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.
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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.
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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.
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.