Psychodynamic Explanation of Bulimia - Research Paper Example

? PSYCHOANALYSIS: TREATMENT OF BULIMIA SUBMITTED BY: SUBMITTED INSTITUTE: CONTENTS Page Introduction……………………………………………………………………………01 1.1 The psychodynamic Approach to psychology………………………………..01 1.2 Basic techniques of modern psychoanalysis………………………………….02 1.3 Bulimia……………………………………………………………………………05 1.4 Psychodynamic explanation of bulimia……………………………………….06 2. Literature available on treating bulimia with psychoanalysis……………………07 3. Discussion……………………………………………………………………………14 4. Conclusion…………………………………………………………………………....17 4.1 Recommendations……………………………………………………………....17 References ABSTRACT This paper was based on literature review and it explored many available research papers evaluating the effectiveness of psychodynamic psychotherapy for the treatment of the eating disorder, bulimia. It was found as a result of a thorough review of available relevant material in different authentic research journals, that psychodynamic therapy is quite effective in treating bulimic patients, psychodynamic therapy is not an easy form of therapy and the psychologist attempting psychoanalysis of a bulimic must be well equipped to handle the transference phase effectively. Finally, CBT is a quicker option in treating bulimic adults, but the results of CBT are not temporally stable as compared to those of psychodynamic therapy. There is need of more research to test and compare the effectiveness of psychodynamic therapy when integrated with CBT for treatment of bulimia. INTRODUCTION This paper attempts to review the effectiveness of psychoanalytic techniques used for successful treatment of the eating disorder, bulimia. Psychoanalysis involves various treatment methods that can be used for treating bulimia. This paper will explore and evaluate different psychoanalytical techniques available for treating bulimia with regard to effectiveness. Relevant literature will be thoroughly searched for any evidence of comparative effectiveness of two or more psychoanalytical treatment methods with patients of bulimia. The literature search will be followed by a discussion and the paper will conclude with a summary of the findings. 1.1 The Psychodynamic Approach to Psychology  The first proper theory of human psychology surfaced in the 1800s. Sigmund Freud is the neurologist and proponent of this theory and school of thought namely the psychodynamic approach. The founder of this school of thought divides human mind into three components: the conscious, unconscious and pre-conscious (Burger, 2008). The conscious consists of the awareness zone and contains thoughts of which one is aware. The thoughts in the pre conscious mind are not readily available, but can be retrieved easily. The last part, namely the unconscious makes up the major part of human mind and is of great interest to psychoanalysts. According to Freud, thoughts in the unconscious are the key to understanding one’s personality and these can only be brought to the conscious mind in certain extreme situations (Burger, 2008). According to the structural model of personality, psychoanalytical school of thought believes in existence of id, ego and super ego. The id is the psychic representative of drives; ego is the component which deals with the ‘relation’ functions of humans and their environment while the super ego consists of the moral precepts. Other main concepts of the psychoanalytical school of thought include defense mechanisms that humans use to deal with conflict (Brenner, 1973). Sigmund Freud was the founder of this school of thought but it hasn’t died with his death. There have been many changes and advancements in the theory and therapy of psychodynamics and it is accepted and used widely by present day psychologists and practitioners to understand explain and cure many disorders of the mind and personality. The basics on which the Freudian theory stood, including infantile neurosis and Oedipus complex have been challenged and reformulated to quite an extent; however the Freudian techniques for treatment continue to exist and are being practiced till date with modifications (Mitchell & Black, 1995). 1.2 Basic Techniques of Modern Psychoanalysis Typical Freudian psychoanalysis has been challenged from time to time by different researchers, psychologists and neo Freudians, and does not exist in practice today in its original form as was practiced by Freud himself. Basic underlying concepts may be the same but psychoanalysis in practice has undergone quite a number of changes with time (Mitchell & Black, 1995). For example, while Freud focused much on the sexual impulses of the id and sexual conflicts of childhood like Oedipus etc, the neo Freudians have de-sexed Freud’s theory to quite an extent. In practice, the main changes are more openness and objectivity in practice, greater reliance on free association and less focus on dream analysis like Anna Freud stated (cited in couch, 1995): dreams may continue to be the royal road to the unconscious, but other techniques like free association and resistance defense mechanisms etc are also pathways which reveal the unconscious; and more open form of therapy. Following is an outline of psychodynamic techniques as they are practiced in present day world of clinicians and psychotherapists who follow the Freudian school of thought. Free association is the most basic technique in psychoanalysis. According to Korchin (1975) free association is one of the most important tools used by psychoanalysts to bring the hidden material to surface. During free association, the patient is discouraged from having attention focused in present. Usually the patient is seated on a couch in a relaxed position, where he/she is not facing the therapist. The patient is encouraged to talk about dreams, fantasies, past life, fears and desires etc. Telling whatever is on one’s mind is not an easy task (Korchin, 1975). As soon as the patient realizes even at an unconscious level that the conflict is about to surface, the therapeutic process is countered by resistance. This resistance basically originates from the ego of the subject and inhibits free admittance of or surfacing of the underlying conflict or conflicts. Dream analysis is also a psychoanalytic technique used by psychoanalysts. Dreams according to Freud are the royal road to unconscious and proper interpretation of a subject’s dreams can shed a lot of light on the person’s conflicts and psychic blocks. The unconscious may reveal itself in various forms like free association, dreams, usage of defense mechanisms. It is the task of a psychoanalyst to identify the conflict and assist the subject in bringing it to the surface by accompanying the subject in a tour into the subject’s past. Transference is yet another important concept in psychoanalysis. Basically, when the conflict finally reaches the surface, the repressed feelings of the past are let out forcefully on the nearest object/subject available mostly the therapist. Transference is the key to cure. It is the last step in bringing the conflict from unconscious to conscious. The therapist at this point gets a complete chance to understand the feelings of past, that were repressed and resolve them in present (Korchin, 1975). While transference is the essence of psychoanalytic therapy, it is also the most critical phase for the therapist. The therapist must use appropriate counter transference. He/she must be cautious not to take transference personally and must react in a soothing way. Counter transference if offered tactfully can be very useful in bulimic cases. It is the core process of treatment (Garner & Garfinkel, 1997). Appropriate interpretation of the subjective material is also of key importance. According to Anna Freud, cited in couch (1995), the process of psychoanalytic therapy is as follows: To analyze ego resistance before Id context. Assist the client as the conflict makes its journey from depth to surface. To offer the analyst as the object of transference for the natural unleashing of conflict material, unconscious feelings, fantasies, memories and expectations of childhood. To analyze the impulses thus revealed. Bringing the conflict material from id back to ego; from unconscious to conscious. Like Freud, Anna Freud also stressed upon the importance of transference phase and the role of therapist in adequate counter transference expertise (Couch, 1995). 1.3 Bulimia Bulimia Nervosa is classified as an eating disorder as per DSM IV. Its symptoms are listed as follows: Episodes of binge eating with a sense of loss of control. Binge eating behavior is followed by compensatory behavior of purging or of non purging type. Binging and compensatory behavior occurs twice a week for three months. General dissatisfaction with body shape, size and weight. Resulting physical weakness and oral symptoms. Feelings of insufficiency and inadequacy. Bulimia can be a life threatening situation and is like other disorders, much more common in females as compared to males. It was added to the DSM and recognized as a disorder in the 1970s. There is evidence of some cases of bulimia before this inclusion in the diagnostic manual as well, only that they were not labeled as bulimia at the time they occurred (Garner & Garfinkel, 1997). 1.4 Psychodynamic explanation of Bulimia According to the psychoanalytic perspective, self image and body image play a lot of role in bulimia. The etiology of bulimia is related to development of a faulty body image (Johnson, 1991). When an infant becomes a toddler, the self representation must be separated from the body representation and the mother-child relationship is crucial in this shift. Verbalizing and communicating inner needs help in this process. The mother’s inability to make the child communicate at this stage about the needs and to recognize them in response may lead to formation of a faulty self image, which is not separated from the body image. Thus self image, if remained connected to body image poses a problem at the time of puberty and the individual not only fails to identify self with the changing body but also fails to accept the changes as parts of his/her body image (Johnson, 1991). 2. LITERATURE AVAILABLE ON TREATING BULIMIA VIA PSYCHOANALYSIS A lot of available literature was explored to determine and evaluate the effectiveness of psychoanalysis in treating bulimia. The review is presented in the following three sections, categorized as per the nature of studies which were reviewed. 2.1 Effectiveness of Psychodynamic Treatment in Bulimia There is a considerable amount of research which has studied the effectiveness of psychoanalysis ion treatment of bulimia. Some of the relevant studies are reviewed below: In one study, Neil and White (1987) provided psychodynamic group psycho therapy to nine adult bulimic females. Three measures were used to detect improvements in the client’s eating behaviors. Measurements on the Janis-Field feelings of inadequacy scale, Hopkins symptoms checklist and EDI ineffectiveness item scale were taken and noted down before and after the psychodynamic therapeutic group sessions. The results showed an increased improvement level in all the nine clients after psychodynamic therapy. Main important factors in etiology and treatment that were identified during the study include; role of parents especially the father regarding body image, sense of adequacy and self esteem, life goals and feminine identification. The researchers have concluded that well planned structured psychodynamic therapeutic sessions can prove to be very effective in treating bulimic adults. Another comprehensive study by Bemporad and colleagues (1992) based on 67 separate cases of different eating disorders concluded that most of the women suffering from bulimia had somewhat similar reasons for it. The main themes leading to manifestation of bulimia in the 67 cases were: disturbed early relationships, lack of security, fear of abandonment, inner emptiness, identity issues and faulty peer relationships. The manifestation of symptoms may differ from individual to individual based on the cultural demands and social values of individual patients, but the manifestation is bound to occur in some form or another. The authors acknowledge that this manifestation is greatly affected by and varies from society to society, but they have concluded that such issues are bound to manifest themselves in one or another form of disorder in all cases, in any culture or society. A detailed literature review based paper by Leichsenring and colleagues (2006) attempted to explore the techniques used and efficacy of treatments based on two most commonly used approaches to treatment of psychological disorders, namely the psychodynamic and cognitive approach. This extensive research studied the efficacy of CBT versus that of Psychodynamic therapy in a range of mental disorders. The results showed that in general, there are more efficacy studies on CBT and less on psychodynamics, however, the review also revealed that the CBT based treatments are not very reliable when it comes to long term outcomes. In the case of bulimia nervosa, the CBT gives quick results in less time but these are more lasting in case of a long, multi-session course of psychodynamic approach as compared to CBT. Temporal stability issues in bulimic patients treated with CBT and other therapies excluding psychoanalysis are also confirmed by Gabbard (2005). 2.2 What makes Psychoanalysis successful in case of bulimics? Some studies were reviewed to explore the common themes of conflict in bulimic patients as revealed by their psychoanalysis conducted by various psychologists. This was done to determine exactly how and why psychodynamic treatment is the right approach to apply while treating bulimics and why do clinicians use this approach. According to Schwartz (1986), Bulimia and binge eating has increased in the recent years and there have been many cases where it has been effectively cured via psychoanalysis of the patient. Reaching the point of catharsis is however a tedious task and requires skill and competence in the psychotherapist. However, the common themes of conflict found in most bulimic adults include; faulty object relations in childhood/ adolescence, laxative abuse, sexual conflicts and impregnation fantasies. A detailed paper based on the works of Balint and Kohut by Swift & Letvan (1984, available online in 2009) was also reviewed. Building on the analysis of different bulimic cases by Balint and Kohut, the authors determine that bulimia occurs as a result of a basic fault in the ego. The function of ego is to regulate tension. These individuals basically cannot regulate inner tension which weakens their inner self and they experience a lack of control. Their dieting, binge eating and purging behavior is a form of reparative defense which they use against the loss of control and high inner tension. These behaviors give them a sense of control and they try to bridge the inner fault of unregulated tension via these faulty behaviors. The above studies have highlighted these conflicts: Ego issues, inadequate or excessive parental attachment, sexual conflicts, fear of rejection, lack of security, negative self image and improper body image. All of these conflict themes fall within the realm of psychodynamics and a clinician trained in the psychoanalytical school of thought is equipped to deal with all these above mentioned conflicts. According to Emmett (1985), it is now widely recognized that successful treatment of those with eating disorders must involve a significant other. This is automatically catered in psychoanalytical approach since the treatment draws upon the exploration of early age conflicting relations and related catharsis. All the studies reviewed above have highlighted one or another conflict issues or block in Bulimics. The psychodynamic approach and object relations theory is rich in unblocking internal psychic conflict and relieving the patients of the symptoms instantly, as soon as catharsis occurs. In a comprehensive paper on the etiology of bulimia, Klingenspor (2004) has clearly established that as per the social identity theory, it is the patients’ sexuality and gender identity that contributes to bulimia. Psychoanalysis is based on gender conflicts of the mind and is therefore the best choice to deal with conflict originating from gender identity issues faced by patients as adolescents or children. One German study by Weitersheim and colleagues (cited in Richardson, 2004) explored the effectiveness of psychoanalytic approach to treatment in case of bulimics who had co-morbidities consisting mostly of narcissism and other personality disorders. The researchers used three different personality assessment tools to study the impact of psychodynamic treatment on bulimic’s aspects of personality. The findings revealed that personality measures were normalized to a greater extent among inpatients than among outpatients. Though the research showed that psychoanalytical therapy has a positive impact on other personality features of the subjects, further research is needed to find out exactly how psychodynamic therapy helps in normalizing other personality traits. Psychoanalysis has proved not only to be an effective treatment option for bulimia but for also complex cases where the diagnosis is multiple. One interesting case study was cited in Schwartz (1992) in this regard. The case study explains the course of psychodynamic treatment intervention successfully undertaken in curing a 26 year old female graduate student who had a ten years history of bulimia and kleptomania (shoplifting). Extensive psychodynamic therapeutic sessions were conducted with the subject while she was assisted in recognizing, accepting and tolerating the fantasies and feelings that were long ago walled off by the inner self and compensated with her somatic and action based negative defenses. The therapy proved to be very effective in this case where two difficult disorders were involved. This literature review has revealed that psychoanalysis is perhaps the best approach in dealing with bulimic patients due to its focus on gender identity issues, early attachments and catharsis to relieve one of inner psychic blocks created due to faulty defenses in response to a childhood conflict. 2.3 Psychoanalysis in Integration Though there is considerable evidence of the effectiveness of psychoanalysis in curing bulimia, there is also evidence that it is too time taking and complex (Murphy, et. al; 2005). Therefore, there have been many attempts by psychologists with integrated approach at various levels to incorporate behavioral approach with psychodynamic in treating bulimia. This according to Murphy and colleagues make the treatment sounder, relatively easy to conduct and more time bound than pure psychoanalytic treatment. In this regard, Murphy and colleagues (2005) experimented using 21 bulimic adults; by applying a psychodynamic approach of treatment that was time bound and had behavioral techniques incorporated therein. The results showed that there was not a significant change in the body mass index of the clients, but there was significant evidence of decrease in binge eating and purging symptoms and behaviors. The study is just preliminary and there is a great need of further research to establish the extent to which psychodynamic approach incorporated with behavioral techniques may be successful in treating bulimic adults. In one study Westen and Brenner (2005) studied a few cases of bulimics under treatment of a random national sample of doctoral level members of the American psychiatric association and American psychological association with at least five years of licensed experience and practice. These were divided into two main groups. One group was using the psychodynamic approach to therapy and the other group was applying CBT as primary approach in treating the bulimics. The results showed that though the global outcomes in the patients undergoing dynamic therapy for bulimia and co-morbidities were greater than those undergoing CBT, the CBT based treatment took less time, showed better improvement on post test GAF ratings and higher recovery rates as compared to the dynamic therapy. This paper hints a possible success of combined usage of the psychodynamic and cognitive behavioral approaches; however more research is yet needed to establish the usefulness of integrated approaches over the sole applications of psychodynamic approach in treating bulimic patients. There is also some evidence against the use of integrative techniques with patients of bulimia. In one very convincing paper, Zebre (1996) has presented arguments in favor of using only the psychodynamic approach in treatment of bulimia. The researcher argues that although other forms of treatment are less time taking, studies have shown that there is greater chance of relapse in patients of bulimia treated with approaches other than psychodynamics. According to Zebre (1996), it is the therapist’s duty to accompany the patient in the journey to past at the patient’s pace. In her famous book normality and pathology (1965, cited in couch, 1995), Anna Freud stated some basic principles of psychotherapeutic technique. These include: the analyst should not bypass the slow unraveling of the client’s un-conscious and neither should the therapist be over eager in surfacing the conflict. It is best when the patients themselves start interpreting their selves and realizing their psychic blocks and conflicts which are being manifested as faulty behaviors. These techniques are themselves perhaps the key to success of a therapy especially in case of disorders like bulimia, where the etiology is so well explained by the psychoanalytic approach. 3. DISCUSSION The above literature review has highlighted many favorable aspects of psychoanalysis in treatment of Bulimia. Firstly, the reviewed studies have revealed that psychoanalysis has been and continues to be an effective treatment option for treating bulimics, by reducing the feelings of insufficiency in the patients (Neil & White, 1987). Other studies have focused on the comparison of psychodynamic treatment of bulimia with other forms of psychotherapy, mostly CBT. Still other studies (Bemporad,1992; Swift & Letvan, 1984 & Schwartz, 1986) focused on the main causes of bulimia revealed in different cases of psychodynamic treatment. These include: disturbed early relationships, lack of security, fear of abandonment, inner emptiness, gender identity issues and faulty peer relationships. Other researchers (Gabbard, 2005 & Leichsenring, et al; 2006; Westen & Brenner, 2005) have attempted to compare some cases of treatment of bulimia via the psychodynamic therapy to that of CBT. These studies have revealed that CBT is clearly quicker in treating the bulimic clients, however, psychodynamic therapy has two plus points over CBT in treating bulimics: first is its temporal stability and second is the ability of psychodynamic psychotherapy to deal with bulimia and its co morbidities simultaneously (Richardson, 2004). It appears from the review that psychodynamic therapy works effectively with bulimics if applied appropriately by a well trained psychologist / therapist. Practicing psychodynamics is not an easy task and it demands expertise. The therapist must know how to make use of transference (Zebre, 1996) and it takes a lot of training and experience to become an expert in interpretation. There have been attempts of using psychoanalytical therapy in combination with some behavioral therapy approaches for the patients of bulimia (Murphy, 1996); however, more research is yet needed in this area to determine whether or not integrated psychodynamic and behavioral approach is more effective in treating bulimia. Klingenspor (2004) argues that theoretically, since etiology of bulimia is related to disturbances in gender identity and body image, therefore psychodynamic approach, which is based on gender conflict in childhood, not only best explains but also best deals the cases of bulimia. More research however is needed to establish why exactly psychodynamic treatment works so well with bulimics. Psychodynamic treatment is a complete psychoanalysis and block relieving therapy which has the power to rid off many symptoms simultaneously with the surfacing and resolving of the underlying conflict. Research studies based on individual case studies have revealed the effectiveness of psychodynamic treatment in dealing with bulimia in combination with other disorders (Richardson, 1994; Schwartz, 1992). Not only the personality issues are resolved, but the co-morbidities are also treated with the psychodynamic treatment of bulimia. 3.1 The Process Of Psychoanalysis Applied To Bulimia: Based on the step wise recommended process of psychoanalytical psychotherapy by Anna Freud (cited in couch, 1995), following is a model of how psychodynamic treatment can successfully be applied in the case of bulimia: 4. CONCLUSION The conclusions drawn from this paper, stated in clear cut words are, firstly that psychodynamic therapy is effective in treating bulimic patients, secondly, this is so, probably because the explanation of the disorder by psychoanalytic approach is very close to what is revealed during many cases of psychoanalysis of bulimics, thirdly, psychodynamic therapy is not an easy form of therapy and the psychologist attempting psychoanalysis of a bulimic must be well equipped to handle the transference phase effectively and finally, CBT is a quicker option in treating bulimic adults, but the results of CBT are not temporally stable as compared to those of psychodynamic therapy. 4.1 Recommendations for Future Research: In light of the gaps in knowledge identified during the review, following are a few recommendations regarding future research in the field: There is more research needed on the effectiveness of Psychodynamics’ integrated use with behavioral and cognitive behavioral therapies to cure bulimia. 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