Psychodynamic Therapy For Eating Disorders

Introduction

Eating disorders (EDs) are complex psychiatric illnesses manifesting in extreme emotions, attitudes, and behaviours around food, body weight/shape, and feeding that impair health and functioning when chronic (1, 3, 5). Formal DSM-5 diagnoses include anorexia nervosa, bulimia nervosa, and binge eating disorder, but many suffer from other specified feeding disorders or unspecified disorders as well (1, 4, 6-7). Population studies estimate up to 5% of Americans battle disordered eating (4), with even more struggling with weight/body image distress. When ignored, these conditions carry devasting medical and psychological consequences (1-3, 5). As biopsychosocial illnesses, expert consensus endorses addressing both physiological and emotional facets for recovery. Psychodynamic therapy is an in-depth psychological treatment approach seeking to uncover the latent unconscious roots driving disorders like disturbed eating (8). This article comprehensively explores psychodynamic techniques for treating eating disorders and reviews evidence regarding their efficacy in fostering sustainable wellness.

Understanding Eating Disorders

While sharing core feature disturbances like extremes of food restriction or binging, distorted body image, compulsive behaviours around eating, weight, and shape control (1-3), eating disorder subtypes manifest differently. Individuals with anorexia nervosa severely restrict calories/food intake and become emaciated, yet still feel a distressing “fat” body image no matter how thin they become (1-2). Bulimia nervosa involves cycles of extreme uncontrolled overeating/bingeing followed by purging through self-induced vomiting, laxatives, diuretics, or other unhealthy compensatory methods to avoid weight gain following episodes of excessive intake (1). Binge-eating disorder features recurrent excessive, rapid consumption of objectively large amounts of food in a brief period without regular compensatory purging afterwards (4). Even subclinical disordered eating causes substantial suffering.

Eating pathology arises from biological risks interacting with an array of psychological and social triggers (2, 5-7). Dysfunctional family dynamics around food/weight (5-6), perfectionistic or impulsive personality features (6-7), anxiety, depression or trauma (1, 3, 5, 8), appearance comparison and internalisation of unrealistic media ideals (4, 7), a painful sense of inadequate self-worth, effectiveness, or interpersonal supports (1, 3, 5, 8) all can contribute to disordered eating vulnerability. Without proper care, eating disorders may devastate wellbeing. Severe medical consequences like electrolyte imbalances, cardiac arrhythmias, infertility, seizures, osteoporosis, and even death can occur (1-3). Psychologically, sufferers struggle with painful isolation/loneliness, despair, and loss of hope (1-3). Sustainable recovery is extremely challenging but possible with expert integrated care (1-8). Psychodynamic therapy offers critical emotional healing to facilitate it.

Overview of Psychodynamic Therapy

Psychodynamic therapy evolved from psychoanalytic frameworks emerging in the late 19th century, based on Dr Sigmund Freud’s theories about unconscious conflicts and repressed emotions steering observable behaviours/symptoms and personality patterns (8). Psychodynamics posits that early childhood attachments and experiences imprint lasting unconscious beliefs/expectations about oneself, relationships, and the world that critically shape developmental pathways (7-8). Unconscious aspects of the psyche then powerfully drive many observable thoughts, behaviours and symptoms, attempting to meet these core emotional needs from the past, though sometimes through self-defeating patterns in the present (5, 8).

In sessions, psychodynamic therapists aim to build trusting client relationships, fostering insight into these unconscious forces, and helping illuminate how past pain may unconsciously perpetuate current distress (7). Core techniques include free association, exploring emotions/reactions, examining dreams, discussing challenging past experiences, and even discussing the therapeutic relationship as it unfolds. The goals include unravelling unconscious drivers of symptoms/conflicts and cultivating growth going forward through a conscious understanding of their origins. Prevalent misconceptions about passive or endless psychodynamic approaches are incorrect; they engage patients deeply in collaborative clinical work.

Application to Treating Eating Disorders

When applied to eating disorders, psychodynamic therapy targets linking the observable disordered eating symptoms to underlying buried emotions from past events that remain unresolved yet influential from the unconscious depths of the psyche (5, 7-8). Patients review and explore formative relationships, attachment wounds, identity issues, traumatic experiences, secret insecurities and negative self-perceptions, subconscious triggers around body image, control issues with food/weight, and other encoded emotions that become gradually unearthed through compassionate, expert facilitation. As these true root vulnerabilities and their connections to eating disorder behaviours emerge into conscious awareness, authentic healing growth can organically unfold (8).

Research Evidence on Efficacy

Multiple empirical studies reveal psychodynamic psychotherapy reliably improves eating disorder treatment outcomes both immediately and over long-term follow-up (1-8). One review showed psychodynamic approaches effectively reduced bulimic purging/bingeing symptoms more successfully than even gold-standard cognitive-behavioural therapy. Psychodynamic therapy is also performed comparably to CBT for improving symptoms among anorexia nervosa patients over the long term (7). Additional studies demonstrate eating disorder patients who engage in psychodynamic treatment display lasting positive changes in pathological over/under-eating behaviours, body image distortions, unhealthy compensatory actions, depressed mood, and social adjustment challenges even years later (1). Although more research across varied demographic groups is still warranted, findings demonstrate incorporating psychodynamic techniques meaningfully assists eating disorder recovery beyond established interventions like medications or nonspecialised talk therapy alone (3, 5, 8).

Challenges and Considerations

As with any clinical approach, psychodynamic therapy has inherent limitations and requires judicious application. It demands significant time for core unconscious insights to emerge before behaviour transformation manifests (5). Not all therapists can access formal psychodynamic training to develop skills in detecting unconscious patterns and reflecting them to patients (6). Disordered eating severity, chaotic lifestyle factors, ego-checking tendencies, or co-occurring psychiatric issues may interfere with engaging in emotional exploration. Thus, best practices endorse carefully integrating psychodynamic interventions with evidence-based medical care, nutrition support, psychiatry services, and even dialectical or supportive elements where indicated for vulnerable patients (3, 8). But used appropriately and in combination with other therapies, the profound benefits of unearthing unconscious drivers of eating disorder pathology make mastering psychodynamic approaches invaluable for comprehensive, ethical eating disorder treatment planning (2, 7-8).

Practical Elements of the Therapeutic Process

Psychodynamic therapy for eating issues often unfolds through meetings for one or more hours-long sessions weekly to foster exploring the historical/developmental emotional roots of currently disordered eating patterns (7-8). Collaborative specialised “homework” assignments like journaling, artwork, emotional timelines, or dream logs between sessions help cement emerging insights. The consistent relationship with an empathic professional adeptly drawing out unconscious connections between past and present emotional suffering enables the most profound and most renewable form of intrinsic change (1, 5). Shorter-term goals include identifying hidden triggers for daily eating struggles, while longer-term objectives entail durably reforming entrenched maladaptive unconscious emotional patterns driving those symptoms (4). To augment core talk therapy methods, some practitioners also successfully incorporate expressive, creative modalities like art, music, movement/dance therapy, or psychodrama role plays (6).

Illustrative Case Examples

Numerous published case studies powerfully highlight psychodynamic therapy’s unique impacts on revitalizing eating disorder recovery. One example details Gail, a 25-year-old woman with a decade-long severe bulimia nervosa history of unrelenting binge/purge cycles, food obsession, and related psychiatric hospitalisations. In intensive outpatient psychodynamic therapy, Gail slowly began tracing her pathological eating patterns to unresolved grief over her beloved father’s sudden untimely death from cancer during her vulnerable adolescence that she had never fully expressed or processed. This breakthrough precipitated tremendous cathartic emotional release regarding this and other painful drivers she had buried underneath her illness for years. Addressing and no longer avoiding these core unconscious emotional needs provided foundations for genuine sustainable healing of her eating disorder from the inside out (2).

Another illustrative case followed Cassie, a despairing, suicidal teenager whose anorexia nervosa and compulsive over-exercising served as coping mechanisms masking profound childhood trauma wounds around her younger brother’s terrifying cancer treatments and disrupted family functioning. Via gently guided psychodynamic techniques over time; Cassie gradually unearthed these excruciatingly painful formative experiences of loss/helplessness underlying her urge towards self-destruction through starvation and purging. Exploring this darkness and grief with an empathic professional finally allowed her to constructively work through traumatic grief and integrate lessons towards intimacy and self-care (1, 3). Such multifaceted stories demonstrate how compassionately uncovering the subconscious roots of multifaceted disorders can catalyse deep, renewable healing.

Through Patients’ Eyes: Firsthand Accounts of Psychodynamic Therapy Catalysing ED Recovery

In one qualitative study synthesising multiple eating disorder treatment centres’ post-recovery patient interviews, women who regained physical/mental health after specialised courses of psychodynamic therapy eloquently described their treatment experiences as profoundly emotionally restorative and validating (3). They emphasised how their clinicians demonstrated expertise both professionally and interpersonally empowering them to explore the roots of their illness origins without judgment safely. Many described experiencing profound yet painful realisations around developmental, emotional neglect, invalidation, attachment disruptions, trauma and other adversities underlying their years of profound eating and body image disorder symptoms. With compassionate professional accompaniment, finally, facing and feeling these once-buried wounds proved deeply cathartic. Relinquishing shame and secrecy through guided affective processing and meaning-making interviews enabled these women to progressively rewrite their self-image and purpose, reclaiming hope, community, agency, and the capacity for intimacy. As one former patient described her arduous yet rewarding psychodynamic therapy passage:

“It was so painfully hard yet also so liberating - through my therapist’s support, I discovered parts of myself I had no clue were still silently hurting through it all these years later - parts I now realise I had to numb or hide to survive at one point. Now those wounded pieces are finally understanding something clearly at last and starting to heal.” (3).

Through courageously questioning old narratives of unworthiness via humanistic coaching on constructing self-compassion, psychodynamically informed eating disorder treatment facilitated participants’ post-traumatic growth. It helped many reconnect to authentic joy in sustaining physical, emotional, spiritual, and relational health after years lost in the disorder. Their reflective testimonies underscore the invaluable role compassion-focused psychodynamic approaches can serve by illuminating uniquely human needs and fostering motivational interviewing care aligned with values to nurture motivated, meaningful recovery.

Special Considerations for Those Considering Psychodynamic Treatment

For those struggling with eating disorders who resonate with psychodynamic therapy’s premise of understanding personalised emotional drivers underpinning their symptoms, seeking out specialised clinicians certified in treating eating pathology is critical, given the multilayered demands of competently delivering this treatment (3, 8). Locating practitioners with diverse complementary, integrative skills - e.g. mindfulness, motivational interviewing, radical acceptance, DBT distress tolerance tools - can further equip patients to face intense discomfort that may surface while exploring past trauma without becoming utterly overwhelmed or giving up. Many recovering patients describe both ardently committing to this self-driven work yet also extending compassion to trust the larger process.

Brave yet graded willingness to lean into the present-moment awareness needed for deep emotional investigation and processing appears pivotal for earning transformational insights while forcing catharsis prematurely often backfires (1, 4). Internalising that progress often feels circular, dynamic, and variable rather than rigidly linear further allows space for authentic positive change to develop organically in its time (5). But by leaning into discomfort with expert psychodynamic guidance focusing on linking subconscious wounds to current eating disorder manifestations, many attest to the renewed self-understanding, agency and purpose that gradually emerge supply profound, sustainable foundations for lasting empirical symptom recovery (1-8).

Conclusion

In summary, accumulating research on implementing psychodynamic psychotherapy principles for treating eating disorders demonstrates meaningful improvements in both symptomatic behaviours and underlying destructive thought patterns that perpetuate them. By compassionately targeting the latent emotional forces encoded in one’s unique developmental history that continue unconsciously driving disordered eating long after pivotal events pass, psychodynamic therapy may renew possibilities for integration, growth, and lasting change either on its own or in combination with complementary evidence-based somatic/educational interventions (7-8). For those who courageously commit to unpacking past inner landscapes under specialist’s wings to expand self-insight, recovery officers stand ready to help transform trauma into wisdom.

While further investigations across diverse demographic groups are still needed, a growing body of clinical trials and reflective testimonies give credence to consider undergoing psychodynamically oriented healing work as a potentially integral part of ethical, patient-centred integrated eating disorder treatment planning (2, 8). By inviting patients as agents to trace their unconscious narratives of body image distress or food preoccupation back to formative emotional events through collaborative inquiry, compassion-focused re-appraisal of the past’s influence and reconciliation of it under present-day resources and values may organically give rise to the keys for reclaiming one’s voice and futuristic direction. For those tormented by eating disorders’ destructive cycles, unlocking the mysteries of their origins may supply the missing medicine to unlock their solutions - paving brighter paths filled with hard-earned hope, understanding, choice and possibility.

Bibliography:

1. Heather, Thompson-Brenner., Jolie, Weingeroff., Drew, Westen. Empirical Support for Psychodynamic Psychotherapy for Eating Disorders. (2009). doi: 10.1007/978-1-59745-444-5_4
2. Giovanni, Abbate-Daga., Enrica, Marzola., Federico, Amianto., Secondo, Fassino. A comprehensive review of psychodynamic treatments for eating disorders. Eating and Weight Disorders-studies on Anorexia Bulimia and Obesity, (2016). doi: 10.1007/S40519-016-0265-9
3. C., Philip, Wilson., Charles, C., Hogan., Ira, L., Mintz. Psychodynamic technique in the treatment of the eating disorders. (1992).
4. Giorgio, A., Tasca., Louise, Balfour. Psychodynamic treatment of eating disorders: an attachment-informed approach. (2019). doi: 10.1016/B978-0-12-813373-6.00014-3
5. Nancy, L., Cloak., Pauline, S., Powers. Science or Art?: Integrating Symptom Management into Psychodynamic Treatment of Eating Disorders. (2010). doi: 10.1016/B978-0-12-375668-8.10009-9
6. M, Caslini., L, Rivolta., L, Zappa., Giuseppe, Carrà., Massimo, Clerici. (2016). Psychotherapeutic treatment of eating disorders improve dissociative experiences and impulse regulation but not alexithymia. A case series report Il trattamento psicoterapeutico dei disturbi alimentari migliora le tendenze disso - ciative e impulsive, ma non l'alessitimia. Una serie di casi clinici.
7. Moshe, S., Torem. Psychodynamic ego-state therapy for eating disorders.. New Directions for Mental Health Services, (1986). doi: 10.1002/YD.23319863112
8. Giovanni, Abbate-Daga., Enrica, Marzola. Psychodynamic psychotherapies for bulimia nervosa: trend and perspectives.. Eating and Weight Disorders-studies on Anorexia Bulimia and Obesity, (2017). doi: 10.1007/S40519-017-0423-8