Eating Disorder Treatment from Perspective of Disorder of Intimacy Preferred Provider Conference, Feb. 2009

1. 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.castlewoodtc.com

2. 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.)

3. 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.

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

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

7. 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

8. 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)

9. 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)

10. 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)

11. 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)

12. 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)

13. 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.

14. 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

15. Temperment

16. 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.

17. 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.

18. 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

19. 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

20. Experience scales (1-9) • 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

21. Experience scales (1-9) • 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

22. 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.

23. 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 adult’s work young.

24. Seeding Development of Self

25. 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)

26. 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.

27. Relationship with Self

28. 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.

29. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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.

38. 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.

39. 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. 26

40. 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. 31

41. Amelioration Involves: • 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