Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia

8/9/2019 Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia

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Facilitatingthe

Shift

from

Disorganized

AttachmenttoSecureAttachment,UtilizingtheTherapeuticRelationshipasaBasewith

EatingDisordered

Clients

MEDAConference,April2009MarkSchwartz,Sc.D.

CastlewoodTreatmentCenterforEatingDisorders800HollandRoad

6363866611

www.castlewoodtc.com 1


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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.)


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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.


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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


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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.


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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


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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.

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Dissociation

Earlydyadicprocessesleadtoaprimary

breakdown orlack

of

integration

of

a

coherentsenseofself,i.e.Unintegrated

internalworkingmodels.

Disorganizedattachmentistheinitialstepinthedevelopmenttrajectorythat

leavesan

individual

vulnerable

to

developingdissociationinresponseto

trauma.

Liotta,2000


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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.

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Qualitiesof

Self

Calmness Joy

Curiosity Gratitude

Clarity Humor

Compassion Equanimity

Confidence Perspective

Courage Peace

Connectedness Kindness


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Seeding

Development

ofSelf


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Relationship

withSelf


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Therapyinvolveshelpingtheclientreclaim

partsof

self

that

were

sacrificed

to

gain

safety.

Intherapy,wecreateacontextand

relationshipwherepain,angeranddifficulty

canbe

safely

acknowledged

while

maintaining

aconnection.


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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.


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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

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FailedProtectors

Wherepartgottheideathatithadtocoerceandshameher

intodieting,working,beingnice usuallyaparentmonitoring

andscorning partlikeasingleparent theseareinnercensorsandtyrantsthatcontrolus,keepournosestothe

grindstoneanddonotriskanybehaviorthatbringsusthe

slightestembarrassment.

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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)


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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)


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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).


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CHANGINGATTACHMENTRULES


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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.

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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


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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.

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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.


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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


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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)

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TheIntergenerationalTransmissionofInsecure

AttachmentResults

in

Problems

With:

AffectRegulation

Selfsoothing

Selfdefininggestures

Affecttolerance

Selfcare

Pacingself(vs.avoidance/immersion)

Interoceptiveawareness


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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.

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FACILITATING EARNED SECURE ATTACHMENT


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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


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Sense

of

CoherenceTheglobalorientationthatonehasa

pervasive,enduring,

though

dynamic,

feeling

ofconfidencethatonesinternalandexternal

environmentsarepredictableandthatthere

isahigh

probability

things

will

work

out

as

wellascanbeexpected.

AronAntonovsky


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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)


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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

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Eating Disorder Residential Treatment Center, Anorexia Nervosa, Bulimia