Manualization of psychoanalytic psychotherapy for bulimia nervosa by MikeJenny


									Manualization of psychoanalytic
  psychotherapy for bulimia

     Susanne Lunn & Stig Poulsen,
The University Clinic, Dept. of Psychology
7th Nordic Congress on Eating Disorders
  Stockholm, September 9.-12., 2008
Why manualize?

• In randomised controlled trials,
  manuals are needed to:
   • Ensure the consistency of the interventions
   • Enable comparisons between RCT’s
Difficulties in the manualization
of PPT

PPT operates in a complex field:
• Few specific rules in PPT
• PPT is non-directive
• PPT focuses on the personality as a
  whole, not just the symptom
• PPT focuses on the therapeutic
Exisiting manuals for
psychoanalytic psychotherapy

• Strupp, H.H. & Binder, J.L. (1984): Psychotherapy in
  a New Key: A Guide to Time-Limited Dynamic
• Luborsky, L. (1984): Principles of Psychoanalytic
  Psychotherapy: A Manual for Supportive-Expressive
• Milrod, B. et al. (1997): Manual of Panic-Focused
  Psychodynamic Psychotherapy
• Clarkin, J.F., Yeomans, F.E. & Kernberg, O.F.
  (2006): Psychotherapy for Borderline Personality:
  Focusing on Object Relations
• Bateman, A. & Fonagy, P. (2006): Mentalization-
  Based Treatment for Borderline Personality
  Disorder: A Practical Guide
Psychoanalytic psychotherapy
for bulimia nervosa

  • General principles of psychoanalytic
  • Psychoanalytic psychotherapy for
    bulimia nervosa
  • Phases of the therapy
  • Development of a case formulation
  • Therapy for different levels of
    personality organization
  • Training and supervision
  • Monitoring the therapy
General principles of
psychoanalytic psychotherapy

• Focus on the inner life of the client and
  the characteristics of the client leading
  to the development and maintenance
  of the symptoms
• The therapist is non-directive, but not
  passive or reticent
• The therapist maintains analytic
  neutrality while being emotionally
General principles of psycho-
analytic psychotherapy (cont.)

• Focus on the therapeutic relationship,
  including the tranference-
  countertransference field
• Techniques: Affirmation, clarification,
  confrontation, interpretation – praise
  and advice is generally avoided
Psychoanalytic psychotherapy for
bulimia nervosa

Central therapeutic aims:
• To develop the client’s recognition of
  her self and her experiences
  (emotions, fantasies, needs)
• To understand the bulimic symptoms
  as reactions to inner states – and to
  understand these inner states in
  relation to current as well as past
  experiences, in as well as outside of
  the therapy
Psychoanalytic psychotherapy for
bulimia nervosa (cont.)

Directions for:
• the therapeutic frame
• the first therapy session
• handling of the symptoms of the eating
Phases of the therapy

The initial phase
• Providing information about the therapy
• Establishing and consolidating the therapeutic
• Establishing a therapeutic alliance
• Develop the analytic space
• Develop a case formulation
• If necessary:
   • Contain acting out
   • Information about healthy eating habits
Phases of the therapy (cont.)

Early work phase
• Help the client develop an increased sense of
  her self and her experiences
• Focus on the client’s defences
• A beginning focus on the client’s reactions
  towards the therapist and the therapy
• Establish connections between the client’s
  behaviour (including the symptoms), mental
  states, and life experiences
Phases of the therapy (cont.)

Later work phase
• Deepened focus on the transference

• Focus on problems related to separation and
  loss, dependency vs. autonomy

Anamnesis and history
Personality organisation:
• Level of organisation on a continuum
  from neurotic to borderline
• Core problem
• Affect regulation and defences
• Psychodynamics and function of
Caseformulation (cont.)

Other dimensions:
• Cognitive function
• Reflective functioning /self-observing capacity/
  psychological mindedness
• Capacity for relationships
• Self-esteem
• Sense of morality / integrity of super- ego
Caseformulation (cont.)

The therapeutic process:
• The clients attitude and behavior in the therapy
• Transference/counter-transference
• Interventions
   • Aims of interventions at a given time
   • Specific technical principles
   • Ways of handling the eating disorder
Manualized therapy and everyday
clinical practice

• The flexibility of the manual
• Definite answers versus proposals
• Cookbook versus tool for supervision/
  tool for monitoring of the therapy
Manual of psychoanalytic
psychotherapy for bulimia nervosa

Elaborated description of:

• a psychoanalytic understanding of bulimia
• psychoanalytic psychotherapy in relation to this
  specific group of patients
• subgroups within bulimics
• advices and proposals of how to handle eating
  symptoms and challenges with this inhomogeneous
  group of clients
• Its use dependent on supervision continuously
  monitoring the therapy and revising the case

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