Eating Disorders - fieldi

134 Individual Psychotherapy
way psychotherapists work. Insurance companies, which traditionally
had reimbursed subscribers for a portion of the cost of psychotherapy,
are increasingly restricting their coverage through the use of managed
care organizations. Short-term cognitive and behavior modification
programs offering symptom management have a large following and
are favored by the managed health system. While many eating disordered
patients respond to such programs, a significant number do not
respond at all or relapse once they have completed the program. In
such programs the emphasis on the eating disorder as a symptom to
be overcome and the prescription of behavior overshadows exploration
of the meaning of past and present experience and the relationship
with the therapist, which are the cornerstones of psychodynamic
or psychoanalytically oriented psychotherapy.
Many of the people I have worked with required and responded
to approaches that were psychoanalytically informed but also
addressed their symptoms. Psychoanalytically informed refers to a perspective
focused on the “development and emergence of the
patient’s authentic, personal voice from the internalization of social
forces and significant others” (Mitchell and Black 1995, 213–14).
The therapist and patient engage in an exploration and analysis of
the patient’s experiences, past and present, with particular attention
to repetitive themes in relationships and behavior, which are often
reenacted in the therapeutic encounter. In the course of the work,
the patient both cognitively reflects on and emotionally reacts to
previously unformulated experience. The accrued insight is believed
to lead to self-awareness and change in the person’s character,
behavior, and relationships. With due regard for the value of techniques
and a knowledge base, let me underscore that relationships,
not techniques, heal. What is curative is the therapist offering some
form of basic parental responsiveness that was missed early on.
Both the process and the goals of cognitive-behavioral treatment
(CBT) are different from psychodynamic psychotherapy. In CBT the
therapist is directive and didactic, even at times authoritative, with the
goal of stopping the symptoms, be they restricted eating or bingepurging,
by changing the thoughts, beliefs, feelings, and pattern of
action that maintain them. Outcome studies have demonstrated the
efficacy of CBT for many patients, but not for those who suffer from
significant and enduring interpersonal and personality difficulties.