© HARMONY PLACE MONTEREY · selves, some therapists insist there is one true self and any other presentation of the client is untrue. This insistence is counter-transferential and

© HARMONY PLACE MONTEREY

© HARMONY PLACE MONTEREY

The Long-Term Course of Severe Anorexia Nervosa Analysis of Recovery, Relapse, and Outcome Predictors over 10–15 years

Years Partial Full

2 10% 0%

5 55% 18%

7 74% 59%

10 84% 73%

Strober,M.,Freeman,R.,Morrell,W.(1997).Thelong-termcourseofsevereanorexianervosainadolescents:Survivalanalysisofrecovery,relapse,andoutcomepredictorsover10-15yearsinaprospectivestudy.InternationalJournalofEatingDisorders22,339-360.

©HARMONYPLACEMONTEREY 4

How is Recovery Measured?  Recoveryisnotjusttheabsenceofsymptoms.Itisthepresenceofafulllife,asevidencedby

theabilitytobehuman.Atrulyrecoveredlifewillreflectspontaneity,freedom,theabilityto

breathe,tohavewants,needsanddesires—knowingthatthequestforperfectionisan

unattainableillusion.It’stheabilitytoembracethefeminine,havingcloseintimate

relationships,andit’sbeingawareofthetearsinyoureyes(whetheroutofintenseorsubtle

sadness—oroutofjoy–offromaflickerofuttergratefulness)andthentoallowyourtears

toflowfreely.Itisalifeinwhichdecisionsandchoicesaremademorefromselfandlessfrom

ashame-orfear-basedprison.Itisalifewhereyoufullyexperiencepleasure,joy,andpassion

andbelieveandknowitisgoodtodesireandenjoysex.


Eating Disorder and Axis II  DataraisesthequestionsabouttheextentofwhichAxisIIisadequatefordescribingclinicallymeaningfulpatternsofpersonalitypathology,atleastforwomenwitheatingdisorders.Patientsinthehigh-functioning/perfectionisticclustergenerallylackeddiagnosableAxisIIpathology;indeed,inourstudy(asinotherstudiesthathaveisolatedatsimilarcluster),theyweredefinedbytheabsenceofsuchpathology.Thesepatientsarearticulate,conscientiousandempathic,andtheytendtoelicitlikinginothers.Yet,theyclearlyhavepersonalitypathology,ie.,enduring,problematicpatternsofthought,feeling,motivation,andbehavior.Theyareself-critical,perfectionistic,competitive,anxiousandguilt-ridden,andtheseaspectsoftheirpersonalityrequiresclinicalattention.


Treatment of ED Premises Philosophically 1.  Differentdevelopmentaltrajectories

2.  Symptomhasdevelopedasasurvivalstrategy

3.  Symptomislogical,rational,andadaptive

4.  Symptomremissionisdependentonunderstandingthelogicaldevelopmentandallowingforamoreoptimalsolution


SELF-INJURY (David Calof, 1991)

§ Self-injuryisthecontainerforunmetabolizedtraumaticstressandunderlyingunresolvedtrans-generationaltraumaandloss.

§ Self-injurious,destructivebehaviorisfunctionalandisalwaysanattempttoprotecttheclient(system).

§ Expresses(communicates)underlyingdynamicsandneedsandis“trancelogical”(“hurtingreleasespain”)

§ Becausebehaviorisdissociatedfromsensation,affectandknowledge,linkagestospecificmeaning,functionorintent,willtypicallybeunclear.




An Eating Disorder is…

1.  Awaytoprovidepredictabilityandthereforecomfort…2.  Inabilitytoexpressinternaldistresstoothers…3.  Waytoshoutforhelp…4.  Waytogetloveandattention…5.  Fearofgrowingupandassumingadulthood…6.  Nothavinganidentity,ananchor…7.  Nothavingthestructuralcapacitiestomakeitasanadult…8.  Fearoroverwhelmingterrortobe…9.  Amanifestationofunresolvedtrauma…10.  Providesconsistencyinlifetransitions…11.  Amanifestationofparent’sunfinishedbusiness…12.  Awayofseparatingfrommotherandfather…13.  Numbing…14.  Awayofstayingconnectedtomothertoprotectherfromher

ownemptiness…15.  Asubstituteforlove…16.  Awaytofunctionwithoutfeeling…


1.  Agoodgirl'swaytorebellion…2.  Amanifestationofcravingsduetoinneremptiness…3.  Arelieffordepression…4.  Awayofcopingwithloneliness–asubstituterelationship…5.  Asolutiontointernaldoublebinds–Imustbe,Ican’t…6.  Anescapefromrequiringperfection…7.  Aneedtocareforaparentandsimultaneouslytoescape…8.  Awaytobeoutofcontrolwithoutappearingso…9.  Asusceptibilitytoinfluenceandneedingtopleasepeople,whilepeoplereject

youandareneverpleased…10.  AnObsessive-CompulsiveDisorder…11.  Themanifestationofaninsolubledouble-bind…12.  Havingsomethingthatisone’sownthatnooneelsecantouch…13.  Aprotectionfromfeelingoutofcontrol…14.  Aneedforfathers'presence…15.  Maintainachildbody…16.  Asacrificeofauthenticneedsanddesiresinordertoseekillusionofideal…17.  Awaytocopewithorcoverupotherhorrificintrusivethoughtsor

memories…18.  Anattempttowasteaway…19.  Anattemptatacquiringperfection…

An Eating Disorder is…

Eating Disorder as a Disorder of Attachment and Intimacy

TWO YEARS — Part 2  Themotheroftheanxiouslyattachedchildren,bycontrast,seemedunwillingorunabletomaintainanappropriatedistance.Somebecameintrusiveandmadeitimpossibleforthechildtohavehisownexperience.“Theycouldn’ttoleratethechildhavinganyfrustration,”Albersheimsays.“Theywouldjustgetinthereandalmostsolvetheproblemforhim,becauseitwastoopainfulforthemtowatchthechildstruggle.Butifchildrendon’tgettostrugglealittlebit–andbeabletoseethateithertheycanaccomplishitorthattheyneedalittlehelp,andtobeabletofigurethatoutontheirown.Ifthat’sinterferedwith,it’sareallossforthechild.”

Karen,R.(1994).BecomingAttached.NewYork:WarnerBooks


Stern’s Work — Part 1  Mollysmotherwascontrollinginadifferentway.SheconstantlytoldMollyhowtoplaywithtoys(“Shakeitupanddown–don’ttollitonthefloor”),andineffect,roderough-shodoverMolly’snaturalrhythmsofinterestandexcitement.HerexertionofpoweroverthebabywassuchthatSternandhiscolleaguesoftenexperiencedatighteningknotofragintheirstomachsastheywatchedthetapes.Molly’ssolutionwascompliance:“Insteadofactivelyavoidingoropposingtheseintuitions,”Sternwrote,“shebecameonofthoseenigmaticgazersintospace.Shecouldstarethroughyou,hereyesfocusedsomewhereatinfinityandherfacialexpressionsopaqueenoughtobejustuninterpretableand,atthesametime..Byandlarge,dowhatshewasinvitedortoldtodo.Watchingheroverthemonthswaslikewatchingherself-regulationofexcitementslipaway.”

Karen,R.(1994).BecomingAttached.NewYork:WarnerBooks


STERN’S WORK – Part 2  Suchmanipulativemisattunementstakemanyformsandare,Sternargued,thelikelyoriginoflaterlying,evasions,andsecrets.Thechild,andlatertheadult,comestofeelthatifpeopleareallowedaccesstohistrueinnerexperience,theywillbeabletomanipulateit,distortit,orundoit.Onlybyfreezingthemoutcanhekeephisinnerexperienceunspoiled.

◦  Karen,R.(1994).BecomingAttached.NewYork:WarnerBooks



 Constantmisattunement,neglectandabuseatthehandsoffamilymemberscausethechildtosplitoffexperiences,relegatingthemtoinaccessiblepartsofself.Theperson’ssenseofselfbecomescorrodedwithinnerbadnessandishidden.

 Thisleadstoanattempttopresentasociallyacceptablepersonawithcompulsiveeffortsforachievementandanidealizedbody.

DISSOCIATION

 Casereportsofdissociativesymptomsandhighlevelsof

‘hypnotizability’inpatientswitheatingdisordersledDemitrack

et.Al(1990)toinvestigatedissociationlevelsinanorexicaswell

asbulimicsubjects.Theyfoundthatbothgroupsproduced

substantiallyhigheroverallDESscorescomparedwithagroup

ofage-and-sex-matchedcontrolsubjects.


 Foodisnotsimplyasymptomtobegottenridof,butratherholdsdissociatedpartsofthepatient'sselfandrelationalhistory.Foodisthemostsignificantrelationshipinaneatingdisorderindividual'slife.Thesymptomshavelostconnectiontotheproblems,andvulnerabilitiesthatstimulatedtheironsetandhavetakenonalifeoftheirown.Theyarenowingrainedhabitswiththeirownrhythmsandexpression–ie.valuedfriend/secretcompanion.Thislessonsanxiety,becomesastricttask-masterorabusivetyrantthatpunishestransgressions.TheTherapistcultivatescuriosity,findingandconnectingpartsofthepatientthathavebeendisconnectedsolong.


DISSOCIATION and FOOD

 Repetitionoftraumaislessacompulsion

torepeatwhatisunresolvedandmorea

needtomakesenseoutofdisparate

elementsofexperienceusingtheonly

meansavailable,whenthinkingand

feelingsareblockedbydissociativeprocess


REPETITION

§ Earlydyadicprocessesleadtoa“primarybreakdown”orlackofintegrationofacoherentsenseofself,ie.Unintegratedinternalworkingmodels.

§ DisorganizedAttachmentistheinitialstepinthedevelopmentaltrajectorythatleavesanindividualvulnerabletodevelopingdissociationinresponsetotrauma.

Liotta,2000©HARMONYPLACEMONTEREY 21

REPETITION

PATHOLOGICAL DISSOCIATION

Fourcharacteristicsdistinguishpathologicalfromnormativedissociation:Onlyinpathologicaldissociationdoweencounterlossofexecutivecontrol,changeinself-representation,amnesticbarriers,andlossofownershipoverbehavior.

Kluft,1993


Denyingtheclient’ssubjectiveexperienceofsplit-off-partsorselves,sometherapistsinsistthereisonetrueselfandanyotherpresentationoftheclientisuntrue.Thisinsistenceiscounter-transferentialandpreventsempatheticconnectionwiththeclient,andthusblockstherapeuticaction.

Saakvitne,K.(1995).Therapistsresponsestodissociativeclients:Countertransferenceandvicarioustraumatization.InL.Choen,J.Berzoff&M.Elin,(Eds.),DissociativeIdentityDisorder,Northvale,NJ:JasonAronson,Inc.


Consensus Proposed Criteria for Developmental § SelfandRelationalDysregulation.Thechildexhibitsimpairednormativedevelopmentalcompetenciesintheirsenseofpersonalidentityandinvolvementinrelationships,includingatleastthreeofthefollowing:

1.  Intensepreoccupationwithsafetyofthecaregiverorotherlovedones(includingprecociouscaregiving)ordifficultytoleratingreunionwiththemafterseparation.

2.  Persistentnegativesenseofself,includingself-loathing,helplessness,worthlessness,ineffectivenessordefectiveness.

3.  Extremeandpersistentdistrust,defianceorlackofreciprocalbehaviorincloserelationshipswithadultsandpeers.

4.  Reactivephysicalorverbalaggressiontowardspeers,caregivers,orotheradults.

5.  Inappropriate(excessiveorpromiscuous)attemptstogetintimatecontact(includingbutnotlimitedtosexualorphysicalintimacy)orexcessiverelianceonpeersoradultsforsafetyandreassurance.

6.  Impairedcapacitytoregulateempathicarousalasevidencedbylackofempathyfor,orintoleranceof,expressionsofdistressofothers,orexcessiveresponsivenesstothedistressofothers.

TheNationalChildTraumaticStressNetwork(NCTSN)


Therapy: Self Integration

 Ifegostatesaresplitoff,projected,rejected,indulgedorotherwiseunassimilated,theybecomeblackholesthatabsorbfearandcreate

thedefensivepostureoftheisolatedself–unabletomakesatisfying

contactwithone’sselforother.Whensplit-offegostatesaremade

conscious—acceptedandtoleratedorintegrated,theselfcanbeat

one,andcompassionbereleased.


 Therapyinvolveshelpingtheclientreclaimpartsofselfthatweresacrificedtogainsafety.

 Intherapy,wecreateacontextandrelationshipswherepain,angeranddifficultycanbesafelyacknowledgedwhilemaintainaconnection.


RECOVERY PART § Capable§ Creative§ Compassionate§ SelfLove!§ Connected§ Clear§ Courage

§ Curiosity§ Tolerant§ Acceptance§ Strength§ Confidence§ Trust


29©HARMONYPLACEMONTEREY

KOHUT  Self-cohesionrequiresthepresenceofothers(self-objects).Therelationshipbetweenthepersonandtheotheristhe“source”andthetransitionalobjectallowsforsymbolicrepresentation. Theneedfortheexperienceofself-objectsisneverending. Aweakselfisthereforetheresultoffaultyself-objectexperiences.


Structural Deficits  Thereisgoodreasontobelievethatlargesegmentsofthepopulationlackmaycriticalcapacities,suchasself-observingabilities,necessaryformentalhealth,andthatevenpatientswhohavethem,havethemonlyinpart.Thesecapacitieswhichcanbecalled“structuralcapacities”(Greenspan,1989)havetodowithcriticalabilitiessuchasself-regulation,relating,presymbolic-affectivecommunicating,representinganddifferentializingexperience,representinginternalexperiencesandselfobservation.

  FromGreenspan,S.(1997).DevelopmentallyBasedPsychotherapy,Madison:InternationalUniversitiesPress,Inc.


Eating Disorder as a Trauma-Bond

 Everydeepdesire,everypowerfulemotion,givesatrailintotheunconscious.Usuallythereisonlyone-waytraffic:outbound,towardtheworldofsensationandaction.Butwecanfollowthetrailtoitssourcebygoingagainstthecurrent.Withthisdesiretogoagainstdesire,tobuckthedemandsofbiologicalconditioning,thejourneyofself-realizationbeingsinearnest.

MeditationinAction EknathEaswaran


Re-Framing the Meaning of Symptoms § Startwiththeassumptionthateverysymptomisavaluablepieceofdata!

§ Usepsychoeducationalmaterialtomakeeducatedguessesaboutthemeaningofsymptoms,asasymptom-memoryoravaliantattempttocope.

§ Askher“Howwouldthis____havehelpedyoutosurviveinanunsafeworld?”“Helpedyoufeellessoverwhelmed?Lesshelpless?Morehopeful?”

§ Lookforwhatthesymptomisstilltryingtoaccomplish:i.e.,chronicsuicidalfeelingsmightoffercomfortora“bail-outplan;”cuttingmighthelpmodulatearousal;socialavoidancecouldbeanattempttoavoid“danger.”

§ Onceitisclearwhatthesymptomistryingtoaccomplish,thenthetherapistandthepatientcanlookforotherwaystoaccomplishthesamegoalinacontextthatdescribesthepatientasaningeniousandresourcefulsurvivor,ratherthanasadamagedvictim.


Failed Protectors  Wherethe‘part’gottheideathatithadtocoerceandshameherintodieting,working,beingnice?Perhapsaparentmonitoringandscorning,ora‘part’likeasingleparent...Theseareinnercensorsandtyrantsthatcontrolus,keepournosestothegrindstone,andwillnotriskanybehaviorthatbringsustheslightestembarrassment.


Compassionate Witnessing  ThisoccurswhentheSelfoftheclientisabletowitnessthestoriesofpartsfromacompassionateposition.Asktheclienttoidentifyanactivatedpart(usuallyassociatedwithextremebehaviors,thoughtorfeelings).Asktheclientwhereinthebodythe‘part’is,(positionofSelf),thisindicatesthatanother‘part’isblendedwiththeSelf.Asktheblendedparttoplease

stepasideandlettheSelfworkwiththe‘activatedpart’.(Thismayincludeaskingmorethanone‘part’tostepaside).


RECOVERY


“Faith is taking the first step even when you don’t see the whole staircase.”

—MartinLutherKing,Jr.

Eating Disorder Takes Away… ü Abilitytobehuman(stayoutofyourbody!)ü Voiceü Abilitytobeinyourbodyü Breatheü Pleasureü Joy

ü Spontaneityü Allowancetohaveneeds,wants,anddesiresü Passionandvibrancyü Balanceü Intimacywithselfandothers…ü Resultinginthelossofself,lossofthesoulandspirit


Writing | Journaling

1.  Yourworsteating-disorderday

2.  Usingajournalentryorintensesituation,followthethoughtsandmapoutthefeelingsandtriggeringevent


It Is About the Food! ü Deconstructingthemeaningoffood

ü Write,indetail,adescriptionofyouraddictivebehaviors

ü Haveamealwithyourclient

ü Explorewaysofallowingselftotaste,enjoy,desirefood.


WRITING ASSIGNMENTS § Dialoguewith“fat”§ Havefamilymemberswritewhytheybelieveclienthasaneatingdisorder

§ Letters:toED,tothebody,fromthebody

§ Howdoesthewayyourelatetofoodresemblehowyourelatetopeople?

§ Havetheeatingdisorderwriteandintroduceitself:likes,dislikes,values,fears,hopes,andgoals

§ Whatwillyourlifelooklikein5years…?

§ Whatdidyoulearninyourfamilyaboutfood,bodysize,femininity,andfeelings?


Eating Disorder Patients Experience of Recovery § Realisticappraisalofmedicaldangers

§ Improvementinthecareofself(e.g.eatinghabits,useofleisuretime)

§ Newwaystoself-soothe,self-regulate§ Abilitytoaccesssocialsupportfromfamily,friends,andfellowpatients

§ Enhancedproblem-solvingskills

§ Improvedcapacitytoinvestinandworkoninterpersonalrelationships

§ GradualrelinquishmentofEDidentityandeatingdisorderthoughts(e.g.“thisfoodwillmakemefat,”“I’llfeelbetterafterIeatthispackageofcookies,etc.)


Eating Disorder Patients Experience of Recover § Abilitytotakeresponsibilityforselfandeschewvictimmentality§ Establishmentofasenseof“trueself,”“realme,”or“knowingwhoIam.”§ Capacitytoformulategoals,toleratesetbacks,yetmaintainpositivemotivationtogetbetter§ Reclamationofthesenseofone'spersonalpower§ Decreaseemphasisonperfectionism§ FirmerInterpersonalboundaries;enhancedcapacitiestosetappropriateboundaries§ Cultivationofsenseofpurpose,ofmeaninginlife


Earned Secure Attachment and Eating Disorders


EXPERIENCE SCALES (1-9) 1.  LOVING—◦  Memoriesofspecialandtenderconcernandsoothingwhenill◦  Memoriesofhavingdonesomethingbad,expectingtobepunished,parent's

caringandforgiven◦  Memoriesofhavingdonesomethingperceivedbadbyteachers,etc.and

supportedbyparents◦  Memoriesofchildhoodfearsandbeingcomforted

2.  UNLOVING–(3)Instrumentalattention(5)Presentoccasionally(7)Good-enoughparenting

WHATISLOVE?TURNCHILDTOOBJECT


EXPERIENCE SCALES (1-9) REJECTION—§  Turningbackonchild'sdependence,affection,attention,needandattachment§  Speakeravoidsdiscussingrelationshipwithparentonemotionalterms§  Speakerreportsrejectionofsiblings§  Speakerrecallsfavoritetowardssiblings§  Speakerdescribesbeing“spoiledrotten”byparent§  Speakerdescribedselfasfavoriteandothersrejected§  Fearparentwouldleave§  Overturestoparentrejected(3)Mildlyrejectingofattachment,aloof,“differentiallyshowingmelove”(5)Childseldomgivenencouragement(7)Parentmadwhenchildsickmisses'graduation(9)Wisheschildwasnotborn


WHATTOLOOKFORiNANINTERVIEW

EXPERIENCE SCALES (1-9)  INVOLVING|ROLEREVERSAL

§  Makingitclearthatthechild'spresenceisnecessaryformaintenanceofownsenseofselforwellbeing

§  (1)Parentlookingtochildforparenting§  (5)Parentislookingtochildassubstitutespouse§  (7)Parentdependsonchild’sattentionforsafety§  Takingcareofchildrenseemsabittoomuch§  Parentconfusedorhelpless;parentnotarealadult§  Parentcomplainschildrenaretoomuch§  Parentafraidtostand-uptoanotherperson§  Childadvisesparentonhowtobehaveasaparent§  Parentover-protective§  Parentmartyr,guilt-inducing“childnotlovingenough”forparent§  Childisfocusedonpleasingparent§  Childfeltguiltyforbadgrade,etc.“hurting”parent§  Childsays,“Iwasmymother’s”wholelife§  Childremembersdesiretoprotectparent§  Parenttreatschildasafriendorspouse


SOIMPORTANTFORINTERVIEW

EXPERIENCE SCALES (1-9)  NEGLECTING◦  Parentinattentiveandpreoccupied,uninvolvedorinaccessible

◦  (Distinguishneglectfromrejection:“Heneverhadtimeforus”wouldbeneglect)

◦  (Distinguishneglectfromrole-reversal:“Parentwasill”canbeneglect)

◦  Parentpreoccupiedwithwork,family,household

◦  Parentunabletospendtime,becausekidsaretoomuchforthem

◦  Childrememberscryingatnight

◦  Parentalwaysbusythinkingofsomeoneelse

◦  Parentalwayswithfriends,atbar,etc.


EXPERIENCE SCALES (1-9)  Pressuredtoachieveduringchildhood◦  Statusorpositionoveremphasized

◦ Over-concernwithschoolperformancewithanemphasisonhowitlooks“regardingthefamily”

◦ Highratingswhenparentswithdrawaffection,whenchildfailstoperform

◦  Childveryanxiousregardingreportcard◦  Parent“pushed”childtocareforself,andparentunloving◦  Earlyexcessiveexcellencestressed◦  Childpushedtodoadultsworkwhenyoung


Deconstructing Attachment  IMPLICATIONSOFPSYCHOTHERAPY1.  Idealization2.  Dismissingderogation3.  Lackofmemory4.  Responseappearsabstractandremotefrommemoriesorfeeling5.  Regardselfasstrong,independent,normal6.  Littlearticulationofhurt,distress,orneeding7.  Endorsementofnegativeaspectsofparent’sbehavior8.  Minimizingordownplayingnegativeexperiences9.  Positivewrap-up10. Nonegativeeffects11. Madememoreindependent


Therapist Job with Attachment Trauma 1.  Transformationoftheselfthroughrelationship

2.  Provideasecurebaseforexploitation,development,andchange

3.  Provideattunementinhelpingtheclienttolerate,modulate,andcommunicatedifficultfeelings

4.  Affect-regulatinginteractionsforaccessingdisavowedordissociatedexperiences,strengtheningnarrativecompetence

5.  Deconstructtheattachmentpatternsofthepasttoconstructnewonesinthepresent

SeeDavidWallin,AttachmentinPsychotherapy,GuilfordPress,2007)


Documents

© HARMONY PLACE MONTEREY · selves, some therapists insist there is one true self and any other presentation of the client is untrue. This insistence is counter-transferential and