Transcript Slide 1

Eating Disorder Treatment from Perspective of
Disorder of Intimacy
Preferred Provider Conference, Feb. 2009
Mark Schwartz, Sc.D. and Lori Galperin, MSW, LCSW
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611
www.castlewoodtc.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,” “I’ll feel better
after I eat this package of cookies, etc.)
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 one’s personal power.
• Decreased emphasis on perfectionism.
• Firmer interpersonal boundaries; enhanced capacitates
to set appropriate boundaries.
• Cultivation of sense of purpose, meaning of life.
Triad for Relational Disturbance
• Attachment
• Self
• Affect & Cognition
Attunement
Concept of Bebe research
and
Intersubjectivity
_______________
42 minutes of age.
Child imitates parents
facial expressions
(Meltzoff, 1980)
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
couldn’t 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 don’t 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 that’s interfered
with, it’s a real loss for the child.”
Karen, R. (1994). Becoming Attached. New York: Warner Books
Stern’s Work – Part 1
Molly’s mother was controlling in a different way. She constantly
told Molly how to play with toys (“Shake it up and down – don’t roll
it on the floor”), and, in effect, rode rough-shod over Molly’s
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. Molly’s 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)
Stern’s 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)
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 experience…The individual who has
developed the capacity to be alone is
constantly able to rediscover the personal
impulse.
(Winnicott)
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)
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)
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.
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 parent’s
ability to attune to the infant’s 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 infant’s subsequent
access to those same emotions at a very early age.
Ref: Pamela C. Alexander, Oct. 1991
Temperment
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 doesn’t validate the
child’s developing self, thus leading to alienation
from the core self. Parenting practices that
constitute lack of attunement to the child’s 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
Experience scales (1-9)
1.
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
What is
love?
Unloving –
(3) Instrumental attention
(5) Present occasionally
(7) Good enough parenting
Turn child to
object
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Experience scales (1-9)
2.
Rejection –
-- Turning back on child’s 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)
3.
Involving/role reversal
-- Making it clear that the child’s 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 child’s 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 mother’s” 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)
4.
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)
5.
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 adult’s work young.
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Seeding
Development
of Self
Therapists Job with Attachment Trauma
1.
Transformation of the self through relationship.
2.
Provide a secure base for exploration, development and change.
3.
Provide attunement in helping the client tolerate, modulate and
communicate difficult feelings.
4.
Affect regulating interactions for accessing disavowed or
dissociated experiences strengthening narrative competence.
5.
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:
1. Idealization.
2. Dismissing derogation.
3. Lack of memory.
4. Response appears abstract and remote from memories or feeling.
5. Regard self as strong, independent, normal.
6. Little articulation of hurt, distress or needing.
7. Endorsement of negative aspects of parents behavior.
8. Minimizing or downplaying negative experiences.
9. Positive wrap-up.
10. No negative effects.
11. Made me more independent.
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Relationship
with Self
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 selfregulation, 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 egotism…If 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
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
MINDFULNESS SKILLS
•
•
•
•
“Notice…”
“Be curious, not judgmental…Let’s 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 wasn’t safe there anymore”
• “What might have been the trigger? Let’s 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 transgenerational 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.
TRAUMA RECOVERY DOMAINS
(Mary Harvey, Ph.D.)
1. Authority Over Memory - Can take event from past, talk about it
with sense of empowerment.
2. Integration of Memory and Affect - Can feel some appropriate
affect with cognition. New affect (adult-oriented)(1995).
3. Affect Tolerance and Trauma - Related Affect - Feeling no longer
overwhelmed, get overwhelmed and back into the trauma,
ignore and walk into danger.
4. 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.)
5. Self-Esteem - Capacity for self-care and regard, properly eat,
exercise, sleep, self-soothe.
6. Self-Cohesion - How one experiences oneself, fragmented,
compartmentalized, self-trust
7. Safe Attachment - Negotiate and maintain safety in
relationships.
8. Making Meaning - Making meaning of their experiences.
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Amelioration
Involves:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Acknowledgement (i.e. how it happened…it wasn’t ideal…I 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, one’s body or other collaterally
damaged through reenactments, trauma-bonded relations.
Ability to move forward without constraint or compulsion.
Lori Galperin 2008