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Winnicottian Object Relations and Behavioral Theory Conceptualizations of Difficult-To-Treat Binge-Type Eating Disorders

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Smith ScholarWorks Theses, Dissertations, and Projects 2010 Winnicottian object relations and behavioral theory conceptualizations of difficult-to-treat binge-type eating disorders : proposal for a synthesized treatment approach through dialectical behavior therapy Christy Erin O'Brien Smith College Follow this and additional works at: https://scholarworks.smith.edu/theses Part of the Social and Behavioral Sciences Commons Recommended Citation O'Brien, Christy Erin, "Winnicottian object relations and behavioral theory conceptualizations of difficult-to- treat binge-type eating disorders : proposal for a synthesized treatment approach through dialectical behavior therapy" (2010). Masters Thesis, Smith College, Northampton, MA. https://scholarworks.smith.edu/theses/494 This Masters Thesis has been accepted for inclusion in Theses, Dissertations, and Projects by an authorized administrator of Smith ScholarWorks. For more information, please contact [email protected]. Christy O'Brien Winnicottian object relations and behavioral theoretical conceptualizations of difficult-to-treat binge-type eating disorders: Proposal for a synthesized treatment approach through dialectical behavior therapy ABSTRACT This theoretical investigation creates a unique conceptualization of difficult-to-treat binge-type eating disorders (DTTBTEDs) based upon the synthesis of psychodynamic and behavioral theoretical perspectives of the disorder. More specifically, a Winnicottian object relations perspective is utilized to provide a framework identifying the manner in which early relational impingements that individuals with DTTBTEDs often experienced in their earliest care-giving relationships and holding environments impacted their ability to internalize affect-regulating abilities and learn adaptive object relational practices to utilize throughout their lifetime. Such a conceptualization will articulate the early reliance on food as a maladaptive transitional object in its trajectory towards the eventual development of a binge-eating disorder. The second theoretical perspective, a behavior theory lens, is applied to better conceptualize how biological vulnerabilities, conditioning processes, and behavioral reinforcement over time all interact to participate in the development, addictive maintenance, and resistance to treatment in the disorder’s lifespan. Together, these perspectives will be synthesized to create an unique comprehensive evaluation of the phenomenon of DTTBTEDs, as well as to propose the utility that dialectical behavior therapy (DBT), a multi-modal treatment approach that amends affect dysregulation through a collaboration of skills-based behavioral treatments, relationally-based acceptance strategies, closely-allied psychotherapy, and interpersonal and behavioral coaching to target life- and therapy- interfering behaviors, can have in treating both the object relational deficits and the behavioral maladaptivies inherent in DTTBTEDs in an integrated way. WINNICOTTIAN OBJECT RELATIONS AND BEHAVIORAL THEORETICAL CONCEPTUALIZATIONS OF DIFFICULT-TO-TREAT BINGE-TYPE EATING DISORDERS: PROPOSAL FOR A SYNTHESIZED TREATMENT APPROACH THROUGH DIALECTICAL BEHAVIOR THERAPY A project based upon an independent investigation, submitted in partial fulfillment of the requirements for the degree of Master of Social Work. Christy O’Brien Smith College School for Social Work Northampton, Massachusetts 01063 2010 ACKNOWLEDGMENTS This thesis could not have been accomplished without the assistance of many people whose contributions are gratefully acknowledged. I wish to extend my gratitude to my research advisor, Edmund DeLaCour, Ph.D., for his attention to and supervision of the construction of a thesis topic that satisfied my deepest psychological curiosities, his deeply-rooted psychodynamic theoretical wisdoms, his patient review of each and every chapter, and for the numerous hours he likely spent reviewing my research. I wish to extend my gratitude to my son, Matthew, for his patient witness to the process of this thesis’s construction. I similarly wish to thank my family, friends, and closest loved ones for their support during the research and writing. Finally, I wish to acknowledge the pain and suffering of those whose struggles have inspired this research. To those that have battled or are currently suffering with difficult-to-treat binge-type eating disorders, publicly or silently in our society, I dedicate this research. ii TABLE OF CONTENTS ACKNOWLDGMENTS ………………………………………………………… ii TABLE OF CONTENTS ……………………………………………………….. iii CHAPTERS I. INTRODUCTION …………………………………………………... 1 II. THE PHENOMENON …………………………………………….… 6 III. THEORY ONE ..…………………………………………………….. 38 IV. THEORY TWO ..……………………………………………………. 88 V. DISCUSSION ……………………………………………………….. 142 REFERENCES ………………………………………………………………….. 204 iii CHAPTER ONE INTRODUCTION As eating disorders began to reach epidemic proportions in certain populations in recent years [e.g., it is widely reported that between 1% and 3% of young women in the United States are reported to suffer from bulimia nervosa while another 3% to 5% evidence significantly disordered eating and weight concerns (e.g., Safer, Lock, & Courier, 2007; Safer, Telch, & Agras, 2001)], research has expanded in a variety of ways, as well. Eating disorders with similar presentations are being categorized together, differentiations between types of disorders are being expanded, and new sub-groups of disorders are emerging in the treatment and research communities. For instance, restricting-type eating disorders of the anorexia variety present in significantly different ways than most other forms of eating disordered behaviors, causing them to often be evaluated in the therapeutic communities and investigated in the research communities in categorically different ways. Correspondingly, individuals with bulimia and binge-eating disorder have become increasingly linked as a sub-group of eating disorders based on their similarities in presentation. Both diagnoses are linked by shared symptomatology, such as affect-regulating binge eating behavior, heightened impulsivity, lack of control, pronounced negative mood, persistent affective dysregulation, and often have co- occurring disorders, as well (e.g., Chen, et al., 2008; Telch, Agras, & Linehan, 2001; Wisniewski, Safer, & Chen, 2007). Moreover, individuals that present with bulimia and binge-eating disorder often evidence binge eating as a maladaptive emotion regulation technique, the absence of other adaptive affect regulation skills, and the perpetuation of additional binge behaviors in an attempt to cope with the shame and guilt that is 1 experienced as a result of their eating behaviors (Chen & Linehan, in press, Sanftner & Crowther, 1998 as cited in Wisniewski, Safer, & Chen, 2008). Importantly, it is the more recent conceptualization of the characteristics and behaviors commonly evidenced in some individuals with bulimia or binge-eating disorder as addictive that have brought new attention to this sub-group of individuals as significantly disordered and symptomatic (von Ranson & Cassin, 2007). Eating disorder research and treatment communities are also rapidly identifying the commonly exhibited resistance to traditionally utilized forms of treatment as characteristic of a sub-group of some individuals within the bulimic and binge-eating disorder populations (Chen, et al., 2008; Telch, Agras, & Linehan, 2001). Where such methods as cognitive behavioral therapy (CBT) and interpersonal therapy (IPT), aimed at behavior change through thought change-driven work and talk therapy, have been found to be successful in treating individuals with AN (Bowers & Ansher, 2008), the treatments have been found to be ineffective for about 50% of individuals with bulimia and binge- eating disorder (Chen, et al., 2008; Fairburn, Marcus, & Wilson, 1993). As a result, the sub-grouping of bulimia and binge-eating disorder in the literature not only helps differentiate the disorders from the symptomology of other forms of disordered eating behavior, it also helps to identify a secondary sub-group based upon their differing treatment needs and calls attention to the need for the development of new treatment approaches. For the purposes of the present research, the sub-group of individuals with treatment resistant bulimia and binge-eating disorder will be identified as difficult-to-treat binge-type eating disorders (DTTBTEDs). The next chapter will provide a more detailed definition of DTTBTEDs as a phenomenon. 2 Treating eating disorders, in general, has been widely identified as challenging, complex, and risky due to the potentially self-harming nature of the control strategies its victims tend to employ as a form of self-regulation and control (Levitt, 2005). However, finding new and more effective treatments for nearly half of the individuals with BN or BED that have been found to be unresponsive to individual implementations of either psychotherapy or CBT has become a challenge for researchers according to recent literature (Telch, Agras, & Linehan, 2001; Wisniewski, Safer, & Chen, 2007). As a result, the current study intends to present an expanded and more comprehensive understanding of the developmental and etiological components of DTTBTEDs that afflicted individuals commonly exhibit and that ultimately contribute to the disorder’s difficult-to-treat nature. This will help identify the specificities of treatment needs and further propose correspondingly appropriate advanced treatment approaches. The present
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