Building Response Flexibility in Clients With Eating Disorders: Improvisation and Embodying Addiction

By Laura L. Wood, MA, RDT-BCT, LPC, CCLS

Currently, statistics show that individuals with eating disorders have a higher mortality rate than those suffering from any other mental illness (Smink, van Hoken & Hoek, 2012). No single type of treatment is universally successful; rather each eating disorder type (Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder) responds to its own unique course of treatment. Even though there has been significant growth over the last twenty-five years in treatment approaches for different types of eating disorders, there is still a significant gap in what we know to be effective (Fairburn & Harrison, 2003). Unfortunately, public interest in eating disorders and common misunderstandings about the disorder far outweigh the research being conducted in eating disorder treatment. In fact, most research is housed in psychiatry department medical schools (Wilson, Grilo & Vitousek, 2007). In 2007, Wilson, Grilo, and Vitousek presented a call to researchers (other than medical doctors) to increase the research for eating disorders, declaring that we as psychologists and counselors are “well positioned to make important contributions to the study of eating disorders…including exploring psychobiological mechanisms that cause and maintain eating disorders, and identify the mechanisms (mediators) of therapeutic change” (p. 212). Answering this call, my work and current research in progress (and this blog submission!) are focused on using drama therapy to help clients with eating disorders to build response flexibility.

It is well known in the field that the cause of an eating disorder is complex. Both genetic predisposition and environmental factors contribute to the use of an eating disorder as a maladaptive coping mechanism (Fairburn, 2008). The different contributing environmental factors can be grouped into the following three broad categories: trauma and abuse, anxiety, and developmental/family of origin issues. Clients with eating disorders often have a make-up of factors from one, two, or all three of these categories. While there are different treatment tracks for eating disorders associated with each category of factors, there are also areas of overlap. All clients with eating disorders (with whatever combination of trauma, anxiety or developmental/family of origin problems), for example, suffer from issues of response flexibility. “Response flexibility enables us to pause before responding as we put a temporal and mental space between stimulus and response and between impulse and action” (Siegel, 2012 p. 33-2). Clients with eating disorders, rather than having healthy response flexibility, suffer from extremes of rigidity and chaos (Cassin and Von Ranson, 2005). With rigidity (most common in clients with Anorexia Nervosa), thought, emotional, and behavioral repetition become the primary way of coping and identifying, rather than a sense of spontaneity, creativity, playfulness, and presence. Extreme chaos is characterized by the intrusion of overwhelming and unpredictable thoughts, emotions and behaviors (most often seen in clients with Bulimia and Binge Eating Disorder) (Siegel, 2010; Claes, Vandereycken, and Vertommen, 2002).

To encourage movement away from rigidity and chaos and towards healthy response flexibility, Siegel (2012) suggests we help clients increase their window of tolerance: the “span of tolerable levels of arousal in which internal or external stimuli can be processed in a flexible and adaptable manner” (p. 85).

Coming to understand the protective functions of an eating disorder is one of the first steps in formulating a treatment approach. This process is often very frightening for clients, triggering their rigid or chaotic response strategies to deal with the uncomfortable feelings that arise when exploring this material. For example, if asked to write, as a means of exploration, about the function of their eating disorder, rigid clients often become entrenched in writing and re-writing. The focus shifts from developing insight about their eating disorder through spontaneity, connection, and discovery, to writing a “perfect paper” that has outstanding grammar and punctuation. Conversely, chaotic clients use the writing as an opportunity to “purge” their feelings. They may write fifteen pages of repetitive and unorganized thoughts that perpetuate their chaotic way of coping, leaving them feeling more dysregulated and confused. I have found that in the early stages of treating clients’ eating disorders, writing is minimally useful. In many ways, this is also true for other traditional verbal methods within the group therapy process. Rigid clients sit, and think, and find a way to give the “perfect” controlled answer that won’t open them up to vulnerability. Meanwhile, chaotic clients ramble on, often getting so lost in the telling of their experience that other group members feel equally lost, and they are left feeling alone, isolated, and misunderstood. When these patterns are mirrored for clients with eating disorders, often their shame and self-hate is so rigid/chaotic they can’t tolerate the feedback. Trapped again, they turn to their soothing friend, the eating disorder, with whom they continue to play out their rigid (restriction) and chaotic (binging and purging) patterns.

Therefore, helping clients to discover the functions of their eating disorder in a way that doesn’t perpetuate their rigid and chaotic coping styles is essential. This is why in the early stages of eating disorder treatment I begin with two different types of groups that work in conjunction with one another to begin to increase clients’ windows of tolerance in order to help build response flexibility:

1) A Drama Therapy group in which we explore the role of the eating disorder through the lens of the Internal Family Systems (IFS) Model.

2) A modified Developmental Transformations (DvT) Group that allows clients to start learning to play with their rigidity and chaos (which also helps minimize the triggering of their shame and self-hate).

Wood lecturing at a recent conference in Alabama helping clinicians to experience drama therapy and it's benefits for eating disorder clients.

Wood lecturing at a recent conference in Alabama helping clinicians to experience drama therapy and it’s benefits for eating disorder clients.

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Harm and Repair in the Playspace

By Adam Reynolds, MFA, RDT-BCT, LCSW, CASAC

Over the years I have run hundreds of Developmental Transformations (DvT) groups with children and adolescents in acute crisis. While their play was often challenging and full of dark and fierce energy, reflecting their chaotic home lives and turbulent inner selves, it also had within it all the colors and vibrancy of the play of healthy, happy children and teenagers. Often those groups were discordant with the desired air of calm and restraint that many clinicians felt was the preferred stance for working with these kids. The physical and emotional freedom of Developmental Transformations generated in some staff members a fear that the patients would use the opportunity to do harm to themselves or to others.

In reality, episodes of aggression and violent outbursts were far more likely to happen during structured periods of the day: the community meeting or within gym class. The playspace (like most drama therapy spaces) allowed for feelings and ideas that could otherwise be overwhelming to find a safe and transformative expression. The group often found beautiful and eloquent ways to play with even the most difficult impulses.

So while I am a strong advocate for the playspace as a device that reduces the threat of real harm, I did continue to think about people’s fears and anxieties about play: about what could happen; the Boogeyman in the Magic Box. And I had to square that with the truth: that many people have experienced feelings of being ‘harmed’ in the play: not so much bruised toes and poked eyes – but hurt feelings and wounded egos, the ache of loneliness when offerings go unnoticed or rejected, the sting of being misunderstood, the shame or guilt of being witnessed when playing a role that had previously been private or unknown to the enactor.

These sorts of ‘wounds’ are not unique to Developmental Transformations: they can happen in any drama therapy encounter (any human encounter, actually) – but within the DvT encounter they are particularly useful because they open up the capacity for repair within the play. We mis-align, we mis-interpret, we miss: and as therapists we are seen in our failing and flailing bodies. We try again, we speak into the fragments and the silence. We repeat. Relationships are re-built and re-storied. Sometimes it happens in the here-and-now, in the play – sometimes it takes place afterwards, in reflection. Other times, these feelings fester, they colonize, they grow.

To explore this landscape of dis-ease, I have been trying to assemble a taxonomy of the experience of ‘harm’ within the playspace:

  • Discomfort when experiences in the play overwhelm or challenge us physically or emotionally and we don’t feel safe.
  • Disharmony when there are ruptures in mutuality, where people playing together may actually be playing quite far apart.
  • Distrust, when insufficient discrepancy makes us anxious about the motives or meaning of an element of the play.

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