When Food Is Family

Key ingredients in the eating disorder mix

Is the False Self really the True Self in Eating Disorders?

A typical understanding of eating disorders is that they serve a purpose to conceal and psychologically protect an individual. D.W. Winnicott coined the phrases, True and False Selves. Are the symptoms of an eating disorder an attempt at expressing and experiencing aspects of the True Self? Are symptoms useful? Read More

Dear Ms. Scheel, The concepts

Dear Ms. Scheel,
The concepts of "false self" and "true self" are used in psychoanalysis and appear to be part of your model for treating eating disorders. Are you aware, however, of the paper published recently in the American Journal of Psychiatry concerning the treatment of bulimia? It's Poulsen, A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa, http://ajp.psychiatryonline.org/article.aspx?articleid=1785749 Seventy BN patients were randomly assigned to either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. After 5 months, 42% of patients in CBT and 6% of patients in psychoanalytic psychotherapy had stopped binge eating and purgeing. After two years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purgeing. CBT was about three times more effective, at about one-fifth the cost.

false self

Thank you for your comment. Of course. You might want to read some of the wonderful studies on Attachment and Eating disorders to see other outcomes. See some of my previous blog posts and the comments. I list several studies. For many patients, it is not usually an either or or treatment modalities, but rather a combination of treatment approaches. This is why it is important that clinicians who treat eating disorders understand the various modalities. Each patient is an individual.

Yes. Re false self. I continue to challenge my own thinking and remain open...not being eternally and rigidly fixed in thinking is preferable.

Best,
Dr. Scheel

Dear Ms. Scheel, May I

Dear Ms. Scheel,
May I suggest that you are the one who is "eternally and rigidly fixed in thinking."
I have read all of your posts. I don't see any that cite objective studies providing evidence that psychoanalysis or "Attachment" treatments are effective compared to CBT in the treatment of bulimia nervosa, either generally or for an identifiable subgroup of sufferers.
How many patients have you personally treated for an eating disorder? How many recovered, what is your definition of recovery, what is the average time to recovery using your methods, and what is the average financial cost?
If your outcomes are better than CBT, why haven't you invited outside, disinterested observers to assess your patients and verify your claims that your treatment methods are effective?

Ms.Scheel, I hope that health

Ms.Scheel,
I hope that health insurance does not pay for the treatments you provide. When insurance pays, the entire public ends up paying because we all contribute premiums to the pool. The public has a right to expect, therefore, that treatments be empirically validated. Yours are not. If sufferers want to pay you out of their own pockets, they have the right to do so, after they are given full disclosure. However, to expect the rest of us to subsidize your psychoanalytic treatments for eating disorders is going too far, now that we know psychoanalysis is a relatively ineffective approach.

Health care reimbursement

I wanted to take some time to consider the motivation behind your comments. I am left with nothing but an awareness that perhaps underneath these attacks has been your own pain and suffering. I cannot assume that someone would make such disparaging and cruel comments without having suffered some ill effects of treatment.

As I say in many of my writings and comments that a solid therapist in eating disorders MUST be aware of all the modalities in treating eating disorders and understand etiology re contributions to causes. There are MANY. There is also solid research to support several modalities of treatment besides CBT. (Again, see my prior comments and posts.). NO one who treats eating disorders these days that I know of uses psychoanalysis and in fact generally a patient with an eating disorder is not physically or mentally in a place to undergo the rigors of psychoanalysis. All solid eating disorder treatment includes cognitive behavioral approaches. Many patients who receive competent care undergo a combination of relational and cognitive approaches. This is how I practice. The bottom line is in finding the correct approach for each patient, generally a combination of approaches is most helpful. A competent therapist knows this. Each patient has different needs.

I wish you well
Judy Scheel

Ms Scheel, Winnicott was a

Ms Scheel,
Winnicott was a psychoanalyst. When you borrow his ideas,you are
using psychoanalysis. There is no evidence this approach is effective in treating eating disorders.
Furthermore, when you say the "goal of eating disorder therapy is to enable the individual to experience and express a true self so that authenticity and real relatedness to others can emerge," you are describing the goal of eating disorder treatment in psychoanalytic terms. Another approach is to say that the goal of eating disorder therapy is to help the sufferer re-establish normal patterns of eating so that the sufferer is not encumbered by the eating disorder behaviors and can therefore return to a normal life. The psychoanalytic approach hasn't worked well, as shown by the recently-published Poulsen study. The second approach works better, based on evidence. If you use the first approach, you are generally prolonging the sufferer's suffering.

Winnicott

Nothing in eating disorder treatment is all or nothing. Approaches are combined. You seem to not
understand the distinction in modalities and how they are applied in terms of understanding patients versus treating them. Winnicott was indeed a psychoanalyst, but that does not mean that psychoanalysis is provided to the patient. Theories fuel sound clinical thinking and judgment. Many Psychological theories provide an understanding of patients. CBT treatment is effective as are others in combination. (Again, for the third time please see my earlier posts and comments for other solid research.) It is a careful balance and how one proceeds is guided by what makes sense for the patient in order to maximize recovery and stability.

Thank you this time for not being attacking and inappropriate.

Dr. Scheel

Ms Scheel, If your eclectic,

Ms Scheel,
If your eclectic, combined approach to treatment is more effective than CBT, then you should invite independent auditors to come into your practice, evaluate the long-term success rate for your patients, and publish a paper in a scientific journal describing what you do. Until you do that, you are asking us all to trust that you know what you are doing. I don't see any evidence we should, and no basis for the public to pay you for your treatments, either through insurance premiums or government programs, such as medicaid. Sounds harsh, but in reality we need to protect patients from dubious treatment methods.

Eclectic

My goodness. Most clinicians do not conduct their own research, however, are guided by solid research that exists. I continue to respond to your posts with rational and educated statements, however, my sensibility has been firmly whispering in my ear that I am merely blowing in the wind.

I wish you well.

Dr. Scheel

Ms. Scheel, Surely you know

Ms. Scheel,
Surely you know that the forward to your book was written by
Kathryn Zerbe, who is identified as Training and Supervising Psychoanalyst at the Oregon Psychoanalytic Institute. Are you sure, therefore, you want to contend that your treatments are not based on psychoanalysis when you 1) write an article, above, based on Winnicott, a psychoanalyst, and 2) the forward of your book was written by a psychoanalyst?
I'm curious: Will the recent experiment showing the failure of psychoanalysis for treating bulimia, discussed above, have any effect on how you practice, or are you so rigid in your thinking that it will have no meaning to you? If the new study will affect how you practice, please describe how. Thanks

Surely

Of course. Yes, sound treatment for many patients is fueled by psychoanalytic principles (which includes object relations theory, drive theory, family systems theory, DBT to name a few). I hope you will continue to become educated that being influenced by various theoretical orientations, including psychoanalytic thought, is not the practice of psychoanalysis. Dr. Zerbe is a master and highly regarded in our field. Patients typically require integrated approaches to treatment. Yes, this is how I practice as do many seasoned and expert clinicians. I continue to integrate CBT in my treatment.

Your posts are becoming less rigid and more aware and certainly more professional versus attacking. I am happy to facilitate.

Best
Judy.

Dear Ms. Scheel, Your claim

Dear Ms. Scheel,
Your claim that eating disorder patients typically require "integrated approaches" sounds good in theory but it hasn't worked well in practice, compared to adherence to treatment models that have been tested in randomized controlled clinical trials. What usually happens with "integrated treatment" is that the clinician ends up picking and choosing from various approaches based on the clinician's subjective prejudices and biases. In many experiments, this approach has resulted in worse outcomes than when the clinician adheres to practices that have been empirically validated by scientific means. For a discussion of this problem, I invite you to read Von Ranson, Psychotherapies Provided for Eating Disorders by Community Clinicians: Infrequent Use of Evidence-Based Treatment,Psychotherapy Research, Vol 23, Issue 3, 2013, pp. 333-343
I'm sure many readers have noticed that you, or someone at psychologytoday, deleted several of my previous comments on this particular article. This is a typical example of censorship and rigidity of thinking. It demonstrates an unwillingness to tolerate views some people find uncomfortable.
Perhaps you, or someone associated with psychologytoday, could explain why my posts were removed.

DR. Scheel's response

Yes, integrated treatment is appropriate for many patients. It is the integrated therapist that is knowledgeable about the theoretical and treatment approaches. I agree, sometimes therapists learn only a little about one or two treatment approaches and then apply them universally. This is not prudent.

ALL eating disorder patients require a CBT approach, perhaps DBT instead. Some require medication. I invite you to read the International Journal of Eating Disorders, published through the Academy for Eating Disorders. The last two issues, December 2013 and January 2014, have research studies on the effectiveness of the therapeutic relationship in recovery and on the concept of shame. Neither of these studies is CBT, however, provides a framework and context for understanding patients with eating disorders. The relationship between patient and therapist, emotions that underly the eating disorder, parenting issues are critical and part of the recovery process. This is NOT CBT, even though CBT will likely be utilized in the treatment.

It is enormously frustrating that you are unwilling to see the merits of how eating disorders are conceptualized and refuse to acknowledge that indeed I agree with you - that CBT is a clinically sound approach to treatment and one in which is used regularly.

The personal attacks you made in some of your previous comments tell more about you than any claim you make in your posts.

DR. Scheel

Dear Ms. Scheel, I'm afraid

Dear Ms. Scheel,
I'm afraid you have some facts wrong. The December 2013 and January 2014 issues of the International Journal of Eating Disorders do not "have research studies on the effectiveness of the therapeutic relationship in recovery." The effect of therapeutic relationship and therapeutic alliance have been studied elsewhere, and the results are contradictory and inconclusive. Therefore, the December 2013 issue of the International Journal of Eating Disorders has an article recommending that more studies need to be conducted before conclusions can be drawn with regard to whether therapeutic relationship plays a postive, negative, or no role in recovery. The paper, by Brown et al, is entitled "Is the Therapeutic Alliance Overvalued in the Treatment of Eating Disorders," IJED Dec 2013, Vol 46, Issue 8, pp 779-82 Readers can check this out for themselves on the website of the International Journal of Eating Disorders.

I'm afraid

Yes, of course. I agree. CBT is a strong and valid method of treatment as per the research. One must look at the approaches in the context of other aspects i.e. the relationship between patient and therapist, the role of family, intra-psychic issues. ALL these play can a role in etiology and guide treatment. You continue to miss the overlapping point and merely focus on on efficacy of CBT. I continue to recommend that you read other research; it may help you. No one is disputing the efficacy of CBT.

Responding to an anonymous blogger is always interesting.

Dr. Scheel

Dear Ms. Scheel, Responding

Dear Ms. Scheel,
Responding to a psychotherapist who is trained in psychoanalysis (not evidence-based treatment or science) is even more interesting.

responding

I have clarified all your misconceptions before in earlier posts. Readers understand.

I hope that you find satisfaction and peace in your life,

Dr. Scheel

research methods

what kind of research method was used based on this article?

Dear Anonymous, There is no

Dear Anonymous,
There is no research method behind this post by Ms. Scheel. There is no evidence that the concepts of False Self and True Self exist beyond the imaginations of psychoanalysts. Meanwhile, as discussed above, psychoanalysis has been thoroughly discredited as a method for treating eating disorders. To continue to employ the concepts of False Self and True Self is therefore dangerous, and not based on reasonable scientific research.

There is no

You continue to misunderstand theory and its use in a complex understanding of treating eating disorders. See all previous posts.

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Judy Scheel, Ph.D., L.C.S.W., author of When Food Is Family, is the Founder and Executive Director of Cedar Associates Foundation.

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