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Castlewood: Residential Eating Disorder treatment center for anorexia nervosa, compulsive binge eating & bulimia nervosa treatment; St. Louis, Missouri.

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Treatment of Process Addictions: Sex, Food, Co-dependency, and Other Forms of Self-Injury

St. Louis Employee Assistance Professionals Association (EAPA), October 2009

Mark Schwartz, Sc.D. Castlewood Treatment Center for Eating Disorders800 Holland Road636-386-6611www.castlewoodtc.com

how is recovery measured
How is Recovery Measured

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…

slide7

On March 9th, 1997, the U.S. Department of Justice released results of a new study which showed that if our present rates of incarceration continue, one out of every twenty babies born in the U.S. today will spend some part of their adult lives in State or Federal prisons.

slide8

California, for example, is now spending more on its criminal justice system than on higher education. Though we have been greatly concerned about the government spending on the U.S. Health Care system, which many deem to be in crisis, we have not noticed that the cost of the criminal justice system is three times the cost of the nation’s entire health care budget.

slide9

If the current rate continues, according to the New York Times, the number of people incarcerated will soon overtake the number of people attending colleges and universities in our country. Already, one in three African-American men in our country are under the supervision of the criminal justice system.

aleksander i solzhenitsyn
Aleksander I. Solzhenitsyn

If 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

parts
Parts
  • 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.
parts14
Parts
  • Sub-personalities or aspects of our personality that interact internally in patterns that are similar to the ways that people interact in human systems.
  • We all have parts: think of your playful part, your organized part, shy part, etc.
  • All parts are valuable and have good intentions. Even though the behaviors might appear to be destructive, they are intended to protect the individual.
self cutting
Self-cutting

To think about my father raping me and his sweat dripping on my small body only begins to turn me to stone. While all this happened, I was stone; I was dead; I was gone, yes, gone far beyond imagination. Far into a world where I walked around like a ghost. I was in this world where life passed me by. I only hoped to come out – and come out alive. But, as it seems, I am alive, and I did come out alive. But my question is, am I alive, am I living? I feel like I’m not. But the truth is, I live on other people, I live – depending on other people to see me to the end. Now, where does that leave me? The cutting makes me real; it helps me fulfill the need for pain. Because without pain, I don’t think I would think I was real.”

abuse related tension reducing behaviors briere 1992
Abuse-Related Tension-Reducing Behaviors (Briere, 1992)
  • Engages in activities designed to provide one or more of the following: a) temporary distraction, b) interruption of dissociation or dysphoric states, c) anesthesia of psychic pain, d) restoration of control, e) distress-incompatible sensory input, f) temporary filling of perceived emptiness, g) self-soothing, and h) specific relief from guilt or self-hatred.
  • Sense of calm and relief ensues. Subsequent guilt or self-disgust at having engaged in such activities may also be present along with sense of not being in control of one’s actions.
  • Reinforces use of tension-reducing mechanisms in the future: “Behavior that reduces pain is likely to be repeated in the presence or threat of further pain.”
suicide dynamics adult children of incest child abuse david calof 1989
Suicide Dynamics Adult Children of Incest & Child Abuse (David Calof, 1989)
  • Ideation natural and inevitable in recovery process.
  • No one wants to be dead. They just want to stop hurting, and work just to be.
  • Client may use suicide fantasy as the ultimate permission to engage in therapy.
  • Homicidal currents/suicidal compliments in poly-abusive families.
  • Child mind lacks ability to think through a trauma. To them, it will never end.
  • Taking the secret to the grave. Not telling.
suicide dynamics adult children of incest child abuse david calof 198919
Suicide Dynamics Adult Children of Incest & Child Abuse (David Calof, 1989)
  • Fear of overwhelming or causing harm to therapist.
  • Intra-psychic homicide/punishment.
  • To punish another – tell me to hurt you (inside-outside boundary indistinction).
  • Don’t deserve to be. World better off without me (damaged goods framework).
  • Identification with another. Be dead for them.
  • Suicidal modeling in the extended family.
  • To demonstrate ownership of life and body.
  • The illusion of control.
compulsive self injury dusty miller 1996
Compulsive Self-Injury(Dusty Miller, 1996)
  • TRS women and men do to their bodies something that represents what was done to them in childhood…
  • For women and men who can be understood as suffering from Trauma Re-enactment Syndrome, patterns of self-harming behavior tell a story of how the child learned to be in relationship and learned to be with (her) self.
central characteristics of trauma re enactment syndrome dusty miller 1996
Central Characteristics of Trauma Re-enactment Syndrome(Dusty Miller, 1996)
  • The sense of being at war with one’s own body.
  • Excessive secrecy as a central organizing principle of life.
  • Inability to self-protect, often evident in a specific kind of fragmentation of the self, and
  • Relationships in which the struggle for control overshadow all else.
compulsions larkin whiting 1991
Compulsions (Larkin & Whiting, 1991)

“Compulsions serve as clues to the deeper stories of our lives, and individual’s history of emotional woundedness.”

A compulsion covers up an interior emptiness. It indicates the presence of a control mechanism – a way of escaping something that is ultimately unescapable and unavoidable.

Compulsions represent attempts to compensate for low self-esteem and powerlessness.

early maladaptive schemas
Early Maladaptive Schemas
  • Self-perpetuating
  • More resistant to change
  • At the core of self-contempt
  • Are actively maintained
  • Are tied to high levels of affect and arousal
  • Lead to distress
repetition
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 that 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

ethnic disorder
Ethnic Disorder
  • The disorder is a final common pathway for the expression of a wide variety of idiosyncratic personal problems and psychological distress; people who develop the disorder can range from mildly to severely disturbed.
  • The disorder is a highly patterned and widely imitated model for the expression of distress; it is a template of deviance, a “pattern of misconduct,” providing individuals with an acceptable means of being irrational, deviant or crazy.
  • They utilize these cultural preoccupations as defenses that enable them to escape from - and achieve some sense of control over - unmanageable personal distress, most of which revolves around issues of identity. Again, similar to hysteria, anorexia and bulimia are socially patterned, the fashionable style of achieving specialness through deviance.

Richard Gordon, 2000

web general
Web - General

The number of people in the United States who use the World Wide Web is estimated at 158.3 million, averaging six accesses per week, six sites per visit, and spending an average of three hours and 22 minutes per week online (Nielsen-Net Ratings, 2001). This translates into over half of all American households and reflects a trend that grew by 58% over a 20-month period (Department of Commerce, 2000). The amount of information and opportunities is overwhelming, with an estimated one billion unique web pages available in January, 2000 (Inktomi, 2000).

cybersex
Cybersex
  • As of January 1999, there were 19,542,710 total unique visitors/month on the top five pay porn websites, and there were 98,527,275 total unique visitors/month on the top five free porn websites.
  • In November 1999, Nielsen Net Ratings figures showed 12.5M surfers visited porn sites in September from their homes, a 140% rise in traffic in just six months.
  • Nearly 17% of internet users have problems with using sex on the net.
  • Severe problems with sex on the net exists for 1% of Internet users, and 40% of these extreme cases are women.
cybersex cont
Cybersex, cont.
  • Most e-porn traffic, about 70%, occurs weekdays between 9 a.m. and 5 p.m.
  • There are 100,000 Websites dedicated to selling sex in some way; this does not include chat rooms, e-mail or other forms of sexual contact on the Web.
  • About 200 sex-related Websites are added each day.
  • Sex on the Internet constitutes the third largest economic sector on the Web (software and computers rank first and second), generating $1 billion annually.
  • The greatest technological innovations on the Web were developed by the sex industry (video streaming is one example).
sexual desire as a self function
Sexual Desire as a Self-Function
  • Sexual desire in such cases can be largely anxiety driven, as the desire to conquer the other, or multiple others. In order to continually feel accepted, the individual is driven to compulsively seek affirmation of their acceptability as a way of combating deep self-hatred. Thus, hypersexual individuals starving for attention, affection, touch or validation, but without the structural capacities to substantially meet these needs, can achieve a tenuous, fleeting sense of reassurance and pseudo-intimacy. Hyposexuality, on the other hand, sets up a shield to protect the individual from anticipated rejection and prevent the vulnerability of allowing another close enough to recognize perceived self-defectiveness.
treatment of ed premises philosophically
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.
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The Eating Disorder allows you to bypass, override and transcend

It puts you in control, binds your anxiety, makes you invincible and allows you to serve only one master.

eating disorder patient s experience of recovery
Eating Disorder Patient’s Experience of Recovery
  • 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.
re framing the meaning of symptoms
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 symptoms 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 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)

failed protectors
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 – those 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.

shame
Shame

Feeling of exposure inherent to the experience that can accompany extreme amount of utter worthlessness. Feeling exposed results in the individual critically scrutinizing the minutest detail, heightening the awareness of being looked at and seen. The feeling of exposure can produce rage.

gottman
Gottman
  • Of the 35% of couples making initial gains in marital therapy, 30-50% relapsed in two years. Of couples presenting for marital therapy, 44% divorced within 5 years.
  • Anger in marital interaction does not predict divorce, whereas contempt and defensiveness did so reliably.
  • Conflict avoiding and bickering passionate couples can have stable happy marriages. Still have romance after 35 years.
  • Sharing power, accepting the wife’s influence is critically important for stability.
  • Even the best marriages, marital problems do not get solved at all, they become perpetual issues. What is important is the affect surrounding the way people talk about perpetual issues. 69% of the time couples are discussing the perpetual problem.
  • In failing marriages, people communicate clearly, but what they communicate is negative.
  • People who have the highest expectations have the best marriage.
  • The first three minutes of interaction was predictive for 96% of couples of stability. Harsh astart up by the wife followed by husbands stonewalling (looking away or down, stiffen neck, controlled facial expressions) was the most lethal prediction. Contempt (statement and putting self above) are the best predictor of divorce.
false self from winnicott
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.

assumptions regarding relationships freeman 1992
Assumptions Regarding Relationships (Freeman, 1992)
  • Unfinished business – is a present emotional reaction shaped by a past experience. It is a reactive response guided by strong emotional feelings based on past experience of anxiety. Unfinished business does not allow for a thoughtful, creative response to a here and now situation; rather it triggers an emotional reactive response. Who we bring into our life, our major life decisions, how we embrace important people and the amount of closeness and distance we need emotionally are all shaped by unfinished business carried into adult life. Relationship problems are more a reflection of unfinished business than expressions of lack of commitment, caring and love.
disorganized attachment
Disorganized Attachment

The difficulties encountered during the complex process of social adjustment, poor flexibility and resilience in facing life’s painful events, the possibility of building a sense of self that is coherent and integrated, of producing a fluid and coherent narration, ultimately psychopathological suffering itself, seem to point to the attachment pattern as an important aetiopathogenic factor.

target symptoms for earned secure attachment
Target Symptoms For “Earned Secure Attachment”
  • 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.
metacognitional
Metacognitional

Metacognition means treatment of one’s mental contents as “objects” on which to reflect, or in other words “thinking about one’s thinking.” Distinct skills contribute to its characterization, such as the ability to reflect on one’s mental states, elaborating a theory of the other’s mind, decentralizing, and the sense of mastery and personal efficacy.

compassionate witnessing
Compassionate Witnessing

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).

steps in trauma resolution
Steps in Trauma Resolution
  • Develop safety and trust.
  • Establish grounding and containment.
  • Establish control over out-of-control behavior.
  • Teach cognitive errors, affect modulation and life skills.
  • Establish relationship between injured and executive selves.
  • Allow injured self to “tell,” reassociating affect, sensation and knowledge.
homework assignment cognitive processing therapy for rape victims resick schnicke 1993
Homework Assignment Cognitive Processing Therapy for Rape Victims (Resick & Schnicke, 1993)

Assignment #1

Please write at least one page on what it means to you that you were raped. Please consider the effects the rape has had on your beliefs about yourself, your beliefs about others, and your beliefs about the world. Also consider the following topics while writing your answer: safety, trust, power and competence, esteem, and intimacy. Bring this with you to the next session.

Assignment #2

Start over and write the whole incident again at least one more time. If you were unable to complete the assignment the first time, please write more than last time. Often, the first version reads like a police report with nothing but facts. Add more sensory details as well as your thoughts and feelings during the incident. Also, this time, write your current thoughts and feelings in parentheses (i.e., “I’m feeling very angry”). Remember to read over the new account at least once before the session. If there was a second incident, please begin writing about that event.

Assignment #3

Please choose two of your stuck points and answer the questions on the Challenging Questions Sheet with regards to each of these stuck points. Write your answers on a separate sheet of paper so that you can keep the list of questions for future reference.

three conditions necessary for information reprocessing
Three Conditions Necessary for Information Reprocessing
  • Therapist activates fear structure by providing information that matches the information represented in the structure.
  • Information provided during therapy must be incompatible with pathologic elements in the structure.
  • Trauma memory, including emotional element, must be repeatedly activated by contact with trauma-related structure.
resistance group
Resistance Group
  • How am I avoiding remembering?
  • How am I avoiding feeling?
  • How am I avoiding talking about it?
  • How am I minimizing it?
  • How am I avoiding focusing on enjoying parts of life?
  • How am I avoiding noticing triggers that cause me to hurt self?
  • How am I avoiding dealing with current life stresses?
  • How am I still protecting my family?
  • How am I avoiding being close to others?
  • What secrets have I not yet discussed?
  • How am I fighting my therapist and working my program?