**Application of Psychodrama and Object Relations Psychotherapy – An Integrated Approach to the Treatment of Bulimia Nervosa Based on Selected Elements of the Theory and the Author's Own Experience**

Bernadetta Izydorczyk

*Department of Clinical and Forensic Psychology, University of Silesia in Katowice, Poland* 

#### **1. Introduction**

12 New Insights into the Prevention and Treatment of Bulimia Nervosa

Walsh, T., Roose, S. P., Glassman, A. H., Gladise, M., Sadik, C. (1985). Bulimia and

Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2000). *Comprehensive guide to* 

Weissman, M. M., Markowitz, J. C., & Klerman, G. L. (2007). *Clinicians quick guide to interpersonal psychotherapy*. Oxford University Press, 978-0195309416, USA. Whight, D., McGrain, L., Langham, C., Baggott, J., Meadows, L. & Arcelus, J. (2010). *A new* 

Wilfley, D. E., Agras, W. S., Telch, C. F., Rossiter, E. M., Schneider, J. A., Cole, A.G., Sifford,

comparison. *Journal of Consulting and Clinical Psychology*, 61, 296-305. Wilfley, D., Stein, R., & Welch, R. (2003). Interpersonal Psychotherapy. In J. Treasure, U. Smith & E. van Furth (2003). *Handbook of eating disorders*. John Wiley and Sons.

*version of interpersonal psychotherapy for bulimic disorders*. The manual, LPT, Retrieved

L., & Raeburn, S. D. (1993). Group cognitive-behavioral therapy and group interpersonal psychotherapy for the nonpurging bulimic individual: A controlled

*interpersonal psychotherapy.* Basic Books, 978-0465095667, New York.

Depression. *Psychosomatic Medicine*, 47, 123-131.

from www.wix.com/leicesteript/ipt-leicester

Bulimia nervosa is an eating disorder characterized by self-destructive behaviours which gradually affect the sufferer's mental well-being and lead to body emaciation. The results of the scientific research conducted in the past few decades point to a multitude of determinants of this disorder, including biological, familial, socio-cultural and individual factors [Mikołajczyk, Samochowiec, Kent,Waller, Dagnan, Hartt, Wonderlich , Rorty, Yager, Rossotto, Lacey, Evans].

Chronic stress and traumatic events which the person experiences in his or her life (e.g. acts of violence or sexual abuse) are considered to be significant triggering factors for bulimia nervosa [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan, Hartt, Wonderlich, Rorty, Yager, Rossotto]. Traumatic experiences which bulimia sufferers are exposed to, and their emotional deficits affect the recovery process. In the therapeutic process, the patient needs to develop a cognitive and emotional insight into psychological mechanisms underlying the disorder which he or she suffers from, and to undergo a corrective emotional experience in the contact with the other person. This points to the significance of an "encounter with the other person and establishing a positive emotional bond (the therapeutic alliance) with this person". Thus, psychodrama is the therapeutic method which allows to intensify reactive actions and facilitates positive changes in the emotional structure of the patient's personality, and proves to be an effective technique of reducing bulimic symptoms.

Eating disorders belong to the category of psychopathology which is characterized by various levels of personality dysfunctions which range from neurotic disorders to psychosis. The choice of diagnostic and therapeutic interventions applied in the process of treatment should then be determined by the kind of a personality disorder identified in the given individual. Developing insight into psychological mechanisms underlying eating disorders, as well as establishing a therapeutic bond, constitute a crucial element of therapeutic interactions which can be supported by such methods as psychodrama and object relations technique.

Integrating psychodrama, which allows to gain insight into psychological mechanisms underlying bulimia nervosa, with the approach that focuses on corrective interactions in

Application of Psychodrama and Object Relations Psychotherapy – An Integrated

Alcohol and drug abuse turns out to be a common coping strategy.

Recent scientific research demonstrates that the pathomechanisms underlying eating disorders, particularly bulimia nervosa, develop in response to such difficult life experiences as acts of violence or sexual abuse, which an individual is exposed to either during childhood or adult life [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan, Hartt,

A number of personality profile studies conducted on bulimia sufferers prove that they display the following personality disorders: borderline and histrionic personalities, impulse control disorders, impulsivity, or an obsessive-compulsive disorder. Bulimics tend to be quick-tempered, and have low frustration tolerance and frequent dysphoric moods. They also display a tendency to withdraw and to get depressed [Mikołaczyk, Samochowiec]. Lacey and Evans defined the notion of a "Multi-Impulsive Personality Disorder" and specified its characteristic behaviours (such as psychoactive substance abuse, repeated selfharm, compulsive dozing of substances, shoplifting and gambling), placing bulimia nervosa among them [Lacey, Evans]. Inadequate impulse control, present in bulimic patients, leads to regular episodes of binge eating, vomiting, using drugs, drinking alcohol, compulsive smoking, repeated self-harm and indulging in a variety of impulsive, tension-releasing behaviours. Such behaviours are frequently accompanied by the feelings of self-loathing and disgust towards one's own body, guilt and shame. By contrast with patients suffering from anorexia nervosa, who tend to deny their illness, bulimic individuals go through their illness

experiencing negative emotions.

Wonderlich , Rorty, Bruch, Izydorczyk]

Approach to the Treatment of Bulimia Nervosa Based on Selected Elements of the Theory … 15

2. Playing the role of "a good child", causing no troubles, thereby meeting expectations set by parents who encourage the desired behaviour and reward the child for it. This gradually hinders the child's ability to express alternative feelings and pursue behaviours which their parents regard as "bad=wrong" and "needy". The child feels he or she is a disappointment to the parents. A child lives, as it were, in the world which is merely "good" or "bad", and this bipolar view of the world affects his or her selfperception. As a result, the child denies the "bad", "needy" aspect of his ore her personality to gain his or her parents' approval. In this respect, bulimia nervosa can serve as a means of externalizing (e.g. through eating) and denying undesirable aspects of personality. However, despite the fact that eating is considered to be an "external activity", it has a direct impact on the feelings and emotions which bulimic individuals have towards themselves. When a bulimic has a good day, because she or he has eaten only "good" food, the individual feels good. Such a condition lasts until the bulimia suffer decides to consume "bad" food, which results in reversing the process of selfevaluation. It proves that self-assessment is influenced by external factors. When talking to my female patients suffering from bulimia nervosa, I notice that they often use such expressions as: "I should" or "I shouldn't". The need for approval, which goes hand in hand with failure to comply with self-set standards, makes it difficult for bulimia sufferers to establish social relationships. When selecting partners, bulimics oscillate between individuals who need to be taken care of and those who need to take care of others. Due to their low self-esteem bulimia sufferers find it difficult to acknowledge that their partners perceive them as attractive. The fact that bulimic individuals disapprove of and reject their own bodies triggers problems in the sexual sphere.

with parents, who "cast" her in the role of "a responsible child". The anger is directed mainly towards the mother, who the person, as a child, was trying to protect against

emotional relationships with significant others (objects), proves to be an effective method of reducing destructive symptoms of this eating disorder. I witness this in my own therapeutic work. The effectiveness of various psychological therapies applied in the treatment of anorexia and bulimia nervosa has been discussed in the subject literature[Hay, Bacaltchuk, Byrnes, Claudino, Ekmeijan, Yong, Bahar, Latzer, Kreitler, Berry].Psychoanalytic and psychodynamic psychotherapies, which include therapeutic interventions based on the theoretical assumptions of classical psychoanalysis, object relations theory and psychology of the self [Bahar, Latzer, Kreitler ,Berry], are regarded as the most significant in the process of treatment. They prove to be effective especially in the long-term treatment of personality disorders in adult patients. Similarly, it has been demonstrated that application of psychodynamic therapy in the treatment of eating disorders can give positive effects [Bruch, Glickauf- Hughes , Wells, Hay , Bacaltchuk, Byrnes, Claudino, Ekmejian, Yong]. As viewed in psychological literature cognitive therapy as well as the therapy based on eclectic approach which involves integrating various theoretical elements, can be used in the treatment of anorexia and bulimia nervosa. However, application of artetherapy and psychodrama, combined with psychoanalytic and psychodynamic psychotherapy (based on object relations theory) in the treatment of eating disorders has not been thoroughly discussed in subject literature [Levens, Jay]. It applies mainly to Polish references.

According to early psychoanalytical conceptions concerning the origins of an eating disorder, bulimia nervosa is a psychosomatic illness [Bruch]. Conversion symptoms have primitive symbolic significance (e.g. oral fantasies where the mouth is symbolically equated with vagina, and eating is accompanied by the fear of "oral impregnation") [Bruch]. The etiology of eating disorders is also related to such factors as the person's psychopathological personality structure and disturbances in the process of solving internal conflicts by the bulimia sufferer. The conflicts are predominantly related to destabilization occurring during such processes as development and emotional experiencing of sexuality, and accepting one's own femininity (in case of female patients). Bulimia sufferers attempt to solve the conflicts by distorting their body image and making a cognitive interpretation of their body stimuli [Bruch]. An appropriate relationship between a caregiver (a mother) and a child (which means that a caregiver adjusts to the child's experiences) is considered to have a significant impact on the development of pathological mechanisms which underlie the aforementioned dysfunctions. Thus, eating disorder symptoms, including bulimic patterns, constitute a substitute of affect regulation.

Broadly defined object relations theories represent a significant contribution to a new understanding of eating disorder psychopathology, viewed from the perspective of the significance of object relations and the characteristics of internal object representations developed in the later stages of the person's mental life [Glickauf- Hughes, Wells].On the basis of the subject literature [Bruch, Izydorczyk] as well as my own experience, gathered in the course of therapeutic work with bulimic patients, I can state that these individuals resort to certain "external measures", or activities (such as eating) in order to cope with their internal emotional conflicts. The specific life experiences which bulimia sufferers (predominantly women) tend to report in an anamnestic interview include:

1. Playing the role of the so called "responsible child", who takes over the parents' duties such as taking care of younger siblings or running the house. The child learns how to recognize and satisfy other people's needs, which consequently leads to suppressing his or her own needs. Such childhood experience usually takes its toll on the life of a female who finds it difficult in her adult life to accept the feeling of anger in her relationship

emotional relationships with significant others (objects), proves to be an effective method of reducing destructive symptoms of this eating disorder. I witness this in my own therapeutic work. The effectiveness of various psychological therapies applied in the treatment of anorexia and bulimia nervosa has been discussed in the subject literature[Hay, Bacaltchuk, Byrnes, Claudino, Ekmeijan, Yong, Bahar, Latzer, Kreitler, Berry].Psychoanalytic and psychodynamic psychotherapies, which include therapeutic interventions based on the theoretical assumptions of classical psychoanalysis, object relations theory and psychology of the self [Bahar, Latzer, Kreitler ,Berry], are regarded as the most significant in the process of treatment. They prove to be effective especially in the long-term treatment of personality disorders in adult patients. Similarly, it has been demonstrated that application of psychodynamic therapy in the treatment of eating disorders can give positive effects [Bruch, Glickauf- Hughes , Wells, Hay , Bacaltchuk, Byrnes, Claudino, Ekmejian, Yong]. As viewed in psychological literature cognitive therapy as well as the therapy based on eclectic approach which involves integrating various theoretical elements, can be used in the treatment of anorexia and bulimia nervosa. However, application of artetherapy and psychodrama, combined with psychoanalytic and psychodynamic psychotherapy (based on object relations theory) in the treatment of eating disorders has not been thoroughly

discussed in subject literature [Levens, Jay]. It applies mainly to Polish references.

constitute a substitute of affect regulation.

According to early psychoanalytical conceptions concerning the origins of an eating disorder, bulimia nervosa is a psychosomatic illness [Bruch]. Conversion symptoms have primitive symbolic significance (e.g. oral fantasies where the mouth is symbolically equated with vagina, and eating is accompanied by the fear of "oral impregnation") [Bruch]. The etiology of eating disorders is also related to such factors as the person's psychopathological personality structure and disturbances in the process of solving internal conflicts by the bulimia sufferer. The conflicts are predominantly related to destabilization occurring during such processes as development and emotional experiencing of sexuality, and accepting one's own femininity (in case of female patients). Bulimia sufferers attempt to solve the conflicts by distorting their body image and making a cognitive interpretation of their body stimuli [Bruch]. An appropriate relationship between a caregiver (a mother) and a child (which means that a caregiver adjusts to the child's experiences) is considered to have a significant impact on the development of pathological mechanisms which underlie the aforementioned dysfunctions. Thus, eating disorder symptoms, including bulimic patterns,

Broadly defined object relations theories represent a significant contribution to a new understanding of eating disorder psychopathology, viewed from the perspective of the significance of object relations and the characteristics of internal object representations developed in the later stages of the person's mental life [Glickauf- Hughes, Wells].On the basis of the subject literature [Bruch, Izydorczyk] as well as my own experience, gathered in the course of therapeutic work with bulimic patients, I can state that these individuals resort to certain "external measures", or activities (such as eating) in order to cope with their internal emotional conflicts. The specific life experiences which bulimia sufferers

1. Playing the role of the so called "responsible child", who takes over the parents' duties such as taking care of younger siblings or running the house. The child learns how to recognize and satisfy other people's needs, which consequently leads to suppressing his or her own needs. Such childhood experience usually takes its toll on the life of a female who finds it difficult in her adult life to accept the feeling of anger in her relationship

(predominantly women) tend to report in an anamnestic interview include:

with parents, who "cast" her in the role of "a responsible child". The anger is directed mainly towards the mother, who the person, as a child, was trying to protect against experiencing negative emotions.

2. Playing the role of "a good child", causing no troubles, thereby meeting expectations set by parents who encourage the desired behaviour and reward the child for it. This gradually hinders the child's ability to express alternative feelings and pursue behaviours which their parents regard as "bad=wrong" and "needy". The child feels he or she is a disappointment to the parents. A child lives, as it were, in the world which is merely "good" or "bad", and this bipolar view of the world affects his or her selfperception. As a result, the child denies the "bad", "needy" aspect of his ore her personality to gain his or her parents' approval. In this respect, bulimia nervosa can serve as a means of externalizing (e.g. through eating) and denying undesirable aspects of personality. However, despite the fact that eating is considered to be an "external activity", it has a direct impact on the feelings and emotions which bulimic individuals have towards themselves. When a bulimic has a good day, because she or he has eaten only "good" food, the individual feels good. Such a condition lasts until the bulimia suffer decides to consume "bad" food, which results in reversing the process of selfevaluation. It proves that self-assessment is influenced by external factors. When talking to my female patients suffering from bulimia nervosa, I notice that they often use such expressions as: "I should" or "I shouldn't". The need for approval, which goes hand in hand with failure to comply with self-set standards, makes it difficult for bulimia sufferers to establish social relationships. When selecting partners, bulimics oscillate between individuals who need to be taken care of and those who need to take care of others. Due to their low self-esteem bulimia sufferers find it difficult to acknowledge that their partners perceive them as attractive. The fact that bulimic individuals disapprove of and reject their own bodies triggers problems in the sexual sphere. Alcohol and drug abuse turns out to be a common coping strategy.

Recent scientific research demonstrates that the pathomechanisms underlying eating disorders, particularly bulimia nervosa, develop in response to such difficult life experiences as acts of violence or sexual abuse, which an individual is exposed to either during childhood or adult life [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan, Hartt, Wonderlich , Rorty, Bruch, Izydorczyk]

A number of personality profile studies conducted on bulimia sufferers prove that they display the following personality disorders: borderline and histrionic personalities, impulse control disorders, impulsivity, or an obsessive-compulsive disorder. Bulimics tend to be quick-tempered, and have low frustration tolerance and frequent dysphoric moods. They also display a tendency to withdraw and to get depressed [Mikołaczyk, Samochowiec].

Lacey and Evans defined the notion of a "Multi-Impulsive Personality Disorder" and specified its characteristic behaviours (such as psychoactive substance abuse, repeated selfharm, compulsive dozing of substances, shoplifting and gambling), placing bulimia nervosa among them [Lacey, Evans]. Inadequate impulse control, present in bulimic patients, leads to regular episodes of binge eating, vomiting, using drugs, drinking alcohol, compulsive smoking, repeated self-harm and indulging in a variety of impulsive, tension-releasing behaviours. Such behaviours are frequently accompanied by the feelings of self-loathing and disgust towards one's own body, guilt and shame. By contrast with patients suffering from anorexia nervosa, who tend to deny their illness, bulimic individuals go through their illness

Application of Psychodrama and Object Relations Psychotherapy – An Integrated

**of the object relations theory and J.L. Moreno's psychodrama** 

stages of the person's life [Glickauf- Hughes, Wells]

several years.

Approach to the Treatment of Bulimia Nervosa Based on Selected Elements of the Theory … 17

**2. The psychopathology of bulimia nervosa – as viewed from the perspective** 

In my psychotherapeutic work with patients suffering from bulimia nervosa, I refer to a psychoanalytic and psychodynamic paradigm of the psychopathology of this disorder, grounded on the concepts of object relations. Taking into account the psychodynamic principles and the structure of the therapeutic process (e.g. conducting the unconscious input analysis; applying verbal therapeutic interventions including clarification, confrontation and interpretation; taking into consideration the significance of insight, developing a therapeutic relationship, and conducting transference analysis), I have applied Moreno's psychodrama in individual and group therapy which I have been conducting for

According to the fundamental assumptions of psychoanalytically oriented therapies for bulimia nervosa, which underpin the classical psychoanalytic theories based on Freudian concepts, this eating disorder is a biologically determined condition. An object relations approach to the origins of the illness is slightly different. Although the major theoreticians who employ this approach belong to various schools such the British Object Relations School (Klein, Fairbairn, Guntrip, Winnicott), the American Object Relations School (Mahler, Kernerg, Kohut), and the American School of Interpersonal Relations (Sullivan), they put forward unanimous views on the issue of the etiology of eating disorders. They maintain that the origins of the eating disorder psychopathology lay in the person's traumatic life experiences, emotional deficits and patterns (the matrix) of internalized, emotionally destructive interactions of an individual with significant objects, especially the relationships established during childhood, which are "replicated" in all social interactions in the later

Identification of this internal pattern of relationships with a caregiver (object) facilitates the process of psychotherapy. A therapist is able to recognize and better understand the client's interpersonal behaviours, as well as modify the internal structure of the individual's personality (object representations, self-representations, feelings). The object relations theory is considered to be in opposition to Freud's classical theory of psychoanalysis, since the person's need for emotional relationships with other people is seen as replacing sexual drive and aggressive impulses as the original motivational system for human behaviour. Focusing on social interactions as a significant element in the development of a human being, the object relations theory resembles a psychodrama approach to an emotional difficulty and an

In my diagnostic and therapeutic work with patients suffering from bulimia nervosa I refer to the fundamental assumptions of the object relations theory which provide a basis for psychotherapy for this kind of disorder. Whenever I try to diagnose bulimic symptoms (such as episodes of binge eating, self-induced vomiting or purging), I attempt to identify the current as well as the past pattern of the bulimic's relationships with a caregiver (a significant object). Most frequently, I focus on my patient's relationship with his or her mother, not disregarding the significance of the father-patient relationship [Glickauf-Hughes, Wells]. The infant-mother pattern of relationship, formed during infancy and early childhood, related to breastfeeding, proves to be an important factor determining the development of an eating disorder in the later stages of an individual's life. This can be confirmed by many years' research and clinical experiments conducted by Hilda Bruch and other authors [Bruch]. It can be stated that the object relations school emphasizes the

illness symptom in the process of psychotherapy [Glickauf- Hughes, Wells].

accompanied by pain and the feeling of shame. They are filled with great remorse for their behaviour towards themselves as well as others, their nearest and dearest. That is why it happens quite frequently that they do not reveal their illness for a long time. The need for control plays an important role in the life of a bulimic, who makes attempts to keep control of food intake (the person controls the quality and quantity of food, performs compulsive eating rituals, etc.), weight, as well as his or her internal experiences and external behaviours. A bulimic individual finds it difficult to accept the fact that he or she is not able to control all aspects of his or her life. In order to become aware of it, the person has to undergo psychotherapy, which is aimed at unblocking the bulimia sufferer's creativity and spontaneity.

Exposure to social situations provokes anxiety in patients with bulimia nervosa, since it triggers the fear of loss of control, or reveals its lack. Once a bulimia sufferer realizes that he or she is unable to control his or her impulses or compensatory behaviours, or even other reactions in the person's life, the individual becomes frustrated and tends to experience intense emotional states (e.g. depression), which the person wishes to avoid. This implies that patients suffering from bulimia nervosa find it difficult to ask for help and seek psychological support. Making a decision to participate in psychotherapy might be the first step in strengthening the bulimic's motivation for introducing changes into his or her life.

Theoretical fundamentals of psychoanalytic and psychodynamic psychotherapy point to the fact that the development of these impulsive (psychopathological) symptoms is underlain by incorrect (destructive) psychological (unconscious) mechanisms which function within the structure of the bulimic individual's personality.

An object relations approach to psychotherapy emphasizes great significance of human relations which play a key role in the recovery process and replace drives as the main determinant of the person's mental development. The approach focuses on the possibility of making changes within these relations [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan]. Object relations theories are based on an assumption that the patterns of relationships with significant others (objects) formed during early childhood (the early interactions between a child and the most important objects such as the mother, father, or a caretaker) significantly affect the individual's adult relationships and the person's social and emotional functioning (the phenomenon of transference) [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan, Glickauf- Hughes, Wells]. This correlation seems to relate the object relations theory to Moreno's concept of psychodrama, according to which the key to understanding the genesis of the person's emotional problems should be sought in psychological background related to social relationships, which engenders dysfunctions in the sphere of an individual's reactions and behaviours. Hence integrating the approach which utilizes the corrective influence of "good" object relations therapy with psychodrama techniques such as surplus reality, might prove to be an effective method in the treatment of eating disorders, including bulimia nervosa.

Based on a review of subject literature, and drawing from my own experience gained in the course of individual and group therapy conducted on patients suffering from bulimia nervosa, I wanted to stress in this paper the importance of integrative approach to diagnosis and treatment of bulimia nervosa. My intention was to demonstrate the basic similarities between psychodrama and the object relations theory, and point to the fact that these two therapeutic approaches may complement each other.

accompanied by pain and the feeling of shame. They are filled with great remorse for their behaviour towards themselves as well as others, their nearest and dearest. That is why it happens quite frequently that they do not reveal their illness for a long time. The need for control plays an important role in the life of a bulimic, who makes attempts to keep control of food intake (the person controls the quality and quantity of food, performs compulsive eating rituals, etc.), weight, as well as his or her internal experiences and external behaviours. A bulimic individual finds it difficult to accept the fact that he or she is not able to control all aspects of his or her life. In order to become aware of it, the person has to undergo psychotherapy, which is aimed at unblocking the bulimia sufferer's creativity and

Exposure to social situations provokes anxiety in patients with bulimia nervosa, since it triggers the fear of loss of control, or reveals its lack. Once a bulimia sufferer realizes that he or she is unable to control his or her impulses or compensatory behaviours, or even other reactions in the person's life, the individual becomes frustrated and tends to experience intense emotional states (e.g. depression), which the person wishes to avoid. This implies that patients suffering from bulimia nervosa find it difficult to ask for help and seek psychological support. Making a decision to participate in psychotherapy might be the first step in strengthening the bulimic's motivation for introducing changes into his or her life. Theoretical fundamentals of psychoanalytic and psychodynamic psychotherapy point to the fact that the development of these impulsive (psychopathological) symptoms is underlain by incorrect (destructive) psychological (unconscious) mechanisms which function within

An object relations approach to psychotherapy emphasizes great significance of human relations which play a key role in the recovery process and replace drives as the main determinant of the person's mental development. The approach focuses on the possibility of making changes within these relations [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan]. Object relations theories are based on an assumption that the patterns of relationships with significant others (objects) formed during early childhood (the early interactions between a child and the most important objects such as the mother, father, or a caretaker) significantly affect the individual's adult relationships and the person's social and emotional functioning (the phenomenon of transference) [Mikołajczyk, Samochowiec, Kent, Waller, Dagnan, Glickauf- Hughes, Wells]. This correlation seems to relate the object relations theory to Moreno's concept of psychodrama, according to which the key to understanding the genesis of the person's emotional problems should be sought in psychological background related to social relationships, which engenders dysfunctions in the sphere of an individual's reactions and behaviours. Hence integrating the approach which utilizes the corrective influence of "good" object relations therapy with psychodrama techniques such as surplus reality, might prove to be an effective method in the treatment of eating disorders, including

Based on a review of subject literature, and drawing from my own experience gained in the course of individual and group therapy conducted on patients suffering from bulimia nervosa, I wanted to stress in this paper the importance of integrative approach to diagnosis and treatment of bulimia nervosa. My intention was to demonstrate the basic similarities between psychodrama and the object relations theory, and point to the fact that these two

the structure of the bulimic individual's personality.

therapeutic approaches may complement each other.

spontaneity.

bulimia nervosa.
