Eating and the Self: Focal Psychodynamic Therapy Modules

When I became the senior program director of Western Psychiatric Hospital of UPMC's inpatient eating disorder program, patients wanted more alternatives to DBT. As a psychodynamically oriented integrative therapist, Focal Psychodynamic Therapy (FPT) was an immediate interest. While cognitive behavioral manuals tend to be very tangible, specific and circumscribed, psychodynamic ones don't lean on behavioral or paper-and-pencil interventions and consequently set guidelines for verbal interventions or the experience of therapy instead. Eating and the Self aims to split the difference.

Eating and The Self - a Focal Dynamic Manual

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The Eating and the Self treatment guide provides a structured (integrative cognitive behavioral components) approach to psychodynamic content (informed primarily by FPT). This offers a hugely unique experience for patients to explore who they are, how others have treated or related to them, how they relate to others in both dyadic and triadic matrices, and how intrapsychic and interpersonal relationships are symbolized or repeated in the relationship to food. Experiences begin to make sense, and consequently can be verbalized rather than repressed beyond the consciousness barrier only to resurface as acted-out eating behaviors and somatic symptoms.

The result of this is agency and increased free-will (new ways to respond to emotions and interpersonal situations). The relationship with the treatment team improved - often the dietitian/nutritionist and psychiatrists in the acute eating disorder programs as split and seen as mean and controlling, but conversations became more peaceful.

In the outpatient setting, many clients have enjoyed completing 1 module per week and discussing it as part of the next session (some clients have gone through the whole manual the week they get it).

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Conclusion

Despite working with eating disorders for many years, I still find there are times when it is helpful to have a workbook model, and structured paper-and-pencil experiences for certain clients. Even if you don't typically work with clients who have eating disorders, these concerns are common and will come up with other clients. While at times it may make sense to refer out or seek consultation, many aspects of our relationship to food can be address without referring, and having a structured guide to lean on can be helpful for therapist and client alike.

References

Herzog, W., Wild, B., Giel, K. E., Junne, F., Friederich, H. C., Resmark, G., ... & Zipfel, S. (2014). Focal psychodynamic therapy, cognitive behaviour therapy, and an optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): 12-month follow-up of a randomised controlled trial. The Lancet, 383(9912), 127–137.

• Application: Establishes the landmark empirical foundation for Focal Psychodynamic Therapy (FPT) as a validated manualized alternative to cognitive behavioral therapies in eating disorder treatment programs.

Lemma, A., Target, M., & Fonagy, P. (2011). Brief dynamic interpersonal therapy: A clinician's guide. Oxford University Press.

• Application: Supports the mechanics of structuring psychodynamic therapy into highly focused, weekly modules. It anchors the methodology of targeting core relational patterns (such as dyadic and triadic matrices) within a brief, manualized format.

McWilliams, N. (2020). Psychoanalytic supervision. Guilford Press.

• Application: Explores the systemic dynamics of treatment team splitting within high-acuity settings (such as inpatient units). It explains how underlying borderline or eating disorder pathologies cause patients to project a "mean and controlling" image onto dietitians and psychiatrists, and how manualized structure can stabilize the milieu.

Schilder, P. (1935). The image and appearance of the human body: Studies in the constructive energies of the psyche. Kegan Paul, Trench, Trubner & Co.

• Application: Provides the foundational baseline framework explaining how deep intrapsychic structures, ego boundary defense, and personal conflicts are symbolically projected or repeated through somatic symptoms and an altered relationship with food.

Waller, G. (1992). Sexual abuse and the eating disorders: A review of the literature and some clinical implications. British Journal of Clinical Psychology, 31(2), 113–131.

• Application: Substantiates the psychological process where severe, overwhelming trauma or emotional distress is repressed beneath the consciousness barrier, only to resurface as acted-out, self-destructive eating behaviors and intense bodily focus.