Anorexia and Psychotherapy
Dr Jonathan Haverkampf
Anorexia nervosa is an eating disorder which leads to restrictions in food intake. However, someone suffering from anorexia usually does not regard herself or himself as underweight. This can make it difficult for friends and relative to motivate this person to enter adequate treatment.
To get someone interested in treatment requires a deeper understanding of anorexia. In the psychoanalytic literature much has been made of aggression turned against oneself as a key concept. The more one tries to care for the client the greater the resistance becomes. My experience is, however, a different one. Empathically helping the patient to discover true values and interests often leads to a collapse in the symptoms.
The process of finding these values and interests requires a deeper exploration than most therapies allow for. This means that one needs to find those things the individual cares strongly about. It requires stripping away much of the things the individual has learned from society or the immediate environment. Societies that value thinness have a higher percentage of this disease. Especially when people are in the process of developing their identity they can be more susceptible to such influences. If the body proportions on a billboard are attractive, why is that?
In anorexia life is no longer as clear and predictable as the individual suffering from anorexia wants it to be. A sense of what is important to the person is no longer clear and individuals try to orient themselves externally. Socially accepted images gain in importance. The loss of direction is the reason why anorexia often begins after a stressful life event or a major change in life. A BMI of less than 15 points to extreme anorexia, 15 to 16 to severe, 16-17 to moderate, and a BMI of greater than 17 to light anorexia. In children a different scale is used. Anorexia is far more common in females than in men. 0.9% to 4.3% of women are estimated to have it at some point in their lives.  Anorexia often begins in the teen years or during young adulthood. Anorexia is a condition not to be taken lightly. 
There probably is a predisposition for anorexia. Half of identical twins of someone with anorexia develop anorexia themselves. But this does not mean that one will get it no matter what. As with most other psychiatric conditions social and psychological factors play a significant role. Uncertainty about existential dimensions, like the orientation and path in life often contributes to psychiatric conditions.
Communication and the interactions with the environment play a significant role in anorexia. The incidence of autism is higher in anorexic patients. This could either mean that it shares a similar pathology or that the difficulties with communicating with the outside world can lead to the symptoms or anorexia. This could point to the fact that we form our values and interests through communication, listening into ourselves and to the messages from the environment we live in.
This means in anorexia two things need to be explored early on:
- the communication the client has with herself and with her environment
- the elements that make it difficult for the client to see what she truly values and what is important to her
Family therapy has been shown to help since the communication and self-regulatory mechanisms in the immediate social environment have often become dysfunctional.
In clinical experience there are often a low self-esteem and low self-confidence. To approach this in therapy means building up a strong identity. This requires looking at values, needs, dreams and aspirations. In adolescents there is still a lot of variation, but the important part is not so much to identify these things but to get the thinking process started in a healthy way. In therapy this kind of communication can itself have a significant effect on the condition.
The communication with the environment has often deteriorated. To many patients with anorexia a lot of the communication around them becomes irrelevant and meaningless, because they doubt their own relevance. The need to achieve a certain body scheme illustrates how much communication has been reduced to superficial appearance, but it also shows that the world has to be made predictable by creating a rigid corset for oneself. The unpredictability derives from the sense of insecurity that comes with not knowing oneself, one’s values, interests and aspirations as much as one needs, which is a result of the partial disconnectedness with oneself that can often be observed in anorexia.
To summarize, the following points appear to have special relevance:
First, the medical conditions should be covered. Especially in the more severe cases a hospitalization may be necessary. In less severe cases this may not be necessary. Hospitalization may actually lead to inferior outcomes. This underlines the importance of the communication environment in cases of anorexia. However, this should also be discussed with a medical specialist.
Secondly, it is important to take a look at the communication environment the client is in. Are emotions communicated about freely? What are the interactions like? Here it is important to look at communication patterns as the patient experiences them – and, if this is helpful – to involve other people who are important in the patient’s life. This needs to be done carefully, and with a view to help the patient to gain a greater sense of self-efficacy in her/his life. Often anorexia comes with a fear of losing control over a number of emotions of that often lie below this disorder.
Thirdly, it is important to build up a healthy and stable sense of self. This require looking at what is important and relevant to the client. It means looking at one’s values, needs and aspirations. Often it seems, individuals suffering from anorexia are reluctant to take the next step in their life. To help them on this path predominantly means, bringing them into the communication patterns of life and helping them on their way to find out where they are headed.
© Dr Christian Jonathan Haverkampf. All rights reserved. Unauthorized reproduction and/or dissemination prohibited.
This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a medical condition.
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 Smink, FR; van Hoeken, D; Hoek, HW (August 2012). “Epidemiology of eating disorders: incidence, prevalence and mortality rates.”. Current psychiatry reports. 14 (4): 406–14. doi:10.1007/s11920-012-0282-y.PMC 3409365. PMID 22644309.
 Diagnostic and statistical manual of mental disorders : DSM-5 (5 ed.). Washington: American Psychiatric Publishing. 2013. pp. 338–345. ISBN 9780890425558