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).