Understand the Roots of Pain Addressing patient pain requires active engagement rather than passive empathy, as confronting one’s own fear can enable a more effective response. Recognizing the developmental history of patients is crucial, as their current state is shaped by past experiences and struggles. Additionally, the challenge of lexithymia, or the inability to articulate emotions, complicates patient interactions by intertwining emotional expression with their pain, emphasizing the necessity for healthcare providers to navigate these complexities thoughtfully. Transcript: Speaker 2 Okay. So you kind of, when I ask you about the empathy for the patient, first, I think importantly talk about how we can in our own fear move more to action and less to sitting with them in the midst Of their pain and understanding their pain. It’s like it’s almost too much. Is that what that’s what you’re saying? And then, yeah. So what have you found is the pain, you know, and then for this, maybe this individual and other patients as well. And how’s the lexithymia or the lack of the ability to express in emotion? How is that sort of intertwined in that pain? Speaker 1 When we encounter a patient, if we have a psychoanalytic lens, I think that part of what we’re holding in mind is that the place that they are today as they come to us is a result of a developmental Process that came before. They’ve lived a life that’s brought them to where they are now. (Time 0:07:10)
Understanding Symptoms as Expressions of Unresolved Psychological Pain When assessing a patient, it’s important to recognize that their current condition is the culmination of a developmental journey marked by various life experiences. Understanding the context of their symptoms requires an exploration of their past and the psychological pain that manifests through behaviors such as self-starvation or bingeing. These actions often serve as coping mechanisms for unprocessed emotional distress, hindering their developmental progress. The concept of alexithymia highlights the challenge some individuals face in articulating their feelings, underscoring the need for therapists to decipher these emotional expressions and guide patients toward integrating their experiences into a cohesive understanding of self. Transcript: Speaker 1 When we encounter a patient, if we have a psychoanalytic lens, I think that part of what we’re holding in mind is that the place that they are today as they come to us is a result of a developmental Process that came before. They’ve lived a life that’s brought them to where they are now. That life has had components in it that have shaped the journey to this point. And so, you know, whenever I’m sitting with a patient, I’m thinking about what have they been through, you know, what, what has, has shaped this expression, the symptomatic expression Of pain. And that’s what I think, you know, psychoanalysts mean when they talk about the meaning of the symptom. What’s the developmental history that has gotten this person here today? And if somebody’s doing something like starving themselves or, you know, binging to the point of physical pain, or, you know, binging and then vomiting. The underlying assumption is that that’s an expression of some psychological pain that they haven’t been able to work through, digest, make sense of, integrate into their personality, Into a meaningful way. So that’s always the question I’m holding in mind. The symptom is a way to forestall a developmental process that could move them through whatever it is that they’re contending with. And depending on the patient, what they’re contending with could really, really, really vary. And I think that links to the idea of alexithymia because, you know, alexithymia is this idea that there’s no words for feelings. There’s something about the person’s ability to translate their emotional experience into words or images, symbols, representations that is circumscribed or undeveloped. (Time 0:07:58)
1min Snip Transcript: Speaker 1 And I think that links to the idea of alexithymia because, you know, alexithymia is this idea that there’s no words for feelings. There’s something about the person’s ability to translate their emotional experience into words or images, symbols, representations that is circumscribed or undeveloped. That’s the alexithymia. So alexithymia is highly correlated with eating disorders. And it’s one component of what prevents the person with an eating disorder from using words and making use of another person to kind of express their psychological pain so that something Different could be done with it. Speaker 2 It’s good, yeah. I love how you’re really searching to find the depths of what’s going on inside of them. How do people respond to that when you do that? Speaker 1 Well, I think it depends, right? So, you know, as I kind of alluded to at the beginning, I very much think of a psychoanalytic approach as one component of a larger treatment team. So, people with eating disorders, they need multiple modes of intervention. There needs to be, depending on the individual situation, potentially a (Time 0:09:33)
Beyond Descriptive Diagnoses: Understanding Unique Patient Groups Recent research utilizing the Shedler-Weston assessment protocol has highlighted the existence of distinct groups within patients diagnosed with anorexia nervosa and bulimia nervosa. This study emphasizes the importance of moving beyond the surface-level operationalizable symptoms typically outlined in the DSM-5 or ICD. While these classifications offer essential diagnostic criteria, they can obscure the unique experiences and needs of individual patients. Recognizing these differences is crucial for providing more tailored and effective treatment strategies. Transcript: Speaker 2 You talk about this study where they looked at the Shedler-Weston assessment protocol for a group of patients with anorexia nervosa and bulimia nervosa, and how the study really found Three different groups of patients. And I think this is an important study to look at, because I think often we think of these groups of patients as kind of in the descriptive lens of the DSM, but I think that this study added Something. Can you talk about that? Speaker 1 Yeah, yeah, thank you for that question, because I think that really does help unfold what is a kind of essential point here, which is that nowadays with the DSM-5 or the ICD or whatever, Our field is very oriented towards descriptive diagnosis, which really looks at surface-level operationalizable symptoms. And in that sense, a person with anorexia is similar to another person with anorexia. (Time 0:12:08)
Diversity of Diagnosis: The Need for Individual Understanding Current diagnostic frameworks like DSM-5 and ICD focus heavily on surface-level symptoms, leading to a homogenized view of conditions such as anorexia. However, the psychoanalytic approach highlights the importance of recognizing heterogeneity among patients, suggesting that multiple developmental pathways can lead to similar diagnoses. A study utilizing the Shedler-Weston Assessment Protocol (SWAP) identified three distinct categories of patients with eating disorders: high-functioning perfectionists, constricted over-controlled individuals, and emotionally dysregulated under-controlled patients. This differentiation indicates that effective psychotherapeutic approaches must go beyond standard DSM classifications to tailor treatment based on individual psychological structures. Transcript: Speaker 1 Yeah, yeah, thank you for that question, because I think that really does help unfold what is a kind of essential point here, which is that nowadays with the DSM-5 or the ICD or whatever, Our field is very oriented towards descriptive diagnosis, which really looks at surface-level operationalizable symptoms. And in that sense, a person with anorexia is similar to another person with anorexia. They’re kind of homogeneous categories in some sense, whereas I think the psychoanalytic sensibility is much more, one, of heterogeneity. You know, there are two people with anorexia. I wouldn’t make assumptions about the kind of underlying psychological structure of those two people. I wouldn’t assume that they’re the same. I would assume that there are probably multiple developmental pathways that can lead to that same DSM diagnosis. I guess that’s the idea of equi-phenality and psychiatric jargon. So this particular study, it was a study with the Shedler-Weston Assessment Protocol, the SWAP. And it used that, that’s an instrument that therapists complete themselves to assess their patients. And it looked at patients with DSM diagnoses of anorexia and bulimia. And in the results of the SWAP, three different categories of patients emerged. So there was a high-functioning perfectionistic group. There was a constricted over-controlled group, and there was an emotionally dysregulated under-controlled group. So, you know, in a psychotherapeutic process, that has really important implications because if you’re just thinking in terms of DSM diagnosis, (Time 0:12:41)
Pursue Progress, Not Perfection Individuals with perfectionistic tendencies often struggle with a demanding ego ideal that sets unattainable standards. This pursuit creates a significant fear of failure and an ongoing pressure to live up to an idealized self-image, which can lead to emotional constriction and over-control in their lives. Recognizing the impact of these beliefs is crucial for personal growth and emotional well-being. Transcript: Speaker 2 Yeah, and so that type. The second one you said was a constricted over-controlled group. Yeah. Yeah. Tell me about that one. Speaker 1 Yeah, which seems very related. You’ve got high-functioning and perfectionistic versus constricted and over-controlled. Maybe I blended the two in a little cases and yet I gave there. So if I think of someone who’s perfectionistic, you know, they have a very, well, you know, one possibility is that they have a kind of ego ideal that’s very difficult to attain. You know, they have an image of who they should be that they’re trying to live up to. Maybe they also have a very pronounced fear of failure, something around this kind of idea of image of who I should be, what I should live up to. (Time 0:17:56)
Beyond Description: The Depth of Understanding in Psychotherapy To truly grasp the complexities of an individual, one must move beyond descriptive understanding to recognize the deeper elements that shape a person’s personality and history. This depth is crucial because it informs the goals of psychotherapy, which should focus on fostering a developmental relationship that enhances ongoing psychological growth. Such an approach emphasizes the significance of understanding underlying factors instead of merely surface-level descriptions. Transcript: Speaker 2 And so understanding this, how does that change kind of our conceptualization of this from the descriptive to the, to this kind of descriptive way of understanding or is this this is Beyond descriptive because now we’re talking about like there’s things that are leading to this. Speaker 1 Yeah, deeper Yeah, deeper things, deeper things. You could think of that as a kind of personality structure. Maybe that’s the depth component or a person’s kind of history that’s led them to where they are. That’s another component of depth, but it is, I think, much more than just the descriptive level. And you know, why does that matter? I think it matters because, and you know, again, I think this is the frame I bring to psychotherapy. It’s not, I recognize it’s not shared by all psychotherapists. But for me, the goal of psychotherapy is to create a relationship with a person, you call it a kind of developmental relationship, that is going to facilitate their ongoing psychological Development. (Time 0:21:19)
Understanding Through Openness and Emotion Radically Open Dialectical Behavior Therapy (RO DBT) is an intervention designed for individuals with eating disorders, emphasizing openness and countering emotional constriction, in contrast to standard DBT that focuses on emotional regulation. The connection between alexithymia—a condition characterized by difficulty in identifying and expressing emotions—and eating disorders has been well-documented in literature, dating back several decades. Recognizing this link enhances treatment approaches for this population, as alexithymia often correlates with attachment issues, trauma, and abuse experiences. Transcript: Speaker 1 Yeah, and you know, I can’t say too much about this because it’s not something I feel I know a lot about, but I think there is a kind of implicit recognition of this and say, you mentioned DBT earlier being a kind of intervention that you were familiar with for people with eating disorders. We’ve now got RO DBT, Radically Open DBT, which is a very different form of intervention that’s much more organized to people like that. It’s very much about promoting a kind of openness and working against constriction instead of, say, DBT, working to increase regulation. So I think it’s recognized in other forms of intervention, this difference we’re pointing to. Speaker 2 It seems like one thing I’ve pulled from your work is Alexithymia seems to be a theme that I hadn’t really thought about with eating disorders per se. How did you stumble upon this connection there and how has that helped you in treating this population? Speaker 1 Yeah, yeah, yeah. I think, you know, for me, I stumbled upon it in two ways. I mean, it’s certainly something that is spoken about in the literature on eating disorders. It’s been recognized for a long, long time, at least back to the work of, you know, Hildebrooke in the what, 60s, 70s. But certainly it’s noted in the empirical literature now over and over again, this correlation between eating disorders and alexithymia. Alexithymia is also associated with attachment and security. It’s associated with histories of trauma, abuse, et cetera. (Time 0:26:15)
Redefining Masculinity: Embracing Vulnerability in the Face of Eating Disorders Cultural definitions of masculinity create significant barriers for men seeking help for eating disorders. The pressure to conform to male body ideals, such as the desire for a lean, muscular physique, complicates the presentation and perception of eating disorders in men. Unlike women, who may primarily aspire to a thin body, men often contend with issues like muscle dysmorphia, creating a different set of challenges. The relationship between these disorders is complex and highlights the need for greater awareness and understanding of men’s experiences with body image and mental health. Transcript: Speaker 1 And then there may also be things about, you know, male, how would you put it, what it means to be a man or a boy in our culture that are at odds with seeking help in the first place, just more Generally. So what I’m getting at is that there may be additional obstacles to getting treatment as a male. So those were some of my kind of initial concerns. And then, you know, I think there’s also the fact that eating disorders in general in men may tend to present differently. So, you know, for a woman, for example, with anorexia, you know, there’s a seeking of a kind of thin body. There’s a kind of body ideal that’s very much reflected in our culture very thin, kind of insubstantial physicality. And that certainly can be the case for a boy or a man. There are definitely men or boys with anorexia who seek out that kind of body. But there are also a lot of young men who are much more oriented towards a lean, hypertrophic, muscled physique. And this is what you’d see in, like, muscled dysmorphia. And so, you know, how muscled dysmorphia and anorexia are related is a really complex question. But it may be that there’s something about, you know, the male gender that (Time 0:31:34)
Navigating Body Ideals: Risks of Sports and Dieting Sports and exercise contribute positively to health, yet certain practices, such as weight cutting and adherence to specific body ideals, can increase the risk of eating disorders, particularly among young men. Pre-existing body image issues, often stemming from childhood teasing related to weight, can lead to unhealthy dietary choices, such as adopting extreme diets like the ketogenic diet. This developmental background plays a significant role in shaping unhealthy behaviors toward food and body image. Furthermore, although rough and tumble play has its benefits for children, it also requires careful consideration to prevent harmful outcomes linked to competitive body dynamics. Transcript: Speaker 1 Yeah, yeah, yeah, it’s a good point, right? Because I mean, I think, I mean, again, as you said, sports and exercise, those things are great. But there are sports that, because of the practices that they incorporate, say, making weight or things like this, where you have to cut for the sport, or sports that hold out certain Kinds of body ideals is very desirable. That certainly are risk factors for eating disorders. And then I think with young men, just to stay with that, often there’s a kind of premorbid overweight. Maybe this kid, 12, 13, was a little pudgy or had some belly fat or whatever. And maybe they got teased for that. That’s often something you see that there’s a history of teasing. And so they decided to try a ketogenic diet. Maybe dad had had a lot of success with a ketogenic diet. And so now they’re going to try a ketogenic diet. And that kind of entryway into starting to mess around with the body and with eating. So, again, there’s a developmental history that got them to this place. Speaker 2 Yeah. And in one of your articles, you talk about the value of rough and tumble play, but you also talk about when it goes wrong. Is this specifically something you’ve seen in male anorexics or is this something in general? Speaker 1 Yeah, yeah. So the ideas about rough and tumble play, they were part of a very kind of nuanced and in-depth way. I was trying to think about anorexia and maybe other eating disorders. So it’s not so much about just rough and tumble play in itself, though there is research that rough and tumble play can potentially be very facilitative for children. But just to kind of lay out that idea. (Time 0:35:12)
Understanding Anorexia: The Family Dynamic Connection Rough and tumble play can be beneficial for children, but its connection to eating disorders like anorexia requires a deeper examination of family dynamics. Research indicates that individuals with anorexia often come from specific familial backgrounds that may impact their development. However, attributing anorexia to just these family dynamics is contested and risk stigmatizes families. Anorexia can result from various factors, forming a complex interplay of biological, psychological, and social influences. A recurring observation suggests that individuals with anorexia struggle with separating from their maternal figures, influenced by cultural and familial structures. Transcript: Speaker 1 Yeah, yeah. So the ideas about rough and tumble play, they were part of a very kind of nuanced and in-depth way. I was trying to think about anorexia and maybe other eating disorders. So it’s not so much about just rough and tumble play in itself, though there is research that rough and tumble play can potentially be very facilitative for children. But just to kind of lay out that idea. So beginning with Hildebrooke, there’s this idea that people with anorexia emerge from families that have certain dynamics in place or can emerge from certain families that have Certain dynamics in place. And I think this is a very contested idea because, you know, we don’t want to stigmatize families. We certainly don’t want to hold up some idea of like an anorexogenic family, you know, that doesn’t look at many other factors that play. People can develop anorexia from many, many different pathways. And, you know, it’s really a kind of perfect storm, a biopsychosocial perfect storm. But, you know, there is a kind of clinical observation that’s been made again and again and again. And my experience does often hold up, though not always, that people with anorexia are struggling with the process of separation and individuation, often because of the culture we Live in and the way families are structured, separation and individuation from mother. (Time 0:36:45)