Work is one of the most distinctive components of the therapeutic community (TC) treatment model. Indeed, the telling mark of the TC social environment is the vibrancy of its work activities. Work in the TC is a fundamental activity used to mediate socialization, self-help recovery, and right living. This chapter describes how work mediates essential educational, therapeutic, and community goals. For disadvantaged, antisocial, or nonhabilitated substance abusers, many of whom have few work skills, social identity and self-esteem are first acquired through participation in the work structure of the TC. Work in the TC addresses characteristics of the person and the disorder. These characteristics can be classified into related categories: personal habits, work habits, work relations, self-management, and work value. Job functions are utilized in three main ways: for skills training and education, for therapeutic change, and to enhance the peer community.
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Residents in the therapeutic community (TC) engage in a variety of interpersonal roles and relationships both within and outside of the program. Friendships and attachments, romantic or sexual, “naturally” emerge within the peer community and are profoundly affected by the insistent intimacy of the TC community life. This chapter examines how these interpersonal relationships are utilized to transmit community teachings on right living and recovery. The poor quality of past friendships and romantic attachments has been implicated in the drug problems of substance abusers in general. Among residents in TCs, the relationship problems that most commonly surface are related to sexuality, interpersonal fears, and lack of relationship skills and values. Of special importance to the individual and the community, however, are three main types of relationships: sexual relationships, romantic relationships, and friendships. Contemporary TCs have changed their tolerance levels toward greater acceptance of homosexuality.
A theoretical framework of the therapeutic community (TC) grounded in clinical and research experience can maintain the unique identity of the TC and the fidelity of its wider applications. This chapter illustrates several broad initiatives: generic TC model, general guidelines for adapting and modifying the TC for special settings, special populations, and funding limits; the codification of principles and practices of the TC into explicit standards to maintain the integrity of the program model and method, training and technical assistance, and research agenda. Staffing compositions have changed to reflect a mix of traditional professionals; correctional, mental health, medical, educational, family, and child care specialists; social workers; and case managers to serve along with the experientially trained TC professionals. The evolution of the contemporary TC for addictions over the past 30 years may be characterized as a movement from the marginal to the mainstream of substance abuse treatment and human services.
In the therapeutic community (TC), surveillance means supervision and management of the orderliness and safety of the physical environment, as well as the health and conduct of the social environment. This chapter describes the main facility-wide surveillance activities of the general inspections (GI), the house run, and urine testing, actions implemented in the management of the community. The GI is a useful community and clinical management activity. The house run is the main system of surveillance in the TC. In terms of management goals, house runs permit early detection of potentially larger problems such as those related to fire, sanitation, and security. However, its fundamental clinical purpose is to assess the status of individuals in terms of self-care, self-management, and their relationship to the community. The main urine test procedures used by most TCs are unannounced random urine screens and incident-related testing procedures.
The idea of the therapeutic community (TC) recurs throughout history implemented in different incarnations. In its contemporary form, two major variants of the TC have emerged. One, in social psychiatry, consists of innovative units and wards designed for the psychological treatment and management of socially deviant psychiatric patients within mental hospital settings. In the other form, TCs have taken are as community-based residential treatment programs for addicts and alcoholics. This chapter explores the sources and evolution of these communities to illustrate how they contribute to the theoretical framework of the TC. It describes the direct and indirect influences shaping the essential elements of the modern TC. The early religious influences on the Oxford group and Alcoholics Anonymous (AA) reappear as elements of the modern TC. The search for an “essential TC” reveals a universal idea recurring in various forms throughout history: that of healing, teaching, support, and guidance through community.
At the core of the change process in the therapeutic community (TC) is the relationship between the individual and the community. Internalization is a familiar psychodynamic concept connoting learning that involves “taking in” the behavior and teachings of others. In the TC, internalization is evident when new learning becomes a “natural” part of the individual’s repertoire. In the TC internalization is inferred from patterns of behavioral, experiential, and perceptual change occurring over time. These may be described in terms of several broad characteristics: cognitive dissonance and behavioral conflict, generalization, learning to learn, and confirmatory experiences. The course of internalization can be characterized as a gradient that depicts changing levels or stages of internalization. Four stages refer to changes during treatment, compliance, conformity, commitment to program, and commitment to self. A change in identity is the distinctive marker of the integration stage.
Encounter group is a profoundly significant component of the therapeutic community (TC) approach, illustrating by example some of the TC’s basic teachings: compassion and responsible concern, the necessity for confronting reality, absolute honesty, and self-awareness as the essential first step in personal change. The encounter group is pre-eminently a verbal forum employing everyday personal and social vernacular. All encounter groups in the TC are similar in their preparation, structure, and process. An encounter unfolds as a process characterized in terms of four phases: the confrontation, the conversation, the closure, and the socializing phase. Ideally, each encounter accomplishes its general purpose of strengthening group cohesion and its goals for specific individuals. Depending upon its purpose or group composition, the encounter can be modified in intensity and format and the extent of staff involvement as facilitators.
In the therapeutic community (TC), peers are the primary change agents. In their varied social roles and interpersonal relationships, residents are the mediators of the socialization and therapeutic process. This chapter details how peer roles and relationships are utilized by the community to facilitate the goals of socialization and psychological change. The socialization history of serious substance abusers is marked by negative peer influences. Functional roles in the TC are those involving performance demands, prescribed skills and attitudes, and defined relationships with others. Three prominent community member roles are peers as managers, as siblings, and as role models. A defining element of the TC model is the use of peer roles for social learning. The chapter describes how the various community and functional roles in the social organizations are utilized by peers to change themselves and others and how socially conditioned race-ethnic and gender roles and issues are addressed.
In the recovery perspective of the therapeutic community (TC), lifestyle and identity changes reflect an integration of behaviors, experiences, and perceptions. The essential experiences can be conceptualized under three broad themes: emotional healing, social relatedness and caring, and subjective learning. Emotional healing refers to moderating the various physical, psychological, and social pains that residents experience in their lives directly or indirectly relating to their substance use. The essential experiences reflecting psychological safety are blind faith and trust, and understanding and acceptance. Trust problems are prominent in the lifestyles of substance abusers. Hallmark characteristics of substance abusers in general are their lack of self-understanding and self-acceptance. Personal isolation or unhealthy attachments with others characterize the past social relationships of residents in TCs. The key social relatedness and caring experiences are identification, empathy, and bonding. In the TC, social learning unfolds as an interaction between the individual and the community.
This chapter describes the various roles and functions of the treatment program or clinical management staff in the residential facility. It characterizes the roles of support staff and agency personnel. Teachers, physicians, nurses, psychologists, social workers, lawyers, and accountants in the TC ply their professions in the usual way. The relationship between staff and peer roles is rooted in the evolution of the Therapeutic Community (TC). In the TC approach, the role of staff is complex and can be contrasted with that of mental health and human service providers in other settings. An array of staff activities underscores the distinctively humanistic focus of the TC. The chapter describes how primary clinical staff in the treatment program supervise the daily activities of the peer community through their interrelated roles of facilitator, counselor, community manager, and rational authority. Other staff provide educational, vocational, legal, medical, and facility support services.
In the therapeutic community (TC), recovery is viewed as a change in lifestyle and identity. It is a view that can be contrasted with the conventional concept of recovery in medicine, mental health, and other substance abuse treatment approaches. In the public health experience of treating opioid addiction and alcoholism, drug abuse is viewed as a chronic disease, which focuses treatment strategies and goals on improvement rather than recovery or cure. The TC view of recovery extends much beyond achieving or maintaining abstinence to encompass lifestyle and identity change. This chapter outlines this expanded view of recovery and details the goals and assumptions of the recovery process. It presents the TC view of right living, which summarizes the community teachings guiding recovery during and after treatment. The terms “habilitation” and “rehabilitation” distinguish between building or rebuilding lifestyles for different groups of substance abusers in TCs.
The therapeutic community (TC) for addictions descends from historical prototypes found in all forms of communal healing. A hybrid, spawned from the union of self-help and public support, the TC is an experiment in progress, reconfiguring the vital healing and teaching ingredients of self-help communities into a systematic methodology for transforming lives. Part I of this book outlines the current issues in the evolution of the TC that compel the need for a comprehensive formulation of its perspective and approach. It traces the essential elements of the TC and organizes these into the social and psychological framework, detailed throughout the volume as theory, model, and method. Part II discusses the TC treatment approach, which is grounded in an explicit perspective that consists of four interrelated views: the drug use disorder, the person, recovery, and right living. The view of right living emphasizes explicit beliefs and values essential to recovery. Part III details how the physical, social organizational, and work components foster a culture of therapeutic change. It also outlines how the program stages convey the process of change in terms of individual movement within the organizational structure and planned activities of the model. Part IV talks about community enhancement activities, therapeutic-educational activities, privileges and sanctions, and surveillance. The groups that are TC-oriented, such as encounters, probes, and marathons, retain distinctive self-help elements of the TC approach. Part V depicts how individuals change through their interaction with the community, provides an integrative social and psychological framework of the TC treatment process, and outlines how the basic theory, method, and model can be adapted to retain the unique identity of contemporary TCs.
Therapeutic communities (TCs) are designed to enhance the residents’ experience of community within the residence. This chapter explores how the physical environment of the TC, its setting, facilities, and inner environment, can contribute to this perception and affiliation with community. Its separateness from the outside community in addition to its living spaces, furnishings, and décor are all utilized to promote affiliation, a sense of order, safety, and right living. TCs for the treatment of addiction are located in a variety of settings, which may be determined by funding sources and the external resistance to or acceptance of rehabilitation programs. Within the context of the TC perspective, privacy is considered an earned privilege based on the individual’s social and psychological growth. There are four physical features of the inner environment that instantly identify what is unique about a TC program: the front desk, the structure board, wall signs, and decorative artifacts.
In the therapeutic community (TC) perspective, changing the whole person unfolds in the continual interaction between the individual and the community. This chapter provides the multidimensional picture of social and psychological change in terms of behaviors, cognitions, and emotions. Four major dimensions reflect the community’s objective view of individual change. The dimensions of community member and socialization refer to the social development of the individual specifically as a member of the TC community and generally as a prosocial participant in the larger society. The developmental and psychological dimensions refer to the evolution of the individual as a unique person, in terms of personal growth, personality, and psychological function. Each illustrates typical indicators of individual change in terms of objective behaviors, cognitions, and emotions. Changing the “whole person”, however, includes how individuals perceive and experience the program, the treatment, and themselves in the process.
This chapter presents the formulation of the therapeutic community (TC) as theory, model, and method. The TC has proven to be a powerful treatment approach for substance abuse and related problems in living. The TC is fundamentally a self-help approach, evolved primarily outside of mainstream psychiatry, psychology, and medicine. The TC’s basic approach of treating the whole person through the use of the peer community, which was initially developed to address substance abuse, has been amplified with a variety of additional services related to family, education, vocational training, and medical and mental health. The evolution of the TC reveals the vigor, resourcefulness, and flexibility of the TC modality to expand and adapt to change. The sophistication of the TC is evident in the fact that Therapeutic Communities of America (TCA) has established criteria and procedures for evaluating counselors and certifying their competency.
The therapeutic community (TC) is a culture of change. All of the activities, social roles, interpersonal interactions, and community teachings focus upon the theme of individual change. The perceptions that are considered to be essential to recovery are interrelated, although they can be organized into classes to clarify their contribution to the process. Perceptions related to treatment reflect the individual’s motivation, readiness, and suitability to engage in the process of change in the TC. Self-control is indicated when individuals perceive the problem as internal rather than external, as one of regulating their impulses. Perceptions of self-management of patterns of behaviors, attitudes, and feelings depend upon previously learned control of specific behaviors in various situations. Assessing and affirming individual progress is a central activity in the TC. Staff evaluations formally assess the levels of self-change, while peers and staff assess them informally.
In the therapeutic community (TC) perspective, the substance abuse disorder is not distinct from the substance abuser. A picture of dysfunction and disturbance of individuals entering treatment reflects a more fundamental disorder of the whole person. This chapter presents the TC view of the disorder in the context of current biomedical, social, and psychological understanding of chemical dependency. Overall, the picture that individuals present when entering the TC is one of health risk and social crises. In the TC perspective, drug abuse is a disorder of the whole person, affecting some or all areas of functioning. In the TC view, social and psychological factors are recognized as the primary sources of the addiction disorder. Substance abusers themselves cite a variety of reasons and circumstances as causes of their drug use. TC policy on the use of pharmacotherapy is currently undergoing modifications.
Privileges and sanctions constitute an interrelated system of community and clinical management through behavioral training. The management of the community is the responsibility of peers and staff. This chapter details the formal system of community privileges and sanctions prescribed by staff and the informal system of verbal affirmations and correctives implemented primarily by peers. Privileges are used to promote individual socialization and personal growth. It confirms the resident’s overall personal autonomy and ability for self-management. Money is a major problem in the lives of substance abusers. However, money difficulties also reflect social and psychological problems among substance abusers in therapeutic communities (TCs). Sanctions may be grouped into verbal correctives and disciplinary actions. Sanctions promote community awareness and peer self-management and maintain social order through addressing individual and collective infractions. Sexuality is approached differently from the other rule-governed behaviors in the TC.
As components of the therapeutic community (TC) treatment model, the stages define the program’s plan for moving individuals toward the goals of social and psychological change. This chapter describes the process of change in the TC in terms of participation and levels of involvement. It focuses on participation and community as method through the program stages. The chapter outlines some relations between the social and psychological dimensions of individual change and the community expectations for participation. It also describes the process of multidimensional change through treatment in terms of levels of involvement in the community. Participation and involvement link community as method to the individual in the change process. The terms engagement, immersion, and emergence label the individual’s level of involvement in the community. Perceptions related to self and identity are incremental through the levels of involvement.
In the therapeutic community (TC), the therapeutic and educational component that focuses specifically on the individual consists of the various forms of group process. The groups that are TC-oriented, such as encounters, probes, and marathons, retain distinctive self-help elements of the TC approach. This chapter provides an overview of general elements and forms of group process in the TC. Conventional psychotherapy and group therapy have not been particularly effective with substance abusers entering TCs for various reasons. Group tools are certain strategies of verbal and nonverbal interchange that are employed by participants to facilitate individual change in group process. There are two main classes of group process strategies: provocative tools and evocative tools. Provocative tools, hostility or anger, engrossment, and ridicule or humor, are most pointedly used to penetrate denial and break down deviant coping strategies such as lying.
Community is the primary means of teaching and healing in the therapeutic community (TC). This chapter presents an overview of the four main facility-wide community meetings, namely, morning meeting, seminar, and house meeting, and general meeting, as organized components of the daily regimen. The common purpose of the main meetings in the TC is to enhance the perception of community among the participants. These differences reflect community and clinical management as well as psychological considerations. Each meeting focuses on a specific component of community business and clinical transactions involving a large number of residents. This provides oversight of the physical security of the house and facilitates assessment of overall clinical status of the residents. Changes in individual or collective mood, attitude, and behavior can be quickly detected within a single day’s observation. Overall the various meetings are essential for efficient community as well as clinical management of the facility.
The quintessential element of the therapeutic community (TC) approach is community. It is the element of community that distinguishes the TC from all other treatment or rehabilitative approaches to substance abuse and related disorders. TCs differ profoundly from other communities in their rationale and purpose. This chapter discusses the general characteristics of community as a treatment approach: its relationship to the TC perspective, its healing and learning properties, and its social and cultural features. It translates this approach into a specific method the components of which are the “active ingredients” in the treatment process. Residents in TCs have been labeled as bad or rebellious kids, dangerous addicts or criminals, failures or losers, sick or crazy. The negative social labels become embedded in self-perceptions regarding their social and personal identities. The community approach fosters change in the social and personal elements of identity.
From a social and psychological perspective the therapeutic community (TC) can be distinguished from other institutional or treatment settings in that its social environment is the treatment model. The main elements of this model, its social organization, and social relationships are utilized for a single purpose the reintegration of the individual into the larger macrosociety. The social organization of the TC model may be described in terms of four major components: program structure, systems, communication, and the daily regimen of schedule activities. In the TC, however, each component is utilized to facilitate the socialization and psychological growth of the individual members. This chapter provides an overview of these components and how they contribute to the TC treatment approach. Each of these components of the social organization reflects an understanding of the TC perspective and each is used to convey community teachings and promote self-examination and self-change.
In the therapeutic community (TC) perspective, the core of addiction disorder is the “person as a social and psychological being” how individuals behave, think, manage emotions, interact, and communicate with others, and how they perceive and experience themselves and the world. This chapter details the TC view of the person in terms of typical cognitive, behavioral, emotional, social, and interpersonal characteristics. Residents in TCs display a variety of cognitive characteristics associated with their substance abuse and lifestyle problems. Residents in TCs have difficulties experiencing, communicating, and coping with feelings. Their lack of emotional self-management is associated with much of their self-defeating social behavior. The social and interpersonal context of community life in the TC provides a setting for the emergence of all varieties of guilt. Although the TC view of the person pictures a typical profile of characteristics and problems, it does not necessarily depict an addictive personality.
In the therapeutic community (TC), program stages are prescribed points of expected change. Individual status can be described in terms of typical profiles at various points in the plan of the program. This chapter provides a description of the program stages as the main structural component of the TC model, specifically designed to facilitate the change process. In traditional long-term residential TCs, there are three main program stages, induction, primary treatment, and re-entry, consisting of several phases or substages. These stages are described in terms of main goals, stage-specific activities, and typical outcomes. Individuals who complete all stages of the planned duration of treatment are candidates for program graduation. Aftercare plans are a special activity of the late re-entry phase of the program. Each stage-phase marks signify where individuals are in their socialization and psychological growth.
This chapter presents a conceptual framework of the treatment process in the therapeutic community (TC). The essential elements of the perspective, model, and method are reformulated into the three broad components of the treatment process. First, the multiple interventions in the process consist of the program structure, the people, daily regimen of activities, and social interactions in the TC. Second, individual change is multidimensional, described in terms of objective social and psychological domains as well as subjective perceptions and experiences. Third, social and behavioral learning principles and subjective mechanisms such as critical experiences, perceptions, and internalization are integral in the process itself. The main elements of the treatment process in the TC have been described in terms of community interventions, behavioral dimensions, and the essential perceptions and experiences. All change in the TC is viewed from a behavioral orientation in terms of learning and training.
This chapter provides a brief description on trauma-focused cognitive behavior therapy (CBT) and eating disorders (EDs). CBT has proven to be the most well-supported approach for EDs in the empirical research. It is considered the first-line “treatment of choice” for individuals diagnosed with bulimia nervosa and recommended for the treatment of anorexia nervosa (AN), atypical EDs, and binge eating disorders (BED). Furthermore, multiple studies have demonstrated the efficacy of using CBT for post-traumatic stress disorder and trauma symptoms. CBT for EDs is approximately 20 sessions for treating bulimia nervosa or BED, whereas treatment for anorexia nervosa can require a much longer treatment, typically lasting 1 to 2 years. Addressing trauma work will add to the number of sessions. CBT for EDs and for trauma can be done concurrently or sequenially. Deciding on the format can be done on the basis of clinical presentation and in collaboration with the client.
Neurofeedback therapy is a modality that can help a stuck brain get unstuck and learn new and better ways to fi re and function. This chapter describes what neurofeedback therapy is, how it works, and how it can be a valuable part of treatment for eating disorders (EDs). Neurofeedback therapy, also called EEG biofeedback or neurotherapy, makes use of the brain’s capacity for change to reshape brain networks. Neurofeedback uses EEG information to provide feedback to the trainee. Neurofeedback is a powerful training tool that can be used within a comprehensive treatment plan to assist clients to begin to have more control over how their brain fires. Neurofeedback therapy shifts arousal in the brain, which helps clients to alter the state they experience and to create a new narrative about themselves and the world around them.
- Go to chapter: Second Helpings: AEDP (Accelerated Experiential Dynamic Psychotherapy) in the Treatment of Trauma and Eating Disorders
Second Helpings: AEDP (Accelerated Experiential Dynamic Psychotherapy) in the Treatment of Trauma and Eating Disorders
Accelerated experiential dynamic psychotherapy (AEDP) is an attachment-oriented, emotion-focused model of psychotherapy and trauma treatment. This chapter details the course of AEDP treatment for clients with active eating disorders (EDs). It uses vignettes and a transcript from a live therapy session to highlight salient concepts and illustrate AEDP interventions in action. AEDP is fundamentally an experiential model. AEDP uses two versions of the triangle of experience to conceptualize the process and the piece of work. The first represents what AEDP calls the client’s self-at-best, or the resilient self. The second represents what AEDP calls the client’s self-at-worst, or compromised self. At the beginning of treatment, AEDP interventions are focused on building safety and regulating anxiety so that core affect can surface. Metaprocessing is an essential element of any AEDP treatment process. It undoes our clients’ aloneness with dysregulating new experiences and helps them to metabolize them instead.
This chapter provides an overview of recovery and beyond: dealing with triggers and setbacks. Recovery means holding tight to foundational ways of living that were learned in treatment and generalized into daily life during the healing process. Recovery can be inconsistent and unpredictable at times, demanding strength and courage to continuously redefine ne one’s self-story and live from one’s authentic self. Negative life events, whether they are large or small traumas, can act as powerful triggers, leading to the return of the eating disorders (ED). Stressful life events and daily life stressors can easily disturb unprocessed traumatic material, activating memory networks and causing pain and suffering, along with adding new traumatic material to the brain and body system. In the end, the therapist supports and celebrates the unique image of recovery that is self-defied, value-based, inclusive of fractures and imperfections, and created by the client.
Eating disorders (EDs) are common chronic illnesses that most clinicians, regardless of specialty, will encounter at some point, and trauma is universal in those who have EDs. Trauma from physical and/or psychological injuries overwhelms the mind and body’s capacity to adapt, and can set off or perpetuate an already present ED. The nutritional support of an individual who struggles with an ED and is a trauma survivor can be one of the most challenging tasks a dietitian encounters. One of the most accurate ways to assess the nutritional status of the body is to do two types of tests: metabolic testing and body composition analysis. Physicians, dietitians, and nutritionists who treat EDs will be treating trauma. Physicians, specifically, have a critical role in diagnosing and treating EDs. Medical caregivers need to let the patients know that they will stay the course and support them for as long as it takes.
Trauma-Informed Approaches to Eating Disorders is clearly a much needed and long overdue book about treatment, written by a diverse group of clinicians and carefully edited to focus on the needs and strengths of clinicians. The complexities and challenges that undergird, surround, and even haunt the nature, diagnosis, treatment, management, and understanding of eating disorders (EDs)-in-relation-to-trauma are so great, even for veteran clinicians, that they can leave practitioners at any level of experience feeling helpless and exhausted. This book, in a way that would be appreciated by practitioners of acceptance and commitment therapy, accepts the reality of those feelings and is committed to improving treatment, understanding, and compassion. The book is designed to foster respect for complexity and link it to humility in the presence of tragedy, tribulations, and suffering, framed all too often by our own shortcomings as healers. EDs are dangerous, ubiquitous, usually chronic in nature, and difficult to treat. Anorexia nervosa (AN) has the highest fatality rate (4%) of any mental illness. Bulimia nervosa reveals a fatality rate of 3.9%. EDs offer an enormous challenge to therapists because of their complexity, which includes severe medical risk, co-occurring anxiety, depression and personality disorders, an addiction component, and body image distortion—all of this within a mediadriven culture of thinness in which starving and purging can for some become lifestyle choices. This complexity is further exacerbated by the presence of painful life experiences or trauma. The book elucidates the connection between trauma and EDs by offering a trauma-informed phase model, as well as chapters describing the ways in which various therapeutic models address each of those phases. It offers an in-depth exposition of a fourphase model of trauma treatment.
- Go to chapter: Trauma-Informed Approaches to Body Image Disturbance: A Historical Review for a Holistic Future
The chapter analyzes the gestaltists view, psychoanalytic view, feminist and sociocultural views, and tries to come to some understanding of where one might be going in promoting change from body image disturbance (BID) to positive experience. The gestaltists sought to recognize the incredible power of the mind to organize information, so that one can effortlessly make sense of all we take in via one’s senses. The psychoanalytic view greatly helped our understanding of BID in various forms of psychopathology. However, the denial of the traumatizing effect of sexual abuse, it also greatly limited the potential for care. For many disorders, treatment models followed the historical sequence from psychoanalysis to behavioral to cognitive behavioral. The treatment of BID in eating disorder drew in one more viewpoint in1970s, that of the feminist view. Finally, the cognitivists sought to explore the internal processing that links cultural influence and learning history to psychopathology.
This chapter provides a brief description on eating disorders and the case for emotions. Throughout this chapter, the author have used the terms “emotion” and “feeling” interchangeably, although neurologically they can be understood as different stages of the emotional experience. Much of this chapter is how the author teach clients emotional courage and competence, but it has also helped many clinicians in their own journeys. Change is what we most often fear, even if it means shaking off toxic residue and stepping into the unknown of a different and healthier identity. So-called “good” feelings often end up scaring us as much as the “bad” ones, because they, too, invite change. Feeling requires courage. The emotion knocking on your door is letting you know that you have reason to be excited or fearful and that your aliveness is calling you to a larger version of yourself.
Overwhelming evidence exists that traumatic experiences leave traces in our minds and bodies. Traumatic experiences such as sexual, physical, and emotional abuse have a negative impact on our capacities to relate to and trust other people, but also on the neurobiological functioning of our brain and thus our mind. They also affect our immune systems. Hence, traumatic experiences make dealing with emotions, both positive and negative, quite challenging. In this chapter, a “state-of-the-art” review reveals the presence of a wide variety of traumatic experiences and their consequences in anorexia nervosa, bulimia nervosa, and binge eating disorder patients. Almost all studies investigated the association of retrospectively reported childhood abuse with current ED symptoms using cross-sectional designs. A special focus is on the presence of dissociation in ED patients, as it is one of the main characteristics in EDs with severe trauma.
- Go to chapter: Recognizing the Territory: The Interaction of Trauma, Attachment Injury, and Dissociation in Treating Eating Disorders
Recognizing the Territory: The Interaction of Trauma, Attachment Injury, and Dissociation in Treating Eating Disorders
This chapter briefly discusses the interaction of trauma, attachment injury, and dissociation in treating eating disorders (EDs). What is it that causes some people to develop an ED, and others to manage eating behaviors in a relatively normal manner? The answer is anything but simple. EDs are a biopsychosocial illness. They are the result of a complex interplay of factors including genes, temperament, social interactions, early attachment, culture, and of course life experiences. These variables come together and affect each other in a perfect storm fashion and may result in ED psychopathology. The cycle of being flooded with early, unprocessed trauma upon remittance of ED symptoms, followed by relapse, reduces the foundation of treatment to shifting sand. Unless the trauma and the ED are treated simultaneously, treatment becomes futile at best: fraught with multiple relapses, behavioral substitutions, feelings of hopelessness, and premature termination.
This chapter deals with structural dissociation in the treatment of trauma and eating disorders. Dissociation is the inability to stay present when intolerable feelings and mental contents are activated. It is a way of making the overwhelming less overwhelming. A dissociative process is an unconscious attempt to sequester the intolerable away into the recesses of the mind, never to be contacted again. The chapter uses structural dissociation theory of the personality. Structural dissociation theory distinguishes two action systems that govern human behavior. The first action system is daily life and second action system is defense. The theory defines three levels of dissociation, primary dissociation, secondary dissociation, tertiary dissociation. Treating dissociation is a phase-oriented approach. The first phase is stabilization and preparation for trauma reprocessing. This is where the dissociation is treated. The second phase is reprocessing the painful memories. The third phase is full consolidation and integration.
Trauma is unrelenting and pervasive; it bleeds into the present moments of daily life, often stealing joy, muting a person’s ability to fully connect and accomplish tasks of daily living. Starting with an overview of the internal family systems (IFS) model, this chapter discusses how IFS conceptualizes eating disorders (EDs) and approaches trauma treatment. IFS differs from other approaches to trauma treatment in several ways that we elaborate, especially eschewing the idea that stabilization and explicit skills training are necessary prerequisites for processing traumatic memories. Instead, IFS asserts that clients can learn to interact with the different parts of themselves without getting overwhelmed or needing the therapist to actively manage the process. The chapter uses case vignettes to illustrate how IFS achieves the goals of phase-oriented trauma treatment to heal EDs in a nonlinear, relational way.
- Go to chapter: Discovering the Power of Movement: Dance/Movement Therapy in the Treatment of Eating Disorders and Trauma
Discovering the Power of Movement: Dance/Movement Therapy in the Treatment of Eating Disorders and Trauma
Dance and movement therapist and psychologist Ann Krantz believes that “the symptoms of eating disorders (EDs) serve to disconnect affect from the body, particularly as sexuality, trauma, and cultural influences contribute to conflicts in the woman’s [individual’s] developmental struggle toward self-identity”. Individuals suffering from both trauma and EDs have difficulty making their “house” a “home”. They often run away from “home” in an attempt to feel safer, centering their lives on using emotionally driven behaviors as a way of attempting to alleviate the often horrific anxiety they might otherwise experience. Dance and movement therapists weave together nonverbal dialogues that transform everyday movements into expressive communication. The cognitive markers can be used by therapists and patients alike to decode, track, and understand the experiences that fit into the bigger picture of their lives.
This chapter explores parts or ego states somewhere in the middle of the two that are invested in one or the other form of eating disorder (ED). “Ego state” and “part” are used interchangeably in this chapter. The chapter provides a short neurological explanation of ego states, their purpose, and the difference between dysfunctional and dissociated ego states. It provides an overview of various traditions of parts, which, although not exhaustive, can uncover the common and universal characteristics of ego state work. EDs are very difficult to treat in that they demand attention on so many levels: psychological, emotional, physical, behavioral. The authors believe that it is the reality of dissociation that makes this work all the more difficult, a reality that demands an invitation to all parts of our client to come together and collaborate in the service of healing.
This chapter discusses what happens in the aftermath of trauma, abuse, and disordered eating. This aftermath includes connection to illness as identity and disconnection from sense of self, spiritual identity, higher power, and significant others. Furthermore, there is disconnection from spirituality, passion, purpose, meaning in life, internalized principles, dreams, and deepest desires. We have also provided a few of the many interventions that we have found valuable in reducing suffering and helping clients to reclaim their identity. It focuses our attention on the processes of assessment and therapeutic intervention, and, by so doing, directly addresses the building and nurturing of self. The chapter attempts to describe the journey from ED and trauma identity to knowing, strengthening, valuing, honoring, and sharing self. It is through this that an individual is able to withdraw trust and faith in illness as a way of dealing with life.
This chapter offers ways to be an effective therapist for clients who suffer from both an eating disorder and trauma (ED&T). It describes the importance of therapeutic presence and how to facilitate safety and healing through the therapeutic relationship. The information provided is equally applicable to all phases of treatment. Therapy for ED&T clients involves providing safety, education, insight, and a corrective emotional experience, thereby allowing the client to rectify faulty thought, emotional, and behavioral patterns. Therapists need to use their training and the therapeutic relationship for this to happen. The author’s experience treating ED&T clients corroborates the need for therapy training programs to increase their focus on training therapists how to achieve therapeutic presence, establish a positive alliance, and use the relationship to put the client’s symptoms out of a job.
Eating disorders (EDs) may be among the most self-destructive and persistent behaviors that emerge in the aftermath of trauma. Researchers are becoming curious about the role of the body, and, in particular, the nervous system, as it relates to ED symptoms and the management of dysregulated affect states. This chapter highlights the psychobiological processes that somatic experiencing (SE) is built upon with regard to working with trauma, with specific considerations for its application when working with the ED population. A natural starting point for understanding the intersection between trauma and EDs involves a brief overview of the effects of trauma on the nervous system. SE treatment goals are accomplished not only by listening to the client’s narrative but also by closely watching the body’s expression of the nervous system to slow the process down and explore the various elements of an experience.
This chapter conceptualizes the preparation phase in three parts for teaching and learning purposes. The preparation phase of the four-phase model is not a one-and-done event. It is visited and revisited often during the therapeutic journey. The first part of preparation is stabilization, sometimes referred to as case management. It is the sine qua non for the remaining parts. The goal here is to make sure that the client is externally safe, as well as internally stable. A second part of the preparation phase is developing skills and resources. Among these are skills that involve changing internal states (self-soothing) and containment of disturbing affect. The third aspect of the preparation phase focuses on short-term successes in which the client gains mastery and confidence in dealing with changeable life circumstances, something of a personal trainer approach.
Energy psychology comprises a body of knowledge and a family of therapeutic modalities that are concerned with the interface between mind and body, mediated by working with the body’s subtle energy system. Although the mechanism is uncertain, research indicates that such methods do work, bringing about emotional, cognitive, and physiological changes rather faster than would be expected with purely talk-based psychotherapies. Another important component used by some practitioners is “energy testing” sometimes known as “muscle testing”, although it is not the muscles tested, but small variations in muscle tone are considered to provide information about both psychological and energetic states. This chapter discusses two case studies where, energy testing revealed significant internal objections to resolving their eating disorders (EDs). It concludes that energy psychology modalities form useful additional components of psychotherapeutic approach to EDs, helping to alleviate the intensity of emotional distress and facilitate the flow of energy and information.
- Go to chapter: Boats and Sharks: A Sensorimotor Psychotherapy Approach to the Treatment of Eating Disorders and Trauma
Boats and Sharks: A Sensorimotor Psychotherapy Approach to the Treatment of Eating Disorders and Trauma
This chapter presents a case study of a sensorimotor psychotherapy (SP) approach to eating disorder (ED) treatment. In contrast to traditional psychotherapeutic approaches, such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT), that lean heavily on the impact of thoughts on emotional experiences and somatic patterns, also known as top-down processing, SP also uses bottom-up processing, the effect that one’s somatic organization has on affect and affect regulation, cognitive functioning and specific beliefs about self and other. The very core of SP is four foundational principles that cultivate therapeutic presence and guide both content and quality of interventions: organicity, nonviolence, unity, body/mind/spirit holism. SP understands human experience through the lens of five core organizers: thoughts, emotions, and three somatic organizers. SP explores actions as a cycle with four stages: clarity, effectiveness, satisfaction, and relaxation.
This chapter discusses art therapy: images of recovery. Art therapy is a mental health profession that provides an alternative means of communication and often can be the treatment of choice for clients processing recovery from traumatic events, as well as eating disorders (EDs). Through the art making process, a visual dialogue between the client and the art images is created. The client’s self-talk and internal messages can be documented in an imagistic form. Art therapists are extensively trained to assist the client in creative expression and in facilitation of the client’s self-exploration. Using art therapy with EDs is a unique therapeutic approach that exposes conflicts, problems, thoughts, and behaviors that are not simply about food or a number on the scale. ED patients have extreme fear of being negatively evaluated. The art therapist works toward eliminating those fears by giving the clients creative control over their selfexpression.
This chapter presents a guide for assessing comorbid eating disorders (EDs) and trauma in a way that shapes and directs treatment. It draws together a combination of assessment tools and principles from the fields of EDs, trauma, and generic mental health, as there is limited literature available on this specific area of assessment. The chapter summarizes various aspects of assessment into distinct sets of guidelines, to help steer the clinician and client through a vast maze of information toward a meaningful formulation and treatment plan. It provides a road map to facilitate comprehensive assessments that lead to the construction of insightful formulations and the delivery of engaging treatment plans. The authors believe that trauma-informed ED assessment guides safe and effective treatment, shining a beacon of light on the road toward transformation and healing.
Eye movement desensitization and reprocessing (EMDR) is an integrative, client-centered psychotherapy developed by Francine Shapiro, PhD, in 1987. EMDR engages the natural information processing systems in the brain to process disturbing life experiences that are, according to Shapiro, the bases of pathological behaviors. The Adaptive Information Processing (AIP) model was developed by Francine Shapiro to explain the effects of EMDR therapy; guide case conceptualization, treatment planning, and interventions; and predict treatment outcomes. The AIP model assumes that both pathology and health are the development of early life experiences that are stored in neurobiological memory networks. Early life experiences, therefore, are the building blocks of perception, attitudes, and behaviors. Neurobiologically speaking, our life experiences get translated into physically stored memories on which we rely to guide us in life choices and interpretations.
This chapter explores the neurological link between trauma and eating disorders (EDs) by describing one of humans’ basic functions: response to stressors. Adverse life events interact with the genome and developmental processes, leading to biological changes that predispose one to a broad range of psychiatric problems, including EDs. The mechanisms involved include abnormalities in the stress response, changes in appetite, altered reward sensitivity, and increased sensitivity to rejection. Specific genes increase one’s susceptibility to stressful experiences, and stressful experiences have the ability to alter one’s genes (i.e., epigenetics). Epigenetics refers to the way in which environmental exposures have the capacity to influence the genome in a way that affects later gene expression. Findings from epigenetic research and neural-based interventions offer evidence against the long-standing understanding of genes and neurocircuitry as “rigid” structures.
- Go to chapter: The Many Faces of Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Other Specified Feeding or Eating Disorder (OSFED), Bulimarexia, and Orthorexia
The Many Faces of Eating Disorders: Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Other Specified Feeding or Eating Disorder (OSFED), Bulimarexia, and Orthorexia
Feeding and eating disorders (EDs) are severe mental illnesses. This chapter gives a concise overview regarding EDs, their diagnostic configuration, and comorbidity with other mental illnesses. Moreover, the focus included vulnerability and psychological aspects of EDs, with particular attention given to the impact of dysfunctional attachment dynamics and relational trauma on the onset of each type of ED. The chapter covers EDs such as anorexia nervosa, bulimia nervosa, binge eating disorder, and other specified feeding or eating disorder (OSFED). Types of EDs also included those that are not present in Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), but are frequently found in clinical practice. Such disorders (e.g., bulimarexia or orthorexia) are symptomatological manifestations that require further investigation to clarify risk factors related to their onset and to shed light on their mechanism of action.
Hypnosis relates to when a person’s behavior shows he or she is in a trance like frame of mind, dissociated from his or her usual conscious awareness. Hypnosis challenges the polarization between the different aims of behavioral and analytical therapy. The reports of many of the patient shows the real source of their distress, and sometimes seem to make the problem worse. This has been eloquently expressed by a young doctor, a survivor of childhood anorexia. “When you live with anorexia, you fight your own thoughts and fears, your own self, every second of every minute of the day. Recognizing this spontaneous hypnosis or trance state as a clinical sign involves a different level of listening skills, a modified approach to history taking and to all the advice given. The focus of therapy is turned from the past to the future from regression to progression.
This chapter focuses on an interpersonal/relational psychodynamic approach to working with eating disorders (EDs), which illuminates the links between symptom and meaning, action and words, isolation and relatedness. The work of any treatment of EDs is an ongoing, complicated mixture of direct intervention with the symptom and exploration of what the intervention means to the patient, including the role the symptom plays in the patient’s intrapsychic and interpersonal world. Understanding this as it unfolds relationally allows the intersubjective experience of both patient and therapist to collide, mingle, and ultimately coexist. Thinking about working with patients with EDs from this vantage point means that the experience of conflict is a therapeutic gain, not obstacle. Multiplicity and the capacity for dissociation are seen as part of the manifestations of what happens with patients with EDs.