Working therapeutically with people with disordered eating: a conceptual framework - Julia Buckroyd

Despite decades of work there is little consensus on how disordered eating can be understood. There is still a dominant focus in treatment on the modification of the eating behaviour. Research into therapeutic responses to disordered eating has largely focused on the relative merits of differing modalities and their success in modifying the behaviour. Yet recovery rates are poor and many clients find therapy unhelpful. Many therapists regard work with eating disordered clients as particularly challenging and often unrewarding.

My approach to this subject has been to investigate the research literature with a view to understanding what it tells us about the history and emotional development of the person with disordered eating. There is a surprising amount of literature of this kind, although to my knowledge little of it has guided therapeutic interventions. Moreover there is considerable agreement that there are constant features across the spectrum of disordered eating from anorexia to compulsive eating/binge eating disorder.
The basic commonality seems to be that those with disordered eating of whatever kind are highly likely to have had a history of insecure attachment. That history will in turn have made affect regulation difficult, which will have led to emotional management via food. (Flores 2001; Heatherton and Bauermeister 1991; Maunder and Hunter 2001; Schore 2001, 2003; Ward et al.2000; Zimmerman 1999). There is a copious literature on the psychological background of eating disordered people which additionally suggests that attachment difficulties have often been associated with a history of trauma and that disordered eating functions as a kind of self-medication (Dallman et al. 2005; Epel et al. 2001; Schoemaker et al. 2002; Smolak and Murnen 2002). It is known, for example, that bingeing produces chemical reactions in the brain which in effect provide a fix of opioids (Colantuoni et al. 2002)

The strategy of management via food (and of course starvation is as much a way of managing with food as bingeing) masks a number of characteristics, which again seem to be common across the spectrum of disordered eating. The most obvious of these is alexithymia, or the lack of an emotional language (Cochrane et al. 1993; De Chouly de Lenclave et al 2001; De Zwaan et al 1995; Pinaquy et al 2003; Rastom et al 1997; Schmidt et al. 1993). This implies both a lack of awareness of feelings, and/or a confusion about what is being felt, and a lack of language in which to describe or express them. This in turn leads to the impossibility of reflecting upon (and therefore doing anything about or understanding anything about) emotional history or experience (Allen et al. 2008, Damasio 1995, 1999; Fonagy and Target 1997; Goleman 1995) and a consequent impoverishment of the development of the self (Allen 2008, Fonagy 2002, Heatherton and Bauermeister 1991; Schore 2003).

This history and the consequent emotional deficits together create a serious impediment to emotional development. Disordered eating is merely the symptom of these deficits and the attempt to repair them. Our job as therapists is to provide the empathic and containing relationship within which clients can begin to bear to feel, to name feelings and to reflect upon their history. These processes will in turn enable the development of the self, the capacity to self-soothe and self-nurture and the capacity to form mutual and intimate relationships.

There is room within this conceptual framework for parallel on-going cognitive work in relation to eating behaviour. Disordered eating at the extremes is threatening to health and may very well need attention. Its modification however, is only one of the tasks to be undertaken. The process of focused work on the issues described above attempts the development of the person to the point where strategies of food misuse are no longer necessary.

WORKING WITH PEOPLE WITH
DISORDERED EATING

REFERENCES
Allen, Jon, Fonagy, Peter and Bateman, Anthony (2008) Mentalizing in Clinical Practice.

Cochrane, C., Brewerton, T., Wilson, D. and Hodges, E. (1993) Alexithymia in the eating disorders. International Journal of Eating Disorders. 14: 219-222.

Colantuoni, C., Rada, P., McCarthy, J., Patten, C., Avena, N. M., Chadeayne, A. & Hoebel, B. G. (2002) Evidence that intermittent, excessive sugar intake causes endogenous opioid dependency. Behaviour Modification, 27, 478-488.

Dallman, Mary F., Pecoraro, Norman C. and la Fleur, Susanne E. (2005) Chronic stress and comfort foods: Self-medication and abdominal obesity. Brain, Behavior and Immunity. 19: 275-280.

Damasio, A.R. (1995) Descartes’ Error: Emotion, Reason and the Human Brain

Damasio, A.R., Dolan, R.J. (1999) The feeling of what happens: body and emotion in the making of consciousness. Harcourt

De Chouly De Lenclave, M. B., Florequin, C. & Bailly, D. (2001) Obesity, alexithymia, psychopathology and binge eating: a comparative study of 40 obese patients and 32 controls. Encephale, 27, 343-350.

De Zwaan, M., Bach, M., Mitchell, J. E., Ackard, D., Specker, S. M., Pyle, R. L., Pakesch, G. (1995) Alexithymia, obesity and binge eating disorder. International Journal of Eating Disorders.17: 135-140.

Epel, E., Lapidus, R., McEwen, B., and Brownell, K. (2001) stress may add bite to appetite in women: a laboratory study of stress-induced cortisol and eating behaviour. Psychoneuroendocrinology. 26: 37-49.

Flores, Philip J., (2001) Addiction as an Attachment Disorder: Implication Therapy. International Journal of Group Psychotherapy.51: 1.pp 63-81.

Fonagy, Peter and Target, Mary (1997) Attachment and reflective function: Their role in self-organization Development and Psychopathology 9 : 679-700

Fonagy, Peter (2002) Affect regulation, mentalization and the development of the self. Other Press, LLC

Gerhardt, S. (2004) Why Love Matters: How Affection Shapes a Baby's Brain, Hove, Brunner Routledge.

Goleman, Daniel (1995) Emotional Intelligence. USA. Bantam Books.

Heatherton, TF. and Baumeister RF. (1991) Binge eating as escape from self-awareness. Psychological Bulletin. 110. 86-108.

Logue, A.W. (2004) The Psychology of Eating and Drinking. New York, Brunner-Routledge.

Maunder, Robert and Hunter, Jonathan (2001) Attachment and Psychosomatic Medicine: Developmental Contributions to Stress and Disease, Psychosomatic Medicine, 63: 556-567.
Ogden, J. (2003). The psychology of eating. Oxford: Blackwell Publishing.

Pinaquy, Sandrine, Chabrol, Henri, Simon, Chantal, Louvet, Jean-Pierre and Barbe, Pierre (2003) Emotional Eating, Alexithymia and Binge Eating Disorder in Obese Women. Obesity Research 11:195-201

Rǻstam, M.,Gillberg, C., Gillberg, I.C. and Johansson, M. (1997) Alexithymia in anorexia nervosa: a controlled study using the 20-item Toronto Alexithymia Scale. Acta Psychiatrica Scandinavia. 95: 385-388

Schmidt, U., Jiwany, A. and Treasure, J. (1993) A controlled study of alexithymia in eating disorders. Comprehensive Psychiatry. 34: 54-58.
Schoemaker,C., McKitterick, C.R., McEwen, B.S. and Kreek, M.J. (2002) Bulimia nervosa following psychological and multiple child abuse: support for the self-medication hypothesis in a population based cohort study. International Journal of Eating Disorders. 32: 381-388.
Schore, A.N. (1997a) Early organization of the nonlinear right brain and development of a predisposition to psychiatric disorders. Developmental Psychopathology. 9(4): 595-631.

Schore, A.N. (2001) Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal. 22 (1-22): 7-66.

Schore, A.N. (2003) Affect Regulation and the Repair of Self. W.W. Norton & Co.

Smolak, Linda and Murnen, Sarah K. (2002) A Meta-Analytic Examination of the Relationship Between Child Sexual Abuse and Eating Disorders. International Journal of Eating Disorders. 31: 136-150.

Ward, Anne, Ramsay, Rosalind and Treasure, Janet (2000) Attachment Research in Eating Disorders. British Journal of Medical Psychology, 73: 35-51.

Zimmerman, P. (1999) Structure and functions of internal working models of attachment and their role for emotion regulation. Attachment and Human Development, 1, 291-306.

 Julia Buckroyd April 2009
These notes are copyright. Please do not reproduce without acknowledgement.
References given are only an indication of the literature available.