Long-Term Treatment of Eating Disorders: Tools for a Journey

In this article I’ll describe four principles I find useful in working with patients who come to us in need of longer-term psychotherapy, or who tend to stay in our practice for at least one year. Even in an age with impactful reimbursement constrictions from third parties and pressure to ensure that our efforts are ‘evidence based,’ and thereby explicitly scientific and worthy of payment, a significant number of patients benefit from a treatment process when a “longer dose” from “50 to 100s of visits” is given.⁴ These patients tend to have histories of early attachment difficulties, trauma and maltreatment, co-occurring personality disorders, substance abuse, and severe anxiety or depression. They have not been adequately helped by less-intensive psychoeducational, or exclusively manualized cognitive-behavioral, pharmacological, and family-based interventions.^{5, 6}

For these patients, who have many symptomatic difficulties and who have not yet formed a core sense of themselves, research demonstrates that experienced clinicians consciously and intuitively blend psychodynamic and cognitive behavioral methods, regardless of the theoretical orientation that we may consciously espouse.^{4, 7, 8} This crucial research data from “real-world” practice is beginning to tell us much about the technical skills, personal attributes, and treatment stance clinicians bring to the treatment setting that can engage a patient in need of therapy that promotes the development of a sense of self and heralds better self-care overall.^{4, 6-8}

Four Principles Can Guide Our Therapy

The research perspective also tells us a bit about how we engage with our patients and technically blend skills to keep the process going. Yet, to fully understand how patients actually get better and change over time, as well as those quagmires a therapist likely encounters while on the journey with them, continues to beguile us. The four principles I describe below by no means form an exhaustive list, but they have helped me to stay sane and somewhat steady when working with eating disorder problems that appear refractory to intervention or when treatment appears to be at a stalemate. They are also principles that students and staff members find helpful and salutary, even as they gainsay an easy answer to sticking with a patient when life itself seems to be on the line, precious monies for care may be limited, and the treatment process may appear to be deadlocked.

Principle 1: Patience in Practice, or the ‘Resistance Phase’ of Treatment

Drawing upon his experience of working intensively on an inpatient unit with highly disturbed adolescent girls, psychiatrist Donald B. Rinsley coined the term ‘resistance phase of treatment’ in the late 1970s.⁹ He observed that teens with severe interpersonal and family difficulties often needed up to 16 months of persistence by staff members on the residential unit to help them work through numerous resistances and behaviors before they could actually begin what he called ‘definitive treatment.’ In other words, resistance is not a single behavior or maneuver to be overcome, such as curtailing one’s denial of emaciation or refusal to stop binge eating, but a multiplicity of self-destructive patterns, secondary gains from illness, and other impoverished adaptations to constructive living.

Once the therapist understands that resistance is a phase to be weathered more than an action to be overcome, she is able to wait out and work with the patient’s tendency to try to defeat the treatment. While trying her best to be useful to the patient in providing new tools and simply listening to the patient’s story unfold, she is also inclined to be less self-critical when her patient does not immediately benefit. She understands that the resistance phase of treatment is where she and her patient are, and that it cannot be rushed. When a therapist can be less critical of herself, her patient has a new object of hope to identity with in a constructive way that will serve him better in life. To such patients in this stage I often find myself saying over and over again, “I can wait longer than you!” and “Remember, we are aiming at improvement, not perfection.”

During the resistance phase of treatment the therapist is also gaining essential data about the patient that will be useful later. On the surface the patient may not seem to be taking anything in, but in reality an attachment relationship is unfolding and gaining strength. As feelings of safety increase, the patient may reveal a little more about her history. With both a safer attachment and more knowledge of the patient’s life comes the opportunity to speak to the problems with which the person struggles. When the patient is manifestly resisting in this phase, the therapist is not curtailed from responding in a very human way by asking questions, making simple observations, nodding and affirming, uttering subtle “umms” or “ahhs,” and zeroing in on past and present losses. Why is it particularly important to talk about loss? Loss is the most ubiquitous of psychological issues. None of us escape it. Even positive changes are filled with a sense of leaving something of value behind. Letting patients know that their losses can be expressed and not dodged is one of the gifts of the therapeutic process, and may accelerate movement into a more active treatment phase when grief may be more actively expressed and worked on.

Principle 2: Permission to Feel and Express Pain

Regardless of our professional discipline, imbued in our training is the concept of reducing suffering to a minimum. Even as we all appreciate that life is hardly a pain-free enterprise, we undertake our work as healers to defeat it. Counterintuitive is the notion gaining traction in contemporary psychoanalysis and psychodynamic psychotherapy that the best way to alleviate suffering is to actually help the patient “observe, process, speak about, draw attention to, and bear”¹⁰ emotional pain in order to eventually transform it.

“When we find we can face our fears, a sense of confidence and acceptance begins to grow naturally,” writes psychoanalyst Jeffrey Eaton.¹⁰ He continues to provide balm for therapists as he continues, “I have no magic answers or solutions. Part of my pain is that I cannot simply remove the pain my patients must face…Over the years of work together people grow a deeper capacity for loving connections, and perhaps most importantly, some soften into strength and become curious about, even compassionate toward, some of the most pained parts of themselves. The pain is not gone, but one has a very different relationship to it, and to the idea of how others might experience it.”

Sitting with, processing, and containing pain is some of the hardest work that we therapists do. Patients often want and need to stay in treatment longer because the therapist’s office is the safest and really the only place they have to pour out their angst. We bear witness to their cumulative losses and their life transitions. How many culturally sanctioned places are available where one’s private self is held sacred? One patient in my practice who made substantial progress early on with her eating problems continues to make an investment in herself by coming weekly. She calls psychotherapy a place where she “drinks water from a well,” and likens her thirst to a lifetime draught to speak her truth. Most therapists who do longer-term work will resonate with this example because they hear similar tales daily and absorb the shock waves of the other person’s anguish and joys. “Today I need containment” is the plaintive cry of many an experienced clinician who seeks out supervision or consultation less for concrete direction or specific advice than for the place it provides to feel, to express, and to work on the pain of others that accompanies our tasks.

Principle 3: Staying the Course. Expectable ‘Plateau Phases’

One of the most valuable lessons I have learned about life from my patients is that there are inevitable and necessary plateau phases where nothing much seems to be going on in therapy and where patient and therapist both feel stalled. In part these plateau phases occur because on the surface nothing is going on. In reality the action is happening below the surface, as a kind of consolidation of gains before a new growth spurt occurs. The problem for the therapist is that it may be difficult to ‘hold’ a patient in treatment at these times and to have any faith that something will enfold anew with the fullness of time.

In the therapeutic work the patient retreads old ground, may even complain that she is growing bored and impatient, and wonders if she has achieved maximum benefit, and is ready to quit. The therapist also has her doubts and is wondering similarly: The pair appear to have caught the same virus — the ‘hurry-up and move-on’ virus — but in the best of scenarios they find a way to slow down, to wonder what is happening, and perhaps to even enjoy a bit of a slower pace. Then, imperceptibly, something shifts, and the pair is on another incline pathway — delving into a new issue, confronting an old source of discomfort with new resources, and deciding on a different venue for work or in personal life. Something new has sprouted —magically and mysteriously — and we are as amazed as when we were as preschoolers who left the classroom in the afternoon and returned to school the next morning to find that a baby pea plant peeks out from the egg carton garden we and the teacher had planted the week before.

Therapists and patients would never fault a farmer who left her garden fallow for a season or two, because we know that crop rotation is essential to keep the soil vibrant. Yet we expect ourselves to have no fallow periods of our own, periods when we can replenish our stock and ourselves before something new can emerge in its season. Supervisors can also be pushy about progress and not see the need and value of plateau phases. As a result the staff member feels an anxious need to make things happen and pushes the patient, when exactly the opposite is needed. This can intensify resistance and lead the patient to experience more shame and guilt even when the therapist is trying her best to be benevolent. While a plateau phase must be judiciously teased out from an actual resistance to taking a new step, requiring judgment and tact, pausing in psychological work and making space is part of the process that has been given too short shrift in psychotherapy.

Principle 4: Noticing Growth/Valuing Grit

One unfortunate legacy of early psychoanalytic theory is the notion that the therapist should ‘maintain neutrality’ except in the most extreme situations, such as a suicidal crisis or medical emergency. Yet consider how many times, even in Sigmund Freud’s most famous cases, the importance of providing support and affirmation was noted. When Freud failed to understand this need, the case faltered. Also consider the personal history of Freud himself. Although Freud had difficulty sustaining professional relationships with some of his creative partners like Alfred Adler and Carl Jung when they differed with him, his work flourished when he had a partner who served in part as an ancillary therapist and facilitating other. One need only scratch the surface of the lives of many creative and productive artists, scientists, and authors to see that there is often a person behind the scenes who is noticing and valuing an individual’s talent and ability long before it is recognized by the public at large.

If this necessary function is sought after and found to be essential to our most able and laudable achievers, how important might it be for our patients, who come to us with stormy histories bereft of stable attachment and love? While a therapist or supervisor should never offer false praise, recognizing steps forward and commenting on perseverance and resolve offer those in our care hope and emotional sustenance in real time. When I listen to a staff member present a case that is going reasonably well despite inevitable symptomatic regressions on the part of the patient, I invariably find myself saying, “Don’t forget to comment on how far the two of you have come together. Be as specific as you can be. Remember the initial sessions and recall some developmental leap that you have witnessed.” Almost invariably the staff member will return and let me know that the patient lit up at being recognized for the progress and was “amazed” or “touched” that the therapist had cared enough to notice. The universal need for recognition, particularly when undertaking all the difficult tasks inherent in deeper psychotherapeutic work, needs to become an essential part of our everyday practice.

Increasing evidence from neurobiology supports the concept that support is good for the brain as much as the soul. When the brain’s seeking,’ ‘loving,’ and ‘playing’ regulatory systems are aroused at the level of the prefrontal cortex, positive affective circuits of the brain are strengthened.¹¹ While each of these systems has highly specific individual pathways still to be completely ferreted out, current data suggest that they culminate in dopaminergic neurons at the level of the prefrontal cortex and oxytocin release in the medial subcortex. Dopamine generates enhanced self-esteem, and oxytocin promotes social bonding and nurturance. Both neurochemicals facilitate emotional readiness for prosocial growth we hope to help induce in our patients. Noticing our patients’ growth and valuing their grit is both a neurobiological and psychological intervention and bedrock upon which lasting change is likely built. And, like our patients, therapists also derive similar benefits from having those in our circle that value these qualities in us. Creative partnerships in the form of peer supervision, ongoing consultation, and study groups are just some of the arenas that enable therapists to value ourselves, and that have the potential to nurture our growth by mirroring grit and determination.

Conclusion

These four principles that guide longer-term treatment of eating disorders are offered to assist therapists in negotiating stalemates and fallow periods of the work. Sometimes we are unable to help patients relieve their suffering directly but we can assist them in changing their relationship to their pain and sense of loss. This process is more difficult than it appears because remediation of symptoms and relief of suffering are what we are taught to do in our training and encouraged to try to emulate from studying the scientific literature.

Cultivating a therapeutic stance wherein the patient can bring forth inner pain that may not be superficially apparent fosters resilience over time. Recent studies in neuroscience support this approach as having substantial benefits for the brain. Both therapist and patient are likely to maintain a healthier sense of well-being when we pay attention to our need for secure spaces to process emotional needs, respect phases of resistance when not much may be directly happening in the therapeutic work, and cultivate supportive people and ‘creative partnerships’ who value and encourage us during the most inscrutable periods of the journey.