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movement therapy of eating disordered patients: A model
The Arts in Psychothrrrrp.v,
Vol. 13 pp. 323-331,
DANCE/MOVEMENT
o Ankho International
THERAPY
Inc., 1986. Printed
0197-4556186
in the U.S.A.
OF EATING DISORDERED
$3.00 + .OO
PATIENTS:
A MODEL
DAVID
W. KRUEGER.
MD and ELLEN
INTRODUCTION
SCHOFIELD,
and their evolution and change over developmental time (Lichtenberg, 1984; Schwaber, 1981).
Many individuals with anorexia nervosa and bulimia, whether in-patient or out-patient, are different from other patients when they present themselves for treatment. In general they have a limited ability to describe themselves and their feelings in a meaningful way. They constrict emotional expression and tend to describe endless details of symptoms as substitutes for feelings and internal experience. They inhibit fantasy, which limits their capacity to symbolize and to play. These patients are frequently quite wellto-do and privileged, and the adults are frequently in high-functioning positions. Despite this, they are unaccustomed to taking themselves as a point of reference, of staying inside their experience, or expanding and elaborating upon it. They perform for others, attempt to be perfect, and yearn to be recognized (Bruch, 1978). They engage in obsessive vigilance about their bodies, food, calories, and how they appear to others. They are secretive. Many patients, when asked how they feel, ask that their mother or spouse be consulted. The approaches we will describe are designed to broaden the applicability of treatment for these patients who are not as yet insightful, verbal. psychologically minded, or creative. The vantage point taken therapeutically in both verbal and nonverbal modalities is in the internal experience of the patients-an empathic perspective focused on emotions, perceptions, causal explanations. self and body experience,
PSYCHODYNAMIC
ASPECTS
Patients who suffer from anorexia nervosa and bulimia have painfully inadequate means to regulate themselves internally, even to know such a basic sensation as hunger. They oscillate rapidly between grandiosity and self-deprecation, and rely on external cues. It may mean obsessively counting calories or weighing numerous times a day. They cannot take themselves or even their bodies for granted. They may binge or vomit simply because they feel they are incapable of assimilating and using food. This disorder is one of deficient selfregulation, using food as the most basic external source to attempt to supplement both a deficient internal regulator and a deficient integration of mind and body (or, even more basically, a concept of mind and body). Relying on other people for their supply of affirmation, enhancement, function, and esteem, they attempt to find a way to internalize this source. The almost manic-like activity of excruciating exercise, running, and swimming may appear objectively to be for the purpose of losing weight, but it is often perceived by the patients as a way to experience themselves, as a way to feel real. It is self-stimulating behavior. They need to experience the reality of their body, for which they do not have an accu-
*David Krueger. in the private practice of psychiatry and psychoanalysis in Houston. of Psychiatry. Baylor College of Medicine. and Director, Eating Disorders Treatment Houston, Texas. Ellen Schofield. a movement-dance Shadows Glen Hospital, Houston,
MA*
psychotherapist. was formerly a member Texas and is presently in private practice 323
Texas, is also Clinical Associate Professor Program, Spring Shadows Glen Hospital,
of the Eating Disorders in Geneva, Illinois.
Treatment
Program,
Spring
KRUEGER
AND
rate or distinct mental representation (Krueger & Schofield, 1984a). It is also an effort (as is controlling eating, or of vomiting) at countering the anguish of internal emptiness, boredom, and deadness. One young woman put it succinctly, “I feel completely helpless and ineffective, and I don’t know what’s wrong or how to feel better. At least when I focus on food and exercise. I have sor77ctl7i77g I can control and do something about.” The anorexic, bulimic, and some compulsive overeaters experience a dreaded state of feeling that their body, indeed their self-organization. is easily invaded, influenced, exploited. and overwhelmed by external forces (especially important people). They feel, in essence, only one calorie away from being out of control. These individuals have little or no recognition of an internal center of initiative or reference. They have struggled for their entire lives to be perfect in the eyes of others, to please, or make themselves over to gain some sense of recognition. identity, effectiveness, and control.
THE
DEVELOPMENT
OF BODY
IMAGE
Body image is the mental representation, or internal picture, of our physical body. Freud (1923) described the ego as first a body ego. The body concept grows from awareness of internal and external kinesthetic sensations, somatic momental representation, and tions, awareness, maturation of the concept of the body self is a basic foundation (or, to be more exact, container) of the psychological self. These patients, by and large, do not experience the distinctness of their body boundaries (Bauman. 1981; Bruch, 1973; Freud, 1923). Lacking this internal evocative image of a body self or psychological self, they rely on external feedback and referents. such as other people or mirrors. There is a distinct lack of object and internal image constancy. The early developmental arrests that affect their sense of self seem to be based on the lack of formation of a coherent, cohesive, organized body image. At the beginning of treatment patients are asked to draw, with crayon, the mental picture they have of their body. In all of these projective drawings the body boundaries are blurred and indistinct: there is no clear beginning
SCHOFIELD and ending, no distinct inside or outside. This indistinctness of body boundaries is similar to the blurring of emotional boundaries that they experience during closeness with another individual. Emotionally, where one individual ends and another individual begins becomes uncertain. Some specific developmental events have either not occurred, or occurred so sporadically as to make an inconsistent nucleus for further evolution (Lichtenberg. 1978). Specifically. we have seen evidence that some preverbal and early verbal experiences forming the beginning sense of self do not seem to have developed (Krueger & Schofield, book in prep.). It is as though these children’s emotions and their bodies were not seen by their parents as separate entities. The parents are typically incapable of perceiving or unwilling to perceive their children in their own right-as having a distinct body, feelings, and initiative. One patient said, “My mother fed me whenever she was hungry.” The children are perceived as an extension of the parents. or their desires, interests, and even of the mother’s own bodily experience. Finally the children come to perceive themselves in that way also. Later. it is as if the only way to prove their distinct existence is to begin at the beginning and create a distinctness of the body-to refuse to eat and to control the ins and outs of food despite repeated entreaties and attempts to control this by the parents. The children try to experience internal sensations by extremes of food deprivation or engorgement. They try to experience external bodily sensations by exercise, by wearing loose clothing that stimulates the skin, or by other actions which stimulate their skin in either a caressing or painful manner. Bruch (1973) described the outstanding aspects of the anorexic in particular as disturbances of body image and body concept. of difficulties with the accuracy. perception. and interpretation of stimuli coming from within the body, and of a paralyzing and pervasive sense of ineffectiveness. The central feature of all three predominant symptoms is the experience. perception, and image of the body. Other clinicians also trace the initial interruption to the stage of separation-individuation (Rizzuto, Peterson & Reed. 1981: Swift & Letven. 1984). crystallized by the third year of life. We can now extend that further on the basis of
DANCE/MOVEMENT
THERAPY
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our work-the failure to achieve autonomy and separation stems from an even earlier nucleus of arrested development encountered when the nascent sense of self emerges from mirroring experiences with the mother beginning in the first weeks and months of life, extending, in changing forms, thought development. The preverbal experiences in the first year of life have failed to acknowledge and confirm a separate body self from the mother for almost every one of the patients we have seen (Krueger & Schofield, 1984a; b; & book in prep.). It is as if the mother is incapable of accurate, consistent mirroring, of reflecting the child’s aliveness, special distinctness, and body and psychic boundaries. It appears the mother is unable to allow the child the opportunity for an autonomous, internally directed origin of experience and action. Winnicott (1971) has indicated that the mother’s face serves as a mirror for her baby. The mother is able, hopefully, to reflect what she sees in the baby and therefore be attuned to what is emanating from the infant rather than from herself. This mirroring, as it is the first entunement to body sensations and awareness, is necessary for the development of the body image. It is imperative if the infant is to ever accurately perceive internal stimuli and elaborate a consistent and defined internal representation of the body self (Lichtenberg, 1984). From this early experienced and confirmed body self the ego and psychological sense of self emanate (Krueger & Schofield, in prep.). This seems to form the cornerstone for a true and accurate representation of the self, individually fashioned. If the sensations, movements, and affects generated by the infant are not met and affirmed to some significant and accurate extent, or if they are supplanted by the mother’s own needs, and her internal state is projected onto the baby, the baby must comply. This process of affirmation continues to occur in varying forms throughout development. A false or distorted body image and the failure of recognizing an internal focus of sensation form the basic foundation, then, of some types of pathology. The nucleus of this pathological process is in the earliest phase of the formation of the nascent sense of the self. This occurs in the autistic and symbiotic stages of life, in the first weeks and months of life, before separation-individuation begins.
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This pathological process, with its origin in preverbal time, makes words and language to describe it (or, especially, to affect it therapeutically) difficult at best. It is just such a basis of psychological experience that we believe is most profoundly and vividly elaborated in the disorders of mind and body of anorexia and bulimia. This line of development (or non-development) of body image, wholeness, and function is the preverbal bedrock of mixed experience that our therapeutic efforts directly scrutinize and address. The “cohesive self’ and the “body self’ are intimately related in these patients and, we speculate, in development as a whole.
A DEVELOPMENTAL APPROACH TO THERAPY One way of viewing this pathology is through the process of regression back to a fixation point (a conflict model and top-down approach). However, this implies the attainment of a certain developmental level, i.e., of psychic structuralization. We view these patients as not yet able to develop conflict in certain areas because of developmental arrest (a deficit model). Consequently, a developmentally informed therapeutic process that utilizes both verbal and nonverbal therapies must be applied in order to address what was missed. The complete basic elements of body and self experience can then progress through a normal hierarchy. In general, these individuals are not defensively denying body awareness and feelings because they have never initially integrated mind and body to be able to defensively split them. This deficit model, applicable to many of our patients, recognizes that an individual may not be simply denying a painful affect, but that he/she may developmentally be unable to recognize or distinguish different affects and bodily sensations. That is, many narcissistic individuals have not developed a consolidated body image to deny or to attain to perfection. The nuclear formation of a sense of self has not been formed in a cohesive manner and remains disorganized and primitive. For these individuals, a combination of verbal and nonverbal techniques is as imperative as the integration of body self and psycholog-
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ical self. The two modalities are integrated to meet the need for developmental synthesis from the very earliest stages of psychological birth and growth. In most eating disorder patients, development has occurred along some lines, but has been suspended entirely along others. Especially neglected are the sense of self, separation-individuation, somatic recognition and expression with the maturing desomatization to take one’s body for granted, to live in and through one’s body. Catharsis, insight, and working-through are aspects of conflict theory and therefore apply to more well-structured personalities. We see conflict emerge as an aspect of development only after first addressing the earlier developmental experiences. The individual can then progress to an awareness of altering and opposing urges and fears, wishes and defenses, and can develop the capacity and the anxiety tolerance to be able to have and deal with conflict. Developmentally, one is first aware of his/her own body sensations through the mirroring of the mother, then from within his/herself. Later, one develops an internal representation of the body, consolidating into a body image as one can think in pictures, i.e., develops a capacity for mental imagery. Later still, words are possible, and subsequently abstractions are possible for both the images and the experience of the body, of thoughts, and of feelings. This normal developmental sequence informs the therapeutic approach that we will describe. The shaping of the developing self occurs in the orbit of the body as well as the psyche, and especially in the consistent integration of the two. The combined frameworks of dance/movement therapy and psychoanalytic theory and application are integrated to treat the psyche and soma as a whole. A synthesis of the preverbal techniques of dance/movement therapy with psychodynamically informed verbal psychotherapy follows. A MODEL OF INTEGRATING MIND AND BODY VIA VERBAL AND NONVERBAL THERAPIES The work described here is based on the collaborative efforts of a psychiatrist and a dance/movement therapist with patients in a pri-
vate out-patient setting as well as with patients in an in-patient setting. is individually The type of treatment prescribed for each patient. Some patients can benefit most from an intense joint effort of both psychiatrist and dance/movement therapist on an out-patient basis. These patients are typically seen several months with sessions with the psychiatrist l-2 times per week and with the dance/movement therapist l-3 times per week, based on individual assessment. Some patients, however, require more intensive treatment in the contained environment of a hospital. The in-patient setting described here is a private residential psychiatric hospital with an eating disorders treatment program. Patients are housed in either a Young Adult (1%30 years) or Adolescent (12-17 years) Unit. There is not a separate Eating Disorder Unit but rather a separate program. The patients are treated by a multi-specialty treatment team (comprised of a psychiatrist, family physician, dietitian, dance/movement therapist, psycho-dramatist, clinical social worker, biofeedback/stress management psychologist, and certified occupational and recreational therapist). The patients are seen by all members of the treatment team, although the material for this paper is based on the collaborative efforts of the psychiatrist and dance/movement therapist. This work evolves from daily meetings with the psychiatrist and twice weekly meetings with the dance/movement therapist. The average length of hospitalization for patients on the Young Adult Unit is approximately 8 weeks and 11 weeks for patients on the Adolescent Unit. We have evolved a particular way to address this needed developmental change by integrating psychodynamically-oriented dance/movement therapy with verbal psychotherapy. We view our work together as an effort at synthesizing mind and body in a cohesive manner. There are two primary dyadic relationships of the patient in dance/movement psychotherapy and in verbal psychotherapy. Siegel (1984) has demonstrated that an integration of the movement-expressive-bodily asnects with verbal cognitive-affective comoonents Is crucial in development and in therapy. Emphasis on only one area (mind or body) may create or perpetuate a mind-body split in therapy
DANCE/MOVEMENT as it may nally.
have
occurred
THERAPY
in development
DANCE/MOVEMENT INTRODUCTION AND
OF EATING
origi-
THERAPY: PHILOSOPHY
Dance/movement therapy is a process that furthers the physical and psychic integration of As in verbal therapy, a individual. an dance/movement therapy model of regression back to a fixation point is not applicable for these eating disorder patients who are not viewed as repressing somatically or defensively armoring their bodies, for this implies the attainment of a certain developmental level. Conceptually our work most closely aligns itself with the psychoanalytic model described by Siegel (1984). Additionally it includes clinical and theoretical aspects of early infant development and self psychology adapted to a dance/ movement therapy model. We differ from her conceptualization, however. in two areas. First. we do not view the process as one of regression back to a fixation point (a top-down approach), for this implies the attainment of a certain developmental level. As we conceptualize it. it is one of a bottom-up approach that starts with missed and incomplete developmental experiences that begin at the very basic element of development and move progressively upward (Krueger & Schofield, 1985). There is a different conceptualization and, therefore, approach needed for someone stuck in an early developmental stage as opposed to someone who has psychic structure and has defensively regressed back to an earlier phase. Secondly, we differ with her inclusion of the elements of catharsis, insight, and working through, as they are aspects of conflict theory and therefore apply to more well-structured personalities. We see conflict emerge as an aspect of development only after addressing the earlier developmental issues. Our clinical work has shown that for eating disorder patients there is no “authentic” movement. Because of the missed early experience of accurate mirroring the children have not experienced any internally directed autonomous communication of feeling. Their bodies are not seen as vehicles for their own expression. but rather as mirrors for the feelings of others.
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PATIENTS
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The model we utilize in a developmentally informed sequence that focuses on the integration of mind and body fosters an integrated body and self image and leads to the evolution of the capacity to symbolize and play. The model also includes the use of projective drawings and videotape to directly address the early preverbal developmental arrest. It is closely integrated with verbal therapy to allow a cohesive and complete developmental sequence. Integrated therapy that is begun at this level of awareness of the body self allows resumption of growth processed in a much more profound and rapid manner. In addition, the patient’s desperate sense of helplessness and ineffectiveness is immediately addressed by beginning in this manner. The techniques and sequences we describe as designed to integrate the mind and body are especially needed in eating disorder patients, as this basic body awareness has never been completely established (Freud, 1923; Krueger & Schofield, 1984a). An approach that parallels a normal developmental sequence beginning in infancy starts with an internal focus of bodily sensations, feelings, and awareness. It is an attempt to assist the patient to define the original body self in a cohesive manner. Since the first awareness of self is the body self (Bauman, 1981; Freud, 1923), dance/movement therapy activates and dramatizes this awareness in a rapid and active manner. The sequences and techniques described foster progression through the developmental stages of an autistic-like state, to establish a symbiotic union with an accurate, adequately-mirroring self-object, through the separation-individuation subphases, and finally with an emergence into autonomy. DANCE/MOVEMENT THERAPY: TECHNIQUES
The beginning phase of dance/movement therapy utilizes relaxation techniques that include deep muscle relaxation, breathing exercises, guided imagery, and centering exercises. The intent is to create an exclusive focus on internal experience-focusing in, concentrating on internal sensations of tension and release. This therapeutic experience is analogous to a
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primary autistic stage concerned with the inner core of bodily experience and awareness that will become the basis for a body image. Focusing internally in this manner allows an opportunity to distinguish the most basic of internal sensations-those of the body. It is from this core awareness of body self that a sense of self is elaborated-the body self becomes the container of the emotional self. This internal focus fosters a beginning distinction between inside and outside and is an essential prerequisite of body ego formation (Mahler & Furer, 1966; Schilder, 1951). An important experience for patients during this beginning phase is a progressive recognition and distinction of a body “center.” In a very relaxed state patients are asked to focus internally to locate their “center,” the part of the body that feels and reacts first. When the patients have sensed this spot they are asked to visualize and experience it as the source of radiating The patients are then energy. encouraged to allow the radiating energy to evolve into some form of movement and consciously experience it as originating from within themselves and in their control. The acknowledgment and acceptance of a personal body center are vital to establishing an awareness of body self and of initiating a cohesive body image. These techniques address the basic developmental deficit of most eating disorder patients-the failure to establish a distinct body image. These techniques attempt to establish an internal center of reference. This center forms the core of the self, the center point around which a sense of identity will be established (Greenacre. 1958; Rose, 1966).
As patients become more aware of their bodies, the role of the therapist takes on added significance. Initially the therapist acts as a nonjudgmental, unobtrusive presence who facilitates the patients in experiencing themselves. As patients become more aware of their body selves the presence of the therapist serves to give recognition and validity to internal sensations. At this point the therapist-patient pair begin a phase of physical mirroring in which the therapist initiates a flowing continuous movement pattern that the patient follows. Both patient and thera-
SCHOFIELD pist are seated face to face with simple hand movements and the opening and closing of the arms and body, initiated by the therapist and followed by the patient. Observed, this looks like pantomime in front of a mirror. The seated position is less threatening than standing and is reminiscent of the early pre-ambulatory tie. During this phase the bodies come very close, but do not touch. This mirroring allows the opportunity to experience another close physical presence and experience movement that appears neither inwardly nor outwardly directed, but shared. In a sense, the patient is re-creating the experience of the original symbiotic organizer. As the patient becomes more and more comfortable following the therapist’s movements, the therapist switches roles with the patient and requests that the patient initiate the movement. This transition allows the center of initiative of movement to now reside in the patient. The therapist listens attentively to how this is experienced by the patient, as it frequently crystallizes initial separation anxiety, since the patient is no longer following but leading. Most patients describe the mirroring as a very relaxing, comfortable. and freeing experience. For some, however. the experience is initially very upsetting. even overwhelming, for reasons they cannot yet verbalize. The relaxation and centering exercises are continued as part of each session to allow the continuous experience of affirming an internal point of reference.
The next phase of treatment is similar to what Mahler (1958) described as the practicing subphase of separation-individuation. As patients begin to experience complete security during mirroring they then turn to face themselves in a real mirror, to move and mirror with themselves. This is the next step in an awareness of separateness and movement toward individuation. The patients are encouraged and supported by the presence of the therapist (analogous to Mahler’s “rapprochement” [ 1968]), but the patients move alone. This process of seeing. of leading. and of totally experiencing their own movement initiative is a major step in establishing the link between mind and body (Krueger & Schofield, 1984a).
DANCE/MOVEMENT
THERAPY
OF EATING
Slowly the patients experience and recognize their entire image in the mirror, and experience something similar to what Mahler (1958) describes as the “hatching” process. At this point the patients are ready to turn their attention to the external world with a cohesive internal point of reference. Throughout treatment, work with the mirror maintains an important role. This is done for several reasons. The mirror provides an immediate affirmation of body self unlike any other medium. The body is the visual component of the self and must be totally integrated. Greenacre (1960) states, “Vision is not only an adjunct but an indispensable one in establishing the confluence of the body surface and promoting awareness of delimitation of the self from nonself. Touching and taking in of the various body parts with the eyes (vision) helps in drawing the body together, into a central image beyond the level of mere immediate sensory awareness” (p. 208). In addition, the mirror encourages the conscious realization of the body as real and acceptable. So many eating disorder patients have confused feelings when viewing their image. As one thing. I hate patient stated, “It’s this love-hate the mirror but I know I can’t live without it.” Many anorexics who have spent so much energy on creating a body based on some external set of standards say, “I never knew I was allowed to like it.” Touching the body and attempting movement intervention can be contraindicated during specific developmental stages and with specific problems. With eating disorder patients in particular, the issue of control is extremely powerful. Any attempt to direct or dictate movement may be countered with strict resistance in an attempt to maintain control. Because of the powerful wish/fear of merger, touching is usually initiated, if at all, by the patients rather than the therapist, and only after an internal center becomes more familiar and boundaries less tenuous. Just as free upright locomotion is important in the emotional development of children, so too is it important in treatment. It provides an enormous increase in discovery and testing of the world from their own initiative. Walking upright for the first time creates body exhilaration and sensory responsiveness unlike any other devel-
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opmental step. Piaget (1936) parallels it with the beginning of representational intelligence. The patients can now allow memories and feelings to emerge first through movement, a new process, and then verbally. This integration is now with the newly established link between mind and body. The relationship with the dance/movement therapist has slowly changed during the course of treatment. The patient now acts as leader but the therapist must still be quietly available to witness and share. This is essential if the patient’s emerging autonomy is to attain optimal capacity. The centering exercise and use of the mirror are employed with decreasing frequency with the increasing autonomy and verbalization of the patient. The patient has a need at times for “refueling” and “rapprochement” but the emphasis is on enhancing independent movement. As the process continues the patient’s emerging individuality consolidates. The patient is experiencing his/her own autonomous self at a much higher level which now includes symbolic language and play. This is expressed in almost equal portions of words and movement. However, in the final phase, both dance/movement therapist and verbal therapist are working exclusively in the verbal modality to reinforce the newly attained level of development.
At the end of each session each patient is asked to express in a drawing what he/she experienced during the dance/movement session. This projective drawing is utilized as part of the treatment process for several reasons: It provides an immediate visual re-creating of the patient’s movement experience. This aids the patient in understanding what was felt by providing an additional expression of the original feeling. By translating the experience into a concrete, visual symbol it becomes objectified; symbolization and verbalization of the experience are furthered by this means. A potential space between the patient’s subjective and objective process occurs via this drawing. _. The projective drawing depicts current developmental issues with focus on body and self concept. 4. For both therapists a drawing serves as a transition vehicle from nonverbal to verbal therapy. In addi-
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tion it serves patient. 5. The drawing
as a link between
both therapists
AND and
becomes appropriate and objective criterion by which to measure changes.
At the time of the drawing, the patient works with the dance/mov~ment therapist in understanding the process of the projective drawingthe creative urge, the sequence, and process; the use of space, colors, and shapes vis-8-vis body image and psychic experience. The verbal therapist microscopically examines the drawing with the patient in terms of the overall developmental issues being negotiated. The drawing is also integrated with other material and scrutinized microscopically to understand symbols, associations to meanings, and the conscious and unconscious processes.
Videotape feedback has become an important tool in our work and will also be summarized briefly. It provides an additional way for patients to experience themselves objectively. Even in a mirror, we can look at only one part of ourselves. Patients may be too involved in the present action to view themselves objectively. The video allows a direct view of one’s entire body as expressed and in movement. It is also an aid in establishing an accurate body image. The videotape viewing has a profound and dramatic impact on the emaciated anorexic or the obese compulsive eater. It provides a direct, objective confrontation to their denial, an irrefutable view of one’s body. A frequent response of the patient with knew I really anorexia nervosa is. “I never looked that bad.” These are the words of an emaciated anorexic on seeing herself on video for the first time: “I became aware of what 1 was doing to myself, and it wasn’t what I wanted. It’s like it’s not me. Rut that’s my whole self there. Even in a fui~-length mirror I focus only on one spot. I’ve never been able to get completely on the outside of myself until seeing this video of me. I’ve always felt I was some enormous person.” An additional and important part of treatment has become the process of viewing the videotape with both therapists and patient together. A dis-
SCHOFIELD cussion can occur with all three that further integrates the verbal and nonverbal therapies. Additionally, it enhances the progression of the developmental frame of reference from dyadic to triadic relatedness. CONCLUSIONS The eating disorders of anorexia nervosa and bulimia can be conceived as disorders of the sense of self, with the origin appearing initially at the developmental level of the mirroring phase. With this arrested development. an entire developmental experience in treatment offers the most thorough and definitive possibility for persons in this category. Techniques addressing the nuclear primitive and preverbal-level issues can be integrated with higher-level verbal and symbolic functions and experience to provide a comprehensive and cohesive development of sense of self.
DANCE/MOVEMENT
THERAPY
LICHTENBERG, J. (1984) Empathy I and II. New York: The Analytic Press. MAHLER, M. (1958) On two crucial phases of integration of the sense of identity: Separation-individuation and bisexual identity. J. Amer. Psychorrnul. Assoc~. 6: 136-139. MAHLER, M. & FURER, M. (1966) Development of symbiosis, symbiotic psychosis and the nature of separation anxiety: Remarks on J. Weiland’s paper. Inr. J. Ps.vchoAnrrl. 47: 559-560. MAHLER, M. (1968) On humun symbiosis und the vicissitudcs of’individuution. Vol. I. Infirnfilr Psvchosis. New York: International Universities Press. PIAGET, J. (1936) Thr Origins ofIntelligrnce in Children. Paris: Delachaux and Niestle. RIZZUTO, A., PETERSON, M. & REED, M. (1981) The pathological sense of self in anorexia nervosa. Psychirrt. Clin. N. Amer. 4: 471-487. ROSE, G. (1964) Creative imagination in terms ofego “core” and boundaries. Int. J. Psycho-Antrl. 45: 75-84.
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ROSE, G. (1966) Body ego and reality. Inr. J. Psycho-Arm/. 47: 502-509. SCHILDER, P. (1951) The Image und Appeuruncr of the Humun Body: Studies in the Consfrucfive Energies ofthe Ps_vche. New York: International Universities Press. SCHWABER, E. (1981) Empathy: A mode of analytic listening. Psychoanal. Iny. 1: 357-392. SIEGEL, E. (1984) Dance-Movement Therapy-Mirror of Our S~lws: Psychoanalvtic Appr0ac.h. New York: Human Sciences-Press. SWIFT. W. & LETVEN, R. (1984) Bulimia and the basic fault: A psychoanalytic interpretation of the bingingvomiting syndrome. J. Amer. Acod. Child. Psychiut. 23: 489-497. WINNICOTT, D. (1971) Pkt.ving and Recr1it.v. New York: Basic Books.
Vol. 13 pp. 323-331,
DANCE/MOVEMENT
o Ankho International
THERAPY
Inc., 1986. Printed
0197-4556186
in the U.S.A.
OF EATING DISORDERED
$3.00 + .OO
PATIENTS:
A MODEL
DAVID
W. KRUEGER.
MD and ELLEN
INTRODUCTION
SCHOFIELD,
and their evolution and change over developmental time (Lichtenberg, 1984; Schwaber, 1981).
Many individuals with anorexia nervosa and bulimia, whether in-patient or out-patient, are different from other patients when they present themselves for treatment. In general they have a limited ability to describe themselves and their feelings in a meaningful way. They constrict emotional expression and tend to describe endless details of symptoms as substitutes for feelings and internal experience. They inhibit fantasy, which limits their capacity to symbolize and to play. These patients are frequently quite wellto-do and privileged, and the adults are frequently in high-functioning positions. Despite this, they are unaccustomed to taking themselves as a point of reference, of staying inside their experience, or expanding and elaborating upon it. They perform for others, attempt to be perfect, and yearn to be recognized (Bruch, 1978). They engage in obsessive vigilance about their bodies, food, calories, and how they appear to others. They are secretive. Many patients, when asked how they feel, ask that their mother or spouse be consulted. The approaches we will describe are designed to broaden the applicability of treatment for these patients who are not as yet insightful, verbal. psychologically minded, or creative. The vantage point taken therapeutically in both verbal and nonverbal modalities is in the internal experience of the patients-an empathic perspective focused on emotions, perceptions, causal explanations. self and body experience,
PSYCHODYNAMIC
ASPECTS
Patients who suffer from anorexia nervosa and bulimia have painfully inadequate means to regulate themselves internally, even to know such a basic sensation as hunger. They oscillate rapidly between grandiosity and self-deprecation, and rely on external cues. It may mean obsessively counting calories or weighing numerous times a day. They cannot take themselves or even their bodies for granted. They may binge or vomit simply because they feel they are incapable of assimilating and using food. This disorder is one of deficient selfregulation, using food as the most basic external source to attempt to supplement both a deficient internal regulator and a deficient integration of mind and body (or, even more basically, a concept of mind and body). Relying on other people for their supply of affirmation, enhancement, function, and esteem, they attempt to find a way to internalize this source. The almost manic-like activity of excruciating exercise, running, and swimming may appear objectively to be for the purpose of losing weight, but it is often perceived by the patients as a way to experience themselves, as a way to feel real. It is self-stimulating behavior. They need to experience the reality of their body, for which they do not have an accu-
*David Krueger. in the private practice of psychiatry and psychoanalysis in Houston. of Psychiatry. Baylor College of Medicine. and Director, Eating Disorders Treatment Houston, Texas. Ellen Schofield. a movement-dance Shadows Glen Hospital, Houston,
MA*
psychotherapist. was formerly a member Texas and is presently in private practice 323
Texas, is also Clinical Associate Professor Program, Spring Shadows Glen Hospital,
of the Eating Disorders in Geneva, Illinois.
Treatment
Program,
Spring
KRUEGER
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rate or distinct mental representation (Krueger & Schofield, 1984a). It is also an effort (as is controlling eating, or of vomiting) at countering the anguish of internal emptiness, boredom, and deadness. One young woman put it succinctly, “I feel completely helpless and ineffective, and I don’t know what’s wrong or how to feel better. At least when I focus on food and exercise. I have sor77ctl7i77g I can control and do something about.” The anorexic, bulimic, and some compulsive overeaters experience a dreaded state of feeling that their body, indeed their self-organization. is easily invaded, influenced, exploited. and overwhelmed by external forces (especially important people). They feel, in essence, only one calorie away from being out of control. These individuals have little or no recognition of an internal center of initiative or reference. They have struggled for their entire lives to be perfect in the eyes of others, to please, or make themselves over to gain some sense of recognition. identity, effectiveness, and control.
THE
DEVELOPMENT
OF BODY
IMAGE
Body image is the mental representation, or internal picture, of our physical body. Freud (1923) described the ego as first a body ego. The body concept grows from awareness of internal and external kinesthetic sensations, somatic momental representation, and tions, awareness, maturation of the concept of the body self is a basic foundation (or, to be more exact, container) of the psychological self. These patients, by and large, do not experience the distinctness of their body boundaries (Bauman. 1981; Bruch, 1973; Freud, 1923). Lacking this internal evocative image of a body self or psychological self, they rely on external feedback and referents. such as other people or mirrors. There is a distinct lack of object and internal image constancy. The early developmental arrests that affect their sense of self seem to be based on the lack of formation of a coherent, cohesive, organized body image. At the beginning of treatment patients are asked to draw, with crayon, the mental picture they have of their body. In all of these projective drawings the body boundaries are blurred and indistinct: there is no clear beginning
SCHOFIELD and ending, no distinct inside or outside. This indistinctness of body boundaries is similar to the blurring of emotional boundaries that they experience during closeness with another individual. Emotionally, where one individual ends and another individual begins becomes uncertain. Some specific developmental events have either not occurred, or occurred so sporadically as to make an inconsistent nucleus for further evolution (Lichtenberg. 1978). Specifically. we have seen evidence that some preverbal and early verbal experiences forming the beginning sense of self do not seem to have developed (Krueger & Schofield, book in prep.). It is as though these children’s emotions and their bodies were not seen by their parents as separate entities. The parents are typically incapable of perceiving or unwilling to perceive their children in their own right-as having a distinct body, feelings, and initiative. One patient said, “My mother fed me whenever she was hungry.” The children are perceived as an extension of the parents. or their desires, interests, and even of the mother’s own bodily experience. Finally the children come to perceive themselves in that way also. Later. it is as if the only way to prove their distinct existence is to begin at the beginning and create a distinctness of the body-to refuse to eat and to control the ins and outs of food despite repeated entreaties and attempts to control this by the parents. The children try to experience internal sensations by extremes of food deprivation or engorgement. They try to experience external bodily sensations by exercise, by wearing loose clothing that stimulates the skin, or by other actions which stimulate their skin in either a caressing or painful manner. Bruch (1973) described the outstanding aspects of the anorexic in particular as disturbances of body image and body concept. of difficulties with the accuracy. perception. and interpretation of stimuli coming from within the body, and of a paralyzing and pervasive sense of ineffectiveness. The central feature of all three predominant symptoms is the experience. perception, and image of the body. Other clinicians also trace the initial interruption to the stage of separation-individuation (Rizzuto, Peterson & Reed. 1981: Swift & Letven. 1984). crystallized by the third year of life. We can now extend that further on the basis of
DANCE/MOVEMENT
THERAPY
OF EATING DISORDERED
our work-the failure to achieve autonomy and separation stems from an even earlier nucleus of arrested development encountered when the nascent sense of self emerges from mirroring experiences with the mother beginning in the first weeks and months of life, extending, in changing forms, thought development. The preverbal experiences in the first year of life have failed to acknowledge and confirm a separate body self from the mother for almost every one of the patients we have seen (Krueger & Schofield, 1984a; b; & book in prep.). It is as if the mother is incapable of accurate, consistent mirroring, of reflecting the child’s aliveness, special distinctness, and body and psychic boundaries. It appears the mother is unable to allow the child the opportunity for an autonomous, internally directed origin of experience and action. Winnicott (1971) has indicated that the mother’s face serves as a mirror for her baby. The mother is able, hopefully, to reflect what she sees in the baby and therefore be attuned to what is emanating from the infant rather than from herself. This mirroring, as it is the first entunement to body sensations and awareness, is necessary for the development of the body image. It is imperative if the infant is to ever accurately perceive internal stimuli and elaborate a consistent and defined internal representation of the body self (Lichtenberg, 1984). From this early experienced and confirmed body self the ego and psychological sense of self emanate (Krueger & Schofield, in prep.). This seems to form the cornerstone for a true and accurate representation of the self, individually fashioned. If the sensations, movements, and affects generated by the infant are not met and affirmed to some significant and accurate extent, or if they are supplanted by the mother’s own needs, and her internal state is projected onto the baby, the baby must comply. This process of affirmation continues to occur in varying forms throughout development. A false or distorted body image and the failure of recognizing an internal focus of sensation form the basic foundation, then, of some types of pathology. The nucleus of this pathological process is in the earliest phase of the formation of the nascent sense of the self. This occurs in the autistic and symbiotic stages of life, in the first weeks and months of life, before separation-individuation begins.
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This pathological process, with its origin in preverbal time, makes words and language to describe it (or, especially, to affect it therapeutically) difficult at best. It is just such a basis of psychological experience that we believe is most profoundly and vividly elaborated in the disorders of mind and body of anorexia and bulimia. This line of development (or non-development) of body image, wholeness, and function is the preverbal bedrock of mixed experience that our therapeutic efforts directly scrutinize and address. The “cohesive self’ and the “body self’ are intimately related in these patients and, we speculate, in development as a whole.
A DEVELOPMENTAL APPROACH TO THERAPY One way of viewing this pathology is through the process of regression back to a fixation point (a conflict model and top-down approach). However, this implies the attainment of a certain developmental level, i.e., of psychic structuralization. We view these patients as not yet able to develop conflict in certain areas because of developmental arrest (a deficit model). Consequently, a developmentally informed therapeutic process that utilizes both verbal and nonverbal therapies must be applied in order to address what was missed. The complete basic elements of body and self experience can then progress through a normal hierarchy. In general, these individuals are not defensively denying body awareness and feelings because they have never initially integrated mind and body to be able to defensively split them. This deficit model, applicable to many of our patients, recognizes that an individual may not be simply denying a painful affect, but that he/she may developmentally be unable to recognize or distinguish different affects and bodily sensations. That is, many narcissistic individuals have not developed a consolidated body image to deny or to attain to perfection. The nuclear formation of a sense of self has not been formed in a cohesive manner and remains disorganized and primitive. For these individuals, a combination of verbal and nonverbal techniques is as imperative as the integration of body self and psycholog-
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ical self. The two modalities are integrated to meet the need for developmental synthesis from the very earliest stages of psychological birth and growth. In most eating disorder patients, development has occurred along some lines, but has been suspended entirely along others. Especially neglected are the sense of self, separation-individuation, somatic recognition and expression with the maturing desomatization to take one’s body for granted, to live in and through one’s body. Catharsis, insight, and working-through are aspects of conflict theory and therefore apply to more well-structured personalities. We see conflict emerge as an aspect of development only after first addressing the earlier developmental experiences. The individual can then progress to an awareness of altering and opposing urges and fears, wishes and defenses, and can develop the capacity and the anxiety tolerance to be able to have and deal with conflict. Developmentally, one is first aware of his/her own body sensations through the mirroring of the mother, then from within his/herself. Later, one develops an internal representation of the body, consolidating into a body image as one can think in pictures, i.e., develops a capacity for mental imagery. Later still, words are possible, and subsequently abstractions are possible for both the images and the experience of the body, of thoughts, and of feelings. This normal developmental sequence informs the therapeutic approach that we will describe. The shaping of the developing self occurs in the orbit of the body as well as the psyche, and especially in the consistent integration of the two. The combined frameworks of dance/movement therapy and psychoanalytic theory and application are integrated to treat the psyche and soma as a whole. A synthesis of the preverbal techniques of dance/movement therapy with psychodynamically informed verbal psychotherapy follows. A MODEL OF INTEGRATING MIND AND BODY VIA VERBAL AND NONVERBAL THERAPIES The work described here is based on the collaborative efforts of a psychiatrist and a dance/movement therapist with patients in a pri-
vate out-patient setting as well as with patients in an in-patient setting. is individually The type of treatment prescribed for each patient. Some patients can benefit most from an intense joint effort of both psychiatrist and dance/movement therapist on an out-patient basis. These patients are typically seen several months with sessions with the psychiatrist l-2 times per week and with the dance/movement therapist l-3 times per week, based on individual assessment. Some patients, however, require more intensive treatment in the contained environment of a hospital. The in-patient setting described here is a private residential psychiatric hospital with an eating disorders treatment program. Patients are housed in either a Young Adult (1%30 years) or Adolescent (12-17 years) Unit. There is not a separate Eating Disorder Unit but rather a separate program. The patients are treated by a multi-specialty treatment team (comprised of a psychiatrist, family physician, dietitian, dance/movement therapist, psycho-dramatist, clinical social worker, biofeedback/stress management psychologist, and certified occupational and recreational therapist). The patients are seen by all members of the treatment team, although the material for this paper is based on the collaborative efforts of the psychiatrist and dance/movement therapist. This work evolves from daily meetings with the psychiatrist and twice weekly meetings with the dance/movement therapist. The average length of hospitalization for patients on the Young Adult Unit is approximately 8 weeks and 11 weeks for patients on the Adolescent Unit. We have evolved a particular way to address this needed developmental change by integrating psychodynamically-oriented dance/movement therapy with verbal psychotherapy. We view our work together as an effort at synthesizing mind and body in a cohesive manner. There are two primary dyadic relationships of the patient in dance/movement psychotherapy and in verbal psychotherapy. Siegel (1984) has demonstrated that an integration of the movement-expressive-bodily asnects with verbal cognitive-affective comoonents Is crucial in development and in therapy. Emphasis on only one area (mind or body) may create or perpetuate a mind-body split in therapy
DANCE/MOVEMENT as it may nally.
have
occurred
THERAPY
in development
DANCE/MOVEMENT INTRODUCTION AND
OF EATING
origi-
THERAPY: PHILOSOPHY
Dance/movement therapy is a process that furthers the physical and psychic integration of As in verbal therapy, a individual. an dance/movement therapy model of regression back to a fixation point is not applicable for these eating disorder patients who are not viewed as repressing somatically or defensively armoring their bodies, for this implies the attainment of a certain developmental level. Conceptually our work most closely aligns itself with the psychoanalytic model described by Siegel (1984). Additionally it includes clinical and theoretical aspects of early infant development and self psychology adapted to a dance/ movement therapy model. We differ from her conceptualization, however. in two areas. First. we do not view the process as one of regression back to a fixation point (a top-down approach), for this implies the attainment of a certain developmental level. As we conceptualize it. it is one of a bottom-up approach that starts with missed and incomplete developmental experiences that begin at the very basic element of development and move progressively upward (Krueger & Schofield, 1985). There is a different conceptualization and, therefore, approach needed for someone stuck in an early developmental stage as opposed to someone who has psychic structure and has defensively regressed back to an earlier phase. Secondly, we differ with her inclusion of the elements of catharsis, insight, and working through, as they are aspects of conflict theory and therefore apply to more well-structured personalities. We see conflict emerge as an aspect of development only after addressing the earlier developmental issues. Our clinical work has shown that for eating disorder patients there is no “authentic” movement. Because of the missed early experience of accurate mirroring the children have not experienced any internally directed autonomous communication of feeling. Their bodies are not seen as vehicles for their own expression. but rather as mirrors for the feelings of others.
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PATIENTS
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The model we utilize in a developmentally informed sequence that focuses on the integration of mind and body fosters an integrated body and self image and leads to the evolution of the capacity to symbolize and play. The model also includes the use of projective drawings and videotape to directly address the early preverbal developmental arrest. It is closely integrated with verbal therapy to allow a cohesive and complete developmental sequence. Integrated therapy that is begun at this level of awareness of the body self allows resumption of growth processed in a much more profound and rapid manner. In addition, the patient’s desperate sense of helplessness and ineffectiveness is immediately addressed by beginning in this manner. The techniques and sequences we describe as designed to integrate the mind and body are especially needed in eating disorder patients, as this basic body awareness has never been completely established (Freud, 1923; Krueger & Schofield, 1984a). An approach that parallels a normal developmental sequence beginning in infancy starts with an internal focus of bodily sensations, feelings, and awareness. It is an attempt to assist the patient to define the original body self in a cohesive manner. Since the first awareness of self is the body self (Bauman, 1981; Freud, 1923), dance/movement therapy activates and dramatizes this awareness in a rapid and active manner. The sequences and techniques described foster progression through the developmental stages of an autistic-like state, to establish a symbiotic union with an accurate, adequately-mirroring self-object, through the separation-individuation subphases, and finally with an emergence into autonomy. DANCE/MOVEMENT THERAPY: TECHNIQUES
The beginning phase of dance/movement therapy utilizes relaxation techniques that include deep muscle relaxation, breathing exercises, guided imagery, and centering exercises. The intent is to create an exclusive focus on internal experience-focusing in, concentrating on internal sensations of tension and release. This therapeutic experience is analogous to a
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primary autistic stage concerned with the inner core of bodily experience and awareness that will become the basis for a body image. Focusing internally in this manner allows an opportunity to distinguish the most basic of internal sensations-those of the body. It is from this core awareness of body self that a sense of self is elaborated-the body self becomes the container of the emotional self. This internal focus fosters a beginning distinction between inside and outside and is an essential prerequisite of body ego formation (Mahler & Furer, 1966; Schilder, 1951). An important experience for patients during this beginning phase is a progressive recognition and distinction of a body “center.” In a very relaxed state patients are asked to focus internally to locate their “center,” the part of the body that feels and reacts first. When the patients have sensed this spot they are asked to visualize and experience it as the source of radiating The patients are then energy. encouraged to allow the radiating energy to evolve into some form of movement and consciously experience it as originating from within themselves and in their control. The acknowledgment and acceptance of a personal body center are vital to establishing an awareness of body self and of initiating a cohesive body image. These techniques address the basic developmental deficit of most eating disorder patients-the failure to establish a distinct body image. These techniques attempt to establish an internal center of reference. This center forms the core of the self, the center point around which a sense of identity will be established (Greenacre. 1958; Rose, 1966).
As patients become more aware of their bodies, the role of the therapist takes on added significance. Initially the therapist acts as a nonjudgmental, unobtrusive presence who facilitates the patients in experiencing themselves. As patients become more aware of their body selves the presence of the therapist serves to give recognition and validity to internal sensations. At this point the therapist-patient pair begin a phase of physical mirroring in which the therapist initiates a flowing continuous movement pattern that the patient follows. Both patient and thera-
SCHOFIELD pist are seated face to face with simple hand movements and the opening and closing of the arms and body, initiated by the therapist and followed by the patient. Observed, this looks like pantomime in front of a mirror. The seated position is less threatening than standing and is reminiscent of the early pre-ambulatory tie. During this phase the bodies come very close, but do not touch. This mirroring allows the opportunity to experience another close physical presence and experience movement that appears neither inwardly nor outwardly directed, but shared. In a sense, the patient is re-creating the experience of the original symbiotic organizer. As the patient becomes more and more comfortable following the therapist’s movements, the therapist switches roles with the patient and requests that the patient initiate the movement. This transition allows the center of initiative of movement to now reside in the patient. The therapist listens attentively to how this is experienced by the patient, as it frequently crystallizes initial separation anxiety, since the patient is no longer following but leading. Most patients describe the mirroring as a very relaxing, comfortable. and freeing experience. For some, however. the experience is initially very upsetting. even overwhelming, for reasons they cannot yet verbalize. The relaxation and centering exercises are continued as part of each session to allow the continuous experience of affirming an internal point of reference.
The next phase of treatment is similar to what Mahler (1958) described as the practicing subphase of separation-individuation. As patients begin to experience complete security during mirroring they then turn to face themselves in a real mirror, to move and mirror with themselves. This is the next step in an awareness of separateness and movement toward individuation. The patients are encouraged and supported by the presence of the therapist (analogous to Mahler’s “rapprochement” [ 1968]), but the patients move alone. This process of seeing. of leading. and of totally experiencing their own movement initiative is a major step in establishing the link between mind and body (Krueger & Schofield, 1984a).
DANCE/MOVEMENT
THERAPY
OF EATING
Slowly the patients experience and recognize their entire image in the mirror, and experience something similar to what Mahler (1958) describes as the “hatching” process. At this point the patients are ready to turn their attention to the external world with a cohesive internal point of reference. Throughout treatment, work with the mirror maintains an important role. This is done for several reasons. The mirror provides an immediate affirmation of body self unlike any other medium. The body is the visual component of the self and must be totally integrated. Greenacre (1960) states, “Vision is not only an adjunct but an indispensable one in establishing the confluence of the body surface and promoting awareness of delimitation of the self from nonself. Touching and taking in of the various body parts with the eyes (vision) helps in drawing the body together, into a central image beyond the level of mere immediate sensory awareness” (p. 208). In addition, the mirror encourages the conscious realization of the body as real and acceptable. So many eating disorder patients have confused feelings when viewing their image. As one thing. I hate patient stated, “It’s this love-hate the mirror but I know I can’t live without it.” Many anorexics who have spent so much energy on creating a body based on some external set of standards say, “I never knew I was allowed to like it.” Touching the body and attempting movement intervention can be contraindicated during specific developmental stages and with specific problems. With eating disorder patients in particular, the issue of control is extremely powerful. Any attempt to direct or dictate movement may be countered with strict resistance in an attempt to maintain control. Because of the powerful wish/fear of merger, touching is usually initiated, if at all, by the patients rather than the therapist, and only after an internal center becomes more familiar and boundaries less tenuous. Just as free upright locomotion is important in the emotional development of children, so too is it important in treatment. It provides an enormous increase in discovery and testing of the world from their own initiative. Walking upright for the first time creates body exhilaration and sensory responsiveness unlike any other devel-
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PATIENTS
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opmental step. Piaget (1936) parallels it with the beginning of representational intelligence. The patients can now allow memories and feelings to emerge first through movement, a new process, and then verbally. This integration is now with the newly established link between mind and body. The relationship with the dance/movement therapist has slowly changed during the course of treatment. The patient now acts as leader but the therapist must still be quietly available to witness and share. This is essential if the patient’s emerging autonomy is to attain optimal capacity. The centering exercise and use of the mirror are employed with decreasing frequency with the increasing autonomy and verbalization of the patient. The patient has a need at times for “refueling” and “rapprochement” but the emphasis is on enhancing independent movement. As the process continues the patient’s emerging individuality consolidates. The patient is experiencing his/her own autonomous self at a much higher level which now includes symbolic language and play. This is expressed in almost equal portions of words and movement. However, in the final phase, both dance/movement therapist and verbal therapist are working exclusively in the verbal modality to reinforce the newly attained level of development.
At the end of each session each patient is asked to express in a drawing what he/she experienced during the dance/movement session. This projective drawing is utilized as part of the treatment process for several reasons: It provides an immediate visual re-creating of the patient’s movement experience. This aids the patient in understanding what was felt by providing an additional expression of the original feeling. By translating the experience into a concrete, visual symbol it becomes objectified; symbolization and verbalization of the experience are furthered by this means. A potential space between the patient’s subjective and objective process occurs via this drawing. _. The projective drawing depicts current developmental issues with focus on body and self concept. 4. For both therapists a drawing serves as a transition vehicle from nonverbal to verbal therapy. In addi-
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tion it serves patient. 5. The drawing
as a link between
both therapists
AND and
becomes appropriate and objective criterion by which to measure changes.
At the time of the drawing, the patient works with the dance/mov~ment therapist in understanding the process of the projective drawingthe creative urge, the sequence, and process; the use of space, colors, and shapes vis-8-vis body image and psychic experience. The verbal therapist microscopically examines the drawing with the patient in terms of the overall developmental issues being negotiated. The drawing is also integrated with other material and scrutinized microscopically to understand symbols, associations to meanings, and the conscious and unconscious processes.
Videotape feedback has become an important tool in our work and will also be summarized briefly. It provides an additional way for patients to experience themselves objectively. Even in a mirror, we can look at only one part of ourselves. Patients may be too involved in the present action to view themselves objectively. The video allows a direct view of one’s entire body as expressed and in movement. It is also an aid in establishing an accurate body image. The videotape viewing has a profound and dramatic impact on the emaciated anorexic or the obese compulsive eater. It provides a direct, objective confrontation to their denial, an irrefutable view of one’s body. A frequent response of the patient with knew I really anorexia nervosa is. “I never looked that bad.” These are the words of an emaciated anorexic on seeing herself on video for the first time: “I became aware of what 1 was doing to myself, and it wasn’t what I wanted. It’s like it’s not me. Rut that’s my whole self there. Even in a fui~-length mirror I focus only on one spot. I’ve never been able to get completely on the outside of myself until seeing this video of me. I’ve always felt I was some enormous person.” An additional and important part of treatment has become the process of viewing the videotape with both therapists and patient together. A dis-
SCHOFIELD cussion can occur with all three that further integrates the verbal and nonverbal therapies. Additionally, it enhances the progression of the developmental frame of reference from dyadic to triadic relatedness. CONCLUSIONS The eating disorders of anorexia nervosa and bulimia can be conceived as disorders of the sense of self, with the origin appearing initially at the developmental level of the mirroring phase. With this arrested development. an entire developmental experience in treatment offers the most thorough and definitive possibility for persons in this category. Techniques addressing the nuclear primitive and preverbal-level issues can be integrated with higher-level verbal and symbolic functions and experience to provide a comprehensive and cohesive development of sense of self.
DANCE/MOVEMENT
THERAPY
LICHTENBERG, J. (1984) Empathy I and II. New York: The Analytic Press. MAHLER, M. (1958) On two crucial phases of integration of the sense of identity: Separation-individuation and bisexual identity. J. Amer. Psychorrnul. Assoc~. 6: 136-139. MAHLER, M. & FURER, M. (1966) Development of symbiosis, symbiotic psychosis and the nature of separation anxiety: Remarks on J. Weiland’s paper. Inr. J. Ps.vchoAnrrl. 47: 559-560. MAHLER, M. (1968) On humun symbiosis und the vicissitudcs of’individuution. Vol. I. Infirnfilr Psvchosis. New York: International Universities Press. PIAGET, J. (1936) Thr Origins ofIntelligrnce in Children. Paris: Delachaux and Niestle. RIZZUTO, A., PETERSON, M. & REED, M. (1981) The pathological sense of self in anorexia nervosa. Psychirrt. Clin. N. Amer. 4: 471-487. ROSE, G. (1964) Creative imagination in terms ofego “core” and boundaries. Int. J. Psycho-Antrl. 45: 75-84.
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ROSE, G. (1966) Body ego and reality. Inr. J. Psycho-Arm/. 47: 502-509. SCHILDER, P. (1951) The Image und Appeuruncr of the Humun Body: Studies in the Consfrucfive Energies ofthe Ps_vche. New York: International Universities Press. SCHWABER, E. (1981) Empathy: A mode of analytic listening. Psychoanal. Iny. 1: 357-392. SIEGEL, E. (1984) Dance-Movement Therapy-Mirror of Our S~lws: Psychoanalvtic Appr0ac.h. New York: Human Sciences-Press. SWIFT. W. & LETVEN, R. (1984) Bulimia and the basic fault: A psychoanalytic interpretation of the bingingvomiting syndrome. J. Amer. Acod. Child. Psychiut. 23: 489-497. WINNICOTT, D. (1971) Pkt.ving and Recr1it.v. New York: Basic Books.