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Psychoanalytic Inquiry: A Topical Journal for Mental

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Identity conflicts in bulimia nervosa: Psychodynamic

patterns and psychoanalytic treatment
a b d c
Günter Reich Ph.D. & Manfred Cierpka M.D.
a
Training and Supervising Analyst, Lou Andreas‐Salomé Institut für Psychoanalyse Göttingen
(DPG)
b
Trainer and Supervisor in psychoanalytic family therapy, Center for Family Therapy ,
University of Göttingen
c
Professor of Psychosomatics and Psychotherapy, Department of Psychoso‐matics and
Psychotherapy and Director, Center for Family Therapy , University of Göttingen
d
Georg‐August‐Universität Göttingen , Humboldtallee 38, Göttingen, 37073, Germany
Published online: 20 Oct 2009.
To cite this article: Günter Reich Ph.D. & Manfred Cierpka M.D. (1998) Identity conflicts in bulimia nervosa: Psychodynamic
patterns and psychoanalytic treatment, Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 18:3,
383-402, DOI: 10.1080/07351699809534199
To link to this article: http://dx.doi.org/10.1080/07351699809534199
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Identity Conflicts in Bulimia Nervosa:
Psychodynamic Patterns and
Psychoanalytic Treatment
G Ü N T E R R E I C H , Ph.D.
M A N F R E D C I E R P K A , M.D.
Downloaded by ["Queen's University Libraries, Kingston"] at 21:24 30 December 2014
I N GERMANY, AS IN MANY OTHER COUNTRIES, psychoanalytic and psy-

chotherapeutic practice is becoming more and more concerned with
the treatment of Bulimia nervosa. The treatment of bulimic patients
often calls for certain modifications in psychoanalytical technique.
The specific symptoms of the disorder; the conflicts and the ego
structures, particularly defense; and the nature of the patients' inter-
personal relationships must be taken into consideration. The following
observations are based on many years of experience gathered in our
special outpatient department for eating disorders. Various types of
treatment are used, sometimes in combination with one another (e.g.,
psychoanalytic and psychodynamic individual therapy, family ther-
apy, cognitive behavioral therapy, group therapy). This has presented
grounds for discussion on the various parameters of psychoanalytic
therapy.
In Germany, the background for this discussion is as follows:
1. In the conflict concerning the effectiveness of various therapeu-
tic methods for the treatment of mental disorders, psychoana-
lysts are under increasing pressure to justify the time and costs
their approach involves.
Dr. Reich is Training and Supervising Analyst, Lou Andreas-Salomé Institut für Psycho-
analyse Göttingen (DPG). Trainer and Supervisor in psychoanalytic family therapy, Center for
Family Therapy, University of Göttingen.
Dr. Cierpka is Professor of Psychosomatics and Psychotherapy, Department of Psychoso-
matics and Psychotherapy and Director, Center for Family Therapy, University of Göttingen.
383
384 Gt)NTER REICH AND MANFRED CIERPKA
2. Efforts to combine or integrate elements of different therapeutic

approaches are on the increase. Some of these result from
research or theoretical projects (Orlinsky 1994; Grawe, Donathi,
and Bernauer, 1994) and some from practice. For example,
Tobin and Johnson (1991), following on from Wachtel (1977),
suggest the integration of psychodynamic and behavioral ther-
apy in the treatment of eating disorders.
3. These discussions have an "external" effect on psychoanalytical
psychotherapy. At the same time an "internal" discussion is
emerging, demanding the adaptation of the psychoanalytic tech-
nique to the individual characteristics of the syndrome being

treated. For example, Thoma and Kachele (1996a, b) suggest
phases of ego-support in the psychoanalytic treatment of anxiety
neuroses. Wurmser (1987, 1994, 1995) also promotes this idea
for the psychoanalytic treatment of severe depression, obses-
sional neurosis and anxiety, and addictive disorders. In many
cases, he recommends the combination of psychoanalysis with
behavioral therapy, couple and family therapy, or medication.
The combination of methods often achieves better results than
one method used alone (Wurmser, 1987).
Against the background of these discussions and the accompanying

changes in psychoanalytic theory and the theory of treatment tech-
niques (e.g., Wurmser, 1987, 1995; Lichtenberg, 1989; Schwaber,
1996; Thoma and Kachele, 1996a, b), we will begin by outlining the
psychodynamic patterns of Bulimia nervosa. We will then proceed to
describe the resulting technical considerations.
Psychodynamic Patterns in Bulimia Nervosa:

Action Symptoms and Identity Conflicts
From a psychoanalytic point of view, bulimia is an "elaborated habit-

ualized impulsive action" (Habermas, 1990), a form of impulsive
neurosis as described by Fenichel (1945). This impulsive action is a
way of dealing with internal psychic tension by means of physical
objects and lies between an involuntary symptom, an unconscious
intrapsychic defense and a sanctioned cultural technique. It is some-
times ego syntonic, but at other times ego dystonic. The alternation
between ego syntonicity and ego dystonicity arises from a deep-seated
IDENTITY CONFLICTS IN BULIMIA NERVOSA 385
identity conflict that bulimia patients typically suffer from, that is, the
conflict between two contradictory parts of the self.
The first part represents activity, intactness, self-control, and inde-
pendence; this is the part that patients like to display outwardly in
everyday life, that is, the ideal self. The other part consists of needi-
ness, weakness, and lack of control; it is experienced as faulty, the
defective self, and is thus hidden away. The two elements involved in
this conflict are expressed in an aspiration to be slim, a general
concern with outward appearances, an occupation with food and
eating, and bouts of eating and vomiting. If the body weight were to
increase over a certain limit, the defect would become visible to
others. This must therefore be avoided. This experience is the result of

a displacement from the psychic self onto the perception of the body
(see also Sugarman 1991; Reich 1994, 1997). The notion of being
afflicted with a fault or a defect is usually extremely intense. The
patients feel that the core of their self is unworthy of love and esteem.
This essential conflict between incompatible parts of the self or iden-
tity determines the experience of bulimic patients suffering from the
illness to varying degrees.
Empirical studies have shown that bulimia occurs to varying
degrees and that it is a mistake, when confronted with the symptoms,
to simply assume an "early," "narcissistic," or "borderline" disorder.
Extensive bulimic symptoms also occur as an expression of a
"disorder of the self in individuals who are otherwise relatively
undisturbed, or they can be part of a wider spectrum of symptoms that
suggest a more serious personality disorder (see Reich, 1997, and the
literature quoted there). The development of the identity conflict
described above and subsequently of bulimia comprises so-called
preoedipal, oedipal, and adolescent experience and also conflicts
arising in the launching phase. We consider these elements to be
complementary to one another.
The Genesis of the Identity Conflict
Disturbances in the Affective Dialogue

Within Primary Relationships
As a rule we find a disturbance in the emotional dialogue in primary
relationships, where the basal needs of the patient for anaclisis,
386 GONTER REICH AND MANFRED CffiRPKA
emotional intimacy, affective resonance, and approval are insuffi-

ciently met, rejected, or even met with derision. Sometimes attention
is alternated with neglect, so that the later patients have no reliable
means of orientation. These experiences seem to form a consistent
pattern and are not confined to the preoedipal era. (see Reich, 1996a,
b; Cierpka and Reich, 1997). The wishes outlined above and the
central part of the identity they represent are repressed by the patient,
for example, she becomes unapproachable or impervious, as the
following shows.
"Yesterday I met my friend M at a party. I ignored him. He asked
me how my thesis was going. I just said, 'Sometimes good, sometimes

bad.' He was a bit surprised, almost hurt, but he didn't show it. I could
tell he was trying to pull himself together. He didn't ask me anything
else. I just let him stand there. It's often like that. If I want to, I can
just let everything bounce off me. I pretend I don't care and act unap-
proachable, as if I had a mask on. The others have to do all the work. I
can decide whether or not to let them in."
This patient describes the following incident, immediately leading
up to the above situation: "I sat in the seminar, waiting for M. He was
late, as usual. I was mad. I'd kept a place free for him. He finally
arrived, sat down, and took the handout from me. That made me angry
too. It's often like that. Then we went out together; we were going for
something to eat. I.had to stop and buy something at the stationer's.
He waited for me outside. When I came out, he was deep in conversa-
tion with L: I almost felt as though I was interrupting something. So I
said, 'Am I interrupting something?' They just carried on talking."
The patient felt neglected, helpless, and furious. After a bout of eating
and vomiting, she decided to turn the tables. She often reacted in this
way in such situations, unless she became depressed and withdrew
completely. A fundamental biographical factor for this behavior and
experience emerged during psychoanalysis. The patient's younger
sister had suffered from asthma and other allergic reactions as a child.
She often received the parents' entire attention, while the patient was
ignored. "They only took any notice of me if I was ill myself." Thus,
the experience of being left standing alone resulted in helpless-
ness and anger—a deep fear of being forgotten—a feeling of
worthlessness.
Intimate Boundary Conflicts
In the genesis of many bulimic patients, a lack of respect for their

intimate barriers and a tactless intrusion of their privacy can be found.
This is not restricted to sexual abuse. Although sexual abuse can be a
considerable factor contributing to the development of eating disor-
ders, it is not more commonly found here than in other forms of severe
mental illness (see Connors and Morse, 1993). Interactions of a more
day-to-day, less spectacular nature, producing feelings of weakness,
helplessness, and powerlessness again and again, seem to be more
relevant, for example, letting confidential information slip out to

others or making fun of important experiences. For example, one
father was always telling friends and relatives how much his growing
daughter weighed and what clothes size she wore—to her huge
embarrassment. These interactions confirm the central fear of the
patients, that every form of intimacy culminates in betrayal.
Persisting Oedipal Conflicts
Patients suffering from bulimia find themselves in a persisting oedipal

conflict situation, often against a background of extreme marital
tension between the parents. The following constellations may be
observed.
The Idealized Father and the Mother as Adversary

The relationship between the patient and her father is close and
"chummy." The fathers accentuate the "manly," "boyish" aspects of
the patients, who consequently identify with these. They wish to fulfill
the father's expectations. This demands a performance-oriented and,
particularly with regard to "soft" feelings, self-controlled, phallic ego
ideal and a corresponding body ideal. At the same time an erotized
relationship between patient and father often develops, causing the
patient to feel that she is the "better partner." This is generally accom-
panied by repressed feelings of shame and guilt. The fathers of
bulimic patients often seem to display a tendency for impulsive
actions, for example, impulsive alcohol abuse, irascibility, or even
violence (see Johnson and Connors, 1987; Reich 1996a, b; Cierpka
388 GtiNTER REICH AND MANFRED CIERPKA
and Reich, 1997). The processing of this aspect is also ambivalent. On

the one hand, the patients disapprove of the impulsive actions.
However, in a deeper layer of their personality they admire them and
identify with them because they are a sign of strength, that is, a sign of
the fact that the fathers disregard rules, not least importantly the rules
advocated by the mother. This identification manifests itself in eating
binges.
There is a strong rivalry between mother and daughter, particularly
concerning attractiveness, which is often displayed openly. Femininity
such as that represented by the mother is often rejected. Simultane-
ously, at a deeper level it is the standard the patients use to measure

themselves by, since the father finds or has found certain aspects of
the mother attractive.
The Despised Father and the Mother as Adversary

Here the patient is also in competition with the mother, who this time
appears as a dominant, controlling figure. The father is disappointing
as an object of oedipal, narcissistic admiration because of his
"softness," his "pliability," or "seclusion." The patient identifies with
the phallic mother, who is how she would like the father to be. The
father is contemplated with barely disguised contempt and derision,
sometimes relieved by phases of understanding because he is more
caring than the mother.
The Distant, Unreliable Father and the Helpless Mother

In this constellation the patient becomes a partner substitute for an
overstrained mother, while the father evades his "duties." The patient
does this in his place, by supporting, counseling and caring for the
mother. She often "receives" far less from the mother than she
"gives." On the one hand, she identifies with the partner ideal and
the—often depressive—superego of the mother. Unconsciously, she
admires the father, who is able to withdraw and go his own way.
These fathers also often display various kinds of impulsive actions.
Traumatization and Overstimulation
The close, erotized relationship with the father, along with the impul-
sive actions outlined above and violent family conflicts, can lead to
the traumatization or overstimulation of the patients. This can cause

difficulties with affective regulation, which in their turn result in the
fear of affective overflow, constriction, and powerlessness and in
defense against affects through actions and blocking of feelings.
Contradictory Superego Demands
The demands of the superego are, in keeping with the development

described thus far, also contradictory. This particularly applies to the
ego ideal and the introspective part of the superego. On the one hand,
the superego demands self-control, perfection, and an attractive

outward appearance. Because of this, however, the patient is likely to
be highly dependent on the goodwill of others. This contradicts the
ideal of autonomy. If she behaves in an impulsive way, for example,
by giving way to eating binges or fits of rage, she is defying conven-
tional barriers. She is thus obeying the ideals of power and autonomy,;
however, she is out of control. She probably experiences herself as not
feminine in the conventional way; therefore, she cannot compete with
the mother and fears criticism from internalized aspects of the mother
(often also from the real mother).
Empirical studies show that bulimic patients put themselves under
enormous pressure, wishing to conform to several completely contra-
dictory social roles, which proves too much for them. Additionally,
because of the strong outward orientation of their superego, they
accede to the social ideal of being slim to a far larger extent than
women who do not suffer from eating disorders (see Reich, 1996a, b).
One patient described the following scene: "Recently, my sister was
passing our house. She came into the garden and looked through into
the kitchen. I didn't want to see her. She always noses around looking
at everything and usually starts trying to arrange some family get-
together. But she saw the chaos in my kitchen. I hadn't started tidying
up. I felt bad, really awful, terrible. I hate this tidying up business. It
ties me down so much. My mother always insisted on everything
being tidy. My sister's just the same. But on the other hand I long for
boring, old middle-class tidiness. It makes me feel miserable when
someone sees how messy I am. When my sister had gone, I ate and ate
and then I was sick. It's the same with work. I could look for a steady
job again now. But where? I prefer to carry on temping. Starting new
390 GttNTER REICH AND MANFRED CIERPKA
things is more interesting. If I'm at the same place all the time, I have
to prove myself. It can turn out all wrong. I want new things and I
want stability and contentment. There are two sides of me. As soon as
I've got one side sorted out, I get criticized by the other."
This kind of alternating pattern—rebellion against certain parts of
the superego driven on by other parts, followed by submission to the
demands initially rebelled against—is common to many patients. It
can also be seen in the symptom itself, the action of giving way to an
eating binge: Something "forbidden" is done; food is taken from the
"black list." This is followed by contrition and humiliation, vomiting,
and other ways of trying to undo the action. The demands of the
superego often also dichotomize in an absolute way between good and
bad, strong and weak, right and wrong, justified and unjustified. The
judgments are often inexorable, directed either against the self and the
outside world or projected onto the outside world, restaged so that the
patient is either the judge and the despiser or she is judged and
despised.
The Defense Structure
The dominant factor in the patient's defense structure is the reversal

into opposites, particularly reversal of affects, and turning from
passive to active. Reversal of affects transforms fear into anger,
humiliation into defiance and contempt, shyness and uncertainty into
stridency. The reversal from passive to active manifests itself mainly
in activity, which protects the patient against the perception of
conflicts and affects. To perceive these without taking immediate
action is often unbearable. This is especially the case for feelings such
as sorrow, fear, disappointment, humiliation, guilt, or shame. Patients
are able to perceive these affects and the corresponding wishes in
others and react to them, but they can barely tolerate them in them-
selves. Other forms of defense are identification with the aggressor;
denial, which is often employed globally; and affective blocking,
which has the effect of numbing the patient from within, so that she
feels nothing at all and others leave her completely cold. Also, glob-
alization and exaggeration may be observed, making the patients'
feelings seem disproportionate; sometimes the patients themselves
appear unconvincing. The impairment in interoceptive perception that
IDENTITY CONFLICTS EN BULIMIA NERVOSA 391
results from this complex development of defense has been empiri-

cally shown to represent a considerable risk factor for the formation of
eating disorders, particularly bulimia (see Reich, 1997).
The Fantasy of'Defectiveness"
Because of the above-mentioned factors, the patients are afraid of

losing control, being shown up, or scorned if they allow more intimate
aspects of themselves to come into the open. Affects such as sorrow,
anxiety, sadness or pain, the desire for attention, intimacy, passivity,
and abandon are dismissed as signs of weakness. The desire for sexual
intimacy also gives rise to the fear of powerlessness and inadequacy.
This leads to a deep-seated feeling of shame for central aspects of the
self. The patient becomes thoroughly convinced that she is inferior,
essentially unworthy of love and respect. This fault, the "defective
self," must be concealed at all costs. This notion of the defective self
is her central fantasy.
Shame Conflicts
Shame, the central narcissistic affect, seems also to be the central

affect in Bulimia nervosa (Reich, 1992, 1994; Silberstein, Striegel-
Moore, and Rodin, 1987). Wurmser (1994) groups eating disorders
explicitly under the "shame syndrome." Shame arises when a person
fails to reach the ideal state she aspires to; she observes this in herself
or feels observed by others. Shame leads to isolation and produces
powerful vegetative reactions. It has a bearing on the whole self.
Protection can be gained by concealment. "Shame anxiety is specif-
cally self-potentiating and thus especially prone to traumatic mobi-
lization and loss of control" (Wurmser, 1994, p. 55).
Displacement to the Body
The fantasy of having a defect, of being inferior and faulty, is

displaced to the body. This displacement is a means of defense
through concretization or a pars-pro-toto defense; the body or single
parts of the body represent the whole person or essential parts of the
self. In this way the fantasy of the defect and the shame it produces
392 GONTER REICH AND MANFRED CIERPKA
can be limited and becomes easier to handle, more controllable

(Reich, 1994; Silberstein et al., 1987; Wurmser, 1994). The following
factors contribute to this process of displacement and condensation:
• Shame is by nature a very physical affect; it often involves inten-

sive body reactions.
• Eating or oral regression is often one of the few forms of regres-
sive behavior possible within the families. Other possibilities,
especially those of a non-performance-related nature, are not
cultivated. Thus oral regression becomes the central means of
affect and conflict regulation and affective exchange.

• Because of excessive outward orientation, the patients accept
the social ideal of being slim to a high degree. Being slim
means: "There is no fault, no defect. I can control myself. I am
strong. I am okay. I am fit to be seen." On the other hand, eating
symbolizes regression, being cared for, intimacy, and the gratifi-
cation of instinct, but is also connected with this lack of control,
weakness, being overpowered, being penetrated, inferiority, and
consequently, humiliation. This contrast represents a continual
focus of attention and a constant dilemma.
• A further significant factor is the development during adoles-
cence, in two respects. First, the moral part of the superego
becomes partly replaced by the ego ideal. "Any discrepancy
between ego ideal and self-representation is felt as a lowering of
self-esteem; this state can assume intolerable proportions" (Bios,
1962, p. 186). At the same time, because of their previous
history, patients are extremely distressed by the overwhelming
insecurity caused by the physical developments that take place
during adolescence. Any real or imagined differences between
their own physical development and that of "others" (e.g., the
onset of menstruation) reinforce the patients' notion of being
afflicted with an abnormality, a fault. The development of the
superego, the profound lack of self-confidence, and the resulting
insecurity with regard to their bodies lead bulimic women to
accept the social ideal of being slim to a greater degree than
nonbulimic women (Habermas, 1990; Silberstein et al., 1987).
As a defense mechanism against their insecurity, they develop
the internal image of an "ideal body." This becomes an essential
part of the ego ideal. The experience of physical self-control, for

example, physical exercise, produces a fusion with the ego ideal
that often corresponds with an idealized phallic image of the
father, raising self-esteem and even leading to the "grandiose
self."
Strong identification with the social ideal, which of course can

never be conformed to, produces shame. Patients deny the fact that
substantial differences in build and weight are genetically determined.
These are attributed to will alone; being slim is a sign of willpower.
The "typical" dieter is bound to fail, and this is taken as proof for her
lack of willpower, her inadequacy. This leads to new attempts at
sticking to diets (Silberstein et al., 1987).
Trigger Situations
The causes for the outbreak of bulimic illnesses often appear to be

situations where patients feel under pressure to prove themselves,
compare themselves with others, or be compared. This is the case, for
example, when they take their first independent steps outside of the
parental home at school, at college, or at work but also when they
experience their first emotional encounters in intimate relationships.
All these situations contain a moment of being observed and assessed
in the patients' internal reality and also often in external reality. Here
the patients feel inadequate or are rejected.
One patient told us that she was "incredibly thin" until the age of
fifteen. She had no real feeling for her body; she could eat anything
she wanted without putting on weight. Because she was "so tall and so
thin," she could never find trousers to fit her. She was the last in her
class to start menstruating, but rather than admit this, she pretended
she had. Her mother was very concerned about her development. Over
the next 3 years she met several men some years older than herself.
Through them, she gained an awareness for her body; as they told her,
she "looked really good." "I was a kind of sex symbol, I had a good
figure. I was proud of it, although I couldn't really see it myself." She
began taking the pill and quickly gained weight. "That was drastic, I'd
never known anything like it before. Not only my body fell apart. I
started to feel really insecure. Then Peter split up with me. The rela-
394 GfJNTER REICH AND MANFRED CIERPKA
tionship had been holding me up; I had been orienting, stabilizing

myself on him. Now he had dropped me, and suddenly I was abso-
lutely worthless. I thought it was because I was too fat. I was shit, and
that's why he finished with me. I felt guilty because of my figure.
Then I started dieting. I felt as though I'd got some imperfection in the
way I looked. My appearance became really important to me—I
would do anything I could to look good. The better I look, the more
I'm worth. The thinner I am, the better I look." Since then, she has
continually been on diets and becomes caught up in cycles of eating
and vomiting. She blames every new episode of oedipal disappoint-
ment on her appearance.
The Psychodynamic Functions ofBinging and Purging
Various aspects of the regulation of affect and conflict are concen-

trated in the eating binge and counterregulation, according to the
"principle of multiple function" (Waelder, 1930). Bulimic symptoms
are action symptoms, and as such, they correspond with the individual
(and familial) defense system; they work by reversing passive to
active, by taking action. They serve to restore control in situations
where the patients feel powerless in the face of strong impulses and
affects. Bouts of eating always contain an element of rebellion against
the superego or dominant parts of the superego. Furthermore, bulimic
symptoms can also spring from a desire for support, anaclisis, security,
and recognition (Benninghoven et al., in preparation), or from sexual,
aggressive, and autoaggressive impulses. Counterregulation, particu-
larly vomiting, has the function of erasing the eating binge, restoring
the desired body weight or shape, cleansing away filth and inade-
quacy, and eradicating violation of interpersonal boundaries or pene-
tration and aggressive or autoaggressive impulses.
Psychoanalytic Therapy of Bulimia Nervosa
Diagnostic and Introductory Phase
Only a small number of women suffering from Bulimia nervosa enter

into psychotherapy. These patients particularly tend to avoid intensive
psychoanalytic therapies, because of their strong ambivalence towards
the idea of giving up the symptoms, as is often observed in cases of

substance abuse or addiction. A more profound reason is usually the
fear of confrontation with the inner self, particularly the parts of the
self considered to be "defective," and the strong action orientation
associated with it (see also Reich, 1994, 1997). Thus, we attach great
importance to the preliminary phase of the treatment, beginning with
the diagnosis itself.
The first step in this phase consists of an exact definition of the
symptoms, behavior, and experience related with the eating binges
and counterregulation; the patient's eating habits and eating rhythm
(basic eating behavior); her acceptance or rejection of certain parts of

the body; and the effects a loss or gain in weight have on her body
image and self-confidence. An exploration of other symptoms and
disorders (e.g., addiction, affective disorders) and a medical investi-
gation to establish any physical damage caused by Bulimia nervosa
may also be indicated during this phase. Sometimes it is necessary to
discuss specific eating behaviors with the patient, suggesting possible
alternatives. Some patients require general information on eating
behavior, diet, and their implications. For example, they may not be
aware that their cravings, feelings of starvation, and drastic reductions
in blood sugar levels are often a direct result of their eating behavior.
They may not know that cravings can occur in some women prior to
menstruation bleeding. They are under the impression that all physical
reactions are associated with will, or rather, their own lack of
willpower. In addition, they may not know or may deny the fact that
body weight and the shape of the body are often constitutionally
bound and that diets do not lead to continual, lasting weight loss.
Sometimes it can be helpful for patients to take part in nutrition coun-
seling at the same time as beginning the psychotherapy.
The next step is to establish which affective conditions and
conflicts are currently associated with the bulimic symptoms. Patients'
accounts are often global. It is an essential task of the therapy to begin
work on the differentiation of perception at this early stage. Here we
work according to ego psychological considerations; because of the
patients' ego regression and the restriction of the ego caused by the
defense patterns and the duration of the symptoms, it is often neces-
sary to support the observational ego and the working alliance, partic-
ularly the active participation of the patient in the treatment. For this
396 GtiNTER REICH AND MANFRED CIERPKA
purpose it is often useful to introduce an eating diary. Unfortunately,

psychoanalysts often tend to disregard and neglect these important
first steps of the treatment. This is certainly one of the main reasons
for the failure of intensive psychoanalytic therapy in this group of
patients. The patients feel that their problem, in their eyes first and
foremost the symptom, is not being taken seriously enough. This is
often a repetition of a traumatic childhood experience—being left
alone with their troubles. In other patients, the first control conflicts
begin to emerge even at this early stage.
The procedure we suggest has the following advantages:
• It picks the patients up where they stand.

• It gradually directs their ego attitudes towards affects and inter-
personal and psychic conflicts and stimulates the differentiated
perception of intrapsychic space.
• It encourages their active participation.
• Later on in the course of the therapy; it helps in the analysis of
symptomatic behavior and its significance or reinforcement or in
the recognition of why patients fail to adopt modes of behavior
that make it easier to keep the symptoms under control in the
light of transference and intrapsychic conflicts.
Extended Introductory Phase—The Lead-up to Psychoanalysis
In the treatment of many bulimic patients, it has sometimes proved

useful to extend the introductory phase over the first 10-20 sessions or
even longer. This encourages the patient to get used to working with
intrapsychic processes and interpersonal experience. At the same time
it intensifies the relationship with the therapist and the working
alliance (see also Wurmser, 1995; more generally Gray, 1994).
Defense against psychoanalytic psychotherapy and the fears that
cause it can be considerably reduced by careful preparatory work.
During these introductory sessions, attention is drawn to significant
psychodynamic factors in the current and biographical context. Their
manifestations in the transference are analyzed and suitable hypothe-
ses are developed. The starting point is the trigger situation and the
development of bulimia, the significance of eating, appearance, and
weight in the biography of the patient, in her primary family, and
among her peers. The other important psychodynamic aspects

mentioned above are then actively explored, and their implications for
current experience are examined with the patient. In this way, the
mutual working focus for the psychoanalytic process is widened.
Main Treatment Phase
As the analytic process continues, the situations that cause bouts of

eating and vomiting to occur remain an important starting point for
discussion. As is the case with any material, we begin on the surface
and then start work on the clarification and differentiation of affects

and conflicts. Global, undifferentiated perceptions hinder the progress
of the therapy and the working through. The work generally demands
a high degree of perseverance because a number of typical problems
can stand in the way of progress.
The psychoanalytic situation itself repeatedly takes on the form of a
bulimic scene. Particularly if the introductory phases described above
are not adhered to, an invitation to free association often leads to
material being "vomited" into the session; in other words, the patient
bombards the analyst with ideas. These are often unconnected with
the patients' actual experience. The sheer quantity of material makes
it "indigestible," impossible to process. In countertransference the
hungry, addictive expectations of the patients for a magical cure and
their idealizations can produce a desire to cure the patients quickly, to
feed or to nurse them. Here the analyst is in danger of "stuffing" and
"overfeeding" them with interventions, for example, by introducing
deep interpretations too quickly or being "particularly empathic,"
offering himself as a purely "good," approving or permissive object.
Confrontations, mirroring, and interpretations are usually processed
in a "bulimic" way. They are consumed greedily, but not properly
"digested." During or after the session they are "brought up" or
"purged" by vigorous physical activity, long discussions with other
people, bouts of eating and vomiting, or alcohol abuse. This is partic-
ularly likely to happen if too many, too "deep" interpretations are
given or if the analyst is too approving and caring. The patients are
always ready with a supply of new superficial events or sensations,
diverting the attention away from internal experience and thus
hindering the psychoanalytic process.
398 GONTER REICH AND MANFRED CIERPKA
In addition to tendencies of globalization, affective poverty and

emptiness can also frequently occur. This is often caused by a power-
ful defense when intensive memories such as traumas threaten to
emerge or in the presence of powerful transference conflicts. All these
patterns in the transference relationship and defense mechanisms are
aimed at avoiding confrontation with the self. The patient uses exter-
nal activity to defend against intrapsychic experience and keep it
under control.
The patients cannot imagine that it is possible for another person to
be interested in them without the ulterior motive of wishing to instru-
mentalize them. For this reason, shame is a constant companion

throughout the entire treatment process. Therefore it has proven most
helpful to pay close attention to the various possible manifestations of
this affect and its defense, particularly the turning from passive to
active and the reversal of affect (see also Wurmser, 1994).
Defense through action can be observed in almost every session
throughout the psychoanalytic process. It is a sign of considerable
progress when patients can bear to experience feelings of sadness, fear
or isolation in the presence of another person. Often, such phases are
followed by the fear of being despised by the therapist. This fear can
lead to aggression against the therapist or against the self in the form
of depressive self-accusation. For example, a patient cried for the first
time during the 76th session, having been very hectic up until this
point. In the following session she was reserved and tense. After
approximately 10 minutes of silence, she shouted angrily at the thera-
pist: "Don't think I didn't see you smirking yesterday when I left!"
During the course of the session it became clear how exposed and
belittled the patient had felt as a result of her open display of emotion
and the attentive reaction of the therapist. This incident helped the
treatment along considerably in its progress.
In situations such as these, a worsening of the symptoms may be
observed. This can also happen when traumatic memories threaten to
emerge. Here the symptom can serve to numb memories and feelings,
directing the focus of attention elsewhere. During these phases it is
also essential to establish links with eating behavior. Gradually, this
gains considerable importance in the transference relationship; the
patient can act out unspoken or unconscious transference desires, for
example, the desire for approval or sexual contact, with excessive
eating and vomiting. She can also attempt to anesthetize feelings of

humiliation, anger, or fear with bouts of eating and vomiting. In so
doing she can punish herself for "evil desires" or show that therapy is
hopeless in her case. For example, one patient began having more
frequent eating and vomiting binges after she had made several
important steps to further her career. She was in direct competition
with a colleague at work and found herself in a stalemate situation; if
she appeared inferior to her rival, she felt small, ashamed, and furious.
If she was better, she felt guilty, and she felt sorry for the colleague.
At the same time she was afraid of becoming closer to the therapist if
she made too much progress. She was afraid of being instrumentalized
by him, feared that he would boast about his "successful therapy" in
the same way as her parents had broadcasted her good school results
to friends and relatives. Eating and vomiting was a kind of "brake",
protecting her against oedipal closeness and exploitation in the
transference.
An increase in bulimic symptoms can also be the expression of a
wish to punish the therapist, to prove his inadequacy, rendering him
impotent and powerless because he seems so disappointing or so
intrusive and overwhelming. Conflicts of interpersonal boundaries
often occur in the treatment of bulimic patients. These conflicts can be
provoked by a worsening of the symptoms, as shown above, or by
other problematic or self-destructive forms of behavior. They can
produce strong emotional reactions in the therapist such as helpless
rage. The patient often then reacts with feelings of guilt, shame, or
contrition.
Generally speaking, the conflicts described above are governed by
various elements of the superego. The therapist becomes the repre-
sentative of constricting, controlling elements of the superego, against
which the patient rebels. Here she is obeying her ego ideal of strength
and self-control. Then the previously repressed elements of the
superego come back into the picture. The patient is afraid of retalia-
tion, disapproval, and contempt. She submits again.
In our experience the therapist must allow himself to be drawn into
this conflict to some extent, so that the full force of the affects
concerned is really felt within the relationship between therapist and
patient. If the therapist behaves in too neutral a way, simply
commenting on these sequences "from the outside," the analytic
400 GONTER REICH AND MANFRED CDERPKA
process is likely to run dry. Confrontations in which the therapist

displays emotional involvement and interest in clarification usually
help to lead the process out of the deadlock of so-called "negative
therapy reactions." These confrontations show that there is an alterna-
tive to the conflict between the permissive, purely consenting and the
dominant superego—namely, a superego that sets boundaries in the
interest of the analytical process and consequently in the interest of
the patient's development, at the same time allowing confrontation to
take place.
Final Phase
It is advisable to pause at intervals throughout the analysis to take a

closer look at the stage the treatment has reached: which discoveries
have the patient and the therapist made together, what changes have
taken place, and what remains unclear or unchanged? This strengthens
the working relationship and the ego autonomy of the patient. In the
final phase it has also proved beneficial to cast a retrospective glance
over the treatment as a whole and to make a final summary of devel-
opments together.
As is the case in any psychoanalysis, the lines of conflict processed
are clustered in the final phase. The themes of parting and, linked with
this, limitation and limits within the treatment become important.
Feelings of disappointment and anger caused by unfulfilled desires for
completeness, perfection, and absolute support are often expressed. A
painful parting from these values and ideals usually takes place during
the process of this conflict; subsequently, they are seen in more of a
relative context and become more appropriately integrated.
Conclusion
Continuing on from current discussions concerning changes in the

clinical theory of psychoanalysis and its consequences for the treat-
ment of "difficult" patients; we have developed an integrated model
for the understanding of bulimic illnesses, which views the various
psychoanalytic approaches as being complementary to one another.
These considerations have led to the development of a treatment
model that requires certain modifications to be made to the classical
psychoanalytic technique, particularly during the introductory phase.

In this way, bulimic patients can be encouraged to enter into treatment
and can be more successfully initiated in the psychoanalytic process.
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Psychoanalytic Inquiry: A Topical Journal for Mental

Identity conflicts in bulimia nervosa: Psychodynamic

To link to this article: http://dx.doi.org/10.1080/07351699809534199

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I N GERMANY, AS IN MANY OTHER COUNTRIES, psychoanalytic and psy-

2. Efforts to combine or integrate elements of different therapeutic

nique to the individual characteristics of the syndrome being

Against the background of these discussions and the accompanying

Psychodynamic Patterns in Bulimia Nervosa:

From a psychoanalytic point of view, bulimia is an "elaborated habit-

others. This must therefore be avoided. This experience is the result of

The Genesis of the Identity Conflict

Disturbances in the Affective Dialogue

emotional intimacy, affective resonance, and approval are insuffi-

me how my thesis was going. I just said, 'Sometimes good, sometimes

Intimate Boundary Conflicts

In the genesis of many bulimic patients, a lack of respect for their

relevant, for example, letting confidential information slip out to

Persisting Oedipal Conflicts

Patients suffering from bulimia find themselves in a persisting oedipal

The Idealized Father and the Mother as Adversary

and Reich, 1997). The processing of this aspect is also ambivalent. On

ously, at a deeper level it is the standard the patients use to measure

The Despised Father and the Mother as Adversary

The Distant, Unreliable Father and the Helpless Mother

Traumatization and Overstimulation

the traumatization or overstimulation of the patients. This can cause

Contradictory Superego Demands

The demands of the superego are, in keeping with the development

the superego demands self-control, perfection, and an attractive

The Defense Structure

The dominant factor in the patient's defense structure is the reversal

results from this complex development of defense has been empiri-

The Fantasy of'Defectiveness"

Because of the above-mentioned factors, the patients are afraid of

Shame, the central narcissistic affect, seems also to be the central

Displacement to the Body

The fantasy of having a defect, of being inferior and faulty, is

can be limited and becomes easier to handle, more controllable

• Shame is by nature a very physical affect; it often involves inten-

affect and conflict regulation and affective exchange.

part of the ego ideal. The experience of physical self-control, for

Strong identification with the social ideal, which of course can

The causes for the outbreak of bulimic illnesses often appear to be

tionship had been holding me up; I had been orienting, stabilizing

ment on her appearance.

The Psychodynamic Functions ofBinging and Purging

Various aspects of the regulation of affect and conflict are concen-

Psychoanalytic Therapy of Bulimia Nervosa

Diagnostic and Introductory Phase

Only a small number of women suffering from Bulimia nervosa enter

the idea of giving up the symptoms, as is often observed in cases of

(basic eating behavior); her acceptance or rejection of certain parts of

purpose it is often useful to introduce an eating diary. Unfortunately,

• It picks the patients up where they stand.

Extended Introductory Phase—The Lead-up to Psychoanalysis

In the treatment of many bulimic patients, it has sometimes proved

among her peers. The other important psychodynamic aspects

Main Treatment Phase

As the analytic process continues, the situations that cause bouts of