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Anorexia Nervosa: Focal Psychodynamic Psychotherapy

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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