A retrospective view of psychodynamic treatment: Perspectives of recovered bulimia nervosa patients

Introduction

Bulimia nervosa is a debilitating disorder associated with significant impairments in physical, psychological, and social functioning. The lifetime prevalence of this disorder among women is approximately 1 percent to 4 percent in clinic and population samples; at least 90 percent of individuals with bulimia nervosa are female (American Psychiatric Association (APA), 2004). Clinically speaking, bulimics present with a variety of symptoms, such as differences in amount of bingeing and vomiting and use of laxatives and diuretics (APA, 2004). In addition to symptomology, bulimics vary greatly in their ability to engage in treatment, and predictors of treatment success in bulimia nervosa still remains to be fully established for any form of therapy (Keel and Mitchell, 1997; Thompson-Brenner et al., 2003; Walsh, 2001). Researchers note that a true incidence of bulimia nervosa may be difficult to determine because of secrecy and shame associated with the disorder and a shortage of community-based studies (Hoek and van Hoeken, 2003).

The majority of bulimia treatment research to date has focused on cognitive-behavioral therapy (CBT) and short-term interpersonal therapy (APA, 2004). These studies evaluate treatment outcome based on physical and behavioral parameters, such as frequency of bingeing and purging, weight, and menses, excluding other characteristic features of the disorder, such as poor body image and self-esteem. Although controlled studies have established CBT as a first line of treatment of choice for bulimia nervosa, on average, less than 50 percent of patients cease binge eating and purging (Wilson et al., 2007).

Additionally, outcome studies do not yet tell clinicians about how patients get better or why they get better (Zerbe, 2008: 6); they focus more on what the patient does rather than what she feels or who she is (Herzog et al., 1987: 546).

A growing body of research provides a wider lens into eating disorders by considering the point of view of the patient (Daniels, 2001; Lamovieux and Bottorff, 2005; Patching and Lawler, 2009; Peters and Fallon, 1994; Reindl, 2001; Wasson and Jackson, 2004; Weaver et al., 2005). These studies have examined various social and psychological variables that have facilitated progress such as internal shifts, changes in interpersonal relationships, self-help groups, and spiritual factors. While these studies have provided useful information on contextual variables that have promoted recovery, they have not focused exclusively on a specific treatment approach. This qualitative study using a phenomenological approach and naturalistic inquiry, emphasizes psychodynamic treatment factors influencing recovery and potentially provides the recovered bulimic a formal means of contributing to the professional research literature.

According to the literature, psychodynamic psychotherapy as it is practiced today for eating disorders incorporates many theoretical models: 1) Freud and conflict theory; 2) ego psychology; 3) self-psychology; 4) object relations; 5) family systems theory; 6) attachment theory; 7) feminist theory; 8) relational theory; 9) trauma theory; 10) intersubjectivity.

While psychodynamic treatment is generally not considered evidenced based, it has been shown to be effective in a number of controlled studies of eating disorder patients, with short-term outcomes equivalent to CBT in a comparative study (Bachar et al., 1999). Researchers and practitioners generally agree that psychodynamic treatment works best in combination with behavioral intervention (Cloak and Powers, 2010; Davis, 2009; Hamburg et al., 1996; Zerbe, 2008).

The aim of this qualitative study is to gain a better understanding of the therapeutic factors in psychodynamic psychotherapy for bulimia because it continues to be widely used in clinical practice and yet has not been extensively studied.

Subjects

The fourteen participants in the study were women between the ages of 22–46, who were recovered bulimics and have maintained 1) an absence of DSM-IV criteria for bulimia for a minimum of two years; and 2) have had no occurrence of relapse in the past six months. Respondents were in individual long-term (at least two years) psychotherapy with a psychodynamic orientation. The study was open to using respondents with affective disorders such as depression and anxiety because studies have shown that bulimia nervosa is associated with a high rate of co-morbidity (Hamburg et al., 1996; Hudson et al., 2007). A number of participants in the study were also diagnosed as having an affective disorder. One participant had a bi-polar diagnosis, and five others suffered from depression. Additionally, the study did not exclude patients who were on medication for their eating disorder or for associated psychological symptoms while in treatment. Nine participants were on medication and spoke about its role in treatment in their interviews.

A purposive sample of 14 women was obtained through responses to a recruitment flyer that was placed on: 1) Craigslist in all of the major cities; 2) at the MultiService Eating Disorders Association in Newton, MA; 3) national eating disorder websites such as ANAD (Association of Anorexia and Associated Eating Disorders). The researcher received New York University IRB approval and followed IRB standards for all procedures in the study. The recruitment ad specified the importance of confidentiality that was maintained by deleting names, places, and all other identifying information from tapes and manuscripts. Actual names of participants were coded and not used in any written or spoken report generated from the research. The recruitment ad included eligibility requirements along with a confidential phone and email contact information. A telephone prescreening determined eligibility for the study and included information about 1) research criteria; 2) agreement to fill-out a demographic questionnaire; 3) agreement to sign a consent form.

Additionally, in the recruitment ad, psychodynamic treatment was defined as 1) a focus on gaining psychological insight and perspective about the meaning of the symptom; 2) a focus on how the past influences the present; 3) a focus on examining feelings and reactions to the therapist and therapy relationship.

Research method – a constructionism and feminist research framework

Constructionists believe that knowledge, and the meaning we imbue with it, is created and not discovered (Rosen, 1996). Given this view, the participants’ narratives and my interpretation of them were constructed through historical and social contexts. This post-modern constructionist view was used as an orienting framework throughout the study. Additionally, this author sought to follow a tradition of feminist and critical thinking throughout the study. As Peters and Fallon (1994) note, although feminist theories of bulimia acknowledge the complexity of the disorder and the meanings that symptoms have for women, few studies have amplified the voice of eating-disordered women and allowed them to teach us what is involved in the process of recovery (p. 340). Key to feminist-oriented research is recognizing that participants are authorities on their own subjective experiences. This principle was carried out throughout the study by allowing the women who participated in the study to be the experts about what constituted successful treatment and why.

A semi-structured interview guide of 43 questions was used and focused on the participants’ treatment experience in long-term individual psychodynamically-oriented therapy, asking questions such as, ‘How did your relationship to food change during the course of treatment? What were the specific things the therapist said or asked about which you found helpful? Was there a particular time or stage of treatment that stands out for being particularly productive or not?’

The researcher implemented a grounded theory method; inductive analysis was the principal technique used to discover patterns, themes, and categories that emerged out of the data. In the data analysis, codes were first assigned and then grouped on a line by line reading of transcripts and across case comparisons. The data’s themes and sub-themes emerged from the relationship between codes and categories (Padgett, 1998). The researcher did not come up against negative case analysis. Additionally, as conceptual themes emerged from the data, this researcher shared emerging insights, concepts, and narrative accounts with two experts who agreed to perform a professional debriefing function. These professionals were chosen for their extensive experience as eating disorder researchers and practitioners. The contributions of the experts’ insights refined those of this researcher, added to the authenticity and rigor of the findings, and yielded a consensus on the study’s categories. The study’s rigor was also enhanced by keeping an audit trail of raw data and a two-part log of 1) themes, nonverbal gestures, and other observations that might inform and improve understanding of recorded words (Taylor and Bogdan, 1984); and 2) personal observations and reactions to increase the study’s objectivity, decrease bias, and enhance the study’s trustworthiness.

Results

The empirical research conducted clarified assumptions anchored in the existing literature on the research topic. Coding of the data yielded categories and themes portraying a rich panoply of participants’ feelings, thoughts, and ideas related to their experiences of treatment. The major themes signify overarching statements expressed by most participants. The five categories are: 1) engagement and building the therapeutic alliance; 2) decoding the adaptive meaning of the symptom; 3) the therapy relationship; 4) signs of progress as the therapy work deepened; 5) adjunctive treatments within psychodynamic work.

Engagement and building the therapeutic alliance

The narratives reflected six reoccurring themes associated with engagement and building the therapeutic alliance. The six central themes are: 1) building trust and safety; 2) validation; 3) empathic attunement; 4) listening and continuity; 5) identifying and verbalizing difficult thoughts and feelings; 6) providing a direct and/or challenging stance.

A majority of participants discussed how trust and safety developed in the therapy relationship, which was instrumental in engaging in the treatment and building a strong therapeutic alliance. For example, ‘Amy’ expressed how hard it was initially to trust someone, to tell her secrets, and to be honest in the therapy. Over time, she began to realize that her therapist was genuinely invested in helping her.

For other participants, such as ‘Hannah’, the therapy setting was a safe space to express painful feelings without getting a punitive response:

She made it safe to talk about my father …. Making peace with that was so helpful. I was able to put words to a lot of the feelings that I had for him. It was in a controlled setting. I knew he couldn’t hit me or scream or yell at me, and it was a relief to say what I needed to say without a backlash.

‘Shauna’ described specific gestures and words on the part of her therapist that were helpful in establishing safety so the work could proceed:

I think the thing about her, she created a really positive therapeutic environment. She would make a point of being like, okay, I’m going to turn off my cellphone, we are going to shut the drapery on the doors, making a very distinct space, a safe space, saying whatever happens in here is just between the two of us …

Additionally, most participants identified validation as being instrumental to engaging in the treatment, and strengthening the therapeutic alliance. Validating experiences consisted of feeling understood, being treated with compassion, reframing responses, and receiving affirming statements from the therapist. Participants expressed feeling validated when their therapist allowed their experiences ‘to be what they were’ and saying, ‘no, that was ridiculous, you should have never been treated that way, tell me more about what that was like for you.’

Descriptions in the narratives also illuminated expressions of empathic attunement by the therapist which involved knowing when to intervene, not being pushed, being specific, and asking relevant questions. For instance, ‘Susan’ described her therapist as ‘almost kind of being able to tune in and have a sense of where I needed to go and let me go there.’ For ‘Jesse,’ empathic attunement involved ‘being pushed when I needed to be pushed, but not overdoing it, or not crossing a boundary.’ She thought it was helpful when her therapist would ask, ‘did you think about that, would this fit, would that fit,’ rather than just saying, ‘this is the way it is.’

Thus, therapeutic change was fueled by therapists’ carefully aligning with the client’s emotional state in the present moment. Moreover, a majority of participants described being listened to, and having their words remembered, as an important dimension in their experience of treatment. Many participants talked about being listened to for the first time in their lives, which made them feel acknowledged, important, valued, and real. For example, ‘Nancy’ revealed that she was ‘fascinated’ by her therapist’s ability to remember what she said, which made her feel valued and ‘truly invested in.’ She remarked, ‘I was always amazed at what she retained and that she listened and really took in what I was saying.’ Moreover, consistency and continuity, ‘sustaining the thread’ in the words of ‘Shauna,’ were subthemes mentioned by a number of participants as being helpful to recovery. Likewise, ‘Melanie’ appreciated her therapist being ‘the same throughout’ while ‘Jesse’ appreciated her therapist’s ‘consistent acceptance’ of her and ‘being there for me no matter what, no matter how I acted out.’

Additionally, all of the participants poignantly discussed the value in talking about their conflicts as a way to integrate their emotional experiences, which led to a major shift in their relationship to food. Food became less important as participants used the safe container of their therapy to work through their painful feelings. As ‘Nancy’ said, ‘I was not utilizing it (the bulimia) anymore to make me feel a release of anything so over time because I was addressing situations and getting the feelings out verbally, I think my relationship changed to the point where I wasn’t using food to push down my feelings.’ In a different manner, ‘Lena’ described how the therapy was used to explore difficult feelings about her Latin culture:

I could say what I was feeling and I didn’t feel like, oh, I’m going to make someone mad, or angry, or feel hurt by what I was feeling or saying. It was validating because I grew up in a household where that wasn’t okay, I grew up in a culture where it wasn’t okay, women should be the caretakers, the nurturers and should make everyone look better.

Moreover, the majority of participants spoke in a lively manner about their therapists’ being direct and challenging which provided an impetus to stay accountable and committed to their recovery. The following example by ‘Susan’ speaks to this theme:

I remember her challenging me on some deflecting. I had a tendency to smile at inappropriate times which wasn’t congruent with what I was talking about, you know I’d be talking about a really sad situation and I would smile throughout it and just kind of calling me on that kind of behavior … I remember us really working through that and her not letting me off the hook …

Decoding the adaptive and psychological meaning of the symptom

All of the participants reported that they began to see progress and change once they attended to and focused on the psychological and adaptive meaning of the bulimia symptom in their therapy process. Four major themes emerged out of this category: 1) exploring and discussing family preoccupation with food, weight and appearance; 2) exploring traumatic experiences related to the past; 3) exploring bulimia as a coping mechanism to provide control over difficult thoughts and feelings; 4) exploring triggers related to the symptom.

The women described the way in which treatment helped them work through feelings about their early family life where appearance and thinness was equated with being adequate and acceptable. For example, ‘Hannah’ described how her therapist helped her express and work through painful memories of her mother putting her on a diet when she was just four years old and comparing her to Piglet from Winnie the Pooh. Similarly, ‘Kara’ said that her therapy ‘made me realize … food was also seen as a reward and as a punishment in my family … instead of physically spanking us … she (mother) just used food and body image and weight, as a way to control us.’

A majority of the women reported on a range of traumatic experiences that involved sexual abuse, physical abuse, psychological abuse, invalidating childhood experiences, and grief. Over time, the psychodynamic technique of exploring traumatic past experience created a psychic space in which the women could freely and openly experience their traumatic feelings and reflect on them. In one particularly poignant and moving narrative, ‘Paula’ said,

The process of talking about that was helpful, I guess what helped was that she treated it with compassion … asking questions, making the connections was helpful … my father was obese but I think more than that, losing my mother, my mother died when I was five. I think everything stems from that to be honest … that sort of abrupt … it was out of left field … and my dad with that sort of trauma … the subsequent not dealing with it because it was 1970 and kids really didn’t go into therapy.

The majority of participants also identified bulimia as a coping mechanism used to provide control over difficult thoughts and feelings. The particular feelings that participants identified as needing to be controlled were: anger, guilt, sadness, hate, depressive feelings, loneliness, and being scared. Some participants talked about their bulimia as a way to control every feeling they had. ‘Jesse’ remarked,

I hadn’t been taught healthy coping mechanisms and I didn’t know how to deal with the myriad of feelings that I was having from my upbringing. It taught me that I was using food or bulimia to deal with pretty much any feeling because I didn’t know how to deal, whether they were good, bad, or in-between.

Another salient theme highlighted by a majority of participants was exploration of triggers that were involved in the bulimic episode. Triggers can be feelings, memories, actions, interpersonal situations, environmental conditions, and internal object relations. Most participants revealed how this particular intervention was a part of the ongoing therapy work that helped them to understand the connection between their emotional lives and the bulimic symptom. The women in the study described a wide range of triggers that were implicated in their bulimic symptom, such as feeling based triggers based on loss and abandonment, and object triggers, such as food.

Additionally, the women in the study named physiological states such as hunger that would peak during certain points during the day and lead to bingeing and purging later on. Many participants underscored the importance of verbalizing and working through the meaning associated with a specific trigger. ‘Susan’ remarked, ‘And so I think being able to bring that back to sessions and process that and I think that is what helped me kind of decrease that behavior as time went on …’

The therapeutic relationship

The interviews provided significant information about aspects of the therapy relationship. Three major themes that emerged out of the narratives about the dynamic between participant and therapist are: 1) working through resistance; 2) authentic and respectful interactions; 3) internalizing the therapeutic relationship.

A majority of participants talked about resistant behavior that was worked through in the therapeutic dyad that led to a strengthening of the therapeutic alliance and provided a model for personal effectiveness. This theme is captured in the following narrative by ‘Nancy’:

I think finally being able to say to somebody, like I’m really mad that I’m here, I’m feeling really angry, I’m tired and I want to go home and I have to stop here after work, I think that talking through it really helped me get beyond the feeling and be able to utilize it down the road … I wasn’t up for talking about uncomfortable things, so it helped me practice talking about uncomfortable things on her.

Most of the participants talked about authentic and respectful interactions that occurred while addressing difficult feelings related to anger and hurt feelings over things the therapist said, curiosity about a therapist’s pregnancy and life, disappointment when the therapist was absent, and positive feelings that brought out the more ‘real’ aspects of the therapeutic relationship. These exchanges seemed to promote a greater capacity for self-observation and self-regulation. This is reflected in ‘Miranda’s’ narrative about working through grief about her therapist’s move to another state:

Finally, she said, do you think we should talk about this? As it got closer and closer, I would come in and start crying. But I think that taught me a lot. First of all, it stopped me from pushing everything away. And it helped me to deal with her leaving and grieve it and eventually understand that I can be really upset but that everything is going to be okay.

Additionally, a majority of participants described episodes of disclosure on the part of the therapist. Self-disclosure became a powerful technique because it seemed to promote the core feminist principle of egalitarianism. This is made vivid in ‘Tess’s’ statement: ‘I mean she was in a position of power but she was also fallible and she was comfortable with that and in that sense that was helpful. One might think that that might undermine her authority, but it didn’t.’

Disclosure also seemed to foster an ability to view the therapist as a real person they could relate to, and also helped the participants experience themselves in more human terms. This is seen in the following statement by ‘Lena’:

Especially with grad school and some of the issues that I had to confront … he helped me to understand what was normal … for him to say, in my experience, this happened to me too, it’s normal, people are going to be competitive or steal ideas, you have to be guarded but at the same time you need to start building some allies, and this helped me be successful. He helped me to understand that I was never going to be perfect … that that was okay and I need to create my own path.

All of the participants spoke about the ways in which they internalized the therapeutic relationship, a process that fostered connection and recovery. Participants were able to recall powerful therapeutic exchanges by remembering what their therapist said to them, and by gaining the ability to assume those self-regulatory functions or roles that the therapist previously served. As ‘Paula’ poignantly stated,

I had like zero self-esteem when I started therapy. I have to say that my therapist was so good at helping me to recognize my own power, strength, and abilities. I felt very empowered and respected as an adult and I think that she had the power of a woman’s perspective on things that helped me to have a stronger sense of myself.

Signs of progress as the therapy work deepened

Six major themes represent the range of experience described by participants for the category, signs of progress as the therapy work deepened. These include: 1) developing insight and the capacity to self-reflect; 2) demystifying food; 3) positive and sharing experiences; 4) shifting to a more positive and realistic body image; 5) shifting to a more positive and realistic self-image; 6) shifting to a more realistic and empathic view of others.

According to most narrative accounts, as the therapy work progressed and deepened, participants described moving beyond a preoccupation with symptoms to focusing on exploring their symbolic meaning so difficult material could be addressed and worked through. As a consequence, a greater capacity for insight and self-awareness was developed about the ways in which the body was being used to re-enact and control internal conflicts. ‘Kara’ remarked, ‘I was able to pause and ask myself, okay, what is really the issue here, what really is going on and make that break instead of just resorting back into the bulimic behavior.’

Moreover, narrative accounts reflected how the women began to gain insight into the connection between their eating disorder and their past, specifically their early identifications with critical familial images that had become more conscious in their treatment process. As ‘Caroline’ stated, ‘I was having a lot of emotions related to the past that I had repressed or tried to forget about.’ Thus, eating disorder symptoms were linked to emotional states about feeling deprived or invalidated in the past, and needing to conform in order to meet the demanding expectations of others. This theme is reflected in the account provided by Tess, in which she talks about gaining insight into her bulimia, and recognizing her own desires:

… I was always worrying about meeting other people’s expectations and that’s when I started to think about my body as something to be concerned about and something that made my parents unhappy and that’s when the onset of my eating disorder began ….

my eating was my private sphere of control, um and when you don’t have that, being able to find your private sphere, and feeling, truly being able to be yourself, and that’s something I still work on, just trying to be myself, if people like me, they like me, and if they don’t, they don’t, screw’ em.

The majority of women also spoke about how their body image improved as the treatment progressed. They were able to shift their negative body image from self-contempt and desperation to accepting their bodies as they were, albeit with some room for improvement. The women described being ‘less obsessed’ by their bodies over time, and being able to weigh themselves less or not at all. ‘Hannah’ movingly asserted, ‘there are things about my body that I enjoy now, like my freckles, my bottom teeth, my crooked toes, that is me.’

All of the women revealed that their self-image became more positive over the course of their treatment. Participants came to accept themselves in more realistic and positive ways, and came to enjoy their lives more fully. The following excerpt by ‘Amy’ illustrates this theme:

I think it helped me to take a more confident and positive view of myself than I had before … my self-image isn’t completely tied to my weight, and to, you know, to try to find happiness in everyday life.

Another prominent theme within this category was shifting to a more realistic and empathic view of others. All of the participants discussed a variety of ways in which their perspectives on family members and significant others changed during the work of therapy. The work promoted an enhanced ability to view their families and significant others in more compassionate and human terms. As participants learned to be more self-accepting and developed a greater sense of agency, they were able to be more compassionate and forgiving towards others. Caroline remarked, ‘I guess my views of my family became more forgiving during treatment because when I entered treatment I was pretty angry at my mom, so that changed as a result of treatment seeing her more as a person who had reasons for doing the insane things she had done in my childhood.’

Adjunctive treatments within psychodynamic work

These include: 1) Journaling; 2) Food Diaries; 3) Medication.

A majority of women described how journaling became an effective tool for managing their bulimia, and for expressing powerful affect in a safe and contained format outside of their individual psychotherapy. Participants underscored the importance of having a safe space entirely for themselves in which to express their feelings and to self-reflect. ‘Kara’ noted, ‘It was just the act of getting out emotions and trying to focus that rage, sorrow, or whatever I felt into the book that I was writing in rather than having it manifest itself in a binge and purge cycle.’ The women talked about sharing their journal entries with their therapists, which they found useful.

The second major theme in the category of adjunctive treatments within psychodynamic work for bulimia is keeping food diaries. Self-monitoring through the use of food diaries is widely used in cognitive-behavioral therapy for eating disorders. A majority of women discussed the use of a food diary as another complementary tool in their treatment and recovery process. Food diaries were important in 1) helping the patient and therapist evaluate eating habits; and 2) helping the patient and therapist increase their awareness of eating in relation to specific triggers. This is exemplified in ‘Nancy’ explaining that her food diary helped her ‘connect the feeling with the action,’ and helped her focus more on what she was eating. For other participants, the food diaries helped them realize how much weight they had lost, and helped the women realize, in ‘Hannah’s’ words, ‘it’s in front of you and you could not escape it.’ Overall, the diaries were an effective complementary strategy within psychodynamic work that helped manage and diminish bulimic symptoms.

Lastly, a majority of participants discussed how they were helped by pharmacological treatment during their treatment. Specifically, the women described how medication stabilized depressive and anxiety-based symptoms and helped them cope with the larger psychodynamic issues embedded in their bulimia. Participants emphasized the use of medication as a way in which they achieved more ‘stability,’ ‘safety,’ ‘balance,’ ‘more evenness’ and the ability to engage more constructively in the work of psychotherapy.

Discussion

Fourteen women in the study expressed their unique perspectives on what was essential and effective about individual psychodynamic psychotherapy for bulimia and how recovery was facilitated through their therapy process. In their own words, the women reported a gradual internalization of the therapeutic alliance and understanding of the psychological dynamics that were involved in their bulimic symptom. All of the women in the study conveyed that as they were able to express and identify their feelings more in the treatment process, their bulimic symptom came to have less power over their lives.

Notably, the participants underscored the value of the ‘dialogic nature’ (Zerbe, 2008) of the therapeutic relationship that consequently facilitated greater ego-strength and generated an enhanced ability in the women to define their own needs and desires more clearly. The participants identified aspects of treatment that unfolded within the therapeutic dyad such as the development of trust, validation, attunement experiences, authenticity, and confrontation that helped promote integration of difficult and traumatic material. An essential component of treatment described by the women in the narratives was the ability to share their lives with someone who honored their experience and fostered connection, a dynamic that recalls the ‘self-in-relation’ model which believes that women come to understand their sense of personal identity and personal power in the context of relationships (Surrey, 1991).

In addition, the narratives exemplified the clinical formulation that the analyst’s affective participation is a mutative factor in the analytic process (Aron, 1996). In their own unique ways, all of the study’s participants emphasized the healing power of having an impact on their therapists who responded to them with sensitivity and compassion as they worked through the challenging aspects of a long-term psychotherapy process. Moreover, the study demonstrates how psychodynamic psychotherapy for bulimia can work effectively when incorporating behavioral, expressive, and pharmacological interventions. The women talked about specific techniques, such as keeping food diaries and journaling, as complementary tools that contributed to recovery within the context of psychodynamic work.

Recent formulations hold that successful treatment for bulimia requires an integration of empathy, interpretation, support, and behavioral intervention (Hamburg et al., 1996). Maine (2009) asserts that a woman’s relationship to food mirrors other disconnections in her life, and that once she has other satisfying connections, the food and body will no longer be the focus of relational energy (p. 9). The study confirms these positions and extends them by elucidating the aspects of psychodynamic treatment that made a significant contribution to bulimia recovery for participants, and by highlighting adjunctive treatments that worked successfully in combination with core psychodynamic interventions.

Implications for practice and policy

In the current health care climate, short-term and behavior modification programs are favored and promoted by the managed health care system. While many patients respond to such programs, a significant number of eating disorder patients do not find them effective and relapse once they have completed the program (Ortmeyer, 2001: 134). Silber and Rob (2002) note that the relation between health care providers is less fractious when empirical research strongly supports certain treatment. The detailed information that emerged from the study could be used to complement and enrich data derived from more traditional, empiricist methods.

Kohut (1977) maintains that the capacity to reflect, to plan, and to create initially requires the presence and activity of self-regulating others. Elson (1989) observes that although Kohut wrote for analysts, he believed that his theories had relevance for social workers because of the kinds of patients clinical social workers treat: patients who have experienced early deprivation and are lacking in many of the psychic tools needed that reflecting, planning, and creating requires. The study was able to highlight the ways in which the women were able to constructively use the therapist as a self-regulating other to gain the insight, self-esteem and regulation needed to endure their therapy process and eventually achieve recovery from their eating disorder.

The foundation of eating disorders treatment is strengthened when careful attention is paid to the mutative events and observations described by patients who have been in the trenches of clinical practice. The study was an effort to document those events and observations so that practitioners and patients can have a better understanding of the common factors in psychodynamic treatment that were perceived by recovered patients as clinically effective, conducive to recovery, and as ultimately, life affirming.

Limitations/strengths

The lack of generalizability places some limitation on its impact on current bulimia research, however the study produced significant data on an insufficiently studied topic: the point of view of the patient with respect to effective treatment. Maine (2009) notes that only recently has the mental health field begun to value the patient’s voice or beliefs in the treatment process. Additionally, the APA Clinical Practice Guidelines for Eating Disorders (2006) emphasize the need for more studies on psychodynamically-informed treatment and studies of longer-term results of psychotherapies. The findings from the study contribute to a growing body of research that includes the complex etiology of bulimia nervosa, treatment considerations, and necessary ingredients for bulimia recovery.

Conclusion

The study captured the authentic experiences of fourteen women in recovery from bulimia nervosa who successfully completed long-term individual psychotherapy with a psychodynamic orientation that combined behavioral and expressive treatment interventions for their disorder. The study provided an understanding about many aspects of psychodynamic treatment that have not yet been articulated by recovered patients within eating disorders research. Multiple data sources yielded five prominent thematic categories consistent with existent theory and research on the topic. These aspects include building the therapeutic alliance, decoding the adaptive meaning of the symptom, the therapy relationship, signs of progress as the therapy work deepened, and adjunctive treatment approaches within psychodynamic work. The study confirmed Loewald’s (1960) belief that the very essence of psychotherapy is the patient’s internalization of the therapeutic dialogue. Participants were able to emotionally experience situations and attitudes with their therapists that were not previously available and/or experienced during their formative years. The outgrowth of the internalization of the therapeutic alliance helped the participants regulate painful affect that was enacted in their bulimia, contributed to the development of self-esteem and positive body-image, and promoted better relations with significant others.