The Gold Standard of Eating Disorder Treatment with Douglas W. Bunnell
In the world of mental health and therapy, there's often a buzz around "evidence-based treatment" or EBT. It sounds great, right? But what exactly does it mean, and is it the be-all and end-all of effective therapy? Is there a difference between EBT and psychodynamic psychotherapy (deep work therapy)? Why has CBT gotten a monopoly on the evidence-based title? So many questions!
In today’s episode, I am joined by Douglas Bunnell. Douglas W. Bunnell, Ph.D., FAED, CEDS-S is a clinical psychologist in Fairfield, Connecticut. He has specialized in the treatment of people with eating disorders for the past 30 years. Dr. Bunnell is a past board chair of the NEDA and recipient of their Lifetime Achievement Award. Dr. Bunnell has helped to design, develop, and manage PHP and residential programs for several national eating disorder programs. He is a Fellow of the Academy for Eating Disorders and a Certified Eating Disorder Supervisor for IAEDP. Dr. Bunnell has co-authored numerous chapters and journal articles on the treatment of eating disorders and the training of clinicians. He is particularly focused on the integration of evidence-based treatment into higher levels of eating disorder treatment programming. More recently, Dr. Bunnell has been working on clinical protocols for addressing eating disorders and co-morbid psychiatric issues such as PTSD. He is currently a Senior Clinical Advisor for Eating Recovery Center and Pathlight Mood and Anxiety Treatment Programs. Dr. Bunnell is a co-editor, along with Dr. Margo Maine and Dr. Beth McGilley, of Treatment of Eating Disorders: Bridging the Research Practice Gap.
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What is Evidence-Based treatment?
The conventional definition says that evidence-based treatment is defined by the incorporation of three principles.
Empirical Research - This refers to actual research that has been conducted and tested, through direct and indirect experience. Many think of this as concrete evidence.
Clinician Experience (Healthcare Professional) - This involves the subjective and individual experience of each clinician and client, focusing on what has worked anecdotally or experientially.
Patient or Individual Preference - Patient preference plays a significant role, particularly when conventional EBTs (Evidence-Based Treatments) don't work, and clinicians need to consider alternative approaches guided by principles rather than empirical data.
One size does not fit all
It’s important to note that while this therapy treatment is an option, it doesn’t work for everybody, and not every patient wants this type of treatment. This is particularly true for those battling eating disorders. However, the same goes for cognitive and behavioral-based therapies. Therapy, in general, is not a one-size-fits-all situation. It’s not easy to just simply pick a therapy type and go with it. It’s much more complicated than that.
Is this type of therapy something he or she really wants to be doing?
Is there a prior treatment history of success or failure with it?
Are you the person to be delivering that treatment?
Debunking CBT for eating disorders
Doug then shifts to talk exclusively about CBT–cognitive behavioral therapy–a common approach in treating eating disorders. What does it look like?
Basically, CBT for eating disorders is a structured, manualized approach. In research settings, it follows a predefined set of guidelines. However, there's a catch. In real-world practice, it's not always as rigid as you might think. While research studies have these strict manuals in place, many therapists don't stick to them. It's a bit like following a recipe - sometimes you add your own secret ingredients to make it just right.
In fact, studies have shown that a significant number of therapists who claim to be delivering CBT are actually quite flexible in their approach. It involves understanding thought patterns, exploring beliefs about dieting, body image, and the role of emotions in driving behaviors. It's about identifying patterns in eating behavior, often using tools like dietary and thought logs. CBT also emphasizes active listening and employs elements of motivational interviewing.
Insert Rachelle’s peanut gallery: flexible approach to CBT sounds familiar?
Flexible treatment
According to Doug, in a perfect world, therapists should have the flexibility to lead with evidence-based treatments but have the ability to adjust if they don’t suit a particular individual. Therapy should adapt to the unique needs of each patient, focusing on what works rather than sticking to predefined methods. Sound familiar again?
Limitations of evidence-based treatments
We need to acknowledge that no treatment, whether evidence-based or not, works for 100% of individuals. Even the most effective treatments may not yield the desired results for everyone. This is not a criticism but rather a realistic perspective on the complexities of treating eating disorders.
Dropouts
One factor to consider is the issue of dropouts. When a patient doesn't resonate with CBT-E or finds it ineffective, ethical questions arise. Should therapists simply withdraw from treatment, or do they need to explore alternative approaches? In other words, consider what Plan B or even Plan C might entail.
Key aspects
So let’s just get to the point - what does it mean to think dynamically to provide deep work therapy?
Dynamic therapy is the ability to identify and prioritize the most critical factors contributing to a patient's eating disorder. We’re not saying there should be a specific course of action. But if we can recognize, say the top 10 factors, then we can help the patient connect the dots between their experiences, emotions, and behaviors.
Therapists may choose to incorporate dynamic elements into their treatment plans, such as exploring the transference, focusing on adaptability, or asking questions like, "What would you have to feel if you didn't engage in these behaviors?"
Balancing it all
Dynamic therapists working with individuals dealing with eating disorders have a critical responsibility: they must carefully manage two key aspects of therapy – symptom stabilization and deep emotional work.
Yes, we need to understand the patient’s psyche, but we also need to address immediate health concerns and nutritional rehabilitation. (Although if you understand jargon, behavioral modification isn’t anti-analytic work at all. It’s just called ego strengthening).
Therapeutic approaches have transformed to meet the complex needs of those struggling with eating disorders. Not too long ago, dynamic therapy was the dominant perspective in mental health treatment.
Art in therapy
So picture this: therapy is a choreographed dance–each step is carefully planned and executed to meet the patient's needs.
As therapists gain experience, they often transcend the boundaries of specific therapeutic labels. The best therapists don't identify solely as CBT practitioners, dynamic therapists, or any particular category. Instead, they just help patients.
The power of small changes
One of the most profound aspects of therapy is witnessing patients make even the smallest changes in their behavior. Whether it's a day without binge eating or a step towards self-acceptance, these shifts are monumental. It's not about rigid adherence to a specific approach but about supporting individuals in their journey of self-discovery and change.
Think outside the box
In the realm of eating disorder treatment, therapists are encouraged to think outside the box. If there's an approach that might benefit a patient, it's worth considering. However, any departure from the norm should be supported by a clear and defensible rationale.
It's not enough to say, "I'm doing this because it's what I'm comfortable with." Therapists should be able to understand why a particular approach is being pursued.
The Cognitive Model vs. The Psychodynamic Model
CBT prioritizes rationality over emotion. It uses cognitive strategies to enhance self-awareness and change thinking patterns. This approach is effective for many individuals, emphasizing the power of the frontal lobes to drive behavioral change. Basically, rationality is above emotional exploration.
Psychodynamic therapy takes a different route. It understands that emotions are at the core of human experience. Rather than prioritizing rationality, it dives deep into the emotional realm, uncovering underlying needs, desires, and fears. This approach seeks to understand the function of behaviors and the emotional landscape behind them.
Both approaches recognize the importance of creating distance between patients and their behaviors. This distance allows patients to gain perspective and connect the dots between their actions and emotions. It's a crucial step in understanding the root causes of eating disorders.
Resistance
Record-keeping is a common tool used in therapy, especially for tracking behaviors related to eating disorders. For CBT therapists, it's crucial to emphasize the rationale behind it. For psychodynamic therapists, the focus may shift to exploring the resistance itself.
When there's something stopping a person from being able to do whatever it is that they want or need to do, emphasizing the importance of the thing may not cut it. (Who are we kidding, it doesn’t.) By not having a conversation about it, then we miss the “why?”
It’s almost like we’re doing a disservice if we don't have that conversation. Even though you’ll probably hear pushback like “Seriously, are you asking me this again?” But they realize it’s a question that needs to be asked every time.
So, which approach is better?
First of all, whichever you choose, choose because you have information. And not the kind from TikTok or your best friend who’s a therapist.
Ultimately, eating disorder therapy is a multifaceted field. It requires flexibility, empathy, and a deep understanding of the human psyche.
Most importantly, whether you choose cognitive-behavioral or psychodynamic approaches, what truly matters is the ability to connect with patients, explore their emotions, and guide them toward lasting change.
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Tweetable Quotes
“What people tend to hear is that it's just the empirical research and that's sort of case closed. But with anything else in behavioral health and certainly anything else regarding eating disorders, nothing is ever that simple.” - Douglas W. Bunnell
“I wouldn't want to look for something that wasn't evidence-based if there was an evidence-based treatment out there. It's sort of like the gold standard.“ - Rachelle Heinemann
“Personally speaking, I don't think CBT, as written in the manuals and the books, has been really clear about the role of the dietician in treatment for eating disorders.” - Douglas W. Bunnell
“I often say if the conversation is either only about food or not about food at all, there's an issue. There has to be some sort of medium.” - Rachelle Heinemann
Resources
Jonathan Shedler’s work on Debunking Myths on Dynamic Therapy
Related Episodes
Episode 74. The Best Advice You’ll Ever Get
Episode 59. When It’s Not Working Out With Your Therapist
Episode 36. The Inner Workings of Therapy with Jack Heinemann, LCSW-R
More From Rachelle
Hey there! I’m Rachelle, the host of the Understanding Disordered Eating Podcast. As a Licensed Mental Health Counselor, I work with clients to make sense of life’s messy emotional experiences.
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