stopped right away. The patient will benefit from these interventions, both physically and mentally – even if the “reason” for the eating disorder is unknown.
6.). Too much attention is paid to early experiences, often at the expense of solving problems in the here and now.
Psychodynamic theory presumes that psychiatric disorders stem from early childhood experiences. In reality, childhood experiences are generally irrelevant to the patient’s eating disorder. Even in instances in which early experiences are relevant to the current illness, there is no evidence that an ill patient can overcome her eating disorder “exploring” or “processing” such experiences.
7.) Too much value is placed on the relationship between therapist and patient.
While I completely agree that the therapeutic relationship is very important to the healing process (and there is solid research supporting this), I believe that this relationship must take a backseat to treating the eating disorder aggressively. This means that in order to be optimally effective, the therapist must listen to the patient’s basic needs rather than her expressed wishes (translation: the ED’s wishes), consistently nurturing her relationships with family members when she (translation: the ED) wants them to leave her the f*** alone, and setting firm limits on her ED behavior immediately rather than waiting for her to develop the motivation and insight to do so herself. In my experience, this often means that the patient (translation: the ED) will hate me at the beginning of treatment, then gradually grow to trust, admire, and respect me as treatment progresses and her brain returns to healthy functioning. Most patients eventually express gratitude for that early toughness and understanding of what had to be done, recognizing that they wouldn’t have been able to recover without it.
8.) It undermines the relationship between the patient and his or her parents.
Psychodynamic therapy involves deep exploration of childhood experiences and family relationships in attempt to uncover the seeds of the patient’s current mental conflict. The typical result of this type of therapy is that the patient begins to distrust and resent her parents for making her ill, and the parents back off even further out of fear of making problems worse. This results in further exacerbation of existing family conflict and the creation of new problems, once the patient “realizes” how pathological her family really is.
We now know, through research on family-based treatment, that empowering parents to help their children overcome eating disorders is actually the most effective way to help them recover. I believe that nurturing positive relationships between the patient and her family members is essential for full recovery and ongoing relapse prevention, as family members are usually the first to notice signs of struggle, and the first ones to intervene.
9.) It is extremely difficult to undo the damage done by psychodynamic treatment.
A substantial amount of the trauma that patients and families endure is not the result of the eating disorder itself, but rather the result of bad treatment and protracted illness. Often, patients and their families come to me for family-based treatment after months or years of traditional therapy which has not been effective. Even a newly-diagnosed patient will struggle with re-feeding, but having a history of traditional treatment makes the process much more tumultuous. It is extremely difficult for the patient to accept meal support from their parents when they have been conditioned to believe that separation/individuation issues are at the root of their illness, or that they have developed their eating disorder as a way to survive in a dysfunctional family, or that they will recover when they choose. Further, parents struggle enormously to become empowered to act on their child’s behalf when they have been blamed for causing the illness, either overtly or subtly, by their child’s previous clinicians.
10.) It does not bode well for relapse prevention.
Unfortunately, eating disorders have a very high rate of relapse, in part because the underlying biological vulnerability stays with the patient for life. In order to maintain full recovery, it is extremely important for the patient to maintain his or her optimally healthy body weight, practice excellent self-care, manage stress adaptively, and eat a complete, well-balanced diet. The beliefs that one’s eating disorder resulted from internal conflict, or that “it’s not about the food,” are not terribly conducive to these protective measures.
As science has progressed and newer, more effective treatments have been developed, there has been a backlash from the “old school.” Those who remain entrenched in outdated, unproven psychodynamic theories will defend their beliefs like a lioness defends her cubs because – let’s face it – these theories are their babies. They have built careers on these ideas; written books about them; conceptualized their own recovery through these lenses. But that does not make these theories correct, or evidence-based, or useful, or effective in treatment.
Let’s welcome a new generation of clinicians who use evidence-based treatment that strengthens family relationships, treats deadly symptoms rather than hypothesized causes, and promotes full and lasting recovery for all patients. Let’s welcome a new generation of patients and families who are not blamed for the illness, but are empowered to pursue aggressive, effective treatment upon initial diagnosis. Let’s welcome treatment that actually works and refuse to support treatment that doesn’t.
16 Replies to “Why Psychodynamic Therapy is Harmful for Eating Disorder Patients”
Yes times 10! Glad to see you back, Dr. Ravin! Your words are always so appreciated. I, for one, will be sharing your comments all over the place. Keep your posts coming!
I am sorry we did not connect while at AED. I very much appreciate your comments here in this article about psychodynamic psychotherapy. I know this to be absolutely true and yet I am not listened to at all, especially by mental health providers, because I am only a PhD, RD. I believe many mental health providers think all people like me do is write up high calorie menus. I currently am practicing in a small town, work with several reasonable therapists yet find many will “relapse” into psychotherapy and “finding what family dynamics contribute to the ED’ often and I am tactfully trying to get them to give up this time and money wasting practice. I hope to copy and send your article to them. I wondered if you worked with RDs at all? I would love to compare some notes.
Since starting private practice, I haven’t worked with RDs because I do FBT (or some modification thereof). However, during my training at hospital clincs and counseling centers, I did work with RDs as part of treatment teams. Some of the RDs were extremely helpful; others were well-meaning but counterproductive to treatment goals.
You mention working with some therapists who are intent on “finding what family dynamics contribute to the ED.” This type of intervention can be either helpful or harmful depending on what is meant by “family dynamics” and “contribute to the ED.” In my opinion, it can mean one of two things:
1.) What did the family do wrong that caused the ED or contributed to the development of the ED?
2.) How are family members responding to the patient (and the ED) now? What behaviors by family members promote recovery, and what behaviors impede it?
Any intervention predicated on meaning #1 is likely to be useless at best, harmful at worst. There is no reliable scientific evidence that parenting or family dynamics cause or contribute to the development of ED. Searching for some problem or dysfunction within a family tends to make the family more problematic and dysfunctional – it’s a self-fullfilling prophecy.
On the other hand, interventions predicated on item #2 are what FBT is all about! Clearly, parents and other family members can respond to the ED in ways that help the patient achieve recovery (hence the efficacy of FBT), and they can also respond to the ED in ways that impede the patient’s recovery (hence the lower rates of success with other treatment approaches). It is the job of the FBT to help the family draw upon their strenghts to change their reactions to the ED so that they can help the patient get well.
Please feel free to share my article with anyone whom you think could benefit from it.
I agree with much of what you have written in this blog post Dr Ravin, but there are some things I would like to point out from the position of being an individual with a PhD in the Biomedical Sciences and also a former sufferer of severe anorexia nervosa (AN).
I am very much in favour of recognising and describing AN as a biologically based illness, wherein starvation plays a significant role and genetic factors likely play some sort of role – although as yet we do not know precisely how genetics influence the risk of developing AN. Neither do we know, for certain, what is happening in the brains of people with AN that causes them to develop the illness and remain within it. For example, techniques such as fMRI have enabled metabolic activity in various regions of the brain to be examined in response to various cues (e.g. food cues) in individuals with and without AN, and for comparisons to be made between ‘patients’ and ‘controls’; however, none of these data definitively account for the aetiology of AN.
It is common for individuals who support the hypothesis that AN is a biologically based illness to dwell upon hard empirical data, describe such data as ‘evidence based’ (which it is), but discard data from qualitative research studies that investigate (e.g.) commonalities in the lived experience of the disorder. Yet, qualitative studies also count as evidence based and pass through a peer review process! Of course, it could be argued that interviewing patients who are sick with AN is merely listening to the anorexic voice, and that voice may change with weight gain and recovery.
From a personal standpoint, I feel 100% confident that my AN was biologically based. I come from a loving family and I have never had any interest in thin models/celebrities or felt ‘triggered’ by thin images. However, I also admit that it is not entirely clear how biology played a role in my illness. I will hazard a guess that the most likely genetic role has been through an influence on temperament, personality and cognitive processing. We have a lot of autism and OCD in my family. I, myself, have OCD (that existed loing before the onset of AN), significant autistic traits – especially in the realms of attention to detail, poor set shifting and extreme systemising. Starvation accentuated these traits. Yet, I am also certain that environmental triggers – in the form of sexual abuse by an adult outside of my family and serial bullying by peers at school played a role. I became so depressed at age 10-11, one year before I developed AN, that I wanted to disappear. I loathed what was happening to my body at puberty (the change was frightening) and this loathing and depression preceded the onset of AN by a couple of years.
Weight gain to a healthy weight for each individual is absolutely essential to the recovery from AN, and I remain ambivalent about the efficacy of many forms of therapy, including psychodynamic therapy. I don’t think we have reached a stage where we can categorically state that AN has a definitive biological cause, or is a ‘brain disorder’. Neither do I think that there is an effective one-size-fits-all treatment for AN.
By the way, the term for an absense of menses is spelt amenorrhea (US) and amenorrhoea (UK).
Psychodynamic therapy has been found to be much less effective than FBT in the treatment of anorexia nervosa in adolescents. Randomized Clinical Trial Comparing Family-Based Treatment to Adolescent Focused Individual Therapy for Adolescents with Anorexia Nervosa, Arch Gen Psychiatry. 2010 October; 67(10): 1025-1032 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038846/?tool=pmcentrez
Consequently, I agree with you, Sarah, and would say that psychodynamically informed therapy should not be used as a first line treatment except in very rare instances and only if parents are fully informed of the research data and give consent.
You have been sorely missed! I so agree with everything you have said in this post!!
Am I an exception then? At the time my eating disorder developed, my 10 year old sister had just passed away (I was 14). Our already shaky family dynamic was turned on it’s ear as our world would never be the same again. My father’s rage, violence, and alcoholism grew worse and matched the chaos level of when he had been using both drugs and alcohol in years past. My mother, grief stricken, did not have the support and strength to defend herself and me and so we took turns protecting one another from the emotional amd physical violence. I drew inwards and wanted so badly to disappear and need not even food so that I would be essentially hidden and safe from this madness. Also, completely zoning out of far less scarier things like calories was a welcome distraction.
I think my family dynamic played a significant role in my descent into my AN, not just in that crisis point that was reached at the onset of illness, but in the years prior as well. Sure, not every family has significant issues because every one is different, but so many do that I don’t think the stress a family shows can be necessarily put into the category of caused by the presence of the eating disorder alone.
Just as I’d hope that treatment providers would not presume there must be an unhealthy family dynamic in every case of a child with an eating disorder, I’d hope that neither would they presume that there is nothing to explore and decide on outset that any distress is as result of the disorder alone.
Thank you for your comment. You raise some very important points. I can’t really comment on your specific situation, since I don’t know you, but I do know that a families with an abusive or alcoholic parent are not appropriate for Family Based Treatment (FBT). And I certainly believe that any family with an abusive or addicted parent needs treatment, regardless of whether any family member has an ED.
Families of patients with AN run the gamut from awesome to average to abusive and severely dysfunctional. Just like families without eating disorders. A good clinician would perform a thorough evaluation of the patient and family before beginning treatment, and the results of that evaluation should guide the course of treatment. The immediate safety of the patient and other family members must always be the first priority, so a good clinician should address any threats to the patient’s safety immediately. If a parent is abusive, he/she would need to be removed from the patient right away, and he/she would certainly not be involved in FBT.
Any other family issues, such as unresolved grief in your case, would definitely need to be taken seriously addressed in treatment. In my opinion, though, the immediate priorities in AN treatment should always be protecting the patient’s physical safety (separating patient from abuser in your case, and treating any medical issues), ensuring that the patient gets full nutrition without compensatory behaviors, and restoring the patient to a healthy weight. Other psychological issues and family issues should be addressed after these goals are achieved. Not because they aren’t real sources of distress, but because they can be dealt with much more effectively when the patient is physically and mentally well.
Can a family dynamic play a significant role in a patient’s descent into anorexia? Many patients believe it can, and many psychodynamic theories propse that it does, but the science does not support this hypothesis. I do believe, very strongly, that family dynamics have a profound influence on our emotional wellbeing, for better or for worse. Traumatic events and family dysfunction can cause extreme distress and must be addressed in therapy, whether or not a patient has an eating disorder. And if someone does have an eating disorder or another mental illness, any existing family problems can certainly make recovery more difficult.
Temporal proximity (two events occuring near the same time in a person’s life) does not necessarily indicate causation. For some people, an episode of AN is precipitated by a serious trauma. For many other people, the stressor that preceeds an episode of AN is much more run-of-the mill, such as a breakup with a boyfriend, teasing by peers, entering high school, or competing on an elite sports team. And for many people, the onset of AN is not precipitated by any known stressor. Our understanding of the etiology of AN is in its infancy.
If you have recovered through psychodynamic therapy, yes, you would be the exception. But there are exceptions to every rule. Achieving recovery is the most important thing, and there are many paths to recovery. If you have found your path, that is fantastic. I wish you all the best!
Thank you for response here, Dr Ravin, and thank you even more for voicing you opinion on Laura’s blog. I really admire that you are able to see the more middle ground where genetics certainly contribute to the development of a brain disorder like eating disorders but also are open to the concept of environmental factors, including family, having an impact. I totally agree that we need to move away from the old assumptions that eating disorders are caused by cold dads and oppressive moms, but I don’t think it would be wise to take the stance that parents had zero influence on their child, the environment the child grows up in has little matter, and don’t even think to question if there is anything less than an ideal family dynamic.
Not all families are so healthy and happy, some need to have those issues addressed ASAP in order to provide the best nurturing environment for recovery possible. If the tide had swung too far at the time I entered treatment with my family, and the belief was along the lines I’ve read in the comments on various blogs that parents are never to be blamed or questioned because there is no correlation between eating disorders and abuse, and environmental factors even such as a parent going on an extreme diet and encouraging the child to do the same doesn’t contribute to the brewing eating disorder mindset, I’m not sure I would have truly reached out for help.
Some parents are great and healthy role models and their children may still develop an eating disorder. Other parents do not facilitate the same healthy family dynamic. Assessing each family on an individual basis and avoiding both inaccurate statements that eating disorders are ALL caused by family dysfunction or that parents are NEVER to be blamed for in some way contributing to the development. (note: not the cause, but a contributing factor). Gotta look for the somewhere in between. It’s never as black and white as the old theories versus new theories advocates attempt to paint it.
I love this. I was one of those patients who you said was conditioned to believe that her family was the reason behind the disease. My family does have a part in shaping me, but I was continually asked “Have I been abused in any way shape or form or was my family alcoholics?” as in that was the only reason I could have gotten anorexia. I’ve never be abused, raped, or no one I know is an alcoholic, so it really confused me. It made me feel as if I really wasn’t sick, I had just made up this disease, or everyone thought I was lieing. I like your approach to this. The comments are great as well.
Thanks for this terrific post! My question is how much can a very undernourished individual do with therapy at all–CBT, DBT, family therapy–even if it is evidence based, if they are so compromised?
You raise an excellent question. In my experience, most undernourished patients cannot benefit from any type of therapy, whether it is evidence-based or not. Family-Based Treatment (FBT) is quite different from family therapy. FBT is so helpful because it focuses on the family as the agent of change, rather than the patient herself, in the early stages of recovery. Even though undernourished patients cannot benefit from therapy, their family members certainly can. Also, just knowing that your family is coming together to understand your disease and help you in a proactive way, without blaming you or blaming themselves, is very therapeutic in and of itself.
maybe the title of this article should say ‘anorexia’ not ‘eating disorders.’ as a psych i agree psychodynamic psychotherapy is useless when it comes to anorexia (which is possibly a brain disorder involving neurological deficit), but when i work with patients with bulimia i find i am doing a lot of ‘trauma’ work, and the psychodynamic psychotherapy can be very effective. i also find there tends to be particularly dysfunctional families with bulimia – not all the time, obviously, but certainly more so than anorexic families, which as you have pointed out are often unreasonably labelled “dysfunctional” when in fact the anorexia may have caused the “dysfunctional” behaviours. In bulimia I think it’s quite different though – the binging and purging seems more about emotional dysregulation and a result of family dysfunction.
I think the points I made apply to both anorexia and bulimia, which are both “brain disorders” involving neurological deficits.
I completely agree with you that bulimic symptoms are very much related to emotional dysregulation. However, I disagree with your assertion that bulimia is the result of family dysfunction.
Correlation does not equal causation. The observation that family dysfunction is often present in the families of patients with bulimia does not necessarily support the hypothesis (and it is just that – a hypothesis) that family dysfunction caused the bulimia.
Just as likely are two other hypotheses: 1.) Bulimia caused the family dysfunction or 2.) Some third variable causes both bulimia and family dysfunction. I believe both of these latter hypothes are true.
Many families with an ill child will become conflicted or dysfuntional as they struggle to cope with the illness, all the more so when the ill child has anorexia or bulimia (two highly stigmatized diseases in which the patient and the family are often blamed, and there is little support for anyone). Also, given that mental illness is largely genetic, it is quite likely that the parents and siblings of a bulimic child may also suffer from a mental illness. Addiction and mood disorders and chaotic patterns of interaction may occur in many families with a bulimic child not because the patient is using her symptoms to cope with a dysfunctional family (which a psychodynamic therapist may presume), but because there is a shared diathesis amongst family members which manifests differently across generations.
Wow, what an interesting read. This really speaks out to me as I’ve been in treatment for a year – the first 6 months were psychodynamic and the second 6 months have been more intense and family orientated. I made no progress in the first 6 months, I made progress initially with the new treatment methods but it’s very slow and very up and down. I still can’t eat by myself at all and this article really helps – it might explain why the new treatment isn’t being as effective as it should be and as it has been for other people I know.
#7 resonated with me because my therapist is going to stop seeing me if I’m not a certain weight. She started weighing me a few months again and I got to the weight that she said I had to be at, though it was only because of my clothes and not my real weight. I was pissed at her when she said she wouldn’t see me if I wasn’t that weight. I told her how I don’t understand how she would drop me when I needed her the most. I was depressed and really mad about all of this. I’m still dealing with getting weighed every week and now that it’s hot and I’m in shorts, I don’t weigh as much and she thinks that I’ve lost weight. I was just away for 5 days and and wasn’t able to eat real meals because of my work schedule (Totally not an excuse and she knows that) so my weight was lower today. I just hate that it’s like “Gain weight of goodbye.” ugh!
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