The European Journal of Counselling Psychology
ejcop.psychopen.eu | 2195-7614
Eclectic Therapy for Dual Diagnosis: A Case Study
Stamatia Soundia*
a
[a] Department of Eating Disorders “18 Ano”, Attica Psychiatric Hospital, Bournazou, Athens, Greece.
Abstract
This paper discusses the case of Helektra, a 28 year old female who was diagnosed with bulimia nervosa and borderline personality disorder
using DSM-IV diagnostic criteria. The patient had referred herself to a state-run service in Athens, Greece. Therapy lasted for two and a half
years. The patient’s therapeutic schedule included an integrated therapy model which was based on Fairburn`s diary (Fairburn, 1995, 2008)
and on psychodynamic psychotherapy for personality disorders (McWilliams, 1994; Roberts, 1997). The findings of this case study are
supportive of the benefits that have been associated in the psychological literature with the integration and eclectism of psychotherapeutic
models.
Keywords: bulimia nervosa, BPD, dual diagnosis, counselling psychology
The European Journal of Counselling Psychology, 2014, Vol. 3(1), 42–53, doi:10.5964/ejcop.v3i1.26
Received: 2013-08-09. Accepted: 2013-11-13. Published (VoR): 2014-03-28.
*Corresponding author at: Department of Eating Disorders “18 Ano”, Attica Psychiatric Hospital, Bournazou 37, 11 521, Athens, Greece. E-mail:
[email protected]
This is an open access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Case Context and Method
Clinical practice has shown that every psychotherapeutic model has distinctive ways in which it achieves its aims
and different models are appropriate for use with different patient needs. Additionally, as patients' needs evolve
during therapy they require the use of knowledge and skills from different psychotherapeutic approaches. This is
increasingly recognised in counselling psychology (e.g., O'Hara, 2012; Scott & Hanley, 2012; Ward, Hogan, &
Menns, 2011). Taking into consideration that therapy for eating disorders is considered to be very challenging
(Νational Institute for Health and Care Excellence guidelines 1.3.4.: Service Interventions for Bulimia Nervosa)
(National Institute for Health and Care Excellence, 2004) and that complex cases such as those with a dual diagnosis of eating disorders and borderline personality disorder often require a pluralistic approach, the integration
of therapeutic models, is of particular benefit to patients with such complex needs.
Rationale for Choosing the Client
Helektra, the patient that I have selected for this case study is an example of a complex case that required the
use of an integration of therapeutic approaches. Diagnosis identified bulimia nervosa and borderline personality
disorder with acute suicidal ideation. This case is additionally interesting due to the fact that therapy was mediated
by cultural factors as these operate in Greece.
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43
Clinical Setting: Theoretical Orientation of the 18 Ano Unit
The 18 Ano Unit, in Athens, is a state-run service which offers free therapy both to self-referred clients and to clients
who have been referred by other health-care professionals. The theoretical orientation of the Unit is reasonably
inclusive and therapists are free to use the therapeutic models that they deem appropriate for their clients. Nevertheless, the main therapeutic interventions used are based on cognitive models and particularly on Fairburn`s
diet diary model. Therapy is provided to national standards and it is accompanied by clinical supervision on a
regular basis.
Selection of Therapeutic Approach
Counselling psychology has embraced the challenge of integrating therapeutic models. A way of achieving this
objective is for counselling psychologists to include CBT and psychodynamic interventions (Parpottas, 2012;
Rabinovich & Kacen, 2009) in their practice. The inclusion of these two approaches was deemed appropriate for
the client case presented here on the basis of the nature of the material that the client brought to therapy.
It was decided that Helektra’s clinical presentation called for the use of an appropriate cognitive model such as
Fairburn`s diary (Fairburn, 1995, 2008) in combination with psychodynamic psychotherapy (McWilliams, 1994;
Roberts, 1997) for borderline personality disorders. A cognitive approach could help with the management of the
client’s eating disorder. The psychoanalytic perspective is recognised for its ability to encourage the expression
of patient feelings and this function makes this well-regarded therapeutic approach appropriate for use with the
diagnostic category of borderline personality disorder (Arthur, 2000). Moreover, in recognition of the psychotherapeutic importance of the therapist-client relationship, issues of transference and counter-transference can be explored through the psychoanalytic approach.
In addition, the therapeutic team of the Unit takes into consideration any material that patients bring to their therapy
(such as drawings, various kinds of text, objects etc.). The fact that Helektra had brought material like poems she
had written and her dream content to her intake interview indicated at first that Helektra would potentially respond
well to the psychodynamic approach. On the basis of this it was thought that the patient in this case study would
benefit from the inclusion of the psychodynamic approach in her therapeutic regime. To achieve this, it was thought
necessary to offer up to two further appointments to Helektra when required. I was appointed Helektra’s therapist
and I started my therapeutic work with Helektra under the supervision of a senior psychoanalyst.
It is worth noting that the clinical team had suggested the use of Dialectical Behaviour Therapy (DBT) (Fonagy,
2007) as an appropriate therapeutic approach for use with this client. Unfortunately, this option could not be taken
as there was no suitably trained professional in DBT in the clinical team of the Unit.
Ethical Considerations
Confidentiality and patient anonymity are standard practices among the Unit’s staff members Patients ordinarily
sign a therapeutic contract and a separate consent form which allows Unit therapists, under certain conditions,
to use anonymised material from their therapeutic work with Unit service users for publication purposes. Helektra
had signed such a consent form. Permission to publish this paper was granted by the 18 Ano Eating Disorders
Unit of the Department of Addictions, Attica Psychiatric Hospital, Athens, Greece. Additionally, in order to protect
confidentiality and the anonymity of the patient in this paper, I have used a pseudonym, and I have omitted or
amended details or facts of the patient’s life that could potentially reveal the patient’s identity.
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Theoretical Basis of the Therapeutic Work
Bulimia is characterised by an immense concern about body weight and shape. The main features of bulimia
nervosa are binge eating (eating excessive amounts of food) and inappropriate compensatory behaviour (purging,
vomiting) in order to avoid gaining weight. Many researches confirm that CBT is very effective for bulimia (Grave,
2005). CBT has been shown to be the most effective technique with regards to food normalization and to nonrelapsing attitudes (Spangler, 1999). However, it is not certain whether CBT addresses all the therapeutic needs
of bulimic patients (Wilson, 1999) and this leaves space for improvements (Wilson, Grilo, & Vitousek, 2007). More
specifically, there is consensus that there is a need for improvements in the use of CBT with patients who have
complex needs or severe psychopathology as these patients do not appear to be responding to CBT. One such
solution would be to use CBT in combination with other therapeutic approaches.
There is sufficient evidence that, generally, comorbidity in eating disorders is associated with personality disorders
(Marañon, Echeburúa, & Grijalvo, 2004) and, in particular, with borderline personality disorder (BPD) (Sansone,
Fine, Seuferer, & Bovenzi, 1989). With regards to bulimic patients, there seems to be no significant difference in
the effectiveness of therapy for those patients with or without BPD comorbidity (Zanarini, Reichman, Frankenburg,
Reich, & Fitzmaurice, 2010). Nevertheless, there is consistent evidence that patients diagnosed with bulimia and
BPD suffer more intense disturbances in their eating behaviours (Wonderlich & Swift, 1990) and, additionally,
their prognosis is poor (Wonderlich, Myers, Norton, & Crosby, 2002). Overall, research in this area has shown
that the severity of personality disorders which are concurrent with bulimia affects the overall psychopathological
profile of these patients (Zeeck et al., 2007). Moreover, BPD personality traits (e.g., self-harm, impulsivity, emotional fragility especially in rejection, promiscuous sexual behaviour etc.) seem to additionally affect therapy effectiveness in eating disorders since BPD patients are inclined to be more impulsive and more highly sensitive to rejection (Selby, Ward, Joiner, & Thomas, 2010). There is evidence (Selby et al., 2010) that impulsivity and rejection
sensitivity are related to the mechanism of negative emotional affect which is subsequently related to dysregulated
eating behaviour in a process of alleviation of negative emotions. This indicates that eating disorders are psychopathologically complex and this complexity affects the therapeutic process and the therapeutic outcome (Vitousek
& Stumpf, 2004). On the basis of this, it can be argued that therapy for complex cases could benefit from the use
of pluralistic approaches, such as integration and eclecticism, as these could address different issues with the
same patient, in the same session or in the same therapeutic regime.
Eating disorders are a form of self-injury (Sansone & Levitt, 2004; Sansone & Sansone, 2007). Evidence in psychoanalytic bibliography suggests that self-harm and excessive disturbances in the perception of body image in
BPD are associated with childhood traumas (Watson, Chilton, Fairchild, & Whewell, 2006). Psychoanalytic psychotherapy targets the client’s early stages in life, when the dysfunctional parental and environmental conditions
contributed to the formation of a personality disorder (Korner, Gervil, Meares, & Stevenson 2008). Psychoanalytic
psychotherapy enables the patient to make subtle and gradual improvements in their condition. This is important
considering that the emotional insecurity and the mood swings which are prevalent in BPD make it difficult for
more marked improvements to be achieved in a reasonable period of time.
Furthermore, BPD is considered “notoriously difficult to treat” (Levy et al., 2006, p. 483) owing to its complexity
and to the patient’s unresponsiveness and aggressiveness. This adds to the difficulty in achieving a positive
therapeutic outcome with BPD patients. Generally, there is evidence that psychodynamically orientated psychotherapy is more effective in reducing suicidality and anger in BPD (Aaltonen, Alanen, Keinänen, & Räkköläinen,
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2002). Considering the complexity inherent in eating disorders and the recognised individual differences in responsiveness to specific therapeutic approaches it would be reasonable to suggest that therapeutic integration
would be an appropriate and effective way to achieve a positive therapeutic outcome in patients with complex
needs.
A perusal of the literature indicates that evidence in the use of eclectic or integrative therapy in eating disorders
is limited. Nevertheless, issues of severe and complicated psychopathology make it imperative to explore the
potential benefits of pluralistic (eclectic or integrative) therapeutic interventions. Cooper and McLeod (2010) claim
that the exploration of all potentialities in psychotherapy is likely to lead to an improvement in the effectiveness
of therapy. The expected outcome of the integration of therapeutic models has been eloquently described as the
Dodo Bird in Alice in Wonderland which declares “Everyone has won and so all must have prizes”, (Shorrock,
2012, p. 26).
Case Study
Summary of Therapeutic Progress
Helektra’s therapy proved to be long term and it lasted for two and a half years during which time the patient attended psychotherapy sessions, on average, once a week. Long-term psychotherapy was deemed necessary
owing to the severity of the patient’s case. Approval to provide psychotherapy to this client for an extended period
of time was granted by my clinical supervisor and by the Hospital authorities. Initially, therapy concentrated on
symptom relief for bulimia and for suicidal ideation. In later stages, therapy became more in depth and Helektra
was able to explore deeper traumatic issues. Overall, I managed to develop a good therapeutic relationship with
Helektra. Additionally, there was a gain of experience for me as a counselling psychologist as I was able to use
different psychotherapeutic approaches with the same patient and this offered me the opportunity to explore the
therapeutic potential of eclectic therapy.
As part of my work with Helektra, I kept records from each session along with any kind of notes, poems and
drawings that the patient kept bringing to her therapy. Additionally, I had the opportunity to cooperate with the art
therapist and the occupational therapist of the Unit and my cooperation with these therapists enriched my understanding of Helektra’s situation. Furthermore, I was in contact over Helektra’s therapy with the psychiatrist of the
Unit whom Helektra kept seeing once a month for the medication she was on.
Presentation
Helektra’s presentation was that of what would be considered in Greece to be an “elegant woman”. It looked like
she cared for her appearance. She was slim and she was well-dressed when she came to her therapy sessions.
She lived alone in Athens where she had moved from provincial Greece to take up an undergraduate course in
Architecture. She did not work and she was fully financially supported by her father.
Her bulimic behaviour commenced at the age of seventeen. She suggested that her bulimic episodes and vomiting
occurred twice a day on average. At the same time, she also made use of psychotropic substances such as
cannabis, cocaine and MD. The use of drugs lasted for about six years. On the previous year, the patient had
stopped using drugs but she had started drinking alcohol. Additionally, the patient reported impulsive sexual behaviour. She used the expression “destructive liaison” to describe her sexual practices which appeared to be quite
risky. At the time she referred herself to the Unit she was in a relationship which was characterised by emotional
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turmoil and where there was no sexual contact between partners. In recent years, the patient experienced severe
suicidal ideation and she made three suicide attempts. In the last two years she started visiting the priest of her
local church from whom she sought solace and spiritual guidance.
Goals
At intake Helektra’s stated goals were to stop her bulimic behaviour and to receive support that would help her
complete the write-up of her dissertation. She appeared to be desperate for help and this was evident when she
claimed to have used another Eating Disorders Service where she was advised to seek further help at the 18 Ano
Unit.
Assessment of the Patient’s Goals — Helektra defined her difficulties in the initial session as:
1. I cannot bear this habit, I need help to stop bulimic episodes.
2. I desperately need help to concentrate on my dissertation.
3. I feel completely alone, I struggle with my social relationships.
4. I do not have any friends.
Therapeutic Goals — At the end of her initial assessment, the therapeutic goals which were agreed upon with
Helektra were:
1. At the first stage of therapy: To keep a diary of her eating habits.
2. Take precautions not to fight with her boyfriend. Leave the place when she felt that an argument was
coming up.
After this stage was stabilized the goals were agreed as:
1. To quit the bulimic behaviour.
2. To stop self-harming.
3. To concentrate on her dissertation.
4. To feel more confident in her relationships and more aware of her feelings and to feel comfortable enough
to share her feelings with important others.
5. To feel more confident in making decisions about her life.
Patient’s Protective Factors
Helektra was very intelligent. She was capable of deep thinking and she seemed able to understand psychological
concepts. She also demonstrated a strong will to find ways to understand herself better. Additionally, she was
extremely sensitive and kind-hearted, very well-informed about topical social issues, very keen to be involved in
charity and to volunteer in social care.
She was talented in painting, she was very well-read, and she could draw insightful pictures or write poems being
inspired from her own life experiences. She also enjoyed listening to classical music and she played the piano.
Furthermore, she appeared to have a good sense of humour.
Patient’s History
Helektra was raised in a small town. She had one brother with whom she maintained a warm relationship. Her
father was the main breadwinner and he worked hard to support the whole family. The patient described her
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father as a man with a terrible temper which he needed to control by taking medication. She additionally described
him as someone with an impulsive and violent behaviour who also drank heavily. At a later stage, the patient
claimed that her father had a mental illness which was a well-kept family secret. The mother was ten years older
than the father. She was a homemaker and she took care of everyone including her mother-in-law who lived with
the family.
Helektra was the younger of two children in the family. She claimed that the relationship with her father was contradictory (cf. Wade, Bulik, & Kendler, 2001, for a discussion of the connection between bulimia and the quality
of parent-child relationship). Her father always told her that he wanted Helektra and himself to be friends and to
talk to him about her relationships with boys. On the other hand he would beat her for disobeying him if she went
against his wishes. She described him as very demanding especially about anything related to his children’s
education. Later she said that he showed off to other parents as the perfect parent. She also claimed that he
pressed on her for excellent school results so he could boast to other parents and eventually run for chairman of
her school’s parents committee. It would be appropriate to assert that it is a wide-spread cultural characteristic
that school performance is considered to reflect good parenting practices in Greece. Greek parents ordinarily put
pressure on their children to do well at school as this has a direct effect on their perception by others as good
parents and worthy members of the society. In the latter part of her therapy Helektra realized that her father wanted
to appear as a good and caring father to hide his own mental health problems.
Ever since her early childhood Helektra recalled her father being very cruel to both children. She claimed that
there had been many occasions where she froze her feelings when her father screamed at her. Later on in her
therapy she claimed to have realized that her mother was terrified of him, too, and that she suffered silently unable
to react to his violence and to protect her children.
Treatment
There were four stages in the patient’s personal therapy. In the first stage, (duration: six months), therapy was
mostly based on cognitive approaches such as Fairburn`s diet diary reports and psychoeducation on how to enrich
her diet report and to cease the bulimic and vomiting behaviour. In the second stage, (duration: twelve months),
there was a combination of the use of a cognitive approach, a continued use of the diet diary reports and psychoanalytic interpretations of the patient’s dreams. In the third stage (duration: six months), the therapeutic procedure
was mostly focused on the existential issues which arose whilst the bulimic behaviour started to dissipate. In the
fourth stage (duration: six months), there was re-decision and, ultimately, discharge.
First Stage — Helektra was seen by a psychiatrist who made an assessment of her situation and issued her
diagnosis. The psychiatrist also prescribed medication to Helektra. This was deemed necessary as Helektra was
experiencing severe psychological difficulties which affected her mood considerably. She had violent arguments
in her relationship, she had an unstable social life and she exhibited signs of acute suicidal ideation. According
to National Institute for Health and Care Excellence BPD Guidelines (National Institute for Health and Care Excellence, 2009) priority should be given to suicidal ideations whilst the patient has to be referred to a specialist centre.
It should be noted that Helektra was seen by a specialist Unit which is part of a state psychiatric hospital and
which is the only psychiatric Unit in the Greek National Health Service that specialises in eating disorders that are
accompanied by comorbidity. Helektra saw the Unit psychiatrist for six sessions. Following this, she was referred
for psychotherapy and I was appointed her therapist.
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In the next five sessions Helektra was punctual for her appointments. However, she appeared hesitant or unwilling
to discuss her issues. On most occasions she started crying before talking or she claimed to have shortness of
breath that made her unable to stay until the end of the session. This seemed to indicate to me that Helektra was
testing my acceptance and sympathy and that this was useful to her in preparing the ground for a therapeutic
contract with me. I had to be clear setting the rules and conditions of the Unit but very understanding to her personal story and individual needs. My approach was confirmed in clinical supervision to have been an appropriate
response to the patient’s needs.
In this stage the “key moment” was when Helektra once arrived late for her appointment. She said that she felt
tired and desperate because every close person to her never showed understanding towards the disappointment
and the pressure she has always felt and she started crying again. I asked her if she feared that this would happen
with me too. She nodded “yes”. Then I told her that if she felt tired and reluctant to talk we could reschedule her
appointment. She said she was relieved. She was never late again and she always gave me a week’s notice when
she anticipated that she could not attend her next appointment.
She faithfully kept her diet diary. In the first six months her bulimic episodes were reduced from two or three per
day to one. She increased her ability to articulate and to discuss the reasons for the episode. At the end of the
first year she had almost stopped her bulimic behaviour from occurring on a daily basis but she still occasionally
continued to have bulimic episodes. In this phase, her diet diary showed great dietary improvement. She had
started eating foods that she previously considered to be forbidden and she could join her family or boyfriend for
food without thinking of vomiting after eating.
In this stage Helektra had a determinative dream for the process of her therapy. She dreamed of a ruined house
without doors and windows which had a big cistern which was visible from any angle. She realized that she could
not hide behind the doors of the toilet and anybody could watch her vomiting. During the session she made links
between the house in her dream and her bulimic behaviour and she said that she thought her condition was like
the ruined house in her dream. At this point I kept my intervention to a minimum, offering Helektra the chance to
express how she felt. This was consistent with my clinical supervisor’s suggestion that therapist comments and
interpretations should be avoided, especially in relation to the dreams that the client was bringing to therapy. It is
documented that there is a therapeutic benefit for clients when they name their emotions without distractions from
the therapist (Yeomans, Clarkin, & Kernberg, 2002).
Ιn the following sessions she talked about the need for change and self-improvement and the need to stop lying
to herself about her bulimic behaviour. She also started talking more openly about her father’s violent behaviour.
She connected the bulimic episodes with her father’s screams which occurred almost every time the family sat
around the table for a meal. She also realized that vomiting was mostly a reaction to the feelings of discomfort
with her father’s screams than a way to maintain her low weight.
Second Stage — In the second stage therapy concentrated on helping Helektra find a way to feel and express
her feelings. There were occasional relapses of bulimic episodes. Helektra realized that stress and disappointment
were a strong factor of relapsing. In this phase of therapy she was motivated to start her dissertation. There were
many difficulties to deal with, especially low self-confidence and self-esteem. This phase was more narrative, she
spoke about the past and cried a lot for admitting false acts she impulsively did. Using psychoanalytic psychotherapy
(Masterson, 1983; Masterson & Lieberman, 2004) I listened to her carefully and explained every suggestion with
caution. Helektra was very descriptive and although the whole process was exhaustive for her, most of the times,
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she did not give up her effort to connect with her feelings. She also said that she was very surprised she had remembered details of the past.
Third Stage — In the third stage I encouraged Helektra to explore ways to handle her feelings of discomfort and
to realise how to address her feelings towards others. During this stage of therapy, she could express her anger
without self-harming. Furthermore, her relationship with her boyfriend had improved and the fights they had had
were reduced. Personal and existential issues prevailed during the sessions and she spoke mostly about her relationship with her parents. Most of the dreams she had caused tremendous fear in her about mental illness. She
linked this with her perception of her father’s mental illness. She was able to relate this experience with her fear
about never being able to recover from her own psychological difficulties. She also connected her grandmother’s
“difficulty” to communicate with probable signs of mental illness. Additionally, Helektra finally talked about her
anger towards her mother, a matter that she had always avoided. She expressed her fear that she could never
bear to be like her mother.
In this period many issues about Helektra’s sexual life preoccupied her. She had many dreams about this matter.
I chose to take a supportive and non-directive approach during this stage. Helektra talked about her sado-masochistic fantasising and practices in ways that revealed feelings of guilt for having those fantasies and experiences.
Under the auspices of clinical supervision, my role was to help Helektra get over her feelings of guilt and to stop
her from feeling “dirty” for her sexual life. Following this stage, Helektra stopped having sex altogether. This was
probably related to the religious guidance and influences which she had been under towards the end of her therapy.
Fourth Stage — The fourth stage was taken up by reflection. Helektra was encouraged to reflect on the initial
therapeutic goals and to consider how these had been achieved. Meanwhile, it was particularly fulfilling to learn
that, during this period, Helektra completed and handed in her dissertation and she also got engaged to her boyfriend. Lastly, to help Helektra prepare for her discharge, the sessions were arranged in larger time intervals,
every second week. Helektra continued to take her prescribed medication and her new target was now to make
herself feel well enough so as not to be in need of this medication anymore.
Τhis new target essentially involved further therapy regarding her personality disorder. The therapeutic group,
under the supervision of the scientific coordinator of the unit, reviewed the case of Helektra and decided that the
intervention about her eating disorder was successful and that she could now be discharged. Furthermore, Helektra
could now be referred to a specialized Unit for group therapy for her personality disorder. Group therapy would
also give her the chance to improve her social skills (Campo-Redondo & Andrade, 2000) since making friends
and feeling comfortable in social activities was still a difficult issue for Helektra.
Discussion
Overall, Helektra’s therapy was challenging but it was also extremely rewarding to see that Helektra achieved her
therapeutic goals. The challenges that had emerged during Helektra’s therapy made me feel pessimistic about
the course of her therapy. Helektra’s life had such complexity that it took particular skill to avoid getting involved
personally in her situation. Additionally, I found that the use of two different therapeutic approaches with the same
patient required skilfulness and great care. An added difficulty was the fact that the scientific literature on the use
of pluralistic models, particularly in the case of eating disorders, is sparse. I was able to get around this with help
from clinical supervision.
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The CBT approach that I used with Helektra was shown to be very helpful in enabling the patient to manage her
eating disorder. Helektra’s co-morbidity was an added difficulty in the therapeutic process. CBT-E appears to be
very effective even in more complex cases of eating disorders (Murphy, Straebler, Cooper, & Fairburn, 2010) and
research is needed to help explore further the advantages of this approach. As it was mentioned earlier, the patient
was diagnosed with borderline personality disorder and she had emotional instability and severe impulsive behaviour. Helektra’s total financial dependence on her father forced her to tolerate his abusive behaviour and this
made her relapse on occasions. Helektra’s psychological state made it difficult for her to keep up a job and when
her condition later improved the financial crisis which had set in in Greece had affected job availability considerably.
Hence, it was difficult for her to find employment.
Furthermore, I used the psychodynamic approach with Helektra mainly to give her an opportunity to explore the
childhood issues that she brought to therapy. In addition, this approach helped analyse Helektra’s dreams as well
as her poems and drawings. I was assisted in the application of the psychoanalytic approach through discussions
with my clinical supervisor which helped me achieve a better understanding of the role of transference and countertransference in the formation of trust in the therapeutic relationship. Additionally, these discussions encouraged
me to identify scientific sources which explored the contribution of psychoanalytic theory in the understanding of
the therapeutic relationship in counselling psychology (e.g. Laughton-Brown, 2010).
Helektra is now continuing with therapy for her personality disorder. Additionally, she has had three follow up
sessions with me in the Unit since her discharge. In the first two sessions I offered Helektra support for her experiences in group therapy and I helped her reframe the difficulties that she had faced with the group. The third follow
up session took place because Helektra wanted to announce to me that she was getting married.
Conclusion
In conclusion, although there are arguments against the practice of integrated and eclectic psychotherapy (Cutts,
2011), I personally found the use of two different therapeutic approaches with the same patient to be effective
and I would encourage the integration of therapeutic approaches where this is deemed to be of benefit to the
patient. After all, our goal as therapists, as Wheelis (2010) has suggested, is “to discover what works to alleviate
our patients’ suffering” (p. 335).
Lastly, in the case of Helektra’s therapy, Ι managed to encourage the formation and maintenance of a good
therapeutic relationship by drawing significantly on techniques from psychoanalytic theory such as the use of
positive transference - counter-transference. Additionally, I achieved integration by resorting to empathy, congruence
and unconditional positive regard. This was necessary in order to form a trustful therapeutic alliance.
Funding
The author has no funding to report.
Competing Interests
The author has declared that no competing interests exist.
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Acknowledgments
I would like to thank Dr. Katerina Matsa, Head of the Addictions Department, 18 Ano Eating Disorders Unit of the Department
of Addictions, Attica Psychiatric Hospital, Athens, Greece for the group supervision and the chance to let the initial ideas come
true.
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