Psychotherapy and Eating Disorders
In Denmark and other European countries, psychoanalytic psychotherapy and associated techniques have been widely practiced as a treatment for eating disorders. In a 2014 randomized controlled trial comparing the efficacy of cognitive behavior therapy and interpersonal psychotherapy, researchers found that interpersonal psychotherapy is as effective as cognitive behavior therapy in reducing bingeing and purging through the facilitation of heightened affect tolerance and insight into the psychological function of the symptoms (Poulsen et al., 2014).
Limitations
There are several limitations with traditional psychoanalysis that led to the emergence of psychodynamic modalities. Whereas psychoanalysis has historically relied on the applications of case studies to demonstrate its usefulness, psychodynamic approaches have external reliability and evidence-based support.
Another limitation of traditional psychoanalysis is that its treatment is highly individualized, is lengthy in duration, and seeks to show how early childhood experiences have affected the formative aspects of one’s personality development. The treatment is prolonged and expensive; an analysis, or course of counseling, is estimated to require 5 years or more with four or five sessions per week. The time and expense involved with psychoanalysis make it prohibitive to many, and there are few practitioners of traditional psychoanalysis. This is because of the intensive training required and the limitations of coverage by health insurance and managed care. In contrast, a modern psychodynamic approach may be effectively applied in 10 to 12 sessions.
A strong criticism of psychoanalytic theory is its inherent exclusion of cultural paradigms owing to its strong focus on sexual development without consideration of the important contributions of cultural identity during early development. Contemporary psychodynamic approaches are now considering the influences of culture formation and identification in personality development, as well as the sociocultural implications in the formation of trauma. For example, psychoanalysis assumes that humans across cultures are conceptualized largely in terms of biological instincts and psychological drives, and maladaptive behaviors are symptomatic of a subconscious response to social interactions that the mind interprets as unsafe, thereby threatening the stability of the human personality structure. Within an evolved psychodynamic framework, however, culture is viewed as having defensive hierarchies that result in cultural patterns and ethnic characteristics. There is a commonality of defenses and conflicts that are both provided and facilitated by a particular culture, and concepts such as anxiety, depression, defense mechanisms, and dreams are present in people of all cultures (Lijtmaer, 2006). An assumption of this theory is that the modes of expression of these concepts may differ in diverse cultures (see Sidebar 3.5).
Sidebar 3.5 Culture and Hysteria
The evolution of the definition of hysteria led to the clinical conceptualization of somatoform, conversion, dissociative identity, and amnestic disorders. The diagnosis of these disorders is culture bound, and the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) addresses this directly in a distinct section, “Culture-Related Diagnostic Issues,” which helps counselors diagnose syndromes in an appropriate cultural context. For example, ataque de nervios comprises a constellation of symptoms that would have been analogous to a diagnosis of hysteria in 1890. In Hispanic culture, this is interpreted as an “intense emotional upset, including acute anxiety, anger, or grief; screaming and shouting uncontrollably; attacks of crying; trembling; heat in the chest rising into the head; and becoming verbally and physically aggressive” (p. 833) or otherwise feeling out of control.
THE CASE OF CLARITA: A BRIEF PSYCHODYNAMIC APPROACH
Goal 1: Developing Insight
Clarita arrives for her appointment 15 minutes early and appears motivated to reduce her depressive symptoms. The counselor may assume her eagerness is a consequence of anxiety resulting from a conflict between her id (or her basic drives) and her superego (the moral and ethically responsible component of her personality), evolving from past attachment-based experiences. The counselor helps Clarita set the goal of raising her awareness of her unconscious processes into consciousness and recognizing how her symptoms are a manifestation of painful life experiences and to learn new coping skills.
Goal 2: Expansion of Choice
Clarita expresses strong concern about her dreams, which represent the parts of herself that she is struggling to repress, or her id impulses and desires intruding on her carefully articulated reality. This aspect of her dream also indicates the rapidity of her unconscious struggle, which indicates a strong desire to merge her unconscious with her conscious. As she runs from the figures in her dreams, she is faced with boxes and crates with arrows pointing in all directions. This would indicate options and opportunities with multiple choices, but the contents of the containers remain hidden. The counselor uses interpretation and metaphors to help Clarita interpret the content of her dreams, exploring the symbols in the dreams and engaging her in connecting those symbols to themes in her life. For example, the counselor may illustrate how the shadowy figures represent the repressed, unconscious drives that Clarita is feeling increased pressure to acknowledge and confront, and then address the boxes and arrows as symbolic of a needed change in her life. Clarita and her counselor will likely meet weekly for approximately 12 sessions until both she and the counselor are satisfied that her symptoms have reduced and her coping skills are not reliant on defenses against external circumstances or past disrupted development and attachment.
Goal 3: Liberation From the Past
Although Clarita is aware of her depressive symptoms and is able to articulate her history and the current circumstances that are contributing to her symptoms, she is mostly unaware of the primary origin of her unconscious conflicts and how her early life has shaped her adult experiences and contributed to her current presentation. Additionally, she is experiencing an elevated level of guilt, indicating the strong presence of the ego (or the mediator between the id and superego). The counselor, practicing from an interpersonal psychodynamic perspective, assumes that Clarita is experiencing unconscious psychological conflicts between her personal need to gain autonomy and her need to remain loyal to her cultural traditions and family expectations.
Goal 4: Improvement of Interpersonal Relationships
Clarita mentions that she has considered suicide. The counselor associates this death instinct with her depressive symptoms and explores her trauma reactions to family separation and climate instability leading to cultural displacement. The counselor understands that the energy created by the life instincts is known as the libido and is exemplified in love, cooperation, and other prosocial actions, and thus emphasizes Clarita’s resilience through applied coping skills, which may now be more healthfully adapted to her current circumstances. As Clarita shares her history of negative relationship experiences, the counselor helps her make meaning of these experiences and articulates her need for unconditional love that is currently unmet. The counselor also explores the implications and consequences of Clarita’s psychosexual development and elucidates how any unaccomplished tasks at these levels have greatly contributed to her relationship issues and the manifestation of her anxious and depressive symptoms. For example, because Clarita was immersed in family responsibilities during her adolescence, she was unable to engage in her own self-development. Consequently, she is now struggling to maintain a healthy balance between all aspects of her life. The counselor will help her recognize how the manifestation of maladaptive behaviors and symptoms indicates a psychic struggle that she must fully explore in terms of mental and personality processes.
Goal 5: Corrective Emotional Experience