Dance/movement Therapy And Bulimia Nervosa (manual)

Repairing the broken mirror (Manual) 1
 
 
 
 
 
 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
 
 
 
 
 
 
 
 
 
 
 Pocket
Manual
 
 October
2009



Repairing the broken mirror (Manual) 2
 


TABLE OF CONTENTS

LIST OF TABLES.………………………………………………………………………..3 Chapter 1. Introduction……………………………………………………………………4 2. Eating disorder fundamentals…………………………………………………7 3. Etiology………………………………………………………………………..9 4. Eating disorder symptoms……………………………………………………11 5. Diagnosis……………………………………………………………………..13 6. DMT treatment themes………………………………………………………14 7. DMT treatment goals………………………………………………………...16 8. Specific movement interventions…………………………………………….18 9. Monitoring
DMT
intervention
results………………………………………………….25
 10. Conclusion…………………………………………………………………………………………26
 Recommended
reading..……………………………………………………………………………………..28
 Bibliography……………………………………………………………………………..30

Repairing the broken mirror (Manual) 3
 
 List
of
Tables
 Figure 1. Roadmap Table 1. Emerging
themes
in
the
treatment
of
women
with
Bulimia
nervosa  Table 2. Therapeutic goals Table 3. Specific movement interventions

Repairing the broken mirror (Manual) 4
 
 Introduction The rising incidence of eating disorders, among which bulimia nervosa (BN), and the difficulty of treating this complex illness, have prompted the use of new therapies such as DMT to address critical mind-body integration issues not easily dealt with by other medical and psychological treatments. To promote the use and credibility of this relatively young discipline, it was judged useful to provide a structured consolidation of key knowledge and best practices that would help guide dmts engaging in the treatment of women with BN. The aim of the pilot manual is to help provide the framework for the therapeutic use of DMT and is open to further enrichment by the DMT community and BN specialists. The author does not claim for this manual to be exhaustive but supports its role as a base for further exploration. To facilitate the practical use of this pilot manual, the contents are organized to mirror the normal therapeutic process, from knowledge acquisition to DMT implementation and effectiveness assessment. This outline is summarized in the road map diagram Figure. 1. For each step of the process, the key elements have been summarized to serve as a guide for further work specific to each dmt’s objectives and patient needs. As a complex, multi-factorial illness, BN requires treatment contributions by other medical professionals. The consultation and/or coordination steps with these professionals have been included (right side of diagram). This and other quality assurance suggestions are expected to reinforce the effectiveness of the dmts’ own interventions.

Repairing the broken mirror (Manual) 5
 
 Figure 1 Road map Eating Disorder Etiology

Symptoms

DMT Diagnosis Medical, Psychiatric & Nutrition input Enquire

Observe

Test/monitor

- Patient personal, family and social history - Significant life events/trauma

- Symptoms - Movement characteristics - Psychological behavior - Social behavior

- Movement characteristics - Transference - Countertransference

Formalize and document cumulative observations

Themes emerging in treatment (cf. full list Table 1)

Mother-infant Relationship

Trauma

Mind-body connection

Validate selected themes with other professionals

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 Derive Therapeutic Goals (cf. full list Table 2)

Develop Autonomy

Develop positive coping mechanisms

Increase body awareness

Movement Interventions (cf. full list Table 3)

Flocking

Exploration of polar Opposites

Self-massage

- Ensure compatibility with interventions of other treating professionals. - Integrate pertinent environmental variables (group or individual setting, music, props, etc.

Monitoring results/consequences - Check coherence with other treatment specialists - Secure external review Therapy Effectiveness

- Patient observations and feedback - Treatment progress - Analyze potential risks and issues - Determine need for additional investigation /diagnosis

Patient-Therapist Interaction

- Assess trust status - Evaluate transference and countertransference

Adjust
and
pursue
 






Implement
therapist self-care Treatment

Repairing the broken mirror (Manual) 7
 
 Eating Disorder Fundamentals To understand the complex etiology of eating disorders as well as their mental and physical effects for the practice of DMT, clear definitions are needed. The three following definitions provide a comprehensive summary of the most important elements concerning eating disorders 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). Davis (2009) defines eating disorders as primarily psychological disorders where, “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). Eating disorders comprise two major subtypes, anorexia nervosa and bulimia nervosa (BN). Anorexia nervosa is defined as “a refusal to maintain a minimally normal body weight” (DSM-IV-TR, 2000, p. 583). It is divided into two subtypes: restrictive and binge-eating/purging type. As the focus of this pilot manual is on BN, no further discussion of anorexia is included. The DSM-IV-TR (2000) text revision, defines BN 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 is definitely larger than most individuals would eat under similar consequences” (p. 589). 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

Repairing the broken mirror (Manual) 8
 
 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. 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 use this method of purging. Bulimia nervosa is also divided into purging and non-purging types. However, the two are very similar in their psychological development and symptomology. 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.

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 Etiology Eating disorders are complex disorders that affect individuals mentally and physically. According to current knowledge, the most prevalent medical hypotheses of etiology are: - Genetic predispositions - Neurobiological vulnerabilities (neuropeptide dysfunction in neuron message transmission, hormonal dysregulation, appetite control disturbances related to serotonin fluctuations) - Brain abnormalities Although these factors are not directly actionable by DMT practices, it is important that this knowledge be taken into account to insure compatibility of DMT interventions with other medical treatments. Current psychological research demonstrates the critical role of the mother infant relationship and how impingement and mismatches in this relationship can greatly affect normal child development and potentially lead to the development of BN. Examples of these are: - Deficit or trauma in nurturance from primary caregivers within the family environment - Non-negotiation of critical stages of separation-individuation - Development of unsecure, avoidant, and ambiguous attachment patterns - Underdeveloped sense of self and body self - Negative self-worth perception - Distorted body image

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 - Lack of adequate coping mechanisms - Limited self-awareness - Difficulties with self-regulation (emotions and physical sensations) These issues are central to the psychological development of the child and are often translated into future eating and behavioral disorders. Another compounding factor is trauma from: - Childhood sexual abuse - Physical abuse - Mental/verbal abuse Trauma can be considered either a causal or an aggravating factor in the development of eating disorders. Cultural and societal influences can also play a significant role in the development and maintenance of eating disorders. In particular influence from the media and the bodycare industry, which impose standards and pervasive stimuli (advertisements, body care products, dieting products, etc.) that are not necessarily consistent with one’s body makeup and psychological dispositions.

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 Eating Disorder Symptoms The intermingling of multiple mental and physiological causes in this illness is reflected in a variety of symptoms, which can be clustered as follows: Body related elements - Distorted body image/self-perception - Negative feelings about body shape and weight - Specific body tensions - Inhibited movement range/vocabulary - Reactivity to touch Self-worth issues -Negative self-worth perception -Feelings of inadequacy - Sense of failure Relationship to food and eating - Binge and purge behavior (excessive eating followed by self induced vomiting, use of laxatives, diuretics, generally done in hiding) - Inability to differentiate hunger from satiety - Excessive dieting episodes Sexuality - Hyper/hypo sexuality - Anxiety around sexuality

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 Mood - Dysphoric mood states - Aggression/anger - Depression - Anxiety Social Relationships - Difficulty forming interpersonal relationships - Social isolation - Reduced eye contact Self-Regulation - Impulsive behavior - Psychomotor agitation episodes - Poor frustration tolerance - Poor coping mechanisms (difficulty tolerating intense emotions and feelings) - Excessive exercising

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 Diagnosis As summarized in the roadmap diagram Fig. 1, the diagnostic methodology can be subdivided into three steps of input gathering and analysis. Namely: 1) Inquire about the patient’s background in relation to the occurrence of the illness. Similarly investigate the family and social context as well as significant events (e.g. trauma) that can explain the emergence or maintenance of the illness. 2) Observe, in the appropriate settings, the symptoms associated with the psychological, physical and social behaviors. 3) Perform tests chosen by the dmt in order to reveal symptoms, which cannot readily be identified without action and challenges. For example engaging the patient into a body expression exercise or organizing specific interactions with the therapist can help assess transference and countertransference patterns which would further clarify the diagnosis. To enrich and validate the dmt’s diagnosis for this multi-factorial illness, it is appropriate to share views with psychiatric, medical and nutrition professionals and to formalize a coherent diagnosis from which respective interventions will be derived. 
 
        

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 DMT treatment themes From the analysis of BN etiology, diagnoses and the survey of experienced DMT therapists, the most significant themes that emerge in the treatment process of women with BN have been compiled in table 1. These themes have been categorized in general themes and the corresponding specific themes. Table 1 Emerging themes in the treatment of women with Bulimia nervosa General themes in treatment

Specific themes

1. Mother-infant

-Patient starvation for care and affection

relationship and personal

-Poor ego strength as manifested by a need for self-

development

validation through others - False-self

2. Trauma

- Reenactments of trauma - Difficulty with touch

3. Mind-body connection

- Mind-body disconnection - Lack of body awareness - Difficulty understanding internal signals

4. Body-image

- Body image distortion - Dissatisfaction with own body - Unclear body boundaries

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 General themes 5. Self-worth

Specific themes - Low self-esteem - Feelings of inadequacy - Sense of failure - Shame - Guilt

6. Mood

- Depression - Anxiety - Anger/ aggression

7. Self-regulation

- Loss of control/need for control - Search for relief through binge/purge behaviors - Inadequate coping mechanisms

8. Relationship to food and

- Emotional eating

eating

- Disrupted eating patterns

9. Social relationships

- Social isolation - Difficulty forming relationships - Secrecy

10. Sexuality

- Avoidance - Anxiety/fears - Hypo or hyper sexuality

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 DMT treatment goals The themes illustrated previously can serve as a guide to identify specific themes for each patient and the corresponding therapeutic goals. The most meaningful therapeutic goals identified through the study are listed in table 2. Table 2 Therapeutic goals General themes in treatment

Therapeutic Goals

1. Mother-infant

- Develop sense of autonomy/ self-differentiation

relationship and personal

- Renegotiate stagnations of separation-individuation

development

- Promote impetus to move forward with self-development - Develop alternative secure attachments - Development of authentic self

2. Trauma

- Safe processing of traumatic material

3. Mind-body connection

- Foster mind-body integration - Develop sense of psychological and body self - Regenerate body’s potential to move - Develop/increase ability to express self through movement - Develop capacity to symbolize and play - Improve overall body awareness

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General Themes in

Therapeutic Goals

Treatment 4. Body-image

- Decrease of body-distortion - Clarification of body boundaries - Development of stable body image

5. Self-worth

- Foster positive self-esteem

6. Mood

- Decrease depression - Reduce level of anxiety - Increase movement vocabulary

7. Self-regulation

- Develop capacity for self-nurturance - Development of positive coping mechanisms - Provide alternatives to binge/purge behaviors - Releasing body tensions/stress - Increase ability to express emotions safely through movement

8. Relationship to food

- Understand and manage emotional eating

9. Social relationships

- Develop trusting relationship with therapist - Decrease social isolation - Develop improved social skills

10. Sexuality

- Increase patient comfort with own sexuality

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 Specific movement interventions Specific movement interventions gathered from the literature review and those recommended by experienced therapists, through the survey, have been classified in table 3 and are matched with the most relevant therapeutic goal. Understandably, these movement intervention examples are not exhaustive or exclusively limited to one therapeutic goal. It is up to the dmt’s judgment and creativity to apply these movement interventions to other relevant therapeutic goals. For some of the therapeutic goals listed, recommended movement interventions were rather limited. This highlights the need for further research and a more extensive survey of experienced therapists to enrich treatment options and to complete this first pilot manual. Table 3 Specific movement interventions Therapeutic Goals - Decrease social isolation

Specific Movement Interventions - In group setting, movement synchronization through use of rhythm can foster a sense of relatedness, identification and belonging to a group. - Use of imitative walking. Patient(s) adopt each other’s walk pattern.

- Increase patient comfort

- Self-massage

with own sexuality

- In group setting, if appropriate trusting relationships have been established, patients can give each other foot or

Repairing the broken mirror (Manual) 19
 
 shoulder rubs. Therapeutic Goals

Specific Movement Interventions

- Develop sense of

- Utilizing Chacian circle concept, pass leadership from

autonomy/self-

patient to patient.

differentiation

- Use of conga lines, alternating leaders - Flocking

- Renegotiate stagnations of

- Seated mirroring with therapist as leader (reminiscent of

separation individuation

early pre-ambulatory tie) (Krueger and Schoefield).

process/ Promote impetus to

- Patient led mirroring

move forward with self-

- “Facing the mirror” (Krueger and Schofield): patients

development

move facing a mirror (this simulates the practicing subphase of separation-individuation process)

- Develop alternative secure

- Use of mirroring and moving in synchrony with patient

attachments

to show empathy and give patient experience of being understood and accepted

- Development of authentic

- Movement improvisation by patient as means of

self

awakening the unconscious - Use of authentic movement technique by patient as means of discovering own unconscious process

- Processing of traumatic material safely - Regenerate body’s potential to move

- Improvisation

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 Therapeutic Goals - Mind-body integration

Specific Movement Interventions - Use of Bartenieff fundamentals - Mobilization (Evans): encourage self-created movements that reconnect movement and feelings. - Functional technique (Evans): targeted movement exercises aimed at supporting psychological shifts.

- Develop capacity to

- The use of props such as balls, parachutes, scarves, etc

symbolize and play

can facilitate the development of play

- Clarification of body

- Self touch

boundaries

- Self-massage - Exploring personal space defined with a rope. This is used as a metaphorical delimitation. One can remain alone in this space or invite others in. - In pairs, one person stands still and the other slowly advances till the standing person asks them to stop. This is an exploration of comfort with distances between self and others.

- Increase/foster positive

- Leadership activities such as conga lines, flocking and

self-esteem

so on.

- Decrease depression - Provide alternatives to binge/purge behavior 


- cf. self-regulation interventions.

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 Therapeutic Goals

Specific Movement Interventions

- Development of stable

- “Mirror image” (Totenbier): the patient is asked to

body image

imagine looking at herself in a mirror then progressively imagines looking at herself from different angles. She then moves to the examination of her body as a whole unit. Next, she is asked to hold out her right hand and examine it from various angles. This is then repeated with the other arm, legs, torso, neck and head. Again she is asked to view her mirror image as a whole unit and not as fragments. This is followed by a discussion of feelings, associations, and so on that emerged during the activity.

- Reduce levels of anxiety

-Relaxation techniques (e.g. stretching, vigorous shaking, self-massage) - Simple breathing techniques - Progressive relaxation - Guided imagery

- Increase ability to express

- Physicalization (Evans), which consists of transforming

emotions safely through

an experience into actions with feelings.

movement - Understand emotional eating 
 


- Improvisation around topics related to eating

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 Therapeutic Goals - Decrease body-distortion

Specific Movement Interventions - “Bigger than life” intervention by Stark et al. (1989). Utilizing music, patients are asked to focus a part of their body that they dislike, then dance with the image of it getting bigger and bigger. At the end of the intervention, the patients are asked to strip that image off and place it in a pile in the middle of the room, symbolically removing the negative image from themselves. - Have patient place 2 chairs side by side at the distance they believe represents their body width. Then ask them to stand between them and assess the dimensional difference between perception and reality.

- Increase movement

- Improvisation: the process of free association of

vocabulary

movements - Authentic movement with therapist as witness - Working in groups, patients can pick up movement from others. - Mobilization (Evans): encourages self-created, spontaneous movement exploration and the reconnection of movement with feelings.

- Develop improved social

- Rehearsal of social situations through movement with

skills

therapist or peers

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 Therapeutic Goals

Specific Movement Interventions

- Improve overall body

- Self-massage

awareness

- Breath work (e.g. any form of deep breathing) - Touching body with objects that have different tactile properties - Pressing body parts against different surfaces - Exploration of posture - Body-focusing (Dosamantes-Alperson): patients are first led through a relaxation sequence, then they are ask to gauge levels of comfort and discomfort in this state.

- Develop capacity for self

- Use of fabrics to wrap around body

nurturance

- In group setting, sitting back to back in pairs and rocking to music - In circle, holding hands and rocking/swaying to music

- Development of positive

- Exploration of polar opposites (e.g. push/pull,

coping mechanisms and

open/close) and the gradual transition between the two

ability to self-regulate

opposites. The patient is asked to notice feelings and sensations emerging during this process. - The use of props: pillows, punching bags, balls, parachutes, etc. can provide a less threatening way to release emotions such as anger.




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 Therapeutic Goals

Specific Movement Interventions

- Development of positive

- Exploration of polar opposites (e.g. push/pull,

coping mechanisms and

open/close) and the gradual transition between the two

ability to self-regulate

opposites is supported by the therapist. The patient is asked to notice feelings and sensations that occur during this process. - The use of props such as pillows, punching bags, balls, parachutes, etc. can be helpful in providing a less threatening way of releasing emotions such as anger.

- Releasing body

- Relaxation techniques

tensions/stress

- Breathing and identification of areas of tension with progressive release (e.g. body scan). - “Full Breathing”: technique using the image of threedimensional breathing.

- Develop trusting

- The use of mirroring or moving in synchrony with others

relationship with therapist

can be effective.

and peers

* People with BN are very self-conscious and mirroring must be done carefully so that the patient does not feel mocked. - “Trust falls”: patients let themselves fall backwards into a parachute held by the group or into the arms of the therapist or a peer.




Repairing the broken mirror (Manual) 25
 
 
 Monitoring DMT intervention results DMT is clearly a dynamic process, during which the therapist further discovers the patient and her response to the chosen interventions. For this result-monitoring phase, a well-planned methodology and formal documentation of the conclusions are recommended. The assessment of therapy effectiveness ought to include patient feedback, treatment progress and illness relief, emerging issues or risks and the need for further diagnosis. The evaluation of the patient-therapist relationship ought to cover the level of trust established and the transference/countertransference outcomes emerging from their interaction. To complement the evaluation of intervention effectiveness and patient-therapist relationship, input from external reviewers (e.g. supervision) and other professionals contributing treatment would be beneficial. The conclusions of these evaluations can then be exploited to fine-tune the patient treatment and to address the therapist’s need for self-care.

Repairing the broken mirror (Manual) 26
 
 Conclusion With the hope that this pilot manual would contribute to greater use and effectiveness of DMT for BN treatment, the author wishes to share her perspectives on additional initiatives that could encourage the use of this type of manual, enrich its contents and reinforce its credibility. To broaden the use of the manual, the following actions are recommended: - Distribute this manual to DMT therapists and other professionals dealing with eating disorders for a constructive review and improvement suggestions. - Devise a forum for ongoing exchange between dmts (websites, blogs, meetings, etc.) and develop a consensus about the format and contents for an optimal manual. To enrich the contents: - Broaden the survey of dmt therapists and plan periodical updates to gain additional input about their field experience. - Investigate important topics for which sufficient information was not available for this manual (intervention sequencing guidelines in the therapeutic process, age specificity for movement interventions, additional methods to reduce binge/purge behaviors, etc.). - Use the exchange forum to share novel movement interventions/techniques developed by dmts. To reinforce DMT credibility for BN treatment: - Organize broader national surveys or specific evaluations that can yield quantitative data about the most successful DMT interventions.

Repairing the broken mirror (Manual) 27
 
 - Develop a reliable and collaborative methodology to assess intervention effectiveness and to create a shared data bank. - Determine an official process for the validation of proven and specific movement interventions.

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 Recommended reading Bartenieff, I. & Lewis, D. (1980) Body movement: Coping with the environment. New York: Routeledge. Dosamantes-Alperson, E. (1981). Experiencing in movement psychotherapy. American journal of dance therapy, 4(2), 33-43 Gillespie, J. (1996). Rejection of the body in women with eating disorders. The Arts in Psychotherapy, 23(2), 153-161. Hornyak, L. M., & Baker, E. K. (Eds.). (1989). Experiential therapies for eating disorders. New York: The Guilford Press. 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. Musicant, S. (2001, Spring/Summer). Authentic movement: Clinical considerations. American Journal of Dance Therapy, 23(1), 17-28. doi:10.1023/A:1010728322515

Repairing the broken mirror (Manual) 29
 
 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. 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.

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 Bibliography American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) text revision. Washington, DC: Author. Bartenieff, I. & Lewis, D. (1980) Body movement: Coping with the environment. New York: Routeledge. 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-Alperson, E. (1981). Experiencing in movement psychotherapy. American journal of dance therapy, 4(2), 33-43 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,

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 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. 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

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 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. 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

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