As any clinician will attest, one of the most difficult and intractable mental disorders to treat is eating disorders. One of the major factors that makes the treatment of eating disorder so challenging is that individuals afflicted with the disorder are usually highly intelligent. That may cause the clinician to try to reason with the patient instead of recognizing that eating disorders are based on irrational thoughts and perceptions. So, reasoning with a person suffering from an eating disorder is destined to failure because eating disorders are predicated on emotions, not logic or reason. That is why a highly intelligent patient with an eating disorder may not understand or recognize that without appropriate intervention, they might be in the process of committing suicide.
When it comes to treating eating disorders, it is necessary for the clinician not to look for logic in the client’s thinking and conceptualize the case from a psychodynamic approach. Persons with eating disorders have deeply entrenched feelings of inadequacy and a completely distorted view of their body image. No amount of cajoling and pointing out cognitive distortions will help.
There is a better way of treating eating disorders. When considered from a perspective of internal rage in the subconscious, then eating orders can be better understood. The eating disorder victim might be so emotionally injured due to a trauma that he/she feels a compulsion for control. A hallmark of trauma is the loss of control. What could be a more powerful form of control than how much food is consumed?
There is a remarkable similarity between cutting (self-imposed physical harm) and eating disorders. Both offer a form of emotional release to divert from confronting the pain of dealing with a trauma. Both eating disorders and cutting are manifestations of misplaced anger/rage which has been directed inward instead of being projected outward. The need for control can be so great that in the effort to survive, the eating disorder patient unintentionally self-destructs. Eating disorder patients are not known for being suicidal. Quite to the contrary, they have the delusion that through rigid control they are increasing their chances of survival.
The concept of “compartmentalized psychosis” is a novel approach in treating eating disorders. It helps explain why a person who is completely rational on all other topics has a total eclipse of insight as to the nature of eating disorders and how deadly it can be. They are delusional about the topic. They have a false belief that they are fat (or overweight) when in fact they are woefully underweight and are suffering from a mental disorder that will kill them without effective intervention.
When eating disorders are viewed from the clinical perspective of the will to survive, as counterintuitive that might be, then why a person might become obsessed with food begins to make sense. That is why a psychodynamic approach is much more effective than behavioral or cognitive interventions. Unfortunately, most eating disorder clinics rely on behavioral and cognitive interventions for eating disorders. That is one of the reasons that eating disorders are so deadly.
Using Cognitive Behavior Therapy (CBT) is not only useless in the initial stages of treating eating disorders it can also be harmful. Miscommunication and misunderstanding are inevitable. While the patient is resistant to “rational” explanations, they are likely to feel misunderstood. It destroys any possibility of therapeutic rapport because the client is likely to perceive the clinician as being condescending and clueless about why he/she has a need to have control.
If, however, the clinician can actively listen to why the patient is convinced that he/she is overweight, then the condition starts to make sense. When eating disorders are conceptualized in the context of control, anxiety, fear, lack of self-esteem and self-confidence and a distorted perception eating/body image, then the clinician can focus on a client centered intervention which emanates from the clinician having a clear understanding of the complexities inherent in treating eating disorders. The clinician can see the issue from the client’s perspective, which is fundamental to all forms of therapy.
Conceptualizing eating disorders as a form of “compartmentalized psychosis” allows the clinician not to look for logic or rational judgment in his/her client’s thought process. It is easy for a clinician to be deceived by the high level of intellectual functioning in clients with eating disorders and have the temptation to believe that a logical breakthrough is possible. That would be a fool’s errand.
Eating disorders do not occur without reason or explanation. They originate in conjunction with a traumatic event. Unless there is a medical cause for not eating, then eating disorders must have a psychological basis. EMDR is predicated on the idea that when trauma is successfully identified and processed, there is a paradigm shift in the client’s thinking and the client realizes that their previous way of thinking was distorted. EMDR focuses on emotions, not reason. That is why it is effective in treating eating disorders. EMDR allows the patient to come to realizations that help create an entirely new perception of the world. It has a transformative and lasting effect.
The generic profile of persons with disorders is that they are from good homes, tend to be highly accomplished, frequently having undertones of perfectionism. The traumas they have experienced are prone to be nuanced and difficult to detect because they are buried in the subconscious.
EMDR facilitates access to the subconscious. When EMDR is successful, the client is suddenly able to understand that their obsessive need for control to deal with their traumatic past is self-destructive. EMDR is predicated on the premise that a positive (true) cognition needs to replace a negative (false) cognition. The client is likely to have an epiphany that in his/her obsessive need for control, he/she was in the process of self-destruction. The quest for control, ironically, leads to out-of-control behavior.
The beauty of EMDR is that the client comes to his/her own realization that his/her previous way of thinking was distorted and delusional. No explanations are required from the therapist at this point. The explanation is that the psychological and emotional impact of trauma is beyond reason. It is at this stage of treatment that CBT should be introduced because it reinforces a new way of thinking—a way of thinking that is now based on accurate cognitions. Using compartmentalized psychosis as the conceptual framework for treating disorders is a new and effective method for treating eating disorders.
Mr. Leslie Szasz is a Licensed Independent Social Worker-Supervisor with his license having been issued by The Counselor, Social Worker, Marriage, and Family Therapy Board in Ohio. Mr. Szasz is also a Licensed Clinical Social Worker, license issued by the Social Worker Board in Idaho. He practices in Boise, Idaho at Foothills Counseling & Wellness LLC.
Mr. Szasz specializes in treating PTSD with a focus on sexual assault and/or domestic violence. Mr. Szasz also specializes in treating first responders, health care workers and military personnel suffering from PTSD. Mr. Szasz is an EMDR Certified Therapist with experience in crisis and suicide intervention. He is formerly a Special Agent of the Federal Bureau of Investigation where he worked as An Employee Assistance Program Coordinator (EAP) and where he developed an interest in counseling as a second career. He helped develop a suicide prevention protocol for the FBI. Mr. Szasz responded to critical incidents involving adversarial incidents (e.g., shootings) in the capacity of an EAP Counselor.