Dr. Gupta is a licensed psychologist and professor at Barnard College, Columbia University. She specializes in the treatment of anxiety and eating/weight issues at 
Five months of CBT vs two years of psychoanalytic therapy for bulimia
December 6, 2013
It’s hard enough to reach out for therapy when suffering from bulimia, but figuring out what kind of therapy to get can be even more overwhelming. Different therapists have different kinds of training and allegiances when it comes to the therapy they practice. A new study came out last week in which researchers directly compared two different types of therapy, psychoanalytic and cognitive behavioral therapy (CBT), for the treatment of bulimia. Interestingly, the lead authors, who practice psychoanalytic therapy, found that CBT was superior.
The study, released online last week in the American Journal of Psychiatry, was the first to compare long-term (i.e. years) psychoanalytic therapy to short-term (i.e. months) CBT. That alone makes it a groundbreaking study. Moreover, it was designed as a randomized controlled trial (RCT), which is considered the gold standard for testing treatments.
Psychoanalytic psychotherapy is widely practiced in parts of Europe and the U.S. as a long-standing treatment for eating disorders. In this study, the focus of 2 years of weekly psychoanalytic therapy was to help patients reflect on and tolerate strong emotions, understand underlying causes and triggers of their eating disorder, and gain insight into related unconscious experiences. The therapy had an unstructured style such that patients spoke freely about whatever came to mind.
CBT is a more recent type of therapy with growing research support (read about other studies of CBT). A specific type of CBT, Enhanced CBT, is used to treat a range of eating disorders. In this study, the focus of 5 months of CBT was addressing body image concerns and learning skills to cope with binge eating and purging. The therapy had a structured style in which sessions were focused on specific goals and the frequency of meetings decreases over time (twice weekly to weekly to bi-weekly).
The study was led by Stig Poulson, PhD, and Susanne Lunn, M.Sc, psychoanalytic researchers in Denmark, and also included Christopher Fairburn, PhD, who developed Enhanced CBT. They recruited 70 adults suffering from bulimia to participate in the study and measured eating disorder symptoms via interviews before treatment, 5 months into treatment (when CBT ended), and 19 months into treatment (when psychoanalytic treatment ended).
The study found that after 5months of treatment, 42% of patients receiving CBT stopped binge eating and purging compared to 6% of patients receiving psychoanalytic therapy. That’s a major difference. What about after 2 years when the CBT patients were no longer a part of the study and the psychoanalytic group was just ending treatment? At that point 44% of patients receiving CBT stopped binge eating and purging compared to 15% in the psychoanalytic group.
There are a few questions left unanswered in this study. What can be done to help most of the people in this study who didn’t stop binge eating or purging from either type of therapy? This problem comes up in almost every treatment study – while we may have treatments that are empirically shown to reduce symptoms for many people, no one treatment can help everyone. Additionally, the psychoanalytic treatment specific to bulimia was designed for this study while the CBT treatment has been conducted in many previous studies. Although psychoanalytic therapy has been in use for decades, there was no manual describing exactly how to apply it for bulimia. Perhaps the results might be more favorable for psychoanalytic therapy as it is refined for bulimia in future studies. The sample of 70 adults is also relatively small and limits our ability to generalize the findings.
What does the study mean for someone looking for treatment for bulimia? It’s worth considering CBT over psychoanalytic/psychodynamic therapy if you are interested in reducing binge eating and purging. But researchers still have a lot of work to do in terms of developing treatments that help most people suffering from bulimia.
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Dr. Gupta is a professor at Barnard College of Columbia University and provides individual therapy at Tribeca Psychology
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