Behavioural Therapy

Behavioural therapy focuses upon the individual changing behaviours.

It is an approach based on the theory that psychological disorders (including eating disorders) stem from faulty learning. That is, the person involved has either failed to acquire the skills and behaviours they need for coping with the problems of daily life and/or they have acquired maladaptive habits and reactions that cause considerable distress. Within this context, the key task for therapy is to change current behaviours by using such principles as reinforcement and punishment. It also seeks to change the way that people respond to things (such as stress, anxiety, or depression) and hence improving people's coping skills.

Who practices behavioural therapy?
Behavioural techniques can be practiced by absolutely anyone - sometimes therapists will even educate families so that behavioural techniques can be implemented in the home. Most commonly however, psychiatrists, psychologists, occupational therapists, and nurses within a hospital setting use behavioural therapy techniques.

How common is it?
Overall behavioural approaches are a very common technique (probably the most common technique) to be used in an inpatient setting or with children. It is not a treatment that is generally used in any one-on-one therapy.

How effective is it?
Behavioural techniques can be highly effective in the treatment of the symptoms of eating disorders (for example, low body weights, obsessive behaviours, over-exercising, binge eating etc.). It does not however deal with any of the underlying issues or causes of the eating issue. For this reason unless the behavioural therapy is paired with another complementary technique (for example, counselling type therapy), the symptomatic relief is generally brief and relapse often occurs.

How long does it go for?
Generally, behavioural therapy is relatively brief, typically lasting from a few weeks to a few months.

Who is behavioural therapy most aimed at?
Behavioural techniques are often incorporated (to varying degrees) into most treatment approaches. They are however used most commonly with children, sufferers who are highly emancipated, and people with co-morbid (co-existing) disorders. As these two groups lack the cognitive capacity or health to be responsive to other forms of therapy. They are also heavily used in the treatment of eating disorders when the co-morbid disorder (such as Obsessive Compulsive Disorder) is highly responsive to such treatment.

This approach is also used a lot with people who are severely ill, as it is a relatively rapid technique, which reaps benefits quickly.

Additional information:
Many people have had bad experiences with behavioural therapies in the past (especially in the 70's and 80's). They will often be heavily scared from their treatment encounter and for this reason will be reluctant to seek more treatment. Nowadays however the behavioural approaches which are used are far more flexible, and humane than they were in the past. The extent of their use has also been heavily reduced.

Cognitive-Behavioural Therapy

The term 'cognitive' refers to people's thinking processes.

Cognitive-behavioural therapies are based on the principle that our emotions, feelings, and behaviour are inextricably linked with our thoughts, influencing how we feel and how we behave. It is an approach based on the idea that eating disorders (and many other psychological disorders) stem from faulty or distorted modes of thinking, which in return lead to the development of maladaptive or distorted feelings and behaviour. Cognitive behavioural therapy (CBT) therefore aims to change these 'faulty' thinking patterns related to harmful eating behaviours and in return alleviate the disorder. To achieve this the therapist works with the patient to identify destructive thoughts and beliefs that trigger harmful behaviour, and substitute such thoughts with more adaptive and rational ones, hence changing the maladaptive behaviour.

Who practices cognitive-behavioural therapy?
CBT is practiced by psychologists and psychiatrists, as it requires specialist training. In some cases it may also be used in a modified from by general practitioners, general counsellors, or social workers. It is used in both an inpatient and one-on-one setting. Modified forms may also be used in group work.

How common is it?
CBT is widely used in the treatment of eating disorders, however it is often used in conjunction with other therapeutic approaches.

How effective is it?
CBT is a relatively new form of therapy, so investigations into its effectiveness are in their infancy. Studies so far however, show promising results, demonstrating that CBT is more effective than any other currently offered form of therapy. At the moment this is considered to be the most promising treatment technique for people with eating issues (anorexia and bulimia in particular).

How long does it go for?
Overall CBT is a reasonably effective and efficient form of therapy with treatment often spanning from weeks to months - CBT does not normally last for more than a year, but it depends on the individual and the therapist.

Who is CBT most aimed at?
Due to the large focus on cognition in this therapy, the technique is not used for children or young adolescents (approximately 12-17 years) as there are lower levels of cognitive development amongst such populations. A high level of cognitive functioning, cognitive awareness, and cognitive ability is required for this technique to be useful. Children and adolescents are not often believed to be capable of functioning at this level. Also the technique is not used amongst seriously emaciated (very ill/at very low body weight) people, as their cognitive abilities are seriously impaired when they are so ill. CBT will still be used once weight (and hence cognitive functioning) has been restored.

Additional information:
CBT is a real "click" term at the moment, and is used by many different therapists to mean very different things (sometimes greatly removed from what the therapy is supposed to entail, and can be very misleading). It is therefore important to inquire about the therapist's level of training and practice in CBT before commencing therapy in order to ensure that you can make the most informed decision, and get the most out of treatment. Also ask your therapist about their approach to CBT.

Psychodynamic Therapy

NOTE: Psychodynamic approaches do differ from psychoanalytic approaches, but not a lot. Essentially psychodynamics is just a more modern adaptation of Freud's psychoanalytic approach, with the therapy being briefer and more focused (i.e. rather than being a lifelong process and exploring every aspect of the personality, it will remain focused on one task (such as the eating disorder) and last for not much more than a year or two).

Psychodynamic treatment approaches view psychological problems as rooted in early childhood experiences and unconscious conflicts (meaning inconsistencies in internal personal characteristics). More specifically they conceptualise eating issues as stemming from a disturbance in personality development during the 'Oral Phase' (This is the first months of your life, as described by Freud. It generally is from the age of 0 months to 12 months). As a result, therapists using this approach will seek to determine the underlying issues (for example, physical abuse, neglect, emotional abuse etc experienced in childhood) that have given rise to such pathology (e.g. interrupting personality development, causing unconscious conflict etc), believing that once the causes of such pathology are identified, the pathology will be relieved.

Who practices psychodynamic therapy?
Psychodynamics is only practiced by psychologists and psychiatrists - but used by psychiatrists far more commonly. Most of the time practitioners using this approach have undergone additional study specialising in psychodynamic techniques.

How effective is it?
There is very little research into the effectiveness of the psychodynamic approach in the treatment of eating disorders. There is a body of literature and general consensus amongst mental health professionals however, that psychodynamics is effective in some cases. It is generally accepted however that some of the other approaches are more efficient and effective.

How common is it?
Although the principles of psychodynamic practices underlie almost all types of therapy and therapeutic intervention, psychodynamics is not commonly practiced today in its most pure form. Similarly, it is not generally used for the treatment of eating issues due to the nature (severity/potential fatalness) of the illness, and the longevity of psychodynamics as a technique.

Who is it most aimed at?
This technique is not generally used with children or adolescents. It is most commonly used with adults (especially women) who are at a reasonably safe weight. It is used in an outpatient setting usually by private practitioners.

How long does it go for?
This is a relatively long lasting therapy, usual lasting for one or two years (minimum).

Pharmacological Approach

The role of medication in the treatment of eating issues is not conclusive. Although hundreds of studies have been conducted, there has been no evidence of any drug having a significant positive effect in the case of anorexia - antipsychotic medications, antidepressants, anxiolytics, and appetite-enhancing agents have all been investigated. Medication has however, been shown to have a positive effect in the treatment of bulimia, and binge eating disorder (also in some cases of anorexia where binge and purging behaviour is displayed), with antidepressants commonly being used.

In all cases however, medication is particularly useful, and most commonly used in the treatment of co-morbid disorders (eg. depression, OCD, anxiety etc). By treating such co-morbid disorders the management and treatment of the eating disorder becomes far simpler. Many doctors however may be reluctant to prescribe such medication until eating has stabilised. Firstly because many issues can be side effects of the starvation or irregular eating, hence may be alleviated simply through weight restoration and improvement in the condition; or secondly, because when sufferers are highly emancipated their bodies are not able to process and deal with the medication appropriately which is ineffective and can cause complications. Working out dosage is also very hard, and risky in such situations (due to the low body weight and poor metabolic processes).

Additionally, other non-psychiatric medication such as zinc replacement tablets, multi-vitamins, pro-kinetic agents, and so on are also often used in order to stabilise body functioning, which has become abnormal due to the eating disorder. In most cases these attempts are effective, and in some cases life saving.

Medical/Biological Approach

This approach investigates possible medical consequences of eating disorders.

Physical complications may include:

- disruption in growth and development;
- infection (due to compromised immunity);
- gastrointestinal complications (constipation / ulcers);
- cardiac status (the heart muscle is effected with poor nutrition);
- osteoporosis;
- effects on fertility;
- blood disorders (anaemia), and;
- dehydration, etc.

Medical and/or biological investigations also investigate biological reasons for eating disorders. For example, a virus may have triggered a decrease in appetite or the consequences of dieting and/or starving. Alternatively, there may be problems with digestion and/or hormones.

Narrative Therapy

Narrative therapy is a different approach in counselling and community work that centres people as experts in their own lives and sees people as having many skills, abilities, values, beliefs and competencies that are all drawn on to minimise the problem on the person's life. Narrative therapy is characterised by the problem being externalised and named. The therapist explores the issue in the person's life by asking questions and exploring alternative stories.

This style of therapy originated in Adelaide by Michael White (family therapist) in the 1980’s and can be used with individuals and families. General counsellors who have specialist training in narrative therapy from the Dulwich Centre practise it.

Feminist Approach

A feminist approach in therapy explores how women are socialised and the expectations placed on them. The therapist considers: gender, socio-cultural, family and individual factors and how these all interact with each other and the impact they have on the person. Concerning eating disorders, the therapist examines how symptoms of eating issues reflect the culture that we live in and the contradictory expectations placed on women. This involves exploring how the beauty myth works and effects our daily life.

Kindly written by Corree Guerin, additional information by Billie Murdoch