Body-States:Interpersonal and Relational Perspectives on the Treatment of Eating Disorders

Jean Petrucelli, Jean Petrucelli

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317635376
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

In this edited volume, Jean Petrucelli brings together the work of talented clinicians and researchers steeped in working with eating disordered patients for the past 10 to 35 years. Eating disorders are about body-states and their relational meanings. The split of mindbody functioning is enacted in many arenas in the eating disordered patient's life. Concretely, a patient believes that disciplining or controlling his or her body is a means to psychic equilibrium and interpersonal effectiveness. The collected papers in Body-States: Interpersonal and Relational Perspectives on the Treatment of Eating Disorders elaborates the essential role of linking symptoms with their emotional and interpersonal meanings in the context of the therapy relationship so that eating disordered patients can find their way out and survive the unbearable.

The contributors bridge the gaps in varied protocols for recovery, illustrating that, at its core, trust in the reliability of the humanness of the other is necessary for patients to develop, regain, or have - for the first time - a stable body. They illustrate how embodied experience must be cultivated in the patient/therapist relationship as a felt experience so patients can experience their bodies as their own, to be lived in and enjoyed, rather than as an 'other' to be managed.

In this collection Petrucelli convincingly demonstrates how interpersonal and relational treatments address eating problems, body image and "problems in living." Body States: Interpersonal and Relational Perspectives on the Treatment of Eating Disorders will be essential reading for psychoanalysts, psychotherapists, psychologists, psychiatrists, social workers, and a wide range of professionals and lay readers who are interested in the topic and treatment of eating disorders.

Part I
Finding Beauty in the Beast

Interpersonal Perspectives and Treatment of Eating Disorders

1
Mermaids, Mistresses, and Medusa

Getting ‘Inside Out and Outside In’ the Relational Montage of an Eating Disorder

Jean Petrucelli

Yesterday, I thought that because ‘I’m fat,’ eating was a bad habit. You want me to associate to the word ‘Curves’?… OK… Marilyn Monroe, child bearing hips, fat, sexual prey, shaped like your mother, large breasted, fat, hour glass, made fun of, puberty, sexy, overweight, the opposite of a model, get stared at, not like my friends growing up, not petite, fat. Fat, fat, fat… I know it is time to sink or swim but it’s a big ocean and I don’t know where to go. Even if I were a mermaid, the current I follow seems to always lead me into the shark’s den. I feel helpless. Yesterday, I wanted to flee where the pain would not follow me. Yesterday, I would not have believed that you or anyone would have any interest in my self-hatred, understand my starvation, or feel my hunger to not live. Today, I sort-of-know differently. But tomorrow, I want to not just know but feel things that will help my life never be the same.

(Anonymous voices)

Familiar words, but many voices evoke the haunting chill of living on the precipice of life and in the emotional abyss of an eating disorder. Past, present, and future collapse for patients with eating disorders: The insidious negative self-talk is too loud, and/or the aftermath of trauma too pervasive and/or the affects are too overwhelming.

What might have been a full life becomes reduced to the myopic world of a ‘single bagel.’ Certainly culture, with its many offerings of visual objectification, provides eating-disordered patients much opportunity to feel scrutinized, objectified, and cut off from their bodies. And, when bodies are experienced as ‘mere aesthetic wrappers of the self’ (see Chapter 6), while simultaneously being thought of as central signifiers of one’s identity, one is more vulnerable to expressing pain via an eating disorder. Yet cultural influences on the development of eating disorders are only one part of a much larger mystery.

Eating disorder symptoms, for all their painful behavioral constrictions, hold complex, personal stories of the sufferer’s relationship, not only to food and her body but to the caretakers who fed and didn’t feed them—to the relational context in which needs were met or dismissed, and in which life came to feel as if it could or could not hold the potential for satisfaction, possibilities, and meaning. At their core, eating disorders are disorders of desire in which wanting, longing, hunger, and the vulnerability of reaching with one’s appetite towards the ‘world of others’ has been subverted. Like mermaids in search of a sea, mistresses in search of a Madame, or Medusa in search of a man, eating-disordered patients remain mythically haunted and psychically alone. They live between two worlds: the world of food and the world of people. In this chapter, I will discuss how an interpersonal/relational psychoanalytic approach to working with eating disorders clarifies the links between symptom and meaning, action and words, isolation and relatedness.

Working psychoanalytically with the treatment of eating disordered individuals requires the necessary integration of behavioral change and behavioral techniques. Harry Stack Sullivan, one of the founders of interpersonal theory, had a behavioral sensibility. He was not a behaviorist in the strict sense of the term but was fascinated by what actually goes on between people in the real world. As Steve Mitchell (1999, p. 90) recognized, “The roots of this sensibility for Sullivan were in the philosophical pragmatism that dominated the American social science of his day. There is no use talking about what you can’t see or measure operationally, Sullivan believed. In trying to understand ‘human difficulties in living,’ it is much more conceptually economical to study what people actually do with one another.” With an eating-disordered patient, food often takes the place of ‘an Other.’ Therefore, we understand our patient’s relationships to food and others and their day to day lived experience as being relevant information, as important as what we wish to understand about an inner fantasy life. Our work, as analysts, involves actively intervening. In particular, I will focus on the ways in which the direct, concrete engagement with eating disorder behaviors can build bridges to elaborating personal and interpersonal meanings trapped in these actions.

Eating disorders require integrative thinking. They are complex illnesses that are multidetermined and require a multidisciplinary approach. They must be thought about and treated in a sociocultural context, while taking into account the individual’s biology, genetic predisposition and vulnerability, as well as a host of psychological determinants. A person’s underlying genetic structure shapes his or her vulnerability and resilience, which affects how she perceives, organizes, and responds to experiences (Maine, 2010).

Eating disorders interfere with a normal ability to hold the conflicting tensions of hunger and satiety: Therefore, one must also consider the effects of early developmental feeding and issues of attachment. Alongside attachment issues, we must also take into account how self and affect regulation difficulties play a role in understanding how eating is felt and symbolized: “If affects are the metaphorical juice of life—the aliveness that on some level everyone yearns for” (Glennon, 2012) then to be fully engaged in life, one must have access to a broad range of emotional experiences. For an eating-disordered patient, symptoms truncate emotional experience, serving both expressive and defensive functions. These behavioral enactments often demonstrate something that is not yet articulated about the patient’s subjective state, in which the body is used in the service of the mind (Stolorow & Atwood, 1991). When patients’ affects are split off by an unconscious fear that their experience will be unbearable, they end up living a marginal existence. Our eating-disordered patients struggle with their underlying terror of interpersonal relatedness, which is often obscured by their symptoms.

Unlike classical psychoanalytic approaches, which are sometimes less receptive to alternative treatment models, interpersonal and relational treatment offers models flexible enough to integrate other modes of thinking and working. Confronting some of the challenges of working with patients with anorexia, bulimia, bulimarexia, and binge eating, we, as psychoanalysts, are forced to clarify and expand our thinking and practice.

Contemporary understanding of successful treatment for these eating-disordered patients demands an integrated and profound appreciation for how genetic vulnerability, attachment, family history, affect regulation, and cultural context mesh in the clinical picture. More and more, we realize we need to fine-tune our interpersonal and relational thinking about therapeutic action—both our successes and failures with eating-disordered patients—and recognize that treatment often requires creativity to step outside of the proverbial box.

An interpersonal/relational perspective values the unique fit between patient and therapist by offering an opportunity for a mutually regulating system. There is a link between a patient’s self-regulation with food and the way in which the patient regulates relatedness with the therapist. The relational dyad between patient and choice of food (as part of the symptom) is highly textured. Why do some patients binge on sugar, some on salt or a combination of both, while still others only on healthy foods? Does it have to do with someone’s capacity to recognize the after effects of ingesting salt versus sugar, for example, as they affect the individual differently? Thinking clinically then, to what ‘flavor’ is our patient intuitively responding in our personality that allows this patient to feel comfortable enough to begin this work? And how do we, as therapists, stay empathetic to a human condition that, at times, seems alien, destructive, and unbearable? How do we begin to see the interpersonal meanings and unique ways our patients choose to take us in or spit us out?

An interpersonal/relational approach takes as a starting point the idea that an eating disorder symptom is not something to simply get rid of, but rather something that holds dissociated parts of oneself and one’s relational history. A patient with an eating disorder may feel like the symptoms have ‘minds of their own’ as they find voice through the body. Our work requires helping these patients learn how to have a different relationship to their self-states, body-states and their bodies—a relationship that allows them to “feel generative and animated as well as alive to ordinary discontents and longings” (Orbach, 2009, p. 76). This is a tall order.

Symptoms, Self-States, and Body-States

Throughout this work, as we discover the disowned or dissociated parts of a person, we experience and witness various self-states and body-states that accompany eating disorders. We observe the adaptive function of dissociation processes as patients attempt to maintain “self-continuity and self-organization” (Bromberg, 1998, p. 206) with the use of symptoms, such as starving, bingeing, and purging. Since eating-disordered patients communicate through these dramatic bodily actions, they comprise a population where alexithymia (Barth, 2001; Krueger, 2001) and unformulated experience (Stern, 1997) rule.

Not only do these patients have difficulty identifying their emotions, but they often also have difficulty distinguishing and appreciating the emotions of others. And for those who do have a sense of what they feel, spoken words may not be enough to completely express their experience. The fear of not being understood and the shame they bear dampens curiosity that is required for self-exploration. Not knowing what they feel can be unbearable in and of itself. Eating disorders speak to a loss of faith in the reliability of human relatedness. Words fail these patients and their trust in the reliability of the other is broken.

In the eating-disordered patient, symptoms are “used” to compensate for a lack of a capacity to reflect and deal with conflict, or to counteract difficulty in mentalizing. Unable to reflectively experience a part of oneself or another, this patient has difficulty experiencing having a mind of one’s own. Meanwhile, self-development is sadly derailed. On a gut level, eating-disordered patients do not feel that others can imagine what they feel on the inside. They never feel like they are ‘good enough.’ For these patients, self-states—ways of being and expressing that allow a certain representation or part of the self to emerge—might be defined as the experience of what they can and/or cannot be curious about, relative to the self-state they are in. Sometimes, what is needed is for the patient to experience that we can know her experience, and feel it viscerally in our bodies (Sands, 1997), creating an uncanny, ‘shared’ body-state. Patients can experience relating to the analyst—another body in the room sometimes—by projecting his or her disowned parts onto the analyst and by relating to the analyst as an embodied other. In turn, processing this mutual experience allows the patient to experience body-states relationally and to reflect upon this experience. A body-state has to do with embodiment: how one lives in the body, at a given moment, relative to the felt experience. This can be internally accepted as a part of oneself—or not. By definition, body-states are nonverbal experiences and may not be known through the mind with words. The body ‘articulates’ the unspoken.

Interpersonal/relational perspectives recognize that the therapist, engaging with the patient’s disowned/dissociated self- and body-states, will inevitably be pulled into the relational dynamics implicated in the patient’s symptoms. You cannot treat this group from the outside; you have got to get your hands dirty and dig in the dirt. Interpersonal and relational psychoanalysis has always taken this as foundational to treating anyone.

Digging in the Dirt

How can we understand a patient’s relationship to food—what he or she does with it and how he or she thinks of it—in relational terms? Entering treatment, a person’s relationship with food is often the single-most significant relationship in his or her life. The symptoms have lost connection to the problems and vulnerabilities that stimulated their onset and have a life of their own: They are now ingrained habits, with their own rhythms and expressions. For example, food may begin as a “valued friend/secret companion that helps” lessen anxiety or soothe unbearable feelings. Over time, however, food may become a “strict taskmaster or abusive tyrant that harshly punishes transgressions” (Davis, 2009, p. 37). The therapist is often pulled into this relational configuration, first idealized and valued, and then feared as the rule maker.

With the eating-disordered patient, the analyst lives in the interplay between attending directly to the food and disengaging from the pull to do so, compulsive patterns that have roots in relational interactions. When we feel the tug to attend or disengage, we are simultaneously sensing patients shifting from one part of them to another—in other words, shifting in self- or body-states. Let’s say you are talking with an actively symptomatic patient and you realize you have spent an entire session talking about things other than the symptom (i.e., no discussion of the patient’s relationship to food and eating). Most likely you have been pulled into a dissociative process, alerting you that the eating-disordered part of the patient is no longer in the room.

It is crucial to create a safe and reliable relationship with a patient with an eating disorder, but it is also very difficult. It means finding traction and a way to intervene between the patient’s relationships to food. The next section addresses this difficulty.

Finding Traction, Getting Gritty, Coming Clean

A central feature of working in an interpersonal or relational way involves focusing on the uniqueness of each patient, each analyst, and, therefore, each analytic dyad. If a crucial ingredient in therapeutic action involves being known by one’s analyst, then the question becomes this: How is the patient’s uniqueness best revealed or uncovered (Glennon, 2012)? How do we obtain a historical narrative and enter into an eating-disordered patient’s ritual-obsessed private world of food? For starters, we must try to understand the reasons that food and body image issues may have been important in the family of origin. Food is a central issue in most people’s lives. We all have memories of and feelings about family mealtime, family food behaviors, cultural and family messages around image, appearance and success. Food is also, of course, a particularly compelling substitute for what Kohut (1972) called an internalized “self-object function”—the aspect of a parent/child relationship that provides the first medium for the transmission of soothing and comfort. By turning to food, the person attempts to circumvent the need for human self-object responsiveness in order to avoid further disappointment and shame. Food is trustworthy. How do we, as therapists, become ‘trustworthy,’ and help legitimize our patients’ needs and yearnings, sometimes giving these feelings words before the patient can?

We live in an era of uncertainty, where sort-of-knowing (Petrucelli, 2010) predominates. Although the eating-disordered population wants immediate results, recovery involves a long-term therapeutic process. Therapists who work with multiple eating-disordered patients often report an accumulation of tension in themselves. Some of this tension arises from their patients’ urgent need to gain immediate control over their lives. Thus, the delayed gratification of a psychoanalytically oriented psychotherapy poses a particular challenge for the therapist who then may, countertransferentially, feel a patient’s sense of urgency.

Further complicating matters, social trends are at odds with participating in meaning-centered long-term treatment. Through texting, tweeting, twittering, swiping, and Skyping, the concepts and experiences of ‘sitting with feelings,’ ‘holding thoughts,’ and ‘delaying gratification’ are challenged as obsolete modes of being, doing, or operating in the world. This adds an additional layer to an already complex problem with patients with eating disorders because of their difficulties with discriminating, holding, and choosing. Their tendency toward emotional anesthetization via ...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• About the Editor
• Contributors
• Foreword
• Acknowledgments
• Introduction: ‘With a Little Help from My Friends’
• PART I Finding Beauty in the Beast: Interpersonal Perspectives and Treatment of Eating Disorders
• PART II The Mindbody and the Bodymind: Reflections Inside and Outside Reality and Subjectivity
• PART III Treating the Family, the Young, the Hormonal, and the Religious: Developmental, Familial, and Cultural Contexts
• PART IV Appetite Regulation in an Interpersonal and Cultural Context
• PART V Beyond the Interpersonal: Clinical and Assessment Tools Across Modalities
• Index