There are different types of psychological treatments for eating disorders and you may be offered a combination of them. Medication should only be offered alongside other treatments.
Physical treatments like acupuncture, weight training and yoga should not be offered as a treatment for eating disorders.
Guided self-help programme
This is a programme where you’ll look at the thoughts, feelings and actions that you have in relation to eating. You should also have some support sessions to help you follow the programme.
Psycho-education
This means you will learn about your symptoms and how to manage them.
Treatments for anorexia
The key goal when treating anorexia is to reach a healthy weight. Your weight will be monitored and possibly shared with your family members and carers by your doctor.
There are different psychological treatments for anorexia in adults. Your doctor should talk to you about different treatments. You should be given your preferred treatment if it is available.
Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
This is long-term individual therapy which aims to reduce risk to your physical health by teaching you about nutrition and new ways to think about food, your body image and self-esteem. You will be asked to monitor what you are eating and how this makes you feel.
Group eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Group CBT-ED is used to help treat binge eating disorder. It aims to help you monitor your eating behaviour and identify and learn how to cope with triggers for bingeing. It will help you to change negative beliefs you have about your body.
Maudsley anorexia nervosa treatment for adults (MANTRA)
This type of therapy teaches you about nutrition and how to change your behaviour, once you’re ready. It will involve your family members and carers, to help you understand your condition, the problems it causes and how to change your behaviour.
Specialist supportive clinical management (SSCM)
This type of therapy aims to help you recognise the link between your symptoms and eating behaviours. It educates and advises you on nutrition and allows you to decide what else should be included in your therapy.
Eating-disorder-focused focal psychodynamic therapy (FPT)
You will only be offered FPT if individual CBT-ED, MANTRA or SSCM hasn’t worked, or if your doctor thinks that the other therapies shouldn’t be used.
FPT is long-term therapy looking at what your symptoms mean to you, how they affect you and how they affect your relationships with other people. It examines the beliefs, values and feelings you have about yourself, and helps you to take what you learn into everyday life.
Glossary of terms
Approved Mental Health Practitioner
This role relates to the Mental Health Act 1983. If someone needs compulsory treatment, they will be involved in that decision. They act in the best interests of the patient and ensure that they understand their rights and are treated with dignity.
Approved Mental Health Practitioner
This role relates to the Mental Health Act 1983. If someone needs compulsory treatment, they will be involved in that decision. They act in the best interests of the patient and ensure that they understand their rights and are treated with dignity.
Cognitive Analytic Therapy (CAT)
Cognitive analytic therapy is a kind of therapy that can be recommended for the treatment of anorexia. It looks at past events that may explain the unhealthy thoughts that cause your anorexia, and helps you to recognise and find ways to break the unhealthy patterns.
Cognitive Behavioural Therapy (CBT)
Cognitive behavioural therapy helps you to deal with problems by breaking them down into smaller parts. It focuses on current problems and how to change negative thought patterns to develop healthy ways of coping with them. This therapy is often recommended as part of the treatment for all kinds of eating disorders. It can be adapted to the needs of people with particular illnesses, such as bulimia (CBT-BN) or binge eating disorder (CBT-BED).
Counselling
A type of talking therapy where you can talk about your thoughts and feelings, which aims to help you overcome emotional issues that you’re struggling with.
CPN (Community Psychiatric Nurse) / CMHN (Community Mental Health Nurse)
A mental health nurse who may visit patients at home to support them as they go through treatment.
Dietician
A qualified health professional who can assess, diagnose and treat dietary problems. They are registered with a professional body, the Health and Care Professions Council.
Family therapy
Family interventions may be recommended for children and adolescents with eating disorders. This kind of therapy involves family members, acknowledging that the eating disorder can impact the people around the sufferer and helping them to better understand the illness.
Focal Psychodynamic Therapy (FPT)
This is a form of therapy based on the idea that mental health conditions may relate to past unresolved conflicts. The therapy encourages people to think about early events that may have impacted their mental health and helps them find healthy ways to cope with negative feelings.
General practitioner (GP)
Usually the first port of call when seeking treatment for an eating disorder. They can assess your physical and mental health, give a diagnosis, prescribe treatment, and refer you for specialist care.
Interpersonal therapy (IPT)
This is a form of therapy that looks at the effect your relationship with others and with the outside world has on your mental health. It helps you to understand the feelings involved and develop healthy coping strategies. This can be part of the treatment for all kinds of eating disorders.
Modified Dialectical Behaviour Therapy (DBT)
This is a kind of therapy that focuses on your ability to control and regulate your emotional responses, and it can be adapted to help treat binge eating disorder.
Psychiatrist
A doctor who specialises in psychiatry, the field of medicine that involves the assessment, diagnosis and treatment of mental health conditions.
Psychologist
Someone trained in psychology, the study of how people think and behave. You might work with a clinical psychologist if you go through some form of therapy as part of your treatment. It’s advisable to check your psychologist is registered with the British Psychological Society.
Psychotherapist
Someone who is trained to deliver one or more types of therapy. You can see whether your psychotherapist is registered at the British Association of Counselling and Psychotherapy.
Issue date: September 2017 Review date: September 2020 Version 2.0 Sources used to create this information are available by contacting Beat. We welcome your feedback on our information resources.
Written by Hans-Christoph Friederich, Beate Wild, Stephan Zipfel, Henning Schauenburg, and Wolfgang Herzog
Reviewed by Nancy Eichhorn
Anorexia nervosa. Two words that often summon an image of emaciation: the kind where skin hangs off bones, darkened sockets shield distant eyes refusing to see, the smell of one’s body feeding on itself, the remnant of a cannibalization process meant to perpetuate life.
Classified as an ‘eating disorder’, anorexia is extremely challenging to treat. To confront this life-threatening disease, people try to contain it. They classify diagnostic criteria (ICD-10, DSM-5). They link predisposing factors (i.e., female, between ages 11 and 25, emotional instability, low self-esteem). They look at comorbidity (i.e. anxiety, depression, obsessive compulsive disorder). Then they create theories for its existence and persistence and from there methods to intervene.
Despite a plethora of programs, remission rates for eating disorders trend toward dismal. Furthermore, there is no one-size-fits-all when it comes to working with people living with eating disorders. When you consider anorexia, some feel successful everyday no nutrients pass their lips. Others eat buckets-full-of-food only to purge it and then follow-up with a laxative cocktail to make sure nothing remains in the intestines to be absorbed and turned into fat. The denial, the refusal, the lack of concern on the part of the client frustrates many a clinician. It’s hard to work with someone who is potentially dying but does not seem to care, does not see the potential end- result so lost in rituals like restricting food intake to keep themselves safe. The fear of fat appears to be one constant factor, but I dare not even make that a fact. It’s just a ‘seems to be’ thought.
I applaud those who accept these clients with a heartfelt intention to help; yet, it breaks my heart when I hear stories of the hurt inflicted by well-meaning but misinformed therapists, counselors, doctors, and the like who truly have no clue what is at the heart of this experience. It’s one thing to “treat”, it’s another to live it. Still, we need options, ideas.
A Focal Psychodynamic Psychotherapy Manualized Approach
“This book is the first-ever evidence-based psychodynamic psychotherapy treatment manual for clinicians working with people with anorexia nervosa. It was written by leading experts in brief psychodynamic psychotherapy and in clinical management and research into psychobiology of anorexia nervosa. Based on their rich clinical and research experience, these authors have modified the psychodynamic treatment approach to tailor it to the characteristics and needs of this challenging patient group” (Ulrike Schmidt, pg. v-vi).
When I received word of this new treatment manual based on focal psychodynamic psychotherapy from Germany, I was interested. (Note this manual was initially published in German, April 2014. The English version is now available). I wanted to see how these clinicians viewed anorexia and how their “manualized” process worked.
With that said, this book is written for therapists trained in the psychodynamic psychotherapy approach. The overall treatment focus is determined by results from the Operationalized Psychodynamic Diagnosis system, (which you must be trained and certified to use). Treatment plans are based on these findings that include central relationship themes and structural impairments. The authors provide a useful explanation on the basic characteristics of psychodynamic therapy and its focus on anorexia characteristics, on conflicts in relationship patterns, and the structure-based limitations of emotion processing that cause disruptive relationships (36).
To assist readers there are pull-out boxes with clinical vignettes highlighting the most common life-threatening conflicts and the most frequent structural foci. There are patient-therapist dialogues to potentially help readers experience the client’s experience of the conversation and their situation and the therapist’s response. Bulleted graphics, aka charts and pictures, highlight critical points made in the text. Illustrative case studies and examples of intervention strategies add to the readers’ understanding as well. An appendix addresses nutrition guidelines, in a general sense based on the US Department of Agriculture and Department of Health and Human Sciences in their Dietary Guidelines for Americans (2015-2020). I’m not certain how useful this information is in the condensed form provided (it fits in the book with small font and tight space for detailed information). A therapist will need to tailor it for individual clients considering food preferences (vegan, vegetarian, carnivore, grain intolerant—many people with eating disorders trend toward wheat and gluten sensitivities), seeing actual portion sizes, accepting a program that involves eating three meals and two snacks a day, etc.
The Program
The entire program, 40 to 50 sessions, is divided into three phases (initial middle, closure). The authors offer their interventions as “suggestions” and note that individual therapy requires adjustment.
“The basic concept of focal psychodynamic short-term therapy, when applied to patients with anorexia nervosa, is the focused treatment of a specific therapy theme (i.e., the focus,) which is described in relationships dynamic terms and considers not only central conflict themes, but also structural weaknesses” (pg. 23).
Treatment is centered around specific foci as determined from the diagnostic material and the initial interview, and is based on symptomatic, maladaptive relationship patterns, central life-threatening conflict themes, and structural deficits of the patient (pg. 25). Progress in therapy is based on changing aspects of the foci.
Once the psychodynamic interview is complete, therapy foci are determined. Therapeutic goals are determined, especially around the goal of weight gain. The therapeutic framework must include a clear-cut treatment agreement that includes weight parameters, meal structure, and accompanying medical examinations (pg. 33). Patients’ subjective goals are also considered.
From the psychodynamic perspective, patients with anorexia are seen as “attempting to stabilize their fragile feelings of self-worth, identity and autonomy, with key function of triumphing over their powerful feelings of ‘hunger’ and denouncing other primary needs. Interconnected with this are feelings of uniqueness and exceptionality” (pg. viiii).
It’s hard to convince these patients they need help. Most are ambivalent, don’t want treatment, and most certainly don’t want to gain weight. The “therapist has to strive to convince patients that treatment is required (pg. 43). It is “difficult to win over patients, have them adhere to therapy”.
During the initial phase there is much work on the therapeutic alliance as well as uncovering proanorexic beliefs, self-esteem issues and depression. Time is spent on body image and working with the entire family.
During the middle phase, therapists continue work with foci but move from reliance on the therapist with a focus on affective-emotional experiences. The closure phase looks at autonomy and personal responsibility. Relapse is anticipated and ways to address it if it does occur. According to the authors, “40 sessions was adequate for over one third of patients” (pg. 65).
Evidence from the Anorexia Nervosa Treatment of Outpatients (ANTOP) study, funded by the German National Ministry of Education and Research (2006-2013), supports the efficacy of this approach. Chapter 6 is devoted to the efficacy of the study. Overall, the authors contend the results showed that a “manualized and specifically tailored psychodynamic approach could be superior to treatment as usual (conventional treatments) at 1-year follow up” (p. x). You can read the actual study here
I appreciated the inclusion of this chapter. The authors are honest. It’s just as hard to study treatment processes involving anorexia as it is to treat it. In total there were 242 patients at 10 outpatient centers throughout Germany. They were randomly assigned to the psychodynamic approach, the cognitive behavioral approach or treatment as usual. Almost one-fourth of the patients dropped out in the first 10 months of treatment (pg. 92). After one year, dropout rates rose to 30.1% (wish they would be consistent with reporting, either percentages of fourth, third, half etc..). Even though there were no differences at the end of the evaluation, at the one-year mark, the psychodynamic group “had significantly more patients showing remission than the control group” (pg. 93). The details in this chapter are interesting and worth time considering.
To close
The book is well designed (graphics, layout, size) and easy to comprehend. It offers appropriate guideposts for readers to understand what is being said and why. It shows an insider’s look at one treatment plan based on focal psychodynamic psychotherapy that is “shown to produce lasting changes for patients with anorexia nervosa”. It’s no miracle cure. But that wasn’t their intent. What they offer is a sound, peer reviewed study, and how it formed the basis for a manualized process to address this truly insidious disease that can be beyond challenging to address.
To preview the book, click here for one example and here for another
