eating disorder residential treatment center, anorexia nervosa, bulimia
TRANSCRIPT
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
1/41
Facilitatingthe
Shift
from
Disorganized
AttachmenttoSecureAttachment,UtilizingtheTherapeuticRelationshipasaBasewith
EatingDisordered
Clients
MEDAConference,April2009MarkSchwartz,Sc.D.
CastlewoodTreatmentCenterforEatingDisorders800HollandRoad
6363866611
www.castlewoodtc.com 1
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
2/41
2
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
3/41
EatingDisorderPatients Experienceof
Recovery Realisticappraisalofmedicaldangers
Improvement
in
care
of
self
(e.g.
eating
habits,
use
of
leisuretime)
Newwaystoselfsoothe,selfregulate Abilitytoaccesssocialsupportfromfamily,friends,and
fellow
patients Enhancedproblemsolvingskills Improvedcapacitytoinvestinandworkoninterpersonal
relationships
Gradualrelinquishment
of
ED
identity
and
eating
disorder
thoughts(e.g.thisfoodwillmakemefat, IllfeelbetterafterIeatthispackageofcookies,etc.)
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
4/41
EatingDisorderPatients Experienceof
Recovery,cont.
Abilitytotakeresponsibilityforselfandeschewvictim
mentality Establishmentofasenseoftrueself, realme, orknowingwhoIam.
Capacitytoformulategoals,toleratesetbacks,yet
maintainpositive
motivation
to
get
better.
Reclamationofsenseofonespersonalpower. Decreasedemphasisonperfectionism.
Firmerinterpersonalboundaries;enhancedcapacitatesto
set
appropriate
boundaries.
Cultivationofsenseofpurpose,meaningoflife.
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
5/41
Howis
Recovery
Measured?
Recoveryisnotjusttheabsenceofsymptomsitisthepresenceofafull
lifeas
evidenced
by
the
ability
to
be
human.
A
truly
recovered life
will
reflectspontaneity,freedom,theabilitytobreathe,tohavewants,needs
anddesires,knowingthatthequestforperfectionisanunattainable
illusion. Havingtheabilitytoembracethefeminine,havingcloseintimate
relationships,anditisbeingawareofthetearsinyoureyes(whetherout
ofintenseorsubtlesadness oroutofthejoy orfromaflickerofutter
gratefulness)andthentoallowyourtearstoflowfreely. Itisalifein
whichdecisionsandchoicesaremademorefromselfandlessfroma
shameandfearbasedprison. Itisalifewhereyoufullyexperience
pleasure,joy
and
passion
and
believe
and
know
it
is
good
to
desire
and
enjoysex
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
6/41
RuptureinAttachmentImpingement(Greenburg
&
Mitchell)
Thechildspsychologicalsurvivalmustnotdependupon
meetingthe
mothers
needs.
The
major
consequence
of
prolongedimpingementisfragmentationoftheinfants
experience. Outofnecessity,he/shebecomesand
requestsofothers. Thechildstrueself, thesource
ofspontaneousneeds,imagesandgestures goesintohiding,becomesdetachedandatrophied. Thefalse
self providesanillusionofpersonalexistencewhose
contentis
fashioned
out
of
maternal
expectation.
The
childbecomesthemothersimageofhim.
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
7/41
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
8/41
FalseSelf:
Etiology
Asaresult,theinfantlearnsthatanexerciseofautonomyis
metby
awithdrawl
of
love,
and
this
is
sufficient
to
skew
formationoftheselfawayfromtheindependentgoal.
Instead,afalseselfisdefensivelyconstructedto
accommodatethemothersemotionalrequirements,and
soto
secure
enough
positive
response
(or
lack
of
negative
response)topermitpsychicsurvival.Formsofdefensive
falseselftaketheircharacterologicalcolorationfrom
particular
conditions
imposed
by
the
particular
mother
child
dyad.
FromMasterson,J.&Klein,R.(1995).DisordersoftheSelf,NewYork:Brunner
Mazel,Inc.
8
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
9/41
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
10/41
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
11/41
DISSOCIATIONAND
SELF
DEVELOPMENT
Sexualandphysicalabuseatthehandsoffamilymembers
causethe
child
to
split
off
experiences,
relegating
them
to
aninaccessiblepartofself.
Dissociation
of
ones
experiences
sets
the
stage
for
loss
of
onestrueself. Thetrueselfbecomescorrodedwithinnerbadnessandisconcealedatallcosts. Persistentattemptstobegood,thusleadingtoasociallyacceptableself,are
experiencedas
non
authentic.
The
adolescent
is
compelledwiththedemandtocreatemultipleselvesindifferentcontexts.
11
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
12/41
4
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
13/41
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
14/41
Dissociation
Earlydyadicprocessesleadtoaprimary
breakdown orlack
of
integration
of
a
coherentsenseofself,i.e.Unintegrated
internalworkingmodels.
Disorganizedattachmentistheinitialstepinthedevelopmenttrajectorythat
leavesan
individual
vulnerable
to
developingdissociationinresponseto
trauma.
Liotta,2000
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
15/41
SelfDifferentiation
1.Absenceoftruesenseofself
2.Hypersensitivityandhyperreactivitytoothers,especiallyin
reactiontorejectionorabandonment.
3.Gullibility
and
suggestibility
in
relation
to
authority.
4.Complaintsofisolationandneediness,withoutselfsupport
5.Boundary
problems,
inability
to
conceive
of
self
without
referencetoothers.
15
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
16/41
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
17/41
Qualitiesof
Self
Calmness Joy
Curiosity Gratitude
Clarity Humor
Compassion Equanimity
Confidence Perspective
Courage Peace
Connectedness Kindness
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
18/41
Seeding
Development
ofSelf
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
19/41
19
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
20/41
Relationship
withSelf
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
21/41
Therapyinvolveshelpingtheclientreclaim
partsof
self
that
were
sacrificed
to
gain
safety.
Intherapy,wecreateacontextand
relationshipwherepain,angeranddifficulty
canbe
safely
acknowledged
while
maintaining
aconnection.
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
22/41
SELFINJURY(DavidCalof,1991)
Selfinjuryisthecontainerforunmetabolizedtraumaticstressandunderlyingunresolvedtransgenerational
trauma
and
loss.
Selfinjurious/destructivebehaviorisfunctionalandisalwaysanattempttoprotecttheclient(system).
Expresses(communicates)
underlying
dynamics
and
needandistrancelogical (hurtingreleasespain).
Becausebehaviordissociatedfromsensation,affectandknowledge,linkagestospecificmeaning,
functionor
intent,
will
typically
be
unclear.
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
23/41
RE
FRAMING
THE
MEANING
OF
SYMPTOMS
Startwiththeassumptionthateverysymptomisavaluablepiece ofdata! Usepsychoeducationalmaterialtomakeeducatedguessesaboutthe
meaningof
symptoms,
as
asymptom
memory
or
avaliant
attempt
to
cope
Askher,Howwouldthis____havehelpedyoutosurviveinanunsafeworld? Helpedyoufeellessoverwhelmed? Lesshelpless? Morehopeful?
Lookfor
what
the
symptom
is
still
trying
to
accomplish:
i.e.,
chronic
suicidalfeelingsmightoffercomfortorabailoutplan; cuttingmighthelpmodulatearousal;socialavoidancecouldbeanattempttoavoiddanger
Onceitisclearwhatthesymptomistryingtoaccomplish,thentherapistandpatientcanlookforotherwaystoaccomplishthesamegoalinacontext
that
describes
the
patient
as
an
ingenious
and
resourceful
survivor,ratherthanasadamagedvictimFisher2001
23
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
24/41
FailedProtectors
Wherepartgottheideathatithadtocoerceandshameher
intodieting,working,beingnice usuallyaparentmonitoring
andscorning partlikeasingleparent theseareinnercensorsandtyrantsthatcontrolus,keepournosestothe
grindstoneanddonotriskanybehaviorthatbringsusthe
slightestembarrassment.
24
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
25/41
DiagnosticDilemmas
Severalinvestigationswithbulimic(AmeFinkeletal.,1992)ormixed(Gartneretal,1989;Kennedyetal.,1990)sampleshave
notedatendency
for
Axis
IIdiagnoses
to
erode
when
treated
samplesarereassessed;forexample,inonestudytheclassification
ofsubjectsasborderlinefellfrom80%atintaketo32%by
discharge(Kennedyetal.,1990). Anoppositepatternmayholdfor
restrictinganorexics,
at
least
in
the
immediate
aftermath
of
treatment. Inonestudy,thissubgrouptendedtodisclosemore
personalitypathologyafter12weeksofinpatienttreatment
(Gartneretal.,1989),perhapsasafunctionofdecreaseddenialor
reactivityto
rapid
and
typically
unwelcome
weight
gain
(Vitousek&Manke,1994)
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
26/41
Table1.ImpulsiveBehaviorsintheFourDiagnosticSubgroupsofEatingDisorderSubjectsWholesample
(n=554)
RestrictingAN(n=183)
Bingeeating/PurgingAN(n=65)
Purging
BN
(n=244)
Nonpurging
BN
(n=62)
Suicide
attempts*
55(10%) 6(3%) 9(14%) 35(14%) 5(8%)
Skincutting 87(16%) 21(12%) 10(15%) 48(20%) 8(13%)
Skinburning 18(3%) 5(3%) 1(2%) 10(4%) 2(3%)
Otherself
damaging
behaviors
96(17%) 20(11%) 14(22%) 50(20%) 12(19%)
Seekingout
dangerous
situations*
77(14%) 10(6%) 13(20%) 47(19%) 7(11%)
Aggressive
towardsothers
71(13%) 18(10%) 8(12%) 39(16%) 6(10%)
Runningaway* 101(18%) 20(11%) 15(23%) 59(24%) 7(11%)
Stealing* 137(25%) 26(14%) 16(25%) 81(33%) 14(23%)
Substance/
alcoholabuse*
110(20%) 16(9%) 17(26%) 68(28%) 9(15%)
*Thedifferenceamongthefourgroupsissignificantatp 0.001.
(A.Favaroetal.,2005)
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
27/41
CompassionateWitnessing
ThisoccurswhentheSelfoftheclientisableto
witnessthe
stories
of
parts
from
acompassionate
position. Asktheclienttoidentifyanactivatedpart
(usuallyassociatedwithextremebehaviors,thoughts
orfeelings).
Ask
the
client
where
in
the
body
the
part(positionofSelf)indicatesthatanotherpartis
blendedwiththeSelf. Asktheblendedpartto
please
step
aside
and
let
the
Self
work
with
the
activatedpart. (Thismayincludeaskingmorethan
oneparttostepaside).
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
28/41
CHANGINGATTACHMENTRULES
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
29/41
Rulesof
Attachment
Therulesofattachmentarequiteliterallyrulestoliveby giventhattheyemerge
outofinteractionsbetweenbiologicallychanneled,survivalbasedattachment
systems. Thebehavioral/communicativestrategyeventuallygeneratesrepressed
internal/attachmentstrategies.
Avoidantscouldneitherbeawareof,orexpress,attachmentrelatedfeelings they
inhibitorminimizeinternalexperiences.
Preoccupiedsamplify
or
maximize
awareness
and
expression
of
attachment
related
feelingsandneeds,toensurecontinuingcare.
Disorganizedhavetheirattachmentfigureunsafesothepersonthatcomfortsis
dangerous. Suchinteractionscreatedeeplyentrenchedtemplates forrelatingthat
resultin
distorted
beliefs
about
self
and
others
causing
enactments
and
do
not
learn
toseparateanddevelopselfagencyoracoresenseofself,theyareoverinvolvedin
watchingandcaringfortheirinconsistentmom,theyinhibitthe attachmentsystem
anddistractattentionawayfromunmetneeds.
29
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
30/41
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
31/41
SecureAttachment
I
Becausetheircaretakershavebeenroutinelyavailabletothem,sensitivetotheirsignals,andresponsewith
somedegree
of
reliability
(though
by
no
means
is
perfectcarerequired),theseinfantsdevelopaconfidencethatsupportivecareisavailabletothem.
They
expect
that
when
a
need
arises,
help
will
be
available.
Ifthey
do
become
threatened
or
distressed,
thecaregiverwillhelpthemregainequilibrium.
Suchconfidentexpectationsarepreciselywhatismeant
by
attachment
security.
L.AlanStroufe,2000
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
32/41
Dismissingof
Attachment
1. Idealization.
2. Dismissingderogation.
3. Lackof
memory.
4. Responseappearsabstractandremotefrommemoriesorfeeling.
5. Regardselfasstrong,independent,normal.
6. Littlearticulationofhurt,distressorneeding.
7. Endorsementof
negative
aspects
of
parents
behavior.
8. Minimizingordownplayingnegativeexperiences.
9. Positivewrapup.
10. Nonegativeeffects.
11. Mademe
more
independent.
32
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
33/41
MetacognitionalMetacognitionalMetacognitionmeanstreatmentofones
mentalcontents
as
objects on
which
to
reflect,orinotherwordsthinkingabout
onesthinking. Distinctskillscontributetoits
characterization,such
as
the
ability
to
reflect
ononesmentalstates,elaboratingatheory
oftheothersmind,decentralizing,andthe
senseof
mastery
and
personal
efficacy.
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
34/41
CRITICALPART Comparingmyselfto
unrealistic/impossiblestandards. Icriticizeforcriticizingmyself Youcantrecover! Imdead Failure Youreworthless Youllalwaysberejected Bethinagain
Mydreams
will
never
come
true Disgusting
Stupid Nosuccess Disappointment Beperfect Therapyisnotworking Youllneverbehappy Youreafailure Ihatemyself! Insecure
Why
did
you
give
in? Comparing Bottledup Iwanttokillmyself! Ialwaysquit Unworthy Dontexist Nohelp!Nosupport! Icantrecover Suffer! Selfisneveraccessibleandneverwillbe! Yourepathetic FAT! YOUWILLNEVERRECOVER! Hurt Nobodycares Unappreciative Ihatemyself! Depression Pesticides
Errors Youllnevergotocollege Why? Toojudgmental Intoxicated Youwillneverrecover! Youshouldof WillI Toohardforyoutohandle!
Toxic Imhopeless Yourenotcapable Whydidyoutrust? Youreapieceofshit Mistakes Dontletanybodyin Neveracceptyourself Bemiserable. INSANE Youllnevertraveltheworld.
Youll
always
have
ED TOOHARD!
Helpless Fuckmeandeveryoneelse! UGLY Exposed Noprogression Empty Howdareyouletgoofyourrestrictive
side! Incapable Dontmotivate Nothing
pays
off
Ihavetoliveuptocertainstandards Mentallyill Getitright! Pointless Additives Pessimistic Idontcare
Uncontrollable Killyourself! Inadequate Nothingsworking Endyourlife Youregoingtobecomeobese SHAME Criticism
Dontupset
people
Humiliation Vulnerable Ihavenocapacityofsucceedinginthefuture!
Icanneverchange Pollution! Toodifficult Fakeandunreal Ostracized Norisks
Poison! Youllalwaysbelonely Liar! Prison Lazy Youllneverhavesex Graduate?No! Whybother? Suffer! PAIN
Preservatives! Feelworse Pushaway Artificial Everythingandeveryonewillrejectyou Artificial Nothingpaysoff Sink! Theresnowayout Isolate
Anger 34
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
35/41
Therapists
Job
with
Attachment
Trauma
1. Transformationoftheselfthroughrelationship.
2. Provideasecure
base
for
exploration,
development
and
change.
3. Provideattunementinhelpingtheclienttolerate,modulateand
communicatedifficult
feelings.
4. Affectregulatinginteractionsforaccessingdisavowedor
dissociatedexperiencesstrengtheningnarrativecompetence.
5. Deconstructthe
attachment
patterns
of
the
past
to
construct
newonesinthepresent
(seeDavidWallin,AttachmentinPsychotherapy,GuilfordPress,2007)
35
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
36/41
TheIntergenerationalTransmissionofInsecure
AttachmentResults
in
Problems
With:
AffectRegulation
Selfsoothing
Selfdefininggestures
Affecttolerance
Selfcare
Pacingself(vs.avoidance/immersion)
Interoceptiveawareness
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
37/41
DeconstructingAttachment
ImplicationsofPsychotherapy:
1. Idealization.
2. Dismissingderogation.
3. Lackofmemory.
4. Responseappearsabstractandremotefrommemoriesorfeeling.
5. Regardselfasstrong,independent,normal.
6. Littlearticulation
of
hurt,
distress
or
needing.
7. Endorsementofnegativeaspectsofparentsbehavior.
8. Minimizingordownplayingnegativeexperiences.
9. Positivewrapup.
10. Nonegative
effects.
11. Madememoreindependent.
37
FACILITATING EARNED SECURE ATTACHMENT
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
38/41
FACILITATING EARNEDSECUREATTACHMENT1. Facilitatingacoherentcohesiveandreflectivenarrative
2. Neutralizingidealizationandloyaltiestofamilysystem
3. Facilitatingmetacognition
4. Facilitatingselfcompassion
5. Utilizinganattunedrelationshipwiththerapistasahomebaseforexplorationofdevelopmentalchange
6. Askingothersforselfsoothingunderstress
7. Reexaminedetailedbeliefsaboutselfandothers
8. Relinquishingdefenseofdissociationandreassociatingaffect,sensation,andknowledge
9. Notinhibit
or
minimize
internal
experiences
and
learn
to
tolerate,
express
attachment
and
related
emotions
10. Resolutionofinternalrelationalexchangesbetweenpartsofself
11. Internalizeselfparenting,isforgivingofmistakes,listenstodisownedpartsofself
12. Setsandteacheshealthyboundaries
13. Resolutionofsignificantlossesinoneslife
14. Deconstructtheattachmentpatternsofthepastandconstructnewones
15. Integratetraumaticattachments, lossesandreenactments.
16. Establishingappropriateentitlementsrelatedtohavingneeds,expressingneeds,andmeetingneeds
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
39/41
Sense
of
CoherenceTheglobalorientationthatonehasa
pervasive,enduring,
though
dynamic,
feeling
ofconfidencethatonesinternalandexternal
environmentsarepredictableandthatthere
isahigh
probability
things
will
work
out
as
wellascanbeexpected.
AronAntonovsky
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
40/41
PhaseII:NarrativeStoryTelling:
NST Repeatednarration
Organizationof
trauma
memory
Fearreductionthroughhabituation
Meaninganalysis/contextualization
Revisionof
beliefs
about
self
and
others
(trauma
schemas
arepartofpastvs.present)
Integrationoftraumamemoryintoalifehistory
Explorationandresolutionoffeelingsotherthanfear:shame,guilt,angerandloss
(MaryleneCloitre,2008)
-
8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia
41/41
RepetitionNevertheless,theneedtorepeatalsohasapositiveside. Repetitionisthelanguageusedbya
childwho
has
remained
dumb,
his
only
means
of
expressinghimself. Adumbchildneedsaparticularlyempathicpartnerifheistobeunderstoodatall. Speech,ontheotherhand,is
oftenused
less
to
express
genuine
feelings
and
thoughtsthantohide,veilordenythemand,thus,toexpressthefalseself. Andso,thereoftenarelongperiodsinourworkwithourpatientsduring
which
we
are
dependent
on
their
compulsion
to
repeat forthisrepetitionisthentheonlymanifestationoftheirtrueself.
AliceMiller
41