BETWEEN THE MONKEY AND THE KANGAROO

1
BETWEEN THE MONKEY AND THE KANGAROO

• WS 27 - 830 -1030 AM
• Sunday, December 9, 2007
• Norma Barretta, PhD
• Philip Barretta, MA, MFT

2

• ANOREXIA NERVOSA or BULIMIA
• Each one is a serious eating disorder
• Anorexia and Bulimia -
• a compounded challenge

3

• About 20 to 23 million Americans suffer from
  depression (Gardner 2004)
• World Health Organization expects an increase in
  these numbers.

4

• Many reports of increases in the number of cases
  of bulimia between 1988 and 2000 (Hag in
  Psychiatric Times 2005)

5

• Depression and eating disorders collide(!) in 36
  to 68 of cases (Maser, Weise and Gwertman 1995)
  creating a scenario for SUICIDE. A dilemma for
  us to use hypnosis going against established
  protacols at the time (Kroger - NEVER
  hypnotize a suicidal patient.)

6

• But.hypnosis is useful for eating disorders
  (Barabasz and Watkins 2005 Lynn, Rhue, Kvaal
  Mare 1993 others).
• Lots of anecdotes very little controlled
  research hypnosis for depression is bad.
  Recently hypnosis works when carefully applied
  with depressed suicidal patients.

7

• Yapko (1993)
• 1. Hypnosis makes active and experiential
  learning possible
• 2. Hypnosis brings about faster integration of
  germane learning
• 3. Hypnosis establishes therapeutic
  associations in a more concerted manner.

8

• 4. Hypnosis disrupts ones habitual experience
  of oneself that augments developing an unstable
  attributional style and,
• 5. Hypnosis models flexibility by inspiring
  experiences beyond ones usual constraints.

9

• More energy leads to suicide?
• Hypnosis does NOT
• 1. strip away defenses,
• 2. dissolve ego boundaries or impulse
  control
• 3. create or amplify hopelessness

10

• 1907 Pierre Janet used hypnosis with patients
  who were entertaining eating disorders.
• They ALREADY are in a dissociated state! making
  them relatively easy to hypnotize

11

• (Pettinati et al, 1985) eating disordered
  patients have a tendency to dissociate when they
  engage in purging behaviors.
• And because they naturally are more prone to
  dissociate they are more prone to be hypnotized
  because hypnosis necessitates dissociation to a
  certain degree.

12

• Erickson used indirect suggestion and paradox
  with a 14 year old anorexic girl
• 1. Distracting frames of reference Lectures
  on oral hygiene and absurdly precise
  instructions for mouth care were presented.

13

• 2. Depotentiating masochistic defenses The
  patient was instructed to rinse her mouth daily
  with cod liver oil. Punishment for failure was
  eating food. The patient , of course, failed.

14

• 3. Therapeutic double bind The patient was
  instructed to oversee her parents weight gain.
• 4. Emotional Catharsis The therapist provoked
  the patient by accusing her of being a liar and
  a coward.

15

• We use the patients own hypnotic talent and
  reframe the interval perspective.

16

• Yapko patients often use their hypnotic
  talent to construct the depression
• 1. Age regression, by primarily focusing on
  past painful events.
• 2. Age progression, by projecting pain of the
  past as always following them into the future.

17

• 3. Amnesia, manifested by inability to remember
  positive experiences and achievements.
• 4. Catalepsy, shown by typical depressed
  behavior of low energy, lack of motivation and
  psychomotor retardation.

18

• 5. Dissociation, shown by continuous focus on
  negative and angry self- parts.
• 6. Positive and negative hallucinations, used
  by depressed persons to create and focus on
  perceived hurts and rejections and to ignore
  pleasant, positive events.

19

• 7. Sensory alteration, shown in depression by
  decreased awareness of pleasurable activities
  and sensations.
• 8. Time distortion, created when depressed
  individuals mentally extend the periods of past
  pain and project the idea of continuous pain
  and discomfort in the future and minimize the
  possibility of future success.

20

• And CONTROL!
• JULIA
• Bulimic cycle eat and purge up to
• 24 times each day
• Anorexic cycle after weight gain starvation
  only water or diluted juice

21

• Poetry reference to open wounds, death, abuse,
  rape, insanity, betrayal, despair.
• Gymnastics many awards and medals. (Eating
  disorders are common among elite athletes.)
• Ive conquered the beam CONTROL

22

• Enter Milton Erickson
• Bizarre ideas
• 1. Contest
• 2. Focus
• 3. How rather than the emotional why.
• 4. Paradox up the ante! (48 times)
• 5. Divide and Conquer be a fifty
  percenter
• 50 normal 50 purge

23

• During anorexic phase
• I cant swallow a single bite I may never
  be able to swallow again.
• CAPISTRANO!
• The fasting stopped.
• Tracking for differences
• Self monitoring.
• Refusal to involve family
• Inability to stop the eat-purge behavior STUCK

24
THE METAPHOR

• You remember when you told me how you were able
  to make a transition from holding onto the
  balance beam and then being able to release it
  and you felt like you had wings and you were
  free to move . on the balance beam, of course
  Well, I wish you could have had a chat with a
  polar bear at the Denver
• Zoo

25

• Every behavior has a positive intention.
• Destructive even stupid behavior is a
  misguided but
• WELL INTENTIONED effort to cope.

26

• Issues about food represented a survival
  mechanism.
• Purging kept her alive
• Fasting gave her control They couldnt
  make me do ANYTHING (nor can I)
• The Geyser

27

• What it takes
• 1. Patience she would NOT be pushed!
• Trusting our pre-suppositions Though she
  refused to address the abuse by her father (it
  never even entered the discussions), she was
  dealing with it in her own way through poetry.

28

• Taking extraordinary metaphorical risks The
  geyser story was a mirror image of her situation.
  Had she not been in a state of readiness for it,
  we might have lost rapport.
• Willingness to forego insight and focus on
  behavioral change she repressed and avoided any
  reference to the early abuse (from 3 ½ to 13).
  It was hidden yet obvious ghost in our sessions.

29

• The Past to be learned from NOT lived in.
• Hypnosis is the empowering phenomenon.

30

• This case is described and discussed in greater
  detail in Hypnosis and Treating Depression
  Applications in Clinical Practice, edited by
  Michael D. Yapko, Routledge Taylor Francis
  Group.
• ISBN 0-415-95305-7
• Chapter 8 Using Hypnosis and Metaphor in the
  Treatment of Comorbid Depression and Eating
  Disorders.