Eating Disorder Treatment from Perspective of Disorder of Intimacy

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• Eating Disorder Treatment from Perspective of
  Disorder of Intimacy
• Preferred Provider Conference, Feb. 2009
• Mark Schwartz, Sc.D. and Lori Galperin, MSW,
  LCSWCastlewood Treatment Center for Eating
  Disorders800 Holland Road636-386-6611www.castle
  woodtc.com

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Eating Disorder Patients Experience of Recovery

• Realistic appraisal of medical dangers
• Improvement in care of self (e.g. eating habits,
  use of leisure time)
• New ways to self-soothe, self-regulate
• Ability to access social support from family,
  friends, and fellow patients
• Enhanced problem solving skills
• Improved capacity to invest in and work on
  interpersonal relationships
• Gradual relinquishment of ED identity and eating
  disorder thoughts (e.g. this food will make me
  fat, Ill feel better after I eat this package
  of cookies, etc.)

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Eating Disorder Patients Experience of Recovery,
cont.

• Ability to take responsibility for self and
  eschew victim mentality
• Establishment of a sense of true self, real
  me, or knowing who I am.
• Capacity to formulate goals, tolerate setbacks,
  yet maintain positive motivation to get better.
• Reclamation of sense of ones personal power.
• Decreased emphasis on perfectionism.
• Firmer interpersonal boundaries enhanced
  capacitates to set appropriate boundaries.
• Cultivation of sense of purpose, meaning of life.

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• Triad for Relational Disturbance
• Attachment
• Self
• Affect Cognition

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Attunement

• Concept of Bebe research
• and
• Intersubjectivity
• _______________
• 42 minutes of age.
• Child imitates parents facial expressions
• (Meltzoff, 1980)

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Two Years Part 2

• The mothers of the anxiously attached children,
  by contrast, seemed unwilling or unable to
  maintain an appropriate distance. Some became
  intrusive and made it impossible for the child to
  have his own experience. They couldnt tolerate
  the child having any frustration, Albersheim
  says. They would just get in there and almost
  solve the problem for him because it was too
  painful for them to watch the child struggle.
  But if children dont get to struggle a little
  bit and be able to see either that they can
  accomplish it or that they need a little help,
  and to be able to figure that out on their own
  if thats interfered with, its a real loss for
  the child.
• Karen, R. (1994). Becoming Attached. New
  York Warner Books

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Sterns Work Part 1

• Mollys mother was controlling in a different
  way. She constantly told Molly how to play with
  toys (Shake it up and down dont roll it on
  the floor), and, in effect, rode rough-shod over
  Mollys natural rhythms of interest and
  excitement. Her exertion of power over the baby
  was such that Stern and his colleagues often
  experienced a tightening knot of rage in their
  stomachs as they watched the tapes. Mollys
  solution was compliance Instead of actively
  avoiding or opposing these intrusions, Stern
  wrote, she became one of those enigmatic gazers
  into space. She could stare through you, her
  eyes focused somewhere at infinity and her facial
  expressions opaque enough to be just
  uninterpretable and, at the same time..by and
  large, do what she was invited or told to do.
  Watching her over the months was like watching
  her self-regulation of excitement slip away.
• (Karen, R. (1994). Becoming Attached. New
  York Warner Books)

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Sterns Work Part 2

• Such manipulative misattunements take many forms
  and are, Stern argued, the likely origin of later
  lying, evasions and secrets. The child, and
  later the adult, comes to feel that if people are
  allowed access to his true inner experience, they
  will be able to manipulate it, distort it, undo
  it. Only by freezing them out can he keep his
  inner experience unspoiled.
• (Karen, R. (1994). Becoming Attached. New
  York Warner Books)

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The Capacity To Be Alone

• In the course of time there arrives a sensation
  or an impulse. In this setting, the sensation or
  impulse will feel real and be truly a personal
  experienceThe individual who has developed the
  capacity to be alone is constantly able to
  rediscover the personal impulse.
• (Winnicott)

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The Capacity To Be Alone

• When alone in the sense in which I am using the
  term, and only when alone, the infant is able to
  do the equivalent of what in an adult would be
  called relaxing. The infant is able to become
  unintegrated, to flounder, to be in a state in
  which there is no orientation, to be able to
  exist for a time without being either a reactor
  to an external impingement or an active person
  with a direction of interest and movement
• (Winnicott)

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The Capacity To Be Alone

• Although many types of experience go to the
  establishment of the capacity to be alone, there
  is one that is basic, and without a sufficiency
  of it the capacity to be alone does not come
  about this experience is that of being alone, as
  an infant and small child, in the presence of the
  mother. Thus, the capacity to be alone is a
  paradox it is the experience of being alone
  while someone else is present.
• (Winnicott)

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Kohut
Self-cohesion requires the presence of others
(self-objects,) the relationship between the
person and the other is the source and the
transitional object allows for symbolic
representation. The need for the experience of
self objects is never-ending. A weak self is
therefore the result of faulty self-object
experiences.
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The Intergenerational Transmission of Insecure
Attachment

• The infant learns to view those affective
  experiences to which the mother misattuned as
  falling outside the realm of shareable experience
  and to deny or disavow such feelings. To the
  extent, then, that defensiveness, denial,
  confusion or inability to recall interferes with
  a parents ability to attune to the infants
  needs and feelings accurately and empathically, a
  parent is more likely to repeat past patterns of
  behavior. Furthermore, the relative comfort or
  discomfort of the mother with certain kinds of
  emotional states can influence the infants
  subsequent access to those same emotions at a
  very early age.
• Ref Pamela C. Alexander, Oct. 1991

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Temperment
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False Self(From Winnicott)

• Parents who are intensively over-involved with
  their infant cause the child to develop a false
  self based upon compliance. Care-giver doesnt
  validate the childs developing self, thus
  leading to alienation from the core self.
  Parenting practices that constitute lack of
  attunement to the childs needs, empathetic
  failure, lack of validation, threats of harm or
  coercion and enforced compliance, all cause the
  true self to go underground.

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Self Differentiation

• 1. Absence of true sense of self
• 2. Hyper-sensitivity and hyper-reactivity to
  others, especially in reaction to rejection or
  abandonment.
• 3. Gullibility and suggestibility in relation to
  authority.
• 4. Complaints of isolation and neediness,
  without self-support
• 5. Boundary problems, inability to conceive of
  self without reference to others.

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Dissociation

• Early dyadic processes lead to a primary
  breakdown or lack of integration of a coherent
  sense of self, i.e. Unintegrated internal working
  models.
• Disorganized attachment is the initial step in
  the development trajectory that leaves an
  individual vulnerable to developing dissociation
  in response to trauma.
• Liotta, 2000

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Experience scales (1-9)

• Loving
• -- memories of special and tender concern and
  soothing when ill.
• -- memories of having done something bad,
  expecting to be punished, parents caring and
• forgiven.
• -- memories of having done something perceived
  bad by teachers,etc. and supported by
• parents
• -- memories of childhood fears and being
  comforted
• Unloving
• (3) Instrumental attention
• (5) Present occasionally
• (7) Good enough parenting

• What is love?
• Turn child to object

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Experience scales (1-9)

• Rejection
• -- Turning back on childs dependence,
  affection, attention, need and attachment.
• -- Speaker avoids discussing relationship with
  parent on emotional terms.
• -- Speaker report rejection of siblings.
• -- Speaker recalls favorite towards siblings.
• -- Speaker describes being spoiled rotten by
  parent
• -- Speaker described self as favorite and others
  rejected.
• -- Fear parent would leave.
• -- Overtures to parent rejected.
• (3) Mildly rejecting of attachment, aloof,
  differentially showing me love.
• (5) Child seldom given encouragement
• (7) Parent mad when child sick misses graduation
• (9) Wish child not born

• What to look for in interview

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Experience scales (1-9)

• Involving/role reversal
• -- Making it clear that the childs presence is
  necessary for maintenance of own sense or well
  being
• (1) Parent looking to child for parenting.
• (5) Parent is looking to child as substitute
  spouse
• (7) Parent depends on childs attention for
  safety.
• -- Taking care of children seems a bit too much.
• -- Parent confused or helpless parent not a
  real adult.
• -- Parent complains children are too much.
• -- Parent afraid to stand-up to another person.
• -- Child advises parent on how to behave as a
  parent.
• -- Parent over-protective.
• -- Parent martyr, guilt-inducing child not
  loving enough for parent.
• -- Child focused on pleasing parent.
• -- Child felt guilty for bad grades, etc.
  hurting parent.
• -- Child says, I was my mothers whole life.
• -- Child remembers desire to protect parent
• -- Parent treats child as friend or spouse.

• So important for interview

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Experience scales (1-9)

• Neglecting
• -- Parent inattentive preoccupied, uninvolved or
  inaccessible.
• (distinguish neglect from rejection he never
  had time for us would be neglect)
• (distinguish neglect from role-reversal
  parent ill can be neglect)
• -- Parent preoccupied with work, family,
  household.
• -- Parent unable to spend time because kids are
  too much for them.
• -- Child remembers crying at night.
• -- Parent always busy thinking of someone else.
• -- Parent always with friends, at bar, etc.

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Experience scales (1-9)

• Pressured to achieve during childhood
• -- Status or position overemphasized.
• -- Over-concern with school performance with
  emphasis on how it looks regarding the family.
• -- High ratings when parental withdrawal of
  affection if child fails to perform.
• -- Child very anxious regarding report card.
• -- Parent pushed child to care for self and
  parent unloving.
• -- Early excessive excellence stressed.
• -- Child pushed to do adults work young.

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• Seeding Development of Self

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Therapists Job with Attachment Trauma

• Transformation of the self through relationship.
• Provide a secure base for exploration,
  development and change.
• Provide attunement in helping the client
  tolerate, modulate and communicate difficult
  feelings.
• Affect regulating interactions for accessing
  disavowed or dissociated experiences
  strengthening narrative competence.
• Deconstruct the attachment patterns of the past
  to construct new ones in the present
• (see David Wallin, Attachment in
  Psychotherapy, Guilford Press, 2007)

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Deconstructing Attachment

• Implications of Psychotherapy
• Idealization.
• Dismissing derogation.
• Lack of memory.
• Response appears abstract and remote from
  memories or feeling.
• Regard self as strong, independent, normal.
• Little articulation of hurt, distress or needing.
• Endorsement of negative aspects of parents
  behavior.
• Minimizing or downplaying negative experiences.
• Positive wrap-up.
• No negative effects.
• Made me more independent.

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• Relationship with Self

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Structural Deficits

• There is good reason to believe that large
  segments of the population lack many critical
  capacities, such as self-observing abilities,
  necessary for mental health, and that even
  patients who have them, have them only in part.
  These capacities which can be called structural
  capacities (Greenspan, 1989) have to do with
  critical abilities such as self-regulation,
  relating, presymbolic-affective communicating,
  representing and differentializing experience,
  representing internal experiences and self
  observation.
• From Greenspan, S. (1997). Developmentally Based
  Psychotherapy, Madison International
  Universities Press, Inc.

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• Love is not primarily a relationship to a
  specific person it is an attitude, an
  orientation of character which determines the
  relatedness of a person to the world as a whole,
  not toward one object of love. If a person
  loves only one other person and is indifferent to
  the rest of his fellow men, his love is not love
  but a symbiotic attachment, or an enlarged
  egotismIf I truly love one person I love all
  persons, I love the world, I love life. If I can
  say to somebody else, I love you, I must be
  able to say, I love in you also myself.
• From The Art of Loving, 1956, Erich Fromm

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ALEKSANDR I. SOLZHENITSYN

• If only there were evil people somewhere
  insidiously committing evil deeds, and it were
  necessary only to separate them from the rest of
  us and destroy them. But, the line dividing good
  and evil cuts through the heart of every human
  being, and who is willing to destroy a piece of
  his own heart?
• Gulag Archipelago

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MINDFULNESS SKILLS

• Notice
• Be curious, not judgmentalLets just notice
  what is happening
• Notice what happens in your body when you start
  to talk about this
• Notice the sequence you were home alone,
  feeling bored and lonely, then gradually you
  started to get agitated and feel trapped, and
  then you just had to get our of the house-as if
  it wasnt safe there anymore
• What might have been the trigger? Lets go back
  to the start of the day and retrace your steps
• Did you notice any early warning signs that you
  were starting to get overwhelmed?
• How present in the room are you feeling right
  now? What would happen if you changed position?
  How present do you feel now?
• Fisher 2000

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Repetition

• Nevertheless, the need to repeat also has a
  positive side. Repetition is the language used
  by a child who has remained dumb, his only means
  of expressing himself. A dumb child needs a
  particularly empathic partner if he is to be
  understood at all. Speech, on the other hand, is
  often used less to express genuine feelings and
  thoughts than to hide, veil or deny them and,
  thus, to express the false self. And so, there
  often are long periods in our work with our
  patients during which we are dependent on their
  compulsion to repeat - for this repetition is
  then the only manifestation of their true self.
• - Alice Miller

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Treatment of ED Premises Philosophically

• Different developmental trajectories
• Symptom has developed as a survival strategy
• Symptom is logical, rational and adaptive
• Symptom remission is dependent on understanding
  the logical development and allowing for a more
  optimal solution

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RE-FRAMING THE MEANING OF SYMPTOMS

• Start with the assumption that every symptom is a
  valuable piece of data!
• Use psychoeducational material to make educated
  guesses about the meaning of symptoms, as a
  symptom-memory or a valiant attempt to cope
• Ask her, How would this ____ have helped you to
  survive in an unsafe world? Helped you feel
  less overwhelmed? Less helpless? More hopeful?
• Look for what the symptom is still trying to
  accomplish i.e., chronic suicidal feelings might
  offer comfort or a bail-out plan cutting might
  help modulate arousal social avoidance could be
  an attempt to avoid danger
• Once it is clear what the symptom is trying to
  accomplish, then therapist and patient can look
  for other ways to accomplish the same goal in a
  context that describes the patient as an
  ingenious and resourceful survivor, rather than
  as a damaged victim
• Fisher 2001

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Failed Protectors

• Where part got the idea that it had to coerce
  and shame her into dieting, working, being nice
  usually a parent monitoring and scorning part
  like a single parent these are inner censors
  and tyrants that control us, keep our noses to
  the grindstone and do not risk any behavior that
  brings us the slightest embarrassment.

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SELF-INJURY(David Calof, 1991)

• Self-injury is the container for unmetabolized
  traumatic stress and underlying unresolved
  trans-generational trauma and loss.
• Self-injurious/destructive behavior is functional
  and is always an attempt to protect the client
  (system).
• Expresses (communicates) underlying dynamics and
  need and is trance logical (hurting releases
  pain).
• Because behavior dissociated from sensation,
  affect and knowledge, linkages to specific
  meaning, function or intent, will typically be
  unclear.

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TRAUMA RECOVERY DOMAINS (Mary Harvey, Ph.D.)

• Authority Over Memory - Can take event from past,
  talk about it with sense of empowerment.
• Integration of Memory and Affect - Can feel some
  appropriate affect with cognition. New affect
  (adult-oriented)(1995).
• Affect Tolerance and Trauma - Related Affect -
  Feeling no longer overwhelmed, get overwhelmed
  and back into the trauma, ignore and walk into
  danger.
• Symptom Mastery - Hypervigilant, anxiety,
  depression, dissociation, somatic, compulsivity,
  how much do we need to measure remission.

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TRAUMA RECOVERY DOMAINS (Mary Harvey, Ph.D.)

• Self-Esteem - Capacity for self-care and regard,
  properly eat, exercise, sleep, self-soothe.
• Self-Cohesion - How one experiences oneself,
  fragmented, compartmentalized, self-trust
• Safe Attachment - Negotiate and maintain safety
  in relationships.
• Making Meaning - Making meaning of their
  experiences.

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Amelioration

• Involves
• Acknowledgement (i.e. how it happenedit wasnt
  idealI was impacted).
• Access (to memory or details or aspects stored
  often state specifically)
• Assimilation (of that which was previously
  compartmentalized, dissociated, denied or
  disowned).
• (Accompanied by) Affective Expression consonant
  with the experience, and
• Accurate Attributions
• Allowing for Alleviation of shame and
  inappropriate self blame.
• Acceptance, not necessarily forgiveness.
• Amends where needed to parts of self, ones body
  or other collaterally damaged through
  reenactments, trauma-bonded relations.
• Ability to move forward without constraint or
  compulsion.
• Lori Galperin 2008