The Case of Mistaken IdentityEMDR, EGo States, Attachment & Eating Disorders • with Andrew Seubert, NCC, LPC • ClearPath Healing Arts Center • Mansfield, PA/Corning, NY • www.clearpathhealingarts.com • email: firstname.lastname@example.org
today’s goals • Authentic identity: our ultimate clinical goal • Trauma-informed perspective in treating eating disorders • EMDRwithin a phase model • The inevitable presence of dissociation • The need for ego state work • The need for attachment repair
From Dr. Seuss Today you are you, This is truer than true. There is no one alive Who is you-er than you.
T H E W O R L D x x x x x x x x False fronts Identitites Frozen images Roles
Identity and Experience • The Real Self was lost and false identity formed through painful experiences of omission and commission. • Re-formation, re-discovery, re-gaining, re-claiming, re-membering authentic identity require new experience • Tearing down and building up metaphor: desensitizing and reprocessing/relearning • The neurological lens: Brain lock vs. the changing brain. The influence of trauma, dissociation and poor attachment.
ED Theories • Genetic: predispositions, temperament • Family and attachment patterns • Reviving Ophelia: the influence of culture and advertising • The role of dieting and restrictive eating • Managing painful experience - trauma
Two aspects of an eating disorder • How is got started: the original reason and need for the disorder. • How it grows into an addiction via reinforcement: a life of its own • William Davis: primary and secondary disorder
New definition of trauma • DSM limited definition • Anything that negatively colors our perception of self and the world redefines us • Instead of being digested, it is pushed behind a wall • Buried, but buried alive - creates a “sore spot” • Broadened definition includes variety of events, temperament, loss and attachment injury. Lens theory.
treatment • Trauma-informed Phase Approach • incorporating Ego State Therapy, Attachment Repair, and the Search for Authentic Identity
phase 1 - evaluation • Client History, case formulation, goals, tx plan
Phase one variations • Medical management • Test for dissociation • Include thorough attachment history • Include history of eating disorder • Agree upon goals that are relevant and do-able
gathering information • Physical safety first - medical treatment • Histories, including disorder (includes use of exercise, laxatives, weight control pills) and family relationship to food and meals • EDI (Garner ), EDE (Fairburn and Cooper) and SDQ - 5 (Nijenhuis, Van der Hart & Vanderlinden)
More information • History of addictions, ED and mood disorders via genogram • DES/DDIS - check for levels and styles of dissociation • Trauma history, including events connected to ED
phase 1 - where to begin • History - pacing and frontloading • Primacy of the relationship vs. relying on ED: active and worthwhile (Wm. Davis, PhD): first goal • Beginning of attachment repair - therapeutic relationship • Case formulation as phase fulcrum - deferred?
more Beginning • Determining goals - immediate and short-term vs. long term. Motivational interview. • Possible immediate goals: dealing with emotions, particularly anxiety; short-term life successes; “passion pursuits” (Ira Sacker) • Eventual case formulation, longer-term goals (work in progress) • Case formulation + goals = treatment plan • Organizing NC: I’m fat and disgusting
phase 2 • Preparation
Phase Ii-components • Medical updates continuous/eating plans - stability • Awareness continuum • Emotional competence • Body awareness - body hunger/satiety. • Resources and templates • Dissociation - grounding and ego state preparation • Attachment repair • Short-term successes
Awareness Components • Outside (visual, auditory, tactile) • Inside (breath, body, thoughts, body sensations, feelings, open awareness) • Who is awaring?
preparation • Affect Education: the Courage to Feel • The why and how of feelings • The Four Steps • Dealing with anxiety, guilt and shame
the four steps - A-b-c-d • Be AWARE of the feeling • BE with the feeling • CHECK the message of the feeling • DECIDE to express, act or not from The Courage to Feel, 2008
the guest house This being human is a guest house.Every morning a new arrival.A joy, a depression, a meanness,some momentary awareness comesas an unexpected visitor.Welcome and entertain them all!Even if they're a crowd of sorrows,who violently sweep your houseempty of its furniture,still, treat each guest honorably.He may be clearing you outfor some new delight.The dark thought, the shame, the malice,meet them at the door laughing,and invite them in.Be grateful for whoever comes,because each has been sentas a guide from beyond.
Body awareness • Body and breath awareness • Satiety and hunger - Judy Lightstone (EMDR Solutions II) • Body-centered Gestalt - Edward Smith (The Body in Psychotherapy) - experiments to complete action • Somatic resourcing, Ogden, et al. (Trauma and the Body)
resource development • Building up and tearing down • Sources of resources - 4 “M”s (memories, models, mirrors, imaginings) • Resources based on RSVP (Earl Grey) - the “circle”
3-part preparation“Personal trainer model” • Stabilization, safety, case management • Skills and resources • Small and immediate successes
what lies beneath ed • In the face of trauma, protective avoidance is the need and dissociative strategies are the mechanisms of achieving that protection • ED as a dissociative strategy • The ego state both contains and protects against the dissociated pain by identifying with ED - “cut” metaphor • In challenging the symptoms (eating consciously), painful and dissociated material is revealed (urge interruption).
Trauma and Dissociation • New definition of “trauma” • The “wall”, pain cannot be digested • A “part” is born - state of consciousness • The part takes on ED - usually unintentionally. • Purpose: protection against pain and survival • Looking with part-ial vision - narrow focus of awareness • The dissociative continuum
Dissociative Continuum Ego States Spacing Out DID DDNOS
Ego States • The states in the union - normative flow • The part takes over the whole • Forgetting who you really BE - lost identity. Lost Self. • ED becomes the new identity • Avoids pain, creates suffering
ED Parts Work/Tasks • Make contact with source of ED • Understand that part • Appreciate its purpose • Educate - old strategies no longer working; ED education; space/time orientation • Collaborate in giving a new job description • Find and support healthier parts - trauma treatment
What now? Adult CSS ED part HP
preparation - Ego states • Gestalt Polarity work • Ego State Therapy (Watkins and Watkins): dialoguing with the part that holds on to ED. • Carl Forgash: Healing the Heart of Trauma and Dissociation. • Van der Hart, et al: The Haunted Self • Richard Schwartz - Internal Family Systems • Tsultrim Allione - Feeding your Demons
Contact • You can’t change what you don’t know • What you ignore, avoid or cave in to will eventually control you. • The conference table • Spontaneous contact with parts: the “easy flow” approach
Background - J.B. • Early 40’s, two sons, critical/impatient husband • Mother - efficient, not nurturing • Father - unpredictably explosive and anxiously protective • Teased by siblings about being “fat” @ 7 • Fondled by teacher in grade school • ED since 7 - 5 hospitalizations • Began to restrict before early adolescent.
ego state basics • To recognize and dialogue with “parts” • To discover the purpose, desires and common pain of each part - becoming known. Understanding leads to compassion. • To create common goals: new job descriptions. Avoid making ED the enemy. Therapeutic relationship needs to become more important. • To create collaboration that will move client towards desired goals, including trauma resolution.
Educate • Education of the stuck part: trauma-informed • Through the eyes of the beholder: “we see the world (and ourselves)not as it is, but as we are.” All-or-nothing thinking. • Education takes place within the relevant ego state
strengthening before trauma tx • Need to reduce behaviors before trauma tx. Building confidence towards end of preparation phase • Can’t wait for perfection of reduced behaviors • Importance of tolerating anxiety and shame • Internal collaboration and attachment repair
civil war - J.B. J/ I’m so disgusted with myself! I’m so ashamed, ‘cause I’m so fat now. A/ So what brings this on? J/ I gained weight. I’m fat, and I’m disgusting. And I don’t have any other choices. Either I get fat or I starve. A/ Sounds like a rock and a hard place. J/ Exactly. I’m just so tired of feeling so crumby about myself. [Tears, release follow] A/ Would you be willing to try something? (she nods) I’d like you to really pay attention to how disgusted and ashamed you feel…. A/What else are you noticing? J/ I’m sad, so sad. No one knows how hard this is or how awful I feel. A/ When you feel this sad, and disgusting and ashamed, how old do you feel? J/ Anywhere between 10 and 13. A/ Is there anything you would like me to know about you? J/ Just that no one knows how hard this is for me. A/Do you have anyone to talk to? J/ (shakes her head) [More tears…then affect subsides]
J.B. continued A/ Would you be willing to try something else? (nods) I’d like you to sit somewhere else…Now from this place, I’d like you to look over to 10/13, and is there anything you’d like to say to her, now that you’ve heard how sad and disgusted she feels? J/ I just hate her. She’s fat, and I just had to take over. A/ And not eat? J/ Yeah. She’s made my life miserable. Now I have to starve or I become like her [anger apparent]. A/And how old are you? J/ Oh, older teen. And now I only have two choices: be fat or give in to the eating disorder. A/ If there were another possibility, would you be interested in hearing about it? J/ Yeah. A/ Okay, now I’d like you to move back to the chair for 10/13 and slip back into that 10/13 year old place. There yet? J/ Yes. A/So how was it to hear what the older teen had to say? J/ I think I deserve it.
J.B. end A/ Well, I’d like you to hear something…. [developmental stage for body] J/ I wish I could believe that. A/ So now return to the older teen (changes seats). How was it for you to hear how it is For 10/13? J/ I still hate her. She’s making my life miserable. But, but then (more tears), as an adult, I just know that if I gain weight, I become her (pointing to the 10/13 chair). A/ Okay, would you sit in a different place for the adult? (she moves again) Say more about what it’s like for you. J/ I…I [the adult] don’t like her either. Confluence of parts and the adult
Attachment repair • Re-parenting - supplying the missing pieces. As adult self, reparenting when attachment injury leads to absence of adaptive skills and self-acceptance needed for processing. • core self, nurturer, protector (S.J. Schmidt), • Life Span Integration (P. Pace) - moving forward in time • Imaginal Nurturing - April Steele • Self development required to manage trauma work
attachment strategies • Attachment history required. Can’t repair what you don’t understand • Contacting younger aspects of Self via conference room, body or emotional clues, memories, photos to determine what is missing, needed. • Bring adult capacities and other resources back in time to younger part. It begins with recognitionand rescue (R&R). • Bring younger part forward in time - bridging
conference room experience • Choose a repeated negative reaction to a person or situation. Negative thoughts about self? Feelings? Body sensations? • Tune in to your breathing • Imagine an internal conference room. Notice details. • Invite the part(s) of you that are involved with that negative reaction into the room.
experience - 2 • Ask: Do you know who I am? How old are you? What is your purpose? What do you want me to understand about you? • Thank that part for showing up. Perhaps tell him/her what she needs to hear from a loving adult. Express your intention to keep in touch, if that fits for you. • Ask that part to leave and bring yourself back from the experience.
Trauma Processing - phases within a phase • Ego State attention and attachment repair continue • Present - immediate need to take the edge off • PAST: trauma history, especially related to ED • PRESENT: triggers, conditioned situations, body image • FUTURE: templates of positive behaviors • FUTURE: potential places of relapse
SG - Background • Mother competitive, absent • Father - sexual abuse • S.A. by neighbor teen, person she babysat for, gang raped at 17 • Alcohol abuse, promiscuous behaviors • ED by 15 • Very creative, D&A counselor • Angry at adolescent ego state - need to address first