Dance/movement Therapy And Bulimia Nervosa

REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA by Ariele L. Riboh

© 2009 Ariele L. Riboh

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science (Dance/Movement Therapy) School of Art and Design Pratt Institute October 2009 


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REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA by Ariele L. Riboh

Received and approved: ______________________________________ Date _____________________ Thesis advisor -Valerie Hubbs, MS, ADTR, NCC, CGP, LCAT, LMHC ______________________________________ Chairperson—Jean Davis, MPS, ATR-BC, LCAT

Date _____________________

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TABLE OF CONTENTS LIST OF TABLES………………………………………………………………………...v ABSTRACT……………………………………………………………………………...vi Chapter 1. Introduction………………………………………………………………………..1 History of Eating Disorders Defining Eating Disorders Medical Etiology Psychological Etiology The Mother-Infant Relationship Mismatches and Impingements Trauma Role of the Media and Body Care Industry Dance/Movement Therapy Treatments 2. Methodology……………………………………………………………………..32 Rationale Apparatus Participants Procedure Data Collection and Analysis 3. Results……………………………………………………………………………37 DMT Theoretical Practices Treatment Themes and Goals Movement Characteristics Movement Interventions Transference and Countertransference Therapist’s Self-Care

Repairing the Broken Mirror iv 4. Discussion………………………………………………………………………..48 Findings Literature review Questionnaire Significant Findings and Recommendations Need for collaboration Need for Further Clarification and Exploration Validity and reliability Conception of movement patterns Utilization of specific interventions Monitoring DMT effectiveness Therapist self-care Study Limitations REFERENCES………………………………………………………………………56 Appendixes…………………………………………………………………………..61 Manual…………………………………………………………………………...pocket





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List of Tables Table E1. Answers to Questionnaire Concerning DMT Experience of Participants.

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Abstract Today eating disorders, in particular bulimia nervosa, are rising at an alarming rate despite the current available treatments. Due to the somatic nature of this illness, dance/movement therapy appears to be an appropriate and perhaps more relevant therapeutic modality. In order to investigate this, a case study examining the work of four dance/movement therapists working with women suffering from bulimia nervosa (BN) was conducted. Factors examined included: themes emerging for patients in treatment; movement characteristics; specific movement interventions; the therapist’s use of transference and countertransference, and the self-care methods used by dance/movement therapists. It seems that there are commonalities among women suffering from BN, such as issues surrounding self-esteem and a sense of self. There also appears to be themes that emerge in treatment that are characteristic of this population, such as shame and control. Despite similar characteristics in certain areas, there was significant disagreement when it came to the actual practice of dance/movement therapy (DMT).

Repairing the Broken Mirror 1

Repairing the Broken Mirror: A Theoretical Dance Movement Therapy Manual for the Treatment of Women with Bulimia. Today, the incidence of eating disorders is reaching concerning levels. According to the National Institute of Mental Health (as cited in Eggers & Liebers, 2007), “0.5 to 3.7 percent of women develop anorexia nervosa and some 1.1 to 4.2 percent experience bulimia nervosa (BN) in their life time” (p. 2). In addition to these troubling percentages it appears that, despite treatment efforts, the prevalence of eating disorders continues to increase in our Western society. According to the National Eating Disorder Association (2006), the incidence of bulimia in the USA has tripled for women ages 10-39 between 1988 and 1993. Many approaches have been used for the treatment of people with eating disorders, including psychodynamic, action-oriented, cognitive-behavioral, interpersonal, self-psychology, structural family therapy, developmental, feminist, pharmacological, group and individual therapy, and short- and long-term therapy (Krantz, 1999, p. 83). Studies with promising results have been conducted on the short-term effectiveness of cognitive behavioral therapy and on interpersonal therapy. Yet, there are few studies that show efficacy in the long-term treatment of this population. Although many modes of treatment for eating disorders are currently in place, the recovery rates are relatively low among patients receiving treatment with approximately 30% of full recovery for people with anorexia and 50% for people with bulimia nervosa. In an effort to contribute towards a more holistic and effective treatment of bulimia nervosa in women, the current

Repairing the Broken Mirror 2 study aims towards the compilation of a pilot treatment manual presenting dance/movement therapy (DMT) as primary modality for the treatment of women with BN. History of Eating Disorders Eating disorders are not new phenomena, and have been documented within psychiatric literature since the 17th century. At that time, they were known as a nervous disease or hysteria (Maine, 2009, p. 6). Different hypotheses regarding BN etiology have since been explored. Freud originally attributed eating disorders to “neurotic conflicts about sexuality” (Maine, 2009, p. 7) he viewed these conflicts as involving “oral incorporative mechanisms and oedipal genital wishes” (Schneider, 1995, ¶ 4). Schneider (1995) suggests that Freud attributed the purging involved in bulimia nervosa to the following: . . . [an underlying] oral sadistic, cannibalistic, sexual fantasy. This fantasy was that, from the young, eating-disordered girl’s point of view, she could eat the father’s penis and be impregnated with his baby (Freud, 1905/1953). Psychogenic vomiting was the girl’s neurotic, hysterical symptom resulting from this unconscious sexual conflict and subsequent compromise formation. (¶ 4) In the 1960s, behavioral treatment emerged as the popular choice of treatment. Today, according to Vanderlinden (2008), cognitive behavioral therapy (CBT) remains the treatment of choice and is highly recommended by most “evidence-based treatment guidelines” (p. 329). As Vanderlinden explains, the CBT approach suggests that a “dysfunctional scheme of evaluation” (p. 329) is central to the maintenance of eating disorders. This signifies that most people suffering from eating disorders present

Repairing the Broken Mirror 3 unrealistic beliefs about their bodies and weight. CBT treatment is thus believed to target these dysfunctional beliefs directly. It was not until Hilde Bruch’s assessment of eating disorders in the 1970s, that their origins were viewed as both biological and psychological. Bruch (as cited in Schneider, 1995), in opposition with Freud, attributed eating disorders to issues that arose during the separation-individuation process. She believed that eating disorders were an unconscious struggle between the wish to be separate and the wish to remain one with the mother figure. Anorexia nervosa was the first identified eating disorder and the mental illness now known as bulimia nervosa was initially seen as a subset of anorexia. In 1976, Boskind-Lodahl identified a disorder known as bulimarexia, but it was not until 1979 with Russell that bulimia nervosa was named and differentiated as a separate disorder (Maine, 2009, p. 7). Many studies have continued to explore the causes of eating disorders linking their origin to primary biological abnormalities, gastrointestinal problems, disruptions of various cerebral components, an inability to negotiate critical developmental stages, cultural and societal influences, and several other causes. A number of studies have investigated the etiology of these disorders, yet there is much discordance in the findings and a notable lack in longitudinal studies. Waller and Sheffield (2008) claimed that studies have had “a tendency to investigate factors in isolation . . . [and that they] focus on diagnostically pure groups which fail to reflect [real life] clinical populations” (p. 152). A significant amount of research has been done to investigate the phenomenology of eating disorders and many plausible hypotheses have been put forward. However, none have lead to significant scientific data serving to either

Repairing the Broken Mirror 4 confirm or deny the etiology of eating disorders. In a recent report, the U.S. Department of Health and Human Services (as cited in Maine, Davis, & Shure, 2009) “lamented the lack of reliable, clinically relevant empirical findings and emphasized the importance of more qualitative studies to broaden the base of available treatment information and expertise” (p. i). It is thus necessary to further understand the lack of reliability of current studies and explore alternative options for the effective treatment of eating disorders. Many risk factors are thought to be associated with this mental illness, including genetics, family experiences, traumatic experiences, as well as a host of other factors that can be attributed to environmental and socio-cultural influences. However, specific responsible factors have yet to be determined. According to Krantz (1999), “Eating disorders refer to disturbances of eating behaviors and body-image distortions with underlying psychodynamic, cultural, and gender conflicts” (p. 82). It is essential to identify a clear definition of eating disorders in order to understand the implications of their complex etiologies and their effects on treatment options. Defining Eating Disorders According to Davis (2009), eating disorders are primarily psychological disorders as, “food and eating are symbolized or given meaning beyond ordinary nourishment and consumption and because, as food and eating is symbolized, a variety of medical, psychological and social problems are created” (p. 36). Anorexia nervosa is primarily characterized by the refusal to eat and by a low body weight accompanied by significant body-distortion. The main symptoms of BN are recurrent episodes of binging and

Repairing the Broken Mirror 5 purging by self-induced vomiting, abuse of laxatives, and vigorous exercise (Krantz, 1999, p. 82). According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (2000) text revision, eating disorders are “severe disturbances in eating behaviors” (p. 583), and anorexia nervosa is defined as “a refusal to maintain a minimally normal body weight” (p. 583). Anorexia is divided into two subtypes: restrictive and binge-eating/purging type. The anorexic person is said to fear the thought of gaining weight or becoming fat and is subject to significant body image distortion (p. 583). This fear is not alleviated by weight loss and one often utilizes drastic measures such as minimal caloric intake, frequent mirror checking, and repetitive weighins in an attempt to alleviate subsequent anxieties. This weight loss is often dramatic and represents a health hazard that can lead to death. Weight loss appears to give the person with anorexia a sense of self-control and any weight gain is seen as a dramatic failure (p. 584). Several physical side effects, such as amenorrhea and the growth of lanugo, a form of peach-like hair all over the body, are present as diagnostic features. There are also psychological symptoms that accompany this illness which are thought to be a result of starvation. Such symptoms may be expressed as “depressed mood, social withdrawal, irritability, insomnia and diminished interest in sex” (DSM-IV-TR, 2000, p. 585). Obsessive-compulsive features, such as “preoccupied thoughts of food” (p. 585) and rigid thinking, have also been identified as symptoms. According to the DSM-IV-TR (2000) text revision, bulimia nervosa is defined as, “repeated episodes of binge eating followed by inappropriate compensatory behaviors” (p. 583). A binge is defined as, “eating in a discrete period of time an amount of food that

Repairing the Broken Mirror 6 is definitely larger than most individuals would eat under similar conditions” (p. 589). Bulimia nervosa is also divided into purging and non-purging types. However, the two are very similar in their psychological development and symptomology. Binging behavior is characteristically done in secrecy and is associated with intense feelings of shame and guilt. The DSM-IV-TR (2000) text revision states that binging is “typically triggered by dysphoric mood states, interpersonal stressors, intense hunger following dietary restraint, or feelings related to body weight, body shape and food” (p. 590). This behavior is utilized as a means of self-regulation and provides temporary relief for the person. It is thought that often during these phases of binge and purge the person enters into a dissociative state that is subsequently felt as an utter loss of control. In order to compensate for this loss of control, many engage in compensatory behaviors known as purging. The most common means of purging is by self-induced vomiting. Some 80% to 90 % of people with bulimia adopt this method of purging. Other disordered behaviors are also used to compensate for binging behavior and to prevent weight gain. Such behaviors include abuse of laxatives and diuretics, excessive exercise, fasting between binges, and so forth. Associated with this symptomology, people suffering from bulimia nervosa often suffer from depressed mood states and present symptoms fulfilling the criteria for mood disorders, anxiety disorders, and personality disorders. The DSM-IV-TR (2000) text revision also offers a definition for eating disorder Not Otherwise Specified (NOS) among this diagnostic category. This category is utilized for diagnosing all other eating disordered behaviors that do not fall under the criteria for either anorexia or bulimia. Further diagnostic criteria and a detailed description of this category can be found in the DSM-IV-TR (2000) text revision (p. 592), or in the desk

Repairing the Broken Mirror 7 reference to the DSM-IV-TR (2000) text revision (p. 265). Considering the complexity and expansiveness of each separate diagnosis, it is beyond the scope of this study to examine each diagnostic category in depth. The current study will focus solely on the diagnosis of bulimia nervosa. Also, due to the overwhelming 90% incidence of this eating disorder among women (Maine et al., 2009, p. xxii), the current study will solely focus on the female population. Now that a preliminary understanding of the symptomology of this disorder has been presented, it is important to present the origins of this illness in order to better serve potential BN patients. Medical Etiology Eating disorders are complex disorders that affect individuals not only mentally, but also physically. According to Kaye (2008), eating disorders are currently of unknown etiology; however, there is “growing acknowledgement that neurobiological vulnerabilities make a substantial contribution to the pathogenesis of anorexia nervosa and bulimia nervosa” (p. 121). These findings are not yet fully understood and more studies are needed to further clarify the matter. Some researchers have attributed neurological disturbances associated with eating disorders to neuropeptide dysregulation. Neuropeptides are molecules involved in message transmission by neurons in the brain/body communication process. Hence, neuropeptide dysregulation can directly affect brain activity and body physiology (Kaye, 2008). For example, essential hormonal activity, such as gonadal, thyroid, and so forth could be affected. However, it appears that the disturbance of neuropeptides might be in itself the result of the eating disorder. Kaye has noted that there are various hypotheses investigating the roles of monoamine neurons,

Repairing the Broken Mirror 8 tying abnormal levels of serotonin (5-HT), an essential neurotransmitter, to “appetite dysregulation, anxious and obsessional behaviors and extremes of impulse control” (p. 124). This disturbance of serotonin level appears in parallel to the disorder and seems to persist after recovery. Twin studies on eating disorders have also been conducted and results suggest that there is possibly a biological nature to these disorders. According to Kaye (2008): There is approximately a 50 to 80% genetic contribution to liability accounted for by additive genetic factors. These heritability estimates are similar to those found in schizophrenia and bipolar disorder, suggesting that anorexia nervosa and bulimia nervosa may be as influenced as disorders traditionally viewed as biological in nature. (p. 122) Also, with the advance of technology, recent research using brain-imaging techniques, such as computerized tomography (CT) and magnetic resonance imaging (MRI), has contributed to the emergence of new hypotheses about brain abnormalities in individuals with eating disorders (Kaye, 2008). Although sample sizes and the number of studies are limited, “differences in ill and recovered eating disordered individuals in frontal, cingulated, temporal, and/or parietal regions compared to controls” have been observed (Kaye, 2008, p. 125). Brain imaging studies have also shown elements such as atrophied areas, enlarged ventricles, deficits in both grey and white matter, and decreased cortical mass for individuals suffering from eating disorders (Kaye, 2008). Some of these elements appear to normalize themselves with recovery from eating disorders, but again these findings remain in their preliminary stages because of the lack of longitudinal studies.

Repairing the Broken Mirror 9 Psychological Etiology Having explored various medical hypotheses, it is important to explore other models and schools of thought to fully understand the many components of this illness. The following is an examination of the symptomology for bulimia established by the Psychodynamic Diagnostic Manual (PDM) (2006). According to the PDM (2006), depression, social isolation, low self-esteem, anxiety, and loss of libido appear to be some of the predominant issues that arise for these patients. Panoply of symptoms, feelings, and affective states can be linked to bulimia nervosa. Common feelings that can accompany these affective states are “feelings of being starved for care and affection” (PDM Task Force, 2006, p. 120), feelings of failure, shame, anger, aggression, and loss of control. The PDM (2006) advances the hypothesis that these emotions and affective states emerge from cognitive patterns that have been established in the individual’s childhood. Psychodynamic theoreticians also hypothesize that many of these affective states and associated feelings and emotions emerge not only psychologically, but also somatically. These somatic states seem to be frequently expressed as feelings of numbness and of disconnection from or confusion about the body. Another area that appears to be problematic for this population is that of relational patterns. Social isolation and difficulty forming relationships are typically present. The PDM indicates that among these patterns, issues around control, perfectionism, and secrecy emerge significantly. Indeed, the PDM advances relevant hypotheses as to the etiology of bulimia and illustrates some of the main characteristics of this population. These are essential elements for the current study,

Repairing the Broken Mirror 10 as they will aid in better understanding individuals suffering from eating disorders, hence allowing for more comprehensive and adaptive treatment plans. The Mother-Infant Relationship From psychodynamic, self-psychology, and object relations perspectives, the origins of eating disorders can be traced back to infancy. These approaches emphasize the importance of the mother-infant relationship for the future psychological development of the infant. From birth, an infant begins to learn about the world through the eyes and body of the mother/caregiver. It is through this attachment that an interpersonal relationship is formed between mother and infant and allows for the “immature brain [to] use the mature functions of the parent’s brain to organize its own processes” (Siegel, 1999, p. 67). Through these processes, the child begins to learn modulation of positive and negative feelings, forming the basis for the capacity to self-regulate. It is through the formation of an adequate attachment between a mother and her infant that the infant is able to establish and feel a sense of internal safety and emotional security which is “a reflection of confidence in the availability of attachment figures”, which lead to a secure attachment (Mitchell & Black, 1995, p. 136). The opposite is known as an insecure attachment, which “may serve as a significant risk factor in the development of psychopathology” (Mitchell & Black, 1995, p. 68). It is also through the mother-infant relationship that the elements of merging and differentiation come into play. Merging occurs when the infant and the mother’s internal rhythms are synched and in tune with one another. Merging allows for the occurrence of symbiosis and attunement, two essential elements in the creation of a secure attachment. “Attunement involves the alignment of states of mind in moments of engagement during

Repairing the Broken Mirror 11 which affect is communicated with facial expression, vocalizations, body gestures, and eye contact” (Siegel, 1999, p. 88). Through differentiation, which naturally results from merging, the infant is able to develop a sense of identification, leading to the future development of the self. Consequently, the self is developed “through the ongoing process of identification with (or . . . merging) and differentiation between internalized images of one’s own self and those of external objects-real objects or persons” (Pallaro, 1996, p. 113). This pattern of merging and differentiating, once internalized, will be the basis of engagement for future relationships. The role of the mother-infant relationship is also essential in the physical and neurological development of the infant. These relationships are crucial in organizing not only ongoing experience, but the neuronal growth of the developing brain. In other words, these salient emotional relationships have a direct effect on the development of the domains of mental functioning that serve as our conceptual anchor points: memory, narrative, emotion, representations, and states of mind. In this way, attachment relationships may serve to create the central foundation from which the mind develops. (Siegel, 1999. p. 68) The subjective experience of the infant as lived through the body is also of utmost importance, as it is “the crucial and principal organizer of object representations in infancy” (Pallaro, 1996, p. 114). Indeed, the infant begins with the identification of the self as subject and it is through interaction with the parents and the family of origin that the infant begins to develop a sense of self as an individualistic entity.

Repairing the Broken Mirror 12 As important as the mother/caregiver is for the psychological development of the infant, one must not forget the importance of touch and physical contact between the mother and the infant. Renee Spitz (as cited in Mitchell & Black, 1995), one of the first to explore the significance of touch, studied children in orphanages whose basic needs were met, but who were deprived of nurturance. He found that, after 3 months in these conditions, the infants demonstrated reduced eye contact and appeared withdrawn and depressed. By age 2, some had died and others were considered to be nonfunctional. Referring to what he found as failure to thrive, Spitz explained that this phenomenon was due to the lack of touch and adequate nurturance. Harry Harlow further explored the importance of touch through experiments with baby rhesus monkeys that were separated from their mothers. In Harlow’s experiment, the monkeys were provided two surrogate mothers, one that was a wire doll with a bottle for feeding and one that was covered in a soft material and was heated. The babies fed from the wire doll but immediately went to the cloth doll for nurturance (Orbach, 2009, p. 47-8). Through this study, “[Harlow] demonstrated that a sense of touch and warmth were crucial for bonding” (Orbach, 2009, p. 47). These studies have been essential for understanding where elements of trauma and impingement can occur in infancy. These may help formulate tailored interventions, which can compensate for and help overcome deficiencies that potentially contribute to eating disordered symptomatology. It is also through the repeated and consistent contact with the mother’s body and through the awareness of its own bodily sensations that the “infant develops its own boundaries, as delimiting and containing a personal sense of self” (Pallaro, 1996, p. 114). According to Orbach (2009):

Repairing the Broken Mirror 13 Every aspect of our body sense embodies something about our mother’s own physicality. If she is awkward and physically reticent, we pick that up. If she is bold or intrusive, our personal body sense will accommodate that in some form. If she fails to touch us in a firm yet gentle manner, we may become confused or fearful about our bodily sensations. We might not know where our body begins and where it ends. (Orbach, 2009, p. 50) It can therefore be postulated that the skin represents the body’s boundary for the self. It is consequently this physical boundary that allows for differentiation between internal and external. This knowledge is of great importance, as women with bulimia nervosa often struggle with elements of self-differentiation. Mismatches and Impingement Having explored the different ways in which the role of the mother-infant relationship affects infant development, it seems clear that this critical relationship affects not only the immediate experience of the infant and the satisfaction of his or her most primitive needs, but that it also serves in the normal development of the self and of body boundaries. Consequently these elements lay the groundwork for future relational patterns, which fall into the different attachment categories established by Ainsworth. These relational patterns consist of secure, anxious/avoidant, anxious/resistant (Tracy & Ainsworth, 1981, p. 1341) or secure, avoidant, ambivalent and disorganized/disoriented (Mitchell & Black, 1995). Ainsworth’s strange situation was a test done to investigate the different types of mother-infant attachments. This study was conducted in a controlled setting consisting of a playroom with a one-way mirror from which the researchers observed. The actual study consisted of observing the interactions of a mother and her

Repairing the Broken Mirror 14 infant and the reactions of the child following the introduction of a stranger with and without the mother present. A securely attached child is reportedly able to explore and engage with strangers while the mother is present. However he/she will become distressed upon the mother’s departure and will cease to engage with the stranger. The infant is soothed and reassured upon the return of the mother. The anxious/avoidant either avoids or ignores the mother and shows little emotion upon the departure or return of the mother. Engagement with the stranger is similar to with the mother. Anxious/ambivalent behavior is characterized by the infant demonstrating a significant amount of anxiety around strangers even with the mother present. Upon departure of the mother, the child is extremely distressed and when she returns the infant demonstrates mixed emotions, where he/she might seek proximity but at the same time might attempt to hit or push the mother. The last category, disorganized/disoriented, was an addition to Ainsworth’s work. In this case the child becomes distress when the mother departs but avoids and ignores her upon her return. The child might also demonstrate odd behaviors such as freezing or falling to the floor upon the mother’s return (Wikipedia online encyclopedia). As seen above, the mother-infant relationship can be a subtle and quite intricate one, and even when a mother is striving to be what Winnicott termed, the good enough mother, “mismatches” (Stern, 1977, p. 140) can occur. These mismatches occur when there are regulatory failures due to overstimulation, understimulation, or paradoxical stimulation. Overstimulation is often the result of a caregiver who is controlling and intrusive, which in turn interferes with the infant’s ability to self-regulate. As a result of these

Repairing the Broken Mirror 15 behaviors, the infant “may then be forced to develop more extreme regulating or terminating behaviors” (Stern, 1977, p. 140). This overstimulation by the caretaker also sends the message to the infant that he or she cannot regulate his or her external world or internal experiences through emotional communications. If this behavior of overstimulation is chronic, the infant will progressively display inhibited motor expression and affective facial expressions. If a mother is depressed, schizophrenic, inhibited due to character pathology or has a limited repertoire of social behaviors, under-stimulation of the infant can occur. Further, if the infant “is hypoactive or has a significant developmental lag or minimal brain damage, then a normally effective amount of stimulation may not move him up to or keep him within the optimal range” (Stern, 1977, p. 148) and under-stimulation may be the result. Mothers who respond appropriately to their infants only in the case of danger or distress are examples of paradoxical stimulation. These caregivers are often referred to as neglectful or abusive. Indeed, such caregivers only become animated when the infant who has a “‘repertoire’ of common self-hurtful or discomforting mishaps [displays these behaviors]. . . . Many of these mishaps are funny in the way that slapstick is funny, and most caregivers may laugh (if there is no real injury)” (Stern, 1977, p. 149). However the paradigm that is learned by the infant in these instances is that of masochism, or “pain as the condition for pleasure” (Stern, 1977, p. 150). Another form of paradoxical stimulation is that of the “mutual approach-withdrawal dance” (Stern, 1977, p. 150). This form of stimulation can lead to difficulties during the negotiation of separation-individuation.

Repairing the Broken Mirror 16 These types of interactions with the mother form the basis for later relational patterns of the infant. If, indeed, these are troublesome and inadequate, they can lead to difficulties in social interactions and relationships, which appear to be characteristic of many women with bulimia. Separation-individuation is a model of infant development established by Margaret Mahler (Mitchell & Black, 1995, p. 43). This model reinstates the role of the caregiver as capital for the future psychological development of the child. The process of separation-individuation is divided into three sub-phases. The first is hatching, which takes place from 0 to 9 months. During this phase, the infant demonstrates “increased alertness” (Mitchell & Black, 1995, p. 46), a more outwardly directed gaze that is used to check back with the mother/caregiver as a point of reference. Following this, is the subphase of practicing, where the toddler is “infused with a sense of omnipotence: despite actual moving away from his mother, he experiences himself, physically, as still one with her, sharing in her perceived omnipotence” (Mitchell & Black, 1995, p. 47). Finally, from 15 to 24 months, the child reaches the sub-phase of rapprochement in which the child undergoes “physic disequilibrium” (Mitchell & Black, 1995, p. 47). This disequilibrium is experienced as the realization of the physical and mental separation that begins to occur. The once fearless toddler begins to lose his or her previous sense of omnipotence and fear begins to settle in. The constant desire for proximity with the mother reappears. During development, all of these sub-phases are essential as they contribute to the development of the child’s ego and ability to self-regulate. Newton (2005), further notes that if the mother/caregiver is not emotionally and physically available, the infant is susceptible to ego deficiencies and disturbances. These deficiencies and disturbances can

Repairing the Broken Mirror 17 lead to poor ego strength, which can manifest itself in many forms, such as poor coping mechanisms including difficulty coping with stress. These appear to be issues encountered in the bulimic population. Newton postulated that: If this was not experienced psychological ego development may become vulnerable to self-pathology, with disturbances in internal and external object representations corresponding to sub-phases in separation and individuation. Pine (1979) articulates two adult self-pathological manifestations. A “lower order” disturbance is marked by an uncertain self and other boundaries, leading to a loss of self. A “higher order” disturbance is distinguished by an inability to tolerate aloneness, by attempts to reestablish coercive omnipotent control over external objects, and by object constancy deficits. (p. 173) As a result of these mismatches, impingements, and lack of consistent nurturance, the infant can develop a sense that there is something “not quite right” (Orbach, 2009, p. 81) with him or her. In consequence to this feeling of inadequacy, the infant develops a misconstrued sense of self. Orbach saw this as the grounds for the development of a false self. There are numerous ways in which the mother/caregiver and the infant develop a relationship. Ultimately, one hopes that a caregiver will be able to encompass the qualities of Winnicott’s concept of good enough mother, which provides optimal levels of frustration tolerance and nurturance, and which avoids impingement (Mitchell & Black, 1995, p. 129). Impingement occurs when the mother fails the child by “allowing external stimulation to reach painful levels, by intruding into the base state of drifting quiescence, or by allowing the child’s internal needs to build to frustrating levels”

Repairing the Broken Mirror 18 (Mitchell & Black, 1995, p. 209). In other words, impingement can be understood as the failure of the mother “to protect the delicate state necessary for psychological growth and health” (Mitchell & Black, 1995, p. 209). Unfortunately, there are many interactions possibilities that can lead to what Beattie (1988) described as: [a] child with an ego structure inadequate to the tasks of autonomy and selfregulation, with little capacity to monitor inner bodily states such as hunger and satiety, and with a resulting tendency to act out conflicts over independence and self-control via excessive control of the body and its food intake. (p. 453) This reinforces the idea that to develop a healthy ego and a sense of self, the infant must be raised in an adequate environment that stimulates normal development. According to Mahler (as cited in Mitchell & Black, 1995), mental illness is the direct result of a basic failure of an individual to form a self (p. 41). This failure can be understood as the non-negotiation of the process of separation-individuation or, more specifically, the non-negotiation of any given sub-phase of the separation-individuation process. It is hence fair to hypothesize that eating disorders could possibly emerge from impingement, poor development of frustration tolerance, inadequate nurturance, or any combination thereof. Trauma Another unfortunate factor that can lead to impingement is trauma, resulting from physical, verbal, and/or sexual abuse. According to Wonderlich, Brewerton, Jocic, Dansky, and Abbott (1997), childhood sexual abuse (CSA) is a significant risk factor for the development of bulimia (p. 1107). Many studies have evaluated the effects of abuse

Repairing the Broken Mirror 19 and its correlation to eating disorders. However, some general inconsistencies are apparent and it is not clear how exactly childhood abuse “affects the basic symptom of eating disorders” (Truer et al., 2005, p. 108). Yet, most of the literature agrees that there is a positive correlation between abuse and bulimia. Leonard et al. (as cited in Brewerton, 2007) conducted a study in which “women with bulimia nervosa reported higher levels of CSA, childhood physical abuse, and combined childhood sexual/ physical abuse compared to the non-eating-disordered women” (p. 289). In summary, genetic predispositions, neurological disturbances, troubles in the mother-infant relationship and trauma need to be taken into account for the development of therapy guidelines and dance/movement interventions. In addition to these personal variables, one needs to acknowledge and understand the influence of external factors such as the media, and the body-care industry on the development and maintenance of eating disorders. Role of the Media and Body care industry In today’s consumption driven society where instantaneous satisfaction, easy accessibility to products, competition, permissiveness, women’s stress and forced ideals dominate, a pervasive marketing emphasis is placed on the body as a commodity. Daily or even hourly, one is solicited by advertisements, magazines, media events and product or service offers portraying standards and ways to make our bodies fit into the societal ideals. “The sense that biology need no longer be destiny is gaining ground, and so it follows that where there is a (perceived) body problem, a body solution can be found” (Orbach, 2009, p. 2). Today, beauty no longer appears to be equated with individuality and variety, but with set standards established by the media and body-care industry.

Repairing the Broken Mirror 20 One’s weight and shape now determines one’s place in society. Beauty and thinness are associated with power and acceptability. As highlighted by Orbach, “The right body is trumpeted as a way of belonging in our world today . . . while failing to get one’s food and size right can signify shame, failure or a rejection of the values we are presumed to aspire to” (pp. 3, 13). Consciously or unconsciously the media and body-care industry induce women to think that they are not good enough if they do not fit within societal norms of the “thinideal” (Grabe, Hyde, & Ward, 2008, p. 461). The images and messages with which we are regularly bombarded create a sense of shame, and when women fall short, it results “in a sense of inadequacy” (Shure & Weinstock, as cited in Maine et al., 2009, p. 165). As a result, women are put in a position where their bodies are the battlefields and they are shamed for wanting to eat (p. 165). Acceptance and worth become associated with repression of needs, and deprivation has become common lieu. According to Grabe et al. (2008), 50% of undergraduate women report being dissatisfied with their bodies, which is of particular interest, as “research from prospective and longitudinal designs has identified body dissatisfaction as one of the most consistent and robust risk factors for eating disorders such as bulimia” (p. 460). Much research has been conducted examining the correlation between body-image dissatisfaction, eating disorder symptomology and the influence of the media. According to Grabe et al., laboratory experiments have been conducted with random samples of women assigned to view thin-ideal and non-thin-ideal media stimulus. Following exposure, levels of body dissatisfaction were measured. An overwhelming percentage of women exposed to thin ideal stimulus reported an increase in body-image dissatisfaction

Repairing the Broken Mirror 21 (p. 461). One may however question these findings and the reliability of these studies as a large percentage of women are regularly exposed to thin-ideal media, yet, only a fraction report being dissatisfied with their body image, and an even slimmer fraction develop an eating disorder. One may hence question the role of the media as either causal or supportive. In summary, it is apparent that eating disorders, among which BN, are complex illnesses associated with a genetic predisposition, external factors such as environment, the mother-infant relationship, trauma, family dynamics, media, and so forth. These variables can enable and exacerbate eating disorders. Also, it appears that despite the availability of current psychiatric, physiological, and behavioral modes of treatment, the incidence of bulimia continues to rise. Accordingly, dance/movement therapy appears to be equipped to contribute innovative treatments dealing uniquely with body awareness, self-expression as well as body-mind integration through a more targeted method of treatment. Dance Movement Therapy Treatments As with any discipline, DMT has evolved since its conception in the 1960’s with Marian Chace. Although most therapists base their practices on widely acknowledged concepts and principles that are central to DMT, there is quite a panoply of approaches that can be used for the treatment of women with BN. To fully understand the application potential of these options, their review is warranted. Krueger, a psychiatrist, and Schofield, a dance/movement therapist, have been working with eating disordered populations for over 20 years. Informed by developmental theories, they have assumed a “deficit model” (Krueger & Schofield,

Repairing the Broken Mirror 22 1986, p. 325), which hypothesizes that individuals suffering from an eating disorder have a developmental deficit resulting from an impingement or a frustration, which arose during critical developmental stages. Stagnation, in Krueger and Schofield’s experience, appears to have occurred in the following areas: “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” (p. 326). This model also hypothesizes that the mother has failed to acknowledge and confirm a separate body self for the child, thus leading to a distorted body image and body self. Building on these hypotheses, Krueger and Schofield (1986) have developed a therapeutic model targeting these specific variables to ensure a comprehensive treatment plan. They state that, “a combination of verbal and nonverbal techniques is as imperative as the integration of body self and psychological self” (p. 325). According to Krueger and Schofield, this treatment model relies on the collaboration between a psychiatrist and a dance/movement therapist to synthesize “mind and body in a cohesive manner” (p. 326). This model has been used both in the context of an inpatient and outpatient setting and it is customized according to the patient’s needs. The goals of this model of treatment are to foster body-mind integration, to help patients develop the capacity to “symbolize and play” (Krueger & Schofield, 1986, p. 327), and to promote transmuting internalization, a term coined by Kohut, describing the “inherent impetus to go forward in one’s development” (Rowe & MacIssac, 1995, p. 61). Although the primary modalities utilized in this model are verbal psychotherapy and DMT, projective drawing and videotaping are also utilized. Treatment begins by working with an “internal focus of bodily sensations, feelings, and awareness” (Krueger &

Repairing the Broken Mirror 23 Schofield, 1986, p. 327). This is done in order to simulate a normal development between infant and mother, and is intended to help the patient actively “define the original body self in a cohesive manner” (Krueger & Schofield, 1986, p. 327). Treatment then progresses through the developmental stages, utilizing targeted therapy interventions, such as mirroring, relaxation, and centering. Anne Krantz (1999), another dance/movement therapist who works with eating disordered populations, has created a model of treatment that is based on the methods of Blanche Evans, a DMT pioneer. Krantz’s model assumes the following: (a) Meaningful affective information is exchanged between the mother’s and child’s bodies from before birth throughout development; (b) the body is the vehicle for expressing and storing life experience; (c) the child requires genuine interaction with caregivers in order to become a separate individual, able to connect with others; and (d) where emotion is not experienced, particularly distressing affects may become misinterpreted or disconnected from psychophysical reality. Disconnected affect may lead to symptoms, which impact the body and behavior. The eating disorder is seen as a cumulative effect of disrupted development of self, body, affect and relatedness. (p. 84) According to Krantz (1999), Blanche Evans’ methods revolved around the principle that “by regenerating the body’s potential to move, both emotional and mental states can be changed” (p. 84). Given the psychosomatic characteristics of eating disorders, DMT is uniquely suited for the treatment of this population. In Krantz’s opinion, women with eating disorders often attribute the origin of their suffering to their bodies. It appears that one’s body becomes the battlefield for repression, dissociation, and

Repairing the Broken Mirror 24 denial of emotions and sensations. Hence, one can see the applicability of DMT, since it engages the body as an ally in the treatment process rather than as an impediment. Evans also hypothesized that individual characteristics and one’s environment influence a person’s life; and indeed, that stress and trauma can become embedded in the body’s muscle memory as tensions and restrictions. Evans thus believed that it must be through movement that these elements are worked out and released. This is done through the exploration of the unconscious and the individual’s use of defense mechanisms, resistances, and so forth. Building on Evans’ theories, Krantz (1999) claimed that many clients with eating disorders have a predisposition towards the use of dissociation, which leads to a split between the body and the self, often due to early failures in the mother-infant developmental process of “experiencing affect, body, self and others” (p. 85). DMT is thus used to reconnect this split, to achieve a harmonious body, and to aid in the development of self-knowledge and insight, utilizing the body as a “point of reference, and a vehicle for expression” (p. 85). Krantz (1999) also believed that it is through movement that one must address body image distortions so as to aid in the creation of “a dialogue between the subjective feelings and attitudes, and the body reality” (p. 86). It is both through movement and through the therapeutic relationship that the body image begins to clarify itself and become more realistic. According to Krantz (1999), sexuality also appears to be of great relevance when dealing with body image, as it is related to issues surrounding “self-image, autonomy, and self-assertion; give and take; letting-go and control; intensity of body feelings and

Repairing the Broken Mirror 25 sensations; tension and apathy; and the limits of potential action” (p. 86). Specifically, Krantz believed that “sexual conflicts are intrinsic to eating disorders, whether or not sexual abuse has occurred” (p. 87). Krantz further claimed that, for some, the eating disorder replaces sexual experiences. This hypothesis is based on her observations of patients associating highly sexualized movements with themes such as eating and vomiting. In order to adequately treat women with eating disorders, Krantz (1999) has suggested that the therapist must be curious as to how the woman defines herself in the world: her sexual history, her family history, her ability to experience pleasure, and so forth. This allows the therapist to identify areas in which the eating disorder has “functioned to prevent the client from knowing about these experiences” (Krantz, 1999, p. 87). Krantz also states the importance of working with the body, from the very start of treatment in an expressive way, and of working “with what the client brings” (p. 88). Krantz utilized several specific methods including mobilization, a technique that “encourages self-created spontaneous movement exploration and reconnection of movement and feeling, leading to expanded expressiveness” (Evans, as cited in Krantz, 1999, p. 88). This method is used to help mobilize the body to develop “new alternatives for movement and expression” (Krantz, 1999, p. 89). Physicalization is also a specific technique created by Evans and utilized by Krantz to transform “an experience into action with feeling” (Krantz, 1999, p. 89). This method encourages the patient to communicate an experience through movement instead of only talking about it. Physicalization is said to aid in the discovery of inner experiences. Improvisation is

Repairing the Broken Mirror 26 another tool often utilized to awaken the unconscious, which can lead to the discovery of unused potentials and repressed materials. Another method called Functional Technique is used as a “non-stylized dance technique, which is rehabilitative and re-educative” (Krantz, 1999, p. 90). This technique utilizes specifically targeted movement exercises for the individual so that “as the client’s feelings change, her body must change in order to physically support the new feeling state, and to counteract unconscious repetition of the problem” (Krantz, 1999, p. 90). Homework is also useful as a means of facilitating the applicability of treatment in the patient’s day-to-day life. According to Krantz (1999), homework can serve “to help the client study patterns of eating and purging, to identify their emotional triggers, and to create healthier alternatives” (pp. 91-92). Real life situations are also integrated into the treatment and explored in order to ease the transition from therapy to everyday life. Methods, such as rehearsal, are employed to help alleviate anticipatory and situational anxiety. Although these rehearsals are not strictly DMT-specific, they can help the patient practice alternative methods for coping with anxiety in a safe environment before having to confront the real situation. The methods applied vary depending on the therapist’s individual therapeutic approach and on the needs of the patient. Stark, Arronow, and McGeehan addressed the topic of the treatment of individuals with bulimia nervosa in their article, “Dance/Movement Therapy with Bulimic Patients” (1989). Stark et al. state that dance is a direct expression of the self through the body and is thus a powerful tool for the treatment of the eating disorder population. Given the repressive, dissociative, and somatic nature of this disorder, the authors believe that movement experiences can help

Repairing the Broken Mirror 27 patients reconnect with their body and learn to identify areas of tension that are often associated with repressed emotions and feelings. Stark et al. also stressed the development of social skills as an essential part of treatment and asserted the need for the therapist to support the patient in developing new coping mechanisms and strategies. Stark et al. (1989), identified three main goals for the treatment of patients suffering from bulimia nervosa: “(1) the body and its action; (2) interpersonal relationship; and (3) self-awareness” (Stark, as cited in Hornyak & Baker, 1989, p. 123). The body and its action represent the idea that one must begin to aid the patient in activating the body through movement. This allows for the release of areas of tension and repressed feelings. It is postulated that through this activation of the body, cathartic release, the development of a more realistic body image, bodily integration and coordination can occur. When it comes to interpersonal relationships, it is postulated that through the use of rhythm, a sense of relatedness can occur in the group experience. Such relatedness through rhythm can foster identification with others; it can allow for the development of self-awareness and can provide a learning opportunity for new movement options. Finally, the third goal of self-awareness is based on the concept that, through movement and the experience of the body, one can promote a deeper sense of selfunderstanding and self-knowledge. According to Stark et al. (1989), other specific goals in the treatment of bulimia are to: Develop trust; develop body-awareness and a more realistic body image . . . a clearer sense of self and body boundaries; encourage autonomy and enhance selfesteem; encourage more appropriate interpersonal relations, thereby overcoming

Repairing the Broken Mirror 28 loneliness, isolation and depression; and facilitate identification, tolerance, and expression of emotion in appropriate, constructive ways. (p. 127) Having discussed treatment goals, corresponding examples of movement interventions are then presented. These are discussed in terms of Mahler’s object-relations theory. The first goal presented is that of developing trust in the therapeutic relationship, as it mirrors the original symbiotic relationship between infant and caregiver. However, special attention is brought to the fact that there is often a need to address nurturance, safety, and acceptance before a trusting relationship with the patient can be established. Elements such as body awareness and body trust might also emerge as elements needing to be negotiated before the development of a trusting relationship can occur. To illustrate these concepts, several specific interventions are listed accordingly. The first example highlights empathizing with the patient through mirroring and synchronization in order to understand the patient more clearly and to give the patient the “experience of being understood and accepted on an unconscious body level” (Stark et al., 1989, p. 128). Next, the use of touch and massage is elicited to aid in the development of trust. The following sets of interventions are aimed at increasing body awareness and promoting positive body image. Stark et al. (1989) suggested that through increased body awareness, one can begin to differentiate their own bodily signals, thus creating a sense of control over their “body and eventually over the external world” (p. 130). To aid in the development of this bodily awareness, simple use of breath is of utter importance. It is through rhythmic and synchronized breathing that a special and intimate relationship is developed between mother and infant, thus it is an essential tool for the therapist.

Repairing the Broken Mirror 29 Breathing is also used as a tool in the reconnection with the body, which often leads to the discovery of areas of tension and sensation. Other means utilized in the development of body awareness are interventions, such as body scans and focalization on specific body parts. Techniques such as Feldenkrais, Alexander, and the Bartenieff fundamentals can also be used (Stark et al., 1989, p. 132). For women with BN, the development of body awareness is essential in laying the foundations for the formation of positive body image. This, in turn, can help establish a sense of self, differentiation and body boundaries. Stark et al. (1989) point to the importance of developing strong body boundaries as this helps patients with BN contain and tolerate “the intense feelings they have previously controlled through binging and purging” (p. 133). The next Malherian phase is that of separation-individuation, which is associated with the development of autonomy and self-esteem. To begin the developmental process of establishing autonomy, Stark et al. (1989) emphasized the need for patients to experience “their real body center and the two weight centers. This includes a clear sense of balance and awareness of stability and mobility in both the upper and lower parts of the body” (p. 135). Having renegotiated the separation-individuation process, one must begin to learn about the other/not-me modes of social interaction and ways of developing healthy and appropriate interpersonal relationships. The next treatment step is associated with the rapprochment phase in Mahler’s developmental theory, which deals with interpersonal relationships. Since social isolation is often associated with mental illness, it is of great importance to aid the patient in reconnecting with others and developing appropriate relationships with peers. These

Repairing the Broken Mirror 30 elements are thought to help sustain remission. It is often postulated that people with bulimia have great difficulty being authentic in relationships and that “the real self in touch with spontaneous impulses, feelings, and desires is split off and repressed. As a result, bulimics often attempt to validate themselves through others” (Stark et al., 1989, p. 137). It is therefore important for the dmt to devise interventions that help these patients reconnect with their bodies and rekindle their creative expression to yield increased pleasure from genuine social interactions. The last goal in treatment, as defined by Stark et al. (1989), is “authentic selfexpression” (p. 139). The authors associate this goal with the developmental process of object constancy, in which the child’s “own individuality begins to consolidate and one’s contradictions find some resolution” (Mahler et al., as cited in Stark et al., 1989, p. 139). It is through authentic self-expression that previously intolerable feelings can emerge and that the patient can begin to reclaim control of his or her body and of him or herself in relation to others. The development of authentic movements can also help the patient learn modes of self-regulation. In order to help women suffering from bulimia nervosa reclaim and find their authentic self, a method known as authentic movement is often used as a modality of treatment for this population. Authentic movement was created by Mary Stark Whitehouse and was highly influenced by Jungian theory, in particular by a concept known as active imagination: The process Jung used was meant to provoke unconscious images using as little conscious intervention as possible. The patients were instructed in how to become conscious witnesses of their own unconscious process and then to enter the scene,

Repairing the Broken Mirror 31 becoming part of the picture or action. After the images stopped, the patients were asked to write, draw, or paint the story. (Taylor, 2007, p. 48) Whitehouse worked with this idea and applied it somatically, utilizing movement as the means of tapping into the unconscious process. Indeed, this method focuses on the internal experience of the person moving and, consequently, the therapist’s role is indirect, as the observer/witness. It is a powerful tool, as Musicant (2001) described: The mover is involved in an immediate, direct, and intimate relationship with the self in the presence of another. This process can be profound as clients are seen and accepted as they enter the unknown in themselves and listen deeply to themselves. For those whose relationship to their own knowing has become distorted, this process can be both challenging and healing. (p. 20) As seen above, there are many approaches for the treatment of women with bulimia nervosa, even within the field of DMT. It is thus one goal of this study to directly solicit information from experienced DMT practitioners to evaluate the existing methods and to put forth a comprehensive overview of movement interventions.

Repairing the Broken Mirror 32

Methodology Rationale According to Wilson, Grilo, and Vitousek (2007), “The development of more efficient treatments will depend on improved understanding of the mechanisms whereby psychological treatment produces therapeutic change” (p. 205). Building on this concept, a case study design (Cruz & Berrol, 2004, p. 72) was used for this study, which focused on the analysis of the current use of DMT as a primary means of treatment for women suffering from bulimia nervosa.

In particular, the

principal investigator sought to understand when and how DMT could be utilized and what factors conditioned the effectiveness of this therapy. For this purpose, the investigator reviewed relevant literature and solicited input from professional dance movement therapists with significant experience and recognized expertise in treating bulimia in North America. The goal of the study was to compile the learning acquired from therapists with the knowledge selected from the literature review into a treatment manual for practitioners working with women suffering from bulimia nervosa and utilizing dance/movement therapy as the primary modality for treatment. The manual, which will be presented as a pocket appendix, would cover the following main topics: 1.

ED fundamentals

2.

Etiology

Repairing the Broken Mirror 33 3.

Eating disorder symptoms

4.

Diagnosis

5.

DMT treatment themes

6.

DMT treatment goals

To begin with, the principal investigator conducted a review of the literature, utilizing primarily scholarly, peer-reviewed, and primary source references when possible. Secondary and tertiary references were only used when primary sources were unavailable. In order to adequately understand the population being studied and to increase the reliability of the information and the hypotheses or conclusions drawn, the principal investigator incorporated literature from a variety of fields including psychology, psychiatry, nursing, social work, and alternative therapies. Through this research, an update of the etiology, development, and maintenance of bulimia nervosa in women, as well as treatment implications, was obtained. Apparatus Input from experienced DMT therapists was acquired through a questionnaire (see Appendix A) created by the author and distributed for completion to registered dance/movement therapists. The questionnaire was designed according to the knowledge and guidelines extracted from the literature review. The questionnaire design aimed at gaining firsthand knowledge from the experienced clinicians concerning the mechanisms, characteristics, and treatment implications for patients with BN. It was also utilized to evaluate proposed movement characteristics observed in women diagnosed with bulimia nervosa, as well as to assess the relevance and effectiveness of specific movement interventions selected from DMT literature. Another goal of the questionnaire was to

Repairing the Broken Mirror 34 examine the roles of transference and countertransference between patient and therapist. The last goal was to understand modes of self-preservation used by the therapists. The 15 questions developed to address all these elements were composed as follows: The first three questions requiring short answer responses were utilized to obtain information on the therapists, their experience, and their professional orientation; Questions 4-7 consisted of Likert scale responses evaluating characteristics of the selected population and prompting for further information; Questions 8-10 evaluated specific interventions; and Questions 11 and 12 utilized both Likert scale responses and short answers to explore the therapists’ use of transference and counter-transference. The remaining questions sought to explore the effect, if any, of this work on the therapist and her/his methods of self-preservation. As stated, the questionnaire was ultimately developed and utilized in order to assess the accuracy of information gathered through the review of literature and to evaluate specific interventions for their potential inclusion in the final manual. Participants Participants were recruited on a voluntary basis through extensive e-mailing (see Appendix B), to the American Dance Therapy Association’s (ADTA) listserv and through personal contacts of the investigator. The participants ultimately recruited were female. Two dance movement therapists were located in New York, one in Florida, and one in Canada. The participants worked both in individual and group treatment settings, such as inpatient hospitalization programs, outpatient day treatment, and private practice. To qualify for participation in this study, participants were required to be registered dance

Repairing the Broken Mirror 35 therapists (ADTR) by the American Dance Therapy Association and have a minimum of 5 years experience treating patients with eating disorders. Procedure Participants were asked to complete the questionnaire that was submitted either electronically, via a secure email account, or via a hard copy, and an optional semistructured interview was utilized when deemed necessary. In order to abide by ethical standards established by Pratt Institute, by the ADTA, and by the American Psychological Association (APA), each participant was required to fill in a consent form (see Appendix C) informing them of the potential risks and benefits of participating in the study. Participation in this study was voluntary, and all participants were informed of the purpose of the study and of their right to refuse and/or to cease participation at any time without consequences. Participants were treated with the utmost respect and in accordance with standards established by the organizations mentioned above. Participants were encouraged to respond within 45 days upon receipt of questionnaire and to complete and return documents to the principal investigator. No remuneration was attributed to participants. All sensitive information was kept in a locked drawer by the investigator in her locked apartment. To further ensure privacy, each participant was assigned a confidential code. The response data was then coded by an alphabetical system identifying the participants. Following receipt of the completed questionnaires, the principal investigator evaluated the need to utilize a 30-minute semi-structured interview (see Appendix D) to further clarify or to expand on information gathered from the questionnaires. These semi-

Repairing the Broken Mirror 36 structured interviews were to be conducted via phone or in person, depending on the availability of the participants. The responses to the questions were to be recorded via note taking and/or via voice recording. To ensure the security of sensitive material, all data will be deleted and destroyed within 6 months of completion of the thesis project and the email account will be permanently closed. Hard copies of information will be retained for no less than 3 years. No other person will have access to the information. Data Collection and Analysis The quantitative data gathered from the questionnaire was summarized in four sections of the Results chapter: treatment goals and themes that emerged during treatment, movement characteristics specific to patients with BN, specific movement interventions, transference, countertransference, and self-care of the therapist. For each numerical question (scored on a Likert scale, ranging from 1 to 5) response frequency was calculated to assess its relevance for inclusion in the manual. All data was summarized in a table (see Appendix E). Qualitative responses were transcribed and summarized for each participant according to section themes. When necessary, direct quotations were used to remain authentic to the answers provided by the participants. These responses were included in the manual according to topic and relevance for treatment. Only data deemed relevant was compiled to create a DMT manual for practitioners treating women with bulimia nervosa.

Repairing the Broken Mirror 37

Results The following section consists of a descriptive analysis of the data collected via responses to the questionnaire (see Appendix A). A mass email (see Appendix B) was sent to the American Dance Therapy Association listserv and four respondents expressed interest in participation and represents the final sample size. The identities of the dance therapists were kept confidential through letter coding (A, B, C, and D). Each dance/movement therapist had a minimum of 10 years clinical experience with an eating disordered population. Participants A, B, and C had over 45 years of cumulated experience working with women with eating disorders. Participant D was not included in this calculation as this particular question was left blank. The questionnaire consisted of Likert scales ranging from 1 to 5 and short answer questions which sought to explore the mechanisms, characteristics, treatment implications, and movement characteristics of this population. It also sought to assess the applicability, utility, and effectiveness of specific movement interventions, to examine the roles of transference and countertransference between patient and therapist, and to understand modes of self-preservation used by the treating therapists. Data was scored accordingly. For a full description of the raw data and select writing samples please see Appendix E. After an in-depth review of the data (as presented in Appendix E), only significant findings will be presented in the following sections: DMT theoretical practices, treatment

Repairing the Broken Mirror 38 goals and themes, movement characteristics, movement interventions, transference and countertransference, and therapist’s self care. Significance of the data from the entire questionnaire was determined by the principal investigator based on repetition of themes found in the literature and in the participants’ responses. Also, based on the thorough responses and wealth of information gathered via the questionnaires, the optional interviews were not utilized as initially outlined in the Method Section. DMT Theoretical Practices As highlighted previously in the literature review, it appears that DMT is uniquely suited for the treatment of eating disorders and, in particular, of bulimia nervosa. As specified in the Psychodynamic Diagnostic Manual, people suffering from bulimia often experience feelings of numbness, as well as feelings of disconnection from or confusion about the body (PDM Task Force, 2006, p. 120). According to participant B “all successful therapy involves an interaction between the mind and the body.” This concept of body-mind integration is a primary focus in DMT. Indeed, DMT is the “psychotherapeutic use of movement as a process which furthers the emotional, physical and cognitive integration of the individual” (ADTA, as cited in Levy, 2005, p. 11). Keeping the body-mind connection as an omnipresent guideline, the DMT participants reported utilizing dance/movement therapy theories as a basis for their practice. The dance/movement therapists reported utilizing concepts advanced by field pioneers, including Marian Chace, Mary Whitehouse, and Blanche Evans. They also reported being influenced by prominent psychological figures, such as Sullivan and Jung, and adhering to concepts put forward by psychoanalytic, feminist, object-relations, and

Repairing the Broken Mirror 39 attachment theoreticians. As presented in the literature review, through the exploration of various DMT treatment theories, such as Krantz (1999) and Stark et al. (1989), it is visible that there are many ways within DMT to approach the treatment of BN. This element of variety was salient as participants reported informing their approaches to therapy through different means. Treatment Themes and Goals Having explored the dance/movement therapists’ theoretical frameworks and clinical experience, the questionnaire sought to further explore their methods of treatment. In particular, it sought to understand and predict therapeutic goals and themes that might emerge over the course of treatment. Several goals appeared to emerge consistently throughout the literature, among which reducing binge-purging behavior, addressing body image distortion, increasing one’s ability to self-regulate, increasing one’s connection to one’s body, and expanding one’s movement vocabulary, spatial awareness, and spontaneity. These goals were evaluated in the questionnaire through a Likert scale, ranging from 1 not applicable to 5 extremely relevant (see Appendix E, Question 4). Participants A, B, C, and D all rated reducing binge/purge behaviors, increasing self-esteem, and increasing a sense of body-self as extremely relevant. Both participant A and B rated all of the above goals as extremely relevant and participant C and D rated the above goals from relevant to extremely relevant, thus supporting their importance and relevance for treatment. The participants were also invited to share goals specific to their practices. Responses included: improving social skills, helping manage stress, increasing one’s ability to express emotion, increasing creativity and play, and understanding one’s relationship to food and eating (see Appendix E).

Repairing the Broken Mirror 40 Predominant themes emerging throughout the course of treatment were also evaluated in the questionnaire through a Likert scale, ranging from 1 never to 5 all the time (see Appendix E, Question 5). These themes were evaluated in order to increase the principal investigator’s general therapeutic knowledge and to aid in the development of specific and efficient movement interventions to be included in the final manual. The theme of control was rated as emerging often by participant C to all the time by A and B. The DSM-IV-TR (2000) text revision indicates that elements of losing control emerge for those suffering from bulimia, especially surrounding instances of bingeing and purging. The theme of control was again referenced by Krantz (1999) and was hence deemed significant. The DSM-IV-TR (2000) text revision also alludes to depression, which participants also rated as emerging often to all the time. Anxiety also stood out, both in the literature and in the responses to the questionnaire, and was therefore deemed significant. The theme of most important significance was that of shame. As all 4 participants rated it as emerging all the time. Once again the participants were given the opportunity to share themes that they considered relevant. Participant D suggested the inability to experience pleasure. Participants B and C mentioned various forms of trauma (developmental, violence, and neglect). As Truer et al. (2005) have stated, there appears to be a positive correlation between abuse and the development of bulimia nervosa. In fact, Leonard et al. (as cited in Brewerton, 2007) conducted a study in which “women with bulimia nervosa reported higher levels of CSA, childhood physical abuse, and combined childhood sexual/physical abuse compared to the non-eating-disordered women” (p. 289). Thus, trauma as a general category was deemed of high significance.

Repairing the Broken Mirror 41 Movement Characteristics According to Stark et al. (1989) and Deihl (1999), there appears to be movement characteristics that are specific to women with bulimia nervosa, which include stopping and going, lack of shaping, rigid pelvis, and so forth (p. 45). The questionnaire evaluated the suggested movement characteristics found most often in the literature and their relevance in current DMT practices through a Likert scale, ranging from 1 strongly disagree to 5 strongly agree (see Appendix E, Question 6). For this question, participant A’s answers were not incorporated as she reported, “guessing” to respond that she does not “access in this way.” Out of the 7 movement characteristics proposed in the questionnaire, 4 were deemed significant. These four characteristics were described as relevant in the literature and the participants agreed and strongly agreed that these movement patterns were characteristic of women with BN and the characteristics were mentioned either directly or indirectly in the optional responses (Question 7). The characteristics deemed significant were: a lack of movement in the chest, rigidity of the pelvis area, a primary utilization of peripheral movements, and an indirect use of space. Participants B and C also provided supplemental input and suggested several other characteristics including: “lack of integration between upper and lower body”; “lack or energy in or connection to the pelvis”; “agitated urgency and little sense of time”; and “minimal movements in the near reach zone.” For movement characteristics there appeared to be less agreement between participants in comparison to previous questions.

Repairing the Broken Mirror 42

Movement Interventions Having examined individual approaches to therapy, goals, themes, and movement characteristics, the next step was to explore the actual therapy process as seen through the utilization of specific movement interventions. These interventions were taken from examples offered in the DMT literature (Deihl, 1999; Krantz, 1999; Krueger & Schofield, 1986; Stark et al., 1989; Totenbier, 1995). Overall, the responses to this question were quite different for each participant. Responses ranged from 1 never use to 5 use all the time (See Appendix E, Question 8). There were three categories of movement interventions were rated as use often (4) to use all the time (5) by 3 of the dance/movement therapists and hence deemed significant. These were improvisation, centering exercises and relaxation techniques. Participant C reported utilizing authentic movement all the time. Apart from the significant use of improvisation, centering, and relaxation techniques, no other conclusions were drawn from this question. It appears that the dance/movement therapists’ background and informing theories influence their choice of interventions. Continuing with the evaluation of specific movement interventions, 11 interventions were described (see Appendix E, Question 10) and the dance/movement therapists were asked to evaluate them via a Likert scale, ranging from 1 not effective to 5 extremely effective. Here, again, it was difficult to find sufficient participant agreement, as the responses were quite diverse. Nevertheless, the use of physicalization was evaluated by 3 participants (A, B, and C) as extremely effective and hence deemed significant by the principal investigator. Participants suggested other interventions

Repairing the Broken Mirror 43 including: mirroring, walking meditation, focus based exercises, and sculpting of feeling states. Participant A reported that she “work[ed] with process rather than providing specific dance techniques.” She reported picking up on and developing the patients’ movements, emotions, and verbalizations in order to understand and help them understand their issues. Transference and Countertransference Having explored the treatment process and the characteristics of this population, it was of interest to explore the experience of the treating therapists through their use of transference and countertransference. This was done via a Likert scale, ranging from 1 never use to 5 use all the time (see Appendix E, Question 11). Participants A, B, and C reported using transference regularly to all the time. Participant D reported not using it at all as she worked in a short-term setting. However, its use was deemed significant. Freud (as cited in Dosamantes-Beaudry, 2007) originally referred to transference as the “patient’s reproduction of past relationships in the current relationship established with a neutral analyst” (p. 75). This definition has evolved over the years, but is generally understood as “an unconscious phenomenon in which the patient transfers core feelings, ideas, and methods of relating onto the figure of the psychoanalyst” (Waska, 2008, p. 333). Dosamantes-Beaudry also referred to somatic transference, which she defined as the following: The totality of the patient’s bodily-felt experience and enacted behavior (experienced as bodily-felt sensations and expressed via bodily-felt expressive movement and through kinesthetic and kinetic images) that function as

Repairing the Broken Mirror 44 transitional objects for the patient and provide critical relational psychodynamic meaning that at the outset of treatment is unknown to the patient. (p. 76) Participant A reported utilizing transference “sometimes actively and sometimes passively,” either verbally or through movement, situation depending. Participant B described transference as “important diagnostic information” that allows her to gain important information about clients and their inner world. She also utilizes transference to guide her in her work with individuals. Participant C explained that she too used transference as a way of gathering information about the client, but that she only addressed it with the client when deemed necessary and/or beneficial for the client and the therapeutic process. Next, participants’ use of countertransference was rated via Likert scale, ranging from 1 never to 5 use all of the time (see Appendix E, Question 12). Participant A reported using countertransference regularly, participant B rarely, participant C moderately, and participant D all the time. According to Racker (as cited in Dosamantes-Beaudry, 2007), there are two forms of countertransference: (a) concordant countertransference reactions in which the analyst felt compelled to identify empathically with the patient’s thoughts and feelings and (b) complementary countertransference reactions where the analyst experienced himself being transformed by the patient into an unwanted or despised aspect of the patient’s self. (p. 75) Participant A alluded to countertransference as a means of gathering information about patients. Similarly, participant D reported that the use of countertransference

Repairing the Broken Mirror 45 served as a means “to understand metaphors of their [the patient’s] experience and to understand useful and not useful responses within the context of the therapeutic relationship. Participant A emphasized, however, that it “always need[s] to be considered as hypotheses, not the ‘truth’ of the client.” Participant A reported paying attention to the emotions/feelings that emerge for her in the therapeutic relationship and seeking to understand the underlying issues that are emerge for the patient. She gave the example of feeling anxious, angry, or impatient as a potential indicator of the patient’s fear of survival or of annihilation. She reported holding these emotions and reflecting them back to the patient in a more neutral manner that allows the patient to work with them in a less threatening fashion. Participant A also referred to the use of somatic countertransference, which is of particular interest to the field of DMT. She defined somatic countertransference as cues that emerge in her own body that may be “clues to what might be happening in clients.” Dosamantes-Beaudry (2007) defined somatic countertransference as “somatic reactions a therapist has toward her patient at a particular moment during treatment” (p. 76). Orbach (2004), a leading psychologist in the field of eating disorders, also argued that, contrary to popular trends, one must pay attention to these body symptoms that patients bring forth, as they can serve as fundamental keys to the patient’s mental state and may potentially be signs of “disorganized body attachment(s)” (p. 142). In a similar fashion, participant C reported beginning a session by noticing what is occurring in her body and by assuming that the countertransference is induced. She then questions what patients want her to know about them. However, she reported not

Repairing the Broken Mirror 46 involving her countertransference directly into the session, but rather using it to understand the client’s experience. Participant B chose not to respond to this question and gave no explanation. Therapist’s Self-Care Considering the fact that the dance movement therapist utilizes her body in a multitude of ways in the therapeutic relationship, it seems inevitable that this work would have an effect on her. The questionnaire sought to understand if indeed this was the case and if the participants’ work with women suffering from BN affected their sense of bodyself and their body image (see Appendix E, Question 13). Participants were asked to evaluate the effect of their work via a Likert Scale, ranging from 1 never to 5 most of the time. Participant A reported the work rarely affecting her. Participant D reported it affecting her sometimes in that her use of eating as a defense mechanism was heightened. Participant B reported it affecting her more than often in that it has made her highly aware of ways in which she has “been brainwashed by the cultural images of beauty and [she has had] to work to counteract those consciously to find all bodies beautiful.” In her own words, “It has affirmed and strengthened the commitment of my own journey to value my body as home and expression of my presence in the world.” Similarly, Participant C also reported a heightened awareness of cultural ideals of beauty, but that this work had predominately brought more awareness to her own relationship with food and eating. Methods of self-care were then explored (see Appendix E, Question 15). The main methods utilized overwhelmingly by all 4 therapists were one-on-one supervision, peer supervision, and group supervision. The other self-care options were rated according

Repairing the Broken Mirror 47 to personal preferences. Due to unclear participant completion of this question, specific ranking could not be determined. In conclusion, it is apparent that the dance/movement therapists selected to participate had extensive clinical experience working with women with eating disorders and, in particular, with women suffering from BN. Although all trained in DMT, the therapists differentiated themselves by their individual approaches to therapy. Through their responses, significant elements concerning the BN population were deduced. First, therapeutic goals that emerged as significant were those of reducing binge/purge behaviors, increasing self-esteem, and deepening a sense of body-self. The unanimous theme that emerged as significant was that of shame. Movement patterns were difficult to assess, due to little agreement in the responses. As far as proposed interventions, improvisation and physicalization emerged as significant. Transference was deemed important as a diagnostic tool and was often utilized, whereas countertransference was utilized much less frequently. The therapist’s self-care evaluation was difficult to score as responses varied, but the three following modalities emerged as significant: one-on-one supervision, peer supervision, and group supervision. Overall, there was significant agreement on elements surrounding psychological factors and characteristics of this population. However, the picture became unclear around questions concerning DMT theories and practices. What does this mean and what are the implications for the use of DMT as a therapeutic modality for this population? These questions need to be examined through more extensive surveys as suggested in the discussion chapter.

Repairing the Broken Mirror 48

Discussion In an effort to understand the increasing prevalence of BN in today’s society (despite the available treatments), the principal investigator evaluated current literature and research. In addition, experienced dance/movement therapists were surveyed about characteristics and needs of patients with BN, themes emerging during treatment, therapeutic goals, treatment methods, specific movement interventions, and self-care of the therapist. The ultimate goal of this research was to compile a pilot manual for therapists utilizing DMT as the primary modality in the treatment of women with BN (see Pocket). Findings Literature review. The literature review provided a summary of the fundamentals that dance movement therapists need to know when applying their skills to the treatment of eating disorders, and specifically to BN. However, this review identified more information about causes, symptoms, and therapeutic goals associated with BN illness but less input about themes for intervention and recommendations for specific movement patterns. The literature review also helped reveal the most significant factors and methods of treatment available, to date, for the construction of the proposed manual. Questionnaire. The questionnaire utilized for this case study contributed a rich and diversified qualitative input. Through it, the author was able to gain insight into the practices of four experienced dance/movement therapists. The information gathered via

Repairing the Broken Mirror 49 the questionnaire confirmed elements found in the literature and revealed areas needing clarification and further exploration. The data collected via the questionnaire served to support and confirm the themes and goals of treatment considered relevant in the literature, but also allowed the participants to share information and thoughts on other goals and themes that they deemed important. The questionnaire also served to evaluate the current usage and applicability of specific methods and interventions and allowed the author to collect further information and ideas for specific movement interventions to be compiled in the pilot manual. The questionnaire also helped bring to light areas that needed further exploration; namely, better insight into the actual use (how, when, and why) of specific interventions, a need to further monitoring and recording patient’s responses to the different interventions, a systematic and normalized recording of the patient’s progress, and so forth. Furthermore, it served to highlight the diversity and wealth of options one has to choose from when utilizing DMT methodology. In light of these findings, the principal investigator suggests that for future research which utilizes this thesis model, the questionnaire be further revised to help clarify elements such as dance/movement therapists’ training, reasoning for the utilization of specific methods, and means through which effectiveness of methods were established, in addition to the areas mentioned above. The author believes that this would help researchers better understand the usage of DMT with women suffering from BN, allow for an more thorough review of current treatment options, and allow for a more complete conceptualization of a treatment manual.

Repairing the Broken Mirror 50

Significant Findings and Recommendations Need for collaboration. The information gathered through the literature review and the results collected via the questionnaire support the premise that DMT is an appropriate means of treatment for BN, due to the somatic nature of BN and the body oriented approach of DMT. It is also apparent, through the debate surrounding the etiology of BN (medical and psychological), that there are multiple dimensions that must be taken into consideration for the effective treatment of this illness. It is hence apparent that preserving current team model of treatment is essential, but that the inclusion of DMT in this model could contribute infinitely towards a more holistic and effective treatment plan. Need for Further Clarification and Exploration Validity and reliability. As seen in the literature review, there are various methods recorded by experienced DMT clinicians that have been deemed efficient (Deihl, 1999; Krantz, 1999; Krueger & Schofield, 1986; Stark et al., 1989; Totenbier, 1995). However, it is unclear how the validity, reliability, and effectiveness of these interventions were established. This lack of information about the methods used to assess specific treatments was also visible in the questionnaire. It is hence recommended that, upon revision of the questionnaire, these elements be included and further explored in order to promote technical validity of DMT methodology. Conception of movement patterns. Through the literature analysis and the responses recorded from the questionnaire, it became evident that the translation of therapeutic goals into specific movement patterns emerged as a major challenge. While

Repairing the Broken Mirror 51 the literature analysis and the surveyed therapists revealed a number of pertinent movement patterns, this contribution was relatively modest and not sufficiently documented. Moreover the therapists’ feedback did not exhibit sufficient agreement on particular movement patterns, but it did show the diversity of movement interpretations. The literature review showed that specific suggestions for movement patterns originated from a rather limited number of specialists (Deihl, 1999; Stark et al., 1989). These observations show that DMT applied to BN has established some solid roots, but it is a rather young discipline, which is still in the freelance experimentation phase. The author believes that this is perhaps a normal evolution and that it could explain the current diversity of approaches and prevailing disagreements. Utilization of specific interventions. Significant concepts that emerged from the questionnaire were an emphasis on the therapist-patient relationship and the therapist’s ability to utilize elements such as transference and countertransference. These elements emerged as techniques utilized to further understand the patient’s experience as an individual and, in response, to tailor the treatment towards their specific needs. Thus, it seems essential that DMT be practiced with great flexibility and openness and that the therapist remains dynamic in order to cater to the individual’s healing process. It is within this framework that the specific movement interventions were evaluated. Visible in the literature was the utilization of specific DMT methods, such as physicalization and improvisation. These and other DMT interventions were evaluated in the questionnaire in order to assess their utility and applicability in the treatment of women with BN. This evaluation clarified the therapists’ preferences and agreement on

Repairing the Broken Mirror 52 the most effective interventions and underlined the flexibility with which one can practice DMT. It also served to focus the selection of interventions to be included in the final pilot manual. There was, however, a visible lack in the literature on the specific application and utilization of these interventions. There were no specific guidelines and one was left to speculate as to their applications for individual or group settings, age appropriateness, and so forth. These elements bring attention to the notable lack of outlined guidelines for dance/movement therapists. Indeed there are no diagnostic or evaluative tools, such as the DSM-TR-IV (2000) text revision, that help classify and organize acquired information. It is evident that further investigation of standardized methods for diagnosing and treating would be of great benefit to the field and for the teaching and transmission of knowledge to colleagues in other medical domains, as well as, to new dance/movement therapists. This may be a shortcoming of the questionnaire in that it did not sufficiently explore the ways in which these methods were used. In consequence, the author would encourage further clarification and exploration of the ways in which these interventions are used. This would ultimately aid less experienced DMT clinicians in properly using the proposed methods. Monitoring DMT effectiveness. In acknowledging that DMT application to BN is a relatively young discipline where creative experimentation by dance/movement therapists prevails, there are several aspects that merit further attention. The author believes that it is critical to formalize the process of monitoring the patient reactions, the effectiveness of the movement interventions, and the coherence of all professional interventions. This would not only help clarify the therapeutic process for less

Repairing the Broken Mirror 53 experienced dance/movement therapists, but it would also help to validate the field of DMT at large. However, it appears that this important monitoring aspect has not yet received sufficient attention, structuring, and coordination. Although this is not the sole responsibility of DMT practitioners, the author encourages dance/movement therapists to take a proactive role, possibly with the help of the ADTA, in shaping the monitoring process and standards of treatment. Therapist self-care. The literature review and feedback from the surveyed therapists confirmed adequate awareness of the importance of self-care. It brought attention to the critical use of supervision. The author believes that the use of supervision demonstrates a willingness to examine one’s shortcomings and a desire to constantly improve one’s ability to treat clients. However, the extent and ways in which supervision is utilized was not clear. This may be of interest for future examination to better understand therapists’ individual therapeutic approaches and processes. It could further clarify the reasoning and methodology behind specific interventions, which would be of great interest for the future development of standardized methods and the development of treatment manuals. Considering the level of direct mental and body involvement devoted by dance/movement therapists to BN therapies, this author recommends that the DMT community secures self-preservation through the identification of more self-care techniques and training for their application. A meaningful initiative in this direction would be to further organize with the ADTA and other BN health professional events, such as national/international surveys, symposiums, and dedicated project task forces to promote exchange and build consensus on best practices.

Repairing the Broken Mirror 54 Study Limitations As in all research, unexpected limitations to this study emerged and reduced the investigator’s ability to collect appropriate and relevant data. The first limitation and perhaps the most significant one, was the limited timeframe and lack of funding. This in itself restricted the sample size and the overall ability of the principal investigator to conduct a more in-depth exploratory study. In particular, the author believes that future studies would greatly benefit from the utilization of longitudinal outcome studies. The limited number of willing participants was also a large impediment in this study. Although, an email was sent to over 50 dance/movement therapists, only two responded. The other two dance/movement therapists were recruited via personal request of the principal investigator. It is unclear why so few dance/ movement therapists responded. One might hypothesize that some dance/movement therapists might have been reluctant to share therapeutic knowledge because of the difficulties translating their work into words. Others might underline the possibility of resistance (perhaps unconscious) to the development of the DMT field. Other practical considerations, such as a lack of time, a lack of interest in the study, no compensation for completion, and so forth could also have contributed to the low response rate. In conclusion, this investigation has confirmed that the application of DMT to BN is pertinent, but it is still in its developmental stage, which requires acceleration and dealing with important issues such as those highlighted in the discussion. Future growth and credibility of DMT application to bulimia would benefit from further consolidation of DMT research advance, as well as from stronger coordination of interventions by all

Repairing the Broken Mirror 55 disciplines concerned with bulimia. This would further promote a holistic approach to the treatment of BN in balance with its multifactorial complexity.

Repairing the Broken Mirror 56 References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) text revision. Washington, DC: Author. Beattie, H. J. (1988, July). Eating disorders and the mother-daughter relationship [Electronic version]. International Journal of Eating Disorders, 7(4), 453-460. Benninghoven, D., Jürgens, E., Mohr, A., Heberlein, I., Kunzendorf, S., & Jantschek, G. (2006, March/April). Different changes of body-images in patients with anorexia or bulimia nervosa during inpatient psychosomatic treatment [Electronic version]. European Eating Disorders Review, 14(2), 88-96. Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD. Eating Disorders, 15, 285–304. doi:10.1080/10640260701454311 Cash, T., & Deagle, E., 3rd. (1997, September). The nature and extent of body-image disturbances in anorexia nervosa and bulimia nervosa: A meta-analysis. The International Journal Of Eating Disorders, 22(2), 107-25. [Electronic version]. Dosamantes-Beaudry, I. (2007, Winter). Somatic transference and countertransference in psychoanalytic intersubjective dance/movement therapy. American Journal of Dance Therapy, 29(2), 73-89. doi:10.1007/s10465-007-9035-6 Eggers, C., & Liebers, V. (2007). Through a glass, darkly. Scientific American Mind, 18(2), 30-35. Retrieved March 20, 2009, from New York Public Library – EBSCOhost Web site: http://nylp.org Gillespie, J. (1996). Rejection of the body in women with eating disorders. The Arts in Psychotherapy, 23(2), 153-161.

Repairing the Broken Mirror 57 Grabe, S., Hyde, J. S., & Ward, L. M. (2008). The role of the media in body image concerns among women: A meta-analysis of experimental and correlational studies. Psychological Bulletin, 134(3), 460-476. doi:10.1037/00332909.134.3.460 Hornyak, L. M., & Baker, E. K. (Eds.). (1989). Experiential therapies for eating disorders. New York: The Guilford Press. Kaye, W. (2008). Neurobiology or anorexia and bulimia nervosa. Physiology & Behavior, (94), 121-135. Retrieved March 20, 2009, from http://www.sciencedirect.com Kleinman, S. (2008, October). Challenging body distortions through the eyes of the body. Retrieved January 9, 2008, from http://www.eatingdisorderhope.com/bodydistortions.html Kleinman, S., & Hall, T. (2005). Women with eating disorders. In F. Levy (Ed.), Dance movement therapy: A healing art (2nd rev. ed., pp. 221-228). Reston,VA: National Dance Association. (Original work published 1988) Krantz, A. M. (1999, Fall/Winter). Growing into her body: Dance/Movement therapy for women with eating disorders. American Journal of Dance Therapy, 21(2), 81103. Kruger, D., & Schofield, E. (1986). Dance/movement therapy of eating disordered patients: A model. American Journal of Dance Therapy, 13, 323-331. Lausberg, H. (1998, Fall/Winter). Does movement behavior have differential diagnostic potential? Discussion of a controlled study on patients with anorexia nervosa and bulimia. American Journal of Dance Therapy, 20(2), 85-99.

Repairing the Broken Mirror 58 Maine, M., Davis, W. N., & Shure, J. (Eds.). (2009). Effective clinical practice in the treatment of eating disorders: The heart of the matter. New York: Routledge, Taylor & Francis Group. Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York: Basic Books. Musicant, S. (2001, Spring/Summer). Authentic movement: Clinical considerations. American Journal of Dance Therapy, 23(1), 17-28. doi:10.1023/A:1010728322515 National Eating Disorder Association. (2006). Statistics: Eating disorders and their precursors [Fact sheet]. Retrieved January 25, 2009, from National Eating Disorder Association Web site: http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=286&Profile_ID=41 138 Neuropeptide. (n.d.). In Wikipedia, the free encyclopedia. Retrieved June 3, 2009, from http://en.wikipedia.org/wiki/Neuropeptide Orbach, S. (2004, June). What can we learn from the therapist's body? Attachment and Human Development, 6(2), 141-150. doi:10.1080/14616730410001695349 Russel, T. L., & Ainsworth, M. D. S. (1981, December). Maternal affectionate behavior and infant: Mother attachment patterns. Child development, 52(4), 1341-1343. doi:10.1111/1467-8624.ep8861096 Schmidt, U. (2003). Aetiology of eating disorders in the 21st century: New answers to old questions. [Electronic version]. European Child & Adolescent Psychiatry, Suppl 1(12), 30-37.

Repairing the Broken Mirror 59 Schneider, J. A. (1995, Spring). Eating disorders, addictions, and unconscious fantasy. Bulletin of the Menninger Clinic, 59(2), 177-90. Retrieved March 20, 2009, from Academic Search Premier database. Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York: The Guilford Press. Stark, A., Aronow, S., & McGeehan, T. (1989). Dance/movement therapy with bulimic patients . In L. M. Hornyak & E. K. Baker (Eds.), Experiential therapies for eating disorders (pp. 121-143). New York: The Guildford Press. Stern, D. N. (1977). Missteps in the dance. The first relationship; Infant and mother (pp. 133-156). Cambridge, MA: Harvard University Press. Taylor, J. (2007, March). Authentic movement: The body’s path to unconsciousness. Body, Movement and Dance in Psychotherapy, 2(1), 47-56. doi:10.1080/17432970601025402 Totenbier, S. L. (1995). A new way of working with body image in therapy, incorporating dance/ movement therapy methodology. In D. Dokter (Ed.), Art therapies and clients with eating disorders (pp. 193-207). Philadelphia: Jessica Kingsley Publishers. Truer, T., Koperdak, M., Rozsa, S., & Furedi, J. (2005). The impact of physical and sexual abuse on body image in eating disorders. European Eating Disorders Review, 13, 106-111. Retrieved March 20, 2009, from ebscohost database: http://nypl.org

Repairing the Broken Mirror 60 Vanderlinden, J. (2008, September/October). Many roads lead to Rome: Why does cognitive behavioral therapy remain unsuccessful for many eating disordered patients? European Eating Disorders Review, 16(5), 329-333. doi:10.1002/erv.889 Waller, G., & Sheffield, A. (2008, April). Causes of bulimic disorders. Psychiatry, 7(4), 152-155. Walsh, T. B., & Devlin, M. J. (1998, May 29). Eating disorders: Progress and problems. Science, 280(5368), 1387-1390. doi:10.1126/science.280.5368.1387 Waska, R. (2008). Using countertransference: Analytic contact, projective identification, and transference phantasy states. American Journal of Psychotherapy, 62(4), 333351. Retrieved March 20, 2009, from http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,url,cpid &custid=nypl&db=f5h&AN=36011829&site=ehost-live Wonderlich, S. A., Brewerton, T. D., Jocic, Z., Dansky, B. S., & Abbott, D. W. (1997). Relationship of childhood sexual abuse and eating disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 36(8), 1107-1115.

Repairing the Broken Mirror 61 Appendix A Questionnaire 1) What are your professional credentials? 2) How many years have you worked with women diagnosed with bulimia nervosa? 3) What theories inform your work with this population? 4) Of the following options, please rate the treatment goals for women suffering from bulimia nervosa according to relevance, utilizing the following scale. 1 not applicable

2

3

slightly relevant

relevant

4

5

moderately relevant extremely relevant

a) Reducing of binge/purging behaviors 1

2

3

4

5

3

4

5

3

4

5

3

4

5

4

5

4

5

b) Reducing of body image distortion 1

2

c) Increasing self-esteem 1

2

d) Improving self-regulation 1

2

e) Developing better coping skills 1

2

3

f) Increasing sense of body-self 1

2

3

Repairing the Broken Mirror 62 g) Increasing body boundaries 1

2

3

4

5

4

5

h) Increasing spontaneity of movement 1

2

3

Please list other important treatment goals not mentioned above. 5) Among the following to what degree do these themes emerge in treatment for this population? Please rate according to following scale: 1 never

2 rarely

3 sometimes

4 often

5 all the time

a) Control 1

2

3

4

5

2

3

4

5

2

3

4

5

2

3

4

5

3

4

5

3

4

5

3

4

5

b) Depression 1 c) Anxiety 1 d) Shame 1

e) Obsessive thinking 1

2

f) Obsessive behaviors 1

2

g) Sexual trauma 1

2

Repairing the Broken Mirror 63

Please list any themes that emerge in the treatment of women with bulimia nervosa that were not mentioned above. 6) Please rate to what extent the following movement patterns are characteristic of women with bulimia nervosa, utilizing the following scale. 1 strongly disagree

2 disagree

3 neither agree nor disagree

4 agree

5 strongly agree

a) Purge position (a c-like curve, a sunken chest and a protrusion of the chin): 1

2

3

4

5

3

4

5

3

4

5

b) Lack of movement in chest: 1

2

c) Rigidity of pelvis: 1

2

d) Primary utilization of peripheral movements: 1

2

3

4

5

3

4

5

3

4

5

4

5

e) Difficulty grounding weight 1

2

f) Indirect use of space 1

2

g) Sporadic stop and go movements 1

2

3

7) Are there other movement patterns not mentioned above that you find characteristic of this population?

Repairing the Broken Mirror 64

8) Please rate your personal use of the following interventions according to the following scale: 1 never use

2

3 use moderately

4

5 use all the time

a) Guided Imagery: 1

2

3

4

5

3

4

5

3

4

5

3

4

5

3

4

5

2

3

4

5

2

3

4

5

b) Centering Exercises: 1

2

c) Relaxation techniques 1

2

d) Improvisation 1

2

e) Authentic movement 1

2

f) Bartenieff fundamentals 1 g) Props 1

9) Are there any specific interventions that you utilize regularly that merit attention? If yes, please describe.

10) To what extent do you find the following movement interventions effective? Please rate according to following scale. 1

2

3

4

5

Repairing the Broken Mirror 65 not effective

somewhat effective

never use / not applicable

effective

extremely effective

a) Having the patient pick a hated or disliked part of the body, exaggerating its size and having them move with this pretend exaggeration. 1

2

3

4

5

b) Self-touch to promote body boundary awareness. 1

2

3

4

5

c) Have the patient take two chairs that she places next to each other leaving space in between them to represent her perceived width. Then having her verify and adjust to become aware of potential misevaluation or distortion of reality. 1

2

3

4

5

d) Games such as freeze or red light green light to work on elements of starting and stopping. 1

2

3

4

5

e) Physicalization (Blanche Evans) used to move an experience instead of talking about it. 1

2

3

4

5

f) Functional technique (Blanche Evans) an individually catered dance technique that is used to strengthen specific areas, retrain others and decrease tension in order to help support mental transformations that occur on a bodily level. 1

2

3

4

5

g) Rehearsal of stress inducing or potentially triggering situations in the therapeutic session to help prepare patient for real situations. 1

2

3

4

5

h) The use of touches and massage to elicit a trusting relationship between therapist and patient. 1

2

3

4

5

Repairing the Broken Mirror 66 i) Synchronous breathing between therapist and patient, a dyad of patients or group of patients. 1

2

3

4

5

j) Having patients roll, lay, etc. on the floor to explore tactile sensations in order to improve body boundaries. 1

2

3

4

5

k) Exploration of weight utilizing polarities of pushing and pulling either alone or with a partner. 1

2

3

4

5

Are there any specific techniques/interventions that you have developed and utilized that have proven themselves effective? If yes, please explain: 11) To what extent do you use transference in the treatment of this population? Please rate according to the following scale: 1 never use

2

3 use moderately

4

5 use all the time

Please describe how you utilize transference of the patient in treatment.

12) To what extent do you use countertransference in the treatment of this population? Please rate according to the following scale: 1 never use

2

3 use moderately

4

5 use all the time

Please describe how you use your countertransference in the treatment of this population.

13) To what extent does working with women suffering from bulimia nervosa affect your own sense of body-self and body image? Please rate according to the following scale. 1 never

2 rarely

3 sometimes

4 more than often

5 most of the time

Repairing the Broken Mirror 67

14) If this work does affect your body-self and body image, please describe in what ways it is experienced.

15) Of the following, what methods do you utilize to promote self-preservation? Please rate from 1 to 12 with 1 being the most important and 12 the least. -

Personal Therapy One on one supervision Peer supervision Group supervision Massage therapy Authentic movement Dance classes Yoga Martial arts Meditation Exercise Other

please provide details:

Repairing the Broken Mirror 68 Appendix B Recruitment Email Dear ________, As a current Master’s candidate in Dance/Movement Therapy at Pratt Institute in New York, I am conducting research on women suffering from Bulimia Nervosa as part of my thesis project. I am currently recruiting ADTR’s and other accredited therapists primarily using movement, with at least 5 years experience working with this population, to participate in my study. Participation in this study would include the completion of a questionnaire (completion will take no more than one hour) including questions on movement qualities, the evaluation of specific interventions and self-care. Participation might also include a semistructured interview to clarify responses to questionnaire and expand on topics of interest, not to exceed thirty (30) minutes. This interview would be done at the discretion of the principal investigator via phone or in person depending on location and availability. Participation in this study is completely voluntary and no remuneration will be provided. The data being collected will serve to create a comprehensive treatment manual for dance/movement therapists working with women suffering from Bulimia nervosa. If you are interested in participation please respond to this email and I will send you the necessary information to make an informed decision about participating or not. Thank you for you time and consideration Ariele Riboh

Repairing the Broken Mirror 69 Appendix C Pratt Institute 200 Willoughby Avenue Brooklyn, NY 11205

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

TITLE OF STUDY: Repairing the Broken Mirror: a Theoretical Dance/Movement Therapy Manual for the Treatment of Women with Bulimia. RESEARCH STUDY: I, __________________________________________, have been asked to participate in a research study under the direction of Ariele Riboh (Dance/Movement Therapy student - Masters candidate at Pratt Institute). PURPOSE: The purpose of this study is to establish a more comprehensive understanding of eating disorders and characteristics in order to establish more effective modes of treatment through dance/movement therapy interventions. DURATION: Participation in this study will last for no more than 2 hours. PROCEDURES: During the course of this study, the following will occur: • •

Completion of a questionnaire. A 30 minute semi-structured interview

PARTICIPANTS: There will be 4 to 8 participants this research. EXCLUSIONS: I will inform the researcher if any of the following apply to me: - I am under 18 years of age. - I have not worked with eating disordered populations.

Repairing the Broken Mirror 70 - I am not a registered dance/movement therapist (ADTR) or licensed creative art therapist (LCAT) or a credentialed therapist utilizing movement specific interventions. - I do not have at least 5 years experience working with this population. RISK/DISCOMFORTS: I have been told that the study described above appears to involve no risks or discomforts known at this time. However there may be risks and discomforts that are not yet known. I fully recognize that there are risks that I may be exposed to by volunteering in this study which are inherent in participating in any study; I understand that I am not covered by Pratt Institute’s insurance policy for any injury or loss I might sustain in the course of participating in the study. CONFIDENTIALITY: Every effort will be made to maintain the confidentiality of my study records. Officials of Pratt will be allowed to inspect sections of my research records related to this study. If the findings from the study are published, I will not be identified by name. My identity will remain confidential unless law requires disclosure. PAYMENT FOR PARTICIPATION: I have been told that I will receive $____0_____ compensation for my participation in this study. RIGHT TO REFUSE OR WITHDRAW: I understand that my participation is voluntary and I may refuse to participate, or may discontinue my participation at any time with no adverse consequences. I also understand that the investigator has the right to withdraw me from the study at any time. INDIVIDUAL TO CONTACT: If I have any questions about my treatment or research procedures I may discuss them with the principal investigator: Ariele Riboh, Masters candidate (608) 345-0002 or [email protected]. If I have any additional questions about my rights as a research subject, I may contact:

Repairing the Broken Mirror 71

Vladimir Briller, Ed.D. Chair, IRB (718) 399-4245

SIGNATURE OF PARTICIPANT I have read this entire form, or it has been read to me, and I understand it completely. All of my questions regarding this form or this study have been answered to my complete satisfaction. I agree to participate in this research study. Subject Name: ____________________ Signature: __________________________ Date: __________

SIGNATURE OF INVESTIGATOR OR RESPONSIBLE INDIVIDUAL To the best of my knowledge, the participant, ______________________________, has understood the entire content of the above consent form, and comprehends the study. The participant’s questions have been accurately answered to his/her/their complete satisfaction. Investigator’s Name: ____________________ Signature: _______________________ Date: ______________

Repairing the Broken Mirror 72

Appendix D Semi-Structured Interview Text. These are potential questions that will be used to guide the interview. However the interview will not be limited to these exact questions. Further questions will be potentially used for further clarification and exploration of topics that may arise during the interview. 1) What has your experience been like working with women with bulimia nervosa? 2) Over the years how have you dealt with issues of transference and countertransference? 3) What methods of self-care do you utilize for self-preservation and to avoid burnout? 4) Given your answers on the questionnaire could you please further explain the following intervention? 5) What is your goal for treatment when utilizing this specific intervention? 6) How do the patients respond to this intervention?

Repairing the Broken Mirror 73 Appendix E Table 1 Answers to Questionnaire Concerning DMT Experience of Participants Question

Participant A

Participant B

Participant C

Participant D

1. What are your

Registered

MA, ADTR,

ADTR, LCAT MPS, ADTR,

professional

clinical

NCC

(Licensed

ATR-BC,

qualifications?

counselor,

(National

Creative Art

LCAT

ADTR, RDT

Certified

Therapist)

(Drama

Counselor)

therapy) 2. How many years

18

17

10

Not answered

have you worked with women diagnosed with bulimia nervosa? 3. Informing

Object

Chace,

Modern

Psychoanalytic,

theories?

relations,

Sullivan, Jung

analytic

feminist

bioenergetics,

perspective,

attachment

Chace,

theory,

Whitehouse

Jungian, and

and Evans

sensori-motor.

Repairing the Broken Mirror 74

Question 4. Goals

Participant A

Participant B

Participant C

Participant D

1 (not applicable) 2 (slightly relevant) 3 (relevant) 4 (moderately relevant) 5 (extremely relevant)

a) Reducing of

5

5

5

5

5

5

3

4

5

5

5

5

5

5

4

5

5

5

4

5

5

5

5

5

5

5

3

4

5

5

4

3

binge / purging behaviors b) Reduction of body image distortion c) Increasing selfesteem d) Improving self regulation e) Developing better coping skills f) Increasing sense of body self g) Increasing body boundaries h) Increasing spontaneity of movement

Repairing the Broken Mirror 75

Question Other:

Participant A

Participant B

Participant C

Participant D

Increase

Experience

Understanding Increased

pleasure and

feelings-

one’s

creativity and

comfort in

connecting

relationship to

play.

body, help

with the inner

food and

manage stress,

self,

eating,

increase ability

expressing

increasing

to manage

feelings,

bodily

relationships,

identifying

understanding.

increase

and

communication understanding skills.

connection between discoveries in treatment and applicability in day to day life.

Repairing the Broken Mirror 76

Question 5. Themes

Participant A 1 (never)

Participant B

Participant C

2 (rarely) 3 (sometimes)

Participant D

4 (often) 5 (all the time)

a) Control

5

5

4

5

b) Depression

4

5

5

5

c) Anxiety

5

5

4

5

d) Shame

5

5

5

5

e) Obsessive

4

5

3

5

4

5

2

5

4

5

3

4

thinking f) Obsessive behaviors g) Sexual trauma Other:

Dissociation,

Fear of

Trauma such

Inability to

attachment

loosing

as neglect,

experience

issues,

control.

violence. Self- pleasure.

developmental

hatred, self-

trauma, shock

doubt, social

trauma and

pressure to be

grief-loss.

thin.

Repairing the Broken Mirror 77

Question 6. Movement

Participant A

Participant C

Participant D

1 (strongly disagree) 2 (disagree) 3 (neither agree nor disagree)

patterns a) Purge position

Participant B

4 (agree) 5 (strongly agree) 4

Responses

3

3

considered N/A b) Lack of

5

N/A

4

3

5

N/A

4

3

5

N/A

4

5

5

N/A

2

5

4

N/A

4

3

3

N/A

4

3

movement in chest c) Rigidity of pelvis d) Primary utilization of peripheral movements e) Difficulty grounding weight f) Indirect use of space g) Sporadic stop and go movements

Repairing the Broken Mirror 78

Question

Participant A

Participant B

Participant C

Participant D

7. Other movement

Lack of

Explosive

Minimal

Decreased

patterns:

integration

movements.

movements in

lack of body

between upper

near reach

experience,

and lower

space, a lack

inability to use

body, agitated

of full efforts.

body

urgency or

experience to

little sense of

guide

time, focused

actions/choice

directional

s/thoughts.

movement, poor spatial awareness, rigid spine, lack of energy and connection to pelvis.

Repairing the Broken Mirror 79

Question 8. Interventions

Participant A 1 (never use)

Participant B 2

Participant C

3 (use moderately)

4

Participant D

5 (use all the time)

a) Guided imagery

3

1

3

3

b) Centering

5

5

2

4

5

5

2

4

d) Improvisation

4

5

4

3

e) Authentic

2

1

5

2

2

1

1

1

4

4

2

1

exercises c) Relaxation techniques

movement f) Bartenieff fundamentals g) Props 9. Other

Grounding,

Participant

Mirroring.

Use of basic

interventions used:

body

chose not to

stretching

awareness,

respond

exercises to

breath work

increase

and boundary

awareness of

work.

body experience.

Repairing the Broken Mirror 80

Question

Participant A

10. Effectiveness of movement

Participant B

Participant C

Participant D

1 (not effective) 2 (somewhat effective) 3 (never use/not applicable) 4 (effective) 5 (extremely effective)

interventions a) Exaggeration of

3

disliked body part

Participant

3

1

chose not to respond

b) Self touch

3

2

3

4

c) Chairs and body

4

2

3

3

4

1

3

3

e) Physicalization

5

5

5

3

f) Functional

3

1

5

5

g) Rehearsal

4

2

3

4

h) Touch and

3

1

3

5

4

2

3

3

j) Floor work

4

2

3

3

k) Polarities

4

3

3

2

image distortion d) Freeze, red light/green light

technique

massage i) Synchronous breathing

Repairing the Broken Mirror 81

Question

Participant A

Participant B

Participant C

Participant D

Other

Sculpting

Participant

Mirroring,

Focusing

interventions:

feeling states,

chose not to

walking

based

moving in

respond

meditation,

exercises, use

stretching.

of movement

relationship to emotions and

phrasing.

cognitions, exploration of kinesphere through body and visualization. 11. Use of

1 (never use)

2

3 (use moderately)

4

5 (use all the time)

transference Scores: Other:

5

5

4

Transference

Explores

provides

therapeutically support

to short-term

diagnostic

actively and

client’s

setting

information,

passively.

process.

guides interventions.

Used to

N/A Didn’t use due

Repairing the Broken Mirror 82

Question 12. Use of

Participant A 1 (never use)

Participant B 2

Participant C

3 (use moderately)

4

Participant D

5 (use all the time)

countertransference Scores:

4

Participant

4

5

chose not to respond Other:

Also provides

Participant

Gather

To understand

information

chose not to

information:

metaphors of

about client.

respond

what does the

the patient’s

client want me experience to know?

and to

Used to

understand

understand the useful and non client’s

useful

experience.

responses within the therapeutic relationship.

13. Effect of work

1 (never)

on body–self and

2 (rarely)

4 (more than often)

3 (sometimes)

5 (most of the time)

body image Scores:

4

2

3

3

Repairing the Broken Mirror 83

Question 14. What effects?

Participant A

Participant B

Participant C

Participant D

Awareness of

Participant

More aware of Eating used as

effects on self

chose not to

personal

a defense is

of cultural

respond

relationship to

heightened.

images of

food and

beauty

eating. Awareness of cultural ideals of beauty on self.

15. Methods used

Personal

One on one

Personal

Personal

for self-

therapy, one-

supervision,

therapy, one-

therapy, one

preservation

on-one

peer

on-one

on one

supervision,

supervision,

supervision,

supervision,

massages

group

group

group

therapy,

supervision,

supervision,

supervision,

authentic

personal

meditation,

meditation,

movement,

therapy.

authentic

exercise.

meditation, and

movement,

exercise.

social life.