Treating Eating Disorders Counseling Center of Iowa City November, 13 th , 2009

1. Treating Eating Disorders Counseling Center of Iowa City November, 13th, 2009 Mark Schwartz, Sc.D. Castlewood Treatment Center for Eating Disorders800 Holland Road636-386-6611www.castlewoodtc.com

3. Control of Symptom vs… Recovery

4. Recovery is not just the absence of symptoms…it is the presence of a full life as evidenced by the ability to be human. A truly recovered life will reflect spontaneity, freedom, the ability to breathe, to have wants, needs and desires, knowing that the quest for perfection is an unattainable illusion. Having the ability to embrace the feminine, having close intimate relationships, and it is being aware of the tears in your eyes (whether out of intense or subtle sadness – or out of the joy – or from a flicker of utter gratefulness) and then to allow your tears to flow freely. It is a life in which decisions and choices are made more from self and less from a shame and fear based prison. It is a life where you fully experience pleasure, joy and passion and believe and know it is good to desire and enjoy sex… (Theresa Chesnut, 2002) How is Recovery Measured?

5. 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

6. 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. Eating Disorder Patients’ Experience of Recovery, cont.

7. Triad for Relational Disturbance • Attachment • Self • Affect & Cognition

8. Parents affective expressive becomes the child’s first representation of their own affects: • Mentalize • Intersubjectivity • Inteface of two minds (Trevarthen, 1979) • Basis of psychotherapy • At 42 minutes of age child imitates parents facial expressions (Meltozoff, 1985) Intersubjectivity

9. The affective attachment between infant and care-taker established during the first year of life evolves into a capacity for object permanence and evocative constancy during the second year that provides a “secure base” – enabling the child to explore and master. These cogitive-affective schema provide templates that maintain continuity of interpersonal behavior beyond infancy. Secure Base

10. 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 Two Years – Part 2

11. 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 1

12. 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) Stern’s Work – Part 2

13. Cecilia displays distress immediately upon finding herself in the unfamiliar laboratory environment, even though her mother -- a slightly disheveled, overwhelmed-appearing woman -- is present. When the stranger enters, Cecilia looks suspicious and ill-at-ease, and refuses to engage in interactive play. Immediately upon separation, she begins to cry, while angrily resisting the stranger’s attempts to comfort her. Reunited with her mother, Cecilia cries loudly; when picked up, she does not settle, but continues crying, wriggling uncomfortably on her mother’s lap. She does not calm even after the mother has held her for a full minute. As her mother attempts to interest her in the toys, she looks momentarily out into the room, then turns back to cling again to her mother, crying and apparently still uncomfortable. The mother repeats, “Calm down, calm down, you’re OK,” but Cecilia refuses to get off her lap and engage in play. Main

14. Here the reunion is characterized by behaviors that are not solely aimed at searching for intimacy. It is as if the child has not succeeded in organizing a single strategy when his attachment needs are activated. Disorganized Attachment

15. The rules of attachment are quite literally rules to live by – given that they emerge out of interactions between biologically channeled, survival-based attachment systems. The behavioral/communicative strategy eventually generates repressed internal/attachment strategies. Avoidants could neither be aware of, or express, attachment-related feelings – they inhibit or minimize internal experiences. Preoccupieds amplify or maximize awareness and expression of attachment-related feelings and needs, to ensure continuing care. Disorganized have their attachment figure unsafe so the person that comforts is dangerous. Such interactions create deeply entrenched templates for relating that result in distorted beliefs about self and others causing enactments and do not learn to separate and develop self-agency or a core sense of self, they are overinvolved in watching and caring for their inconsistent mom, they inhibit the attachment system and distract attention away from unmet needs. Rules of Attachment

16. The avoidant infant actively restricts attention to mother – as if to distract from the anxiety and distress of wanting mother’s comfort. The preoccupied actively seek and confines self to monitoring mom’s whereabouts, ignoring the toys and exploring the environment. Gives up the development of self to survivor. The disorganized capitulate in external relationships, they also extend internal relational exchanges between parts of the self, leading to chronic inner conflict, internal abandonment of parts of self holding traumatic affect and ruthless self-criticism. Outpatients actively live by the rules of attachment. Dismissive clients find attention focused on needs of others, denying their own needs. Preoccupieds are consumed with doubts about self and others and yearnings. They store up strategies to justify and maintain pre-existing beliefs. Active Implementation

17. 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. Deconstructing Attachment

18. Loving – -- memories of special and tender concern and soothing when ill. -- memories of having done something bad, expected 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 Experience scales (1-9)

19. Rejection – -- Turning back of child’s dependence, affection, attention, need and attachment. -- Speaker avoids discussing relationship with parent or 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 other’s rejected. -- Fear parent would leave. -- Overtures to parent rejected. (3) Mildly rejecting of attachment, aloof, “differently showing me love.” (5) Child seldom given encouragement (7) Parent mad when child sick misses graduation (9) Wish child not born Experience scales (1-9)

20. Involving/role reversal -- Making it clear that the child’s presence is necessary for maintenance of own sense of 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 on 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. Experience scales (1-9)

21. 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. Experience scales (1-9)

22. Pressured to achieve during childhood -- Status or position overemphasized. -- Over-concern with school performance with emphasis of 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. Experience scales (1-9)

23. 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) Therapists Job with Attachment Trauma

24. Turning towards other people for self-soothing and intimacy. Establishing a coherent narrative regarding one’s life. Establishing metacognitional thinking in relation to family of origin. Minimize idealization and family loyalties. Establishing clarity with regards to self and self-in-relation to significant others Resolution of significant losses in one’s life. Target symptoms for “Earned Secure Attachment”

25. The Self

26. Attachment becomes a highly structured vehicle through which increasingly complex information about the self becomes available. Developmentally, attachment contributes to acquired selfhood structures. Children abstract their uniqueness from the experience of being involved in a unique relationship with and then transform that relationship to identity. Attachment and Self Fantasy

27. Therapist is no longer “healer” but more “mid-wife,” facilitating the birth of that which already exists inside the client, waiting to be born. Self Healing

28. 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. False Self(FROM Winnicott)

29. 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. Self Differentiation

30. “What am I as a person? You’re probably not going to understand. I’m complicated! With my really close friends, I am very tolerant. I mean I’m pretty understanding and caring. With a group of friends, I’m rowdier. I’m also usually friendly and cheerful but I can get pretty obnoxious and intolerant if I don’t like how they are acting. I’d like to be cheerful and tolerant all of the time, that’s the kind of person I want to be, and I’m disappointed in myself when I’m not. At school, I’m serious, even studious every now and then, but on the other hand, I’m a goof-off too, because if you are too studious, you won’t be popular. So I go back and forth, which means I don’t do well in terms of my grades. But that causes problems at home, where I’m pretty anxious around my parents. They expect me to get all A’s and get pretty annoyed with me when report cards come out. I care what they think about me, and so then I get down on myself, but it’s not fair! I mean I worry about how I should get better grades, but I’d be mortified in the eyes of my friends if I did too well. So I’m usually pretty stressed out at home, and can even get very sarcastic, especially when my parents get on my case. But I really don’t understand how I can switch so fast from being cheerful with my friends, then coming home and feeling anxious, and then getting frustrated and sarcastic with my parents. Which one is the real me? I have the same question when I am around boys. Sometimes I feel phony. Say I think some guy might be interested in asking me out. I try to act different, like Madonna. I’ll be a real extrovert, fun-loving and even flirtatious, and I think I am really good-looking. And then everybody and I mean everybody else is looking at me like they think I am totally weird! They don’t act like they think that I’m attractive so I end up thinking that I look terrible. I just hate myself when that happens! Because it gets worse! Then I get self conscious and embarrassed and become radically introverted, and I don’t know who I really am. Am I just acting like an extrovert, am I just trying to impress them, when I am really an introvert? But I don’t really care what they think, anyway. I mean, I don’t want to care, that is. I just want to know what my close friends think. I can be my true self with my close friends. I can’t be my real self with my parents. They don’t understand me. What do they know what its like to be a teenager? They treat me like I’m still a kid. At least at school, people treat you more like you’re an adult. That gets confusing, though. I mean, which am I? When you are 15, are you still a kid or an adult? I have a part-time job and the people there treat me like an adult. I want them to approve of me, so I’m very responsible at work, which makes me feel good about myself there. But then I go out with my friends and I get pretty crazy and irresponsible. So which am I, responsible or irresponsible? How can the same person be both? If my parents knew how immature I act sometimes, they would ground me forever, particularly my father. I’m real distant with him. I’m pretty close to my mother though. But it’s being distant with one parent and close to the other, especially if we are together, like talking at dinner. Even though I’m close to my mother, I’m still pretty secretive about some things, particularly the things about myself that confuse me. So I think a lot about who is the real me, and sometimes I try to figure out when I write in my diary, but I can’t resolve it. There are days when I wish I could just become immune to myself! The Construction of Self Middle Adolescence

31. 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. Kohut

32. DISSOCIATION

33. 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 developmental trajectory that leaves an individual vulnerable to developing dissociation in response to trauma (Liotta, 2000) Part I: OverviewDissociation

35. Multilevel developmental disturbances are produced by the segregation or compartmentalization of information, skills, and behavior into discrete dissociative states, such that this knowledge is only erratically (as opposed to reliably) available to the individual. Difficulties with the integration of dissociatively compartmentalized information impair metacognitive executive functions and iteratively disrupt the developmental consolidation of sense of self over the life course. Putnam “Developmental Model”

36. 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 developmental trajectory that leaves an individual vulnerable to developing dissociation in response to trauma. (Liotta, 2000) Dissociation

37. Four characteristics distinguish pathological from normative dissocation: Only in pathological dissocation do we encounter loss of executive control, change in self-representation, amnestic barriers, and loss of ownership over behavior. Kluft, 1993 Pathological Dissociation

38. Believing it exists and understanding the classic manifestations. Awareness of distinction between DID and borderline personality disorder – adoption of ego state model. Awareness of distinction between DID manifestations of alter activity vs. psychotic process. Self functions – dealing with the omissions. Self-structure – understanding the basic form of the triadic self-structure that underpins internal dynamics. Internal Family Therapy – formatting communication, joining with, not getting triangled in, facilitating problem identification and solution generation within the self-system. Cognitive Restructuring Work on belief systems and self-attritions – identifying and reworking beliefs about self derived from early, continual and trauma-based attributions. Schema Work – identifying and countering trauma learning – altering representational systems. Trauma Reassociation and Resolution – identifying and enabling client to work through key experiences that originated and maintain compartmentalization and dissociation. Specialized Work for Addictions for the ego states manifesting addictive, compulsive and dangerous self and self-other behaviors, utilizing relapse prevention models. DISSOCIATIVE IDENTITY DISORDER: TEN EASY PIECES FOR SELF-REBUILDING

39. Internal Family Systems presumes an innate multiplicity, i.e. the unfolding of parts is natural, whether under normative, optimal or abysmal life circumstances. The degree of access and smooth interplay of parts vs. the compartmentalization and degree of polarization of parts, relates back to the kind and degree of burdening, i.e. how much has to be “exiled” and the amount of “protection” it takes to keep it so. Multiplicity

40. In response to life experiences, parts can become extreme and destructive, obscuring the leadership of the Self. People who have undergone severe trauma typically have more discrete, polarized parts. parts

41. Calmness Joy Curiosity Gratitude Clarity Humor Compassion Equanimity Confidence Perspective Courage Peace Connectedness Kindness Qualities of Self

42. Sincere letter of gratitude to Protective Parts for their efforts on behalf of survival or safety (relatively speaking). Celebrating the Symptom

43. This occurs when the Self of the client is able to witness the stories of parts from a compassionate position. Ask the client to identify an activated part (usually associated with extreme behaviors, thoughts or feelings). Ask the client where in the body the part (position of Self) indicates that another part is blended with the Self. Ask the blended part to please step aside and let the Self work with the activated part. (This may include asking more than one part to step aside). Compassionate Witnessing

44. The concept of “burdens” is brilliant in its widespread application. It sidesteps the need to compare, contrast, count symptoms to diagnose, and postulates instead more of a “no one escapes unscathed” framework. Thus, “burdens” can encompass beliefs, feelings, and energetic residue of events and experiences that overwhelmed the internal and/or external accessible resources of the organism and its attachment environment at the time, thereby creating constraint. Burdens

45. Burdens are thoughts, feelings or energies that constrain parts and keep them from assuming their natural healthy roles. After compassionate witnessing has taken place, ask the part whether it might like to get rid of the (burdensome) thoughts and feelings it took on, related to the scenes just witnessed. Ask where in the body the burden is located, and what they would like to give it up to. Unburdening

46. Attachment

47. Each person’s resilience or vulnerability to stressful life events is determined, to a very significant degree, by the pattern of attachment during early years. Bowlby’s Hypothesis (Bowlby, 1990)

48. COHERENCE: (truthful, succinct, relevant, clean) Steady flow of ideas, intent thoughts, feelings, clear truthful, consistent, plausible, reponses, complete, but not long. COLLABORATIVE: Speaker appears to value attachment relationships and experiences. CONSISTENCY: Descriptions of relationships with parents are supported by specific memories. State of Mind Regarding Attachment

49. Peter Fonagy and colleagues have described this ability as a product of the adults’ “reflective function” in which parents are able to reflect (using words) on the role of states of mind influencing feelings, perceptions, intentions, beliefs and behaviors. For this reason, reflective function has been proposed to be at the heart of secure attachments, especially when the parent has had a difficult early life. Fonagy: Attachment & Mentalization

50. Loving – there for child emotionally (cherish) Rejection – turning away attachment (rebuff/minimize) Involving/Preoccupying – guilt induction (spousification) Neglect – inaccessible when physically present (workaholic, narcissistic parents) Pressure to Achieve – perform or risk love