eating disorders: n adlerian approach to behavioral addictions berrier mp 2016.pdf · adlerian...

Running head: ADLERIAN APPROACH TO EATING DISORDERS 1

Eating Disorders: An Adlerian Approach to Behavioral Addictions:

A Literature Review

Presented to

The Faculty of the Adler Graduate School

___________________________

In Partial Fulfillment of the Requirement for

the Degree of Master of Arts in

Adlerian Counseling and Psychotherapy

___________________________

Chair: Richard Close, DMin, LPCC, LMFT

Reader: Rachelle Reinisch, DMFT

____________________________

By:

Donna M. Berrier

____________________________

September 2016

ADLERIAN APPROACH TO EATING DISORDERS 2

Abstract

Disordered eating is an ever-increasing problem in America today with a majority of the

population classified as obese. Current treatment methods focus on the medical model of

treatment, aimed at stabilization of the biomedical complications. As important as that is, it does

little for the overall recovery of the individual and leads to a lifelong pattern of relapse into the

behaviors associated with eating disorders (ED’s). Effective recovery from ED’s requires a

holistic approach that takes into consideration the family values and culture, private logic, social

interest, compensation and over compensation, and the mistaken beliefs of the individual.

Addressing the individual from a holistic perspective using Adlerian principles in psychotherapy

may improve the outcomes in the treatment of ED’s in all areas of functioning of the individual,

thus reducing the risk of co-occurring disorders, specifically substance use addiction. This

review explored, compared, and contrasted current treatment methods of ED’s by identifying

Adlerian techniques that could improve outcomes, thereby decreasing the incidence of relapse

and cross addiction to substances. Past research of Adlerian principles in the treatment of ED’s

was addressed. The discussion included how Adlerian principles included the behavioral

addiction associated with an ED. Recommendations to include Adlerian principles were

incorporated into the treatment planning for ED’s as a behavioral addiction. The conclusion

includes suggestions for future research and treatment modalities regarding ED’s as a behavioral

addiction.

Keywords: addiction, Adlerian, CBT, DBT, eating disorders, nonchemical addiction,

substance use disorders


Acknowledgements

I would like to thank the following individuals: Richard Close, DMin, LPCC, LMFT, for

his support and encouragement through the challenge of narrowing down the topic I was meant

to pursue for my Master’s Project, your guidance throughout this entire process is greatly

appreciated, and willingness to be the Chair for this Master’s Project has been a blessing;

Rachelle Reinisch, DMFT, for your ongoing support and encouragement to stay focused and

follow the path towards my self-defined goals as an individual, finding ways to overcome the

obstacles that often accompany adult learners, as well as accepting the role of the Reader; Susan

Pye Brokaw, MA for your encouragement and insight during individual and group supervision

that has allowed for my continued growth as a therapist; Thomas Wright, MTh, for a very

dynamic didactic experience, in both individual and group didactic, your gentle approach

opened the window to see and accept myself in ways unimaginable; Adler Graduate School

support staff for your availability for the past two years.

Thank you to my friends and family who have supported me through many cancelled

events, listened to my frustrations with this journey, and for being my greatest cheerleaders over

the course of my life, especially the past seven years. Thank you to my best friend, Marta

Parsons, for the time you dedicated to editing and revising in order that this project would

represent the intellectual and professional position I am establishing in the world. Thank you to

my parents, Dorwin and Deborah Berrier, for your support and guidance throughout my life, in

all the ups and downs and through my addiction. You have loved and supported me my whole

life. Thank you all for your part in making me who I am. I love you.


Table of Contents

Abstract ......................................................................................................................................... 2

Acknowledgements ....................................................................................................................... 3

Introduction ................................................................................................................................... 5

Eating Disorders ............................................................................................................................ 7

Anorexia Nervosa ........................................................................................................... 7

Bulimia Nervosa ........................................................................................................... 10

Binge Eating Disorder................................................................................................... 12

Adlerian Connections.................................................................................................... 14

Social interest ............................................................................................................ 14

Private logic .............................................................................................................. 16

Mistaken beliefs ........................................................................................................ 17

Life tasks ................................................................................................................... 18

Addiction ..................................................................................................................................... 19

Causes and Risks ......................................................................................................................... 22

Mental Health................................................................................................................ 24

Co-morbidity ................................................................................................................. 26

Cross Addiction ............................................................................................................. 26

Physical Dangers ........................................................................................................... 27

Treatment Options ....................................................................................................................... 28

Medical Model .............................................................................................................. 28

Psychotherapy ............................................................................................................... 30

Cognitive behavioral therapy .................................................................................... 30

Dialectical Behavioral Therapy ................................................................................ 32

Adlerian psychotherapy ............................................................................................ 33

Discussion ................................................................................................................................... 40

Conclusion ................................................................................................................................... 42

References ................................................................................................................................... 45


Eating Disorders: An Adlerian Approach to Behavioral Addictions

Introduction

According to the Centers for Disease Control, (2015), more than one-third of the adult

population in the United States and nearly 20% of minors are classified as obese. The Substance

Abuse and Mental Health Services Administration (SAMHSA) reported that 10% of the

population of the United States, age 12 and over meet criteria for a substance use disorder (SUD)

in 2014 (Substance Abuse and Mental Health Services Administration, 2015). Abundant

research exists to identify the cause of eating disorders (ED’s) and substance use disorders

(SUD’s). Past studies included ED’s and the following as contributing factors to ED’s: education

level, socioeconomic status, genetic predisposition, biomedical causes, and SUD’s (Keith et al.,

2006). An overwhelming focus of research favors the medical model of treatment (The National

Center on Addiction and Substance Abuse, 2016). The medical model of treatment for ED’s

focuses efforts on regulating food intake, exercise, and treatment of the biomedical

complications of ED’s (Ambrose & Deisler, 2010). The medical model of treatment for SUD’s

focuses efforts on detoxification, withdrawal management, and harm reduction, with some

treatments including cognitive behavioral therapy and psycho-education.

Eating disorders are associated with obesity and malnourishment (World Health

Organization, 2016). Both obesity and malnourishment present significant health threats to the

individual, resulting in a reduced life expectancy and quality of life. The World Health

Organization (WHO) monitors the statistics and risks associated with the increased numbers of

obese individuals across the globe and stated that “most of the world’s population live in

countries where obesity kills more people than underweight” (WHO, 2016, p. 1). The WHO


warned that obesity had become an epidemic and numbers had doubled in the past 30 years

(WHO, 2016).

The WHO defined obesity as “abnormal or excessive fat accumulation that may impair

health” (WHO, 2016, p. 2). Excess fat is measured according to a scale of Body Mass Index

(BMI) which is a ratio of height to weight. A BMI ratio at 25 or above is considered overweight

while a ratio above 30 is considered obese. A BMI ratio that falls between 18 and 24.99 is

considered “normal” while a ratio under 18 meets the diagnostic criteria for Anorexia (American

Psychiatric Association, 2013). The BMI standard of measure has become the professionally

accepted standard to diagnose a feeding and eating disorder. In 2013, the American Medical

Association officially recognized obesity as a disease, though it was not recognized as a

diagnosis by the American Psychiatric Association. Historically, many viewed weight problems

as a defect of character, implying that an individual was lacking self-will and motivation

necessary to maintain a healthy lifestyle and weight (DePierre, Rebecca M, & Luedicke, 2013).

Professionals in the field of addiction aligned with the belief that it was a moral defect or a

character defect when an individual failed to self-regulate and restrain from substance use

(DePierre et al., 2013). However, an addiction to food is more socially acceptable than addiction

to substances such as alcohol or nicotine (DePierre et al., 2013).

In the disease model, weight problems and ED’s are viewed as an implied inferiority in

one or more parts of the body. In the case of addiction, the disordered part of the body is the

brain, more specifically, the limbic system and prefrontal cortex (McCauley, 2009).

Unfortunately, identifying the disordered part or parts of the body that contribute to weight

problems and ED’s is not a simple task. The inferiority may be one specific organ, or a group of


organs, separately, or in conjunction with the brain. Research has not been able to clearly

identify an exact cause for ED’s.

This paper will discuss the similarity of effects of ED’s and SUD’s on the individual

including the impact of the disease on life expectancy, current treatment methods, and existing

research on ED’s and SUD’s. Specific attention to how social interest, private logic, and

mistaken beliefs must be addressed in order to maintain recovery from the disease and

achievement in all life tasks. The paper will conclude recommendations for the possible future

research and treatment of individuals coping with ED’s.

Eating Disorders

ED’s are defined by a “persistent disturbance of eating or eating-related behavior that

results in the altered consumption or absorption of food and that significantly impairs physical

health or psychosocial functioning” (American Psychiatric Association, 2013, p. 329). ED’s are

further broken down into differing types, defined by the specific behaviors that are associated

with each type. Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED),

Ruminating Disorder, and Pica are the identified types of ED’s in the current Diagnostic and

Statistical Manual of Mental Disorders, (5th ed.; DSM-V; American Psychiatric Association,

2013). Each type of ED poses a significant physical and mental health risk on the individual.

The individual engages in behaviors that distort normal eating patterns, leading to consequences

in all life areas (Schneider, 2015, p. 151). The focus of this paper will be AN, BN, and BED.

Anorexia Nervosa

AN, more commonly known as Anorexia, is a condition that is often identified when an

individual’s weight is significantly below what is considered normal or typical for the

individual’s height and age. The individual has an excessive focus on body image accompanied


by a fear of gaining weight (Schneider, 2015, p. 153). This fear manifests itself with a set of

distorted perceptions that lead the individual to engage in atypical behaviors aimed at

minimizing the risk of the fear becoming a reality. AN is more common in females, and 10 times

more prevalent in higher-socio-economic countries (American Psychiatric Association, 2013).

Approximately one percent of the population of the United States has AN (Wilfley, 2015). AN is

most commonly presented in adolescence or early adulthood and is associated with a higher

value on thinness (National Eating Disorders Association, 2015). This disease may be chronic

and is often accompanied by co-occurring depressive disorders, substance use disorder, and

obsessive compulsive behaviors (Wiffley, 2015). AN most often develops in adolescence, rarely

before puberty or after age 40 (American Psychiatric Association, 2013).

The DSM-V diagnostic criteria for AN includes:

Restriction of energy intake relative to requirements, leading to a significantly low

body weight in the context of age, sex, developmental trajectory, and physical health.

Significantly low weight is defined as a weight that is less than minimally normal or,

for children and adolescents, less than that minimally expected.

Intense fear of gaining weight or of becoming fat, or persistent behavior that

interferes with weight gain, even though at a significantly low weight.

Disturbance in the way in which one’s body weight or shape is experienced, undue

influence of body weight or shape on self-evaluation, or persistent lack of recognition

of the seriousness of the current low body weight (AMERICAN PSYCHIATRIC

ASSOCIATION,2013, pp. 338-339).

The restriction of food intake occurs when an individual maintains a minute number of

calories per day (National Eating Disorders Association, 2015). When limited calories are


consumed, an individual lacks adequate calories to supply the necessary energy for the body to

function. Over the course of the disease, the individual will have a reduced BMI. The severity

of the disease is rated by the individual’s BMI ratio (American Psychiatric Association, 2013).

For instance, a BMI ratio under 17 is considered a mild specifier for AN, while a BMI under 15

is considered an extreme specifier for AN (American Psychiatric Association, 2013).

The compensatory behaviors that accompany AN can lead to severe physical distress.

Bone density is decreased, menstrual cycles cease to occur, gastric disorders develop, and

suicidal risk is increased with individuals with AN (Schneider, 2015, p. 154). Brain scans of

individuals with AN noted a decrease in grey matter (Kaye, Wierenga, Bailer, Simmons, &

Bischoff-Grethe, 2013). Kaye et.al. (2013) reported that fMRI imaging showed changes in the

reward circuits of the brain when an individual with AN engages in compensatory behaviors.

These individuals reported a temporary relief of dysphoric mood when engaging in food

restriction (Kaye et al., 2013).

AN is one of the most dangerous of all ED’s. As the individual continues their

compensatory behaviors, the body becomes starved of the necessary nutrition for normal

functioning. This leads to major medical complications, up to and including death (Mayo Clinic

Staff, 2016). This is one of the primary reasons that the treatment for ED’s is focused on the

medical model. Achieving stabilization of the medical complications resulting from AN require

attention from a biomedical perspective in order to preserve life, as it has a very high mortality

rate. The mortality rate of death for AN is 12 times higher than that of all leading causes of

death for females between the ages of 15-24 (American Psychiatric Association, 2013, p. 343)

and was reported as the most lethal of all psychiatric illnesses (Vazzana, 2009). Approximately

five percent of individuals diagnosed with AN die from suicide.


Bulimia Nervosa

BN, more commonly known as Bulimia, is another type of ED that involves feeding

binges followed by self-induced purging. These individuals will often eat very large amounts of

food and then stimulate themselves to vomit in an attempt to rid their body of the food consumed

and avoid weight gain. BN is 10 times more common in women than men (Schneider, 2015, p.

158). BN affects roughly one and a half percent of the population of the United States (Wilfley,

2015).

DSM-V Diagnostic criteria for BN includes:

Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following: eating, in a discrete period of time (e.g., within any two-hour

period), an amount of food that is definitely larger than what most individuals would

eat in a similar period of time under similar circumstances, and a sense of lack of

control over eating during the episode (e.g., a feeling that one cannot stop eating or

control what or how much one is eating).

Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such

as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting,

or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average,

at least once a week for three months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of anorexia nervosa

(American Psychiatric Association, 2013, p. 345).


Individuals diagnosed with BN report a lack of control during a binge and often refer to

their behavior as an addiction (Schneider, 2015, p. 158). The episodes of binging often occur in

private and are accompanied by symptoms of depression, anxiety, social anxiety, and a

preoccupation with weight and body image (2015, p. 158). This disorder, like AN, has a

significant co-morbidity rate with other mental illnesses, substance use, and an increased risk of

suicide. The severity of the disorder is determined based upon the frequency and duration of

episodes per week (American Psychiatric Association, 2013).

Like AN, BN has a list of biomedical effects that occur as a result of the compensatory

behaviors of the disorder. Due to the increased presence of acid from the purging cycles, dental

problems are increased as well as laxative dependence, tissue damage, cardiac disorders, and

irregular menstrual cycles, hormonal changes, infertility, osteoporosis, anemia, organ failure, and

neurological problems (Schneider, 2015, p. 159; Vazzana, 2009). Dental professionals play an

important part in identifying BN, as they are often the first to see the damage caused by acid

erosion during routine dental appointments (Mayo Clinic Staff, 2016).

Mortality rates for BN are not as high as with AN (American Psychiatric Association,

2013). Both AN and BN show an increased risk of suicide. The increase in suicide rates are

often the result of the individual’s co-occurring mental illness and their inability to achieve their

body image and weight (Suzuki, Takeda, & Yoshino, 2011). The individual seeks to achieve a

body image and weight that is irrational, unrealistic, and rooted in private logic that values a

particular body type as a condition of individual worth. When the individual is unable to

maintain their privately held standard, other compensatory behaviors are engaged (Suzuki et al.,

2011). This can often include substance use, obsessive compulsive behaviors, and suicide

attempts that are aimed at reducing the distress from an unachievable goal.


Binge Eating Disorder

BED became a formal diagnosis in the DSM-V, though it was first documented in the

previous edition as a provisional diagnosis (Wilfley, 2015). BED is the most common of all of

the ED’s, affecting three and a half percent of the population of the United States (Wilfley,

2015). BED involves a similar pattern of eating that is seen in BN, that is, eating large quantities

of food in a short period of time (Wilfley, 2015). The individual frequently eats to the point of

physical discomfort and describes a loss of control during the binge. Compare this to the

excessive amounts of food that some people eat at Thanksgiving dinner, the individual with BED

engages in this manner of eating as a regular occurrence, ranging from once a week to over 14

times per week (American Psychiatric Association, 2013, p. 350). The eating behavior is not

done as a manner of satiating a feeling of hunger, rather, it is out of control and without

conscious awareness of how much has been consumed. This is often followed by feelings of

shame and embarrassment, with the individual feeling marked distress (Wilfley, 2015). The

difference between BED and BN is the absence of purging following an eating episode for BED

(American Psychiatric Association, 2013).

The DSM-V diagnostic criteria for BED includes:

Recurrent episodes of binge eating. An episode of binge eating is characterized by

both of the following: eating, in a discrete period of time (e.g., within any two-hour

period), an amount of food that is definitely larger than what most people would eat

in a similar period of time under similar circumstances, and a sense of lack of control

over eating during the episode (e.g., a feeling that one cannot stop eating or control

what or how much one is eating).


The binge-eating episodes are associated with three (or more) of the following: eating

much more rapidly than normal, eating until feeling uncomfortably full, eating large

amounts of food when not feeling physically hungry, eating alone because of feeling

embarrassed by how much one is eating, or feeling disgusted with oneself, depressed,

or very guilty afterward.

Marked distress regarding binge eating is present.

The binge eating occurs, on average, at least once a week for three months.

The binge eating is not associated with the recurrent use of inappropriate

compensatory behavior as in bulimia nervosa and does not occur exclusively during

the course of bulimia nervosa or anorexia nervosa (American Psychiatric Association,

2013, p. 350)

The severity of the disorder is determined by the frequency of binge-eating episodes that

occur in a week. Mild severity is indicated by one to three binge-eating episodes in a one-week

period. Extreme severity is indicated by 14 or more binge-eating episodes in a one-week period

(American Psychiatric Association, 2013). The compensatory behaviors of BED include a

pattern of dieting and attempts at dietary restriction (Schneider, 2015, p. 165). Binge eating is

also part of the criterion for impulsive disorder, a disorder that accompanies borderline

personality disorder (American Psychiatric Association, 2013).

There are accompanying biomedical risks associated with BED. The risks include

increased body weight, heart problems, increased risk for Type II diabetes, gall bladder

complications, digestive gastrointestinal problems, muscle and joint pain, and co-occurring

mental health disorders including bipolar disorders, depressive disorders, anxiety disorders and


substance use disorders (American Psychiatric Assocation, 2013, p. 353). Obesity increases the

risk of BED by up to four times over individuals who are not obese (Wilfley, 2015).

Individuals with BED often resort to bypass surgery as a final attempt at managing their

eating behaviors and as a way to satisfy their irrational preoccupation with losing weight

(Mitchell et al., 2015).

Adlerian Connections

The medical health risks of ED are significant. There are also psychological factors to be

considered. There are further implications in the social interest, private logic, and mistaken

beliefs that are often in line with perfectionism and inferiority feelings experienced by the

individual with ED. The ED impedes the individual from growing in other life task areas

(Schneider, 2015, p. 152).

Social interest. Social interest, identified by Alfred Adler by the term,

Gemeinschaftsguefühl and also referred to as community feeling, is related to an individual’s

connection and belonging to the community and humanity (Griffith & Powers, 2007, p. 11).

Alfred Adler stated that striving for perfection is a way to find a place to belong and engage in

social interest (Adler, 1992). Adler believed that belonging was an essential need for all

individuals, that without belonging, there is no internal value and connection to the community

(Adler, 1992). Social interest refers to one’s responsibility to the community in which one lives

and by how that community is impacted by the individual and the individual’s contributions

(Griffith & Powers, 2007). Griffiths described social interest as the “universal human capacity”

as a learned behavior that must be fostered and developed much like one develops language and

speech ((Griffith & Powers, 2007).


An individual with an ED or SUD lacks social interest. If the individual grew up in a

home where a particular appearance was valued, their focus is turned to obtaining and

maintaining that appearance ideal (Belangee, 2006). The individual is preoccupied with a need

for perfection in order to feel value, worth, and connection. The individual is motivated toward a

model of perfection that is skewed by an inaccurate ideal of body image as the goal to be

achieved in order to be loved.

Egan, Wade, and Shafran (2010) stated that perfectionism was one of the maintaining

factors for ED. Their research indicated that elevated levels of perfectionism increased

vulnerability to the disorder. This increased vulnerability leads to a perpetuation of the obsessive

behaviors associated with ED and co-occurring substance use (Egan et al., 2010). Kaye et al.

(2013) also identified a correlation between perfectionism and ED, noting that a reduction in the

behaviors associated with the ED did not reduce the level of perfectionism in the individual. In

addition to the increase in vulnerability, retrospective reports of childhood perfectionism

correlated with later development of an ED (Egan et al., 2010). The individual with a high level

of perfectionism becomes consumed with self and engages in compulsive behaviors in an effort

to achieve perfection, thus impairing their engagement and connection with others. This

behavior pattern further limits their feeling of love, worth, and connection to others. Ansbacher

discussed this by stating, “children who have a noticeable organ inferiority . . .who are insecure

and feel humiliation . . . dispose to neurosis” (Ansbacher & Ansbacher, 1964, p. 164)

Neurosis was defined by Alfred Adler as a behavior pattern in which the individual holds

a mistaken opinion of him or herself in comparison with the world and, therefore, resorts to

various forms of abnormal behavior that strives to preserve the individual’s opinion of him or

herself (Ansbacher & Ansbacher, 1964, p. 240). When the individual is unable to meet the


perceived demands of the world, the individual retreats into a pattern of self-centered behavior

that lacks connection to others and is not in the conscious awareness of the individual engaging

in the behavior (Ansbacher & Ansbacher, 1964). This neurotic behavior prevents the individual

from achieving social interest and is perpetuated by the individual’s private logic. When the

individual feels unable to maintain and overcome their perceived deficit,

the danger arises that in striving for compensation she will not be satisfied with a simple

restoration of the balance of power. She will seek to tip the scales in the opposite

direction. In such cases the striving . . . may become so exaggerated and intensified that it

must be called pathological, and the ordinary relationships of life will never be

satisfactory (Adler, 1992, p. 71).

This constant pressure to strive for compensation and perfection creates increased levels

of anxiety in the individual. The high-anxiety that is associated with AN is often persists after

weight restoration, increasing the relapse risk for the individual with AN (Kaye, Wierenga,

Bailer, Simmons, & Bischoff-Grethe, 2013). Perfectionism and striving to overcome are also

highly correlated with SUD’s.

Private logic. Private logic is a term that was adapted from Alfred Adler’s term, “private

intelligence” (Griffith & Powers, 2007, p. 81). Private logic is defined by a false sense of

reasoning that is derived from the individual’s inner world. It is attached to an individual’s self-

identified meanings that the individual uses to attempt to make sense of their world and explain

otherwise senseless behaviors (Griffith & Powers, 2007). Private logic is basically described as

the absence or departure from common sense (Griffith & Powers, 2007).

An individual with an ED is operating from a private logic that influences their behavior.

The general population would not likely resort to the compensatory behaviors associated with an


ED as a solution to managing weight and body image. Sperry et al. stated that “within the social

context, the anorexic develops a psychological belief system and set of fictive goals, such as

perfectionism or the desire to remain a child (2015). Body image distortion in the individual

with AN is a prime example of private logic. Research indicates a distinct brain alteration that

points to impaired integration of visual information (Kaye et al., 2013). This may explain why

the individual with AN sees him or herself as overweight when they look in the mirror, when in

reality the individual is severely emaciated and underweight. As a result of the fictive goals

rooted in private logic, the individual with AN is driven to compensatory behaviors in an effort

to achieve their self-defined ideal of perfection.

Mistaken beliefs. Similar to private logic is the Adlerian concept of mistaken beliefs.

Alfred Adler proposed that an individual is consistently motivated towards a self-defined goal

based upon a perception of the world as the individual interprets it. This perception, regardless

of accuracy, is embraced as truth, and establishes itself as a belief that lacks evidence or

credibility. Based upon an individual’s early life experiences, the individual develops a pattern

of beliefs about what one is, what one should be, how certain genders should operate, and ethical

codes for the world at large (Ansbacher & Ansbacher, 1964, p. 93).

An individual’s mistaken beliefs about him or herself and the world can be a major

influence on behavior and are often not in the conscious awareness of the individual (1956).

Without conscious awareness, the individual is likely to perpetuate behaviors that are not

purposeful and productive in the context of the world or social interest. This further alienates the

individual from the connection and belonging that their purposeless behavior is aimed at

overcoming, thus perpetuating the neurosis (Ansbacher & Ansbacher, 1964, p. 244). One

commonly held mistaken belief is that an individual must be perfect in order to be loved.


The exact cause of ED is not defined. The Mayo Clinic lists a variety of causes,

including psychological distress relating to low self-esteem, perfectionism, troubled

relationships, and impulsive behaviors (Mayo Clinic Staff, 2016). Egan and colleagues also

identified perfectionism as a maintenance factor with ED (Egan, Wade, & Shafran, 2010).

Ansbacher and Ansbacher stated that “. . . the ever-unsatisfied seeking for solution to the

problem of life, belongs to this longing for perfection of some sort” (Ansbacher & Ansbacher,

1964, p. 156). Every individual has a desire to overcome some challenge, to reach some self-

identified goal. The individual with an ED seeks to overcome and achieve the goal of perfection,

an unobtainable goal. Perfectionism is one of the maintaining factors of EDs, even during

periods of remission from the ED behaviors (Kaye et al., 2013).

Life tasks. An individual that is caught in a neurotic way of life is unable to meet the

tasks of life. Alfred Adler identified three life tasks, which he referred to as the “three general

social ties” (Ansbacher & Ansbacher, 1964, p. 231). The three life tasks include: love and

marriage, occupation, and social relations (Griffith & Powers, 2007, p. 64). Each individual

must meet all three life tasks. The three life tasks are interconnected and inseparable. The life

tasks are viewed as the bond that links people together for “association, for the provision of

livelihood, and for the care of offspring” (Ansbacher & Ansbacher, 1964, p. 231).

The life task of love and marriage includes the connection and cooperation of an

individual with a member of the opposite gender for the sake of procreation and continuation of

humanity. Human life cannot be created without the cooperation of a man and a woman when

the male sperm penetrates the female egg (Baby Center Medical Advisory Board, 2014). The

life task of occupation involves cooperation with others to work in order to meet the basic needs

of existence such as food and shelter. Each individual has a responsibility to contribute


something in exchange for what they need to exist and is limited to the resources of the planet

(Griffith & Powers, 2007). The life task of friendship, also referred to as the social task,

identifies that we are born into a world of other people and all are affected by our existence in the

world. Building social connections enriches the value of the community and are based upon our

respect and value for one another. Without the connection to one another, no one individual can

exist.

ED behavior occurs in private. The individual with ED engages in their behavior when

no one is around. The individual with BN often excuses him or herself to the restroom after a

binge in order to self-induce vomiting and rid their body of the food they just consumed. The

individual with AN uses strategic methods to escape eating all together, often avoiding situations

where they would be forced to eat in front of other people. The individual with BED engages in

their behavior in isolation out of a fear of embarrassment over how much they are eating. Each

of these ED’s involves removing the individual from their connection to others, and as the

disease progresses, the isolation increases. Isolation from others prevents the individual from

engaging in the social life task. Their relationships are strained by the medical complications

that accompany the ED. Work is missed due to illness and hospitalizations that are necessary to

preserve the life of the sufferer. An individual with an ED is unable to engage the tasks of life.

Addiction

According to the American Society of Addiction Medicine, the short definition of

addiction is “a primary, chronic disease of brain reward, motivation, memory, and related

circuitry” (American Society of Addiction Medicine, 2011). Addiction impacts the biological,

psychological, social, and spiritual dimensions of the individual. The individual presents with an

impairment in behavior, relationships, and emotional responses to their environment (2011).


Generally speaking, public perception of addiction focuses on substance use (DePierre, Puhl &

Luedicke, 2013), with current identification of addiction as a substance use disorder (SUD).

More recently, addiction now includes certain identified behaviors such as gambling, sex, video

gaming, and internet use (American Society of Addiction Medicine, 2011). The public view of

addiction is stigmatic, evoking disapproval and rejection (Boekel, Brouwers, Weeghel, &

Garretsen, 2013).

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.: DSM-V) identifies

addiction under the category of substance-related and addictive disorders (American Psychiatric

Association, 2013). Within the category of substance-related disorders, a broad array of

substances is listed and differentiated. The types of substances that are included in the diagnostic

category include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative-

hypnotic-or anxiolytics, stimulants, and tobacco. The only non-substance-related disorder

included in the DSM-V, is gambling disorder.

The diagnostic criteria for a substance-related use disorder includes:

A problematic pattern of use leading to clinically significant impairment or distress, as

manifested by at least two of the following, occurring within a 12-month period:

The substance is often taken in larger amounts or over a longer period than was

intended.

There is a persistent desire or unsuccessful efforts to cut down or control use.

A great deal of time is spent in activities necessary to obtain, use, or recovery from

the its effects.

Craving, or a strong desire or urge to use the substance.


Recurrent substance use resulting in a failure to fulfill major role obligations at work,

school, or home.

Continued substance use despite having persistent or recurrent social or interpersonal

problems cause or exacerbated by the effects of substance.

Important social, occupational, or recreational activities are given up or reduced

because of substance use.

Recurrent substance use in situations in which it is physically hazardous.

Substance use in continued despite knowledge of having a persistent or recurrent

physical or psychological problem that is likely to have been caused or exacerbated

by the substance.

Tolerance, as defined by either of the following: a need for markedly increased

amounts of the substance to achieve intoxication or desired effect, or a markedly

diminished effect with continued use of the same amount of the substance.

Withdrawal, as manifested by either of the following: the characteristic withdrawal

syndrome for the substance, or use of the substance (or a closely related substance) is

taken to relieve or avoid withdrawal symptoms. (American Psychiatric

Association, ,2013).

The DSM-V includes a code to indicate the current severity as a specifier. A mild

specifier is indicated by the presence of two or three symptoms. A moderate specifier is

indicated by the presence of four or five symptoms. A severe specifier is indicated with the

presence of six or more symptoms.

The International Classification of Disease, tenth edition (ICD-10), a coding system

developed by the WHO includes a category for “mental and behavioral disorders due to


psychoactive substance use” to identify ED, SUD, and behavioral addictions (World Health

Organization, 2010). The diagnostic criteria are differentiated according to frequency, use,

abuse, intoxication, and dependence levels. Coding levels are used to indicate the level of use

and the current stage of treatment. The ICD-10 is the universally accepted coding system for

managed care and insurance billing.

Causes and Risks

The causes of ED’s and SUD’s vary depending upon the school of thought.

Psychodynamic theorists identified ED’s and SUD’s as the manifestation of unresolved early

childhood conflicts or responses to childhood traumas (Torrens, Rossi, Martinez-Riera,

Martinez-Sanvisens, & Bulbena, 2012). Cognitive behavioral theorists attribute ED’s and SUD’s

to faulty cognitive function resulting in irrational thought patterns (Belangee, 2006). Family

systems theorists attach the causes to family environment (2006). The medical model focuses on

the effects of improper nutrition and the activity level of the individual (Ambrose & Deisler,

2010).

The complications associated with ED’s and SUD’s tend to be the primary focus of

treatment. Both ED’s and SUD’s have high mortality rates, co-occurring mental illness

considerations, and medical complications that result from the behaviors that accompany ED’s

and SUD’s (American Psychiatric Association, 2013).

The risk factors associated with ED’s begin with the age of the individual. Symptoms

often appear in early adolescence (Kaye et al., 2013). Late adolescent Caucasian females have

the highest rates of ED’s (Vazzana, 2009). Life transitions such as moving from junior high to

high school or a geographical change can place additional stress on the adolescent individual

(Vazzana, 2009). Navigating these types of transitions can increase the risk of developing an


ED. Additionally, certain personality traits associated with perfectionism, anxiety, and

impulsivity are risk factors (Vazzana, 2009). Extracurricular activities such as ballet, modeling,

or occupations that require optimum physical form can also increase risk (Vazzana, 2009).

Lastly, a history of physical or sexual trauma is a significant risk factor for developing an ED

(Vazzana, 2009).

SUDs have a similar pattern of causes and risk factors. In addition to the risk factors

associated with ED’s, SUD’s have a genetic component related to family history of SUD’s.

Initial substance use often occurs in early adolescence, triggered by the pressure from the

individual’s peer group (National Institute on Drug Abuse, 2014). The National Institute on

Drug Abuse reported that abuse of substances often occurs in adolescence and early adulthood

(National Institute on Drug Abuse, 2014). The symptoms and phases of use for individuals with

SUD’s starts with early experimentation and ends with late-stage dependence (Larson, 1999).

The first contact with substances usually occurs in early adolescence and progresses as the

individual continues to use (Larson, 1999). With continued use, the individual is less inhibited

and places him or herself at risk for other injuries and illnesses, such as car accidents and blood-

borne diseases. Drug seeking behavior places the individual in dangerous environments.

Withdrawal and relapse are significant risk factors for the individual with an SUD.

Alcohol withdrawal can cause central nervous system failure and seizures, sometimes leading to

death (Sutton, 2016). A relapse on opioids can be fatal due to changes in tolerance after

sustained abstinence (Woody, Krupitsky, & Zvartau, 2016). Engaging in substance use during

adolescence can impair brain development and function, leading to permanent damage (Conrod

& Nikolaou, 2016).


The common causes and fatal outcomes for both ED’s and SUD’s indicates an association

between the two. Co-morbidity statistics indicate a strong relationship between ED’s and SUD’s,

with the exception of AN (American Psychatric Association, 2013). Binge Eating Disorder has a

strong correlation with SUD’s, most commonly, alcoholism (Gregowski, Seedat, & Jordaan,

2013). Both ED’s and SUD’s can lead to fatality (American Psychiatric Association, 2013).

Mental Health

The WHO defined mental health as, “a state of well-being in which every individual

realizes his or her own potential, can cope with the normal stresses of life, can work productively

and fruitfully, and is able to make a contribution to her or his community” (World Health

Organization, 2014). This definition encompasses the overall functioning of the individual and

includes the ability for self-regulation of emotional responses to life that enable the individual to

perform life tasks in a positive and contributory manner. An individual with a positive state of

mental health is able to participate in daily life without a limit to their functioning or significant

impairment. An individual with a mental disorder is impaired in their ability to function in one

or more life areas, as indicated by the diagnostic criteria for the specific disorder (American

Psychiatric Association, 2013).

The WHO stated that roughly 20% of the children in the world have a diagnosable mental

disorder (World Health Organization, 2016). The WHO also identifies mental disorders as the

leading cause of disability (World Health Organization, 2016). Having a mental disorder also

increases risk for other medical complications including heart disease and diabetes (World

Health Organization, 2016).

The exact cause of mental disorders is unknown. Research and public opinion on the

causes of mental disorders are wide ranging, including, but not limited to, heredity, organ


inferiority, environmental influences, and trauma responses or other adverse events (Belangee,

2006). Regardless of the cause of mental disorders, treatment and management is a significant

financial burden on society and takes an emotional toll on families and community.

Mental health disorders vary and affect different areas of functioning. Some mental

health disorders are more limiting than others. Differentiation of the mental health disorders is

provided in the DSM-V according to categories that separate based on symptomology and level

of impairment. Some mental health disorders appear to be organic in nature, caused by a

medical or physical disease, while others likely to have environmental causes (Laegeforen,

1990). Eating Disorders and Substance Use Disorders are listed in the DSM-V as mental

disorders.

Organic illnesses are indicated by biochemical indications. Non-organic disorders are

indicated by distressing experiences or undesirable behavior (Laegeforen, 1990). Eating

Disorders are believed to be both organic and non-organic. Having a family member with an ED

increases the individual’s risk of developing an ED (Vazzana, 2009). Recent research has

identified a 50 – 80% genetic hereditability risk for development of ED’s (Kaye et al., 2013).

Substance Use Disorders are often to be both organic and non-organic, as there is both a

genetic and an environmental link (Bevilacqua & Goldman, 2009). McCauley stated that SUD’s

are a disease based on a combination of genetics, brain function, memory, environment, and

choice (McCauley, 2009), Despite the organic link of SUD’s, an individual will not develop an

SUD without using a psychoactive substance or engaging in addictive behaviors. Likewise, an

individual will not develop an ED without engagement in ED defined behaviors.


Co-morbidity

The National Institute on Drug Abuse indicated that co-morbidity occurs when two or

more illnesses or disorders are indicated in the same person (National Institute on Drug Abuse,

2010). Co-morbidity is common in individuals with ED’s (Hughes, et al., 2013). A review of

several studies indicated that ED’s and anxiety disorders frequently occur (Swinbourne & Touyz,

2007). Deep et al. reported a 79% co-morbidity of an anxiety disorder preceding the diagnosis of

an ED (Deep, Nagy, Weltzin, Rao, & Kaye, 1995). Hughes et al. reported 88-97% of individuals

with ED’s have a co-morbid psychiatric disorder (Hughes et al., 2013). Research has not

established causality of a psychiatric disorder for development of ED’s. However, Swinbourne

and Touyz identified several studies that indicated co-morbidity of ED’s and anxiety disorders

and Lüthi and Lüscher identified similar synaptic mechanisms and circuity between individuals

with anxiety disorders and addiction (Lüthi & Lüscher; 2014 Swinbourne & Touyz, 2007).

Those studies implied a need for thorough assessment and treatment options when working with

individuals with ED’s and SUD’s in order to address possible co-morbid disorders.

Cross Addiction

Cross-addiction relates to the risk of an individual who is dependent on a psychoactive

substance to become dependent on another psychoactive substance (Troncale, 2014). The

disease of addiction impairs the dopamine regulation in the brain, resulting in a dysregulation the

limbic system (Troncale, 2014). The brain is not able to identify the difference between

psychoactive substances, thus increasing the risk of cross addiction to a new psychoactive

substance (2014). Behavioral addictions such as gambling, shopping, and sex can all be linked

to the same reward circuits in the limbic center of the brain (Blum et al., 2014). In their review,

Blum et al. identified the dopaminergic pathways that are involved in both substance and non-


substance addictive behaviors (2014). Demetrovics stated that the “diagnostic symptoms of

some psychiatric disorders and accompanied behavioral features of drug problem may

significantly overlap” and that “substance use compensates for a psychological disorder” (2009,

p. 426).

Suzuki, Takeda, and Yoshino completed a study that linked past research with their study,

which indicated that comorbid alcoholism is a major factor in the death of ED patients (2011).

The overall results of the study reported the causes of death included alcohol related disorder,

suicide, and eating disorder-related causes such as heart disease (Suzuki et al., 2011, p. 329).

Interestingly, the deaths occurred within five years of initial admission for treatment of either ED

or SUD, indicating an increased mortality risk when faced with cross addiction.

Physical Dangers

Both ED’s and SUD’s have physical dangers. For the individual with an ED, the physical

dangers are the medical complications that result from engaging in ED behaviors. Substance

Use Disorders have physical dangers that include medical complications as well as

environmental dangers that result from engagement in the addictive behaviors.

The medical complications that result from SUD’s vary in severity based upon the

substance used, method of use, and frequency of use. Harm reduction models seek to mediate

the physical dangers of SUD’s by reducing drug-seeking behavior that leads to physical danger

and medical complications (Clarke et al., 2016). Some harm reduction models include programs

for needle exchange for intravenous drug users, medication assisted treatments for opioid

dependence, and wet houses for individuals with chronic alcoholism (Clarke et al., 2016).

A wet house is a residential facility that provides an individual with alcohol, provided

they remain on site during consumption. By providing an environment that is staffed and


supervised, the wet house alleviates some of the risks of chronic alcoholism by reducing public

intoxication and emergency room visits (Maremmani, Cibin, Pani, Rossi, & Turchetti, 2015).

Harm reduction is one treatment option for ED’s and SUD’s (Westmoreland & Mehler, 2016).

Treatment Options

Current treatment options for ED’s, behavioral addictions, and SUD, include

psychoeducation that focuses on the risk factors of the disorders, psychopharmacological

interventions, harm reduction, and biomedical stabilization (Gregowski, Seedat, & Jordaan,

2013). Screening and assessment for ED’s and SUD’s is limited in primary care due to the

individual’s psychological investment in maintaining the disorder and reluctance to seek

treatment (Gregowski et al., 2013). There are standardized screening or assessment

questionnaires available to identify the presence of an ED or a SUD. However, the guilt, shame,

and reluctance to report symptoms can reduce the reliability of the screening and assessment

tools (Gregowski et al., 2013). Conason et al. (2006) advised that direct interviewing was most

effective at detecting an ED or SUD. The co-morbidity statistics of ED’s and SUD’s indicated

the importance of a full medical and psychiatric evaluation when one disorder has been identified

(Gregowski et al., 2013). Regardless of the diagnosis, medical stabilization is necessary prior to

engaging in any therapeutic treatment interventions (Torrens et al., 2012).

Medical Model

The medical model of treatment varies among the differing types of EDs. Anorexia

Nervosa, BN, and BED each have their own host of medical complications. Anorexia Nervosa

leads the individual to an emaciated physical condition, often with accompanying cardiovascular

and hormonal irregularities that impact all bodily systems. Anorexia Nervosa has the highest


mortality rate of all psychiatric illnesses, up to 25% (Vazzana, 2009). Malnutrition from AN is

associated with changes in brain structure and a reduction in grey matter (Kaye et al., 2013).

An individual with AN does not usually seek treatment willingly. The cognitive

distortions, guilt, shame, and embarrassment prevent the individual with AN from openly asking

for help (Hart, Jorm, & Paxton, 2012). Treatment is avoided for an average of 5 years (2012). If

the individual with AN has reached the point of immediate danger, treatment begins in the

emergency department of the hospital to stabilize heart dysrhythmia, dehydration, and electrolyte

imbalances (Mayo Clinic Staff, 2016). In extreme cases of AN, the individual may require a

feeding tube to provide adequate nutrition for bodily function (Mayo Clinic Staff, 2016). Care

for the individual with AN is managed and coordinated by the primary care doctor. According to

Mayo Clinic staff, the first goal for treatment of AN is weight stabilization that is within a

normal range for age, size, and body composition (Mayo Clinic Staff, 2016).

Once the individual is stabilized, and has established a normal heart rhythm, proper

hydration, and electrolyte balance, the individual is recommended for additional treatment

(Mayo Clinic Staff, 2016). Additional treatment for AN occurs in a setting that is staffed by

providers with training and education in ED’s (Vazzana, 2009). These treatment options include

outpatient, partial hospitalization, day treatment, and residential programs (Vazzana, 2009). The

level of service is recommended based upon the severity of the disease, and the individual’s

willingness to engage in treatment.

In the medical model of treatment for AN and BN, the focus is on eating patterns and

nutrition. The Melrose Center, a division of Park Nicollet, is a treatment center for ED’s located

in Minneapolis, MN. The Melrose Center identified the primary goals of residential treatment

for AN as: restoring weight, stopping symptoms, and understanding and managing emotions


(Park Nicollet: Melrose Center, 2016). The individual is offered psychiatry, psychology services,

24-hour nursing care, nutrition counseling, and medical services from a physician (Melrose

Center, 2016). There are three known facilities in Minnesota that provide similar residential and

inpatient services. They are The Melrose Center, The Emily Program, and Timberline Knolls.

Many hospitals provide treatment for ED’s as part of their psychiatric units. Residential and

inpatient programs are indicated by the presence of significant medical complications.

The treatment for BED in a medical setting is commonly managed by the individual’s

primary care provider. The goals of treatment include stabilization of the complications of BED,

including obesity, cardiovascular disorders, diabetes, and other organ complications relating to

BED.

Psychotherapy

Merriam Webster dictionary defined psychotherapy as, “treatment of mental or emotional

illness by talking about problems rather than by using medicine or drugs” (Psychotherapy, n.d.).

Psychotherapists vary in their theoretical orientation and in the techniques they use in practice.

This review will discuss the theoretical orientations and techniques that have most commonly

been used in treatment of ED’s and SUD’s.

Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) was developed by

Aaron T. Beck in the 1960s (Foundation for Cognitive Therapy and Research, 2016). Beck’s

practice in psychoanalytic theory coupled with research on depression led him to the discovery

of the power of thought in the symptomatic presentation of depression (Foundation for Cognitive

Therapy and Research, 2016). After years of further research, CBT has become one of the most

common forms of treatment for a variety of mental disorders. Cognitive Behavioral Therapy is


widely used in treatment settings and is considered an evidenced based practice that can be

applied to a variety of disorders (Witkiewitz & Marlatt, 2011).

CBT is based on the idea that individual perceptions to situations cause emotional

responses to the situations (Foundation for Cognitive Therapy and Research, 2016). Each

individual perceives the world through a different lens. CBT proposes that the individual’s

perceptions of the world are plastic, changing according to the individual’s emotional state at the

time of perceiving (Foundation for Cognitive Therapy and Research, 2016). Cognitive Behavior

Therapy can be applied to the development of coping skills training and relapse prevention by

identifying the cognitions related to the situation that is challenging (Witkiewitz & Marlatt,

2011).

The process and technique of doing CBT are based on Beck’s “ABC” model of

identifying contributing factors to the disturbance (Foundation for Cognitive Therapy and

Research, 2016). The process begins with the individual recognizing the activating event, or

“A”, that precipitated the emotional disturbance (Foundation for Cognitive Therapy and

Research, 2016). The “B” in the ABC model is the individual’s belief about the activating event

(Foundation for Cognitive Therapy and Research, 2016). The “C” in the ABC model is the

consequence of having the belief that was identified.

The technique of CBT involves working to gain insight into the connections between

specific events and their beliefs about the events. This is believed to be the cause of the behavior

or symptoms present (Foundation for Cognitive Therapy and Research, 2016). The belief is the

area of focus of CBT, as this is most often the source of the distress. The clinician works with

the individual to challenge the belief for rationality in the present environment and move towards


changing irrational beliefs into more rational, acceptable beliefs. The changed belief can result

in a reduction in distress responses.

Dialectical Behavioral Therapy. Dialectical Behavior Therapy (DBT) was developed by

Marsha Linehan in the early 1990’s for the treatment of chronic suicidal behavior in adults

(Ritschel, Lim, & Stewart, 2015). Dialectical Behavior Therapy is now used with both adults

and adolescents with problems of emotional regulation (2015). It is done with a multi-modal

approach that includes individual therapy, coaching sessions, and group-based skills training

(2016).

The core of DBT involves acceptance and change-based strategies (Ritschel, Lim, &

Stewart, 2015, p. 112). The acceptance element in DBT encourages the individual to accept

themselves, their behavior, and their environment without judgment (2015, p. 112). This

involves the individual learning to observe and describe their internal thoughts and their

environment as is without trying to change them (2015, p. 112). Acceptance without change

strategies is insufficient in and of itself, as acceptance does not evoke movement towards goals

(2015, p. 113).

The change element in DBT are very similar to the foundations of CBT in that it involves

cognitive restructuring and problem solving skills (Ritschel, Lim, & Stewart, 2015). In order to

evoke change, exposure and contingency management are used along with cognitive

restructuring and problem solving (2015, p. 112). It is important to include both acceptance and

change strategies to address the emotional dysregulation in order to maintain long-term benefit

and prevent relapse.

Recent research indicated DBT as an evidenced-based practice as a transdiagnostic

treatment strategy across a variety of diagnostic categories including borderline personality


disorder with and without co-morbid SUD (Linehan, et al., 1999), post-traumatic stress disorder

(Harned, Korslund, & Linehan, 2014), eating disorders (Safer, Telch, & Agras, 2001), and

depression in older adults with mixed personality features (Lynch, et al., 2007).

Both CBT and DBT involve developing an understanding of one’s thoughts as the

precipitating element of behavior. Both CBT and DBT are limited in scope in that they do not

address the underlying cause of the thought or source of the belief that is contributing to the

target behavior. Cognitive behavior therapy and DBT both require a considerable amount of

training for the clinician (Ritschel, Lim, & Stewart, 2015). Dialectical behavior therapy also

requires a long-term commitment for the individual, as the treatment requires a significant time

commitment from the client due to the intensive nature of DBT (2015).

Adlerian psychotherapy. Alfred Adler was a pioneer in the field of psychology. Adler

expanded his quest for understanding the human condition in 1902 when he was invited to join

Sigmund Freud as part of a group of psychoanalytic thinkers (Ansbacher & Ansbacher, 1964, p.

3). As Alder increased his understanding in psychology, theoretical differences emerged that

resulted in his departure from collaboration with Freud. That movement in 1911 sparked the

development of Alfred Adler’s theory of Individual Psychology (1964, p. 3).

The work of Adler is described in personal writings and journals, originally scribed in

German, have been translated and published by others who believe in the Basic Propositions of

Individual Psychology. One such piece of work is The Individual Psychology of Alfred Adler: A

Systemic Presentation in Selections from his Writings (Ansbacher & Ansbacher, 1964). The

Basic Propositions of Individual Psychology provide the framework for the application and

practice of Adlerian Psychotherapy, also known as Individual Psychology. The Basic

Propositions of Individual Psychology include:


1. There is one basic dynamic force behind all human activity, a striving from a felt

minus situation towards a plus situation, from a feeling of inferiority towards

superiority, perfection, totality.

2. The striving receives its specific direction from an individually unique goal or self-

ideal, which though influenced by biological and environmental factors is ultimately

the creation of the individual. Because it is an ideal, the goal is a fiction.

3. The goal is only “dimly envisaged” by the individual, which means that it is largely

unknown to him and not understood by him. This is Adler’s definition of the

unconscious: the unknown part of the goal.

4. The goal becomes the final cause, the ultimate independent variable. To the extent

that the goal provides the key for understanding the individual, it is a working

hypothesis on the part of the psychologist.

5. All psychological processes form a self-consistent organization from the point of

view of the goal, like a drama which is constructed from the beginning with the finale

in view (Ansbacher & Ansbacher, 1956/1912, p. 46). This self-consistent personality

structure is what Adler calls the style of life. It becomes firmly established at an early

age, from which time on behavior that is apparently contradictory is only the

adaptation of different means to the same end.

6. All apparent psychological categories, such as different drives or the contrast between

conscious and unconscious, are only aspects of a unified relational system (Ansbacher

& Ansbacher, 1964, p. 402) and do not represent discrete entities and quantities.

7. All objective determiners, such as biological factors and past history, become relative

to the goal idea; they do not function as direct causes but provide probabilities only.


The individual uses all objective factors in accordance with his style of life. “Their

significance and effectiveness is developed only in the intermediary psychological

metabolism, so to speak” ( Ansbacher & Ansbacher, 1964., p. 402).

8. The individual’s opinion of himself and the world, his “apperceptive schema,” his

interpretations, all as aspects of the style of life, influence every psychological

process. Omnia ex opinione suspense sunt was the motto for the book in which Adler

presented Individual Psychology for the first time (Ansbacher & Ansbacher,

1956/1912, p. 1).

9. The individual cannot be considered apart from his social situation. “Individual

Psychology regards and examines the individual as socially embedded. We refuse to

recognize and examine an isolated human being” (Ansbacher & Ansbacher, 1956, p.

ix).

10. All important life problems, including certain drive satisfactions, become social

problems. All values become social values.

11. The socialization of the individual is not achieved at the cost of repression, but is

afforded through an innate human ability, which, however, needs to be developed. It

is this ability which Adler calls social feeling or social interest. Because the

individual is embedded in a social situation, social interest becomes crucial for his

adjustment.

12. Maladjustment is characterized by increased inferiority feelings, underdeveloped

social interest, and an exaggerated uncooperative goal of personal superiority.

Accordingly, problems are solved in a self-centered “private sense” rather than a task-

centered “common sense” fashion. In the neurotic this leads to the expereince of


failure because he still accepts the social validity of his actions as his ultimate

criterion. The psychotic, on the other hand, while objectively also a failure, that is, in

the eyes of common sense, does not experience failure because he does not accept the

ultimate crierion of social validity (Ansbacher & Ansbacher, 1964, pp. 1-2).

Using the Basic Propositions of Individual Psychology as the foundation for

psychotherapy, the therapist can begin working with the individual to build the therapeutic

alliance. Expressing empathy through the ideal that the therapist seek “to see with the eyes of

another, to hear with the ears of another, to feel with the heart of another” is the beginning of

understanding of an individual’s life style (Adler, 1979, p. 42). Once the therapeutic alliance is

established, the therapist begins to apply Adlerian techniques for determining the individual’s life

style through the process of a life style assessment.

A life style assessment is a structured process of inquiry, completed through face to face

interviews between the therapist and the individual (Griffith & Powers, 2007, p. 62). The

therapist gathers information about the individual’s early development, focusing on the family

constellation and birth order, gender guiding lines, family atmosphere and values, and the

challenge of adolescence and gender identity (2007, p. 62). Early recollections are gathered and

explored (p. 62). Through this process, private logic and mistaken beliefs that contribute to

compensation and over-compensation are identified. This process provides the individual with

new insights to address their problems and re-engage in the community with social interest.

Establishing the family constellation involves a process of identifying the parents,

siblings, and others in the family of origin (Griffith & Powers, 2007, p. 37). The therapist can

create a picture of the family through the use of a genogram. In addition to the basic components

of family structure, the process of creating the family constellation takes into consideration the


ordinal and psychological birth order of the individual (2007, p. 37). Adler believed that the

family constellation and psychological birth order serve as the foundation of how the individual

positions themselves in the world, that “It is not, of course, the child’s number in the order of

successive births which influences his character, but the situation into which he is born and the

way in which he interprets it” (Ansbacher & Ansbacher, 1964, p. 377). Whether the individual is

first, second, middle, last, or only is subject to their interactions within the family system rather

than by ordinal position. This family constellation is the first system of belonging for the

individual and establishes the patterns of interaction that continue throughout the life of the

individual (Griffith & Powers, 2007, p. 37). It is in this family system that family values and

atmosphere are established.

Family values are best described as being values that are shared by both the mother and

father (Griffith & Powers, 2007, p. 36). Family atmosphere relates to the emotional tone within

the family and are sometimes described in meteorological terms, such as stormy, warm, or cold

(2007, p. 36). Family values are often unstated, but remain understood by the members of the

family as imperatives to be followed. The child may choose to turn towards, turn away, or turn

against the family values in their own life style. A family value may be centered on the

requirement of all members of the family for contribution towards the maintainence and upkeep

of the home or an expectation of achievement in educational pursuits. It is important to note that

family values are those that are held by both parents. A value held by only one parent establishes

gender guilding lines.

Gender guidling lines, a concept developed by Adler, describes the individual’s ideas

about masculine and feminine and the underlying meaning of being a man or a woman. Gender

guiding lines are uncovered by the therapist’s ability to use information gathered in the life style


assessment to identify the individual’s memories of the father and mother in their early childhood

(Griffith & Powers, 2007, p. 43). The concept of gender guiding lines was expanded in

therapeutic application through the proposition that an individual’s childhood images of mother

and father form the expectation of what it means to be a man or woman and is the basis of

evaluation of all men and women (2007, p. 43).

Adler stated that, “In the soul of the child, a guiling line forms which urges toward the

enhancement of the self-esteem in order to escape insecurity” and that “the goals are

comprehended by the abstracting form of apprehension of the human mind also as fixed points

and are interpreted rather concretely” (Ansbacher & Ansbacher, 1964, p. 99). The gender

guiding lines become more apparent as the individual approaches the challenge of adolescence

and gender identity. Positioned between childhood and adulthood, the challenge of adolescence

relates to the direction the individual takes in establishing their position as an independent

individual.

The onset of adolescence presents with the individual attempting to express equality with

adults, simulating what is perceived as “grown up” through the expression of their gender

guiding lines (Ansbacher & Ansbacher, 1964, p. 441). The adolescent begins to evaluate their

sexuality and establish their position as a man or a woman, often overvaluing the importance of

masculinity or femininity, sometimes protesting their biological gender (1964, p. 442). If the

individual is not encouraged to engage in social interest, their protest may encoruage the

development of other disorders and limiting their ability for healthy relationships (Griffith &

Powers, 2007, p. 65). The value and meaning the adolescent has established in their life style

can be uncovered through the collection and interpretation of early recollectiosn.


Early recollections are described as stories from early childhood, before the age of 10

(Griffith & Powers, 2007, p. 26). The recollections are specific incidents that the individual uses

to reconstitute their present experience as focused sensory memories (2007, p. 26). Adler

proposed that the individual’s memories are the most revealing as they serve as reminders of his

or her own limits and the meaning of circumstances (Ansbacher & Ansbacher, 1964, p. 351).

The memories that are recalled as stories in any given moment are thought to be projective of the

individual’s present state of being (p. 351). Adler noted that the most telling of all memories is

the earliest incident that is recalled (p. 351). The earliest incident recalled was believed to show

the individual’s “fundamental view of life” (p. 351). Schneider identified early recollections as

one way the therapist can identify the individual’s line of movement (Schneider, 2015, p. 152).

Adlerian psychotherapy is not a a brief model of therapy, nor does it require an extensive

time commitment that is associated with DBT. It is an ongoing process that begins with the

therapeutic alliance and proceeds through the life style assessment process. Once the life style

assessment has been completed, the work begins to uncover the private logic and mistaken

beliefs that drive the individual towards the target behaviors. The process of uncovering private

logic and mistaken beliefs is not addressed in CBT or DBT, as they are both focused on a “here

and now” ideal of understanding. Adlerian pscyhotherapy connects the experiences that have

occurred throughout the life of the individual to their present circumstance.

There are many components to Adlerian psychotherapy not mentioned, though each have

their importance in the treatment of addressing the human condition. The proposed techniques

within this paper are considered the core concepts of Adlerian psychotherapy. Gathering a full

life style assessment goes more in depth into the core of the individual as compared to CBT or

DBT. A life style assessment provides both the clinician and the individual an opportunity to


gain insight into the underlying contributing factors that instigate the symptoms that lead the

individual to therapy.

Discussion

This review focused on the research and treatment of ED’s, connecting the similarities to

the symptoms and treatment of SUD’s. Current and past research is limited when considering

Adlerian Psychology. Research is extensive for CBT and DBT as evidence based treatments for

ED’s. Giordano, Clarke, and Furter addressed Adlerian theory in relation to SUD’s (2014).

They supported the position of relapse as stemming primarily from “internal experience of

negative emotional states” (Giordano et al., 2014, p. 114). The medical model of treatments is

the norm in hospital-based settings, the most common approach to treatment of ED’s. The

medical model is aimed at addressing the immediate physical complications. Pharmacological

treatments are used despite lack of evidence of clinically significant benefits for treatment of

ED’s (Bergh et al., 2013). Biological interventions are limited in their ability to address the

emotional state of the individual. Primary care providers have limited training and experience in

identifying ED’s in the early stages of the disorder, leaving the ED undetected until symptoms

and complications are more severe.

There is a wide range of interventions available for the treatment of ED’s and SUD’s,

ranging from hospital-based care to outpatient treatment models. Each intervention offers a

measure of success, though a gold standard has not been established. This may be due, in part, to

the lack of standardization of the studies and the increasing diversity of needs of the individuals

being treated. Co-occurring disorders present additional challenges to the treatment of ED’s,

creating complex concerns for providers. Treatment is often aimed at treating the most evident

presenting problem, which tends to be the physical complications.


Managed care is focused on the overall cost of treatment, seeking to provide the most

affordable solution. Life-long continuous health care associated with EDs has led to increasing

health care costs, increasing the financial burden to managed care networks. Treatment is

focused on stabilization of the immediate physical dangers, often overlooking the underlying

issues and contributing factors that lead to chronic relapse of the ED. Remission is indicated

when the individual no longer meets the criteria for an ED. The criteria, for diagnosis of ED’s

rely heavily on weight and eating behavior. For BN, remission is measured by absence of

purging behavior for at least three months (Bergh et al., 2013, p. 880)

In order for any particular treatment to be included as an accepted method of treatment is

dependent on the cost benefit analysis (Lynch et al., 2010). The most effective treatments for

EDs are those that approach the disorders from an interdisciplinary and holistic manner (Bergh et

al., 2013, p. 884). Treatment from a biological, psychological, social and spiritual perspectives

addresses the problem from all areas of functioning, thereby improving the overall quality of life.

The medical model of treatment was focused on the physical complications of ED’s. Current

psychotherapy models of CBT and DBT address the thought patterns of the individual from a

here and now perspective. Adlerian Psychology is a holistic approach that works to identify the

history and presenting problem by identifying thought and belief patterns that are contributing to

the behaviors of ED’s, acknowledging the organ inferiorities that may be present.

Hippocrates, often referred to as the father of modern medicine, believed that diseases

were caused by a combination of environmental factors, diet, life style habits, and organic causes

(Punjabi, 2015). Modern medicine has evolved greatly since the days of Hippocrates. The

Affordable Care Act has allowed for all Americans to have access to health care. The Mental

Health Parity Act promotes an individual’s access to mental health services at a level that is


equivalent to the level of care afforded for medical illnesses. Prior to these acts, medical and

mental health benefits were separate benefits within an individual’s health care insurance.

Despite the changes in law, the course of treatment remains rooted in the old system where

medical and mental health were divided. This may be a contributing factor to the lack of

treatment in an interdisciplinary manner that addresses the biological, psychological, social, and

spiritual aspects of the individual.

Conclusion

Much like SUD’s, ED’s do demonstrate an addiction correlation. Addiction is accepted

and treated as a biopsychosocial disease that is rooted in the reward circuits of the brain.

Individuals with ED’s report similar symptoms when engaging in the behaviors associated with

the disorder, noting distress and dysphoria when prevented from engaging in the behaviors.

Both SUD’s and ED’s present significant physical complications that require a medical model of

treatment. Once physical stabilization is achieved, successful recovery involves an

interdisciplinary approach that addresses the whole individual. Adlerian Psychology provides an

effective framework for a holistic approach to the treatment of ED’s.

While the medical model and current psychotherapy treatments of CBT and DBT have

been shown to be effective for the treatment of ED’s, remission statistics and quality of life show

room for improvement. It is the belief of the author that addressing the individual from an

Adlerian Psychology format of psychotherapy will allow for greater remission and improved

quality of life. Adlerian Psychology can be used in conjunction with CBT and DBT, which

would provide greater understanding and awareness to the individual in the identification of their

thought and belief patterns.


Working with an Adlerian trained therapist, the individual would complete a full life style

assessment. The assessment provides the individual and the therapist with opportunities to gain

insight into the current behavior patterns that contribute to the ED. The therapeutic alliance that

is developed fosters a sense of encouragement and acceptance for the individual and increases

the possibility of further self-exploration. Early recollections create an opportunity to identify

the private logic and mistaken beliefs that further perpetuate the problematic behaviors

associated with ED’s. As the individual uncovers the values and beliefs that direct their

purposeless behavior, they are able to engage in the tasks of life in a manner that contributes to

social interest. Increased social interest was correlated with increased self-worth, thereby

reducing the negative focus of self-centered neurosis. Adlerian techniques could be very helpful

to the clinician in identifying the underlying contributing factors that perpetuate the ED

behaviors.

The implications of eating disorders can affect one’s whole existence and all life tasks.

Those who have an ED are further stigmatized by the world view and societal expectation of

perfection. This contributes to the disordered behavior that then contributes to the physical

complications. Accessing treatment is often delayed until physical complications become severe,

thereby increasing mortality risk. Anorexia Nervosa has the highest mortality risk, followed by

Bulimia and Binge Eating Disorder, respectively. Each of the ED’s are listed in the DSM-V as

mental disorders, implying the psychological component of the disorder. Addressing ED’s from

an Adlerian perspective could be helpful in identification of underlying contributing beliefs. The

therapeutic alliance that is developed could be a supportive factor in achieving remission and

avoiding relapse.


Little research is available to confirm the hypothesis of this review. Future research is

needed to confirm the appropriateness of Adlerian psychotherapy in the treatment of ED’s.

Research incorporating Adlerian techniques in conjunction with CBT and DBT may be useful in

determining the most efficacious. Adlerian psychotherapy has been shown to have a positive

impact on addressing many aspects of purposeless behavior, including SUD’s. It is believed to

be indicated as effective for the ongoing treatment of ED’s once physical complications are

stabilized.


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