Integrating Treatment Interventions: Five Points to Enhance Clinical Practice, Part 1

Contemporary clinical practice with eating disorder patients has evolved considerably in the past two decades, offering more specific interventions, points of view, and evidence-based guidelines than when Hilde Bruch began her groundbreaking clinical work and publications in the 1960s. For many of us who ‘toil in the trenches’ daily with patients  who suffer from full-blown and subclinical eating disorders, difficulty often arises when we attempt to apply the latest research or theory to the unique individual sitting before us in the office. Not surprisingly, recent psychotherapy research that examines what mental health practitioners actually do in ‘real-world’ clinical practice demonstrates how we practitioners often blend and borrow from different theories, schools of thought, manualized guidelines, and all the tried and true advice from memorable teachers and books in crafting our interventions and treatment strategies in the office setting.

Regardless of our conceived theoretical biases or training, most of us routinely use educative, supportive, cognitive-behavioral, and psychodynamic principles. Although it may sometimes seem that our field is mired down in a veritable Tower of Babel, contemporary psychotherapy research is demonstrating that this is actually far from the case.

Using Multiple Perspectives for Treatment

In my recent clinical textbook, Integrated Treatment of Eating Disorders:  Beyond the Body Betrayed (W. W. Norton, 2008; see EDR, May-June 2008), I set out to illustrate how and why multiple perspectives can and should be used to improve symptom control and quality of life for eating disorder patients. Many clinical examples from my own and my staff’s work speak to the human cost and emotional angst of family members and the patients themselves. This includes lessons learned about helping patients in their quest to face down denial, say goodbye to and mourn their eating disorder identity, become more autonomous human beings while maintaining a healthy sense of dependency on others, and generally become more anchored in the world emotionally and spiritually. These lessons are the heart of a comprehensive treatment plan aimed at giving birth to a true self. This true self will have both greater control of symptoms and an enhanced quality of life (e.g., improving self care; maintaining better interpersonal relationships; establishing boundaries; developing a career path; owning a sense of one’s personal power).  

Patients have been my best teachers. They have educated me about the importance of being practical, staying relatively self-aware, and drawing on multiple points of view from clinical and nonclinical resources to try to be helpful. Their courage and tenacity in the face of severe psychosocial and medical problems is humbling but has been a prod to make a fresh assessment of what really works and to make course corrections when the therapy seems to be turning sour. This essence of an integrative treatment approach derives from taking biological, cultural, and psychological perspectives into account and educating the patient about his or her illness, to help establish a therapeutic alliance in the opening phase of therapy, and it continues right up to termination.

Because at least one-third of our patients do not improve rapidly or with medication, or with education about diet and relapse prevention, or with other directive cognitive strategies, novice and experienced mental health professionals alike frequently experience frustration and anxiety. Although an extensive overview of an integrated approach is beyond the scope of this article, the following five points illustrate some of the ideas that I have found to be relatively helpful for even the most difficult and refractory cases. Each point is followed by a brief clinical vignette.

One: Help Patients Face Down Their Inner Critic

Most patients with an eating disorder tend to be highly self-critical. They magnify their faults and mistakes; they have a sense of impending doom (i.e., catastrophic feelings) if they eat a forbidden food or have a forbidden thought, and are beset by assumptions of what they ‘should’ or ‘must’ do to be a better human being.

Cognitive/behavioral and psychodynamic approaches address this vexing problem in order for patients to use their healthy ego to reflect and gently confront the tendency to always see the defect within themselves. The desired result is that over time patients can come to not only appreciate their strengths but face down the tendency to have their inner critic rule their lives. A punitive inner critic is the polar opposite of the benevolent superego that enables each of us to deal constructively with our real blunders and to acknowledge when we must rectify a transgression or gaffe (e.g., the capacity to differentiate true from false guilt). 

Clinical example:  Ms. A had made significant strides in overcoming her tendency to binge and purge. She had learned in her psychotherapy that her 18-year history of dysregulated eating, overexercising, and vomiting was a way she coped with a host of feelings, particularly those of abandonment and insecurity.  However, her heightened sense of self-criticism was getting in the way of her application to graduate school, and her eating disorder symptoms exacerbated as she prepared to take the GREs and planned for the interview process.  

Her therapist grasped the opportunity to work with how guilty Ms. A felt about moving forward because she falsely believed she would harm others by making gains, specifically ‘abandoning’ the therapist  to start life anew. Frequently Ms. A would devalue her own accomplishments and attempt to sidestep the ways in which her immediate family had been cruel to her. Her therapist confronted this aspect of the patient’s overly active inner critic by repeatedly intervening and asking, “Why are you being so mean to you?” The therapist added, ” Your symptoms once again increased, perhaps, as a way of punishing yourself for getting better. It must be very painful for you to feel so let down by your loved ones who you wish would encourage and appreciate your gifts more than they do.”

Two: Listen for Secrets  ‘Hidden in Plain View,’ and Make Them Expressible in Treatment

Harboring family secrets and the emotional cost to the patient of remaining silent is one of the old chestnuts in mental health training that cuts across disciplines and theories. Sometimes our patients are not consciously aware of such a secret, but their disorder is a subterranean and camouflaged method of protecting what ‘they really know but are not supposed to know.’ Before such secret knowledge can be judiciously and tactfully brought into the therapy, however, the clinician must be open to the possibility thata concealed piece of history or inexpressible feelings may be impacting the forward momentum of symptom control. Sometimes the treasured secret may be cryptic, repressed, or dissociated and, hence, covert, but in many circumstances it is screaming to be heard–if we clinicians only have the ears to pick up on it.

Clinical Example:  Ms. B was 14 and applying for early admission to a prestigious boarding school that she wanted to attend when she developed anorexia nervosa (AN). She was hospitalized twice and received excellent supportive outpatient care. Her inability to maintain her target weight and to focus on her studies led to the school administration’s good judgment to delay matriculation. A consultant with extensive experience in the treatment of eating disorders interviewed Ms. B’s parents at their request, even though extensive family work had already been done. 

In the first three interviews the consultant was totally stymied: the couple appeared to be reasonably happy, invested in their child’s age-appropriate differentiation and self-directed personal goals, and substantially worried about their child’s unremitting AN despite treatment. On the way out the door of the third hour, Ms. B’s father offhandedly remarked, “By the way, our daughter is adopted, but we have never told her.” At further interviews, the consultant worked with Ms. B’s parents to consider the possibility that the patient ‘knew’ she was adopted but did not want to share her secret for a myriad of intrapsychic reasons, possibly related to protecting them. Suffice to say that when this issue was addressed in individual and family sessions with Ms. B, she did have more than an inkling of being adopted. The family then began to actively process its meaning and the reasons (e.g., guilt, shame, and a desire to be protective) that lay behind a secret that was truly ‘hidden in plain view.’ Ms. B’s eating improved and she achieved her target weight over the next year, and  eventually graduated from the boarding school with honors and no residual symptoms of AN.

Three: Address Issues of Loss and Grief and Help the Patient Mourn the Eating Disorder Identity

Issues of loss are ubiquitous in life. The capacity to mourn is a developmental achievement and crucial to an individual’s full immersion and growth in the life cycle. A wise mentor once told me, “One must laugh at life, Kassy, because none of us get out of it alive!” In the humorless and dark world of the eating disordered patient, issues of loss are profound and often go unnoticed, unspoken, and consequently not worked through.

The identity of having an eating disorder itself must also be mourned in order for the patient to get well, just as all of us must say goodbye to our former identity to solidify a new one. In working with patients, it is important to not only to be on the lookout for major life losses, such as death of a parent, spouse, child, sibling, or best friend, but all of those important life transitions that conjure nostalgia and a degree of heartache in each of us.

Empathic resonance with the patient might begin by silently recalling the mixture of feelings one had while going off to college or making a career change. Paralleling the axiom in real estate that the most important attribute of selling a house is ‘location, location, location,’ we find in psychotherapy that the most essential and overarching theme may be focusing on ‘loss, loss, and more loss.’ Bringing tissues to hold the tears, carefully raising and clarifying real and perceived losses, and being present as a person with an open heart and mind to help process the meaning of what has been taken away are all the tools one needs in making this assortment of issues come into the open and ultimately become more manageable.  Sages of all spiritual traditions also emphasize that ‘loss must be shared to be borne.’ 

Clinical example: Mr. C. is a lonely, schizoid patient who suffered for years with bulimia nervosa. He made some headway in symptom control during his 4 years in therapy as he addressed many different issues, including those of loss in his early life. When the patient’s 17-year-old Maine Coon cat became ill and died, he told his therapist he ‘had lost his one and only life companion.’ Because the patient had had the life experience of being told to buck up and be strong when his family made moves from one city or country to another (he was raised by parents in the Foreign Service), he now repeatedly squashed any experience of being sad and tried hard to distance himself from any appearance of needfulness. His therapist noted this reluctance to speak about the importance of the loss, but knew it was essential to address lest the feelings go underground and lead to depression or a recrudescence of eating disorder symptoms. He told Mr. C that they needed to ‘find a safe way to say goodbye’ to the cat. The Gestalt technique of placing the lost object (i.e., the cat) in a chair, talking about its life and its meaning by the patient, addressing pent-up anger, deprivation of companionship, sadness, and so forth, helped this patient weather the storm, and increased the sense of healthy dependency on the therapist, another human being. The therapist silently wondered if, down the road, he and Mr. C might be able to employ a similar technique to finally say goodbye to or have a ‘funeral’ for his eating disorder. However, at this point in treatment it was all that Mr. C. could do to work on this formidable life lesson.