**6. Summary**

28 New Insights into the Prevention and Treatment of Bulimia Nervosa

working on the stage in the role of a protagonist, its participants experience an incresed feeling of guilt once they realize that they "have taken up other participants' time, focusing other group members' attention on their own problems". Thus they repeat a pattern of a bulimic cycle: obsessive compulsive eating and vomiting followed by a sense of guilt [Jay]. However, in the early stages of group therapy, the similar diagnostic background (the problems and difficulties related to eating disorders) of its participants allows to create a sense of group identification and build mutual trust among group members. A common feeling among group therapy members, especially when a group is just starting, is that of being isolated, unique, and apart from others. Enormous relief accompanies the recognition that they are not alone, which is a special benefit of group therapy. The phenomenon of sharing experiences among group members, which Yalom refers to as "universality", is a major therapeutic factor which helps group therapy participants overcome their sense of

It is a common case that people suffering from bulimia nervosa spend their energy on satisfying others. The therapy group, watching the protagonist acting out the roles he or she chooses (e.g. the role of "a loving sister", "a loyal friend", or "a diligent student"), provides supportive witnessing and helps the individual get in touch with the denied, "needy" aspects of him/herself, as well as acknowledge those aspects of his or her personality which the person regards as satisfactory. Thus, a patient has a chance to build a more complete self-image, which is, as it were, contrary to the "bad/poor" bulimic self-representation [Jay]. Group members need the therapist's assistance when the therapy proceeds from the preliminary stage of identification into the phase of establishing the relationships which are not related to the sphere of eating. There are certain structured exercises that the therapist might employ as an effective tool to facilitate the aforementioned process. An example might be an exercise in which the therapy participants' task is to follow the therapist's instruction: "Put eating aside for a while and think about two feelings which you often experience. Take on the roles of these feelings and introduce yourselves to your partners." This exercise helps to increase group identification [Levens]. Spontaneous behaviour is regarded by bulimic patients as irresponsible and reckless, and is usually followed by a sense of guilt. Hence it is necessary for the therapist to prepare clients for such spontaneous reactions by means of exercises aimed at increasing the participants' self-esteem and building up mutual trust within the group [Lacey, Evans, Jay]. The more structured the exercises are, the more relaxed the group becomes. As the therapy proceeds, the level of tolerance increases and it makes it possible for the therapist to gradually abandon the structured exercises. Prior to feeling accepted by other group members, the therapy participant feels he or she must take on the role of a protagonist and act out the particular bulimic aspects of his or her life, very often using symbols (e.g. a fridge, favourite food consumed during the episode of binge eating). Role reversal proves to be an effective technique aimed at facilitating the patient's understanding of the symbolic context, which in turn allows the person to explore his or her problems concerning the issue of relationships. A bulimia sufferer has a chance to encounter his or her despair, inner emptiness, denied needs and repressed anger. The patient finds it difficult to acknowledge the fact that he or she "is given to" by others, which is followed by a sense of guilt. "Being given to", as opposed to "giving", is what bulimics feel uncomfortable about. According to Yalom, altruism is an important healing factor in group therapy [Yalom]. It fosters unconditional satisfaction of needs, which in turn, in case of therapy for bulimia nervosa, facilitates therapeutic investigation, e.g. it leads to discovering the roots of guilt which follows the act

isolation.

Since psychodrama is a method which utilizes a universal concept of time (the past, the present and the future), place and a scene, as well as the so called surplus reality, it can support psychodynamic psychotherapy applied in the treatment of bulimia nervosa.

Psychodrama is a therapeutic method which takes into account a variety of aspects which include social relationships, personality features, internal conflicts, attitudes and beliefs. Thus, the technique provides an opportunity to intensify and accelerate the process of developing emotional and cognitive insight into the mechanisms underlying an eating disorder. Through role playing and spontaneous behaviour, psychodrama triggers constructive feedback from a patient who discovers effective problem solving strategies to replace old destructive ones, and thus finds an alternative to his or her disease symptoms. Spontaneity and creativity in the here and now, which are focused on in psychodrama sessions, allow the participant to explore his or her internal conflicts which the person tends to "transfer" onto his or her body. This proves that psychodrama is an effective therapeutic method, which can be combined with the fundamental principles of psychodynamic psychotherapy, based on the patient-therapist relationship. It can be concluded that the core idea which underpins both of the aforementioned therapeutic approaches is the patienttherapist encounter aimed at accomplishing the objective specified in the therapy contract.
