Clin Soc Work J (2008) 36:373–383 DOI 10.1007/s10615-008-0157-1
ORIGINAL PAPER
Conflict-Oriented Cognitive Behavioral Therapy (CO-CBT): An Integrative Approach to the Treatment of Bulimia Nervosa Patients Yael Latzer Æ Tamar Peretz Æ Sarit Kreutzer
Published online: 23 April 2008 Springer Science+Business Media, LLC 2008
Abstract The paper describes an integrative approach to the treatment of Bulimia Nervosa that combines Cognitive Behavioral Treatment (CBT) with short-term dynamic treatment, called conflict-oriented cognitive behavioral treatment (CO-CBT). The need to develop an integrative model emerges from the lack of focus on the underlying emotional dynamics in the traditional CBT approach. This article provides a brief literature review of CBT and shortterm dynamic therapy as applied to Bulimia Nervosa patients. It describes the CO-CBT treatment model, followed by clinical examples, and a discussion of the importance of incorporating this additional dimension in order to most successfully treat Bulimia Nervosa. Keywords Integrative treatment model Short-term dynamic therapy Group CBT Bulimia Nervosa
Introduction Bulimia Nervosa is an eating disorder that was recognized in the late 1970’s (Russell 1979). The diagnostic criteria was defined in 1994 (APA 1994) in the DSM IV as a disorder characterized by recurrent uncontrollable episodes of binge-eating that lead to the rapid consumption of large amounts of food within a short period, followed by purging through vomiting, use of laxatives or diuretics, compulsive
Y. Latzer (&) T. Peretz S. Kreutzer Eating Disorders Clinic, Division of Psychiatry, Rambam Medical Center, P.O. Box 9602, Haifa 31096, Israel e-mail:
[email protected] Y. Latzer School of Social Work, University of Haifa, Haifa, Israel
exercise, or prolonged fasts. This is a complex disorder connected with physical illness as well as with interpersonal, familial, and social elements. In accordance with its dynamic nature, it is a syndrome that encompasses different personality structures: the neurotic personality, the narcissistic personality with psychosomatic symptoms, the borderline personality including antisocial behaviors, the impulsive personality, and the psychotic structure with primitive mechanisms (Williamson et al. 2004). Bulimia Nervosa is treated by a multi-disciplinary team utilizing a number of treatment approaches, including behavioral, interpersonal (IPT), pharmacological, psychodynamic, dialectic behavioral (DBT) and cognitive behavioral (CBT) (Mitchell et al. 2002). According to Fairburn the most effective approach for the treatment of Bulimia Nervosa, in comparison with other methods, is the CBT approach (Fairburn et al. 1995; Freeman 1995). Wilson (1999), however, argues that although CBT offers considerable assistance in reducing the occurrence of binge eating and is considered an essential and effective treatment of the syndrome, it does not meet the needs of the entire population suffering from Bulimia Nervosa. Another treatment intervention, described by Ryle and associates (Ryle 1995; Ryle and Beard 1993; Ryle and Golynkina 2000), is that of time-limited cognitive analytic therapy (CAT), which has been used successfully in the treatment of borderline personality disorder patients. To our knowledge, no one has described a combined integrative model for the treatment of eating disorders. Until recently, dynamic psychotherapy and CBT were considered to be widely different conceptual worlds that were competitive and diametrically opposed to one another. However, Hamilton (2001) has raised the question as to whether these two approaches are entirely different, or if they share a common denominator.
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According to Hamilton (2001), the cognitive-behavioral model is centrally-focused on the symptoms and on the accompanying emotional experience, but it does not enable a deeper exploration of the underlying conflict. In contrast, the dynamic model attempts to reach the depth of the bulimics deprivation, but does not offer immediate relief for the symptoms. The existing gap between these approaches must be bridged before any kind of internal integration can truly be achieved. The present study aims to address this challenge of treating bulimic patients by combining short-term dynamic group treatment with CBT which we call conflict orientedCBT treatment ‘‘Conflict-Oriented CBT’’ (CO-CBT). The uniqueness of this model is its deep and focused exploration of the psychopathological basis of the underlying conflict, combined with treating the symptoms. The article begins by presenting a brief literature review on the theory and research pertaining to cognitive-behavioral and short-term dynamic treatments as applied to Bulimia Nervosa, followed by a delineation of a clinical application of the proposed treatment model and a case example. The discussion at the end of the article addresses the dilemma that arises from combining these two approaches and provides recommendations for future research. (Monteleone et al. 2006; Triosi et al. 2006; McFarlane et al. 2005; Williamson et al. 2004). The Cognitive-Behavioral Model The cognitive-behavioral model was originally developed by Beck (1963) in his early research on depression. As a psychoanalyst, Beck (1963) tried to apply Freud’s approach by analyzing the thoughts and dreams of patients suffering from depression. The models of cognitive treatment initiated by Beck (1963) and Ellis (1962) became established and were influenced by a number of psychopathology theories: phenomenological psychology (Adler 1936; Horney 1950; Sullivan 1953); structural theory and psychoanalysis (Freud 1911/2001); and cognitive psychology (Lazarus 1984) and behavioral (Bandura 1977). The cognitive-behavioral approach is based upon the assumption that the individual has non-rational thoughts and beliefs that lead to excessive pre-occupation on certain subjects. In the case of eating disorders, the focus is on body image, weight and shape. This may lead to the development and preservation of the eating disorder. Therefore, the treatment is focused on the modification of these beliefs and ultimately behavior through a combination of behavioral and cognitive procedures. Beck’s (1963) cognitive model focuses on cognitive components, such as the modification of negative thoughts and accompanying behaviors, by challenging the automatic thoughts that arise in the context of threatening or upsetting
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situations. The treatment is conducted by educating the patient with the emotional-cognitive model and by asking the patient to be the scientific observer of his/her own thoughts from a logical perspective, with the aid of selfreports. Further development of cognitive treatment was carried out by Kreitler and Kreitler (1976). CBT Model for Bulimia Nervosa The central theme of this model is that dysfunctional thoughts and beliefs about food, weight, and body image along with inadequate problem solving skills, play an essential role in the development and maintenance of Bulimia Nervosa. The most important cognitive dysfunction is the relentless pursuit of thinness. The ideas of bulimic patients about diet may not be unrealistic, but rather, are often unhealthy and based upon various misconceptions about nutrition and weight control. Their eating practices cause a disturbed internal perception of body stimuli, distorting their sense of hunger/satiation and causing them to feel threatened by the swelling of the stomach that accompanies food ingestion. Thus, they perceive themselves to be fatter than they actually are, and they can no longer enjoy eating. Unconscious of the medical risk of their behavior, the frequency of their binging increases resulting in rapid weight changes. The cognitive schema of bulimics is characterized by pronounced perfectionism and dichotomous thinking. They suffer from feelings of insecurity and therefore, use food both as a punishment and as a coping mechanism in order to protect themselves from negative feelings and difficult situations. This behavior leads to increasing social isolation as their involvement with food occupies more of their time and energy. The implications of the cognitive model for therapy depend on the specific functional analysis of the problematic behavior. The application of the cognitive-behavioral model to the treatment of Bulimia Nervosa was first developed in the early 1980’s by Fairburn (1981) and was implemented in several eating disorder treatment centers in the US and England. Subsequently, a complete CBT manual for the treatment of Bulimia Nervosa was published in 1997 (Fairburn et al. 2003). It was analyzed empirically in comparison with other treatments and was found to be the most efficient treatment for Bulimia Nervosa, with one notable exception, interpersonal psychotherapy. Research conducted by Wilfley et al. (1993) identified interpersonal psychotherapy (IPT) as an equally successful treatment model for Bulimia Nervosa. Although the results are the same, IPT does not focus on the eating habits and symptoms and the treatment is conducted over a 1-year period, while CBT is 3 months long and focuses on changing eating habits and behavior (Fairburn et al. 1993, 1995;
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Fairburn 1997). All CBT treatment programs for Bulimia Nervosa are time-limited and can be applied either within a group or individual framework. The final conclusion drawn from a number of studies is that the most significant improvement, maintained over either the long or the short term, may be expected from those undergoing cognitive-behavioral treatment (Mitchell et al. 2002). The findings have also demonstrated that not all Bulimia Nervosa patients will respond to CBT. In an attempt to identify which patients can be expected to respond positively to cognitive-behavioral treatment, it was found that those with low self-esteem, those with borderline personality disturbances, and women with a history of sexual abuse had a lower response to CBT (Fairburn 1993). CBT programs include strict selection criteria regarding the suitability of patients for treatment. All include a treatment contract, whereby the patients agree to maintain their present body weight, to follow a balanced diet as planned, to keep a diary during the entire period of treatment (e.g. reporting the amount of food consumed and describing in detail the sensations and thoughts connected with food consumption), in addition to making a commitment to attend all treatment sessions).
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Lacey’s Treatment Model for Bulimia Nervosa Lacey (1983) considers Bulimia Nervosa to be a heterogeneous syndrome, both from the point of view of its clinical picture as well as its etiological aspects. The clinical characteristics are important in order to determine which type of treatment should be applied. He distinguishes three groups of Bulimia Nervosa patients: The Neurotic Group This is the largest group, consisting mainly of women who are motivated to receive treatment and whose dominant symptom—apart from the eating disorder itself, is anger. In addition, there is a prevalence of depression and sadness. These women describe their disorder in terms of de-personalization (‘‘my head is separated from my body…’’). The Personality Disorder Group This is a smaller group in which binge-eating and purging patterns are accompanied by the abuse of alcohol and drugs, a lack of sexual inhibitions, kleptomania, or other forms of behavior that express difficulty with impulse control. From a clinical point of view, signs of emotional shallowness and histrionic traces are prominent as well.
A Fairburn’s CBT Model Secondary Bulimia Group Fairburn’s (1993, 1995, 1997, 2003) problem-oriented paradigm is focused mainly on managing the present symptoms and teaching methods for preventing future reoccurrences. It deals with the factors and processes that preserve the eating disorder, but not with those factors that were initially responsible for creating the disorder. The treatment is an active process, whereby patients are responsible for changing their own condition, while the therapist supplies information, guidance, and support, as well as assistance in identifying recurrent patterns that stimulate binge eating and in adapting behavior to alternative patterns. The treatment plan consists of three stages: In the first stage, patients are taught about the cognitive process that preserves the disorder and the behavioral techniques used for controlling binge-eating episodes. Among the most important is keeping a record. In the second stage, maximal use is made of cognitive processes through focusing on the thoughts, beliefs and values that render the problem acute. The final stage consists of follow-up meetings with the patients, aimed at assisting them in preserving the advances achieved through treatment. The treatment is conducted over the course of 20 weeks; commitment to the entire treatment contract is essential for the success of the plan.
For a small number of patients, Bulimia Nervosa is secondary to another physical disease, the most common of which are epilepsy and diabetes. Lacey emphasizes that this plan is suitable only for patients who are within a normal weight range and is designed mainly for patients belonging to the neurotic group, whereas patients with personality disorders, such as substance abuse or lack of sexual inhibitions, need more prolonged treatment. Likewise, careful consideration should be given to the acceptance of patients with suicidal inclinations. According to Lacey, the aim of the plan is to terminate all pathological symptoms of eating while at the same time preventing the development of weight disorders. Short-Term Dynamic Treatment Our proposed model, combining CBT and short-term dynamic therapy, is based upon Mann (1996) and Sifneos (1997). According to Mann (1996) successful therapy is achieved through a sense of mastery. The treatment is very short and limited to 12 sessions. Due to the time limitations, the therapist has to be very actively involved. The treatment focuses around the central conflict, which is identified by the patient as being of paramount importance
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in the course of her life and as preoccupying her mind. The dynamic treatment aims to deepen understanding of the conflict, focusing on its origin and its implications for the present situation. At the same time, emphasis is placed on dealing with the process of ending and separation. Sifneos (2005), Malan (1963), and Davanloo (1979) represent a model claiming that change can be achieved through insightful experiences. In their method of treatment, between 15 and 40 sessions are held and the date for terminating the treatment is not set in advance. To the best of our knowledge, there is no report in the literature of short-term dynamic treatment being used among a population suffering from eating disorders in general or from Bulimia Nervosa in particular. Dynamic and Psychoanalytic Treatment of Bulimia Nervosa The dynamic view of Bulimia Nervosa tries to understand the intra-psychic meaning of the disorder, a meaning that differs from patient to patient. Certain psychodynamic theories consider Bulimia Nervosa as reflecting a lack of basic self-control, while the symptoms are seen as helping to regulate internal tension and self-determination (Johnson 1995). Klein (1950) makes a connection between the difficulties in feeding small children who have a fear of dangerous objects as a manic defense against the cruel domination of introverted parents. The self-psychology approach views eating disorders as representing a disorder within the self. The essence of such disorders and their cure is that anorexic and bulimic patients cannot rely on others to meet their needs, but only on themselves. Instead of turning to other people to satisfy those needs and using them as a selfobject, they turn to food (Goodsitt 1997). Other interpretations of bulimic symptoms are that they represent a final attempt to assert oneself and to reach autonomy (Bruch 1973). Britton (1992) speaks about the great difficulty in seeing one’s parents as sex partners with a relationship exclusive of the subject. Failing to cope with this reality may have pathological ramifications, including the emergence of eating disorders. The bulimic patient derives satisfaction through the intake of food, experiencing it as an all-powerful force that supplies tranquility, warmth and safety, while also serving as a regulator for painful emotions, such as anger, shame, guilt, depression, and anxiety (Sands 1991). Since the eating and the ritual connected with it are experienced as a main source for fulfilling one’s own needs, it is protected with great strength. The gluttony and vomiting of Bulimia Nervosa have been described as a ‘‘no entry’’ mechanism to protect against the burden of the fantasies projected by the mother
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(Williams 1997). Lawrence (2001) considers the symptoms as emerging from the desire to rule the introverted parents. Through the bulimic symptoms, one can attack the introverted parents, swallow them through binge eating, and kill them through vomiting. That way, the patient tries to achieve a command over her inner world. Ogden (1989) sees the problem as one of difficulty in identifying and expressing feelings. The urge to eat serves as a way of blocking unpleasant feelings. The many variations and nuances of psychoanalytic techniques make it very difficult to assess the efficiency of the psychodynamic technique for the treatment of Bulimia Nervosa. Johnson (1995) claims that despite the results of comparative research, which point to an advantage of CBT over the dynamic approach, the use of dynamic psychotherapy is most effective after the treatment phase for the termination of symptoms. This concept is also supported by Israeli research (Bachar et al. 1999) on the self-psychology approach, which favors the dynamic approach as compared to the cognitive. The Cognitive Analytic Therapy (CAT) Model for Borderline Personality Disorders Patients To the best of our knowledge, the only model that combines CBT with dynamic analytic therapy was used by Ryle (1997, 1998) in the treatment of patients with borderline personality disorders (BPD). The features of BPD are understood to reflect the partial dissociation of personality into a small number of ‘self-states,’ each characterized by mood, by the extent of access to the control of affect, and characterized reciprocal-role repertoire manifesting in patterns of self-management and interpersonal relationships. Psychotherapy involves the collaboration of patient and therapist in identifying and characterizing the self-states and the constant switching back and forth between them. These understandings are recorded in writing and in diagrams that become the tools of therapy, providing the patients with a new basis for self-reflection, and the therapist with a means of avoiding or correcting responses likely to reinforce negative interpersonal patterns and maintain fragmentation. Nevertheless, case histories (Ryle 1997; Ryle and Beard 1993; Ryle and Golynkina 2000; Ryle and Marlowe 1995) demonstrate that despite the effectiveness of dynamic CBT with borderlines, challenges remain in treating severe cases of BPD. Group Treatment for Bulimia Nervosa Group therapy was a common feature found in treatment models for eating disorders (Wanlass et al. 2005; Wilfley
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et al. 2002; Wilfley et al. 2006). The popularity of group treatment may be due to a combination of economic factors, as well as the fact that groups tend to quickly facilitate growth by reducing feelings of isolation, low self-esteem, difficulty identifying feelings, and trouble communicating—all characteristics of bulimic patients (Hendren et al. 1987). In addition, the group reduces the shame factor, in part because people feel they are not alone with this problem. (Barth and Wurman 1986; Levine and Mishna 2007). Barth and Wurman (1986) illustrate how long-term psychodynamic group therapy can be an important tool that addresses both the behavioral symptoms and the underlying problems of the disorder. Using self-psychological concepts such as self-object needs and empathy, they describe how this stance can be effective with patients who suffer from Bulimia Nervosa. Levine and Mishna (2007) describe a psychodynamic group therapy approach for female university students, informed specifically by self-psychological and relational frameworks including mirroring, idealizing, twin-ship, and adversarial experiences. The interpersonal context of the group provides a context for members to reflect upon their symptoms and the dynamics that occur both within and outside the group. The group allows for positive network building among the patients, which according to the literature, enables a better recovery among bulimic patients (Rorty et al. 1999). In a multi-dimensional meta-analysis of psychotherapy study, Thompson-Brenner et al. (2003) describe the slight efficacy of individual CBT as compared to group CBT. However, Nevonen and Broberg (2006) found no significant differences between individual and group psychotherapy in treating bulimic patients. Group psychotherapy in general is considered to be more cost effective, and several research studies have utilized this method in the treatment of eating disorders, and found it to be clinically effective (Moreno et al. 1996; Nevonen and Broberg 2005). The popularity of group therapy, in addition to its economic benefits, is based on the assumption that it offers opportunities for growth, which is less common in other treatment modalities. Moreno, in 1994, concluded that group psychotherapy was both a clinically and statistically significant treatment approach for addressing eating disorders, as compared to no treatment (Moreno et al. 1996). However, Moreno also noted that other retrospective studies revealed that group treatment was not superior to other treatment modalities (Moreno et al. 1996; Nevonen and Broberg 2006). While the treatment modalities were not significantly different in their overall success rates, Moreno did demonstrate that in group treatment, the power of the group fosters a sense of universality, cohesion, insight, as well as the development of concrete social skills (Moreno et al. 1996).
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The Proposed Model: CO-CBT Group Treatment The desire to create a dynamic component within a structured CBT group therapy approach posed some questions and concerns. The primary concern was that the inclusion of a dynamic component in the group might create an unstructured element, allowing for a ‘‘free’’ group dynamic. This ‘free-floating environment might lend itself to the unloading by the patients of competing behaviors, one against the other, as well as potentially hurting each other emotionally. The fear was that this ‘‘free’’ atmosphere and the subsequent behaviors that might occur between the group members could cause the patients to feel overwhelmed, and frustrated, as if they had metaphorically experienced a ‘‘verbal binge’’ or ‘‘verbal restriction’’. In order to allow for the inclusion of the dynamic components, while at the same time protecting the patients and using the original CBT group model, our groups were structured to be psycho-educational, which allowed for combining a psychodynamic approach within the existing structure of CBT (Reiss 2002). This structure engendered an environment in which the patients were able to support each other. It also created an internal social network that the patients could rely upon, reach out to, and benefit from. This setting highlighted the differences between the patients and invited positive comparison analysis between core conflicts and coping mechanisms, which differed from patient to patient. It also fostered a learning environment instead of a competitive one. The treatment model included an individual interview prior to acceptance. The meetings were held once a week for one and a half hour, for a total of 13 sessions. The group was led by clinical psychotherapists, trained in both CBT and dynamically-oriented psychotherapies, as well as a dietitian. All patients were committed to fulfilling the entire CBT protocol requirements (Fairburn 1997). The model was based on three groups that included 21 young females, with seven females per group ranging in age from 20 to 35 years old. Within the overall female bulimic population that was interviewed, 70% were selected for group intervention based upon the selection criteria. Of the three Bulimia Nervosa group cycles receiving the CO-CBT intervention in our clinic, 60% of the women completed the full course of treatment. The remaining 40% left the clinic during the course of their treatment because they felt that the treatment method did not suit them. The First Meeting: The Group and the Individual Treatment-Contract In the first meeting, the patients are presented with the main concepts of the treatment plan. The requirements for inclusion in the group include: an agreement to eat nutritious, balanced meals on a daily basis, keeping an eating
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diary, maintaining a normal weight, and attending all the group sessions. The main purpose of the eating diary is to identify the patterns and connections between their underlying emotional conflicts and binge/purging behaviors. Patients are instructed to write exactly what, where and the amount of food eaten, the time, who was present, if they experience an urge to binge or purge, if they did binge or purge, if laxatives or diuretics are used, if they exercise, the type of exercise and the length of time they work-out. They are required to add the feelings and thoughts associated with each meal. In addition, they are asked to record any special events occurring during the day. The eatingdiary, which asks patients to describe their feelings and thoughts at the same time that they record their food consumption, enables patients to identify and understand the relationship between their pathological eating patterns and their emotional world. The patients are required to keep the diary with them 24 h a day and write about the aforementioned issues in real time. In this way, the diary may also serve as a transitional object by fostering a sense of connection to themselves and knowing that the therapist will be reviewing the diary on a daily basis. The awareness that the therapist will be reading about their feelings and food related activities also helps to reduce destructive behaviors. Maintaining a balanced diet and writing in the diary dramatically reduces binge-eating episodes. Additionally, the diary facilitates awareness of the underlying issues, as the patient is not in actuality hungry. Patients begin to understand that their eating, binging, purging behaviors are in reaction to their emotions. The diary, the diet and the group all serve to help them understand the underlying conflict between eating behaviors and actions. The contract also requires patients to attend meetings with the dietician once a week which takes place prior to the therapeutic group meetings, and also to eat according to a recommended and balanced menu. The main objective is well defined: for patients to become acquainted with the treatment plan in order to achieve control over their symptoms. The contract emphasizes the time element and the strictness of the setting, which are needed to overcome the symptoms. The patients are presented with the stages of the treatment and how to use the treatment tools. The patients are then invited to introduce themselves and to tell the history of their eating problems, as well as to accept the commitment attached to the treatment contract. All participants are limited in the amount of time allotted to express their thoughts. The Second to Fourth Meetings: Reviewing the Eating-Diary These meetings are devoted to reviewing the food consumption diary. Attention is first given to the order and
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composition of the meals, checking whether the patients are capable of eating according to the balanced menu and maintaining orderly meals in spite of their binge-eating and purging. This is followed by examining the accompanying thoughts that the patients reported having while eating. Throughout this process, the patients are given tools for coping with the various components of their abnormal eating patterns—the primary eating pattern being an expression of physiological needs—and for understanding their own emotional world. The Fifth to Twelfth Meetings: Identification of the Central Conflict The fifth meeting is devoted to the identification of recurrent and conflicting motives that are linked with the symptoms. Each patient, with the help of the moderator and the group, is encouraged to pinpoint the main conflict underlying the eating disorder so as to better understand its connection with the symptoms. The remaining meetings are focused on the central conflict of each individual patient in order to facilitate a deeper understanding of all the underlying issues and to find alternative ways of coping with the conflict, incorporating behavioral tasks such as writing about the main issues preoccupying them. Starting from the fifth meeting, the patients in the group are invited to assist each other, thereby making the group a more significant element in the process of coping with the symptoms and the conflict. The Thirteenth Meeting: A Conclusion For this meeting, the patients have to prepare themselves in advance by writing a summary about the emotional stages they have undergone and about the process of gaining control over their symptoms. This is an opportunity for every patient to sum up their current condition, the conflict formulating the background to the problem, and the issues that the patient would like to focus on going forward.
Case Example Longing for Mother Anna (name has been changed), is a 22-year-old female patient who has been suffering from acute Bulimia Nervosa for the last five years, since her arrival to Israel from Russia. She was one of the participants in a group that included seven females from ranging in age from 19 to 22 years old. A description of Anne’s experience in the treatment group, and her recovery process is elucidated.
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Anna was born in Russia, immigrating alone to Israel as an adolescent while her parents stayed behind in Russia. She referred herself to the Eating Disorder Clinic and was diagnosed with Bulimia Nervosa. She reported having four uncontrolled binge episodes per day, which were terminated by self-induced vomiting. She said that since her immigration to Israel she has suffered from this problem and only recently had the courage to ask for help. Since finishing high school she has been working odd jobs. A few weeks prior to her self-referral to the clinic, she moved in her with boyfriend. All her attempts to cure herself on her own were not successful. She was desperate, yet highly motivated for treatment. During her assessment, to determine if she was appropriate for the group, she expressed a high degree of motivation including accepting the possibility of gaining weight. During the first meetings, when she read her eatingdiary, she described multiple daily binge episodes that were accompanied with numerous rituals surrounding food. Her preparation for her binges began with a ‘‘shopping journey’’ in which she would purchase roughly nine pounds of assorted baked goods, such as croissants, pizza, and donuts. Afterwards she would return home and wait for the ‘‘perfect moment’’ when she would be alone and be able to ‘‘unite with her forbidden foods’’. She describes how the first moments of the eating rituals were very pleasant and gave her feelings of fullness and relaxation. However, within a short period of time, she would experience feelings of anxiety which led to feelings of severe hunger and a subsequent loss of control. During her eating experiences she reports feeling like a monster, inhaling all her food without any thinking or control. Her anxiety and loss of control were accompanied with feelings of guilt, low selfesteem, feelings of self-hatred, and self-disgust. The food, which initially felt like a ‘‘good object’’ that nurtured and relaxed her, soon became a negative object of aggression, requiring immediate elimination. At this moment she would rush to the toilet, and induce vomiting by putting her finger down her throat, all the while sitting in the bathroom feeling helpless, empty and that her life was meaningless. The thoughts which she documented in her diary, included memories relating to an ambivalent relationship with her mother who had stayed in Russia, as well as an ambivalent relationship with her boyfriend, with whom she currently resided. The conflict, which became apparent during the therapy, was a cyclical battle in which she missed her mother and wished to unite with her, but at the same time she would become angry at herself for her feelings of maternal need. Anna told the group that when she was a child, she felt that her mother disliked her, was disappointed in her, and wished that she did not exist. She reported that her decision to immigrate to Israel on her own was an expression of this internal conflict and that by
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leaving the country, she suppressed her need to be near to and supported by her mother. In this way, the food replaced the maternal contact she desired, and provided her with the necessary soothing, nurturing, and calming effects she needed. However, at the same time, the food became her enemy, destroying her own body. The sessions allowed her the ability to understand that the binge episodes were her attempts to reduce the pain she experienced of missing her mother who had rejected her and was far away. The binge episodes were also explained as a form of self-object deprivation, and her attempt to use the food as a compensation for her need to soothe herself from the pain of not having a mother. The continuous frustration and pain would lead to the next binge episode. Subconsciously, the decision behind her desire to immigrate to Israel, at such a vulnerable, young age, was her fantasy that she would find an idealized mother within the State of Israel, which would compensate for her rejected mother. However, this fantasy was quickly shattered and the need for a new mother re-appeared, and this time even stronger. Meeting her boyfriend partially enabled her to provide an alternative answer to this need. According to the therapist’s explanation, the fact that she moved in to live with him reawakened the fear of loss and rejection, while at the same time it allowed her the strength and support to seek help. The patient defined the main conflict as two opposing feelings, e.g. the need to be close but also the fear and guilt associated with needing and wanting closeness. She understood that the binge episodes were the safest place to be close to an un-human object, which compensated for the far away mother and symbolized her need for human contact. She also came to understand that associated with her guilt feelings was her preference for the intimate closeness and eroticism of the food instead of her boyfriend. Understanding this conflict and identifying it in terms that were not connected to food, enabled her to view the connection between her disordered eating behavior and her feelings of deprivation. In this moment of understanding, the patient was given a behavioral assignment in which she was asked to offer alternative coping behaviors for this conflict, rather than binging and purging. Among other alternative behaviors, she choose to write an essay to herself in which she gave herself the permission to allow herself her needs without feelings of guilt. She was further asked to create a list of some other areas, other than eating, which allowed her to feel satisfaction. The behavioral assignment was bi-directional. One assignment was to eat the forbidden foods once a day, which she generally only permitted herself during binges. The other assignment was to find one area in her life where she could interact with others and establish stronger interpersonal relationships.
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Anna, like the other members in the group, expressed great fear of exposing herself in front of the other group members at the beginning of the treatment. The structure of the group, which allowed each member an equal time to share their thoughts and behaviors, enabled her to overcome this difficulty and slowly open up. The group members supported her and by sharing their own stories, helped Anna realize that she was not alone in her struggle, and therefore, her problems were not as embarrassing as she had always perceived them. The combination of requirements of completing a daily food diary, the commitment by all the members to participate at each meeting, and the required balanced eating behavior acted as a source of relaxation, which then provided a context for Anna to feel safe and secure. As the therapy progressed, she shared her newlyacquired coping mechanisms for stopping her binge desires with the group. In response to this, Anna received a lot of support and encouragement as well as some new ideas to incorporate into her coping strategies. The group became like a family for her, providing her the power to start making changes in her life. At the end of the treatment, Anna described her experience in the following manner, At the beginning when I arrived in the group I was very scared and I did not know where I was coming to. Everything was very strange for me. I did not know what I really wanted. All I knew I wanted was to get rid of the miserable feelings I was experiencing through my constant binging and purging. I was watching all of my new friends in the group and realized that they are not as different from me as I had thought. I was able to identify and sympathize with them. For the first time in my life I realized that I was not alone and that there are people in my life who can understand me. I was able to say, that perhaps I am not so different and strange as I had thought. After each meeting I felt more secure to allow myself to open up to the group and to rely on them. I had feelings of love for my group members and a sense of belonging. Anna reported in the past she often binged four times daily but that this had been curtailed and she had only binged once within the past 4 weeks. She was attuned to her drive towards binging and immediately was able to connect it to her painful conflict. She began showing an interest in studying at the University and talked about feeling closer to her boyfriend. Although she was aware of the conflict underlying her symptoms, facing the pain of deprivation was very difficult for her and she needed more support and treatment. Her therapist recommended that she should continue treatment privately, and focus on addressing this conflict.
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This case example represents a typical process of giving up a symptom while understanding the underlying dynamic conflict supporting it. This case also demonstrates the process of separation and replacement, from the previous maladaptive coping mechanism with a new coping mechanism, which targets the fulfillment of the underlying need in an adaptive manner. The group format enabled Anna to work on both interpersonal and intrapersonal skills while the members of the group are being helped by her and helping her in each step of the process. For both the therapists and the patients the group format offers many opportunities of mutual observation, support and exchange of feelings and ideas. The group format also provides a more comfortable and relaxed environment than in individual setting as the likelihood to feel lonely and deserted is seldom. Additionally the modeling and encouragement by others endorse the participants to experiment with new ways of communication and interaction. Anna mentioned that the group setting gave her a feeling of unity, solidarity, of being understood and a great relief by recognizing her own condition in other participants. The patient’s therapists understood the conflict to represent an engulfment and a craving for her faraway mother, an attempt to deny her craving, and a sense of guilt for daring to have such a need. The conflict of this patient was interpreted as an attempt to ‘‘swallow’’ the subject in order to ameliorate her pain and craving for her faraway mother. This young woman was guided by her therapists to understand the underlying conflicts. She came to understand that her binge eating was being used as an area of privacy and pampering and that it was serving as a substitute for the connection with her mother. Accordingly, she was given the behavioral task of writing an essay on the subject and making a list of all other areas, apart from eating that enabled her to feel pampered. Subsequently, she was encouraged not to fight the need, but rather to find a way to cope with it emotionally other than through eating.
Discussion and Conclusion Bulimia Nervosa is an eating disorder characterized by recurrent uncontrolled binge episodes, with the consumption of large amounts of food within a short period of time followed by purging behavior. The physical and emotional effects of Bulimia Nervosa have engendered a number of treatment modalities using a variety of theoretical approaches, some of which have been considered as separate or even contradictory to each other. CBT was found to be an effective approach for the treatment of BN however, only about half of BN patients make a full and lasting recovery making it necessary to explore more effective treatment options (Fairburn et al.
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2003). While the model seems to provide an immediate answer for coping with symptoms, it is suitable only for a narrow group of patients who are able to meet the acceptance criteria. Even among those patients who fit within this narrow parameter, the model still does not provide a solution for the underlying conflicts. The CO-CBT treatment model, attempts to address the limitations of CBT by trying to create an in-depth intervention by also focusing on the conflict underlying the BN pathology (Wanlass et al. 2005; Hendren et al. 1987). This model connects the range of cognitive-behavioral techniques and short-term dynamic treatment. This merging of techniques makes it possible to target a wider range of people requiring treatment and to meet a greater variety of needs. Likewise, it makes it possible for therapists from different schools of thought to treat eating disorders. The CO-CBT model defines the objective not only in terms of the behavioral e.g. changing the binge/purge symptoms, but also strives to make connections to core beliefs, thoughts and feeling. This alternative approach tries to reduce the tension associated with immediate termination of the symptoms and thereby, enable patients to cope with their symptoms with less anxiety, relieving them of the feeling that they failed in their task. At the same time, when symptoms are alleviated, it is considerably easier to identify and resolve the underlying conflict through the use of cognitive programming and to assign patients appropriate behavioral tasks. Hamilton (2001) concluded that the success of combining the cognitive and psychodynamic worlds rests on the ability of the therapist to integrate the various theoretical techniques into the treatment process. This raises the question as to what extent it is possible to bridge the gap between the internal and the external worlds with the use of psychotherapy in general and for the treatment of EDs’ in particular. In the classical psychodynamic model, the two worlds were seen in a dichotomous manner, while any attempt from either the therapist or the patient to connect cognitive and dynamic influences was seen as either as resistance or as superficial (Klein 1950). Attempts to understand the phenomenon of EDs through dynamic theories have failed to provide a satisfactory explanation. Goodsitt (1997) addressed this issue, claiming that in the treatment of AN or BN it is difficult to separate between the inner and the outside worlds, as there is an injury on a very deep level involving deprivation of basic needs. Bachar (2001) strengthens this approach, adding that the therapist must assist the patient in the process of selfawareness by relating to the point of view of the patient, through which eating is conceived as fulfilling the function of self-preservation, and by respecting the importance of the symptoms to the patient.
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The ability of the therapist to integrate the two worlds in treatment also makes it easier for the patient to relinquish the split between fantasy and reality in favor of belonging socially and culturally, as well as belonging to oneself. This combination of therapeutic approaches may act as a ‘‘transitional object’’ as Winnicott (1951), called it, which is important to the creation of the real self and foster an inner expansiveness that will enable the individual to digest the food, rather than to swallow and vomit it. Even with the development of this integrated proposed model, there are still some clinical and theoretical problems that need to be resolved. Therapists are inclined, by nature of their training, beliefs and ethical codes, to stick to a single theory and treatment approach. Thus, there is a need to deepen and enlarge the proposed model on both the theoretical, research and practical levels; to analyze the effectiveness and the limitations of CO-CBT with empirical tools, and to develop a training plan for therapists to move in the direction of a more integrated approach to the treatment of eating disorders. Acknowledgment We would like to thank Ms Shelley Horwitz for her valuable contribution to the article and to Galia Golan Sprinzak.
References Adler, A. (1936). The neurotic’s picture of the world. International Journal of Individual Psychology, s2, 3–10. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed., pp. 539–550). Washington, DC: Author. Bachar, E. (2001). The fear of occupying space. Jerusalem: The Hebrew University Magnes Press. Bachar, E., Latzer, Y., Kreitler, S., & Berry, E. M. (1999). Empirical comparison of two psychological therapies: Self psychology and cognitive orientation in the treatment of Anorexia and Bulimia. The Journal of Psychotherapy Practice and Research, 8, 115–128. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Barth, D., & Wurman, V. (1986). Group therapy with bulimic women: A self-psychological approach. International Journal of Eating Disorders, 5, 735–745. Beck, A. T. (1963). Thinking and depression: 1. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324–333. Britton, R. (1992). The oedipal situation and the depressive position. In Clinical lectures on Klein and Bion (pp. 34–45). London: Routledge. Bruch, H. (1973). Eating disorders: Obesity, anorexia nervosa and the person within. New York: Basic Books. Davanloo, H. (1979). Techniques of short-term dynamic psychotherapy. New York: Jason Aronson. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Fairburn, C. G. (1981). A CBT approach to the treatment of bulimia. Psychological Medicine, 11, 707–711. Fairburn, C. G. (1997). Eating disorders. In D. M. Clark & C. G. Firburn (Eds.), Science and practice o cognitive behavior therapy (pp. 209–241). Oxford: Oxford University Press.
123
382 Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behavioral therapy for eating disorders: ‘‘A transdiagnostic’’. Theory and Treatment. Behavior Research & Therapy, 41, 509–528. Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., & O’Conner, M. E. (1993). Psychotherapy and bulimia nervosa: The longerterm effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Archives of General Psychiatry, 50, 419–428. Fairburn, C. G., Norman, P. S., Welch, S. L., O’Conner, M. E., Doll, H. A., & Peveler, R. C. (1995). A prospective study of outcome in bulimia nervosa and the long term effects of three psychological treatments. Archives of General Psychiatry, 52, 304–312. Freeman, C. (1995). Cognitive therapy. In G. Szmukler, C. Dare, & J. Treasure (Eds.), Handbook of eating disorders: Theory, treatment and practice (pp. 309–331). London, UK: Wiley. Freud, S. (1911/2002). Psychoanalytic treatment essays, 1890–1938 (E. Berman & E. J. Rolnik, Eds.). Am Oved Publishers Ltd.: Tel Aviv. Freud, S. (1911). Formulations on the two principles of mental functioning. S. E., XII: 218–226. Goodsitt, A. (1997). Eating disorders: A self-psychological perspective. In D. M. Garner & P. E. Garfinkel (Eds.), Handbook of psychotherapy for eating disorders (2nd ed., pp. 205–228). New York: Guilford Press. Hamilton, J. (2001). Psychoanalysis and cognitive behavior therapy— rival paradigms or common ground? International Journal of Psychoanalysis, 82, 431–477. Hendren, R. L., Atkins, D. M., Sumner, C. R., & Barber, J. K. (1987). Model for the group treatment of eating disorders. International Journal of Group Psychotherapy, 37, 589–603. Horney, K. (1950). Neurosis and human growth: The struggle toward self-realization. New York: Norton. Johnson, C. (1995). Psychodynamic treatment of bulimia nervosa. In C. G. Fairburn & K. D. Brownell (Eds.), Eating disorders and obesity (Chap. 61, pp. 349–353). New York: The Guilford Press. Klein, M. (1950). Contributions to psychoanalysis. London: Hogarth Press. Kreitler, H., & Kreitler, S. (1976). Cognitive orientation and behavior. New York: Springer. Lacey, J. H. (1983). Bulimia nervosa, binge eating and psychogenic vomiting: A controlled treatment study and long outcome. British Medical Journal, 286, 1609–1613. Lawrence, M. (2001). Loving them to death: The anorexic and her objects. International Journal of Psychoanalysis, 82, 43–55. Lazarus, R. (1984). On the primacy of cognition. American Psychologist, 39, 124–129. Levine, D., & Mishna, F. (2007). A self psychological and relational approach to group therapy for university students with Bulimia. International Journal of Group Psychotherapy, 57, 167–185. Malan, D. H. (1963). A study of brief psychotherapy. NY: Plenum Press. Mann, J. (1996). Time-limited psychotherapy. In J. E. Groves (Ed.), Essential papers on short-term dynamic therapy (pp. 66–96). New York: New York University Press. McFarlane, T. L., Olmsted, M. P., & Goldbloom, D. S. (2005). Beliefs and expectations regarding etiology, treatment and outcome in Bulimia Nervosa. Eating and Weight Disorders, 10, 187–192. Mitchell, J. E., Halmi, K., Wilson, G. T., Agras, W. S., Kraemer, H., & Crow, S. (2002). A randomized secondary treatment study of women with bulimia nervosa who fail to respond to CBT. International Journal of Eating Disorders, 32, 271–281. Monteleone, P., Castaldo, E., Di Filippo, C., & Maj, M. (2006). Physiopathology, diagnosis and management. Minerva Psichiatrica, 47, 59–78. Moreno, J. K. (1994). Group treatment for eating disorders. In A. Fuhriman & G. Burlinghame (Eds.), Handbook of group
123
Clin Soc Work J (2008) 36:373–383 psychotherapy: An empirical and clinical synthesis (pp. 416– 457). New York: Wiley. Moreno, J. K., Fuhriman, A., & Hileman, E. (1996). Significant events in a psychodynamic psychotherapy group for eating disorders. Group, 19, 56–62. Nevonen, L., & Broberg, A. G. (2005). A comparison of sequenced and group psychotherapy for eating disorder not otherwise specified. European Eating Disorders Review, 13, 29–37. Nevonen, L., & Broberg, A. G. (2006). A comparison of sequenced individual and group psychotherapy for patients with Bulimia Nervosa. International Journal of Eating Disorders, 39, 117–127. Ogden, T. H. (1989). The primitive edge of experience. London: J. Aronson. Reiss, H. (2002). Integrative time limited group therapy for bulimia nervosa. International Journal of Group Psychotherapy, 52, 1–26. Rorty, M., Yager, J., Buckwalter, G., & Rossotto, E. (1999). Social support, social adjustment, and recovery status in bulimia nervosa. International Journal of Eating Disorders, 26, 1–12. Russell, G. F. M. (1979). Bulimia nervosa: An ominous variant of anorexia nervosa. Psychological Medicine, 9, 429–448. Ryle, A. (1995). Transference and counter-transference variations in the course of the cognitive-analytic therapy of two borderline patients: The relation of the diagrammatic reformulation of selfstates. British Journal of Medical Psychology, 68, 109–124. Ryle, A. (Ed.). (1997). Cognitive analytic therapy and borderline personality disorder: The model and the method. Hoboken, NJ: Wiley. Ryle, A. (1998). Transferences and countertransferences: The cognitive analytic therapy perspective. British Journal of Psychotherapy, 14, 303–309. Ryle, A., & Beard, H. (1993). The integrative effect of reformulation: cognitive analytic therapy with a patient with borderline personality disorder. British Journal of Medical Psychology, 66, 249–258. Ryle, A., & Golynkina, K. (2000). Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: Factors associated with outcome. British Journal of Medical Psychology, 73, 197–210. Ryle, A., & Marlowe, M. J. (1995). Cognitive analytic therapy of borderline personality disorder: Theory and practice and the clinical and research uses of the self states sequential diagram. International Journal of Short Term Psychotherapy, 10, 21–34. Sands, S. (1991). Bulimia, dissociation and empathy: A selfpsychological view. In C. Johnson (Ed.), Psychodynamic treatment of anorexia nervosa and bulimia (pp. 34–50). New York: Guilford Press. Sifneos, P. E. (1997). Psychoanalytically oriented short-term dynamic or anxiety-provoking psychotherapy for mild obsessional neuroses. In M. H. Stone & D. J. Stein (Eds.), Essential papers on obsessive-compulsive disorder (pp. 113–123). New York: New York University Press. Sullivan, H. S. (1953). The Interpersonal Theory of Psychiatry. New York: Norton. Thompson-Brenner, H., Glass, S., & Westen, D. (2003). A multidimensional meta-analysis of psychotherapy for bulimia nervosa. Clinical Psychology: Science and Practice, 10, 269–287. Triosi, A., DiLorenzo, G., Alcinic, S., Nanni, R. C., Di Pasquale, C., & Siracusano, A. (2006). Body dissatisfaction in women with eating disorders: Relationship to early separation anxiety and insecure attachment. Psychosomatic Medicine, 68, 449–453. Wanlass, J., Moreno, J. K., & Thomson, M. H. (2005). Group therapy for eating disorders: A retrospectives case study. Journal for Specialists in Group Work, 30(1), 47–66. Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A. G., et al. (1993). Group cognitive behavioral therapy and group interpersonal psychotherpay for the non-purging
Clin Soc Work J (2008) 36:373–383 bulimic individual. Journal of Consulting and Clinical Psychology, 61, 296–305. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., et al. (2002). A randomized comparison of group cognitive behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge eating disorder. Archives of General Psychiatry, 59, 713–722. Wilson, G. T. (1999). CBT for eating disorders. Behavioral Research Therapy, 37, s79–s95. Williams, G. (1997). Internal landscapes and foreign bodies. London: Duckworth. Williamson, D. A., Martin, C. K., & Stewart, T. (2004). Psychological aspects of eating disorders. Best Practice & Research in Clinical Gastroenterology, 18, 1073–1088.
383 Winnicott, D. (1951). Through pediatrics to psycho-analysis. London: Karnac.
Author Biography Yael Latzer Founder and director of the Eating Disorders Clinic, in Rambam Medical Center, since 1992. Academically, she is an associate professor at The School of Social Work at Haifa University. She has published more than a hundred articles in scientific and clinical journals, as well as few chapters in various books.
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