The effectiveness of enhanced cognitive behavioural therapy for eating disorders: an open trial

The aim of this study was to examine the effectiveness of Enhanced Cognitive Behaviour Therapy (CBT-E) for eating disorders in an open trial for adults with the full range of eating disorders found in the community. The only previously published trial of CBT-E for eating disorders was a randomised controlled trial (RCT) conducted in the U.K. for patients with a BMI ≥ 17.5. The current study represents the first published trial of CBT-E to include patients with a BMI < 17.5. The study involved 125 patients referred to a public outpatient clinic in Perth, Western Australia. Patients attended, on average, 20–40 individual sessions with a clinical psychologist. Of those who entered the trial, 53% completed treatment. Longer waiting time for treatment was significantly associated with drop out. By the end of treatment full remission (cessation of all key eating disorder behaviours, BMI ≥ 18.5 kg/m², not meeting DSM-IV criteria for an eating disorder) or partial remission (meeting at least 2 these criteria) was achieved by two thirds of the patients who completed treatment and 40% of the total sample. The results compared favourably to those reported in the previous RCT of CBT-E, with one exception being the higher drop-out rate in the current study. Overall, the findings indicated that CBT-E results in significant improvements, in both eating and more general psychopathology, in patients with all eating disorders attending an outpatient clinic.     

Description of an Intensive Dialectical Behavior Therapy Program for Multidiagnostic Clients With Eating Disorders

The authors describe an intensive outpatient dialectical behavior therapy (DBT) program for multidiagnostic clients with eating disorders who had not responded adequately to standard, empirically supported treatments for eating disorders. The program integrates DBT with empirically supported cognitive behavior therapy approaches that are well established for the treatment of eating disorders. Attention is given to inclusion and exclusion criteria, how the program differs from standard treatments for eating disorders, and the application of specific DBT treatment components for multidiagnostic clients with eating disorders.     

Everything Has Changed: An Interview With Judy Jordan

Judy Jordan is one of the founding scholars of relational‐cultural theory (RCT). In this interview, Judy (a) gives historical and personal insight into the development of RCT, (b) describes how the theory has been received both in the United States and internationally, and (c) discusses possible future directions for RCT scholarship.     

Spirituality and Ten False Beliefs and Pursuits of Women With Eating Disorders: Implications for Counselors

Women with eating disorders often struggle with deep spiritual conflicts that can be a major impediment to their recovery. On the basis of clinical experience with more than 350 women in an inpatient eating disorder treatment facility, the authors describe 10 false beliefs that women with eating disorders may hold; the authors explain how the pursuit of these beliefs can prevent the women from connecting with God and with others in genuine ways. The authors also suggest some therapeutic strategies that may help women with eating disorders find a healing and helpful spiritual perspective.     

Systemische Therapie bei Störungen des Erwachsenenalters

Background

Systemic therapy is a scientifically acknowledged form of psychotherapy in the US and many European countries, but not yet in Germany.

Method

All randomized (or parallelized) controlled trials (RCT) evaluating systemic couples/family/individual therapy with adult index patients published in English, German or Spanish up to the end of 2004 were identified via data base searches and cross-references in other meta-analyses and reviews. A meta-analysis of the identified RCT was performed.

Results

28 RCT (43 publications) evaluating systemic therapy with adult index patients suffering from clinical disorders (ICD-10) were identified. Systemic therapy is efficacious with regard to substance disorders, mental/social factors interacting with somatic disorders, schizophrenia, depression and eating disorders. The results are stable across follow-up periods of up to 5 years.

Conclusion

According to the criteria of the German Scientific Advisory Board Psychotherapy (Wissenschaftlicher Beirat Psychotherapie) there seems to be good evidence for the efficacy of systemic therapy in at least four fields of application of adult psychotherapy.     

The Semantics of Power Among People With Eating Disorders

The study aimed to empirically test the hypothesis, developed within the systemic-constructionist theory of family semantic polarities, that the semantics of power are particularly meaningful for people with eating disorders. The repertory grid technique was used to elicit constructs from 30 young patients (10 anorexic, 10 bulimic, and 10 obese) and from a matched control group; the two sets of constructs were compared in terms of their semantic content. Overall the results confirmed the hypothesis, although further investigation into the semantic peculiarities of individual eating disorders is required. Methodological limitations and possible clinical applications are discussed.     

The Use of Relational‐Cultural Theory in Counseling Clients Who Have Traumatic Stress Disorders

Counseling scholarship has increasingly demonstrated the utility of relational‐cultural theory (RCT) in promoting the relationship‐building and growth‐fostering connections many clients require to manage problems in living. The authors applied RCT to counseling clients with traumatic stress disorders rooted in traumas of an interpersonal nature (e.g., child abuse, interpersonal partner violence, sexual assault). An overview of traumatic stress disorders and RCT, as well as the ways in which RCT can inform trauma conceptualization and treatment approaches with victims, is provided.     

Supervision for Counselors Working With Eating Disorders Groups: Countertransference Issues Related to Body Image,Food, and Weight

Because of similarities in age, education, and background, group counselors and members of eating disorders groups may easily identify and connect with each other. Although it can be positive, such overidentification may also create countertransference issues and demand attention in supervision. A model of supervision based on parallel process is presented to address these issues. The article describes (a) societal values related to eating disorders and countertransference; (b) specific themes in eating disorder groups and their impact on group process; (c) examples of countertransference related to body image, food, and weight; and (d) guidelines for supervision of female counselors working with eating disorders groups.     

Autistic Patterns

Abstract

Over the last three decades, researchers have tried to identify the etiology of eating disorders. In examining the connections between different types of self-and-body dissatisfaction evident in eating disorders, the psychodynamic approach is the most feasible. Implicated are deficits of the self, unresolved problems in separation-individuation and self-definition, and the difficulty in expressing needcalled the “Black Hole.” The current article presents three case studies of anorexia, bulimia, and obesity and compares them through the ability to express neediness. Basic terms from the research of Tustin and others are used to explain the dynamics related to the capacity to express need, as exemplified in the different types of eating disorders.     

Personality disorder cognitions in the eating disorders

The eating disorders are frequently found to be comorbid with Axis II cluster B and C personality disorders. It is important to identify the personality-level cognitions that typify these disorders. This study of a clinical group examines the personality disorder cognitions in the eating disorders. The cognitions that were most relevant to the eating disorder pathology were those relating to avoidant and obsessive-compulsive personality disorder. Other personality disorder cognitions were associated with comorbid psychopathology in largely clinically meaningful ways. These findings extend our understanding of the comorbidity of eating disorders and personality pathology, suggesting that some cases need to be assessed and formulated with such cognitions in mind. Treatment strategies are required that address both the eating and the personality pathology, while considering the impact of these cognitions on the therapeutic relationship.     

Eating Issues in Schools: Detection,Management, and Consultation With Allied Professionals

School counselors play a crucial role in the prevention, assessment, treatment, and overall management of eating‐related problems among children and adolescents. This article provides a framework for conceptualizing these difficulties on a continuum of severity and includes recommendations at each level for intervention and consultation. Collaboration with other professionals is encouraged when confronted with these multifaceted issues. Efforts by school counselors are vital to prevention and recovery from eating disorders.     

The efficacy of systemic therapy with adult patients: a meta-content analysis of 38 randomized controlled trials

Systemic therapy is a widely used psychotherapy approach. Yet there exist few systematic reviews on its efficacy. A meta-content analysis was performed to analyze the efficacy of systemic therapy for the treatment of mental disorders in adulthood. All randomized (or matched) controlled trials (RCT) evaluating systemic/systems oriented therapy in various settings (family, couple, individual, group, multifamily group therapy) with adult index patients suffering from mental disorders were identified by database searches and cross-references in other reviews. Inclusion criteria were: index patient diagnosed with a DSM or ICD listed mental disorder, trial published in any language up to the end of 2008. The RCTs were content analyzed according to their research methodology, interventions applied, and results. Thirty-eight trials published in English, German, Spanish, and Chinese were identified, 34 of them showing systemic therapy to be efficacious for the treatment of mood disorders, eating disorders, substance use disorders, mental and social factors related to medical conditions and physical disorders, and schizophrenia. Systemic therapy may also be efficacious for anxiety disorders. Results were stable across follow-up periods of up to 5 years. There is a sound evidence-base for the efficacy of systemic therapy for adult index patients with mental disorders in at least five diagnostic groups.     

The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder

Body dysmorphic disorder (BDD) and eating disorders are body image disorders that have long been hypothesized to be related to obsessive-compulsive disorder (OCD). Available data suggest that BDD and eating disorders are often comorbid with OCD. Data from a variety of domains suggest that both BDD and eating disorders have many similarities with OCD and seem related to OCD. However, these disorders also differ from OCD in some ways. Additional research is needed on the relationship of BDD and eating disorders to OCD, including studies that directly compare them to OCD in a variety of domains, including phenomenology, family history, neurobiology, and etiology.     

Implicit memory bias for eating- and body appearance-related sentences in eating disorders: an application of Jacoby's white noise task

Jacoby's white noise task and an explicit recognition task were used to investigate whether individuals with eating disorders demonstrate implicit memory bias and explicit memory bias, respectively, for information related to eating and body appearance. Included were 33 women with eating disorders (seven with anorexia nervosa and 26 with bulimia nervosa), 29 with nonclinical eating disorder-related concerns, and 36 healthy controls. Results showed partial support for implicit memory bias but no support for explicit memory bias. These findings suggest that eating disorders may be characterized by relative initial automatic bias for eating disorder-relevant information but not by bias at later stages of information processing. However, previous studies have demonstrated explicit memory bias in eating disorders, which is inconsistent with this interpretation. Future research is required to clarify the precise cognitive biases associated with eating disorders.     

Loneliness and eating disorders

This article examines the link between loneliness and eating disorders. This concept is evaluated through a systematic review of the literature that links loneliness and eating disorders and through a survey of themes connecting the 2 conditions. Eating disorders-including anorexia nervosa, bulimia nervosa, and eating disorders that are not otherwise specified, which include binge eating disorder-are challenging health issues. Each of these diagnoses specifically relates to loneliness. This negative emotion contributes to and fuels eating disorder symptoms. Negative interpersonal relationships, both real experiences and individuals' skewed perceptions, exacerbate eating disorders and feelings of loneliness. Characteristics that have been associated with loneliness clearly relate to eating disorders. Understanding this relationship is vital, so that we can appreciate our patients' struggles and work to target these intense emotions within the treatment setting. We need to be aware of the power of loneliness as it applies to individuals in general and specifically to those struggling with disordered eating.     

The interpretation of symptoms of severe dietary restraint

A recent cognitive-behavioural theory of eating disorders proposes that people with eating disorders interpret symptoms of dietary restraint in terms of control. The primary aim of the present study was to test this hypothesis. A second aim was to test the hypothesis derived from clinical observation that people with eating disorders view these symptoms positively. Forty-four participants meeting DSM-IV criteria for a clinical eating disorder and 80 control participants with no history of an eating disorder completed an ambiguous scenario paradigm and self-report measures of eating disorder features and depression. Patients with eating disorders were significantly more likely to interpret symptoms of dietary control in terms of control, providing support for the cognitive-behavioural theory. There was only partial support for the second hypothesis. The implications for the new cognitive-behavioural theory and therapy are discussed.     

Role of attention, memory, and covariation-detection processes in clinically significant eating-disorder symptoms

Cognitive theorists implicate a role for cognitive processing of shape- and weight-related information in the maintenance and potential etiology of eating disorders. The present study examines the role of women’s processing of information regarding other women’s body size and affect in eating disorder symptoms among young women. 253 female undergraduates completed attention, memory, and covariation-detection tasks that presented full-body photographs of young women, as well as an eating-disorder measure. High-Symptom women, relative to Medium- and Low-Symptom women, showed greater relative attention to body size than affect, better memory for body size and worse memory for affect, and enhanced sensitivity to the manipulated covariation between body size and affect. All participants perceived an illusory correlation between body size and affect. These findings suggest that cognitive theories may be extended usefully by considering processing of other-relevant and affective information, as well as the role of covariation-detection processes in eating disorders.     

The Role of Self-Objectification in the Experience of Women with Eating Disorders

Objectification theory has linked self-objectification to negative emotional experiences and disordered eating behavior in cultures that sexually objectify the female body. This link has not been empirically tested in a clinical sample of women with eating disorders. In the present effort, 209 women in residential treatment for eating disorders completed self-report measures of self-objectification, body shame, media influence, and drive for thinness on admission to treatment. Results demonstrated that the internalization of appearance ideals from the media predicted self-objectification, whereas using the media as an informational source about appearance and feeling pressured to conform to media ideals did not. Self-objectification partially mediated the relationship between internalized appearance ideals and drive for thinness; internalized appearance ideals continued to be an independent predictor of variance. In accordance with objectification theory, body shame partially mediated the relationship between self-objectification and drive for thinness in women with eating disorders; self-objectification continued to be an independent predictor of variance. These results illustrate the importance of understanding and targeting the experience of self-objectification in women with eating disorders or women at risk for eating disorders.     

The Efficacy of Systemic Therapy for Internalizing and Other Disorders of Childhood and Adolescence: A Systematic Review of 38 Randomized Trials

Systemic therapy (ST) is one of the most widely applied psychotherapeutic approaches in the treatment of children and adolescents, yet few systematic reviews exist on the efficacy of ST with this age group. Parallel to a similar study on adults, a systematic review was performed to analyze the efficacy of ST in the treatment of children and adolescents. All randomized or matched controlled trials (RCT) evaluating ST in any setting with child and adolescent index patients were identified by database searches and cross‐references, as well as in existing meta‐analyses and reviews. Inclusion criteria were: index patient diagnosed with a DSM‐IV or ICD‐10 listed psychological disorder, or suffering from other clinically relevant conditions, and trial published by December 2011. Studies were analyzed according to their sample, research methodology, interventions applied, and results at end‐of‐treatment and at follow‐up. This article presents findings for internalizing and mixed disorders. Thirty‐eight trials were identified, with 33 showing ST to be efficacious for the treatment of internalizing disorders (including mood disorders, eating disorders, and psychological factors in somatic illness). There is some evidence for ST being also efficacious in mixed disorders, anxiety disorders, Asperger disorder, and in cases of child neglect. Results were stable across follow‐up periods of up to 5 years. Trials on the efficacy of ST for externalizing disorders are presented in a second article. There is a sound evidence base for the efficacy of ST as a treatment for internalizing disorders of child and adolescent patients.     

On Targeting Emotion Regulation Deficits in Eating Disorders through Defense Analysis

ABSTRACT

Psychodynamic approaches to the treatment of individuals with eating disorders are underrepresented in research and in academia. This will increasingly deprive patients of a viable therapeutic alternate to the dominant behavioral family-based models. As psychodynamic approaches may have unique benefits, there is value in resolving this loss. Recent models of dynamic therapies for eating disorders within modern, empirically derived theory show promise for future psychodynamic viability. An attachment-focused approach targeting disordered attachment patterns that are common in individuals with eating disorders has recently been introduced. To complement this model, this article proposes an approach for individuals with eating disorders that is hypothesized to target emotion regulation deficits that are also commonly found in individuals with eating disorders. Observed parallels between the implicit branch of the emotion regulation system and that of contemporary constructs of defense mechanisms guide this proposal. Developmental considerations reveal important connections between this biologically based model and a two-person model based in attachment theory. In this way, this proposal offers a flexible psychodynamic approach that integrates with the existing literature. Further development of this approach could one day help patients to have a greater range of therapeutic options for recovery from eating disorders.